£573 million is spent on diabetes inpatient admissions every year in the UK. Erin Dean reports on how nurses can help to reduce this bill

We have much to do

SUMMARY

Most healthcare professionals are aware of the challenge the NHS is facing when it comes to caring for people with diabetes. But the scale of the problem set out in a new report is staggering. According to the Joint British Diabetes Societies for Inpatient Care report, Admissions Avoidance and Diabetes (tinyurl.com/qf4g9nn), there are three million people in the UK diagnosed with diabetes and a further 850,000 estimated to have undiagnosed type 2 diabetes. One in six patients in hospital has diabetes. The report urges the NHS to ensure that people can access well co-ordinated and good quality care. It points out that poor care, as well as being harmful to people’s health, puts an increasing strain on NHS finances, with the extra bed days needed by diabetes patients already costing an estimated   £573 million per year. Many patients end up repeatedly going into hospital with a wide range of complications related to poorly managed diabetes. These include conditions that are costly to the NHS and have a devastating effect on quality of life, including amputation of limbs and renal, stroke and heart problems. Rates of re-admission

What is diabetes? Type 1 diabetes develops when the insulin-producing cells in the body have been destroyed and the body is unable to produce any insulin. It accounts for about 10 per cent of all adults with diabetes and is treated by daily insulin injections, a healthy diet and regular physical activity. It can develop at any age but usually appears before the age of 40. Type 2 diabetes typically appears in people over the age of 40, though in South Asian people, who are at greater risk, it often appears from the age of 25. It accounts for between 85 and 90 per cent of all people with diabetes and is treated with a healthy diet and increased physical activity. Medication and/or insulin are often required. Type 2 diabetes develops when the insulin-producing cells in the body are unable to produce enough insulin or when the insulin that is produced does not work properly.

One in six hospital beds is now filled by a patient with diabetes. Integration between primary, community and acute services and improved access to specialist nurses are vital. Some innovative specialist nursing teams are reducing hospital admissions by educating clinicians and patients in diabetes management and providing expert advice. Author Erin Dean is a freelance journalist

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within 28 days for people with diabetes are 59 per cent higher than those without the condition. Angus Forbes, professor of diabetes nursing at the Florence Nightingale School of Nursing and Midwifery, says that while many diabetes patients are, inevitably, at increased risk of admission, opportunities to keep them out of hospital are being missed. ‘The average admission age of a person with diabetes into hospital is 76, so it is predominantly older people. We know admissions are caused by complications, increasing prevalence in older frail people and multiple comorbidities. But there is often a failure of primary care to be able to recognise high-risk patients and implement interventions at this level to stop admissions.’

A recurrent theme in the report is the importance of prompt access to specialist care for patients with urgent or complex issues. For example, GPs, practice nurses and community nurses need to be able to access specialist advice when caring for a patient who has a foot ulcer or is struggling to control his or her blood glucose levels. It also urges NHS commissioners to recruit and train sufficient numbers of diabetes specialist nurses (DSNs) in the hospital and community. Unfortunately, the evidence suggests that specialist nurses are an increasingly rare resource. A Diabetes UK workforce survey published in 2011 found that 43 per cent of posts were unfilled due to cost savings at trusts. It also found that one fifth of DSNs were due to retire by 2016. Meanwhile, the National Diabetes Inpatient Audit for 2012, published last June,   found that almost one third   of hospitals did not have an   inpatient DSN.

Specialist wards

Siobhan Pender, a DSN for Guy’s and St Thomas’ NHS Foundation Trust and a member of the RCN diabetes nursing forum, says the sheer number of patients can overwhelm specialist services. ‘There are so many patients with diabetes who are scattered throughout the hospital. There needs to be a debate on whether specialised diabetes wards should be reintroduced, so that we would know where the high-risk patients are, and that the nurses there are skilled and experienced   in diabetes care.’

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Ms Pender warns that the major reorganisation in the NHS in England, which has seen primary care trusts replaced by GP-led commissioning groups, is increasing fragmentation of services and making a difficult situation worse. ‘We used to have links between secondary and community colleagues, but this has been split by the changes to commissioning. The problem is making sure that someone is following up patients who come in and out of hospital when you are not all in the same team. It is concerning that the whole idea of integration does   not seem to be happening.’

Decision making

those with type 2 diabetes who are not managing their blood glucose levels on medication and need to go onto insulin, people suffering from frequent hypoglycaemic episodes and people with mental health or learning difficulties. The team has ten whole-time equivalent DSNs, along with the diabetes care technicians, administrative staff, a dietitian and podiatrist, and support from a medical consultant. Ms Joynson says: ‘If we can help people manage their diabetes themselves, it can have benefits for years, as people have this condition for life.’

Super Six

Another successful model of diabetes care introduced in Portsmouth and South East Hampshire appears to be reducing unnecessary admissions. In the Super Six approach, an integrated, multidisciplinary, community-based specialist team works in partnership with colleagues across primary and secondary care. The community team supports the care of newly diagnosed people with diabetes, as well as those requiring ongoing follow up, unless they fall into 

DANIEL MITCHELL

The report says that primary care practitioners should have access to a diabetes specialist team to which they can refer when deciding if a patient requires admission to

hospital. Access to blood ketone testing will identify those patients with type 1 diabetes at risk of diabetic ketoacidosis needing hospital admission and those who can be managed at home. This approach is used by Staffordshire and Stoke-on-Trent Partnership NHS Trust’s community diabetes team,   which offers rapid access to specialist staff. Community DSN and team lead Jane Joynson says that as well as providing a service through clinics, the team has a daily on-call DSN for patients   and healthcare professionals in need of advice. ‘The DSNs on this rota are   very responsive and give   avoiding admission a priority,’   she says. ‘They will provide advice over the phone, go out and see   the patient, or send out the diabetes care technician to   check ketone levels.’ The service sees people in need of specialist care, such as

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The 15 diabetes healthcare essentials Diabetes UK lists 15 healthcare essentials for people with diabetes. These include the nine care processes that NICE says all people with diabetes should receive annually: An HbA1c blood test should be administered at least once a year.

 1  2  3  4  5  6  7  8  9 10 11 12 13 14

SUPERSTOCK

15

Blood pressure should be measured once a year or more often. There should be an annual check of blood fats such as cholesterol. An eye screen should be given each year to check for signs of retinopathy. The feet’s skin, circulation and nerve supply should be checked annually. There should be a urine protein test and blood test every year. An annual weight check and waist measurement should be undertaken. Patients should be supported on how to quit smoking, as diabetes increases the risk of heart disease and stroke. Care planning should be individually tailored for every person with diabetes. Patients should attend an education course to help them to understand and manage their diabetes. Children with diabetes should receive care from specialist paediatric teams. Inpatients should receive high-quality care from specialists. Women with diabetes planning to have a baby should get information and specialist care. People with diabetes should see specialist healthcare professionals to help them manage their diabetes. Emotional and psychological support should be provided.

Find out more at tiny.cc/DiabetesUK_ 15checklist Read an RCN resource on diabetes www.rcn.org.uk/development/ practice/diabetes

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 categories that remain with  the secondary care team, such as  pregnant women, adolescents,  and people requiring renal dialysis. The aim is to boost the  knowledge and self-management  of diabetes through education  programmes for clinicians  and patients. This approach has led to  90 per cent of patients being  discharged from secondary care  back to primary care. Research  suggests more than £90,000 a  year is being saved on secondary  care appointments. In the  fi rst 12 months, there was an  18 per cent reduction in  episodes of diabetic ketoacidosis  and a 16 per cent fall in  hypoglycaemic admissions. 

Theresa Smyth, nurse  consultant in diabetes at  University Hospitals Birmingham  NHS Foundation Trust, says  nurses can help improve care  by ensuring that patients go on  these types of courses if they  are available.  ‘Structured education can  prevent admissions by reducing  the numbers of patients  experiencing hypos and diabetic  ketoacidosis,’ she says.  ‘It can help patients  to know what to do when they  are unwell.’ Unfortunately, an education in  diabetes is not an option for most  patients. Data from the National  Diabetes Audit, published in  November, found that less than 

IT IS UNACCEPTABLE THAT WE HAVE A POSTCODE LOTTERY Gwen Hall, a DSN who works  for the Solent NHS Trust, says  primary care staff feel supported  by specialists. ‘If there is a complex  patient, we see them with the GP  or district nurse so that while we  are helping the patient, we are also  upskilling the staff. It works really  well for patients as the continuity  of care is there with the staff that  they normally see. There is also a  consultant on call from 5.30pm  to 7pm at the end of a phone if  a practice nurse or GP needs to  discuss a patient.’

Self-management

Two well known schemes to give  patients confi dence when  managing their condition  are dose adjustment for  normal eating (DAFNE),  which teaches people with  type 1 diabetes to adjust  their insulin injections  to fi t their lifestyles,  and diabetes education  and self-management  for ongoing and  newly diagnosed  (DESMOND),  which is  for those with  type 2 diabetes.

14 per cent of people newly  diagnosed with the condition  were offered the chance to attend  a structured course. Another problem is that  patients often do not receive  basic health checks that show  how well they are managing their  complex conditions and fl ag up  issues requiring attention. The National Institute for  Health and Care Excellence sets  out nine checks that people with  diabetes should have every year,  including tests of eyes, feet and  blood glucose levels. However, the  National Diabetes Audit revealed  large regional differences in how  good the NHS is at carrying out  these checks.  When the inpatient admission  report was published, Diabetes  UK chief executive Barbara Young  called it ‘a clarion call to improve  the care standards people with  diabetes get, right from the  moment they are diagnosed with  the condition’.  She added: ‘It is unacceptable  that we have a postcode lottery,  where one of the biggest  predictors for how likely someone  with diabetes is to end up in  hospital is where they live’  NS

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We have much to do.

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