Managing Diabetes - putting NICE into practice

Category:           Scheme best reducing the Burden of Chronic Disease

Name:                Ruth Ludford

Job Title:            Practice Nurse

Organisation:     Chesterfield PCT

Email:                 ruthludford@onetel.net.uk

Telephone:         01246 272139

Key team:           Dr D I Anderson – GP, Ruth Ludford - Practice Nurse, Kate Field - Practice Nurse

Title:                  Managing diabetes - putting nice into practice

The need for change was identified following

• the publication of the Diabetes NSF
• preparing to put the NICE guidelines into practice for people with diabetes. 

Our core argument is that

• lasting change requires client concordance  Clients must take a larger responsibility in managing their diabetes. 
• This would require them to be better educated concerning the issues
• AIMS
• To help patients and professionals work together to reduce the risk of Cardiovascular Disease.
• To encourage patients to understand diabetes and take more control of their own lifestyle.
• To assess the impact of working differently in terms of patient outcomes, satisfaction and knowledge.

We reviewed our diabetes population using the Primary Care Toolset to:

• Increase out understanding of diabetes.
• Identify areas of need and decide where to target our resources
• Define which groups of patients to focus our activity towards
• Build our own practice’s diabetes Group Education Meetings

We developed a rolling programme of structured education to address both patient and professional needs, with respect to:

• Diabetes the disease
• Cardiovascular risk management (HbA1c, cholesterol, BP, microalbumin, smoking and BMI)
• Patient empowerment

Starting with the risk factor cholesterol, we identified those people with a last result above agreed target (5mmol/l), reviewed their records against NICE guidelines and invited the appropriate patients to a two hour group education meeting.  A second meeting focused on glycaemic control applying the same process to those people with a last Hba1c above agreed targets.

• The first meeting was led by a GP, 2 practice nurses, a dietician and 23 patients
• We worked with Dr. Stuart Bootle and Mr. Peter Jessamine, using the Primary Care Toolset, to help us decide where to focus our efforts and resources resulting in changes at professional and patient levels alike.  
• From a practice list size of 9745, 288 people with a recording of diabetes, 238 had a recording of cholesterol, 135 had a last cholesterol  >5mmol/1.  85 were not on a strain.
• We assessed success in terms of results and patient satisfaction:
• Re-audit 8 weeks later: 9870practice list size, 307 people with diabetes; 288 had cholesterol recorded; 86 had a last cholesterol >5mol/l, 56 not on statin.
• Patient questionnaire
• 68% of questionnaires were completed
• 100% would like to be invited to future meetings 
• 100% felt that this new type of initiative within the practice had been worth the time invested.       
• In choosing our cohort we had to take care that we were non-discriminatory in terms of age and educational ability and that all patients were given an equal opportunity.  
• The structure of the programme had to be set at a patient level of understanding and that professionals did not become too clinical or take over the meeting. 
• Whilst addressing the patients’ needs we also had to ensure that we were effective in our own time management.
• A significant reduction in the number of people with a last cholesterol >5mmol/l.
• Influence on our clinical behaviour in routine consultations leading to more cholesterol related interventions.  
• We observed during the educational session that patients interacted with each other.  They openly admitted problems and were comfortable with one another, which does not always happen in group sessions.
• The team has benefited by listening to patient’s views of their disease.  The structured educational format has been repeated with equally successful results.
• We hope to continue this way of working with patients as we feel it has benefited both professionals and patients alike.  We are at present working with a cohort of 20 patients in intensive blood glucose monitoring, the aim being to demonstrate to patients the relationship between HbA1c, diet, exercise and therapeutic intervention.  Our early findings reveal increased decision making, intervention and patient ownership of the problem. 

One patient invited to the first meeting is a lay member of the PCT and she has taken the idea of structured group education meetings back to the PCT