Special Report – Improving Expertise in Diabetes Management Through Postgraduate Training BMJ by The Magazine Production Company

SPECIAL REPORT

Improving Expertise in Diabetes Management Through Postgraduate Training The Diabetes Revolution: Tight Control of Blood Glucose Levels Why Should I Bother Improving my Knowledge of Diabetes? Then it DAWNed on me . . . We Need a Well-Trained Multidisciplinary Team! Agents of Change: The Expanding Role of the Diabetes Specialist Nurse within the Multidisciplinary Team

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“As a GP I see a high volume of patients. Enhancing my knowledge about diabetes has enabled me to improve the care I give to my patients” Dr Alexander Christopoulos, GP

SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

SPECIAL REPORT

Improving Expertise in Diabetes Management Through Postgraduate Training The Diabetes Revolution: Tight Control of Blood Glucose Levels

Contents

Why Should I Bother Improving my Knowledge of Diabetes? Then it DAWNed on me . . . We Need a Well-Trained Multidisciplinary Team! Agents of Change: The Expanding Role of the Diabetes Specialist Nurse within the Multidisciplinary Team

Foreword

Dr Robert Sykes, Editor

Introduction

Dr Eleanor D Kennedy, Managing Editor, Diabetes Qualifications, BMJ

Published by Global Business Media

The Diabetes Revolution: Tight Control of Blood Glucose Levels

Published by Global Business Media

Susan Thomas, Medical Correspondent

Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom

Changing the Goalposts in Type 1 DM? The UK Prospective Diabetes Study (UKPDS) â&#x20AC;&#x201C; A Familiar Landmark A Mountain of Research Conclusions

Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor Dr Robert Sykes Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

Why Should I Bother Improving my Knowledge of Diabetes?

Dr R A Sykes, Editor

The National Service Framework for Diabetes Quality and Outcomes Framework (QOF) We Still Have a Long Way to Go Conclusions

Then it DAWNed on me . . . We Need a Well-Trained Multidisciplinary Team!

Dr R A Sykes, Editor

A Call to Action DAWN2 Postgraduate Training Conclusions

Agents of Change: The Expanding Role of the Diabetes Specialist Nurse within the Multidisciplinary Team 15 G A Hood

The Role of the MDT Meeting Changing Needs The Importance of Supporting Practice Staff Continuing Education is Key

ÂŠ 2013. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner. WWW.PRIMARYCAREREPORTS.CO.UK | 1

SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

Foreword D

IABETES IS increasingly common, affecting people of all ages in all populations. It can have a major impact on the physical, psychological, and material well-being of individuals and their families, and can lead to significant complications including heart disease, stroke, renal failure, amputation, and blindness. However, the problem continues despite mounting evidence that effective management increases life expectancy and reduces complications. Moreover, it is increasingly acknowledged that selfmanagement in the context of multidisciplinary support is the key to care. Empowering patients through properly educated members of the multidisciplinary team (MDT) is essential. Whether you are a doctor, a Diabetes Specialist Nurse, a dietician, or another member of the MDT, keeping up to date in this highly evidence-based and fast moving field is crucial. But how do you do that in a busy work environment with ever mounting pressures? How do you justify the expense of a course both financially and in terms of time lost to other activities? First, I would like to draw your attention to online learning, which helps many people to fit courses around their busy schedules.

Why Online Learning? Although online learning has fast become a mainstream educational tool, until recently the evidence had been sporadic and weak1. In 2009, the U.S. Department of Education published a meta-analysis2 offering substantial evidence in favour of the format. It identified over 1,000 empirical studies of online learning published between 1996 and 2008, of which 51 independent studies met the strict inclusion criteria. Each study compared online to face-to-face teaching, and was required to measure learning outcomes and to produce sufficient data for statistical analysis. The meta-analysis concluded that students undertaking online tuition performed better than those receiving face-to-face tuition. A particularly relevant finding to the current educational environment is that those who took blended courses that combined both formats, performed even better. The study found statistically significant results for all types of undergraduate, postgraduate, and higher education courses, regardless of discipline. Although clear benefits emerged with online learning, the study was unable to conclude whether these were due entirely to the positive impact of the technological format. For example, it states that using technology to give students “control of their interactions” positively affected student learning, with “learner activity or… reflection and self-

monitoring of understanding... effective when students pursue online learning as individuals”2. On the other hand, time constraints were considered critical, with the report concluding that “studies in which (online) learners … spent more time on task than… face-to-face (learners) found a greater benefit for online learning”2. Interestingly, the analysis also concluded that course design remained important. This is certainly a feature that is supported by many educationalists1. On balance, a combination of factors almost certainly contributed to the overall positive outcomes associated with online learning. Indeed, it appears that choosing the right course is as essential in the virtual world as it is in the real world. Successful education has always been about engaging students whether it is in an online environment, face to face, or in a blended setting1,2. BOX 1: The Benefits of Online Learning • Saves time and money • Convenient and flexible •S tudents can apply study immediately into clinical practice • Greater access to expertise •M ulti-national tutor groups, bringing expertise from across the globe •D evelops knowledge of the internet and computer skills • Increases English language ability •E ffective collaboration between students from around the world and from across multidisciplinary teams. Source: Eleanor Kennedy BSc PhD MBA, Managing Editor – Diabetes Qualifications, BMJ. BMJ, BMA House, Tavistock Square, London, WC1H 9JR. www.diabetesonline.bmj.com

There are many benefits to online learning, particularly for the MDT (Box 1). In this report, the editorial by Dr Eleanor Kennedy discusses these further, before we move on to consider some essential research findings and the increasing importance of the MDT in diabetic care; this concludes with an interesting perspective from the Diabetic Nurse Specialist Gill Hood. Taken together, the articles in this Report seek to both inform the reader and to motivate them on the need for further training.

Robert Sykes Editor

Dr Robert Sykes qualified with a degree in medicine (MBChB Honours) in 2004 from the University of Liverpool where he was awarded the George Holt Medal for high academic achievement, along with commendations for a number of his clinical reviews. As a postgraduate he entered into a GP vocational training scheme before opting to work in a portfolio career, and in 2008, he set up Northern Editing (www.docrob.co.uk/nothernediting) for medical writing and editing. Currently, he is also the Executive Editor for the UK’s only peer support organisation for doctors with mental illness, the Doctors’ Support Network (registered charity 1103741; www.dsn.org.uk).

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SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

Introduction Dr Eleanor D Kennedy, Managing Editor, Diabetes Qualifications, BMJ

CCORDING TO the International Diabetes Federation, the global number of cases of diabetes is set to increase from todayâ&#x20AC;&#x2122;s figure of around 370 million to over 550 million in the next couple of decades (1). This growth is pushing the healthcare systems around the world to breaking point with the estimated expenditure hitting an annual figure of $465 billion(1). Although diabetes is a chronic condition, research has established that, for both type 1 diabetes and type 2 diabetes, tight control of blood glucose levels can reduce the risk of the long-term complications of diabetes including stroke, blindness, kidney failure and

amputation(2,3). Key to this, however, is selfmanagement and it should be at the core of all diabetes care services. Healthcare delivery teams need to be kept abreast of how to deal with diabetes, its clinical presentation and treatment and the new therapies that are being developed to help manage the condition more effectively. And they need to work together to empower their patients to take control of the day-to-day management of their condition. Increasingly, modern diabetes care now relies on the effective collaboration of the multidisciplinary team (MDT). Diabetes is no longer treated only by doctors. Instead, the team now incorporates diabetes specialist nurses, nurse educators

Increasingly, modern diabetes care now relies on the effective collaboration of the multidisciplinary team

SOME OF OUR NEW INTAKE OF STUDENTS

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SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

DR MAGDY MEGALLAA TALKS TO STUDENTS AT INTRODUCTORY LECTURES IN DUBAI, UAE

BMJ has partnered with the University of Leicester to offer unique Postgraduate Diabetes Qualifications that give healthcare professionals from around the world the opportunity to learn from experts in an engaging online environment

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and dieticians, podiatrists, optometrists and ophthalmologists and psychologists. The move to providing collaborative, holistic patient care allows for a more tailored, individualised approach. And the aim is to improve the patient’s quality of life and to support a shared decisionmaking process. With this in mind, the provision of cutting edge educational packages that address the needs of all members of the MDT is becoming more and more essential. BMJ has partnered with the University of Leicester to offer unique Postgraduate Diabetes Qualifications that give healthcare professionals from around the world the opportunity to learn from experts in an engaging online environment. The postgraduate qualifications offered by us have a proven track record in providing an innovative, e-learning, modular-based platform aimed at providing continued education and professional development to medics, nurses and allied healthcare professionals keen to develop their skills in the care and treatment of diabetes. Given the demanding and often difficult lifestyle changes like diet modification and exercise programme adherence and, of course, glucose monitoring regimens that need to be adopted, it is vital that the MDT members have the skills to help their patients to manage their condition. With that in mind, the course has been developed to offer students modules currently offered span all elements of diabetes care and treatment: •M odule 1 – Prevention, Early detection and Screening in Diabetes •M odule 2 – Clinical Presentation and Management in Diabetes •M odule 3 – New and Advanced Therapies in Diabetes • Module 4 – Self–Management in Diabetes • Module 5 – Insulin Management • Module 6 – Diabetes and Obesity

Based on the International Diabetes Federation’s curriculum, our qualifications have been designed to be delivered using state-of the art teaching methods and online learning technology. This gives our students the flexibility to study around their busy schedules but, importantly, the immediacy of e-learning allows students to evaluate their own practice in the context of the latest scientific evidence in diabetes care and to apply this to improve patient outcomes. In addition, our international team of expert tutors support students throughout their studies. These tutors are practising clinicians and leaders in the field of diabetes, dedicated to providing a positive experience for students. We are proud to be at the heart of this resultsdriven and growing global community of healthcare professionals striving to provide the very best clinical care for their patients around the world. If you would like to become a part of it, visit our website and sign up today.

DR NOMA SALMAN AT INTRODUCTORY LECTURES, APRIL 2013

References: 1

www.idf.org/diabetesatlas/5e/the-global-burden (last accessed 19th August 2013)

The Diabetes Control and Complications

Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus N Engl J Med. 1993 Sep 30;329(14):977-86. UK Prospective Diabetes Study (UKPDS)

Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) Lancet. 1998 Sep 12;352(9131):837-53.

SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

The Diabetes Revolution: Tight Control of Blood Glucose Levels Susan Thomas, Medical Correspondent

HE SAD fact is that many people die unnecessarily; the basic concept of avoidable mortality is that “deaths caused by certain conditions, for which effective public health and medical interventions are available, should be rare and ideally, should not occur”1. Most of you will be aware that diabetes is one such condition. It is true that we have come a long way from the position where diabetic complications could be regarded as a natural outcome. But how did we get here? This article seeks to remind the reader of several key pieces of research that have revolutionized our understanding and practice of diabetic care.

Changing the Goalposts in Type 1 DM? The Diabetes Control and Complications Trial (DCCT)2 was a major randomised clinical study conducted from 1983 to 1993 and funded by the National Institute of diabetes and Digestive and Kidney Diseases. It involved 1,441 volunteers with Type 1 diabetes aged 13 to 39, across 29 medical centres in the United States and Canada. Volunteers had to have had diabetes for between 1 and 15 years, and no (or only early signs of) diabetic eye disease. The study compared the effects of standard control of blood glucose versus intensive control (see box 2) on the complications of diabetes. Intensive control essentially meant keeping haemoglobin A1c levels (HbA1c) as close as possible to 6% or less. The DCCT reported several results that changed the focus of medical care for diabetes; specifically, intensive blood glucose control reduced the risks of eye disease (by 76%), kidney disease (by 50%), and nerve damage (by 60%). Thus, it demonstrated clearly that maintaining nearnormal blood glucose levels could slow the onset and progression of eye, kidney, and nerve damage caused by diabetes. In fact, it demonstrated that any sustained lowering of blood glucose helps, even in the context of otherwise poor control.

BOX 2: Elements of Intensive Management in the Diabetes Control and Complications Trial (DCCT) •T esting blood glucose levels four or more times a day • I njecting insulin at least three times daily or using an insulin pump •A djusting insulin doses according to food intake and exercise • Following a diet and exercise plan • Making monthly visits to a health care team composed of a physician, nurse educator, dietician, and behavioural therapist

It demonstrated clearly that maintaining nearnormal blood glucose levels could slow the

•R isks: the main issues with intensive care are the risks of hypoglycaemia and the increased costs

onset and progression

Source: The Diabetes Control and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus N Engl J Med. 1993 Sep 30;329(14):977-86.

nerve damage caused

of eye, kidney, and by diabetes

When the DCCT ended in 1993, researchers continued to follow around 90% of its participants in the Epidemiology of Diabetes Interventions and Complications (EDIC) study3, under a much broader remit. In addition to considering the diabetic complications covered in the DCCT, this considered the incidence and predictors of cardiovascular disease events (heart attack, stroke, or need for heart surgery), and also assessed intensive control versus standard control in terms of both quality of life and costeffectiveness. The EDIC found that intensive blood glucose control reduces the risk of any cardiovascular disease event by 42%, and the risk of nonfatal heart attack, stroke, or death from cardiovascular causes, by 57%.

The UK Prospective Diabetes Study (UKPDS) – A Familiar Landmark The DCCT and EDIC studies conclusively confirmed the benefits of tight glucose control in WWW.PRIMARYCAREREPORTS.CO.UK | 5

SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

Although there have been many gains in our understanding, not all studies have been as successful as the landmark DCCT and UKPDS studies

Type 1 diabetes, but our understanding of Type 2 diabetes remained unclear. Starting life as a pilot scheme, the UKPDS4 has become a landmark trial of glycaemic therapies in patients with newly diagnosed Type 2 diabetes. This was also a randomised, multicentre study (23 sites) with a sizeable cohort (5,102 patients). It ran for twenty years from 1977 to 1997, with blood pressure control considered from 1987 onward, and has provided a wealth of knowledge. The UKPDS randomly allocated patients to diet, sulphonylurea, metformin, or insulin therapy, and found that intensive blood glucose control decreased the risk of diabetic complications. Specifically, optimal outcomes were achieved by using sulphonylureas or insulin to reduce glucose exposure to a median HbA1c of 7.0 % versus 7.9 % over 10.0 years. This approach reduced the risk of “any diabetes-related endpoint” (by 12%) and microvascular disease (by 25%), with a trend to a reduced risk of myocardial infarction (16%), with conclusive evidence of reduced risks of laser treatment of the eye (by a quarter) and early kidney damage (by a third). Early in the UKPDS, it became apparent that high blood pressure and heart attacks frequently complicated diabetes, and so in 1987 a study of 1,148 hypertensive patients was added. This found that improving blood pressure from an average of 154/87 mmHg to 142/82 mmHg, over a median 8.4 years, reduced the risk of both microvascular and macrovascular disease. ACE inhibitors and beta-blockers were demonstrated to be equally effective. Moreover, the savings from reduced diabetic complications far outweighed the additional cost of medical therapy, if not for the extra staffing costs. In terms of diabetic complications, tight blood pressure control decreased, by a third, the risk of strokes, death from complication (e.g., heart attacks or strokes), and deterioration in vision, and also decreased the progression of microvascular disease. Overall, the UKPDS confirmed that Type 2 diabetic patients have a 2-fold greater mortality than the general population, and that after 10 years, a third have complications requiring clinical attention, including heart attacks, strokes, renal failure, amputations, retinopathy, and cataracts. Moreover, it showed conclusively that the complications of Type 2 Diabetes, previously often regarded as inevitable, could be reduced by improving blood glucose and blood pressure control. In the context of a condition that was thought to be self-inflicted and “diet-controlled” at the time, the findings of the UKPDS were truly remarkable.

A Mountain of Research Research since these has grown exponentially, and has sought to consolidate the evidence, 6 | WWW.PRIMARYCAREREPORTS.CO.UK

to investigate the nuances in therapy, and to compare the various therapeutic strategies, while continually searching for novel treatment modalities. Indeed, the advances in medical care are legion5 and constantly evolving6; this means that the health care practitioner must remain up to date with the most relevant knowledge. A simple example that has found its way into the popular domain recently is the report that people with Type 2 Diabetes may benefit from eating a large low-calorie breakfast rich in protein and fat instead of a low-calorie morning meal7. Here, the important feature is that patients were randomly assigned to balanced hypocaloric diabetic diets with either a big breakfast (33 percent of total daily energy intake, with a higher percentage of protein and fat) or a small breakfast (12.5 percent of total daily energy intake); the emphasis being that their total daily intake remained comparable and low. After 13-weeks, the researchers found that in 59 patients, the big breakfast group had significantly greater reductions in HbA1c, systolic blood pressure, and hunger scores, and greater improvements in fasting glucose readings. While interesting, taken out of context with the global picture of diabetic care, and the need for a calorie-controlled diet, this information could be harmful. Furthermore, although there have been many gains in our understanding, not all studies have been as successful as the landmark DCCT and UKPDS studies. A good example is the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial8, which studied 10,251 adults with established Type 2 diabetes over 77 clinical sites across North America. The ACCORD trial sought to assess the treatment options in patients at particularly high risk for cardiovascular events, because of age, subclinical atherosclerosis, or pre-existing clinical cardiovascular disease in light of the findings of the UKPDS. It was designed to test the effects on major cardiovascular events of the following in comparison to controls: (1) intensive glycaemic control; (2) fibrate treatment to increase HDL-cholesterol and lower triglycerides (in the context of good LDL-C and glycaemic control); and, (3) intensive blood pressure control (in the context of good glycaemic control). Unfortunately, the glycaemia trial was terminated early due to higher mortality in the intensive compared with the standard glycaemia strategies. Further, there were no significant differences between intensive and standard blood pressure treatment, or with outcomes using fibrates. This is yet another example of the many studies that professionals treating diabetics should be aware of5, and that may lead patients to question the need for tight control. However, being able to differentiate it from the truly revolutionary DCCT and UKPDS studies,

SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

and appreciating the position of the research in the wider picture is important. This brings into focus the need for evidence-based training and for learning directed by experts.

Conclusions It is clear that intensive control of blood glucose, blood pressure, and blood lipid levels reduce the likelihood of later macrovascular and

microvascular complications in Type 1 and Type 2 diabetes. Courtesy of these findings, few practicing doctors would fail to strive for optimal blood glucose control. So, what of the future? Once, diabetic complications were regarded as a natural outcome of the chronic disease process, yet studies clearly demonstrate this to be false in the context of consistently good management. We know that tight control of blood glucose levels can reduce the risk of the long-term complications of diabetes including stroke, blindness, kidney failure and amputation. Practically, obtaining near-normal blood pressure and improved lipid profiles are often easier than maintaining near-normal blood glucose levels because more therapies are available. While research continues to fine-tune the optimal, increasingly individualized therapy, it is important for health care providers to arm themselves with the knowledge to provide optimal care.

Overall, the UKPDS confirmed that Type 2 diabetic patients have a 2-fold greater mortality than the general

References: 1

Statistical bulletin: Avoidable mortality in England and Wales, 2011. Office for National Statistics. Available at: http://www.ons.gov.uk/ons/rel/subnational-health4/avoidable-mortality-in-england-and-wales/2011/stb-avoidable-mortality--2011.html

The Diabetes Control and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus N Engl J Med. 1993 Sep 30;329(14):977-86.

Epidemiology of Diabetes Interventions and Complications (EDIC). Design, implementation, and preliminary results of a long-term follow-up of the Diabetes Control and Complications Trial cohort. Diabetes Care. 1999 Jan;22(1):99-111.

population, and that after 10 years, a third have complications requiring clinical attention, including heart attacks, strokes, renal failure, amputations, retinopathy, and cataracts

UK Prospective Diabetes Study (UKPDS) Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) Lancet. 1998 Sep 12;352(9131):837-53.

Diabetes research through the years. Diabetes UK online resource. Available at: http://timeline.diabetes.org.uk/ Dr Eleanor Kennedy. New diabetes treatments: is the future bright? Summer 2013 | diabetesupdate. Pages 20-22. Available online at: http://www.diabetes.org.uk/upload/Professionals/Publications/Summer%202013/NewMedicinesSummer2013.pdf

http://www.diabetes.co.uk/news/2013/Oct/large,-rich-breakfast-better-for-type-2-diabetes-control-96093131.html

https://www.accordtrial.org/public/index.cfm

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SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

Why Should I Bother Improving my Knowledge of Diabetes? Dr R A Sykes, Editor

A 2012 Diabetes UK report quotes that diabetes causes a tenth of hospital admissions, and that complications result in a fifth of all coronary heart disease, foot, and renal admissions, and around one third of intensive care unit admissions

VER THE last century, diabetes has progressed from being a death warrant to a manageable, if chronic condition. From the discovery of insulin in the 1920s, to the DCCT (Diabetes Control and Complications Trial)1 and UKPDS (UK Prospective Diabetes Study)2, there have been huge strides forwards in our ability to effectively manage the condition and to improve the quality of people’s lives. Despite the ability to live near-normal lives, there remains no cure. This shift from care to cure has also created spiralling healthcare costs and health inequalities that pose very real issues for the future of diabetic care. In this article, we consider government intervention in the form of the National Service Framework (NSF) for Diabetes and the Quality and Outcomes Framework (QOF), which have sought to tackle these issues. Although there are many other programmes, including the NHS health check programme , a full review of the field is beyond the scope of this article. However, we will briefly consider the recently identified failings of the current system.

The National Service Framework for Diabetes Motivated and evidenced by core trials such as the DTTS and the UKPDS, the 2001 NSF for Diabetes established twelve standards and interventions aiming to improve diabetes care (BOX 3)4. Although it was clear that both money and lives could be saved by targeted diabetic care in the NHS, the NSF was more than a clichéd political tool “making best practice the norm”; it represented best practice. By improving blood glucose and blood pressure control in diabetics, it is possible to reduce diabetic complications, including heart attacks, strokes, blindness, and renal failure by as much as a third. By detecting those complications earlier, sight, limbs, and lives can

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be saved. At its core, the NSF aimed to improve the support structures that facilitate improved and individualized care, with an emphasis on self-management. Many of us will have witnessed many of these changes over the last decade, including the influx of highly dedicated and specialised professionals, and community-based diabetes clinics bringing core services together. An important progression has been the increase in the role of the Diabetic Specialist Nurse, initially present on hospital wards to reduce the duration of hospitalization and the incidence of complications. However, as the NSF has developed, so too has their role; it is now increasingly demanding, involved, and critical to effective multidisciplinary diabetes care.

Quality and Outcomes Framework (QOF) The QOF was established to provide financial incentives for best practice, and has previously been a flagship government policy. Although there is debate over whether it truly benefits the patient, it is clear that its intentions are good. To practices, QOF incentivises GPs to improve their services to patients, including improved clinical care and better outcomes. QOF also incentivises practices to work with commissioners to improve management and integration of care for patients across the primary–secondary care interface. For patient care and public health, QOF aims to reduce health inequalities between deprived and affluent communities. Moreover, there is a clear bias toward the management of chronic, preventable illness. Indeed, 16 of the 95 QOF domains are dedicated to diabetes care (BOX 4), with the National Institute for Health and Care Excellence (NICE) seeking to add more6 – by far and away the biggest single area, and clearly prioritizing diabetes as a healthcare target.

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BOX 3: National Service Framework (NSF) Standards Table Source: https://www.gov.uk/government/publications/national-service-framework-diabetes

Standard 1: Prevention of Type 2 diabetes

1: The NHS will develop, implement and monitor strategies to reduce the risk of developing Type 2 diabetes in the population as a whole and to reduce the inequalities in the risk of developing Type 2 diabetes

Standard 2: Identification of people with diabetes

2: The NHS will develop, implement and monitor strategies to identify people who do not know they have diabetes

Standard 3: Empowering people with diabetes

3: All children, young people and adults with diabetes will receive a service which encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle. This will be reflected in an agreed and shared care plan in an appropriate format and language. Where appropriate, parents and carers should be fully engaged in this process.

Standard 4: Clinical care of adults with diabetes

4: All adults with diabetes will receive high-quality care throughout their lifetime, including support to optimise the control of their blood glucose, blood pressure and other risk factors for developing the complications of diabetes

Standards 5 & 6: Clinical care of children and young people with diabetes

5: All children and young people with diabetes will receive consistently high-quality care and they, with their families and others involved in their day-to-day care, will be supported to optimise the control of their blood glucose and their physical, psychological, intellectual, educational and social development. 6: All young people with diabetes will experience a smooth transition of care from paediatric services to adult diabees services, whether hospital or community-based, either directly or via a young peopleâ&#x20AC;&#x2122;s clinic. The transition will be organised in partnership with each individual and at an age appropriate to and agreed with them.

Standard 7: Management of diabetic emergencies

7: The NHS will develop, implement and monitor agreed protocols for rapid and effective treatment of diabetic emergencies by appropriately trained health care professionals. Protocols will include the management of acute complications and procedures to minimise the risk of recurrence.

Standard 8: Care of people with diabetes during admission to hospital

8: All children, young people and adults with diabetes admitted to hospital, for whatever reason, will receive effective care of their diabetes. Wherever possible, they will continue to be involved in decisions concerning the management of their diabetes.

Standard 9: Diabetes and pregnancy

9: The NHS will develop, implement and monitor policies that seek to empower and support women with pre-existing diabetes and those who develop diabetes during pregnancy to optimise the outcomes of their pregnancy.

Standards 10, 11 & 12: Detection and management of long-term complications

10: All young people and adults with diabetes will receive regular surveillance for the long-ter complications of diabetes. 11: The NHS will develop, implement and monitor agreed protocols and systems of care to ensure that all people who develop long-term complications of diabetes receive timely, appropriate and effective investigation and treatment to reduce their risk of disability and premature death. 12: All people with diabetes requiring multi-agency support will receive integrated health and social care.

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SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

BOX 4: The 2013–14 Proposed Quality and Outcomes Framework (QOF) Contains 16 Diabetes-Specific Domains

DM001: The contractor establishes and maintains a register of all patients aged 17 and over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed. DM002: The percentage of patients with diabetes on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less. DM003: The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less. DM004: The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less. DM005: The percentage of patients with diabetes, on the register, who have a record of an albumin:creatinine ratio test in the preceding 12 months. DM006: The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with an ACE-I (or ARBs) DM007: The percentage of patients with diabetes, on the register, in whom the last IFCCHbA1c is 59 mmol/mol or less in the preceding 12 months.

Reducing the personal

DM008: The percentage of patients with diabetes, on the register, in whom the last IFCCHbA1c is 64 mmol/mol or less in the preceding 12 months.

and societal burdens of

DM009: The percentage of patients with diabetes, on the register, in whom the last IFCCHbA1c is 75 mmol/mol or less in the preceding 12 months.

diabetes, and tackling

DM010: The percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 September to 31 March.

health inequalities are

DM011: The percentage of patients with diabetes, on the register, who have a record of retinal screening in the preceding 12 months.

within the power of the individual practitioner

DM012: The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 12 months. DM013: The percentage of patients with diabetes, on the register, who have a record of a dietary review by a suitably competent professional in the preceding 12 months. DM014: The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register. General Practice Extraction Service (GPES) Customer Requirement Summary DM015: The percentage of male patients with diabetes, on the register, with a record of being asked about erectile dysfunction in the preceding 12 months. DM016: The percentage of male patients with diabetes, on the register, who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 12 months. Source: http://www.hscic.gov.uk/media/11559/QOF-2013---14-Customer-Requirement-Summary---Feb-2013/pdf/QOF_2013-14_Customer_Requirement_Summary_-_Feb_2013_(NIC-180052-XY10T).pdf

We Still Have a Long Way to Go Annually, the NHS spends approximately 10% of its budget (£10 billion) directly on diabetes; the total, including indirect costs, is estimated at £23.7 billion, which is predicted to rise to £39.8 billion by 2035/67. A 2012 Diabetes UK report quotes that diabetes causes a tenth of hospital admissions, and that complications result in a fifth of all coronary heart disease, foot, and renal admissions, and around one third of intensive care unit admissions 8. 10 | WWW.PRIMARYCAREREPORTS.CO.UK

A report from the eighth year of the National Diabetes Audit (NDA) 2010-20119 also reported our progress based on NICE Guidelines10,11, and Quality Standards (QS6)12. Interestingly, it reports that treatment targets for glucose and blood pressure control are less likely to be achieved in Type 1 than in Type 2 diabetes patients; given the longer average duration, this predicts higher future levels of complications in this group. Perhaps this is due to the more recent shift in awareness of Type 2 diabetes, or inherent

SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

characteristics of the respective diseases. The NDA found that young diabetes patients aged 16–55 years are less likely to attend annual checks or to achieve treatment targets. Shockingly, 19 PCTs delivered core care in just 60% of patients, while 2 PCTs managed 10%. Notably, half the population with diabetes fail to receive all nine annual health checks. Over 800,000 diabetics are at high risk of future complications due to glucose control above recommended levels: 300,000 children and younger adults at high risk, and 144,000 at dangerously high risk. Furthermore, 9% of children and young people with diabetes experienced at least one episode of DKA in 2009–2010. Moreover, there were large variations in recurrence rates between treatment centres.

Conclusions Diabetes continues to be a major public health issue that, in spite of significant efforts, looks set

to continue a seemingly inexorable growth as specific groups fail to receive optimal treatment. There is no doubt that new developments have advanced the management of diabetes, but they have also opened a Pandora’s Box of new issues. Although these require strategic intervention, they also require the individual health care provider to be up to date with best practice, and able to intervene when necessary. There is no doubt that the information, knowledge and political will exists to improve diabetes care, reduce costs, and improve profits. However, achieving the NSF goals and maximising the benefits of QOF demands real change in the way that both the NHS, and individuals within it, deliver care to diabetes patients. Reducing the personal and societal burdens of diabetes, and tackling health inequalities are within the power of the individual practitioner to achieve. Improving diabetes care must start with someone . . . why not you?

Diabetes continues

References: 1

insulin compared with conventional treatment and risk of complications in patients with Type 2 diabetes (UKPDS 33) Lancet. 1998 Sep 12;352(9131):837-53. Special Report on NHS Health Checks. Published by Global Business Media. Available at: http://

issuu.com/magazineproduction/docs/special_report_-_15_-_nhs_health_checks_-_alere_ ez?e=1127854/3555548 4

National Service Framework for Diabetes. Department of Health. Published 14 December 2001. Available at: https://www.gov.uk/government/publications/national-service-framework-diabetes

to be a major public health issue that, in spite of significant efforts, looks set to continue a seemingly inexorable growth as specific groups fail to receive optimal treatment

General Practice Extraction Service (GPES). Customer Requirement Summary. QOF.

Source: http://www.hscic.gov.uk/media/11559/QOF-2013---14-Customer-Requirement-Summary---Feb-2013/ pdf/QOF_2013-14_Customer_Requirement_Summary_-_Feb_2013_(NIC-180052-XY10T).pdf

NICE Menu of Indicators. August 2013. Viewed at: http://www.nice.org.uk/aboutnice/qof/indicators.jsp

Hex, N., Bartlett, C., Wright, D., Taylor, M., Varley, D. Estimating the current and future costs of

Type 1 and Type 2 diabetes in the United Kingdom, including direct health costs and indirect societal and productivity costs. Diabetic Medicine. 8

Diabetes in the UK 2012. Key statistics on diabetes. April 2012. Available at: https://www.diabetes.org.uk/Documents/Reports/Diabetes-in-the-UK-2012.pdf

National Diabetes Audit - 2010-11; Publication date: September 28, 2012. Viewed at: http://www.hscic.gov.uk/nda CG15. Type 1 diabetes: Diagnosis and management of Type 1 diabetes in children, young people and adults. Viewed at: http://publications.nice.org.uk/type-1-diabetes-cg15 CG66. Type 2 diabetes (partially updated by CG87) (CG66). Clinical guidelines CG66. Type 2 diabetes: the management of Type 2 diabetes (update). Viewed at: http://guidance.nice.org.uk/CG66 QS6. Diabetes in adults quality standard. March 2011. Viewed at: http://publications.nice.org.uk/diabetes-in-adults-quality-standard-qs6

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SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

Then it DAWNed on me... We Need a Well-Trained Multidisciplinary Team! Dr R A Sykes, Editor

I The feedback from healthcare professionals in DAWN2 indicates the need for better resources, education, training, and interdisciplinary collaboration among the team of healthcare professionals

N 2001, the Diabetes, Attitudes, Wishes, and Needs (DAWN) study evaluated the non-medical factors that prevent people with diabetes from achieving optimal treatment outcomes1. DAWN revealed that the educational needs of both people with diabetes and their healthcare professionals were not being adequately addressed. Specifically, DAWN concluded that improved multidisciplinary collaboration was essential to improving outcomes for people with diabetes2; moreover, it argued that this should be ‘patientcentred’, with the patient as part of a team that included specialist healthcare professionals... a claim that has since been echoed3,4,5.

A Call to Action Indeed, although it was recognised that effective interaction and understanding between diabetics and their healthcare providers were critical if selfmanagement was to work, many deficiencies and barriers were identified within national healthcare systems. The DAWN “Call to Action” programme6 was therefore initiated shortly after these results, and sought to focus on new evidence-based strategies for psychosocial and self-management education. However, despite many advances and improved collaboration, truly person-centred diabetes remains elusive to many patients.

DAWN2 Over a decade after DAWN, the DAWN27 study has recently provided an update on the progress toward achieving the goals of diabetes care (Box 5). DAWN 2 has once again considered the state of healthcare for the management of people with diabetes from the perspectives of healthcare professionals, diabetics, and their families. In total, over 15,000 people with both Type 1 and Type 2 diabetes were interviewed across 17 countries; a study group is currently reviewing the UK results, and published updates are anticipated. Unfortunately, the DAWN2 report has continued to highlight healthcare professionals’ concerns over the provision of diabetes care, 12 | WWW.PRIMARYCAREREPORTS.CO.UK

self-management, and professional training. Furthermore, psychosocial support remains a frequently identified aspect necessary for excellent diabetes care, yet the healthcare professionals interviewed still report a lack of adequate resources, training, and reimbursement to provide it. Despite individual variations, the general trend was for healthcare professionals to consider current healthcare provision for people with diabetes to be inadequate, internationally, intranationally, and at the individual level. Furthermore, although self-management education was recognised as important, many found it to be poorly implemented.

Postgraduate Training In the interim between DAWN and DAWN2, several postgraduate education programmes have been implemented to help professionals to improve their knowledge of diabetes. Although the type of specialist training offered differs between countries, the benefits of such programmes are clear8,9. Training may ultimately help, but unless all members of the multidisciplinary team (MDT) access such programmes, their impact will be peripheral. Successful management is facilitated by good relationships between patients with diabetes, their families, and the MDT. At a bare minimum, this should include doctors with specific training in diabetes, together with dieticians, nurses, and psychologists. Close collaboration within the MDT is key to ensuring that people with

SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

BOX 5: Key Results From the DAWN2 Study For patients: • Approximately 14% with depression •4 4.6% experienced diabetes-related distress •1 2.2% rated their quality of life as poor or very poor •4 0% said their medication interfered with their ability to live a normal life •O nly 48.8% had participated in any form of educational programme •5 5.5% were worried by the risk of hypoglycaemia. For family members: •3 5.3% found supporting a family member with diabetes as burden •6 1.3% were worried by the risk of hypoglycaemia •4 4.6% felt their emotional wellbeing was negatively affected •3 7.1% did not know how to support the person with diabetes •O nly 23.1% had been offered participation in educational programmes. For healthcare professionals (HCPs): •6 0% felt there was a need for improved diabetes self-management education •6 1.4–92.9% felt that people with diabetes needed to improve various self-management activities • I n some countries, up to a third of HCPs had not received any formal diabetes training •3 2.8% reported societal discrimination against people with diabetes. Source: https://www.diabetes.org.uk/Professionals/News--updates/DAWN2-study--results-released/

• National accreditation body for type 2 diabetes prevention • Commissioners and providers of public health services • Managers of type 2 diabetes risk-assessment and prevention services •S chools of medicine, healthcare faculties, royal colleges and professional associations offering professional healthcare qualifications such as: - dietetics,

- nursing,

- physiotherapy,

- Podiatry

- occupational health

must facilitate a patient’s care as part of a multidisciplinary team, and embrace the

BOX 6: Who should take action?

Today, practitioners

psychosocial dimension of the illness to provide truly holistic care

• Voluntary organisations • Commercial training organisations Source: National Institute for Health and Clinical Excellence (NICE). Public Health Guidance on Diabetes. 2012. Available at http://www.nice.org.uk/nicemedia/live/13791/59951/59951.pdf.:

diabetes receive the correct level of support at the correct time. Effective communication though, is only possible if all members of the MDT are aware of both their own roles, and those of the other members. As roles evolve and change, it is incumbent on all members to remain appraised of the latest developments in care. Indeed, NICE (the National Institute for Health and Care Excellence) have emphasised the need for proper training in their guidance for diabetic care (see

Box 6)10. Postgraduate training can facilitate this, but is only part of the solution.

Conclusions The original DAWN study highlighted the inadequacy of poorly equipped healthcare systems to deliver effective diabetic care. However, despite improvements in healthcare provision and healthcare organization, the feedback from healthcare professionals in WWW.PRIMARYCAREREPORTS.CO.UK | 13

SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

It is no longer adequate to have a knowledgeable physician at the centre of health care provision.

DAWN2 indicates the need for better resources, education, training, and interdisciplinary collaboration among the team of healthcare professionals. While DAWN2 was interesting, the results of DAWN2 are a damning indictment of nearly a decade of work to improve the situation. Empowering patients at the centre of a wellprovisioned, knowledgeable MDT is considered key to effective diabetes care. Indeed, as the DAWN2 authors commented “The increasing prevalence of diabetes and the lack of resources for effective care calls for a new, proactive and

References: 1

Today, all health care professionals must have

Peyrot M, Rubin RR, Lauritzen T, Snoek FJ, Matthews DR, Skovlund SE. Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study. Diabet Med 2005; 22: 1379–1385. Skovlund SE, Peyrot M. The Diabetes Attitudes, Wishes, and Needs (DAWN) program: a new approach

up-to-date, relevant knowledge. Only then

to improving outcomes in diabetes care. Diabetes Spectr 2005; 18: 136–142.CrossRef Murphy K, Casey D, Dinneen S, Lawton J, Brown F. Participants’ perceptions of the factors that

influence diabetes self-management following a structured education (DAFNE) programme.

can we hope to truly effect change in diabetic outcomes

preventive approach, in which psychosocial issues are managed within collaborative teams, including people with diabetes and their family members.” Implementing these recommendations will be a major challenge to health care practitioners. Modern diabetic care is very different to traditional physician-centred care; no longer is it adequate to simply “do our best” as individual, isolated practitioners. Today, practitioners must facilitate a patient’s care as part of a MDT, and embrace the psychosocial dimension of the illness to provide truly holistic care. In this context, it is the patient who is the driver of their own care, and all healthcare professionals must empower patients to achieve effective self-management. With these changing care needs, the training and educational needs of practitioners have also evolved. It is no longer adequate to have a knowledgeable physician at the centre of health care provision. Today, all health care professionals must have up-to-date, relevant knowledge. Only then can we hope to truly effect change in diabetic outcomes.

J Clin Nurs 2011; 20: 1282–1290. Rasekaba TM, Graco M, Risteski C, et al. Impact of a diabetes disease management program on

diabetes control and patient quality of life. Popul Health Manag 2012; 15: 12–19. 5

American Association of Clinical Endocrinologists (AACE). Diabetes care plan guidelines. Endocr Pract 2011; 17: 1–53.

Conference Report: 2nd International DAWN Summit: a call-to-action to improve psychosocial care for people with diabetes. Pract Diabetes Int 2004; 21: 201–208.

Holt, R et al. The DAWN2 Study Group. Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross-national comparisons on barriers and resources for optimal care – healthcare professional perspective. Diabet. Med. 30, 789–798 (2013). Available at: http://onlinelibrary.wiley.com/doi/10.1111/dme.12242/full

Murugesan N, Shobana R, Snehalatha C, Kapur A, Ramachandran A. Immediate impact of a diabetes training programme for primary care physicians – an endeavour for national capacity building for diabetes management in India. Diabetes Res Clin Pract 2009; 83: 140–144.

Donicová V, Brož J, Sorin I. Health care provision for people with diabetes and postgraduate training of diabetes specialists in Eastern European countries. J Diabetes Sci Technol 2011; 5: 1124–1136.

National Institute for Health and Care Excellence (NICE). Public Health Guidance on Diabetes. 2012. Available at http://www.nice.org.uk/nicemedia/live/13791/59951/59951.pdf.

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SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

Agents of Change: The Expanding Role of the Diabetes Specialist Nurse within the Multidisciplinary Team G A Hood

ANAGING DIABETES requires the support of a multidisciplinary diabetes team (MDT) due to the many facets of the condition and its progressive nature1. The main purpose of the MDT is to help promote greater health and well-being in their patients by providing clinical care and improving diabetes self-management skills. In addition to this, a well-focussed team can now be expected to contribute to T2 diabetes prevention strategies, and liaise with local communities such as schools and other public bodies to raise awareness of the condition2.

The Role of the MDT The remit of the Diabetes MDT is therefore expanding all the time but the core members can still be described as the diabetes physician (Diabetologist or GP), the Diabetes Specialist Nurse (DSN), the Specialist Dietician, and of course the Patient. The team may then expand further depending upon the needs of the patient, and so a podiatrist, psychologist, counsellor, exercise therapist, pharmacist, practice nurse, diabetes educators, ophthalmologist, social worker, and diabetes research nurses may become temporary or permanent members of this ever flexible MDT line-up.

According to the National Diabetes Education Program2 the main components of a successful MDT are: a collaborative approach to promoting patient self-management and quality of life; the involvement of primary care and other community services; having a good communication policy; providing a comprehensive follow-up service; and the expanding use of health technology. All members of the team are important contributors to this successful management of diabetes but it can be argued that the role of diabetes specialist nurse in particular is crucial in bringing cohesion and leadership to this specialised group.

Meeting Changing Needs

We need to support the continuing education of DSNs with funding and protected study time because their evolving role gives us a window into future of diabetes management

The role of the DSN has developed significantly in the last few decades to reflect a growth in new treatment regimens, insulin pumps, educational packages for patients and health care professionals, prevention strategies, and specialist diabetes services such as T1D adolescent clinics, joint clinics for diabetes and hypertension, obesity, pre-pregnancy care and diabetes prescribing3. It is perhaps for this reason that the role remains difficult to define due to this inevitable response to changing diabetes needs4. One conventional role for DSNs has always been the education of patients, carers and other health professionals which usually takes place in conjunction with routine clinical commitments. In this aspect DSNs have been agents of change as they embrace a number of cultural differences in adult education provision. For example, DSNs need to understand the condition thoroughly and follow the evidence from studies such as the Diabetes Control and Complications Trial (DCCT, 1993)5 and the UK Prospective Diabetes Study Group (UKPDS, 1998)6. They need to keep up to date on a raft of WWW.PRIMARYCAREREPORTS.CO.UK | 15

SPECIAL REPORT: IMPROVING EXPERTISE IN DIABETES MANAGEMENT THROUGH POSTGRADUATE TRAINING

All members of the team are important contributors to this successful management of diabetes but it can be argued that the role of diabetes specialist nurse in particular is crucial in bringing cohesion and leadership to this specialised group

diabetes guidelines on prescribing oral and insulin therapy and observing diabetes competencies. In addition to keeping themselves updated they need to be aware of a patient centred approach with regards to consultations7, to observe SMART objectives8, and to understand the rudiments of targets and goal setting within the clinical encounter. They are also becoming more versed in the art of motivational interviewing9 and other behaviour modification skills and they are also facing a more “informed” type of patient who may be using the internet and media to research latest treatments. DSNs need to know how to react to personal requests for information and how to create personal plans of care based on individual and family requirements, even though provision for their own personal development can sometimes be problematic.

The Importance of Supporting Practice Staff DSNs also increasingly need to support practice staff as more and more diabetes is managed in primary care. Supporting the primary care team in terms of education is becoming a key role and many DSNs are pushing for a standardised approach to providing diabetes education for all nurses10. They are also in contact with Commissioning Groups to safeguard the investment locally for diabetes and lobby for new funding for additional insulin pumps etc. Given the multicultural landscape of the UK and beyond DSNs are also involved in tailoring education packages for high risk ethnic minority groups, and prevention strategies with public health. They also seem to be more involved in managerial aspects of diabetes care in comparison to their clinical partners4.

DSNs demonstrate a distinctive position within the MDT which includes a whole continuum from provision of holistic and individualised diabetes care right through to managing services, commissioners and engaging with public health officials. Their leadership and expertise is regularly sort by a diverse group of people in both primary and secondary care. To continue in this specialist role DSNs need to have a tailored and comprehensive development programme11. These important members of the MDT will continue to evolve their roles further but to do this they need the support of first class post graduate designed courses and the protected time to attend and study. Such courses not only update DSNs on the latest diabetes evidence, but also provide the skills needed to identify priorities and guide the MDT further. The courses also have evolved to meet the changing needs of DSNs in terms of research methodology, motivational interviewing, public health, communication skills, health technology, and developing a MDT which responds to local diabetes needs.

Continuing Education is Key We need to value all members of the MDT and provide them with on-going and structured education in diabetes which is fit for purpose. In particular we need to support the continuing education of DSNs with funding and protected study time because their evolving role gives us a window into future of diabetes management. In this way we can ensure and be confident that the quality of care for people with diabetes will remain at the forefront of the NHS in the UK and other health care systems further afield.

References: 1

Bayless M and Martin C (1998) The Team Approach to Intensive Diabetes Management. Diabetes Spectrum Volume 11 Number 1, 1998, Pages 33-37

Redesigning the Health Care Team. Diabetes Prevention and Lifelong Management. National Diabetes Education Program NIH Publication No. 11-7739

NDEP-37 Revised June 2011 Specialist Diabetes Services: Roles and Responsibilities of Diabetes Specialist Nurses (2009). Diabetes UK: London 624/0109/a

Davies M. and Davis R (1998) Role of the hospital diabetes specialist nurse: perception vs reality. Journal of Diabetes Nursing Vol 2 No 4 1998

The Diabetes Control and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long-

term complications in insulin-dependent diabetes mellitus N Engl J Med. 1993 Sep 30;329(14):977-86. UK Prospective Diabetes Study (UKPDS) Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and

risk of complications in patients with type 2 diabetes (UKPDS 33) Lancet. 1998 Sep 12;352(9131):837-53. Type 2 Diabetes: The Management of T2 Diabetes (May 2009) CG87 NICE Guidelines. National Institute for Health and Care Excellence.

Doran, G. T. (1981). There’s a S.M.A.R.T. way to write management’s goals and objectives. Management Review, Volume 70, Issue 11(AMA FORUM), pp. 35–36.

Miller, W.R.; Rollnick, S. (2002). “Motivational Interviewing: Preparing People to Change’”. Guilford press.

Royal College of Nursing (2013) RCN Submission to the London Assembly Health Committee review of diabetes services in London.

Gosden C., James J., Winocour P., Turner B., Walton C., Nagi D., Williams R., and Holt R. (2009) Journal of diabetes Nursing Vol 13 No 9: 330-337

Available at http://www.nice.org.uk/nicemedia/live/13791/59951/59951.pdf.

16 | WWW.PRIMARYCAREREPORTS.CO.UK

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