It’s fascinating to see how NHS England is tackling the challenges of diabetes care.
I have seen measures in development, which have now surfaced and are on the cusp of being ready to be rolled out in the coming financial year.
A debate has been gathering pace for a while now about the required expertise, training, appropriate support, and the holy grail of integration and its importance, when redesigning diabetes care.
Leaving aside the politics, the personalities and indeed issues of tariff, then diabetes care, on its own, isn’t that complicated a nut to crack. It crystallises itself on a debate as to where exactly a specialist contributes most and where his or her role as an educator or support for primary care exists.
The Portsmouth Super Six model of care is one of those which tried to answer the million dollar question: which bits of diabetes care need to be in hospitals?
In the main, it boils down to areas of care which need multidisciplinary care, access to investigations or are specific issues related to a hospital, such as antenatal care, inpatient diabetes to name just a couple.
The area of controversy, however, has tended to be the vast majority beyond the “Super Six”, and that question has attempted to be answered in areas such as Leicester, Reading, Ipswich and Gateshead. What they’re doing in these areas is using the specialist as an educator, a support for primary care whether the specialist concerned is a doctor or nurse.
Various models have looked at virtual clinics, tele consults and data review. Whatever it may be, the idea is to have advice readily available, focusing on individualised care and in turn helping primary care when it needs it. Another question which stems from that is whether all patients with diabetes need the exact same care? Unfortunately for me the evidence has never supported that; for example the care and support a 19-year-old Type 1 diabetes patient needs is fundamentally different from an 82-year-old frail Type 2 diabetes patient in a residential home.
The Super Six Model is by no means the holy grail of integrated care but local experience suggests two fundamental issues and principles which can and should form the bedrock of any diabetes care redesign
Curtailing the debate around what needs to “stop being in hospital”: A lot of time is lost debating what should and shouldn’t be in the community. A belief in “more in community” Is a laudable aim as long as the resource follows it, and the appropriate expertise is present to support primary care. The bigger question is what shape this debate would have taken if the tariff structure was different
Strengthening ties between primary and secondary care: The whole point of going out and visiting GP surgeries has been to build relations and help primary care colleagues who are struggling with the demands from various quarters. Looking past the titles or employer status – going back to the basics and meeting each other to discuss care has been a huge step forward for all concerned.
It is agreed by many that much needs to change, whether that be in attitudes, financial structures or indeed investments. What is apparent is that the Super Six model gives us a starting point for a discussion about the role and responsibilities of diabetes specialists whether within or outside a hospital setting. Many versions of this theme are starting to emerge, that in itself is very encouraging. If we were viewing this as a long term condition we would have to then look at the debate into tariff structures, whether payment by results is indeed a valid form or whether we look at areas such as a year of care tariff.
For me the importance is to know where we need to get to. Whatever the views on Vanguards or STPs, the focus is clearly on organisations working together, not functioning as disparate bodies. This is not to be interpreted as which should be the dominant force in any area, but to help facilitate integration. For that to happen we need to start with collaboration.
The Super Six Model binds acute and community providers into one pathway but a fundamental issue is to have the same team of specialists across the organisations. There should be no place for isolated terms such as “community diabetologist” in the modern restructured NHS. The hospital is a part of the community and that should be reflected when designing pathways. Specialists need to be able to work across pathways across the defined structured organisations, whether it be in a hospital or the community.
In my opinion there should be no acute or community diabetologist, we should simply be a diabetologist who brings specific specialist skills to bear in a hospital and be an educator where needed.
It isn’t necessary per se, to replicate the Super Six model of care but the principles are ones which should be addressed in the modern NHS. For me the key to this change is within our own mind set and how willing we are to change and be part of a new system.