An advanced clinical practitioner and nurse partner has developed how annual diabetes checks are organised at her practice, leading a successful scheme that has been copied across the local area.
Becky Wych, who works at Combe Down Surgery in Bath, took advantage of staff departures to change the way the practice was managing diabetes, to develop ‘more of a nurse-led service’.
This began by suggesting that patients were reminded of their annual diabetes checks during their birthday month, instead of at random points throughout the year.
‘It was led by the nursing and the admin team to do this. Having done that, what it allowed is for a really practical approach to be taken. So everybody was clear about what their roles were,’ Ms Wych told Nursing in Practice.
Since the scheme has been introduced, 67% of patients have been proactively getting in touch to arrange to book their appointments, freeing up workload and time.
Before the change was introduced, no patients contacted the surgery to book an appointment before their reminder.
‘Having reminders in the month of birthplaces puts the ownership on the patient, so they know when their annual review is due. So hopefully they’ll book the appointment rather than relying on us to book them in,’ Ms Wych explained.
All patients are initially seen by healthcare assistant (HCAs) in their annual reviews.
‘A more holistic approach’
Alongside changing when reminders were released, Ms Wych stratified patients along ‘classification codes’ of D1, D2 or D3, depending on the ‘complexity’ of their diabetes – with D1 patients having the most severe diabetes alongside other health conditions that need to be monitored.
The practice classification codes were based on diabetes care guidance, as set out in the NHS Long Term Plan.
Individuals can also move between the three categories, helping to deliver a ‘fluid’ and more personalised diabetes care.
While guidelines specify that D1 patients should typically be treated by a GP, Ms Wych noted that most of the patient’s categorised as D1 by the practice were usually seen in a secondary care environment due to the severity of their condition.
To avoid unnecessary hospital visits, Combe Down Surgery instead noted that many D1 patients also had mental health problems or rheumatoid arthritis, so were going to see their GP anyway.
These appointments were changed, with patients now addressing their diabetes, mental health and arthritis concerns, all within the same appointment.
‘We recognised that there is often a link between your diabetes and your mental health, so whoever is dealing with your mental health will also deal with your diabetes. It’s a more holistic approach,’ Ms Wych explained.
Another change was made in the treatment of D3 patients – who are typically older patients – focused on maintaining their HbA1c at a safe level.
If blood pressure results from the HCA examination show that the patient’s blood pressure is ‘on track’, they will automatically not be offered an appointment. However, patients can request an appointment, if they wish to speak to a GP or general practice nurse (GPN).
‘What we’re hoping is we’re seeing patients on their need, rather than everybody being treated the same,’ Ms Wych explained.
She described how categorising patients after an initial HCA examination meant fewer patients were being seen overall, but that the patients who did come in for an appointment were treated ‘for the right length of time and by the clinicians with the right skills’.
In addition to reducing diabetes appointments in the practice, the Combe Down diabetes team works closely with local hospital staff to ‘organise primary care in a way which reduces the burden of staff in hospitals’.
This is achieved by ensuring that all diabetes checks which can be organised at primary care level are completed before a patient arrives at hospital.
‘For example, when they attend their hospital appointment, rather than the consultant saying, “it depends on what your HbA1c is”, that test has already been done, and they’re able to get a direct plan in place,’ Ms Wych explained.
Strengthening the nursing team
Combe Down Surgery has significantly grown its nursing team since the scheme was launched, with the practice now having a team of 12 nurses for 13,000 patients.
‘They enjoy the variety of roles that they’re doing, but they feel that they feel valued, and they feel trained and they feel happy with the variety of what they’re doing.
‘It’s important that we train up [GPNs]. Why should just GPs have a portfolio career? That should be the same for nursing.’
Since launching the scheme, the practice has achieved a reduction in HbA1c among patients with diabetes, something that Ms Wych sees as proving the value of nurse-led care.
Ms Wych added that having nurses lead the diabetes scheme has ‘improved patient outcomes’, with patients ‘seeing the right person with the right skills’ to care for them.
‘Conversation was geared at the right levels of that patient. The outcomes have been brilliant,’ she said.
