Diabetes nursing: checked out but not checked off

1 July 2012

From July 1, free Get Checked diabetes annual reviews are no longer. Funding for the maligned scheme gave a kickstart to many nurse-led diabetes clinics in primary care. What happens next?

Turning up for their free annual ‘warrant of fitness’ was starting to become a well-worn habit for many people with diabetes. A number were seen in nurse-led clinics that went beyond the free Get Checked scheme’s tick box list and helped patients self-manage their diabetes.

However, the government decided last year that Get Checked was not returning enough bang for its bucks and axed the $8 million scheme.

“The carpet was pulled from under our feet, really,” is how nurse leader Rachael Calverley puts it. She and many other nurses saw Get Checked providing the portal, kick-start, or incentive for practice nurses upskilling themselves in diabetes and offering nurse-led clinics.

They now wait with interest what happens from July 1 onwards when Get Checked checks out and the 20 district health boards’ new Diabetes Care Improvement Packages (DCIPs) check in. Boards are frantically pulling together the packages that aim to be local solutions for improving diabetes outcomes (see DHB survey sidebar).

What is to come? It’s a matter of ‘watch this space’ – or as diabetes nurse practitioner Helen Snell puts it: “that’s the million dollar question”.

She, like many who saw the first drafts of the DHBs’ diabetes improvement packages sent to the Ministry of Health earlier this year, is wary whether the DHBs are on the right track.

“Singularly unimpressed,” is how College of Nurses executive director Jenny Carryer summed up her response to the draft plans.

“Boy, oh, boy, did they need to go back and do better,” was the response of Chris Baty, the chair of consumer group Diabetes New Zealand.

“Very little change from business as usual,” is how Rosemary Minto, chair of the NZNO College of Primary Health Care Nurses, viewed them.

“There was an overarching recipe, but there wasn’t a lot of meat in them,” was the savoury comment of Rachael Calverley, the executive member of the Primary Health Nurse College who sits on the General Practice Leaders Forum.

Concern was also expressed at many boards’ lack of meaningful consultation with grass roots clinicians, or most importantly, the 200,000 plus potential consumers.

Strong nurse feedback

When nurses are asked, they are pretty clear about what they don’t want to risk losing now Get Checked is scrapped.

This was brought home by the strong nurse response to the joint NZNO and College of Nurses Aotearoa online research late last year, which attracted about 750 responses – nearly all from nurses. Most considered the Get Checked programme a success or partial success (see nurse feedback sidebar).

Nearly 600 of them had been delivering the free Get Checked annual reviews. The majority believed it had improved their confidence with diabetes management and half feared the loss of the dedicated funding for annual reviews would reduce their ability to see patients independently of the doctor.

NZNO’s Diabetes Nurse Specialist Section (DNSS) told the Ministry of Health it was imperative to maintain and enhance nursing roles in diabetes, including increasing CarePlus funding so primary care nurses could offer more targeted care for people with chronic conditions such as diabetes.

There is no argument from nurses that the free Get Checked reviews only involved two-thirds of people with diabetes and many of those missing out were the hardest to reach patients with the highest risk of complications from poor diabetes management.

Nor is anybody against promoting schemes to target and support those hard-to-reach, high-risk people with diabetes.

What nurses do argue about is why funding should be snatched from one – albeit imperfect – programme to fund the unknown.

“The thing that upsets people the most was that, when the Minister announced this, there was no suggestion of what would happen in its place,” says Pip Mason, a registered nurse and long-term conditions leader at Canterbury’s Pegasus Health.

Carryer also wonders about ending funding for one programme without providing any clear direction on what will replace it.

Throwing baby out with the bath water?

Many nurses fear that the baby could be thrown out with the bath water after a decade of building up primary health nursing skills in offering Get Checked-funded diabetes clinics.

Carryer says to assess the Get Checked programme based just on HbA1c levels was probably premature for a programme still gaining momentum.

“It’s a long, slow process of upskilling the workforce on how to work with people with diabetes and building a relationship with patients.”

She says the joint research report indicated Get Checked had led to new nursing models of care for helping patients manage their diabetes but “it wasn’t an overnight process”.

Calverley agrees the nurse-led clinic is one workable model of diabetes care delivery the improvement packages can support.

“They don’t just pop up out of nowhere. They need an educated workforce and nurses who are mentored and supported.”

If general practice is going to work with more people with high clinical needs, then there would also need to be more insulin starts in the community.

“We need to raise our game in terms of education and training and make sure our workforce is equipped to do that,” says Calverley.

She says that the National Diabetes Nursing Knowledge and Skills Framework should be used as the education benchmark and that education and training funding for diabetes remains scarce despite diabetes being a “catastrophic problem” affecting more than 208,000 New Zealanders.

Calverley says outreach models that take general practice services out to maraes and community centres in low decile areas are a “fantastic option” for helping target high-risk populations, but she doubts the improvement package has the funds to support it.

Meanwhile, it was unknown how “well” patients will respond to being told they aren’t high risk enough any more for a free annual review and they’ll have to cough up and pay.

Calverley fears the response may be “they obviously think, ‘I’m all right now – I’d rather spend that money on bread and milk’.”

“We could risk them flipping into a clinical risk area by slipping up the scale because they don’t want to bother coming in now and they don’t want to pay.”

She believes the Government lost a golden opportunity to hold a national publicity campaign highlighting the changes so as to keep consumers on board and hooked into maintaining their diabetes care.

Mixed signals with targets

In another mixed signal, the Government has not only scrapped funding free Get Checked reviews but also its previous national health target for increasing the number of diabetes annual reviews. Also scrapped as a national health target is improving the levels of the diabetes management indicator HbA1c.

Instead, the Government has tacked the requirement for a diabetes test onto its new combined “more heart and diabetes checks” national health target.

However, the Government still expects diabetes annual reviews to take place and HbA1c levels to improve, but they’ve now been relegated to DHB performance indicators rather than high profile national health targets.

Minto says the Primary Health Nurses College agrees that introducing targets with proven health benefits makes sense, like combining a cardiovascular risk assessment and diabetes test target.

But she says the “tick box” criticism made of Get Checked could also be made of the new target, as there was no proof required that the patient had been engaged in the process.

“For example, some practices have just sent out letters requesting the blood tests be done and loaded the results without any targeted education to patients about the implications of the results.”

Calverley is also worried about HbA1c being the only clinical marker used to measure how well diabetes is being managed when there are so many other ways of measuring effective management, including blood pressure, kidney function tests, and patients’ motivation to change their lifestyle.

Mason says a concern for PHOs is that scrapping funding for free diabetes annual reviews will see some practices dropping reviews despite DHBs still allocating performance funding based on how many annual reviews are carried out.

She agrees that tick box medicine isn’t an indication of good diabetes management but says the new packages could suffer the same criticism if they ended up just “measuring widgets again” rather than meaningful outcomes for patients.

Mason, a member of clinical operations group involved in developing Canterbury’s improvement package, said the region was “running very close to the wind”, as by mid-June, the outcome indicators for the package were still to be set up and the package was yet to be communicated to the region’s GPs and nurses.

Losing ground?

So will nurse-led diabetes clinics grow or lose ground and falter under the new packages?

Calverley, who is also director of nursing for Waitemata PHO, says the message given to their practices was to continue with “business as usual” while an action plan is finalised. Other nurses around the country will also face different levels of uncertainty as contracts and targets are still to be nailed down.

With new programmes not fully ready on July 1, there is a risk of losing momentum and for targets to dip while the new packages are introduced and bedded down.

Calverley believes a transition phase would be helpful as nurses and GPs struggle through the change process, let alone for consumers hooked into free annual reviews.

“We’re going to upset their apple cart.”

There is a question mark over whatever programmes check-in to replace Get Checked end up better serving the ever-growing numbers of New Zealanders joining the diabetes epidemic. Time will tell.

FACTS AT A GLANCE

Get Checked began in 2000, offering people with diabetes a free annual review with GP or suitably trained practice nurse, including blood and urine tests, blood pressure test, foot and eye exam, and diabetes management plan.

• About two-thirds (122,089) of the 183,940 people eligible had their free check in 2011 at a cost of about $8 million.

• 2011 report by Brandon Orr-Walker concludes Get Checked has not “systematically resulted in improved management or outcomes for people with diabetes”, particularly in lowering the diabetes marker HbA1c levels.

• September 2011, Health Minister Tony Ryall decides to scrap funding for free Get Checked reviews from 1 July 2012.

• Late 2011, the $8m in Get Checked funding re-distributed to district health boards to develop their own primary care-focused Diabetes Care Improvement Package due to start 1 July 2012.

• The funding cannot be used for diabetes annual reviews (DARs) but Government still requires DHBs to report on DARs, as they are a “measure of how well primary care is delivering diabetes services”.

Nearly 700 primary health nurses participate in online Get Checked survey in late 2011, with most considering the programme a success or partial success.

• April 2012, the General Practice Leaders Forum (including College of Primary Health Care Nurses NZNO) write to Director General to express “widespread concern” at the loss of Get Checked funding from the general practice setting.

Nursing Review survey of DHBs Diabetes Care Improvement Package plans a month out from 1 July finds wide disparity in depth and detail of plans, with most yet to inform general practices of how the new package will work.

CONSUMERS SAY: Get mobile and innovate

“Stop ticking boxes in clinics and take services out to the people who need them most,” says Diabetes New Zealand chair Chris Baty.

The head of the diabetes consumer body advocates using Get Checked funding to get innovative, get mobile, and target the high-risk people with diabetes that the former programme failed to reach.

“There was nothing that technical in Get Checked that it couldn’t be done out of the back of a van in the community,” says Baty.

In a time of meager resources in the midst of an ever-growing diabetes epidemic, she believes the best investment is focusing on those people at most risk of damaging, life-risking, and expensive complications like renal failure.

“Last year, diabetes grew by almost 10 per cent. Year on year, that’s pretty scary. It’s mostly type 2.”

Baty says the Get Checked programme became all about ticking boxes and mostly attracted compliant patients who were probably prepared to pay for an annual review anyway to ensure they stayed well.

“Understandably, general practices went for the low hanging fruit – people who would come after a single letter or phone call. Those people are going to come regardless.”

Redirecting the Get Checked funding was a “huge opportunity” for innovation rather than trotting out the “same old” ideas once again and getting the same old results, says Baty.

She gets frustrated by reading plans that use “high and lofty language” that sounds great but once you “boil it down” says nothing about what’s actually going to be done. She is also tired of hearing clinicians talk about so-called “patient-centred” services that fail to ask consumers what they need and want. A further pet hate is attending meetings where primary health providers ask how they are going to be “incentivised” to deliver a diabetes service.

However, exciting work is under way by Māori health providers (see whānau ora feature this edition) and the opportunity is there for regions to address specific needs by introducing services like mobile retinal screening, health promotion workers in Pacific Island churches, or offering more podiatry services.

Baty agrees some general practices and nurses were delivering good services under Get Checked, particularly outreach services in high-risk communities, but says there were still inconsistencies in nurses’ skills and diabetes knowledge.

She does see great potential for nursing in diabetes care, pointing to the “incredibly sophisticated” diabetes knowledge framework, the many fantastic diabetes nurse specialists, and the diabetes nurse prescribing project as ways to motivate, support, and upskill primary health care nurses in diabetes.

Having just changed general practices herself, she says she was “blown away” by the thoroughness of her first nurse-led diabetes clinic (Baty has type-1 diabetes, so her regular diabetes management is undertaken by secondary services).

“It may well be that some of the (former Get Checked) money could be used to upskill all of the nurses to be able to do that. Those are the opportunities that exist with this money.”

She says that diabetes largely is a lifestyle disease that will not be resolved in “doctors’ rooms”.

“We need to leave our hospitals and our clinics and meet them somewhere along the way.”

Nurse feedback

NZNO and College of Nurses Aotearoa Get Checked Perceptions Survey

• Just under 750 people completed the survey, with 729 of those registered nurses or NPs.

• About 600 of those nurses offered free annual Get Checked reviews.

• Most included a full health assessment, cardiovascular risk assessment, and arranged follow-up care as part of the check.

• Nearly 90 per cent had received some education before offering Get Checked, with the most common a two to five day course or on-the-job training.

• The biggest difference Get Checked made to the nursing practice was being able to spend more time with people with diabetes and to target their work to high needs patients.

• Most said it had improved their confidence with diabetes management significantly (44 per cent) or quite a lot (35 per cent).

• Half believed removing Get Checked funding would reduce their ability to see patients independently of the doctor.

Suggestions for improved diabetes care include:

• Improve consistency of education for nurses and doctors.

• A ‘wrap-around”/”one-stop” approach involving the multidisciplinary team.

• Outreach programmes, mobile nurses, and community initiatives to improve access and support for hard-to-reach clients.

NZNO Diabetes Nurse Specialist Section Get Checked submission

• Members opposed ceasing Get Checked but agreed some aspects of the programme didn’t work and needed revisiting.

• Positives had included building a platform for primary and secondary care services to work together on addressing the burden of diabetes and increased diabetes self-management awareness.

• Many believed while the programme had improved access to patients with diabetes in their populations, it had not focused on the patients most in need.

Suggestions for improved diabetes care include:

Implement the National Diabetes Nursing Knowledge and Skills framework by developing a structured pathway for nurses to build their diabetes skills and knowledge.

Support innovative approaches to targeting support for people with diabetes in high-risk groups, like Māori and Pacific, and/or with poorly controlled diabetes.

Maintain and enhance nursing roles to improve treatment and outcomes for targeted groups with diabetes.

Continue funding for an annual diabetes review to build relationships with people with diabetes.

Increase of Care Plus funding to allow nurses to implement more care in primary care for persons with chronic care conditions, including diabetes.

DHB survey results: Plan? what plan?

Nursing Review surveyed the 20 DHBs in early June on how they plan to spend their Get Checked funding when their new Diabetes Care Improvement Packages kick off on July 1.

A number said their packages were still on the drawing board and awaiting sign-off from the Minister of Health, so they would not release details. Those that were available varied from the vague and broad-brush stroke stage, to having decided to invest the funds into existing well-established diabetes programmes in primary care or opting to bulk-fund general practices to deliver diabetes services against new targets.

A number were focusing their allocated Get Checked funding on targeting Māori, Pacific, high deprivation communities, and patients with poor diabetes control.

Only one of the respondents specifically mentioned using nursing’s National Diabetes Skills and Knowledge Framework for workforce development.

Several boards pointed out that they already funded diabetes nurse specialists or long-term condition nurses/coordinators to work in the community (MidCentral 6, Auckland 3, and Canterbury 2).

Funding

The DHBs’ share of the $8 million funding was based on the amount of Get Checked funding their region had attracted in 2011-12, which varied from: $68,880 (Wairarapa) to $102,000 (South Canterbury) for the small DHBs; $270,000 (Lakes), $260,000 (MidCentral), and $656,000 (Bay of Plenty) for the mid-sized boards; and $461,000 (Counties Manukau), $530,000 (Capital & Coast), $580,000 (Canterbury) and $605,574 (Auckland) for the large boards.

Several small boards had already devolved their Get Checked funding to bulk-funded regional diabetes or long- term conditions services (i.e. Whanganui, $70,000, and West Coast, $32,000).

Summary of sample plans

Wairarapa – Get Checked funding to be transferred to GP practices for use in guided care model Tihei Wairarapa, including using nurse time to pursue patients with poor diabetes management, nurse-led clinics, and a whānau ora approach for Māori.

Northland – Package being developed with Manaia PHO and Te Tai Tokerau PHO, with focus on reducing inequitable outcomes for Māori with diabetes and developing capacity of PHC workforce, including supporting nurse-led diabetes care.

Auckland – focus on delivering the Northern Region Health Plan for diabetes with a particular focus on Māori, Pacific, and low socio-economic communities. Contract specifics are still to be negotiated, but PHOs and practices will have flexibility how funding is spent.

Counties Manukau – package links in with long-term conditions framework and main components are incentive payments for improved outcomes for highest clinical risk patients, funding for clinically-indicated insulin starts in primary care (including by nurses), and improved access to dietetic and podiatry services.