Diabetes: patchy but progressing

1 July 2013

Nursing Review checks out the momentum on the new Diabetes Care Improvement Packages and finds report cards ranging from ‘excellent’ to ‘could do better’.

Fifty people a day are diagnosed with diabetes in New Zealand.

More than 200,000 Kiwis have already been diagnosed and the Ministry of Health believes there are probably another 100,000 people out there with diabetes yet to be diagnosed.

From July 1 last year, the targeted funding for diabetes in primary health care was redirected from the Get Checked free annual diabetes check to region-by-region driven Diabetes Care Improvement Packages (DCIPs). Local plans means no national consistency with some regions targeting their high needs Māori and Pacific population, many offering increased retinal screening and most promoting greater access to nurse-led care and support of people with diabetes.

The jury is still out on how successful the redirected funding will be in helping improve diabetes management and stem the down-the-track complications of the diabetes epidemic. Some are cautiously optimistic, others are wary, and most agree it is early days.

Chris Baty (left), chair of consumer group DiabetesNew Zealand, last year called for primary health post-Get Checked to stop ticking boxes in clinics and take services out to the people with diabetes who need them most.

She says outreach and fresh initiatives are underway in some areas under the new Diabetes Care Improvement Packages (DCIPS) with a few district health boards (DHBs) and primary health organisations (PHOs) being “really notable leaders” but in other places change has been “regrettably slow”.

Rosemary Minto, a primary health nurse practitioner (NP) and chair of NZNO’s College of Primary Health Care Nurses, says from her personal experience the implementation of the package has been “patchy”.

“Many GPs have found the lack of directives from DHBs/PHOs problematic as they don’t have the time or the capacity to set up their own processes within their general practice, unless there are nurses who are able to drive this and provide the services, including insulin initiation.”

Lorna Bingham (left), a diabetes clinical specialist for Capital & Coast DHB and NP candidate, believes the shift to packages has provided increased flexibility and opportunities to build on what was developed through Get Checked.

“But we need to ensure we don’t lose too much momentum or traction until the new plans and packages are in place and implemented.”

Rachael Calverley (left), director of nursing for the Waitemata Primary Health Organisation (PHO), says it can take several years for change to get embedded in primary health care. She says one positive has included a focus on nurse education – including the new online learning modules in diabetes care for primary health care nurses – and her own PHO has been able to review and revamp its three face-to-face diabetes courses for nurses.

She sees a downside of the change as the “very real danger” that some people with type-2 diabetes will let their diabetes slide because they don’t qualify for targeted funding support under her region’s new package .

An example could be an Indian patient in their 30s or 40s who feels okay and has no complications or co-morbidities with their diabetes (so isn’t eligible for Care Plus funding) and puts off paying to see their GP or nurse until issues arise.

“We’ve really got to watch those ones as we know diabetes can escalate quite rapidly and these people have significant risk of complications,” says Calverley who is also a member of the primary health care nurses college board. “That’s a potential risk that we have to be aware of as health service providers and planners.”

No single approach

But every DHB and PHO is slightly different in how they target their DCIP funding and in their willingness to be flexible in using other funding sources as a “back stop” so nurses can offer sufficient support to people with uncomplicated diabetes so they stay that way.

Baty says while some areas packages have identified podiatry services as a real area of need and others retinal screening, more often than not, the packages were about nurse-led initiatives.

“That’s one of the things we are really excited about within the diabetes sector – it’s a very collegial sector from a professional point of view and we’ve had things like diabetes nurse prescribing which is hugely exciting.”

However, it will take time to get a critical mass of nurse prescribers qualified, particularly in primary care.

Baty encourages people to check out their local DHB website and become familiar with their region’s package. Diabetes New Zealand is also working with the Ministry on how to foster local consumer feedback.

“When you have 20 individual plans you (groups like Diabetes New Zealand) cannot give a national response apart from saying (packages) can be variable.”

Changes can take time to filter through to the consumer level.

Donna McArley, RN and general practice coordinator for the Western Bay of Plenty PHO, says her PHO continues to fund one annual free diabetes assessment at its 27 practices. The PHO also has targeted funding to help manage patients with an HbA1c over 75, with many of the practices running diabetes nurse-led clinics and special subsidies for the eight practices whose nurses are offering insulin starts for patients.

Alyson Clare, a senior practice nurse at Kaikohe’s Broadway Health Centre, which has about 600 patients with diabetes and has been offering nurse-led insulin starts for more than a decade, says it is business as usual for its diabetes care. The centre still offers diabetes annual reviews, provides nurse-led diabetes care, and sends Clare to attend regular meetings with the Whangarei-based diabetes specialist nurses, who are available for phone advice when needed.

Bingham says Capital & Coast wants to support practice development in diabetes, and one initiative she has been involved in for several years is an outreach programme where she and a DHB consultant go out to general practices to hold case conferences and promote new research, guidelines, and educational opportunities.

During the usually hour-plus length conference, the pair discusses with the practice team the care of about six to eight complex patients. She says the conferences build professional relationships, making it easier for nurses and GPs to contact the DHB diabetes clinic to ask for advice and improving the specialist service’s awareness and understanding of some of the difficulties encountered by primary care colleagues.

“It allows for clarification around accountability of who is actually looking after which patient, especially for those who fail to turn up for appointments and may fall between the cracks.”

Trend for less amputations

Karen Evison, the Ministry of Health’s national programme manager for diabetes, says while there has been “variation in progress” between DHBs in implementing packages, the DHB reports for the third quarter had shown “significant progress and some excellent results”.

She says it had reviewed a range of DCIP plans from across the DHBs and was pleased with the approach and confident in the quality of services they were delivering.

“Data from the Virtual Diabetes Register (VDR) from December 2012 shows a reduction in the number of people having to undergo amputations as a result of their diabetes,” says Evison. “This indicates that people with diabetes are receiving more effective care under the DCIP approach and gaining better control over their condition.”

Minto says she is not convinced that diabetes outcome measures will show much improvement from the packages because the nature of diabetes was always to get worse rather than better.

“We are not measuring patients’ perceptions of quality of service or improved self-management skills, which should be the focus.”

She has also personally found that the people eligible for targeted funding in her region are the “hard to reach” population (often people who are seasonal workers or whose working hours make mainstream general practice services hours unsuitable) or those who are “difficult to assist because they have other priorities other than their diabetes and therefore will not take advantage of the funding, no matter what the incentives”.

The recent Budget (see basic facts sidebar) has seen more funding invested in both the packages and extra heart and diabetes checks and green prescriptions for those found at risk of developing diabetes.

Baty says the extra Budget funding, while never enough “is a step and you have to start a journey somewhere”.

“We’re obviously pleased that diabetes had been highlighted … if we don’t start something at the stage when intervention can really make a return on investment, then we haven’t got a hope.”

Calverley agrees that intervening at the pre-diabetes stage is an issue that needs to be addressed to “whittle” away at the diabetes “iceberg” that is about to emerge.

Meanwhile, she says it is early days for the packages with the change from Get Checked still to imbed down and further change coming thick and fast.

“If we consider the changes that are happening around (health services) integration, PHO agreement changes and also the potential changes and developments around nurse prescribing, plus pharmacist and dietician prescribing, we could see a whole new picture developing in a year’s time.”

It may well be a case of watch this space.


What can make up a diabetes care improvement package?

Nursing Review asked the Ministry of Health for some examples of what a good diabetes care package can look like. Karen Evison, the Ministry’s national programmes manager for CVD, diabetes, and long-term conditions, responded saying different regions have taken different focuses but some broad themes are:

Improving access

For some, access to services is a key issue and some district health boards have introduced a number of initiatives addressing this “very effectively” such as: mobile outreach clinics and screening services, co-located services, transport vouchers, and additional prescription subsidies.

Northland, Waikato, Counties Manukau DHBs are good examples of these initiatives.

Education and self-management

In other regions, education/self-management are key issues and DHBs and primary health organisations (PHOs) have responded with initiatives like community education evenings, nurse-led clinics and group workshops, and innovative tools such as ‘conversation maps’ that walk people visually through the journey of diabetes care and management.

West Coast and Northland DHBs are two examples of these approaches.

Other common approaches

Some common initiatives being included in packages across all DHBs include: green prescriptions, workplace screening programmes, self-management programmes, increased access to retinal screening, and greater access to nurses to deliver care and provide community education to people with diabetes and their supporters.

The basic facts

  • Funding for Get Checked free annual diabetes review stopped on June 30 2012 after being offered for 10 years because scheme not getting desired results.
  • The $8 million funding is instead redistributed to district health boards to develop primary-care focused Diabetes Care Improvement Packages (DCIPs).
  • 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”.
  • Packages are built on core diabetes services already underway, differ from DHB to DHB, and can involve nurse-led services such as diabetes nurse clinics, patient education groups, community outreach, and may include ‘upskilling of staff’.
  • Nursing Review survey of DHBs Diabetes Care Improvement Package (DCIP) plans a month out from 1 July 2012 finds wide disparity in depth and detail of plans, with most yet to inform general practices of how the new package will work.
  • A year on, Ministry of Health reports there has been “variation in progress” but recent DHB reports for the third quarter show “significant progress” and some “excellent results”.
  • Late last year, a free online learning web site was launched offering seven self-directed learning modules in diabetes
  • care for primary health care nurses.
  • The programme provided by NZ Society for the Study of Diabetes (NZSSD) with the support of diabetes nurse specialist section of NZNO can be found at: www.healthmentoronline.com
  • The May Budget announced additional funding for DCIPs bringing overall funding up to about $11 million a year.
  • The Budget also announced an extra $15.9 million (over four years) to increase the number of heart and diabetes checks nationwide.
  • Plus an extra $7.2 million (over four years) to double the number of nurse and GP ‘green prescription’ programmes that encourage healthy lifestyles for people found to be at increased risk of diabetes or heart disease.