SKILLS & LEARNING
MDT WORK: DIABETES IN PRIMARY CARE Claire Chaudhry Community NHS Dietitian/ Private Dietitian, from Betsi Cadwallader University Health Board; Freelance
“Wales has the highest prevalence of diabetes in the UK,” quotes Dr Julia Platts, National Clinical Lead for Diabetes in Wales.1 The plan for primary care services in Wales up to 2018 identifies the need to invest in the development of the wider primary care workforce and suggests using a wide range of professions according to prudent healthcare principles.2
In Claire’s 16 years’ experience, she has worked in acute and community NHS settings. Claire has taught Nutrition topics at universities and colleges and regularly provides talks to groups, NHS and private.
The diabetes delivery plan for Wales also highlights the need for a range of healthcare professionals working together with national structures and initiatives of local diabetes service planning. Multidisciplinary teams (MDTs) working together will have a significant benefit to all those living with diabetes in Wales.3
www.dietitian claire.com
REFERENCES Please visit the Subscriber zone at NHDmag.com
Thank you to Teresa Davies, Diabetes Specialist Nurse, for her contribution and to Elaine Jennings, Diabetes Lead Dietitian, for her continued support and contribution.
A NEW WAY OF WORKING
Funding opportunities have enabled the development of a new innovative model of diabetes care across Wales. Through a range of funding from Betsi Cadwallader University Health Board (BCUHB) and/ or the locality general practitioner (GP) clusters, diabetes MDTs are currently working within North Wales. The aim of the service is to promote joint working between primary, community and specialist services for the benefit of people living with diabetes in each identified locality. Each team consists of a full-time Diabetes Specialist Nurse (DSN), parttime Diabetes Specialist Dietitian (DSD) and a part-time Diabetes Health Care Assistant (DHCA). These MDTs are currently in Anglesey, Arfon, Conwy West, Meirionnydd, North Denbighshire and South Wrexham. My role of DSD for South Wrexham locality commenced in October 2016. I work alongside Teresa Davies DSN who started in March 2017. Teresa and I cover eight GP surgeries within the South Wrexham locality. There are currently over 3055 patients with diabetes registered within this cluster. Teresa and I explained our roles and the
services we intended to provide to the HCPs of South Wrexham at the cluster locality meeting July 2017. WHAT HAVE WE ACHIEVED?
“Dietitians in primary care ...”4,5 1 Enabling self-care of long-term conditions. 2 Reducing demand on GP time. 3 Make prevention happen. 4 Managing usage of borderline substances. 5 Managing prescribed medicines. 6 Reducing referrals to secondary care. 7 Reducing need for hospitalisation. We have enabled patients to selfmanage their conditions, which for the future will reduce demand on GP time. Teresa and I are both X-PERT educators and between us we have delivered five X-PERT courses within the locality with positive feedback from patients and family members who have attended.6 We meet bi-annually with other X-PERT educators across North Wales. I deliver a monthly two-hour group session aimed at newly diagnosed Type 2 patients. Patients are referred from primary care and are seen within four to six weeks from diagnosis, average attendance per group is 10 participants. What is diabetes, portion sizes of food groups; labelling, alcohol, snacks, eating out and addressing any misconceptions of the group are part of the session. In order to make prevention possible in primary care, we provide Nurse Link meetings every two months for nursing staff. Practice Nurses (PNs), District www.NHDmag.com June 2018 - Issue 135
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SKILLS & LEARNING Nurses (DNs), student Nurses and Healthcare Assistants (HCA) are all invited to attend for networking and training and to discuss individual patient concerns. We have so far provided updates on insulin, blood glucose monitoring machines, structured education and Podiatry. We have run a half-day Diabetes Study Day, aimed at Managers, Registered General Nurses (RGNs) and HCAs employed within nursing homes and residential homes in the Wrexham and Flintshire area. This Study Day was attended by 25 HCPs with positive feedback. Teresa and I have also taught TOPICAL to GPs and PNs. TOPICAL is a three-day course incorporating various topics on diabetes prevention and management.7 Feedback included: “Informative, relevant” and “Excellent speakers!” I have also been providing updates on dietary diabetes prevention and management to staff in the GP surgeries when requested. Feedback included: “A highly enjoyable overview of diet with practical advice.”; “Excellent content.”; “Very useful and thoroughly interesting session.”; “Come again please!” I have been working closely with Elaine Jennings (Diabetes Clinical Lead Dietitian for North Wales) and the diabetologists in Wrexham Maelor Hospital looking at managing medicines effectively and efficiently. Very Low calorie diets (VLCD) are being offered to secondary care patients with Type 2 diabetes. Patients attending VLCD group sessions are provided with information, literature, instructions on individual deprescribing and individual weekly support as telephone follow ups. The publication of the DiRECT study has highlighted the effectiveness of the VLCD in the remission of Type 2 diabetes, plus the reduction and discontinuation in prescribing antihypertensive medication.8 The Diabetes nutritional guidelines were also updated in March 2018 to incorporate the DiRECT study.9 The diabetes delivery plan highlights the importance of changing behaviours through education. Lifestyle interventions aimed at changing an individual’s diet and increasing the amount of physical activity, aims to halve the number of people with impaired glucose tolerance who go on to develop Type 2 diabetes.3 The Cost of Diabetes report 2014 states: “The best way to reduce the cost of diabetes is to prevent 36
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Type 2 diabetes...”.10 In January 2018, with a GP, I undertook a VLCD pilot for patients with an HbA1c between 42-47 (pre-diabetes); four patients undertook a VLCD for eight weeks. The results of this local service improvement were very encouraging: • Total weight loss 39.1kg (average weight loss 9.75kg) • BMI range reduction 1.9-4.8kg/m2 • HbA1c range reduction 2-5mmol/mol • Feedback: “I have more energy.”; “I have a reduction in cravings.” Education for primary care HCPs is paramount, with the aim of reducing the need for expensive referrals to secondary care and reducing the need for hospitalisation. The super six model of diabetes care was developed in South East Hampshire and Portsmouth hospitals. The super six is based on defining clearly with local GPs, commissioners and specialists as to which services need to exist within the settings of an acute Trust. This was due to the need for MDT or a higher expertise involvement.11 The six services defined for secondary care diabetes care were: 1 Inpatient diabetes 2 Foot diabetes (with predefined criteria) 3 Poorly controlled Type 1 diabetes, including adolescents 4 Insulin pump services 5 Low eGFR or patients on renal dialysis 6 Antenatal diabetes Discussions are currently taking place across North Wales regarding the return of patients from secondary care into primary care that do not come under the super six. Thus further training is required from us regarding the long term management of these patients within the community. Hypoglycaemia what do you use? The feedback from South Wrexham residential and nursing homes was “Anything to hand!”. Teresa designed a ‘Hypo Box’ with quick acting glucose examples and easy-to-read instructions on treatment, which cost less than £3. During Hypo Awareness Week back in October 2017, Teresa and I visited care homes and nursing homes to demonstrate the cheap and effectiveness of the hypo box.
Utilising technology effectively is using both EMIS (primary care) and Therapy Manager (secondary care) whilst ensuring that ‘Information sharing’ is conducted safely, transparently, confidentially and with patient’s knowledge. All of the teams across North Wales are asked to provide one Microsoft PowerPoint slide on a monthly basis to show their contribution, worth and activity over a monthly period. This is called ‘A day in the life’ and is used to highlight and celebrate our work whilst sharing workable ideas across North Wales. WHAT HAVE I LEARNED?
Being patient and sticking to our aims Some healthcare centres/surgeries were unwilling for us to be integrated into their practice at first. Other surgeries wanted us to take over their entire diabetes case load. Being patient and sticking to our aims was very important. Educating healthcare professionals on understanding individual dietary goals There were HCPs who were ‘one size fits all’ in recommending a dietary approach. Ultimately, the patient’s choice of what works for them is the key to successfully managing their diabetes and and could also reduce GP time. More knowledge about VLCD and Script analysis The VLCD was introduced to me whilst as a student dietitian in Glasgow Hospital in 2001. Since working alongside Elaine and the Diabetologists on the VLCD, I have learned a wealth of knowledge. Getting to know the patients participating on the VLCD, through weekly follow ups has provided me with further experience on eating behaviours and how they have developed throughout their lives. Whilst on the VLCD patients have reported that their eating behaviours have completely changed. Feedback from the VLCD: “I really appreciated the introduction of foods; I am enjoying all foods now. I had got into a rut and was eating without thinking and the VLCD has put the thinking into perspective.” Script analysis is part of the counselling theory of Transactional Analysis by Dr E Berne and is the
Locality Specialist Diabetes Dietitians in North Wales
method of uncovering the early decisions, made unconsciously, as to how each of our lives are lived, e.g. what and why we eat. THE FUTURE OF THE DIABETES MDT
I am currently developing a VLCD tier service. The VLCD triangle tiered service will be part of the intervention across the complexity of patients with Type 2 diabetes and will take place between primary and secondary care as a prudent healthcare approach.12 Parts of the education will be complementary across the tiers with those at Tier 3 and 4 requiring core education and further individualised support. The aim is to develop the tier service so that level 1 could be delivered in primary care by a trained HCA. I am planning on another prediabetes VLCD cohort this summer within the same GP surgery. The next rung of the triangle level 2 will be primary care patients with newly diagnosed diabetes who are on single therapy. Teresa and I are hoping to recruit a diabetes HCA for two and half days a week, which will help us considerably in our future goals. Traditionally, GPs and specialist prescribing pharmacists are the HCPs responsible for prescribing. With the changing role of dietitians and the possibility of future supplementary prescribing, this is exciting times ahead for diabetes dietitians within the primary care setting. www.NHDmag.com June 2018 - Issue 135
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