Successful outcomes from this change

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• We are setting up virtual clinics with a Diabetes Consultant and Specialist Diabetes Nurse at Musgrove.  Should a patient become more complex we will no longer need to refer to a Specialist Diabetes Nurse or Consultant.  Instead we can skype or telephone for advice and then support our patients without them needing to travel to hospital. 

• Reduced GP input

• Stopped over medicalising patient

• Annual diabetic bloods managed by nurse not GP

• Adhering to gold standard

• Managed by audit – either a letter, speak on phone etc

• Freeing up slots allows ability to do other work e.g. gestational reviews

 

Why we had to change

 

At Burnham & Berrow Medical Centre we felt as though we were ‘firefighting’ to keep abreast of our roughly 1293 diabetic patients with a presentation of 2-3 new ones per month.  As with most of the challenges we face as a team, a few of us got together to plan how we could provide a better service for our patients.  We wanted to empower our patients to take more responsibility for their own health. We saw that time was being absorbed by 6 month and annual reviews leaving little time to review anomalies e.g. pre-conception, gestational diabetes.  We were also inviting patients back into the surgery to basically say ‘well done’ for maintaining their blood sugar levels!

 

The doctors were happy for the staff to take charge and revamp the model that we were using.

 

Our aim

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• Empower and educate patients better so that they were confident and able to manage their health better

• Reduce the number of face to face contacts

• Not ‘over medicalise’ patients in the normal range

• Unclog the system to allow for more effective appointments with those who need it

• Release time to look at anomalies and provide the appropriate interventions

 

We knew that to make a sustainable and significant difference we needed to make a big shift to include patients in their own care.  Trained in Motivational Interviewing techniques, we decided to put this in practice to manage our more difficult cases. 

 

What has changed

 

• Developed a better system for diagnosing and coding

• Dropped an initial appointment where we explained their condition.  Instead patients are immediately invited for a pre-diabetic check and put on a course of action.  This early intervention has seen very positive results for patients and released appointment time

• Follow-up appointment face to face in 2 weeks

• If on diagnosis their HBa1c is very high– they will immediately start meds and they have an appointment booked as protocol

• Minimal input required from GP.  Specialist nurse is the main point of contact

• Patient can have a telephone slot with the nurse

• If all markers are clear a letter is sent to the patient saying ‘well done’ as opposed to being invited back in.  This is good for patient and staff

• Patients are signposted to support – link with Lions Club peer support group

• Adhering to gold standard we book another appointment in 6 months

• We no longer chase the patient to make this and leave it up to the patient.  We do however,  have a back up audit to make sure that a follow up takes place.  We discuss over the phone and sometimes it is not necessary to bring the patient 

• Lucy has developed a simple tool using a traffic light system to help patients interpret their results and  to see if they are above recommended target levels.  Feedback from patients is that it has really helped them gain an insight and they have found it easier to interpret their results. Using this tool, together with motivational interviewing techniques has enabled patients to set measurable and achievable targets and identify what they need to change to take responsibility for their own health.  It is also easy for patients to see if their results have improved or worsened.  This very simple health profile is a small step in changing the patient culture and putting some of the onus and responsibility back on to them by education instead of dictation of results.