There are around 20,000 people in Cardiff and the Vale who live with type 2 diabetes and this is one of the reasons we have focused our attention as a health board on this particular health issue. Diabetes is one of those long term health care illnesses that are sometimes referred to as ‘long term conditions’.
In some parts of the world, there has been a move to downplay the disease specific treatment pathways and at least in planning terms try and aggregate up the care that people with many different kinds of long term conditions need. There are good reasons for this – not least that many people have to contend with more than one form of long term condition. Indeed in our health board the Primary, Community and Intermediate Care Clinical Board has done some fantastic work looking at some common conditions that are amenable to treatment without a need for admission to hospital and have shown that it is possible to organise some of these treatments along pathways that overlap or share many similar components.
However there is a dilemma: how can we balance the depth of knowledge required about possible treatment options for individual patients with the growing patient numbers and increasing treatment complexity?
Sharing knowledge and sharing the care we offer is a challenge when the knowledge that individual practitioners have of necessity is getting deeper, but arguably narrower too. It is worth persevering with as doing so helps us see the whole patient rather than responding to the patient one illness at a time. All of this is the natural territory of primary care which is where the vast majority of our population’s contact with our services takes place. The fact that the public continue to see primary care as a real strength of our system is a real tribute to those who work in this part of our NHS. There is no denying that the pressure on primary care is rising due in part to the ageing of the population but also as the result of more complex and demanding treatment choices – which includes diabetes.
So how can this dilemma about the depth of knowledge acquired by a few and the breadth of knowledge required by many be handled? That was the question that our physicians who look after patients with diabetes asked themselves. The facts are startling: the prevalence of type 2 diabetes is around 5% in South Wales but the condition accounts for 9% of our expenditure and audit data shows that 18% of all inpatients will have diabetes. Recognising the increasing demands that diabetes places on the NHS, the physicians are in the final stages of developing an integrated model of type two diabetes care with closer integration between primary and secondary care providers than has been possible in the past. The model aims to deliver care as close to the patients home as possible and to provide support and education to primary care (General Practitioner and Practice Nurse primarily) as well as allowing secondary care to better understand the difficulties of managing a complex chronic disease such as diabetes in the community.
The model is centred on the principle that each of six consultants in diabetes will be attached to between eight and ten named general practices and will remain with those practices for community clinics, case notes review and advice by email. The expectation is that this will allow primary care physicians to get access to senior decision making in a timely manner and without having to make a formal referral to the hospital outpatient clinic with the delays that may be incurred. Having a named consultant will offer continuity of care and will facilitate the development of closer links between primary and secondary care. GPs will quickly develop enhanced skills through discussion with the hospital specialist that will allow them to feel more confident in managing patients with increasingly complex needs.
Because of the increasing number of patients with type 2 diabetes and the increasingly complex treatment options and algorithms available it is often difficult for general practitioners to decide on the best treatment for an individual. Capacity in secondary care clinics is limited and increasingly restricted to managing the most complex type 2 diabetes cases as well as type 1 patients. It is important to recognise that each person’s diabetes management and treatment targets needs to be individualised and as patients are often taking many other drugs for other co-morbid conditions it can be challenging to decide on the best option. Giving access to consultant Diabetologists for help with complex decision making will allow most patients to have their treatment delivered by their GP in the practice without the need to travel or wait.
The physicians have a big and positive vision for the future. They aim to facilitate the delivery of high quality care to patients, whilst reducing inequalities in care from area to area and assuring an accountable and auditable service is maintained. This project is one of the biggest reorganisations of service delivery in the field of diabetes for many years and as such offers the opportunity to be innovative and forward thinking, keeping the patient at the heart of the service.
You might say that really is hitting the sweet spot.