Pilot scheme could reduce pressure on Diabetes services

Monday 08 January 2018

GP practices and specialists nurses will be running clinics to help islanders who live with Diabetes better manage their condition be more involved in how their care is planned, as well as relieving some of the burden on the island's Diabetes Centre.

It is hoped that the year-long pilot scheme will help individuals become more confident in managing their condition. This will help relieve the workload of the Diabetes Centre, who will then be more able to deliver enhanced care to complex patients.

A second scheme to help patients affected by Chronic Obstructive Pulmonary Disease (COPD) has also been launched. According to Statistics Unit data, the numbers of islanders affected by Diabetes and COPD could rise by as much as 42% and 50% by 2036. If the pilots are successful, they could not only help sufferers of these conditions, but help change the way other long-term conditions are managed.

The schemes' implementation comes as part of the Sustainable Primary Care Strategy, which was launched in December 2015.

The Diabetes pilot is being trialled with GP practices HealthPlus and Cleveland Clinic, and is open to patients of those practices who live with Type 2 Diabetes, are over 18, and not pregnant. It is estimated that around 800 people - around a quarter of adult diabetics in Jersey - are eligible.

Through a partnership with the Diabetes Centre, the GP practices will run dedicated clinics with specialist diabetes nurses from the Centre as well as practice nurses who will share expert knowledge with the patients and help them set their own health objectives.

Pictured: Cleveland Clinic is one of the two practices where the diabetes pilot scheme is being trialled. 

Patients will continue to pay for the service at a slightly lower rate than what would normally be paid for annual GP checks. The package of care include diabetes checks, a care planning appointment and a GP follow-up appointment, all in a convenient and familiar for patients. Blood glucose monitoring strips will also be available at the practice, on the same terms as the Diabetes centre.

The pilot scheme has been designed in partnership by clinicians, including GPs, nurses and consultants from general practice, HSSD Diabetes Centre and Family Nursing and Home Care, as well as service user represented by Diabetes Jersey has represented service users in the pilot design.

Understanding how the pilot is working will help to redesign services that manage other long-term conditions in Jersey.

Dr Philippa Venn from Cleveland Clinic said: “We are delighted to be taking part in this pilot scheme which allows our diabetic patients to have care for their condition in a familiar setting. We believe this is a great concept for this important group of patients, and allows our expert nurses to talk with and reassure patients.

“We know that individuals living with Diabetes visit their doctor more often than the average person, at least four times a year for regular checks, blood tests and prescriptions - we know that some visit the GP many more times, sometimes for Diabetes-related complications. The pilot aims to provide annual Diabetes checks in general practice with specialist support at a marginally lower cost: the service has been designed on the principle that patients in the pilot should not be financially disadvantaged. To support this, the pilot is part-funded by Health and Social Services. Charges for other monitoring and prescription appointments will remain the same as they are now."

Pictured: It is hope the pilot scheme will help reduce the number of patients visiting their GP or the Diabetes centre for complications related to their condition.

The Doctor says that the addition of a Diabetes Centre specialist service to a GP service at no extra cost should also reduce the number of visits to the Diabetes Centre and GP practices for Diabetes-related complications.

The second pilot scheme is run in partnership with Cooperative Medical and involves around 100 COPD patients who are either already diagnosed with COPD or who are thought to be at risk from it. 

Free basic screening and assessment will be offered to all patients, who will be seen by the COPD Care Manager. Depending on the severity of their condition, the patient's GP and the Respiratory Team based at health and Social Services might also be involved.

The Care Manager will help to coordinate access to services and deliver some interventions. They will advise patients who need additional support on which services can help them if needed, those services include Jersey Talking Therapies, Help2Quit or Pulmonary Rehabilitation.

The service, funded by HSSD, will be free, but GP appointments will have to be paid for in the normal way. The patients will also be offered a Medicines Use Review, either in one of the Co-op pharmacies or, if considered necessary, at home.

Pictured: A care manager will help patients living with COPD deal with their conditions and access the support they need.

Sara Kynicos from Cooperative Medical said: “For a primary care provider to work so closely with patients who have COPD is a great opportunity. We hope that the pilot scheme will allow patients to be empowered to better understand their condition and feel that they can be confident in their self-care, while if they have greater need, services can be better co-ordinated for them. In addition, to have access to a multi-disciplinary team when needed is a great boon, and we hope that the pilot will reduce Emergency Department attendances and hospital admissions for issues related to COPD.”

Senator Andrew Green, the Minister for Health and Social Services, expressed his gratitude to all those involved in the schemes and said that he looks forward to seeing the outcome. "It’s great to see true partnership at work which is at the heart of the re-design of services which is ongoing to make them as accessible as possible for patients. We need to treat and care for everyone, and I’m pleased to see this happening, with patients who have long-term conditions,” he commented.