How to promote patient centred care and self-management in diabetes, including a culture where professionals work as equals with patients
Opportunities to improve diabetes care are there, but achieving the necessary transformation, which puts patients genuinely at the centre, will take a paradigm shift.
Campaigners say that this will require a change of mindset to ensure patients are engaged, and equipped with the skills, knowledge and confidence to be full partners in their care.
It will also involve changing pathways, making better use of the healthcare team – in communities as well as hospitals – and involving patients at every stage.
While prevention is important, it is not the only challenge, says Simon O’Neill, director of health intelligence and professional liaison at Diabetes UK. “For many people it’s possible to reduce risk or delay onset by losing weight or becoming more active,” he says.
“But for the rest of us, who will have diabetes, it’s important to get self-management right.”
For many, this starts with education. But he points out that despite national guidelines stressing the importance of this, only 18 per cent of patients are offered it – and only a quarter of these take it up.
The engaged patient is more likely to adhere to treatment, reducing the risk of complications, he adds. “At the moment there are more than 100 amputations a week, nearly all preceded by ulceration of the foot,” he says.
“But some people don’t realise they have a foot ulcer because they don’t feel pain. Around 80 per cent of these amputations are preventable.”
Adrian Sieff, an assistant director at the Health Foundation, says that engaging patients and co-creating care brings great opportunities to the NHS.
Shifting the balance
But it is a major change to the doctor-patient relationship and challenging to both, he adds.
“The doctor can tell you to stop smoking, but you won’t do it. You’ve got to encourage behaviour change.”
There are three main enablers for this: shared agenda setting, goal setting, and goal follow-up. Rather than the clinician automatically setting the agenda, the patient should be asked to state what is important to them – and discuss ways of meeting their goals.
“I think the health service ‘gets’ agenda setting, and sees that goal setting makes sense. But it’s really important that there’s goal follow-up as well, and we know that it needs to be soon after.”
He says that some commissioners shy away from this approach because they fear it will be resource intensive, but that there are ways of following up patients that do not require one on one clinician-patient time.
He cites work in Bolton with people being treated for alcohol dependency. Goals are set while they are in rehabilitation, then targeted and personalised text messages are used in follow-up.
If all is going well, then that is fine, but if the patient needs help then they will get a phone call and follow up.
Making better use of the whole healthcare team also brings opportunities – including thinking outside traditional settings.
A project in Devon, for example, using community pharmacies to support patients to get the best out of diabetes medicines, showed great promise.
Most patients liked it and, on follow up, almost 90 per cent were adhering to all or some of the pharmacist’s recommendations. Afterwards, 82 per cent said the project had motivated them to stay in control of their diabetes.
“The care and advice that pharmacists offer can really help patients to self-manage their condition, says Mark Stone, Devon Local Pharmaceutical Committee project pharmacist. “Investment is needed to take projects like this to scale.”
Don Redding, director of policy with National Voices, is encouraged by the changing environment signalled by the NHS Five Year Forward View.
“What we hear from National Voices members who have long lobbied for these changes is that they remain frustrated and sceptical. They see that we could really improve health and quality of life for people but not enough is happening on the ground. But for a long time, talking about person centred care has been the province of a few advocates – all of a sudden it seems to have become common currency.
“The opportunity is there to set a goal to make care more person centred but the risk is that people underestimate what is involved.
“If we want to move to a model that supports self-management, it’s much more than one action: it’s about retraining health professionals and patients, it’s about changing choices and customs, it may involve moving from single disease pathways to something that’s much more coordinated and designed to support the person rather than the process.
“It’s challenging, but the potential gains for the individual and the health service are huge.”