Primary care - key issues

The following issues are highlighted:

Care planning

Every person with diabetes should have an individualised care plan which is shaped by the tests and discussions that take place as part of an annual or six-monthly review. In England this was reinforced by 'Our health, our care, our say' (Department of Health 2006) which set the target for all people with long-term conditions to have an individualised care plan by 2010.

Increasingly care planning is seen as a partnership approach with the GP, practice nurse and other members of the healthcare team working with the patient towards effective management of diabetes. This approach to care planning should allow a person more active involvement and give them more ownership over their care and treatment. The NHS Diabetes website describes the person-centred process as the emphasis moving away from the clinician doing things ‘to’ the person to a partnership approach that delivers tailored personal support to develop the confidence and competence the person needs - see NHS Diabetes: Care planning.

A care planning model is also described in guidance developed jointly by Diabetes UK and the Department of Health - see Care planning in diabetes.

The Year of Care project which commenced in 2008 has further developed collaborative approaches between healthcare professionals and people with long-term conditions. Information from effective care planning can also be used to support commissioning of local services. Diabetes UK describe the aims of the project at What is the Year of Care?.

The Year of Care project has developed a care planning training package based on experience and expertise that came from the sites that piloted the Year of Care. The point is made that in order for training to be successful there has to be a total commitment to the philosophy and principles of care planning across an entire organisation.  The package is made availabe on the NHS Diabetes website Partners in care: a guide to implementing a care planning approach to diabetes care. 

Supporting self-management 

The shared care planning is also important in supporting self-management of diabetes and self care. The Health Foundation have published a rapid review looking at evidence about the effects of supporting self-management on people’s quality of life, clinical outcomes and health service use and finds that the evidence suggests that supporting self-management works. The review also considers evidence for the effectiveness of different interventions to support self-management. For details see the Health Foundation publication Evidence: Helping people help themselves.

There is further comment on self-management and resources to support this in the section on patient involvement within this resource – see the heading self care at patient involvement. 

Emotional and psychological support 

Emotional and psychological support for people with diabetes is an important component of diabetes care. Diabetes UK advocates the provision of emotional and psychological support as an integral part of a diabetes care (Diabetes UK 2007c). The first detailed survey of the availability of psychological care for people with diabetes in the UK found that only 31.5 per cent of diabetes services state that they have access to specialist psychological service provision (Diabetes UK 2008d).

A report produced by the joint Diabetes UK and NHS Diabetes Psychological and Emotional Support Working Group and published in March 2010 makes the following points:

  • it is estimated that 41 per cent of people with diabetes experience poor psychological wellbeing
  • people with diabetes have a significantly increased risk of depression, anxiety and eating disorders, which can limit their ability to self manage their condition, especially as such self care requires motivation and behaviour change to achieve the best possible quality of life
  • the prevalence of psychological conditions such as depression, anxiety and eating disorders is significantly higher among people with diabetes than in the general population
  • poor emotional and psychological wellbeing in people with diabetes is associated with suboptimal glycaemic control, increasing the risk of the development of diabetes-related complications.

See page eight of the report from Diabetes UK at Emotional and psychological support and care in diabetes report.

The report uses the Pyramid of Psychological Problems model as a way of presenting the complexity of their impact. The report includes recommendations to improve emotional and psychological support around: commissioning of psychological services; workforce skills and support from specialist services; the delivery of psychological services to meet the range of needs identified in the Pyramid model.

NHS Diabetes have gathered together key guidance and research on emotional and psychological support in diabetes  in a publication in their Knowledge and Information Repository series. You can access this in the section of the NHS Diabetes website on emotional and psychological support. 

Quality and Outcomes Framework

A number of studies have looked at the impact and effect of the Quality and Outcomes Framework (QOF) on health care.

Although not an explicit aim of the Quality and Outcomes Framework (QOF), a study from the King’s Fund looked at the impact that QOF targets may have had on this, for example through improved case finding. This was done by examining the gap between reported and estimated prevalence. The study suggests that the correlation between higher scores and more complete recording of disease prevalence, even after adjusting for other factors, suggests that well-organised practices that are able to achieve better QOF scores may also be more systematic in their case finding.

In discussing implications of the research findings the study report recommends that the QOF and GP contract should take a more patient-centred approach to chronic disease management and self care and self-management. The study cites the QOF requirement for annual measurement and recording of, for example, blood sugar levels or blood pressure – “this approach runs counter to the evidence that ongoing patient monitoring (through remote devices , for example) is effective in the management of patients with chronic illness”  – see page ten of the King's Fund report at Impact of Quality and Outcomes Framework on health inequalities.

The report of a research study looking more specifically at the effect of QOF on diabetes care was published in 2009 by the British Medical Journal. The study covered a period three years before QOF was introduced and three years after and aimed to assess whether changes in quality of care were the direct result of the implementation of QOF.

Findings showed significant improvements in all of the Quality and Outcomes Framework clinical indicators with particular achievement in improvement of process measures. However direct linking with the QOF implementation was not straightforward as diabetes care in this period of time (2001-2007) was also influenced by other initiatives such as national guidelines and service frameworks. The study also highlights the complexities of a target and incentive based scheme and its influence in sustaining and improving on targets. For the detailed findings and discussion in this BMJ article see: Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study.

A recent study looking at the effects of the QOF generally, investigating whether the QOF scheme led UK general practitioners to neglect activities not included in the scheme was published by the British Medical Journal in 2011. As with the study on QOF effects on diabetes care, improvements in quality for all indicators between 2001 and 2007 were noted and are described as substantial in this study.

However the findings raise some concerns about potential detrimental effects on aspects of care that were not incentivised. The report of the study discusses aspects of the QOF scheme that may impact in different ways and pointing to some limitations of financial incentive schemes in health care that may need to be accommodated – see: Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework.

A review authored by G Flodgren et al and published in the Cochrane Library Issue 7 2011, attempted to evaluate the effect of financial incentives on the quality of health care in primary care. The review looked at incentives across different countries and included the Quality and Outcomes Framework. The study concluded that there is” insufficient evidence to support or not support the use of financial incentives to improve the quality of care provided by primary care physicians. Implementation should proceed with caution and incentive schemes should be carefully designed and evaluated”. For the full review on the Cochrane Library website see The effect of financial incentives on the quality of health care provided by primary care physicians.

References

Full details of the bracketed citation in the text above and, in many cases, links to the actual documents are available in the reference list within this resource. Go to the Reference list.

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