Complexities of service provision in nursing
Integrated pre-diabetes management prevents the development of type 2 diabetes. In essence, pre diabetes is characterized by high blood glucose levels than normal but not enough to be classified as diabetes (Barnett 2010). The increasing number of pre diabetes cases is a worldwide concern on healthcare. First, if pre-diabetes is undiagnosed, it develops into type 2 diabetes. For example, in the United Kingdom pre diabetes has affected more than seven million people thus they have high chances of developing type 2diabetes. Most, the condition develops without symptoms. The recognized diagnostic tests for pre-diabetes include fasting plasma glucose and oral glucose tolerance tests that indicate pre-diabetes state (Airey 2002). On the other hand, the predisposing factors for developing pre-diabetes are high blood pressure, overweight and old age. However, identifying the symptoms of pre-diabetes early prevents them from developing into type 2 diabetes. The necessary considerations include appropriate changes to lifestyle such as diet and physical exercise.
The National Institute for Health and Care Excellence guidelines on identifying pre-diabetes recommends a two-stage approach. First, it recommends that GP practices should use a valid and computer based risk assessment tool for people who are vulnerable of developing type 2 diabetes. In addition, the tools will identify young patients with risk factors such as ethnicity, obese and genetics. They include Cambridge diabetes risk score, Leicester practice risk score and Q diabetes (McIntosh 2003). Alternatively, opportunistic screening is required through a valid patient questionnaire like diabetes risk score assessment tool. Therefore, anyone found as being at high risk are recommended to the GP for a blood test.
Secondly, patients with a higher risk score are required to undergo surgery to have fasting plasma glucose reviewed. Further, the patients are required to be classified in three groups according to the HbA1c levels. For example, patients with HbA1c of less than 42mmol/mol have a moderate risk. General practitioners and practice nurse consultation need to discuss the risks of developing type 2 diabetes. In addition, support services such as losing weight are needed to be offered. Further, it is necessary to study the potential risks of the patients after a minimum of every three years. High-risk people have HbA1c levels ranging between 42 and 47 mmol/mol. Mostly, they are recommended for intensive lifestyle change such as regular physical exercises, weight loss and diet. Alternatively, the progress of the patients should be evaluated every year by reviewing body mass index.
Moreover, it is important for intensive lifestyle program for those people at risk. First, patients with symptoms of pre-diabetes should undertake a minimum of more than 150 minutes of moderate intensity physical activity per week (Unger 2007). Secondly, they are expected to increase consumption of whole grains, green vegetables and other foods rich in fiber. Further, intensive lifestyle programs are appropriate for groups of ten and fifteen people. For example, participants are required to have a minimum of sixteen hours of contact time in a group. Later, follow up sessions are needed at regular intervals for two years after the intervention period.
Alternatively, National Institute for Health and Care Excellence (NICE) recommends metformin for those people who do not respond to lifestyle change program (Bensimon 2009). Initially, low dosage is needed and then increase gradually to a maximum of 2,000 mg daily. Metformin should be administered for a period of twelve months. In addition, practice nurses usually discuss the potential benefits and limitations of metformin with clients.
However, there are several barriers to the implementation of National Institute for Health Care Excellence guidelines. First, the lifestyle intervention programs recommended by NICE are not implemented in many practices. On the other hand, diabetes risk assessment is included in the NHS health check program. Therefore, accurate and timely communication is essential to coordinate risk identification in different settings. In addition, the application of metformin is unlicensed and not recognized by the regulatory authorities. Further, there are gaps especially of how limited evidence of the diabetes prevention translates to UK practice.
The diabetes pathway outlines levels of care and activities recommended by the National Institute for health Care Excellence. First, prevention and self-care services to support healthy lifestyles are important in the management of pre-diabetes. For example, the ways of preventing the risk of type 2 diabetes include eating a balanced diet and moderate physical activity (Unger 2007). Further, avoiding smoking and drinking responsibly reduce chances of becoming diabetic and developing related complications. Secondly, primary health care experts within the general practice deliver diabetes care. They include early diagnosis and annual report. In addition, the major services offered in level one are screening of people at high-risk, identifying diabetes and pre-diabetes cases and diagnosis and management. Mostly, early detection and control of diabetes is done at primary care (Unger 2007). For example, all general practitioners and nurses have knowledge in the general diabetes management options. Alternatively, basic control is performed by the diabetic cases themselves. Thirdly, there are enhanced services in the general practice. In essence, level two is an advanced version of level 1. However, care is delivered in collaboration with other communities based diabetes service. The primary activities at this level include provision of care to type 2 patients, administration of oral glucose treatment, and control of high blood pressure, referral to diabetic and counselling services (Barnett 2010). In addition, advanced service requirements of the general practice are monitoring and treating the heart related risks associated with diabetes.
Level three management of diabetes involves consultant and specialist multidisciplinary service in the community setting (Barnett 2010). In essence, this approach means that patients receive the specialized service for diabetes at the appropriate level without going to the hospital. The major activities at this level include specialists and dietetics input, retinal screening, referral to lifestyle services such as patient expert program and counselling.
Furthermore, patients with diabetic complications are managed at the community. It is a combination service with both health and social care. The objective of the service is to minimize the emergency admissions and fits between level 3 and level 4 (Henderson 2009). Further, high-risk patients for hospital admission are selected through risk stratification of data from both general practice and hospital. Moreover, selected patients are scrutinized at the multi-disciplinary meeting comprising of the professionals. For example, a community matron and care navigator can coordinate home care delivery. In addition, patients stay at the community ward up to twelve months.
Finally, secondary care is a multidisciplinary service in the hospital environment. For instance, many patients attended at the service have greater diabetic complications. On the other hand, secondary care includes inpatient and emergency services. The activities at this level include newly diagnosed type 1 patients, existing female diabetes patients who are pregnant and diagnosed adolescents and young people (Unger 2007). In addition, it includes inpatient care and diabetic emergencies and management of severe and acute complications. For example, diabetes cases have emotional needs from the disease.
Mostly, type 2 diabetes is the prevalent disease that is preventable. For example, it accounts for about 95% of undiagnosed cases of pre-diabetes. Almost 26 million people in the United Kingdom are diabetic, and seven million are undiagnosed of the disease (Ashavaid 2012). Furthermore, in adults aged 20 years there are one in every ten people suffering diabetes and the figures are expected to increase among the seniors. In 2010, more than 2 million new cases of diabetes were diagnosed in the United Kingdom and are expected to increase. Further, the cost of diabetes in United Kingdom was £ 174 billion by 2007 (Gadsby 2009).
Pre-diabetes contributes to about 24,000 premature deaths every year. Also, it increases the risk of cardiovascular diseases such as heart attacks and strokes. Further, more than 80% of the total cost is spent in treating diabetes complications. For example, in 2011 more than forty million items were spent to cater for hospital expenses of diabetic cases in UK (Unger 2007). Further, about £ 700 million were used on drug to treat patients in the primary health care (Gadsby 2009).
Health care organizations are finding gaps to improve the quality of care in managing diabetes. First, the health care system and methods of reimbursement are not properly designed for managing diabetes. For example, they fail to satisfy the needs of patients and health care providers as per the NICE guidelines and protocols (Niebylski 2010). In addition, there is poor coordination between health providers, interventions and providing incentives to the physicians. Secondly, health care physicians find challenges to develop the skills and educating diabetic patients’ behavioral strategies. In addition, physicians are mostly unclear about the treatment objectives. Further, there is a lack of organizational support and computerized system to track patient care and results. Lastly, patients perceive personal barriers to managing diabetes as severe and numerous (Warner 2007). Therefore, they are required to overcome personal challenges to managing the disease successfully. Finally, other significant barriers include inadequate health education, poor reading skills and cultural differences. For example, the quality gap to diabetes and pre-diabetes of usual gap is measured more than 10% points (Niebylski 2010).
In addressing the gaps to pre diabetes prevention, people need guidance to avoid personal barriers and making lifestyle changes. The solutions include making changes in the way care is delivered, addressing low literacy levels among patients and physicians support for using clinical guidelines (Barnett 2010).
Health education allows people to understand and use health information to improve health. For example, low literacy levels can cause patients to make mistakes especially to general health and routines (Niebylski 2010). Moreover, people with poor reading skills are associated with health problems especially accessing the health system and integrating health care information. Further, almost half of people with inadequate health education do not know how to take medication and interpreting low blood sugar levels. On the other hand, the written information provided to the patients’ needs literacy skills. Therefore, health education strategies can help health care experts to communicate better to clients. The strategies include the use of plain language, pictures and combinations of both visual and presentation of information (Henderson 2009).
NHS wanted to create a funding gap of £ 20 million between 2013 and 2014 and will continue to grow (MacIntosh 2003). This gap can only be solved by freeing up of NHS services and staff from the old practices and structures. The latest reforms addressed on NHS include competing demands for services, changing demographics of the patients and long-term conditions such as diabetes. Also, the NHS treats more than one million people after every 36 hours. On the other hand, over 15 million people have long term conditions such as diabetes and account for 15 % of general practice appointments in a hospital bed (Airey 2002). Therefore, NHS UK and other partner organizations will be providing support to local GPs and diabetic patient groups.
Finally, technology is an important tool to improve the quality of care. It allows physicians to monitor treatment procedures for pre-diabetes (Krentz 2009). Also, it offers an intervention tool for easing time and knowledge on the team managing diabetes. For example, the technology allows patients to provide options on the diet, physical activity and behavior (Henderson 2009).
In conclusion, diabetes is a disease that requires patient self-management to show a significant role. People need guidance to enable them cope with necessary lifestyle changes. The gaps identified to improve the quality of care to managing diabetes such as lack of health care system as per NICE guidelines and protocols and low literacy skills among patients. However, educating patients, NHS reforms and use of technology will breach the gaps in managing diabetes.
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