Diabetes Care for the Most Vulnerable in Society

Results

Summary of Main Messages From Focus Groups

All six groups shared the same main concerns, which we describe in detail. Additional issues raised by only one or two groups are also discussed. Direct quotes are shown in italics.

Communication. All groups agreed on the need to improve communication and gave examples of failure at several different levels:

Hospital

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  Discharge planning is often non-existent with hospitals routinely pressurising the care home to take back the patient with an attitude of now it's their problem. Staff resented this. We're not second-class nurses.
  
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  Patients with dementia are sometimes returned from an outpatient visit without any feedback. Appointments at the hospital are a waste of time.
  

GPs and mental health

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  These services routinely provide incomplete information when transferring a patient to a care home.
  

Specialist diabetes services

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  Support is patchy and access is difficult. The local service has deteriorated dramatically since a community specialist nurse resigned.
  

Relatives

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  They are sometimes unaware of details of diabetes care.
  
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  Lack of integrated care plans between social and medical services is a systemic error in the care we provide.
  

Training. All groups agreed on the need for training in diabetes to allow them to provide high quality care for residents. They felt this would improve staff morale and confidence and thus enhance their status.

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  One hour every six months focusing on person centred care would be perfect.
  
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  Education does not have to be delivered by a high level specialist.
  
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  The ideal would be to combine coherent education and care in diabetes and dementia.
  
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  KNOWLEDGE IS THE KEY – the group asked for this to be in capital letters.
  

Several participants referred to a community diabetes nurse who helped them with specific problems related to diabetes. She also put aside time for staff training in the homes. These sessions were greatly valued and staff would come in during their off duty time to take part. The nurse was very person-centred and taught both theory and practice. She retired in 2009 and has not been replaced.

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  E-learning using the programmes available was seen as an inferior form of education and was not a realistic alternative to the services of a skilled and experienced educator.
  
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  Buying in professional education is an expensive option, though drug companies may provide sponsorship.
  

Resources.

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  Lack of resources is keenly felt – budgets are very tight.
  
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  The number and calibre of staff directly affects the quality of care. Lack of staff limits the time available to spend with residents and to access training.
  
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  There may be conflicts with agencies about the classification of residents' status which has financial implications
  
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  Because resources are in such short supply, we sometimes try to develop services from somebody else's budget.
  

Support From Diabetes Team. There was a serious reduction in the level of support from diabetes specialist services, following the retirement of the only community-based diabetes specialist nurse in 2009. She had been available for advice about individual patient management and for training of staff at all levels. Specialist care and knowledge is now hard to access and staff feel that this puts them at risk of complaints.

Identification of Risks of Diabetes

Hypos.

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  Every care plan contains individual symptoms of a hypo.
  
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  Experienced staff know the signs of their patients, but they are not on duty all the time. You need to know your residents well to prevent hypos.
  
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  Risks may be reduced by looking for patterns of behaviour.
  
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  Detailed communication between shifts and regular blood testing may also increase hypo recognition.
  
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  Blood glucose strips are a source of conflict. Some general practitioners (GPs) refuse to prescribe them even for elderly residents at risk of hypo.
  
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  Even if test strips are available, residents may refuse a test, particularly if they are hypoglycaemic at the time.
  
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  Regular medication reviews may reduce the hypoglycaemic impact of drugs.
  
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  Care workers receive opportunistic training about hypos from more experienced staff. No formal training is provided.
  

Feet, Eyes and Teeth.

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  Access to these specialist services is patchy.
  
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  A specialist podiatrist provides valuable advice in one area of the county.
  
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  Links with opticians are becoming more difficult to maintain.
  
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  Domiciliary dental care is no longer available – only one dentist provides home care.
  
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  GPs may refuse to treat dental infections with antibiotics.
  

Care Planning and Quality Indicators.

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  Care homes are obliged to produce a care plan within 72 hours of arrival of a new resident. This may not give time to make all necessary assessments and talk to all involved parties.
  
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  Care plans are reviewed at monthly meetings.
  
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  Polypharmacy is a real problem and regular medication reviews are a help. Change in medication may lead to conflict with family who may feel that a reduction in tablets equates to a reduction in the quality of care.
  
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  Some homes have constructed their own templates for diabetes care – no one used the template produced by Diabetes UK.
  
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  Diabetes is frequently one of several problems and the presence of co-morbidities, both medical and psychiatric increases the complexity of management.
  
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  Above all residents must feel safe and secure – decisions about treatment are individual and there may be conflict between personal choice and quality indicators. It may be hard to strike the right balance and there may be uncertainty about who carries the final responsibility.
  

Additional Messages From Individual Groups Groups 3 and 4 (Mainly Care Assistants).

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  Financial tensions may lead to a clash between profit and quality of care.
  
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  Relatives bring in 'treats', which often cause conflict, if staff perceive that these are 'bad' for diabetes.
  

Groups 5 and 6 (Domiciliary Carers).

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  Education sessions in groups would be an opportunity to network with colleagues – share ideas.
  
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  Good diabetes care relies on the timing of insulin, given before meals. We depend on the district nurse who appears when it suits her and not the patient.
  
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  Care plans should include exercise.
  
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  Patient may make food choices which are anti-diabetic.
  

Educational Needs

The groups identified their educational needs as follows:

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  Understanding diabetes and its classification.
  
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  How to carry out an in-depth diabetes assessment.
  
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  Dietary details – and the balance of dietary care (too much/too little).
  
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  Background info on diabetes and modern drugs now available.
  
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  How to carry out assessment of dementia (Kitwood model).
  
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  Training on practical person-centred dementia care.
  
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  The ideal would be to combine coherent education and care in diabetes and dementia