Diabetes Specialist Nursing (DSN) Service South Gloucestershire

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1 Diabetes Specialist Nursing (DSN) Service South Gloucestershire Introduction This document introduces Sirona care & health s plan to deliver a Diabetes Specialist Nursing (DSN) Service in South Gloucestershire. This service has been commissioned by South Gloucestershire CCG as a high priority to tackle the prevalence of diabetes within South Gloucestershire. There can be complications from diabetes such as amputation, blindness, kidney failure and stroke. Early intervention has the potential for significant health benefits; identifying potential complications and treating them as early as possible will limit the impact on an individual s life. Our aim is to give those with the condition as much choice and control over its management as possible and reduce the number of crises they experience. We particularly want to reduce the need for hospital admission and help those with diabetes to live longer and healthier lives. The Proposal The DSN Service will put the individual at the very heart of everything it does; it will work with people to find the best diabetes care and treatment for them. This will be provided either through the new community based specialist service or by calling on other experts or services. We will improve education and support within the community and for community and primary care staff. The service can be accessed either directly by individuals or through a referral from healthcare professionals. The service will sit alongside Sirona care & health s community health service provision within South Gloucestershire which will mean we call on colleagues from other services, if or when they are needed, therefore providing integrated care for the individual. We will work closely with all 25 GP practices and other partner organisations in secondary care, voluntary and community sectors. We will deliver high quality care to individuals and develop strong links between healthcare professionals. We will also provide advice and support to the prison health care service as required. The design of the service will include the trial of the Consultant Link Model which means a member of the DSN service can speak to a consultant to discuss an individual s care to ensure continuity of care.

2 We will also develop new community diabetic nurse specialist routes which are easy to understand and follow for those with type 1 or type 2 diabetes. We aim to begin the service from September 2015 with recruitment starting in the summer Proposed Delivery Model Please be aware this is an outline and is subject to change This service will be available to those registered with a South Gloucestershire GP practice. The service will be available five days per week, during office hours, however we will be developing a flexible approach to meet the needs of the individuals in our care. The service will be based in the community with individuals able to contact us by telephone and this may be followed up by home visits. Individuals will be able to self-refer or be referred by their GP or healthcare professional. The DNS Service will provide routine telephone advice during office hours and, where needed, will follow up with home visits and clinics. Initially this will be during normal office hours as we develop flexibility to ensure a holistic wrap around approach to the needs of the individual. The team will be led by a senior trained prescriber. The team will be supported by Sirona care & health s head of specialist services. Our Key Aims To put the individual at the heart of the service to give them as much choice and control over the condition s management as possible. To improve education within the community and for those providing diabetes care. To reduce the number of crises an individual experiences and reduce the need for hospital admission. Provide a fully staffed DSN Service in South Gloucestershire which will work closely with all 25 GP practices. Over the longer term we aim to see an increase in Quality of Life indicators life expectancy; quality adjusted life years and a reduction in the number of health issues currently faced by those with diabetes. To reduce the need for medical intervention by improving education and support for individuals. To review and evaluate the service, implementing the lessons learnt and monitor progress. Case for change The prevalence of diabetes is growing rapidly and is forecast to continue increasing in the coming decades. A DSN Service will contribute significantly to both improving the health of individuals and reducing the number of hospital admissions. We believe with sufficient and well organised resources in the community, treatment and support can be provided effectively in a planned way. This, coupled with education and the opportunity to integrate

3 with other services, will improve the service for those with the condition as well as strengthening links between those providing care. Benefits Improved quality of life for individuals A reduction in the number of admissions to hospital. Improved monitoring of individuals. A reduction in medical intervention for individuals through education and support for lifestyle changes. What will success look like? Success will be a community DSN service which is fully integrated into the community health provision within South Gloucestershire with seamless links with healthcare professionals working with GP practices and hospitals, voluntary and community sectors. The service will be led by a trained senior prescriber with a team of specialists and admin support. New community diabetic nurse specialist routes for those with type 1 or type 2 diabetes will be developed. Education and support will be improved and individuals will feel they have as much control and choice on the management of the condition as possible. Timescales The service is due to go live in September The service will be continually reviewed and lessons learned implemented to continually improve the service. Patient and Public Involvement (PPI) South Gloucestershire CCG and Sirona care & health are committed to PPI being at the heart of its work. We will continue to listen and act on the feedback from individuals and their families and carers at all stages of the cycle because of the value of providing services which are informed by the experiences and aspirations of local people. There is a Patient and Public Involvement and Communications Plan for this new service, which sets out in greater detail the intentions to involve and engage patients and public. In summary the aims are: To ensure that the views and experiences of individuals, families and carers and the public across South Gloucestershire influence the Diabetes Specialist Nurse Service To address variation in standards of care To deliver high quality care To use individual experience as a driver for continual improvement of services.

4 To ensure that the Diabetes Specialist Nurse Service South Gloucestershire is always focused on the individual. To ensure that all sections of the populations within South Gloucestershire have the opportunity to influence and comment upon the Diabetes Specialist Nurse Service. To provide timely feedback on engagement describing who we engaged, what we heard, and how the feedback has influenced the work. To ensure that people have a good understanding of the Diabetes Specialist Nurse Service South Gloucestershire, where it is in operation, how people can use it and what people can expect from it. To ensure that any learning takes account of the views of patients and the public. Research Throughout our engagement online and face-to-face we will be using the following questions: Diabetes Nursing Specialist Service South Gloucestershire - Survey Thank you for taking the time to help Sirona care & health with our plans for changing the way we provide care and support for people with diabetes in South Gloucestershire. Our aim is to give greater control and choice to people who have diabetes and we value your thoughts on whether this new service will meet that aim. Before you answer the following questions, please read the information on Diabetes Nursing Specialist Service South Gloucestershire. This tells you about Sirona s new service for people with diabetes, which we will launch in the autumn. Your answers will help us to understand if there are any ways we could change these plans to make them even better. Answer as many questions as you can. 1. Please answer yes, no, not sure to each of these statements a. I have diabetes b. I am a carer/relative/friend of a person who has diabetes c. I am a healthcare professional d. I am a member of the public e. I live or work mainly in South Gloucestershire 2. Having read about the new Diabetes Nursing Specialist Service South Gloucestershire, please could you tell us of any suggestions you have for making the proposed new service even better? 3. What difference(s) do you think the new service might make to you, or to the lives of people who have diabetes? 4. Will this new service give you, or people with diabetes, better choice and control than you, or they, currently have? a. Yes/no

5 b. Please explain how. 5. What s the best way to give you, or people with diabetes in South Gloucestershire, information about this new service? Tick as many as you wish. a. Leaflets in public places (eg. GPs surgery, community centres) b. Face to face c. Internet (eg. Sirona s website) d. Social media (eg. Facebook, Twitter) e. Personal letter f. Local media (eg. newspapers, radio) g. Telephone call h. Other i. Please state 6. Would you like to be involved in helping improve the service once is starts? If you would, please add your details, and we will get in touch with you. Thank you. a. Name b. Address (optional) c. Telephone d. (optional) 7. Is there anything else you would like to add, ask or comment on? Thank you very much for your answers. Sirona care & health is grateful to you for helping us develop our new diabetes service. Equalities An equality impact assessment will be undertaken to inform who we should be continuing to involve in this project, and to identify any potential negative implications of the implementation on particular groups, and any mitigation required. This will be undertaken by the commissioners with support from the Sirona care & health s PPI team. The public sector equality duties outline how South Gloucestershire CCG as a public body must, in the exercise of its functions, have due regard for the need to: (a) eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010; (b) advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it; (c) foster good relations between persons who share a relevant protected characteristic and persons who do not share it. How you can get involved:

6 Complete the online survey ( Diabetes Nursing Specialist Service South Gloucestershire Survey ) at Also, please visit our website follow us on us via or write to us at the following address: Martha Cox Service User Involvement Quality and Business Development Team Sirona care & health St Martin s Hospital Clara Cross Lane Bath BA2 5RP

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