Over 2 million people in the UK are known to have diabetes and it is estimated that a further 750,000 have the disease without being aware of it. Diabetes is a condition in which the amount of glucose in the blood is too high due to a lack of, or resistance to, insulin.
The symptoms of diabetes include increased thirst, going to the toilet frequently, extreme tiredness, weight loss, blurred vision and slow healing of wounds. Although diabetes cannot be cured, it can be treated very successfully by medication and changes to diet and lifestyle. This reduces the chance of developing serious health problems.
The development of leaders in healthcare is integral to improving the quality of care for patients in areas such as diabetes. However, where traditional leadership training focuses on the individual, it is increasingly accepted that all team members need to be involved if lasting improvements are to be made. The Health Foundation's Shared Leadership for Change scheme is based on the principle that teams work together more effectively if all team members assert their individual leadership qualities. Through this approach, we aim to create lasting improvements in the care of diabetes patients.
The patient’s perspective
The successful treatment of diabetes cannot happen without the full engagement of the patient. This is why each of the Shared Leadership for Change teams includes a patient. Gerry Shapiro is the patient representative on the Lothian team. He believes that there are inherent cultural differences between patients and healthcare professionals, which the scheme needed to address.
“It was necessary for the members of those two groups to appreciate the traditional behaviour patterns to which they reverted and to develop more constructive alternatives,” Gerry explains. “By having an impartial facilitator for the group, we were able to have ineffective interactions brought to our attention and to respond to them more effectively.”
In order to work together successfully, the Lothian group developed tools such as better minuting of meetings and 360 degree evaluations, in which members of the group commented anonymously on the behaviour of other members. “We learned a lot about our strengths and weaknesses and were assisted to become more effective, both within the group and in our interactions with the wider world of patients and healthcare professionals,” Gerry says.
Eye on the ball
Ultimately, the purpose of the project was to improve services for patients and a key role for Gerry was in keeping the group focused on this. “My role as a patient was to help the professionals appreciate the extent to which we were responding culturally to the goal of providing a patient-centred, patient-responsible service,” he says. “We needed to move away from the more consultant-centred attitude that traditionally exists in the UK.”
One of things the team did was arrange for GPs and consultants to meet with their staff and review patient lists to ensure the care pathway was as effective as it could be. Through this, the team designed a new pathway that they hope will become a key tool for professionals to see how care should be delivered.
One of the key areas that Gerry’s team worked on before Shared Leadership for Change was the redesign of eye care services for diabetes patients. “Three years ago, in my particular area, diabetic retinopathy, including eye measurements and digital photographs, were only being done locally,” Gerry explains. “The results depended on which centre you went to and there was no central quality assurance. Some of it was very good, but some of it was more mediocre.”To address this problem, the team managed the move to a more centralised system. This proved challenging, with issues around computer software and communications, but the quality of information provided to patients has improved substantially. “We’re still in the transition period but there is now a central appointment making scheme and central quality assurance, which is superb,” Gerry says. “I recently had an eye test via the new system. The amount of information I gained and the improvement in the quality of reporting was amazing. There have been really significant improvements made.”
More work remains to be done but the team are clear about where the problems lie. “The weakness is that we don’t have an integrated communication system between the local service providers,” Gerry says. “A lot of extra work has to be done but we have clarified that this is a weak point in the system and that greater care has to be taken in communicating because of the distribution of responsibility.”
Moving forward
Through their participation in the Shared Leadership for Change scheme, the Lothian team have learned skills and team working techniques which they plan to continue using. Gerry has also benefited personally from the scheme, becoming more politically sensitised and proactive.
“I’ve emphasised among our diabetes patient group the need to take responsibility for becoming more active and have tried to get as many patient representatives as possible participating in the various committees and discussion groups,” he says. “I’m also getting involved with patient groups which are concerned with other aspects of NHS quality, in areas other than diabetes.”
The GP’s view
Dr Clare Davidson is the lead GP for the Newham team. She says that the team was encouraged to take part in Shared Leadership for Change by their Director of Public Health. “We have lots of different units in our diabetes services that were performing well but it sometimes felt as though we were all coming at it from different angles,” she explains. “Patients were getting good care in different places but sometimes they were falling between the stalls. So it seemed like a good opportunity to take some time out and develop a joined-up vision of the best way to approach the problem.”
As in Lothian, the Newham team focused on more effective team working across professions and disciplines. “We spent approximately a day a month having time out and the facilitator used a variety of techniques during that time,” Clare says. “Sometimes it was about individual assessment and profiling, sometimes it was looking at the team and sometimes it was looking at the service itself and where there were issues that needed to be addressed.”
One of the main challenges for the team was moving away from a culture where people came to meetings with their own agenda to negotiate on behalf of their particular professional group or organisation. “The facilitator always brought us back to the purpose of the network, which was to improve patient care,” Clare says. “We learnt how to identify and use each other’s skills and to step back and look at issues over the whole service, rather than within professional groups or organisations.”
Stop breaking down
One of the problems the team tackled was that some services needed by diabetes patients in Newham, including renal care and retinal eye care, took place outside the borough. This could lead to a gap in care after they were discharged. “There were sometimes problems when patients were admitted for care under the vascular surgeons at the local teaching hospital,” Clare comments. “The hospital would discharge them but the local podiatry team, who like to keep a close eye on those patients because they’re high risk, weren’t always informed. It was about trying to get better communication in that part of the pathway.”
To address this problem, the team has improved information transfer between the different units around admission and discharge. Ultimately, they hope to set up an intensive therapy ‘one stop shop’ for patients with complex needs. “We did a joint presentation to the senior management of the primary care trust and the local acute trust,” Clare comments. “We realised that if you have a team of senior clinicians across both units and the professional groups, all saying the same thing, that’s actually very powerful.”
“The consultant and I have also met with the local MP who covers the patch where we think the centre should be based, judging by our public health data,” she continues. “It’s a big project that would involve strategy plans and agreement from North East London-wide commissioning but we think it will happen sooner rather than later, because we’re all agreed and lobbying for it.”
Spreading the net
Clare is keen to spread the learning from Shared Leadership for change beyond the borough boundaries of Newham. She recently went to the House of Commons with Diabetes UK to persuade MPs of the need to redesign diabetes services across the UK. “I think the national strategy for diabetes has been very divisive within healthcare professions, particularly between diabetologists and primary care,” she comments. “I was very upbeat about sharing the work that we’ve done with The Health Foundation to break down those barriers.”
“You’ve got to have cooperative working, otherwise the patient experience could suffer,” Clare continues. “My concern is that at the moment the incentive is for primary care to hold onto patients, even when it’s not in the patient’s best interest. Through Shared Leadership for Change, the local hospital consultant and I understand each other a lot better. It can be difficult in the current climate but ultimately we’re both interested in improving the patient experience and pathway.”
05 November 2007