Primary healthcare teams with a diabetes nurse is a solution

Trond Geir Jenssen, Beryll Kristensen, Inger Uglenes, Lill Sverresdatter Larsen, Bjørnar Allgot About the authors
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The prevalence of diabetes is increasing in Norway. We believe that primary healthcare teams consisting of a doctor, a diabetes specialist nurse and a medical secretary are a suitable response to this challenge in general practice.

New data show that the prevalence of diabetes, especially type 2, is increasing in Norway (1). Approximately 350 000 people have diabetes, most of whom have type 2. This trend can be expected to continue, given the increasing bodyweight and ageing of the population.

Good treatment of diabetes requires follow-up of blood sugar levels, blood pressure, lipids and findings in urine tests to avoid sequelae (micro- and macrovascular), that affect more than one-half of persons with type 2 diabetes (2, 3). Recent figures from the Swedish diabetes register show that complications and sickness absence caused by diabetes give rise to costs of SEK 20 000 per person with type 2 diabetes per year (3). The symptoms and afflictions caused by the disease in each patient are equally important.

Persons with type 2 diabetes shall primarily be followed up by primary healthcare services, in practice the general practitioner (GP) (4). Diabetes is not treated only with drugs. Type 2 diabetes requires patients to be knowledgeable about their own disease, not least regarding how to cope with it. In addition to good monitoring of their diabetes, the patient should also be able to have a good quality of life. The GPs are doing a good job within the prevailing framework. However, there are 8 760 hours in the year, and an average diabetes patient has up to four consultations, each lasting 20–30 minutes, per year. In other words, the patient spends 1.5–2.0 hours per year in the GP’s surgery; for the remaining hours of the year, he or she must cope with the situation alone.

Care for patients with chronic diseases was the background for the Norwegian Directorate of Health’s launch of a pilot project for primary healthcare teams in 2018, based on Report no. 26 to the Storting (2014–2015). The project started on 1 April 2018 in 13 GP practices, and the number of practices was further increased in 2019. Primary healthcare teams are limited to include doctors, nurses and medical secretaries in GP practices. The team is headed by the doctor.

In other words, the patient spends 1.5–2.0 hours per year in the GP’s surgery; for the remaining hours of the year, he or she must cope with the situation alone

Austevoll medical centre provides a good example. In 2018, the centre established a primary healthcare team consisting of five GPs, six nurses (whereof one is a diabetes specialist nurse) and two medical secretaries. All patients with type 2 diabetes are invited for an annual check-up, as stipulated in the guidelines (4), and more frequently as needed, alternatively a home visit is made to frail patients. Before the consultation, the doctor and the nurse coordinate between themselves. During the consultation, the diabetes specialist nurse undertakes practical procedures as part of the check-up (blood pressure measurement, monofilament test, referral to START training courses etc.). The consultation lasts for 40–60 minutes. In addition, the diabetes specialist nurse has monthly meetings with the physiotherapist, occupational therapist and the community nursing service. Feedback from primary healthcare teams in Norway indicates that when the patient is also monitored by a nurse, the users (patients) feel safer and there is more continuity in the follow-up (5).

In both primary healthcare teams and larger medical centres, employing a nurse with a specialisation in diabetes care will enhance service quality. The diabetes specialist nurse has advanced skills in diabetes care and can assist the doctor in providing adapted guidance, training and follow-up to patients (and their relatives). Lifestyle change is a key element in the treatment of diabetes. The diabetes specialist nurse has both knowledge and time to assist in providing guidance and can thus free up the doctor’s time for other tasks. Together they can ensure compliance with national guidelines and help achieve treatment goals.

The diabetes specialist nurse has advanced skills in diabetes care and can assist the doctor in providing adapted guidance, training and follow-up to patients (and their relatives)

The action plan ‘Fra kunnskap til handling’ [‘From knowledge to action’] (2008–2013) from Northern Norway Health Authority says the following about the diabetes specialist nurse (6): ‘In the team, the diabetes specialist nurse is the one to pull the strings and hold responsibility for coordinating the services provided to the patient.’

No overview is available of the number of municipalities and/or medical centres in Norway that have a diabetes specialist nurse among their staff, but we have some indication. As a result of the Northern Norway Regional Health Authority’s diabetes initiative, the region currently has 24 municipal and private medical centres with a dedicated diabetes specialist nurse (Elin Røst, diabetes coordinator, Nordland Hospital Trust, Northern Norway Regional Health Authority, personal communication). In the other health regions, which have a far larger population than Northern Norway, the number is far smaller and virtually absent. Why is this so? A good step towards bringing diabetes specialist nurses to more medical centres would be to include them in the services that are subject to reimbursement, as is the case in the specialist health service.

Judging from the study from the Swedish diabetes register (3), complications from type 2 diabetes cost Norwegian society approximately NOK 7 billion per year in hospital costs and sickness absence alone. In other words, there is no doubt that good diabetes treatment is not only cost-effective in socio-economic terms; it also enhances quality of life and adds years to life expectancy.

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