Sheffield has a large student population of about 50,000, attending two universities. Not surprisingly a considerable number of them have diabetes. In November 2015 the practice nurses and diabetes specialist nurses for young people were keen to help improve the service for patients. A new pathway was developed but in 2017 it was found to be suboptimal. A better option was to recreate the specialist secondary care clinic in the University GP practices. The result has been high patient satisfaction and, for those with a starting HbA1c of >58 mmol/mol, HbA1c has improved from an average of 77 to 70 mmol/mol.
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All university students are encouraged to register with a local GP and most big universities have a university health service. For the majority of those with a long-term health condition it is their first experience of being responsible for organising and collecting repeat prescriptions. They also need regular review by specialist consultants, involving either by returning to their original clinics close to the parental home, or by being referred to the nearest consultant at university. Neither option is easy. Seeing a new consultant near university means finding their way to a new hospital, navigating the hospital site, meeting new people, explaining their past medical history, and seeing people who may have a different approach to their condition. So, many students end up not getting specialist consultant care at home or university. This means poorer control, either worsening HbA1c or more problematic hypoglycaemia, and missed screening checks for retinopathy and so on. Poor control can impact on studies too, and the stress of assignment deadlines and exams adversely affects diabetes. In 2015 in Sheffield a pathway was devised to show who should be referred, and how the process worked. It aimed to streamline the process for primary and secondary care but, within 18 months it was clear it was not working for the students or the healthcare professionals.
The main issues were: referrals being sent from primary care, but students denying they had been offered an appointment; first contact with secondary care was often when the students were admitted in diabetic ketoacidosis (DKA), or with a severe hypo; a high non-attendance rate in specialist clinics; students asking whether they could be seen at their GP practice; ensuring consumables were available for those on pumps; primary care nurses and doctors being asked questions about diabetes beyond their knowledge and capability, and receiving timely guidance from secondary care colleagues. A major reason for the success of this project was using the ideas and drive of the people nearest the problem – the practice nurses and diabetes specialist nurse. They made the two GPs and consultant listen and agree to find a suitable solution. Their suggestion was to move the entire specialist clinic to the university health centres.
In January 2017 it was agreed to set up a secondary care specialist clinic within the university GP surgeries once a month, alternating between university sites. Very good glycaemic outcomes and excellent care process completion had been achieved by operating a one-stop clinic in secondary care. To ensure that the level of service would not be compromised by moving location, minimum requirements were set out: two consulting rooms, one for a doctor and another for a DSN/eye screener; all appointments to be arranged by university health staff; electronic referrals to be sent pre-clinic to the co-ordinator; DIASEND box to be used at each clinic; a Point-of-Care Testing (POCT) machine for real-time HbA1c assessment; practice nurse provision for routine measurements. The primary care colleagues successfully applied for some neighbourhood funding from the CCG so that the clinics could proceed. Eye screening services also try to coordinate their clinics with the monthly sessions. Follow-up is usually by the DSN at mutually agreed times. Within-clinic reviews are offered six- to 12-monthly. Home specialist service reviews are encouraged, but the university clinics offer a second layer of support. Some prefer to leave their home clinic and have follow-ups with the university clinic.
At the first clinic in November 2017, nobody missed an appointment and just a handful missed their appointments over the first year. The decision to continue the clinics was not difficult. The clinics and the treatment plans are as individual as the students. However, some of the issues do have common themes and will be transferable to other settings. Students reporting more hypoglycaemia, but unsure what to change are advised to decrease background insulin, as Sheffield is often much hillier and more physically demanding than home. Also, having a treatment plan for days involving more alcohol than usual is recommended. In cases where HbA1c is deteriorating, individual reviews with dieticians are offered and organised. If there is a drop-off in testing, meaning episodes of hyperglycaemia go unnoticed, a diagnostic libre is offered. If background insulin appears to be running out, switching to ultra-long versions is recommended. Higher HbA1cs are associated with higher rates of DKA, so all Type 1 patients receive blood ketone testing strips and understand sick day rules. Of 79 students seen since November 2017, 54 have had repeat HbA1cs. For those with a starting HbA1c of 58 or more their average HbA1c has fallen from 77.1 to 70.7 mmol/mol. The proportion of students achieving the target HbA1c of <58 mmol/mol has increased from 30.4% to 37.0%
Sustainability and Spread
This new model works, there is good job satisfaction, and all stakeholders are committed to continue. A young person’s coordinator provides quarterly reports on all those under 25 years and the university clinics are integrated into this process. HbA1c data and the care process are reviewed regularly. The students value the clinic; they want their diabetes to be better and travelling short distances to familiar surroundings means they can and do prioritise appointments.
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