Public health is concerned with, reducing health inequality minimising health risks and improving the health status of populations’ (Brocklehurst, 2004). Wanless (2004, p23), defines public health as, ‘The Science and art of preventing disease, prolonging life and promoting health through organised efforts and informed choice of society, organisations public and private, communities and individuals”.
Throughout this paper the author will critically discuss the effectiveness of policies frameworks and assessment tools, used in public health disease management; in relation to the prevention and management of adults at risk of or with type two Diabetes Mellitus (DM) in the United Kingdom (UK). The Author will consider how environmental, epidemiological and demographic data can be used to highlight the underlying social determinants of a population’s health, influencing policy making, and public health frameworks.
Key issues to arise at local level following strategic plans to reflect government policy will be identified, and the role of the nurse and Multi Disciplinary Team (MDT) in implementing such policies will be examined. Within this strategy’s employed in the authors’ local area will be identified. The focus will then turn to empowerment, and the effectiveness of nursing frameworks and assessment tool, used to enable individuals and groups to become responsible for their own health.
Type 2 DM occurs when the body ceases to produce adequate levels of insulin, and or when the action of the insulin that is produced becomes less affective; this is termed insulin resistant (Becker, 2003). It is most prevalent in ethnic minorities and older age however, there is a growing number of younger people and children developing DM (Roberts, 2007). Another factor that may increase an individual’s susceptibility to DM is mental illness, in particular depression and schizophrenia (Holt, 2005).
There are numerous underlying reasons for the growing prevalence of DM in the UK including, industrialisation and urbanisation leading to changes in lifestyle and eating habits (Helms, et al 2003). The results of these changes can be seen in the escalating level of obesity within the UK. In 2006 twenty-four percent of adults and sixteen percent of children, aged between two and fifteen, were classed as obese. A dramatic rise when compared to, fifteen percent of adults in 1993 and eleven percent of children in 1995 (National Statistics, 2008).
Diabetes and obesity are closely linked; eighty percent of patients that are diagnosed with diabetes are obese at time of diagnosis (Diabetes UK, 2006). Policies that have been implemented to reverse this trend include the five a day program, and the school fruit and vegetable scheme. These policies were introduced following recommendations outlined in the white paper Choosing Health (DoH, 2004a) and aims to raise the consumption of fruit and vegetables by raising awareness and increasing accessibility.
In 2006, front of pack signpost food labelling was also proposed by the Food Standards Agency (FSA), to reduce poor dietary intake by providing clear, easy to understand information concerning the nutritional content of food. The FSA also recommends that a traffic light system is used to denote low medium and high levels of fat, saturated fat, sugars and salt in food (FSA, 2007). However, these recommendations are not compulsory or consistent, and although it has been supported by a number of major supermarkets and retailers, many have individual hybrids of this system, which may cause confusion.
Furthermore, the information shown is often only accessible to those able to read English, meaning that a large proportion of the public may fail to benefit due to the presentation of the information. In addition to this, the list of participating supermarkets provided by the FSA seems to suggest that the scheme has not been adopted by the majority of budget supermarkets, meaning that it may fail to impact on lower socioeconomic groups (FSA, 2007).
There is a strongly association between lower socioeconomic groups and increased levels of obesity, this is thought to be due to, poor diet and low levels of physical activity. In addition to this, there are also increased levels of smoking and poor blood pressure control in lower socioeconomic groups; all of which contribute to the onset of DM, creating inequalities. Meaning that within the UK the most deprived are 2. 5 times more likely to develop DM, and at a 3. 5 times increased risk of developing severe complications such as heart disease, stroke and kidney damage. Diabetes UK, 2006) The Saint Vincent’s declaration (1989) was the first major move towards reform within DM services, recognising that diabetes is a massive and growing public health concern throughout Europe. The declaration resulted in the setting of five year targets to achieve reform at European, government and local levels. Reform within the UK began much later than this, with the National Health Service (NHS) plan in 2000, which aimed to modernise services, rise standards, tackle under funding and make a shift towards patient centred care (DoH, 2000).
One of the key strategies to emerge from the NHS plan was the introduction of National Service Frameworks (NSF) in 2001. NSF’s provide national standards to reduce variations in care (Dimond, 2008). The NSF for DM (2001) set out a ten year agenda, based on twelve standards, covering all aspects of DM care and prevention. To improve standards, increase quality and reduce inequalities; with the aim of reducing the cost to individuals, the NHS and society, by reducing incidence and complications (DoH, 2001) this was supported by a delivery strategy in 2003 (DoH, 2003).
The government did initially face some criticism regarding funding when the NSF was published, as although it did offer funding for retinal screening no other finical support was initiated (Cavan, 2005). This was addressed in 2004, with the introduction of General Medical Service. A fundamental component of this is the Quality Outcome Framework (QOF) which offers financial reward for target attainment. Numerous aspects of the QOF support the NSF for Diabetes for example, the maintaining of a practise based register.
However, it is important to note that participation in the QOF is voluntary (NHS, 2004). In 2001 when the NSF was published there were 2,002,000 people living with diabetes in the UK (Forouhi et al, 2006). This figure has now increased to 2,321,532 (Diabetes UK, 2007). However, this is not necessarily an indication that the strategies implemented following the introduction of the NSF are failing. The increase may be related to increasing longevity. Life expectancy at birth in the UK has risen from 71. in males, and 77. 6 in females, born between 1984-86 to 76. 9 and 81. 3 respectively in those born 2004-06 (National Statistics, 2007). Which may be significant when considered in relation to the fact that the incidence of DM significantly increases with age (Diabetes UK, 2006). The implementation of the NSF has also seen an increase in local screening strategies, which could go some way to accounting for a rise in the number of people gaining diagnosis.
It was estimated that in 2001 there was 1,000,000 Undiagnosed cases of DM in the UK (Day, 2001) this is now thought to have fallen to 60,000 (Holt et al, 2008). The implementation of such plans and reform has resulted in radical change to the philosophy of care, signalling a move away from the traditional didactic approach with patients viewed as passive consumers of care, to patient centred care, with an emphasis on empowering patients to self manage their diabetes and make informed decisions regarding the care received (Vile, 2004).
Key issues that have emerged from the implementation of local strategic plans to improve the health and well being of communities include, the need for structured patient education, the development of lifestyle management and obesity strategies, one stop clinics allowing multiple health issues to be addressed simultaneously, improvements in screening services for diabetes and its complications, and the recruitment and training for health care professionals (Dr Foster & Diabetes UK & Diabetes UK, 2004).
These issues have been addressed at local level across the UK by proactive strategies to identify at risk groups, reduce this risk and monitor health status. Community nurses now take an opportunistic approach when meeting patients, carrying out individual holistic assessments to identify those with multiple risk factors, enabling early intervention, educating and screening (Dr Foster & Diabetes UK, 2004).
Diabetes care is increasingly moving into a primary care setting, resulting in the formation of integrated diabetes networks facilitating MDT involvement with nurses, school nurses, health visitors, district nurses, dieticians, opticians, podiatrist, physiologists and general practitioners working together in a collaborative way to effectively manage care. Farooqi et al (2004), identified inconsistencies in the range and quality of services provided between different practices.
Mould et al (2008), also highlighted significant variations in diabetes care across different practises and proposed that this may be due to differing levels of recourses and demand; suggesting that the quality of care a patient receives is very much linked to where they receive it creating inconsistency and inequality across the UK. In addition to opportunistic assessment, nurses and health care professionals now engage with communities to identify the characteristics of the community, by community profiling.
A process involving the collaboration of community members and service providers in order to discover and distinguish the needs and wants of the community, and some common or potential barriers to accessing services (Jack & Holt, 2008). Enabling services to be tailored to meet the needs of the community and empowering patients to partake in planning, to ensure ease of access and encourage up take of services (Earle, 2007).
When identifying the need within a community the nurse will need to utilise demographic, environmental, and epidemiological dater to identify the characteristics of the community, this will also highlight factors that may be contributing to the underlying social determinants of health (Hitchcock et al, 2003). Areas with a large elderly population for example will have different needs and require different services to those with high ethnic population.
Stone et al (2005) highlights the importance of cultural sensitivity when designing diabetes services and cites preferences in gender specific group sessions as more appropriate in some cultures. Community profiling also facilitate, the identification of populations that may require specialist services such as, travellers, asylum seekers, the homeless, those with learning difficulties, the elderly, individuals living in rural or isolated areas, residential care settings and prisons (Jack & Holt, 2008).
Nurses will need to take a problem solving approach to supporting hard to reach and vulnerable groups for example; nurses could deliver support outside of the traditional setting where vulnerable groups may be unwilling or unable to access services into areas where particular groups meet regularly such as community centres (Croghan, 2005). Or provide education regarding diabetes its management and complications to staff working in residential care homes and prisons. The adequate provision of care for adults with chronic diseases is a central aspect of the community matrons’ role (Boyden ; Edwards, 2007).
Masterson (2007), suggest that community matrons play a key role in managing the complex need of the most vulnerable supporting patients in a holistic way and identifying there physical, emotional, social and spiritual needs; to achieve positive health outcomes and successful self management. However, diabetes UK Suggest that the needs of these vulnerable groups are still not adequately met despite the reform in services (Diabetes UK, 2006). The authors local area is relatively deprived (DoH, 2006a). The recorded incidence of diabetes is 4. % considerably higher the UK recorded prevalence of 3. 55% (QOF Database, 2005/6). This may be partially due to the fact that obesity, the number of people with mental health problems, and the number of people living on low income and unemployment are all higher than the average for England (DoH, 2007a). However, this has been recognised by the local authority and strategies have been implemented in conjunction with government initiatives to raise diabetes awareness, encourage healthy eating and physical activity and increase patient education (Singleton 2006).
Local schemes include, change for life, a gender specific weight management course for women, and Waist watches which targets men, taking health education and weight management into areas including workplaces and Miners Welfare Clubs, in an attempt to target men typically thought of as hard to reach (Derbyshire County PCT 2008 a). These initiatives are supported by the Derby and Derbyshire strategic framework for obesity 2007-10 (Derby and Derbyshire County PCT, 2006).
This framework also sets guidance for reducing obesity in children recommending that all schools provide opportunities for children to increase physical activity and develop healthy eating habits. These recommendations are supported by NSF for children (DoH, 2004b). It is hoped that such strategies will reduce the prevalence of obesity and its complications such as diabetes, by targeting children to develop healthier lifestyles and perhaps encourage parents to follow their example.
Alongside this the department of health published The National Child Measurement Program in 2005, which requires school nurses to weigh and measure all four to five year olds and ten to eleven year olds annually, facilitating the evaluation of obesity reduction strategies and monitor prevalence (DoH, 2005). The big blue bus mobile healthy living centre, a collaboration that started in 2003 between Derbyshire County Primary Care Trust (PCT) and sure start provided a range of services including health promotion, smoking cessation, blood pressure monitoring and health screening at the point of need in the eight most deprived wards of the area.
However, as of March 2008 this scheme was discontinued due to lack of funding. Although the PCT is assessing how these services may be provided in other community settings, no replacement services have currently been implemented (Derbyshire County PCT 2008 b). Other scheme that have been adopted locally include the expert patient program, enabling people to become more involved in self management of long term conditions such as diabetes and Rapid response nursing service, available to people with diabetes on a twenty-four hour basis to support people in their own home and reduce the number of hospital admissions (Derbyshire County PCT, 2007).
All of which has seen community nurses becoming more involved in providing health education, information and support outside of the traditional setting. Meeting the need of the community and reducing health inequalities by empowering people to become responsible for their own health. Standard three of the NSF for diabetes relates to empowerment the author will now focus on role of the community nurse and MDT in implementing this standard; exploring strategies that may be employed to empower individuals and groups to be responsible for their own health.
Empowerment is the process of supporting individuals to gain the skills, knowledge and confidence they need to make informed decisions regarding the treatment and management of their condition, allowing the patient to take grater control of their health (Nadoo ; Wills, 2005). This can be achieved by care planning; a process that involves the health professional and the patient working together to plan the most appropriate course of action to achieve the best health outcome, taking into account the patients cultural and religious beliefs, personal preferences and social circumstances’.
Care plans also provide a structured framework allowing the health care professional to assess, plan, implement and evaluate care. Care planning was cited by the NSF delivery strategy, as “at the heart of a partnership approach to care and a central part of effective care management” (DoH, 2003 p21). Care planning is an ongoing process, which should begin at time of diagnosis and involve management strategies and goal setting.
Nurses also need to offer patients support and information regarding the implications and complications of DM and the benefits of appropriate lifestyle change and monitoring, to reduce anxiety and the risk of complications (Selby, 2004). The White Paper Our Health, Our Care, Our Say (DoH, 2006b) states that all diabetic patients should have a personal care plan by 2010 but, in 2004 only 41% of PCT had care plan protocols in place (Dr Foster & Diabetes UK, 2004).
In addition to this in 2007 the healthcare commission identified continuing weaknesses in involving diabetic patients in their own care (Healthcare Commission, 2007). All information given at time of diagnosis should be supported by relevant literature and information, provided in an appropriate format and language concerning diabetes services and local support groups. The nurse will also make referral to podiatrist, optometrist, dieticians and other members of the diabetes specialist team where necessary (Brooker & Nicol, 2003).
The Department of Health has recommended that, the planning of care is combined with structured education empowering patients to respond to changes in there condition, enabling effective self care (DoH, 2006c). The National Institute of Clinical Excellence (NICE) recommends that, “structured patient education is made available to all people with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need” (NICE, 2003 p4).
Due to lack of evidence regarding patient education NICE did not recommend any specific program however, key criteria was recommended. The Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) is the first educational programme to meet these criteria providing group education and empowering people to self manage their DM (Roberts, 2007). This approach would seem to be the key to reducing the long term complications of DM however, Diabetes UK, identified that only 73% of pct had structured education in place that adhered to NICE guidelines (Dr Foster & Diabetes UK, 2004).
Furthermore in 2007 the Department of Health identified knowledge deficit with regards to medication and the timing of administration, an area that if addressed could clearly reduce long term complications and inequality (DoH 2007b). Especially when coincided in relation to the fact that on average patients spend, 8758 hours per year managing their condition independently and only three with health care professionals (DoH, 2002).
Managing diabetes can be extremely demanding all members of the diabetic care team will need to support patients in making lifestyle changes, which may include smoking cessation, weight management, changes in levels of physical activity and diet. Promoting a healthy lifestyle is key to implementing government strategies such as, Choosing Health Making Healthy Choices Easier (DoH, 2004a), and is supported by The Nursing and midwifery council who state that “you must promote the interests of patients and clients” (NMC, 2004, p4). It is imperative that the nurse utilises an appropriate model to support patients through behaviour change.
Beckers (1974) health belief model states that in order to make and maintain change people must feel that the change is feasible and that the benefits of the new behaviour outweigh the costs (Tones & Green, 2004). However, this model does not account for habitual behaviours, meaning that it may not be appropriate for all diabetic patient (Harari & Legge, 2001). One model that has proved to be particularly effective in changing habitual behaviours especially smoking is Prochaska and DiClemente, (1984) Transtheoretical Stages of Change Model; as relapse is accounted for.
However, the nurse may need to utilise different aspect of several models in order to take a holistic view and tailor interventions to meet the needs of the individual. Regardless of the model used the nurse will need to assess the individuals readiness to change, plan in-collaboration with patients the strategies that will result in effective behaviour change, taking into account the patients personal and social circumstances and barriers to change, support the patient in implementing the agreed strategies and evaluate the effectiveness each intervention (NICE, 2007).
Throughout this process it is imperative that the nurse remains non-judgemental and respects the patients’ autonomy accepting that patients may make an informed decision to continue with health damaging behaviours (Holland, 2007). In conclusion the author has discussed the effectiveness of policies, frameworks, and assessment tools, used in public health disease management, in relation to the management of adults with or at risk of DM in the UK.
The author has highlighted how epidemiological environmental and demographic data can be utilised at both national and local level to identify the underlying social determinants of a population’s health and identify vulnerable, at risk, and hard to reach groups allowing policies to be targeted appropriately. After reviewing government policy and local strategies it would appear that public health frameworks provide structure to and improved diabetes care.
However, it would seem that although funding has been addressed there is still under funding issues and inconsistency in care across the UK. The role of the nurse and the MDT in the implementation of national standards is crucial and education, care planning and health promotion have emerged as key to reducing prevalence, complications and empowering patients to become responsible for managing their own health but this self care message should be delivered in a non-judgmental way which supports an individuals autonomy.
It is also important to note that the successes of all of the policies, frameworks, and assessment tools discussed lays with the skill of the professional with regards delivery and there ability to provide care outside of the traditional setting to target specific groups within communities. In the Authors opinion the evidence seems to suggest that despite major reforms in services there is still some way to go to adequately address and reduce inequalities within the UK.