Outcome measures and service development

July 2013

We have been encouraged for some time to try to establish a measure of the value of the work done by Dietitians. It is part of the ongoing 'modernisation' of the NHS, because we are all aware that if what we do does not appear to be of benefit (and when I write 'of benefit' what I mean is 'cost-effective') then our services will not be commissioned and we'll all be out of a job. For example, the Medicines Management people have latched on to the very low carb lifestyle as something that may help the Trust to save money because some patients with diabetes can reduce their medication, but against that must be balanced the cost of the Dietitian and Nurse time in helping them to succeed with the lifestyle.

With a surgeon or a physician it is sometimes possible to compile statistics on mortality and recovery from acute conditions; with a chronic condition like diabetes then improvement is unlikely - preventing progression is worthwhile, but difficult to measure. How can we tell whether the Dietitian made a contribution that made a patient better or saved the NHS money? Would the patient have got worse without the dietetic input? We have no way of knowing.

The Dietetics department has finally succumbed to the pressure to measure 'Outcomes', and my Dietitian colleagues and I have been trying out a set of four parameters specific to diabetes that have been proposed and are being used elsewhere. They are fairly easy to apply (although a bit of thought is needed), and we could conceivably start to record these Outcome Measures, but the next step is to find out how they will be used, and that subject will be discussed in a forthcoming meeting. It is a meeting that I will not have to attend, thankfully, but there are a number of questions that I hope will be answered - do we do this for every patient? What about those in groups? What will happen to the data that we generate - how will it be used?

There is also a change coming to the way that our services are organised, following the 'consultation' earlier in the year. It was a fairly token consultation given that the patients were not given anything like the information they would have needed to make informed choices, but if they had, most of them would have been unable to understand and process it (I am still not entirely sure what's going on - it's inordinately complicated). But the Clinical Commissioning Group (CCG) can state that it has consulted patients, and proposals for change towards an 'Integrated Diabetes Service' in the community have been made.

I have been to more than one meeting about this (I definitely don't intend to go to any more) and I still barely understand any of it. What does seem straightforward is that many people with well-managed Type 2 Diabetes should be discharged back to the care of their GPs instead of being seen by specialists such as those in the team where I work. Despite the fact that this message was delivered by the consultant who is working with the CCG on managing the change, he himself has failed to discharge any of such patients from his own clinics. So I am about 60% confident that little will change in my particular working area, but that leaves 40% of a chance that I am wrong. It's due to start in the new financial year, so we'll have to wait and see what happens then.

Not much more to say about work, although my full time hours have unofficially been extended to September. I don't yet have the paperwork to support the extension, so nothing is for certain. If it goes ahead, though, it should give me enough time to be fully certified as a DESMOND educator - an external assessor is attending my next course to provide some feedback towards my accreditation. I've also been standing in as an educator on a different course for people with Type 2 diabetes. DESMOND is for people who are newly diagnosed, but the other course is to promote the lower carb approach to people who've had diabetes for some time. It's much shorter in duration, and neither I nor the Diabetes Specialist Nurse who delivered it with me had done one of these before, so we launched ourselves at it and charged through at a gallop to make sure we squeezed everything in. Part 2 is this week, and perhaps we'll be able to moderate our speed. It was quite a ride.

If only I could tell you the details of some of my consultations! They have been particularly interesting in this post-holiday period, as people find different ways to explain how they really let things go over Christmas, but they are definitely going to get going again now. I had one afternoon when my input was more in the way of marriage guidance than dietetics; another appointment with a patient who had a lot to say and hardly gave me a chance to introduce myself. Occasionally I feel I can really make a difference with just one nugget of information.

But there are still a few patients who are baffling - their understanding of diabetes and their ways of managing it have been deeply embedded over many years, and trying to get to the bottom of what is going on can be frustrating, and sometimes futile. For these people it is a question of working within the parameters they set, and trying to find a way to ensure the best outcomes possible. Most of the time I would encourage the patient to plan just one or two small changes, although there is so much that could be done. But it is impossible to know what would have happened if I'd acted otherwise, and I do think that succeeding with one thing is better than being faced with too many challenges and not overcoming any of them.