A Qualitative Evaluation of Consultant-led Diabetes Virtual Community Clinics in Coventry (QUAL-ECLIPSE)

Background and aims
Managing diabetes within healthcare budgets in an ageing and multimorbid population is challenging providers globally. Deprivation and multi­cultural communities in inner city practices add to these challenges for primary care teams. Coventry is a medium-sized ethnically-diverse UK city where low health literacy and language barriers hamper access to diabetes care, leading to poorer self-management. This study aimed to explore the operational activities of Diabetes Specialist Consultant-led Virtual Clinics (the intervention) in deprived inner-city areas. The feasibility of this service and identification of innovative approaches to managing people with diabetes at high risk of developing complications, were also studied.

Methods
A qualitative evaluation was undertaken in seven general practices in Coventry participating in the intervention (weekly diabetes specialist consultant, diabetes specialist nurse and diabetes specialist dietitian sessions) between November 2016 and October 2017, using weekly participant observations, monthly interventionists’ team meetings and one-to-one post-intervention semi-structured interview with nineteen participants. Data were analysed using thematic analysis.

Results
Over the ten months intervention period, 28 Diabetes Virtual Clinic sessions (comprising 154 consultations) and five interventionists’ team meetings were observed. Nineteen participants (eight patients; eight primary care clinicians [5 General Practitioners and 3 senior practice nurses]; and 3 interventionists [a Diabetes Specialist Consultant, Diabetes Specialist Nurse and a Diabetes Specialist Dietitian]) were interviewed. There was intra and inter-group variation on the perceptions of the operational activities of the Diabetes Specialist Consultant-led Virtual Clinics. The virtual clinics were feasible: Fifteen (94%) of interviewed primary care clinicians and patients valued the Diabetes Specialist Consultants’ and Dietitian’s contributions, with 100% (n=8) of the primary care clinicians stating that the Consultant-led sessions helped primary care clinicians’ understanding of complex cases; enhancing their knowledge and skills. Seven (88%) of the primary care clinicians stated they would prefer the Diabetes Specialist Consultant-led Virtual Clinics service to be implemented at practice-level compared to referring complex diabetes cases into the hospital setting. All eight patients interviewed, reported enhanced self-management post-intervention, with seven stating they would like the intervention to become part of their routine diabetes care in their practice. Seven of the primary care clinicians (88%) valued the ECLIPSE database (a system to identify patients at high risk of diabetes complications) and sought integration of this database into the EMIS system currently used by general practices.

Joint diabetes clinic sessions involving the Diabetes Specialist Nurse (DSN) and practice nurse were not often valued by the primary care clinicians; the DSN therefore often worked independently and not with the practice nurse due to a lack of nursing manpower in the practice.
Patients with low health literacy skills still found it difficult to self-manage their diabetes and reported less concordance with taking medication. The majority (75%) of patients experienced difficulty with using the National Health Service (NHS) Prescription Ordering Direct service, a system for repeat prescriptions. A range of innovative approaches of managing patients with diabetes at risk of developing complications were identified. They included:
• Additional psychological support and also peer support from other patients with diabetes
• Joint diabetes sessions involving them, their primary care provider and the Diabetes Specialists to facilitate decision-making.
• The clinicians suggested a routine monthly Diabetes Specialist Consultant-led Virtual Community Service, integration of databases, an on-call service with a diabetes specialist and specialist clinical workshops.

Conclusions
A Diabetes Specialist Consultant-led Virtual Community Clinic supported, stimulated and upskilled primary care clinicians and empowered patients to self-manage. A randomised control trial and a cost-effectiveness analysis of the service are warranted.