Reducing Variability and Improving Diabetes Care in General Practices in deprived and ethnic areas (ECLIPSE Project): A Qualitative Evaluation of Consultant-led Diabetes Virtual Community Clinics in Coventry

Aim
The aim of this study, QUAL-ECLIPSE, was to evaluate the operational activities of primary care Diabetes Specialist Consultant-led Virtual Clinics (the intervention) in deprived inner-city areas of Coventry. 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 inner-city deprived areas participating in the intervention (weekly - diabetes specialist consultant, diabetes specialist nurse and diabetes specialist dietitian - consultations) between November 2016 and October 2018, using weekly participant observations during the intervention, observations at monthly
interventionists’ team meetings and one-to-one post-intervention semi-structured interview with nineteen participants (patients, primary care clinicians and diabetes specialist interventionists). Data were analysed using thematic analysis.

Findings
Over the ten months observing the intervention, 28 ‘Diabetes Virtual Clinic’ sessions (comprising 154 consultations) and five interventionists’ team meetings were observed.
Nineteen participants [eight patients; eight primary care clinicians, comprising of five GPs and three senior practice nurses; and three interventionists (a Diabetes Specialist Consultant, Diabetes Specialist Nurse and a Diabetes Specialist Dietitian)] - participated in the post-intervention semi-structured interviews.

There was intra and inter-group variation on the perceptions of the operational activities of the Diabetes Specialist Consultant-led Virtual Clinics, involving primary care clinicians, interventionists and patients, brought together by the
first-rate value of the virtual clinics and to put this model of care into practice. The Diabetes Specialist Consultant-led Virtual Clinics were feasible: It was evident from the participant observation and primary care clinicians’ interviews that ‘high-risk’ patients with low health literacy skills found it difficult to self-manage their diabetes and reported less concordance with taking medication and developed confidence with the intervention. The ethnicity of the interventionists contributed to successful change of traditional diet, adherence to medication
for the majority of the patients from ethnic minority groups. The majority (75%) of patients interviewed, experienced practical difficulties with using the NHS Prescription Ordering Direct service, a system for repeat prescriptions; this was addressed by the specialist team. A range of innovative approaches of managing complex patients with diabetes were identified including having monthly diabetes specialist consultant-led sessions which were found to upskill primary care clinicians (GPs and senior practice nurses) in managing complex cases.
Fifteen (94%) of the primary care clinicians and patients who were interviewed, highly valued the diabetes specialist consultants and dietitians’ contributions, with 100% (n=8) of the primary care clinicians stating that the consultant-led clinic sessions helped their understanding of complex cases; enhancing their knowledge and skills. All eight patients interviewed reported enhanced self-management following the intervention, with seven stating they would like the
intervention to become part of their routine diabetes care in their local GP practice. Furthermore, three of the eight patients felt that joint diabetes sessions involving them, their primary care provider and the Diabetes Specialists helped decision-making. Psychological and peer support were suggested by the patients as areas of service improvement.

Seven of eight primary care clinicians stated they would like the intervention to be implemented at practice-level compared to referring complex diabetes cases into the hospital settings. Furthermore, the majority of primary care clinicians 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. All primary care clinicians who were interviewed reported the development of an effective working relationship with the interventionists, in particular the two diabetes specialist consultants. The primary care clinicians felt highly appreciative of the interventionists’ effort, time and expertise in making a positive impact in their service.
The Diabetes Specialist Nurse (DSN) service was predominantly used by one practice, mostly due to lack of engagement from the other practices. Joint diabetes clinic sessions involving the 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.

The interventionists had passion for their work and built positive relationships with the primary care teams. Two diabetes specialist consultants reported that although the initial engagement with GP practices was sometimes challenging, excellent working relationships with the primary care clinicians developed over time. The interventionists received complimentary feedback from their patients and in general, from the primary care clinicians. They worked well together,
upskilled the primary care staff and most importantly, made a difference to the lives of patients with diabetes at high risk of complications.

Conclusions
A Diabetes Specialist Consultant-led Virtual Community Clinic to support, stimulate and upskill primary care clinicians and empower patients to self-manage their diabetes, is feasible.
Involvement of a broad group of stakeholders in the Consultant-led clinic was perceived by the majority of primary care clinicians to improve primary care clinicians’ knowledge and skills striving for improved patient care. In order to promote innovative working approaches to minimise the delay in the treatment of diabetes patients at high risk of developing complications and to ensure prompt and effective implementation of care, a Diabetes Specialist Consultant-led Virtual Community Service is recommended. This would improve individualised patient care and support primary care clinicians. Further research with a cost-effectiveness analysis of this service is also warranted.