Implementing structured education: time to act for primary care trusts

Journal of Diabetes Nursing, March, 2006 by Gwen Hall

In 2003 the National Institute for Health and Clinical Excellence (NICE; formerly the National Institute for Clinical Excellence) published guidance on patient education models for diabetes through Technology Appraisal 60 (NICE, 2003). Normally Technology Appraisals are accompanied by a directive to provide funding to carry them out. In this case the funding directive was waived in favour of development of local schemes. In 2005 an influential working group published a new report on patient education (Department of Health [DoH], 2005b). A press release in June of that year heralded the report, reinstated the Technology Appraisal and directed that primary care trusts needed to allocate funds to provide structured patient education for people with diabetes from January 2006 (DoH, 2005c). Two national programmes met the report's criteria for structured patient education: Dose Adjustment for Normal Eating (DAFNE; Table 1) and Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND; Table 2). There are other local programmes in various stages of development.

The National Institute for Health and Clinical Excellence (NICE; formerly the National Institute for Clinical Excellence) Technology Appraisal on patient education models for diabetes (Technology Appraisal 60; NICE, 2003) defines structured patient education as:

   'a planned and graded programme that is comprehensive in scope,   flexible in content, responsive to an individual's clinical and   psychological needs, and adaptable to his or her educational and   cultural background.' 

What structured patient education is not is the old medical model of a healthcare professional telling a patient what to do and expecting good results. It recognises that it is only through patients' engagement in their own care that true empowerment can take place. Structures are needed that ensure people with diabetes have access to accurate information in whatever form suits them best and at a speed with which they can cope.

Key criteria required to deliver this effective teaching and learning system (Department of Health [DoH], 2005a) accompanied the report on patient education (DoH, 2005b).

Structured curriculum

The curriculum needs to:

1 have a philosophy of supporting self-management attitudes, beliefs, knowledge and skills for the learner

2 be person centred, incorporating the assessment of individual learning needs

3 be reliable, valid, relevant and comprehensive

4 be theory driven and evidence based

5 be flexible and able to cope with diversity

6 be able to use different teaching media

7 be resource-effective and have supporting materials.

The curriculum also needs to be recognised as an evolving one based on new evidence, new situations and the ability to adapt to changes that affect individuals and the care system.

Trained educators

Trained educators need to:

1 have an understanding of education theory appropriate to the age and needs of the programme learners

2 be competent in the delivery of the education theory of the programme they are offering

3 be competent in the delivery of the principles and content of the specific programme they are offering.

Quality assurance

A quality assurance programme needs to be in place. The programme needs to be peer reviewed by independent assessors who assess against agreed criteria:

1 environment

2 structure

3 process

4 content

5 use of material

6 whether the programme has actually been delivered

7 evaluation and outcome information.

Audit

The outcomes from the programme need to be audited. The outcomes might include:

1 biomedical

2 quality of life

3 satisfaction

4 patient experience

5 user involvement

6 the degree of self-management achieved as a result of the programme.

Education session format

Group education sessions were highlighted as effective measures (NICE, 2003) but the report recognised that in some cases one-to-one consultations would continue to be appropriate. This is particularly true for disadvantaged groups (such as housebound people, those in care, travellers, non-English speakers and those with learning difficulties).

Why is structured patient education needed?

The National Service Framework for diabetes (DoH, 2003) advocated that education be built into patients' reviews and rated its impact very highly.

Programmes that meet the criteria have demonstrated improvements in quality of life as well as improved metabolic control and a consequent reduction in complications (DoH, 2005b). And people with diabetes appreciate it (Audit Commission, 2000):

   'My attitude has always been "it ain't going to beat me" and I believe   that the most important care is education in all aspects of the   disease [...] I have been insulin dependent for 43 years and can still   do 10 press-ups [...] It is not all doom and gloom!' 

It is thought that most people diagnosed with diabetes are offered some sort of education, at least when they are diagnosed (NICE, 2003). There is, however, huge variance in how this is delivered and how its effectiveness is measured. NICE (2003) summed it up thus:

   'the length, content and style of educational options varies greatly   between services; some of the educational programmes offered are   unstructured, very few have been formally evaluated, and few   individuals who deliver education have been formally trained for this   purpose.' 

What healthcare professionals and patients themselves perceive as a priority in education are not necessarily the same. Individuals are more likely to learn if they have identified a need (DoH, 2006). Most of the time it is the patients who will make decisions concerning their health. Healthcare professionals see them for a relatively short time in the average year--patients must have accurate information to help them make informed choices in self-care. Patients and carers need to be involved not only in receiving education but in planning it to fit their needs.