Shared learning database

Dime Square Ltd
Published date:
July 2014

The Programme for injectable Therapies (PITstop) is the advanced, university and RCGP accredited, diabetes-training course. The 2.5-day course prepares GPs and practices nurses to support people with type 2 diabetes on more complex medication regimens, including injectable therapies. This enables teams to provide enhanced services for their patients and prevent unnecessary referrals to specialists.

PITstop refers to the NICE CG87 Type 2 diabetes - Newer agents, recommendation 1.6.3 for initiating both GLP-1 receptor agonists and recommendation 1.7.1 Oral agent combination therapy with insulin, encouraging participants to audit the progress of patients with a baseline, 3-months and 6-months HbA1c, weight and medication prescribed. The programme is also delivered in line with NICE QS6 Statement 6: 'Trained healthcare professionals initiate and manage therapy with insulin within a structured programme that includes dose titration by the person with diabetes'.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Aim: to enable primary care workforces keen to provide high quality, structured enhanced diabetes services to learn and embed the necessary skills.
- To establish an accredited, advanced diabetes course in line with NICE guidance for insulin initiation, incorporating other complex medication regimens for people with type 2 diabetes.
- For training to be practical, with structured pathways and patient information, encouraging a consistent approach to initiation of GLP-1 and insulin therapy.
- Following the training, encourage mentorship (including observation) and competency assessment (based on national competencies).
- Design the training to be transferable and delivered by other specialist teams
Course learning objectives:
- Understand the treatment pathway for people with type 2 diabetes
- Understand how to initiate GLP-1 receptor agonists
- Understand the additional aspects of support required for people on injectable therapies
- Know when it is appropriate to start a person with Type 2 diabetes on to insulin, using the PITstop handbook
- Be able to initiate a simple insulin regimen
- Understand the education required over the first six-months, including insulin titration
- Learn from the experience of other students about initiating and supporting people on injectable therapies
- Know how to discuss:
o How both the amount and type of carbohydrate impacts on blood glucose levels
o Causes of weight gain associated with insulin and how to minimise weight gain
o Dose alterations of certain insulins based on carbohydrate intake
- Become more confident in understanding the general rules associated with insulin titration and insulin regimen changes
- Explore how and where to access additional clinical support
- Understand the accreditation process and requirements and now how to access support

Reasons for implementing your project

PITstop was developed and piloted in Bexley, South London (28 General Practices, approximate type 2 diabetes population size 11,000). The need for on-going advanced level training had already been established by a needs assessment completed by the Practice Development team, comprising of a GP, Diabetes Specialist Nurse and Patient. This was partially motivated by a service enhancement payment focusing on starting and supporting people with type 2 diabetes on injectable therapies. The aim, to provide care closer to home by appropriately skilled teams, in line with national policy.

The strong patient voice in Bexley highlighted the need for a consistent, structured approach to insulin initiation which lead to the first edition of the Programme for Insulin Therapy (PITstop) patient handbook in 2011, a resource for patients, informing them about insulin therapy and mapping out the six-month pathway following insulin initiation. Prior to this, a a number of industry-funded courses were co-delivered by the local Specialist team, but the development of the PITstop handbook gave the initial structure for a new course. The Programme for Injectable Therapy was developed to incorporate the insulin pathway, alongside a GLP-1 therapy pathway, both in line with current NICE guidelines and the NICE education criteria for insulin initiation.

PITstop training has now been commissioned by a number of clinical commissioning groups following local training needs analysis focusing on the number of practice teams wanting to maintain or develop enhanced diabetes services, including GLP-1 and insulin initiation. Participants are expected to have already attended a Foundation level course when they apply for PITstop.

How did you implement the project

Initial pilots took place in Bexley, but in order to complete the necessary work to gain university accreditation and develop the content and resources to a high standard, I set up my own company and eventually became a diabetes-training provider for Bexley. I gained University Accreditation with Greenwich University, requesting diploma level to ensure the course remained practical and not an academic exercise. I was also able to establish links with other commissioners, advising on their training models and went on to develop a 'train the trainer' course allowing specialist teams to deliver PITstop in their local area. A quality development tool was established and a quality development lead, responsible for ensuring trainers delivered PITstop to the required standard. More recently PITstop has been granted RCGP accreditation.

Running a training course to a high standard is a timely process and not one individual / organisations should take on unless they can maintain the standard of the course material and programme delivery. Establishing the quality of the course through accreditation, developing and updating the course material, training trainers and delivering courses is timely and resource intense. NICE education criteria for insulin initiation definitely helped to structure the content of the course and NICE treatment guidelines are quoted throughout. This, and PITstop's independence from pharmaceutical companies, is appreciated by medicines management and commissioning teams. However PITstop's independence has been a barrier in some respects, due to the direct funding required. Some commissioners have provided direct funding while others have found a solution, working in partnership with a number of pharmaceutical companies and local charities who contribute toward the training cost.

Key findings

The original PITstop pilots look place in Bexley, South London and the number of injectable initiations in primary care were monitored over a twelve-month period. Results: a total of 45 insulin starts took place in primary care (mean HbA1c reduction 1.4%, mean weight gain 1.8kg at six-months). A total of 34 GLP-1 therapy starts were reported (mean HbA1c reduction 1.3%, mean weight reduction 5kg at six-months). In conclusion 79 patients were able to remain under the care of their practice team for more complex service provision, also reducing the number of new referrals to Specialist teams and follow-up appointments, a cost saving of £32,966.

More recently a survey was completed to determine if PITstop and mentorship influences healthcare professional?s (HCP) confidence in providing enhanced diabetes skills. The results indicated that a minimum of nine-months after completing the course, 22 out of 23 students felt more confident in supporting people with type 2 diabetes in all six categories. The categories included supporting people with type 2 diabetes in a review appointment, managing complex oral agents, inititating GLP-1 and basal insulin therapy, titrating insulin and changing an insulin regimen. In conclusion, PITstop and mentorship improves HCP confidence in delivering enhanced diabetes services and supporting more complex patients with type 2 diabetes in primary care.

179 primary care HCPs attended a PITstop course between January 2013 and July 2014. 96 HCPs are registered to attend a course between in the autumn. There are now seven CCGs commissioning PITstop.

Key learning points

- The education criteria for insulin initiation (NICE CG66) helped structure the course content. The emphases placed on insulin initiators being appropriately trained and skilled, encouraged me to develop a competency assessment tool using nationally recognised competencies, which helped gain University and RCGP accreditation. I would avoid trying to replicate a competency tool and use the national frameworks available. The cost of accreditation needs to be taken into account when developing a course.
- Having criteria for entry onto an advanced diabetes course is key. This ensures HCPs registering have experience in delivering essential diabetes services and are ready to develop their skills further.
- Focusing a course on injectable therapies alone is not possible. With emerging oral therapies and an emphasis on patient-centered care a more holistic approach is required. The use of case studies throughout PITstop allows this to happen and increased confidence in supporting people with type 2 diabetes in general was evident in the survey.
- Participants value a structured approach to initiating injectable therapies. Having clear assessment, initiation and follow-up pathways, including audit, and a patient handbook reinforcing the education structure of the insulin initiation pathway. This encourages a standardised, consistent approach.
- Developing and maintain an accredited course is timely and costly. It has become a full-time job, with a team of five national trainers and a quality development lead.
- The background I have has allowed me to develop a practical, effective course. (A Diabetes Specialist Nurse in a diabetes centre, as part of a primary care service redesign and training team and as part of a practice team within GP practices).

Contact details

Anne Goodchild
PITstop national lead
Dime Square Ltd

Is the example industry-sponsored in any way?