Strengthening diabetes service delivery at the primary care level in Iceland
- Rising prevalence of type 2 diabetes.
- Diabetes care delivery concentrated in higher-level care settings.
- Increasing waiting times for diabetes services.
- Geographic inequities in access to diabetes-related care.
- Following grassroots efforts to increase the role of primary care providers in managing patients with diabetes, formal clinical guidelines to support diabetes care delivery at the primary level were published in 2009. The delivery of diabetes-related care in primary settings is increasing as a result.
- Knowledge gained through experiences working abroad provided inspiration for the initiative and fostered local innovation.
- Informal discussions among providers had sufficient power to initially motivate and direct change.
- Incorporating trainings for providers into the formal education system helped to establish a new standard of care and ensured sustainability of knowledge.
Prevalence of type 2 diabetes in Iceland has grown steadily over time. However, with diabetes service delivery concentrated in higher-level settings, the increasing prevalence of this disease placed pressure on the health system to treat a growing number of patients, straining the capacity of specialist providers and increasing waiting times for services. Furthermore, the lack of diabetes care provision at the primary level made accessing services difficult for patients living in rural areas, who had to travel to the nearest urban centre in order to obtain care.
Upon returning to Iceland after a period working abroad, a provider organized colleagues to discuss observed inefficiencies in diabetes care delivery in Iceland. After finding widespread enthusiasm for change, a small-scale conference was organized to bring providers together to discuss and strategize issues, including the need to develop new diabetes care guidelines to support service delivery in primary settings. As a result of these actions, responsibility for delivering diabetes care gradually shifted to general practitioners and other primary care providers. Nurses were brought into primary care teams to support diabetes service delivery and help empower patients with education and counselling to improve self-management. Informal changes to reorganize diabetes care implemented by providers later gained government support, which led to the development of official care guidelines for managing diabetes in primary settings. A two-day training programme for primary care providers was developed to provide education on the new care guidelines and systematically equip providers with the necessary skills to deliver comprehensive diabetes care. Given Iceland’s relatively low population size, a personalized, small-scale training system was adopted. Trainings are carried out in practices and clinics with approximately 20 providers participating in each session. So far, around 80 general practitioners (approximately half of all those practicing in Iceland) have received training. Ad hoc trainings continue to support professional development in diabetes service delivery and incorporation of the training into formal medical education has secured future sustainability. As a result of efforts, diabetes services now offered in primary settings include lifestyle counselling, blood glucose testing and monitoring, drug therapies, and provision of insulin; particular emphasis is placed on counselling and education services for patients.
Change was led by an individual practitioner who, upon return to Iceland after a period working abroad, recognized inefficiencies in the Icelandic system for delivering diabetes care. Discussions about key issues held with colleagues and other providers highlighted widespread enthusiasm for change and providers self-organized to voluntarily drive improvements. Later support from the Ministry of Welfare enabled the development of official care guidelines, helping to formalize new practices and solidify the delivery of diabetes care at the primary level as the new norm.
No official outcomes have been reported by the initiative. However, both efficiency of services and access to diabetes care in primary settings have reportedly increased. This is evidenced by the greater number of general practitioners registered to treat diabetes.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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Ministry of Welfare