Summary
In East London NHS Foundation Trust (ELFT) a number of service users are reliant on the community nursing teams to administer their insulin. They remain on the caseload indefinitely while it continues to increase year on year. This project examined how to empower service users and their carers to self-administer insulin and thereby reduce the district nursing caseload. The aim was to train them at the point of diagnosis and work with partner organisations to reduce the number of diabetic patients on the district nursing caseload by 20% by January 2025.
Innovation/Novel approach to an existing problem
Educating patients and carers at the point of diagnosis, and delivering structured support throughout their care journey, the team sought to enhance personalised care, promote autonomy, and uphold trust values. This QI project had a sponsor, coach, and a multidisciplinary team including: pharmacy team, district nurses, performance lead, lead nurse, and trainee psychologist, plus a service user, who featured in a video about insulin education and self-administration. The service users’ feedback underscored the benefits of this approach, highlighting increased confidence, satisfaction, and self-efficacy. Based on the Theory of Change (Driver Diagram) approach, the project aimed, by January 2025, to increase the number of diabetic patients on the caseload self-administering their insulin through targeted training and collaboration with partner organisations. Additionally, the team would: develop and deliver a teaching package for patients and carers; conduct mental capacity assessments to determine suitability for self-administration; carry out home visits for insulin education; use interpreters where needed; provide dummy insulin pens for practice; refer patients with needle phobia for psychological support; introduce a Diabetes Champion role for Band 5 nurses to lead on this initiative. The project team manually collected data across all four localities on: the number of patients receiving district nurse visits for insulin administration; the number of service users living with a carer or family member who could be trained to administer insulin; plus patients’ treatment plans, HbA1c review dates, medication profiles, and test results.
Equality, Diversity and Variation
A comprehensive education package was created, including written materials, visual aids, and demonstration tools tailored to varying levels of health literacy and learning needs. All patients considered underwent a mental capacity assessment to ensure support was tailored appropriately. District nurses/diabetes specialist nurse home visits provided one-to-one insulin training to patients and/or their carers in a familiar, supportive environment, enhancing engagement and learning outcomes. Service users led on when they were ready to start trying under supervision. Professional interpreters were arranged where needed. This ensured equitable access to training and supported patient safety and confidence. Patients and carers were provided with dummy insulin pens to practise correct technique. Patients with a fear of needles were referred to psychological services, ensuring emotional barriers to independence were addressed. The carers supporting service users were provided with care plans. This increased self-efficacy led to better treatment adherence, more effective symptom monitoring, informed decision making and faster achievement of goals.
Impact to Patient Care
The experiences of patients and feedback from carers reveal that self-management training delivers more than clinical benefits – it restores personal freedom, reduces psychological burden, and enhances engagement in life and community. Patients can structure their days according to their own needs and preferences, rather than being dictated to by healthcare routines. This increases satisfaction and well-being, while fostering the skills and confidence necessary for ongoing, safe self-care. Although the QI project has now closed, the outcome and implementation plan continues to improve on service delivery.
Results
A total of 53 service users were discharged from district nursing caseloads because they, or their families, had become competent in managing and self-administering their own insulin. This demonstrates tangible progress in empowering patients and carers through effective training and support, allowing service users to take greater responsibility for their health while reducing dependency on professional input. Another 11 service users had reduced visits as their families and carers were trained to undertake shared care. This freed up district nursing time and fostered a more collaborative approach. As of January 2025, it is estimated that 2,109 clinical hours had been redirected to other service users with more acute or complex needs. Additionally, there was a significant reduction in travel times, leading to measurable carbon savings. The service implemented insulin caseload RAG (Red, Amber, Green) meetings helped clinical teams triage and prioritise caseloads. By identifying which patients can move towards self-care (green), which need ongoing support (amber), and which are higher risk (red), the team ensures that resources are allocated most effectively and patient safety remains paramount. The new Diabetes Champion role for Band 5 nurses allows them to act as clinical leads and resource persons, delivering ongoing education, overseeing safe delegation of insulin administration, and acting as key contacts for problem-solving and escalation. This role also fosters professional development for nurses, supporting skill enhancement and job satisfaction.
User Feedback
Joint working between home care agencies and health professionals on insulin self-administration focused on safely delegating, training, and supporting patients and care staff to promote independence while maintaining high standards of care. It also helped workforce development as the team ensured that the health care assistants were trained and had their skills signed off. ELFT launched a ‘GP communication QI project’ to improve joint working with GPs and community services. This uncovered that about 80% of medication patient safety events between primary care and community health services involved insulin management. A cluster review of the cases was undertaken. Findings and actions included the following. Issues with communication between healthcare professionals around dose changes (GP to district nurses): a new process included a prompt on EMISS for GPs to email the CHT for people under its care. Lack of optimisation of medications: service users reviewed. In response to the lack of self-management education, the Diabetes Specialist Nurse role was created. Homecare providers were asked to prompt/remind service users to self-administer their insulin and to record medication taken during scheduled visits. District nurses agreed to add detailed information about how service users needed to be supported and the role of the homecare provider to the person’s London Universal Care Plan.
