Ongoing Care

Working together with your healthcare team

To achieve the best possible diabetes care, it is essential for you to work in partnership with your diabetes healthcare team and use your combined experience and expertise to agree what care and support you need.

Your diabetes care may be provided in different settings depending on your specific needs, such as your GP surgery or your local hospital. If you are referred to see a specialist, this may be in a health centre, your local hospital or at another hospital.

You need to discuss with your consultant or GP the roles and responsibilities of those providing your diabetes care. Also, it is important to identify the key members of your diabetes healthcare team and agree the name of your contact, who you are likely to see most often. You may see some members of your team more often than others and they may change over time.

Your diabetes healthcare team

Remember, your diabetes healthcare team includes you. Some of the different people who may be part of your diabetes healthcare team and may contribute to your care plan include:

  • a consultant physician/diabetologist
  • a diabetes specialist nurse (DSN)
  • a registered dietitian – with special interest in diabetes
  • a district nurse, midwife or health visitor
  • a GP – general practitioner
  • an ophthalmologist – eye consultant
  • an optometrist – optician
  • a practice nurse
  • a pharmacist
  • a podiatrist
  • a psychologist

Planning your care

The process of care planning describes the partnership with your diabetes healthcare team, where you are actively involved in deciding how your diabetes will be managed. During your appointments, you should discuss your concerns and questions with members of your healthcare team. It is important that you work together to set realistic goals and decide how you are going to achieve them.

The goals you agree as a result of your discussion will form the basis of your care plan. The care plan is the written summary of what you are both going to do to help you to manage your diabetes day-to-day. A paper copy of your care plan should be given to you by a member of your diabetes healthcare team. If not, ask for one. You should have a full review at least once a year and at ongoing intervals as agreed in your care plan.