Improving Diabetes Care - Dr Clare Hambling Long-Term Conditions Lead, WNCCG - 2015-2016: Report 1, Care ...
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Improving Diabetes Care
Dr Clare Hambling
Long-Term Conditions Lead, WNCCG
c.hambling@nhs.net
Plan for the afternoon: • National Diabetes Projects • Structured Education • Achieving the 3 NICE Treatment Targets – Local data – Models of Care • Foot Care
Diabetes is expensive……
• for affected individuals:
leading cause of vascular disease (MI, CVA, PVD & lower limb amputation)
leading cause of ESRF & renal dialysis
leading cause of preventable visual impairment
doubles the risk of dementia
contributes to 22,000 premature deaths every year
• for the NHS…….
treatment for T2D accounts for 9% of the NHS budget (£8.8billion p.a.)
1 in 6 people in hospital have diabetes – longer LOS
5 million people in England at high risk of developing diabetes
If this trend persists, NHS England estimates that by 2034
1 in 3 people will be obese & 1 in 10 will have diabetes
Source: https://www.england.nhs.uk/ourwork/qual-clin-lead/diabetes-prevention/
3 New National Diabetes Projects, 2017: 1) National Diabetes Treatment and Care Programme • Value-based transformation within the Five year Forward View • Aims to improve clinical outcomes • reduce long-term complications (££££) 4 clinical areas: 1. Improving uptake of structured education ✅ 2. Improving achievement of NICE treatment targets ✅ 3. New/expanded multidisciplinary foot care teams (MDFT)❌ 4. New/expanded diabetes inpatient specialist nursing services ❌ call to bid for transformation funding, December 2016
Structured Education - Attended
Key Findings
• There are good reasons to believe that attendance is much higher than recorded.
• The decrease in attendance more recently should be addressed through the dissemination of
supporting guidance for data recording to CCGs who commission education providers.
Type 1 Type 2 and other
60
50
40
Attended Structured Education
within one year of diagnosis
Percentage 30
Attended Structured Education
20 within two years of diagnosis
10 Attended Structured Education
(no time limit)
0
2009 2010 2011 2012 2013 2014 2009 2010 2011 2012 2013 2014 2015
Year of diagnosis Year of diagnosis
5Care Processes – People with Type 1 Diabetes
Key Finding
The striking variation at locality level is evident and can also be seen between
similar specialist services.
6Treatment targets – People with Type 2 Diabetes
Key Finding
Striking variation at locality level is evident and can also be seen between
similar General Practices
HbA1c2) NHS Intelligence Programme – Diabetes reducing unwarranted variation to improve people’s health and outcomes and reduce inequalities in health access, experience and outcomes: right care, right place, right time, making best use of available resources 3) NHS Diabetes Prevention Programme Started in 2016, planned roll out to the whole country by 2020 Tailored, personalised help to reduce risk of T2D Focus on healthy eating, weight management, exercise Proven benefit in other nations
National Diabetes Audit, 2015-2016 Structured Education England and Wales 31 January 2017
Structured Education - Comment
The NHS …. underestimates, or undervalues, the provision of
structured education for people with diabetes.
Diabetes is a lifelong disorder with no periods of remission.
Treatment demands are all day, every day.
People with diabetes rarely spend more than two to three hours per
year with a healthcare professional, and for the remaining 8,757
hours they must manage their diabetes themselves. They need the
knowledge and skills to do this.
Attendance at structured education forms one of the indicators in the
CCG improvement and assessment framework 2016/17
– practice recording of attendance at structured education now included
within the Referrals Management LES
11Structured Education - Offered
Key Findings
• Timely offers of structured education have improved over the last three years
• Of those offered education, the majority are offered within one year of diagnosis
Type 1 Type 2 and other
100
Percentage
90
80 Offered Structured Education
within one year of diagnosis
cation (no time limit)70
60
50 Offered Structured Education
40 within two years of diagnosis
30
20 Offered Structured Education
10 (no time limit)
0
2009 2010 2011 2012 2013 2014 2009 2010 2011 2012 2013 2014
Year of diagnosis Year of diagnosis
12Recommendations
• Structured education providers and their commissioners
should follow the recently agreed communication guidance to
improve recording of structured education attendance
• GP and specialist services and CCGs/LHBs should use
relevant parts of this report ….to identify areas for
improvement and implement local action plans.
• All services seek new approaches to diabetes service delivery
for those aged under 65 to narrow the gap between them and
older people.
• People with diabetes to review the results for their practice or
specialist service and support any improvement initiatives.
13Structured Education Why wouldn’t you?
Kings Lynn Insulin For Food • Insulin dose adjusting for people with type 1 and 2 diabetes on a basal bolus regimen • Try to see people before and after attending the KLIFF course • Friendly small 1 day group session • Monthly group sessions • Either at Tapping House or Tesco in Wisbech • Annual refresher sessions • Last year 117 referred; Attendees 86 (73%) • Attendance rate is 77% over 3 years • Average HbA1c drop post KLIFF is 13.2 mmol/mol. • Which is maintained for up to 2 years
KLIFF • “Please carry on – the day was SO helpful – thank you” • This is the exactly the course I have needed to attend since October 1965 (year and month of diagnosis)” • I would like to say a massive thanks to you and your team for the course. My partner and I have found it very informative and we have already begun work on improving our lives”
KLIFF Why wouldn’t you?
Newly Diagnosed Type 2 Diabetes Patient Education By Community Diabetes Team
Newly diagnosed patient education programme • Started over 10 years ago • Based on DESMOND • Referrals from GP practices sent to Community Diabetes Team on diagnosis • Topics covered - complications, diet, foot care, self management and lifestyle advice.
Aims of the programme • To promote patients self management, motivation and quality of life • Allow time to speak to qualified healthcare professionals and other people with diabetes to share experiences • To improve long term glycaemic control and reduce complications of diabetes
2016
• 783 patients referred
• 271 attended (35%)
• 25 sessions held across West Norfolk in Kings Lynn,
Watlington, Necton and Heacham
• Feedback
Meeting people with Friendly, helpful staff.
Clear course yet easy Good
the same condition
to understand presentation
and useful
visual aids and
literature
Openness and frankness.
Made me feel comfortable Healthy eating top tips and
and not adversely treated how to avoid complicationsNumber of patients referred and attended in 2016
Number Number Percentage Number Number Percentage
Surgery Surgery
referred attended attended referred attended attended
St James Medical
69 23 33% Hunstanton Surgery 26 9 35%
Practice
Terrington St John
Upwell Health Centre 68 23 34% 23 9 39%
Surgery
Southgates Medical
59 16 27% Wootons Surgery 20 11 55%
Centre
Gayton Road Health
58 12 21% Howdale Surgery 18 6 33%
Centre
Manor Farm Medical Heacham Group
54 19 35% 17 11 65%
Centre Practice
Campingland Surgery 47 11 23% Burnhams Surgery 15 5 33%
Bridge Street Surgery 45 28 62% The Hollies Surgery 14 5 36%
Terrington St
Feltwell Surgery 43 7 16% 14 3 21%
Clements Surgery
Plowright Medical
39 15 38% Fairstead Surgery 13 3 23%
Centre
Watlington Medical Litcham Health
35 14 40% 12 5 42%
Centre Centre
Great Massingham
31 13 42% Boughton Surgery 8 4 50%
Surgery
Carole Brown Health
28 9 32% Marham Surgery 1 0 0%
Centre
Grimston Medical
26 10 38%
Centre10%
20%
30%
40%
50%
60%
70%
0%
Heacham Group Practice
Bridge Street Surgery
Wootons Surgery
Boughton Surgery
Great Massingham Surgery
Litcham Health Centre
Watlington Medical Centre
Terrington St John Surgery
Grimston Medical Centre
Plowright Medical Centre
The Hollies Surgery
Manor Farm Medical Centre
Hunstanton Surgery
Upwell Health Centre
Burnhams Surgery
Howdale Surgery
St James Medical Practice
Carole Brown Health Centre
Southgates Medical Centre
Campingland Surgery
Fairstead Surgery
Terrington St Clements Surgery
Gayton Road Health Centre
Percentage of referred patients who attended in 2016
Feltwell Surgery
RAF Marham SurgeryQuestion? How can we improve the uptake of diabetes structured education?
National Diabetes Audit, 2015-2016 Care Processes & Achievement of Treatment Targets England and Wales 31 January 2017
Care Processes – People with Type 2 Diabetes
Key Finding
The striking variation at locality level is evident and can also be seen between similar
General Practices.
26Care Processes – By Age
Key Finding
Younger people with either Type 1 or Type 2 and other diabetes are less likely to receive their
annual diabetes checks than their older counterparts.
Percentage 70%
60%
50%
40%
Type 1
30%
Type 2 and Other
20%
10%
0%
20 30 40 50 60 70 80 90
Age of person with diabetes
27Treatment Targets – People with Type 1 Diabetes
Key Finding
Striking variation at locality level is evident and can also be seen between
similar specialist services.
HbA1cTreatment Target – By Age
Key Finding
Younger people are less likely to achieve all three treatment targets than their
older counterparts. This is primarily due to poorer glucose and cholesterol
control in those aged under 65 years.
Percentage 100%
90%
80%
70%
60%
50%
Type 1
40% Type 2 and Other
30%
20%
10%
0%
20 30 40 50 60 70 80 90
Age of person with diabetes
29Treatment Targets – Comments
• Target achievement differences between CCGs/LHBs are
substantial. Differences in patient demographics do not
explain the extent of the variation.
• Differences between specialist services and between general
practices are substantial and the differences in patient
demographics do not explain the extent of the variation.
• Younger people are less often achieving treatment targets.
30National Diabetes Treatment and Care Programme
• Primary aim is to increase the proportion of people with diabetes
receiving all care processes and the achieving the 3 NICE treatment
targets
• Changes that reduce variation and improve average achievement
levels would yield great health benefits
31Improving achievement of NICE treatment targets
• For both adults and children with diabetes
– HbA1c, BP & cholesterol in adults
– HbA1c in children
– without increasing the risk of hypoglycaemia or hypotension
• Investigate alternative care models
– understand variations in care and plan to tackle these
– Consider how to target hard to reach groups e.g. young people with
T1D, people of working age
– Better integration between primary and secondary care
– Improve access to specialist advice
– Ensure all patients receive all 9 care processes at least annually
– Minimise clinical inertia
– Ensure all patients have a personalised, shared & agreed care plan
32Local data
• 11,750 (8.2%) adults with diabetes
– 12th highest prevalence of 209 CCGs
– 5th highest prevalence amongst those aged > 65 years
33
Source:http://healthierlives.phe.org.ukWest Norfolk diabetes prevalence by age (ECLIPSE)
1600
1400
1200
1000
number
800
600
400
200
0
Age (years)Local data
• 11,750 (8.2%) adults with diabetes
– 12th highest prevalence of 209 CCGs
– 5th highest prevalence amongst those aged > 65 years
• Care Processes
– QoF data for 2015/16 shows that 83.3% had a foot check
– Which is better than national average
• Complication rates
– For heart disease, stroke, major & minor amputations
– Generally in line with national average
35
Source:http://healthierlives.phe.org.ukAchievement of treatment targest
• 56.8% “good” glycaemic control (Hba1c ≤ 59mmol/mol)
– considered worse than national average
– between practices range 49 – 78.4%
• 73.7% BP well controlled (All 3 treatment targets
HbA1c BP
56.8% 73.7%
41% achieve all
3 treatment targets
better than the national
average
Cholesterol
70.5%
Nonetheless, expectation is that more people should safely
achieve all three treatment targets
38Why does NHSE want us to consider models of Care?
• potential to improve processes and target achievements in
diabetes care
• Efficiencies from better integration between primary, intermediate
and secondary care services - access to specialists
• most people, with uncomplicated diabetes, managed within
primary care
• processes to identify higher risk groups who would benefit from
more specialist attention
• many models within federated primary care systems making use of
specialist GP expertise, practice diabetes nurses & facilitating
liaison with more specialist services
39Super - Six
Portsmouth
defined clinical groups/problems continue in secondary care
o Inpatient care
o pregnancy & pre-pregnancy
o People with poorly controlled type 1 and all young people & adolescents
o diabetes patients on the diabetic foot pathway
o people with low eGFR or ESFD
o insulin pump users
all else supported in primary care by Community Diabetes teams
• Clinical & educational support – twice yearly
• Virtual clinics (case-based discussions)
• QoF targets, audits
• Patient reviews (in conjunction with GP or practice nurse if needed)
• advice & guidance – telephone hot line for urgent problems, email access
for less urgent problems
• educational programmes & support for primary care practitioners
40One Norwich
• Providing diabetes services across a federated model
• Builds on strengths of individual practices, pools
resources and makes best use of skill mix – hub & spoke,
4 localities
• Ensures all patients who need it have access to more
specialised primary care diabetes teams
• Planning to incorporate many of the principles of
integrated community diabetes model with consultant
diabetes support
• Virtual clinics
• Advice & guidance – different levels of access
41West Berkshire - the model proposed in our bid
Similarities with Portsmouth model
Secondary care services defined by similar criteria
Primary care support also similar:
Virtual clinic-based approach
care planning either remotely or with case discussion in practice,
supports HCP education
Twice yearly practice visits
Making use of ECLIPSE
• easier to select groups by a variety of identifiers - clinical parameters
e.g. renal impairment, high hbA1c or by medications
• can be predefined and set up as searches
• potential to manage a larger population
• Can target areas of relatively lower achievement as priority
Advice & guidance
42Questions?
• What elements do we want in our local
model?
• How do we ensure all practices can improve
the achievement of care processes?
• How can we safely improve achievement of
all three NICE treatment targets for our local
diabetes population?
43Foot Care
• A project for the Autumn
• Aim to reduce variation in diabetes foot care across the STP area
• Currently
– Variation in amputation rates
– Pathways of care
– GYW still without a MDFT
• NDFA highlighted points of weaknesses
– Delays in patient presentation
– Delays in referral from primary care
• Plan to review & optimise pathways of care across the whole
STP area
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