19/01/2017 9:40 AM National Diabetes Treatment and Care Programme Application Form- Part B

Transcription

1 19/01/2017 9:40 AM National Diabetes Treatment and Care Programme Application Form- Part B The application form is composed of two parts: a) An Excel document, largely for the collection of numerical and data-based information. b) A Word document where textual information is collected. Further details of the application process are contained with INTRO AND in the Excel and Call to Bid documents. As a minimum, bids should be on a Clinical Commissioning Group (CCG) footprint. CCGs are encouraged to collaborate and submit joint bids, ideally on Sustainability and Transformation Plan (STP). Bids must be submitted via STPs. Bids should be collaboratively developed with relevant providers. Where bids are for Multi-disciplinary Footcare Teams (MDFTs) or Diabetes Inpatient Specialist Nursing (DISN) services and a single MDFT or DISN team is/will be provided across the footprint of several CCGs, it would be expected that, as a minimum, bids are agreed across those CCGs. Bids should be jointly agreed with relevant providers and should be jointly developed with key clinical leads and with people with diabetes. A key principle of use of the funding is that it should be expected to generate savings through reduction in the rate of development of complications and other deterioration in people with diabetes and that such savings should be reinvested in the services in order to help make them self-sustaining. Joint agreement between commissioners and providers to commit to such reinvestment will be a key factor in considering whether to approve bids for funding. All applicants are required to complete: 1. Diabetes Application Form Part A (the excel document), 2. The overall details section below (on page 2 to 4 of this document), and 3. The relevant sections below (on page 5 to 20) which are applicable for the interventions that you wish to bid for. Note: You do not need to complete the whole form unless you are applying for all interventions. 4. Bids must be via STPs The guidance notes on the Introduction tab in the Excel document should be read in conjunction with answering the questions below. 1

2 Overall details Please expand the boxes below as required for your answers. 1. Please list all CCGs included in this bid The eight CCGs in North West London are bidding together for support for parts of our planned two year intensive NWL STP Diabetes Transformation Programme which will include Value Based Commissioning, and development of an integrated diabetes service across all 8 CCGs, therefore reducing variation at all ages, levels, practices, providers and CCGs. The CCGs are: Brent, Central London, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, and West London. Approximately 134,000 people have been diagnosed with diabetes (6.5% of the overall population) with an estimated 40,000 remaining undiagnosed at present. Throughout this bid we refer to people with diabetes, which includes those with all forms of diabetes, and for children and young people. Reasons for a bid at this scale are: In NWL STP diabetes is a clear priority, and we have significant involvement in national and local schemes that we now plan to pull together into our Diabetes Transformation Programme. The local initiatives are; 1) NHS Right Care: The NWL STP Commissioning for Value Pack released in December 2016 by NHSE identified Diabetes as one of five STP Rightcare priorities. Hammersmith and Fulham and Brent CCGs are Wave One Right Care CCGs and will be sharing the learning and principles with the remaining 6 NW London CCGs. 2) Sustainability and Transformation Plan (STP): The CCG 5 year strategy created collaboratively for NWL footprint. Two key delivery areas: Delivery Area 1 (Radically upgrading prevention and wellbeing) and Delivery Area 2 (Eliminating unwarranted variation and improvement long term condition (LTC) management). Delivery Area 2 is seen as a key objective for Local services development. 3) Accountable Care Partnership (ACP) development: Accountable care systems involve a single contract and single pooled budget across all providers focused on longer term outcomes based contracts. They are clinically led, are organised around the same quality and financial incentives across organisations, and focus on primary and secondary prevention. NWL CCGs are working with the ACP team to develop an outcomes-based new model of care for diabetes as an exemplar for other Long Term Conditions. 4) CCG Improvement and Assessment Framework: CCGs are now being assessed on 3 measures for diabetes -participation in the National Diabetes Audit, achievement of 3 NICE targets (HbA1c, BP and cholesterol) and uptake of structured education. Two new measures will be introduced soon amputation rates and in-patient care. 5) Out of Hospital Services: contracts for improving diabetes and non-diabetic hyperglycaemia care across CWHHE GP practices. This approach of primary care investment and at scale population health management will be expanded to all 8 CCGs in NWL STP. 2

3 6) Mental Health: in NWL STP our IAPT development will have a focus on diabetes. In the NW London STP footprint, diabetes accounts for a significant proportion of the population and health and care costs and activity: Approximately 134,000 people diagnosed with diabetes (6.5% overall) with an estimated 40,000 remaining undiagnosed at present At least 10% of the North West London health cost (over 350m) 29.4% of NW London emergency admissions 28.3% of NW London bed days Over 25,000 patients with diabetes across North West London are living with poorly controlled diabetes (HbA1c >64) and around 55% of these are under the age of 60. This translates into substantial numbers of complications and admissions due to complications over 70,000 bed days for some of the more common diabetes cardiovascular complications and over 290,000 bed days in total for patients with diabetes at a cost of over 110m annually. Additionally London Ambulance Service callouts for hypoglycaemia in 2015 can be seen below for each CCG. Ambulance callouts: Number of call outs Conveyed to emergency department Region NWL London (Harrow) (56%) Hillingdon (68.5%) Brent (67%) North Central (56%) Hounslow (61%) Hammersmith/ Fulham (68%) TOTAL (63.5%) 3

4 2. Please list all providers included in this bid The providers included in this bid are: Acute and Community Organisations: Central and North West London NHS Foundation Trust Central London Community Healthcare Chelsea and Westminster Hospital NHS Foundation Trust (including West Middlesex University Hospital) Hillingdon Hospitals NHS Foundation Trust Imperial College Healthcare NHS Trust London North West Healthcare NHS Trust West London Mental Health Trust GP Federations: Brent GP Federation Central London Healthcare CIC Ealing GP Federation Hammersmith and Fulham GP Federation Harrow Health CIC Hillingdon GP Federations (Clover, Concorde, Metro Health and Wellcare) Hounslow GP localities West London GP Federation Councils and Public Health Departments; Brent, Central London, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, and West London CCGs 3. Please list other partners included in this bid People with diabetes, commissioners and clinicians and from all aspects of the health economy, Public Health teams from all 8 NWL boroughs, social care and council colleagues have all assisted us with developing this bid and our vision for the NWL STP Diabetes Transformation Programme. They have also taken part in multi-disciplinary, multi-ccg workshops recently. We have also had support from CCG Diabetes Patient Reference Groups e.g. Hounslow. The existing CWHHE (Central London, West London, Hammersmith and Fulham, Hounslow and Ealing CCGs) Diabetes strategy group has been meeting on a regular basis for nearly 3 years and has had regular input from public health teams across the 5 boroughs, CCG leads, NHS England (Strategic Clinical Network), Healthy London Partnership Children and Young people s programme and the North West London Paediatric Diabetes Network patient and parent representatives, clinical teams from the acute and community providers, GP Federations and Diabetes UK and JDRF. We are now expanding this to all 8 CCGs in March

5 4. Confirm STP lead(s) support for this bid Dr Mohini Parmar, Lead for North West London s Sustainability and Transformation Plan (STPs), has signed off this bid on behalf of the STP leadership team. The bid document has also been endorsed by NWL Joint Healthcare Transformation Group, NWL Clinical Board and STP Strategic Finance and Estates Group. 5. Lead contact details for the bid Name of lead contact Job title address Dr Tony Willis GP, Diabetes Clinical Lead (NWL STP) Clinical Lead for IT, Diabetes and CKD tony.willis@nhs.net Telephone number Where the application covers multiple CCGs and/or providers or other partners, the application should have been agreed via the appropriate governance processes in each partner for bidding process of this nature and a lead CCG identified. The chief officer of the lead CCG should confirm below that this has taken place. I confirm that all organisations which are partners to this bid have agreed to support it though their relevant governance processes for bids of this nature Name Job title CCG Clare Parker Chief Officer, Central London, West London, Hammersmith & Fulham, Hounslow & Ealing CCGs NWL STP 5

6 7. A Senior Responsible Officer (SRO) for the bid, together with a clinical lead and implementation lead, should be identified with their details set out below. These may be from any organisation that is a portion to the bid. Appraisal dashboard criteria reference(s): All - clinical outcomes, safety/quality and sustainability SRO Clinical Lead Implementation Lead Name Juliet Brown Dr Tony Willis Lesley Roberts Job title Programme Director, Strategy & Transformation Team Diabetes Clinical Lead (NWL STP) Programme Director Organisation NHS North West London CWHHE CCG Collaborative NHS North West London address Juliet.brown@nw.london.nhs.uk tony.willis@nhs.net l.roberts@nhs.net Telephone number

7 8. Please set out below what priorities for diabetes are included within local strategic plans, including Sustainability and Transformation Plans (STPs) and how they relate to this bid. Appraisal dashboard criteria reference(s): All - clinical outcomes, safety/quality and sustainability 8 What priorities for diabetes are included within local strategic plans including North West London Sustainability and Transformation Plan In NWL STP diabetes is a priority area for transformation and will be used as an exemplar to inform our strategy to improve wellness, prevent development of long term conditions and support self-care for patients diagnosed with long term conditions. The NWL STP priorities link very well with transforming diabetes care: Support people who are mainly healthy to stay mentally and physically well, enabling and empowering them to make healthy choices and look after themselves Improve children s mental and physical health and well-being Reduce health inequalities and disparity in outcomes for the top 3 killers: cancer, heart diseases and respiratory illness Reduce social isolation Improve the overall quality of care for people in their last phase of life and enabling them to die in their place of choice Reduce the gap in life expectancy between adults with serious and long term mental health needs and the rest of the population Ensure people access the right care in the right place at the right time Reducing unwarranted variation in the management of long term conditions diabetes, cardiovascular disease and respiratory disease Improve consistency in patient outcomes and experience regardless of the day of the week that services are accessed. Extensive collaborative work in diabetes has already begun across CWHHE (5 of 8 CCGs in NWL STP). It has resulted in the implementation of enhanced contracts and improved collaborative working amongst the Diabetes Clinical Leads. The work is already showing positive results, including reducing inter-practice variation and reshaping the support practices receive from the community diabetes services commissioned by the CCGs. We plan to extend this model to all 8 CCGs. Delivery Areas within the NWL STP that focus on diabetes are: DA1: Radically upgrading prevention DA1a: Enabling and supporting healthier living DA2: Eliminating unwarranted variation and improving LTC management DA2a: Delivering the Strategic Commissioning Framework and Five Year Forward View for Primary Care DA2c: Better outcomes and support for people with common mental health needs, with a focus on people with long term physical health conditions DA2d: Reducing variation by focussing on Right Care priority areas DA2d: Improve self-management and patient activation DA3: Achieving better outcomes and experiences for older people 7

8 DA5: Ensuring we have safe, high quality sustainable acute services Our key aims within the scope of this bid are to: Redesign and align diabetes care pathways across NW London using value based commissioning as a vehicle for development of an integrated diabetes team with common metrics and outcomes to better align with NICE recommendations and best practice Ensure patients with diabetes are better supported in the management of their condition by providing training and support to healthcare professionals working with them - support diabetes self-care Improve management of people with diabetes and their carers to delay complications and unnecessary admissions to hospital Encourage and support healthcare teams by improving diabetes knowledge and expertise, networking and sharing of care. Improve consistency in patient outcomes and reduce diabetes related complications Within the CCG Improvement and Assessment Framework, all 8 CCGs are shown to be in need of improvement, with 2 scoring red and 2 amber for the 3 treatment targets, and all but 1 CCG scoring red for structured education attendance. CCG Overall CCG IAF 3 treatment targets Structured education Brent Greatest need for Amber Amber improvement poor participation Central London Needs improvement Green Red Ealing Greatest need for Red Red improvement Hammersmith and Needs improvement Green Red Fulham Harrow Greatest need for Green Red improvement poor participation Hillingdon Needs improvement Green Red Hounslow Greatest need for Red Red improvement West London Needs improvement Amber Red A successful bid would enhance our ability to achieve diabetes transformation at scale and pace with adequate support; we already have all the stakeholder buy-in to ensure the programme is a success. 8

9 Further detailed information on how the diabetes bid links to our delivery areas and enablers can be found below: DA1: Radically upgrading prevention DA1a: Enabling and supporting healthier living The national mandate is for at least 500 people per 100,000 populations to be referred annually into the NDPP by The CWHHE (Central London, West London, Hammersmith and Fulham, Hounslow and Ealing CCGs) collaborative has been one of the most successful partners in the National Diabetes Prevention Programme to date, with over 3826 referrals into the programme and over 1931 accepted for initial assessment since September This is in large part due to the contractual arrangements, IT infrastructure and shared approach that we have developed across a large footprint. Additionally we have submitted an expression of interest to work with the NDPP on the planned implementation and evaluation of digital interventions for diabetes prevention. We intend to build on this work across North West London to ensure that targeted interventions are delivered earlier in the pathway to prevent people developing diabetes. We will be sharing our learning from the NDPP and digital diabetes prevention with the BHH (Brent, Harrow and Hillingdon) CCGs which were not part of the wave 2 sites and support and prepare them to be fit and ready to take on the next wave of NDPP and Digital diabetes bid DA2: Eliminating unwarranted variation and improving LTC management 1. Vastly increase those patients offered Diabetes Structured Patient Education reducing variation within and across 8 CCGs and improving diabetes selfmanagement 2. Embed the use of Diabetes Dashboards to monitor progress and identify variation 3. Supporting primary care with additional specialist staff who can coach and mentor practices GPs and Practice Nurses and help identify patients who need to be reviewed 4. Supporting primary care to modify practice processes to embed protocols and IT processes to manage patients with diabetes better. 5. Collaboration with medicine management teams to implement best practice and achieve better control of lipids, BP and cholesterol 6. Increase Inpatient Diabetes Specialist Nurses to reduce the length of stay. 7. Standardising diabetes foot pathways and delivering specialist diabetes podiatry input at weekends through collaborative working across the whole STP. DA2: Eliminating unwarranted variation and improving LTC management The NWL STP specifically references diabetes as an exemplar in the financial and outcomes benefits that can be attained through better management of long term conditions, using modelling from the Swedish Diabetes Registry and other models to illustrate potential impact through multifactorial risk reduction (HbA1c, blood pressure and lipids) on the incidence of coronary heart disease in patients with diabetes in North West London. DA2a: Delivering the Strategic Commissioning Framework and Five Year Forward View for Primary Care Significant investment in primary care to support a more integrated approach, federation development and self-care programmes. 9

10 In 2016/7 this includes: a. Supporting the development of GP federations, enabling the delivery of primary care at scale important for reducing inter-practice variability b. Developing two clinical pathways (including diabetes) and testing against provider models and outcome-measures. We have initiated this work already with the launch of the North West London diabetes transformation programme. By 2021 this means we will: c. Implement integrated, primary care led models of local services care that feature principles of case management, care planning, self-care and multidisciplinary working d. Integrate mental health and physical health support so that there is a coordinated approach e. Deliver this range of co-ordinated and population-based care through a system of networked hubs, with facility for both physical and digital access by patients f. Enable general practices and multi-disciplinary hubs to access and share digital patient records, including crisis care-plans and LTC pathway management g. Provide access to a spectrum of care, for appropriate population-based interventions for urgent, LTC and on-going care needs h. Develop relevant LTC clinical pathways in light of co-ordinated and proactive care experience. DA2c: Better outcomes and support for people with common mental health needs, with a focus on people with long term physical health conditions The NWL Like Minded Programme s common mental health needs work stream is focused on improving the emotional health of people living with diabetes, including work on integrated IAPT services, GP engagement to assist with case finding and health economic modelling. The work is supported by Imperial College Health Partners, the North West London Academic Health Science Network. Within NWL, Hillingdon CCG is a first wave area where sharing and learning will support and prepare wave 2 sites. We are also looking to extend across NWL the learning from the Diabetes Wellbeing Pilot in Hillingdon and the Diabetes Psychological Medicine Service in Hammersmith and Fulham, which was commissioned to address the needs of patients at the more severe end of the mental health spectrum (including stable psychosis and personality disorder) and has shown substantial improvements in HbA1c (average 22mmol/mol reduction at months) and reduction in service utilisation resulting in cost savings of 1980 per patient. The North West London diabetes transformation programme will ensure that mental health support is an integral part of care delivery for both adults and children and young people as it impacts significantly on various aspects of the bid including achievement of NICE targets, development of foot complications and acute admission and length of stay. DA2d: Reducing variation by focussing on Right Care priority areas By 2020/2021 this means: Patients receive timely, high quality and consistent care according to best practice pathways, supported by appropriate analytical data bases and tools Reduction in progression from non-diabetic hyperglycaemia to Type 2 diabetes 10

11 Reduction in diabetes-related CVD outcomes: CHD, MI, stroke/tia, blindness, ESRF, major and minor amputations Joined up working with Public Health team to address wider determinants of health. This will also allow clinicians to refer to services to address social factors Patients with LTC supported by proactive care teams and provided with motivational and educational materials (including videos and elearning tools) to support their needs throughout their life course. Diabetes is the top focus area for Right Care across NWL as it has been identified as an opportunity in all 8 CCGs. However, the principles, structures, commissioning framework and informatics requirements are readily transferrable across multiple long term conditions including cardiovascular disease (hypertension, AF, CHD, heart failure), respiratory (COPD and asthma) and renal and will allow a rapid extension of this work to the much broader population with one or more LTCs with relatively less resource and project management requirement. The understanding of diabetes as a priority focus has allowed for initial commitment of a Programme Director leading this work from 24 th November until end March Priorities for implementing Right Care have been agreed in Brent as follows: Develop up to date 'directory' of existing services (health & community) for sharing with patients and healthcare professionals to improve care and consistency of care Improve patient peer support, through support groups and diabetes champions Understand & share variation in current GP outcomes, and target support to those practices who have poorer outcomes to help them improve the care offered GP education programme Increase participation in the National Diabetes Audit Develop improved diabetes registers - especially for Type 1 and pre-diabetes These priorities will act as a blueprint and will be aligned with the other CCGs in NWL to ensure that all parties are working towards the same goals. DA2d: Improve self-management and patient activation In 2016/7 the aim is to: Develop protocols for approved health apps to support self-care in collaboration with Digital Health London. This will begin with the piloting of one or more tools for diabetes self-care in at least one CCG in 2017 Develop Third sector programme framework, supporting development of the voluntary sector infrastructure to support self-care Patient Activation Measure (PAM) programme implemented across NW London with target patients receiving assessment and tailored approach to self-care (target 43,920 patients in 2016/7 with expansion to 428,700 by the end of 2020/21). Self- Care programmes delivered in NW London to be aligned to PAM levels, supporting a tailored approach to self-care and a NW London mental health and wellbeing guidance to PAM levels to be developed. Maximise use of patient activation measure (PAM) scoring among people with diabetes in order to stratify and tailor self-care and supported care options. Care planning was established initially through the North West London Integrated Care Pilot (ICP) it is an integral part of the CWHHE Diabetes Enhanced contracts for Primary Care and this learning has been built upon since, with a year of care approach now adopted in the 11

12 majority of CCGs and care planning now an integral part of the CWHHE Out of Hospital diabetes contract. DA3: Achieving better outcomes and experiences for older people Includes the implementation of Accountable Care Partnerships, improvements in rapid response and intermediate care services and improvements in care in the last phase of life. Whilst the implementation of accountable care partnerships based on outcomes based contracts is clearly a priority for elderly care, the accountable care model is also highly relevant to diabetes and other long term conditions, and we are keen to commission an integrated outcomes-based new care model for diabetes across North West London. DA5: Ensuring we have safe, high quality sustainable acute services Our bid includes an increase in the Diabetes Inpatient Specialist Nurses so that we can deliver more effective care to people with diabetes when they are in hospital, thereby reducing risk of further complications we also anticipate that this will decrease the length of stay. The DISN will also work with colleagues in community, primary and social care to optimise discharge for the elderly. Additionally within Children and Young Adult services, improvements in transitional care are essential if we are to ensure continued lifelong engagement with services and improvements in targets across the life course. A 2015 South East Coast and London Children & Young Adults with diabetes survey found: Teenagers comprise 30% of secondary care clinics Teenagers have higher HbA1c Teams struggle with overcoming the traditional adult/paediatric divide Lack of resources Lack of teenage focused training courses/resources For this reason we are exploring the Netherlands Diabeter model which has vastly improved treatment target outcomes in children and young people, as we want to prioritise optimising care for young adults in NWL STP to prevent complications of diabetes. ( NWL STP Enablers Estates Investment in local services hubs across North West London, providing locations for integration of health, social care and voluntary providers to tackle lifestyle factors and improve health outcomes. Workforce By 2020: Using 1.5m Health Education England funding to support new models of care, self-care and LTCs Train up to 180 health and care professionals to support self-care 12

13 Supporting 24 professionals to become health coach trainers to enable patients to take greater responsibility for their health Expand the programme in 2017/18 to develop carers as health trainers Embed the NW London Healthy Workplace Charter to promote staff health and wellbeing initiatives and ambassadorship Digital Digital capability is central to successful diabetes transformation and improvements in diabetes outcomes and consists of four main components: 1) A shared record viewable to all clinicians involved in diabetes care. Within North West London, the CCGs have been working with GPs and community providers to consolidate on two shared records: SystmOne (CWHHE CCGs and some of our community providers) and EMISweb (BHH CCGs and one of the other community providers). In the acute trusts, Imperial College Healthcare NHS Trust (ICHT) and Chelsea and Westminster trusts are now sharing a common Cerner Millennium EPR, with other PAS systems used in London North West and Hillingdon trusts. Work is already underway to integrate these systems via the North West London Care Information Exchange and the North West London diagnostics cloud this will be significantly enhanced with the arrival in 2017 of GP Connect and FHIR interoperability standards allowing real-time viewing of GP records in other systems. Furthermore, NWS NW London has recently been awarded (Estates and Technology Transformation Funding (ETTF) to develop interoperable care planning standards in conjunction with NHS Digital. This builds on extensive work done over the last few years in conjunction with lay members and other patient groups to define the core components of a care plan. Within CCGs, we are already using common shared records (SystmOne and EMIS) across GP Federations where patients are being seen in other GP practices or by community specialists for insulin initiation or other input, and we will be working closely with clinicians to ensure consistency in coding for key diabetes parameters in clinical templates across the different systems. 2) Population health and analytics. There are some key informatics requirements for effective management of diabetes patients across the system using linked primary, community, acute and social care datasets as well as public health intelligence. The benefits of this include: Comparing of actual vs estimated disease prevalence Identification of at risk groups of patients using prediction tools such as the Leicester Diabetes Risk Tool run across a target population Disease management comparison across providers (including GP practices) in order to understand where variability exists and what may be the cause Per patient costing across a population or pathway Proactive care management identification and safety netting of people with out of range results, those who may have been lost to follow up or those not actively engaging in care. Trend analysis to understand whether care and outcomes are improving Predictive modelling for diabetes this would include an analysis of the cost and outcome implications if treatment was improved e.g. if all providers improved to 13

14 the 95% centile for NICE treatment targets Intelligence gathering understanding over time the real implications of differences in achievement of treatment targets within the population (the Scottish and Swedish Diabetes Registries are prime example of this) For patients how am I doing compared with other people and what is my risk? This would allow focussed targeting on highest risk patients e.g. those with HbA1c > 75 and end-organ damage or recently diagnosed patients with HbA1c > 48. Support for further development of population health capability was included in the successful joint ICHT and Chelsea and Westminster Global Digital Exemplar bid. 3) Patient facing records: The aspiration is for the patient to be able to achieve the following: View their own GP clinical record (Patient Online) View their diabetes record in context using the latest data from multiple systems where needed (My Diabetes, My Way is an option we are considering) Interact with the wider care team digitally (including care navigators and health coaches) Access information about their own condition (including diabetes), ideally in their own language and with culturally appropriate changes Upload glucometer data where needed Use apps to help manage their health and wellbeing including integration with activity trackers and smart scales. 4) Robust information governance: The North West London care community already works closely together on IT, co-ordinated by NHS NW London CCGs, with a Chief Informatics Officer and digital team working across all 8 CCGs and a high degree of collaboration between the individual clinical leads for both IT and diabetes. The monthly NWL Digital Design Authority is attended by commissioner and provider leads,, reporting to the NWL Digital Programme Group (where all commissioners and health and social care providers are represented) and from a commissioning perspective feeds into the NWL CCG Collaboration Board and individual CCG IT committees. North West London Digital IG Governance Group (NWL Digital IG GG) was established in January 2015 and is made up of IG experts from across health and social care. The group oversees and supports the NWL Digital Information Sharing Protocol and related Information Sharing Agreement, maintaining the secure sharing of information for all partner providers and the programmes noted within, supporting the established governance model of data controllers in common. This group also drives the digital information governance agenda locally and provides assurance to the NWL provider partners by working collaboratively to implement information governance best practice mechanisms across organisational boundaries. North West London is cited as an exemplar of good practice on page 27 of the National Data Guardian Review of Data Security, Consent and Opt-Outs (2016) 4/data-security-review.PDF 14

15 North West London Local Digital Roadmap work streams that link with this bid include: Automate clinical workflows and records, particularly in secondary care settings; to support transfers of care through interoperability (including fully digital ordering and reporting of diagnostics), thus removing the reliance on paper and improving quality; Build a shared care record across all care settings to deliver the integration of health and care records required to support new models of care, including the transition away from hospital; Enable Patient Access through new digital channels and extending patient records to patients and carers to help them become more involved in their own care including novel ways to access care such as virtual consultations; Provide people with tools for self-management and self-care, enabling them to take an active role in their care and wellbeing; Use dynamic data analytics to inform care decisions and support integrated health and social care, both across the population and at patient level, through whole systems population health intelligence. 9. Please set out details of your engagement with each of the following during development of this bid a) Please set out what engagement with primary and secondary care clinicians (taking adult and children s services in account as appropriate), has taken place during the development of bids within each intervention area selected and whether they are supportive of the improvements and actions proposed. b) Please set out what engagement with provider organisations has taken place during the development of bids within each intervention area selected and whether they are supportive of the improvements and actions proposed. c) Please set out what engagement with relevant local patient groups has taken place during the development of bids within each intervention area selected, whether they are supportive of the improvements and actions proposed and any plans for continuing engagement if this bid is successful. Appraisal dashboard criteria reference(s): All relationship risk 9a) Engagement with primary and secondary care clinicians Over the last 3 years there has been significant collaborative effort across all primary and secondary care clinicians within all CCGs to try and work together to improve diabetes care in order to reduce complications, improve outcomes and reduce expenditure. We together planned an event in November. Following the incredibly well attended and successful NWL diabetes stakeholder event in late November, (over 100 clinicians and managers and people with diabetes) it became clear that there was substantial appetite to work collaboratively on diabetes across the NWL STP footprint. 15

16 When the bid paperwork was released shortly before Christmas, we implemented our Bid development Communication Strategy. This was led by our Clinical Director and Programme Director and consisted of weekly meetings with leads from each of the 8 CCGs. Those leads in turn cascaded information in each of their CCGs to Senior Managers, senior clinicians, provider leads, voluntary sector, council members and patient groups. Collating all these (now over 200) contacts allowed us to work quickly, eliciting comments and gaining support from all sectors with one master mailing list. This will be the basis for implementation of the programme. 9b) Engagement with provider organisations Provider leads and STP leads have been sighted on early drafts of this bid and commented and supported it whole-heartedly. They also attended and participated in the event in November. 9c) Engagement with relevant local patient groups Local patient groups and individual people with diabetes who work as advocates for the wider diabetes population have had sight of this bid and usefully commented, often things we had not made clear. Our local Diabetes Patient Focus group sent comments. We have also engaged with London Diabetes Network, and for children s diabetes services we have collaborated with the Healthy London Partnership Children and Young Peoples Long term conditions Programme lead (who is also a nurse and parent of a child with diabetes). As well as the Lead for the London and South Coast Children and Young Peoples Network, JDRF all of whom are fully supportive of the approach being taken. We have had bid writing teams working on each section and then the Clinical Director and Programme Director have collated this. Even with such a short turnaround for such a substantial area, there has been an overwhelming response from commissioning leads, clinicians from primary and secondary care, provider management, public health teams and patients to pull together in a collaborative process to write the document. Since the November workshop we have had weekly meetings with the CCG Diabetes Leads in each CCG to develop our common understanding of working together as 8 CCGs, developing a strategic vision set out in this document, supporting each other with pieces of work relating to the bid production and other aspects of diabetes improvement work. We have openly developed a SWOT analysis across all 8 CCGs to assist with implementation of the Programme. We have collectively focused responses to the bid through one Programme Director, who is leading this collaborative working. As part of the overall programme plan that is being developed communications and engagement will be a key enabler to ensuring on-going buy-in to the work. This is in place through CCG diabetes engagement leads and will be a key component of the implementation. Due to this high level of clinician, management and patient engagement we believe that we have a huge opportunity to achieve something truly transformational at scale for 140,000 16

17 people with diabetes. In preparation for this bid being successful we are all working together in the following areas to develop a new outcomes-based model of care for diabetes: Achieving effective clinical and patient participation Engaging the local community Engaging local GP practices individually as well as through federations and clinical commissioning groups (CCGs) Ensuring that we build in understanding of the different needs of our diverse population, and segment into different population groups, to design and implement the new diabetes care model Work with social care teams on the development of the model Maximise prevention and wellness opportunities Systematically plan, schedule and manage the implementation of the changes in line with the emerging design specifications, and the value proposition timetable Generating timely monitoring and evaluation loops covering (a) initial implementation of change, broken down change-by-change, team-by-team; (b) the on-going management of the services; and (c) the quantified impact on outputs and outcomes. Developing a clear understanding of the different costs, the expected throughputs, and the methods for selecting patients for proactive case management. Commissioners are deciding which budgets should be brought together and how they can be transferred to providers under a single contractual framework. Partnerships and organisational forms among providers - assessing which providers should hold the budget for services and how they should be organised to deliver more integrated services. Exploring a range of options, including sub-contractor relationships, joint ventures or mergers. Governance, decision-making and management of providers systems; Providers are starting To consider the governance and decision-making arrangements needed to manage care and quality effectively for example, how to ensure that each partner delivers their commitments, how to promote effective joint working, and how to motivate teams and individuals to work differently. Approaches to measuring and incentivising performance - As part of the contracting process, commissioners and providers are agreeing objective measures to assess the quality and outcomes of care. They are also considering options for motivating and incentivising performance. Building collaborative leadership around a shared local vision based on a new clinical model. Establishing a transparent governance structure so that everyone knows how decisions are made, and to ensure collective responsibility. Roles of commissioners in the new system - Commissioners are considering their future role in overseeing more integrated systems, including which activities they should continue to carry out and which to share with or transfer to providers. They are working towards commissioning for outcomes. Creation of a dedicated PMO / engine room to drive and manage the local transformation programme, with adequate dedicated resources and capabilities. This requires our best people. Developing and maintaining a clear and explicit description (a logic model ) that explains how the proposed transformations in care are intended to lead to the outcomes that the new model of care wants to achieve. Logic models provide a simple visual means of showing complex chains of reasoning. Establishing the 17

18 financial case (a value proposition ) for developing the new model of care. Commit to a clear return on investment, so that there is a compelling and credible proposition for service change. This includes setting out how the new model of care will help moderate demand, and increase provider efficiency. It has to fit with the NWL sustainability and transformation plans (STPs). Designing and documenting each of the specific component parts of the care redesign. This includes clinical and business processes and protocols, team design and job roles. Commissioning and contracting for the new model, so that organisational forms and financial flows are supporting our goals rather than hindering progress. 18

19 10. Describe how local governance, oversight and implementation arrangements will oversee and support delivery of each of the priorities and key outcomes within the timescales described above, including: a) How they will monitor progress and take corrective actions as necessary. b) How there will be ongoing input from relevant clinicians and from people with diabetes to the governance arrangements. Please specifically refer to how the governance, oversight and implementation arrangements will operate with regard to the each of the priorities for which funding is sought. Appraisal dashboard criteria reference(s): All - clinical outcomes, safety/quality and sustainability 10a) How they will monitor progress and take corrective actions as necessary. All 8 CCGs (including Public Health and Councils) in NWL STP have a shared vision for diabetes. We are now beginning to use an integrated approach between commissioners, longestablished high quality diabetes service providers, patient groups and council staff to work together using a life-course approach to the same clinical and patient reported outcomes. We will focus improvements on outcomes, improved quality of efficient communication, and reduced duplication of tests. This governance plan covers Structured Education, improving the three treatment targets and both DISN and MDFT bids. They are a part of the NWL Diabetes Transformation Programme. Our strategic aim with this programme is to develop diabetes as a single service specification across NWL delivered by one or more Accountable Care Partnerships with a capitated budget and one NWL STP diabetes team. We will commission the NWL Diabetes Team through a partnership agreement with a shared governance approach. This team will coordinate and be ultimately responsible for the delivery of outcomes across all primary, community, secondary care and council providers. To develop this, a Programme Team is meeting weekly, representing all 8 CCGs. This group will lead the transformation and re-organisation whilst reporting to a Strategic Programme Board all parties will be responsible for redesigning of services and the development of actual costs, refined local costs within contracts in order to ensure outcome delivery. This integration aims to streamline processes, reduce duplication, improve communication and deliver cost-effective, evidence-based, patient-focused diabetes care. We plan that a Diabetes Consultant as joint Strategic Clinical Lead with our Primary Care Clinical Lead, supported by managerial support from Programme Director. Strategic Board will be chaired by the Strategic Clinical Leads, and this Board will be accountable for the provision of robust and integrated diabetes services as defined by NICE, the Diabetes Guide for London, clinical governance and quality arrangements in addition to the comprehensive engagement with partners, both providers and commissioners. The Strategic Board will be responsible, for ensuring issues identified by any partner are 19

20 dealt with in a timely fashion and are resolved to mutual satisfaction. They will also be responsible for ensuring corrective action is taken and will have responsibility for coordinating on-going service developments with partners in a proactive way. 10b) How there will be on-going input from relevant clinicians and from people with diabetes to the governance arrangements. Programme Governance: The North West London Diabetes Programme Board is led by the NW London Diabetes Clinical Lead and Programme Director with clinical and management leads from all 8 CCGs and Specialist Care, Community Care and Primary Care providers together with lay representatives. ACP Governance: 3e ACP governance.pdf In the programme governance plans there are designated joint operational clinical leads (Diabetes Consultants) for each provider, these Consultants have dedicated session in their job plans to ensure the success of this integration. They will work at Tier 4 and 3 and will support GP practices through specific virtual clinics, mentoring and coaching clinics and specific structured training. This Consultant level leadership will be essential for ensuring the requirements are met. They will be pivotal in setting up operational plans to deliver on the objectives and liaising with the commissioners on clinical issues. The clinical leads will be held responsible for delivery on the objectives and this will form part of their appraisal. The Lead Provider would be accountable for stakeholder satisfaction related to the Diabetes service, including GP practices. GPs, along with patients are the key 20

21 stakeholders in our hospital (Tier 4) and community (Tier 3) service and patient satisfaction is paramount. People with diabetes will, along-with clinicians, sit on each of these groups. Clinical commissioners would also continue to maintain high-level responsibility for overseeing payments, contracting and system architecture. In the longer term, the commissioners will transfer whole population budgets to providers, who would then be responsible for allocating them across services in order to improve outcomes. We will retain oversight of particular operational decisions within the provider system for example, whether to be able to veto decisions that might undermine the cost base and viability of a provider, or decisions by a lead provider to stop sub-contracting particular services and bring them in-house. CLINICAL GOVERNANCE, PERFORMANCE & QUALITY ( All 4 bids) It is likely we will use the Lead Provider or Lead Providers model for the new care model. The Lead Provider/s will be accountable for robust clinical governance and quality arrangements, across all organisations. The partnership of key providers offers a unique opportunity to capture learning and bring about service improvement. The Lead Provider/s will subcontract to other partners who will have a contracting mechanism in place to ensure that all sub-contractors have robust, appropriate arrangements in place for the delivery of key performance indicators relating to the diabetes service. The NWL STP Diabetes Strategic Board / Steering Group will oversee this. The Lead Provider/s will have transparent reporting of clinical governance indicators and quality assurance, which meet the specification requirements and offer a sound basis for further development to encompass the wider integrated Diabetes service across NWL STP. Risk and incident review will be fed into the NWL STP Diabetes Operational Board / Implementation Group to monitor governance issues, identify trends and agree actions to address poor performance. We will identify a senior governance facilitator, who reports on all registered incidents and ensures actions are identified to this Board. These Boards will be led clinically but supported by managerial leadership. The Lead Provider/s via the Strategic Board will be accountable for ensuring that clinical incidents are dealt with safely and that lessons are learned within all providers. As all partners are represented in the Strategic Board, this structure will ensure shared learning across the sector with overall improvements for the health economy. Clinical Director level attendance (or equivalent) will be expected from each partnership organisation. All provider partners will be expected to comply with policies and procedures on the management and reporting of all incidents, serious incidents and near misses through a comprehensive incident reporting system supported by the senior governance facilitator. Incidents will be reported and investigated locally within each provider organisation as per normal routine practice, but will be reported simultaneously to the Strategic Clinical Lead and the Programme Director, who will monitor these and present a summary of incidents and learning to the Strategic Board to allow transparent scrutiny of partner response and shared learning. The Lead Provider will ensure all providers have an integrated approach to learning from incidents related to the integrated diabetes service to improve and assure services, whether clinical or non-clinical. The Clinical Lead will be responsible for commissioning the appropriate data flow and audit structures in each provider organisation including GP 21

22 practices as defined necessary by the Strategic Board. All providers will retain responsibility for ensuring mandatory training and annual appraisals are carried out and the Diabetes managerial staff will assist in competencies and objective setting to ensure staff can deliver on the outcomes required. STRUCTURED EDUCATION ( See above diagram) The Chair of the Structured Education Project Group is responsible for linking into the governance processes, and has an oversight role to achieve the key outcomes of the group. They also lead the implementation. This group is represented by CCG Diabetes Leads, senior clinicians, people with diabetes ensuring that those from disadvantages groups are well represented. 3TTs The Chair of the Clinical Transformation Project Group is responsible for linking into the governance processes, and has an oversight role to achieve the key outcomes of the group. They also lead the implementation. This group is represented by CCG Diabetes Leads, senior clinicians, people with diabetes ensuring that those from disadvantages groups are well represented. DISN The Chair of the Clinical Transformation Project Group will ensure we transform inpatient care. MDFT The Chair of the Clinical Transformation Project Group will ensure we transform diabetes foot care within MDFTs. In summary, the Board along with robust governance processes will be responsible for assessing the health needs of the population, setting appropriate objectives for the provider system, overseeing performance, and holding the provider system to account for its overall use of resources. 22

23 11. Describe how you plan to increase participation by GP practices in the in the National Diabetes Audit to 90% by 2018/19 and when you aim to achieve this by (In CCGs where <25% of practices participated in the 2014/15 NDA, the plan should also include how participation will be increased to significantly above 25% by 2017/18). Appraisal dashboard criteria reference(s): All patient experience NDA / NPDA participation will be embedded as a core contractual requirement in the service redesign across North West London. Additionally, we will increase the participation in NWL to greater than 90% by March 2018 by supporting practices to participate, we will do this through Ensuring understanding of the process locally Support and education of the importance of this linkage for clinical care and new uses for this data in CCG IAF reporting IT linkage IT staff will help any struggling practices to link this model was used in Camden and moved participation rate up considerably. Implement population health model, which would just need one feed from NWL rather than from all GP practices (380 +). Within the CWHHE Collaborative ( 5 of the 8 CCGs), participation in the National Diabetes Audit is part of the Out of Hospital Services contract, which has resulted in a significant improvement in participation rates, and we will continue to work on getting the last few remaining practices to participate this year. Key to this is our integrated population health solution. Three of our CCGs that were low on NDA participation have also made significant improvements recently: 1. Hillingdon: In Hillingdon CCG, this requirement will be embedded from 2017/8 in the enhanced diabetes primary care contract. 2. Brent: Brent CCG is working with the Local Medical Committee and GP practices on an action plan to increase participation. It was recognized in Brent, that the lack of the NDH register was, one of the reasons, for not being successful in the NDPP bid. They are working on rectifying this. Participation in the CCG wide NDA register has improved this year in Brent. Brent has set itself a target of achieving at least a 90% participation rate in the current year. They are developing ways of achieving this, including IT help to get practices to sign up, and other incentives. They are planning to work with their integrated diabetes service, and the audit team, to develop the NDH register, over the next 6 months. 3. Harrow: Harrow CCG has made considerable progress, with participation rates increasing from 17% in 2014/5 to 79% in 2015/6. All 8 CCGs will communicate with practices regularly via , practice newsletters, locality subgroups and reminder phone calls during the last weeks before submission, highlighting the importance and benefits of registering with the programme. 7 out of 8 CCGs now have NDA participation levels above 75% (2 at 100%) with commitment by the 8 th to increase participation substantially for the 2016/7 audit. 23

24 24

25 (1) Complete this section as part of your application for funding to increase attendance at structured education Please expand the boxes below as required for your answers. Please use this sheet to describe your detailed implementation plans to increase attendance at structured education. Where there is more than one CCG covered by this aspect of the bid and the analysis of issues and proposed actions differs between CCGs (or groups of CCGs), please duplicate and complete separate copies of the this section for each CCG/Group of CCGs as appropriate. Please note: the modelling of the costs and savings have been developed from the evidence base on face to face structured education. 1. Please set out the CCGs that are bidding for funding with respect to this priority. Eight CCGs in North West London are bidding together, they are; Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Central London and West London CCGs. Within the CCG Improvement and Assessment Framework, all 8 CCGs are shown to be in need of improvement, with all but 1 CCG scoring red for structured education attendance. CCG Overall CCG IAF Structured education attendance Brent Greatest need for 6.0% improvement poor participation Central London Needs improvement 0.8% Ealing Greatest need for 1.1% improvement Hammersmith and Needs improvement 0.7% Fulham Harrow Greatest need for 0% improvement poor participation Hillingdon Needs improvement 1.5% Hounslow Greatest need for 1.4% improvement West London Needs improvement 0.8% Our strategic aim is an integrated NWL STP Diabetes Transformation Programme that reduces variation at all levels, practices, providers and CCGs. This includes a workstream on Structured Education, and we detail below the workstream. We share one Programme Team thereby having economies of scale in the implementation stage. 25

26 Operational Division Specialist Health Professionals Sign Posting Disease Specific/ Symptom Management Information and Communication End of Life Tele-health In NWL STP we have 134,200 people with diabetes. Diabetes accounts for approximately 10% of the North West London health cost, 29.4% of emergency admissions and 28.3% of NWL bed days. Over 25,000 patients with diabetes across North West London are living with poorly controlled diabetes (HbA1c >64) and around 55% of these are under the age of 60. This translates into substantial numbers of complications and admissions due to complications over 70,000 bed days for some of the more common diabetes cardiovascular complications. Below we recognise the complexity of self-management Diabetes Clinical Networks Diabetes Care Pathways Patient/Family/Carer Disease Specific and Generic Equipment Key Stages of Support Health Professional Disease Specific and Generic Education (condition impacts pre diagnosis) Patient Family Carers Diagnosis Living for Today, Transitions and Progression Symptom Management Self Care /Action Plans Support Networks Self Monitoring Buddying Voluntary Organisations and Support Groups Carers Support General Practices Community Health Partnership Social Care Services Allied Health Professionals 2. What is your understanding of the reasons for low uptake of, and where relevant low completion of, structured education for Type 1 and Type 2 diabetes and for adults, and for children/young people, in your area, including: a) Identification of specific population groups and GP practices from which attendance is low and consideration of the reasons why. b) Feedback from patients on reasons for non-attendance and what could help improve attendance? Appraisal dashboard criteria reference(s): Structured Education (SE) clinical outcomes, patient experience and safety/quality 2a) Identification of specific population groups and GP practices from which 26

27 attendance is low and consideration of the reasons why. At present the attendance data from all 8 CCGs are so small that it precludes statistical analysis. In reality, we know that attendance is likely to be somewhat higher than this and the current figures reflect under-reporting and poor coding by the providers. For example, we have recently found examples of coding structured education attendance in one of our providers as Dietary advice given. We are now working with them to ensure uptake of the standardised NDA coding set. Analysis of the data for coding of referral into structured education across our practices reveals a number of points: 1) There is a huge variance in referral coding, from 0 to 100% of eligible patients coded as referred 2) There is very poor correlation between coding of referral and either completion of the 9 key care processes or achievement of the NICE treatment targets (correlation coefficients 0.37 and 0.47 respectively) 3) There is some inter-ccg variability and this may reflect awareness of structured education courses or whether an individual CCG has focused on increasing awareness of its importance. 4) Since adding a requirement for coding structured education referral to the CWHHE Out of Hospital Services contract 6 months ago, coding (in part likely to reflect increased referral) has increased by 14% (48% to 62%) and is likely to increase further before the year end. From discussions with clinicians there is a perception that structured education is of limited value, there is sometimes confusion about how to refer and patient feedback has not always been very positive locally. 2b) Feedback from patients on reasons for non-attendance and what could help improve attendance? Our understanding of the reasons for poor uptake include (from recent patient survey, commissioner and provider feedback): Limited non-english course capacity Limited success in engaging hard to reach groups Disruption in one-step referral for structured education due to introduction of a new referral management service in some areas, leading to a less efficient and delayed referral pathway which may also impact attendance rates In one CCG capacity is still relatively low due to high prevalence of diabetes (25,000+ T2DM patients) Relatively poor engagement from young type 1 diabetes patients feedback was that we need to try something different for this cohort Limited structured educational resources for children and young people. There is a need for a more individually tailored approach based on Kaufman competences which dictate the education needs primarily with modifications based on how the family learns and what health beliefs they have. Working age people often find attendance difficult, particularly where there is little flexibility on course times Some people from certain ethnic groups find the stigma of a diabetes diagnosis within their cultural framework difficult to accept and therefore struggle with accepting outside help and input for this diagnosis. 27

28 Lack of outcome data on effectiveness in different cultural/ethnic groups Lack of separate funding for Type 1 structured education (e.g. DAFNE) Another CCG reported that their capacity relatively low due to high prevalence of diabetes - DESMOND courses in Hillingdon are at capacity running 3 full day sessions every month apart from August, and this just sees newly diagnosed leaving a huge gap in the on-going or BME education and diabetes prevention. Lack of outcome data on effectiveness in different cultural/ethnic groups No NDPP work via national programme in Brent, Harrow and Hillingdon Limited venues to run DESMOND No group insulin start sessions No separate SE sessions for transitional type 1 diabetes (DAFNE adapted for teenagers) Variable referral rates from practices; need to monitor numbers of newly diagnosed to number of referrals to see what percentage of newly diagnosed population is being referred in. Variable referral rates from practices; do not monitor numbers of newly diagnosed to number of referrals to see what percentage of newly diagnosed population are being referred in. 3. Describe the current funding arrangements for this service (e.g. Do the courses have bespoke funding or are they funded via a wider contract? Is payment of providers linked to attendance/near completion of attendance or to coded reporting of attendance to GPs? Is there the ability to flex the no. of places provide up or down according to demand?) Appraisal dashboard criteria reference(s): SE sustainability and resources CURRENT STATUS IN NWL STP The current provision for 140,000 people with diabetes is woefully inadequate. We have a long way to go to improve the invite, attendance, completion, attendance and then recording of Structured Education in NWL STP ( as shown above in the CCG IAF results) To reach capacity for Type 2 diabetes Structured Education across the 8 CCGs we will need to have education programmes running daily (each session only covers 20 people). This will still only cover those diagnosed in last year. Most funding is within block contracts and it is generally not monitored for uptake. There is no funding for Type 1 diabetes education e.g. DAFNE. Payment is not linked to attendance, completion of attendance or to coded reporting of attendance to GPs There is currently no ability to flex the number of places we provide up or down according to demand A fairly typical example of how one CCG funds SE can be seen below: For the community provider (CNWL) in Hillingdon, DESMOND is funded as part of the diabetes block contract. They run 3 courses per month (apart from August (1 course) and December (2 courses)) including 3 weekends per year. Each course can have 10 patients attend. Payment is not linked to attendance. 28

29 No ability currently to increase number of courses. However for non-english speakers or those with disabilities, individualised 1 hour education sessions are ran and the number of sessions is flexible and average 4-6 per month. Only currently accept referrals for new diagnoses (1st year of diabetes) for DESMOND. For secondary care in Hillingdon there is funding directly for DAFNE to run approximately 3 times per year, GPs are informed if their patient does not attend DESMOND. 4. Describe how you plan to improve reporting of attendance and completion of courses including any plans to: a) Support accurate recording of attendance, such as by requiring coded reporting of attendance for use on primary care information systems. b) Link payment of providers to attendance or near completion of attendance at structured education, including coding reporting of attendance. Appraisal dashboard criteria reference(s): SE cohort size, clinical outcomes and resources 4a) Support accurate recording of attendance, such as by requiring coded reporting of attendance for use on primary care information systems. We are bidding to improve our referral, uptake and offer of Structured Education within the 8 CCGs of North West London CCG. This includes plans for accurate recording of attendance on our population health system, using the national agreed SE codes and processes. Providers of Structured Education will have direct access to this and it will be back populated into GP systems to reduce burden on GP Practices. Evidence clearly demonstrates the positive impact of sustained behaviour change support and People engaged on lifestyle intervention support lost 8.6% of body weight 1. A systematic review in BMJ identified that those with behavioural interventions centered on physical activity and diet achieved an incremental 1.56% sustained loss in body weight 2. Another systematic review and meta analysis published by Diabetes Care found that using behavioural interventions increased physical activity generating improved HbA1c and BMI 3. Professor Roy Taylor has published that individuals have their own Personal Fat Threshold, noting that 1 3 of those in UKPDS who developed Type 2 had a BMI below 25, but outcomes improved for all with weight loss 4. A systematic review of interventions to increase physical activity and improve HbA1c identified five specific behaviour change techniques that addressed both 5. 4b) Link payment of providers to attendance or near completion of attendance at structured education, including coding reporting of attendance. Within the new contracting process across the 8 CCGs where we are developing a new care model we will; Contract via an integrated outcomes-based new care model (single capitated budget and set of outcomes) 29

30 Commission diabetes care at scale across all 8 CCGs Commission to build in support to primary and community care to reduce variability of structured education on offer across the health economy Greater collaboration between sectors to support patients to receive education where it best suits them We have also had positive discussion with South London to allow patients to attend education there (e.g. if that s where they work and it is more accessible). 5. Describe your proposed implementation plan including; a) Describing the initiatives you plan to put in place to increase uptake of structured education and completion of attendance at the course, across all relevant ages addressing the issues identified in Q1 above and taking into account relevant other evidence. b) Consideration of how to support GPs and providers to work with patients to maximise attendance. c) Whether you plan to focus on the newly diagnosed or prevalent diabetes populations across all ages (or a combination). d) Why you consider the proposed levels of increase in structured education attendance will be sufficient to reflect the number of diabetes patients that need to attend the course. e) Whether there will be the ability to flex the number of places provided up or down according to demand. f) Describing how you plan to develop the workforce involved in delivering structured education so that the expansion of education provision does not reduce the capacity of existing specialist diabetes clinical staff to deliver other key duties associated with their role. (It should be noted that the potential for developing digital structured education options are being separately considered. This bid should focus on face to face structured education.) Please also use the table below to outline the specific actions, who will be responsible for delivering these and the expected timescales for completion. Appraisal dashboard criteria reference(s): SE clinical outcomes, safety/quality and resources 30

31 5a) Describe initiatives to increase uptake of SE We will begin by systematically evaluate current NWL SE programmes in terms of both uptake and outcomes to encourage sharing of best practice. Work with local authority Public Health teams to pilot the use of behaviour change techniques in promotional material (including the One You campaign and social media) and invites to increase uptake into structured education. Our approach supports the findings of Taking Control: Supporting people to self-manage their diabetes (All Party Parliamentary Group for Diabetes, 2015). We have conducted stakeholder engagement to advise and inform our proposals. The National Diabetes Audit data informs us there is variation in referral rates both across and within the North West London STP footprint. Attendance rates for Type 1 education are largely unavailable. Type 2 education referral rates are generally in line with or slightly above the national average but with attendance rates showing marked variation from less than 5% to just below 25% at a practice level. We are currently not providing the appropriate skills to enable self-management to at least 70 per cent of people with Type 1 and Type 2 diabetes. Evidence shows that structured patient education can stabilise blood glucose levels, reduce the risk of diabetes-related complications, improve quality of life for patients and their families, and reduce the burden of healthcare costs on the NHS. Where diabetes education is signposted, people affected by the condition are often given little information or explanation about the aims and benefits of attending and consequently many people reported doubts about the usefulness of the programmes available. The X-PERT Diabetes programme found that when people are offered education in a positive manner, up to 75 per cent choose to attend. (All Party Parliamentary Group on Diabetes, 2015). Additionally, we have achieved remarkable success over the last few months with the National Diabetes Prevention Programme locally using a system-wide approach across the CWHHE collaborative - a single standardised mailshot from individual GP practices inviting patients to ring the provider. For the prevalent population, a similar phased approach for increasing uptake would be adopted. Based on these findings, this structured education bid is composed of two interrelated elements to meet the needs of both newly diagnosed and prevalent diabetes population for adults and young people in transition (note a phased approach would be taken to meet the North West London (NWL) Local Services programme aims to improve the quality of care for individuals, carers and families. Through supporting patients to maintain independence, we hope they will lead fuller lives as active participants in their community. In NWL, we have identified a particular need to improve how we care for patients with long term conditions (LTC s). Our aim is to increase support for self-care through a collaborative relationship with our patients, supporting them to become active partners in managing their own health and wellbeing. It is known that increasing a patient s activation, improves their ability to selfmanage. STRUCTURED EDUCATION OPTIONS We plan to commission a range or menu of structured education options and will refer people into this dependent on their PAM level. Those at the higher PAM levels will be offered telephone +/- face to face individual / group coaching if lower PAM / needing support to make lifestyle change. 31

32 We will offer fitness trackers feeding data into our Diabetes Digital Innovation Centre supporting change. Some patients may need ongoing lifestyle change support following the structured education programme and doing this digitally for many would reduce costs and probably increase effectiveness. The following menu of Structured Education options and support that will be available to people with diabetes in NWL STP will be: 1. X-PERT 2. DESMOND 3. DAFNE 4. BERTIE 5. HELP diabetes As well as spreading the use of: Conversation maps Eating Blueprint Linking with other initiatives such as Healthy Hearts, an intensive lifestyle management programme commissioned by Public Health Diabetes champions and mentors Exercise on prescription And lastly online options (for example / Changing Health / OurPath / Oviva. (These are digital programmes consisting of various combinations of app, web portal, fitness tracker and Wi-Fi scales along with telephone / in-app coaching. Due to the volume (140,000 people with diabetes in NWL we will also need to consider rolling out digital education at scale. 5b) Consideration of how to support GPs and providers to work with patients to maximise attendance. 5 bi) Patient Activation Measure In NWL, through a competitive bidding process, we have successfully secured Patient Activation Measure (PAM) licences from NHS England, initially for 44,000 patients across the eight Clinical Commissioning Groups (CCGs) in 2016/17 and increasing incrementally to all patients with a LTC by 2020/21. Therefore we plan to Use Patient Activation Measure to establish the most appropriate Structured Education offering that is right for the person with diabetes, at this time. 32

33 Level 1 Level 2 Level 3 Level 4 What is PAM? Patient activation is defined as an individual s knowledge, skills and confidence for managing their health and healthcare. The PAM score is produced through a patient s responses to 13 statements scored on a 100 point scale and then assigned to one of four levels of activation giving an indication of a patient s health style. Depending on the PAM score we will direct people to the most appropriate Structured Education offering, that is right for them, at this time. Overwhelmed & disengaged Becoming aware, but still struggling Taking action and achieving many behaviors at guideline levels Maintaining behaviours and pushing further How will this improve care in North West London? A tailoring tool PAM levels can be used to support professionals to tailor their approach to patients, enabling them to become successful self-managers. An outcome measure PAM can be used as a patient centred outcome measure to evaluate whether our services are being delivered successfully and to influence future commissioning decisions. Evidence suggests that supporting patients to increase their activation level improves clinical indicators (e.g. HbA1c, blood pressure and cholesterol), leads to more appropriate use of health services and reduces costs to the health system. Five year ambition for PAM in North West London Patient activation features heavily in our Sustainability and Transformation Plan (STP). By 2020/21 our aim is for all patients with a LTC in NWL (430,000 patients) to have a PAM assessment and their care tailored accordingly, leading to an increase in activation levels across the population of NWL. We know we can improve the control achieved by people with diabetes though education and behavior change support. In so doing, we also know we can reduce the costs of treating complications at both primary care and acute settings. The graphic below illustrates that if we reduce the HbA1c of a 40 year old by 1%, we can save 25,000 on complications alone. Prescribing savings come on top of these. The evidence base for people to receive education and self-management support is overwhelming e.g. X-PERT generates a reduction in HbA1c of 1.4% while UKPDS identified that for a 1% reduction, a 37% fall in the microvascular complications, 43% fall in amputations, 22% reduction in deaths, 14% reduction in heart attacks and 12% fewer strokes are achieved. 33

34 5b ii) Structured education should be embedded in clinical transformation as a part of treatment 1. We will develop a script that receptionists, practice nurse, GPs or others can use to encourage people with diabetes, to attend structured education it will ensure that SE is seen as part of treatment. 2. We will train staff and patients about PAMs 3. Structured education is part of the care planning data set 4. We plan to have a single point of access, for all aspects of diabetes including structured Education this will build on learning locally for a similar SPOA for MH care. 5. Improve the knowledge and understanding of GP practice staff of diabetes and the benefits of structured education 6. Support practice with coding but also allow providers of structured education to input to the clinical record (EMIS or SystmOne) so that practice staff don t need to do this. 5b iii) Supporting GPs and providers to make more effective referrals to structured education. The HIN (AHSN) in South London are seeking to improve referrals to structured education by supporting the designing, commissioning and delivering an elearning tool that will be used to educate primary care clinicians. We would hope to also use this within NWL STP. It is anticipated that the increased understanding of GP practices of the importance of Structured Education will result in more referrals translating to actual attendance. This education will focus on: General information about Type 1 and Type 2 diabetes General information about the content of a structured education course Outcomes associated with completing a structured education course How to motivate and encourage people with diabetes to attend a structured education course (i.e. meaningful referrals more likely to convert to attendance and completion) The importance of using standardised read codes and submitting data for the NDA The importance of recall, patient reminders, refresher courses and appropriate use of social media Understanding options available for people with diabetes to meet cultural needs and whose first language is not English Knowledge of the referral mechanism to the Structured Education Hub 34

35 5biv) Supporting GPs and providers - Incentives and/or payment for primary care There have been multiple discussions, both formally and informally over the past several months about how we will address diabetes as part of the STP work on unwarranted variation. The emerging consensus is that a robust care coordination function for people living with diabetes and other long term conditions / frailty can best be built at the primary care level. This represents a relinquishing of control by the CCGs through possible delegated commissioning and acceptance of the need for a new level of up-front investment in primary care. We are proposing a whole new type of diabetes programming and are confident this model will become a UK wide best practice standard for patient prevention and self-management. These sustained proactive interventions in diabetes care will be a departure from the current volume-driven, reactive approach that is currently dictated by piecemeal reimbursement. The NW London diabetes programme will explore new value based payment methodology. These include wrap around quality bonuses, bundled disbursements and capitation payments. We intend that GP practices will be incentivised: To complete the elearning module / understand better the importance of structured education To case find patients who have not attended structured education To refer into the Structured Education Hub. 5bv) Supporting GPs and providers - Diabetes Community Champions / peer educators / mentors We plan to expand on and extend the role of diabetes community champions*, peer educators and mentors as a fully integrated part of the NW London care team together with technology enabled supported self-care, creating a highly effective and scalable diabetes education programme intersecting two complementary interventions - digital technology with grass-roots outreach. We are excited about this model as a catalyst to empower people in North West London to have more involvement and control over their diabetes management and care. We envision these combined interventions as having powerful population health impact that will support primary care to deliver care to patients closer to where they live. *(

36 5bv) Supporting GPs and providers - More systematic self-care support Due to the volume (140,000 people with diabetes in NWL we will also need to consider rolling out digital education at scale. Our plans are: Digital self-care support: Provision of digital tools to support those that can selfcare (including online therapies developed for people with diabetes). In conjunction with Imperial College Healthcare Partners and digitalhealth.london accelerator programme, we will be piloting one or more diabetes self-care and/or supported self-care (i.e. in conjunction with online/telephone coaching/mentoring) apps in Options include: Changing Health OurPath Oviva Vitrucare Expanding functionality of the Harrow Health Help Now app being rolled out across most of the rest of NWL Encourage take up of free resources and apps e.g. the free Low Carb Programme (average achievements in 165,000 participants over 6 months: 9cm waist reduction, 10kg weight loss, 16% reducing or stopping medication), MyFitnessPal, Google Fit, Apple health, etc. We are now signposting these resources on our printable care plans. The excellent Type 1 resource website - and NHSGo Source (and/or develop where necessary) self-care information including motivational and educational videos, with translation into common languages and providing culturally appropriate dietary and lifestyle information Maximise prevention and lifestyle change opportunities Identify individualised treatment targets and ensure patient is aware of their numbers through care planning (37,969 patients already have collaboratively developed care plans we want to increase this percentage and make these also available electronically to patients to increase ownership and engagement.) 5c) Whether you plan to focus on the newly diagnosed or prevalent diabetes populations across all ages (or a combination). We will implement the guidance in the London Type 1 Commissioning Pack. To support new Type 1 people with diabetes we will ensure that all staff caring for patients with type 1 diabetes will be trained in DAFNE (or a NICE compliant alternative). Care for adults with type 1 diabetes in North West London comes with unique challenges. The demographics of the population are younger and more ethnically diverse. Our National Diabetes Audit showed that people under 40 years of age with type 1 diabetes are less likely to receive all of their annual care processes. There are also a wide range of deprivation levels. 5ci) TYPE 1 Newly diagnosed - All patients with a new diagnosis of type 1 diabetes should be encouraged to complete a structured education course within a year of diagnosis. All adults with type 1 diabetes will be offered a diabetes structured education programme prioritising in the following way: All people newly diagnosed with type 1 diabetes within one year of diagnosis. 36

37 Those with problematic hypoglycaemia or an HbA1c above target. All women of childbearing age with type 1 diabetes. All patients with type 1 diabetes on an ongoing basis throughout their lives to ensure motivation is maintained and skills are refreshed and up to date with new developments. Carbohydrate counting All patients with a new diagnosis of type 1 diabetes will be taught an awareness of carbohydrate counting and the ability to adjust doses of insulin. The teaching of formal CHO counting can be daunting for some at the very beginning of their diagnosis and also not always suitable during the honeymoon phase. T Therefore, the aim will be to initiate CHO counting within the first year where possible / when practical. 5cii) TYPE 1 Existing DAFNE research clearly demonstrates that there is no difference in benefit from DAFNE based on duration of diabetes. Therefore we would offer this to all using our prioritisation matrix seen on previous page. We also plan large scale patient conferences for Type 1 people with diabetes focusing on carbohydrate counting, insulin management and the psychological aspects of diabetes. This will educate 1000 or more people with diabetes at a time this model was used in Scotland to great effect. Vulnerability We will take account of vulnerability when we offer structured education. The vulnerable adult is defined as an individual who is or may be in need of community care services by reason of disability, age or illness; and is or may be unable to take care of /unable to protect him/herself against significant harm or exploitation. Some groups may be less able to monitor and self-manage their condition and so are at particular risk of both significant hyperglycaemia, or of problematic hypoglycaemia. This includes adults who are / have:»» Learning disabilities / Frail elderly / Dementia / Severe mental illness / Living in residential homes / Homeless, in hostels, in prisons or remand centres / An eating disorder / Housebound / A previous amputation 5civ) TYPE 2 Newly diagnosed We will ensure newly diagnosed people with type 2 diabetes get lifestyle advice appropriate to their PAM level. ( see menu of options above.) 5cv) TYPE 2 Existing We plan large scale patient conferences to educate 1000 or more people with diabetes at a time this model was used in Scotland to great effect. We will work with XPERT and DESMOND colleagues to produce this. 5d) Why you consider the proposed levels of increase in structured education attendance will be sufficient to reflect the number of diabetes patients that need to attend the course. Diabetes education / diabetes management resource centre North West London CCGs see an opportunity to create a highly effective and scalable diabetes education programme by intersecting two complementary interventions - digital 37

38 technology with grass-roots outreach. We are excited about this model as a catalyst to empower people in North West London to have more involvement and control over their diabetes management and care. We envision these combined interventions as having powerful population health impact that will support primary care to deliver care to patients closer to where they live. This new approach will also bring to the table a different level of patient perspective and involvement in care that will drastically improve diabetes clinical outcomes. The creation of a diabetes education / diabetes management resource centre will enable NW London to develop, test, and implement exploratory diabetes prevention and promotion methods that syndicate high touch with high tech community based solutions. There would be a particular focus on immigrant and disadvantaged populations. We know that social and environmental factors are key determinants of health in these populations and low levels of education, English proficiency and health literacy are factors which not only contribute to the growing prevalence of diabetes but also poorer control of HbA1c in some populations. Furthermore, language and education are not the only barriers, as many London residents are fearful of deportation and have no experience with the NHS system or preventive services. This state-of-the-art education resource centre would shape a community health worker model to be a part of the care delivery team. They will play a key role to bridge cultural mediation between communities and the health and social care systems. We will leverage community volunteers that have unique access to populations through greater flexibility to meet patient needs, e.g. amount of time spent, time of day services are provided, place of contact and range and extent of services. Moreover, because community health workers are peers from patients own communities, they will have particular insight to understand and communicate social, emotional and spiritual issues more clearly. Community health workers will have greater patient trust that can break the symptom cycles by encouraging behaviour changes that are culturally sensitive and result in increased patient involvement in their own diabetes care. Concurrently we will be evaluating technology enabled care that will leverage the hands on support of community health workers. Telehealth can include interventions as simple as automated phone calls reminding London residents with diabetes about appointments, medication or lab tests, or can be quite extensive in installing devices in homes that allow diabetes residents to check their blood sugar, blood pressure, and weight regularly, all of which can be transmitted to the healthcare team to help adjust treatment plans accordingly. The resource centre will serve to support primary care while working with patients to fact-find self- management and education interventions for different cohorts of patients. 5e) Whether there will be the ability to flex the number of places provided up or down according to demand. We plan a hub to allow us to monitor and flex according to demand. We believe the above methodology will allow us to vastly upscale diabetes structured education at scale. The purpose of this element is to maximise choice and information for people with diabetes to attend a structured education course at a time, place and location that meets and reflects their personal needs. This would be achieved by commissioning a North West London Structured Education Hub in partnership with the lead CCG, to enable adults and young people with diabetes to attend the right course at the right time with language and cultural options. Building on the existing Bexley Health model in South London the Hub will provide a single point of referral and centralised booking system for structured education in North West 38

39 London. The model builds on the current commissioned Hub service by Bexley GP Federation that has increased referrals and attendance. This centralised Hub model draws on the learning of the success of this model which included adapting the days and times of courses to meet patients preferred choices, providing language options and the model of education e.g. the diabetes manual. The North West London Structured Education Hub will be commissioned to: Provide a single point of electronic referral for the existing Structured Education courses that meet NICE guidance offered by CCGs for Type 1 and Type 2 diabetes for all North West London CCGs Remove any boundaries to attending Structured Education i.e. all courses will be available to all NW London CCG registered patients with diabetes with access available to patients results. Where barriers exist, consider solutions to enable attendance (e.g. crèche facilities to allow parents to attend, delivery in community venues, etc.). Include self-referral Include completed Patient Activation Measure Be responsible for maintaining and increasing year on year referral and attendance at Structured Education e.g. through proactive patient finding with low referring GPs, ensuring sufficient capacity to deliver this is commissioned and reported on. Provide a service that includes digital and telephone engagement to: Promote the benefits of Structured Education to individuals Identify a Structured Education course that meets the needs of individuals, including delivery of courses across NWL in different languages. Offer peer to peer support (online and by phone) Offer information and advice including how to secure time off work to attend Reduce stigma Actively contact people from the diabetes register who have not attended Structured education in an agreed phased approach Work with the IAPT services to facilitate referrals for mental health therapies Signpost to relevant services to include Diabetes UK, JDRF and local support groups Use social media to promote the site (Facebook, Twitter) Be digital ready (for future digital Structured Education options) Inform GP practices on referral attendance and completion Collect data by GP practice on referral attendance and completion Inform GPs of attendance and completion of SE using relevant read codes Monitor uptake of Structured Education by course e.g. (Desmond, X-PERT, DAFNE etc.) Monitor and flag demand and unmet need with STP diabetes leads and CCG Commissioners Actively suggest / innovate solutions to meet unmet need Signpost people with diabetes to local research opportunities Facilitate engagement between people and diabetes champions at the point of referral to SE to encourage group attendance Host Structured elearning tool Develop a North West London Structured Education Hub Advisory board led by people with diabetes to inform and develop existing and future initiatives. 39

40 5f) Describing how you plan to develop the workforce involved in delivering structured education so that the expansion of education provision does not reduce the capacity of existing specialist diabetes clinical staff to deliver other key duties associated with their role. Improving the capacity of current diabetes specialist staff: A North West London Structured Education Hub will provide an additional resource to manage referrals for all North West London CCGs. The Hub will remove the current requirement by diabetes specialist nurses to chase missing referral information, arrange dates and venues, invite and motivate people with diabetes to attend Structured Education and following up on non- attenders, as all of this activity will be managed by the proposed Structured Education Hub. Self-referral will also be available. Freeing up this time will enable diabetes specialist nurses to focus on their key duties. The sustainability of the Hub will be met by CCGs using the return on investment made. Outcome measures % of GP practice staff completing elearning % of GP practices with diabetes champion % Increase in SE referral rates % Increase in SE attendance % Increase in SE completion rates Reduction in Days lost from work Reduction in Days lost from school Existing staff will plan our diabetes education project and deliver this, but we will supplement this with additional patient champions / health coaches / lay trainers wherever we can so that our skill mix focuses staff on the things they can do best. 40

41 6. Please set out the specific actions you propose to take to improve uptake of structured education. Appraisal dashboard criteria reference(s): SE clinical outcomes Actions Responsible organisation / individual Timescale for completion All Specialist staff to be offered DAFNE update / training Develop support to primary care Develop and publicise our plans amongst all stakeholders Implement PAM licences for people with diabetes Local DAFNE trainers, supported by DAFNE central team Programme Director and Strategic Clinical Lead Programme Director and Strategic Clinical Lead Various staff Sept 2017 is next course From April onwards From April onwards Ongoing Develop all SE options Programme Director By April Decide digital offerings * funded outwith this bid Set up choose and book with menu of options across NWL with clear info on sites etc. Develop prioritisation strategy further and communicate to all. Develop support for primary care Develop plans for new and existing Type 1 and Type 2 patients Develop large scale education conferences Develop carbohydrate offering at scale Strategic Clinical Lead Strategic Clinical Lead Programme Director Programme Director and Strategic Clinical Lead Programme Director Programme Director Programme Director with specialist By April By April By April By April By April By April By April 41

42 6. Please set out the specific actions you propose to take to improve uptake of structured education. Appraisal dashboard criteria reference(s): SE clinical outcomes colleagues Workforce development and skill mix project Programme Director By August 7. Please set out what risks to successfully increasing attendance at structured education you have identified, the likelihood of these occurring and mitigating actions you propose to take. This risk assessment should include: Risks to implementation. Risks arising from relationships with stakeholders. Risk that interventions are not well targeted. Risks based on inter-relationships with other strategic plans. Appraisal dashboard criteria reference(s): SE risks Risk Mitigation L C S Delays in setting up the hub Clear programme plan developed and monitored Lack of sufficient communications to assist operational running of the Sufficient admin capacity in place to support hub (staffing, timing) Lack of access to patient data Set up integrated IT solution to enable shared results across Inequity of service provision currently different CCGs commission different programmes Insufficient engagement with patients and carers different systems Standardise the offer across NWL, use the hub to ensure patients can attend courses according to their preference Clear communications plan to be developed as part of the overall programme 42

43 8. In addition to the costs set out in the Excel application form please set out: a) Any non-financial resources you will need in order to carry out these actions and how these will be provided? b) Any capital requirements to ensure delivery of this bid? This should include the amount required and confirmed plans for how these will be successfully addressed outside of this bid. Appraisal dashboard criteria reference(s): SE sustainability and resources 8a) None 8b) All capital needs are covered in normal diabetes funding 9. Taking into account the evidence on structured education being cost-saving in the medium term, please confirm whether there is commitment from CCGs and providers to continue to maintain the expanded level of structured education provision set out in this bid after bespoke national funding ceases, using savings generated in order to fund this. Appraisal dashboard criteria reference(s): SE sustainability We are developing a commitment to develop integrated outcomes-based new care models we will set up all four projects and in doing so will generate savings that can be reinvested in diabetes care. 43

44 10. Do you have a specific service specification for structured education? If so, does it require structured education providers to adhere to relevant NICE guidelines and quality standards? If not, will these form a core requirement of your service specification from 2017/18? Appraisal dashboard criteria reference(s): SE safety/quality There is not currently a single service specification in place across the geography of NWL. In addition, individual local contracts do not always have a specification for delivery of structured education; it is included in the specification for the whole community diabetes service. Part of the work as described in the answer to question 5 above will be developing standards for delivery of structured education in accordance with NICE guidelines. This will be a key requirement for delivery moving forwards by the provider of structured education. It is envisaged that a number of courses will be available, and NWL is able to learn from the various programmes that are delivered in different CCG geographies to see which provide the best outcomes, as well as the most effective method of delivery. 44

45 11. Will the structured education courses provided under this funding: a) Be externally accredited by nationally recognised accreditation body (state which). b) Be externally accredited by non-nationally recognised accreditation body (state which). c) Be internally accredited against published criteria. d) Have quality standards to meet, but will not be accredited. Appraisal dashboard criteria reference(s): SE safety/quality We plan to work specifically with university practices to target improving the uptake of Structured Education by young people. We also plan to establish interest from universities and colleges to use the e-learning module to inform undergraduate health and care professionals of the importance of structured education. Development of the elearning resource would include engagement with the following: Patient participation groups Community champions/ Health watch Voluntary organisations Self-management initiatives University health and social care courses / any other relevant organisation. 12. What do you consider to be the key learning that could come out of your proposal that could inform improvement in other localities? In answering, please take into account whether your proposal is dependent upon other specific local services that may not be available elsewhere, whether it is focussed on specific populations and whether it would take a short (less than one year) or longer (more than one year) period to implement elsewhere. Appraisal dashboard criteria reference(s): SE replicability of model We have a massive task to educate as many as possible of our 140,000 people with diabetes we will do this in a systematic prioritised way that will be automated and use digital as much as possible. All other areas can learn from the hub aspect we hope this will compliment the South London hub and allow patients to access care over a much wider geography too. 45

46 (2) Complete this section as part of your application for funding to enable an increase in achievement of the 3 NICE recommended treatment targets (including one Hba1c- for children) Please expand the boxes below as required for your answers. Please use this sheet to describe your detailed implementation plans to increase achievement of the 3 NICE recommended treatment targets for adults with Type 1 diabetes and adults with T2 diabetes, together with increasing achievement of one treatment target Hba1c for children. Where there is more than one CCG covered by this aspect of the bid and the analysis of issues and proposed actions differs between CCGs (or groups of CCGs), please duplicate and complete separate copies of the this section for each CCG/Group of CCGs as appropriate. 1. The average national achievement level of the treatment targets is 40.2% of patient with diabetes. Please set out below your analysis of where achievement of the treatment targets at CCG or GP practice level may be lower than this, drawing on data sources such as the NDA, NPDA, NaDIA and HES, and local data sources and intelligence as appropriate, and the reasons for it including consideration of : a) The separate levels of achievement of each of the three treatment targets and one for children Hba1c. b) Different cohorts within local diabetes populations. c) Whether there are differential achievements against the treatment targets within these groups. d) The possible causes of underachievement. Appraisal dashboard criteria reference(s): Treatment Targets (TT) cohort size, clinical outcomes 46

47 1a) The separate levels of achievement of each of the three treatment targets and one for children Hba1c. Within the CCG Improvement and Assessment Framework, all 8 CCGs are shown to be in need of improvement, with 2 scoring red and 2 amber for the 3 treatment targets, and all but 1 CCG scoring red for structured education attendance. CCG Overall CCG IAF 3 treatment targets Structured education Brent Greatest need for 39.8% Amber improvement poor participation Central London Needs improvement 44.3% Red Ealing Greatest need for 36.5% Red improvement Hammersmith and Needs improvement 42.6% Red Fulham Harrow Greatest need for 40.9% Red improvement poor participation Hillingdon Needs improvement 41.4% Red Hounslow Greatest need for 35.9% Red improvement West London Needs improvement 40.1% Red Across North West London, there is significant variation in achievement of the treatment targets between CCGs, groups of patients (Type 1 vs Type 2) and between practices. The National Diabetes Audit Data for 2014/15 are provided below, indicating a difference of 8.4% in CCGs across NWL between the highest achieving CCG and the lowest. CCG Name All 3 treatment targets % /15 Type 1 Type 2 All Types Type 1 HbA1c < 58 BP < 140/80 Cholesterol < 5 Type 2 All Types Type 1 Type 2 All Types Type 1 Type 2 All Types Brent 19.8% 40.7% 39.8% 27.3% 64.8% 63.1% 78.9% 73.4% 73.7% 79.3% 79.7% 79.7% Central London 35.4% 45.0% 44.3% 51.6% 75.3% 73.5% 79.9% 70.7% 71.4% 74.2% 77.4% 77.2% Ealing 19.6% 37.3% 36.5% 32.1% 61.6% 60.2% 77.1% 71.8% 72.1% 73.6% 77.6% 77.4% Hammersmith and Fulham 27.4% 43.8% 42.6% 43.5% 71.0% 68.8% 81.7% 73.3% 74.0% 70.1% 76.7% 76.2% Harrow 20.6% 41.6% 40.9% 32.4% 63.5% 62.3% 71.6% 75.6% 75.5% 77.2% 78.5% 78.4% Hillingdon 19.6% 42.4% 41.4% 27.1% 64.2% 62.4% 81.5% 77.1% 77.3% 74.8% 80.5% 80.3% Hounslow 22.1% 36.6% 35.9% 33.9% 60.7% 59.3% 80.6% 72.4% 72.8% 72.6% 76.7% 76.4% West London 28.4% 40.9% 40.1% 45.2% 69.7% 68.0% 77.9% 71.1% 71.6% 72.9% 76.4% 76.2% It was this variability in part that led to the commissioning of the CWHHE Out Of Hospital Services (OOHS). The aim was to improve care and outcomes for patients by addressing some of the inter-practice differences in monitoring of the 9 key care processes and achievement of NICE targets using performance related payment across GP networks 47

48 against the following Key Performance Indicators: % of patients with record of 9 key care processes % of patients reaching all 3 NICE treatment targets (HbA1c 58, cholesterol 4, blood pressure 140/80) % of patients with record of care planning consultation (requires results shared with patient prior to appointment, collaborative goal setting and care plan development, offer of printed care plan to patient at the end of the consultation) % of patients on sulphonylureas and/or insulin who have been asked about the presence of symptoms of hypoglycaemia % of newly diagnosed patients referred to structured education (since 2016/7) Using a single SystmOne reporting module across the 240 GP practices in CWHHE, we have been providing monthly reporting dashboards to GP practices and are beginning to understand some of the causes of variability in achievement across practices and groups of patients at a very granular level. Discussion with colleagues in Brent, Harrow and Hillingdon CCGs suggests that they are facing similar issues and reasons for variability getting the IT infrastructure in place to support this intelligence gathering across the whole of North West London will be one of our initial aims. An example of the dashboard is shown below, with each row representing a GP practice within the CWHHE collaborative. The dark blue box is around the OOHS metric for the NICE 3 treatment targets (cholesterol 4) and light blue box is around National Diabetes Audit achievement note that the denominator for the OOHS 3 treatment target KPI is all patients with diabetes, whereas the NDA denominator is only those patients who have had the measurement done within the timeframe which is potentially misleading and can lead to overestimation of achievement in practices where a key care process hasn t been recorded: 48

49 1b) Different cohorts within local diabetes populations. What is clear from our data is that there is significant variability between practices in achievement of all 3 treatment targets HbA1c, blood pressure and cholesterol (both at a target of 5mmol/L and the NICE recommended 4 mmol/l). We have been looking to understand the reasons for this variability and have analysed a number of factors including: 1. Deprivation using per practice Index of Multiple Deprivation (2015) scores 2. Age 3. Ethnicity 4. English speaking status 5. Mental health diagnosis 6. Prescribing according to NICE guidelines (analysed so far for statins vs cholesterol target achievement) 1) Deprivation: Analysis of achievement of treatment targets against practice IMD(2015) scores below shows a slight but non-statistically significant trend towards worse HbA1c achievement in practices with higher IMD but otherwise no correlation with achievement of blood pressure and lipid targets. Each point represents an individual practice within CWHHE. Furthermore, we have mapped achievement of the key care processes by Lower Super Output Area in order to understand any geographical factors as a cause for variability, but there is no clear pattern that relates to particular demographic factors. However, we will be working closely with public health colleagues over the next year to analyse the data. 49

50 2) Age: There is a trend towards worsening mean HbA1c with younger age, with a peak at Poor control in adolescents and those looked after by specialist transition services is a well-documented trend and is an area that we will look to address within the transformation programme. In those in the under 65 group with predominantly Type 2 diabetes, this may represent other competing life priorities, ease of engaging with existing services or else other factors which need further understanding. Some aberrations exist at either age extreme due to small numbers. 50

51 3) Ethnicity: Analysis of average HbA1c between different ethnicity groups (below) reveals significant differences between patients from different ethnicities. Patients of Pakistani origin appear to have the highest mean HbA1c values within the collaborative and thus the poorest control. 4) English language: Analysis of average HbA1c by English speaking status reveals significant differences between non-english speakers and English speakers for some CCGs and not others. The causes for this variability between CCGs are not fully understood at present, but may in part represent differences between the proportions between different ethnic groups. 5) Mental health diagnosis: We have analysed the data to understand any linkage between mental health diagnoses and poor glycaemic control. The clearest correlation is between the diagnosis of personality disorder and mean HbA1c as shown in the data below: 51

52 6) Adherence to NICE guidelines: One of the clearest areas of correlation with achievement of NICE targets is between prescribing of Atorvastatin 20-80mg and mean cholesterol level in diabetes patients. This is illustrated on the graph below each point represents an individual practice, showing a clear and significant correlation between % of patients on Atorvastatin 20mg or more and mean cholesterol in diabetes patients in the practice (and also % achieving target cholesterol and therefore 3 treatment targets data not shown). We are now working with the medicines management teams, surfacing this information on the monthly reporting dashboards and encouraging practices to switch patients on lower intensity statins to moderate/high intensity statins with the aim of maximising numbers of patients achieving the NICE recommended target of 4mmol/L. We aim to analyse similar data for HbA1c and blood pressure and the prescribing of hypoglycaemic agents and antihypertensives. Since the service was commissioned in August 2015, we have seen an overall improvement in recording of the 9 key care processes from 23.8% to 47.1% across CWHHE though significant inter-practice variability remains with achievement ranging from 14.8% to 93.7%, largely relating to the recording of indicators which were phased out of QOF approximately two years ago: BMI, urine ACR and retinal screening. Additionally there has been a 4.8% increase in the number of patients with HbA1c 58 mmol/mol, though again this has been extremely variable at a practice level. 52

53 2. Please set out the CCGs that are bidding for funding with respect to this priority. The eight CCGs in North West London are bidding together, for a diabetes transformation programme that reduces variation at all levels, practices, providers and CCGs. They are; Brent, Central London, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, and West London CCGs 3a) Please set out the specific actions you propose to take across the pathway, including as appropriate where primary and secondary care will work together, to secure improvement against the treatment targets including as relevant actions for Type 1 diabetes, Type 2 diabetes and children and young people and specific communities where action is required. This should include as appropriate: I. Commissioning and quality improvement actions. II. Promoting improvement. III. Incentives and other levers. IV. Identification of actions focused on the identified areas requiring improvement. Together with why you consider these actions to be appropriate, taking account of any relevant evidence. For each key action, please also set out in the table below who will be responsible for implementation and the timescales for completion of them. Appraisal dashboard criteria reference(s): TT clinical outcomes Summary of plans for improving the treatment targets Using federated model, improve competency, capability and capacity Closer integration of workforce / potential of one team for diabetes across the 8 CCGs Improved training for staff across healthcare Ensure competencies of secondary care staff delivering care to people with type 1 diabetes (through clearly commissioned NICE accredited programmes e.g. DAFNE, BERTIE or other quality assured programme). Up-skill practice nurses, GPs, clinical pharmacists, care home staff through education programmes including TOPICAL, MERIT, pre-pitstop and PITStop etc. Flexible specialist support driven by the right incentives: high quality integrated specialist diabetes hubs seeing patients where the competencies are not available in the practice Use Diabetes Specialists Clinicians more effectively as they mentor and coach other HCPs (e.g. GPs, Practice Nurses, Community Nurses, Tier 3 Diabetes staff in the community, and others such as diabetes specialist pharmacists) for example through virtual clinics, video consultations, etc. Build on existing care navigator and diabetes mentor models to develop trained community health workers (mentors, educators, coaches) as a key (and accountable) part of the wider MDT team to work with higher 53

54 risk/higher dependency patients on self-management and lifestyle change. (Use of IT off loads some non-clinical tasks and provides clinicians with increased capacity) Workforce development for health care professionals and community health workers on having a conversation about mental wellbeing (eg. RSPH level 2 mental wellbeing), signposting to IAPT and screening for common mental health needs as part of Making Every Contact Count (MECC) developments. In summary, we will: Develop a mixed MDTs of clinicians Develop GP practices and federations to work effectively as groups Develop the clinical network to support the Diabetes Service Pathway Organise clinical skills training Workforce and organisational development working with and supporting CCG s and their Diabetes Services to operationally deliver: Clinical Networks in CCG s formed Meet Clinical Outcomes against NICE, Public Health England specifications metrics in place Reduce population Type 2 Diabetes by prevention interventions Appropriate clinical skill mix / Clinical Pathways / Patient at the Centre of Care /Patient Self Management / Patient Support and management of Diabetes / Working/Integration with Secondary Care pathway/ Referral Criteria and Pathways Overview of funding request Our bid is to request support for the following: 1) Development / procurement of pan-nwl diabetes information system to support diabetes risk stratification and segmentation, proactive care monitoring, virtual multi-disciplinary review and patient self-care 2) Investment in primary care team: GP Clinical Leadership Case managers Diabetes nurse educators for primary care team development Health coaches / Care navigators Clinical psychologists 3i) Commissioning and quality improvement actions Carry out continuous review of and pathways leading to recommendations for commissioners on additional services/improvements in pathways based on evidence and patient feedback and experience. We would expect evidence based changes in practice to be rolled out and implemented early, driven by the NWL network Work clinically across the health system to support best practice in primary, 54

55 community and specialist settings for people with diabetes including people in nursing and residential care An important element of this work will be continuous evaluation and audit, ensuring any development of best practice is shared with the national programmes Promote awareness of integrated care pathways (including mental health) and act as liaison between primary, secondary and community care services for people with diabetes Develop the clinical aspects of the diabetes new care model Support greater joint working between commissioners planning services for people with diabetes and mental health commissioners. Opportunity to replicate the work of the Newham youth commissioners in redesigning transition pathway abetes%20youth%20project.pdf 3ii) Promoting Improvement Key achievements to date in North West London: Outcomes based primary care contracts (CWHHE Out of Hospital Services) across a diabetes population of over 70,000 demonstrating continued improvements in key outcomes demonstrating ability to deliver change at scale: 9 key care processes from 29% (August 2015) to 47% (December 2016), with some practices now achieving rates in excess of 70% HbA1c 58 mmol/mol from 53.2% (August 2015) to 58% (December 2016) with greatest improvement across a single GP practice network of 15.4% Collaboratively developed care plans from 2% (August 2015) to 53.4% (December 2016) Patients on sulphonylurea and/or insulin monitored for hypoglycaemia symptoms from 9.7% (August 2015) to 61.5% (December 2016) Outcomes focussed primary care contracts have also been rolled out in Hillingdon that have improved NDA participation, enabled early identification of pre-diabetic patients and shifted the setting of care for newly diagnosed patients. NDA participation in Harrow has increased from 17% in 2014/15 to 79% in 2015/ /17 LIS incentivised two audits in Harrow: NEL attendances / admissions with diabetes as primary diagnosis; and pre-diabetes Primary care workforce development (MERIT, TOPICAL and PITStop training courses locally developed and delivered) Standardised clinical guidelines, templates, and invitation letters in use within both SystmOne and EMIS clinical systems Map of Medicine accessed via single sign on with EMIS, implemented across all GP practices in Harrow, with over 500 practice users set up. Access to over 250 clinical pathways, including several on diabetes. Savings from preferred prescribing options of oral and injected hypoglycaemics and test strips, lancets and needles and adherence to NICE guidelines Highly successful implementation of the National Diabetes Prevention Programme and expression of interest submitted to pilot NDPP digital offering in CWHHE Harrow had significant local engagement in diabetes transformation in 2016, 55

56 including a stakeholder event with over 50 people representing 15 organisations. This included Diabetes UK and other patient representatives; the local diabetes health, social, and voluntary care system; Harrow CCG; and members of the Harrow Public Health team. Networking enabled more joined up working and improved patient outcomes. Brent have had a lot of success with structured education programmes; DESMOND has been amended locally and well attended, Moving Away from Prediabetes has also been delivered in Brent for people at high risk of diabetes Integrated diabetes teams in place in Hillingdon and Brent include DSN staff linked to primary care. Care is delivered via MDTs, virtual clinics and clinics in GP practices Hillingdon has also amended their foot care pathway and deliver specific foot care clinics to reduce amputations The team in Hillingdon operates from a single point of access (SPA) with a clinical advice helpline that has reduced referrals into secondary care Introduction of diabetes guide for schools document developed by Healthy London Partnership and Hillingdon team and Hillingdon work holding clinics within schools to increase engagement and minimise disruption to schooling Improved 24 hour access to paediatric diabetes team Case studies illustrate possibility of improving at scale We have interviewed some of the practices that have made the most significant improvements in diabetes care over the last 6 months in order to understand some of the previous barriers to improvement and some of the ways that they have overcome these: Case study 1: GP practice in Hammersmith and Fulham: Before: Had no standardised process for management of patients with diabetes No dedicated staff or clinics After: Trained call centre staff to action all pending diabetes queries and indicators on the clinical system homescreen Looked at business processes to ensure standardisation across different personnel Team approach with strong communication and troubleshooting through significant event process. All receptionists, telephonists and Health Care Assistants (HCAs) provided with training programme at different levels Employed two lead clinicians within practice dedicated time and performance incentives an advanced nurse practitioner (ANP) and a GP Every HCA trained to use set protocol what to say and what to do with assigned supervisor lead for guidance and queries Clear understanding of who needs to be seen and by whom Weekly clinic with ANP and GP for patients off target Both ANP and GP are going on advanced diabetes training (injectable management) Virtual clinics every quarter to review overall performance and difficult patients. Tight management processes in place and monthly meetings of leads with senior management to ensure performance is maintained. Costs and clinical requirements have gone up substantially but remain within the funding envelope provided by the Out Of Hospital Services. Financial control and 56

57 expertise to ensure tight control of expenses. June 2016 December 2016 Diagnosed numbers % receiving 9 key care processes % patients with care plan % hypoglycaemia monitoring in patients on SU and/or insulin % patients reaching NICE treatment targets (cholesterol ) % patients reaching NICE treatment targets (cholesterol 5) Case study 2: GP practice in West London CCG Before: Most deprived ward in London, practice Index of Multiple Deprivation (2015) score years lower life expectancy than more affluent parts of the borough Large North African population Acceptance that low achievement was related to deprivation and other factors which were unsurmountable After: Data was shared with the practice showing little to no effect of practice deprivation score on variability in treatment target outcomes in May 2016 Clinical leadership approach taken Staff roles and protocols were clarified (manager, admin, HCAs, nurse, lead clinician) Action plan made with close monitoring of improvements and changes Virtual clinics with community specialist physician Celebrated team successes, now sharing experience with other GPs within the locality June 2016 December 2016 Diagnosed numbers % receiving 9 key care processes % patients with care plan % hypoglycaemia monitoring in patients on SU and/or insulin % patients reaching NICE treatment targets (cholesterol ) % patients reaching NICE treatment targets (cholesterol 5) Case study 3: Hounslow GP practice 4654 patients, 264 with diabetes 57

58 High proportion South Asian population Monthly CCG education and training events attended by all practices, sharing of per practice diabetes dashboards and discussion within each locality about how care can be improved Many practices using patient level dashboards proactively to identify off target patients and/or those not engaging in follow up April 2015 December 2016 Diagnosed numbers % receiving 9 key care processes % patients with care plan % hypoglycaemia monitoring in patients on SU and/or insulin % achieving HbA1c % patients reaching NICE treatment targets (cholesterol Not available ) % patients reaching NICE treatment targets (cholesterol 5) Not available 56.4 Case study 4: Hillingdon GP practice Before Ranked as one of the worst achieving practices in North West London with poor governance, disorganised management structure and lacking good clinical leadership Based in area of high deprivation After 2 salaried GPs, clinical pharmacist and practice nurse attended prepitstop and/or PITstop training Weekly nurse run clinics, developing as an independent prescriber with mentorship and clinical supervision Audits to check adherence with NICE glycaemia management pathways Greater clarity about team roles within the practice Understanding of variable personalised HbA1c targets Key success factors: The CCG and GP Federation highlighting diabetes as a priority to help reduce morbidity and mortality. This led to swift coordination and funding for the initial wave of training by the CCG. Leadership within a previously failing practice, with a team motivated to lead the way Sourcing a practical suite of training that met the needs of the local primary care workforce and allowed individual HCPs to choose the appropriate courses for them. Having structured care pathways to follow, preventing inconsistency of care, with clinical templates to record actions. Having a mentorship service following the course to help embed the skills learnt Taking time to look at the actions of the practice diabetes team, including administration, and put into place processes to improve the patient 58

59 experience and ensure appropriate patients are recalled more frequently, including audit of high risk patients. Considering new ways of delivering services in general practice, including successful integration of a clinical pharmacist who now runs a weekly diabetes clinic and plans to accept referrals from other practices within the federation. Completing a baseline audit allowing patients to be invited to specific diabetes review appointments. This audit can be repeated to evaluate progress April 2014 April 2016 Diagnosed numbers % HbA1c < 59 (QOF) % BP 140/80 (QOF) % Cholesterol 5 (QOF) % Referred to structured education 0 89 Case study 5: Harrow Non-elective Admissions Audit A 2016 audit amongst GP practices in Harrow of 76 non-elective admissions analysed reasons for Emergency Department attendance where diabetes was the primary diagnosis. These were: hyperglycaemia (33%), hypoglycaemia (26%), foot infections (21%), DKA (17%) and other (3%) with over 80% representing patients with Type 2 diabetes. Key characteristics of the hyperglycaemia group were as follows: Medication review within the previous 12 months and average number of GP attendances within the previous 6 months was Medication review within the previous 12 months 94% HbA1c < 64 mmol/mol 32% Number of visits to GP in previous 6 months 6.96 People attending with hypoglycaemia NOT on insulin 55% What was clear from subsequent discussion following this analysis was that many nonelective admissions for diabetes are potentially preventable through better glycaemic management, more effective MDT working, patient empowerment and information (including better information about sick day rules) and avoiding overtreatment especially of frail/elderly patients with sulphonylureas through monitoring for symptoms of hypoglycaemia. We can use these examples to promote achievement. 3iii) Incentives and other levers. We have used incentives within the CWHHE Out of Hospital Services to drive some of our transformation work to date and although this has created some clinical change already, there is need for further support from a wider multidisciplinary team and IT infrastructure to maximise the impact. We plan to replicate all the achievements seen in CWHHE ( 5 of our 8 CCGs) across the 8 59

60 to reduce the variation. 3 iv) Identification of actions focused on the identified areas requiring improvement. Some common themes begin to emerge. Deprivation, age, ethnicity, mental health diagnosis and language all have a role to play in variability, but more important are systems and protocols within organisations, creating capacity within the team through effective use of the workforce, clinical leadership, awareness of diabetes guidelines, CCG / federation support and virtual multi-disciplinary teamwork incentivised with the right outcomes-based contractual framework. Informatics also plays a crucial role: monthly reporting dashboards allow organisations to monitor changes in near real time and clear patient level information helps identify patients who are off target and/or warranting further intervention. However, even when patients are being managed to by experienced, enthusiastic clinicians in practices with good systems in place, there are significant challenges in providing adequate support for patients to self-manage their condition effectively and in many cases make substantial lifestyle changes in the intervening periods between appointments. In many ways, this is one of the most substantial challenges, and requires much more continuous support during periods of attempted change than is currently provided. Across North West London, we have begun to commission services to address these issues, but more needs to be done at a system wide level in order to achieve the step change that is needed. Our aim is to put in place the infrastructure, workforce, funding and support to implement these improvements across the whole diabetes care system in North West London. This will include: Diabetes care managers to work across GP federations and localities to support improvements, develop and embed system-wide recall and review protocols Increase in clinical team capacity: primary care clinical leads, nurse educators, trained health coaches and further specific training for primary care pharmacists Driving cross-organisational collaboration through a single contract Improvements in informatics systems: further development of clinical templates, selfcare plans, clinical and performance dashboards, automated monitoring systems and a single source of truth for diabetes information A Diabetes Education Program developed and delivered by local clinicians which focuses on areas of diabetes care relevant to NW London, helping to address cultural and language barriers as well as specific programs targeting specific populations, e.g. Diabetes in Ramadan, and cultural and religious beliefs in the management of diabetes Ensuring our medicine management teams support and share best practice in the management of diabetes to achieve better control of lipids, BP and cholesterol To begin to address these issues, a NWL Diabetes Stakeholders Workshop took place on 24 th November In attendance were around 100 clinical, managerial and commissioning representatives from all 8 CCGs, consultants, patients, Diabetes UK, NHSE, Public Health and medicines management. The event was highly successful and we emerged with a clear mandate that all organisations wanted us to develop a NWL wide level Diabetes Strategy Group with a common project and 60

61 clinical team to drive forward and implement the NWL Diabetes Programme Plan and Strategy ( in development). FEEDBACK FROM NWL DIABETES STAKEHOLDERS WORKSHOP ( ) Greater focus on IT integration to allow for data sharing, analytics etc. Reduce variability across primary care and build a primary care plan to increase more appropriate interventions Better workforce training up-skill practice nurses, GPs, care home staff, pharmacists etc. Investment in identification and intervention of people with non-diabetic hyperglycaemia (NDH). Reduce the number of admissions to secondary care Greater collaboration between sectors to involve social prescribing, third sector, expert patients, mentors and coaches as core members of the multi-disciplinary team. Individualise treatment targets especially in frail elderly and those with multiple comorbidity Involve patients to keep them engaged in their healthcare Early education for patients and use of expert patients NWL DIABETES TRANSFORMATION PROGRAMME Develop a NWL Diabetes Transformation Programme with appropriate clinical, managerial and administrative support. Work across all 8 CCGS to develop NWL Diabetes Strategy Group - this will include representation from CCG diabetes clinical and commissioning leads, GP federations, acute and community provider clinicians, medicines management, public health, Diabetes UK, JDRF, NHS England and people with diabetes. Links will also be made with the local councils to ensure any strategic overlaps are noted and explored, particularly regarding lifestyle change / structured education courses for people at risk of cardiovascular issues including diabetes Develop common projects within the programme projects with supporting work streams see structure below. 61

62 The NWL Diabetes Transformation Programme will include representatives of primary care, secondary care and community care, exisiting diabetes networks, and voluntary sector to support the delivery of population improvements in diabetes management as well as leading the education and training of patients, parents and carers and care professionals ( including social care) in this area. PROJECT Clinical Transformation To achieve optimum diabetes outcomes, save patients from the pain of diabetes complications, and reduce health economy cost (Diabetes Complications in NWL STP cost around 270m) we have begun this work with the support of the CWHHE Diabetes Clinical Lead (0.3 WTE) and newly appointed at Programme Director (0.4WTE). These resources are limited and will need to be added to in order to deliver this programme across 8 CCGs to cover the whole of NWL STP, which is our aim and the clear mandate from our stakeholders. This offers great economies of scale, and savings to reinvest in preventing complications so becomes sustainable. As part of the transformation programme we would aim to streamline and standardise pathways and care processes and ensure implementation of any relevant local best practice achievements across the whole NWL geography Continue to drive the NWL group on the ultimate goal of re-designing the pathway across the life course, end to end; from prevention to inpatient and community care Focus this work on the 4 identified national priorities plus a focus on diabetes in the integrated IAPT work across NWL: Improve the uptake of structured education (this will include prevention and NDPP for patients at high risk of diabetes) Improve performance against the 3 NICE treatment targets (building on existing work done on OOHS contracts) Improvement in inpatient care 62

63 Improvements in foot care The ambition is to align services across the whole diabetes pathway using a longer term outcomes-based contract. We will thoroughly appraise the available options including MCP contracts and accountable care partnerships using capitated budgets. Examples of the key patient outcomes for a 10 year diabetes contract could include: Increase % receiving 9 key care processes Increase % attending structured education Increase % reporting satisfactory experience Increase % screened for common mental health problems Increase % with lifestyle change (e.g. weight loss, smoking rates) Increase % achieving NICE targets Reduce amputation rates Reduce cardiovascular complications (5-10 years) Reduce premature mortality rate Decrease non-attendance at appointments Increase self-care A Think Digital focus, ensuring maximal use of digital services to connect patients with clinical teams and clinical teams with each other. Work streams: Full implementation of the NICE diabetes pathways in North West London including segmentation of patients by duration of diagnosis, frailty and comorbidity to ensure optimum management and avoid overtreatment (see example of target segmentation below) Proactive care management and monitoring - case management and care management for patients not at target ( see below) non-diabetic hyperglycaemia in CWHHE, this will be further developed in BHH including a register for NDH Where variations in outcomes are mapped, work will be done to ensure that CCGs, networks and practices are supported to move to the best achieved baseline Single Point of Access for clinicians (and patients to self refer) where there is not one in place already Improve outcomes for women with type 1 and type 2 diabetes of childbearing age and gestational diabetes Reduce the number of inappropriate admissions to secondary care and adult patients in secondary care out-patient clinics, continue to move patients to the appropriate tier of care* and support greater self-care (Diabetes Guide for London Guide.pdf) 63

64 More systematic self-care support Digital self-care support: Provision of digital tools to support those that can selfcare (including online therapies developed for people with diabetes). In conjunction with Imperial College Healthcare Partners and digitalhealth.london accelerator programme, we will be piloting one or more diabetes self-care and/or supported self-care (i.e. in conjunction with online/telephone coaching/mentoring) apps in Options include: 64

65 Changing Health OurPath Oviva Vitrucare Expanding functionality of the Harrow Health Help Now app being rolled out across most of the rest of NWL Encourage take up of free resources and apps e.g. the free Low Carb Programme (average achievements in 165,000 participants over 6 months: 9cm waist reduction, 10kg weight loss, 16% reducing or stopping medication), MyFitnessPal, Google Fit, Apple health, etc. We are now signposting these resources on our printable care plans. The excellent Type 1 resource website - and NHSGo Source (and/or develop where necessary) self-care information including motivational and educational videos, with translation into common languages and providing culturally appropriate dietary and lifestyle information Maximise prevention and lifestyle change opportunities Identify individualised treatment targets and ensure patient is aware of their numbers through care planning (37,969 patients already have collaboratively developed care plans we want to increase this percentage and make these also available electronically to patients to increase ownership and engagement.) Structured education embedded in clinical transformation as a core part of treatment Early education for patients Expand on and extend the role of diabetes community champions, peer educators and mentors ( KXXWGgg, as a fully integrated part of the NW London care team together with technology enabled supported self-care, creating a highly effective and scalable diabetes education programme intersecting two complementary interventions - digital technology with grassroots outreach. We are excited about this model as a catalyst to empower people in North West London to have more involvement and control over their diabetes management and care. We envision these combined interventions as having powerful population health impact that will support primary care to deliver care to patients closer to where they live. Diabetes Innovation Centre The creation of a Diabetes Innovation Centre will enable NW London to develop, test, and implement exploratory diabetes prevention and promotion methods that syndicate high touch with high tech community based solutions. There would be a particular focus on immigrant and disadvantaged populations. We know that social and environmental factors are key determinants of health in these populations and low levels of education, English proficiency and health literacy are factors which not only contribute to the growing prevalence of diabetes but also poorer control of HbA1c in some populations. Furthermore, language and education are not the only barriers, as many London residents are fearful of deportation and have no experience with the NHS system or preventive services. This state-of-the-art education resource centre would shape a community health worker model to be a core part of the care delivery team. They will play a key role to bridge cultural mediation between communities and the health and social care systems. We will leverage community volunteers that have unique access to populations through greater flexibility to meet patient needs, e.g. amount of time spent, time of day services are provided, place of contact and range and extent of services. Moreover, because community health workers are 65

66 peers from patients own communities, they will have particular insight to understand and communicate social, emotional and spiritual issues more clearly. Community health workers will have greater patient trust which can help break the symptom cycles by encouraging behaviour changes that are culturally sensitive and results in increased patient involvement and diabetes self-care. We already have experience of piloting diabetes mentors in some of the NWL GP practices, working alongside and frequently sitting in on consultations, and then working on a one to one basis with patients. Concurrently we will be evaluating technology that will facilitate supported self-care, ranging from simple interventions such as increased use of text reminders for diabetes appointments or lab tests to a comprehensive Think Digital approach newer glucometers offering NFC and Bluetooth mobile integration, apps, patient monitoring, exercise trackers and tele-health coaching. The Diabetes Innovation Centre will serve to support primary care while working with patients to determine the best self- management and education interventions for different cohorts of patients. Integrated mental health input Psychological support partly through the community health workers at a basic level but increasing referral into IAPT (as per ambitions of the Mental Health Five Year Forward View) if/when needed. Mental health support will become a core part of the diabetes service with IAPT workers integrated into diabetes teams as part of integrated IAPT service development work, providing disease specific support. Enhanced training for care teams on psychological support for patients Services available for those with more severe mental health problems including personality disorder and stable psychotic illness. Data shows that this group is one with poorer health outcomes and disease control, and at least two models of care in London (3DFD in Southwark and the Diabetes Psychological Medicine Service in Hammersmith and Fulham) have shown evidence of improvements in glycaemic control and reduced healthcare resource utilisation. We aim to commission this as part of the integrated diabetes service across North West London. Ensure that those with low Patient Activation Measure scores are screened for depression and anxiety Increased support for those with mental health and diabetes through structured tiered approach to IAPT and Clinical Psychologists, and an improved self-care offer. Improved physical health checks for those with serious and long term mental health needs. Effectively manage patients with diabetes in primary, secondary and community care: Increase percentage of patients in NWL achieving all 3 NICE treatment targets from 39% (2014/5) to 55% (2020/21) Provide a service for patients with diabetes based on short term intervention, to support improvements in diabetes related health outcomes. Reduce the overall burden of complications through the establishment of better diabetes management within the community including the patient s own ownership of their care. Provide a NWL diabetes service based on best evidence for patients with 66

67 challenging management problems that do not require a secondary care referral where they can be seen by a multidisciplinary team. Ensure that all patients have a personalised glycated Haemoglobin (HbA1c) target appropriate to their condition with regular monitoring to detect deterioration from that target. In elderly people, targets of less than 53mmol/mol (7.0%) should be used with caution. Ensure access to regular eye screening and foot care as appropriate Patients will also be provided with access to their electronic records. Work in partnership with patients with diabetes to support self-management of their care, including their emotional health and greater awareness and support for those with depression (which is currently under detected). This will include meaningful care planning consultations, based on agreement of self-management goals, action plans and clarity around how the plan will be followed up and formal education sessions where appropriate Maximise use of patient activation measure (PAM) scoring among people with diabetes in order to stratify and tailor self-care and supported care options. 43,920 PAM Licences are available to use across NWL in 2016/7, increasing to 428,700 by the end of 2020/21 Patient activation is defined as an individual s knowledge, skills and confidence for managing their health and healthcare. The PAM score is produced through a patient s responses to 13 statements scored on a 100 point scale and then assigned to one of four levels of activation giving an indication of a patient s health style. ( More details in our Structured Education bid) 67

68 Effectively utilise practice system data to case find and monitor quality of care Facilitate extraction and presentation of information on quality of care that can be regularly reviewed and used to monitor progress in improving diabetes care and identifying barriers to progress Implement with practice and provider locality targeted screening of people to identify unidentified cases of diabetes and those who may also have mental health needs. Continually seek to improve the diabetes service by evaluating, auditing and monitoring the delivery of the Service, including quality outcomes. Work with the Commissioner to respond to the variation in performance and clinical indicators of care between highest-scoring and lowest-scoring practices in diabetes key performance indicators particularly the three NICE treatment targets as well as type, rates and quality of referrals by targeting and supporting poorer performing practices. Work with diabetes networks, federations to ensure all practices are working together to reach the same high level of quality care. Increase detection and diagnosis of diabetes Utilise informatics systems / dashboards (including systematic use of Leicester risk score and/or QDiabetes) across all providers to case find people at risk of developing diabetes and invite for screening Increase numbers diagnosed with diabetes in North West London from approximately 132,000 (76% of predicted) in 2016/7 to 170,000 (90% of predicted) in 2020/21 through active case finding. Partnership with public health and local authorities: Improve targeted and opportunistic detection of diabetes in primary care and the community. We have also begun some work with public health teams to develop our population health analytics further. Work with diabetes champions and existing community groups to raise diabetes awareness particularly in high risk and BME groups. Raise awareness of the signs and symptoms of the disease to promote early recognition and reduce the number of people arriving in ED in DKA Provide early access to diagnosis and treatment to avoid admission in DKA PROJECT - Workforce Development (skills mapping, training and development ) Primary care Facilitate better management of diabetes in primary care by supporting GP practices and other community services with mentorship, education and skills training. Work with clinical leads to promote best practice management of diabetes to prevent complications from these conditions, including greater awareness of co-morbidity with mental health needs. Undertake a skills audit and education needs assessment for primary care. 68

69 Community care Support Community Matrons and District Nursing services in providing case management to patients with diabetes who are at high risk of unplanned hospital admission and facilitate timely discharge from hospital. Provide advice and support to social services / residential and nursing homes. For paediatrics diabetes specialist nurses to support schools and families to manage their diabetes effectively Support better integration between community teams, hospital teams and primary care, ensuring IT systems are in place to enable this Secondary care In secondary care ensure staff skills are developed within all settings to ensure patients with diabetes receive high quality evidence based care, including psychological support. These skills need to also ensure appropriate support is available to children and people transitioning to adult services Ensure all staff working in secondary care (inpatients and outpatients) are able to manage patients with diabetes effectively and meet their needs; for example DAFNE or equivalent quality assured programme for those who manage Type 1 patients and carbohydrate counting education and resources available on all wards. DIABETES IT, ANALYTICS CLINICAL AUDIT, RESEARCH AND REPORTING Work streams: Agree consistent data set for recording diabetes related activity using existing NDA and NPDA standards with local supplementation where needed Care planning work with NWL Digital team and NHS Digital to develop interoperable care planning standards (based on successful ETTF bid) Population health inform and engage with development / procurement of population health system, allowing real time monitoring of cost and outcomes, proactive case management, risk stratification using predictive algorithms and ensuring that there is safety netting of high risk / non-engaging patients Work to develop key population health and proactive disease management capabilities has already begun with the Out of Hospital Services contract monitoring dashboards and a patient level dashboard which is used by practices to identify patients off target, not-engaging in care and aids virtual MDT discussion and ease of recall/review (see below). At the moment these are manual processes and work and investment is required to procure and/or develop automated systems. 69

70 Over the last few years in North West London, we have been developing an integrated data warehouse and care management system (the Whole Systems Integrated Care data warehouse) linking primary, community, acute and social care data by NHS number, allowing the viewing of health data at an individual (for direct care) or aggregated level, following patient journeys across the care system and calculating per patient costing for different patient groups. More recently we have been working on diabetes-specific patient views with further work on population health views in development (see below). Patient level dashboard integrating GP, acute/community and social care data (in user acceptance testing): allows ranking by HbA1c, identification of patients not engaging with care teams and other key information to allow virtual MDT working across different locations. 70

71 Outcomes based executive dashboard view (concept under development). Per patient costing is already incorporated into the warehouse tool, and work is underway to develop the datasets required to show this view. Full appraisal of population health and diabetes care management solutions including: Whole Systems Integrated Care dashboards Cerner Healthe Intent SCI-Diabetes Diabetes Complete Solutions within the NHS England Business Intelligence Lead Provider Framework (NW London is currently in the process of appraising BI solutions to replace the outgoing system) Interoperability use of equivalent structured data entry templates and views across different clinical systems and providers. Real time viewing of all pertinent clinical data, messaging, appointment viewing / creation and virtual consultation across care settings. Build on the new GP Connect capabilities and FHIR APIs becoming available in Potential use of Map of Medicine, learning from its roll out in Harrow. Patient facing view of diabetes record and care plan, ability to upload home measurements: weight, activity, glucometer, CGM and insulin pump data. A full appraisal of options needs to be undertaken to include: Diasend (nearly universal glucometer upload capability and used by many secondary care centres) Low cost NFC and Bluetooth glucometers Building on the functionality of the Harrow-based Health Help Now app Building on the functionality of the Patients Know Best system adopted as part of the North West London Care Information Exchange Other options included supported self-care systems combining telehealth coaching, fitness trackers, smart scales, app and web portal (e.g. Changing Health and OurPath) A NW London Diabetes Innovation Centre combining proactive case management, structured education, monitoring and support for patients. 71

72 3a) Continued - Specific actions for Type 1 diabetes The NDA data for type 1 PWD re BP/Chol and Hba1c is worse than those for type 2 - we will implement the London Type 1 Commissioning pack Utilising the document ( we have surveyed our patients to see what care they want using this and the document developed by several of our STP members (including representation of people with diabetes) 3a) Continued - Specific actions for Children and Young People Improving HbA1c achievement in children All aspects of the NWL Diabetes Programme will consider the needs of children with diabetes too, however specifically we will; a) Commissioning Diabeter model - We will scope the commissioning of the Netherlands Diabeter model in NWL STP( b) Promoting Improvement - Improve the transition process through implementation of existing resources such as ready steady go or Newham Youth Commissioners Model. c) Work with schools and community groups to improve engagement and understanding of diabetes to help longer term improvements d) There is a national NOVO endorsed package that healthcare professionals should be using to check the CYP s understanding of diabetes and their management - this has been endorsed by the national paediatric diabetes networks - we will implement this. Overview of commissioning and quality improvement actions for all types of diabetes and ages We intend to work towards contracting via an integrated outcomes-basednew care model with a shared budget and single set of outcomes across the system). Doing this we would commission diabetes care at scale across all 8 CCGs Further work needed on integrating pathway, ACP / MCP / VBC / CoBic approach (as there are still perverse incentives) We will work with NW London STP ACP team who are working to try and mobilise the development of ACPs with a 10 yr contracting time frame. We will use diabetes as an exemplar, as there is substantial alignment of STP Delivery Area 2 (reducing variation), Area 1 (wellbeing and prevention), ACP development, Out of Hospital Services, RightCare, CCG Assessment framework. Commission to build in support to primary and community care to reduce variability across the health economy Greater collaboration between sectors involving health, social care, social prescribing and the third sector Embed the governance within the programme as an exemplar across NWL STP 72

73 Data driven active case management and intervention. Alignment of outcomes based incentives is crucial in order to drive the system - focus all providers on the three treatments targets Scope, commission and prepare adult services for the increased numbers of paediatric patients coming through the system on pumps In summary, this will be a large scale change that should lead to the development of a long term contract and will deliver huge improvements in patient care and savings based on primary and secondary prevention of diabetes and associated complications, optimisation of pathways and improvements in systemwide efficiency. As outlined in the programme plan and the funding requirements, the programme will require experts in finance, Business Intelligence and contracting to help develop project documentation including a PID and recently we have developed a full business case. Full consideration to all of the potential costs highlighted above will be detailed in these documents, which will be subject to individual CCG governance processes. Costs based on staffing have been included in the financial modelling. 73

74 4. Please set out what risks to successful improvement of the treatment targets you have identified, the likelihood of these occurring and mitigating actions you propose to take. This risk assessment should include: Risks to implementation. Risks arising from relationships with stakeholders. Risk that interventions are not well targeted. Risks based on inter-relationships with other strategic plans. Appraisal dashboard criteria reference(s): TT risks Description of risk L C Score Clinical and organisational buy-in to service review and redesign from provider organisations is limited and effectiveness of review is subsequently reduced Getting agreement on the programme plan and critical path that will set timeline expectations for Providers and Partners Review results in short term investment needs for new model implementation before full benefits can be realised. Previous Integrated Care Pilot focused on an MDG approach to diabetes care showed limited scope and outcomes. This may risk clinical buy in to a new programme of service review / enhancement through selfcare, prevention and focus on high needs. Improvements in clinical outcomes take a longer time to realise than modelled leading to a delay in projected savings Patient buy in/engagement Our diabetes services stock take of resources/ staffing / project support already in place in each CCG may have over estimated current staffing or underestimated new staff needed to achieve improvements 74

75 5.In addition to the costs set out in the Excel application form please set out: a) Any non-financial resources you will need in order to carry out these actions and how these will be provided? b) Any capital requirements to ensure delivery of this bid? This should include the amount required and confirmed plans for how these will be successfully addressed outside of this bid. Appraisal dashboard criteria reference(s): TT sustainability and resources 5a) None 5b) None 75

76 6.Taking into account the evidence on the wider benefits from improved achievement of the treatment targets, what do you anticipate to be the savings/reductions in the increase of expenditure on diabetes that will arise as a result of your plans? Appraisal dashboard criteria reference(s): TT sustainability Add finalised spreadsheet info and costings Table 2: Treatment Targets; 2017/ / / /21 Costs 1,744,184 1,371,847 1,371,847 1,371,847 Estimated incremental annual gross savings 0 410, ,842 1,580,699 Estimated cumulative annual gross savings (starting from 2017/18) ,200 1,326,042 2,906,741 76

77 7. Please set out which of the proposed actions are considered to be only necessary over the short/medium term to promote improvement and which are considered necessary to maintain over the longer term. Where actions are required to continue over the longer term, please set out what commitment there is from the CCGs and partners to sustain these as transformation funding reduces. Appraisal dashboard criteria reference(s): TT sustainability Short to medium term Development of the Programme Changes to contracting model Process changes in primary care practices, community services and specialist diabetes clinics in hospital. Statement from NWL STP 77

78 8.What do you consider to be the key learning that could come out of your proposal that could inform improvement in other localities? In answering, please take into account whether your proposal is dependent upon other specific local services that may not be available elsewhere, whether it is focussed on specific populations and whether it would take a short (less than one year) or longer (more than one year) period to implement elsewhere. Appraisal dashboard criteria reference(s): TT replicability of model There is a wealth of key learning that will come out of our proposal: We have already implemented some of the diabetes transformation programme and are beginning to see the results of this approach. In doing so we have implemented ideas from other areas such as Tower Hamlets (dashboards, primary care outcomes based contacts, network targets), Portsmouth (Super Six and shifting specialist input to primary care networks). We have learned some lessons from the first year of the contract which would already be of value to others implementing local incentive schemes at scale. Our approach to maximise the functionality of the primary care system through standardised templates, letters and reports The Diabetes Innovation Centre: understanding the link between PAM and different self-care / structured education / supported self-care approaches Per patient costing for diabetes across the whole health and social care system for a large population Primary care at scale: developing federation teams to improve diabetes care across their population Improvements in understanding about UK new care models for diabetes: both from an organisational and a data analytics perspective Organisational development lessons about CCGs collaborating effectively across an STP to develop a unified vision for diabetes care improvements 78

79 (3) Complete this section as part of your application for funding for a diabetes inpatient specialist nursing service (DISN) Please expand the boxes below as required for your answers. Please use this sheet to describe your plans to put in place a new or expanded DISN service. (If there is more than one DISN service covered by this bid, please duplicate and complete separate version of this section for each DISN service). 1. Name of provider that will operate the new/expanded DISN service. Chelsea and Westminster Hospitals NHS Foundation Trust Imperial College Healthcare NHS Trust NWL London North West Healthcare NHS Trust Hillingdon Hospitals NHS Trust 2. Are you bidding for a new or expanded existing DISN service? Appraisal dashboard criteria reference(s): DISN cohort size, clinical outcomes Expanded. C&W existing service delivered as part of DSN job plans 1WTE WMUH about to be expanded to 0.5 WTE LNWH existing service funded as part of establishment. Northwick Park/St Marks 1 WTE DISN, Ealing Hospital 1 WTE, Central Middlesex Hospital 0 WTE 3. If you currently have a DISN service, please describe its current role and approach in terms of: a) Criteria for which patients are referred to DISNs. b) How referral processes operate so as to ensure timely, appropriate referrals. c) How the service enhances the diabetes skills of other inpatient staff. d) What other services offer specialist support to inpatients with diabetes (e.g. consultant diabetologist, podiatry) and how these services work together to offer an integrated diabetes inpatient service. e) What the current funding arrangements for the DISN service. Appraisal dashboard criteria reference(s): DISN cohort size, clinical outcomes, patient experience, sustainability and resources 79

80 3a) Criteria for which patients are referred to DISNs. Multiple current providers with different models. Criteria is based around ThinkGlucose criteria. 3b) How referral processes operate so as to ensure timely, appropriate referrals. Referrals via faxed form or telephone call. Have in patient podiatry with referrals triaged by DSNs. SpR and Consultant support but no dedicated consultant time for in-patient diabetes. 3c) How the service enhances the diabetes skills of other inpatient staff. Much of the service is delivered by general diabetes specialist rather than dedicated inpatient nurses and strengths as well as weaknesses of this approach. All include an element of opportunistic teaching and formal teaching sessions to ward staff 3d) What other services offer specialist support to inpatients with diabetes (e.g. consultant diabetologist, podiatry) and how these services work together to offer an integrated diabetes inpatient service. Most hospitals in region either have or will shortly have connected glucose meters allowing automatic identification of patients with out of range glucose levels. 3e) What the current funding arrangements for the DISN service Funding is through block contracts. DSN posts are funded as part of current diabetes establishment, not dedicated DISNs. 4. Does the service fully or partially adhere to NICE guidelines and quality standards? (If partially please set out how the service does not conform with NICE) If the service does not fully conform, please confirm whether this will form a core requirement of your service specification from 2017/18. Also, has there been any external or internal (please state which) assessment of whether the service meets NICE guidelines and quality standards: a) Within the last two years or b) More than two years ago (Please state which?). If not, has there been any formal internal consideration as to whether the service meets NICE guidelines and quality standards? Appraisal dashboard criteria reference(s): DISN safety/quality and clinical outcomes NICE guidelines are followed. Quality Standards are partial met at some sites, but many sites across region do not currently meet the standard of 1 WTE DISN per 300 beds. Coding issues means many patients with Type 1 Diabetes will not be identified so reporting is challenging. 80

81 Currently diabetes teams are NOT informed of every person with diabetes who is an in-patient. Much of the service is delivered by general diabetes specialist rather than dedicated in-patient nurses and strengths as well as weaknesses of this approach. We are not aware of any review in any of our provider sites. 5. Please describe the future role and approach of the DISN service (whether enhancing an existing team or introducing a new team) in terms of: a) Analysis of required staffing year by year to 2020/21. b) Why you consider that the staffing set out in Q5 below will be sufficient to meet this need. c) How your knowledge of the needs of differing cohorts of local diabetes populations and their communities/services have influenced this model. d) Criteria for which inpatients will be referred to DISNs. e) How referral processes when in hospital will operate so as to ensure timely, appropriate access. f) The impact upon length of stay and the reasons for this. g) How reductions in harms in diabetes inpatients across the hospital, such as from medication errors and from hypoglycaemic and hyperglycaemic episodes, will be supported, including in terms of reviewing such episodes and promoting change in clinical practice. h) How the service will enhance the diabetes skills of other inpatient staff. Appraisal dashboard criteria reference(s): DISN cohort size, clinical outcomes and safety/quality 5a) Analysis of required staffing year by year to 2020/21. We used KH03 to look at available overnight beds across NW London and compared this against diabetes inpatient nurse staffing data to identify the gap. This data suggests we need 10 additional diabetes inpatient nurses. To reflect varying ethnic groups and increased need for interpreters / cultural specific interventions we propose we require higher than the NICE Quality Standards suggest (we believe we need 1.25 per 300 ) 5b) Why you consider that the staffing set out in Q5 below will be sufficient to meet this need Staffing levels have been calculated from no of beds. However, to reflect the higher than average proportion of inpatients with diabetes across NW London (identified in the National In-Patient Diabetes Audit) varying ethnic groups and increased need for interpreters / cultural specific interventions we propose we require higher than the NICE Quality Standards suggest (we believe we need 1.25 WTE DISNs per 300 beds) 81

82 5c) How your knowledge of the needs of differing cohorts of local diabetes populations and their communities/services have influenced this model. We have used our knowledge of our patient cohort reflecting the varying ethnic groups and increased need for interpreters / cultural specific interventions and suggested 1.25 per d) Criteria for which inpatients will be referred to DISNs Any hypoglycaemic episode in hospital or admitted with hypoglycaemia Admission with DKA / HHS / Poor glycaemic control 2 or more glucose level > 12 mmol/l per day Any foot problem Type 1 Diabetes Pregnancy and diabetes Known diabetes starting steroids or artificial nutrition We will set up processes to receive automatic detection with connected glucometers (Already had GDE bid discussions). 5e) How referral processes when in hospital will operate so as to ensure timely, appropriate access. Referral process to remain local (eg bleep. fax form / electronic referral 5f) The impact upon length of stay and the reasons for this. We will aim for a length of stay comparable with Norwich 5g) How reductions in harms in diabetes inpatients across the hospital, such as from medication errors and from hypoglycaemic and hyperglycaemic episodes, will be supported, including in terms of reviewing such episodes and promoting change in clinical practice. Use additional capacity to educate ward nurses and have ward leads responsible for diabetes results cascade knowledge using Royal Free 10 point training diabetes ward training programme. 82

83 5h) How the service will enhance the diabetes skills of other inpatient staff. Teams will be able to rapidly investigate clinical incidents involving diabetes to share best practice and also share findings across providers in NWL. Operate a rolling education program to up skill non-specialist ward staff in diabetes management. This will be combined with a program of link nurses or equivalent and all trusts will be encouraged to recognise this role. Given the movement of staff around the region and the shared challenges the curriculum will be developed by all providers to offer an interchangeable qualification in diabetes competencies. It is anticipated that this will also create a future pool of possible candidates for DISN training posts. At one of our provider sites (LNWHT) we have an internal 3 day training programme Admission to Discharge for ward nurses to up skill them in basic diabetes management skills and to alert them to which patients will need referral to the specialist diabetes nurse team. This is available across the trust to nursing staff treating patients with diabetes. We need extra resource to extent this to more staff groups. It would be appropriate to extend this across NW London sector. We will offer the training programme in a limited number of sites to nursing staff from the whole of NW London to increase economy of scale. 6. Describe your proposed implementation plan. Arrangements for clinical supervision of DISNs should also be set out. Use the following table to outline key actions, who will be responsible for delivering these and the expected timescales for completion, including for recruitment and/or training of DISNs. Appraisal dashboard criteria reference(s): DISN clinical outcomes Please set out the specific actions you propose to take Actions Responsible organisation / individual Full analysis of all current providers DISN capacity and need based on bed numbers and results of 2016 National Diabetes Inpatient Audit (published March 2017) Identification of key new posts required to equalise current provision and recruitment 83 Diabetes Programme Director with Secondary care diabetes clinical leads / Trust lead DSNs Provider Clinical Leads Timescale for completion June 2017 Sept 2017 Harmonisation of referral criteria / clinical Provider Clinical Sept 2017

84 guidelines across NWL Providers Development of standardised data collection and codesign guidelines for acute trusts Building on the LNWHT exemplar, development of training program for new DISNs including mentoring to complete expansion and replace vacant posts Leads and Lead DSNs Provider Clinical Sept 2017 Leads and Lead DSNs Programme Director Jan Please set out the current and planned future make-up of your diabetes inpatient specialist team by WTE, including DISNs, podiatrists, consultants etc. (Where a DISN service does not currently exist, please set out these details with respect to existing posts that will in the future form part of the DISN). Appraisal dashboard criteria reference(s): DISN resources Staff Type and Banding (Nurse, Consultant, Podiatrist, etc.) 2016/ / / / /21 84

85 8. Of the above, please set out how many of each type are/will be on duty on a Saturday or Sunday. Appraisal dashboard criteria reference(s): DISN resources Saturday Staff Type and Banding 2016/ / / / /21 Sunday Staff Type and Banding 2016/ / / / /21 85

86 9. Do you anticipate any difficulties recruiting appropriate staff within short timescales for these improvements? If so, please set out your recruitment and training strategy for this service including: Any plans to provide existing employees with additional training to carry out this function. Engagement with LETBs. Whether training arrangements have been confirmed (subject to the outcome of the bid). What actions you will take to secure successful delivery should there be delays in recruitment? Appraisal dashboard criteria reference(s): DISN resources Recruitment and retention of Diabetes Specialist Nurses (including DISNs) in NWL is challenging, with a very small pool of suitably qualified candidates, meaning many posts are filled by movement within the region, leading to on-going vacancies. These gaps are an important limitation to current services. Thus a key part of this proposal is to address workforce capacity by the creation of a training and supervision program. This will build on work to increase and recognise diabetes education amongst front line ward based nursing staff, by creating a bespoke education program to allow interested nurses to develop into in-patient diabetes nurses. It is anticipated that this will then have a knock on effect of improving recruitment into other outpatient and community based DSN posts. We will create many new posts at a Band 6 level with close supervision from existing more senior DSNs, to allow those new to diabetes specialist nursing to develop skills. This will be coupled with a training program delivered across NWL and certification will be sought for this. At one of our provider sites (LNWHT )we have an internal 3 day training programme Admission to Discharge for ward nurses to up skill them in basic diabetes management skills and to alert them to which patients will need referral to the specialist diabetes nurse team. This is available across the trust to nursing staff treating patients with diabetes. We need extra resource to extent this to more staff groups. It would be appropriate to extend this across NW London sector. We will offer the training programme in a limited number of sites to nursing staff from the whole of NW London to increase economy of scale. 86

87 10. In addition to any difficulties recruiting appropriate staff within short timescales set out above, please set out what other risks to successful implementation of a new or expanded DISN service you have identified, the likelihood of these occurring and mitigating actions you propose to take. This risk assessment should include: Risks to implementation. Risks arising from relationships with stakeholders. Risk that interventions are not well targeted. Risks based on inter-relationships with other strategic plans. Appraisal dashboard criteria reference(s): DISN risks Risk include a lack of engagement from trusts to free up ward and junior DNS time for training particularly in view of the vacancy rates amongst many acute trusts. This could be mitigated through contracting There is also a risk of lack of engagement from non-diabetes specialists with the service but this should be mitigated through better training and promotion of the advantages of DISN input. 11. Describe how the proposed additional or extended DISN service will support the wider treatment pathway, including how actions agreed with patients will be reflected in the patient's overall care plan and so followed up by others treating the patient after discharge. Appraisal dashboard criteria reference(s): DISN patient experience and safety/quality A key strength of expanding DISN time will be better integration with community and primary care diabetes teams to support the most appropriate follow up arrangement, communicate changes to care plan, and avoid unnecessary follow up in secondary care. This will build on a successful trial at Imperial College Healthcare where a dedicated Diabetes Discharge co-coordinator was able to identify vulnerable patients that required community diabetes input on discharge, or to avoid admission all together working very closely with the local community diabetes teams to ensure promote and safe follow up on discharge. 12. Describe how the funding of the service will operate over the longer term so that savings made from reductions in lengths of stay and complications are reinvested so as to make the service self-sustaining in funding, together with the rationale for the expected levels of savings. Have the CCG and provider agreed that savings will be re-invested so as to make the service self-sustaining? Appraisal dashboard criteria reference(s): DISN sustainability 87

88 Our strategic aim with this NWL Diabetes Transformation Programme is to develop diabetes as a single service specification across NWL delivered by one or more integrated provider partnerships with a capitated budget and one NWL STP diabetes team. The NWL STP includes the implementation of accountable care partnerships, improvements in rapid response and intermediate care services, and improvements in care in the last phase of life. These outcomes based contracts are a priority for elderly care, and highly relevant to elderly diabetes patients, and it is likely that we will use a similar approach for commissioning an integrated diabetes care system across North West London. The new care model is likely to involve a single contract and single pooled budget across all providers focused on longer term outcomes based contracts. They are clinically led, are organised around the same quality and financial incentives across organisations, and focus on primary and secondary prevention. NWL CCGs are working with the ACP team to develop an integrated diabetes new care model as an exemplar for other Long Term Conditions. We will commission the NWL Diabetes Team through a partnership agreement with a shared governance approach. This team will coordinate and be ultimately responsible for the delivery of outcomes across all primary, community, secondary care and council providers. The finance required for diabetes in-patient nurse will be released from improved length of stays. 13. When do you expect the service/expanded service to commence? April In addition to the costs set out in the Excel application form please set out: a) Any non-financial resources you will need in order to carry out these actions and how these will be provided? b) Any capital requirements to ensure delivery of this bid? This should include the amount required and confirmed plans for how these will be successfully addressed outside of this bid. Appraisal dashboard criteria reference(s): DISN sustainability and resources 14 a) None 14 b) None 88

89 National Diabetes Treatment and Care Programme Application (4) Complete this section as part of your application for funding for a multidisciplinary foot care team (MDFT) Please expand the boxes below as required for your answers. Please use this sheet to describe your detailed plans to put in place a new or expanded MDFT. (If there is more than one MDFT covered by this bid, please duplicate and complete separate version of this section for each MDFT). Please note that the core aspect of this funding is for MDFTs. Such bids may include proposals to augment Foot Protection Teams (FPTs) as part of the overall bid where it will promote appropriate use of MDFTs and facilitate greater capacity within them. However, bids should not be focussed solely or primarily on FPTs. There is the ability to make bids with respect to FPTs within the Pathway funding in section (5) of this form. Please attach your footcare pathway, including setting out how patients will be referred to the MDFT in accordance with the times set out in NICE guidance NG19 and as referred to below. 1. Name of provider that will operate the new/expanded MDFT. LNWH NHS Trust and Imperial College Healthcare NHS Trust 89

90 2. Are you bidding for a new or expanded existing MDFT service? Appraisal dashboard criteria reference(s): MDFT cohort size, clinical outcomes The London Diabetic Foot Network and the Diabetes SCN have promoted NICE and Diabetes UK footcare pathways for patients with diabetes and supported the implementation of MDFTs and FPTs across London. The LDFN is a voluntary collaborative of patients, charitable organisations, multi-disciplinary healthcare professionals, managers and commissioners. Although there has been increasing improvements since the LDFN was initiated in 2013, there is certainly more to do to improve the care of patients with foot problems in London. The reason for the need for a more collaborative and consistent approach are that London has: A fivefold variation in amputation rate across CCGs. 15.3% of bed nights for diabetic foot disease in England. A length of stay up to 13.3 nights (average 9.1 nights compared with an 8.1 average in England). This equates to over bed days a year. 10.5% of all diabetic foot related amputations in England. Averages 7577 episodes of inpatient care related to diabetic footcare per annum. Over 50% of patients with acute foot disease are admitted via A & E. To support all STPs having a cohesive approach to MDFT developments, the London Diabetes Foot Network leading a London Programme for Diabetes Footcare (MDFT development) this approach has been taken to reduce variation in outcomes for diabetic foot disease in London. This has led to a unified vision to commissioning of diabetic foot care as well as treatment of foot problems within an enhanced MDFT for renal patients. This has ensured that there is little difference when comparing the larger London STP geographies as evidenced below SW London SE London NW London NE London NC London Number of amputations/1000 diabetics Number of minor amputations per 1000 diabetes Annual episodes in hospital per 1000 diabetics London Diabetic Foot Activity Profiles All data relate to the period 1/4/2012 to 31/3/2015 Data Produced by: National Cardiovascular Intelligence Network (NCVIN) Whilst figures for amputations are lower than that for England, the rate still remains high when considering published data that 80% of amputations are avoidable. 90

91 The aspiration is to ensure excellence in diabetic footcare across London and reduce the variability in access as well as intervention in care. Each STP has different requirements due to the makeup of FPTs and MDFTs in each sector. Whilst NW London has examples of excellent foot care within individual MDFTs (the best performing CCG in England is in the NW London STP footprint), there is substantial variation in performance and overall footcare across the STP footprint is poorly structured. Organisational boundaries affect care provision and access to services. This particularly disadvantages people with diabetic foot problems who frequently have complex health needs. There are over 170,000 people with diabetes in the NW London STP footprint. Bringing amputation rates down to the level of the best performing CCG would mean 200 fewer amputations and 1000 fewer in-patient nights over a 3 year period. Renal and vascular surgery services in NW London have been reorganised using a hub and spoke model with a single renal hub and an inner and outer NW London vascular hub. People with diabetes and end stage renal disease are 30% more likely to develop foot ulcers and revascularisation is a key component of the diabetic foot management. However operational alignment between local MDFTs in NW London and renal and vascular hubs is lacking. Furthermore, the creation of the renal and vascular hubs has substantially increased MDFT demand at these sites. All 8 NW London CCGs have an MDFT pathway. This bid expands and enhances these existing MDFTs in the NW London STP by creating a managed clinical foot network: the NW London STP Diabetes Foot network (please see figure1.) comprised of inner and outer NW London MDFT networks aligned to the to the established inner and outer NW London vascular hubs This will: i) Reduce variation in performance and improve foot outcomes across the NW London STP through shared best practice and sector wide structure for clinical governance, quality improvement and professional development ii) Provide a 7 day MDFT service across the NW London STP iii) Optimise patient flow and navigation through foot pathways and across the NW London STP footprint iv) Standardise and embed foot pathways v) Establish and renal and vascular foot pathways for people with diabetic foot problems This bid will enable this by: i) Providing a dashboard for foot care for the NW London STP ii) Providing the necessary MDFT workforce capacity across the NW London STP iii) Creating inner and outer NW London pathway coordinators who will facilitate pathway navigation and patient flow at the local, network and STP level and support inter and intra network communication and collaboration iv) Creating inner and outer NW London MDFT network clinical leads who will drive forward and maintain transformation in a collaborative manner v) Having strong user engagement in development of the Network 91

92 Figure 1. Organogram of proposed NW London STP Diabetes Foot Network the current MDFTs, FPTs (Foot Protection Teams) and CCGs and their relationship to the established inner and outer London Vascular hubs are shown in white. The blue structures denote the new networks, stakeholders and resources (excluding additional specialist podiatrists) proposed in this bid. The NW London STP Diabetes Foot Network Chair and pathway coordinators will work closely with user engagement groups. Please see response to Q6e) for details. 92

93 3. If you currently have an MDFT service, please describe its current role and approach in terms of: a) Criteria for which patients are referred to MDFTs. b) How referral processes operate so as to ensure timely, appropriate referrals. c) How the service enhances the diabetes skills of other staff. d) What other services offer specialist support to patients with diabetes with footcare needs (e.g. consultant diabetologist, podiatry) and how these services work together to offer an integrated diabetes service. e) What the current funding arrangements for the MDFT service. Appraisal dashboard criteria reference(s): MDFT cohort size, clinical outcomes, patient experience, sustainability and resources The MDFTs in the NW London STP footprint have common referral criteria and similar referral pathways. Therefore, to maintain clarity and reflect the network strategy of this bid, we have completed section (3) of this form for all NW London STP MDFTs rather than the individual MDFTs. 3a) Criteria for which patients are referred to MDFTs. The organisation of the MDFTs in the NW London STP footprint in relation to the 8 CCGs and the inner and outer London NW London vascular networks is shown in appendix 1. Seven of the 8 CCGs have an MDFT but there is no MDFT in Hammersmith and Fulham CCG which includes the renal hub for NW London (Hammersmith Hospital) and an acute site (Charing Cross Hospital). Only 4 CCGs have foot pathways integrated across the community and secondary care with shared clinical staff and only 4 CCGs have pathway documentation for referrers: Table 1. Summary of NW London MDFTs by CCG CCG Hospital MDFT (Hospital) 93 Integrated Foot Pathway Brent CCG CMH Yes Yes Yes Ealing CCG Ealing Yes Yes No Harrow CCG NPH Yes No Yes H&F CCG HH (NW London Renal Hub CX No (refer to SMH MDFT) No MDFT Pathway documentation* Hillingdon CCG Hillingdon Yes Yes Yes Hounslow CCG WMH Yes Yes No K&C CCG C&W Yes No No Westminster CCG SMH Yes No Yes CCGs: H&F, Hammersmith and Fulham; K&C, Kensington and Chelsea, Hospitals: CMH, Central Middlesex Hospital; NPH, Northwick Park Hospital; WMH, West Middlesex Hospital; C&W, Chelsea and Westminster Hospital, SMH, St Mary s Hospital N/A

94 *please see appendix 2 for pathway documentation The 7 NW London STP MDFTs have common risk stratification and referral criteria compliant with NICE guidelines (NG19): Risk stratification Active Foot: Infection, red hot foot; critical ischaemia/gangrene, foot ulcer, suspected acute Charcot s neuroarthropathy High Risk Foot: Previous ulcer/amputation At Risk Foot: No ulcer, no previous ulcer/amputation plus any of the following: Foot deformity/absent foot pulses/sensory neuropathy/corn/callous For all 8 CCGs all active foot disease is referred to local MDFTs. Differences in the referral criteria with respect to the high risk foot reflect the presence or absence of an integrated foot pathway with shared clinical staff across the community and secondary care: 94

95 Brent CCG Ealing CCG Hillingdon CCG Referral pathway for CCGs with an Integrated Foot Pathway* Active Foot Disease referral to local MDFT High risk foot referral to local MDFT At risk foot- referral to Foot Protection Team (FPT) *pathway integrated across community and secondary care with shared clinical staff across community and hospital MDFT clinics Hammersmith & Fulham CCG Harrow CCG Hounslow CCG Kensington and Chelsea CCG Referral pathway for CCGs without an integrated Foot Pathway Active Foot Disease referral to local MDFT High risk foot referral to Foot Protection Team (Tier 3) At risk foot- referral to Foot Protection Team (Tier 3) Westminster CCG Figure 2: Foot pathways for the at risk, high risk and active foot disease according to CCG 95

96 3b) How referral processes operate so as to ensure timely, appropriate referrals. All the MDFTs have referral pathways for referral from community Foot Protection Teams (FPTs) and primary care to local MDFTs (see appendix 2) with specific referral forms (appendix 3). In Brent CCG there is a single point of access for all diabetes referrals including diabetic foot referrals (see appendix 2a). Active limb/life threatening foot problems All MDFTs in the NW London STP provide a walk-in/emergency referral service for active foot problems (please see risk stratification criteria outlined in response to Q3a) as part of their scheduled MDFT clinics. The MDFT clinics all run with immediate access to consultant diabetologist. These MDFT clinics offer immediate access during working hours to acute services for limb and life threatening active foot disease in line with NICE recommendations (NG19). Referrals are by phone/fax/ and all MDFTs will accept referral from primary care, community, and patients (or their carers) known to the MDFT clinic. However, not all MDFTs have sufficient diabetes specialist podiatrist capacity to provide a 5 day service. Also there are significant capacity problems within all MDFTs and emergency patients are usually seen in already overbooked scheduled clinics MDFTs with 5 day walk-in/emergency referral service CMH MDFT (Brent CCG) Ealing MDFT (Ealing CCG) NPH MDFT (Harrow CCG) Hillingdon MDFT (Hillingdon CCG) SMH MDFT (Westminster CCG and Hammersmith and Fulham CCG) MDFTs with less than 5 day walk-in/emergency referral service C&W MDFT (Kensington and Chelsea CCG): 3 x weekly MDFT clinics, WMH (Hounslow CCG): MDFT clinics Mon-Fri, All MDFTs have 24h access, 7 days per week to their vascular hub: St Mary s Hospital (SMH) for Inner NW London and Northwick Park Hospital (NPH) for outer NW London (please see appendix 1). None of the CCGs have access to MDFTs out of hours or at weekends. None of the NW London acute hospitals has in-patient access to diabetes specialist podiatrists out of hours. Active non-limb/life threatening foot problems Patients with active non-life/limb threatening foot problems (non-infected, nonischaemic ulcer; chronic ulcer (>4-6 weeks); suspected acute Charcot s neuroarthropathy) are referred to the MDFT. Seven of the 8 MDFTs in the NW London STP are largely compliant with NG19 triaging patients within 1 working day 96

97 and seeing patients within 1 further working day. However, capacity issues as outlined above mean that some patients (based on risk assessment by triaging diabetes specialist podiatrist) will wait longer than NICE recommendations for MDFT review. C&W MDFT is not compliant with NG19 as it has only 3 half day clinics per week and provides triage within 1 working day and review within 72 hours. The capacity issues in the existing MDFTs mean that many patients present as emergency patients to A&E. In the outer NW London vascular hub (NPH) emergency foot admissions have risen by 45% between 2013 (8817) and 2016 (12,797) and the proportion of patients being admitted as emergency patients rather than planned admissions for revascularisation has increased from 66% in 2013 to 74% in in c How the service enhances the diabetes skills of other staff All NW London MDFTs: - Provide clinical placements for podiatry, medical and nursing students - LNWH NHS Trust Core Medical and Higher Specialist Trainees rotate through the consultant diabetologist led MDFT clinics - The hospital based MDFT clinics at each hospital operate as part of a Diabetes Centre providing holistic diabetes care for foot patients and ensuring the whole multidisciplinary team (clinical and non-clinical) are familiar with diabetic foot complications and management. - Members of each MDFT are active members of the Pan London Diabetes Foot Network and have contributed to the creation of renal foot guidance and commissioning guidance for the diabetic foot for London - MDFT podiatrist participate in-house and community teaching for podiatrists, secondary care doctors and primary care doctors - Work based learning - The MDFTs work closely with each hospital s ambulatory day-case unit, outreach team and/or District Nursing team in the provision of OPAT (outpatient parenteral antibiotic therapy). In addition: CMH/Brent, Ealing and Hillingdon MDFTs: - Community band 6 podiatrists rotate through the hospital based MDFT 3d) what other services offer specialist support to patients with diabetes with footcare needs (e.g. consultant diabetologist, podiatry) and how these services work together to offer an integrated diabetes service All the MDFTs work in the context of a larger multidisciplinary diabetes team with weekly diabetes MDTs providing an integrated service to MDFT patients. Four of the MDFT clinics are located within the Diabetes Centre at each hospital as part of a multidisciplinary team (MDFT podiatrist, consultant diabetologists, diabetes dietician, diabetes specialist nurses +/- clinical psychologist) to provide integrated diabetes care and include weekly multidisciplinary diabetes 97

98 team meetings to discuss patients with complex health needs MDFT (Hospital ) Diabetologis t Podiatrist joint clinic Combine d vascular MDFT clinic Fortnightl y Combined orthopaedi c MDFT clinic/mdt MDT* MDFT clinic within multidisciplinar y diabetes centre CMH Twice weekly No Weekly Yes Yes Ealing Weekly No No Weekly No Yes SMH 3 x /week Fortnightl fortnightly Weekly Yes No y NPH Weekly Weekly No Weekly Yes No Hillingdo Weekly Monthly Monthly Monthl Yes Yes n y WMH Twice No No No No No weekly C&W Weekly No No No Yes No Communit y MDFT clinic Table 2. Formal multidisciplinary services by MDFT *MDT multidisciplinary team meeting to discuss complex patients; minimum membership: diabetes, podiatry, vascular, microbiology, Radiology +/- tissue viability, orthopaedics The MDFTs at all sited work closely with vascular surgery, orthopaedics, microbiology/infectious diseases and radiology. However, for some of the NW London MDFTs this takes the form of running clinics in parallel rather than dedicated combined clinics or scheduled MDTs (multi-disciplinary team meetings) as outlined in table 2 above. All MDFTs works closely with biomechanics, orthotics, plaster room (total contact casting) and tissue viability teams in their respective Trusts In Brent, Ealing and Hillingdon CCGs there are also Community MDFT clinics run by diabetes specialist podiatrists from the hospital based MDFT. In Brent this community MDFT clinic is part of a multidisciplinary clinic with Diabetes Specialist Nurse, Diabetes Specialist Dietician and Consultant Diabetologist 3e) what the current funding arrangements for the MDFT service Table 3. below summarises the funding arrangements for the 7 MDFTs in NW London. The funding for all MDFTs is for outpatient activity only i.e. none of the MDFTs have formal funding for ward review of in-patients 98

99 CCG MDFT DSP Funding Brent CCG Ealing CCG Harrow CCG CMH, LNWH NHS Trust Ealing, LNWH NHS Trust NPH, LNWH NHS Trust H&F CCG No MDFT N/A N/A Hillingdon CCG Hounslow CCG K&C CCG Westminster CCG Hillingdon, Hillingdon NHS Foundation Trust WMH, C&W NHS Foundation Trust C&W, C&W NHS Foundation Trust SMH, ICHT NHS Trust 1.2 wte Contracts held by LNWH NHS Trust (Community and Acute provider), funding through PBR using standard tariff 1.25 wte Contracts held by LNWH NHS Trust (Community and Acute provider), funding through PBR using standard tariff 0.98 wte Contracts held by LNWH NHS Trust (Community and Acute provider), funding through PBR using standard tariff 1 wte Contracts held by Central Northwest London NHS Trust (Community provider); SLA with Hillingdon Hospital NHS Foundation Trust 1 wte Contracts held by Central London Community Healthcare NHS Trust (Community provider), SLA with C&W NHS Foundation Trust 0.3 wte Contracts held by Central London Community Healthcare NHS Trust (Community provider), SLA with C&W NHS Foundation Trust 3.8 wte Contracts held by ICHT (Acute provider), funding through PBR using standard tariff Table 3: Funding arrangements and podiatrist staffing across NW London CCGs DSP: Diabetes Specialist Podiatrist (Band 7/8) LNWH: London NorthWest Healthcare; ICHT: Imperial College Healthcare NHS Trust) 99

100 4. Do access and referral/assessment times for the MDFT and related services reflect recommendations within NICE guidance NG19? (e.g. If a person has a limb-threatening or life-threatening diabetic foot problem, refer them immediately to acute services and inform the MDFT so they can be assessed and an individualised treatment plan put in place. For all other active diabetic foot problems, refer the person within 1 working day to the multidisciplinary foot care service or foot protection service for triage within 1 further working day.). If these criteria are not currently used, how will you ensure compliance with this as part of implementation of the bid? Please also set out what arrangements you will have in place to promote speedy referrals to MDFTs where appropriate. Appraisal dashboard criteria reference(s): MDFT safety/quality All MDFTs have local pathways which direct patients with limb or life threatening foot problems immediately to acute services either within the MDFT emergency clinic or to the on-call vascular team (located at the inner and outer NW London vascular hubs) or on-call medical team (Please see response to Q3b). Table 4 below summarises the access times for the 7 NW London MDFTs in relation to NICE guidance NG19. WMH and C&W are not fully compliant as they do not run Mon-Fri MDFT clinics. The other 5 MDFTs have pathways that are NG19 compliant however in practice because of capacity issues a significant number of patients present via A&E rather than via the MDFT. No MDFT provides 7-day access and inpatients and MDFT access is largely based on informal good-will arrangements as discussed in more detail below. Inpatient MDFT access is a particular problem at Hammersmith Hospital, the NW London renal hub and Charing Cross Hospital (an acute site) as there is no local MDFT on these sites. MDFT (Hospital) Common risk stratification criteria Immediate MDFT access for limb/life threatening foot problem MDFT review within 1 working day for active foot problem CMH Yes Yes Yes No Ealing Yes Yes Yes No SMH Yes Yes Yes No NPH Yes Yes Yes No Hillingdon Yes Yes Yes No WMH Yes No Yes No C&W Yes No No No CXH Yes No MDFT No MDFT No HH Yes No MDFT No MDFT No MDFT review within 24h for inpatients Table 4. Access times to MDFT in relation to NICE guidance NG19 100

101 Inpatient MDFT access None of the MDFTs provides a 7-day service. Therefore, patients admitted over the weekend will not be reviewed within 24h of admission. All the MDFTs will review in-patients who are able to attend the outpatient MDFT clinic. None of the MDFTs have formal funding arrangements for the review of inpatients who are too unwell/frail to be seen in an outpatient setting. The MDFTs at all sites, however, try to review such patients on the ward as an informal goodwill basis where time allows. In-patients at Hammersmith Hospital and Charing Cross Hospital (Hammersmith and Fulham CCG) have no MDFT on site and need to be transferred to St Mary s Hospital if MDFT review is required. 5. What services are available for patients at risk of developing active foot disease who do not satisfy the criteria for accessing the MDFT, such as Foot Protection Teams? Please set out any changes you plan to make to these services. Appraisal dashboard criteria reference(s): MDFT cohort size, clinical outcomes All people with diabetes over the age of 12 years old should receive a foot check at least once a year as part of their annual review as part of the 9 Diabetes Care Processes. All 8 CCGs in the NW London STP have an agreed foot pathway with foot protection teams (FPTs) and MDFT and common risk stratification as outlined in response to Q3a above. The FPTs in all 8 CCGs will accept referrals from any health care professional. Formal documentation outlining local foot pathways are available for 4 of the 7 MDFTs (please see appendix 2). The documentation for the local foot pathways across the 8 NW London CCGs are not standardised and local engagement with foot pathways is variable. The referral pathway for the high risk and at risk foot are summarised in figure 2 in response to Q3a. In all 8 CCGs at risk patients are seen in community clinics by local FPTs. In Brent, Ealing and Hillingdon CCGs high risk patients are seen in community MDFT pathways (by Diabetes Specialist Podiatrists). In the remaining 5 CCGs high risk patients are seen in community clinics by FPTs. Brent CCG has the lowest amputation rates in the country. In 2005 Brent launched the traffic light foot pathway (appendix 2) was launched in 2005 as part of an integrated diabetes pathway across primary, community and secondary care and there has been an ongoing program of engagement with healthcare professionals in the community (including FPTs) and primary care to embed the foot pathway. 101

102 The London Renal SCN (Strategic Clinical Network) together with the Pan London Foot Network have advised that the risk status of all patient with diabetes on renal replacement therapy should automatically be considered as being High Risk, in the absence of any active foot problems, with a referral for specialist expert advice and treatment if an active problem is discovered during the examination. The quality of the foot check/screening depends can be significantly variable, leading to poor screening, misdiagnosis, poor information. The London Renal SCN has identified that people with diabetes on renal replacement therapy are poorly served by current foot pathways 1. This has been confirmed for the NW London STP footprint with audits performed at 4 dialysis sites which found that up to 50% of patients on dialysis were not under regular podiatry follow up. This proposal will optimise the use of local foot pathways and FPTs in the NW London STP footprint through: Improving pathway accessibility: foot pathways across the inner and outer London network will be standardised. The pathway coordinators will provide a single point of access for foot referral queries, ensuring that users are directed to the appropriate local pathway. Raising pathway profile: Foot pathways will be embedded in local diabetes guidelines. The increased specialist podiatry staff will enable investment in training and workforce development of health professionals in community and primary care. Facilitating pathway navigation: pathway coordinators will provide a single coordination point to facilitate pathway navigation. Monitoring pathway performance: performance of local foot pathways will be monitored as part of this proposal through the NW London STP Diabetes Foot Network Dashboard (please see our response to Q6b) and user engagement. The proposed NW London STP Diabetes Foot network will have a responsibility to work collaboratively to improve pathway performance. Investment in professional development: inclusion of the Foot protection teams in 4 monthly NW London STP MDFT education and governance meetings and rotation of all Foot Protection Team podiatrists through MDFT clinics 1 London Diabetes and Renal Strategic Networks: Best Practice Foot care for patients with Renal Disease

103 6. Describe your: a) Gap analysis of the service change required. b) Proposed implementation plan including the expected number of staff you will need in order to deliver this. (Use the table below to outline key actions, who will be responsible for delivering these and the expected timescales for completion). c) Reasons for considering that the actions proposed will address the gap set out, including how the evidence on improving footcare outcomes has been taken into account. d) How the proposal takes into account the assessment of the differing needs of the various local diabetes populations and the approaches needed to address these. e) How the service will work with other groups, such as community organisations, to promote improved footcare outcomes. Appraisal dashboard criteria reference(s): MDFT cohort size, clinical outcomes 6a) Gap analysis of the service change required. The following key priorities for improvement were identified through gap analysis: i) Pan-STP variation in performance and outcomes: Whilst performance and outcomes for the diabetic foot in the NW London STP are better than average for England and Wales, there is significant variation across the STP which cannot be explained by demographic differences (looking at comparator CCGs). The Diabetes Footcare Profiles from Public Health England show a 3- fold variation in amputation rates (0.6 per 1000 v 1.9 per1000) between the best (Brent CCG) and worst performing CCGs in the NW London. The best performing CCG in terms of amputations also has the lowest admission rate per 1000 of the adult population with diabetes. There is an almost 2-fold difference in hospital stay (108 v 192 nights per 1000 adults with diabetes) across the NW London CCGs. Our gap analysis has also identified differences in the organisation and delivery of diabetes foot services between the different MDFTs (outlined in our response to Q3) which may explain some of the variation in performance and outcomes. Despite the significant performance variation and the enormous potential benefit in terms patient experience and outcomes and financial savings, there is no strategy for addressing performance variation and sharing best practice across the NW London STP. Much of the data needed to support quality improvement is collected locally but is not in a format that can be readily shared with other MDFTs. However, there are significant areas where activity is not systematically recorded (e.g. MDFT review of inpatients) 103

104 In addition, although not formally audited, there appear to be significant differences in access times to outpatient vascular investigations across the different MDFTs. Vascular services have been organized according to a hub and spoke model with inner and outer NW London vascular hubs but local foot pathways have not been formally aligned with these. ii) Pathway navigation: Foot outcomes are improved when patients receive the right care in the right place. Difficulties navigating footcare pathways are an obstacle to accessing appropriate care as well as causing anxiety to patients. The MDFTs in NW London have common referral criteria reflecting NICE guidance (NG 19) but there is no standardised documentation. In NW London many patients attend multiple secondary care sites for different aspects of their diabetes care, further complicating pathway navigation. The establishment of the renal and vascular hubs in NW London means that inpatient care frequently crosses CCG boundaries. The frequent rotation of medical and surgical trainees within these hubs gives little time for trainees to become familiar with the different footcare pathways and MDFTs. Difficulties navigating foot pathways means that many patients with diabetic foot problems present to A&E rather than their local MDFT. Awareness of local foot pathways is poor. Our gap analysis identified that patients discharged from A&E were often not referred to the appropriate MDFT further delaying access to the MDFT. iii) MDFT podiatry capacity: Historically podiatry services have been commissioned from the community and most MDFTs began as informal arrangements in response to recognised need. Consequently, podiatry capacity in MDFTs has not kept up with demand. Our gap analysis identified capacity issues at all the NW London MDFTs. The NW London renal hub at Hammersmith Hospital and Charing Cross Hospital (an acute site) do not have an MDFT on site. Provision of inpatient podiatry services for most of NW London rely on ad hoc informal arrangements. Inadequate inpatient podiatry provision results in delays in wound debridement leading to increased surgical intervention, poorer outcomes and increased length of stay. Inpatients with at risk feet are often not identified resulting in preventable foot complications. iv) Weekend MDFT: Across the NW London STP there is no access to an MDFT between Friday 1700h to Monday 0900h. The MDFT provides wound assessment and sharp debridement and access to OPAT (outpatient parenteral antibiotic therapy). Weekend MDFT clinics would reduce delays in wound management and reduce hospital admission. v) Workforce development: There is high staff turnover in the NW London sector. Recruiting and retaining appropriately trained podiatrists at all levels is a challenge. A rolling program of podiatrist continuing professional development including rotation through MDFT clinics. Regular MDFT sector meetings will improve learning and skills across the sector, support quality improvement and improve team cohesiveness. 104

105 vi) Dialysis outreach: Patients with diabetes on dialysis are 30% more likely to develop active foot disease compared to people with diabetes no on dialysis but, are more likely to encounter referral delays, but are less likely to be under an MDFT. 510 patients in the NW London STP are being treated in dialysis units, including units outside the sector Individual dialysis units in the NW London STP will typically have patients from 4 or more different CCGs. Patients with diabetes foot complications requiring admission are admitted to the NW London renal hub at Hammersmith Hospital which does not have an MDFT or any inpatient podiatry provision. An increase in the diabetes specialist podiatrist workforce would provide staff resources needed to provide regular podiatry outreach to all dialysis units in the NW London sector as well as MDFT clinics at the renal hub. The pathway coordinator as outlined in i) above will facilitate referral to the appropriate MDFT/acute foot team. 6b) Proposed implementation plan including the expected number of staff you will need in order to deliver this. (Use the table below to outline key actions, who will be responsible for delivering these and the expected timescales for completion). The project deliverables mapped to the priorities identified in response to Q6a are summarised in table 5 below: Priority for Improvement Performance and outcome variation across the NW London STP footprint Proposed Deliverable Establish NW London STP Diabetes Foot Network comprised of inner and outer NW London MDFT networks aligned to vascular hub with named diabetes and podiatry leads, terms of reference and agenda Senior clinic lead for the NW London STP Diabetes Footcare Network seconded for 2.5 days per week for 4 months to set up network, implement MDFT project proposal and engage stakeholders and then 1 day per week NW London STP dashboard for diabetic foot metrics Pathway navigation Two Foot care coordinators (band 3 and 4) Standardise foot pathways and documentation across the NW London STP MDFT access Workforce development MDFT access for dialysis patients Recruit 6 additional band 7 podiatrists across the STP to enable weekend MDFT clinics at vascular hubs and Mon-Fri 9-5 MDFT clinics at all local hospitals and outreach dialysis MDFT clinics Rotation of all FPT podiatrists through MDFT clinics; STP wide strategy for training of HCPs across community, primary and secondary care Outreach MDFT clinics in dialysis units; MDFT clinics at NW London renal hub Table 5: Proposal Deliverables in response to Priorities identified by Gap Analysis 105

106 i) NW London STP Diabetes Foot network: Please see figure 1 (in response to Q3a) which outlines the structure of the NW London STP Diabetes Footcare network. This proposal creates a managed clinical network for the diabetic foot in the NW London STP footprint. A senior clinical lead will be seconded to the project for 2.5 days per week for 4 months. Responsibilities will include setting up the NW London STP network with agreed terms of reference; overseeing the creation of the NW London STP Footcare Dashboard; setting up the weekend MDFT clinics at the vascular hubs (see 6biv below); appointment of the pathway coordinators (see 6bii) below). Existing foot pathways and documentation will be standardised across this managed clinical network. The Senior Clinical Lead will be supported by a Project manager for the first 2 years of the bid. This proposal includes resources for an IT project manager to create a NW London STP Dashboard for the diabetic foot. This dashboard will enable evidence based, target driven clinical service delivery, audit and research to improve the quality of care, performance and outcomes. The Network will use the Dashboard to address performance variation across the STP and identify inequalities in access. The IT project manager and senior clinical lead will also work with local IT teams to ensure robust data is collected locally. Within this managed clinical network there will be an inner and outer NW London MDFT network. These MDFT networks will align with the existing inner and out London vascular hubs. This structure will strengthen multidisciplinary working between vascular services and the MDFTs, providing more integrated diabetes care. Formal standardised pathways between vascular hubs and local MDFTs will be established. The inner and outer NW London MDFT networks will be chaired by clinical leads from local MDFTs (podiatrist/diabetologist) on a yearly rotation. Membership of the network will be comprised of MDFTs, FPTs, CCG diabetes leads and user group representatives. There will be 3-4 monthly NW London STP Diabetes Foot network meetings for clinical governance, quality improvement and professional development. The inner and outer NW London MDFT network leads will be the chair and vice chair of the overarching NW London STP foot network (once set up) and will also be responsible for driving forward agreed changes at the inner and outer NW London level. ii) Pathway Navigation: This proposal creates 2 pathway coordinators (band 3 and band 4) and a single point of access for pathway queries across the NW London STP. This will simplify pathway access for patients, carers and healthcare providers and facilitate pathway navigation and improving patient flow. The pathway coordinators will also be responsible for coordinating the repatriation of patients from the vascular hubs to local MDFTs. This will reduce hospital admissions and length of stay moving patients from acute care to the outpatient/community MDFT. Pathway coordinators will also 106

107 support the inner and outwork network leads in the activities outlined in i) above including data collation for audit and performance review. iii) MDFT podiatry capacity: This proposal includes establishment of 6 additional band 7 podiatrists across the NW London STP. These podiatrists will be part of existing local MDFTs but will also have formal arrangements for inpatient podiatry provision. As such they will form an interface between inpatient and community components of local foot pathways. Provision of robust inpatient podiatry service across acute sites will address direct clinical care needs and provide an interface with ward staff to improve identification and appropriate management of inpatients. Working with existing band 7 specialist podiatrists across the sector, they will staff the weekend emergency foot clinics at the vascular hubs. It is expected that i) and ii) above will increase patient flow through the MDFTs. The additional podiatrists will provide the increased capacity required in the MDFT outpatient clinics and enable Mon-Fri MDFT provision at all local sites. The additional podiatrists will also participate in the training of FPTs and other health professionals across the NW London STP as outlined in v) below. iv) Seven day MDFT: The increased MDFT podiatry capacity outlined in iii) above will provide a weekend h emergency MDFT service within the two NW London vascular hubs. Initially this will run as a Saturday morning service with activity review after 6 months of operation and a decision based on this as to whether to extend to Sunday service as well. This will bring the service in line with NICE guidance (NG 19) and improve outcomes by ensuring all patients have access to MDFT review within 24 hours. The weekend MDFT service will also support Emergency Departments at the vascular spoke sites with the provision of secure web based virtual clinics which have already been piloted at the LNWH NHS Trust. Both vascular hubs have 24/7 vascular surgical cover (registrar and consultant level) to support the weekend MDFT clinics. The pathway coordinators outlined in ii) above will be responsible for ensuring seamless communication between weekend emergency MDFT clinics, local MDFTs, the community and primary care. v) Workforce development: The increased MDFT podiatrist capacity outlined in iii) will enable a rolling program of podiatrist continuing professional development including rotation through MDFT clinics as well as support development and delivery of a training strategy directed at health professionals in the community and primary care, Urgent Care Centres and Emergency Departments and Nursing and Residential Homes. The regular NW London sector meetings will include MDFTs, FPTs and CCG diabetes leads and will improve learning and skills across the sector, support quality improvement and improve team cohesiveness. Pathway coordinators outlined in ii) above will monitor uptake of training across the NW London STP vi) Dialysis outreach: The increased MDFT podiatrist capacity as outlined in iii) 107

108 will enable regular podiatry outreach clinics to all dialysis units in the NW London sector. MDFT podiatrists staffing these outreach clinics will also provide training for dialysis staff and raise awareness and understanding of local foot pathways. The pathway coordinator as outlined in i) will provide a single point of access for foot referrals and queries from dialysis units. 6c) Reasons for considering that the actions proposed will address the gap set out, including how the evidence on improving footcare outcomes has been taken into account. i) NW London STP Diabetes Foot network: Brent CCG has the lowest amputation rates in the country, 67% lower than its comparator CCGs. If the other CCGs in NW London were to reduce their amputation rates to similar levels in relation to their comparator CCGs we could expect over 200 fewer amputations over 3 years. Admission rates in Westminster and Brent CCGs are almost 80% lower than their comparator CCGs. If the performance other NW London CCGs could be similarly improved, we could expect 7400 fewer nights in hospital over 3 years. The proposed NW London STP diabetes Foot Network will be a managed clinical network (MCN). Evidence from Scotland where MCNs for a range of chronic health conditions have been operating for over 10 years has shown MCNs to be effective at delivering improved performance (a 40% reduction in amputations) and increased clinical collaboration across organisational boundaries 2,3. This is particularly relevant to the management of diabetes in London. Healthcare for London s Diabetes Guide for London advocates the need effective clinical networks based on user input. The proposed NW London STP diabetes Foot Network will support the relationships needed for collaborative clinical working across the sector and the development of a shared clinical STP wide strategy. The proposed NW London STP Dashboard for the diabetic foot will provide the data necessary for the Network identify priorities and monitor interventions. ii) Pathway Navigation: Data from the NDFA (National Diabetes Foot Audit) report 2015 highlights that the quicker patients access urgent care the better the outcomes and shorter the course of treatment required. In Brent CCG, a review of amputations in 2010 found that only 2 of the 16 major amputations involved patients known to the local MDFT. The Diabetes Guide for London has identified organisational boundaries as a particular obstacle to good diabetes care. Feedback from patient representatives at Pan-London Foot Network meetings and at Diabetes UK has also identified difficulties in accessing and navigating foot pathways as a significant obstacle to good footcare. 2 Kennon B, Leese GP, Cochrane L, et al. Reduced incidence of lower-extremity amputations in people with diabetes in Scotland: a nationwide study. Diabetes Care 2012;35:

109 3 Schofield CJ, Yu N, Jain AS, Leese GP. Decreasing amputation rates in patients with diabetes-a population-based study. Diabet Med 2009;26: pmid: This proposal will reduce delays in accessing the MDFT by simplifying navigation with standardised foot pathway documentation across local foot pathways for referrers, patients and carers and creating pathway coordinators for the inner and outer NW London MDFT networks and a single point of access for pathway queries across the NW London STP. These coordinators will also liaise with A+E departments to identify patients who discharged from A+E with active foot disease The pathway coordinators will also be part of the NW London STP network and will be ideally placed to work with users and footcare teams to identify and find effective solutions to pathway problems. iii) MDFT podiatry capacity: MDFTs have been shown to reduce amputations in patients with diabetes. The economic analysis in the NHS diabetes publication Footcare for People with Diabetes: the economic case for change has provided the economic argument for MDFTs. In Ealing CCG, where an MDFT and foot pathway were introduced in 2010 there has been a 57% reduction in amputation rates (from 2.3 to 1.0 per 1000 adults with diabetes in 2015). The MDFTs in NW London do not have sufficient capacity to meet demands and increasing numbers of patients with diabetic foot problems are presenting as emergencies through A+E rather than via MDFTs. There has been a 45% increase in emergency foot admissions to the outer London network since 2013 with and 8% increase in the proportion of emergency to elective foot admissions. Feedback from patient representatives at the Pan London Foot Network meetings and CCG leads in NW London has been to provide emergency walk in services at local MDFTs wherever possible to maintain continuity of care. This proposal will provide the much needed increase in the diabetes specialist workforce capacity in NW London to enable all MDFTs to provide a 5 day service and weekend service at the inner and outer NW London vascular hubs. It will also provide new MDFT clinics at the NW London renal hub and Charing Cross Hospital and outreach dialysis clinics. Job plans for the new Diabetes specialist podiatrists will include dedicated sessions for inpatient podiatry to ensure a sustainable service. These changes will ensure patients across the NW London STP have timely access to their MDFT. Brent CCG is the best performing CCG in the country in terms of amputations since 2009 and continues to show improvement in amputation rates. Experience from Brent has been that successfully embedding a foot pathway requires an on-going process of stakeholder engagement and workforce training. The additional diabetes specialist podiatrists will enable FPT podiatrists across NW London to participate in rotations with MDFT clinics and provide the staff resources needed to provide training of other health professionals across the NW London STP as outlined. 109

110 iv) Dialysis outreach: The London Renal Strategic Clinical Network in its 2015 publication Best practice for foot care patients with diabetes and renal disease has recommended training for dialysis staff and closer liaison and collaborative working between dialysis teams and MDFTs. This proposal will achieve this through outreach MDFT clinics to dialysis units which will provide both specialist foot care and training and support for dialysis teams. v) 6d) How the proposal takes into account the assessment of the differing needs of the various local diabetes populations and the approaches needed to address these. Pathway performance will be reviewed at the regular NW London STP Diabetes Foot Network meetings which will work closely with user engagement groups. Comparison with local demographic data will enable the inner and outer London networks to identify local diabetes populations who are underserved by the foot pathways. The meetings will provide a forum for modifying pathway processes collaboratively to serve these populations better. In addition our proposal has specifically targeted the needs of the local populations below: Patients with complex health needs: Diabetic foot complications are an indicator of late stage diabetes and foot patients will frequently have complex health needs, often attending specialist clinics at several secondary care site. The pathway coordinators outlined in 6bii) will facilitate pathway navigation and enhance communication between care providers, MDFTs and patients to improve the quality and efficiency of the patient journey. Dialysis patients: the proposal creates specific provision for dialysis patients in terms of outreach clinics and education and training of dialysis staff and renal teams. Patients for whom English is not a first language: The creation of the inner and outer London MDFT networks and pathway coordinators will allow pooling of resources for the translation of patient information. Vulnerable adults: The pathway coordinators will provide a single point of access for referral queries for healthcare providers, patients and carers improving access and the quality of the patient journey 6e) How the service will work with other groups, such as community organisations, to promote improved footcare outcomes. The inner and outer NW London MDFT networks will work with local community teams and patient groups to raise awareness and understanding of foot pathways across the networks. This will include working with Community Services, GP practices and Hospitals to better promote the foot pathways on their websites. This will be greatly helped by standardization of 110

111 pathways and documentation and provision of a single point of access for pathway referral queries. Engaging with patients is a key concern and users will be integrally involved in the project and design of systems and service delivery recruiting end users into the project groups but also through engagement with Diabetes UK, the pan London Diabetes Foot network and local Healthwatch groups. The NW London Diabetes Foot Network will work HealthWatch to identify how to best reach out to patients, carers and Patient Participation Groups. The Network will also work with user groups to develop information leaflets for use across NW London covering key areas such as local foot pathways, what to expect from the foot team, what to expect from a vascular referral. The networks will have a leadership role for footcare education and training of health professionals in primary care, the community and secondary care and sharing best practice across the NW London STP. Actions 4 month secondment of 0.5 wte senior clinical lead responsible for implementation of proposal Agree JD, job plans for additional MDFT podiatrists and pathway coordinators Advertise and recruit 6 band 7 podiatrists Advertise and recruit MDFT pathway coordinators Agree SLA between provider organisations for additional MDFT podiatrists Appoint IT project manager to oversee data capture project at all sites and IT Responsible organisation / individual LNWH NHS Trust Senior clinical lead LNWH NHS Trust/ICHT NHS Trust LNWH NHS Trust/ICHT NHS Trust ICHT NHS Trust LNWH NHS Trust LNWH NHS Trust Timescale for completion 1 month 1 month 5 months 1 month 3 months 1 month support for virtual clinics Establish weekend emergency MDFT ICHT NHS Trust and 2 months clinics with existing band 7 podiatrists LNWH NHS Trust initially Agree terms of reference for inner and Senior Clinical Lead 2 months outer NW London MDFT networks And NW London foot network Establish metrics for performance and Senior clinical lead 6 weeks outcome monitoring Establish weekend virtual MDFT clinics to Senior Clinical Lead 6 months 111

112 local vascular spoke site Establish outreach MDFT clinics to dialysis units Schedule NW London MDFT sector meetings Establish training rotations for FPTs Senior Clinical Lead Senior Clinical Lead LNWH NHS Trust and ICHT NHS Trust 6 months 2 months 4 months 7. Please set out the current and planned future make-up of your MDFT by WTE nurses, podiatrists etc. (Where a MDFT does not currently exist, please set out these details with respect to existing posts that will in the future form part of the MDFT). Where a bid also covers FPTs please add separate versions of these tables to reflect staffing within these. Appraisal dashboard criteria reference(s): MDFT resources The figures in the table below regarding the current and planned make-up of the MDFT refer to the whole NW London STP footprint i.e. 8 CCGs with a total diabetic population of over 170,000 people. All the NW London MDFTs work closely with their respective multidisciplinary diabetes team colleagues and the staff time for the rest of the diabetes team has not been included in the table below. Current and future MDFT staffing for the whole NW London STP footprint Staff Type and Banding (Nurse, Podiatrist etc.) 2016/17 Current 2017/18 Current and growth 2018/19 Current and growth 2019/20 Current and growth Band 7 Diabetes Specialist podiatrist Senior STP Network clinical Lead (Consultant/Band 8 podiatrist /21 Current and growth 9.5 wte 15.5 wte 15.5 wte 16.5 wte 16.5 wte wte for 4 months then 0.2 wte thereafter 0.2 wte 0.2 wte 0.2 wte Project Manager wte 0.2wte 0 0 BI support / IT 0 1wte for project manager 4 months Band wte 1 wte 1 wte 1 wte administrator Band wte 1 wte 1 wte 1 wte administrator Consultant Vascular Surgeon wte 0.25 wte 0.25 wte 0.4 wte 0.4 wte Consultant Orthopaedic wte wte wte 0.2 wte 0.2 wte

113 Surgeon 8. Of the above, please set out how many of each type are/will be on duty on a Saturday or Sunday. Appraisal dashboard criteria reference(s): MDFT resources Saturday Staff Type and Banding (Nurse, Podiatrist etc.) Band 7 podiatrist Consultant Vascular Surgeon Vascular surgery SpR Infectious Disease Consultant 2016/ / / / / ( h) one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 ( h) one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 ( h) one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 ( h) one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub Sunday Staff Type (Nurse, Podiatrist etc.) 2016/ / / / /21 Band 7 podiatrist Consultant Vascular Surgeon ( 2 ( h) one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 ( h) one at each vascular hub 2 (24h) - one at each vascular hub Vascular 2 (24h) - 2 (24h) - 2 (24h) - 2 (24h) - 2 (24h) -

114 8. Of the above, please set out how many of each type are/will be on duty on a Saturday or Sunday. Appraisal dashboard criteria reference(s): MDFT resources surgery SpR one at each vascular hub one at each vascular hub one at each vascular hub one at each vascular hub one at each vascular hub Infectious Disease Consultant 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 2 (24h) - one at each vascular hub 9. Do you anticipate any difficulties recruiting appropriate staff within short timescales for these improvements? If so, please set out your recruitment and training strategy for this service including: Any plans to provide existing employees with additional training to carry out this function. Engagement with LETBs. Whether training arrangements have been confirmed (subject to the outcome of the bid). What actions you will take to secure successful delivery should there be delays in recruitment? Appraisal dashboard criteria reference(s): MDFT resources Podiatry Recruitment Podiatry services have been reorganised in NW London over the past 2-3 years. Prior to this re-organisation, patients with non-limb/life threatening diabetic foot ulcers were seen in community clinic by band 7 podiatrists. With the exception of Brent, Ealing and Hillingdon CCGs, band 7 podiatrists in the community no longer see patients with foot ulcers. Informal consultation indicates that many of these community band 7 podiatrists, with appropriate refresher training, would be keen to take part in a weekend rota at the vascular hubs The average recruitment time across NW London for band 7 podiatrists is 6-7 months. However, across the NW London STP we have sufficient numbers of and interest from the band 7 podiatrists described above in the NW London STP to start the proposed weekend rota at the 2 vascular hubs (St Mary s Hospital and Northwick Park Hospital) during the recruitment period. The podiatry providers in the NW London STP footprint do not foresee problems in backfilling any gaps in the community podiatry rotas during this interim period SLAs will be agreed between each vascular hub and NHS providers holding the contracts for these podiatrists. We expect this to be straightforward as the community providers (CLCH NHS Trust, CNWL NHS Trust, LNWH NHS Trust) are fully engaged with this bid proposal. 114

115 There will be local induction for all new members of the team for both mandatory and statutory training and induction packages and competencies specifically designed for podiatry, psychology, administration and assistant roles. Engagement with LETBs Education for both a mandatory and statutory training and competencies will be assessed on an individual basis. Staff requiring mandatory education not delivered by the Trust will be able to apply for funding from the Therapies Education budget and funds from NCL HEE. Whether training arrangements have been confirmed (subject to the outcome of the bid) Potential training needs will be assessed at interview and then during the probationary period. Staff requiring mandatory education not delivered by LNWH NHS Trust or ICHT NHS Trust will be able to apply for funding from the Therapies Education budget. Links with NWL HEE will ensure that there is a clear strategy in place for delivering training. There is also scope to deliver London wide training via the Clinical Network. There has been excellent engagement from the clinical leads of the MDFTs across NW London. It is envisaged that the Clinical Lead (LNWH NHS Trust) for this bid will take on the role of senior clinical lead for the project for the first months with the process for succession to be agreed by the Network once established. We do not foresee problems recruiting to the pathway coordinator posts or IT project manager. 115

116 10. In addition to any difficulties recruiting appropriate staff within short timescales set out above, please set out what risks to successful implementation of a new or expanded MDFT service you have identified, the likelihood of these occurring and mitigating actions you propose to take. This risk assessment should include: Risks to implementation. Risks arising from relationships with stakeholders. Risk that interventions are not well targeted. Risks based on inter-relationships with other strategic plans. Appraisal dashboard criteria reference(s): MDFT risks Nature of Risk Risk impact Risk Mitigation Risks to Implementation Delays in agreeing SLAs IT Delays Establishing inner and outer London MDFT networks and the NW London STP Diabetes Foot Network Low - MDFTs and podiatry managers have been heavily engaged in the writing of this bid so that much of the groundwork for these SLAs has been covered Low - The dashboard that will be created to support the NW London STP Diabetes Foot Network will be part of a much larger NW London STP IT dashboard project. Much of the work for this project has already been undertaken by the CWHHE group* Low - There is strong engagement from DSPs and clinical MDFT leads across NW London and good working relationships have already been established through the Pan London Foot Network and the structure builds on the already established vascular network. The senior clinical lead and project manager will be responsible for overseeing the SLAs and will work closely with the MDFTs and provider organisation in this process Much of the key data required for the NW London STP Diabetes Foot Network is already being collected for (NDIA, NDFA) and within primary care. The pathway coordinators will be able to help pull together this local data for Network meetings if there are any IT delays The bid includes specific resourcing for a senior clinical lead and project manager to drive implementation of the project. The creation of the pathway coordinators will provide a link between local MDFTs which will support the successful creation of this network *CHWHE: The joint Central London (Westminster), Hammersmith and Fulham, West London (Kensington and Chelsea), Hounslow and Ealing CCGs Commissioning group 116

117 Nature of Risk Risk impact Risk Mitigation Risks arising from relationships with stakeholders Conflict between MDFTs Conflict between providers and commissioners Failure to engage relevant stakeholders Maintaining the new networks Low - The Pan London Foot network has established a strong relationship of trust and collaboration across the NW London sector with shared goals. There has been excellent engagement and time commitment from MDFTs in the drafting of this bid Low - This bid forms part of a larger NW London STP Diabetes transformation bid which has been driven by the NW London CCGs with s shared approach to the transformation of diabetes care across NW London Low there has been wide stakeholder engagement in the writing of this bid. However, in the limited time available it has not been possible to engage with all relevant stakeholders Low - Strong clinical leadership is essential to the success of a clinical network. Within the NW London STP the MDFT clinical leads have a track record for quality improvement and sharing best practice. This proposal will provide the necessary resources for this to occur in structured way across the NW London STP. The creation of the NW London STP Diabetes Network provides a governance structure and forum for addressing inequalities in MDFT resourcing. This will build trust between stakeholders and create a forum to resolve potential conflict The creation of the NW London STP Diabetes Network provides a governance structure and forum for addressing inequalities in MDFT resourcing. This will build trust between stakeholders and create a forum to resolve potential conflict The senior clinical lead will have responsibility for identifying and building relationships with stakeholders as part of the establishment of the inner and outer London MDFT networks and the NW London STP Diabetes Foot Network. Moving forward the terms of reference for the NW London STP Diabetes Foot Network will be an on-going program of stakeholder engagement A key responsibility of the senior clinical lead will be to agree terms of reference for the NW London STP Diabetes Foot Network and a process for succession planning with its members 117

118 Nature of Risk Risk impact Risk Mitigation Risk that interventions are not well targeted Risks based on inter-relationships with other strategic plans Low the bid priorities in terms of workforce capacity and specific local populations have been identified through the gap analysis. The actions proposed in this bid have been developed through consultation with MDFTs, managers, patient representatives and commissioning leads Low this bid forms part of a larger NW London STP Diabetes transformation bid and the strategic of the MDFT bid are aligned with those of the overall NW London STP Diabetes Transformation project. At the pan-london level this proposal has consulted the Pan London Foot Network and the London Renal SCN The creation of the NW London STP Diabetes Foot Network creates a structure for ongoing quality assurance with ongoing monitoring of pathway performance, patient experience and foot outcomes. It will also provide a forum for stakeholder feedback. The Network will therefore be able to identify if interventions are not well targeted and take steps to address these through professional collaboration across the network The project manager for this proposal will also be responsible for the larger NW London STP Diabetes Transformation project and will be able to ensure ongoing strategic alignment 118

119 11. In addition to the costs set out in the Excel application form please set out: a) Any non-financial resources you will need in order to carry out these actions and how these will be provided? b) Any capital requirements to ensure delivery of this bid? This should include the amount required and confirmed plans for how these will be successfully addressed outside of this bid. Appraisal dashboard criteria reference(s): MDFT sustainability and resources a) Non-financial resources Engagement and goodwill of existing Diabetes Specialist Podiatrists to establishing weekend MDFT clinics at the Vascular hubs Engagement and time of managers and for acute Trusts and community podiatry to draw up SLAs for shared podiatry workforce resource Commitment of MDFTs and FPTs to working with the new networks to share best practice and work collaboratively to improve the quality of care Commitment of on call vascular surgical teams at the vascular hubs to supporting weekend MDFT clinics Engagement of IT teams at local Trusts with IT project manager and clinical lead in creation of NW London STP Diabetes Foot Dashboard Engagement of vascular team at ICHT NHS Trust to establish a vascular foot MDT meeting for the inner London MDFT network (this already exists for the outer London Trusts). There has been outstanding engagement with the groups above in the development and drafting of this proposal. A key responsibility of the Senior Clinical Lead will be to work with these teams to ensure that this engagement is maintained. b) The bid is expected to generate increased patient activity in local MDFT clinics. The cost of the additional Diabetologist, Vascular Surgeon, Orthopaedic Surgeon, Microbiologist, Infectious Diseases and Radiologist time would be funded locally by individual acute Trusts for the initial two years. The NW London STP CCGs will reinvest funds gained through the development of the bid over the initial two years in order to promote the sustainability of the expanded MDFTs and the NW London STP Diabetes Foot Network as further reinvestment occurs, the network will be able to grow and develop in order to incorporate new members of the MDFT. This service development through reinvestment can be seen with the increase in staffing depicted in the table in sections 7 and 8 of this form. 119

120 11. In addition to the costs set out in the Excel application form please set out: a) Any non-financial resources you will need in order to carry out these actions and how these will be provided? b) Any capital requirements to ensure delivery of this bid? This should include the amount required and confirmed plans for how these will be successfully addressed outside of this bid. Appraisal dashboard criteria reference(s): MDFT sustainability and resources 11a) None 11b) Due to the virtual nature of the podiatry role across a wide geography, one ipad / medopad will be required to link into the integrated record. 120

121 12. How will you measure patient satisfaction with the MDFT service and what steps will you take to increase satisfaction year on year? Appraisal dashboard criteria reference(s): MDFT patient experience The development of the NW London Diabetes Foot Network will include a strategy for engagement with user groups. In the first instance the Friends and Family Test will be used across all MDFTs. The results will be reviewed at the NW London STP Diabetes Foot Network meetings and discussed with local patient groups to develop a strategy to improve patient satisfaction. We will also assess patient satisfaction against Quality Standard for Diabetes in Adults (QS6, updated 2015). We have a PROMS/PREMS developed for NCL foot team by Camden Diabetes IPU and we will use this across the NW London Diabetes Foot network so that ongoing results can be collated from across the London system. This was developed by a clinical psychologist and the completion is pictorial and therefore straightforward, so no requirement to speak English which is any advantage in NMW STP Brent and Ealing CCGs are currently considering the patient satisfaction assessment shown in appendix 3. Other evaluations such as quality of life assessment could be used to measure patient satisfaction. The NW London STP Diabetes Foot Network will work with the Pan London Foot Network to develop a holistic approach to managing the individual with diabetic foot disease. An appropriate score that is not too onerous, would be the Wound QoL score: 121

122 13. Describe how the proposed additional or extended MDFT function will fit into the wider local diabetes treatment pathway and interface with other services such as the inpatient specialist nursing service and primary care, so as to help ensure that actions agreed with patients are reflected in the patient's overall care plan and the actions taken by other professionals. Appraisal dashboard criteria reference(s): MDFT patient experience and safety/quality Standardising foot pathway documentation will facilitate access to and navigation across the NW London foot pathways and across organisational boundaries. The pathway coordinators will provide a single point of access for referral queries to ensure that patients are seen at the right time in the right place. This will reduce length of stay, avoid admissions, reduce A & E attendances/waits and ensure patients who do not require the MDFT are seen closer to home. The coordinators will also facilitate timely and coordinated repatriation of in-patients in the vascular hubs to their local MDFTs The increased diabetes specialist podiatrist workforce will enable regular interface with primary care and community teams to increase engagement and uptake of local foot pathways. The proposal will ensure that there is formal provision of inpatient podiatry across the acute sites. This will enhance the interface between the MDFTs and in-patient teams and the inpatient diabetes specialist nursing teams. The NWL dashboard implementation will enable the NW London STP Diabetes Foot Network to monitor performance across pathways and develop strategies to address areas of underperformance. If the bid is successful there will be a public launch of the project as part of the wider NW London STP Diabetes Transformation project. 122

123 14. Describe how the funding of the service will operate over the longer term so that savings made from reductions in lengths of stay and complications are reinvested so as to make the service self-sustaining in funding. Have the CCG and provider agreed that savings will be re-invested so as to make the service self-sustaining and to continue to fund the service to at least the expanded levels funded under the bid after specific NHS England funding is withdrawn? How will the savings be monitored in order to ensure that they are devoted towards funding the service? Appraisal dashboard criteria reference(s): MDFT sustainability 123

124 The additional Diabetes specialist podiatrists will be employed by the two vascular hubs (LNWH NHS Trust and ICHT NHS Trust). These podiatrists will work across acute provider MDFTs in NW London. It is envisaged that initially there will be specific service level agreements (SLA) between these Trusts and other MDFT providers and between the vascular hubs and the respective CCGs within the sector for the commissioning of weekend working and increased MDFT capacity. Eventually the value based commissioning process will incorporate this contractually.preliminary contacts of liaison with commissioners and other provider organisations within the area have demonstrated that they will be keen to give ongoing support. Round table meetings have taken place with the CCGs and providers at which there was agreement that savings will be re-invested in order to make the service self-sustaining. Furthermore, there was agreement to continue to fund and provide the service to at least the expanded levels under the bid after specific NHS England funding is withdrawn. There has been wide consultation in the drafting of this bid including: Chair of CHWHE commissioning group CCG leads Brent, Harrow and Hillingdon CCG diabetes leads Brent and Hounslow Clinical Leads and Diabetes specialist podiatrists in the 7 NW London MDFTs Community podiatry managers for NW London (CLCH NHS Trust, CNWL NHS Trust Senior management teams at LNWH NHS Trust and ICHT Trust London Renal SCN Pan London Foot Network 124

125 15. Does the service fully or partially adhere to NICE guidelines and quality standards? (If partially please set out how the service does not conform with NICE) If the service does not fully conform, please confirm whether this will form a core requirement of your service specification from 2017/18. Also, has there been any external (for example, peer review) or internal assessment of whether the service meets NICE guidelines and quality standards: a) Within the last two years or b) More than two years ago (Please state when) If not, has there been any formal internal consideration as to whether the service meets NICE guidelines and quality standards? If your answer is no to the above options, do you plan to introduce an assessment? If so, please state what type of assessment and timescales. Appraisal dashboard criteria reference(s): MDFT safety/quality The Central Middlesex Hospital, Ealing Hospital and Northwick Part Hospital MDFTs were reviewed internally by the LNWH NHS Trust Clinical Governance team in The MDFT at CMH is partly compliant with NICE guidelines NG19. The assessment highlighted the need for an increase podiatry services on the wards and an inability to see acute foot patients within 24 hours of referral. Our gap analysis, including all the MDFTs in the NW London STP footprint, indicate that they would also be partly compliant. This bid would enable the NW London MDFTs to be fully compliant with NG19. All the MDFTs have registered with the National Diabetic Foot Audit (NDFA), but limited staffing at some site has reduced the possible input to this national audit. This bid would support compliance with the NDFA. NW London MDFTs have also completed local surveys conducted through the NHS London Clinical Network (including root cause analysis of amputations and the London-wide audits). The Diabetes teams within the NW London STP participate in the National Diabetes Audit and National Diabetes Inpatient audit. 125

126 16. When do you expect the service/expanded service to commence? Between April and July 2017 (*3 months): Weekend Saturday MDFT clinic at St Mary s Hospital (inner NW London vascular hub) and Northwick Park Hospital (outer NW London vascular hub) staffed by existing band 7 specialist podiatrists. July 2017 (3 months): Training of FPTs by rotation July 2017: Inaugural NW London STP Diabetes Foot Network meeting September 2017: Public Launch NW London STP Diabetes Foot Network September/October 2017: Expansion of existing MDFT clinics including MDFT clinics at Hammersmith Hospital and Charing Cross Hospital November 2017: Outreach Dialysis MDFT clinics * 3 months after we are clear there is funding available 126

127 Appendix 2a: Brent CCG Tier 4 referral template 127

128 128 Appendix 2b: Brent CCG Diabetic Foot Pathway

129 Foot Referral Pathway for High Risk Patients Appendix 2c: Harrow Foot Pathway Contact with patient with diabetes - inspect feet- (remove patients shoes, socks and any dressings) YES WOUND Evidence of foot problems? New foot ulceration Active foot ulceration with cellulitus or infection Suspected osteomyelitis/ulcer probing to bone Suspected acute charcot foot Critical limb ischaemia, necrosis or gangrene Chronic foot ulceration failing to improve after 3 weeks Neuropathic Pain Refer Urgently to Diabetes Centre: Tel: Fax: Are any of these present? Neglected Feet Corns or Callus Toe Nail Problems Peripheral Vascular disease Peripheral Neuropathy Structural Foot deformity YES NO WOUND 129 Painful feet/abnormal sensations Does the patient have annual foot assessments by their GP practice or Diabetic Group Education via referral to Diabetes Specialist Nurses Team Refer to Community Podiatry Alexandra Avenue Clinic Tel: Fax:

130 Appendix 2d: Hillingdon CCG Diabetic Foot Pathway 130