SCHEDULE 2 THE SERVICES

Transcription

1 SCHEDULE 2 THE SERVICES A. Service Specification Version 2 Mandatory headings 1 4: mandatory but detail for local determination and agreement Optional headings 5-7: optional to use, detail for local determination and agreement. All subheadings for local determination and agreement. Service Specification No. Service Commissioner Lead Framework Reference XXXX Integrated Diabetes Service Sukeina Kassam Provider Lead 1st December 2015 till 31st March 2018 Period Date of Review TBC TBC 1. Population Needs 1.1 A Shared Vision change to beginning The CCGs Long Term Condition (LTC) Strategy sets out the sequence in which the CCG will address the key LTCs affecting the population of Hillingdon. The Integrated Diabetes Service forms part of Wave 1 of the Strategy. HCCG s Strategic Vision for diabetes disease management is to have an integrated economy working together across health and social care to reduce the current increasing prevalence of diabetes and the long term negative effects of diabetes on the lives of patients. This document summarises the service that HCCG proposes to adopt in response to the Strategic Vision and is the product of a detailed review of diabetes in Hillingdon. The activities that have been undertaken in creating this Service Specification include: Data analysis of the needs, prevalence, risk factors and local/regional and national trends related to diabetes. Review of best practice models for diabetes care across the UK. Review of our current service model within Hillingdon focusing on gaps in service, what is working well/not working from the view of patients and clinicians. Consultation with patients/carers and stakeholders (health professionals) to help shape the service. 1 P a g e

2 Face-to-face consultation with patients across the borough and through our diabetes self-management education programmes. Co- production events with diabetes patients. Multi-faceted Mapping exercise with HCCG s Diabetes Clinical Working group to map the current and future provision of care using the four tiers of care as described in the Healthcare for London s model. A provider and partner event to discuss and consolidate the available data and consultation feedback to formulate options and priorities for the future of diabetes in Hillingdon. Discussions with HCCG s Governing Body members before and after embarking on this review of diabetes services. Engagement with a wide range of clinical staff including GPs, Diabetic Specialist Nurses, Consultants specialising in Diabetes and Public Health specialists as well as non-clinical staff from both health and social care. This Service Specification aims to provide the best fit between the needs of patients, the capabilities of providers and the financial envelope that HCCG has to work within. 1.2 Context Diabetes is a Long Term Condition (LTC) caused by too much glucose in the blood. There are two main types of diabetes, Type 1 and Type 2. Type 1 Diabetes (T1DM) develops if the body cannot produce any insulin. It usually appears before the age of 40 years, especially in childhood. It is the less common of the two types of diabetes. It cannot be prevented and it is not known why exactly it develops. Type 1 Diabetes is treated by daily insulin doses by injections or via an insulin pump. Type 2 Diabetes (T2DM) develops when the body can still make some insulin, but not enough, or when the insulin that is produces does not work properly (known as insulin resistance). Type 2 diabetes is treated with a healthy diet and increased physical activity. In addition, tablets and/or insulin can be required. Ten per cent of people with diabetes have T1DM, and Ninety per cent have T2DM. In addition, there are other less common forms of Diabetes. The Healthcare for London Diabetes Guide (2009) sets out the model of care for diabetes in London and highlights key areas to focus to drive improvements in diabetic care. This is based on four tiers of support (shown in Figure 1 below) that are provided in an integrated manner across Primary, Community and Secondary Care. The model recognises that patients move from one setting to another and that sometimes for best care, health professionals from all these settings need to work collaboratively as a multidisciplinary team. 2 P a g e

3 Figure 1: Four tiers of support The four tiers defined in Figure 1 are summarised below as: Tier 1 (Essential Care) Consistent support in primary care for basic needs. Tier 2 (Enhanced Essential Care) - Enhanced support in primary care that includes support at Tier 1 and also specialist, practice-based support such as the management of foot care. Tier 3 (Specialist Care) Consultant-led community based specialist support. Tier 4 (Hospital Care) Consultant-led support for patients with complex needs. The aim of the CCG is to ensure that at least 80% of the needs of patients with diabetes are met through support at Tiers 1 to 3. 3 P a g e

4 1.2.1 Current Diabetes Service Model in Hillingdon Primary Care In general practice there is currently in place the option to deliver Diabetes care through the Quality Outcomes Framework (QOF) and a Local Enhanced Service (LES). It is not compulsory for General Practice to sign up to both the QOF and LES. Although most GPs sign up to both QOF and the LES, there is variation of care across primary care in Hillingdon. Quality Outcomes Framework (QOF) QOF does not incentivise practices to exceed upper thresholds of achievement (above 60%) in the 9 care processes (as stipulated by NICE); 1. Urinary Albumin 2. Eye Screening 3. Foot Exam 4. Smoking Review 5. BMI 6. Cholesterol 7. Blood Creatinine 8. HbA1c 9. Blood Pressure therefore the LES should also incentivise practices to achieve higher thresholds as well as target and support the higher risk patients (refer to the chart in benchmarking below). The National Diabetes Audit ranked Hillingdon CCG in the second quartile for patients receiving 8 out of the 9 care processes recommended by NICE (note: retinol eye 4 P a g e

5 screening is now excluded). The chart below from national benchmarking data demonstrates the range by Hillingdon GP Practices percentage of patients receiving the eight care processes. Percentage of patients receiving the eight care processes from practices within NHS Hillingdon CCG 2011/12 Local Enhanced Service (LES) The service comprises the following areas: Tier Two - Insulin Initiation Fee and GLP-1 Initiation Fee Foot Pathway Audit Impaired Glucose Regulation Audit Diabetes Pathway Management and Micro-Albuminuria Management Audit Performance Improvement. The LES is designed to facilitate the transformation of primary care diabetes management to adopt the Healthcare for London model of care. The LES was changed in 2013 to take into account the ICP programme as prior to this the LES was also funding care planning [ 20 per care plan] but as this was to be funded by the ICP it was taken out of the LES to avoid duplication. Although the ICP Pilot ceased in March 2015, the new ICP service has been recommissioned via the local GP Networks. However; Current insulin initiation in type 2 is of low volume partly due to the introduction of GLP and newer therapies for type 2 Diabetes which means only larger practices will be able to support the required skills in their healthcare workforce Insulin optimisation training and support in primary care are not covered under the LES There is variability in care and a cohort of patients who are managed in practices are not part of the LES. Public Health/Social Care Prevention Services Public Health preventative work on Smoking Cessation, Obesity, Exercise referral and access to Psychological services is available Smoking Cessation Service Provide an NHS smoking cessation service in line with national guidance. Smoking remains the single largest preventable cause of premature death, disease, disability and health inequalities in the UK. The Key objective of this service is to reduce mortality from: Respiratory illnesses 5 P a g e

6 Cardiovascular Disease Cancer and reduce harm from: Diabetes Age related Macular degeneration Oral diseases The service aims; To maintain a high quit rate through enhancing quality of intervention. Aim to recruit over 3,000 smokers to join the service and over half to quit. Prevent tobacco use Hillingdon especially amongst children and young people Promote smoking cessation before, during and after pregnancy Obesity Mind Exercise Nutrition Do-it (MEND) commissioned Weight management and behaviour change programmes for children who are overweight or obese (recommended but not mandatory which covers children aged 2-19 years across 3 localities. MEND 2-4: commissioned by the Council, provided at children s centres with help from health visitors; MEND 5-7: provided by CNWL School Nursing Team in primary schools across 3 localities; MEND 7-13: provided by CNWL School Nursing Team in primary / secondary schools across 3 localities. Key objectives of this service are to Reduce the level of Excess weight and obesity in Hillingdon Deliver on the mandatory NCMP programme Prevent overweight and obesity through targeting populations and individuals at the highest risk Business case for Lifestyle Adult Weight Management Tier 2 pilot has been successful which will be a new service via pharmacists currently being piloted. A stakeholders workshop was held on 23rd January 2015 on the topic Food, weight and exersize'. The main aim of this workshop was to encourage NHS and Social Care professionals into identification and referral of people with excess weight to local services; and to identify future priorities. Tier 3 Adult Obesity interventions are a clear gap. Physical Activity Increasing physical activity keeps people active, independent and helps prevent many conditions. Hillingdon has low levels of physical activity and this work is integral to Hillingdon s physical activity strategy Early Detection - NHS Health Check The aim of the programme is the early identification of individuals at moderate to high risk of cardiovascular disease, diabetes, stroke, kidney disease and related metabolic risk. The national indicator for NHS Health Checks is for the provision of health checks for 20% of Hillingdon s population aged Health Checks enable GPs to identify undiagnosed patients and patients at risk of developing diabetes. In 2012/13 4,124 Health Checks were completed and picked up diabetic patients as below: Referred to a Diabetes Screening 70 6 P a g e

7 High Fasting Glucose Reading ( 6mmol) 175 Vascular Risk Assessment ( 20%) 150 Improving diagnosis will increase demand on acute services, hence the necessity to free up capacity in secondary care. As Hillingdon currently has ~700 new diabetics added to lists each year it is apparent that a large percentage of patients are not being picked up via annual health checks. Community Diabetic Services The Community Diabetes Service is delivered by CNWL at the Hesa Centre based in Hayes town centre, which is in the south of the borough. The Community Diabetes Team consists off: 4 x Diabetic Specialist Nurses (3WTE DSN) 1 x GP with Special Interest (GPwSI), 2 clinics per week 1 x Consultant Diabetologist, 1 clinic per week; this was initiated in 2012 after retirement of GPwSI who undertook 1 session per week 1 x Diabetic Specialist Nurse (paediatrics) The service was originally designed as a nurse-led service with clinical support from 2 GPwSI in Diabetes. As the Healthcare for London model also includes Community Consultant Diabetologists to allow for more complex patients to be managed in the community, CNWL have negotiated with the Hillingdon Hospital for 1 consultant session per week to be based in the community. The service provides education programmes (DESMOND) for newly diagnosed patients and their carers and the DSNs also support and educate GPs and Practice Nurses. Alongside this there is access to a podiatry service which also undertakes training for primary care, limited dietetics, domiciliary service which supports the District Nursing team and currently, the service is also supporting the Integrated Care Pathway for Diabetes in Hillingdon. It has focused on supporting practices who are not part of the LES [carrying out annual reviews and care planning], undertaking insulin initiation and optimisation and patients who are referred in for poor control. It also provides and supports Diabetes training for other health care professionals. Secondary Care The Hillingdon Hospitals NHS Foundation Trust provides assessments and management of newly diagnosed, type 1 and complex diabetes, children, women planning pregnancy, pregnancy, men s problems, foot problems, wounds and/or infections and older people, as well as DAFNE education courses for newly diagnosed Type 1 diabetics. There is also a Walk-In service (Diabeticare) available Monday to Thursday (9am 4pm) and Fridays (9am 12pm) and a follow-up clinic for patients who need a hospital check-up after they have been an in-patient. There is a diabetic clinic at Mount Vernon Hospital (not walk-in). Patients are treated by a multi-disciplinary team of doctors, nurses, midwives, podiatrists, a psychologist and dieticians. Some of the issues we are currently faced with are as follows: Rising prevalence of diabetes- with patients developing diabetes at a younger age [increasingly affecting adults of working age and patients of child-bearing age] with no adequate prevention programmes in place Variation of care across primary care practices Diabetic population who are living longer with more complex complications Insufficient, appropriate and efficient community and primary care provision Undiagnosed and late diagnosed patients are likely to have more complications and present with acute illness 7 P a g e

8 Failure to systematically discharge patients from high intensity care settings due to inconsistent primary care provision as well as a failure to recognise and step up patients requiring more specialist care which increases the costs of care Decreasing secondary care capacity for follow-up appointments as the secondary care cohort of patients become more complex and high risk. Primary care services need to change to support earlier effective intervention to reduce costs of poorly managed patients and unscheduled care. Poorly managed/controlled diabetics will develop more complications resulting in increased costs of unscheduled and routine secondary care. High percentage of patients not receiving all care process with uncontrolled risk factors despite evidence based protocols for managing people with Diabetes Inconsistent and delayed drug therapy, particularly late insulin initiation in primary care as well as dose titration of insulin to maximise control. A legacy of using more expensive analogue insulins. The above demonstrates the need to implement effective programmes for identifying patients at risk or undiagnosed with diabetes and adequate prevention programmes according to NICE guidelines. This includes structured education, exercise and diet and obesity pathways. There is a need to structure primary care differently as not all patients have the same access to trained healthcare professionals to help them plan and manage their diabetes care, given that about 70 % of patients are managed by primary care this will be a key determinant of improving current levels of patients achieving all care processes. 1.2 National Context Diabetes is one of the major challenges facing the NHS. Diabetes is a major cause of premature mortality with at least 22,000 avoidable deaths each year and the number of people in the UK with diabetes is predicted to rise from 3.1 million in 2012 to 3.8 million by Due to increasing obesity levels in the UK it is expected that the incidence of T2DM (which accounts for approximately 90% of diabetes in the UK) will increase and as a result it is estimated the number of people with diabetes in the UK will continue to rise and will reach 4.6 million by This makes diabetes the Long Term Condition with the fastest rising prevalence. Nationally, diabetes is estimated to have cost the UK 9.8 billion in direct costs in 2010/2011 (Hex et al 2012), this equates to approximately ten per cent of the total health resource expenditure. 80% of this cost was preventable complications. The number of people with multiple long-term conditions (including complications of diabetes) is predicted to increase by 252% by Diabetes care in the UK has improved significantly over the past 15 years and the levels of premature mortality in the UK are lower than in 18 other wealthy countries i. In spite of these developments there is still room to improve service delivery particularly as the quality of care varies across the UK and also because currently only around one in five people with diabetes are achieving all 3 of the recommended standards for glucose control, blood pressure and cholesterol. Frequently, patients with diabetes also have related comorbidities and poor management of their diabetes and/or the comorbidities can lead to a wide range of complications leading to: The most common reason for renal dialysis and the second most common cause of blindness in people of working age Increased risk of cardiovascular disease (heart attacks, strokes) by two to four times Increased risk of chronic kidney disease from an incidence of 5-10% in the general population to between 18% and 30% in people with diabetes 8 P a g e

9 Increased risk of amputations with almost 100 amputations each week occurring in the UK due to diabetes of which it is felt that 80% are avoidable. ii 1.3 Local Context There are more than 15,000 people registered with a diagnosis of diabetes in Hillingdon with a prevalence of 6.4%. This prevalence is higher than that of London (6.0%) and England (6.2%). If nothing is done with the current ways of working, estimated prevalence in Hillingdon in 5 years time will be 8.2% (The Yorkshire and Humber Public Health Observatory now part of Public Health England Diabetes prevalence model using 2012 population statistics). Current prevalence rate puts Hillingdon in 4 th highest place in comparison to the 8 Boroughs in North West London. There are also huge local variations in the management of diabetes in primary care (see Figure 2 below), with the Hayes and Harlington locality having the highest prevalence. Figure 2: Prevalence of Patients with Diabetes, 2013/14 In addition to the prevalence rate it is estimated that one in four people with diabetes in London is undiagnosed which in Hillingdon translates to a hidden demand of 3,750 people. These people are at significant risk of developing longterm complications associated with their undiagnosed and untreated diabetes. The Commissioning for Value Pathway on a Page for Diabetes document provides a comparison of HCCG against 10 CCGs with similar demographic makeup. This indicates and validates local data stating HCCG is performing worse (red) compared to similar CCGs in terms of the percentage of patients with diabetes that meet the guidelines for Cholesterol, Blood Pressure & HbA1c targets. The document goes on to show that the Hillingdon population is at greater risk of heart failure. However, on a positive note, non-elective spend, risk of stroke in people with diabetes and risk of Myocardial Infarction in people with diabetes are better than the comparison group. Taking all of this into account it is clear that the CCG faces significant challenges in supporting the population of Hillingdon with diabetes. Without proactive steps the CCG is at risk of an unsustainable growth in costs associated with diabetes, something that the CCG aims to address through this Service Specification. 1.4 Summary of Benefits Possible 9 P a g e

10 The research undertaken in developing this Service Specification has identified different approaches to delivering an Integrated Diabetes Service that are summarised below: In Tower Hamlets, one of the most deprived boroughs in the UK, using a network model, eight networks of GP providers have each improved the clinical indicators for their patients with diabetes. Improvements in one year included increases in percentage of patients meeting diabetes care goals: BP < 140/80 +11%; Cholesterol < % and HbA1c < %. In Portsmouth a Super Six model has been developed that sees key conditions being treated in Secondary Care and the majority of care provided in the Community and Primary Care. The Inner 5 North West of London CCGs are jointly working to deliver enhanced care together with a diabetes prevention programme. In Derby services are under a single budget and single clinical governance structure, it has managed to provide care closer to home in a coordinated and safe manner, resulting in improved quality of care and improved patient experience. Resources used are within the budget that was spent on diabetes care in previous years, while outcomes have been significantly better. In addition, it has strengthened relationships across traditional NHS boundaries and influenced collaborative working for all long-term conditions. Patients were represented from the beginning and continue to be members of the clinical board, which meets monthly. Specific improvements that have arisen from the above models include: Better patient satisfaction: in particular around care plans in the Tower Hamlet programme which increased from below 10% to over 60% in the space of a few months. 89% of Portsmouth patients felt the Super Six model was strongly beneficial as well as leaving the patients feeling empowered and in control of their diabetes. Better primary care feedback: 91% of the 53 practices in Portsmouth wanted the Super Six model to continue. The remaining practices felt that the model was too early in its development to make a definitive decision. Improved clinical parameters: in the Derby model where they have seen significant improvements in the number of patients reducing their HbA1c with a 38% improvement in the percentage of patients with a HbA1c <7%, 18% improvement in the percentage of patients reducing their blood pressure (BP<145/85) and a 53% improvement in the percentage of patients achieving a cholesterol target of <5mmol/L along with improved retinal screening rates that were raised from 88% to 92%. Reduction in acute activity: as seen in the Derby model, where there was a reduction in emergency admissions of patients with a primary diagnosis of Diabetes and a 50% reduction in the total number of bed days for patients with a primary diagnosis of Diabetes. Reducing unnecessary referrals into secondary care: reducing unnecessary referrals from 15/months to 1/month through increased consultant support in primary care via visits to practices and virtual support in the Portsmouth model. Reduction of episodes of diabetic ketoacidosis: in Portsmouth by 18% (228 to 187) along with a reduction of hypoglycaemic admissions by 16% (116 to 97) and reduction of admissions with hyperglycaemic non-ketotic coma by 22% (nine to seven) all within 1 year of implementation. Acute savings: 90,000 each year has been generated through discharging 90% (approx. 978) of people with diabetes who were currently receiving follow-up secondary care in general/complex diabetes clinics back into primary care. This was achieved by providing incentives to primary care through a local enhanced service and education programmes with support from consultants. Many of the benefits stated above also realised indirect financial savings such as reduced unplanned attendances/admissions, reductions in length of stay and a reduction in outpatient activity. 10 P a g e

11 This Service Specification has drawn from the service models above and the relevant reference and guidance documents listed in section 7 of this document. 2. Outcomes 2.1 National Outcomes This service specification will support the CCG to deliver all five domains of the NHS Outcomes Framework. The five domains are summarised below; Domain 1: Preventing people from dying prematurely Domain 2: Enhancing quality of life for people with long-term conditions Domain 3: Helping people to recover from episodes of ill-health or following injury Domain 4: Ensuring people have a positive experience of care Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm 2.2 Local Outcomes NICE have produced a Quality Standard to help describe what constitutes high quality care for people with diabetes. This Service Specification integrates this standard into pathways of care for people with diabetes with the aim of improving outcomes and reducing costs. This Service Specification covers the entirety of the whole pathway including episodes of specialist care. It is anticipated that a Prime Provider model will be adopted and that the prime provider will act as the lead for the whole system integrated diabetes service in Hillingdon and will take responsibility for coordinating all diabetes care across all four tiers of support within the care pathway. The Prime Provider shall therefore: 1. Coordinate all diabetes care in Hillingdon including pre-diabetic support, general, complex and specialist care across all four tiers. 2. Support primary care (including the development of skills) and manage the relationships with social care. 3. Provide high quality diabetes care, as defined by NICE Quality Standard (QS6) to all Service Users. 4. Provide a holistic approach to the management of diabetes for all Service Users and their carers. 5. Through personalised care planning empower Service Users to self-manage their own diabetes. 6. Provide education (in addition to the formal structured education courses) for patients in all settings to promote selfmanagement. 7. Ensure all Service Users who need to initiate insulin therapy or who need to initiate other injectable therapies are provided with an education package around drug self-administration. 8. Provide a triage system for prioritising referrals from Primary Care. 9. Ensure all Service Users have a designated care coordinator who is accountable for the management of the Service User s care. 10. Ensure all Service Users have a care plan 11. Reduce the number of years of life lost for Service Users with diabetes. 12. Reduce the risk of complications for Service Users with diabetes. 13. Ensure Service Users are appropriately referred for social care support where needed. 14. Reduce duplication and gaps in the current diabetes service provision. 15. Deliver person-centred outcomes in a timely manner. 16. Provide specialist transition services between paediatric and adult services for those of appropriate ages. 17. Ensure Service Users are provided with full access to all elements of the pathway where clinically appropriate. 18. Ensure clinical staff are competent, qualified and/or trained in diabetes care. 11 P a g e

12 19. Provide parity of esteem between mental and physical ill health for those with diabetes by reducing rates of depression, anxiety and self-harm in Service Users with diabetes and by increasing the rates of access to psychological therapies for the 20-40% of Service Users with comorbid depression and diabetes. 20. Support and help manage all inpatient Service users with diabetes in line with NICE Quality Standard (QS) Ensure that patients are provided with information about services available to them. 22. Ensure that services comply with national guidance such as NICE and local diabetes guidelines. 23. Provide a responsive service that is regularly audited within and across all care settings. 24. Proactively engage patients through the co-production of services, a diabetes forum for Hillingdon and the collection of feedback across all areas of diabetic care. NOTE: The existing Empowered Patient Programme (EPP) (also referred to as the Health Champions Programme). The EPP may be incorporated into the Service Specification during the second year of the service. 3. Scope 3.1 Aim of the Service The aim for the Integrated Diabetes Service will be to provide a co-ordinated service for people with or at risk of diabetes across secondary, community and primary care. The service will work closely with social care and public health to ensure alignment of effort and benefits. The integrated service will increase levels of self-care, reduce the presence of complication of diabetes and reduce the number of patients in the secondary care setting (either planned or unplanned). 3.2 Service description/care pathway 12 P a g e

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14 3.2.1 Coordinated Service Management To provide proactive, planned and coordinated care management, changing the way care is delivered, the way of thinking, behaviour and culture whilst moving towards providing truly holistic and integrated care that focuses on outcomes for diabetic patients in Hillingdon. Key principles that underpin the approach: Person-centred care Adopting an enablement approach Proactive care that is multidisciplinary Integrated working An anticipatory approach to assessment, care planning and review Coordination of care Clarity about responsibility and accountability Communication with patient, carer, care team and all agencies Providing the most intensive care in the least intensive setting (at home if safe and appropriate) Ensuring access to appropriate services when required. Critical steps and enabling actions for successful delivery of proactive, planned and coordinated care management: Clear eligibility criteria for the service and each element with the pathway. Proactive case finding and use of risk prediction tools Protocols that enable data sharing across partners and support from practice managers to access records and prescribing information Timely access to a range of services to enable early interventions that improve health, provide support and care and, where safe and appropriate, help people remain or return home Shared protocols and pathways which empower care managers to directly access specialist resources such as day hospital, Allied Health Professional assessment and rapid response/falls prevention services A directory of relevant resources, pathways, protocols/referral templates Opportunities to plan and review care at multidisciplinary team meetings Communication with Out of Hours and interface Services Integrated/Empowered Primary Care Included in Tiers 1 and 2 level of service and shift of Tier 3 out of hospital with education and support. There is a large variation in primary care performance both at practice and locality level. The South of the borough (Hayes & Harlington) is particularly underperforming against the other two localities (North Hillingdon and Uxbridge/West Drayton localities). It is the CCG s aim that the provider works with practices to reduce the variation in performance across the borough. In line with the CCG s ambitions concerning moving services Out of Hospital, we are seeking a transition to a position where 80% of care is delivered in Primary Care settings. This will not only enable treatment to occur closer to home and improve patient outcomes but also reduce costs. The specific elements of the service covered under this section are defined below: 14 P a g e

15 Develop a Network-Based Diabetes Care Package In order to manage the majority of diabetes care in primary care the CCG envisages the need for a network-based approach to managing diabetes that consists of a multi-disciplinary team (MDT) approach to integrated care planning and case management. It is envisaged that there will be engagement with local clinicians and alignment with community healthcare and that each local GP network will nominate a lead practice to be the focus for developing enhanced services at Tier 2. It is also envisaged that there will be a Tier 3 Weight Management Programme developed within at least one network along with an Insulin Hub. The provider will be responsible for coordinating the development of this network-based care package. Some of the benefits of the Network Based Diabetes Integrated Care Package that the CCG expects the provider to realise include: Practices to through Risk Stratification to identify patients at Risk of Diabetes and Diagnosed Diabetes. The selection of appropriate service users for active care planning. Practices to prescribe Human Isophane NPH insulin instead of insulin analogues for all newly diagnosed patients and some historical diabetic patients. Practices to provide proactive care for patients at risk of hospital admissions and actively manage discharge of patients who attend out-patients to reduce avoidable hospital admissions. Practices to work with local Diabetic Specialist Nurses (DSNs) to move follow-up appointments and some 1 st appointments from a hospital into a community setting. The majority, if not all, GLP-1 drug therapies to occur in practices with support from DSNs, reducing referrals to acute care and hence reducing outpatient activity. Network Dashboard The provider will develop a dashboard of agreed key performance indicators that will be used to monitor activity and improvements at network level. Revised Primary Care Diabetes Enhanced Service The current primary care enhanced service is being used to encourage practices to do Insulin Initiation and GLP-1 Initiation as well as a number of audits (Foot, Impaired Glucose Regulation, Micro-Albuminuria Management). It is expected that the current enhanced service financial envelope will be used to develop the Network-Based Diabetes Care Package described above (additional costs may be required for running MDTs). Educational Support to Primary Care The provider will be required to develop, manage and deliver an on-going educational support programme for Primary Care with a significant element of the training being delivered by consultants with the remainder being delivered by DSNs and other specialists. There is a requirement to integrate with Hillingdon CCGs workforce and education programme. Decision Support Line It is envisaged that GPs and other healthcare professionals will have access to an advice service delivered by a secondary care consultant with the aim being to obtain a response to a query within 24 hours. It is further envisaged that GPs will be able to ring consultants with an urgent query with the expectation that they will receive a response within 6 working hours (same day). Providers are invited to suggest additional innovations to support this section of the service where appropriate. This may include such things as virtual clinics and direct access diagnostics. Focusing Acute Care on the Super Six & Complex Patients 15 P a g e

16 The CCG wishes to transition our acute care provider to a position where they are dealing predominantly with the Super Six conditions. This allows consultants to focus on the management of the highest risk patient groups. The Super Six conditions are defined as: Inpatient Diabetes Antenatal Diabetes Diabetic Foot Care Diabetic Nephropathy Insulin Pumps Type 1 Diabetes (specifically young people or individuals with poor control). In addition, it is envisaged that the acute provider will support defined patient groups with complex conditions. Providers are invited to suggest additional innovations to support this section of the service where appropriate Integrated Specialist Care Included in Tiers 3 and 4 level of service. Moving The Majority of Care Out of Hospital Delivering An Integrated Service The CCG recognises that patients are best served by a service that is fully integrated and capable of working across health and social care. The CCG is therefore seeking to appoint a lead provider who will coordinate an Integrated Diabetes service and manage this transformation of change. Aligning Diabetes Workforce/Support To Local Hillingdon GP Networks Diabetes Specialist Nurses (DSNs) are integral to providing cost-effective care and preventing complications (State of the Nation, challenges for 2015 and beyond; Diabetes UK, 2015). DSNs are also key to providing increased support and training to primary care. However, there is a national shortage of qualified and experienced DSNs and therefore if the CCG is to achieve its ambition to move the bulk (~80%) of care Out of Hospital the provider will need to determine how to resource this effectively. It s also been recognised within the CCG workforce plan that GPs are still vital in their role in Care management and delivering proactive. Knowing the variation in skills and workforce and aligning to the CCG strategic plans when looking at specialist roles there are opportunities to use such role as Practice Nurse and Independent Prescribers. Feedback from patients and clinicians highlighted current gaps in community services including the support provided to primary care by DSNs. This is currently variable across Hillingdon. The CCG would like to see greater provision of DSN support that is aligned to the emerging the local GP networks with each having access to one or more DSNs. It is envisaged that the DSNs will work with individual practices to support more complex patients through support as well as providing group education and training for patients. In addition, there is a growing service gap in Hillingdon within the housebound diabetic patient cohort and support from DSNs is seen as the way of addressing this. Finally, it is envisaged that the provider will provide a specialist dietician-led service to support patients with diabetes. It should be noted that the DSNs will need to work closely with the District Nurses working within Hillingdon. Providing a Triage Service The community provider will triage all referrals to secondary care to ensure that only appropriate referrals are sent. This will include any referrals for one of the Super Six conditions. Exclusions will be agreed as appropriate with the CCG s Diabetes Clinical Working Group. A secondary function of the Triage Service will be to improve the quality and accuracy 16 P a g e

17 of referrals through regular feedback to Primary Care and GPs. The service will need to comply with national triage guidance and monitoring processes. Providers are invited to suggest additional innovations to support this section of the service where appropriate. Focusing Acute Care on the Super Six and Complex Patients The CCG wishes to transition our acute care provider to a position where they are dealing predominantly with the Super Six conditions. This allows consultants to focus on the management of the highest risk patient groups. The Super Six conditions are defined as: 1. Inpatient Diabetes 2. Antenatal Diabetes 3. Diabetic Foot Care 4. Diabetic Nephropathy 5. Insulin Pumps 6. Type 1 Diabetes (specifically young people or individuals with poor control). In addition, it is envisaged that the acute provider will support defined patient groups with complex conditions. Providers are invited to suggest additional innovations to support this section of the service where appropriate Delivering An Integrated Service The CCG recognises that patients are best served by a service that is fully integrated and capable of working across health and social care. The CCG is therefore seeking to appoint a lead provider who will coordinate and manage the integration of this new service model. 3.3 Overall Service Objectives The specific objectives we are seeking to achieve through this service are described below: Improve access to, and uptake of, educational tools for patients including information guides and support. Improve the provision of self-management programmes. Work with primary care to reduce variation in the quality of care and outcomes. Support Hillingdon GP practices/networks to deliver enhanced care (Tier 2) services and to develop the relevant skills. Support the development of specialist diabetes skills within primary and community care. Coordinate community health support between primary and secondary care and align community health support with the emerging GP networks in Hillingdon. Transition secondary care services to the Super Six conditions (plus complex conditions). Move the majority of care Out of Hospital. This will require the development of community care-based capacity. Reduce outpatient activity, unplanned attendances and unplanned admissions. Reduce the length of stay of patients admitted with diabetes where diabetes is either the primary cause of admission or where it is a comorbidity. Provide primary care with access to specialist consultant advice and resources. Reduce the overall costs associated with managing diabetes (including the management of any comorbidities). Develop a Tier 3 Weight Management Programme. Work collaboratively with all stakeholders and coordinate the care across the whole of the Hillingdon health. 17 P a g e

18 3.4 Population Covered/Geographic Coverage/Boundaries The service will cover patients registered with a Hillingdon GP and operate within the CCG s boundaries which are coterminus with the London Borough of Hillingdon. 3.5 Acceptance and Exclusion Criteria and Thresholds Inclusion Criteria All patients including patients at risk of or with diabetes who are registered with a Hillingdon based GP. This is an all age service meaning it will cover both children and adults. Exclusion Criteria Any patients not registered with a GP in Hillingdon. Response Times and Operating Parameters The provider will agree response times for routine and urgent referrals and also the working hours of each element of the Integrated Diabetes Service with the CCG during the contract negotiation phase. 3.6 Interdependence with other Services/Providers The provider needs to be aware of the following inter-connected services and issues that currently exist within Hillingdon. Tier 4 - Bariatric Surgery Hillingdon GPs directly refer patients for bariatric surgery outside of Hillingdon as there is no local service. NHS England figures indicate in 2013/14, 52 patients were referred to bariatric surgery from Hillingdon. Integrated Care Older People/Over 65s Hillingdon CCG forms part of a partnership with the North West London Integrated Care Programme which aims to integrate care for people over 65 years of age who have one or more long term condition. The Integrated Diabetes Service will need to align with the Hillingdon Integrated Care Programme (which includes the roll out of Integrated Care Planning (ICP) to local GP networks. Whole System Relationships The Integrated Diabetes Service will need to work across the following organisations: All Hillingdon GP Practices The 4 GP Networks (more mergers are possible) The London Borough of Hillingdon including Public Health Acute providers (The Hillingdon Hospitals NHS Foundation Trust and others) Local community organisations (Central & North West London NHS Foundation Trust) Other Health Organisations Healthwatch Hillingdon Patients/Carers including the local Diabetes User Group Diabetes Clinical Working Group (CWG) Local Diabetes UK Branch 4. Applicable Service Standards 18 P a g e

19 The service will be delivered subject to the following standards, guidance and other reference documents. This is not meant as an exhaustive list and the provider should take steps throughout the contract to remain aware of relevant legislation and standards and will be required to work within the standards set by these. 4.1 National Standards This pathway specification is based on the NICE Quality Standard for Diabetes (QS6) and takes into consideration the following Clinical Guidance: CG10 Type 2 diabetes footcare (2004) CG15 Type 1 diabetes in children, young people and adults: NICE guideline (2005) CG62 Antenatal Care (2008) CG63 Diabetes in pregnancy (2008) CG87 Type 2 diabetes: full guidance (partial update of CG66) (2009) CG91 Depression with a chronic physical health problem: quick reference guide (2009) CG119 Diabetic foot problems - inpatient management: quick reference guide (2012) In addition, the following NICE Technology Appraisals are relevant: TA53 Diabetes (types 1 and 2) - long acting insulin analogues (2002) TA60 Guidance on the use of patient-education models for diabetes (2003) TA151 Diabetes- Insulin pump therapy (2008) TA203 liraglutide (2010) TA248 exenatide (prolonged release) (2012) TA274 Macular oedema (diabetic) - ranibizumab: guidance (2013) TA288 Dapagliflozin combination therapy (2013) TA315 Canagliflozin combination therapy (2014) The following standards also apply: National Service Framework for Diabetes: Standards (2001) National Service Framework for Diabetes: Delivering Strategy (2002) Minding the Gap: The provision of psychological support and care for people with diabetes in the UK - A report from Diabetes UK Emotional and Psychological Support and Care in Diabetes: a report by Diabetes UK 4.2 Local Standards The Integrated Diabetes Service will need to operate within the national quality standards (as described above) and also the CCG s Local Diabetes Guidelines 2015/ /18. These are currently being finalised after a consultation period with local GPs, nurses, consultants and other healthcare professionals and reinforce key national guidelines and standards as well as local expectations. Note: The Local Diabetes Guidelines 2015/ /18 may need to be updated accord to feedback from consultation. The provider must ensure that the Service operates within budgetary constraints (including delivery of any associated financial QIPP targets) and is delivered with appropriate regard to local eligibility criteria and priorities. 4.3 Overall Service Outcomes 19 P a g e

20 Primary Outcomes Service benefits: Timely, responsive and seamless care across care settings delivered by an integrated care model. More effective use of specialist services through clear identification of patients which require complex care. Upskilled primary care workforce with the confidence to provide greater level of routine care, supported by timely access to specialist advice and support when required. Patient benefits: Local access to a full range of services closer to the patients home. Responsive and timely service for patients with no delays in accessing emergency care when required. Access to specialist support if and when required. Improved access to patient education. Financial benefits: QIPP savings achieved through reduced acute activity (inpatient and out-patient attendances) SMART Objectives Patient Safety: To reduce the number of emergency admissions with primary diagnoses of diabetes by 50% using 2015/16 as baseline. To reduce outpatient appointments by 40% using 2015/16 as baseline with new referral pathway to allow only super six categories for specialist care. Reduce renal diabetic outpatient appointments by xx% using as baseline. (Percentage to be agreed when service goes live) Reduce Cardiovascular disease related to diabetic patients in Hillingdon by xx% using as baseline. (Percentage to be agreed when service goes live) Clinical Effectiveness: To enhance primary care capability to manage 85% of Type 2 diabetics and 75% of Type 1 diabetics with 100% achieving the required standard to initiate, manage and provide on-going monitoring of patients requiring conversion to insulin and injectables * Patient Satisfaction: To achieve a high level of patient satisfaction measured regularly via a patient survey which aligns to the National OPD and In-patient surveys. 20 P a g e

21 Secondary Outcomes as a result of clinical effectiveness Overall health gains Improvement in health benefits e.g. reduction in incidence of blindness, amputations and renal failure and overall improvement in life expectancy. Address health inequalities Improved access to services closer to patients home and delivered in a manner which targets the hard to reach which will help address inequalities to health *Effective prescribing of insulin and injectables 100% adherence to NICE guidelines for Exenatide (CG087), prolonged release Exenatide (TA248) and Liraglutide (GLP-1) (TA203) If long acting insulin is required for adult type 2 diabetes patients, insulin analogues detemir, glargine and degludec should not be used first line. 100% adult T2 diabetes patients needing long acting insulin should be initiated on NPH isophane insulin. 5. Applicable quality requirements and CQUIN goals 5.1 Key performance indicators The Integrated Diabetes Service will need to operate within the national quality standards (as described above in section 4.1) and also the CCG s Local Diabetes Guideline 2015/ /18. This is currently being finalised after a consultation period with local GPs, nurses, consultants and other healthcare professionals, reinforces key national guidelines and standards as well as local expectations. Note: The Local Diabetes Guidelines 2015/ /18 may need to be updated accord to feedback from consultation. The following is a summary of the KPIs that will apply to the Integrated Diabetes Service. Penalties will apply where either one KPI is not achieved for three months or three KPIs are not delivered for one month. In the event that this occurs, in the first instance the provider will be given four weeks to put in place corrective actions. Should the breach occur for a second month for 3 KPIs (or a fourth month for one KPI) then 1.5% of the costs associated with each month of breach will be withheld until such time as the service is brought back into line. KPIs will be reported by the 10 th Working Day following the end of each month. Failure to deliver this will be treated as the failure in the delivery of a KPI. Where a target is not stated below it is expected this will be agreed within the first quarter following contract award. Measure Description Target Local Outcomes Patient Experience The provider will assess patient 95% of patients would 4,9 and Satisfaction experience and satisfaction recommend the service. across the service on a quarterly basis using the patient experience survey agreed and developed with Commissioners and Public. Developed. 21 P a g e