Diabetes Annual Report 2014/15. Aneurin Bevan University Health Board

Transcription

1 Diabetes Annual Report 2014/15 Aneurin Bevan University Health Board September 2015

2 Contents Section Title 1 Executive Summary 2 Introduction 3 Diabetes incidence, mortality and emergency admissions in Aneurin Bevan University Health Board 4 Our Approach to Tackling Diabetes 5 Children and young people 6 Preventing diabetes 7 Detecting diabetes quickly 8 Delivering fast, effective treatment and care 9 Supporting living with diabetes 10 Improving Information 11 Targeting research 12 Conclusion and focus for the next 12 months and beyond Page 2 of 42

3 1 Executive summary Published in 2013, Together for Health Diabetes Delivery Plan provides a framework for action by Local Health Boards and NHS Trusts working together with their partners to ensure the provision of high quality diabetes services in what it recognises is a growing area of need. There are currently 37,311 patients on GP Registers across Aneurin Bevan University Health Board (ABUHB) which equates to 6.2% of the practices population. These figures only represent the known burden of disease and are likely to be an underestimate of the true prevalence. The implementation of the Local Delivery Plan is overseen by the Diabetes Transformation Board, the Terms of Reference for which is attached as Appendix A. Much work has been undertaken in collaboration with our partners in 2014/15 to improve the quality of our diabetes services, through the implementation of our delivery plan. An overview is provided below: The development of a Diabetes Integrated Care Model, in which patients were involved in the design. Establishment of Integrated Primary Care-based Diabetes Specialist Nursing Team. Up-skilling our workforce in the management of diabetes increasing the number of patients who can be safely managed in Primary Care, reducing waiting times and ensuring those that need specialist care are able to access it in a timely and effective manner. Improvements in In-patient care, which achieved national recognition by winning the NHS Wales Award for Patient Safety. Regular support and development of Patient Reference groups, in conjunction with Diabetes UK Whilst making progress we recognise that this is a significant area of work for the Health Board. The number of people being diagnosed with diabetes continues to rise. Through our collaborative working with our wide range of partners we will continue to raise awareness through our prevention agenda; strive to shift services so that they are more accessible to our patients and continue to improve the quality of life for people living with this condition; and improving care pathways across our secondary, community and primary health care services. Page 3 of 42

4 2 Introduction Together for Health Diabetes Delivery Plan was published by the Welsh Government in 2013 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government s expectations of the NHS in Wales to tackle diabetes for people of all ages, wherever they live in Wales and whatever their circumstances. The Plan is designed to enable the NHS to deliver on its responsibility to meet the needs of people at risk of, or affected by, diabetes. Aneurin Bevan University Health Board developed and adopted its Diabetes Local Delivery Plan in February This can be found on the ABUHB internet site at 250,000 was received from the Welsh Government Primary Care Services fund to help deliver our plan. This Report provides an update on progress made through this investment and new ways of working during 2014/15, utilising data from both the Welsh Government and local data supported with narrative to describe the achievements so far, which are outlined in section one and further expanded on throughout this report. Aneurin Bevan University Health Board has developed clear Progress Reporting Frameworks and Action Plans within their Delivery Plan. These documents support our understanding of the progress and actions that have been made since the inception of the Delivery Plan. We have made excellent progress this year but still have challenges that we need to tackle which include: The number of people being diagnosed with diabetes continues to rise, and the National Diabetes Audit shows that the current Type 2 Diabetes prevalence rate is in the top 25% in the UK. Although engagement with and delivery of X-PERT structured patient education is the highest in Wales, the absolute levels of uptake by patients with Type 2 diabetes are still very low. Data collection and performance in specialist care needs to improve to help deliver an integrated service, as all diabetes outpatient referrals are counted with all endocrine referrals, and there is no differentiation between the different types of patient being referred. The inability to readily distinguish patients who have one of the Super Six conditions [i.e. Type 1 Diabetes, Renal Dialysis, Very Complex Type 2 Diabetes, Antenatal Conditions, Insulin Pumps, Foot Complications] from Page 4 of 42

5 those who do not, currently has an impact on how we take forward our transformation agenda. Currently, we have many patients waiting for follow up in diabetes outpatient services which contribute to lengthy waits for outpatient follow up appointments. The Diabetes Directorate has developed a plan to deal with the follow up waiting list backlog and aims to reduce the maximum wait to 12 weeks for all referrals, and this has already shown improvements. The plan explains how we will: Provide extra clinics Continue to work with primary care to develop an integrated diabetes service, to improve the skill level in primary care to manage diabetes and to reduce the demand for routine diabetes care in the secondary care Develop a business case for a full-time substantive consultant replacement. Working in collaboration with primary care and key stakeholders in the Third Sector, ABUHB has made much progress over the last 12 months to improve the quality of our diabetes services, through the implementation of our plan. Significant developments include: The development of a Diabetes Integrated Care Model, with patient input. Securing funding to establish a Primary Care Diabetes Integrated Specialist Nursing Team, and successful recruitment of the team. Up-skilling our workforce in the management of diabetes increasing the number of patients who can be safely managed in Primary Care, reducing waiting times and ensuring those that need specialist care are able to access it in a timely and effective manner. Working in collaboration with school nurses and colleagues in education to ensure that there is support and advice available in educational settings. Launching our Integrated Adult weight management service and establishing a childhood weight management project team to develop and implement level 2 and 3 service. Delivery of structured diabetes education programmes for adults. Page 5 of 42

6 Delivery of Information/Activity Days for children aged 9-12 and young people aged and 6 week education clubs for 8-10 year olds. Delivery of transitional educational days for children moving from junior to comprehensive school. Establishment of long standing Patient Reference Groups in Caerphilly and Torfaen and a newly established Group in Newport which alternates each month support and reference sessions. An extremely successful You Said, We Did exercise with patients which will be repeated in December/January. 3 Diabetes incidence, mortality and emergency admissions in Aneurin Bevan University Health Board 3.1 Overview We are using three outcome indicators to measure and track how well diabetes services are doing over time. These are: Diabetes incidence rate (Type 2 only) Cardiovascular disease mortality rate Emergency admissions for diabetes Outcome One Diabetes Incidence Rate This measures how many new cases of diabetes (Type 2 only) are found each year and tells us how well we are doing at preventing type 2 diabetes in Wales. If we are achieving our objectives, we would expect to see over time: A slower rise in the rate of increase compared with what might be expected to happen in line with past experience. A reduced gap between the most and least deprived areas of our region. Incidence rates comparable with the best in Europe 1. According to the latest National Diabetes Audit, Aneurin Bevan University Health Board s diabetes prevalence for its resident population is in the top 25% of all CCGs / LHBs in the UK. This prevalence impacts on an increasing workload for the Health Board s Diabetes Teams and is a reflection both on growing prevalence and improved detection/good diagnosis by Primary and Secondary Care Teams. It is expected that the introduction of the Living Well, Living Longer programme across the Health Board will identify even more people at risk and lead to increased diagnoses. Page 6 of 42

7 Graph 1 below shows the prediction of the increase of the prevalence of diabetes over the next 15 years. Graph 1 Graph 2 below shows that every NCN area has seen an increase from the previous year in the number of patients being diagnosed with diabetes. This supports the prediction of an anticipated rise of newly diagnosed patients with diabetes across Wales. Graph 2 Page 7 of 42

8 Number of patients on diabetes registers across NCNs There are currently 37,311 patients on GP Registers across ABUHB which equates to 6.2% of the practices population. Graph 3 below shows how these 37,311 patients are spread across NCN areas and Table 1 shows the actual number of patients on Diabetes Registers. Graph 3 and Table 1 below show the variations in the incidence of diabetes across NCNs, with Blaenau Gwent having the highest proportion of people with diabetes. It should be noted that these variations are more significant at practice level, as these range from 5.3% in a practice in south Monmouthshire area and 7.2% in a practice in Blaenau Gwent east. These figures only represent the known burden of disease and are likely to be an underestimate of the true prevalence. The Living Well Living Longer programme which is the first of its kind in Wales, will identify those at greatest risk of developing chronic conditions and is likely to increase detection rates in the five most deprived NCN areas which will be targeted. Table 1 GPs by NCN and Practice list size Local Hospital Service Nevill Hall Hospital Royal Gwent Hospital Ysbwty Ystrad Fawr No of Practices Practice Population Size No of Patients on DM Register NCN Blaenau Gwent East % Blaenau Gwent West % Monmouthshire North % Torfaen North % 4 NCNs ,050 11, % Monmouthshire South % Torfaen South % Newport East % Newport West % Newport Central % 5 NCNs ,763 14, % Caerphilly South % Caerphilly East % Caerphilly North % 2 NCNs ,508 11, % Total 12 NCNs ,321 37, % % of Patients on DM Register Page 8 of 42

9 Graph 3 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% % of Patients on DM Register by NCN Area 2014 Outcome Two Cardiovascular disease mortality rate This tells us how many people die from cardiovascular disease each year 2. Cardiovascular disease (CVD) includes all the diseases of the heart and circulation including coronary heart disease (angina and heart attack), heart failure, congenital heart disease and stroke. Cardiovascular disease (CVD) problems are between 1.5 and times more likely in people with diabetes than the general population. Improved control of blood glucose, blood pressure and lipids will reduce the incidence of cardiovascular events. If our strategy is successful, over time we would expect to see: A continued fall in the rate of deaths from cardiovascular disease. A reduced gap between the most and least deprived areas of our region. Mortality rates comparable with the best in Europe. 2 Expressed as an age standardised rate to allow comparisons between years and countries 3 National Diabetes Audit 2011 Page 9 of 42

10 Graph 4 Graph 4 shows that cardiovascular disease across the ABUHB area has shown a downward trend between 2004 and Our Living Well Living Longer Programme which tackles inequalities in health through targeting deprived areas will help continue this trend. Working with primary care to identify those at the greatest risk of developing cardiovascular disease and invite them for a short health check at a local venue. Outcome Three Emergency admissions for diabetes This measure shows us how many people are admitted to hospital for diabetes or diabetes related treatment as an emergency. This is an indication of how well diabetes patients are managing their condition. If our strategy is successful, over time, we would expect to see: A decrease in the emergency admissions rate. A reduced gap between the most and least deprived areas of our region. Emergency admission rates for diabetes comparable with the best in Europe. Page 10 of 42

11 Graph 5 Graph 5 shows the number of admissions by Health Board area with ABUHB having the second highest admission rate during April 2013-March Through our education and support services we will continue to emphasise selfcare and self-management, with personal goal setting being a key component to encourage patients to effectively manage their condition. Graph 6 Graph 6 above shows the number of beds days for patients being admitted with complications associated with their condition. The following graphs reflect Emergency Medical Admissions and associated bed days by the patient s local authority of residence and is sourced from NWIS produced data in relation to the WG Framework Basket of 8 (HbA1c, Blood Pressure, Cholesterol, Serum Creatine, Urine Albumin, Foot Surveillance, BMI and Smoking) drilled down to diabetes. Ysbwty Ystrad Fawr has a different admissions policy from the other two hospitals, tending for patients to have a lower degree of acuity, and this is likely to explain the different pattern of admissions and length of stay. Page 11 of 42

12 Graph 7: All Gwent Acute Hospitals Graph 8: Nevill Hall Hospital Graph 9: Royal Gwent Hospital Page 12 of 42

13 Graph 10: Ysbyty Ystrad Fawr It is important to note that the emergency admissions for diabetes-related diagnoses has not risen in line with the increase in diabetes prevalence. This suggests that there have been improvements in control of diabetes and/or improvements in care outside of hospital. Graph 11 Graph 12 Page 13 of 42

14 4 Our approach to tackling diabetes Together for Health a Diabetes Delivery Plan was published by the Welsh Government in 2013 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government s expectations of the NHS in Wales in delivering high quality critical care ensuring the right patient has the right care at the right time. It therefore focuses on maximising efficiency and effectiveness, tackling variation in access and reducing inequalities in service provision across five themes. The Delivery Plan sets out action to improve outcomes in the following key areas between now and 2016: Children and Young People Preventing diabetes Detecting diabetes quickly Delivering fast, effective treatment and care Supporting living with diabetes These key areas will be supported through: Improving Information Targeting research In 2014, we published our Diabetes Delivery Plan. The Plan is designed to enable us to deliver on our responsibility to meet the needs of people at risk of diabetes or living with the condition. It sets out: The population outcomes we expect The outcomes for patients we expect from NHS care Level of performance we expect set out as NHS Assurance Measures Themes for action by the NHS, together with its partners This is the second annual report for diabetes services and sets out a baseline for future years against which progress can be monitored. 5 Children and young people It is the aim of the Welsh Government to ensure children and young people with diabetes have the best possible start in life and are given the opportunity to fulfil their potential. Type 1 diabetes is one of the most common chronic diseases in childhood. A key factor in reducing the impact of diabetes is good control of blood sugar levels, without frequent hypoglycaemic events. Page 14 of 42

15 All children and young people (CYP) with newly diagnosed diabetes need a care pathway, which includes a structured education component to support and empower them and their families. All CYP must also receive all key care processes recommended by the National Institute for Health and Care Excellence (NICE). We are using three NHS assurance measures to measure and track how well diabetes services are doing over time. These are: Performance Measure 1 - Percentage Of Children And Young People Achieving Improved Glycaemic Control, Through Monitoring: Percentage achieving target HbA1c < 7.5% (DIA PM 10a) Graph 13 Percentage achieving target HbA1c >=7.5%<=9.5% (DIA PM 10b) Graph 14 Percenta Page 15 of 42

16 Graph 15 Performance Measure 2 - DKA Incidence Rate Per 100,000 Page 16 of 42

17 Performance Measure 3 - Hypoglycaemia Incidence Rate Per 100,000 / Over the past 12 months we have put in place a range of activities to support children, young people and their families as follows: All children with newly diagnosed diabetes are seen on the day of referral by the on call paediatric team, initial management is instigated and the diabetes MDT are informed. All newly diagnosed children with diabetes are seen by the diabetes MDT on the same or next routine working day. The paediatric diabetes MDT expects that all children with suspected diabetes are referred to the paediatric on call team as same day referrals. We welcome interaction with Primary care to ensure this happens pan Gwent. The paediatric diabetes MDT continues to strive towards 100% implementation of all key diabetes care processes referred to in the National Paediatric Diabetes Audit. We often do clinics with no phlebotomy support so rely on Families making appointments either with their GP or in the CAUs to return to have bloods done leading to reduced uptake of annual review investigations. Page 17 of 42

18 All children in Gwent with diabetes receive an education programme delivered by the MDT this is structured and standardised, however there is not a structured education package available for children in the UK. An all Wales structured education programme is being developed currently. Currently the members of the diabetes MDT offer an out of hours telephone advice service to CYP with diabetes and their families. This is not however 24/7, although it is anticipated an all Wales solution will be looked at through the diabetes network. The paediatric diabetes team offer an insulin pump service in line with NICE guidance. There are currently 58 patients on CSII (approximately 25% of patients) with an additional 15 patients due to start in the next 6 months. There are national campaigns as well as local projects to educate GPs, practice nurses, school nurses and teachers about the signs and symptoms of diabetes so that same day referrals are made. The Diabetes MDT engage with the 5 LEAs to ensure that diabetes education is delivered and policies are in place to enable staff to manage diabetes in schools. Individual pupils are supported by the MDT to play a full part in school. However individual schools can still refuse to engage with this process. We await legislation in line with England to support all children with medical conditions in school. The paediatric diabetes Team currently work with adult colleagues to deliver a transition Service. There is work on an all Wales level to design a package of care for young people with diabetes going through the transition to adult services. This year has seen the birth of the Children & Young People's Wales Diabetes Network (& Brecon Group) We have joined the English regional Networks, and have undergone our first Peer Review in the Autumn of The individual reports are in the public domain and available on our diabetes team web site. The paediatric diabetes team also submit data annually to the NPDA. The Dietetics Team has held a number of information / activity days during the past year as follows: 1 activity day (June 2014) at Hilston Park for children 9-12 years. Approx 32 children attended and 1 activity day at the Celtic Manor (August 2015) for aged years. 14 teenagers attended. We have completed 2 transitional educational days for children moving from junior to comprehensive school. (July August 2015) 16 children attended. We also completed a 6 week education diabetes education club for 8-10 year olds. (October 2014) Page 18 of 42

19 This was completed in Ebbw Vale Hospital. All activities are funded from charitable funds. We attempted to do a DAFYDD (Dose Adjustment for Your Daily Diet) session specifically for the year old age group, running it over 1 week (4 days) in June. We had hoped this would suit students who had finished their A level courses or who were on their break from university but unfortunately the uptake was insufficient to run the course. Since then, patients from this age group have been successfully incorporated in with our normal course participants. The Dietetics Team recognises a need to clarify terminology regarding Young people for their services, as there is an overlap with the adult services. Young Adult service include patients from about (If newly diagnosed at 16 they come straight into the service, otherwise there are 3-4 transition clinics a year for patients leaving the paediatric service) 6 Preventing diabetes The Welsh Government aims to ensure people are aware how to live a healthy lifestyle, make healthy choices that minimise their risk of developing diabetes and understand the consequences of not doing so. The proportion of adults not maintaining a healthy body weight is increasing in Wales and, despite stabilising in children, remains too high, as in many other countries. A combined approach of promoting healthy eating and increased physical activity is essential as these are key factors in the prevention of obesity and type 2 diabetes. The group ante natal education sessions for patients diagnosed with gestational diabetes also reiterate this. Previous GDM is a high risk for the development of future DM. The Welsh Health Survey in 2011 shows over half the adult population, and around a third of children, are classified as overweight or obese. The Millennium Cohort Survey found more than one in five Welsh three year olds were overweight. It does not have to be this way. Lifestyle interventions promoting moderate weight loss together with an increase in physical activity can result in a more than 50% reduction in the risk of type 2 diabetes amongst at risk individuals 4. Graph 16 below shows where the obesity levels are higher than the Welsh average across the 12 Neighbourhood Care Networks (NCNs). The areas where they are higher are clearly reflective of the levels of deprivation. 4 Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance: Tuomilehto et al 2001; Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin: Knowler et al 2002 Page 19 of 42

20 Blaenau Gwent East Blaenau Gwent West Caerphilly East Caerphilly South Caerphilly North Monmouthshire North Monmouthshire South Newport Central Newport East Newport West Torfaen North Torfaen South Graph % Reporting as Obese Wales Average This will require partnership between Local Government, schools, industry, employers, LHBs and the public. Health care services will need to identify at risk groups and provide evidence based-support and advice to prevent progression to diabetes. This support and advice needs to be reciprocated by people taking personal responsibility for their lifestyle choices and people need to be made aware of the possible consequence their lifestyle choices may have on the benefits of any future care that they may receive. Working with partners to implement the Gwent Obesity Strategy will help tackle obesity and the many health related implications that are associated with being overweight. Graph 17 below shows the percentage of adults reported to be smoking on a daily basis and shows how ABUHB is performing on an All Wales basis. Graph 17 DIA PREV 01 - % Adults Reported Smoking Daily or Occasionally (age standardised) Aneurin Bevan All Wales Page 20 of 42

21 Smoking is a major contribution to complications in diabetes. Smoking cessation is a priority within the 12 NCNs across ABUHB and targeted work by them has seen an increase in referrals into local smoking cessation support services and quit rates. Smoking Cessation is also a key component of our Single Integrated Plan (SIP) Health agenda and we are working with our wider partners, through the SIP infrastructures to reach out into communities and help people to stop smoking, and stop them from starting. Most of the Neighbourhood Care Networks in Gwent (GP Clusters) adopted smoking cessation as a local priority in 2014/15, and supported local efforts to improve smoking cessation. Local data has shown that their efforts are already bearing fruit, with increased referrals to Stop Smoking Wales and also increased numbers of patients who are objectively demonstrating that they are smokefree two months after completing the course. Collaborative working with our partners through the Local Service Board infrastructure will increase awareness of services and available and provide signposting, support and advice across our communities. Furthermore, many Neighbourhood Care Networks have also adopted Obesity as a priority area for development in 2015/16, and so will be exploring and engaging with the public health initiatives to deal with this risk factor for diabetes. The importance of physical activity in patients with diabetes is well recognised, Graph 18 below shows that ABUHB has a lower physical activity rate on an all Wales Basis. Our work with our partners on the Gwent Obesity Strategy will help us to tackle this issue and encourage people to take more exercise. Neighbourhood Care Networks will also continue to encourage practices and partners to exercise through our National Exercise Referral Scheme (NERS). Graph 18 DIA PREV 02 - % Adults report Being Physically Active on 5 or More Days in the Last Week Aneurin Bevan All Wales Page 21 of 42

22 Graph 19 Graph 19 above shows the number of GP referrals into the all Gwent Adult Weight Management Service. This service will continue to be promoted through NCNs and across primary care to raise awareness and encourage referrals into the service. NCNs are also working in collaboration with Communities First to increase referrals into Foodwise a community weight management programme, focussing on deprived areas. We have made much progress over the past 12 months with our prevention agenda and have progressed a range of activities which include: Launching our Integrated Adult weight management service Establishing a childhood weight management project team to develop and implement level 2 and 3 service Sending our Child Obesity Strategy to partner organisations for sign off. Starting to develop a business case for a child obesity service Continuing to provide our successful National Exercise on Referral scheme with NERS staff being trained in Foodwise Encouraging nearly all schools in ABUHB area to sign up to the 'Healthy Schools Scheme' with actions around healthy eating and physical activity. Working with local Housing Associations to encourage them to run healthy cookery programmes for tenants. Providing Brief Intervention training for healthcare professionals in ABUHB to improve skills and confidence in discussing weight issues with patients. Discussing risks of diabetes with many patients around the need to address weight issues. Rolling out Living Well Living Longer' programme in most deprived areas to identify those at risk from obesity and sedentary lifestyle and offer support and encouragement regarding weight management and increasing physical activity. Continuing to develop close working relationships across disciplines with Diabetes UK. Page 22 of 42

23 7 Detecting diabetes quickly The Welsh Government aims to ensure diabetes is detected quickly where it does occur. The benefits of a prompt diagnosis of diabetes are significant. Increased public awareness of the symptoms of diabetes and the risks posed by delayed diagnosis or treatment is needed. Our Diabetes structured education programmes support patients to understand how their lifestyle choices impact on their condition. Our Living Well Living Longer Programme is providing the mechanisms and partnership collaboration to signpost people into community based support services. A new diagnosis of diabetes presents an immediate opportunity to influence lifestyle changes that can positively affect the future health of the person diagnosed. Patient empowerment and effective self management of diabetes is best achieved through education. Every opportunity to provide this education needs to be grasped and a new diagnosis needs to be the starting point for this lifelong learning process. We are in discussion with Cardiff University about supporting research into how earlier recognition of Diabetes Ketoacidosis can be achieved in primary care. Performance measure 4 percentage of patients offered or attended structured education DIA PM 6 % patients offered or attended structured education, all newly 25% 20% 15% 10% Aneurin Bevan Wales England 5% 0% Page 23 of 42

24 Graph 20 During the period February 2014 February 2015 there had been a total of 68 First Step courses held for patients with diabetes. The course is a taster session following which patients can sign up for a longer, six week X-PERT diabetes course. 2,003 invites were sent out, 817 invitees and partners attended First Steps from which 458 invitees went on to attend the X-PERT course. Additionally over the past 12 months we have progressed a range of activities to support the early detection of diabetes which include: Distributing an initial advice leaflet to all GP practices Developing an advice booklet relating to "Advice for people newly diagnosed with Type 2 Diabetes" and circulating to all community pharmacies Establishing a Diabetes Primary Care Specialist Team with 6 Diabetes Specialist Nurses who will provide direct education, mentoring and advice to primary care in the management of diabetes and insulin initiation. Each DSN will spend a day delivering Patient education in their locality, in addition to existing educational services. 8 Delivering fast, effective treatment and care It is important that people receive fast, effective treatment and care so they have the best chance of living a long and healthy life, with patients taking Page 24 of 42

25 responsibility for lifestyle choices that contribute positively to their treatment and care. The majority of diabetes health care is, and should increasingly be, delivered in the community, enabling people to stay in work and lead active lives. The aim is to improve the delivery of planned chronic disease management at a community level, through effective, local, integrated care, with timely access to specialist advice when necessary. Diabetes can occur at any stage of an individual s life and care delivery needs to be designed to take account of this. Diabetes, particularly if poorly managed, can result in cardiovascular and cerebrovascular diseases, loss of vision, kidney disease and potential amputation of feet. It is important diabetes is identified and treated early in each of these areas to prevent further complications. Performance measure 5 readmission within 30 days of previous discharge for diabetes This measure shows how many people are readmitted for diabetes or diabetes related treatment within 30 days of previous discharge. It is an indication that patients are discharged too early or without the proper support in place to allow them to manage their condition. Graph 21 shows that ABUHB saw a significant drop in readmissions, reaching the best in Wales level. Graph 21 Graph 22 Page 25 of 42

26 Graph 23 Graph 24 Performance measure 6 variations in incidences of complications of diabetes This measure illustrates the variance in additional risk of complications associated with diabetes compared to general population. This can reflect differences in geography and levels of deprivation as well as other factors. Not all complications will be closely tracked under this outcome however the following complications are considered important: Page 26 of 42

27 Graph 25: Angina (DIA PM 02a) Graph 26: Renal replacement therapy (DIA PM 02b) Page 27 of 42

28 Graph 27: Major amputation (DIA PM 02c) Graph 28: Minor amputation (DIA PM 02d) Page 28 of 42

29 Graph 29: Heart failure (DIA PM 02e) Retinopathy (DIA PM 02f) DIA PM 08 % patients who have a record of retinal screening in the previous 15 months 100% 90% 80% Aneurin Bevan 70% 60% 50% Wales 40% 30% 20% 10% 0% Performance measure 7 average length of stay for diabetes admissions Page 29 of 42

30 Year on Year ALOS Welsh Benchmarking Detailed Year on Year ALOS Welsh Benchmarking Page 30 of 42

31 Monthly ALOS Welsh Benchmarking Performance measure 8 percentage of patients who have a record of retinal screening in the previous 15 months Page 31 of 42

32 Performance measure 9 Percentage of patients with a record of a foot examination and risk classification within the preceding 15 months The Diabetes Inpatient team of Diabetes Specialist Nurses, lead by the Clinical Director, Dr Leo Pinto, won the coveted 2015 NHS Award for Patient Safety. Their work showed that the introduction of a specialist diabetes team to look after diabetic patients admitted to hospital as an emergency has improved the safety and quality of care. Evidence had shown that many patients were being admitted to Nevill Hall Hospital in Abergavenny as an emergency with a diagnosis of diabetes yet for the majority this was not the actual reason for the admission but a secondary diagnosis. Many were admitted due to incidents involving insulin or other diabetes medication, some were suffering a hypoglycaemic (low blood sugar) episode that was unrecognised or inappropriately treated, and a significant number were not being identified or referred to the diabetes team. With between 15 and 20% of the hospital s in-patients having diabetes, staff knew they need to more closely involved to ensure patients were identified immediately and given early diabetes specialist care. To address the issue, a diabetes inpatient care team consisting of a consultant, doctor and nurses, was established in the hospital, enabling early identification of patients with a diabetes related emergency, optimal care at an early stage and appropriate follow up care. An insulin prescription and glucose monitoring chart was introduced along with a box containing glucose tablets and drinks in all clinical areas and guidelines for treating patients admitted as an emergency. The changes have resulted in significant improvements in both the safety and quality of care provided for patients. Patients are treated quickly and admissions have reduced by around 7 patients per month. Staff have learned how to identify and prioritise patients who need specialist input to maximise the effectiveness of the care. Page 32 of 42

33 The identification and appropriate treatment of hypoglycaemia has also improved from 43% in 2010 to a sustained 97%. During 2014/15 the Diabetes & Endocrinology Directorate implemented some changes to systems and ways of working to help towards the delivery of fast, effective treatment and care including: The roll-out of a secondary care consultant advice line which provides written advice to Primary Care on all aspect of diabetes. Appointment of additional DSN posts to support Primary Care with the integrated care pathway and transfer of patients back to community The planned roll-out of a Primary and Secondary Care diabetes nurse specialist advice line is being progressed and will be available by October 2015 Robust management of e-referrals by consultants A diabetes whole-team workshop to highlight the issues in the outpatient service provided and encourage options for improvement In 2014/15 it was identified that patients were experiencing significant delays when offered a follow up appointment with a secondary care Consultant. ABUHB has been working with Divisions to ensure that no patient waits longer than 52 weeks beyond their follow up target date. In Diabetes 1140 patients were identified waiting past their due date. An integrated approach to micromanage this cohort of patients with the provision of additional clinic slots, validation of the follow up waiting lists as well as identification of patients who can be cared for by their GP has now brought this number down to 187. We expect to have no patients in this cohort by November Diabetes continues to have no patients in the 36 week RTT cohort and we continue to strive to provide a first appointment and treatment with 26 weeks of referral. 9 Supporting living with diabetes The Welsh Government aims to ensure people are placed at the heart of diabetes care with their individual needs identified and met and feel supported and informed, able to manage the effects of diabetes. Diabetes education improves diabetes awareness and self management. A more informed and confident diabetes patient requires fewer unplanned primary care consultations, visits to outpatient departments, hospital admissions and a reduced length of stay in hospital. The Quality and Outcomes Framework for 2013/14 has established an indicator for referral to a structured education programme within 9 months of entry onto Page 33 of 42

34 the diabetes register. It is imperative that LHBs have structured education programmes in place to accommodate these referrals. Performance measure 10 percentage of patients receiving eight care processes (excluding eye screening) The National Diabetes Audit for shows ABUHB to be performing in the top 25% of CCGs / LHBs in England and Wales. This performance is illustrated in the following graph, which shows ABUHB as having performed better than the England and Wales average percentage value for the past three reporting years. Performance measure 11 percentage of patients meeting all treatment targets Page 34 of 42

35 Performance measure 12 Percentage of patients with diabetes in whom the last blood pressure is 140/80 or less in the preceding 15 months Over the past 12 months we have progressed many activities to support people living with including: Discussing the provision and pathway for SDE Providing X-PERT in all 5 localities. Appropriate care planning mechanisms being explored as part of the Diabetes Primary Care Specialist Team. Developing a pathway for treatment of Hyperglycaemia and guidelines regarding blood glucose monitoring and testing. Developing an audit programme around GLP1 and DPP4 Inhibitors. Supported the first Living with Diabetes Day in conjunction with Diabetes UK Cymru in Newport Supported the creation of, and continue to support the running of, a new Newport Patient reference Group run by Diabetes UK Cymru following the Living With Diabetes Day event. 10 Improving information It is important that patients, health professionals and service planners will have access to appropriate information to help them make informed decisions about care and treatment. The public, the NHS, the third sector and the Welsh Government will have access to information on the outcomes that result from NHS Care. Clinical information from primary, community and secondary care services must routinely be added to the national diabetes patient management system. This Page 35 of 42

36 will facilitate benchmarking of existing services and outcome measures, enable participation in National Audit, and identify areas requiring support or service redesign. The National Diabetes Audit has developed key measures to assess the effectiveness of diabetes health care and participation in this audit is crucial in providing an accurate assessment of progress. We have worked with our partners to improve the provision of information as follows: 100% of all General Practices have signed up to contribute their data to the National Diabetes Audits Worked with diabetes patients, their carers and the Third Sector to ensure effective signposting to sources of information and support in the best way that suits them; Worked with NWIS to implement national diabetes patient management system across Local Health Boards Continued to be engaged and represented on All Wales Group and NWIS Group 11 We Targeting have developed research standardised Care Plans and are consulting with patient groups for their feedback Access We have to research developed can standard lead to letters better with outcomes patient for involvement patients. The and NHS feedback must promote in their research design and ensure appropriate access to clinical trials. The Diabetes Research Network in Wales will promote, design and deliver high quality projects to attract funding from Wales and abroad. The network will support the new Academic Health Science Collaboration Initiative (Health Research Wales) to deliver fast-track, high quality pharmaceutical industry sponsored research in diabetes and related areas. We are continuing to be engaged and represented on All Wales Group and NWIS Group. Driving forward developments in the treatment and prevention of all forms of diabetes. 12 Conclusion and focus for the next 12 months and beyond Over the next Financial Year, diabetes services in ABUHB will be developed using prudent healthcare and co-production principles. There will be special emphasis on promoting self-care and self-management, with personal goal setting being a key component to encourage patients manage their condition. Developing a role for an education coordinator would help this task, enabling increased support for initiatives such as XPERT, DAFYDD and pre Diabetes groups. Page 36 of 42

37 To deliver the highest possible level of care for increasing numbers of patients we need to continue to transform our service from the current two stream service to one where we have a fully integrated team. We are working towards a single Directorate of Diabetes, spanning all services in primary care and specialist services, encompassing inpatient, outpatient and primary care support teams. Our community and inpatient nursing teams will be integrated and led by a single Band 8a nurse, using an in-reach model for inpatient and outpatient care. The aim of the Primary Care Diabetes Specialist Nurses (PCDSNs) will be to ensure that patients have better controlled HbA1Cs and rational use of diabetes medication in keeping with prudent healthcare principles. These PCDSNs will provide the following services for patients: Offer direct patient care for patients, e.g. initiating insulin close to home, including care homes Offer indirect patient care by up-skilling Practice Teams to sustainably deliver more complex and better quality care close to the patient s home, including care homes. Patient and carer education in venues close to home Research and audit of services. The PCDSNs in secondary care will continue to provide inpatient diabetes care (20% of hospitalised patients have diabetes), and will provide support to the delivery of Super Six diabetes care areas, working with the consultants in Diabetes & Endocrinology. Similarly specialist diabetes dieticians will provide support to inpatients and the Super Six diabetes care areas where resources and expertise allow. There is recognition of gaps in pregnancy, renal and inpatient services. Pump services need to be expanded to meet the NICE target of 15% type 1 patients on pumps. Our currently level is 2-3% of adults. There is a need for an increased percentage of paediatrics on pumps but this will have knock-on effect in adult services as they will become transitions at age 16. The Podiatry Service will continue to roll out the Foot of the Bed inpatient foot assessment tool, thus screening for those patients with diabetes admitted with at risk foot status, and enabling referral to foot protection programs, as well as providing inpatient treatment where required. The current specialist Diabetologists will exclusively deliver care to those patients with Super Six Diabetic Conditions, as well as inpatient support. The venues for delivery of care to Super-Six patients will be determined by prudent health care principles, with an assumption that care can be delivered closer to home, rather than be hospital-based. Page 37 of 42

38 The development of non medical prescribing for podiatrists with advanced scope of practice within diabetes will enable provision of supplementary prescribing services e.g. antibiotic therapy, pain relief and referral for diagnostic imaging and onward referral to appropriate secondary care. This will ensure quality of care in a timely manner which will aid efficient use of NHS resources, reduce hospital admissions where appropriate and ensure seamless care throughout the patient pathway. The most immediate and significant change in care will be that the initiation of injectables therapy will transfer from a hospital based service to primary care based services. This will be achieved with consultant support and an expanded team of diabetes specialist nurses and specialist dieticians outreaching to NCN areas and working in GP practices. Following integration, we expect to see a significant reduction in the volume of consultant referrals. Bench-marking data suggest referral rates could fall by as much as 90% (evidence as per Portsmouth data). We would expect that there would be a significant change in the prescribing pattern of the types of injectable treatments, to more closely matching NICE guidance, with growth in human insulins from 13% to NICE recommended 28% of injectables. This is in keeping with prudent healthcare as it is likely to release savings to be recycled elsewhere in the diabetes programme. Consultants and DSN s and specialist dieticians will be required to be increasingly available to provide advice to primary care teams on how to care for particular patients, and thus knowledge will transfer into primary care and especially into the practice nursing teams. Diabetes consultants will visit practices on a regular schedule, at least twice a year, to provide virtual outpatient clinics, a model already used in Portsmouth. Patient reference/participation/support groups will be set up in each locality (or NCN where there is demand). These important fora will help further develop coproduction of services. Patient learning and activation (along with their carers) will be enhanced through a significant increase in the delivery of proven evidence-based education programmes. More patients, and their carers, will complete courses, as there will be more sessions delivered, at more venues by more trained educators. However, the availability of suitable venues is a recognised limitation, along with availability of funding for patient resources. The ABUHB will support the formation and development of local Diabetes Peer Review Groups in NCNs, where GPs and practice nurses will be able to share data (e.g. referrals, outcomes etc.) and constructively discuss care using continuous quality improvement methodology. Page 38 of 42

39 Evidence from community integrated teams in Wakefield show that when specialist staff interact with primary care teams, unmet need is identified and prescribing costs will increase. Thus the integrated service will concentrate on the quality of prescribing not cost reduction and ensure prudent healthcare principles are followed. Furthermore, evidence from the Portsmouth integrated model shows that at a population level, an increase in the proportion of patients who are well-controlled does not appear in the first three years. However, admissions for short term effects of poor control do reduce. Consequently, the integrated service will concentrate on reducing unplanned emergency admissions for reversible diabetes complications e.g. hypoglycaemia, hyperglycaemia. (This is a key outcome, for example, for DAFYDD trained patients and those who have undergone 1:1 CHO counting and insulin dose adjustment training with specialist DM dieticians). Care homes will provide a significant focus for diabetes care, through the increased intervention of the Primary Care Diabetes Specialist Nurses, creation of Personal Management Plans, Advanced Care Plans and unplanned emergency admission avoidance work. Progress against the actions outlined above will be continuously monitored inyear and reported in the 2016 Diabetes Annual Report. Page 39 of 42

40 APPENDIX A Aneurin Bevan Health Board Diabetes Together for Health Transformation Board Together for Health - Diabetes Transformation Group Reference Group Terms of Reference Remit: The Diabetes Reference Group has been set up under the authority of the National Services Framework Diabetes Delivery The Diabetes Reference Group is endorsed by the Aneurin Bevan Health Board, Diabetes Together for Health Transformation Group to which the Group receives its direction and support. Aims The aim of the Diabetes Reference Group is to provide expert advice, feedback and support in service planning and delivery of the Diabetes Together for Health Transformation Board Agenda. With the aim of improving clinical outcomes and patient experience. Principles and Objectives: The principles to be adopted are: Provide expert clinical advice to support planning and delivery of clinical services Provide opportunity for wide Patient Involvement to support understanding patient s needs to influence the agenda in relation to service planning and delivery Provide opportunity to engage with and support influences from the Third Sector in initiatives by organisations and support ABHB service planning and delivery The aims and principles will be achieved through the following objectives: Sharing information appropriately with clinical teams through Directorate meetings and other mechanisms to ensure wide consultation and opportunity to influence the agenda. To represent Directorates initiatives in relation to individual service developments for Diabetes. Providing support to Patient Representatives in assisting them to share information in relation to service developments and initiatives, to gain and receive advice and ensure feedback from as many Patient Interest Groups as possible. Receive and provide regular updates, advice, initiatives from the Third Sector ensure wide representation. Page 40 of 42