JANUARY 5, 2018 JULIE LEWIS (BCUHB - DIABETES & ENDOCRINOLOGY) DIABETES SPECIALTY LEAD: BETSI CALWALADER UNIVERSITY HEALTH BOARD

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1 JANUARY 5, 2018 PRIMARY CARE FUNDS SUMMARY OF PROGRESS AND DEVELOPMENT PROPOSAL JULIE LEWIS (BCUHB - DIABETES & ENDOCRINOLOGY) DIABETES SPECIALTY LEAD: BETSI CALWALADER UNIVERSITY HEALTH BOARD

2 CONTENTS INTRODUCTION PLAN ON A PAGE PRIMARY CARE FUNDING PERSPECTIVE: DIABETES BACKGROUND INITIAL FUNDING ALLOCATION WHERE NEW SERVICES ARE DELIVERED RECRUITMENT WHAT AE WE MEASURING? IMPACT TO DATE PRIDIA IT DATA COLLECTION ANGLESEY IMPACT ON 2NDRY CARE SERVICES FOR DIABETES GOING FORWARD: o o o o o o Good Governance Incentivising Primary Care Diabetes Recognising the New Service value Risks of Service Withdrawal Delivery of Structured Diabetes Education Additional Funding Proposal APPENDIX NEW SERVICE SUMMARY FOR DIABETES IN N WALES EXAMPLE OF S. WREXHAM MATRIX

3 INTRODUCTION There is a focus of attention on diabetes and the impact it is having that we have not encountered before the Diabetes Delivery Plan for Wales. Services remained unchanged for many years, unable to develop beyond traditional boundaries. There is a recognition that the majority of diabetes care (especially for Type 2 diabetes) could take place in general practice and community settings, but the barriers in general practice are skill based and contractual. This has led to fragmented and inequitable access to diabetes care in general practice. Some patients with a clinical need miss out on care or are referred into traditional specialist services. This care, education and range of treatments could be provided in general practice IF the requisite resources, training and specialist support were in place. This paper summarises the key benefits of a Locality based diabetes specialist multi-disciplinary scheme that has been established in some BCUHB localities. This was enabled following a budget allocation of 400k from the Primary Care Funds. An illustration of the risks, challenges and process of implementation will be discussed in this paper. Furthermore it will propose additional development potential of this type of service which should be considered as a component within a wider integrated diabetes service vision for BCUHB. It is important to recognise that a wholescale movement to an integrated service model is the key objective here. The wider vision will set the case for a strategic shift in the way adult diabetes services are delivered in BCUHB to one which is more uniformly integrated across all care settings, and where improving quality is the core aim of this service re-design. This direction for change is summarised (in the Appendix) and will show how the locality based diabetes specialist teams will sit in this future integrated model. The success of integration is also dependent on incentivised primary care activity and specialist Super six clinical activities being encouraged to develop. A framework for an Integrated Diabetes Service is appended as the focus of this paper is to discuss the Locality diabetes component.

4 PLAN ON A PAGE: LOCALITY DIABETES MDT SERVICES

5 The Primary Care Funds Perspective: Diabetes. BACKGROUND The locality base diabetes MDT service model evolved from lessons learned that small innovations to integrate existing diabetes specialist service models with Primary care could add tangible quality to the patient experience and the skills of health professionals; but they had failed to influence a more comprehensive shift away from traditional models. Also, diabetes health professional expertise in Primary care had developed in a person dependent fashion, rather than whole system approach. The potential was there but these innovations were small scale and lacked the planning or pursuit of Organisational buy-in to develop into an agreed wider service model. The opportunities arising from the Primary Care funding offered a more sustainable solution to offer a standard approach for Locality based diabetes multidisciplinary teams (MDT s) to improve primary care services for diabetes. Additionally to generate an understanding of the particular development needs of individual practices and match to a series of bespoke interventions to assist practices working at different levels to develop consistently towards a recognised competence of diabetes care. Confidence in this approach developed from the experience of the Anglesey nurse led diabetes MDT which recognised that the utility of (Diabetes) Specialist Nursing had not reached its potential in BCUHB. Such nurses working at an Advanced level of practice in their field possess a level of expertise that can support existing service structures in Primary Care, on the whole are less expensive (than GPSi or pharmacists for example) and are equipped to educate, prescribe and plan care with people diagnosed with a long term condition such as diabetes. Monthly joint Diabetes Specialist Nurse (DSN) clinics in GP practices provided 1:1 review and case discussion. In addition the DSN provided accredited modules of diabetes care for formal HCP education and proactively triaged referrals to the diabetes consultant back to the Locality for joint DSN/Primary Care review. There was an opportunity to diversify the workforce by incorporating a new role to provide follow up and lower level education in key care settings. The Diabetes Assistant role has provided additional profiling for diabetes in care establishments, supported further group education and undertakes data management for service evaluation. The diabetes dietitian role within the MDT has prioritised an increase in the delivery of group education such as X-PERT and DAFNE. This upstream approach is a long term investment to enable better self-care skill acquisition. Additional dietary specific interventions such as weight management, carbohydrate counting and health professional education and training.

6 INITIAL FUNDING ALLOCATION A sum of 400k was allocated from the Primary Care funds to support the further development of this service model Chronic Conditions Management in Primary and Community Care 2015/ / /18 wef Wtes 000s Wtes 000s Wtes 000s Diabetes Delivery Plan Roll Out Diabetes Specialist Nurse (Band 7) Jun Dietician (Band 6) Jun Health Technician (Band 3) Jun Total Pay Non Pay Non recurrent set up costs 5 10 Sub Total WHERE SERVICES ARE DELIVERED The allocation of funding was sufficient to ensure the Anglesey model (secondment) could be made permanent. A further 3 Locality MDT s; one in each area division were planned, plus additional allocation to the self-care office to ensure that sufficient administrative support to increase delivery of structured diabetes education (X-PERT). A 0.4 dietitian was allocated to the cluster funded DSN in Conwy West to ensure there was at least some attempt to replicate a similar service model. In Meirionnydd, the Cluster has invested in a DSN and dietitian (based on the progress from Anglesey) and have in 2017 extended the secondment of this service due to its impact on patient care and support for General Practice education.

7 EAST South WXM CENTRAL North Denbs WEST Arfon WEST Anglesey (project to make permanent) Self Care Office (X-PERT) CONWY WEST CLUSTER DSN band 7 DIETITIAN band 6 Diabetes Assistant band RECRUITMENT Posed one of the more frustrating challenges. One DSN post (Arfon) remains unfilled due to a last minute withdrawal of an external candidate. We are recommencing the recruitment process for this post. Although this process is protracted we are on target to meet the budget allocation during P Care funded Anglesey Fully operational since Sept 2015 North Denbighshire Fully Operational Dec 2016 S Wrexham Operational Jan 2017 (DSN & Dietitian). Diabetes Assistant appointed Dec 2017 Arfon Dietitian and Diabetes Assistant operational. DSN withdrew Sept Re-advertising. Self Care office Band 3 Operational January 2016 Conwy West Dietitian Operational June Recruitment has been largely internal; particularly for the DSN s. This has led to some temporary de-stabilising of the acute based DSN teams as their experienced specialist nurses were successfully appointed to the Locality posts. This has highlighted a significant risk and lack of sustainability within the

8 DSN service (although this is not limited to North Wales). If nothing else, it serves to reinforce how important it is to ensure we have a sustainable DSN service to improve the diabetes skill and competence of other health care providers. WHAT ARE WE MEASURING? The service has provided closer access for patients and health professionals in the localities to specialist diabetes interventions, such as patient education programmes, staff education and training, specific dietary intervention programmes, joint clinical review in a variety of settings including domiciliary, GP practice, Community Nursing, and in Care Establishments. It was important to be consistent with the philosophy of joint approach to clinical review wherever they occurred. These encounters would embed learning, skill and confidence to provide more appropriate care planning. This is not a separate but an integrated service. It was vital for the locality diabetes MDT s to establish a niche within existing strategies to improve health & wellbeing. It has never been the intention to duplicate or take over the work of existing Community or Primary Care services, but to enhance and support them where there is an identified need, and to reduce reliance on traditional medical models that are less suited to long term condition care. The service model project brief identified a series of key deliverables and expectations. Certainly all teams have been delivering a service within the project brief criteria, but measurement of this in an organised fashion has not occurred and the responsibility for reporting (to who) has lacked clarity. This can now be resolved with the formation of a project board (based on the experience of the South Wrexham board) in each of the 3 Area Divisions of BCUHB. Informatics department are currently pulling the required data together for all the Localities where Primary Care and Cluster funded diabetes services take place The project board for South Wrexham diabetes service has been a very successful method where service providers, primary and specialist clinicians, operational managers and informatics have collaborated to produce a robust framework which supports and monitors the delivery of the model. Service impact reports and risks to delivery are addressed every month.

9 More than this, the project board has increased the divisional awareness about the service model and created a greater sense of organisational ownership. A project board has now been replicated in the West Area division and needs to be established in Central. IMPACT TO DATE This table, extracted from the Metrics for ongoing measurement illustrates the standard approach to diabetes team activities in the Primary Care Funded Localities. The impact to date provides a guide to the progress which is being made. Please refer to the full metrics in appendix section. Outcome Deliverable Description Impact to Date To ensure that locality based insulin management is safe. Develop and support competence / confidence of HCP using NPH insulin as per NICE guidance Use competence framework and training for safe management of insulin in T2dm All teams using the Welsh Academy Nursing in Diabetes (WAND) competency structure Improve the skills of the Primary and Community workforce for managing diabetes Develop and deliver a rolling programme of diabetes education for HCP s to access (RCGP / RCN accredited) Deliver identified programme e.g. Topical / MERIT or DIAtips (define number) All teams collaborating across Localities to offer a range of accredited and non-accredited programmes TOPICAL & MERIT (accredited programmes) delivered in Anglesey and Conwy West. Planned for Wrexham Jan-March 2018 Good example of sustainability & cross cover to increase access to such programmes. Offered to other Localities where there is no dedicated MDT Improve access for people closer to home for Specialist diabetes care. Change capacity within 2ndry care Increase repatriation of2ndry care diabetes opd into the identified Locality (Both DSN and Consultant list) Establish regular organized joint clinics in P Care. Work with consultants and hospital based team to make appropriate discharge to the Joint clinics are held in each practice where these services exist. Frequency will depend on size of practice (so may be more frequent than monthly in some cases and 6 weekly in others) Joint DSN / Practice Nurse clinic activity examples: Anglesey Primary Care Funded

10 to manage more acute specialist services (e.g. insulin pumps / inpatient etc) Locality service based upon 45 weeks activity with 8-9 joint P care clinics per practice per year in 12 practices. Seeing 6-9 patients per session - 96 clinic sessions per year face to face contact with 720 patients WTE = 0.8 Band 7 DSN Meirionnydd - Cluster Funded Oct 2016-March clinical sessions in 6 GP practices seeing 6-10 patients per session. Average at 8 patients per session = 544 face to face contacts WTE = 0.8 Band 7 DSN Conwy West Joint Cluster & P Care Funded Based upon 45 weeks activity with 9 joint primary care clinics per year per practice in 10 /12 practices within the Cluster. Seeing 5-6 patients per session. 90 clinic sessions = 450 face to face contacts WTE = 0.6 Band 7 DSN North Denbighshire Primary Care Funded March July clinics total of 42 patients seen in 4 / 8 GP practices. 35 joint visits with Community Nurse service Improve patient experience Increase patient satisfaction with diabetes care closer to home Timely access to specialist review / Improved outcomes General Practice control the clinic caseload and will fill the clinics following requests form practice colleagues. These patients will have an identified care need which would not normally be provided in the practice OR where there has been difficulty improving control with standard P Care approaches. Due to the frequency of the clinics and ability of PN to follow up the plan of care in practice, the services are timely

11 Improve the HCP experience of Specialist diabetes services in the community Increase P Care and community satisfaction with the service Provide timely review of patients in P Care setting. Increase training & communication with GP cluster and community services Survey Monkey Q s in place for S Wrexham. HCP feedback from all other services have been undertaken- albeit these may have been informally requested previously. To reduce No. emergency diabetes admissions and attendances Identify frequent attendee rate for diabetes emergencies in S Wxm who can be supported by the Locality Diabetes MDT to reduce risk for readmission Inpatient DSN to refer for Locality MDT support post discharge Informatics now make available data for frequent admissions where there is a primary code for diabetes. This will be monitored via the Project Boards All teams regularly engage with the acute based service and will follow up those where there is an identified risk for re-admission DAFNE Type 1 structured diabetes education To increase number of people with diabetes who are able to selfmanage their diabetes effectively Increase access to SDE for adults with Type 1 and Type 2 diabetes in line with NICE guidance Promote programmes as routine part of diabetes care in practice. To run more X- PERT (T2) sessions above what is normally available. T1dm DSN and Dietitians to undertake DAFNE training West diabetes team (Anglesey) are now accredited to deliver DAFNE. This is a huge advance in delivery of structured education for adults with type 1 diabetes in this Area. Moreover, delivery is in the locality (hotel) rather than in health board site (this is due to no suitable venue access for patient education). Central Area: N Denbighshire DSN now DAFNE trained and will assist this established service to offer the programme in community locations. Conwy west dietitian due to be trained in 2018 East Area. 2 DSN s & 2 Dietitians booked to undertake DAFNE training in X-PERT Type 2 structured diabetes education 40 courses were delivered in 2017.

12 West 17 courses Central 16 courses East 7 courses Note: Primary Care health professionals are encouraged to attend x- pert as part of education & training Note: the success in increasing access for people with T2DM has been vastly enhanced by the central coordination of the programme by the Self- Care office. In order to ensure that DAFNE can be comprehensively delivered in all 3 Areas, we will need to consider a similar approach to central coordination. Improve compliance to Nice guidance. Cost Reduction Increase use of NPH insulin in T2dm compared to Analogue Initiate NPH insulin as 1st line insulin in T2dm. Review current Analogue use in T2dm & change use where appropriate Data from AWMSG BCUHB records an increasing trend in the use of human NPH insulins in the community (and in acute) compared to the rest of Wales. Cost Reduction Increase compliance with preferred formulary SMBG Ensure where appropriate that people who require SMBG are provided with a preferred meter for their type of diabetes. There is good compliance with the preferred formulary although pan BCUHB there is a need to review the unit strip cost & this work will take place separately Cost Saving Ensure Insulin ABASAGLAR is default analogue insulin when required Review and assess appropriateness for switch. Review initiation of insulin practice All insulin use and its appropriateness to continue are reviewed as part of the joint clinical process.

13 Patient Outcomes Support the patient through the new system to allow them to control their diabetes better Delivery of new patientcentered system with wrap around support. Patient Experience of Diabetes (PEDS) is incorporated into NDA but this data is not collected. A paper version of PEDS has been created and currently being translated for use in joint clinics. Patient stories are routinely collected to illustrate improvement in the quality of care received. Potential increase in Primary Care workloads New diabetes service New system may see patients needing to be seen by Primary Care more frequently The unmet need i.e. people with sub optimally controlled diabetes who were never referred for specialist review who, if not proactively treated in the joint clinic would be at risk for future disabling complications have certainly deserved and benefitted from joint clinical review in practice Some practices have been tentatively concerned that joint clinics with the Practice Nurses would take too much practice time. However, as the models established themselves within this framework, the benefits in learning and patient care have been very well received. Primary Care staff movement. It is worth noting that the skills and competence gained, particularly by the practice nurses has enabled one PN to be successfully appointed to a DSN post. Sustainability is important, but staff movement is a natural process. The Locality diabetes service support for primary care health professionals offers a resilient and stable source of expertise that will continue to support the changing educational needs as staff develop or change. Moreover, such services are in a position to deliver continuing education, training and supervision for any future enhanced service incentive to shift Type 2 diabetes management wholescale into Primary Care. PRIDIA This is an IT software system which is being piloted in Anglesey practices to monitor changes in diabetes control for those who have been seen in the joint clinics. This data needs to be accessed at each individual practice and collection will commence from 11 th January 2018.

14 IMPACT ON 2NDRY CARE SERVICES FOR DIABETES The Anglesey diabetes MDT and the cluster funded Meirionnydd DSN / Dietitian service have been operational for at least 12 months longer than the other locality teams. There is proactive triage of the new referrals into the consultant service at YG and where possible these referrals are seen by the relevant DSN jointly in practice. There is a small but encouraging 15% reduction in demand for new consultant outpatient slots. More significantly is the reduction of DSN general outpatient activity in the West. Prompted by staff movement and maternity leave, the acute based DSN service lost 3.6 WTE. It was no longer possible to continue to offer the number of outpatient appointments. In addition the Anglesey, Meirionnydd (and Conwy West to some extent) locality teams were becoming established, these also reduced the demand for the number of clinics that were usually offered. It has been possible to discontinue 13 DSN clinics per month. The DSN numbers are recovering and this has provided an opportunity to re-shape the activities and focus more upon the Super Six specialists services. Expanding inpatient diabetes reviews and ward education, setting up a transition service from children to adult services, increasing the high risk ante natal service support and strengthening the insulin pump service. There are also plans to provide high risk renal diabetes support. There will be opportunity to move some sessions into the Localities and the team are working with the Diabetes specialty lead to clarify this re-distribution of core DSN service support. Of course these changes in activity are reliant upon the continuation of the existing locality posts as the patients who have been discharged from traditional clinics do have access to a DSN in the joint primary care clinic structure. Furthermore the general practice teams have access to ongoing education and training to sustain a higher level of primary care service than was possible before the locality teams were in place. The starting WTE for the core DSN services differ in each of the 3 diabetes teams and it is not possible at this early stage to generalise scope for redistribution. The priority for the acute based teams will be to meet the national diabetes inpatient audit recommendations and to be more clearly defined to provide essential specialist services i) Inpatients i.e. dedicated diabetes inpatient team and expansion beyond office hours service provision ii) Insulin pumps iii) Transition to adult services iv) High risk foot v) Diabetes and advancing renal disease vi) Diabetes in Pregnancy

15 Going forward What needs to be done next, and how will this be achieved? Good Governance There is a need for all 3 Area divisions to implement the project board monitoring of these services. South Wrexham has provided a managed example of how this can work. This will ensure the deliverables are met, that risks and barriers to implementation are addressed, and will ensure that teams are fully supported. It is vitally important, especially with the size of the Organisation that we avoid silo, unsupported services. It is now important to ensure that the teams settle into their new roles, become accustomed the key requirements which need to be delivered and measured. And importantly build relationships that help to integrate services to improve the quality of patient care. Both Cluster and Primary care funded services will need to be monitored within this governance framework There is a high level of confidence that this model of service is enhancing Primary Care diabetes care. Moreover, building better and more sustainable integrated care is creating a new and improved dialogue between service providers. Incentivising Primary Care diabetes It is widely recognised that an incentivised model for primary care diabetes can assist a shift of care at a scale which is significant enough to stimulate a change towards a more integrated diabetes service model; one which has clearly defined responsibilities for care delivery. BCUHB have yet to determine their position on the negotiated enhanced specification. Work on this is due to start Jan Should the value of the enhanced service for diabetes be implemented in BCUHB; then locality based diabetes MDT s will be pivotal to support this shift within a framework which improves quality and enables ongoing access to education, training and clinical support. It can support practice review of activities within the specification. Recognising the Value The role of the locality diabetes MDT is already showing significant improvements in access to primary care based specialist reviews, education and training. Their contribution has been positively evaluated by PC health professionals and patients. Indeed, as a result, 2 Clusters have invested in this model and North West Flintshire cluster are about to invest in a 3 year secondment. Again it is important to reiterate that this service is not designed to take over care which should be available in the Primary Care and Community setting, but to enhance and improve the quality of diabetes care and to boost access to structured education that will enable more people with diabetes to make better decisions about their self- management. Boosting this approach with further primary care funding would aid progression of these services, but following the lessons learned with protracted recruitment difficulties, it is not realistic to propose that a diabetes mdt in every locality is something we could achieve in the next 12 months. In addition, we may need an amended service response depending on the specialist support that will be required should an incentivised scheme for Primary Care be adopted.

16 Risks of Service Withdrawal There is currently insufficient resilience within the 3 Hospital based diabetes teams to incorporate these locality posts into core funding; although this will be considered as part of usual service development priorities. The chief aim for the hospital based services (as a result of the locality team and potential incentive scheme for primary care) will be to focus attention on the development of super six activities. Moreover, any seconded posts in cluster funded diabetes services will need to be repatriated back to the core team should there be no alternative funding solution for these services to continue in the respective clusters. It is important to recognise that this is the first time (even pre-dating the Diabetes National Service Framework) that diabetes services have been in a position to diversify their service delivery. The Primary Care Funding has enabled this to take place at a scale which is having a positive impact. Diabetes has benefitted from the attention of our provider organisation to support this service improvement. If we are in a position where it is no longer possible to offer the Locality Diabetes MDT service the following activities will cease o Joint clinics in 59 surgeries o Delivery of accredited education o Delivery of non-accredited (informal) study days o Reduced capacity to deliver X-PERT o DAFNE in West Area o Nursing Home and Residential Home diabetes reviews o Nursing Home and Residential Home education o Community Nurse joint case reviews o Community nurse education o No local case management for people identified as a high risk for admission o Carbohydrate counting and weight management (dietitian led) group programmes In addition we will risk o o o o Increasing rate of referrals to 2ndry care diabetes services Disabling service development potential of super six and potential of any incentivised schemes Deterioration of good working relations with Primary Care Perpetuating a mismatch between patient needs and professional skills

17 Delivery of Structured Diabetes Education Central coordination of the X-PERT programme for type 2 diabetes within the Self-Care office has been especially successful. It has enabled the wide scale provision of programmes in every locality. The locality MDT s have delivered 40 (6 week) programmes in We could boost delivery further with a relatively small uplift in coordinator time. With the wider provision of the type 1 DAFNE course which will be offered in localities in central east and west during 2018, it would be sensible to provide this through the Self-Care office too. This is more complex as it is currently organised through traditional outpatient management systems, but that should not prevent a service improvement. ADDITIONAL Funding Proposal A more measured proposal for additional funding should include the following: WEST AREA CENTRAL AREA EAST AREA SELF CARE OFFICE 1.0 Band 6 dietitian 1.0 Band 3 Diabetes Assistant 1.5 Band 3 wte 1.0 Band 7 DSN 1.0 Band 6 Dietitian 1.0 Band 3 Diabetes Assistant 1.5 Band 7 DSN 1.0 Band 6 Dietitian 1.0 Band 3 Diabetes Assistant To boost the locality dietetic activity & to support the Core DSN movement into Dwyfor & Core DSN contribution when the Meirionnydd cluster secondment ends. To work with Conwy West and North Denbighshire teams to offer similar support in Conwy East plus Central & South Denbighshire East Localities are less wellresourced than Central and West. There is also a lower Core DSN provision to enable movement into Primary Care To increase coordination of X-PERT and to provide a service improvement project to trial the delivery of DAFNE through a central office. Core movement: DSN team will: Provide 0.3 support to the 0.5 Arfon post Provide DSN support in P Care for Dwyfor Explore potential contingency for end of the Meirionnydd secondment Core movement: DSN team will: Undertake job planning review to determine level of core service delivery which could be moved to support Primary Care Core movement: Contingency will need to be established for the end of NWF diabetes team secondment (3 yrs)

18 Dietitian Lead for West will: Explore potential contingency for end of the Meirionnydd secondment SUMMARY This paper sets out the background to the development of locality based diabetes MDT services in some localities in North Wales which have been enabled through a significant investment from the Primary Care Funds. It describes the expected service deliverables and impact against these to date. We have also explored the wider context of diabetes and the impact of this new model on traditional secondary care diabetes. Going forward we have discussed the elements which influence the strengthening of this model through good governance, the value this service has contributed to primary care diabetes and the risks that we will encounter should the services be unable to continue. It is accepted that there are interdependencies which can increase the impact of these services and primary care diabetes service delivery in general. These being the benefits of an incentivised scheme for diabetes in Primary care which will enable a defined pathway for diabetes to take shape, and resulting capacity for the acute teams to develop their Super Six responsibilities and promote much greater integration and collaboration for future diabetes services. A summary of this proposal is in the appendix. In addition there is a proposal presented in this paper for further investment from Primary Care Funds to be considered. Finally, it is important to reiterate that diabetes services have not received this level of funding to develop their primary care support services, even pre dating the Diabetes NSF. Indeed Specialist resources for diabetes have remained stagnant against a backdrop of increasing prevalence and complexity. It has been refreshing to be in a position to look forward with more optimism that we are in a better position to contribute to improving the quality of care for people with diabetes with our Primary Care colleagues. Julie Lewis RGN. Cert.Ed. PGDip. MRes. Diabetes Specialist Nurse RCN Credential: Advanced Level Nurse Practitioner Diabetes Specialty Lead for BCUHB.

19 APPENDIX Summary of a Diabetes Service Vision for North Wales. This summary intends to set the case for change in the way adult diabetes services are delivered in North Wales. It provides a framework to enable a strategic shift to a model of care which is more uniformly integrated across all care settings and where improving quality is the core aim of this service redesign. Recently updated data from the Diabetes Eye Screening Wales (DESW November 2017) service indicates that there are now more than 40,000 adults with a registered diagnosis of diabetes in North Wales. We have seen a rate of growth of over 2,500 cases each year for the last 4 years. The largest proportion of adults with diabetes will have Type 2 diabetes and will have their annual review and care planning in General Practice. People with Type 2 diabetes are referred for specialist care when there is an identified need, but there is no defining criteria by which patients are assessed as requiring specialist care. Data from the National Diabetes Audit (NDA) has indicated that there is poor recording of the essential care requirements for Type 2 diabetes and therefore a low confidence that these fundamental elements of diabetes care are being undertaken. There is also a poor (reported) achievement of the three treatment targets (Blood pressure, HbA1c and cholesterol management) for people living with Type 2 diabetes. 10% of adults registered with diabetes will have Type 1 diabetes. Largely their care is provided by one of the 3 diabetes teams in each main hospital site. NDA data similarly records poorly for the essential care requirement and treatment targets. Traditional service models perpetuate reliance on hospital based specialist services. With the year on year increase in diabetes cases, access to specialist advice and care are difficult to provide within this traditional model in a timely manner. Moreover, such services are difficult for patients to access, and are often only provided during traditional working hours. In addition, many primary care health professionals do not have an appropriate level of training and expertise in the treatment of diabetes, a common condition with which an increasing number of the practice based population are at risk of or present with. It is also recognised that primary care services are inundated with demand for access to healthcare closer to home, especially for chronic conditions which cannot be delivered routinely within current capacity. Additional incentives for primary care would therefore need to be at a sufficient scale to enable a real and meaningful shift of services (i.e. to be able to close a hospital based diabetes opd clinic). Complex and fragmented approaches, skill based and contractual barriers, have contributed to a disconnect between hospital based and primary care diabetes services. There is a skills gap in primary care which causes some patients to miss out on care or to be referred to hospital specialists when that care could be appropriately provided in general practice. The development of locality based diabetes nurse led MDT s in six of our Health Board Localities have uncovered a worrying unmet need for improved diabetes care. The work of these teams have increased access to specialist advice, education and training,

20 and clinical support in practice. They have furthermore promoted sustainability within Practice Nursing, educating at all levels of experience within a competency framework which is nationally recognised. Worryingly nearly 70% of NHS spend on diabetes is for in-patient diabetes care and treating costly long term cardio vascular and end stage complications. Such long term complications arise as a direct result of poor control of diabetes. We know that people are living with sub-optimal diabetes control, even early on in their journey of living with diabetes. This care could be provided in the primary care setting IF the education, resources, training and contractual incentives were in place. If we fail to provide the aforementioned primary care support and good access to diabetes specialist support in the community, we will perpetuate the reliance on traditional reactive hospital specialist and inpatient care. These costs will continue to rise unless there is a public health agenda which encourages responsibility to reduce the risks for developing Type 2 diabetes A service design is required which addresses the mismatch between patient needs and timely access to an appropriate level of skills & education that can help the person living with diabetes to effectively manage their condition. There are no robust evaluations of whole scale cost reduction impact; but there is an acknowledgement that funding re-design has lagged behind service re-design and that funding arrangements for new service structures have been patchy and complex. Therefore, guidance from the King s Fund paper on integrated service models would favour a focus on: i) A model which is built on continuous improvement ii) One which is firmly supported with meaningful data management & review iii) One which identifies robust payment approaches iv) One which incorporates academic research & evaluation The intention is to provide a comprehensive service vision for diabetes with key recommendations to provide Core education & training Improved access to an integrated diabetes specialist resource which can be accessed outside of the traditional operational boundaries Clear criteria for specialist activities ( Super Six ) and a service delivery plan which can be accessed outside of traditional communication and time boundaries Enhanced specification to a scale which will enable a meaningful shift of the majority of care planning and delivery in general practice (of Type 2 diabetes) More collaborative approaches with clinical teams and medicines management to ensure that we are able to offer prudent individualised therapies for diabetes.

21 An improved patient experience & access to specialist diabetes care & range of education opportunities for self-management within the GP practice and the local community To include population based approaches to motivate case finding, prevention and self-management education A consideration of the diverse benefits NDA data NaDIA data Local Project performance management