HYWEL DDA UNIVERSITY HEALTH BOARD DIABETES DELIVERY PLAN REFRESH 2016

Transcription

1 ` HYWEL DDA UNIVERSITY HEALTH BOARD DIABETES DELIVERY PLAN REFRESH 2016 Page 1 of 29

2 CONTENTS Background and context 4 Hywel Dda University Health Board s Delivery Plan 4 The Vision 8 The Drivers 8 Organisational Profile 14 Over view of local health needs and challenges for diabetes services 16 Development of Hywel Dda University Health Boards local delivery plan for Diabetes 16 Priorities for coming year 16 Performance measures/management 18 Action Plan 20 Page 2 of 29

3 FIGURES PAGE 1 Treatment target achievement for people with Type 1 11 diabetes in Hywel Dda UHB 2 Treatment target achievement for people with type 2 or 11 other diabetes in Hywel Dda UHB 3 Percentage of newly diagnosed people with Type 1 12 diabetes recorded as being offered or offered and attended a structured education program 4 Percentage of newly diagnosed people with Type 2 or 12 other diabetes recorded as being offered or offered and attended a structured education program 5 Ulcer severity Hywel Dda UHB 13 6 Ulcer severity England and Wales 13 7 Time to assessment Hywel Dda UHB 13 8 Time to assessment England and Wales week outcomes Hywel Dda UHB week outcomes England and Wales 14 Page 3 of 29

4 HYWEL DDA UNIVERSITY HEALTH BOARD DIABETES REFRESH MARCH Background and context Together for Health a Diabetes Delivery Plan was published 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 diabetes services. It therefore focuses on maximising efficiency and effectiveness, tackling variation in access and reducing inequalities in service provision across 7 themes. For each theme it sets out: To ensure delivery of expectations to the right patient, in the right care and at the right time Specific priorities for Responsibility to develop and deliver actions Assurance measures that will be used to ensure that this plan is delivered and effective outcomes achieved. What do we want to achieve? 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 Improving Information Targeting research 2. Hywel Dda University Health Board s Delivery Plan The Health Board produced its first delivery plan in In our delivery plan we set the following priorities for 2015: 2.1 Paediatrics The development of a formal paediatric diabetes managed network Mandatory participation in a quality assurance programme Development of a structured education programme with trained educators and resources; structured education for Children and Young People and families from diagnosis, tailored to their learning needs, with updates and refreshers as they grow older and move into transition. Education programmes for staff within schools particularly primary school age group Page 4 of 29

5 2.2 Preventing Diabetes Preventing diabetes in our population is crucial and the best ways to achieve this is by working in partnership with the Hywel Dda Public Health team to embed Making every Contact Count. We need to recognise that with the support of the Hywel Dda Public Health Team we need to interface with our local population to embed healthy lifestyle into everyday living to support the prevention of diabetes. North Ceredigion GP Cluster Pre Diabetes Project aims to identify up to 3% of the practice population that are at high risk of developing diabetes, to assess and signpost to interventions that will help reduce their risk of developing diabetes- e.g. FOODWISE for life programme Implementation of the Foodwise for Life programme for individuals who are overweight/ uncomplicated obesity in partnership with Nutrition and Dietetic services Acknowledging changes to guidance around management of gestational diabetes- develop a plan to meet increased demand and improve outcomes. 2.3 Making our Services As Effective as Possible Foot Care Improving the whole patient journey for foot care utilising existing tools e.g. Putting Feet First, ThinkGlucose - implementation of standardised documentation, audit review. Improves access to NICE approved Type 1 diabetes education programmes to empower self management Increase the number of people with Type 1 diabetes using Insulin Pump Therapy Improve access to combined antenatal and diabetes clinics Following increased demand to manage individuals with gestational diabetes ages plan to ensure timely access and supportive interventions to meet need and improve outcomes Improved access to Diabetic Retinopathy Screening by working closely with the Head of Programme DRSSW 2.4 Supporting People living with Diabetes Increase the number of people with Type 2 Diabetes completing an education programme across Hywel Dda Ensure all those people with Type 1 diabetes being issued with an insulin pump undertake education prior to pump therapy initiated e.g. DAFNE or one to one sessions based on DAFNE principles Improve equity of access to Type 2 Diabetes education across Hywel Dda Updated and Implemented the Diabetes Resource Folder for Care Homes across all three counties in Hywel Dda and Powys Considerable progress has been made against these priorities as highlighted below: Paediatrics Preventing Diabetes The North Ceredigion GP Cluster Pre Diabetes Project has linked with EPP and Dietetics to train tutors to deliver the Food Wise programme. Established links with Aberystwyth University and their local NERS coordinator to support the Page 5 of 29

6 exercise element of the project and developed a framework to evaluate the project Making our services as effective as possible The Health Board has worked with the DRSSW to provide a fixed screening site in St David s Carmarthen. The Health Board has provided 3 operational satellite bases one in Pembroke Dock and one in Cardigan. The third site needs to be agreed in the Llanelli area. Supporting People living with Diabetes In delivering our services for patients with diabetes, there are a number of service improvements that we have implemented locally that have had a real impact on patient care. Examples of this include: Results of feasibility study show HbA1c in the DSMP group was relatively unchanged (increase of 0.1%) six months post education whilst there was a 0.6% increase in the control group (Table 4). There is however a large standard deviation in the control post group indicative of the small sample size making it difficult to draw any definitive conclusions The Summary of Diabetes Self Care Activities (Diabetes Care 23: , 2000) questionnaire included items focusing on diet and exercise for which those that had participated in the DSMP all demonstrated an improvement There were also four questions related to blood sugar monitoring and foot care, which many participants felt they were unable to answer, as questions were not relevant. These were all general selfcare questions not designed specifically to accompany the Stanford DSMP and as such may not directly measure outcomes addressed by the program. Patients have varying needs in relation to education and DSMP takes a simple approach to deliver invaluable information to enable patients to self-manage. In relation to future delivery, consideration should be given to comparing DSMP to existing education programs in an attempt to develop a tiered approach to supporting patients with diabetes. The program content and delivery were both well received by course participants and tutors. With limited staff resources available to support increasing the availability of programs to ensure access to all those with a diagnosis of Type 2 Diabetes further consideration is required to demand and capacity, as course coordination constitutes a considerable workload. It was felt important that the venue should remain the same for all sessions, including any additional sessions necessary for collecting evaluative data. By closely following the DSMP manual, tutors were able to provide the self-management skills in a confident professional manor to patients with newly diagnosed diabetes in a community setting. Layperson tutors were well received by the participants who felt at ease as tutors could empathise with them as they themselves have been through a self-management programme (i.e. have a chronic condition). With a 77% completion rate participants reported that these courses have been life changing, having a positive impact in how they think and feel about their condition. They also indicated an interest in further education such as attending an X-PERT programme. Following this trial it is thought that the DSMP would form part of a tiered approach to education. This would provide a wider menu of self-management programs for patients, which would accommodate the varying needs of different patients. Since the evaluation period ended there has been a steady increase in recruitment to the DSMP, with five further courses have ran since April 2015 with 66 people completing DSMP. Page 6 of 29

7 Completed the United4Health telehealth project- Lifelong monitoring of people with Type 2 Diabetes. 126 patients with T2DM who were already self-monitoring their blood glucose levels were recruited to the study. Delivery of the intervention was through mobile phones including feedback and health coaching message. Clinical, organisational, technical and economic data was collected as part of the study a lessons learnt log was developed by the clinical team Lessons learnt show the following: o Engagement with General Practice was difficult o Questions over the value/usefulness for healthcare professionals were raised o Those engaged healthcare professionals felt it supported them to have more people on their caseload o Healthcare professionals had instant access to data which supported clinical decision making o Patients were more accepting of a new way of accessing information than their clinicians o They want access to new ways of supporting their healthcare want it simple to start with but to become more sophisticated as time goes on o Age was not the barrier that many perceived it to be o Enjoyed taking more responsibility for their own care o Patients preferred to discuss and sign up to using telehealth once discharged from hospital rather than as an in patient o Using mobile networks alone in Hywel Dda's largely rural geography resulted in some accessibility issues offering different types of technology may overcome this. o Technology does not need to be overly sophisticated for the patient o Moving forward there would need to be integration with clinical systems o Technology can fail in some of the most unexpected ways Positive patient story collected from the United4Health Project Launched the Guidelines for Home Blood Glucose Monitoring (Primary, Community, Acute and Mental Health) Through the ThinkGlucose programme the following were launched in September 2015 o Blood Glucose Monitoring Chart (Adults) & Poster o Blood Glucose Monitoring Chart (Paediatrics) o Blood Glucose Monitoring Guidance (Pathway) & Poster o Diabetes Referral Form (Adults) & Poster o Pilot Diabetes Telephone Referral Form (Paediatrics) o Adult DKA Care Bundle & Poster o DKA Pathway (Adults) Poster o Pilot of Diabetes Medication Chart o Foot Care (Poster) & education pilot o Self Management of Insulin Policy o Blood Glucose Testing Policy o Standardised Diabetes Health Professional Education Programme Page 7 of 29

8 3. The vision: For our population we want: People of all ages to have a minimised risk of developing diabetes. Where diabetes does occur, an excellent chance of living a long and healthy life, wherever they live in Hywel Dda UHB. 4. The drivers: Spending in Welsh hospitals in on diabetes was almost 90m 1, this is an increase of 4% when compared to However NHS expenditure on diabetes related care is almost 500m a year 2. In ; 177,212 people over the age of 17 were registered with their GP as having diabetes. This is 3,913 3 more people than in There were 1,469 children and young people with diabetes, under the age of 25 in Wales. Almost all have type 1 diabetes. Gestational diabetes is a type of diabetes that some women get during pregnancy. Between 2 and 10% of expectant mothers develop this condition, making it one of the most common health problems of pregnancy. It is widely accepted that Wales is facing a huge increase in the number of people with diabetes. The numbers of adults aged 17 and above registered at a GP practice with diabetes has increased by just over 24,000 people in the last 5 years. Much of the increase is type 2 diabetes due to the aging population and the increase in the numbers of overweight people. Prevalence Data Ceredigion 9.2% 9.8% 10.4% Pembrokeshire 10.3% 11.0% 11.7% Carmarthenshire 10.2% 10.9% 11.5% Wales 9.6% 10.3% 10.9% APHO DATA Emergency Admissions 2011/ / /14 Hywel Dda Basket of 8 Emergency Readmissions 2011/ / /14 Hywel Dda Basket of 8 There is evidence to show that: 1 NHS Expenditure Programme Budgets Wales Together for Health a Diabetes Delivery Plan 3 Stats Wales Page 8 of 29

9 the onset of type 2 diabetes can be delayed, or even prevented; effective management of the condition increases life expectancy and reduces the risk of complications; and Supported self-management is the essential element of effective diabetes care. People with diabetes have a substantially higher risk of serious illness, hospitalisation and premature death compared to the non-diabetic population. We have developed a number of outcome and assurance measures, which together, will demonstrate how diabetes services are improving in Wales. Some progress against these measures has been made giving us the reassurance that diabetes care in Wales is developing in line with our vision: Deaths from diabetes are not a common cause of death in Wales. In 2013, 300 people died from diabetes. This has fallen from 420 deaths in Mortality in HDUHB is the same as the national average for both Type 1 and Type 2 Diabetes Half of all deaths from diabetes result from cardiovascular disease including heart attacks and strokes. In 2001, in Wales, almost 14,000 people died from cardiovascular disease, by 2011 this had fallen to just over 9,000 deaths. HDUHB stroke deaths are the same as the national average. HDUHB has a lower than national average death rates from myocardial infarctions and heart failure In Wales in , 98.9% of patients under the age of 25 years had their HbA1c measured and 97.6% in England. This is considerably improved from , where 89.3% of patients in England and Wales had their HbA1c measured. In there has been a decline in diabetic ketoacidosis (DKA) incidence rates for children and young people from 9,662 in to 5, % of inpatients in 2015 stated that they were satisfied or very satisfied with the overall care of their diabetes while in hospital. The Inpatient audit in 2015 showed that across the 4 hospital sites in Hywel Dda UHB the average was 82.4% with the lowest being 59% and the highest 95.6% In , 93% of patients on the diabetes register had a record of retinal screening, and 91% of patients on the register had a record of a foot examination, in the preceding 15 months. HDUHB s foot screening is 81.9% compared to the national average of 85.1%. Emergency admissions for diabetes have dropped by over 230 patients from 2,815 to 2,584 between 2010 and Emergency admissions across Hywel Dda has decreased slightly over the past year 14/15 averaging at approximately 307 compared to 13/14, 313 emergency admissions per month. We need to continue to improve in these areas as well as ensuring that progress is made where performance has not been as good as anticipated: Type 2 diabetes is more prevalent among less affluent populations. Those in the most deprived one-fifth of the population are one-and-a-half times more likely Page 9 of 29

10 than average to have diabetes at any given age 4. 9% of those people living in the most deprived areas of Wales report being treated for diabetes compared to 6% of those living in the least deprived - showing the pronounced impact of poverty and the socio-economic determinants of health. A child with HbA1c levels above 9.5%, according to the National Institute for Clinical Excellence, would be at risk of medical complications in the future. In Wales, 27.1% had poor glycaemic control (HbA1c over 9.5%); with 59.5% having moderate control (HbA1c between 7.5 and 9.5%). Hywel Dda UHB participated in the National Paediatrics Diabetes Audit (NPDA) The Health Board results showed the mean value of HbA1c at Withybush Hospital was 76 mmol/mol, Glangwili Hospital was 69.1mmol/mol, Bronglais Hospital was 68.9 mmol/mol compared to the All Wales value of 74 mmol/mol. The median HbA1c at Withybush Hospital was 72 mmol/mol, Glangwili Hospital was 67.2 mmol/mol and Bronglais Hospital was 68.3mmol/mol compared with the All Wales value of 70 mmol/mol. Obesity is the top risk factor for type 2 diabetes at all ages. 58% of all adults in Hywel Dda and Wales in 2014 are overweight or obese 6. The prevalence of those overweight or obese children aged 4-5 years in Hywel Dda 28.3% was significantly higher than that for England (23%) 5. It is estimated that there are around 66,000 (2014 data)people with undiagnosed type 2 diabetes in Wales. High blood pressure is an important risk factor for diabetes, and while 20% 6 of adults are being treated for high blood pressure, it has been estimated that across the UK around half of people with high blood pressure are not receiving treatment 7. Less than 8% of newly diagnosed patients in Wales received structured education in In Hywel Dda UHB the number of people offered a Type 2 diabetes self management programme in was 2193 and the number completed was 393 compared to where 172 completed. A completer is a person who has attended 4 out of the 6 weeks of a programme. 60% of adults with type 1 diabetes and 33% of adults with type 2 diabetes are not having the annual tests and investigations associated with the national standards. Of those having the annual tests, 86% of type 1 diabetic patients and 65% of adults with type 2 diabetes do not meet the agreed treatment targets. In Hywel Dda UHB 84.2% of GP practices took part in the National Diabetes Audit This audit identified: o Prevalence of all Diabetes in Hywel Dda 5.82%(Wales 4.87%) with Type 1, 0.48% (Wales 0.40%) and Type 2, 5.26% (Wales 4.38%) o The age group with the highest prevalence of Type 1 Diabetes is years more males overall than females. o The age group with the highest prevalence of Type 2 diabetes is years more males overall than females. 4 National Diabetes Audit 5 Child measurement Programme for Wales Report 2013/2014 Public Health Wales NHS Trust Published Welsh Health Survey 2014, Welsh Government Statistics released June Scarborough P, Bhatnagar P, Wickramasinghe K, Smolina K, Mitchell C, Rayner M (2010). Coronary heart disease statistics 2010 edition. British Heart Foundation: London Page 10 of 29

11 The incidence of diabetes is increasing as the prevalence of obesity is rising; diabetes among adults in Wales is predicted to rise to 10.3% in 2020 and 11.5% by Hywel Dda UHB Primary Care Audit Figure 1. Treatment target achievement for people with Type 1 diabetes in Hywel Dda UHB Figure 2. Treatment target achievement for people with Type 2 or other diabetes in Hywel Dda UHB 8 APHO Diabetes Prevalence Model - these figures include estimates for undiagnosed prevalence. Page 11 of 29

12 Figure 3. Percentage of newly diagnosed people with Type 1 diabetes recorded as being 'offered' or 'offered or attended' a structured education program" Figure 4. Percentage of newly diagnosed people with Type 2 or other diabetes recorded as being 'offered' or 'offered or attended' a structured education program Page 12 of 29

13 National Diabetes Foot care Audit 2014/15 ( Figures 5&6. Ulcer Severity Figures 7&8. Time to Assessment 14/15 data Page 13 of 29

14 Figures 9& week Outcomes 14/15 data Vascular services were centralised in AMBU for Hywel Dda resulting in all minor and major amputations and all surgical debridements for diabetes people and high risk vascular foot are referred to Morriston Hospital, and are therefore not treated on any of the hospital sites in Hywel Dda. This causes delays in treatment and bed blocking across sites as patients have to wait for transfer and surgery. There is no agreed pathway to ensure wait times are kept to a minimum, and continuity of care between sites and services e.g. podiatry 5.ORGANISATIONAL PROFILE Primary Care There are 54 GP practices across Hywel Dda Health Board but no primary care diabetes lead. Organisational Overview Hywel Dda University Health Board has the following within the Diabetes teams across the three counties: Secondary Care An increase from 3.2 FTE to 5.5 FTE Consultant Diabetologists Carmarthenshire 3.4 FTE community clinic in Amman Valley Ceredigion 1.0 FTE community clinic in Cardigan Pembrokeshire 1.1 FTE Diabetes Dietitians Ceredigion 0.8 FTE ADULTS providing clinical leadership across the three counties Carmarthenshire Page 14 of 29

15 0.9 FTE Pembrokeshire 0.48 FTE plus additional 0.2 funded to end of August Podiatrists in Diabetes Carmarthenshire 1.7 FTE in specialist care (About 25% of all treatments in the community are on diabetes patients) Ceredigion 1.2 FTE in specialist care (About 25% of all treatments in the community are on diabetes patients) Pembrokeshire 1.6 FTE in specialist care (About 25% of all treatments in the community are on diabetes patients) Diabetes Specialist Nurses Adults Ceredigion 3.2 FTE of whom 1.6 FTE are secondary care based and 1.6 FTE is community based. Currently no Paediatric DSN Carmarthenshire 10.4 FTE of whom 5.4 FTE are secondary care based and 3.0 FTE are community based. Pembrokeshire 2.0 FTE of whom 1.2 FTE are secondary care based; no community based. Paediatric Diabetes workforce Paediatric Consultants 2.25 sessions /week Carmarthenshire 0.75 sessions /week Ceredigion sessions /week Pembrokeshire Paediatric DSN S Carmarthenshire 1.0 FTE Paediatric DSN s Ceredigion 0.6 FTE Paediatric DSN s Pembrokeshire 1.0 FTE Psychology 0.2 FTE across the Health Board Total DSN workforce for the HB is 16.4 FTE of which 8.2 FTE is hospital based; 4.6 FTE is community based; and 2.6 FTE is Paediatric There has been an increase in DSN FTE from 2013/ FTE to 2015/ FTE Page 15 of 29

16 6.Overview of Local Health Need and Challenges for Diabetes Services The identification of a third site for DRSSW remains a challenge and the Health Board and Head of Programme are working together to resolve this issue The reduction in newly diagnosed people with diabetes to retinopathy screening is concerning Links with vascular services that are not provided within Hywel Dda need to firmly establish and agreed pathway needs to be in place to support the reduction in amputees. Providing cost effective education for people with both Type 1 and Type 2 Diabetes education remains a challenge. There is a paucity of diabetes dietetics, which is a concern as diet and lifestyle is the cornerstone of diabetes management and people living with diabetes, rarely have the opportunity for individualised assessment and support ( as recommended by NICE). Only the most complex cases are prioritised, even then access is untimely with people regularly waiting over 14 weeks for an outpatient dietetic appointment. There is no primary care diabetes lead for the Health Board. 7.Development of Hywel Dda University Health Board s local delivery plan for diabetes In response to the Together for Health A Diabetes Delivery Plan (2013), health boards are required, together with their partners, to produce and publish a detailed local service delivery plan to identify, monitor and evaluate action needed within timescales. The health board executive leads for diabetes will need to report progress formally to their Boards against milestones in these delivery plans and publish these reports on their websites at least annually. Following the assessment of the Health Boards progress against our local priorities we have reviewed how service provision may need to change or adapt. We have drawn up actions following review of our plans and what we have achieved during 2014/15 and identified what particular actions and outcomes we want to see happen this year. In addition to this the lead clinicians have been tasked with assessing what we are currently doing, to look at what we can do differently or collectively to set priorities for within this plan. 8. Priorities for the coming year The Together for Health Diabetes Delivery Plan sets out action to improve national outcomes in key areas between now and For the following national priorities have been agreed: Page 16 of 29

17 Eye Care; Health boards to ensure 100% referral rates to DRSSW Measure times from referral by DRSSW to review by an ophthalmologist Ensure suitable local infrastructure to support new DRSSW clinic model. Insulin Pumps; Health boards to provide NICE compliant insulin pump therapy service by improving expertise and annual training updates, meeting safety standards, providing patients with a choice of devices. Health Care Professional Education; Health boards to ensure all inpatient staff and staff caring for people living with diabetes have adequate knowledge and training to safely manage diabetes Pregnancy; A preconception awareness campaign to be developed and implemented across Wales, supported by a preconception film (various languages) and health care professional on line education module In addition to these national priorities Hywel Dda University health board highlights the following priorities for which reflect the needs of the local population. We will continue to progress work that has been undertaken over the past two years to further develop this work and continue to make improvements. Children and Young People The priorities for are: Continue to participate in peer review and, implementing response to peer review within the appropriate timescales. Continue to develop transition services. Preventing Diabetes The priorities for are: Increase the number of people completing a Foodwise for life programme Work with the 3 rd sector to support information events across the Health Board area Continue to work with our Nutrition and Dietetic service, NERS, local Public Health Team and partners to deliver on the All Wales Obesity Pathway. Detecting Diabetes Quickly The priorities for are: Page 17 of 29

18 Continue to improve access to training and education of all professionals involved in diabetes care Monitor numbers of attendance at training and once e-learning implemented monitor numbers completing online modules Delivering Fast, Effective Care The priorities for are: Improve the patient pathway to vascular services Continue to deliver ThinkGlucose Programme across the health board Implement recommendations of Foot Care Audit Supporting Living with Diabetes The priorities for are: Continue to increase the number of people completing diabetes education to support their self management Continue to develop combined antenatal and diabetes care clinics Continue to develop Insulin Pump clinics Improve the number of annual reviews under taken in the community for those who are house bound. Reduce the number of amputations for people with Diabetes in Hywel Dda UHB. Improve access for people living with diabetes to diatetic services. Improving Research The priorities for are: Learn from the evaluation of the e-digital films work and plan next steps Learn from the outcomes of feasibility study for DSMP and implement recommendations Improving information The priorities for are: Work with communications team and Patient support team to review current information and plan for the future including the use of facebook, twitter, telehealth and telemedicine 9.PERFORMANCE MEASURES/MANAGEMENT The Welsh Government s Together for Health a Diabetes Delivery Plan (2013) contained an outline description of the national metrics that health boards and other organisations will publish: Page 18 of 29

19 Outcome indicators which will demonstrate success in delivering positive changes in outcome for the population of Wales. NHS assurance measures which will quantify an organisation s progress with implementing key areas of the delivery plan. Progress with these outcome indicators will form the basis of the Health Board s annual report on diabetes. The next one will be published towards the end of Hywel Dda UHB also reports progress against the local delivery plan milestones to the Board annually and via our website. Page 19 of 29

20 10.ACTION PLAN Children and Young People Priority Actions required Lead Due Date Progress Continue to participate in peer Dr Fountain-Polley/ Yvonne Davies review Implement recommendations from fist peer review Plan next per review Health Board wide no administrative support of any of the three teams Regular monthly minuted MDT meetings started 02. FTE psychology input identified No increase in dietetic input, business case given to County Director Pembrokeshire but no progress to date No 24hour out-of-hours advice service (work ongoing on an All, Wales basis) Carmarthenshire advert out for consultant no applications Continue to develop transition services with adult services Continue to implement agreed work plan Dr Forest Ongoing Ceredigion - Appointed 0.6 PDSN started April 2016 Pembrokeshire- Increase in PDSN to 1 FTE (currently supporting Ceredigion and Pembrokeshire) Paeds Workplan2016.doc Page 20 of 29

21 Preventing Diabetes Priority Actions required Lead Due Date Progress Work with primary Dr Mark Ongoing care to support the Barnard/.Zoe Paul number of people with pre diabetes completing the Food wise programme Gough/ Davies Caroline Work with third sector and other relevant organisations to support information events across the Health Board area Continue to work with the Local Public Health Team to impellent the obesity plan, Increase the number of tutors trained and assessed to deliver Food wise Work with North Ceredigion and Aman Tawe Practice to identify those people who would benefit from attending Food wise Continue to work with Diabetes Cymru Ensure smoking cessation training, alcohol awareness and healthy weight Jason Harding/Dai Williams Beth Cossins/ Zoe Paul Gough Ongoing North Ceredigion Cluster Project Repo Discussions taken place and 2 living with Diabetes days planned for 16/17 March 2016 Childhood Obesity focus on first 1000 days 74 Midwives trained in brief interventions and Eating for 1:Healthy for 2 accredited training Page 21 of 29

22 smoking cessation, alcohol awareness training is part of diabetes education and training package. Insight work being undertaken into professionals views/perceptions of overweight and obesity to inform future planning and delivery. Report due May NERS in pregnancy service established and will be operational mid April Intended to support pregnant women with BMI 30+ to maintain a healthy weight in pregnancy. Materials developed to communicate healthy eating in pregnancy messages to women and families with low levels of literacy. Detecting Diabetes Quickly Priority Actions required Lead Due Date Progress Continue to Monitor Chris Cottrell Ongoing improve access to training and numbers attending training education for all Monitor what professionals involved in diabetes training and education is Ceredigion Think Glucose training to da Page 22 of 29

23 care across primary, community and secondary care Continue to work across primary, secondary and community care to ensure timely access to diabetes support delivered Support the MSc in Diabetes Dr Akhila Mallipedhi Dr Mark Barnard/ Dr Sam Rice Guidelines for Home Blood Glucose Monitor Delivering fast, effective treatment and care Priority Actions required Lead Due Date Progress Health Board to continue to support LES for Diabetes in primary care Elaine Lorton/ Karen Hackett Continue to deliver the ThinkGlucose programme across the Health Board Identify what support primary care would like to continue to deliver the LES and provide care closer to home for people with diabetes Chris Cottrell Review and performance information due July 2016 THINKGLUCOSE REPORT April 2016.do Page 23 of 29

24 Implement recommendations from the foot care audit Work with primary care to ensure 100% referral to DRSSW Continue to work with DRSSW to ensure local infrastructure supports clinic model Implement a new vascular/ diabetic foot pathway from primary care to secondary care, increasing presence on wards for vascular podiatrist and Meet with primary care locality managers initially to understand the support required for primary care to ensure there is an increase in referrals Jo Morris Claire Hurlin/ Andrew Crowder Ongoing Ongoing Andrew Crowder Ongoing Joe Teape/ Jo Morris Ongoing Copy of nati-diab-foot-care-au Pack on foot care developed for primary care and to be sent out to all practices by the end of June 2016 South Carmarthenshire Ana SBAR completed for additional staffing for podiatry. Talk s underway linking Vascular team based in ABMU and Hywel Dda Podiatry Page 24 of 29

25 starting a programme of management of the peripheral arterial disease in primary care linking with GP S and nurses. Supporting living with diabetes Priority Actions required Lead Due Date Progress Continue to work with Brecon Group to implement structured education for CYP Continue to increase the number of people (adults)completing diabetes education to support self management Implement structured education and evaluate as needed Bi monthly updates to all relent health and social care staff Annual planning of relevant courses across all 3 Counties Complete an annual report on evaluation responses and look at any changes needed Continue to Claire Hurlin/ Caroline Davies/Zoe Paul Gough Ongoing Commenced structured education for newly diagnosed diabetics at Key Stage 3 (11-18 year olds) but no increased resource to deliver Ongoing PPH completed 4 Dafydd course, four, 3 hour carbohydrate courses, a one day insulin pump update in 15/16 and more are planned for 16/17 Educational Course Totals Year April 2014 Page 25 of 29

26 Continue to develop combined antenatal and diabetes care clinics Continue to develop Insulin Pump Clinics and provide a NICE compliant service Improve the number of annual reviews undertaken in the community for those house bound Reduce the number of amputations for people living with diabetes in Hywel Dda area encourage relevant people to become tutors Support tutor training Support required updates of tutors Dr Lisa Forest/Akhila Mallipedhi Dr Akhila Mallipedhi/ Debra Tipping/ Glenys Jones New joint antenatal clinic commenced in PPH Ensure all people have DAFNE training to support use of insulin pump therapy Community DSN s In the Llanelli area of Carmarthenshire the community DSN is introducing clinics in care homes due to the numbers needed support and annual reviews. Initially this will take place in 2 care homes and consideration will be given to rolling this out after evaluation Dr Khan/Stuart Bancroft/Jo Morris Ongoing Diabetic Foot Brief 21st April 2016.pdf Page 26 of 29

27 Identify psychological difficulties associated with diabetes management Improve access to evidence based psychological support and treatment Incorporate psychological screening standardised assessment with Develop stepped psychological approach within diabetes Provide training to diabetes workforce in low intensity psychological work with mild psychological difficulties Development of specialist psychological service for diabetes within long term conditions health psychology service Dr Bethan Lloyd Ongoing Dr Bethan Lloyd Ongoing Long term conditions health psychology service has capacity to develop stepped care psychological approach in Ceredigion and 2T s cluster Page 27 of 29

28 Improving information Priority Actions required Lead Due Date Progress Work with communications team and patient support team to review current available information and plan future including the use of technology e.g. face book ThinkGlucose communications Chris Cottrell Sarah Hicks Continue work through ThinkGlucose programme to ensure all inpatient staff and staff caring for people living with diabetes have adequate knowledge and training Pocket Medic licence bought by several GP Clusters across the Health Board. Provide training support to those GP practices that request it. Chris Cottrell Ongoing Implement e-learning models in diabetes care and monitor those who complete modules Page 28 of 29

29 Improving research Priority Actions required Lead Due Date Progress Learn from the evaluation of the Dr Sam Rice/Sarah Hicks diabetes e-digital films and plan next steps Learn from the outcomes of the feasibility study for DSMP and implement recommendations Evaluation complete Use of films in patient pathway in progress supported by Sarah Hicks Dr Sam Rice Presented outcomes at WEDS 5 th May 2016 Page 29 of 29