Diabetes Annual Report. Betsi Cadwaladr University Health Board. January 2015

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1 BCUHB Diabetes Delivery Action Plan Executive Summary Diabetes Annual Report Betsi Cadwaladr University Health Board January 2015 Prepared January 2015 Julie Lewis Diabetes Specialist Nurse Diabetes Specialty Lead BCUHB 1.0 Executive Summary Overview of key achievements and progress over the past 12 months Meeting future challenges BCUHB acknowledges the worrying incidence rates for diabetes and welcomes Together for Health: Diabetes Delivery Plan as an opportunity to focus planning for a more sustainable diabetes service for the future. Tackling diabetes from early detection to identify and reduce risks, through to important interventions to equip individuals who are diagnosed with diabetes to self manage their condition effectively requires significant attention in the planning & distribution of our services. Collaboration within Health and its allied partners will be decisive upon the future impact of incidence rates and also crucially in the work that is undertaken to reduce the risk of debilitating complications associated with a diagnosis of diabetes. Our diabetes action plan will sit within the framework for our Organisations 3 year plan. The vision to deliver this plan in BCUHB is based upon fairness and equity, collaborating with all allied agencies to maximise opportunities to improve health and increasing the potential to realise this vision through clear leadership to influence and support the direction for change. Exec Summary March 2015 (4).doc. J. Lewis Page 1

2 In addition, services planning for current capacity and investment to reduce unscheduled care and length of stay for people with diabetes admitted to hospital have been carefully evaluated. The detail in our priority documents for diabetes aim to promote fully integrated diabetes multi-disciplinary models of care. This follows the Deloitte deep dive into diabetes that was completed at the end of The model design places a particular emphasis upon engaging specialist diabetes services in the Locality settings before problems arise, whilst also recognising the value that prompt specialist diabetes care in the inpatient setting adds to the quality of the patient experience. This report will build upon the initial diabetes action plan from early 2014 with an update of the progress that has been made to date. There is particular emphasis upon the 4 main priority areas identified for us by the All Wales Diabetes Implementation Group (AWDIG). Additionally we have included progress with two local priorities in this submission: Nationally agreed priorities: 1 Children & young people 2 Fast & Effective Care Diabetes Foot 3 Supporting Living with diabetes Delivering Structured Diabetes Education for adults with diabetes 4 Prevention of diabetes. Local Diabetes Priorities: 5 Inpatient Insulin Safety 6 Locality based diabetes service model. Additionally the early 2014 plan identified 4 Local tasks to be addressed. These remain within the commitment of our DPDG and are updated within the Action Plan priorities. Delivery of Structured Diabetes Education for Adults with diabetes (links to Priority 3) Development of a North Wales Diabetes pathway (links to Priority 2) Co-operational working with Medicines Management in order to promote quality and efficiency in prescribing within diabetes (links to Priority 6) Health Professional Education (Supporting Primary & Community Care) (Links to priority 6 in particular). Exec Summary March 2015 (4).doc. J. Lewis Page 2

3 Progress so far: The BCUHB Diabetes Delivery plan was launched in February The principle objective has been to ensure that the systems and processes to monitor our diabetes services are in place. The Diabetes Planning & Delivery Group (DPDG) has been reconfigured into a strategic steering & monitoring group; in particular there has been a shift in focus to link key audit outcomes to shape the response to local needs and to drive service development. Additionally efforts have been employed to ensure that a Local Diabetes Delivery Group sits in each of the three divisional areas of our Health Board to maintain local engagement for key stakeholders linking into and out of the DPDG. Within the Paediatric diabetes services across Wales we will see the impact of the Peer Review process. BCUHB Paediatric diabetes teams welcome this process as progression to establish a benchmark for quality & to support future service development in order to meet the actions required within the Diabetes Delivery Plan. Type Diagnosis: Innovation within the dietetic services for BCUHB has seen the pan North Wales roll out of a structured dietetic session for people who are newly diagnosed with Type 2 diabetes. This programme serves as a pre cursor to and a promoter for future participation in accredited Structured Diabetes Education programmes. X-PERT & Structured Diabetes Education (SDE) for Type 2 Diabetes: In alliance with the Self Care office for BCUHB, dietetics and diabetes nursing, it has been possible to secure a commitment to recommence delivery of the X-PERT programme. Delivery will begin following planned educator training in January This revised approach will provide equality of access to SDE for Type 2 diabetes across the Health Board. To supplement provision, the Self Care office will also offer a lay led diabetes self management programme. The Health Board has also been successful with a bid to secure funding from the Primary Care Support Fund. This will be used to support a new initiative using interactive diabetes education for Health Professionals and people who have diabetes The Balancing Blood Glucose (BBG) Road Show will be launched and delivered across BCUHB in the 1 st Quarter of Insulin Safety: In light of emerging National safety concerns for safe insulin management in particular within the inpatient environment, BCUHB nursing leads from medicines management and diabetes have collaborated to implement a series of key medicines safety standards. This is also supported by competency based training delivered by the diabetes specialist nurses. Launched in the spring of 2014, success so far includes reducing insulin omission and delays and achieving high uptake for training and introduction of standard hypoglycaemia treatment guidelines. Locality Diabetes: A service plan has been completed to introduce a multi-disciplinary diabetes service model in the Anglesey Locality. This service model to integrate specialist diabetes services in the primary and community care setting will address key aims to enable more people with diabetes requiring specialist diabetes advice to be seen within the practice setting; moreover the service will deliver SDE for people living with Type 1 Diabetes (DAFNE programme) Additionally this service will proactively support individuals who have a recent history of frequent hospital admissions with a diabetes related Exec Summary March 2015 (4).doc. J. Lewis Page 3

4 condition to mitigate risk of readmission. As of the 27 th November, this service model has been approved for implementation. Its success will be a determinant for wider roll-out of Locality based diabetes specialist services for N Wales in BCUHB s intermediate term planning. Challenges: Type 2 Diabetes: Data from DRSSW has provided the Health Boards in Wales with a robust account of the number of current and new registrants to their service. In terms of planning for SDE for example, it will be necessary to explore more options to facilitate effective self care. X-PERT delivery for 2015 is planned and will need to be strengthened beyond the current capacity planning that is in place. Medical Staffing: The West division of BCUHB has faced significant challenges to successfully recruit to consultant level in diabetes & endocrinology. The corollary of this impacts diabetes activity in the other two divisions as contingencies are planned into services to support the shortfall in the West. The solutions to this challenge are multi factorial; principally there will be a review of all workforce options to plan for a more sustainable diabetes specialist service in this area. National Diabetes Audit (NDA) participation: There is significant concern regarding the poor participation in the NDA by Primary Care in North Wales. Last year we are informed that only 29% of practices participated in what is seen as a huge opportunity to discern how our population with diabetes are managed and cared for in our Health Board. The DPDG are currently investigating ways to improve participation and how to make best use of this data to inform future service delivery. Thankfully we are now assured by the Wales Diabetes Lead that there is nearly 100% practice agreement for future and ongoing NDA data extraction This is a positive step to inform diabetes service needs for the future and is welcomed by our Health Board. At Risk of Diabetes The increasing prevalence of people at risk of and living with diabetes in North Wales raises a complex challenge for our Health Board and its allied partners. It will be necessary to build upon the Public Health Work that is being undertaken to tackle obesity and smoking not just for diabetes but for the wider benefit to reduce the known risks. Additionally there is a wider consensus that more needs to be done with people who are identified at risk for developing diabetes, clearer detection guidance and signposting to interventions and support that will reduce the risk for developing Type 2 diabetes. This work will be undertaken as part of the wider diabetes pathways development for Type 1 and Type 2 diabetes. Fast Effective Care The Diabetes Action Plan will establish a benchmark for good practice in areas such as foot care to ensure that our services across North Wales strive to achieve the same quality. There is some discrepancy in the National Diabetes Audit (NDA) scorecard data for amputations and more recent data from NWIS. This needs a more thorough evaluation to ensure that our Health Board has a credible understanding of this activity & to begin to address areas for service improvement. Locality Working Exec Summary March 2015 (4).doc. J. Lewis Page 4

5 Innovative approaches will need to be explored, in particular working collaboratively to drive efficiencies into alternative quality models of care that are based within Locality settings. The outcome measures from the Locality service model for Ynys Mon will be a significant determinant of the way in which the specialty of diabetes will be offered in the future. Inpatient Diabetes Care More work is needed to improve the diabetes inpatient journey. We are making good progress with the Insulin safety standards, but will proactively pursue more robust models in this key area of care to create safe, high quality diabetes inpatient services. This will be completed as part of the Diabetes Pathways work and BCUHB welcomes the support for Think Glucose Campaign training which is being facilitated by the Wales Clinical Lead for Diabetes. Signed by Chief Executive.. Conclusion and focus for the next 12 months and beyond The principle aim during 2014 for the BCUHB Diabetes Planning and Delivery group has been to set the structures and processes in place for more effective diabetes service planning linked into our population needs and relevant (representative) audit outcome data. In alliance with key partners this annual report with associated priority action planning sets a direction to address the requirements of the Diabetes Delivery Plan in BCUHB. Establishing more organised connections to support risk reduction for people who have a high probability of developing diabetes in the future needs a more organised approach to: -Identify people at risk of diabetes -Signpost to risk reduction strategies Progress has been made to establish a framework for the Type 2 diabetes newly diagnosed population in BCUHB with the extensive roll out of the group dietary education. Delivery of Structured Diabetes Education, the X-PERT programme will recommence early in 2015, but it will be necessary to examine capacity and demand, and alternative approaches to support diabetes self care. More work is needed to formalise the delivery of DAFNE for adults with Type 1 diabetes uniformly across N. Wales, but there is progress to deliver this in the West division as part of the recently approved Locality Diabetes service (see Priority plan 6). In the East, DAFNE will be undertaken by existing specialist resource currently utilised to deliver their locally adapted type 1 diabetes self management course. This will ensure that BCUHB is fully compliant with the recommended Type 1 programme. Finding a sustainable solution to the West division diabetes medical staffing shortage is an ongoing priority. This is in spite of genuine recruitment efforts. Service development and workforce re-design to Exec Summary March 2015 (4).doc. J. Lewis Page 5

6 help strengthen a multi-disciplinary model will take time to develop fully. Interim contingencies will adversely impact capacity of Central and East divisions diabetes service delivery. Elements of development with inpatient insulin safety and the Anglesey Locality Diabetes service model are steps in the right direction to improve access to specialist diabetes care closer to home and safety for insulin management. There will be further attention paid to strengthen these local priorities during 2015 Priority 1 for Children & young people with diabetes will see further needs analysis and business planning within their detailed action plan as a direct result of the recommendations from the Peer Review process In summary, during the first 12 months of implementation there have been some significant and positive changes in service delivery to support the development and improvement of diabetes services in line with the Diabetes Delivery Plan and BCUHB s Operational plan. Julie Lewis RGN. Cert.Ed. PGDip. MRes. Diabetes Specialist Nurse Diabetes Specialty Lead BCUHB Exec Summary March 2015 (4).doc. J. Lewis Page 6

7 Exec Summary March 2015 (4).doc. J. Lewis Page 7

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