NHS HOUNSLOW CCG GOVERNING BODY Cover Sheet. Date: 23 July 2013

Transcription

1 NHS HOUNSLOW CCG GOVERNING BODY Cover Sheet Report title Author Clinical Lead Manager Lead Audit Trail: Date: 23 July 213 The project profile for Hounslow s Diabetes Strategy Documentation: The Project Profile Implementing the Diabetes Strategy Dr Maha Saeed Public Health Intelligence, on behalf of the Diabetes Clinical Network Dr Raquel Delgado, GP, Chair of Diabetes Clinical Network Ian Carter, AD for Strategy, Intelligence and Engagement, LBH Sue Jeffers, Managing Director, HCCG Presented by Dr Maha Saeed Dr Raquel Delgado Organisation LBH HCCG Page 2 of 4

2 Executive Summary and Purpose of report The Diabetes Strategy for Hounslow outlines the Diabetes Clinical Network plan to improve diabetes care in Hounslow. It is Hounslow s first comprehensive diabetes strategy, and provides a roadmap to address the growing challenge of diabetes in Hounslow through partnership working, focusing on prevention and with patient care at its core. The broad aim of the Diabetes Strategy is to improve diabetes care across Hounslow, in line with the National Service Framework Standards for Diabetes and Diabetes UK s 15 Healthcare Essentials. The Project Profile is an execution plan of the strategy. It displays a list of projects and sub projects which are together are designed to meet the objectives from the strategy. The projects are listed under the following headings: 1. Prevention and early identification of diabetes 2. Improve glycaemic management of patients with diabetes 3. Reduce numbers of emergency admissions 4. Improve management of diabetes on children and young adults 5. Improve management and prevention of complications 6. Improve the medicine management for people with diabetes 7. Increase and improve the knowledge and awareness of patients of the diabetes and improve patient experience 8. Improve health professionals knowledge and skills in management of diabetes Recommended Actions / Next steps The Governing Body is asked to: Links to CCG strategy and objectives Key Issues and Risks CCG Board to receive, review, approve and agree the Diabetes Strategy 213/16 Project Profile 1. Approve the Project Profile of the Diabetes Strategy. 2. Ensure that all aspects of diabetes care are explicitly addressed in future commissioning intentions. CCG commissioning intentions for 213/14: Improve clinical outcomes to patient with diabetes. None. Indicate implications for: Page 3 of 4

3 Patient and public engagement Financial Quality and Performance Information Governance Management Technology (IGMT) Equality impact analysis Legal Issues Patients have been involved in the development of this strategy. Hounslow Diabetes Clinical Network and its subgroups are made up of health professionals from across the diabetes care pathway, Public Health, commissioners, Medicines Management, and patient representatives. No anticipated financial and resource implications. Hounslow Diabetes Clinical Network expects that the redesign/transformation of some of the local diabetes services will be cost neutral. Improved quality of patient care and improved service performance is expected. None expected. EIA Screening conducted? n/a EIA Full Assessment required? No however, the CCG will need to take into consideration its statutory duty to complete an equality impact assessment if and when new services are approved. No implications expected. Page 4 of 4

4 A Diabetes Strategy for Hounslow

5 Foreword from Diabetes mellitus is consistently identified as one of the most important issues of concern for The Hounslow Clinical Commissioning Group (HCCG). The CCG recognise the challenge posed by the disease, and understand the need to ensure that local health services spanning the range of diabetes care needs provide timely and universal access throughout the borough. As of April 212, approximately 6.4% of Hounslow s population aged 17 years and over were registered in primary care as having diabetes, or 12,736 individuals. However, modelling indicates that the prevalence of diabetes in the adult population is approximately 8.4%. Most newly diagnosed patients with diabetes in Hounslow (73.6%) are aged over 45 years. The National Diabetes Audit 21/11 showed Hounslow CCG to be within the bottom 2% nationally for patients receiving all nine diabetes care processes. Only 31% of patients with diabetes in Hounslow received all nine care processes, with large variation of care across GP practices in Hounslow. Furthermore, the number and rate of admissions of children with diabetes have increased year-on-year in Hounslow, with high admission rates due to diabetic ketoacidosis. There is also evidence for lack of effective local transition processes from paediatric to adult diabetes services. The has been working since October 212 to understand many of the challenges and opportunities facing the CCG with regard to the care of our patients with diabetes. We have considered recommendations of stakeholders and reviewed evidence of best practice and research findings. We have engaged in many discussions via the Network s subgroups, and have surveyed local patients living with diabetes to help ensure that we understand the needs around diabetes care in Hounslow. This strategy is in line with the National Service Framework Standards for Diabetes and Diabetes UK s 15 Healthcare Essentials. In publishing our Strategy, the would like to take the opportunity to work collaboratively with the NWL Collaboration of CCGs Transformation Programmes to improve standards of diabetes care locally, and with Hounslow CCG to implement changes which will secure better outcomes for our patients and practices. On behalf of the, we are proud to present the Diabetes Strategy for Hounslow Hounslow s first comprehensive diabetes strategy provides a clear, strategic, and deliberate roadmap to address the growing challenge of diabetes in Hounslow through partnership working, focussing on prevention and with patient care at its core. Dr Raquel Delgado Dr Maha Saeed Diabetes Strategy 213/16 1 V13_11/6/213

6 GP Lead, Diabetes Public Health Lead Diabetes Strategy 213/16 2 V13_11/6/213

7 Table of Contents Table of Contents Background... 7 National Context... 7 The NHS and Social Care Long Term Conditions Model... 7 National Service Framework Standards for Diabetes... 8 Diabetes UK 15 Healthcare Essentials... 8 Context... 9 Background to Hounslow s population Hounslow Intermediate Care Service... 9 Hounslow CCG Commissioning Intentions... 1 Aim and Objectives of the Strategy... 1 Stakeholder Roles and Responsibilities... 1 Prevalence Deprivation comorbidities amongst diabetes patients in Hounslow Mortality Prevention and Early Identification of Diabetes Context Where are we now? Where do we want to be? How do we achieve this? How to monitor progress? Glycaemic Management Context Where are we now? Where do we want to be?... 2 How do we achieve this?... 2 How to monitor progress?... 2 Hospital Admissions and Inpatient Care Context Where are we now? Diabetes Strategy 213/16 3 V13_11/6/213

8 Where do we want to be? How do we achieve this? How to monitor progress? Children and Young People Context Where are we now? Where do we want to be? How do we achieve this? How to monitor progress? Screening & Management of Complications Cardiovascular Disease Context Where are we now? Where do we want to be? How do we achieve this? How to monitor progress? Retinopathy Screening... 3 Context... 3 Where are we now?... 3 Where do we want to be?... 3 How will we achieve this?... 3 How to monitor progress? Renal Screening and Management Context Where are we now? Where do we want to be? How do we achieve this? How to monitor progress? Lower limb complications Context Where are we now? Where do we want to be? How do we achieve this? How to monitor progress? Medicines Management Diabetes Strategy 213/16 4 V13_11/6/213

9 Context Where are we now? Where do we want to be? How do we achieve this? How to monitor progress? Integrated Diabetes Care... 4 Context... 4 Where are we now?... 4 Where do we want to be? How do we achieve this? How to monitor progress? Service User Experience Context Where are we now? Where do we want to be? How do we achieve this? How to monitor progress? Data, IT and Communication Context Where are we now? Where do we want to be? How do we achieve this? How to monitor progress? Priorities for Diabetes Service in Hounslow Annex National Service Framework for Diabetes Annex NICE Pathway: Blood glucose lowering therapy for type 2 diabetes Annex Diabetes UK: Footcare pathway for people with diabetes Annex Foot care survey results... 5 Annex Foot care patient survey Annex Diabetes Strategy 213/16 5 V13_11/6/213

10 Retinopathy screening patient survey Annex Draft Hounslow Annual Diabetes Survey Diabetes Strategy 213/16 6 V13_11/6/213

11 Background National Context 1 There are 2.9 million people in the UK diagnosed with diabetes, expected to rise to 5 million people by 225. In 211, NHS spending on diabetes was almost 1 billion, with around 8% attributable to managing potentially preventable complications. Diabetes is associated with around 24, excess deaths each year. Half of all deaths from diabetes in the UK result from cardiovascular disease. Diabetes is now the biggest single cause of amputation, stroke, blindness, and endstage kidney failure, the rates of which due to diabetes have increased greatly since 26. The NHS and Social Care Long Term Conditions Model At Level 1... Health and social care strategies to support healthy lifestyle choices and reduce the number of people who develop impaired glucose tolerance or diabetes At Level 2... With the right support, information and education, many individuals and their carers can take a more active role in their own care, and in management of their own conditions. 1 Diabetes UK (212) State of the Nation of the Nation 212.pdf; accessed 213 Jan 11. Diabetes Strategy 213/16 7 V13_11/6/213

12 At Level 3... Core diabetes management is ideally placed in primary care, supported by protocols based on current evidence and policy, such as National Service Frameworks, NICE guidelines and current evidence. National Service Framework Standards for Diabetes The Diabetes NSF, released in 21, set out a vision for diabetes services in England to be delivered by 213. Diabetes UK has recognised that despite some improvements to services, this vision is far from being achieved. The twelve standards are attached in Annex 1. Diabetes UK 15 Healthcare Essentials Diabetes UK released its fifteen essential elements of healthcare for patients with diabetes in September 211, based on clinical guidance and best practice. 2 These are: 2 Diabetes UK (212). 15 Healthcare Essentials: checklist. Diabetes Strategy 213/16 8 V13_11/6/213

13 Context Background to Hounslow s population Hounslow has a relatively young population, with a substantially greater than average proportion of the population from Black and Asian minority ethnic groups, and higher than average deprivation (68% of people in Hounslow live in an area more deprived than the national median). (Figure 16) The borough s ethnicity and deprivation profile are risk factors for diabetes, particularly type 2. A considerable proportion of Hounslow s population is aged years. However, Chiswick and Feltham each have populations that are older than the other area committees, which might be expected to indicate a greater number of diabetes patients. (Figure 2) Approximately 46% of people in Hounslow identify as being of Black, Asian and Minority Ethnic (BAME) origin. 3 A greater proportion of people of Black and mixed ethnicity backgrounds live in the most deprived areas in Hounslow, while the opposite is true for people of White ethnicity. This may indicate an inequality in the risk factors for developing type 2 diabetes. (Figure 17) The (HDCN) was established to enhance the quality of patient care and to improve both prevention and diabetes outcomes in the borough. This network of key stakeholders meets quarterly to share best practice, identify areas for improvement and to agree and implement evidence-based changes to improve diabetes care. HDCN is made up of health professionals from across the diabetes care pathway, and commissioners, Public Health, Medicines Management, and patient representatives. Hounslow Intermediate Care Service The Intermediate Care Service (ICS) in Hounslow provides advice and support in a community setting for adults with type 2 diabetes, and some adults with stable type 1 diabetes. The service aims to provide education and clinical support to patients closer to home, in order to reduce the need for hospital attendances. The clinical team at the ICS includes specialist nurses, a GP with special interest in diabetes, dieticians, and a consultant Diabetologist. Clinics are provided in five locations across the borough and at home (for housebound patients). The proportion of adult diabetes patients seen by the community diabetes service in Hounslow declined slightly in the last two years, from 4.6% in 21/11 to 4.4% in 211/12. In comparison, in 211/ % of diabetes patients were seen as inpatients and 16.3% of patients attended an outpatient s appointment. (Table 32) Service specifications of this service are currently under review. 3 Hounslow JSNA 212/13 Diabetes Strategy 213/16 9 V13_11/6/213

14 Hounslow CCG Commissioning Intentions The Hounslow Clinical Commissioning Group has recognised in its commissioning intentions for 213/14 the growing challenge of diabetes in the borough. Not only is the number of people with diabetes in Hounslow forecast to rise by 43% by 215, Hounslow has poorer care and outcomes for diabetes patients than many other areas. The commissioning intentions for 213/14 highlight the following around diabetes care: The rolling out of the integrated care pilot, which is expected to deliver more coordinated and planned care to patients with diabetes; Reduce emergency admissions for diabetes complications through changing the ambulatory emergency care service in Hounslow; and Plans to remodel the care pathway for paediatric diabetes, working with children, young people and their parents/carers to develop this. Aim and Objectives of the Strategy The broad aim of the Diabetes Strategy is to improve diabetes care across Hounslow, in line with national standards. Specifically, our objectives are to: Prevention and early identification of diabetes Improve glycaemic management of patients with diabetes Reduce numbers of emergency admissions Improve management of diabetes on children and young adults Improve management of complications Improve the medicine management for diabetic patients Increase and improve the knowledge and awareness of patients of the diabetes and improve patient experience Improve health professionals knowledge and skills in management of diabetes Provide a strong and reliable network of healthcare professionals who work together at delivering integrated diabetes services in the borough. Network with local, regional and national diabetes and other clinical networks to share best practice Stakeholder Roles and Responsibilities This strategy has been developed in consultation with a multidisciplinary team of healthcare professionals from different clinical backgrounds and settings. The Strategy will be sent out for consultation. The diabetes strategy has identified the following areas of work: Prevention and early identification: Glycaemic management: Admissions and inpatient care: Diabetes Strategy 213/16 1 V13_11/6/213

15 Children and young people: Cardiovascular complications: Retinal screening Renal complications: Lower limb complications: Medicines management: Psychological support: Service user experience: IT Diabetes (data collection, coding diabetes and auditing diabetes care: General Practice and service providers: Multiple stakeholders have been identified who together will deliver the objectives of this Strategy: Paediatric services: Paediatric DSNs and paediatricians with specialist interest in diabetes Intermediate diabetes service: DSNs, GPs with special interest, dieticians, consultant Diabetologist Emergency services : ambulance services, A+E, Urgent Care Centre, 111 service Integrated Care Pilot Hounslow CCG Medicine management team and local pharmacists Patient s representative for children, young adults, Type 1 and Type 2 Psychology support: adult and children psychology services and mental health services Diabetes Strategy 213/16 11 V13_11/6/213

16 Diabetes in Hounslow Prevalence Currently, around 6.4% of Hounslow s population aged 17 years and over is registered in primary care as having diabetes, or 12,736 individuals (as of April 212). However, modelling indicates that the expected prevalence of diabetes in the adult population is approximately 8.4%. (Table 3 and Figure 18) The indirectly standardised rate of diabetes is significantly higher in Hounslow (519.4 per 1, population) than the national rate (412.3 per 1,), and slightly higher than London (497.1 per 1,). (Table 2) There are 5 committee areas in Hounslow, Chiswick, Isleworth and Brentford, Heart of Hounslow, Great West Road, and Feltham. The area committees of Isleworth and Brentford, Feltham, and Great West Road include areas of significant deprivation, with all of Feltham s resident s living in the least deprived 6% of areas nationally. Chiswick is the least deprived area committee in Hounslow. (Figure 3) The prevalence of Type 1 diabetes is highest in Chiswick and Feltham areas (.5% prevalence each), whilst Great West Road and Heart of Hounslow areas have the highest prevalence of Type 2 diabetes (with 7.4% and 7.% of their populations diagnosed, respectively). (Table 3) All committee areas in Hounslow have a lower prevalence of diabetes than we would expect, but the greatest proportional differences are in Chiswick, and Brentford and Isleworth. (Figure 18) Using records from referral to retinopathy screening as a proxy measure of newly diagnosed diabetics, most newly diagnosed patients in Hounslow are over 45 years of age (with 73.6% of all newly diagnosed diabetics in this age group, a proportion which has not changed significantly since 28/9. (Table 4) AGE DISTRIBUTION OF DIABETES PATIENTS There is a greater proportion of males amongst those aged years with diabetes in Hounslow. (Table 41) A relatively small proportion of type 2 diabetics in Hounslow are aged less than 45 years, with 8.3% of female diabetes patients and 11% of male diabetes patients falling into this category. (Figure 2) However, it is essential that these patients are managed well to prevent diabetic complications as they age. The age group with the greatest proportion of females with Type 1 diabetes in Hounslow is years (18.86%), while there are more males with Type 1 diabetes in the age group than any other category (17.61%). 1.8% of all males and 9.53% of all females with Type 1 diabetes in Hounslow are under 18 years of age. (Figure 19) ETHNICITY OF DIABETES PATIENTS Most people with Type 1 diabetes in Hounslow are of mixed ethnicity, with a rate of per 1, females, and per 1, males. The next highest prevalence rates of Type 1 diabetes in Hounslow are amongst Black patients and White patients. (Figure 21) Diabetes Strategy 213/16 12 V13_11/6/213

17 For Type 2 diabetes in Hounslow, the picture is vastly different. The highest Type 2 prevalence rate is amongst patients of Asian ethnicity (with per 1, females, and 9489 per 1, males). People of Black ethnicity in Hounslow have the next highest prevalence rate of Type 2 diabetes, followed by mixed ethnicity patients, and Chinese and other ethnicity patients; with the lowest prevalence amongst White patients. (Figure 22) Deprivation Type 1 diabetes is most prevalent in people who live in the least deprived areas of Hounslow. (Figure 23) The picture is reversed for Type 2 diabetes, with a strong correlation between deprivation and a higher prevalence of Type 2 diabetes. (Figure 24) Comorbidities amongst diabetes patients in Hounslow The prevalence of comorbid conditions amongst patients with diabetes in Hounslow follows a trend of the diabetes diagnosis preceding that of other conditions. For example, 11.3% of type 1 diabetics and 13.4% of type 2 diabetics in Hounslow have chronic renal impairment, with the majority diagnosed with chronic renal impairment after their diabetes diagnosis. This is also the case for the comorbidities of stroke, skin infection, depression, and hypertension. The only morbidity that bucked this trend was hypertension amongst type 2 diabetic patients, which had a greater proportion of patients diagnosed with this condition before their type 2 diabetes diagnosis (34.3%) than afterwards (19.3%). (Table 2) Mortality In the period in Hounslow, diabetes was the primary cause of around 7 deaths per 1, population. The rate of death was slightly higher amongst males than females. Isleworth and Brentford had the highest mortality rate due to diabetes, closely followed by Great West Road and Heart of Hounslow. There were considerably more female than male deaths primarily due to diabetes in the Great West Road and Isleworth and Brentford area committees. (Figure 4) Diabetes was not the direct underlying cause of death in around 51 deaths per 1, population (all-ages) in Hounslow in In all area committees, there were more male deaths than female deaths where diabetes was mentioned as a cause, with the greatest rates in Heart of Hounslow, Great West Road, and Isleworth and Brentford. (Figure 6) Compared to other regions, in 28-1 Hounslow had a significantly higher female mortality rate due to diabetes with 7.6 female deaths per 1, population (versus 4.9 per 1, in both London and in England). PREMATURE MORTALITY In terms of premature mortality (under 75 years) in Hounslow during 28-11, diabetes was the primary cause of around 3 deaths per 1, population. Heart of Hounslow area committee had the highest rate of premature death (significantly higher amongst males), followed by Great West Road. There were more premature Diabetes Strategy 213/16 13 V13_11/6/213

18 female deaths than premature male deaths primarily due to diabetes in the Great West Road area. (Figure 5) Where diabetes was not the main underlying cause of premature death, there were 27 premature deaths per 1, population from in Hounslow. The highest rates were in Great West Road, Heart of Hounslow, and Feltham. Across all area committees, there were more male than female deaths where diabetes was a cause (but not the primary cause). (Figure 7) In 28-1, Hounslow had a lower rate of male deaths under the age of 45 years due to diabetes than both the London and national averages: Hounslow had deaths per 1, population, compared to.5 and.6 per 1, in London and England, respectively. (Table 1) The Heart of Hounslow area committee had by far the greatest number of years of potential life lost due to premature deaths primarily caused by diabetes; almost 3 times the rate for Hounslow as a whole. (Figure 8) Where diabetes had any mention on the death certificate of people under 75 years, the rate of potential years of life lost was significantly higher for men in all areas of Hounslow, but particularly so in Great West Road and Isleworth and Brentford. (Figure 9) PRIMARY CARE VARIATION There is considerable variation in primary care processes across Hounslow, both in type 1 and type 2 diabetes. There is a general trend for better performance in Chiswick and Feltham areas, and worse performance in the Great West Road area, though this is not true across all care processes (see Figures 25 and 26). SPEND AND OUTCOME Hounslow spent less on diabetes in 21/11 than many other CCGs. In many areas of care, including glycaemic control, blood pressure, cholesterol, lower limb amputations, and emergency admissions (see Figures 4-44), this lower spend resulted in poor patient outcomes. Diabetes Strategy 213/16 14 V13_11/6/213

19 Prevention and Early Identification of Diabetes Context Standard 1: The NHS will develop, implement and monitor strategies to reduce the risk of developing Type 2 Diabetes in the population as a whole and to reduce the inequalities in the risk of developing Type 2 Diabetes. Standard 2: The NHS will develop, implement and monitor strategies to identify people who do not know they have diabetes. National Service Framework for Diabetes (21) Dietary, physical activity and weight management interventions are effective in the primary prevention of type 2 diabetes. Interventions targeting people at risk of developing type 2 diabetes using established, well-defined, culturally-targeted behaviour change techniques which promote changes in both diet and physical activity have been shown to result in significant weight loss and improved physical activity, regardless of the setting in which they were delivered 4. Stricter targets in general practice and further measures to motivate patients are needed to achieve the best possible outcomes in ethnically diverse patients with diabetes 5. There is a strong, continuous association between impaired glycaemic control (indicated by HbA 1c ) and subsequent diabetes risk; an HbA 1c value of more than 42 mmol/mol equates to a high risk of developing clinically defined diabetes in the near future (5-year incidence of 25-5%). 6 Where are we now? There are a considerable number of adults without diabetes who are at very high risk for type 2 diabetes (with a fasting sugar of and a BMI of 25-35kg/m 2 ) and 1,437 women and 1,924 men fall into this category (Table 42). This is most prevalent in the areas of Heart of Hounslow, Great West Road, and Chiswick; and particularly amongst males. People of Asian and Chinese and Other ethnicities have the highest prevalence (Figure 55-56). Amongst those without diabetes in Hounslow, the prevalence of being overweight, having high cholesterol, and having high blood pressure is highest in the Heart of Hounslow and Feltham areas, and highest amongst Black females, White males, and Mixed ethnicity females. (Figures 53-54) Greaves CJ et al. (211). Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health 11:119. Bellary S, et al (28). Enhanced diabetes care to patients of South Asian ethnic origin (the United Kingdom Asian Diabetes Study): a cluster randomised controlled trial. Lancet 371: Zhang X et al. (21).A1C Level and Future Risk of Diabetes: A Systematic Review. Diabetes Care; 33: Diabetes Strategy 213/16 15 V13_11/6/213

20 WEIGHT Amongst people without diabetes in Hounslow, the rate of overweight in Hounslow (BMI of over 25kg/m 2 ) is 23,885.7 per 1, women and 25,554 per 1, men, equivalent to 29,51 women and 31,79 men. (Table 42) Being overweight is most prevalent in Feltham, Chiswick, and Heart of Hounslow areas. (Figure 47) Females of Black ethnicity and males of White ethnicity have the highest prevalence of BMI over 25kg/m 2. (Figure 48) CHOLESTEROL Amongst people without diabetes in Hounslow, the rate of high cholesterol levels in Hounslow (greater than or equal to 5mmol/l) is 14,16.8 per 1, women and 11,944.2 per 1, men, equivalent to 17,172 women and 14,131 men. (Table 42) High cholesterol levels (over 5 mmol/l) are more prevalent amongst females in the borough, and highest in Feltham and Isleworth and Brentford areas. (Figure 49) Higher cholesterol levels are more prevalent amongst White and Asian people in Hounslow. (Figure 5) BLOOD PRESSURE Amongst people without diabetes in Hounslow, the rate of high blood pressure in Hounslow (greater than or equal to 14/8) is 16,438 per 1, women and 19,141.7 per 1, men, equivalent to 2,25 women and 23,53 men. (Table 42) High blood pressure (over 14/8) is more prevalent amongst males in Hounslow, and is highest in the areas of Chiswick, Great West Road, and Heart of Hounslow. (Figure 51) People of White ethnicity (particularly males), Black ethnicity, and Mixed ethnicity have the greatest prevalence of high blood pressure in Hounslow. (Figure 52) Where do we want to be? We want our patients at high risk of developing diabetes and those with undiagnosed diabetes to be diagnosed earlier, so that they can improve control over their condition and reduce their risk of developing complications. Specifically we would like to see: Greater prevention of diabetes An increase in the number of practices implementing systematic case finding for diabetes; A reduction in the percentage difference between predicted and actual diagnosed prevalence of diabetes; A reduction in the percentage of patients with diabetes with an HbA 1c reading of greater than or equal to 86mmol/mol at diagnosis; Monitoring of patients with pre-diabetes in primary care Diabetes Strategy 213/16 16 V13_11/6/213

21 How do we achieve this? Adapt The University of Leicester questionnaire to SystmOne to identify patients at high risk of developing diabetes and advertise the template to practices Run data health checks for practices to flag out patients with abnormal glucose test and no diagnoses of diabetes Encourage general practices to keep an up to date register of people with prediabetes and to agree regular monitoring Diabetes Clinical Network to develop strong links with the Diabetes UK and Cardiovascular Alliance Health checks and Diabetes Roadshow to enhance prevention and early detection across the borough. We will work to strengthen health professionals knowledge and skills in diabetes prevention via the intermediate care education program and by encouraging practitioners to refer patients to Holding off Diabetes program. GP practices to be more aware of Diabetes UK s 4 Ts of Type 1 diabetes campaign (Toilet: Going to the toilet a lot, bed wetting by a previously dry child or heavier nappies in babies; Thirsty: Being really thirsty and not being able to quench the thirst; Tired: Feeling more tired than usual; and Thinner: Losing weight or looking thinner than usual) How to monitor progress? Increase in the percentage of persons who are monitored according to recommended guidelines: (percentage with HbA 1c testing, lipid testing, recorded blood pressure) by practice Increase in prevalence to modelled expected prevalence of diabetes. Decrease in late diagnosis i.e. increase in the number of pre-diabetics identified. No formal data collection would allow the measurement of this, but data collected through the pre-diabetics screening template may help. Audit of practice s pre-diabetes registers and frequency of monitoring Diabetes Strategy 213/16 17 V13_11/6/213

22 Glycaemic Management Context Standard 3: All children, young people and adults with diabetes will receive a service which encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle. This will be reflected in an agreed and shared care plan in an appropriate format and language. Where appropriate parents and carers should be fully engaged in this process. Standard 4: All adults with diabetes will receive high-quality care throughout their lifetime, including support to optimize the control of their blood glucose, blood pressure and other risk factors for developing the complications of diabetes. National Service Framework for Diabetes (21) NICE clinical guideline 66 (28) on type 2 diabetes stipulates that patients should be involved in decision-making about their HbA 1c target level (which may be above the general target of 48 mmol/mol (6.5%)), and should be encouraged to maintain their target unless their efforts to achieve their target or side effects impact on their quality of life. NICE clinical guideline 87 (211; a partial update of CG66) and the recent NICE diabetes pathway (June 212) outline the therapies which should be used to help achieve and maintain patients HbA 1c target level (see Annex 1). Achievement of the best possible glycaemic control and blood pressure is a key aspect of diabetes care. Two large trials have shown that, in both type 1 7 and type 2 8 diabetes, there is a correlation between HbA 1c levels above 53 mmol/mol (7.%) and development of complications associated with diabetes. Poor glucose control is associated with increased mortality and an increased risk of microvascular (including diabetic retinopathy, diabetic kidney disease and diabetic neuropathy) and macrovascular (cardiovascular disease and stroke) complications 9,1,11 ; though blood glucose The DCCT/EDIC Study Research Group (25). Intensive Diabetes Treatment and Cardiovascular Disease in Patients with Type 1 Diabetes. NEJM; 353: The DCCT Research Group (1993). The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long Term Complications in Insulin Dependent Diabetes Mellitus. NEJM; 329: Currie CJ, et al (21). Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study. Lancet;375: Stratton IM et al (2). Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ; 321:45. Fowler MJ. (28). Microvascular & Macrovascular Complications of Diabetes. Clin Diabetes; 26(2): Diabetes Strategy 213/16 18 V13_11/6/213

23 control appears to be less effective in preventing cardiovascular disease than controlling either blood pressure or blood lipids 12. Controlling blood glucose is very important, though pursuing intensive control (HbA 1c less than 48mmol/mol (6.5%)), at the expense of other priorities is inappropriate 13 and is not recommended by NICE. Glycaemic management should be undertaken holistically with weight management, smoking cessation interventions, and cardiovascular risk reduction, particularly in older patients with other cardiovascular risk factors 14,15,16. Where are we now? Hounslow s achievement of glycaemic control amongst its diabetes patients is poorer than national and London rates. In 21/11, 53.9% of diabetes patients in Hounslow achieved an HbA 1c of less than 59 mmol/mol (7.5%), while the corresponding rates for London and England were 6.3% and 63%, respectively. Similarly, only 64.3% of diabetes patients in Hounslow had HbA 1c levels under 64 mmol/mol (8.%),well below the national average of 71.9%, and the London average of 69.1%. (Table 19) TYPE 1 Data from April 212 shows: 86.1% of patients had their HbA 1c measured in the preceding months. (Table 4) 23.7% of patient s last HbA 1c value was less than 59 mmol (7.5%) 27.1% of patients had very poorly controlled glycaemic levels with a reading of over 75 mmol (9.%). (Table 5) TYPE 2 Data from April 212 shows: 9.9% of patients had their HbA 1c measured in the preceding months. (Table 4) 51.8% of type 2 diabetes patients in Hounslow had most recent HbA1c values of less than 59 mmol (7.5%) Yudkin JS, et al (21). Intensified glucose lowering in type 2 diabetes: time for a reappraisal. Diabetologia;53:279 8 ACCORD Study Group (28). Effects of intensive glucose lowering in type 2 diabetes. NEJM;358: Montori VM, Fernández Balsells M. (29). Glycaemic control in type 2 diabetes: time for an evidencebased about face? Ann Intern Med;15:83 88 Yudkin JS et al. (211). Intensified glucose control in type 2 diabetes whose agenda? Lancet;377:122 2 Lehman R, Krumholz HM. (29). Tight control of blood glucose in longstanding type 2 diabetes. BMJ; 338:b8 Diabetes Strategy 213/16 19 V13_11/6/213

24 14.4% of patients had a reading of over 75 mmol (9.%), indicating poor control. (Table 5) Where do we want to be? Hounslow should aim to bring the glycaemic control of its diabetes patients in line with national rates. How do we achieve this? Increase referral and attendance rate to existing patient education initiatives (e.g. Expert Patient Programme, X-PERT); Increase the number of patients who have personalised care plans; Ensure that all primary care professionals understand how glycaemic control can be achieve with lifestyle interventions and by optimising medication in line with NICE guidance How to monitor progress? HbA 1c achievement rates: o By practice improvement on Quality Outcomes Framework o % of people in the National Diabetes Audit with Type 1 or 2 diabetes who s most recent HbA 1c measurement was 7.5% (58mmol/mol) or less. Should improve to significantly better than England. Increasing number of patients with care plans Increasing uptake of education programmes. Practices to undertake diabetes medication audits jointly with the medicine management team or the intermediate care team to optimise prescribing SystmOne template: flag up diabetes patients based on their risk factors who have not been invited to education in the last two years, and refer to X-PERT. (Patients who are unable to attend group education (e.g. through language barriers, very elderly) should receive lifestyle management support at diagnosis through referral to Diabetes Specialist Dietician. More complex patients e.g. insulin-requiring Type 2 patients, morbidly obese will also require individualised support from specialist services.) Diabetes Strategy 213/16 2 V13_11/6/213

25 Hospital Admissions and Inpatient Care Context Standard 7: The NHS will develop, implement and monitor agreed protocols for rapid and effective treatment of diabetic emergencies by appropriately trained health care professionals. Protocols will include the management of acute complications and procedures to minimise the risk of recurrence. Standard 8: All children, young people and adults with diabetes admitted to hospital, for whatever reason, will receive effective care of their diabetes. Wherever possible, they will continue to be involved in decisions concerning the management of their diabetes. National Service Framework for Diabetes (21) People with diabetes account for more inpatient activity than patients with any other condition 17. Diabetes patients are more likely to be admitted to hospital overnight than treated as a day case, are more likely to have a longer length of stay, and more likely to experience an emergency readmission, than patients without diabetes 18. Furthermore, the 21 National Diabetes Inpatient Audit found that patients with diabetes experience avoidable complications owing to medication and other errors, a lack of patient involvement in managing their condition and lack of access to specialist inpatient diabetes services 19. Where are we now? ADMISSIONS AND EMERGENCY ADMISSIONS The rate of admission with all types of diabetes (listed in any diagnosis field) has grown year-on-year since 29/1, peaking at 1,562.4 admissions per 1, populations in 211/12. However the proportion of emergency admissions with diabetes (any diagnosis field) has declined from 6.2% of all diabetes admissions in 29/1 to 55.4% in 211/12. (Table 21) VARIATION BY COMMITTEE AREA ALL TYPES OF DIABETES Across the five area committees in Hounslow, Feltham and Isleworth and Brentford had the highest directly standardised rate of admissions for diabetes (as a primary cause), with and admissions per 1, population respectively. (Figure 27) Where diabetes was mentioned as any cause of admission, the rate was considerably higher, with Great West Road area the highest at 3,23.9 admissions per 1,. (Figure 28) NAO (212). The management of adult diabetes services in the NHS. London: The Stationary Office. NHS Diabetes (211). Inpatient Care for People with Diabetes: The Economic Case for Change. NHS Diabetes (211). The National Diabetes Inpatient Audit 21. Diabetes Strategy 213/16 21 V13_11/6/213

26 For both of these measures, Chiswick had the lowest rate of admission due to diabetes. TYPE 1 DIABETES Heart of Hounslow and Feltham area committees had the highest rates of type 1 diabetes-related admissions in Hounslow (primary or secondary cause), with 132 and 12.9 admissions per 1, populations respectively. (Figure 31) The rate of type 1 diabetes-related emergency admission in Hounslow has declined since 29/1, from 82.2 per 1, populations to 7.9 per 1, in 211/12. (Table 27) TYPE 2 DIABETES Rates of admission for type 2 diabetes (primary or secondary cause) are high across all committee areas in Hounslow but highest in Great West Road (642.5 per 1,) and Heart of Hounslow (61.2 per 1,) and lowest in Chiswick (263.5 per 1,). (Figure 34) The rate of emergency admission for type 2 diabetes is on the increase; from admissions per 1, in 29/1 to per 1, in 211/12. (Table 29) COST The cost of admissions for diabetes has increased in Hounslow from 477,8 in 29/1 (accounted for by 24 admissions) to 513,4 in 211/12 (267 admissions). The majority of these costs were attributed to emergency admissions which accounted for 91.2% of admissions for diabetes in 29/1 and declining to 86.9% of admissions in 211/12. (Tables 24 and 25) The cost of all diabetes admissions in Hounslow was 3,424.8 per 1 diabetics in 21/11; less than both London and England. (Table 26) ADMISSIONS WITH COMPLICATIONS Diabetic ketoacidosis The rate of emergency admissions for diabetic ketoacidosis or coma has increased, from 29.6 emergency admissions per 1, in 29/1 to 37.4 per 1, in 211/12. The cost of diabetic ketoacidosis-related emergency admissions in 211/12 was 19,1 (accounted for by 77 admissions). (Table 22) The rate of emergency admission amongst type 1 diabetics due to ketoacidosis has increased, from 24.5 admissions per 1, in 29/1 to 32.8 admissions per 1, in 211/12. (Table 28) Feltham had (by far) the highest rate of admission for type 1 diabetic ketoacidosis, at 7 admissions per 1, population. (Figure 32) Most type 1 patients admitted in an emergency for diabetic ketoacidosis are aged years. (Figure 33) The rate of emergency admission for type 2 diabetes-hyperosmolar coma has slightly increased since 29/1 (4.5 admissions per 1,), to 4.6 admissions per Diabetes Strategy 213/16 22 V13_11/6/213

27 1, in 211/12. The associated costs have increased greatly, from 15,8 to 24,8 in the same period. (Table 3) Isleworth and Brentford and Great West Road areas had the highest rate of admission with diabetic ketoacidosis (any mention), at 9.4 and 5.5 admissions per 1, population, respectively. (Figure 29) These two area committees also had the greatest rates of emergency admission for type 2 diabetes-related hyperosmolar coma with 9.4 and 5.5 admissions per 1,, respectively. (Figure 35) A large proportion of patients admitted in an emergency for type 2-related ketoacidosis is are aged 45-5 years. (Figure 36) LOWER LIMB COMPLICATIONS At 1 st April 212 there were 4 patients with type 1 diabetes (.3%) and 18 patients with type 2 diabetes (.1%) in Hounslow who had a lower limb amputation. (Table 18) The areas of Chiswick and Feltham had the highest rates of admission with diabetes-related lower limb complications, with 11 and 7.7 admissions per 1,, respectively. (Figure 3) The rate of admission for diabetes-related amputation has decreased since 29/1, but the cost of this has increased. In 29/1 there were 17 diabetes-related amputation admissions in Hounslow, costing 118,8, while in 211/12 there were 15 admissions costing 132,4. (Table 23) Where do we want to be? Hounslow should aim to reduce its rate of emergency admissions for diabetes, especially for diabetic ketoacidosis, which are costly and account for a very high proportion of admissions for diabetes in the borough. Develop a care pathway for hypoglycaemia Reduce emergency admissions related to lower limb complications. How do we achieve this? Education program to practices address emergency admissions avoidance for practices that have not signed up to the ICP (Six multi-disciplinary groups) Deliver education regarding admission avoidance via the Integrated Care Pilot (ICP) Identify practices in Hounslow with a high rate of emergency admissions related to diabetes to work closely with these practices to improve clinical outcomes Develop and incorporate a hypoglycaemia care pathway into the London ambulatory care service Work with secondary care to revise care pathways to avoid unnecessary admissions to hospital How to monitor progress? Rate of Emergency admissions due to diabetes (by type). Improvement to lower than the England value. Diabetes Strategy 213/16 23 V13_11/6/213

28 o % of people with previously diagnosed diabetes in the National Diabetes Audit admitted to hospital for diabetic ketoacidosis at least once. o Emergency hospital admissions: diabetic ketoacidosis and coma: indirectly standardised rate, all ages from NHS Information Centre Indicator Portal. Excess length of stay (%) in hospital among people with diabetes when compared with people without diabetes. Currently significantly higher than England should reduce to below England. Activity data for the intermediate care service. Increasing numbers going through structured education. Increasing numbers of patients in primary care offered education. Keep an up to date database of practices that they have undergone foot care education and that they have received refresher courses Work closely with the Local Ambulance Service to ensure care pathways for hypoglycaemia are being followed and to monitor activity. Diabetes Strategy 213/16 24 V13_11/6/213

29 Children and Young People Context Standard 5: All children and young people with diabetes will receive consistently high-quality care and they, with their families and others involved in their day-to-day care, will be supported to optimize the control of their blood glucose and their physical, psychological, intellectual, educational and social development. Standard 6: All young people with diabetes will experience a smooth transition of care from paediatric diabetes services to adult diabetes services, whether hospital or community-based, either directly or via a young people's clinic. The transition will be organised in partnership with each individual and at an age appropriate to and agreed with them. National Service Framework for Diabetes (21) NICE clinical guideline 15 states that children and young people with type 1 diabetes should be offered home-based or inpatient management (by a multi-disciplinary team) according to clinical need, family circumstances and wishes, and residential proximity to inpatient services. Children and their families should receive education about diabetes, to help prevent complications and to help meet their HbA 1c target; and access to psychosocial support should be available to prevent and treat any mental health issues that may impact the management of their condition and general wellbeing. Psychological therapies (including CBT) can significantly improve glycaemic control and significantly reduce psychological distress 2. A 212 report from NHS Diabetes 21 highlighted the lack of effective transition processes in place from paediatric to adult diabetes services. National work is continuing to ensure minimum standards for transitional policies are in place (covering training needs, health plans, and interaction with health professionals) and that local health economies sign up to this. Where are we now? Most children in Hounslow with diabetes are aged years, though the median age of children with diabetes was 12 years. (Figure 45 and Table 36) The highest rates of type 1 diabetes were amongst girls of mixed ethnicity (12.7 diabetics per 1, population), followed by boys of Black ethnicity (1.4 per 1,) and girls of Black ethnicity (67 per 1,). (Figure 46) Children constitute around.1% of all those with type 2 diabetes in Hounslow. (Figure 2) Primary care data from April 212 showed that just under 2% of diabetic children in Hounslow had a record of their blood pressure being measured, 32% of children had 2 21 Winkley K et al (26). Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta analysis of randomised controlled trials. BMJ; 333:65. NHS Diabetes (212). Diabetes transition: Assessment of current best practice and development of a future work programme to improve transition processes for young people with diabetes. Diabetes Strategy 213/16 25 V13_11/6/213

30 a record of their HbA 1c being measured, 1% had a record of their GFR being assessed, and only 29% had been referred to retinopathy screening. The median age at which children had these care processes undertaken was 15 years, except for GFR measurement, which was 17 years. (Table 36) The majority of type 1 diabetic patients in Hounslow are managed in secondary care at WMUH. The number and rate of admissions of children with diabetes have increased yearon-year in Hounslow, from 72 admissions in 29/1 (rate: 4.9 admissions per 1, population) to 117 admissions in 211/12 (68.5 admissions per 1,). The proportion of admissions that were emergency admissions have declined yearon-year, from 79.2% in 29/1 to 44.4% in 211/12. The mean number of attendances per child was 3.4 in 211/12, with a total cost of 264,9 (more than double the cost for 29/1). (Table 37) Children with diabetes who were admitted to hospital between 29/1 and 211/12 had the main primary diagnoses of insulin-dependent diabetes mellitus with ketoacidosis (25.2% of admissions), beta-thalassaemia (16.8% of admissions), and insulin-dependent diabetes mellitus without complications (16.2% of admissions). (Table 39) Where do we want to be? Hounslow should reduce its admissions of children due to diabetic ketoacidosis. Hounslow will ensure a smooth, safe transition of children who are diabetic from paediatric care to adult care. How do we achieve this? Diabetes Network paediatric sub-group to oversee review and audit of transitional policy and practice in Hounslow Review transitional arrangements to adult diabetes care and update our policy Collect data on the age of patients with diabetes who receive education Ensure all children have a care plan in place for their diabetes, developed with parents/carers. Ensure that all 12 year olds with diabetes receive a referral to DRS screening Work collaboratively with WMUH to ensure that all children receive ageappropriate structured education GP practices to be more aware of Diabetes UK s 4 Ts of Type 1 diabetes campaign (Toilet: Going to the toilet a lot, bed wetting by a previously dry child or heavier nappies in babies; Thirsty: Being really thirsty and not being able to quench the thirst; Tired: Feeling more tired than usual; and Thinner: Losing weight or looking thinner than usual) Audit services for children with diabetes to inform service development Review the criteria for the best practice tariff Diabetes Strategy 213/16 26 V13_11/6/213

31 How to monitor progress? % of children aged 15 years in the National Diabetes Audit with Type 1 diabetes whose most recent HbA1c measurement was 1% (86 mmol/mol) or less. Improvement to England or better than England value. % of children aged -15 years with previously diagnosed diabetes in the National Diabetes Audit admitted to hospital for diabetic ketoacidosis five years prior to the end of the audit period. Improvement to significantly lower than England. Prevalence of risk factors for diabetic complications amongst children (e.g. obesity). National Child Measuring Programme data should be monitored and a downward trend in % of Yr 6 children who are obese should be encouraged. Diabetes Strategy 213/16 27 V13_11/6/213

32 Screening & Management of Complications Standard 1: All young people and adults will receive comprehensive annual surveillance for lower limb complications of diabetes to identify and monitor risk status to enable timely access to services and support to reduce or maintain their level of foot risk. Standard 11: Organisations will develop, implement and monitor protocols and systems of care to ensure that all people who develop lower limb complications receive, timely appropriate and effective investigation and treatment to reduce their risk of foot ulceration, lesser or major amputation, disability or premature death. Cardiovascular Disease National Service Framework for Diabetes (21) Context People with diabetes are about twice as likely to develop cardiovascular disease, including heart failure, stroke, and peripheral vascular disease. 22 Cardiovascular disease is a major cause of death and disability in people with diabetes, and is accountable for 44% of deaths in type 1 diabetics and 52% in type 2 diabetics. 23 Cardiovascular disease in diabetes patients is strongly linked to risk factors such as poor diet, poor weight management, physical inactivity, poor glycaemic management, high cholesterol, and high blood pressure. Regaining control of these risk factors has been shown to greatly reduce the chances of developing cardiovascular disease. 23,24,25,26 There is a high burden of cardiovascular disease in patients with diabetes nearly all people with type 2 diabetes are at high risk 27. Coronary artery disease (CAD) is the major cause of mortality in patients with type 2 diabetes; 11% of patients with type 2 diabetes in a large UK study had a myocardial infarction or developed angina over a median 8 years' follow-up 28. Prevention of cardiac events in at-risk patients is a key part of diabetes care; and patients with type 2 diabetes should be supported to Emerging Risk Factors Collaboration (21). Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta analysis of 12 prospective studies. Lancet; 375(9733): Morrish NJ et al (21). Mortality and causes of death in the WHO multinational study of vascular disease in diabetes. Diabetologia; 44(suppl.2): s14 s21. UK Prospective Diabetes Study (UKPDS) Group (1998). Tight blood pressure control and risk of macrovascular and microvascular complications in Type 2 diabetes: (UKPDS 38). BMJ; 317: UK Prospective Diabetes Study (UKPDS) Group (1998). Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk complications in patients with Type 2 diabetes (UKPDS 33). Lancet; 352(9131): Colhoun HM et al (24). Primary prevention of cardiovascular disease with atorvastatin in Type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo controlled trial. Lancet; 364(9435): Krentz AJ (23) Lipoprotein abnormalities and their consequences for patients with type 2 diabetes. Diabetes Obes Metab 5 (Suppl. 1): S19 S27. Turner RC et al. (1998). Risk factors for coronary artery disease in non insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS: 23). BMJ; 316:823. Diabetes Strategy 213/16 28 V13_11/6/213

33 reduce their risk (through targeting modifiable risk factors, e.g. increased low density lipoprotein (LDL) cholesterol, decreased high density lipoprotein (HDL) cholesterol, hypertension, and smoking) 29. Where are we now? From 28-11, the rate of death in Hounslow primarily due to stroke and diabetes was around 6 deaths per 1, population. The highest rate was amongst males in Isleworth and Brentford, with males in all areas unequally represented in deaths due to stroke and diabetes. (Figures 14 and 15) From 28-11, the rate of death in Hounslow where cardiovascular disease and diabetes were mentioned as non-primary causes was 28 deaths per 1, population. The rate of death was higher amongst males, and highest in the areas of Great West Road and Heart of Hounslow. (Figures 1 & 11) In April 212, 88.2% of type 2 diabetics and 82.7% of type 1 diabetic patients had their blood pressure measured in primary care during the preceding months. (Table 12) 76.5% of type 1 patients and 67.3% of type 2 patients in Hounslow had their most recent blood pressure reading less than or equal to 14/8. However, a small proportion of patients had a very high blood pressure of more than 15/9, with 3.6% of type 1 patients and 5.8% of type 2 patients falling into this category. (Table 13) Information on other cardiovascular risk factors in patients with diabetes in Hounslow is available in other parts of this strategy, including the sections Diabetes in Hounslow and Glycaemic Management. Where do we want to be? Reduce the rate of death due to cardiovascular disease amongst diabetes patients, particularly males. How do we achieve this? Reduce the proportion of diabetes patients with high blood pressure Reduce the proportion of diabetes patients who are overweight and obese Reduce the proportion of diabetes patients with high cholesterol Continue to monitor cardiovascular risk factors in diabetes patients to prevent complications How to monitor progress? Improving QOF achievement for the diabetic care processes for blood pressure, cholesterol, BMI and smoking. % of people in the National Diabetes Audit with Type 1/2 whose most recent cholesterol measurement was 5mmol/l (improve to better than England) 29 NICE Clinical Guideline 66: Type 2 diabetes (full guideline). Diabetes Strategy 213/16 29 V13_11/6/213

34 % of people in the National Diabetes Audit with Type 1 2 whose most recent blood pressure reading was within target (improve to better than England). % of people in the National Diabetes Audit with diabetes admitted for myocardial infarction (improvement lower than England), stroke (improvement remain lower than England) and cardiac failure (improvement to lower than England) in the last 15 months. Underlying mortality rate due to cardiovascular disease. NHS IC Indicators data. Retinopathy Screening Context The National Service Framework for Diabetes (21) stated that by 29, all people with diabetes should be offered screening for early detection (and treatment if needed) of diabetic retinopathy. Diabetic retinopathy is one of the commonest causes of preventable blindness in the UK 3. The National Screening Programme for Diabetic Retinopathy aims to reduce the risk of sight loss amongst people with diabetes, by the prompt identification and effective treatment if necessary of sight threatening diabetic retinopathy, at the appropriate stage during the disease process. Modelling indicates that screening and subsequent treatment for retinopathy would prevent 6% of patients going blind within a year and 34% within 1 years. 31 Where are we now? QOF returns data from 21/11 showed that just under four-fifths (79.8%) of diabetic patients in Hounslow had a record of retinal screening in the last 15 months, lower than both London (84.9%) and England (85.4%). (Table 19) Where do we want to be? Improve the rate of retinopathy screening uptake and coverage, at least in line with the London average. Improve the rate of retinopathy screening uptake and coverage of children with diabetes specifically. How will we achieve this? A multidisciplinary group has met to discuss the issues and challenges around diabetic retinopathy screening in Hounslow. These resulted in the following key points: 3 31 Bunce C & Wormald R. (26). Leading causes of certification for blindness and partial sight in England & Wales. BMC Public Health; 6: 58. Bachmann MO & Nelson SJ. (1998). Impact of diabetic retinopathy screening on a British district population: case detection and blindness prevention in an evidence based model. J Epidemiol Comm Health; 52:45 52 Diabetes Strategy 213/16 3 V13_11/6/213

35 We will run a query of primary care data centrally to identify the cohort of diabetics who have not been screened. This should be supported by accurate recording of when a patient is referred to the DRS, and the diabetes template should facilitate that. Hounslow LMC to review governance and medico-legal issues around practices failing to engage with the retinal screening program The retinal screening program (DESP) will work collaboratively with the Diabetes Network to increase uptake by identifying practices that are failing consistently to engage with the program. Retinal screening will be incorporated to the education program deliver to practices to raise awareness around prompt screening and treatment Use SystmOne to improve the call/recall of patients. Urgent work to reduce delays in procuring OptoMize 3.6 software (the official national software for Diabetic Retinopathy Screening from April 213) is necessary and continues. Work with opticians to educate them that their service is not the same as the Diabetic Retinopathy Screening Service. How to monitor progress? Coverage 1% of Hounslow s diabetics referred for screening Reduce number of exemption recording for retinal screening. Monitoring via SystmOne Renal Screening and Management Context Diabetes increases the risk of developing chronic kidney disease (CKD), and the predominant underlying mechanism is cumulative damage over several years to blood vessels. The risk of developing CKD is eight times higher in women with diabetes than without, and over twelve times higher in men with diabetes than without. 32 However, due to its mostly asymptomatic nature, CKD often remains undiagnosed, and therefore screening is especially important and recommended for people with diabetes. 33 Diabetes and hypertension are main causes of CKD and accelerate its progression, and diabetes is the leading cause of end-stage kidney disease. 34, Hippisley Cox, J.,Coupland, C. (21) Predicting the risk of chronic kidney disease in men and women in England and Wales: prospective derivation and external validation of the QKidney scores. BMC Family Practice 21; 11:49 Cavanaugh KL (27). Diabetes Management Issues for Patients With Chronic Kidney Disease. Clinical Diabetes; 25(3):9 97 Kasper DL, Harrison TR. (25) Glomerular diseases. Harrison s principles of internal medicine (16 th ed). New York: McGraw Hill, Middleton RJ et al. (26). The unrecognized prevalence of chronic kidney disease in diabetes. Nephrology Dialysis Transplantation; 21(1):88 92 Diabetes Strategy 213/16 31 V13_11/6/213

36 Intensive glycaemic management can reduce the incidence of microalbuminuria and slow the progression of CKD 36. Treatment and prevention of hypertension (blood pressure maintained at 13/8mmHg or below) reduces the progression of CKD. 37 The NHS Diabetes and Kidney Care programmes have set out the features of Diabetes and Kidney Care Services. They should ensure that: people with diabetes have regular assessment and review of renal function as part of their diabetes assessment and care planning process; patients with CKD and diabetes are seen in a joint nephrology and diabetes services; access to vascular services for vascular access for haemodialysis; access to transplantation services which provide combined kidney and pancreatic transplantation; regular training and development in basic diabetes competencies for hospital staff caring for people who have renal conditions and diabetes; monitored protocols for hospital staff on when to access diabetes specialist advice; monitored protocols to ensure that patients can continue to manage their diabetes themselves whilst in hospital. 38 Where are we now? It is estimated that 2,4 to 4, of the 13,434 diabetics in Hounslow (18-3%) have CKD. 39 In 211/12, 1,827 (14.9%) of the 12,274 patients with diabetes in Hounslow were also on the CKD register, below the lower limit of the expected number. 28% of patients on the CKD register in Hounslow were also on the diabetes register. The observed numbers of diabetics with CKD in Hounslow are expected to increase following an intervention to standardise coding of CKD. From 26-1 in Hounslow, there was less than 1 death per 1, population primarily due to chronic kidney disease (CKD). Mortality due to CKD in Hounslow were concentrated in Feltham, Heart of Hounslow, and Isleworth and Brentford. (Figure 12) In deaths where both diabetes and CKD were mentioned as a cause in 28-11, the rate was higher at 2.3 deaths per 1, population; with no great difference 36 Writing Team for the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group (23). Sustained effect of intensive treatment of type I diabetes mellitus on development and progression of diabetic nephropathy: the Epidemiology of Diabetes Interventions and Complications (EDIC) Study. JAMA; 29: Bakris GL et al. (2). Preserving renal function in adults with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis; 36: NHS Diabetes and Kidney Care (211) Commissioning Diabetes and Kidney Care Services; available from re/ 39 NHS Diabetes and NHS Kidney care report (211) Diabetes with Kidney Disease: Key Facts. Available at Last accessed: 18 th December 212 Diabetes Strategy 213/16 32 V13_11/6/213

37 between males and females. The highest rates were in Great West Road (highest amongst males), and Feltham (highest amongst females). (Figure 13) There are 37 Hounslow GP patients on renal dialysis; 6 with type 1 diabetes (.7% of type 1 diabetics) and 31 with Type 2 diabetes (.26% of type 2 diabetics). This is lower than the national estimates in the National Diabetes Audit of.8% in 23-4 rising to 1.3% in 28/9 among type 1 diabetics and.3% rising to.5% in type 2 diabetics for the same period, but reporting definitions may be different. In 211/12 in Hounslow, 8.3% of diabetics had a record of micro-albuminuria testing in the preceding months and 92.1% had a record of estimated glomerular filtration rate (egfr) or creatinine testing in the preceding months. Where do we want to be? Decline in number of patients with diabetes who develop CKD Decline in deaths due to CKD amongst diabetics How do we achieve this? Improve the number of diabetes patients who have estimated glomerular filtration rate (egfr) or serum creatinine testing in the previous 15 months Improve the number of diabetes patients who have a record of microalbuminuria testing in the previous 15 months Improve the number of patients on the CKD register whose notes have a record of a urine albumin:creatinine ratio(or protein:creatinine ratio) test in the preceding 15 months Improve the number of patients on the CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 14/85 or less Ensure that GP practices can produce a register of patients aged 18 years and over with CKD How to monitor progress? % of people in the National Diabetes Audit with diabetes admitted for renal failure in the last 15 months. Rate of CKD stage 3b and above in diabetic patients. Would need to be based on SystmOne. Lower limb complications Context Foot complications are common amongst people with diabetes. Foot complications result from problems such as peripheral vascular disease (damage caused to large blood vessels supplying lower limbs) or neuropathy (degeneration of the peripheral Diabetes Strategy 213/16 33 V13_11/6/213

38 nerves) 4. Overall, 2-4% of people with diabetes are estimated to have neuropathy and around 5% have a foot ulcer. 41,42 NICE Quality Standard 1 (211) states that all people with diabetes at increased risk of foot complications should receive regular foot reviews, and that people with diabetes should be aware of their risk and their entitlement to regular review. Diabetes UK has recently released a comprehensive pathway to prevent and manage foot complications in patients with diabetes (see Annex 3 for details). The primary care Quality and Outcomes Framework (QOF) includes one measure of diabetic foot care: The percentage of patients with diabetes with a record of a foot examination and risk classification (1. low risk (normal sensation, palpable pulses), 2. increased risk (neuropathy or absent pulses), 3. high risk (neuropathy or absent pulses, plus deformity or skin changes or previous ulcer) or 4. ulcerated foot) within the preceding 15 months. Evidence indicates that education programmes for both health professionals and patients to increase awareness of diabetic foot care, as well as prevention and management, can result in up to a 5% reduction in major amputation rates. 43,44 Where are we now? PRIMARY CARE 45 In 211/12, 78.1% of diabetes patients in Hounslow received their annual foot check as per QOF. This is significantly worse than the national median of 84.1%. The majority of patients who had a foot check in primary care in 211/12 were classified as low risk (left foot: 87.9% of type 1, 91.5% of type 2; right foot: 88.1% of type 1, 91.3% of type 2). Four patients with type 1 diabetes and 19 patients with type 2 diabetes had active foot disease or ulceration; about.8% of type 1 patients and.2% of type 2 patients in Hounslow. (Tables 16 & 17) SECONDARY CARE 46 From 28-11, Hounslow had 681 episodes of care (a period as an inpatient under the care of a specific consultant) for diabetic foot disease, made up of McIntosh A et al (23). Prevention and Management of Foot Problems in Type 2 diabetes: Clinical Guidelines and Evidence. Sheffield, University of Sheffield. Kumar S et al (1994). The prevalence of foot ulceration and its correlates in Type 2 diabetic patients: a population based study. Diabetic Medicine 11: Walters DA et al (1992). The distribution and severity of diabetic foot disease: a community based study with comparison to a non diabetic group. Diabetic Med 9: Lavery LA et al (25). Disease management for diabetic foot: Effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations. Diabetes Res Clin Pract; 7:31 37 van Gils CC et al. (1999). Amputation prevention by vascular surgery and podiatry collaboration in high risk diabetic and non diabetic patients. The Operation Desert Foot experience. Diabetes Care; 22: NHS Information Centre (212). QOF PCT level tables : Diabetes. Available from: and data collections/supporting information/audits and performance/thequality and outcomes framework/qof /qof pct level tables ; accessed 212 Nov 7. Yorkshire and Humber Public Health Observatory (211). Diabetic foot disease profile: NHS Hounslow; January 212. Avail: accessed 212 Nov 7. Diabetes Strategy 213/16 34 V13_11/6/213

39 individuals. This was equivalent to 19.2 care episodes per 1, diabetic adults in Hounslow, higher than the England average (18.1 episodes). Many patients in Hounslow had just one episode of care from (46.5%), but the majority had repeat admissions: 38.3% had two or three episodes of care, while 15.2% had four or more episodes of care. This is comparable to national figures. The annual rate of nights spent in hospital for diabetic foot disease in Hounslow is also higher than the national average, at 18.7 versus nights per 1, diabetic adults. Of the 681 episodes of care between 28/9 and 21/11, 75 resulted in an amputation, which accounted for 438 nights in hospital. There were 16 major (above ankle) amputations, and 59 minor (below ankle) amputations. These figures equate to rates of.45 major amputations annually per 1, diabetic adults in Hounslow (England average 1.1 per 1,), and 1.66 minor amputations per 1, diabetic adults in Hounslow (same as England average). PATIENT VIEWS Adults with diabetes in Hounslow were surveyed about their perception of foot care and their perception of annual checks in primary care. Thirty-eight patients with diabetes completed questionnaires between October and December 212, providing data on the quality of care they received, their self-care knowledge pertaining to their feet, and their views on the foot care provided for diabetic patients in Hounslow. It is recognised that this is not a representative sample (there are 12,736 diabetics in Hounslow), but this is used as a preliminary guide to some of the issues around diabetic foot care in Hounslow. Around 5% of people with diabetes may develop a foot ulcer in any year, and amputation rates are often around.5% per year 47 (approximately 637 people and 64 people per year in Hounslow, respectively). Overall, diabetic foot care in Hounslow was rated as below average by patients surveyed. A full summary of results is available in Annex 4. All findings should be read in the context of the small number of patients surveyed. Where do we want to be? Improve the quality and rate of annual foot checks in primary care. Reduce the rate of admission and length of stay due to diabetic foot disease in Hounslow. Improve the patient experience. How do we achieve this? In October 212, we established a foot care sub-group of the Hounslow Diabetes Clinical Network. This has representation from a Consultant Endocrinologist, GP, Community Podiatry, Diabetes Specialist Nurse, Tissue Viability, patient, and Public Health. The purpose of this group was to discuss Hounslow s foot care (as benchmarked against other areas), establish what services are available in 47 NICE (24) Clinical Guideline 1: Type 2 diabetes Prevention and management of foot problems. Available from: accessed 213 Mar 27. Diabetes Strategy 213/16 35 V13_11/6/213

40 Hounslow to support patients with and at risk of diabetic foot disease, map the patient pathway, and to decide what actions to take to improve diabetic foot care in Hounslow. This group has met twice to inform this strategy and will meet in 213. The diabetic foot working group decided that the following areas need to be focused on, moving forward: Improve the rate of annual diabetic foot checks in primary care through training of primary care staff; Develop the diabetes templates for podiatry and the ICS; Review the service specifications and protocols with HRCH, ensuring good links to the MDT and the Foot Protection Team; Develop a comprehensive local foot care pathway with clear links between services, including X-PERT and other structured education, and clear links particularly between community podiatry, the Foot Protection Team, and the MDT; Improve access to the diabetic foot multidisciplinary team at WMUH; Raise awareness of lower limb complications and outcomes via the ICP Greater awareness-raising of foot complications with HRCH nursing staff and for practice nurses of when to refer on for orthotics, vascular, podiatry and expert wound care assessments; and Promote foot care education for primary care staff to aid appropriate risk stratification and prompt referral to podiatry services Promote patient foot care education at primary care level by delivering structured education programs Create a Foot Protection Team within the podiatry service that provides a seamless care pathway between primary and secondary care Design a care pathway based on Putting Feet First Diabetes UK guidelines and advertise the care pathway to practices Ensure patients foot care is incorporated into their personalised care plans; How to monitor progress? Carry out a health needs assessment for diabetic foot care in Hounslow. % of people in the National Diabetes Audit having major lower limb amputations five years prior to the end of the audit period. Should improve to lower than England. QOF achievement on peripheral pulse checking in patients with diabetes mellitus and neuropathy testing in patients with diabetes mellitus. Audit number of patients that has their foot risk stratification recorded in SystmOne and where agreed referral pathways have been followed Diabetes Strategy 213/16 36 V13_11/6/213

41 Medicines Management Context NICE Clinical Guideline 87 (211; partial update of CG66) recommends that in patients for whom other measures have not brought HbA 1c to less than 58 mmol/mol (7.5%), insulin treatment should be considered. NICE recommends starting with human NPH insulin taken prior to bed-time or twice daily, according to the patient s need. Systematic reviews have shown that both short-acting 48 and long-acting 49 insulin analogues are not significantly different in safety and efficacy compared to human insulin 5 ; though insulin analogues may result in slightly fewer hypoglycaemic symptoms in the short term (no long term studies have been conducted). Insulin analogues have a high marginal cost, which has increased in recent years: if all patients using insulin analogues received human insulin instead in the period 2-29, there would have been considerable financial savings for the NHS (estimated at 625 million). Given the similarities in clinical effectiveness between human and analogue insulin, adherence to prescribing guidelines regarding the preferential use of human insulin is cost-effective 51. Insulin use in diabetes is complex, and incorrect treatment with insulin can require hospital admission. 52 Patients are more likely to receive the correct insulin products if they carry a record of what they should be given, and therefore the use of an insulin passport is recommended to allow patients and health professionals to check the accuracy of prescribing, dispensing and administering of insulin. The passport also provides a mechanism for transferring patient safety information across all healthcare interfaces. 53 Where are we now? Hounslow had a higher average prescribing cost per diabetes patient than the London average, at versus in 29/1, but this was slightly lower than the national average spend ( ). (Table 33) In September 212, 13.7% of type 2 diabetes patients were recorded as being prescribed intermediate and long-acting insulin. (Table 34) Of those patients, 57.9% of type 2 diabetics were on analogue insulin (glargine and detemir). (Table 35) Most Siebenhofer A (26). Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus. Cochrane Database of Systematic Reviews; Issue 2. Art. No.: CD3287 Horvath K et al (27). Long acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus. Cochrane Database of Systematic Reviews; Issue 2. Art. No.: CD5613 Richter B, Neises G (25). Human insulin versus animal insulin in people with diabetes mellitus. Cochrane Database of Systematic Reviews; Issue 1. Art. No.: CD3816 Holden SE et al. (211). Evaluation of the incremental cost to the National Health Service of prescribing analogue insulin. BMJ Open; 1:e Van der Hooft CS et al. (28). Adverse drug reaction related hospitalisation; a population based cohort study. Pharmacoepidemiol Drug Saf; 17: NPSA (211). Patient Safety Alert NPSA: The adult patient s passport to safer use of insulin. Diabetes Strategy 213/16 37 V13_11/6/213

42 of those patients on analogues were registered in the Heart of Hounslow and Chiswick areas (type 2). (Figure 37) It has been observed that diabetes patients in Hounslow with higher HbA 1c readings are more likely to be prescribed intermediate and long-acting insulin. (Figure 38) Around 6-65% of those prescribed intermediate and long-acting insulin who have an HbA 1c reading over 59 mmol/mol are on analogue insulin. (Figure 39) Where do we want to be? Ensure that patients are initiated on insulin in accordance with clinical guidelines (i.e. on human rather than analogue insulin); Ensure that all patients being treated with insulin are given an insulin passport; Ensure that patients receive education on insulin use and monitoring prior initiation Ensure that practices are knowledgeable on insulin management, monitoring and optimization. Address variation across the borough in the type of insulin initiation. Standardise training across practices that initiate insulin to bring in line with NICE recommendations Familiarized practices with prescribing of GLP-1 How do we achieve this? Assemble a protocol on how to initiate insulin and how to teach patients on adjusting their dose, which includes education for primary and community care staff; All patients to have a management plan in place regarding self-monitoring of blood glucose (SMBG) and that testing is limited to only those that need it and where it is clinically indicated. Patients will be taught about the need/no need for SMBG; Undertake a patient survey to understand patients' insulin experience; Adjust the primary care education programme to include insulin initiation and how to educate patients on its introduction and use; Ensure community pharmacies and patients are using insulin passports safely and in line with the National Patient Safety Agency s recommendations, 54 and ensure that housebound patients are supported to use the passports; NICE criteria for use of GLP-1 drugs to be included in the SystmOne diabetes template; and Work with medicines management, practices initiating insulin, and the ICS to promote insulin education and increase the use of human insulin. How to monitor progress? Develop an insulin initiation template for SystmOne Diabetes Strategy 213/16 38 V13_11/6/213

43 Initiation rates analogue vs. human reliant on the use of the insulin initiation template. % patients receiving education at initiation reliant on the use of the insulin initiation template. All patients with diabetes to have a medication review (suggested 6-monthly) to optimise their medication use (particularly around compliance and polypharmacy). Diabetes Strategy 213/16 39 V13_11/6/213

44 Integrated Diabetes Care Context Standard 3: All children, young people and adults with diabetes will receive a service which encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle. This will be reflected in an agreed and shared care plan in an appropriate format and language. Where appropriate, parents and carers should be fully engaged in this process. Standard 12: All people with diabetes requiring multi-agency support will receive integrated health and social care to maximise individuals independence, quality of life and wellbeing. National Service Framework for Diabetes (21) People with diabetes face many challenges in managing their condition. Whilst the specific issues are different for each person, they often include diet and exercise, mental health, medicines and treatment, and illness and disability. Therefore, multidisciplinary input across a range of healthcare settings in required in order to meet diabetes patients complex needs. In particular, professionals in primary, community, and secondary care services have a role to play in providing diabetes support, and in ensuring equal access to healthcare and support services, closer to home. 55 Evidence indicates that integrated care which facilitates patient education and structured and regular review of patients by multidisciplinary health professionals in appropriate settings is effective in improving the process of diabetes care. 56 An Integrated Care Initiative in Cambridge included vertical and horizontal integration between primary and specialist care teams, patient participation, and an integrated specialist diabetes team in the community resulted in improved glycaemic control amongst high-risk patients, improved glycaemic control in patients solely managed in primary care, and fewer diabetic foot-related admissions. 57 Where are we now? Hounslow currently delivers diabetes care in three settings: primary care, the Intermediate Care Service (ICS), and in secondary care. In primary care, Hounslow patients should receive recommended the nine care processes recommended by Diabetes UK, at least annually: blood glucose level measurement, blood pressure measurement, cholesterol level measurement, retinal 55 Diabetes UK, ABCD, CCC, PCDS, and RCN (27). Joint position statement on integrated care in the reforming NHS. 56 Renders CM (21). Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care; 24: Hillson R (211). A time for integrated diabetes care. Diabetes and Primary Care; 13(1):12. Diabetes Strategy 213/16 4 V13_11/6/213

45 screening, foot check, kidney function testing (urine and blood), weight check, and smoking status check. The ICS in Hounslow provides support to help patients with glycaemic management, education and self-management advice (including nutrition), and training to assist primary care professionals to care for diabetic patients. In secondary care, diabetes patients with complications are managed (inpatients, outpatient diabetes clinic, and foot clinic), in addition to children and young people (paediatric and transition clinics), and pregnant women (pregnancy and preconception clinics). All patients with type 1 diabetes are managed in secondary care. An integrated care pilot, which is expected to deliver more coordinated and planned care to patients with diabetes, is currently being rolled out across the borough. Where do we want to be? Ensure that all patients have a personalised care plan, co-developed with a relevant health professional; Ensure that all existing and newly-diagnosed diabetes patients are invited to participate in self-management through structured education programmes; Ensure that pregnant women with diabetes receive antenatal screening and are managed closely throughout the pregnancy to avoid complications; Ensure that carers receive structured education to support the patient to selfmanage; Ensure that all GPs receive ongoing education from the ICS. How do we achieve this? Develop long-term conditions self-management strategy through workshop with service users in 213 Advertise programmes to GPs Develop single referral form for self-management programmes How to monitor progress? % of ICS patients discharged with personal care plan. % of Type 2 patients newly referred to the ICS offered structured education within 3 months of referral. % of ICS Type 2 patients receive structured education in year. % of Type 1 patients referred to the ICS offered structured education within 3 months of referral. Diabetes Strategy 213/16 41 V13_11/6/213

46 Service User Experience Domain 4: Ensuring that people have a positive experience of care emphasises the importance of health services providing a positive care experience for patients, service users and carers. This includes ensuring the provision of a positive care experience in primary care (including GP services, Out of Hours services and NHS Dental services) and in hospital care. The NHS Operating Framework 212/13 Context Active and effective involvement of people with diabetes and their carers is intrinsic to the delivery of the National Service Framework for Diabetes and NICE guidance for diabetes. Understanding what people need and want (such as barriers to treatment adherence or effective prevention strategies against diabetic complications) allow commissioners to plan and deliver quality care that is accessible and avoids the common pitfalls of poor patient experience. 58 An evaluation of the NHS Diabetes/Diabetes UK s User Involvement in Local Diabetes Care project further outlined the importance of service user involvement in planning and improving diabetes services in the UK 59. Evidence indicates that outcomes in diabetes improve through patients taking an active role in their care, including an improved sense of wellbeing 6, mental health 61 and greater control over blood sugar levels 62. Where are we now? This strategy has been developed with the involvement of the patient. In many of the working groups that were set up to develop the Diabetes Strategy, there was patient representation to ensure that patients needs and concerns could be incorporated. This commitment to the patient will continue in workstreams that arise as a result of the Diabetes Strategy and the Diabetes Clinical Network s areas of focus. In addition to the involvement of patients in working groups and in the Clinical Network, patient surveys have been and are being carried out to understand the experience of diabetes patients in Hounslow and what services they need. These include: Diabetic foot disease (general diabetes patients) Distributed in the community; refer to Annex 5. Diabetic foot disease (patients with foot disease) To be used in secondary care with patients experiencing foot complications; in development. 58 Diabetes UK (212) Making involvement happen: Why user involvement is important? 59 TwoCan Associates (211). Evaluation of the User Involvement in Local Diabetes Care project: Final report. 6 Kinmonth AL et al. (1998). Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. BMJ; 317: DH (26). Care Planning in Diabetes: Report from the Joint Department of Health and Diabetes UK Care Planning Working Group. London: Department of Health. 62 Greenfield S et al. (1988). Patients participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med; 3: Diabetes Strategy 213/16 42 V13_11/6/213

47 Diabetic retinopathy screening (general diabetes patients) Distributed in the community; see Annex 6. Annual diabetes patient survey To be used annually in Hounslow with all diabetes patients; see Annex 7. Insulin experience of patients To be distributed in the community; in development. The results of these surveys will be used alongside health intelligence data and clinical guidance to guide the development of diabetes services in Hounslow. Where do we want to be? All patients with diabetes in Hounslow will have an overall positive experience of care. How do we achieve this? Ensure that community healthcare service specifications include the requirement to undertake a patient / carer satisfaction survey, in collaboration with Diabetes UK. How to monitor progress? The provision of and uptake of patient/carer satisfaction surveys, including in primary care and the ICS. GP survey improvement in Q33 Confidence in managing own health - not specific to diabetes though. Diabetes Strategy 213/16 43 V13_11/6/213

48 Data, IT and Communication Context Supportive shared clinical information systems between primary, secondary and community care have been shown to be a main contributor to improved staff adherence to guidelines, reduced hospitalisation, reduced cost and improved patient health, quality of life and satisfaction (although evidence for changes in health outcomes is minimal) 63,64. Information sharing between primary and secondary care as part of a regional diabetes management programme showed improvements in clinical indicators (HbA1c, blood pressure) 65 and patients quality of life 66. The Hounslow CCG commissioning intentions for 212/13 states that SystmOne will enable electronic information sharing between hospitals and GPs with patient permission, and which will underpin integrated and clinically safe care. Where are we now? The 24-5 National Diabetes Audit report found that in 43% of primary care records the specific type of diabetes was not recorded. 67 Disease registers and the coding of a patient s condition in primary care records is heavily influenced by QOF. For example, following the changes in the reporting rules for QOF diabetes indicators in 26 that required that diabetes be reported as Type 1 or Type 2, there was a 22% fall in the number of people on diabetes registers 68. The risk for those patients who are no longer on the diabetes register is that they will not benefit from the prompts used in the incentivised chronic disease management. In Hounslow, the primary care of diabetics is supported by the intermediate care service, who with the appropriate consent can view the primary care records of the patient during consultations. This enables the consultation with the patient to be informed by the most up to date information improving the quality of care they receive. In certain circumstances the ICS is able to record clinical findings from the consultation in the patient s record, which can then be seen by the GP. Record sharing is enabled by the use of SystmOne. Within the diabetic care pathway there are a number of other services where the patient would benefit from the practitioner s ability to see patients primary care records in some form Young B (21). The organisation of diabetes care. J R Coll Physicians Edinb; 4(Suppl 17):33 9 Ham C (28). Integrating NHS care: lessons from the front line. London: Nuffield Trust. Rothe U et al (28). Evaluation of a Diabetes Management System Based on Practice Guidelines, Integrated Care, and Continuous Quality Management in a Federal State of Germany: A population based approach to health care research. Diabetes Care; 31(5): Ose D et al. (29). Impact of primary care based disease management on the health related quality of life in patients with type 2 diabetes and co morbidity. Diabetes Care; 32(9): National Diabetes Audit: key findings about the quality of care for people with diabetes in diabetes in England, incorporating registrations from Wales. Report for the audit period 24/5. 68 Hippisley Cox, J., O Hanlon, S., (26) Identifying patients with diabetes in the QOF two steps forward one step back. BMJ Rapid Response 3 rd October 26 Diabetes Strategy 213/16 44 V13_11/6/213

49 Where do we want to be? Following an RCGP publication which set out good coding practice, we will: Continually improve the clinical record o Specificity e.g. Diabetes Type 1 with (named complication) o One code for one diagnosis. o Linking diagnosis with the relevant prescription o Capture clinical data recorded outside the clinical record e.g. that held in reports or letters. Get the diagnosis right enables the specificity required Evolve classification and diagnostic criteria for diabetes as new codes are developed a process of on-going maintenance should be used to remove redundant codes. How do we achieve this? Develop a template for diabetes that can be used to capture much of a diabetic patient s care pathway (under development by Dr Richard Baxter), which will enable the GP to collect data relevant to QOF, but also whether the patient is referred to education, the intermediate care service, comorbidities and other provider activity (for example podiatry). Work to enable record sharing. How to monitor progress? Uptake of the Diabetes template in SystmOne. Self-audits of data to ensure record maintenance using the RCGP audit tool available at Diabetes Strategy 213/16 45 V13_11/6/213

50 Priorities for Diabetes Service in Hounslow Each Section of the Strategy has key priorities to deliver where we want to be in the next three years. The overall strategic priorities to achieve this are below. Primary care Identify patients at high risk of developing diabetes. Encourage GPs to refer patients to structured education programmes Expert Patient Programme, X-PERT and Holding off Diabetes programme. Increase the number of patients who have personalised care plans Identify practices in Hounslow with a high rate of emergency admissions related to diabetes to work closely with these practices to improve clinical outcomes Assemble a protocol on insulin initiate Continue to monitor cardiovascular risk factors in diabetes patients to prevent complications Continue to identify the cohort of diabetics who have not received eye screening. Improve foot care through the development of a comprehensive local foot care pathway with clear links between services Secondary care Develop the hypoglycaemia care pathway Work collaboratively with WMUH to ensure that all children receive age-appropriate structured education Education and self-management Develop long-term conditions selfmanagement strategy Understanding patients needs and patient experience Continuously undertake a patient survey to understand patients' insulin experience/foot care / Diabetes Strategy 213/16 46 V13_11/6/213

51 Annex 1 National Service Framework for Diabetes (21) 1. The NHS will develop, implement and monitor strategies to reduce the risk of developing Type 2 diabetes in the population as a whole and to reduce the inequalities in the risk of developing Type 2 diabetes. 2. The NHS will develop, implement and monitor strategies to identify people who do not know they have diabetes. 3. All children, young people and adults with diabetes will receive a service which encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle. This will be reflected in an agreed and shared care plan in an appropriate format and language. Where appropriate, parents and carers should be fully engaged in this process. 4. All adults with diabetes will receive high-quality care throughout their lifetime, including support to optimise the control of their blood glucose, blood pressure and other risk factors for developing the complications of diabetes. 5. All children and young people with diabetes will receive consistently high-quality care and they, with their families and others involved in their day-to-day care, will be supported to optimise the control of their blood glucose and their physical, psychological, intellectual, educational and social development. 6. All young people with diabetes will experience a smooth transition of care from paediatric diabetes services to adult diabetes services, whether hospital or community-based, either directly or via a young people s clinic. The transition will be organised in partnership with each individual and at an age appropriate to and agreed with them. 7. The NHS will develop, implement and monitor agreed protocols for rapid and effective treatment of diabetic emergencies by appropriately trained health care professionals. Protocols will include the management of acute complications and procedures to minimise the risk of recurrence. 8. All children, young people and adults with diabetes admitted to hospital, for whatever reason, will receive effective care of their diabetes. Wherever possible, they will continue to be involved in decisions concerning the management of their diabetes. 9. The NHS will develop, implement and monitor policies that seek to empower and support women with pre-existing diabetes and those who develop diabetes during pregnancy to optimise the outcomes of their pregnancy. 1. All young people and adults with diabetes will receive regular surveillance for the long-term complications of diabetes. 11. The NHS will develop, implement and monitor agreed protocols and systems of care to ensure that all people who develop long-term complications of diabetes receive timely, appropriate and effective investigation and treatment to reduce their risk of disability and premature death. 12. All people with diabetes requiring multi-agency support will receive integrated health and social care. Diabetes Strategy 213/16 47 V13_11/6/213

52 Annex 2 NICE Pathway: Blood-glucose-lowering therapy for type 2 diabetes (June 212) Diabetes Strategy 213/16 48 V13_11/6/213

53 Annex 3 Diabetes UK: Footcare pathway for people with diabetes (February 212) Diabetes Strategy 213/16 49 V13_11/6/213

54 Annex 4 Foot care survey results A small number of patients were surveyed using a short form, which was developed by a Public Health Manager and reviewed primarily by a diabetic patient representative, and then by the diabetic foot working group. The results of the survey are summarised below. WHO WERE THE PATIENTS? 38 patients were surveyed, 81.5% of whom had Type 2 diabetes. 1.5% of people asked said that they have Type 1 diabetes, while 3 people (8%) did not know what type of diabetes they had. Approximately 9% of patients said that they had been admitted to hospital for foot complications related to their diabetes. Patients surveyed were from a representative group of patients, the vast majority were of South Asian ethnicity, while others were White, and a small proportion of East Asian ethnicity. There was an even male-female split, and the age profile was in line with what might be expected for Type 2 diabetes (mostly older patients). The majority of surveyed patients predominantly used NHS-provided services (84%). Those patients who predominantly used privately-provided foot care services in Hounslow said that they did so because they couldn t get an appointment in the NHS-provided services within a reasonable timeframe, had too long between appointments, or felt they received a more consistent service. ANNUAL FOOT REVIEWS 74% of patients (26 out of 35) said that they recalled (at any time) having their feet examined by an NHS health professional (e.g. GP) with their shoes and socks/stockings off. However, a much smaller number (15; or 43% of all patients) recalled being offered an appointment to have their feet checked at their GP practice within the last year (as they should per QOF). All patients who recalled being offered a foot check appointment within the last year said that they attended the appointment. Patients who recalled ever having a foot check (n=26) answered questions about the care they received during this check, which should be in line with Diabetes UK recommendations. These answers are limited by the patients abilities to recall the foot check, but give a good general idea of the care received: 69% of patients said that their foot check involved looking for changes and testing sensation (using 1g monofilament or vibration); 35% of patients said that their foot check involved the health professional asking whether they currently had any ulcers, and 38% said that they had been asked about any ulceration in the past; 69% of patients said that their foot check involved the health professional asking them whether they had any pain in their feet; 31% of patients said that their shoes were examined during their foot check appointment; 73% of patients said that the health professional had discussed how to care for their feet during the foot check; and 31% of patients said that their foot check involved the health professional discussing their risk of developing foot problems (and whether they needed to be referred to a specialist). EDUCATION About half of patients surveyed (16 of 31 respondents) said that they had been offered the opportunity to take part in a diabetes education programme, such as X-PERT. This is relevant as patients selfreported understanding of foot care was also poor: 55% said that they understood why diabetes can affect feet; Diabetes Strategy 213/16 5 V13_11/6/213

55 61% said they understand how often they need to check their feet, and the same proportion said that they knew how to check their feet and what changes to look for; 61% said that they knew how to look after their toenails; 45% said that they understood how blood sugar can affect their feet; 65% said that they understood the importance of wearing well-fitting shoes; 65% said that they understood why it is important to have an annual foot check with a health professional; and 42% said that they knew who to contact if they were concerned about their feet. FEELING SUPPORTED In terms of diabetic foot support from health care professionals, about half of respondents (16 of 31) said that they felt supported enough by their GP, 31% of respondents (8 of 26) said that they felt supported enough by the hospital team, and just under half of respondents (13 of 28) said that they felt adequately supported by community health care professionals such as podiatrists and specialist nurses. OVERALL RATING Patients were asked to rate the NHS-provided foot care they have received in Hounslow, on a scale of 1 (very poor) to 5 (very good). Twenty patients responded to this question, with an overall rating of 2.61, which equates to below average (a value of 3 being average). Patients were also asked to elaborate on their views on diabetic foot care in Hounslow. Of the patients that elaborated, many patients said that the community podiatry service was highly valued, especially its location. Three patients said their GP did a good job of caring for their feet. However, many others said that nothing in particular was good about the current service, and that it does not work well at all. A small number of patients said they felt that they had never received a foot care service (which mostly aligned with patients who had never been invited for a foot check). The main issues raised by patients were the poor care they felt they received from their GP (one patient said that their GP had never asked him about whether he had ulcers in the past, and he had); the booking arrangements for a podiatry appointment, and the wait for a podiatry appointment, which they felt was excessive. Many patients said that they would like a better booking system for podiatry appointments, to receive better foot care in general practice (including clearer information given to the patient), and more podiatrists in the community and/or more frequent podiatry appointments. One patient said that they wished podiatrists would listen to his concerns and not just go by guidelines. Three patients mentioned that they wished that podiatry would keep its appointments and not cancel them due to staffing issues or to overrun (which results in expensive parking charges at Heart of Hounslow). An almost equal number of patients highlighted that their preferred place of care is hospital and the community. A small number of patients said they would prefer foot care in a GP setting. Diabetes Strategy 213/16 51 V13_11/6/213

56 Annex 5 Foot care patient survey (October 212) Diabetes Strategy 213/16 52 V13_11/6/213

57 Diabetes Strategy 213/16 53 V13_11/6/213

58 Diabetes Strategy 213/16 54 V13_11/6/213

59 Annex 6 Retinopathy screening patient survey (November 212) Diabetes Strategy 213/16 55 V13_11/6/213