CARDIFF AND VALE UNIVERSITY HEALTH BOARD TOGETHER FOR HEALTH DIABETES DELIVERY PLAN REFRESH MARCH 2016

Transcription

1 CARDIFF AND VALE UNIVERSITY HEALTH BOARD TOGETHER FOR HEALTH DIABETES DELIVERY PLAN REFRESH MARCH 2016 Page 1 of 35

2 1. Background and context Together for Health a Diabetes Delivery Plan was published in 2013 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government s expectations of the NHS in Wales in delivering high quality diabetes services. It therefore focuses on maximising efficiency and effectiveness, tackling variation in access and reducing inequalities in service provision across 7 themes. For each theme it sets out: Delivery expectations to ensure the right patient, in the right care and the right time Specific priorities for Responsibility to develop and deliver actions Assurance measures that will be used to ensure that this plan is delivered and effective outcomes achieved. What do we want to achieve? The Delivery Plan sets out action to improve outcomes in the following key areas between now and 2016: Children and young people Preventing diabetes Detecting diabetes quickly Delivering fast, effective treatment and care Supporting living with diabetes Improving Information Targeting research 2. Cardiff and Vale University Health Board s Delivery Plan Cardiff and Vale Local Health Board produced its first delivery plan in In our delivery plan we set the following priorities for 2016: Children and Young People Ensure children and young people with diabetes have the best possible start in life and are given the opportunity to fulfil their potential. Preventing Diabetes People are aware how to live a healthy lifestyle, make healthy choices that minimise their risk of developing diabetes and understand the consequences of not doing so. Page 2 of 35

3 Detecting Diabetes Quickly Diabetes is detected quickly where it does occur. Delivering fast, effective treatment and care People receive fast, effective treatment and care so they have the best chance of living a long and healthy life, with patients taking responsibility for lifestyle choices that contribute positively to their treatment and care. Supporting Living with Diabetes People are placed at the heart of diabetes care with their individual needs identified and met and feel supported and informed, able to manage the effects of diabetes. Improving Information Patients, health professionals and service planners will have access to appropriate information to help them make informed decisions about care and treatment. The public, the NHS, the third sector and the Welsh Government will have access to information on the outcomes that result from NHS Care. Targeting Research Access to research can lead to better outcomes for patients. The NHS must promote research and ensure appropriate access to clinical trials. Page 3 of 35

4 Progress against headline priorities Considerable progress has been made against these priorities as highlighted below: Children and Young People Cardiff and Vale UHBs paediatric diabetes services have implemented positive changes to enhance the holistic service provided to children and their families following a peer review. These changes include;- Additional Consultant sessions, and new diabetes clinics provided at the University Hospital of Wales, and University Hospital Llandough sites Investment in specialist diabetes nursing service operating across the healthcare system Investment in a specialist paediatric diabetes dietician Investment in point of care measurement of HbA1c and new blood glucose download facilities Additional psychological support to children and their families Preventing Diabetes During , Making Every Contact Count (MECC) training has been delivered to a wide range of staff from the UHB, and also to partner organisations, including third sector and probation services. The training aims to provide public sector workers with the skills to advise, signpost and motivate people to live healthier lives. The training has been adapted following feedback in 2015, and now includes elements of motivational interviewing techniques Podiatry staff have all undertaken MECC and in January and February 2016 all participated in an induction training programme on Motivational interviewing techniques The Cardiff and Vale Making Every Contact Count Team led the organisation of, and participated in a successful national Making Every Contact Count Conference A range of action has been delivered within the Cardiff and Vale Food and Physical Activity action plans (see action plan for progress report) Page 4 of 35

5 Nutrition Skills For Life training is provided to partner organisations to support delivery of nutrition education in communities including Get Cooking Courses and Foodwise weight management programme A Tier 3, multidisciplinary obesity service has been established which provides tailored weight management treatment and therapy. The service commenced in September 2015 and bridges the gap between the tier 2 dietetic led weight management programme delivered via the Eating for Life Programme or 1;1 dietetic clinics, and the Tier 4 specialist bariatric service provided in Swansea.Tier 2 capacity has also been increased as part of implementation of the All Wales Obesity Pathway Detecting Diabetes Quickly The Putting Feet First pathway has been delivered to improve awareness and recognition of the foot conditions related to diabetes, and the podiatry department as part of an all Wales initiative are due to provide education and support to Primary care in diabetic foot awareness and foot screening during the forthcoming year, utilising the putting feet first pathway to directs patients foot health needs Community pharmacies are now required through the community pharmacy contract, to provide opportunistic health promotion advice to people with diabetes A Level 3 smoking cessation service has commenced which is delivered through community pharmacies in deprived areas of Cardiff and the Vale of Glamorgan The All-Wales information booklet for patients with newly diagnosed diabetes have been distributed to all GP practices to provide to patients on diagnosis and training provided by Dietetic Services to practice nurses to support first line education During , the UHB has increased its capacity to deliver structured education (DAFNE and X-PERT) Delivering fast, effective treatment and care Working in partnership with Pharma, a training needs analysis of primary care practitioners has been completed and analysed, with a work stream established to plan training to primary care health professionals. Several MERIT training sessions have already been delivered Page 5 of 35

6 A diabetes retinopathy needs assessment has been undertaken, with recommendations developed and subsequent actions to improve equity of access to services The Putting Feet First pathway was introduced over 18 months ago into the primary care setting, and has now been fully implemented. Podiatrists now treat patients presenting with moderate and above risks in relation to diabetes feet complications. Extra support and training has been planned and will be delivered to further enhance and support the primary care to include Nursing homes by the Podiatry service. A Leading Improvement in Patient Safety project has focussed on the provision of education to prioritised in-patient areas within Cardiff and Vale UHB. Education for professionals (secondary and primary care), has been identified a s a priority area by the Diabetes Service Improvement Group, and is being progressed as part of a formalised programme management approach Point of Care Testing (POCT) data is now routinely available to the specialist inpatient diabetes team. This will allow the targeting of interventions and specialist support to those individuals and in patient areas of greatest need The UHB has developed a plan to educate health care professionals across all of our inpatient settings, beginning with prioritised areas identified with POCT data Diabetic foot awareness has been incorporated into the UHBs Health Care Support Worker induction programme. Diabetic foot education and introduction to a web based learning tool (FRAME) is now incorporated onto the undergraduate Nursing programme in year 1 and 3. Insulin pump services for adults and children are provided in line with NICE guidance Supporting Living with Diabetes Community Pharmacists are now required through the community pharmacy contract to provide health education and awareness to people living with diabetes The UHB s Primary, Community & Intermediate Care Clinical Board has developed "Pacesetter Pathways" in 10 key areas, including diabetes, which have been embedded into General Practice since October There are many components including promotion of self management and the provision of personal care plans for people living Page 6 of 35

7 with diabetes. These will be audited in June Nationally provided National Wales Information Service (NWIS) data will support this Building on the previously established Consultant and GP virtual clinics in all GP practices, as part of the UHBs progress towards a community focussed model of care, GPs now have access to timely advice from Consultants using an e-advice system, to assist effective management of people s diabetes in the primary care setting, and preventing unnecessary referrals. Diabetes education and support (XPERT and DAFNE) for people living with diabetes is routinely offered by the UHB. Twenty-seven XPERT and ten DAFNE programmes have been delivered by UHB staff during Dietetic services also offer diabetes awareness sessions for people who are unable to attend a full education programme The UHBs prudent co-production work delivered a workshop (June 2015) with a range of participants including people living with diabetes. Supported by 1000 lives improvement team, the event aimed to ascertain what living well with diabetes means for people, and what support needs to be in place to support them. The workshop recommended: Progressing the shift to a community focussed model of care, by prioritising;- o peer support and professional support/community organizing o structured education/access to a range of education and support o greater access to physical activity opportunities o an information pathway (information/signposting/social media options) o use of technology o Training for health professionals, and o A personalised plan and patient record In response the UHB has done the following: Established an Education for Patients diabetes self care programme which can be accessed by anyone with type 2 diabetes A peer support pilot has been established in the North of Cardiff, led by Diabetes UK Cymru.This pilot has been successful in achieving its objectives, and is currently being evaluated The UHB is developing a web page aimed at education and support for people with Type 2 diabetes see improving information Page 7 of 35

8 To support a new Diabetes Specialist Nurse role in City and South cluster, the UHB is are ascertaining what type of education and support might benefit the local population where prevalence of type 2 diabetes is highest. This information will be used to deliver an improved service to meet local needs Improving Information The Point of Care Testing system has been developed, and is now supplying real time data to the inpatient diabetes team. This has enabled targeted and timely responses for individuals, and targeting of areas of high risk. The Point of Care Testing Team have recently secured funding to purchase IT equipment to make further improvements in this service, and have developed a plan to use information to improve services in the community Cardiff and Vale UHB has worked closely with the third sector during , to ensure effective signposting to sources of information. This includes collaborating with Diabetes UK Cymru in the successful Living Well with Diabetes Day Through the UHBs prudent approach and building on the prudent workshop in 2015, a multiagency plan has been implemented to improve education and support for people living with diabetes. Further information is included above in relation to progress on preventing diabetes Targeting Research Cardiff and Vale UHB and Cardiff University have a close working relationship, and continue to work together in relation to research into early diagnosis and treatment for type 1 diabetes Page 8 of 35

9 3. The vision: For our population Welsh Government wants: People of all ages to have a minimised risk of developing diabetes Where diabetes does occur, an excellent chance of living a long and healthy life, wherever they live in Wales 4. The drivers in Wales: Spending in Welsh hospitals in on diabetes was almost 90m 1, this is an increase of 4% when compared to However NHS expenditure on diabetes related care is almost 500m a year 2. In ; 177,212 people over the age of 17 were registered with their GP as diabetic. This is 3,913 3 more people than in There were 1,469 children and young people with diabetes, under the age of 25 in Wales. Almost all have type 1 diabetes. Gestational diabetes is a type of diabetes that some women get during pregnancy. Between 2 and 10% of expectant mothers develop this condition, making it one of the most common health problems of pregnancy. It is widely accepted that Wales is facing a huge increase in the number of people with diabetes. The numbers of adults aged 17 and above registered at a GP practice with diabetes has increased by just over 24,000 people in the last 5 years. Much of the increase is type 2 diabetes due to the aging population and the increases in the numbers of overweight people. There is evidence to show that: the onset of type 2 diabetes can be delayed, or even prevented effective management of the condition increases life expectancy and reduces the risk of complications; and supported self-management is the essential element of effective diabetes care People with diabetes have a substantially higher risk of serious illness, hospitalisation and premature death compared to those without diabetes. 1 NHS Expenditure Programme Budgets Wales Together for Health a Diabetes Delivery Plan 3 Stats Wales Page 9 of 35

10 Outcomes in Wales A number of outcome and assurance measures have been developed, which together, will demonstrate how diabetes services are improving in Wales. Some progress against these measures has been made giving Welsh Government the reassurance that diabetes care in Wales is developing in line with its vision: Deaths from diabetes is not a common cause of death in Wales. In 2013, 300 people died from diabetes. This has fallen from 420 deaths in 2009 Half of all deaths from diabetes result from cardiovascular disease including heart attacks and strokes. In 2001, in Wales, almost 14,000 people died from cardiovascular disease, by 2011 this had fallen to just over 9,000 deaths In Wales in , 98.9% of patients under the age of 25 years had their HbA1c measured and 97.6% in England. This is considerably improved from , where 89.3% of patients in England and Wales had their HbA1c measured In there has been a decline in the diabetic ketoacidosis (DKA) incidence rates for children and young people from 9,662 in to 5,683 84% of inpatients stated that they were satisfied or very satisfied with the overall care of their diabetes while in hospital In , 93% of patients on the diabetes register had a record of retinal screening, and 91% of patients on the register had a record of a foot examination, in the preceding 15 months Emergency admissions of people with diabetes have dropped by over 230 patients from 2,815 to 2,584 between 2010 and 2013 Outcomes in Cardiff and Vale of Glamorgan In 2013/14, in Cardiff and Vale, 93% of patients on the diabetes register had a record of retinal screening in the preceding 15 months 4 In 2014/15, in Cardiff and Vale UHB, 91% of patients with diabetes on the register had a record of a foot examination and risk classification within the preceding 15 months 5 In 2014/15, in Cardiff and Vale UHB, the percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 15 months was 79% 6 4 Quality and Outcomes Framework (QOF) Statistics for Wales, (Welsh Government (WG) 5 The classification of risk are: 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 in previous ulcer) or 4) ulcerated foot within the preceding 15 months. Government (WG) Page 10 of 35

11 In 2014/15, in Cardiff and Vale UHB, 79% of patients with diabetes on the register had a blood pressure reading (measured in the preceding 15 months) of 140/80 mmhg or less 6 Challenges We need to continue to improve in these areas as well as ensuring that progress is made where performance has not been as good as anticipated: Type 2 diabetes is more prevalent among less affluent populations. Those in the most deprived one-fifth of the population are one-and-ahalf times more likely than average to have diabetes at any given age 7. 9% of those people living in the most deprived areas of Wales report being treated for diabetes compared to 6% of those living in the least deprived - showing the pronounced impact of poverty and the socioeconomic determinants of health A child with HbA1c levels above 9.5%, according to the National Institute for Clinical Excellence, would be at risk of medical complications in the future. In Wales, 27.1% had poor glycaemic control (HbA1c over 9.5%); with 59.5% having moderate control (HbA1c between 7.5 and 9.5%) Obesity is the top risk factor for type 2 diabetes at all ages. 54% of all adults in Cardiff and Vale UHB in 2013/14 are overweight or obese 8. The prevalence of those overweight or obese children aged 4-5 years in Wales (reception year) (26%) was significantly higher than that for England (22%). In Cardiff and Vale UHB, 22% of children aged 4 to 5 are overweight or obese 9 Physical activity trends show low rates and a flat lining trend, with 27% of adults in Cardiff and the Vale UHB area meeting physical activity guidelines in 2013/14 10 It is estimated that there are around 66,000 people with undiagnosed type 2 diabetes in Wales High blood pressure is an important risk factor for diabetes, and while 20% 11 of adults in Cardiff and Vale UHB are being treated for high blood pressure, it has been estimated that across the UK around half of people with high blood pressure are not receiving treatment 12. Only 4% of newly diagnosed adults in Wales received structured education in In 2014/15, in Cardiff and Vale UHB, 96% of newly diagnosed patients with diabetes had a record of being referred 6 Quality and Outcomes Framework (QOF) Statistics for Wales, (Welsh Government (WG) Quality and Outcomes Framework (QOF) Statistics for Wales, (Welsh 7 National Diabetes Audit 8 Public Health Wales Observatory 2015, WHS lifestyle trends resource. WHS 2013/14 data 9 Child Measurement Programme for Wales, Annual Report 2013/14 10 Public Health Wales Observatory 2015, WHS lifestyle trends resource. WHS 2013/14 data 11 Welsh Health Survey 2013/14, Welsh Government 12 Scarborough P, Bhatnagar P, Wickramasinghe K, Smolina K, Mitchell C, Rayner M (2010). Coronary heart disease statistics 2010 edition. British Heart Foundation: London Page 11 of 35

12 to a structured education programme within 9 months after entry to the diabetes register % of adults with type 1 diabetes and 33% of adults with type 2 diabetes are not having the annual tests and investigations associated with the national standards. Of those having the annual tests, 86% of type 1 diabetic patients and 65% of adults with type 2 diabetes do not meet the agreed treatment targets The incidence of diabetes is increasing as the prevalence of obesity is rising. The number of people aged 16 and over predicted to have type 1 or type 2 diabetes in Cardiff and Vale is predicted to rise from 26,021 in 2020 to 32,154 in Currently there are around 22,200 adults (aged over 17) within Cardiff and Vale UHB who are on a register with their GP with a diagnosis of diabetes (type 1 or type 2), representing about 1 in 20 adults registered within a GP practice in the area 15. European age-adjusted percentages of patients who have a diagnosis of diabetes ranges from 5% in Western Vale GP cluster to 9.3% in City and South GP cluster. The Welsh Health Survey (2013/14) reported that 7% (age-standardised %) of people surveyed in Cardiff and 8% in the Vale of Glamorgan reported being currently treated for diabetes Quality and Outcomes Framework (QOF) Statistics for Wales, (Welsh Government (WG) 14 Daffodil projections-welsh Government. Figures have been taken from the Welsh Health Survey 2012 and prevalence rates have been applied to population projections to give estimated numbers predicted to have diabetes Public Health Wales Observatory, GP profiles (2015) 16 Welsh Health Survey 2013/14, Welsh Government Page 12 of 35

13 5. ORGANISATIONAL PROFILE Cardiff and Vale University Health Board (UHB) was established in October 2009 and is one of the largest NHS organisations in the UK. As a UHB, we have a responsibility for around 475,000 people living in Cardiff and the Vale of Glamorgan (from Trowbridge/St Mellons in the East to Llantwit Major/St Bride s Major in the West). This includes health promotion and public health functions as well as the provision of local primary care services (GP practices, dentists, optometrists and community pharmacists) and the running of hospitals, health centres, community health teams and mental health services. GP Practices, General Dental Practices, Optometry Services and Community Pharmacies are grouped within primary care clusters and support the UHB in planning and delivering services for local communities. Together with some services from other Health Boards, and key partners (for example learning disabilities services are provided by Abertawe Bro Morgannwg UHB and Specialist Children and Adolescent Mental Health Services (CAMHS) are provided by Cwm Taf UHB), the UHB provides a full range of health services for local residents. The UHB also provide specialist services such as paediatric intensive care, specialist children's services, renal services, cardiac services, neurology, bone marrow transplantation and medical genetics for people across South Wales, and in some cases the whole of Wales and parts of England. Specialist links with English Community Care Groups (CCGs), Area Teams and other teaching hospitals and Universities have been developed To deliver these highly diverse and complex services, the UHB spends over 1.2 billion every year and employ around 14,000 staff. As a teaching Health Board, Cardiff and Vale University Health Board has close links to Cardiff University, which boasts a high profile teaching, research and development role within the UK and abroad. This is alongside other academic links with Cardiff Metropolitan University and the University of South Wales. The UHB offers under and post graduate medical education and training as part of its agreement with both the Wales Deanery and Cardiff University School of Medicine. training the largest number of Allied Health Professionals, Healthcare Scientists and Nurses of any health board in Wales...The importance and value of effective and efficient diabetes services is recognised by the UHB, and has been identified as a key priority within commissioning intentions and Integrated Medium Term Plans for The UHB s Shaping our Future Wellbeing Strategy ( ) aims to achieve joined up care based on home first, avoiding harm, waste and variation, empowering people and delivering outcomes that matter to them. An integrated diabetes model of care delivery is one of several key service models and care pathways highlighted for implementation across the UHB as part of a service transformation programme aimed at delivering its strategic objectives. Much of the diabetes work is seen as an exemplar of how pan-system service transformation can make a tangible difference to outcomes for people living with a long term condition. Diabetes services Page 13 of 35

14 Responsibility for the delivery of diabetes services crosses a number of Clinical Board areas. In particular, Children and Women, Clinical Diagnostics and Therapies, Medicine and Primary, Community and Intermediate Care, with clinical diabetes leads identified for paediatric and adult specialities. Diabetes care in Cardiff and the Vale of Glamorgan is divided into services for children and young people under the age of 18yrs, and those over the age of 18ys. Effective transition protocols exist between services to ensure transition between services are experiences as seamless by those who use them. The governance structure for our diabetes work is provided below. Page 14 of 35

15 Diabetes services governance structure Adults Cardiff and Vale UHB s service model for adults with diabetes is transforming from a hospital centric service, to one which is predominately community focused and patient led, which is based on prudent healthcare principles, and which puts the needs of the person with diabetes, and their families, first. This is our Integrated Community Model for diabetes. The intention is to refocus services around the individual, removing barriers between specialties and organisations and introducing an approach that achieves outcomes for individuals and value for the system. The UHB is working to establish services codesigned with people with diabetes and their carers to enable the best possible health outcomes. To do this, we intend to integrate both the health care system, and the coordination of services around the patient, the aim being for the whole health community to join in partnership to own the health outcomes of patients with diabetes in their local area. The UHB s diabetes service planning is based on the following principles: The provision of services as close to where people with diabetes live as possible The provision of coordinated services without duplication or gaps Working in an integrated way (between primary care and specialists) and in partnership with social care and other providers Ensuring the workforce is trained (competency based), and care is delivered via multidisciplinary teams Page 15 of 35

16 The provision of services that support self management for people with diabetes Cardiff and Vale diabetes Integrated model of care Self management, retinopathy, dietetics, podiatry PREVENTATIVE GENERAL CARE COMPLEX CARE IN THE COMMUNITY SPECIALIST CARE Range of actions at different levels of the obesity pathway; includes physical activity, food, environments, policy Action to tackle other cardiovascular risk factors e.g. smoking; alcohol misuse All staff use a Making Every Contact Count approach An individual s practice includes their GP, practice nurse, community podiatrist, community dietician Annual care planning cycle including individual care plan Annual checks and screening Care bundles Peer support for people living with diabetes Community based multidisciplinary Team (MDT) providing support to primary care professionals GPS with managing more complex care Patient education programmes Education and training for primary care professionals Pregnancy advice for women of childbearing age Foot protection team Additional support for those with type 2 diabetes and poor glycaemic control Specialist care services are multidisciplinary transition diabetes foot service diabetes antenatal services T1DM service including insulin pump service Diagnostic service where there is doubt as to type of diabetes Outpatient service Diabetes inpatient service Diabetic kidney disease service Advice on medication and treatment via e mail Joint GP and Consultant virtual clinics Education and training of secondary care healthcare professionals MDT includes, Consultant Diabetologist, Diabetes Specialist Nurse, Diabetes Specialist Dietician, Diabetes Specialist Podiatrist Page 16 of 35

17 Preventative services Preventing diabetes is central to the UHBs plans. Key risk factors such as obesity, are being tackled through the implementation of specific local and national plans to improve physical activity levels, healthy eating and food environments and wider delivery through the obesity pathway work. The Making Every Contact Count programme of work aims to engage a range of professionals to provide General diabetes care The GP is responsible for overseeing management of adults with diabetes, with all patients offered an annual check by their GP, and the GP being responsible for the delivery of diabetes care bundles and care planning and coordination. Practice nurses play a key role in supporting the GP by providing additional support to people with diabetes, and taking responsibility for the provision of information and guidance on self management. Patients also receive clear information about their condition and referral to structured education programmes on diagnosis Complex care in the community GPs are supported to effectively support and treat people with more complex needs by Consultant Diabetologists who are linked to individual GP Practices, and who provide advice by e mail, and through bi-annual virtual clinics held at the Practices. The development of adult diabetic specialist nurse input at a primary care level is being undertaken as part of our service transformation programme, to complement the consultant input. A recent pilot of Diabetes Specialist Nurse support in GP practices has proved that prescribing efficiencies through a greater emphasis on human insulin use in type 2 patients, can release monies that could be used to support primary care with direct access to specialist nurse input. The benefits of this approach are clear. Patients seen in the outpatient department can potentially be discharged back to routine GP care more quickly, as specialist input will continue through the practice. More people with newly diagnosed diabetes can now be started on treatment within the primary care setting. Data from the model to date shows a 35% reduction in new type 2 diabetes referrals to secondary care and a more appropriate reason for referral with fewer referrals because of poor diabetes control. Specialist care People with complex care needs, including all type 1 diabetes patients, are referred to secondary care, and in Cardiff and Vale, around 3,000-4,000 adults with diabetes are seen each year as hospital outpatients. (Roughly one fifth of the people with known diabetes in the area).consultants work with individuals, with the support of a specialized multi-disciplinary team, to stabilise their diabetes, and optimise their diabetes care, before discharging back to primary care, with advice to the GP on ongoing diabetes management Page 17 of 35

18 Sometimes, people will need admitting to hospital to receive very specialised treatment. Cardiff and Vale employ specialist therapists and diabetes nurses who work alongside medical colleagues to ensure that people are able to return home as soon as possible. The benefits of the diabetes inpatient team extends to patients admitted whose primary diagnosis for admission was not diabetes but where the presence of diabetes frequently extends and adds to the complexity of the admission and length of stay. Education of inpatient staff across all hospital sites is central due to recognition of the numbers of patient entering hospital care who have diabetes (20% of the in-patient population) and therefore the need to ensure a much greater knowledge of diabetes management and diabetic needs across the health care system The UHB is working to integrate the team should into the wider community so that re-admissions of patients recently discharged can be avoided, and treatment plans set up within hospital are continued seamlessly in the community. Children and Young People Children and young people with diabetes under the age of 17, all receive their care from specialist (secondary) care. The hospital-based multidisciplinary team co-ordinates the individual s diabetes care, with the GP taking a holistic overview of the child s health and prescribing any medication, often in partnership with specialist care. Young people with diabetes move from paediatric to adult medical care at the age of 17. The risk of Diabetic ketoacidosis (DKA) at diagnosis of diabetes in children and young people has not changed in the last 10 years. Some of these children and young people will have had contact with healthcare professionals in the weeks leading up to their emergency presentation, suggesting there may be opportunities to improve diabetes diagnosis and management. A public and healthcare professionals campaign is currently underway by Diabetes UK (the 4 Ts), to raise awareness of the symptoms of diabetes in children and young people to try and avoid this potentially life threatening presentation of the disease. Overview of Local Health Need and Challenges for Diabetes Services Cardiff and Vale University Health Board (UHB) area is the smallest and most densely populated LHB area in Wales, primarily due to Wales capital city, Cardiff. 74% and 26% of the Cardiff and Vale UHB area population live within Cardiff and the more rural Vale of Glamorgan respectively. The UHB area includes 16% of Wales s population, yet it has an age and sex profile with marked differences to that of Wales (figure 1). Figure 1: Percentage of population by age and sex, Cardiff and Vale UHB and Wales, 2014 Source: Public Health Wales Observatory (2014) Page 18 of 35

19 Wales Males Cardiff & Vale UHB Males Wales Females Cardiff & Vale UHB Females The demographic profile of Cardiff differs from Wales due to the high number of students and young professionals aged resident in the area. However, in the Vale of Glamorgan, the population is similar to the population of Wales. Population projections suggest by 2030, the population of over 65 year olds will increase by 44% in Cardiff (19,710 people) and by 53% (12,480 people) in the Vale of Glamorgan. In particular, the numbers of the very elderly (85 yrs +) will increase markedly. The 2011 Census shows that 15.3% of the population of Cardiff described themselves as non-white. In the Vale of Glamorgan this figure was 3.6%. The Welsh average was 4.4%. Figure 2 shows the Welsh Index of Multiple Deprivation by lower super output area across Cardiff and Vale. It shows higher levels of deprivation around the south and east of Cardiff and Barry in the Vale of Glamorgan. Deprivation is known to be associated with poorer health outcomes. There are substantial gaps in life expectancy between people living in the most and least deprived areas and even more stark differences in healthy life expectancy and disability-free life expectancy. Figure 2: LSOA deprivation fifths within Cardiff and Vale UHB area, Welsh Index of Multiple Deprivation (WIMD) 2014, all residents Source: Public Health Wales Observatory (2014) Page 19 of 35

20 6. Development of Cardiff and Vale University Health Boards local delivery plan for diabetes In response to the Together for Health A Diabetes Delivery Plan (2013), health boards are required, together with their partners, to produce and publish a detailed local service delivery plan to identify, monitor and evaluate action needed within timescales. The health board executive leads for diabetes will need to report progress formally to their Boards against milestones in these delivery plans and publish these reports on their websites at least annually. The planning and development of diabetes services in Cardiff and the Vale of Glamorgan is coordinated through a multi agency group (the Diabetes Service Improvement Group), which represents all the different services and organisations working with people with diabetes in Cardiff and the Vale of Glamorgan. The group is supported by Executive sponsors, and views from people living with diabetes and their families are represented by Diabetes UK. The Diabetes Service Improvement Group meets bi-monthly. A Paediatric Diabetes Management Group is also in place to oversee the paediatric component of the plan. The Paediatric group lead consultant attends the Diabetes Service Improvement Group three times a year in order to consider areas requiring joint work across the two groups. Each work area of the delivery plan is sponsored by the relevant Clinical Board Director This group, following assessment of progress against priorities, has reviewed how service provision needs to change, has consulted people living with diabetes for their views on prudent diabetes care, and has drawn up actions to be undertaken during the period of the national delivery plan and in particular actions and outcomes to be delivered this year. These have been incorporated these into an 18 month transformational programme plan to expedite progress towards our goals. Page 20 of 35

21 The project plan is embedded here;- Copy of Project Plan only.xlsx In addition to this, lead clinicians have assessed what the UHB is currently doing, to establish what we can do differently or collectively, and to set priorities for within this plan. Page 21 of 35

22 7. Priorities for the coming year The Together for Health Diabetes Delivery Plan sets out action to improve outcomes in key areas between now and For the following national priorities have been agreed: Eye Care; Health boards to ensure 100% referral rates to DRSSW Measure times from referral by DRSSW to review by an ophthalmologist Ensure suitable local infrastructure to support new DRSSW clinic model Insulin Pumps; Health boards to provide NICE compliant insulin pump therapy service by improving expertise and annual training updates, meeting safety standards, providing patients with a choice of devices Health Care Professional Education; Health boards to ensure all inpatient staff and staff caring for people living with diabetes have adequate knowledge and training to safely manage diabetes Pregnancy; A preconception awareness campaign to be developed and implemented across Wales, supported by a preconception film (various languages) and health care professional on line education module In addition to these national priorities, Cardiff and Vale University Health Board highlights the following priorities for which reflect the needs of the local population: Children and Young People The priorities for are: Deliver a 24 hour, 7 days per week out of hours advice line for families and children with diabetes. This will be developed by the All Wales network Introduce of the first all Wales structured education module for newly diagnosed children and young people Develop capacity to ensure that every child with diabetes will be offered 4 (30 minute consultation) appointments with a Consultant every year Enhance the education provided to teachers, families and children about managing diabetes during the school day with the appointment of 0.5 wte band 7 paediatric diabetes clinical nurse specialist. Page 22 of 35

23 Participate in a second cycle of peer review (self-assessment) and acting upon outcomes Preventing Diabetes The priorities for are: Deliver concerted and widespread action to reduce obesity in the population of Cardiff and the Vale of Glamorgan Reduce other diabetes key risk factors in the population of Cardiff and the Vale of Glamorgan including smoking and alcohol misuse Raise the profile of Making Every Contact Count by implementing the communication plan Detecting Diabetes Quickly The priorities for are: Work with primary care and allied health professionals to raise awareness of the risks and symptoms of diabetes and explore innovative approaches for early detection Delivering Fast, Effective Care The priorities for are: Design and deliver a sustainable diabetes specialist nursing service model to provide specialist interventions, education, and support across all areas of healthcare delivery Deliver the recommendations of the diabetes retinopathy needs assessment to provide equity of access to services Ensure that people with diabetes who are admitted to hospital are delivered safe, timely, and effective care. Ensure that the NICE Diabetes in Pregnancy guidelines are met. Supporting Living with Diabetes The priorities for are: Establish peer support across additional areas of Cardiff and the Vale of Glamorgan, prioritised according to need Page 23 of 35

24 Deliver training on effective diabetes diagnosis and treatment to primary care professionals Increase access to our Education for Patients diabetes self care programme Design suitable and acceptable education and support provision for highest prevalence local population in City & South cluster Ensure that all people with diabetes have a personal care plan Improving Research The priorities for are: Continue with the current research programme Improving information The priorities for are: Publish a webpage focused on education and support for people living with type 2 diabetes (people living with diabetes have told us that this would be helpful to them). For those without internet access, we will consider other means of providing access to information Continue to work with the third sector to ensure effective signposting to sources of information and support Page 24 of 35

25 8. PERFORMANCE MEASURES/MANAGEMENT The Welsh Government s Together for Health a Diabetes Delivery Plan (2013) contained an outline description of the national metrics that health boards and other organisations will publish: Outcome indicators which will demonstrate success in delivering positive changes in outcome for the population of Wales. NHS assurance measures which will quantify an organisation s progress with implementing key areas of the delivery plan. Progress with these outcome indicators will form the basis of Cardiff and Vale University Health Board s annual report on diabetes. The first of these annual reports was published in 2013, and the next one will be published towards the end of Cardiff and Vale University Health Board also reports progress against the local delivery plan milestones to the Board annually and through its website. Page 25 of 35

26 9. ACTION PLAN Children and Young People Priority Actions required Lead Due Date Progress 24/7 out of hour s Work with the Justin Warner 2017 A proposal will be taken to the DDP emergency advice Network to achieve implementation group in March line this priority on an All Wales basis Create a new Liase with Ambika Shetty April 2016 On target. paediatric diabetes Llandough Out clinic in Llandough twice per month Patients Department Partcipate in the Complete the Justin Warner April 2016 Ongoing 2016 peer review assesment and programme submit a completed operational policy, annual report and workbook. Secure ongoing Ensure that the Mary Glover/Cath Dec 2016 Need for funding post April 2017 has been funding for the need for funding is Heath included in the Clinical Boards IMTP PDCNS education captured in the post from April Clinical Board IMTP 2017 Preventing Diabetes Priority Actions required Lead Due Date Progress Reduce population obesity Implement all levels of the All Wales Suzanne Wood and Helen Nicholls March 31 st 2017 Level 3 Obesity Service for adults now complete and operational. Page 26 of 35

27 Obesity Pathway IMTP bid for children s Level 2 and 3 Obesity Service, in process of development Page 27 of 35

28 Implement the action outlined in the Cardiff and Vale Food and Physical Activity action plans Collate available preventative services for easy Susan Toner Lauren Idowu Sian Griffiths Director of Public Health Report (2014) focused on obesity and used social media for 5 weeks during the summer of 2015 to engage with professionals and the public on further actions Action plans refreshed and agreed with partners. Examples of progress include:- Physical activity and primary care project being piloted with SW Cluster results expected May 2016 Walking Month (May 2015) promoted using social media Food Cardiff awarded bronze level within the Sustainable Food Cities Network Active travel to school project with Sustrans and the Police implemented Hospital Restaurant Food Standards implemented and restaurants progressing towards achieving full compliance GP Referrals to the National Exercise Referral Scheme analysed to inform future actions by Clusters Preventative initiatives for key risk factors including lack of physical activity, poor diet, smoking and alcohol misuse are Page 28 of 35

29 signposting signposted through the UHB Making Every Contact Count (MECC) programme. During , MECC training has been delivered to a wide range of staff from the UHB (including the podiatry team) and also partner organisations, including third sector and probation services. An external evaluation of the training of the podiatry team is due to report. In addition, training slides have been updated in response to feedback to include elements of motivational interviewing. The Cardiff and Vale Team led the organisation of and participated in a successful All Wales MECC Conference. Opportunities to further extend the reach of the programme will be sought in Further embedding the MECC approach within the UHB and improved communications will be a priority. Page 29 of 35

30 Detecting Diabetes Quickly Priority Actions required Lead Due Date Progress Work with primary Progress the Seetal Sal March 2017 care and allied provision of POCT health professionals to raise awareness testing in peoples home environments of the risks and symptoms of diabetes and explore innovative approaches for early detection Deliver adapted MERIT training to primary healthcare professionals Implement outcomes of recent work exploring challenges facing BME communities in accessing preventative health services Gerry Arthur Sept 2016 Training needs analysis completed and reviewed. Training plan being agreed Gerry Arthur Sept 2016 Review completed and plan has been developed Page 30 of 35

31 Delivering fast, effective treatment and care Priority Actions required Lead Due Date Progress Progress the Design and enhancement of delivering a service delivery sustainable within the primary diabetes specialist and community nursing service setting model to provide specialist interventions, education, and support across all areas of healthcare delivery TBC March 2017 Invest to Save funding secured for partial establishment of community service DSN service model and workforce capacity and transformation initiated Introduce MIQUEST data collection in primary care Provide training to primary care professionals on diabetes treatment and management Diabetes care pathway in full use in primary care Lindsay George July 2016 Work is on-going as per plan in relation to the delivery of this action TBC January 2017 A training needs assessment has been conducted and analysed. A work stream has been established to develop and deliver a training plan. Fran Ferner Jan 2017 The care pathway has been introduced in primary care. Use will be audited in June 2016, and any action to ensure full use will be developed as necessary Page 31 of 35

32 Improve timely access to specialist inpatient diabetes services, and ensure diabetes care is delivered effectively and safely on all ward areas Improve and implement foot screening for patients admitted to hospital who have diabetes Progress roll out of the Think Glucose Programme across all inpatient areas Review documentation related to hospital acquired foot damage and develop links with patient safety. Ward based education and development of a foot screening tool to sit alongside pressure ulcer prevention screening tools and body maps Ensure people with diabetes are referred to the specialist diabetes Aled Roberts March 2017 A work stream has been established, and a plan developed to deliver Think Glucose. Plan progressing to timescale, commencing with prioritised areas. Scott Crawley June 2016 Work is on-going to include foot checks on the ward dashboards Scott Cawley March 2017 A service evaluation is currently being carried out through research methodology on two wards in the UHB, which will help direct ward requirements of educational needs to implement diabetic foot screening across whole of the UHB. Funding will be required for Podiatry to undertake the educational support required Aled Roberts March 2017 Continue a schedule of awareness raising and education to ward based staff Page 32 of 35

33 Improve services for pregnant women with diabetes team within 24hrs of admission, Medical antenatal service to be developed on the UHW site Secure investment to screen and manage positive diabetes results in antenatal clinics Aled Roberts March 2017 A plan has been developed to establish this service Rachael Burton March 2017 Included in Children and Women Clinical Board IMTP Supporting living with diabetes Priority Actions required Lead Due Date Progress Improve self Develop alternative Geri Arthur October 2016 Review of challenges completed management of delivery of structure diabetes diabetes education programmes based on a review of the challenges City and South GP cluster implementing a pilot to improve access to services for BME communities in the area. accessing current programmes experienced by Black and ethnic minority communities Establish a March 2017 Partial funding secured through Invest to Page 33 of 35

34 specialist diabetes nursing service in the community setting save bid. Improving information Priority Actions required Lead Due Date Progress Improve the Develop a local Lauren Idowu June 2016 One consultation event held with people availability of website Complete living with diabetes on the format and information about consultation, content. Another event planned in March diabetes support identify a platform, available locally publicise and update as necessary Work with the third Lauren Idowu March 2017 sector to ensure effective signposting to sources of information and support POCT department Seetal Sal March 2017 Work to be initiated March 2016 to develop online training for home users Page 34 of 35