NHS Diabetes Prevention Programme: Expression of interest to participate in the first wave of national implementation

Transcription

1 NHS Diabetes Prevention Programme: Expression of interest to participate in the first wave of national implementation Name of organisation(s) making this application South East (Kent, Medway, Surrey & Sussex) Kent & Medway CCGs NHS Ashford CCG NHS Canterbury & Coastal CCG NHS South Kent Coast CCG NHS Thanet CCG NHS Swale CCG NHS Dartford, Gravesham & Swanley CCG NHS West Kent CCG NHS Medway CCG Surrey CCGs NHS rth West Surrey CCG NHS Surrey Downs CCG NHS Surrey Heath CCG NHS Guildford & Waverley CCG NHS East Surrey CCG NHS rth East Hampshire & Farnham CCG Sussex CCGs NHS Crawley CCG NHS Horsham & Mid Sussex CCG NHS Coastal West Sussex CCG NHS Brighton & Hove CCG NHS High Weald, Lewes & Havens CCG NHS Hastings & Rother CCG NHS Eastbourne, Hailsham & Seaford CCG Local Authority Public Health Kent County Council Medway Council East Sussex County Council West Sussex County Council Surrey County Council Brighton & Hove City Council Hampshire County Council South East Cardiovascular Strategic Clinical Network (Diabetes) (Kent, Medway, Surrey & Sussex) NHS England South (South East) Public Health England South East If this is a joint bid (e.g. multiple CCGs or CCG and Local authority), which organisation is taking the lead? The Paula Carr Diabetes Trust (Kent & Medway wide Joint bid across South East (Kent, Medway, Surrey & Sussex), including all CCGs, Local Authority Public Health Teams, South East Cardiovascular SCN, NHS England South (South East) and Public Health England South East The South East Cardiovascular Strategic Clinical Network (Diabetes) is compiling the bid application on behalf of all organisations. York House 1

2 Lead officer/primary contact for this application Massetts Road Horley Surrey, RH6 7DE Name: Jackie Huddleston Job title: Joint Interim Associate Director South Direct dial: Mobile: Map of the Partnership Organisations Number of Practices and Population per CCG across the South East SCN (Kent, Surrey & Sussex) 2015 CCG/LHB Name Practice Count CCG Population NHS ASHFORD CCG ,968 NHS BRIGHTON AND HOVE CCG ,000 NHS CANTERBURY AND COASTAL CCG ,579 NHS COASTAL WEST SUSSEX CCG ,000 NHS CRAWLEY CCG ,000 NHS DARTFORD, GRAVESHAM AND SWANLEY CCG ,000 NHS EAST SURREY CCG ,000 NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG ,677 NHS GUILDFORD AND WAVERLEY CCG ,072 NHS HASTINGS AND ROTHER CCG ,500 2

3 NHS HIGH WEALD LEWES HAVENS CCG ,612 NHS HORSHAM AND MID SUSSEX CCG ,000 NHS MEDWAY CCG ,000 NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG ,000 NHS NORTH WEST SURREY CCG ,000 NHS SOUTH KENT COAST CCG ,000 NHS SURREY DOWNS CCG ,000 NHS SURREY HEATH CCG 9 90,000 NHS SWALE CCG ,579 NHS THANET CCG ,000 NHS WEST KENT CCG ,730 3

4 Regional Demographic Information There are an estimated 266,350 people in the South East coast with diabetes, when adjustments are made for age, sex, ethnic group and deprivation. This is 7.3% of the adult population, higher than the average prevalence for diabetes for England as a whole of 7.4%. The map below shows the estimated levels of diabetes in the South East coast area for Source: Maps produced by South East KIT Public Health England. Data is available at National Diabetes Information Service, Diabetes Prevalence Model for England Less than 6.5% % % % 8.0% and over By 2030 levels of diabetes in the South East coast are expected to rise to 371,487 people or 8.9% of the adult population, compared with 8.8% for England as a whole. The map below shows the predicted levels of diabetes for each local authority area in the South East coast by 2030, assuming obesity continues to rise at the current rate. 4

5 Estimates of non-diabetic hyperglycaemia in local authorities in England in 2015 The data below gives the estimated number of people aged 16 and over who have non-diabetic hyperglycaemia by local authority across Kent & Medway, Surrey & Sussex. The definition for non-diabetic hyperglycaemia referred to in this document is from the NHS England Consultation Guide: National Procurement for the Provision of Behavioural Interventions for People with n-diabetic Hyperglycaemia Page 10: Individuals who are eligible for inclusion on the behavioural intervention will have non-diabetic hyperglycaemia, defined as having an HbA1c 42 47mmol/mol ( %) or a fasting plasma glucose (FPG) of mmol/mol. Only individuals aged 18 year or over will be eligible for the intervention. Name Number Prevalence Brighton and Hove 20, % East Sussex 57, % Kent 139, % Medway 22, % Surrey 106, % West Sussex 83, % South East Total 430, % England 5,047, % (Cardiovascular Intelligence Network August 26th 2015) 1. What ambitions or commitments to focus the NHS on prevention, or prevent Type 2 diabetes, are included in your local strategies and plans? The South East, which incorporates Kent & Medway, Surrey & Sussex, has a long standing recognition of the volume of people who are likely to progress to a diagnosis of diabetes (see predicted prevalence increases above). There has been a sense of frustration that there is limited, targeted to divert or delay this progression which invariably leads to a life changing diagnosis for patients and potentially lead to life limiting complications (blindness, renal damage, amputations, heart attacks). In addition diabetes currently accounts for 10% of the NHS budget but is predicted to rise to 17% of the NHS budget by The South East already has many examples, shared in this expression of interest, where work has been started to address this issue. This demonstrates the solid position the South East is in to confidently work with NHS England on Wave One of the national roll out of the NHS Diabetes Prevention Programme. This Expression of Interest has been produced at the behest of the constituent partner organisations by the South East Cardiovascular Strategic Clinical Network (Diabetes). The submission is from a collaboration of the 21 CCGs, 6 Local Authorities, Medway CCG/LA demonstrator site, the South East Cardiovascular Strategic Clinical Network (Diabetes) and NHS England South (South East) and the Paula Carr Diabetes Trust (Diabetes Charity covering the whole of Kent & Medway). These organisations cover the 3 counties of Kent & Medway, Surrey and Sussex and are co-terminus. The collaboration of organisations have agreed, by way of signing the expression of interest, to the following commitments: NHS South Regional Diabetes Programme Board 5

6 NHS South have committed to supporting diabetes prevention as part of a wider commitment to the South priority diabetes programme and as such can provide strategic support to the South East and ensure informed roll out to the rest of the South Region during further waves of the programme. Public Health Commitment Local Authorities and PHE Each of the 6 Local Authorities Directors of Public Health and the PHE South East Centre Director are committed to supporting CCGs in the implementation of the programme through the provision of public health support and advice to implement the programme successfully and ensuring that all people with non-diabetic hyperglycaemia identified though the NHS Health Check Programme are referred to the nationally procured service during 2016/17. The South East Cardiovascular Strategic Clinical Network (Diabetes) Commitment The South East CVD SCN has developed an effective Diabetes Clinical Advisory Group (CAG) since its inception in April 2013 with a comprehensive Diabetes work plan which has been agreed with CCGs and includes diabetes prevention. There is a dedicated diabetes clinical lead and programme manager in place who are also supporting this bid. The Diabetes Programme Manager currently provides support to the Medway Demonstrator site. The CVD SCN is committed to providing the strategic link and oversight through the clinical lead, programme manager and the CAG to support the relationships and work between the CCGs/LAs and the South East provider. CCGs Commitment 20 CCGs are committed to the identification and referral of 250 people per CCG with non-diabetic hyperglycaemia into the nationally procured service provider for the South East during 2016/17. This equates to a collective minimum commitment of 5,000 referrals across the South East. Detailed within the application are examples to demonstrate confidence that this is achievable. Medway CCG and LA NHS Diabetes Prevention Programme Demonstrator Site Commitment Medway CCG and LA are committed to supporting the South East partnership approach by providing their expertise and knowledge as forerunners in the region in implementing a diabetes prevention programme. The Paula Carr Diabetes Trust The Paula Carr Diabetes Trust is a Kent & Medway-wide charity covering a third of the partnership area. The charity is able to provide the conduit for patient and public involvement for a large proportion of the partnership to support Wave One. In addition, the Paula Carr Trust, in partnership with the Medway Demonstrator site, is supporting the development and pilot of a Diabetes Prevention Information Pack and the development and piloting of a Diabetes Prevention Taster session to encourage commitment to the Diabetes Prevention Programme if declined upon referral. We believe that the mobilisation of all the constituent partner organisations in developing in inputting into this expression of interest demonstrates the ability, commitment and willingness of Kent, Medway, Surrey and Sussex to successfully support the implementation of wave one of the NHS Diabetes Prevention Programme. 2. Do you have an integrated care pathway for people with non-diabetic hyperglycaemia/people at high risk of developing Type 2 diabetes? If yes, please provide a copy. The following CCGs have a pathway and examples are attached: Hastings & Rother CCG/Eastbourne & Hailsham CCG Horsham and Mid Sussex CCG details can be found here Crawley CCG are about to embark on a programme (details unavailable yet but will be similar to that 6

7 for Horsham and Mid Sussex CCG) It is envisaged that the partnership approach will enable sharing and collaboration to develop pathways across the South East. 3a. Do you have any existing provision of lifestyle interventions specifically tailored for people with non-diabetic hyperglycaemia? (go to question 4) Several areas across the partnership have provision for lifestyle intervention, detailed below. 3b. If yes, please describe current provision, including interventions provided, eligibility criteria, service capacity, numbers currently enrolled and numbers waiting to be enrolled if applicable. Brighton & Hove East Sussex Brighton & Hove CCG currently commission Sussex Community Trust to provide Walking Away from Diabetes which is a 3 hour group intervention for people who have been identified at risk of developing Type 2 diabetes. The intervention explores individual risk factors and how these might impact on the risk of developing diabetes and therefore long term-health. The programme primarily emphasises the role of increased physical activity and to some extent food choices so as to reduce the risk of developing diabetes. There are also services that are currently commissioned by Local Authority Public Health that are indirectly targeted at diabetes prevention, and mainly focus on preventing type 2 diabetes through a healthy weight and lifestyle. These include: Active for Life physical activity interventions; health walks and Shape Up and Weight Management Courses provided by the Food Partnership. NHS Health Checks are offered in primary care and the community. This includes diabetes screening questions and a blood sugar test. A diabetes risk factor awareness campaign was also run in pharmacies during March Hastings & Rother CCG and Eastbourne Hailsham and Seaford CCG have a locally commissioned service for diabetes that includes identification and management of Impaired Glucose Regulation, including nurse lifestyle advice and referral to existing local lifestyle services. This includes; an initial 20 minute appointment for risk communication of preventing diabetes/lifestyle advice; 10 minute follow up appointments at one, two, three, and six months; and an annual review (20 minutes) to review lifestyle compliance and HbA1c. IGR Pathway Hastings and Rother C Public Health have not commissioned any specific high risk diabetes interventions to date but weight management services are commissioned for adults with a high BMI and Health Trainers are commissioned to support lifestyle change. However, adults with a high BMI, including those with elevated HbA1C, would follow the East Sussex Tier 2 Weight Management Pathway and would be offered lifestyle interventions, including group based weight management services and/or a one to one behaviour change service (Health Trainers). Additionally, HR CCG has appointed the National Social Marketing Centre and Uscreates to 7

8 Surrey West Sussex Medway Kent co-ordinate a social marketing framework service. In Autumn 2015, it will work closely with target population groups to better understand health related behaviour and design and implement solutions that will work for them. This will include behaviour change campaigns and developing services for specific population groups. There are no specific programmes in place but Surrey LA PH team are leading on plans to expand and develop Tier 2 weight management programmes and the existing exercise referral programme. There is currently considerable work going into the screening and identification of pre-diabetes and diabetes. Prevention strategies are in place with all the CCGs, several of which focus on prevention, early detection and control of long term conditions, eg G & W, East Surrey, Surrey Downs, as well as the close working between Public Health team and the CCGs. East Surrey CCG: Practices in East Surrey are participating in an SMS study at East Surrey Hospital. It s an MRC-funded randomised investigation of the effect of text message augmentation of diet and exercise advice for people at high risk of developing diabetes. NHS referral required, and no NHS charge for two years of healthy living advice and six-monthly checks of HbA1c, blood pressure, lipids, weight, etc. Randomisation is to texts or no texts, so it s a safe and easy study in which to participate. Coastal West Sussex CCG: have commissioned a local Year of Care service which includes pre-diabetes education programme and annual testing. All practices in the CCG are signed up to the local service. Crawley CCG & Horsham & Mid Sussex CCG have an established commissioned tier 2 weight management service (WOW weight off workshops) and deliver social prescribing through the community hub based wellbeing teams. They also outreach into community and GP practices across the five communities of north west Sussex. Both CCGs are about to start a pre-diabetes programme with the District Council s Health and Wellbeing (HWB) hub, which will be accessed either through self-referral or via GP/Health professional referral using the local Wellbeing Prescription Pad. It will run in the evenings and weekends and offer an educational session led by a HWB champion trained by a Diabetes Specialist Nurse experienced in delivering motivational health behaviour change. People on the programme will be supported to identify achievable personal goals and a plan on how they will successfully reach them, once they have a better understanding of what prediabetes means to them. They will then have ongoing support from the HWB Champions to attend a free weight management support programme with free or low cost exercise opportunities over the following 3-6 months. We are also working on bringing both the public health commissioned T2 weight management and the CCG commissioned T3 programmes closer together in an attempt to support people to reduce their weight/bmi ( our T3 programme also contains psychological support). As a National Demonstrator site Medway are developing their existing tier 2 weight management programme to meet the latest evidence base from PHE for intensive lifestyle interventions for people at high risk of diabetes. This will commence in October. The Paula Carr Diabetes Trust will be developing and piloting Taster Sessions for people in Medway who decline the Medway Intensive Behavioural programme with the aim of converting patients into the full programme attendance or at least providing a short supportive intervention. In addition the Paula Carr Diabetes Trust will be developing an information pack which will be available with the risk identification promotional programme at Medway and be sent to anyone declining the intensive behavioural intervention, again with the main objective of using the pack to support reconsidering attendance at the full programme. West Kent CCG: has developed a Local Incentive Scheme (LIS) for 2015/16 that includes identification and management of IGR, including face to face consultation upon diagnosis and access to an intensive lifestyle programme which includes on-going tailored advice, support and encouragement. East Kent CCGs (Thanet CCG, Canterbury & Coastal CCG, South Kent Coast CCG and 8

9 Ashford CCG): Have been working towards a coordinated approach to non diabetic hyperglycaemia as part of the new diabetes integrated care pathway. Additional Question for CCGs/LAs: The focus of the national team is to have an intervention that is evidence based as described in the systematic review being conducted. This is an intensive programme with a minimum of 13 sessions of at least one hour duration with a defined total number of hours. Could CCGs/LAs indicate whether they would be willing to develop locally available interventions (current tier 2 weight management programmes or pre-diabetes programmes) in line with the evidence. CCG NHS ASHFORD CCG along with public health team and future community diabetes service. In Brighton and Hove we currently have a tier 2 weight (i.e. Shape Up service- offered by the Brighton and Hove Food partnership, we have 8 WTE health trainers, and are in the process of developing a tier 3 weight management service. We also have a pre-diabetes programmes (called walking away from Diabetes). And would link in join this up with the sports, physical activity and active travel work of the council. Brighton and Hove CCG and City Council Public Health Directorate would be keen to further develop any local programmes in line with the evidence to ensure sustainability of the NHS BRIGHTON AND HOVE CCG intervention. NHS CANTERBURY AND COASTAL CCG NHS COASTAL WEST SUSSEX CCG NHS CRAWLEY CCG Tier 2 & 3 are already provided in DGS commissioned by KCC Public Health. As a rth Kent economy we would be willing to develop further tier 2 interventions. NHS DARTFORD, GRAVESHAM AND SWANLEY CCG Willing to develop locally available lifestyle interventions for people with non-diabetic hyperglycaemia, however, we would require NHS EAST SURREY CCG Public Health support for this To meet initial demand, there is potential to modify current T2 weight management services, commissioned by East Sussex County Council Public Health. Service specifications could be altered to match the requirements of the NDPP without the need for local CCGs to develop or commission additional services themselves. Consideration has been given to timescales and capacity within the current service and it is felt that this could be achieved in a relatively short NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG timeframe NHS GUILDFORD AND WAVERLEY CCG 9

10 NHS HASTINGS AND ROTHER CCG NHS HIGH WEALD LEWES HAVENS CCG NHS HORSHAM AND MID SUSSEX CCG NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG NHS NORTH WEST SURREY CCG NHS SOUTH KENT COAST CCG NHS SURREY DOWNS CCG NHS SURREY HEATH CCG NHS SWALE CCG NHS THANET CCG NHS WEST KENT CCG See Eastbourne, Hailsham & Seaford CCG See Eastbourne, Hailsham & Seaford CCG we would be willing to develop this in collaboration with our partners and subject to available costs/ resources Tier 2 & 3 are already provided in Dartford Gravesham and Swanley commissioned by KCC Public Health. As a rth Kent economy we would be willing to develop further tier 2 interventions. - West Kent CCG has developed a Local Incentive Scheme (LIS) for 2015/16 to support earlier detection and management of Impaired Glucose Regulation (IGR) whereby practices are required to create and manage a register of patients with IGR. 4a. Which practice clinical software systems are used by GP practices in your local health economy, and how many (or what proportion of) GP practices use each of these systems? List attached. Appendix 2 SECSU GP Surgeries-E.xlsx 4b. Have you implemented any programmes or services in your local health economy that rely on searches of practice clinical software systems to identify patients eligible for the service/intervention? N.B. All CCGs have examples of programme implemented (dementia, high risk of admissions) but have focused responses on diabetes prevention) CCG Comments A level 1 practices are required to have a at risk NHS ASHFORD CCG register As from Jan 2016 we will have local risk stratification tool will provide the software function to create this NHS BRIGHTON AND HOVE CCG register for all practices. A level 1 practices are required to have a at risk NHS CANTERBURY AND COASTAL CCG register Practices are making lists of people with pre-diabetes as and when they arise, however despite CWS having a risk stratification tool utilised within Proactive care to case find the proactive caseload, it does not currently have a strategy to case find people with prediabetes NHS COASTAL WEST SUSSEX CCG We have a risk stratification tool which can identify NHS CRAWLEY CCG target cohorts on a population or practice level. 10

11 NHS DARTFORD, GRAVESHAM AND SWANLEY CCG NHS EAST SURREY CCG NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG NHS GUILDFORD AND WAVERLEY CCG NHS HASTINGS AND ROTHER CCG NHS HIGH WEALD LEWES HAVENS CCG NHS HORSHAM AND MID SUSSEX CCG NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG NHS NORTH WEST SURREY CCG NHS SOUTH KENT COAST CCG NHS SURREY DOWNS CCG NHS SURREY HEATH CCG NHS SWALE CCG NHS THANET CCG NHS WEST KENT CCG Planning to install PRMIS software to assist in identifying at-risk population part of Diabetes LCS requirements part of Diabetes LCS requirements We have a risk stratification tool which can identify target cohorts on a population or practice level. - but we are considering how best to do this A level 1 practices are required to have a at risk register A pilot has been conducted as part of the Health Inequalities project and evaluation is ongoing for potential inclusion in the Swale Enhanced Service for Diabetes A level 1 practices are required to have a at risk register all Level 1 practices signed up to the Local Incentive Scheme for IGR are required to have an at risk register. 5a. Do any local GP practices have established disease registers for people with non-diabetic hyperglycaemia? CCG NHS ASHFORD CCG We have just agreed that all level 1 practices should have a at non diabetic hyperglycaemia register NHS BRIGHTON AND HOVE CCG - All practices use clinical systems that can form a register for Pre diabetes by the condition being READ coded appropriately then searching on this code. The risk stratification tool is another tool that Brighton and Hove is implementing to support the register function from January NHS CANTERBURY AND COASTAL CCG We have just agreed 11

12 NHS COASTAL WEST SUSSEX CCG NHS CRAWLEY CCG NHS DARTFORD, GRAVESHAM AND SWANLEY CCG NHS EAST SURREY CCG NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG NHS GUILDFORD AND WAVERLEY CCG NHS HASTINGS AND ROTHER CCG NHS HIGH WEALD LEWES HAVENS CCG NHS HORSHAM AND MID SUSSEX CCG NHS MEDWAY CCG NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG NHS NORTH WEST SURREY CCG NHS SOUTH KENT COAST CCG NHS SURREY DOWNS CCG NHS SURREY HEATH CCG NHS SWALE CCG that all level 1 practices should have a at non diabetic hyperglycaemia of diabetes register (i.e. The Whitstable Vanguard have an established register with 600 people identified) as a requirement of the locally commissioned diabetes service Some Practices have access to registers via HISBi our CCG health informatics tool as part of locally commissioned service as part of locally commissioned service Some there is a prediabetes register in NW Surrey We have just agreed that all level 1 practices should have a at non diabetic hyperglycaemia of diabetes register 6/8 have confirmed they do have registers Do not currently have established disease registers for people with non-diabetic hyperglycaemia, however, we will be working to develop this as part of the following PRIMIS audits t currently However, the current diabetes LCS could be modified to include this as a requirement from April We are uncertain and are investigating 2/8 do not have registers 12

13 NHS THANET CCG NHS WEST KENT CCG We have just agreed that all level 1 practices should have a at non diabetic hyperglycaemia of diabetes register In progress part of Local Incentive Scheme 2015/16 5b. If yes, how many practices (in each of the CCG areas covered by the bid) have such registers? CCG / Number NHS ASHFORD CCG NHS BRIGHTON AND HOVE CCG All practices from January 2016 will have these registers. NHS CANTERBURY AND COASTAL CCG NHS COASTAL WEST SUSSEX CCG 53 NHS CRAWLEY CCG NHS DARTFORD, GRAVESHAM AND SWANLEY CCG - All practices have access to the registers 34 NHS EAST SURREY CCG N/A Plan to be able to refer non-diabetic hyperglycaemia throug h existing coded patients as well as identifying new patients through a planned PRIMIS search NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG 20 NHS GUILDFORD AND WAVERLEY CCG NHS HASTINGS AND ROTHER CCG 32 NHS HIGH WEALD LEWES HAVENS CCG NHS HORSHAM AND MID SUSSEX CCG NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG NHS NORTH WEST SURREY CCG Circ. 35 NHS SOUTH KENT COAST CCG NHS SURREY DOWNS CCG NHS SURREY HEATH CCG 6 out of 8 (2 no) NHS SWALE CCG 10 out of 19 practices NHS THANET CCG NHS WEST KENT CCG 5c. How many patients are on these registers? (total for each CCG area covered by the bid) CCG NHS ASHFORD CCG NHS BRIGHTON AND HOVE CCG NHS CANTERBURY AND COASTAL CCG (The Whitstable Vanguard have 600) NHS COASTAL WEST SUSSEX CCG 14,654 13

14 NHS CRAWLEY CCG NHS DARTFORD, GRAVESHAM AND SWANLEY CCG NHS EAST SURREY CCG NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG 266 people on IGR register NHS GUILDFORD AND WAVERLEY CCG NHS HASTINGS AND ROTHER CCG 701 people on IGR register NHS HIGH WEALD LEWES HAVENS CCG 239 people on the combined registers of the 3 (out NHS HORSHAM AND MID SUSSEX CCG of 23) practices who have supplied info so far. NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG NHS NORTH WEST SURREY CCG Approx in 2014/15 NHS SOUTH KENT COAST CCG NHS SURREY DOWNS CCG NHS SURREY HEATH CCG 581 people on IGR register NHS SWALE CCG 443 (reported for 14/15) NHS THANET CCG NHS WEST KENT CCG 5d. How are these registers currently used? CCG NHS ASHFORD CCG NHS BRIGHTON AND HOVE CCG NHS CANTERBURY AND COASTAL CCG NHS COASTAL WEST SUSSEX CCG NHS CRAWLEY CCG NHS DARTFORD, GRAVESHAM AND SWANLEY CCG NHS EAST SURREY CCG NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG NHS GUILDFORD AND WAVERLEY CCG NHS HASTINGS AND ROTHER CCG NHS HIGH WEALD LEWES HAVENS CCG NHS HORSHAM AND MID SUSSEX CCG NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG NHS NORTH WEST SURREY CCG NHS SOUTH KENT COAST CCG NHS SURREY DOWNS CCG NHS SURREY HEATH CCG Comments Currently not used sufficiently but will be used citywide from April Patients recalled annually to check on diabetes status, along with a brief intervention on lifestyle We are prioritising work around a process for utilising existing registers. This will be linked to the community contract from 16/17 N/A Offer intervention and lifestyle advice to patients with IGR Offer intervention and lifestyle advice to patients with IGR Registers are used to provide proactive, rapid access to advice and local lifestyle improvement initiatives through voluntary sector and community partners. To help identify patient annually for blood tests and to link prescribed medication, early initiation of Metformin for example. Aim to see all the people on this register in our diabetic clinic annually for review with the practice nurse for dietary and weight management advice, and for annual HbA1C monitoring to detect those 14

15 progressing to diabetes. NHS SWALE CCG NHS THANET CCG NHS WEST KENT CCG Call and recall of patients on register for annual health check and provision of education and lifestyle advice. Development of individual care plan with patient. 6a.Who is commissioned to provide the NHS Health Check in your area (if provided by general practice please state the number of practices that are contracted to provide the NHS Health Check)? East Sussex: General Practices are the commissioned providers for NHS Health Checks in East Sussex via a Public Health Local Service Agreement (PHLSA). All 72 GP practices across the three CCGs in East Sussex are signed up to provide NHS Health Checks for their patients. East Sussex GP practices are engaged with the NHS Health Check programme, offering and providing NHS Health Checks for their patients. East Sussex ranked in the top quintile of Local Authorities for eligible adults receiving their Health Check during 2014/15, with eligible adults having their Health Check and being assessed for diabetes. This is equivalent to 12.3% of the eligible population (25.2%) eligible adults have received their Health Check since April Surrey: Public Health commission NHS Health Checks mainly from GPs and Pharmacies with outreach and workplace delivery by a charity and leisure centre plus a small team of centrally trained practitioners, Surrey currently commissions form 79 GP practices and 55 pharmacies. (Hampshire Public Health commissions the service for the rth East Hampshire part of Farnham and NE Hampshire CCG.) Medway: All 55 practices are commissioned to provide NHS Healthchecks. Kent: Kent Community Foundation Trust are commissioned to deliver NHS Health Checks across Kent, they roll out the delivery across 40 pharmacies, 5 local authorities, CRI and outreach provider Wellbeing People with the largest proportion of the delivery via GP s as shown below: NHS HC GP status. of GP Practices GPs invite and check 158 GPs Invite only 29 GP Patients invited by KCHFT 12 Total 199 Brighton & Hove: 43 out of 44 practices are commissioned to provide NHS Health Checks. We have small community provision for 1 day a week on a monthly basis within the community. West Sussex: 70 GP practices of which 1 offers invitations only and 1 is a prison 70 Pharmacy sites 3 Prevention & Assessment Community Nursing Teams outreach service 1 Commercial provider outreach service including targeting BME groups, workplaces and deprived communities. 6b. Please describe your current NHS Health Check pathway for Type 2 diabetes testing, including: 15

16 test used (FPG or HbA1c), point of care testing or follow up appointment, who conducts the test? East Sussex: East Sussex follows the NHS Health Check best practice guidance for diabetes risk assessment (see diagram below), and has included this pathway in the PHLSA commissioning requirements with GPs. We are aware PHE and the NHS Health Check Expert Scientific Clinical Advisory Panel (ESCAP) have been reviewing the best practice for diabetes assessment, as the current pathway does not currently follow NICE guidelines for diabetes risk assessment. ESCC will continue to follow the best practice recommended and will update the local pathway subject to any future guidance. East Sussex County Council has made a significant investment in Point of Care Testing (POCT) equipment for the NHS Health Check programme. All practices were offered a grant to purchase POCT equipment that tests both the cholesterol and HbA1c, allowing patients to receive their full Health Check risk assessment, including diabetes assessment, in one appointment. Currently, individuals are assessed using BMI (adjusted for ethnicity) and blood pressure to identify people at high risk, and those high-risk are then offered a blood glucose test (HbA1c in POCT practices; blood glucose test using a venous blood sample in others). The test is conducted by the Health Check practitioner in General Practice (this is normally a Practice Nurse or Health Care Assistant). The NHS Health Check programme in East Sussex pays practices an enhanced rate for a Health Check using POCT to cover the additional cost of POCT consumables and quality controls for both cholesterol and HbA1c, encouraging immediate assessment for diabetes in adults who are identified as high risk. Currently 89% of practices (n=64) in East Sussex are currently using POCT. 86% of practices (n=62) are using the Roche Cobas B101 dual testing equipment that also tests HbA1c. Further grants have been offered to practices not currently using POCT to increase the use POCT for both cholesterol and HbA1c testing in the county. Practices that have the equipment could also use the HbA1c POCT equipment for additional opportunistic case finding of adults high risk for diabetes, outside of the NHS Health Check programme. Surrey: All GP and Pharmacy providers are directed to use point of care testing to assess HbA1c levels and 16

17 follow best practice guidelines on when to deploy. If levels are 6.5% or above on a repeated test, patients are referred to their GP for full diagnostic tests. If below, patients are given intensive lifestyle advice by the Health Check provider or GPs can make an exercise referral to a participating Leisure Centre in Surrey. Kent: If patients are of South Asian or Chinese origin and have a BMI of or of other ethnicities and have a BMI of 30+ then diabetes testing should be carried out. Similarly, if their BP is 140/90 or more, diabetes testing should also be carried out. This is via a follow up appointment carried out by the GP surgery and the surgery can choose either the FPG or HbA1c. Brighton & Hove: In Brighton and Hove HBA1c test is done on patients with BMI over 30. See flow chart attached NHS health check flow chart.docx West Sussex: Where the provider is a GP practice, pharmacy or PAT nurse team, there is no point of care testing within the health check. The diabetes filter is used to refer to GP for further diabetes testing. Our commercial provider undertakes point of care testing (HbA1c) as part of health check. 6c. How many (or what proportion of) people who received an NHS Health Check, required further testing for Type 2 diabetes (based on stage 1 of the NHS Health Check diabetes filter (currently based on BMI, blood pressure measure and ethnicity) Kent, Surrey & Sussex NHS Health Checks Network Data LAs Number of Patients Expected in 2015/16 based on projected NHS Health Check uptake of which 2.3% expected to be diagnosed at risk of diabetes (IGR) based on the NHS Health Check Ready Reckoner Tool Brighton & Hove 255 East Sussex 426 Kent 551 Medway 141 Surrey 391 West Sussex 562 Total 2,326 East Sussex: Information not collected 2013/14: While this data has not routinely been collected from the core General Practice provision (see below) a Community Health Check pilot ran between January and March 2014 targeting areas of deprivation. Of the 839 adults who had a Health Check, 316 people (37.7%) required an HbA1c test to be carried out because they had a BMI >= 30 (27.5 for South Asian) or an elevated blood pressure. 2014/15: This information has not routinely been collected in previous years from GPs. This was due to the legacy of the former Local Enhanced Service for Health Checks that transferred from the PCTs to NHS England on April 2013, and challenges to agree a variation to collect a wider dataset. This has been introduced in the new NHS Health 17

18 Check PHLSA for 2015/16 which intends to collect a larger dataset including additional information on adults identified high risk of diabetes. ESCC are currently working with the three East Sussex CCGs to identify and implement a suitable data extraction process to capture this dataset from clinical systems, with a view to a data capture system being in place by April Surrey: Surrey: Information not routinely collected. Kent: Based on ICAP data 1.1% of people having a health check had diabetes screening within a year of having a health check. We ve provided estimates via our NHS Health Check Network worked out at as follows using population estimates and the Ready Reckoner Tool alongside ICAP data. the figure for 2015/16 Kent is: Eligible population: 455,591 Eligible population to be offered a health check (20%): Estimated checks to be delivered (55%): 50,114 Expected to be at high risk of diabetes Ready Reckoner (2.3%): 1152 Expected to be at high risk of diabetes taken from ICAP Data people given diabetes screen following Health Check (1.1%): %* expected to take up IGR lifestyle change intervention: 979 (based on 2.3% fig) OR 468 (based on 1.1% figure) Brighton & Hove: Information not routinely collected. West Sussex: 2013/14: Total number of health checks undertaken 15,274 of which 12,712 were undertaken by the providers without point of care testing: Provider - Total number of checks Referred on for diabetes testing GP practices (9%) Pharmacies (12%) PAT nurses (15%) 2014/15: Total number of health checks undertaken 19,531 of which 13,309 were undertaken by the providers without point of care testing: Provider Total number of checks Referred on for diabetes testing GP practices (4.4%) Pharmacies (10%) PATS nurse (13%) Caveat t all GPs and pharmacies report full outcome data 2013/14: Total number of health checks undertaken 15,274 of which 2,652 were undertaken by the commercial provider with point of care testing: The figures below show the number and percentage of people referred to their GP for further diabetes test post HbA1c. Provider Commercial delivering an outreach service Number of checks Raised glucose result at check (38%) Referred to GP post HbA1c HbA1c tests taken at check 62 (63%) 2014/15: Total number of health checks undertaken 19,531 of which 6,222 were undertaken by the commercial provider with point of care testing: The figures below show the number and percentage of people referred to their GP for further diabetes test 18

19 post HbA1c. Provider - Commercial delivering an outreach service Number of checks Raised glucose result at check (39%) Referred to GP post HbA1c HbA1c tests taken at check 205 (87%) 6d. How many (or what proportion of) people requiring further tests for diabetes, accepted the offer and were tested? East Sussex 2013/14: 100% of those in the community Health check pilot described in 6c. 2014/15: Information not collected Surrey: Surrey: Information not routinely collected. Kent: Information not routinely collected. Brighton & Hove: Information not routinely collected. West Sussex: Information not routinely collected. 6e. How many (or what proportion of) people requiring further tests for diabetes, had a test result in the following range? East Sussex Test result 2013/ /15 HbA1c 6.5% / 48mmol/mol or FPG 7mmol/l Data for Community Health Check Pilot only (total 839 checks) 14 people i.e % of those HbA1c tested - 1.7% of those who had a Health Check HbA1c 6 6.4% / 42-47mmol/mol or FPG mmol/l Data for Community Health Check Pilot only (total 839 checks) 36 people i.e % of those HbA1c tested - 4.3% of those who had a Health Check Surrey: This Information has not been collected Kent: This information has not been collected Brighton & Hove: This information has not been collected West Sussex: Test result 2013/ /15 HbA1c 6.5% / 48mmol/mol or FPG 7mmol/l Commercial provider data only 17 out 1014 (1.7%) Commercial provider data only 42 out of 2426 (1.7%) HbA1c 6 6.4% / 42-47mmol/mol or FPG mmol/l Commercial provider data only 45 out of 1014 (4%) Commercial provider data only 164 out of 2426 (6.7%) Information not collected t collected from any other provider t collected from any other provider. 6f. How many (or what proportion of) people with a result in the HbA1c 6 6.4% / 42-47mmol/mol or FPG mmol/l range received a lifestyle intervention in response to this 19

20 result? East Sussex This information has not routinely been collected in previous years from GPs. This was due to the legacy of the former Local Enhanced Service for Health Checks that transferred from the PCTs to NHS England on April 2013, and challenges to agree a variation to collect a wider dataset. This has been introduced in the new NHS Health Check PHLSA for 2015/16 which intends to collect a larger dataset including additional information on adults identified high risk of diabetes. ESCC are currently working with the three East Sussex CCGs to identify and implement a suitable data extraction process to capture this dataset from clinical systems, with a view to a data capture system being in place by April Surrey: This Information has not been collected Kent: This information has not been collected Brighton & Hove: This information has not been collected West Sussex: Commercial provider data only for those in this range all received a lifestyle intervention within the health check. 7. Do you have any other existing local systems/programmes in place to identify people with nondiabetic hyperglycaemia? CCG NHS ASHFORD CCG NHS BRIGHTON AND HOVE CCG NHS CANTERBURY AND COASTAL CCG We are currently supporting (although not commissioned) the health and wellbeing board for Arun and Worthing who are running a pilot of half day education people at risk of diabetes NHS COASTAL WEST SUSSEX CCG NHS CRAWLEY CCG t currently but will prioritise via Diabetes Local NHS DARTFORD, GRAVESHAM AND SWANLEY CCG Implementation Group. Willing to develop locally available lifestyle interventions for people with non-diabetic hyperglycaemia, however, we would require NHS EAST SURREY CCG Public Health support for this Local Commissioned Services (LCS) for Diabetes includes Identification of patients with IGR. NHS EASTBOURNE, HAILSHAM AND SEAFORD CCG NHS GUILDFORD AND WAVERLEY CCG NHS HASTINGS AND ROTHER CCG Practices area offered financial incentive to: develop their IGR register; actively identify new cases; provide lifestyle advice and refer to local lifestyle services and follow up every 6 months (including an annual review). Local Commissioned Services (LCS) for Diabetes includes Identification of patients with IGR. Practices area offered financial incentive to: develop their IGR register; actively identify new cases; provide lifestyle advice and refer to local lifestyle services and follow up every 6 months (including an annual review). 20

21 NHS HIGH WEALD LEWES HAVENS CCG NHS HORSHAM AND MID SUSSEX CCG NHS MEDWAY CCG NHS NORTH EAST HAMPSHIRE AND FARNHAM CCG NHS NORTH WEST SURREY CCG NHS SOUTH KENT COAST CCG NHS SURREY DOWNS CCG NHS SURREY HEATH CCG NHS SWALE CCG NHS THANET CCG NHS WEST KENT CCG thing in addition to commissioning of pre diabetes register in primary care Beats and Breaths project (Health Inequalities) identifies at risk patients and advises them to see their GP 8. How many referrals do you estimate your area could generate (from general practice, NHS Health Checks, or other routes) into the diabetes prevention service in the first year, if the service was available in your area from January The South East Region (Kent, Medway, Surrey & Sussex) can commit to a minimum of 5,000 referrals to the nationally procured provider, which would equate to 250 per CCG in 2016/17. Based on the National Diabetes Prevention Prospectus, which quotes 37% take up rate for behavioural interventions, the 5,000 referrals should generate 1,850 attendees on the procured intervention equating to 18.5% - 6% of the 10,000 to 30,000 places expected to be procured nationally. 9. What systems would you put in place to refer people with non-diabetic hyperglycaemia into diabetes prevention programme lifestyle interventions? Across the South East we already have some areas with systems in place to refer people with non-diabetic hyperglycaemia. The CVD SCN would support the learning from the already established systems which would be shared across the partnership and support. We envisage that we will be able to work closely with the Medway Demonstrator site to share learning on systems but also the experience of referring to obesity management programmes. Examples: Swale CCG: Swale s enhanced service requires that education is provided annually to patients at risk register at the time of their annual review by the GP practice but there is no current referral pathway for these patients. Brighton & Hove: In Brighton and Hove we recognise the importance of how the programme is sold to patients in regards to the benefits of attending and impact to people quality of life and preventing diabetes. As well as raising awareness of such an intervention to primary care. We would promote such an intervention through annual update training to primary care practitioners. We would look into the possibility of incentivising case finding function and risk stratification tool for those with pre-diabetes through a Locally Commissioned Service and the new joined up LCS outcomes framework developed jointly between the CCG and public health. The comprehensive and enhanced LCS outcome framework will start April Horsham & Mid Sussex CCG: Currently refer patients using an information prescription to their local pre diabetes. rth West Surrey CCG: Suitable patients can be proactively identified via the CCG s pre-diabetes 21

22 register. Referrals can be coordinated at scale through the CCG s Referral Support Service. 10a. How would you engage general practice and NHS health check providers in developing and agreeing the referral pathway for the diabetes prevention programme? The CVD SCN Diabetes Clinical Advisory Group (including diabetes commissioning and provider) leads and the NHS Health Check Network would provide the overarching conduit for working with CCGs and LAs and the providers commissioned to share and support the development of agreed referral pathways in each area. East Sussex: There is commitment across the three CCGs and ESCC public health to training and developing the workforce to support the focus on reducing diabetes prevalence through the NDPP. Evidence and evaluation from protected learning events in HR CCG demonstrates that such event improve understanding of the importance early detection and prevention in diabetes. They improve awareness of referral pathways to local healthy lifestyle and behaviour change services. Brighton & Hove CCG: We would involve Clinical leads and engage with Local Member groups. A local partnership board (which includes service users and local providers) and the NHS Health Checks Steering Group (which also includes GPs, practice nurse and practice manager representatives) would further support this process. We also have a very limited facility to provide NHS Health Checks within the community led by a community health improvement nurse. 10b. How would you monitor use of the pathway? We would aim, as much as possible, to standardise the approach to diagnosis of non-diabetic hyperglycaemia to enable Region wide audit. While the local programme would need to develop a comprehensive mentoring and evaluation plan in the start-up phase, there are a number of potential sources of data and infrastructure that will support this. Data could be collected to monitor use of the pathway from both the NHS Health Check programme and LCS dataset, for example: 1. Health Check data Number identified high risk diabetes Number high risk referred to lifestyle interventions 2. Annual audit collects: Number patients on IGR register Number of interventions and type referred to Number of annual reviews Progression to T2 diabetes 3. Where Locally Commission Services (LCS) are in place there is potential to make amendments to include data requirements We would support that service provider, where appropriate to provide that dataset outlined in the NDPP consultation document: All KPIs requested in 7.6 of the NDPP consultation document, including but not limited to: o Demographic information of participants o Numbers (%) referred by referral source o Adherence Numbers (%) achieving at least 80% attendance o Change in body weight at 6 & 12 months (% of adults achieving 5% body weight at 12 months) o Change in HbA1c o Change in lifestyle behaviours 22

23 Brighton & Hove CCG: Brighton and Hove CCG and City Council would monitor the number of referrals to the intervention, the number of people who completed the intervention, the overall outcomes achieved by the intervention in terms of delayed onset of diabetes for those who have attended the course by having an annual follow up. We would use the reporting function from risk stratification tool and any other guidance from the pilot sites on measures and monitoring. Dartford Gravesham & Swanley CCG: DGS As above monthly performance data, Multi- agency Diabetes Local Implementation Group and HISBi performance intelligence system. rth West Surrey CCG: Coordinating referrals through our Referral Support Service would enable us to directly monitor referral and uptake levels as well as the proportion of the pre-diabetes register that have been offered preventative interventions. The central Referral Support Service would also be able to track trends relating to the number of referrals at an individual practice level to ensure equity of access across the CCG population. Demographic information can also be collected and monitored in this way. 11. How do you envisage the new nationally procured service would fit with your existing services? Primary care across the South East welcome the opportunity to refer people to a service due to the lack of targeted, evidence based, interventions for people with non-diabetic hypoglycaemia to try and divert or delay the onset of diabetes. A South East partnership approach across the participant organisations will provide fast paced shared learning to enable the identification and resolving of any issues. This will help ensure that the diabetes programme is an asset to the existing services available, specifically around weight management, NHS Health Checks and current pre-diabetes intervention programmes, rather than detraction. East Sussex The EHS/H&R diabetes LCS includes identification of patients with. The LCS aims to: To increase the identification of those with IGR in order to prevent or delay the onset of T2 diabetes To develop IGR register to allow for recall and monitoring To implement appropriate measure to reduce the risk of health problems associated with diabetes e.g. CVD Reduce the future burden of T2 diabetes on patients, their families and the NHS Offer intervention and lifestyle advice to patients with IGR To recognise T2 Diabetes when it does develop, in a timely fashion and before other co-morbidities arise HWLH and Brighton CCGs are in the process of commissioning an integrated consultant led community diabetes service that will be operational in April One key element of the service is to provide system and clinical leadership through a broad and inclusive partnership board to provide oversight across the system. The provider of evidenced based interventions for those at high risk of developing diabetes will be an integral part of the partnership board. Brighton & Hove: In Brighton and Hove we currently have a tier 2 weight (i.e. Shape Up service- offered by the Brighton and Hove Food partnership, we have 8 WTE health trainers, and are in the process of developing a tier 3 weight management service. We have a pre-diabetes programmes (called walking away from Diabetes). Brighton and Hove would be keen to adapt existing programmes and further develop local programmes in line with the evidence to ensure sustainability of the intervention. 23