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1 King s Research Portal Document Version Peer reviewed version Link to ublication record in King's Research Portal Citation for ublished version (APA): Murrells, T., Ball, J., Maben, J., Lee, G., Cookson, G., & Griffiths, P. (015). Managing diabetes in rimary care: how does the configuration of the workforce affect quality of care? King's College London. Citing this aer Please note that where the full-text rovided on King's Research Portal is the Author Acceted Manuscrit or Post-Print version this may differ from the final Published version. If citing, it is advised that you check and use the ublisher's definitive version for agination, volume/issue, and date of ublication details. And where the final ublished version is rovided on the Research Portal, if citing you are again advised to check the ublisher's website for any subsequent corrections. General rights Coyright and moral rights for the ublications made accessible in the Research Portal are retained by the authors and/or other coyright owners and it is a condition of accessing ublications that users recognize and abide by the legal requirements associated with these rights. Users may download and rint one coy of any ublication from the Research Portal for the urose of rivate study or research. You may not further distribute the material or use it for any rofit-making activity or commercial gain You may freely distribute the URL identifying the ublication in the Research Portal Take down olicy If you believe that this document breaches coyright lease contact libraryure@kcl.ac.uk roviding details, and we will remove access to the work immediately and investigate your claim. Download date: 5. Se. 018

2 Managing diabetes in rimary care: how does the configuration of the workforce affect quality of care? Deartment of Health Policy Research Programme, ref. 016/0058 Trevor Murrells Jane Ball Jill Maben Gerry Lee National Nursing Research Unit, King s College London Graham Cookson Deartment of Management, King s College London Peter Griffiths University of Southamton November 013 i

3 Acknowledgements We would like to thank all those who contributed to this study. We are articularly indebted to members of the roject advisory grou for their time and insights throughout the study (listed in the aendix). We would like to articularly thank Henrietta Mulnier for her work to develo the Readcode classification system of activity. Thanks also go to Mary Thomson, Fiona Hill and Anne Costello at Cegedim Strategic Data Market Research for liaising over the use of The Health Information Network (THIN) database and coordinating an additional survey of ractices to inform the research. Finally our thanks go to our administrative colleagues, Stehanie Waller, Isabell Mayr and Karen Pollock for their hel in reort roduction. This is an indeendent reort by the National Nursing Research Unit (NNRU) at the Florence Nightingale School of Nursing and Midwifery, King s College London in collaboration with the University of Southamton. The NNRU received funding from the Deartment of Health through the Policy Research Programme. The views exressed here are not necessarily those of the Deartment. This reort should be cited as: Murrells T, Ball J, Cookson G, Maben J, Lee G, Griffiths P (013) Managing diabetes in rimary care: how does the configuration of the workforce affect quality of care?. National Nursing Research Unit, King s College London. Contact address for further information: National Nursing Research Unit Florence Nightingale School of Nursing and Midwifery King s College London James Clerk Maxwell Building 57 Waterloo Road London SE1 8WA nnru@kcl.ac.uk, NNRU website: htt:// Florence Nightingale School of Nursing and Midwifery website: htt:// ii

4 Contents Summary... 1 Research aim... 1 Background: focus on diabetes... 1 Identifying outcome measures... Key Findings... 4 Diabetes and its management in the last ten years... 4 Primary care activity over the last ten years... 4 How does glycaemic control vary?... 4 The rimary care workforce... 5 Who manages care of atients with diabetes in rimary care?... 5 What range of activities do staff undertake in consultations?... 6 What difference does it make who manages diabetes care?... 6 What are the cost imlications?... 6 Conclusion Introduction and background Introduction Background Diabetes and its management Role of ractice nurses Develoments in the NHS... 1 Quality and Outcomes Framework (QOF) Aim Chater 1 Summary Methods Patient level data set (THIN data set) Patient and ractice selection iii

5 . Defining staff consultations using THIN data... 0 Measures of workforce activity....3 Choice of outcome measure: using HbA1c as a measure of diabetes control Defining other variables Adjusting for co-morbidities Analytical aroach (model) Ethics... 8 Chater Summary Survey of ractices in 01 (workforce and diabetes care) Background: ractice size, location and tye Practice workforce Aroach to diabetes care Chater 3 Summary Staff consultations and atient outcomes Patient Profile Prevalence of diabetes in the THIN ractices Staff activity Doctor and nurse consultation rates Tyes of activity undertaken by doctors and nurses Consultation duration and total contact time Practice oulation achievement of glycaemic control Chater 4 Summary Relationshi between workforce and diabetes control Health rofessional contact Diabetic review... 6 Chater 5 Summary Service configurations and economic imlications The data iv

6 6. Analysis and results Discussion... 8 Chater 6 Summary Discussion & Recommendations Introduction Achievement of glycaemic control over the last 10 years Workforce activity in managing diabetes Performance and cost Strengths and Limitations Conclusion Recommendations References Aendix 1 Project grou members Aendix Technical details: THIN Aendix 3 Additional tables Aendix 4 Read codes (activity labels) Aendix 5. Algorithm for removing weight outliers Aendix 6. Practice survey questionnaire v

7 Summary Research aim This roject continues a rogramme of work led by the NNRU that has sought to exlore the relationshi between workforce configuration in the health service and atient outcomes. In a nutshell we seek to address: what difference does it make who rovides care and treatment to atients? The ramifications of different workforce models have been more thoroughly investigated in the acute sector, but there has been far less research undertaken to determine the imact of emloying different combinations of staff in rimary care. As art of the Policy Research Programme funded by the Deartment of Health the NNRU began research in this field by using secondary data to see if the level of ractice nurses emloyed bore any relationshi with the quality of care rovided in GP ractices, as measured by the Quality and Outcomes Framework (QOF). Findings suggested that there was an association between level of ractice nurse staffing and erformance based on Doran s comosite diabetes measure and certain QOF Diabetes Indicators (HbA1c 7.4%, HbA1c 10%, Total cholesterol 193mg/dl), (Griffiths et al, 010b). This led to an interest in ursuing the research further, focusing in deth on one articular condition using atient level data (as oosed to ractice level quality scores) and more detailed workforce data. Thus the current study was commissioned to examine whether different workforce configurations (and activity) in rimary care are associated with variation in control of diabetes as measured by haemoglobin A1c (HbA1c) level, a recognised and commonly used measure of diabetes control. We focussed in articular on the extent to which eole with diabetes received care from nurses, as oosed to general ractitioners, because there is strong advocacy for a olicy shift at rovider level to ass much routine chronic disease care from doctors to nurses. Background: focus on diabetes Diabetes is an imortant condition to focus on not least because of the hugely increasing revalence over the last ten years (described by some as an eidemic ) and the cost associated with treating it. It is estimated to affect 3.6 million eole in the UK and cost the NHS at least 10 billion a year. Understanding the ways in which the nursing contribution has imacted on the management of atients with diabetes has imlications for the delivery of diabetes care in the future, and otentially the management of other chronic conditions in rimary care. To address this question, we needed to find ways of quantifying both inuts (in terms of who is doing what and the balance between nurses and doctors) and outcomes (variation in control of diabetes). Neither are straight forward. 1

8 Identifying outcome measures After examination of the literature and discussion with clinical colleagues on the roject team, glycaemic control (measured by Hb1Ac) was identified as a key outcome measure, in that it reflects how well controlled an individual s diabetes is, but also because oor control is associated with higher risk of comlications and adverse health (such as Coronary Heart Disease, stroke, renal failure, visual imairment and neuroathy). To get a sense of how well a ractice is doing in managing diabetes, the roortion of their atients with diabetes achieving a certain level of control is measured. A number of HbA1c thresholds have been used as erformance metrics since QOF was introduced in 004. These have included 7%, 7.4%, 8%, 9% and 10%. We chose the lower and uer thresholds for use in this study ( 7%, 10%). To make fair comarisons of the level of successful control between ractices with different workforce configurations the many factors that affect the glycaemic control of diabetes atients need to be accounted for hence the analyses needed to adjust for individual and oulation differences. To do this required us to use data generated directly from atient records to roduce a case-mix adjusted measure of glycaemic control achievement er ractice oulation. We used THIN data sulied by CEDEGIM which gives comlete consultation records extracted from the database of a nationally reresentative samle of 556 general ractices. As well as caturing glycaemic control, the THIN data also rovides details of each consultation atients received. These data were used to tell us about the number of consultations, who they were with, the roortion with nurses or doctors, and the tyes of activities undertaken. Differences in glycaemic control were exlored in two ways: - by comaring change over time. We have a data set generated from atient records that sans ten years, from 00 to 01, and so can exlore differences in glycaemic control over the years in relation to any differences observed in the roortions of consultations undertaken by different staff, or changes in the tyes of activity undertaken. - by comaring ractices within the current year: we examined how glycaemic control varies between ractices and how much variation is associated with differences in the workforce configurations (staffing levels and mix). For 01 we were able to identify the healthcare rofessional (GPs, ractice nurses or secialist ractice nurses) who tyically lead the management of diabetes in each ractice, through a survey undertaken in the sring of 01 (covering 49 ractices). Glycaemic control is artly determined by a erson s individual characteristics and artly by the way care is delivered in each ractice. A multilevel modelling aroach was therefore used to ascertain individual (through risk adjustment) and ractice level (including workforce) effects uon control of diabetes. The table below summarises the key measures this study uses and the data sources they are drawn from.

9 Table 1. Data sources used for quantifying inuts and outcomes Question How measured Source Outcome How well do ractices Proortion of atients with diabetes THIN atient manage atients with achieving glycaemic control (at two records 00- diabetes? different levels) adjusted to account for 01 ractice (e.g. location, ostcode (socioeconomic) variable indicators, revalence) and individual differences (e.g. age, co-morbidity, obesity) Inuts Staffing levels and mix Size of workforce (atients er GP, atients er ractice nurse), and mix (ractice nurses as roortion of clinical workforce) Practice survey 01 How much care is rovided to atients with diabetes? Number of consultations er year THIN Who do atients see GPs or ractice nurses? Average number of consultations er year by GPs and by ractice nurses Proortion of all consultations that are held with ractice nurses THIN THIN Is secialist nursing inut available? Emloying nurses with ostgraduate qualification in diabetes Practice survey What activities are undertaken (by whom)? Activities coded within the consultation THIN Who leads management of diabetes? GPs or ractice nurses (with or without secialist knowledge), shared with hosital/community based secialists Practice survey 3

10 Key Findings Diabetes and its management in the last ten years Our data shows the revalence of diabetes has increased by 66% over the last decade reflecting other national statistics. The average number of atients with diabetes in each ractice has increased from 37 in 00, to 375 in 01. As a roortion of all atients, those with diabetes account for an average of 4.9% of total list size now, comared with 3.0% in 00. Imortant in understanding what this means for ractice activity, is the fact that the clinical identification of atients with diabetes has also changed - eole with diabetes are detected at a much earlier stage than in the ast (because of more rigorous and regular review such as annual health checks) so there is an increased roortion of the diabetic atient oulation that have less severe diabetes now, and are being heled to manage their diabetes earlier. Glycaemic control (that is the ercentage of atients with diabetes that have an Hb1Ac level below a certain threshold) imroved considerably between 00 and 004. Since then imrovement slowed and then lateaued in 005 for the uer threshold ( 10% - reflecting loose control of diabetes) and in 009 for the lower ( 7% reflecting tighter control) of the two thresholds. Primary care activity over the last ten years Across all staff grous there has been an increase in activity, in that the annual number of consultations undertaken with atients with diabetes has increased by 13%. Practice nurses have increased their activity much more than doctors during this eriod a 0% increase in annual consultations with eole with diabetes comared with just 1% increase amongst GPs. The overall effect of these changes means that whilst in 00 70% of consultations were undertaken by doctors, this has fallen to 64% in 011/1. Meanwhile the average roortion of consultations undertaken by nurses in each ractice has increased slightly (from 31% to 3%) and those by other healthcare rofessionals from less than 3% to 8%. However, the amount of activity has not increased as sharly as the number of atients, so although both doctors and ractice nurses are doing more consultations each year with eole with diabetes atients, each erson with diabetes is actually getting fewer consultations er year now than in 00 (the average has fallen from 16 er year to 11.5). Practices with lower staffing levels (e.g. more atients er whole time equivalent GP or er whole time equivalent registered nurse) undertook fewer consultations with each individual erson that had diabetes. How does glycaemic control vary? Glycaemic control is now much more uniformly achieved across ractices, than was the case ten years ago. The amount of variation due to differences between ractices as a roortion of all variation (eole and ractices) fell from 14% to 9% for HbA1c 7% and from 1% to 11% for HbA1c 10% from 00 to 011. Much of the variation that aears to exist between ractices in ability to achieve glycaemic control is therefore related to differences in the atient oulations served. Practice variation was even smaller for the 011/1 atient (eole with diabetes) data linked to the 4

11 ractice survey (166 ractices). This laced limitations on what could be achieved statistically in terms of testing associations between workforce variables from the ractice survey and glycaemic control, however a consistent icture emerged over the ten-year eriod from the analysis of The Health Information Network (THIN) data. Practices where ractice nurses delivered a high roortion of the diabetes care erformed as well as those ractices where doctors delivered most of the care. Indeed otimised DM care is just as good when redominantly rovided by nurses comared to care which is mainly rovided by GPs. The rimary care workforce A key art of this research has been to establish in more detail the comosition of the rimary care workforce, and determine who is doing what in relation to care of atients with diabetes. Do ractices vary in how they are staffed, and the way in which they manage and rovide diabetes care? Our survey (undertaken in Sring 01, n=49 ractices) showed that ractices vary in the size and comosition of their workforce. A tyical ractice emloys an average of 4 GPs, registered nurses (RNs), 1 care suort worker/assistant, a ractice manager and 7 recetionists/admin staff (whole time equivalents). Nurses make u a third of the trained clinical staff (e.g. total GPs and RNs), but this varies considerably: 5% of ractices have no registered nurses whilst in 1% of ractices RNs make u more than half of the clinical staff. Larger ractices (5 or more WTE GPs) are more likely to emloy exerienced nurses (on higher aybands) and to emloy nurses with ost-graduate qualifications in diabetes, comared with smaller ones (less than 3 GPs). 84% of nurses in larger ractices hold a ost graduate qualification in diabetes comared with 44% in ractices with less than 3 WTE GPs. Who manages care of atients with diabetes in rimary care? A nurse (or nurses) who secialises in diabetes leads the management of care of eole with diabetes in 58% of ractices, and non-secialist ractice nurses lead care in 11% of ractices. 18% of ractices say that the GP leads management of diabetes atients. 89% of ractices that emloy a nurse with ostgraduate secialist qualification in diabetes reort that care of atients with diabetes is generally managed by a nurses (or nurses) who is secialised in diabetes. Smaller ractices are more likely to say management of care is shared with hosital or community consultants (% vs. 5% in medium or large), are slightly less likely to use their own ractice nurses (61% vs. 71% of medium sized), and are less likely to have care in the hands of a designated GP or ractice nurse with secialist knowledge (51% vs. 83% in larger ractices). In ractices where nurses hold secialist ostgraduate qualifications, the majority of diabetes care is rovided through regularly held clinics secifically for eole with diabetes (74% comared to 41% of cases where there is no secialist ostgraduate trained diabetes nurse). Practices in which nurses undertake a larger roortion of consultations with atients with diabetes (as defined from the atient records data) are more likely to reort that nurses lead the management of diabetes care. In ractices where nurses see a larger roortion of diabetes atients, doctors 5

12 send nine minutes less a year (61 minutes vs. 70), but atients have 7 minute more contact time in total (13 minutes vs. 105 in the low nurse contact grou). What range of activities do staff undertake in consultations? What activities staff undertake during consultations with atients with diabetes has also changed over the last ten years. Practice nurses have been doing a larger number and range of activities; in 01 they were making.7 times more entries on atient records than doctors. Much more activity is focused on annual review now than ten years ago, articularly by ractice nurses. Statistical modelling suggests that where diabetes review and monitoring is haening more often, then glycaemic control is more likely to be achieved. What difference does it make who manages diabetes care? Whilst there has been an overall reduction in the number of consultations er atient, glycaemic control has been maintained. The changes were greatest between 00 and 005. After alying risk adjustment at the atient and ractice level, ractices in which eole with diabetes had a higher roortion of ractice nurse contact had significantly more atients meeting both the lower threshold ( 7%) and higher thresholds ( 10%) thresholds in 003. The difference was close to significance in 005 for the lower threshold only. The more often eole had their diabetes reviewed the greater the likelihood of glycaemic control being achieved. It did not seem to matter whether it is a doctor or ractice nurse undertaking the review however the ercentage of diabetes reviews undertaken by ractice nurses has increased from 53% in 00 to 65% in 011. Therefore the role of ractice nurses in the delivery of diabetes review could become a key factor in the further reduction of HbA1c levels and the achievement of diabetes control. What are the cost imlications? The study findings indicate that whether doctors or ractice nurses take the lead in delivery diabetes care (or whether they are secialists in diabetes care) has no discernible effect on the robability of a erson reaching good diabetes control. The absence of a strong relationshi, either ositive or negative, indicates that ractices which rimarily use GPs to manage diabetes care could release significant resources by switching their service configuration towards nurse-led care. Practice nurses undertake more diabetes review, which is associated with better glycaemic control and ractices may therefore wish to make even greater use of ractice nurses. Currently ractices that deliver a higher roortion of care for eole with diabetes by nurses save on doctors time but savings are not sufficient to cover the costs of additional nurse consultation time. Nurses are therefore roviding an extra resource. The oortunity costs of using GPs to deliver additional care would be high as would be the costs of delivering the additional care in secondary settings. However, the benefits of the additional care are not demonstrated in terms of HbA1C control. The costs and benefits associated with changes remain uncertain and it should be borne in mind that confining an economic analysis to a short time window may not reveal all the costs going forward. 6

13 Conclusion As diabetes has become increasingly revalent, more care is being delivered and managed by ractice nurses. The roles of doctors and nurses have changed: eole with diabetes have fewer consultations er year, but more of them are undertaken by nurses, who increasingly do review activities (monitoring, follow-u, annual review). Regular diabetes review is associated with imroved glycaemic control, and during the last decade glycaemic control across the ractices has imroved. However whether looking longitudinally or within the latest year s data, little of the variation in ractices erformance is found to relate secifically to differences in the way in which ractices are organised or staffed. The vast majority of variation relates to differences between eole with diabetes. The study shows that where ractice nurses undertake a higher roortion of consultations with diabetes atients, ractices erform the same (in terms of glycaemic control) as ractices where more of the consultations are done by doctors. In this study ractices that made more use of nurses reduced the amount of time atients sent with doctors but also delivered more care (as measured by consultation time) overall with equivalent outcomes. The savings in doctors time does not aear to be offset by the additional costs of time sent with other ractitioners, redominantly nurses. However there are oortunity costs associated with the use of GPs or secondary care to rovide additional services. There is considerable scoe to substitute nurses for GPs in delivering care for eole with diabetes and to use nurses as a means of delivering enhanced care. The costs and benefits of this strategy remain uncertain but there is no evidence of harm. Indeed it is fair to say that otimised diabetes care is just as good when redominantly rovided by nurses comared to care which is mainly rovided by GPs. Other research suggests that atient satisfaction may be imroved. 7

14 1. Introduction and background 1.1 Introduction As the oulation ages, there is a ressing need to cost-effectively manage the care of increasing numbers of eole with long-term conditions, and revent unnecessary hositalisation. Pressure to find cost-efficient solutions to the delivery of health care have been intensified by the recent global and national financial crisis. Currently, it is estimated that as many as 3,636,000 eole in the United Kingdom (excluding Northern Ireland) live with diabetes (Kanavos et al 01). For some grous in the oulation, (for examle black Caribbean and Indian men) the revalence is over 10% (NICE 008). The figure is rising as the incidence of tye II diabetes mellitus, by far the most common form, increases. A diagnosis of Tye II Diabetes Mellitus is associated with a significant increase in the utilisation of healthcare resources (Gulliford et al, 008). The costs of diabetes are significant: a recent reort estimated that aroximately 10% of the NHS budget ( 10 billion) was sent on diabetes in 011 (Hex et al, 01). A large roortion of this (66%) results from hosital care and treatment for comlications that arise including CHD, stroke, renal failure, visual imairment and neuroathy (Kanavos et al 01). With good diabetes control many of these comlications could be revented or onset delayed (Burden, 003) but the roortion of atients achieving tight control, as measured by HbA1C (glycosylated haemoglobin) 6.5% is low, and significant numbers do not achieve less tight but good levels of control (HbA1C 7.5%) (Kanavos et al 01). Primary care has become the focal oint with more diabetes care now taking lace in GP ractices (NICE 008 Forbes et al 011). In order to imrove the quality of chronic disease management in rimary care, a ay for erformance scheme, the quality and outcomes framework (QOF), was introduced in 004/5. This included targets and incentives for imroving the quality of care for eole with diabetes. In many ractices much of the work involved in delivering results against the QOF indicators has been delegated by GPs to nurses (Leese, 006) and over recent years there has been a steady increase in both the number of nurses emloyed in general ractice and the roortion of consultations that are undertaken by them (Hiisley-Cox et al., 007, The Information Centre, 008), although increases in staff numbers have tailed off more recently. Models of nurse-led diabetes care have been advocated and ositively evaluated in a range of settings including rimary care (Vrijhoef et al., 00) and there is evidence of similar outcomes when eole with diabetes are managed by non-secialist nurse ractitioners in rimary care (Mundinger et al., 000). Some have argued that there is considerable scoe to further increase the amount of rimary care delivered by nurses (Sibbald, 008a, Sibbald, 008b) but the otential extent and desirability of substitution is contested (Knight, 008). Evidence of the imact on the quality of diabetes care of a widesread and routine increased nursing contribution is scant and there is little if any data on which to lan otimal skill mix between nurses and GPs in general ractice. 8

15 Researchers have reviously attemted to quantify the imact of nurse staffing olicies on atient outcomes (Rafferty et al 007, Aiken et al., 00, al-haider and Wan, 1991, Blegen et al., 1998, Hartz et al., 1989, Knaus et al., 1986, Sochalski, 001). The majority of studies have been erformed within acute care (e.g. hosital setting) and reort adverse atient outcomes and quality of care (Blegen et al., 1998, Sochalski, 001). The tyes of adverse atient outcomes examined included medication errors, atient falls, infections, atient comlaints and mortality. A systematic review and meta-analysis of 96 studies confirmed these findings; increased nurse staffing was associated with lower odds of hosital related mortality and adverse atient outcomes (Kane, Shamliyan et al., 007). The odds of hosital related mortality was 9 to 16% lower for each additional full time registered nurse er atient day while a curvilinear association between staffing and outcomes was demonstrated. Within the hosital setting, there aears to be consistent evidence that nurse staffing affects atient outcomes. As art of the current rogramme of research we demonstrated that higher levels of ractice nurse staffing is associated with imroved ractice erformance (as measured by QOF) for certain long-term conditions including diabetes (Griffiths et al., 010a). Our research suggested that the effect of ractice nurse staffing remains after controlling for atient, ractice, ractitioner, and organisational factors (Griffiths et al., 011) although ractices with higher levels of nurse staffing are also associated with higher levels of admissions for diabetes, but not other conditions (Griffiths et al., 010b). 9

16 1. Background Diabetes and its management Between 006 and 011 in England, there was a 5% increase in the number of eole diagnosed with diabetes and it is estimated that there are 850,000 eole with undiagnosed diabetes (Diabetes UK, 01). If these current trends continue, it is anticiated that by 05 there will be 5 million eole in the UK with diabetes (Diabetes UK, 01). Diabetes is associated with significant mortality and morbidity. It can lead to cardiovascular disease (coronary heart disease and stroke), renal failure, retinoathy, eriheral neuroathy and limb amutation. For examle, those with diabetes are 48% more likely to have a myocardial infarction than the rest of the oulation (Diabetes UK, 01). Managing otentially reventable comlications consumes as much as 80% of the money allocated to diabetes care. There is an increasing emhasis on the revention of diabetes-related comlications through screening and assessment services in the rimary care environment. For examle to minimise risk of coronary heart disease and stroke, regular cholesterol and blood ressure checks are advised (Diabetes UK, 01). Primary care can successfully manage chronic diseases such as diabetes and otentially reduce the need for hositalisation due to comlications (Basu et al., 00, Zhan et al., 004). However, the numbers of admissions for eole with diabetes aears to be increasing in England (Bardsley et al., 013). Those with diabetes require on-going otimal management to ensure their diabetes is well-controlled and enable early detection of associated comlications. A 6 to 0 year reduction in life exectancy is observed in those with oorly controlled diabetes (Seshasai et al., 011). Hence the revention of comlications is closely linked to good glycaemic control. Nine Key Care Processes were derived from the National Service Framework (NSF) and the National Institute for Health and Clinical Excellence (NICE) and aimed to enable healthcare rofessionals to agree actions with individuals on managing their diabetes. The agreed standards relate to: Blood glucose level measurement Blood ressure measurement Cholesterol level measurement Retinal screening Kidney function testing (urine) Kidney function testing (blood) Weight check Smoking status check Foot and leg check 10

17 Two landmark studies, the Diabetes Control and Comlications Trial (DCCT) and United Kingdom Prosective Diabetes Study (UKPDS) demonstrated that comlications associated with diabetes are reventable or delayed through intensive glycaemic management (The Diabetes Control and Comlications Trial Research Grou (DCCT), 1993, UK Prosective Diabetes Study Grou (UKPDS), 1998). However, the tight glycaemic control needed is not consistently relicated in clinical ractice (Seight, 013). One of the exlanations ut forward is the relatively low number of atients being offered structured diabetes education (Seight, 01). Although tight glycaemic control is not universally achieved, investigators have documented reductions in HbA1c in conjunction with blood ressure and lasma cholesterol reduction in several Euroean studies (Cooer et al., 009, Kloos et al., 011, Mata-Cases et al., 01). However in England there is large variation in the standard of care achieved against the nine standards of care set out by NICE. For examle the roortion of individuals receiving their annual health checks ranged from 6% in some areas to 69% in others (NHS Information Centre for Health and Social Care, 011). The majority of those with diabetes (91%) have their annual blood ressure checks but a recent audit reveals that 1.4 million have hyertension with only between 41 and 61% of eole achieving the recommended levels. Role of ractice nurses General Practices rovide rimary healthcare to the community usually emloying general ractitioners, ractice nurses and other staff including administrative staff, hlebotomists, sychologists and other healthcare rofessionals. Practices vary in size from a single GP to large ractices with five or six GPs and several ractice nurses. As in acute care, some research attention has focussed on the efficacy (and cost-effectiveness) of different staffing configurations. A key question has been: can ractice nurses deliver some asects of care to levels comarative to general ractitioners? Several studies have outlined the changes to ractice nurses workload and their increased role in caring for those with chronic conditions such as diabetes (Gemmell et al., 009, Laurant et al., 005, Richardson, 1999). The findings suggest that nurses rovide comarable high quality care that is comlementary to that of their medical colleagues. One review stated that extending nursing roles within general ractice was feasible at imroving service caacity with no comromise of quality of care or health outcomes (Sibbald et al., 006). However these studies tyically focussed on nurse ractitioners secifically as oosed to ractice nurses and all examined services delivered within the tightly controlled arameters of clinical trials. The workload of ractice nurses has reortedly changed over the ast decade with nursing now dealing with more comlex atient care (Gemmell et al., 009). Nurses are now more likely to rovide atient care via a range of nurse-led clinics that allows for health romotion and surveillance of 11

18 chronic disease such as asthma, diabetes and chronic obstructive ulmonary disease (COPD). The cost imlications of these changes however remain unclear (Laurant et al., 005, Richardson, 1999) Develoments in the NHS Over recent years the NHS has undergone radical reorganisation. The role of general ractice in commissioning has been significantly increased and the nature of general ractice itself is subject to substantial change with new oortunities for a range of roviders to rovide general ractice services. While much of the management of eole with diabetes has shifted from hosital based ambulatory settings to rimary care management, with the suort of community or hosital based secialists, the otimum model of care rovision both within general ractice the otimal method of delivering care remains unclear for both commissioners and roviders. Quality and Outcomes Framework (QOF) The quality of rimary care was difficult to quantify rior to the introduction of a new system of reimbursement linked to erformance indicators known as the Quality and Outcomes Framework (QOF). Since the introduction of QOF in 004, detailed descritive information is now available (National Health Service Confederation, 006). In 004 QOF consisted of a total of 146 indicators that include measures on chronic disease management (76 indictors covering 11 chronic diseases including diabetes), ractice organisation (56 indicators), atient exerience (4 indicators) and additional services (10 indictors) and one indicator on access. The oints are weighted and a score calculated for each ractice with a maximum score of 1050 oints (Deartment of Health, 006). The QOF has allowed researchers to describe the quality of rimary care and the relationshi between social derivation and other factors, such as ractice characteristics (Ashworth and Armstrong, 006). The study revealed that three variables were associated with higher QOF score: training ractices, grou ractices and ractices in less socially derived areas. The conclusion was that ractices in areas of higher social derivation had a lower quality of care when measured using the QOF. There is some evidence that higher QOF scores are associated with imroved outcomes such as reductions in mortality, morbidity, hosital referrals and non-elective admissions (Bottle et al., 008a, Bottle et al., 008b, Downing et al., 007, Srirangalingam et al., 006). One study used the GP Research Database to examine the quality of diabetes care at atient level from re QOF (000/01) to ost QOF imlementation (006/07) in 148 ractices (Kontoantelis et al., 013). The authors recorded imrovement in the first year ost incentive comared to re-incentive at 14.%; this droed to 7.3% in the third year but remained statistically significant. The variation in care between oulation grous decreased over time but in some instances remained substantial. Levels of care varied according to gender, age, years of revious care, co-morbidities and ractice diabetes revalence. The financial incentives for ractices are significant. If diabetes targets are met, the average ractice could earn 7,500 in the first year and 1,500 in subsequent years (NHS Information Centre for Health and Social Care, 007). Interestingly Kontoantelis and colleagues (013) reorted a decrease in emergency hosital admissions but this effect was not sustained. 1

19 Unfortunately, the aer did not rovide details on which members of the ractice undertook atient care. Previous research by the National Nursing Research Unit used the Quality Outcomes Framework to examine long-term conditions such as diabetes, and found that higher levels of ractice nurse staffing were associated with imroved ractice erformance (Griffiths et al., 010b). However, ractices with more nurses also had higher rates of unlanned admission among eole with diabetes. But findings based on ractice level data are constrained. Aggregated data can hide imortant relationshis. There is limited ability to control for individual atient characteristics and no indication how the workforce is actually deloyed to care for eole with a articular condition. Thus there is no guarantee that findings based on aggregated data (e.g. ractice) will be relicated when data (atients) are disaggregated. This led to an interest in ursuing the research further, focusing in deth in this study on one articular condition using atient level data (as oosed to ractice level quality scores) and more detailed workforce data. 1.3 Aim The aim of the current study is to examine whether different workforce configurations (and activity) in rimary care are associated with variation in control of diabetes. We focussed in articular on the extent to which eole with diabetes received care from ractice nurses, as oosed to general ractitioners, to exlore the imact of the more general shift of chronic disease care from doctors to ractice nurses in rimary care. Secifically the study seeks to address the following research questions: What tyes of (diabetes related) activities are undertaken by doctors, ractice nurses and other healthcare rofessionals; to what degree does this vary across ractices and over time? Do ractices where ractice nurses undertake a higher roortion of consultations with diabetes atients erform worse, the same, or better in terms of glycaemic control than ractices where there is a different attern of consultations amongst ractice staff? Are relationshis reviously found between ractice nurse staffing and erformance under QOF for diabetes relicated using atient level data? Which workforce attributes (e.g. nurse led, secialism in diabetes) offer the most effective rovision of care for eole with diabetes in terms of health outcomes and costs? Chater 1 Summary Diabetes is seen as an imortant condition to focus on due to its increasing revalence over the last ten years and the costs associated with treating it: it is estimated to affect 3.6 million eole in the UK and cost the NHS 10 billion a year. 13

20 Several studies have outlined the changes to ractice nurses workload and their increased role in caring for those with chronic conditions such as diabetes (Gemmell et al., 009, Laurant et al., 005, Richardson, 1999). Understanding what difference increasing the nursing contribution has on the management of atients with diabetes may have imlications for other conditions in rimary care. Previous research by the National Nursing Research Unit used the Quality Outcomes Framework to examine long-term conditions such as diabetes, and found that higher levels of ractice nurse staffing were associated with imroved ractice erformance. The aim of the study is to examine whether different workforce configurations (and activity) in rimary care are associated with variation in control of diabetes. 14

21 . Methods As set out in Chater 1, the study aims to examine the nature of relationshi between workforce configurations (and activity) in rimary care and outcomes of atients with diabetes (as measured at the atient level). The aroach taken draws on two main data sources: Patient level data on consultations with 319,649 eole with diabetes from a nationally reresentative samle of 556 ractices that indicates activities undertaken, who consultations were with, and outcomes. (The Health Information Network (THIN) data each year from 00 to May 01). A survey of 49 ractices contributing to the THIN database to rofile their workforce and activities relating to management of diabetes. These data are hierarchical. Medical records over time are nested within atients who are nested within ractice. Data will therefore be analysed using a multilevel modelling aroach (Goldstein, 1995). The amount of care delivered by ractice nurses (and doctors) will be estimated by the roortion of consultations undertaken by ractice nurses, and this will be related to the attainment of HbA1C targets and workforce configuration..1 Patient level data set (THIN data set) THIN Data is sulied by Cegedim Strategic Data Medical Research UK (CSD) and currently covers more than 3.7 million active atients (6.% of all UK Patients) from 556 GP Practices in the United Kingdom (UK). THIN data consists of anonymised data on the following: diagnoses, anonymised commentary written by the health hysician, symtoms, rescritions issued, tests and results, measurements and readings taken in the ractice, demograhic information, dates of entry in and out of the database such as information on death and outcomes of conditions and treatments. Medical conditions are recorded using the Read Clinical Classification Version and 75% of THIN ractices are now electronically linked to athology laboratories and receive test results electronically. THIN Data are gathered from ractices that use an electronic clinical system called Vision for managing atients data (htt:// Data are extracted using unobtrusive anonymous data collection software written by CSD s sister comany, INPS. New ractices joining THIN undergo a Full Data Collection, which includes all retrosective data. Incremental data are then downloaded automatically each month. Data collection commenced in November 00. England, Scotland, Wales and Northern Ireland all contribute GP ractices to THIN although the majority are from England (Aendix A.1). THIN Patients have a similar age, gender and medical 15

22 conditions rofile to that found in the UK oulation. A Comarison of demograhics, derivation (Townsend), Quality and Outcomes Framework condition revalence and deaths from THIN with national and QOF 006/7 data found that demograhics were similar although THIN had fewer eole aged less than 5 years. Diabetes revalence was similar (THIN 3.5% vs. National 3.7%). THIN atients tended live in more affluent areas (THIN 4% vs. National 0%). Adjusting for demograhic and derivation the 006 THIN death rate was close to the national death rate (9.1 er 1000 vs. 9.4 er 1000)(Blak et al, 011). Patient records are regularly udated and therefore it is ossible to track a atient longitudinally whilst they remain on the Vision system and registered in the same ractice. Figure.1 Structure of the THIN Data Source: THIN Data Guide for Researchers Version.6: 8 March 013 (Cegedim Strategic Data Market Research UK) Data can be linked across the three main THIN clinical datasets (Medical records, Additional Health Details, Theray) using the ractice, atient and the consultation IDs. Patient level ostcode variable indicators for each atient can be linked to these datasets using the ractice ID and atient ID. 16

23 Members of the ractice staff can be linked to records on the three main datasets using the Staff ID. The Staff file contains the roles of each member of staff so it is ossible to identify the role of the erson (e.g. doctor, ractice nurse, administrator) who entered or made a change to the atient s record. The Vision System allocates ownershi of the consultation record to one member of staff, usually the erson who oens the record for the first time. It is ossible that one or more other members of staff may add or make changes to the record. For examle a ractice nurse may see a atient initially but a doctor then subsequently rescribes a theray. It is ossible for more than one tye of healthcare rofessional to be involved in a consultation. The ractice file holds information on three key dates: use of Vision, Comuterisation and comliance with Accetable Mortality Reorting (AMR). To enable the analyses to be undertaken, a dataset needed to be generated from the THIN database, selecting eligible atients and ractices. Patient and ractice selection Stage 1 Patients who fulfilled the following criteria were selected for inclusion into the study dataset: Be flagged with an A (Accetable record) or C (Accetable: transferred out deceased without additional death information) code on the atient file thereby confirming the atient is suitable for research. Have a code from the list of 61 Diabetes Readcodes in either their Additional Health Details or Medical Records files. The code must have been entered after the registration, Accetable Mortality Reorting or Vision date. The list of 61 diabetes Readcodes (see Aendix A.) was created from re-existing lists (CSD; Public Health Sciences, King s College London) and from an insection of THIN Readcodes access database (sulied by CSD). These criteria resulted in 406,36 atients being selected from 556 GP ractices. The size of the various datasets is shown in Table.1 below. 17

24 Table.1 Diabetes THIN datasets File Records Patients 406,36 Medical 84,447,383 Additional Health Details 173,058,95 Theray 199,877,160 Consultations 158,50,984 Postcode variable indicator 444,309 Staff 1,339,89 Stage Patients with a Readcode that indicated gestational diabetes were excluded if they had no other diabetes Readcode in their atient record (n=168) reducing the oulation down to 406,195. A second algorithm was then alied to the atient record to identify atients where the medical record, additional health details and theray record gave a strong indication that the erson was diabetic. This necessitated the classification of Readcodes into seven grous (A to G)(Aendix A.3). Only grous A (diagnostic and label codes) and B (Annual review) were used in the algorithm for selection of eole with diabetes. All grous were used when we comared medical record Vision system entries made by doctors and ractice nurses to the medical record (section 4.3). Algorithm for selecting eole with diabetes A erson was included if they satisfied one, or more, of the following criteria alied in the sequence 1 to 6 (Note a erson is only included in the first grou they are allocated to. They may also have satisfied one or more of the other criteria further down the sequence): 1. One or more codes from Grou A and one or more diabetic treatment rescribed (n= 73,169, 67.3%). One or more codes from Grou A and at least two from Grou B with different event dates (n=33,431, 8.%) 3. One or more diabetic treatments rescribed and at least two from Grou B with different event dates (n=3,856, 1.0%) 18

25 4. One or more codes from Grou A and two HbA1c measurements at least 30 months aart (n=545, 0.1%) 5. A HbA1c value 6.5% or higher (n=7,657, 1.9%) 6. Two codes from Grou A recorded at different dates (n=986, 0.%) (Criteria 5 and 6 were added after an initial review) This catured 319,649 (79%) atients. Those eole not selected have been groued by whether they had a diagnosis Readcode, an annual review Readcode, had received diabetic theray and had two HbA1c measurement less than 30 months aart (Table.). Table. Peole not selected by the algorithm Diagnosis readcode Annual review readcode Diabetic Treatment code Months between Hba1c measurement No. % Absent Absent Absent 30 months or more less than 30 months No measurement Present 30 months or more less than 30 months No measurement Present Absent 30 months or more 09.6 less than 30 months No measurement Present Absent Absent less than 30 months No measurement All Those atients not selected were subject to a further review. We samled 10 atients from each category to see whether we were excluding certain atients unnecessarily. We were not, and based on this review we decided to not add any further categories. For the majority of these atients diabetic treatment, diagnosis of diabetes and annual review of diabetes was absent from their records. HbA1c may therefore have been measured for other reasons for examle as art of an annual health check. 19

26 Stage 3: Selection of ractices 1. No ractice was included rior to it joining the Vision System.. No ractice was included rior to AMR being attained % (or more) of all HbA1c measurements had to be recorded in, or could be transformed into, ercentage units % (or more) of consultations could be associated with a member of ractice staff whose staff role was known and was something other than administration. (In earlier eriods, before the year 000, records were entered more often by administrative staff on behalf of their healthcare rofessional colleagues) The number of THIN ractices meeting the eligibility criteria increased from 47 in 00 to 471 in 009. Since 009 there has been fall to 434 in 011/1 (see Aendix A.1).. Defining staff consultations using THIN data Each time a atient has a consultation with a healthcare rofessional a new record is oened on the Vision system. A member of ractice staff can only oen a record, or make changes to a record, if they are authorised to do so. Some of the records oened by ractice staff do not necessarily relate to direct atient contact, for examle the record might indicate that a letter has been written. We therefore restricted our definition of a consultation, or direct contact, to activities that took lace in the GP surgery, or where there was contact with a healthcare rofessional outside of the surgery (e.g. a home visit). Phone conversations with a atient were also included in this definition. Below we have listed the tyes of contact (which may relate also to location of the contact) used: Surgery consultation Clinic (often by nurse) Follow-u/routine visit Home visit Acute Visit by GP to atients home, usually during normal working hours Night Visit (e.g. by ractice doctor, locum GP, colleague, or deutising service) - often an emergency Out of Hours visit by ractice doctor, often an emergency Telehone call to atient Co-o surgery consultation or home visit (collaborative out-of hours service by local GPs) Telehone consultation Children's home visit Twilight visit 0

27 The tye of contact or location that is allocated when a consultation record is first oened remains consistent across the consultation, medical, additional health details and theray datasets. Each member of ractice staff allowed to enter records has their own unique staff ID. The Vision system allocates ownershi of the initial consultation record to one erson. That erson s staff ID, and no other, will aear in the consultations dataset for that consultation. Each time staff make changes to a atient s record (this could be to the medical, additional health details and theray records) their staff ID is added. The medical, additional health details and theray record for a consultation all share the same consultation ID. Therefore it is ossible to link records from the same consultation and ascertain whether more than one member of staff has been involved. Although the consultation dataset holds a record of the duration of each consultation (i.e. the time between oening and closing the consultation record) it was not ossible to aortion time between healthcare rofessionals when a consultation is shared. Each staff ID can be linked to a staff grou (e.g. doctor, ractice nurse, harmacist) using a looku file. The deth of occuational coding has imroved since 00; the ercentage of records coded to missing or administration has decreased for all four datasets (Medical record: 4.3% to 0.8%, Additional Heath Details: 7.0% to 1.%, Theray Record: 0.9% to 0.1%, Consultation file: 6.% to 4.3%). We included administration in the calculation of this ercentage because in the ast administrators were often used to enter data on behalf of their medically trained colleagues, articularly doctors. As will become evident below this ractice aears to have diminished over time. In Table.3 we show how the staff grou derived from the medical, AHD and theray records, which could involve one or more members of staff comares with the single role allocated by the Vision system that aears on the consultations dataset only, for those consultations taking lace in one of the locations listed above for 00 and 011 (Note this dataset also includes atients that were not selected by the algorithm in Stage Section.1 above). The congruence between the two sources for staff grou is good. 1

28 Table.3 Occuational grou allocation to consultations Vision allocated role grou from the consultations file theray record role grous Occuational Grou No. % No. % No. % Doctor Practice Nurse Other nurses, midwives Other healthcare rofessionals Administration Unknown n/a n/a n/a n/a All Doctor Practice Nurse Other nurses, midwives Other healthcare rofessionals Administration Unknown 1099 <0.01 n/a n/a n/a n/a All Vision allocated role grou also aears in either the medical, AHD or Role grou aears in either the medical, AHD or theray record on its own or with other Measures of workforce activity The activity of staff was calculated on the basis of all consultations undertaken in relation to the erson with a diagnosis of diabetes, rather than restricting our study solely to activities that that were exlicitly related to diabetes care. This aroach was adoted to take account of the multile system and diagnoses that are affected by diabetes (as shown in the literature). All consultations, tests, checks and treatments relating to comorbidites associated with diabetes were catured; for examle hyertension, discussions about weight loss, diet, exercise etc. A considerable amount of care received by a erson with diabetes may be directly, or indirectly, related to their diabetes, and is likely to be a factor in much of their care, even when it is not the rimary activity coded to their consultation. We were able to calculate the number of all tyes of consultation er annum for each erson with diabetes, and the number of times they were seen by doctors, ractice nurses and all healthcare rofessionals in total. We used two main measures of workforce activity: the average number of times eole with diabetes were seen by a healthcare rofessional (er annum) and the ercentage of consultations in that year involving ractice nurses, divided into three levels: low (less than 6%), medium (6-35%) and high (over 35%) based on tertiles (three grous of equal or near equal size) derived from data for 00 (the reference year). The ercentage of diabetes reviews undertaken by ractice nurses were similarly groued into low (less than 34%), medium (35-77%), and high (over 77%).

29 .3 Choice of outcome measure: using HbA1c as a measure of diabetes control As the literature shows, good glycaemic control is key to managing diabetes and reventing comlications. Glucose attaches to haemoglobin during the life san of a blood cell. HbA1c reflects average lasma glucose over 8 to 1 weeks and is widely used in the management of diabetes. Blood for the uroses of testing HbA1c can be taken at any time of day; fasting is not required. Since 00 HbA1c has been measured in % units (reviously HbA1c was often measured using other units such as international units. The unit of measurement is now changing to mmol/mol. There has been a transition eriod where Hba1c has been measured in both % and mmol/mol units. However, to enable consistency across the time eriod studies, the measurement as a ercentage has been adoted. The thresholds against which glycaemic control is monitored have varied both between organisations reorting it and over time. Nearly all ractices (>98%) were using %HbA1c to measure glucose levels from 003 onwards, making it a feasible indicator for this research. The nearest HbA1c reading to the 1 st July (mid oint of the year) was selected for each erson with diabetes for each calendar year from 00 to 011. When two Hba1c measures were equidistant either side of 1 st July their mean was taken. For the 011/1 analysis dataset the value nearest to the 16 th May 01 was chosen, in order to coincide with timing of the Practice Survey (undertaken in May 01 to July 01). Each ercentage HbA1c reading was then categorised according to whether the articular threshold was met. We chose thresholds that sanned the full range reviously used for QOF ( 7%, 8%, 9%, 10%).4 Defining other variables In order to examine the ossible relationshi between staffing inuts (in terms of workforce attributes and activity by staff grou) and health outcomes for eole with diabetes (glycaemic control as measured by HbA1c), a number of variables needed to be included in the analysis. The source and definition of each are outlined below. Year of birth and gender for each erson with diabetes was obtained from the THIN Patients file. The Townsend Score (socio-derivation measure), ethnicity (ercent white) and urban-rural classification were all taken from the THIN Postcode Variable Indicators (PVI) file. PVIs could alter if a erson s lace of residence changed. The most recent PVI, rior to the HbA1c reading was linked to that reading. Practice size was obtained from the midyear counts, available by calendar year from CSD. The UK nation (England, Northern Ireland, Scotland, Wales) in which the ractice was located was taken from the THIN Practice file which also included Vision Date, Comuterisation Date and Accetable Mortality Reorting Date. 3

30 a) Age: Year of birth was used to calculate the age of the erson at the time of their HbA1c readings. b) Estimated date of diagnosis: Was based on either the date a erson first received a diagnostic Readcode, when their first diabetic theray was rescribed or when they first received an HbA1c reading 6.5%, whichever came first. Our study was confined to the eriod 00 onwards. Not surrisingly very few eole before 00 had an HbA1c reading 6.5% that receded their first diagnosis Readcode or first diabetic theray. The estimated diagnosis date for 80% of eole was determined from their first diagnosis Readcode (Table.4). Aroximately equal roortions of estimated diagnosis dates were determined from either the erson s first diabetic rescrition or when HbA1c 6.5% for the first time, 10% and 9% resectively. On current trends HbA1c 6.5% could soon overtake the diagnosis Readcode in determining estimated diagnosis date based on this aroach. 4

31 Table.4 Estimated year of diagnosis by source of diagnosis date Estimated year of diagnosis before Missing Source of diagnosis date Total Diagnosis readcode Diabetic theray HbA1c 6.5% No. % No (43.1%) (%) (86.3%) (11.7%) (.0%) No (5.8%) (%) (8.1%) (11.6%) (6.4%) No (5.8%) (%) (81.5%) (9.8%) (8.8%) No (6.1%) (%) (80.7%) (8.7%) (10.6%) No (5.9%) (%) (81.1%) (7.7%) (11.%) No (5.7%) (%) (80.0%) (8.3%) (11.7%) No (5.5%) (%) (79.3%) (8.1%) (1.6%) No (5.4%) (%) (78.3%) (7.8%) (13.9%) No (5.4%) (%) (75.7%) (8.0%) (16.3%) No (5.1%) (%) (70.3%) (8.1%) (1.6%) No (4.7%) (%) (6.6%) (7.9%) (9.5%) No (1.5%) (%) (51.9%) (6.7%) (41.4%) No (0.0%) (%) (100.0%) (0.0%) (0.0%) Total No (100.0%) (%) (80.9%) (9.9%) (9.1%) (100.0%) Data for 01 covers the eriod u to 16 th May c) Prevalence: Estimated date of diagnosis, date of registration, date of transfer out or death were used to calculate the number of erson years of diabetes for each GP ractice for the eriod 00 onwards by calendar year. These figures were divided by the ractice list size for each GP ractice to obtain revalence. 5

32 .5 Adjusting for co-morbidities A rimary care equivalent of the Charlson index was used as our measure of comorbidity (Khan et al, 010). This index was time varying, and would increase as eole acquired new conditions. Alongside this measure a time varying obesity indicator was derived. This was based on the QOF rule set for obesity. All records with inconceivable BMI measurements (age 16 and BMI <13 or BMI >150), where the weight was missing, the weight was zero or less and missing measurement dates were removed. An algorithm (see Aendix 5) for identifying outliers was alied to the data finishing with a final visual insection of remaining susected outliers. This rocess reduced the number of useable weight measurements by 3.7% from 4,706,61 to 4,534,1. Under QOF, obesity has an age based exclusion rule and lase in weight measurement rule is set at 15 months. The age rule excludes anybody under 16 however we did carry weight (BMI) measurements forward. For examle if a erson aged 15 years and 9 months had their weight measured and their BMI was 30 or over this was carried forward to their 17 th birthday. If by their seventeenth birthday they had not been weighed again (to calculate BMI) they would no longer be classified as obese, since there would have been a lase of 15 months since the last weight measurement. A lase in weight measurement at the end erson s medical history could mean that the condition was no longer indicated. The last consultation date for that erson was used to ascertain whether the time lase since the last weight measurement (obesity) was 15 months or more..6 Analytical aroach (model) The hierarchical nature of the data lends itself to a multilevel modelling aroach. Each erson with diabetes is registered with a single ractice and has HbA1c measurements for all, or some of, the years during the eriod 00 to 011. Consideration was given to modelling the data over the full eriod. This required us to secify a three level hierarchical model: GP ractice> erson with diabetes>yearly HbA1c measurements for that erson. Each model included the same set of atient and ractice level indeendent variables. These were as follows (the variable label used in the analysis tables is highlighted in bold): Patient level Age (calculated from date of birth on the THIN Patient File) Gender (1 = Female, 0 = Male) Primary care equivalent of the Charlson Index Obesity (1= BMI > 30, 0=BMI 30) Townsend score (Nationally derived quintiles 1=least derived, 5=most derived) Percent White (Nationally derived quintiles 1=lowest, 5=highest) 6

33 Postcode indicator variables (Townsend, Percent white, Urban-rural classification) were derived for each census outut area (~ 150 households) using 001 census data and matched to the ostcode of the atient. Practice level Practice list size (from the mid-year count sulied by CSD) Prevalence (derived from the THIN data) UK Country (in which the ractice is located) Workforce activity variables (ractice level) Average number of times a erson had a consultation with a healthcare rofessional annually (label shortened to Consultations er healthcare rofessional) Nurse contact; the ercentage of all consultations involving or attributable to ractice nurses categorised into tertiles: low, medium, high (See Section. Measures of workforce activity). Average number of diabetic Reviews with a healthcare rofessional (annually) % Practice nurse reviews; the ercentage of all diabetic reviews involving or attributable to ractice nurses categorised into tertiles: low, medium, high. The following variables were used in the model in their standardised form (mean zero, standard deviation of one): Age, Charslon, Practice List Size, Prevalence, Consultations er healthcare rofessional and Reviews with a healthcare rofessional. Before roceeding a test was erformed to see whether the effect of the indeendent variables uon the outcome remained invariant over time. We attemted to fit this model - all indeendent variables and their interactions (multilicative effects) with time (e.g. age x year, gender x year etc.) - using SAS Procedure GLIMMIX but this model failed to converge. It was also not ossible to test individual interactions on a one-by-one basis using GLIMMIX due to model convergence issues. However we were able to test individual interactions using the ackage MLwiN. Nearly all interactions (see Table.5) were significant suggesting that effects were not time invariant therefore the data should be modelled searately for each year of the study. Another reason for analysing data for each year searately was because the nature of the oulation was changing over time due to earlier diagnosis and treatment. The model was also fitted the data covering the eriod 011/1 using the HbA1c measurement closest to 16 th May 01. Models were fitted to a lower ( 7%) and uer ( 10%) HbA1c threshold, using a multilevel logistic regression model with random intercets. 7

34 Table.5 Tests of interaction with Year (00-011) Interaction with year HbA1c 7% HbA1c 10% Degrees of Freedom Degrees of Freedom Age(linear) x Year < <.001 Age(quadratic) x Year < <.001 Gender x Year < Charlson x Year < <.001 Obesity x Year < <.001 Townsend x Year < Ethnicity x Year < <.001 Urban-Rural Classification x Year < <.001 Practice List Size x Year < Prevalence x Year < <.001 Country x Year < <.001 Consultations er healthcare rofessional x Year < <.001 Nurse contact x Year < < Classification of diabetes Readcodes for the activity analysis The aim of the classification of diabetic Readcodes was to see what doctors and nurses were doing in relation to diabetes care and more secifically to find out who was changing medication and erforming the annual reviews. We also sought to identify how many eole with diabetes in a ractice were being referred onto secialist care or were art of intermediate/shared care. This classification was undertaken by a diabetes nurse on the roject team and went through a number of iterations that resulted in fewer categories (e.g. eye screening, which was initially a searate category, was amalgamated with diabetes review)(see Aendix A.3 Readcode classification). This allowed us to look at activity in broad terms and to identify trends both at the level of the category and by individual Readcode..8 Ethics Based on the information we rovided to National Research Ethics Service (NRES), we were advised that this roject was not considered to be research according to the NRES guidance and therefore it did not require ethical review by a NHS Research Ethics Committee. Cegedim eriodically audits it ractices for administrative information. The instrument and database for the audit had reviously received ethical aroval. Inclusion of the additional questions (for the ractice survey) did not require further ethical aroval. Chater Summary 8

35 The roortion of a ractice s diabetic oulation that achieved glycaemic control (as defined at the 7% and 10% levels) was used as the main outcome measure, using data from atient records (THIN data covering aroximately 30 thousand atients in 400 ractices). Differences in outcome (glycaemic control) were exlored in two ways: - by comaring change over time. We used data from 00 to 01, to exlore variation in glycaemic control over the years in relation to any differences observed in the roortions of consultations undertaken by different staff (recorded by staff on atient records in THIN), or changes in the tyes of activity undertaken (coded under different grouings) - by comaring ractices within the current year to see how much glycaemic control varies between ractices and what, if any variation relates to differences in the ractices their workforce, and who leads management of diabetes. These variables were derived from a survey of ractices undertaken in the sring of 01 (covering 49 ractices) Workforce activity was catured through consultations as: - the average number of times eole with diabetes were seen by a healthcare rofessional (er annum) - the ercentage of consultations er year involving ractice nurses, divided into three levels: low (less than 6%), medium (6-35%) and high (over 35%) A multilevel modelling aroach was used to exlain variation in glycaemic control attributable to characteristics of the erson (age, gender, comorbidity) and the ractice (size, diabetes revalence workforce activity measures). 9

36 3. Survey of ractices in 01 (workforce and diabetes care) Between May and June of 01, the THIN data sulier (CSD) undertook to survey ractices to collect generic data on the ractices they covered, and on behalf of the NNRU, also collected more detailed workforce data relating to how diabetes care was organised (see the Aendix 6 for the questionnaire). The survey was administered by CSD, who obtained resonses from 49 ractices. The survey asked background questions about the size and location of ractices, and also covered questions on the total workforce (including nursing and suort staff) and aroaches to managing diabetes. 3.1 Background: ractice size, location and tye Before we describe the nature of the nursing workforce available to rovide care for eole with diabetes, we start with some background information on the ractices themselves. 43 out of 49 ractices rovided details of the number of whole time equivalent (WTE) GPs. The total ranged from one GP in 15 ractices to 10 or more in five ractices. The total number of GPs racticing across the 43 ractices covered is just under 1000 with an average (mean) ractice of 4.1 WTE GPs (median of 3.8). Practices have been groued into small (less than 3 WTE GPs), medium ( WTE GPs) and large ractices (5 or more WTE GPs). Figure 3.1 summarises these data. Just under a third of ractices (30%) are in rural locations, 54% in urban locations, and 1% in inner city locations; 3% describe their location as combination (erhas where a ractice has more than one surgery). Large ractices are more likely to be found in urban locations (61% comared to 44% of small and 55% of medium ractices). Larger roortions of small ractices are found in inner city locations: 0%, comared to 11% of medium and 7% of large ractices. Nine in ten (89%) indicated that they are a disensing ractice and this did not vary by size of ractice. However, ractices located in urban or inner city areas are more likely to be disensing ractices (99% comared to 70% of rural ractices). Just over half (56%), of all ractices indicated that they are training ractices. Large ractices are more likely to be training ractices than smaller ones; 4% of small ractices are training ractices comared to 80% of large ractices. 3. Practice workforce This section resents data on the total number of staff and the skill mix among GP ractices covered in the survey. Only ractices that were able to rovide data for number of WTE staff and GPs are 30

37 included 1 (n=3). The total number of all staff (including GPs themselves) ranges from 3 to 54 WTE with a mean of The average for small ractices is 8.4 WTE, for medium is 14.0 WTE and in large ractices the mean is 9.6 WTE. Tyically, GPs reresent 7% of all ractice staff and this figure varies from 11% of all staff to 84% of all staff. Table 3.1 and Figure 3.1 summarise these data. Table 3.1. Workforce in GP ractices: mean numbers and ercentages (3 cases) Whole time equivalents (WTE) Mean no. staff Total % of all staff Total GPs % Total number of other staff (not GPs) % Practice nurses Consultant nurse <1 Nurse ractitioner Advanced nurse ractitioner Other registered nurse Total RNs % Total nursing assistant/hca/suort worker % Disensers Phlebotomists/harmacists Total other clinical % Practice manager (clinical) <1 Practice manager (non-clinical) Total Practice management % Recetionist Other staff not secified Admin staff (IT/assistant managers/secretaries) Cleaners <1 Total admin and other staff % All staff (inc. GPs) % 1 If details of WTE equivalent for some staff grous are rovided, blank resonses were treated as no staff emloyed. If all the staffing questions were blank, the resonses are treated as missing and excluded from the analyses 31

38 Registered nurses (ractice nurses, consultant nurses, nurse ractitioners and advanced nurse ractitioners and other registered nurses) account for 15% of all ractice staff or.3 WTE on average. The average number of atients er RN is 3,800 with a minimum of 70 and maximum of 11,00. Figure 3.1 GP workforce summary: Mean number WTEs, ercentage of all staff Number of GPs, 4.1, 7% Total Admin staff, 7.0, 44% Total RNs,.3, 15% Total Practice managers, 1.0, 7% Total Nursing suort, 1.0, 7% There is little difference between tyes of ractice in the roortion of different staff grous emloyed in the ractices covered by the survey. Larger ractices tend to have slightly smaller roortions emloyed as ractice management (5% comared to 1% in small ractices) and higher roortion emloyed as GPs (30% comared to 4% in small ractices). Disensing ractices are more likely to have higher roortion of clinical suort workers (including harmacists and hlebotomists 14% comared to 5% in ractices that are not disensing). Registered nurses account for 15% of the total rimary care workforce. Whilst in relation to the clinical workforce (that is GPs and registered nurses together), RNs make u a third of the clinical workforce. Put another way, on average there is a ratio of one nurse to every two GPs. But this varies considerably, as shown in Figure 3.. One in 0 ractices reort having no ractice nurses whilst in 1% of ractices, RNs make u more than half of the total clinical staff. 3

39 Figure 3. Registered Nurses as a ercentage of all RNs and GPs Most nursing staff (4%) are emloyed on Band 6, 4% are on Band 7 or 8 and 15% Band 5. One in five (0%) of staff are aid on the equivalent of Band 4 or lower (see Figure 3.3). Figure 3.3 Nursing staff (RNs and assistants) by equivalent AFC ay band Band 8.09 Band 7.45 Band 6.95 Band 5.35 Band 4.14 Band 3.09 Band Mean number of nursing staff (WTE) 33

40 Grade mix of registered nurses varies by size of ractice, with larger ractices being more likely to emloy nurses on Band 7/8 (33% comared to 1% in medium sized ractices and 15% in small ractices). Among the 07 ractices roviding data, 59% indicated that some nurses roviding care to atients with diabetes hold a ost graduate qualification relating to diabetic care from a higher education institute. One er cent of ractices did not know whether or not they emloyed nurses with ostgraduate qualifications in diabetes care. Large ractices (5 or more GPs) are more likely to emloy nurses holding ostgraduate qualifications in diabetes care: 84% do comared with 5% and 44% in medium and small ractices resectively. Figure 3.4 Percentage of ractices who emloy nurses holding ostgraduate diabetes qualifications All ractices 59% Large (5 or more wte GPs) 84% Medium ( wte GPs) 5% Small (less than 3 wte GPs) 44% 0% 10% 0% 30% 40% 50% 60% 70% 80% 90% Percentage 3.3 Aroach to diabetes care This section looks at how ractices aroach diabetes care. Figure 3.5 shows that the most frequently cited aroach to diabetes care management is using nurse(s) secialised in diabetes care (73%). In ractices that have nurses with ostgraduate diabetes qualifications, this figure rises to 89%. In more than half of cases (57%) care is managed by GP(s) secialised in diabetes care and a similar roortion of resondents (54%) indicated that management of care is shared between the ractice and hosital/community based consultants. In a third of cases (3%) care is managed by GP(s) with no diabetes secialism. 34

41 Figure 3.5 How care is managed by ractices: ercentages Care managed by nurse (or nurses) (secialised in diabetes) 73 Care managed by designated GP (or GPs) secialised in diabetes Care shared between ractice and hosital/community based consultants Care managed by GPs (but none secialised) Care managed by ractice nurses (not secialised) 9 3 Care managed by hosital/community based secialists Care managed by other combinations Percentage Large ractices are where care is most likely to managed by diabetes secialists, be they GPs or nurses and in small ractices it is more likely to be managed by GPs and nurses that are not secialised in diabetes. For examle, in 88% of large ractices, emloying 5 or more GPs care is managed by nurses with secialist diabetes training comared to 56% of small ractices. When asked to indicate which is the main aroach to managing care of eole with diabetes using a designated nurse or nurses who secialises in diabetes was indicated by more than half of all resondents (58%; this includes 5% that said they use a combination of GPs and nurses both secialised in diabetes care). In a further 11% of cases care is managed by nurses (but not secialists). (See Figure 3.6). Resondents were allowed to indicate more than one management aroach hence figures do not add u to 100%. 35

42 Figure 3.6 How care is managed by ractices (main aroach): ercentages Care shared between ractice and hosital/community based consultants 9% Other aroaches 4% GPs (but none secialised) 3% GP (or GPs) secialised in diabetes 15% Practice nurses (not secialised) 11% Nurse (or nurses) (secialised in diabetes) 58% Smaller ractices are more likely to say management of care is shared with hosital or community consultants (% vs. 5% in medium or large), rather than led by their own nurse (61% vs. 71% of medium sized), and are less likely to have care in the hands of a designated GP or ractice nurse with secialist knowledge (51% vs. 83% in larger ractices). In ractices that have nurses with ostgraduate qualifications in diabetes, 70% reort the nurse secialists manage diabetes care, comared to 33% of ractices where there are no nurses secialised in diabetes. However, this is still the most frequently used aroach in these ractices. Large ractices are more likely to reort that secialist diabetes nurses lead diabetes care management than smaller and medium sized ractices. Peole with diabetes tyically receive most of their diabetes related care and assessment via regularly held clinics secifically for diabetic atients (61%) or through routinely scheduled aointments (5%). A third of ractices say that they rovide aointments as and when needed (3%) and five er cent use other aroaches (again it should be noted that resondents could indicate more than one aroach) to care rovision. Insulin treatment is initiated by a range of different ractitioners. In 46% of cases the GP initiates treatment, in 36% of ractices the ractice nurse initiates treatment, in 3% of ractices a community diabetic nurse secialist initiates treatment and in 40% of ractices outatient diabetes mellitus clinics initiate insulin treatment (8% of resondents indicated that other eole or organisations initiate treatment). In just over half the cases (53%) a single aroach is used while in a third (34%) two strategies are deloyed and in 13% of cases three or more aroaches are used to initiate insulin treatment. Where a single aroach is used, it is most likely to be using diabetes mellitus outatient clinics. 36

43 In ractices where nurses hold secialist ostgraduate qualifications the majority of diabetes care is rovided through regularly held clinics secifically for diabetic atients (74% comared to 41% of cases where there is no secialist ostgraduate trained diabetic nurse). Larger ractices are more likely to rovide care in this way. In large ractices insulin treatment is more likely to be initiated by ractice nurses (47% comared to 39% in medium sized ractices and 19% in small ractices) while small ractices are more likely to use outatient diabetes mellitus clinics (58% comared to 36% of medium sized ractices and 9% of large ractices). Chater 3 Summary A survey of 49 ractices undertaken in Sring 01 found that a tyical ractice emloys an average of 4 GPs, registered nurses (RNs), 1 care suort worker/assistant, a ractice manager and 7 recetionists/admin staff (whole time equivalents). The findings show that overall there is substantial variation between ractices in the comosition of their workforce, how they deliver care to eole with diabetes, and who leads that care. Nurses make u a third of the trained clinical staff (e.g. total GPs and RNs), but this varies considerably: 5% of ractices have no registered nurses whilst in 1% RNs make u more than half of the clinical staff. Larger ractices (5 or more WTE GPs) are more likely to emloy exerienced nurses (on higher ay-bands), and nurses that hold a ost-graduate qualification in diabetes (84% do, comared with 44% in small ractices (less than 3 WTE GPs)). A nurse (or nurses) who secialises in diabetes leads the management of care of atients with diabetes in 58% of ractices, and generalist ractice nurses lead care in 11% of ractices. About one in five (18%) ractices say that the GP leads management of diabetes atients. 89% of ractices that emloy a nurse with ostgraduate secialist qualification in diabetes reort that care of atients with diabetes is generally managed by a nurses (or nurses) who is secialised in diabetes. In ractices where nurses hold secialist ostgraduate qualifications the majority of diabetes care is rovided through regularly held clinics secifically for diabetic atients (74% comared to 41% of cases where there is no secialist ostgraduate trained diabetic nurse). In 46% of ractices the GP generally initiates insulin treatment, and in 36% of ractices the ractice nurse initiates treatment. 37

44 4. Staff consultations and atient outcomes This chater resents analysis of rimary care medical records from the THIN ractices during the eriod 00 to 01. The number of ractices included in the analysis increased over time, varying from 47 to 471. We start by rofiling the atient oulation to consider factors that need to be taken into account when looking at the relationshi between workforce and outcomes for eole with diabetes. We then describe each of the two key areas of interest: 1. Outcomes in relation to their diabetes: a) What is the incidence and revalence of diabetes in the THIN ractice oulations? b) How well controlled is their diabetes?. Staff activity related to diabetes care: based on the activities coded as art of their consultation with individual atients. a) Who is doing what (based on consultations)? b) What are the tyical mix of activities undertaken by doctors and nurses in treating and caring for eole with diabetes in rimary care? c) Does the nature of the roles erformed by nurses and doctors vary between ractices? d) How have these atterns of activity changed over the last ten years? 4.1 Patient Profile Below we briefly describe the atient rofile of those eole with diabetes registered in the ractices that met the study selection criteria. There has been a shift towards eole with diabetes being older than they were ten years ago. In 00, 8.4% were aged under 40, which has fallen to 6.6% in 011/1. Conversely there has been an increase in the roortion of those eole aged 80 and over from 1.5% in 00 to 14.6% in 011/1. There were more men with diabetes than women (55.% vs. 44.8% in 011/1). Using the Townsend score to measure socio-derivation, the overall rofile distribution has remained stable across the study eriod. The study oulation was less derived than the national oulation. There were more eole in the study samle who lived in areas where individuals described themselves as White than is the national average. The majority of eole in the study oulation lived in less sarse urban areas. 38

45 CSD has over the last decade acquired more THIN ractices from the all four UK nations. The majority are from England although recent acquisition of ractices has haened at a far faster rate for Scotland (Aendix A.1). The roortion of ractices that met the criteria for inclusion based on the Vision and AMR dates in 011/1 by nation was England (336, 7%), Scotland (71, 15%), Wales (37, 8%) and Northern Ireland (, 5%). In the study oulation the roortion of eole registered with ractices in Scotland has increased from.7% in 00 to 13.8% in 011/1. There has been a steady increase in the roortion of eole who have one or more comorbidities alongside their diabetes. In 00 5.% had one or more comorbidities. This figure has risen to 60.0% in 011/1. The ercentage of eole with 5 or more comorbidities, at any one time, has risen from.3% to 6.5% over the study eriod. Obesity has also increased considerably between 00 and 011/1 (Table 4.1). In 00 fewer than 30% of all eole with diabetes were morbidly obese; this has risen to almost 47% by 011/1. Table 4.1 Obesity (BMI 30) /1 Obesity Absent Present /1 No % No % Total No Year Note: 011/1 covers the eriod May 17 th 011 to May 16 th Prevalence of diabetes in the THIN ractices Table 4. describes the number of eole with diabetes in each year since 00 (as a number and as a roortion of all eole). Whilst the average total number of atients registered er ractice has changed little (from 8,617 atient in 00 to 7,877 in 011/1), the average number of atients with diabetes er ractice has increased by 58% in the same eriod, and now account for one in 0 atients (4.9% vs. 3.0% in 00). While national estimates of diabetes revalence vary somewhat this figure is consistent with a recent estimate of 4.3% based on the QOF for 010 (Kanavos et al., 01), and 5.8% revalence from QOF in 011/1 (NHS Information Centre for Health and Social Care, 01). These figures reveal the extent of the growing burden of care that has been laced on GP Practices. 39

46 Table 4. Practice registers and diabetes revalence Year Practices (no.) Practice (Mid-year count) Estimated diabetic register size Prevalence Mean SD Range Mean SD Range Mean SD Range / %Change -3.5% 58.3% 66.1% 1 Uses mid-year count for 011 to calculate revalence Note: 011/1 covers the eriod May 17 th 011 to May 16 th Staff activity Doctor and nurse consultation rates We start by describing some of the key trends in care of eole with diabetes that have taken lace over the last ten years (00 to 011/1) in THIN GP ractices. There has been an increase in activity (across staff grous) as the numbers of atients with diabetes has increased. The average total number of consultations er ractice of any tye (e.g. both diabetic and non-diabetic care) involving a healthcare rofessional (based on the Vision system allocated role grou) with eole with diabetes has increased by 14% between 00 and 011/1. The equivalent figures for average total number of ractice consultations derived from the medical, additional health details and theray records are very similar, with an increase of 13% since 00 (see Table 4.3). The increase in activity as measured by consultations - is substantially lower than the increase in revalence (66%). Table 4.3 shows figures on consultations that involve one or more staff grous from the ractice healthcare team. So, for examle, we count any consultation that involves just a doctor and any that doctors shared with a healthcare rofessional from another staff role grou (e.g. ractice nurse, harmacist). An alternative means of caturing consultation by staff grou is to base it on either the Vision system allocation, or restrict consultations to those that belong exclusively to a single staff grou e.g. only doctor or only nurse. These alternatives were exlored and any key differences are reorted in the text below. (Full results using these aroaches are found in the aendices along with a footnote defining the levels of nurse contact) 40

47 Table 4.3 Average number of consultations er ractice of atients with diabetes All healthcare rofessionals (Derived 1 ) Doctors (Any contact) Practice nurses (Any contact) Year Practices (no.) Mean SD Range Mean SD Range Mean SD Range / % Change 13.4% 1.1% 0.% 1 Derived from the medical, AHD and theray records Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 It aears that the increase in consultations with diabetic atients has largely been delivered by ractice nurses. In the average GP ractice, doctors were involved in 673 consultations in 00 which rose only marginally to 703 in 011/1 reresenting a 1% increase over then ten-year eriod. Over the same eriod there has been a 0% increase in the consultations involving ractice nurses. Looking at ractice nurse only consultations (no other staff grou involved) suggests there has been an increase of 3% between 00 and 01. For both staff role grous there was a fall between 00 and 003 which coincides with an increase in eligible ractices from 47 to 375. If 003 is used as the reference year the increases were 7% and 7% resectively. Whichever figures are used, ractice nurses have borne more of the increased workload than doctors based on this articular measure. The roortion of consultations undertaken by each grou has changed only slightly. Table 4.4 exresses the number of consultations by the two main staff role grous (Doctors, ractice nurses) in terms of ercentages. In 00 70% of all consultations with eole with diabetes were undertaken by doctors. By 011/1 this had fallen to 64%. Amongst ractice nurses there was a small increase from 31% to 3%. During this eriod the roortion of consultations involving healthcare rofessionals who were neither doctors nor nurses, increased from 3.4% to around 7.6%. The staff role of these entries was often recorded simly as Other Healthcare Professional, rather than to something more secific (e.g. harmacist, dietician). 41

48 Table 4.4 Proortion of consultations with doctors and ractice nurses (as a ercentage of all healthcare rofessional staff Practices (no.) Doctors (Any contact) Practice nurses (Any contact) Mean SD Range Mean SD Range / % Change -8.4% 4.1% 1 Derived from the medical, AHD and theray records Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 Figure 4.1 resents the data grahically. The modal grou based uon ten-ercent banding is 30-39% for ractice nurses for both 00 and 011/1. There are roortionally more ractices in 40-49% (19.4% vs. 13.8%) and 50-59% bands (7.6% vs. 6.1%) than in 00 for consultations involving any contact with a ractice nurse. The modal band for doctors was 60-69% in 00 and 50-59% in 011/1. There are fewer ractices in the 70-79% (18.% vs. 9.6%) and 80-89% (7.4% vs. 16.%) bands in 011/1 than in 00 for consultations involving any contact with a doctor however there has been a roortionate increase in the very highest band (90%+) from.5% to 5.%. The ercentage of all consultations involving ractice nurses was subsequently categorised into low, medium and high (tertiles) for analysis uroses using 00 as the reference year. 4

49 0-9% 10-19% 0-9% 30-39% 40-49% 50-59% 60-69% 70-79% 80-89% 90% + 0-9% 10-19% 0-9% 30-39% 40-49% 50-59% 60-69% 70-79% 80-89% 90% + Figure 4.1 Consultations involving doctors and ractice nurses 00 vs. 011/1 Doctor Practice Nurse % /1 Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 The average number of consultations a erson with diabetes had with a healthcare rofessional on an annual basis has droed by 8% from 16.0 er annum in 00 to 11.5 er annum in 011/1 (Table 4.5). The average number of consultations with doctors fell by 36% from 11.1 to 7.1 and for ractice nurses by 4% from 5.0 to 3.8 er annum over the same eriod. 43

50 Table 4.5 Number of consultations er erson with diabetes (er annum) with all healthcare rofessionals, doctors and ractice nurses Year Practices (no.) All healthcare rofessionals Doctors (Any contact) Practice nurses (Any contact) Mean SD Range Mean SD Range Mean SD Range / % Change -8.3% -35.6% -3.9% Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 The shift towards fewer consultations with doctors and ractice nurses is shown grahically in Figure 4.. Peole with diabetes are therefore seeing rofessionals from both these two grous less often in 011/1 than they were a decade earlier in 00. Figure 4. Number of times eole with diabetes are seen by doctors and ractice nurses, 00 vs. 011/1 Doctor Practice Nurse % /1 Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 44

51 The number of times eole with diabetes saw a doctor in 011/1 was negatively, and significantly, correlated (Pearson correlation -0., n==10, =.001) with the list size er GP (that is the number of atients registered with a ractice er WTE general ractitioner). Similarly there was a negative correlation between number of eole seeing a ractice nurse (Pearson correlation, -0., n=07, =.00) and list size er ractice nurse. So as might be exected, the more eole doctors and ractice nurses had to care for, the less often eole with diabetes received consultations. We can conclude from these tables that there has been shar increase in the revalence of diabetes. The additional burden of care has been absorbed rimarily by ractice nurses and other healthcare rofessionals, rather than doctors, and eole with diabetes are seeing healthcare rofessionals less often than in the ast. Tyes of activity undertaken by doctors and nurses Since 00 ractice nurses have increasingly been recording more activities about those eole with diabetes who they have contact with than doctors. Table 4.6 shows the average number of entries made by doctors and ractice nurses that aear in the THIN medical records dataset. Individual Readcodes have been groued according to the classification in Aendix A.3. In 00 the average number of entries er ractice for both doctors and ractice nurses (8 vs. 3). By 011/01 ractice nurses were making.7 times as many entries as doctors. Table 4.6 Activity categories /1: mean frequency er ractice Role Grou Readcode classification /1 Doctor Practice Nurse Diagnosis or label Diabetes review Medication review Referral to another arty Care for by secondary clinic Exemtion codes Other All Diagnosis or label Diabetes review Medication review Referral to another arty Care for by secondary clinic Exemtion codes Other All Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 A higher roortion of entries made by doctors relate to diagnosis or labelling than is the case for ractice nurses (Table 4.7). In both grous the category diagnosis or label as a roortion of all entries has declined from 4% to 19% for doctors and from 11% to 4% for ractice nurses. More entries made by doctors relate to annual review now than in the ast rising from 58% of all doctors entries in 00 to 76% in 011/1. In articular there has been a dramatic increase in entries 45

52 concerning foot screening/examination from 0.1% in 00 to 3% in 011/1 (Aendix 4.1b). Entries for care or management lans have increased eightfold from 0.5% in 00 to 4% in 011/1. Annual review has always been the dominant category for entries made by ractice nurses reresenting consistently over 80% of all entries. The roortion fell from 89% in 00 to 80% in 005, but has steadily increased since then to 9% in 011/1. Foot screening, examination or assessment entries have increased from 0% in 00 to 43% in 011/1 and care or management lans entries from 0.% in 00 to.% in 011/1 (Aendix 4.b). Table 4.7 Activity code classification: ercentages for doctors and ractice nurses Role Grou Readcode classification /1 Doctor Practice Nurse Diagnosis or label Diabetes review Medication review Referral to another arty Care for by secondary clinic Exemtion codes Other All Diagnosis or label Diabetes review Medication review Referral to another arty Care for by secondary clinic Exemtion codes Other All Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 Further analysis was undertaken to exlore activities coded under diabetic review in greater detail and to model the relationshi between average number of reviews (er erson) at the ractice level and diabetes control. In Table 4.8 we can see the average number of diabetic reviews erformed by ractices over the eriod 00 to 011/1. Table 4.8 Average number of total reviews undertaken by ractices /1 All reviews with a healthcare rofessional (No.) Doctor reviews (No.) Practice nurse reviews (No.) % reviews by ractice nurses 1 Year Practice (No.) Mean SD Range Mean SD Range Mean SD Range Mean SD Range / only calculated for ractices with one or more reviews; the maximum number of ractices with no reviews in a articular year was 4. Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 46

53 The average number of reviews er ractice with a healthcare rofessional has increased by 69% from 300 in 00 to 513 in 011/1. This measure of activity varies considerably between ractices, erhas not surrising because ractice characteristics, e.g. ractice list size, eole on the diabetic register, derivation etc. are heterogeneous. The degree of variation (as measured by the standard deviation) has increased over the eriod of the study (from 56 to 417). The trends are however different for doctors and ractice nurses. Total number of reviews reached a eak for doctors in 004, and then declined before rising again in 009. For ractice nurses total number of reviews has risen every year, excet for 003, over the eriod from 175 in 00 to 34 in 011/1. The standard deviation has also increased over the eriod. In ercentage terms ractice nurses are undertaking roortionately more of the reviews than in the ast increasing from 53% in 00 to 65% in 011/1. Variation between ractices in the ercentage of reviews undertaken by ractice nurses, has remained quite stable (SD around 34-35%) although this has decreased since 009. What has been described so far however does not reveal how often, on average, eole with diabetes were seen each year for a diabetic review in their ractice. These figures are shown in Table 4.9. Table 4.9 Average number of times eole with diabetes were reviewed by ractices /1 All reviews with a healthcare rofessional Doctor reviews Practice nurse reviews Year Practice (No.) Mean SD Range Mean SD Range Mean SD Range / Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 The number of times eole with diabetes were reviewed decreased from 1.3 times er year in 00 to 1.05 in 007 before rising to 1.3 in 011/1. The variability between ractices as measured by the standard deviation has fallen over the study eriod from 0.86 to Doctors are seeing eole with diabetes less often than in the ast for review uroses falling from 0.48 in 00 to 0.30 in 008 with a small increase since then to 0.34 in 011/1. Between 00 and 010 the number of time atients were reviewed by a ractice nurse remained relatively stable at around times er year. In 011 this increased to The standard deviation has been in the range 0.68 to 0.73 for most years excet for 010 and 011/1 when it decreased to 0.64 and 0.65 resectively. Figure 4.3 shows how the distributions have shifted since 00. The modal band in 00 was 0.00 to 0.49 for reviews 47

54 undertaken by ractice nurses, this had moved u one band by 011/1. In 00 63% of ractices were in the lowest band for reviews by doctors. This ercentage had increased to 75% by 011/1. Figure 4.3 Number of times atients were reviewed by doctors and ractice nurses, 00 vs. 011/1 Doctors Practice Nurses % /1 Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 Turning now to medication reviews Table 4.10 shows that ractices are undertaking more medication reviews now than in the ast. Table 4.10 Average number of total medication reviews undertaken by ractices /1 All medication reviews with a healthcare rofessional (No.) Doctor medication reviews (No.) Practice nurse reviews (No.) % Medication reviews by ractice nurses 1 Year Practice (No.) Mean SD Range Mean SD Range Mean SD Range Mean SD Range / only calculated for ractices with one or more reviews; the number of ractices with no medication reviews ranged from 106 to 198 over the study eriod. Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 48

55 The average number of times eole with diabetes had their medication reviewed by ractices each year is shown in Table There was a shar increase in medication reviews from to between 00 and 004. From 005 onwards the average decreased but has remained around the same level, since 006. However, as indicated by the range, there are a small number of ractices that are now reviewing medications on a much more regular basis, on average, one or more medication reviews every year for each erson with diabetes. Table 4.11 Average number of times eole with diabetes had their medication reviewed by ractices /1 All reviews with a healthcare rofessional Doctor reviews Practice nurse reviews Year Practice (No.) Mean SD Range Mean SD Range Mean SD Range / Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 In 00 there were two ractices (0.8%) where doctors were reviewing the medications of one in every ten eole with diabetes. This increased to seventeen ractices (3.6%) in 010 before falling to 13 (.9%) ractices in 011. For ractice nurses no ractices were reviewing the medications of at least one in ten eole in 00. By 010 this had risen to eleven ractices (.3%) falling to ten in 011 (.%). The figures for the 011/1 were noticeably lower for both doctors and ractice nurses (7 and 4 ractices resectively) which may be exlained by the fact that 011/1 data covers two QOF reorting eriods. In 00 doctors reviewed the medication of one or more eole with diabetes in 41 (17%) ractices. This increased to 59 (56%) of ractices in 010 falling to 14 (49%) in 011/1. For ractice nurses the corresonding figures were 16 (6%), 171 (38%) and 159 (37%) for 00, 010 and 011/1 resectively. Table 4.1 shows that ractice nurses are becoming more involved in rescribing, although still at a low level. Almost 4% of consultations, where a theray was rescribed that was described as acute (e.g. not a reeat rescrition), were undertaken by a ractice nurse in 011/1 comared to 0.1% in 00. For rescritions that were secifically for the treatment of diabetes this figure was 8.5% in 011/1. (see Table 4.13). 49

56 Table 4.1 Consultations where an acute theray (of any kind) was rescribed Prescribed by a: All healthcare rofessionals(no.) Doctor(No.) Practice nurse(no.) Practice nurse (%) Year Practices (no.) Mean SD Range Mean SD Range Mean SD Range Mean SD Range / Table 4.13 Consultations where an acute diabetes theray 1 was rescribed Year Prescribed by a: All healthcare rofessionals(no.) Doctor(No.) Practice nurse(no.) Practice nurse (%) Practices (no.) Mean SD Range Mean SD Range Mean SD Range Mean SD Range / this may include equiment such as syringes; Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 Consultation duration and total contact time The THIN data allows the duration of each consultation to be calculated. The roortion of consultations, by year, where it was not ossible to calculate duration varied from 6.1 to 7.6% across the eriod of the study. Whilst the annual number of consultations er atient has fallen, the duration has increased, for both doctors (10. to 11.1 minutes) and ractice nurses (11. to 13.0 minutes) over the eriod of the study and the duration is consistently lower for other nurses / other healthcare rofessionals (since 004 onwards) (Table 4.14). 50

57 Table 4.14 Duration (minutes) of consultations by staff grou that first oened the consultation record on the Vision System Confidence Percentiles Year Consultation with: No. Mean SD L95% U95% Median 5th 75th 00 Doctor Practice Nurse Other Nurse Other Healthcare Professional Doctor Practice Nurse Other Nurse Other Healthcare Professional Doctor Practice Nurse Other Nurse Other Healthcare Professional Doctor Practice Nurse Other Nurse Other Healthcare Professional Doctor Practice Nurse Other Nurse Other Healthcare Professional Doctor Practice Nurse Other Nurse Other Healthcare Professional Doctor Practice Nurse Other Nurse Other Healthcare Professional Doctor Practice Nurse Other Nurse Other Healthcare Professional Doctor Practice Nurse Other Nurse Other Healthcare Professional Doctor Practice Nurse Other Nurse Other Healthcare Professional /1 Doctor Practice Nurse Other Nurse Other Healthcare Professional Using the frequency of consultations and their duration, we can calculate the total time each atient with diabetes sent with ractice staff (Table 4.15). In 00, eole with diabetes sent a total of 98 minutes in consultation with a doctor, which reduced to 67 minutes in 011/1, a fall of 3%. The total time sent in consultations with a ractice nurse has decreased by 13%, from an average of 54 minutes in 00 to 47 minutes in 011/1. 51

58 Table 4.15 Total annual amount of consultation time (minutes) er erson with diabetes by year and staff role All Healthcare Professionals Doctors Practice Nurses Other Nurses Other Healthcare Professionals Year No. Mean SD Range Mean SD Range Mean SD Range Mean SD Range Mean SD Range / The net effect of these changes is that the roortion of consultation time with a doctor has fallen from 61% (of a total of 160 minutes with all health care rofessionals) in 00, to 54% (of 14 minutes) in 01. Whilst roortionally, the time with a ractice nurse has increased from 33% to 37%, and with other staff (other nurses and other health care rofessionals) from 6% to 9%. Combining the times sent in consultation with all health care rofessionals, we can generate a total time er year er atient, and exlore how contact time varies between ractices, according to whether they have a low, medium or high level of nurse inut (Table 4.16). Table 4.16 Total annual amount of consultation time (minutes) er erson with diabetes by staff role and nurse contact grou, 011/1 Nurse contact (reference year 00) No. Mean SD Minimum Maximum All Healthcare <6.0% Professionals % % and over Doctors <6.0% % % and over Practice Nurses <6.0% % % and over Other Nurses <6.0% % % and over Other Healthcare <6.0% Professionals % % and over

59 The level of inut er year from GPs varies only slightly; eole with diabetes see a GP about 7 times a year, for an average of 11 minutes, whether they are in a ractice with more or less nurse inut (as classified in the three bands). On average they send 67 minutes a year in consultation with each erson with diabetes. In ractices where nurses see a larger roortion of diabetic atients, doctors send nine minutes less er atient a year (61 minutes in the high nurse contact grou as oosed 70 in the low nurse contact grou), but atients have 7 minutes er atient more contact time in total (13 minutes as oosed to 105 in the low nurse contact grou). The level of inut from nurses varies much more between ractices; from seeing atients a total of 3 minutes a year (in the ractices with least nursing contact) through to 50 minutes for the average, and 64 minutes in the ractices with most nurse contact. These findings imly that while there is some substitution of work between nurses and doctors in the high nurse contact ractices there may also be enhanced care being delivered although we cannot discount lower roductivity as a artial exlanation. 4.4 Practice oulation achievement of glycaemic control We used Haemoglobin A1c (HbA1c), the study measure for glucose intolerance, to gauge the extent to which a erson s diabetes is under control. The thresholds for QOF HbA1c indicators have ranged from 7% to 10% over the eriod of the study. At the start of QOF in 004 there were two indicators for HbA1c level: 7.4% or less and 10% or less. The 10% threshold was last used as a QOF indicator in 008/9. An HbA1c value of 6.5% is often used now as a otential indicator of the resence of diabetes. Findings are resented for four thresholds 7%, 8%, 9% and 10%. We focus our attention on the uer ( 7%) and lower ( 10%) end of the QOF indicator range. The roortion of eole meeting these thresholds increased noticeably during the early eriod in the last decade (see Table 4.17 and Figure 4.4). This has taered off subsequently. The higher threshold ( 10%) eaked in 006 whereas there were still small gains in the lower threshold ( 7%) until 009. However there has been a small decrease in the roortions meeting the four thresholds since 009/10. Table 4.17 Poulation achievement for HbA1c by threshold /1 7% % % % Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 53

60 % Poulation achievement Figure 4.4 Poulation achievement for HbA1c by threshold % 8% 9% 10% Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 The amount of variation between ractices in meeting the four HbA1c thresholds ( 7%, 8%, 9%, 10%) is shown in Table 4.18, and is further emhasised in Figures 4.5 and 4.6. The amount of variation between ractices has decreased across all thresholds over time and more so for the highest threshold ( 10%). Table 4.18 Percentage oulation achievement by HbA1c threshold - variation across ractices /1 Year 7% 8% 9% 10% Practice (no.) Mean SD Range Mean SD Range Mean SD Range Mean SD Range / Note: all eole in one ractice failed to meet any threshold during the eriod ; 011/1 covers the eriod May 17 th 011 to May 16 th 01 54

61 Figure 4.5 Percentage of ractice oulation achieving HbA1c 7% (00 vs. 011/1) / % <10% 10% - <0% 0% - <30% 30% - <40% 40% - <50% 50% - <60% 60% - <70% 70% - <80% 80% - <90% 90% + Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 Figure 4.6 Percentage of ractice oulation achieving HbA1c 10% (00 vs. 011/1) /1 % <10% 10% - <0% 0% - <30% 30% - <40% 40% - <50% 50% - <60% 60% - <70% 70% - <80% 80% - <90% 90% + Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 55

62 Chater 4 Summary The revalence of diabetes has increased by 66% over the last decade and has increased steadily year on year (reflecting other national statistics). Peole with diabetes account for an average of 4.9% of average ractice list now, comared with 3.0% in 00. Because of a change in the threshold used to define diabetes, there is an increased roortion of the diabetic atient oulation that have less severe diabetes now, and are being heled to manage their diabetes earlier. Glycaemic control (that is the ercentage of atients with diabetes that have an Hb1Ac level below a certain threshold) imroved considerably between 00 and 004. Since this time it has lateaued; roughly the same roortions of atients achieve control each year as the year before. There has been a 13% increase in the annual number of consultations undertaken in ractices with eole with diabetes. Practice nurses are doing more consultations each year, but as the increase in revalence outstris the increase in activity, each erson is having fewer consultations now than in the ast, although the average length of consultation with ractice nurses is slightly longer (from 11 minutes in 00 to 13 minutes in 011/1). Practice nurses are increasingly undertaking more diabetes reviews and they are becoming more involved in rescribing. Peole with diabetes in ractices with larger caseloads (more atients er GP or RN) receive fewer consultations. Nurses (and other healthcare rofessionals) have increased their activity much more than doctors during this eriod a 0% increase in annual consultations by ractice nurses comared with just 1% increase amongst GPs. In ractices where nurses see a larger roortion of eole with diabetes, doctors send nine minutes less a year (61 minutes vs. 70), but atients have 7 minute more contact time in total (13 minutes vs. 105 in the low nurse contact grou). Glycaemic control is now much more uniformly achieved in the oulation of eole with diabetes across ractices, than it was the case ten years ago. 56

63 5. Relationshi between workforce and diabetes control In this section we consider secifically how oulation achievement of glycaemic control varies by level of nurse contact (low, medium, high) and whether this variation changes after risk adjustment both at the atient and ractice level. The analyses focus on the uer( 10%) and lower thresholds( 7%) ob HbA1c. The contact with health rofessionals was catured through two variables: the average number of times eole with diabetes were seen by a healthcare rofessional (of any sort) and the ercentage of consultations involving ractice nurses. For a more interretable analysis we categorised the latter into tertiles (low less than 6%, medium 6-35%, and high over 35%) using 00 as our reference year (the start of the study eriod). 5.1 Health rofessional contact The roortion of eole attaining the tight (HbA1c 7%) and loose (HbA1c 10%) thresholds was consistently higher in ractices with a high roortion of nurse contact for every year from 00 to 007. However, in absolute terms the differences were generally small. The difference between the high and low ractice nurse contact tertiles for the higher threshold (HbA1c 10%) was more aarent with maximum advantage of 3.5% (003) and consistently in excess of 1%, before 007. (Table 5.1 and Figure 5.1). Table 5.1 Poulation achievement for HbA1c by threshold and ractice nurse contact (any involvement) HbA1c threshold Practice nurse contact /1 Low % Medium High Low % Medium High Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 57

64 % oulation achievement Figure 5.1 Poulation achievement for HbA1c by threshold and level of ractice nurse contact (any involvement) Low 7% Medium 7% High 7% Low 10% Medium 10% High 10% Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 The revious chater indicated that there has been an overall reduction in the number of consultations er erson, but a larger roortion of them are undertaken by ractice nurses, and that this has been accomanied by better glycaemic control. The changes were greatest between 00 and 005, since which time levels of both activity and glycaemic control has lateaued. Multi-level modelling allowed the relationshis between staffing activity and glycaemic control to be tested further, adjusting for the individual characteristics of the erson and other socio-demograhic factors. Table 5. shows that the amount of ractice level variance as a roortion of the sum of both the erson and ractice level variance (known as the variance artition coefficient (VPC) or intra-class correlation coefficient), obtained by fitting the intercet only multi-level model, has fallen from 14% in 00 to 9% in 011/1 for the HbA1c 7% threshold and from 1% to 11% for the HbA1c 10% threshold. Therefore most of the variation observed in these two variables is attributable to eole with diabetes, although there is still variation between ractices that requires exlanation. 58

65 Table 5. Variation at the ractice level Year Residual variance 7% 10% VPC Residual variance VPC % % % % % % % % % % % % % % % % % % % % 011/ % % Note: 011/1 covers the eriod May 17 th 011 to May 16 th 01 The results for the 7% level and 10% HbA1c thresholds, from the multi-level model, are resented in Tables 5.3 and 5.4. After risk adjustment at the erson and ractice level, ractices in which eole had a higher roortion of nurse contact had significantly more atients meeting the lower threshold of 7% in 003. The difference was close to significance in 005 (=.05, full results are found in the Aendices A3.8 and A3.9). 59

66 Table 5.3 Multilevel model, HbA1c 7% - Findings for workforce variables (including nurse contact based on any involvement) β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t Consultations er healthcare rofessional Nurse Contact - any involvement Low Medium High Random Variance Practice Global Test (degrees of freedom) χ χ χ χ χ Nurse Contact - any involvement (df) β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t Consultations er healthcare rofessional Nurse Contact - any involvement Low Medium High Random Variance Practice Global Test (degrees of freedom) χ χ χ χ χ χ Nurse Contact - any involvement (df) /1 60

67 Table 5.4 Multilevel model, HbA1c 10% - Findings for workforce variables (including nurse contact based on any involvement) β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t Consultations er healthcare rofessional < Nurse Contact - any involvement Low Medium High Random Variance Practice Global Tests (degrees of freedom) χ χ χ χ χ Nurse Contact - any involvement (df) β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t Consultations er healthcare rofessional Nurse Contact - any involvement Low Medium High Random Variance Practice Global Tests (degrees of freedom) χ χ χ χ χ χ Nurse Contact - any involvement (df) /1 61

68 While there was some modest evidence of imroved glycaemic control being associated with a high roortion of nurse contacts, the relationshi between average the number of times eole with diabetes were seen by any healthcare rofessional at the ractice level (consultations er healthcare rofessional in Table 5.3) and meeting the threshold, was negative and statistically significant in 00. However, towards the end of the eriod the relationshi had become ositive and statistically significant, or close to significance (010, 011). The residual variance that remained after fitting the model declined noticeably between 00 and 003 from 0.56 to but has not changed fundamentally since then, although there was a small ste-down from in 009 to in 010. The findings at the higher threshold were similar; there was a statistically significant and ositive association between the roortion of eole meeting the threshold and a higher roortion of ractice nurse contact in 003 only. The average number of times eole with diabetes were seen by a healthcare rofessional at the ractice level was negatively associated with meeting the threshold for most years. For the first two years of the eriod (00, 003) this association was statistically significant. The residual variance decreased between 00 and 005 from to 0.379, increasing to in 006 and has remained close to that level (0.371 to 0.400) since then. The inclusion of a erson s reading from the revious year (e.g. meeting the threshold or not) in the model did not change the main findings to any great degree nor did the using nurse contact based on sole involvement or Vision allocation (Aendices , ). Restricting the analysis to ractices who met the inclusion criteria for all years of the study eriod (n=183) also did not change the effect of nurse contact noticeably (Aendices ). For the higher threshold ( 10%), during the second half of the eriod (008, 009, 011), ractices with a medium level of ractice nurse contact were more likely than those with a high level of contact to meet the threshold. The effect of consultations er healthcare rofessional was ositive and stronger than for the unrestricted analysis for the lower threshold ( 7%) from 007 onwards (excet for 010). 5. Diabetic review The data on diabetic review have been modelled utilising most of the indeendent variables used reviously excet that consultations er healthcare rofessional has been relaced by average number of reviews with a healthcare rofessional, and ractice nurse contact by ercentage of reviews with a ractice nurse where ractice ercentages have been categorised into low (less than 34%), medium (35-77%), and high (over 77%). During the early art of the eriod (00-003) ractices that reviewed and monitored eole s diabetes more often erformed better in terms of meeting the HbA1c 7% threshold (Table 5.5). After 003, this effect was no longer as strong although it was statistically significant one final time in 005. There was no significant association between the roortion of these reviews undertaken by nurses and the roortion of atients achieving the threshold, excet in 006 when the likelihood of meeting 6

69 the threshold was higher amongst those ractices that made greater use of ractice nurses in reviewing eole s diabetes. Similarly, ractices that reviewed and monitored eole s diabetes more often erformed better in terms of meeting the HbA1c 10% threshold (Table 5.6) in the early eriod (00-003) and although this effect was less strong after 003, it has still remained statistically significant. Whether these reviews were undertaken more often by doctors or ractice nurses was not significantly associated with atients achieving the threshold. 63

70 Table 5.5 Multilevel model, HbA1c 7% - effect of diabetic review β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t Reviews with a healthcare rofessional < < % Practice nurse reviews Low Medium High Random Variance Practice Global Tests (degress of freedom) % Practice nurse reviews(df) β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t Reviews with a healthcare rofessional % Practice nurse reviews Low Medium High Random Variance Practice Global Tests (degress of freedom) % Practice nurse reviews(df) /01 64

71 Table 5.6 Multilevel model, HbA1c 10% - effect of diabetic review β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t Reviews with a healthcare rofessional < < < % Practice nurse reviews Low Medium High Random Variance Practice Global Tests (degress of freedom) % Practice nurse reviews(df) β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t β SE(β) rob<t Reviews with a healthcare rofessional < < < <.001 % Practice nurse reviews Low Medium High Random Variance Practice Global Tests (degress of freedom) % Practice nurse reviews(df) /01 65

72 Chater 5 Summary Whilst there has been an overall reduction in the number of consultations er erson, a larger roortion of them are undertaken by ractice nurses, and this has been accomanied by better glycaemic control. After risk adjustment at the erson and ractice level, multi-level modelling showed that ractices in which eole with diabetes had a higher roortion of nurse contact had significantly more eole meeting the lower threshold of 7% in 003. The difference was close to significance in 005. Overall however, after risk adjustment at the individual level, there is much less variation between ractices in recent years (ost QOF) than there was in 003. There was some ractice level variation in the data but this diminished over time and was very low in the 011/1 dataset that linked THIN data with the ractice survey. Multilevel modelling indicates that most of the variation in likelihood of diabetes control is exlained by erson level characteristics rather than ractice level characteristics. There is evidence that those ractices that lace more effort on diabetes review have better erformance in terms of control of diabetes. This activity is being increasingly undertaken by ractice nurses. In earlier years, just before, and soon after, QOF was introduced, there was some evidence that those ractices where eole with diabetes were most likely to be seen by a ractice nurse had a higher roortion of eole with good control, although the association was not strong and not consistently significant. 66

73 6. Service configurations and economic imlications The urose of this art of the analysis was to understand the effect of workforce variables and service configuration on the rate of diabetes control within rimary care together with the economic or financial imlications of these. To this end, additional data were collected by the NNRU from 49 GP ractices through a ractice survey (described in Chater 3). The survey collected data on the size and mix of the workforce, and aroach to the management of care for eole with diabetes. For examle, 73% of resonding ractices indicated that nurses (including those secially trained in diabetes care) were involved in the management of diabetes, and 58% of ractices reorted that nurses were rimarily resonsible for this care. A full set of descritive statistics of this survey were resented in Chater 3. In this section we reort on the relationshis between the workforce and service configuration variables and the management of diabetes, building uon the multilevel regression models used in Chater The data The NNRU ractice survey dataset was successfully matched to THIN data for GP ractices surveyed, containing 74,143 atients. After removing ractices with missing data for the variables of interest 3 we were left with 166 ractices and 55,037 diabetes atients. Included and excluded ractices were comared and there was very little difference, none which was statistically significant, between the two sets of ractices. As the NNRU ractice survey was undertaken in May 01, THIN data for the year 17 th May 011 to 16 th May 01, referred to subsequently as the 011/1 data, were matched to the survey. Analysis of the 011/1 THIN data are reorted in chaters 4 and 5 alongside calendar years (00 011). As this analysis is based uon a subset of the data used in the rest of the reort it is worthwhile to comare the descritive statistics between this and the full samle. As Table 6.1 indicates, the data in the full 011/1 dataset and the subset of ractices which resonded to the GP survey are similar in relation to the mean value of the key variables. Although not reorted here, the standard deviations were also virtually identical. It aears that there was no selection bias for the sub-samle articiating in the GP survey. Additional variables from the GP survey which were included in this analysis included: Whether the ractice emloyed any nursing staff with a ostgraduate qualification in diabetes care from a higher education institution. 3 The variables of interest for this section of the analysis relate to the service configuration and the workforce so ractices were excluded if they had missing data for questions 18, 0 or. Please refer to the aendix for the comlete questionnaire. 67

74 Whether nurses commence insulin for atients with diabetes. Who is rimarily resonsible for managing diabetes care in the ractice. This was coded as a factor variable in two different ways. First, to cature whether the distinction between nurse, doctor or other (usually secondary care referrals) was imortant. Second, whether the distinction between secialist, non-secialist or other other (usually secondary care referrals) was imortant. Nurse staffing levels as measured by all eole registered with a ractice (not just eole with diabetes) er whole time equivalent registered nurse. Doctor staffing levels as measured by all eole registered with a ractice (not just eole with diabetes er whole time equivalent GP. Together these variables were chosen to reflect the service configuration and skill mix adoted by the ractice for managing diabetes care. It catures the degree of staff secialism in diabetes care and the doctor/nurse slit. 68

75 Table 6.1 Comarison of ractices resonding to the survey and all THIN ractices (means) Practices articiating Variable Full Dataset 011/1 in the survey Diabetic Control HBA1c < 10% HBA1c < 9% HBA1c < 8% HBA1c < 7% Patient Level Variables Townsend Index (quintiles) Age Charlson Score Obesity Index Male Country England Northern Ireland Scotland Wales Percent White - Quintiles Percent White Percent White Percent White Percent White Percent White Percent White - Unknown

76 Urban-Rural Classification Urban - sarse Town & Fringe - sarse Village/Hamlet - sarse Urban - less sarse Town & Fringe - less sarse Village/Hamlet - less sarse Unknown Other Practice Level Variables Diabetes revalence Practice List Size Patients er HCP Nurse Contact - Low Tertile Nurse Contact - Medium Tertile Nurse Contact - High Tertile

77 6. Analysis and results The baseline regression reorted in column 1 of Table 6., is a simle intercet only hierarchical random effects model 4 which nests atients within their ractice. There are 55,037 eole with diabetes atients nested within 166 ractices with an average cluster of 33 eole with diabetes atients in each ractice (range: ). The intercet (-0.393) reresents the log-odds of diabetic comliance below the HbA1c 7% threshold, which can be exonentiated to give the odds of comliance as 0.7 to 1, which confirms the marginal robability of comliance of 0.4% across all eole in all ractices. This is the same result that was found in the full dataset for 01 and indicates that there is no bias generated by droing ractices that did not comlete the GP ractice survey or those that returned the survey with missing data. In column of Table 6., the erson level fixed effects are included and in column 3 the ractice level fixed effects are included, in columns 4-6, the variables from the GP survey are added. 4 All analysis undertaken in this section used Stata 1 SE and xtmelogit, xtlogit and logit models. 71

78 Table 6. Multilevel Regression Model for HbA1c <7% Model 1 Model Model 3 Model 4a Model 4b Model 5 B (se) B (se) B (se) B (se) B (se) B (se) Patient Level Variables Age - linear 0.098*** 0.098*** 0.098*** 0.098*** 0.097*** (<0.001) (<0.001) (<0.001) (<0.001) (<0.001) Age- Quadratic *** *** *** *** *** (<0.001) (<0.001) (<0.001) (<0.001) (<0.001) Male * * * * * (0.0) (0.0) (0.0) (0.0) (0.0) Charlson Score *** *** *** *** *** (0.01) (0.01) (0.01) (0.01) (0.01) Obesity Index *** *** *** *** *** (0.0) (0.0) (0.0) (0.0) (0.0) Townsend Quintiles 1st (0.065) (0.09) (0.09) (0.09) (0.09) nd (0.065) (0.09) (0.09) (0.09) (0.09) 3rd (0.064) (0.09) (0.09) (0.09) (0.09) 4th (0.064) (0.09) (0.09) (0.09) (0.09) 5th (0.066) -(0.09) (0.09) (0.09) (0.09) Practice Level Variables Percent White Quintiles 1-0.8* -0.79* -0.79* -0.69* (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) (0.14) 7

79 Country Reference: England Northern Ireland (0.18) (0.18) (0.18) (0.18) Scotland (0.14) (0.14) (0.14) (0.15) Wales (0.11) (0.11) (0.11) (0.11) Urban-Rural Classification Reference: Unknown Urban - sarse (0.43) (0.43) (0.43) (0.43) Town & Fringe - sarse (0.9) (0.9) (0.9) (0.9) Village or Hamlet - sarse (0.8) (0.8) (0.8) (0.8) Urban - less sarse 0.145* 0.143* 0.144* 0.138* (0.06) (0.06) (0.06) (0.06) Town & Fringe - less sarse (0.06) (0.06) (0.06) (0.06) Village or Hamlet - less sarse (Omitted) (Omitted) (Omitted) (Omitted) Diabetes Prevalence (0.03) (0.03) (0.03) (0.03) Practice List Size (<0.001) (<0.001) (<0.001) (<0.001) Consultations er HCP 0.000* 0.000* 0.000* (<0.001) (<0.001) (<0.001) Proortion of consultations undertaken by a nurse Reference: Low (<6%) Medium (6-35%) (0.08) (0.08) (0.08) (0.08) High (over 35%) (0.07) (0.07) (0.07) (0.08) Practice Survey Variables 73

80 Nurse with PG Education (0.06) (0.07) Nurse starts Insulin (0.06) (0.06) - Nurse Configuration Doctor rimary lead (0.10) Nurse rimary lead (0.08) Secialist Configuration Non-secialist rimary lead (0.11) Secialist rimary lead (0.09) Peole er WTE nurse (38.5) Peole er WTE GP (188.08) Constant -0.38*** -4.88*** *** -4.69*** -4.8*** -4.09*** (0.09) (0.15) (0.5) (0.5) (0.5) (0.6) Random Effect Variance Log-Likelihood

81 Understanding the variance at each level of analysis (atient vs. ractice) is critical to understanding the contribution of this research to the literature. The ractice level variance of 0.1 is relatively small which is confirmed by an interclass correlation coefficient (rho) of 3.6%. This indicates that almost all (96.4%) of the variation in diabetes control is exlained at the individual erson level rather than at the ractice level. The variation in control rates across ractices is ± 8.7% around the gross mean of 4%. Further evidence of the lack of ractice level variation can be seen in Table 6.3 which comares the regression coefficients for a ooled and multilevel model. Altogether, this indicates that the data could be ooled without loss of generality and that a multilevel (hierarchical) or searated regression model will add little to our understanding. However, for comleteness we continue to model the data as a simle two level (eole nested in ractices) multilevel mixed effects model with a random intercet and all other coefficients set as fixed effects. 75

82 Table 6.3 Regression Results Comaring Pooled and Multilevel Structure Pooled Multilevel Age - linear Age- Quadratic Male Charlson Score Obesity Index Townsend Quintiles Unknown Percent White Quintiles Unknown Country Northern Ireland Scotland Wales England Urban-Rural Classification (omitted) (omitted) Unknown Diabetes Prevalence Practice List Size Patients er HCP Nurse PG Education

83 Nurse Contact: roortion of consultations with diabetic atients undertaken by a nurse (Tertiles based on THIN data ) Nurse Starts Insulin Nurse Configuration Doctor lead Nurse lead Other lead Constant In each case a Chi-Squared test on the change in the deviance (LR test) shows that the models are an imrovement on the revious model, although the inclusion of the GP survey variables rovides a marginally statistically significant imrovement in model fit (one-sided =0.04). However, there is no statistically significant difference (=0.15) in the deviance for the two different workforce configuration secifications 4a (nurse vs. doctor) and 4b (secialist vs. non-secialist). This is suorted by statistically insignificant coefficients in both formulations. One otential exlanation may be the collinearity or association between the existing nurse staffing variable (nurse consultations as a roortion of all consultations with healthcare rofessionals) and the service configuration variable (Mainly managed by nurse, doctor or other). A Pearson Chi- Squared test is reorted in Table 6.4 and indicates that those ractices with a higher level of nurse contact relative to all healthcare rofessional contact in the THIN data are more likely to reort nurses managing diabetes care. Desite this strong association (=0.001), droing one of the two factor variables does not make the remaining variable statistically significant, nor does the deviance imrove significantly. Table 6.4 Association between THIN Survey and GP Practice Survey Measures of Staffing and Configuration Lowest Tertile Middle Tertile Highest Tertile Column Totals Service Configuration (Practice Survey) Other Lead Doctor Lead Nurse Lead RowTotal,633 3,700 10,63 16,956 5% 7% 19% 31% 3,407 3,634 11,899 18,940 6% 7% % 34%,741,499 13,901 19,141 5% 5% 5% 35% 8,781 9,833 36,43 55,037 16% 18% 66% 100% 77

84 The regression coefficients and their statistical significance are broadly similar to those reorted for the full dataset in chater 5 and this will not be dulicated here. The main difference being that the ercentage of the local oulation that is white (recorded as quintiles) is not statistically significant in these models. While the regression coefficients are very close to those obtained using the full dataset, the standard errors are twice as large due to the much smaller dataset. The relatively small imact of the ractice level variables in the model is evidenced by the lack of statistical significance on their regression coefficients and the relatively small reduction in the random effect (intercet) variance from 0.1 in the null model (column 1) to 0.11 in the full model (columns 4a&b). This can be seen most clearly in Figure 6.1 which lots the combined mean intercet and random effect for each ractice. There is relatively little variation in this unexlained ractice level average effect and the absolute size of these effects is very small. Figure 6.1: Practice level effect odds (intercet & random effect) We focus instead on the new variables included in models 4a and 4b. Model 4a and 4b both include the dummy variable for ostgraduate training in diabetes care and the dummy variable for whether nurses start atients on insulin. The difference between models 4a and 4b are in relation to the service configuration variables. In model 4a, the model comares the erformance of ractices which manage care led by nurses and doctors in comarison to others. In model 4b, the comarison is between secialist, non-secialist and others. None of these variables are statistically significant. While the regression coefficients (and odds ratios) are quite small, they are similar in magnitude to the remainder of the variables in the models. However, the standard errors on these ractice level variables are relatively large. This is likely the result of having only 166 ractices in the dataset, and 78