MILTON KEYNES PRIMARY CARE TRUST. Author: Mary Hartley, PCT Commissioning Manager, Chronic Conditions

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1 MILTON KEYNES PRIMARY CARE TRUST Attachment E Subject: Meeting: Diabetes Patient Pathway (Adults) JHSCB Author: Mary Hartley, PCT Commissioning Manager, Chronic Conditions Date: September 9, 2004 Purpose The Board is asked to note the proposed service developments outlined in this paper and the financial resource implications involved. It is hoped that these can be considered as a priority in the next financial planning round. Summary of Contents Diabetes is an increasingly common chronic condition, which can lead to complications that have a significant impact on a person s quality of life, and can be costly in health and social care terms Diabetes is incurable but its effects can be contained and delayed Most diabetics are managed within GP Practices, and by the patients themselves. However, some specialist support is required and this part of the service is currently overstretched The diabetes patient pathway and strategic development describes aims to enhance the community based service with a central role for patient education The diabetes specialist team will concentrate on the management of those people with complex needs, difficult to control diabetes or with diabetic complications Implementing the strategy requires joint management of the diabetes service across primary and secondary care, and requires some additional resources Page 1 of 9

2 Introduction This paper is to inform the JHSCB of the work being undertaken in Milton Keynes to implement a diabetic patient pathway for adults, which aims to provide high quality, effective, patient-centred diabetic care for all patients with both Type I and Type II diabetes mellitus. The developing patient pathway seeks to provide a cross-sector, efficient service that will ensure that there is an improvement in the patient s experience of care as well as improved clinical outcomes. Background Diabetes is increasing in prevalence. Traditionally, the estimated number of adult diabetics in Milton Keynes has been about 3% of the population (6,500 7,000 people). However, as diabetic registers in GP practices are established, the percentage of diabetics is shown to be nearer 4.5%. Consequently, the number of known diabetics may increase beyond 10,000. Of the known diabetics, 85% have Type II diabetes, and the remainder Type I diabetes. Modern management of the disease means that care for both types of patient is becoming increasingly similar. [Note: there are relatively few children with diabetes, and they are all under the care of Paediatric Consultants. Transition of their care from the Paediatric team to the adult team is carefully managed.] Diabetes aetiology has been linked with obesity, which is also increasing in prevalence, and experts are warning that an epidemic of diabetes is imminent within the next few generations, with younger and younger people also being affected. Consequences of diabetes are profound and commonly include blindness, heart disease, stroke, kidney failure, and limb amputation. An estimated 400 people in Milton Keynes will be newly diagnosed with diabetes each year, and the condition is more common in South Asians and African- Caribbeans, and in areas with high deprivation. Evidence shows that early and careful diabetes management is highly cost-effective and that patient education can improve glycaemic control and quality of life. Current service provision Most diabetics are managed in General Practice and with self-management. A PCT service mapping exercise in 2002 highlighted that almost all areas of health and social care in Milton Keynes provide care for diabetic patients. These services have been relying on a centralised specialist medical model of care, which has been stretched beyond current capacity. The need for a more patient-centred, health promotion-focused structure to local diabetic care, where patient need is matched to health care professional competencies, has been recognised. NSF Local Implementation Team The Diabetes NSF Local Implementation Team (LIT), an inter-agency group that includes patient representatives, oversees the planning and implementation of changes in the local Diabetes services in order to achieve the Diabetes NSF standards and targets, and to implement NICE and other national guidance. The LIT acknowledges that the present diabetes services, both in the hospital and in the community, are presently stretched. With the expected growth in population, coupled with the probable rise in the number of diabetic patients, it is unlikely that current service configuration will meet the needs. Therefore service development Page 2 of 9

3 needs to utilise the current resources efficiently and effectively as well as identifying areas to be enhanced, such as patient education. The new GMS (ngms) contract places a large emphasis on diabetes care in General Practice, and GPs in MK are engaged with the process of how to fulfil the criteria set out in the Quality and Outcomes Framework. The LIT seeks to support GPs and their teams in conjunction with the National Primary Care Development Team, phase 3 National Primary Care Collaborative. Strategic development of services The LIT strategic objectives for the patient pathway are: 1. To support a community-based package of care for patients with diabetes and away from a secondary care-led model 2. To incorporate learning from centres of diabetic excellence, both in the UK and abroad 3. To involve people with diabetes in the development of the service and in the management of their chronic condition 4. To inform the local delivery plan for the Milton Keynes health economy 5. To be an example of successful joint working across the primary, secondary and social care sectors, with patient and public involvement. Service principles The service should educate and support people with diabetes in the management of their condition so that they maintain as far as possible healthy and productive lives There should be a team approach to diabetes management, with the team including GP, practice nurse, practice support staff (e.g. HCA, receptionist), health educator, diabetes specialist nurse, GPwSI / consultant physician, dietician, optometrist, podiatrist, plus social worker and others when required Each practice-based diabetes register forms the basis of identifying and providing appropriate care for patients with different diabetic care needs, and therefore there must be consistent efforts by all team members to keep the registers up to date. (This also supports data collection requirements in the ngms contract.) All health care professionals involved in the management of people with diabetes should be familiar with, and use, the same agreed evidence-based protocols and guidelines. Patients with diabetes should be reviewed holistically, with consideration of other co-morbidities, e.g. coronary heart disease. Patient pathway The proposed pathway for a patient with diabetes is outlined on page 6. It is generic and does not include all potential variations, but aims to provide the basics that a patient could reasonably expect during their diabetic life. The pathway as illustrated also shows which member of the broad diabetes team should be expected to provide each step of care and support. The main differences between the proposed model of diabetes care and the current service are that in the proposed model: patient education is supplied at time of diagnosis, at times of deterioration in clinical condition, and in various forms: written, electronic, telephone, etc diabetics are reviewed and cared for predominately in primary care the diabetes consultant and nurse specialists have a greater role in educating and advising primary care staff in the management of diabetes, and care directly Page 3 of 9

4 only for those patients who require more specialised care than can be expected from primary care staff better information acquisition and use means that people with diabetes can be proactively (rather than reactively) managed Progress to date Establishment of LIT/ MK Diabetes Network (as recommended in NSF) Mapping of current diabetes services across sectors, including nursing homes, prison etc. Identification of priority targets for development Establishment of GPwSI post Help for identified GP practices to establish an electronic practice based diabetic register Pilot of an Intermediate Diabetes Care clinic at Stantonbury H/C Development of strategy and patient pathway Programme of education for Nursing Home staff (carers and cooks) Identification of Practice nurses with diabetes qualification (as a PCT resource) Rolling programme of education for professionals Purchase of 8 insulin pumps / training for specialist team Successful bid for central money to roll out retinal screening programme (NSF target) Evolving programme of public and patient involvement (20 volunteers to form diabetic patient/carer forum so far- to commence September 2004) help line for clinicians Planned Future Developments Publication of localised, targeted, written patient information Publication of local Diabetes web page on PCT web site Implementation of DiabetesE, a web based tool for audit and planning - data collection to start October 2004 Group education for newly diagnosed diabetics Programme of patient education in conjunction with rolling Expert Patient Programme Publication of evidence-based, localised, written guidelines for clinicians Establishment of a hospital based retinal screening programme with robust call and recall procedures, audit and QA etc. to achieve NSF targets by 2006/7. Central money is to be made available in order for Diabetes Networks to employ a Network Manager (MK is a designated diabetes network within TVHA) & this role to be defined to best suit local needs. To work in conjunction with other local chronic disease management teams such as in CHD and COPD in order to improve patient care and service quality further, in an integrated fashion Resource Issues Work is progressing in many areas across the health and social care sectors in order to bring about the changes needed. However, to progress further, extra resources are required: Medical staff The consultant diabetologist is a general physician within the hospital and only half of his time is dedicated to diabetes. A second, similar post has been advertised but it has not been possible to appoint to this post. The consultant is now supported by a GPwSI, although this is for only one clinical session per week. Thus there is little time available after their clinical commitments for educational sessions or other service development work. Page 4 of 9

5 Nursing staff The specialist diabetes team are facing a huge pressure of work despite initiatives such as creating GPwSI support and an advice line for professionals. This situation will worsen as the diabetic population grows. GP Practices Moving more diabetic care into General Practice will also put pressure on diabetic clinics in the community. More training is needed for GPs and Practice Nurses in diabetes control and instigation of insulin as well as in service development such as setting up practice-based, one-stop diabetic clinics. Dieticians As diabetes treatment is evolving, patients need more intense education and advice about diet and lifestyle. The Dietetic service is under extreme work pressure and this will increase as more patients have their insulin dose adjusted to their carbohydrate intake (DAFNE) and insulin pumps are prescribed. Podiatry The current podiatric service is also stretched and cannot undertake a rolling programme of preventative foot care, which would help prevent long term complications such as ulceration and amputation. NICE guidance NICE recommends best practice, which in some cases such as insulin pump therapy and microalbuminuria screening, demands significant extra resources to provide the services. There are also costs incurred for education and training for both professionals and patients and more time is needed with each patient. Educational developments Patient education and written information needs to be targeted to stages in the patient pathway. It is now nationally acknowledged that group teaching sessions are an efficient and cost effective way forward. Ideally, Milton Keynes needs a Health Educator to concentrate on developing and delivering this service and resources, equipment and suitable venues are needed. More work is needed to establish an ideal workforce profile for staff looking after the growing diabetic population of Milton Keynes. Likewise, education and training programmes need to be developed with the local Workforce Development Confederation. When this work has been completed, the associated costs can be ascertained. Conclusion The diabetes patient pathway and accompanying local strategy describes an integrated diabetes service which aims to provide high quality, effective, patientcentred diabetic care for all adult patients and, over time, to reduce the healthcare costs associated with people with diabetes. Work is ongoing across the health and social care sectors to establish this pathway, monitored and audited by the MK Diabetes LIT. Progress will be expedited if more resources are made available. Page 5 of 9

6 The developing Diabetes Patient Pathway Diagnosis Assessment of dietary and lifestyle needs and education Creation of individual care plan including stabilisation on diet / medication Review cycle Patient telephoned / texted / ed 6-8 weeks in advance to arrange a convenient time. Blood tests arranged for 3-6 weeks beforehand with forms posted. Reminder of appointment posted / e- mailed / texted to patient one week beforehand By GP or at hospital Patient options: Diabetes education group sessions Diabetes patient group membership Targeted group sessions on other lifestyle issues e.g. smoking cessation, diet, exercise, alcohol Diabetes team contact details provided, Page 6 of for 9 addressing individuals specific problems or questions By nurse specialist/ dietician (initially, possibly moving to health educator in the future) with referral to other specialists (e.g. smoking cessation) as necessary By GP or hospital By GP and primary care team Service organised and delivered centrally or in localities Acute deterioration =>A&E attendance/ hospital admission Development of minor complications (e.g. foot problems, minor retinopathy, microalbuminuria) Development of major complications (e.g. MI/CABG/PTCA, depression, severe retinopathy, ESRD, amputation, gestational diabetes) Nurse specialist care management time-limited programme - protocol driven with diabetologist backup and input from other diabetes health care professionals Checks patient s: coping mechanisms medication willingness and ability to make necessary lifestyle changes Refers back to GP if/when stable Case management - nurse specialist co-ordination of care by diabetologist, relevant other specialists and other diabetes health care professionals Checks patient s: coping mechanisms diabetic medication willingness and ability to make necessary lifestyle changes

7 APPENDIX 1 DIABETES TEAM ROLES WITHIN THE PATHWAY Team member roles and responsibilities To function effectively as a team, each member should understand and work to the roles allocated to them. For the various parts of the team, suggested responsibilities and competencies are listed below. (a) GP / Primary care team Initial diagnosis of diabetes with brief description to the patient of what the disease means, plus onward referral for more detailed 1:1 patient education Stabilisation of diabetes by diet and/or medication Introduction of insulin therapy and insulin-dependent diabetic specific dietary advice Annual review of stable diabetic patients, including setting and reviewing patients goals in diabetic control and lifestyle choices Proactive care of diabetic patients who also have learning difficulties or mental health problems and may be less able to take responsibility for their own diabetic care If there are management problems, to telephone or the Diabetes Advice Line for further advice If the patient is developing complications, or has difficult to manage diabetes even after receiving help from the Advice Line (e.g. HbA1c consistently greater than 8%), or has attended A&E or been admitted with a diabetes-related condition, to refer the patient to the Diabetes Specialist Team for entry into care or case management Keeping the diabetes register (using the national diabetes dataset) up to date Take part in continuing education and development activities in diabetes Act as gatekeeper to the Diabetes Specialist Team if the patient is not currently in care/case management programmes (b) Diabetes nurse specialists More detailed 1:1 patient education at time of diagnosis, and refresher group education sessions for all diabetic patients Input into developing protocols/guidelines for consistent health economy-wide management of diabetes Help respond to queries received through the Diabetes Advice Line from primary care Ability to prescribe per protocol (in the longer term) Act as point of referral for patients with complications or difficult to manage diabetes from primary care (and from other teams in secondary care?) Run care management programme: protocol-led time-limited programmes of more intensive work with diabetic patients referred from primary care. Case manages those patients with more complicated diabetes, in close conjunction with diabetologist, in order to ensure co-ordination of care with other specialists (e.g. cardiology, nephrology, obstetrics, etc) Educate and train primary care staff and nursing staff in residential/nursing homes Act as first point of call for patients involved in care and case management (c) Diabetologist / GPwSI Develop protocols / guidelines for: Initial management and review of patients with diabetes in primary care Page 7 of 9

8 Care management Drug treatments of choice for diabetics across primary and secondary care Other common issues, e.g. transfer of patient onto insulin therapy Also to: Help respond to queries received through the Diabetes Advice Line from primary care See and manage problematic patients in care management programme See and advise in (at least initial) management of patients with major complications (i.e. in case management), in conjunction with other specialist colleagues Educate and train GPs and practice staff In the new era of patient choice, provide some basic diabetic care for patients who elect to have centralised specialist care rather than care based in the community. However, this should be seen as a minor part of the specialist team s workload. d. Specialist diabetes dietitians Forms part of the specialist diabetes team and ensures dietary interventions are integrated with the rest of diabetic treatment particulary the timing of medication. Initiates specific therapeutic dietary intervention alone or alongside changes to medication where control is elusive. Detailed 1:1 patient education at time of diagnosis, and refresher group education sessions for all diabetic patients, annual review. With DSNs insulin pump training, DAFNE or DAFNE style training for patients on daytime insulin and carbohydrate counting techniques. According to current protocols is first line educator for patients with Type 2 diabetes in MKGH Is de facto diabetes educator for patients with Type 2 diabetes from practices where practice nurse intervention is under-developed. Input into developing protocols/guidelines for consistent health economy-wide management of diabetes Help respond to queries received through the Diabetes Advice Line from primary care Educate and train primary care staff and nursing staff in residential/nursing homes and the prison. Supports women with gestational diabetes or pregnant Type 1 diabetics at antenatal diabetic clinic. Annual review e. Other hospital dietitians Assesses, nutritionally supports, and monitors patients in hospital requiring artificial nutrition. Specialist intervention for patients in renal failure, with CHD or following MI or other illness unrelated to diabetes. f. Dietitians working in the Community Provide dietetic support to patients in primary care either through attendance at clinics in local health centres, hospital based clinics for GP referrals or educational group work for type 2 diabetics. Where essential provides a domiciliary service to patients at home or in care homes. Provides weight management groups Page 8 of 9

9 Provides workshops etc for training other health professionals. Educate and train primary care staff and nursing staff in residential/nursing homes and the prison. Provides specialist support for diabetic patients with learning disabilities Supports diabetic patients at home requiring artificial nutrition support g. Allied Health Professionals - dietitians, podiatrists Meeting the Challenge (DOH, 2003) describes a strategy for Allied Health Professionals to develop their roles in order to provide improved care for patients with chronic conditions such as diabetes. Ten key roles are identified for AHPs which include first contact services, requesting and assessing diagnostic tests, referral to other services, developing extended practitioner roles, health promotion, patient education and to improve collaborative working with other professions and services. This means that dieticians and podiatrists, already an integral part of the primary and secondary care teams, are an important resource for making the new strategy work. e. Optometrists, Community Pharmacists These groups of professionals provide basic information to all diabetics as well as tailored patient advice to individuals who require more specific help. Optometrists also have a growing role in the retinopathy screening service. The development of the role of Pharmacists with a Specialist Interest, as outlined in the Department of Health document A Vision for Pharmacy, will provide the opportunity for community pharmacists to develop further expertise in diabetes and to play a growing role in a number of areas of care, such as encouraging compliance in order to prevent complications. References A Vision for Pharmacy in the New NHS (2004) Department for Health, London Meeting the Challenge: A strategy for Allied Health Professionals (2000) Department of Health, London NSF Diabetes: Delivery Strategy (2002) Department of Health, London. The Chief Health Professions Officer s Ten Key Roles for Allied Health Professionals (2003) Department of Health, London Page 9 of 9