Improving Diabetes Care

Transcription

1 Improving Diabetes Care Dr Clare Hambling Long-Term Conditions Lead, WNCCG

2 Plan for the afternoon: National Diabetes Projects Structured Education Achieving the 3 NICE Treatment Targets Local data Models of Care Foot Care

3 Diabetes is expensive for affected individuals: leading cause of vascular disease (MI, CVA, PVD & lower limb amputation) leading cause of ESRF & renal dialysis leading cause of preventable visual impairment doubles the risk of dementia contributes to 22,000 premature deaths every year for the NHS. treatment for T2D accounts for 9% of the NHS budget ( 8.8billion p.a.) 1 in 6 people in hospital have diabetes longer LOS 5 million people in England at high risk of developing diabetes If this trend persists, NHS England estimates that by in 3 people will be obese & 1 in 10 will have diabetes Source:

4 3 New National Diabetes Projects, 2017: 1) National Diabetes Treatment and Care Programme Value-based transformation within the Five year Forward View Aims to improve clinical outcomes reduce long-term complications ( ) 4 clinical areas: 1. Improving uptake of structured education 2. Improving achievement of NICE treatment targets 3. New/expanded multidisciplinary foot care teams (MDFT) 4. New/expanded diabetes inpatient specialist nursing services call to bid for transformation funding, December 2016

5 Structured Education - Attended Key Findings There are good reasons to believe that attendance is much higher than recorded. The decrease in attendance more recently should be addressed through the dissemination of supporting guidance for data recording to CCGs who commission education providers Type 1 Type 2 and other Percentage Attended Structured Education within one year of diagnosis Attended Structured Education within two years of diagnosis Year of diagnosis Year of diagnosis Attended Structured Education (no time limit) 5

6 Care Processes People with Type 1 Diabetes Key Finding The striking variation at locality level is evident and can also be seen between similar specialist services. 6

7 Treatment targets People with Type 2 Diabetes Key Finding Striking variation at locality level is evident and can also be seen between similar General Practices HbA1c <48mmol/mol (6.5%) HBA1C <=58mmol/mol (7.5%) HbA1c <=86mmol/mol (10.0%) Treatment target BP <=140/80 Cholesterol <4mmol/L Cholesterol <5mmol/L Meet all three treatment targets 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of patients 7

8 2) NHS Intelligence Programme Diabetes reducing unwarranted variation to improve people s health and outcomes and reduce inequalities in health access, experience and outcomes: right care, right place, right time, making best use of available resources 3) NHS Diabetes Prevention Programme Started in 2016, planned roll out to the whole country by 2020 Tailored, personalised help to reduce risk of T2D Focus on healthy eating, weight management, exercise Proven benefit in other nations

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10 National Diabetes Audit, Structured Education England and Wales 31 January 2017

11 Structured Education - Comment The NHS. underestimates, or undervalues, the provision of structured education for people with diabetes. Diabetes is a lifelong disorder with no periods of remission. Treatment demands are all day, every day. People with diabetes rarely spend more than two to three hours per year with a healthcare professional, and for the remaining 8,757 hours they must manage their diabetes themselves. They need the knowledge and skills to do this. Attendance at structured education forms one of the indicators in the CCG improvement and assessment framework 2016/17 practice recording of attendance at structured education now included within the Referrals Management LES 11

12 Structured Education - Offered Key Findings Timely offers of structured education have improved over the last three years Of those offered education, the majority are offered within one year of diagnosis Percentage n (no time limit) Type Year of diagnosis Type 2 and other Year of diagnosis Offered Structured Education within one year of diagnosis Offered Structured Education within two years of diagnosis Offered Structured Education (no time limit) 12

13 Recommendations Structured education providers and their commissioners should follow the recently agreed communication guidance to improve recording of structured education attendance GP and specialist services and CCGs/LHBs should use relevant parts of this report.to identify areas for improvement and implement local action plans. All services seek new approaches to diabetes service delivery for those aged under 65 to narrow the gap between them and older people. People with diabetes to review the results for their practice or specialist service and support any improvement initiatives. 13

14 Structured Education Why wouldn t you?

15 Kings Lynn Insulin For Food Insulin dose adjusting for people with type 1 and 2 diabetes on a basal bolus regimen Try to see people before and after attending the KLIFF course Friendly small 1 day group session Monthly group sessions Either at Tapping House or Tesco in Wisbech Annual refresher sessions Last year 117 referred; Attendees 86 (73%) Attendance rate is 77% over 3 years Average HbA1c drop post KLIFF is 13.2 mmol/mol. Which is maintained for up to 2 years

16 KLIFF Please carry on the day was SO helpful thank you This is the exactly the course I have needed to attend since October 1965 (year and month of diagnosis) I would like to say a massive thanks to you and your team for the course. My partner and I have found it very informative and we have already begun work on improving our lives

17 KLIFF Why wouldn t you?

18 Newly Diagnosed Type 2 Diabetes Patient Education By Community Diabetes Team

19 Newly diagnosed patient education programme Started over 10 years ago Based on DESMOND Referrals from GP practices sent to Community Diabetes Team on diagnosis Topics covered - complications, diet, foot care, self management and lifestyle advice.

20 Aims of the programme To promote patients self management, motivation and quality of life Allow time to speak to qualified healthcare professionals and other people with diabetes to share experiences To improve long term glycaemic control and reduce complications of diabetes

21 patients referred 271 attended (35%) 25 sessions held across West Norfolk in Kings Lynn, Watlington, Necton and Heacham Feedback Meeting people with the same condition Openness and frankness. Made me feel comfortable and not adversely treated Friendly, helpful staff. Clear course yet easy to understand Healthy eating top tips and how to avoid complications Good presentation and useful visual aids and literature

22 Number of patients referred and attended in 2016 Surgery St James Medical Practice Number referred Number attended Percentage attended Surgery Number referred Number attended Percentage attended % Hunstanton Surgery % Upwell Health Centre % Southgates Medical Centre Gayton Road Health Centre Manor Farm Medical Centre Terrington St John Surgery % % Wootons Surgery % % Howdale Surgery % % Heacham Group Practice % Campingland Surgery % Burnhams Surgery % Bridge Street Surgery % The Hollies Surgery % Feltwell Surgery % Plowright Medical Centre Watlington Medical Centre Great Massingham Surgery Carole Brown Health Centre Grimston Medical Centre Terrington St Clements Surgery % % Fairstead Surgery % % Litcham Health Centre % % Boughton Surgery % % Marham Surgery 1 0 0% %

23 Percentage of referred patients who attended in % 60% 50% 40% 30% 20% 10% 0% Heacham Group Practice Bridge Street Surgery Wootons Surgery Boughton Surgery Great Massingham Surgery Litcham Health Centre Watlington Medical Centre Terrington St John Surgery Grimston Medical Centre Plowright Medical Centre The Hollies Surgery Manor Farm Medical Centre Hunstanton Surgery Upwell Health Centre Burnhams Surgery Howdale Surgery St James Medical Practice Carole Brown Health Centre Southgates Medical Centre Campingland Surgery Fairstead Surgery Terrington St Clements Surgery Gayton Road Health Centre Feltwell Surgery RAF Marham Surgery

24 Question? How can we improve the uptake of diabetes structured education?

25 National Diabetes Audit, Care Processes & Achievement of Treatment Targets England and Wales 31 January 2017

26 Care Processes People with Type 2 Diabetes Key Finding The striking variation at locality level is evident and can also be seen between similar General Practices. 26

27 Care Processes By Age Key Finding Younger people with either Type 1 or Type 2 and other diabetes are less likely to receive their annual diabetes checks than their older counterparts. Percentage 70% 60% 50% 40% 30% Type 1 Type 2 and Other 20% 10% 0% Age of person with diabetes 27

28 Treatment Targets People with Type 1 Diabetes Key Finding Striking variation at locality level is evident and can also be seen between similar specialist services. HbA1c <48mmol/mol (6.5%) HBA1C <=58mmol/mol (7.5%) HbA1c <=86mmol/mol (10.0%) Treatment target BP <=140/80 Cholesterol <4mmol/L Cholesterol <5mmol/L Meet all three treatment targets 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage of patients 28

29 Treatment Target By Age Key Finding Younger people are less likely to achieve all three treatment targets than their older counterparts. This is primarily due to poorer glucose and cholesterol control in those aged under 65 years. Percentage 100% 90% 80% 70% 60% 50% 40% Type 1 Type 2 and Other 30% 20% 10% 0% Age of person with diabetes 29

30 Treatment Targets Comments Target achievement differences between CCGs/LHBs are substantial. Differences in patient demographics do not explain the extent of the variation. Differences between specialist services and between general practices are substantial and the differences in patient demographics do not explain the extent of the variation. Younger people are less often achieving treatment targets. 30

31 National Diabetes Treatment and Care Programme Primary aim is to increase the proportion of people with diabetes receiving all care processes and the achieving the 3 NICE treatment targets Changes that reduce variation and improve average achievement levels would yield great health benefits 31

32 Improving achievement of NICE treatment targets For both adults and children with diabetes HbA1c, BP & cholesterol in adults HbA1c in children without increasing the risk of hypoglycaemia or hypotension Investigate alternative care models understand variations in care and plan to tackle these Consider how to target hard to reach groups e.g. young people with T1D, people of working age Better integration between primary and secondary care Improve access to specialist advice Ensure all patients receive all 9 care processes at least annually Minimise clinical inertia Ensure all patients have a personalised, shared & agreed care plan 32

33 Local data 11,750 (8.2%) adults with diabetes 12 th highest prevalence of 209 CCGs 5 th highest prevalence amongst those aged > 65 years Source: 33

34 number West Norfolk diabetes prevalence by age (ECLIPSE) Age (years)

35 Local data 11,750 (8.2%) adults with diabetes 12 th highest prevalence of 209 CCGs 5 th highest prevalence amongst those aged > 65 years Care Processes QoF data for 2015/16 shows that 83.3% had a foot check Which is better than national average Complication rates For heart disease, stroke, major & minor amputations Generally in line with national average Source: 35

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37 Achievement of treatment targest 56.8% good glycaemic control (Hba1c 59mmol/mol) considered worse than national average between practices range % 73.7% BP well controlled (<140/80mmHg) considered better than national average between practices range % 70.5% cholesterol well controlled considered In line with national average between practices range % Source: 37

38 All 3 treatment targets HbA1c 56.8% BP 73.7% 41% achieve all 3 treatment targets Cholesterol 70.5% better than the national average Nonetheless, expectation is that more people should safely achieve all three treatment targets 38

39 Why does NHSE want us to consider models of Care? potential to improve processes and target achievements in diabetes care Efficiencies from better integration between primary, intermediate and secondary care services - access to specialists most people, with uncomplicated diabetes, managed within primary care processes to identify higher risk groups who would benefit from more specialist attention many models within federated primary care systems making use of specialist GP expertise, practice diabetes nurses & facilitating liaison with more specialist services 39

40 Super - Six Portsmouth defined clinical groups/problems continue in secondary care o Inpatient care o pregnancy & pre-pregnancy o People with poorly controlled type 1 and all young people & adolescents o diabetes patients on the diabetic foot pathway o people with low egfr or ESFD o insulin pump users all else supported in primary care by Community Diabetes teams Clinical & educational support twice yearly Virtual clinics (case-based discussions) QoF targets, audits Patient reviews (in conjunction with GP or practice nurse if needed) advice & guidance telephone hot line for urgent problems, access for less urgent problems educational programmes & support for primary care practitioners 40

41 One Norwich Providing diabetes services across a federated model Builds on strengths of individual practices, pools resources and makes best use of skill mix hub & spoke, 4 localities Ensures all patients who need it have access to more specialised primary care diabetes teams Planning to incorporate many of the principles of integrated community diabetes model with consultant diabetes support Virtual clinics Advice & guidance different levels of access 41

42 West Berkshire - the model proposed in our bid Similarities with Portsmouth model Secondary care services defined by similar criteria Primary care support also similar: Virtual clinic-based approach care planning either remotely or with case discussion in practice, supports HCP education Twice yearly practice visits Making use of ECLIPSE easier to select groups by a variety of identifiers - clinical parameters e.g. renal impairment, high hba1c or by medications can be predefined and set up as searches potential to manage a larger population Can target areas of relatively lower achievement as priority Advice & guidance 42

43 Questions? What elements do we want in our local model? How do we ensure all practices can improve the achievement of care processes? How can we safely improve achievement of all three NICE treatment targets for our local diabetes population? 43

44 Foot Care A project for the Autumn Aim to reduce variation in diabetes foot care across the STP area Currently Variation in amputation rates Pathways of care GYW still without a MDFT NDFA highlighted points of weaknesses Delays in patient presentation Delays in referral from primary care Plan to review & optimise pathways of care across the whole STP area 44