Cumbria Diabetes Dr Cathy Hay Clinical Director Cumbria Diabetes Cumbria Partnership NHS Foundation Trust

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1 Cumbria Diabetes 2011 Dr Cathy Hay Clinical Director Cumbria Diabetes Cumbria Partnership NHS Foundation Trust

2 Forecasted Numbers for Diabetes in Cumbria (Source: PBS Prevalence Model) 45,000 40,000 35,000 30,000 25,000 23,962 27,463 30,891 34,781 38,773 20,000 15,000 10,000 5, Year

3 Healthcare Commission Data Cumbria Performance v England Data Data Source England Average Cumbria Average Diabetics offered Retinal screening QOF % 85.81% % of patients who have attended an education or training programme National Survey of People with Diabetes Healthcare Commission 10.51% 5.78% % Diabetics with record of micro-albuminuria testing QOF % 89.89% % Diabetics with proteinuria or micro-albuminuria treated with ACE inhibitors or A2 antagonists QOF % 88.76% % Diabetics with record of presence/absence of peripheral pulse QOF % 91.46% % patients with diabetes with record of neuropathy testing QOF % 91.21% % Diabetics who have a record of HbA1c QOF % 98.20% % Diabetics who have a HbA1c of less than 7.5 QOF % 68.85% % Diabetics who have a HbA1c of 10.0 or less QOF % 94.40% % Diabetics with record of total cholesterol QOF % 97.21% % Diabetics whose last measured total cholesterol of 5 or less QOF % 83.46% % Diabetics with record of blood pressure QOF % 98.84% % Diabetics with record of blood pressure of 145/85 or less QOF % 80.79% % of patients that almost always discuss goals for their diabetes management National Survey of People with Diabetes Healthcare Commission 39.32% 46.52% Number of items prescribed per registered person with diabetes epact (April June 07) Net ingredient cost of diabetic items per person with diabetes epact (April June 07) Significantly worse than England at 95% No significant difference Significantly better than England at 95% 2006/2007 data

4 Commissioner Concerns How could the diabetes service respond to the increasing prevalence of diabetes? Evidence of high quality of care in Cumbria but also areas of weakness E.g. Minimal structured patient education Variability in care across Cumbria

5 Commissioner Decisions Stakeholder meeting Jan 2007 April 2008 Reference Group formed: Chair Sue Roberts GP s Consultant Diabetologist Medicine s Management Public Health Commissioner

6 What Happened Next? April 2008 The Reference group was tasked: To develop and implement a model of care for people with diabetes in Cumbria To fit with the strategic direction of the PCT e.g. Closer to Home Advertised and recruited to a User Group Lead Commissioning GP s for each Cumbria locality, joint working via PEC

7 The Cumbria Diabetes Model of Healthcare Primary care (core) Primary care setting Primary care (enhanced) Specialist support for Primary Care Complex care Secondary and tertiary care setting

8 Diabetes Specialist Services 2008 Staff employed by 3 providers Separate teams in North and South Cumbria Inequity in service provision across Cumbria DAFNE in North Cumbria only Pump service in South Cumbria only

9 Cumbria

10 Cumbria Diabetes The Vision A Cumbria wide team of multidisciplinary clinical specialists and support staff Responsible for Specialist support into primary care, complex and secondary care Clinically led Hosted by a single provider

11 The Journey to Cumbria Diabetes October 2008: Nominations for Lead Clinician November 2008: Clinical Director appointed NHS Cumbria chose a preferred provider Proposed start date for Cumbria Diabetes agreed as 1 st April 2009

12 The Journey continued.. Dec 2008 Transition group formed = clinicians from all current providers + User representation Staff consultation process Contract negotiations start between the Commissioner and Preferred Provider April 2009 deadline missed July 2009 deadline missed October 2009 deadline missed

13 The Marathon. No financial agreement between NHS Cumbria and the Preferred Provider Demoralised staff, stagnant service February 2010 Decision to change the provider to the PCT October 2010 Staff TUPE transfer to the PCT provider arm

14 Cumbria Diabetes 2011 Includes all the Consultants, DSN s and dietitians in Cumbria Retinal screening service included North, West and South Locality Specialist Teams Transfer to Cumbria Partnership FT April 2011

15 Key Developments Structured Education available throughout Cumbria Successful staff recruitment EMIS web now implemented by the team Training for primary care e.g. Care planning Diabetes LES to encourage change in primary care

16 Learning Points Need to see the big picture NHS changes compounded the difficulties GP s evolving into Commissioners Commissioner/ Provider split Foundation Trust application by Preferred Provider Commitment needed for change Need key people involved Resource is needed

17 Final Points Opportunity Need to engage the key decision makers Need to include all the stakeholders Communication vitally important Change is hard

18 Thank you

19 20 per patient (total) Care Planning (mandatory) Care of specific groups Housebound patients Nursing and Residential home patients Pre-conception advice for woman of child bearing age Insulin and GLP-1 initiation in Type 2 Titration of insulin

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21 Diabetes and Cumbria 20,000 people diagnosed in 2007 Predicted increase in number diagnosed of 15,000 by 2025 Cumbria obesity rate is comparable to the England average (24%) Aging population

22 The Journey to Cumbria Diabetes Reference group start writing the Cumbria Diabetes Service Specification September 2008: Funding agreed for DAFNE/ DESMOND October 2008: NHS Cumbria formally decommissioned existing diabetes services

23 Reference Group Decisions How could the diabetes service respond to the rising prevalence? Increasingly manage people with diabetes in a Primary Care setting Primary Care staff would need support and training Reserve specialist input for specific individuals requiring complex care

24 Reference Group Decisions Modernisation of the current structures was required: Ensure appropriate resource and clinical governance Redefine the role of the specialists Shift in culture required to promote the psychosocial aspects of diabetes and recognise the importance of self management

25 Description of services draft Primary care (core) Delivers holistic annual review (care planning) for patients with Type 2 diabetes Complete QoF measures Primary care setting Primary care (enhanced) Specialist support for Primary Care Complex care Secondary and tertiary care setting

26 Description of services draft Provides core care Care planning and management in patients with Type 1 diabetes Primary care (core) Primary care (enhanced) Primary care setting Specialist support for Primary Care Complex care Secondary and tertiary care setting Insulin initiation Supervision of insulin therapy

27 Description of services - draft Primary care (core) Primary care setting Primary care (enhanced) Specialist support for Primary Care Secondary and tertiary care setting Complex care

28 Description of services - draft Primary care (core) Primary care setting Primary care (enhanced) Specialist support for Primary Care Complex care Secondary and tertiary care setting Reviews newly diagnosed Type 1 before referring to Enhanced Care Provides staff training both formally and informally Coordinates/provides patient education and Type 1 post education support Ad hoc specialist advice to other professionals Locality based individual case discussion with specialist team Contributes to developing clinical guidelines Supports development with Core Primary Care Practices to become enhanced practices Provides enhanced services to core practices Co ordinates the specialist support services for Primary Care eg nutrition, psychology, retinal screening

29 Description of services - draft Primary care (core) Provides care to individual patients with complex needs Provide/coordinates multi specialty services eg Pregnancy, renal, eyes, vascular, heart and feet Provides transition and young adult services Provides inpatient care Primary care setting Primary care (enhanced) Specialist support for Primary Care Complex care Secondary and tertiary care setting