1 Diabetes Network - 2019 Network Manager: Alison Featherstone Aims/Objectives Clinical Lead(s) Network Lead 1.0 Support the delivery of the national NHS Diabetes Prevention Programme for Dr Caroline Sprake Elaine Stephenson Type 2 Diabetes 2.0 Support the delivery of increased and improved participation in National Diabetes Audit by shining a light on performance sharing best practice Support the delivery of improved uptake of care processes to reduce unwarranted variation 3.0 Support the delivery of improved treatment targets to reduce complications through increased uptake of structured education. 4.0 Support the delivery of improved diabetic foot care across Northern England ensuring adequate capacity in place to reduce major amputation rates ensuring early referral to multidisciplinary teams for assessment 5.0 Support CCGs by ensuring secondary care providers have inpatient specialist teams 6.0 Raise awareness of the CCG Improvement and Assessment Framework and support local CCGs as identified as having poor outcomes to help them identify the opportunities for local improvement, and develop plans to deliver improvements through planned investment from 17/18 onwards 7.0 Provide leadership to facilitate local understanding of effective service delivery through sharing best practice in diabetes prevention and treatment, bringing together local/regional/cross regional networks to share insights, learning to support continuous improvement and high quality outcomes Dr Caroline Sprake Dr Rahul Nayar and Dr Caroline Sprake Dr Rahul Nayar Annette Routledge Dr Rahul Nayar Dr Rahul Nayar Dr Caroline Sprake Dr Rahul Nayar Dr Caroline Sprake Elaine Stephenson Elaine Stephenson Kate MacKay Sue Long Elaine Stephenson Elaine Stephenson
2 Diabetes Network Clinical Leads: Dr Rahul Nayar (NECN Diabetes Clinical Lead, Foot care and Pregnancy), Dr Caroline Sprake (NECN Clinical Lead for Primary Care, Diabetes Prevention, Structured education, National Diabetes Audit), Dr Sath Nag, (Hypoglycaemia pathway) Dr Simon Ashwell (Inpatient insulin prescribing chart) Annette Routledge (NECN Network Nurse Lead for Diabetes Inpatient Care) Network Support Team Leads: Elaine Stephenson, Kate MacKay, Sue Long Network Manager: Alison Featherstone Enabling themes Working with service users, patients, families and carers is a commitment of NECN and will feature throughout the delivery of the proposed business plan. We work with organisations representing a range of service users and carers to ensure we gather a range of views. More detailed plans to design NECNs contribution to the delivery of each of the national priorities will be co-produced with these organisations and we will continue to ask for their advice and support to ensure service users and carers are involved in the most appropriate way throughout the delivery of each of NECNs aims. The importance of workforce, communication, training and data (including analytics) will run throughout the delivery of these aims. Similarly we will work collaboratively with Connected Health Cities towards improved information sharing and exploiting digital technology to achieve safer, quality care in complex environments for the clinical network priority themes, and offer the collective voice in shaping and implementing the Great North Care Record.
3 1.0 Support the delivery of the national NHS Diabetes Prevention Programme [NHS DPP] for people with Type 2 Diabetes Support the delivery of NHS DPP by (a) (b) (c) Disseminate the lessons learnt from the NHS DPP demonstrator sites and first wave of the national programme and maintain active relationships. Facilitate STP workshops to discuss readiness requirements for implementing Wave 3 NDPP rollout supporting communication of this priority within STP footprints. Support readiness for Wave 3 and coordination of Wave 3 STP bids (if appropriate) for NDPP. Planned workshops 2 nd Feb and 10 th Feb summer. (a) One forum to discuss across the region national NHS DPP. Involve local sites in shaping Wave 3 using their local learning (b) Actively engaging colleagues by facilitating two STP workshops (one NTW and one Tees) to discuss Wave 3 readiness requirements. STP bids submitted for Wave 3 NDPP (if appropriate) (c) Continue to support (where appropriate) readiness for Wave 3 by bringing people together and facilitating local discussions to ensure STP s are ready for Wave 3 NDPP. (Indicative times for Wave 3 bid information being released Summer. If successful bids supporting Wave 3 implementation during 2018/2019) By 2020 local economies to have developed local strategies for tackling obesity and diabetes prevention with aim of referring 500 people per 100,000 population annually to an evidence based Type 2 diabetes prevention programme. National priority Five Year Forward View NHS England Business plan Durham and Cumbria identified as NHS DPP sites Wave 1 within network geography Note: For aims/objectives numbers 2-5 overarching action - Support implementation of successful diabetes transformation funding bids in line with the actions set out within them
4 2.0 Support the delivery of increased and improved participation in National Diabetes Audit (NDA) by shining a light on performance and sharing best practice 2.0 a Understand 2015/16 National Diabetes Audit (NDA) participation and identify where further improvements can be made across the region and share best practice and approaches. Disseminate literature and actively support communication of this priority 2.0 b Explore and encourage better uptake and participation in National Diabetes Audit a) Promotion of benefits of participation by local champions. b) Explore opportunities for collaborating with Diabetes UK to encourage uptake. c) Monitor the performance of care processes and share local data with North Region Assurance team as requested. d) Use the Diabetes Advisory Group as a forum to address variation and 3 times per year 2.0 a Identify localities where improvements in participation can be made and share best practice at least one forum and promote approaches adopted across the region to encourage participation. Develop local case study where NDA participation increased locally based on 15/16 participation data 2.0 b Engaging with local CCGs/GP Practices for example at time in time out sessions/practice Manager Forums. Attend at least 2 in 2016/ Provide a forum to discuss variation. 2.0.c Integrated working with DCO team, monitoring performance at Diabetes Advisory Group 2.0 d. Include performance reports at least annually to the Network CVIN Cardiovascular Disease Profiles for Diabetes. Key indicator targets for BP, Cholesterol and HbA1c to determine outcomes - explore potential regional data workshop hosted by CVIN. CCGs achieving greater than 10% of diabetes population achieving 3 treatment targets. The Diabetes network team work with the local Directors of Commissioning Operations (DCO) team to support the achievement of the targets, advising the DCO team on clinical matters to support assurance
5 Support the delivery of improved uptake of care processes to reduce unwarranted variation performance issues in a learning and sharing environment. e) Regions/ Clinical Networks to encourage STP footprints to review local pathways against optimal pathways for diabetes treatment (when available) f) Development of a Community of Practice for CCG GP Clinical Leads to share best practice, look at how they function and help support each other, come up with ideas to feed into national agenda. Jan 18 Present relevant audit findings at annual event (Spring ) 2.0 e To be determined and agreed 2.0 f At least one meeting by Q4, with a minimum of 5 GP clinical leads in attendance from the region. Consensus on how they function, support each other and come up with ideas to feed into the national agenda. NHS Right Care Programme being rolled out nationally Data suggests current regional position for treatment targets: Type 1 11% of patients achieve the target; Type 2 42% of patients achieve the target. Regional improvement over the next 12 months - Aim of Type 1 5% improvement and Type 2 10% improvement 3.0.a Develop a briefing for CCGs setting out the problem in Northern England for diabetes education building on the work of Diabetes UK Freedom of Information setting out best practice, raising awareness of what localities are doing across the region. Facilitate 3.0.a Have at least one event where structured education is the topic to start a culture change - local awareness of uptake of structured education across our region. Understand the number of newly diagnosed with diabetes being referred to a structured National Diabetes UK Taking Control campaign aims to ensure every person with diabetes has an opportunity to learn about their diabetes through attendance at structured education
6 3.0 Support the delivery of improved treatment targets to reduce complications through increased uptake of structured education. links with neighbouring localities to share best practice 3.0.b Disseminate national guidance to CCGs to introduce the improved data recording for structured education and review CCG IAF indicator findings for structured education attendance in. December 2016 education programme 3.0b All localities aware of the national READ codes for data recording and are working towards embedding these locally. Improvement in data reporting for people with diabetes attending structured education Across STP footprints, CCGs should aim to deliver an additional 10% of newly diagnosed people with diabetes attending structured education per year to 2021 as measured in the NDA to improve treatment outcomes/reduce complications associated with diabetes Delivery of improvements at CCG level to be monitored via NDA 4.0.a Continue to support regional foot care group enabling it to discuss variation. 4.0.a Four meetings per year. Representative and robust membership. Up to date website content Minimum Aim for 10% reduction in major amputation rates across the region over next 12 months 4.0.b Understand current footcare provision across network geography including makeup of MDfT teams December 2016 4.0.b Baseline understanding of MDfT teams across Network geography National Diabetes Foot care Audit NCEPOD Report implementation 4.0 Support the delivery of improved diabetic foot 4.0 c Support CCG areas to ensure each have a footcare pathway with adequate capacity for early referral 4.0.c Footcare pathway established for each CCG area with adequate capacity for early referral Operational Delivery of the Multi-Disciplinary Care Pathway for Diabetic Foot Problems (April 2016)
7 care across Northern England ensuring adequate capacity in place to reduce major amputation rates ensuring early referral to multidisciplinary teams for assessment Please refer to Footcare Group work plan for greater detail of group deliverables. 4.0 d. Support areas with no Foot Protection Team or MDfT to establish one 4.0.e Continue close working relationship with Vascular Network and implementation of share diabetes foot care goals. 4.0.f Encourage participation in National Diabetes Foot care Audit. Audit data to be published approx. April 4.0.d.Each CCG area to have established MDfT or Foot Protection Team 4.0.e. Aligning with the Vascular Network on reconfiguration of arterial and non-arterial centres 4.0 f 100% of units participating in National Diabetes Foot care Audit and continued monitoring of participation CCGs should ensure that providers have a foot care pathway with adequate capacity in place to enable early referrals for people at risk of diabetic foot disease to foot protection teams and for people with active foot disease to multidisciplinary foot care teams 5.0 Support CCGs by ensuring secondary care providers have inpatient specialist teams 5.0 a Recruit Network Nurse Clinical Lead. This role will involve 5.0 b Supporting the transformation change programme for diabetes 5.0 c Undertake benchmarking of inpatient diabetes services to understand regional picture. Jan 5.0 a Network Nurse Lead recruited and in post 5.0.b Supporting CCGs/Secondary care and inpatient specialist teams with transformation projects 5.0 c Undertake mapping and benchmarking process of inpatient services to understand regional picture. Use regional and National Audit of Inpatient Diabetes Care (NaDIA) data to establish local and regional themes and address insulin safety. CCGs to ensure that all secondary care providers have inpatient specialist teams to assess and help manage inpatients with diabetes Diabetes UK: Diabetes Specialist Nursing 2016 Workforce Survey
8 6.0 Raise awareness of the CCG Improvement and Assessment Framework and support local CCGs as identified as having poor outcomes to help them identify the opportunities for local improvement, and develop plans to deliver improvements through planned investment from 17/18 onwards 6.0.a Identify and establish relationships with North Regional Assurance Team and understand ratings of the diabetes component of the CCG IAF for Northern England. Support locally identified CCGs to develop opportunities for local improvements. 6.0.b Maintain links with Children and Young People diabetes network. CCG IAF indicator for HBa1c relates also to Children and Young people with diabetes 5.0.a Integrated working with DCO team and understanding of baseline position of diabetes component of CCG IAF Action plans developed based on ratings (where appropriate) Encourage participation in NDA as means of improving data completeness within CCG IAF indicators 5.0.b Attendance at 50% of meetings per year National priority North Region Assurance Team undertaking assurance of local CCG IAF position National Diabetes Transition service specification Children and Young People Diabetes Network establishing work stream on transition and welcome representation from adult teams 7.0 Provide leadership to facilitate local understanding of effective service delivery 7.0.a Establish Diabetes Team meetings 7.0.b Continue regional diabetes network and be the conduit for information sharing between national, regional and local partners. 7.0.c Attend National and North Region meetings to strengthen relationships with clinical networks, particularly in North Region. Quarterly 7.0.a Three meetings per year 7.0.b At least three meetings per year. Representative and robust membership and attendance. Up to date website page 7.0.c Representation at national clinical network and Diabetes UK quarterly meetings for 75% per year National Priority Addressing regional clinical needs 1: Patient safety 2: CQC review of diabetes provision in secondary care 3: National Audit of Inpatient Diabetes Care (NaDIA) participation and improvement in care
9 through sharing best practice in diabetes prevention and treatment, bringing together local/regional/cross regional networks to share insights, learning to support continuous improvement and high quality outcomes 7.0.d Continue to work with Diabetes UK to ensure continued engagement in the diabetes work programme and patient voice represented 7.0.e Host annual event based around national priorities. 7.0.f Insulin Safety and awareness, to address issues regarding insulin safety embed regional hypoglycaemia pathway. 7.0.g Pilot regional inpatient insulin prescribing chart in South Tees NHS Foundation Trust. Review April/May 7.0.d Understand how CCGs are using patient and public involvement through their local patient forums 7.0.e Minimum of 65 delegates from across region attending. 70% of delegates found the event useful 7.0.f Regional collaboration and operational hypoglycaemia referral pathway across the region agreed by October 7.0 g Evaluation report from pilot to inform regional roll out. Report delayed revised timescales April/May South Tees Foundation Trust to evaluate the pilot. Launch July/August 2016; 3 month pilot and evaluation December 2016 (Timescale delayed due to printing requirements)