Cumbria Diabetes 2011 Dr Cathy Hay Clinical Director Cumbria Diabetes Cumbria Partnership NHS Foundation Trust
Forecasted Numbers for Diabetes in Cumbria 2005 2025 (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 5,000 0 2005 2010 2015 2020 2025 Year
Healthcare Commission Data Cumbria Performance v England Data Data Source England Average Cumbria Average Diabetics offered Retinal screening QOF 0607 88.55% 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 0607 85.63% 89.89% % Diabetics with proteinuria or micro-albuminuria treated with ACE inhibitors or A2 antagonists QOF 0607 88.86% 88.76% % Diabetics with record of presence/absence of peripheral pulse QOF 0607 90.68% 91.46% % patients with diabetes with record of neuropathy testing QOF 0607 90.20% 91.21% % Diabetics who have a record of HbA1c QOF 0607 97.06% 98.20% % Diabetics who have a HbA1c of less than 7.5 QOF 0607 67.65% 68.85% % Diabetics who have a HbA1c of 10.0 or less QOF 0607 92.66% 94.40% % Diabetics with record of total cholesterol QOF 0607 96.18% 97.21% % Diabetics whose last measured total cholesterol of 5 or less QOF 0607 83.11% 83.46% % Diabetics with record of blood pressure QOF 0607 95.55% 98.84% % Diabetics with record of blood pressure of 145/85 or less QOF 0607 78.74% 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) 3.81 3.95 Net ingredient cost of diabetic items per person with diabetes epact (April June 07) 76.32 84.83 Significantly worse than England at 95% No significant difference Significantly better than England at 95% 2006/2007 data
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
Commissioner Decisions Stakeholder meeting Jan 2007 April 2008 Reference Group formed: Chair Sue Roberts GP s Consultant Diabetologist Medicine s Management Public Health Commissioner
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
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
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
Cumbria
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
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
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
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
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
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
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
Final Points Opportunity Need to engage the key decision makers Need to include all the stakeholders Communication vitally important Change is hard
Thank you
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
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
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
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
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
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
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
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
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
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