DIABETES MANAGED CLINICAL NETWORK Wednesday 1 March 2017 at 1.30pm in Boardroom 1, Royal Infirmary of Edinburgh Present: Nicola Zammitt, David Jolliffe, Smita Grant, Carol Holmes, Alison Cockburn, Lynn Kean, Adele Dawson, Karen Adamson, Sarah Gossner, Jill Little, Paula Collings, Isobel Miller, Linda McGlynn, Stuart Ritchie, Sarah Wild, Carl Bickler, Emma Brewin, Mairi Simpson, Fiona Huffer, Alyson Cumming N Zammitt welcomed MCN members to the second meeting of the refreshed MCN. 1. Apologies Marie McCallum, Liz Mackay, Dawn Arundel 2. Minute of Previous Meeting 24 November 2017 A Cumming highlighted the note of the previous meeting circulated to the MCN included amendments provided by F Huffer. N Zammitt highlighted following a period to allow refreshment of the MCN to bed down, going forward, it is envisaged MCN sub groups provide a formal update (A4 page) to be circulated for each meeting. MCN meetings will focus on significant updates and other items requiring discussion. Action: Sub Group Chairs The minutes of the previous meeting were approved as an accurate record. 3. Matters Arising 3.1 Role and Remit Diabetes MCN N Zammitt reminded the MCN, the draft MCN role and remit is aligned to support delivery of key objectives associated with the national diabetes improvement plan which includes: Public Health, Prevention, Primary Care and Prescribing Type 1 and Innovation Inpatient Diabetes Diabetes Foot Care (a specific priority as features heavily within improvement measures) Feedback from the Lothian Diabetes Representative Group (LDRG) circulated for the meeting suggested a separate sub group is established to focus on Type 2 and highlighted it is not obvious how equality of access, person centred care and improving information will be met for those with type 2 diabetes. L McGlynn enquired as to why the patient group (LDRG) is not recognised as sub group of the MCN. N Zammitt responded to indicate the LDRG is an autonomous group which has set their own work pattern over the years, if the LDRG was to 1
become a sub group of the MCN, the LDRG would then need to have their work directed by the MCN and would lose the autonomy under which they currently work. The LDRG have nominated members to join the MCN sub groups therefore ensuring patient representative input to the work of MCN. N Zammitt commented the LDRG has always been valued as an independent group, however there have been difficulties in ensuring a mechanism is in place to ensure there are representative views from individuals with diabetes who are not members of the LDRG therefore linkages with Health and Social Care Partnership representatives on the MCN are important. Discussion took place relating to LDRG comments concerning the suggestion to establish a sub group for Type 2 Diabetes. It was noted Type 1 is a priority within the improvement plan as performance indicators relating to Type 1 in Scotland is poor compared to other European countries. The sub group with a remit for primary care and prevention will consider areas relevant to Type 2 diabetes and there will also be a short life working group established to review Type 2 diabetes patient education. From a patient perspective the majority of individuals with Type 2 will be managed entirely within primary care therefore appropriate that this features as a remit within the primary care sub group. It was noted the House of Care approach is embryonic in primary and secondary care (pilot St John s Hospital). L McGlynn commented the inpatient care sub group will include both Type 1 and Type 2 diabetes. The professional education group will also consider professional education needs for both Type 1 and Type 2 diabetes. S Ritchie commented 93% of hospital admissions who have diabetes will have Type 2 diabetes therefore this will be a focus within the inpatient sub group. D Jolliffe highlighted the co-ordination and feedback at MCN meetings will ensure all groups are functioning appropriately and will support interaction and discussion between sub groups. On the basis of discussion, it was agreed there was not a need for a separate Type 2 sub group. N Zammitt summarised discussion indicating it was not possible for the MCN to ratify the refreshed role and remit due to the need for discussion out with the meeting regarding the role of the LDRG within the MCN and indicated it was agreed the PPPP sub group will largely be considering Type 2 diabetes with other sub groups considering both Type 1 and Type 2 diabetes within their work plans. Action: MCN Steering Group / LDRG 3.2 Ethnicity Recording and Equality of Access S Grant referred to the need to ensure equality of access and ethnicity is considered through all MCN sub group work to ensure embedded within work plans. It was noted the Diabetes Improvement Plan does not include equality sensitive indicators therefore there is potential those most risk of complications may be disadvantaged. N Zammitt suggested if a specific equality sub group was established, there would then be a need to have involvement with all the MCN sub groups. M Simpson suggested equality should be considered within all the MCN sub groups and there is a need work of the sub groups to be accountable through the wider MCN to ensure equality and ethnicity has been considered in work plans. 2
L McGlynn commented NHS Greater Glasgow and Clyde has a separate group considering equality of access, however this should be embedded in every day practice and highlighted within Glasgow equality of access is being reviewed across the 9 care indicators. It was agreed M Simpson and S Grant and others could lead on this area within the MCN and in particular if sub groups were taking forward specific actions and sought expertise, there was an opportunity to seek this from S Grant and M Simpson. C Bickler highlighted equality and ethnicity needs to be explicit to ensure all sub groups consider in discussions. S Wild referred to equality audit which is undertaken across Lothian which might be helpful to consider. F Huffer indicated Lothian health and social care partnerships diabetes prevention work engages with smaller minority groups which supports linkage to Councils who provide local support. It was agreed the MCN steering group will review the role and remit of sub groups to ensure equality and ethnicity is embedded within the work of the sub groups. 3.3 Lothian Year of Care Taster Training Sessions C Bickler provided an update indicating House of Care taster sessions had been held involving general practitioners and larger training sessions had been held for the West Lothian team who are adopting the House of Care model. K Adamson commented that the team at SJH is supporting work to pilot the House of Care model in diabetes clinics. It was also noted there is potential for West Lothian general practices and Braid Medical Centre. Dr Payne has been trained in House of Care and is happy to offer support. S Wild indicated she has a meeting the following week to discuss funding to support the West Lothian pilot. 3.4 Weight Management Leaflet - BMI Threshold F Huffer confirmed BMI threshold is 30 or 28 if South Asian. Details are available on RefHelp. 3.5 Type 2 Diabetes Local Enhanced Service (LES) N Zammitt provided an update on developments with the LES which was approved by NHS Lothian s Corporate Management Team. C Bickler indicated funding has been identified to continue the LES from 1 April 2017. A Cumming referred to the Acute / IJB Interface Group which is supporting LES discussions and N Zammitt commented on recent Scottish Government policy relating to outpatient redesign and the need to ensure care is provided closer to home and within local communities which the LES will support to deliver. 3.6 DESMOND Appointing Using TRAK A Cumming indicated she has discussed appointing DESMOND courses on TRAK with C Galley, DESMOND co-ordinator and her manager and is awaiting contact from a TRAK expert to review and consider potential for the management course on TRAK. 3
4. MCN Activities, Sub Groups and LDRG N Zammitt requested sub group chairs to provide an A4 (or shorter) summary of activities for circulation prior to future MCN meetings. Action: Sub Group Chairs D Jolliffe updated on the activities of the MCN steering group. He referred to an approach from VOCAL seeking MCN support for education sessions for carers of those with diabetes. It was hoped the sessions could be held in September / October 2017 over 6 weeks, therefore the MCN would be seeking professional support for the sessions once topics were finalised. C Bickler suggested there might be potential in considering provision of a single patient and carer education course. D Jolliffe responded to indicate carers of those with diabetes have a need for support and education and DESMOND capacity is limited to allow attendance of carers at DESMIOND session and there was a need to focus DESMOND on meeting the needs of those with diabetes rather than their carers. It was suggested some DESMOND venues are difficult for those referred to attend and the MCN should consider alternative education models such as Living It Up. Improvements to SCI Diabetes were highlighted which are relevant to House of Care. The difficulties associated with linkage of SCI Diabetes to GP systems (EMIS / VISION) have been raised with the Scottish Government. The first edition of the refreshed MCN newsletter is being finalised and will be circulated as soon as possible. Action: M McCallum The MCN was reminded that the Lothian Diabetes Professional Education Conference will take place on Thursday 30 March 2017 at Heriot Watt Conference Centre. Details of the conference programme, workshops and registration have been circulated via NHS Lothian s Intranet, NHS Lothian s public website, all staff emails at hospital sites and through the Primary Care Contracting Organisation weekly bulletin to general practices. In the absence of F Gibb, N Zammitt referred to discussions involving Paul Nelson who is offering to pilot Guidepost, a 1:1 phone coaching initiative for those with insulin-treated Type 2 diabetes who have not managed to achieve good control with a view to considering if this would be a useful intervention for future investment. P Nelson has put together business case outlining cost benefits. The Guidepost approach involves trained administrators who gather blood glucose readings and arrange appointments with individuals to support coaching and management of diabetes. Depending on the pilot evaluation if NHS Lothian wish to consider funding in the longer term, costs are circa 50 per patient for 6 months 1:1 coaching through 2 weekly appointments which may potentially be better value that this support being provided by Diabetes Specialist Nurses. I Miller requested clarification as to whether the intended outcome of the coach intervention is to support patients to self-manage at end of the 6 month period. It was confirmed this is the intended outcome. L McGlynn enquired who will identify appropriate patients and raised concern that Paul Nelson had contacted a local patient group to discuss Guidepost. N Zammitt indicated the pilot will run with 4
specific criteria to ensure most appropriate patients are identified. Patients will be provided with information relating to Guidepost at appointments and will be asked if they wish to opt in to the pilot. The pilot will operate in the same way as a research study. N Zammitt agreed to discussion with P Nelson his approach to a local patient group which was deemed to be inappropriate. F Huffer commented agreements are closely screened by the procurement department and the pilot with run as a study with an evaluation of outcomes. It was noted P Nelson is aware of the NHS health system in Scotland having previously been a public health consultant. Action: N Zammitt The Primary Care Laboratory Interface Group (PLIG) has reviewed the pathway for diagnosis of Type 2 diabetes. The revised pathway has been rolled out across Lothian, feedback from general practitioners over the past 3 months has been positive. The introduction of the revised pathway no longer requires a glucose tolerance test. Discussion took place at the national diabetes MCN clinical leads regarding the Scottish Government announcement of 10m funding to support provision of insulin pumps and continuous glucose monitoring (CGM). The additional 10m is for a period of four years for whole of Scotland with 2m available for 2017-18 however the allocation of funds across NHS Boards is unknown. Funding is to be utilised to expand pump provision and is not to substitute current pump spend within NHS Boards. NHS Lothian does not have a funding stream for CGM therefore Lothian insulin pump group keen NHS Lothian s funding allocation is invested in CGM. L McGlynn enquired if there was any national recognition of the need to up-skill and train staff to provide additional staffing support to patients. N Zammitt indicated NHS Boards are seeking clarity on the utilisation of funds. L McGlynn referred to the Diabetes UK campaign relating to appropriate treatment at the appropriate time and the need for an appropriate skills base for both patients and staff. N Zammitt highlighted NHS Boards will be required to pick up recurring costs post the national four year funding cycle and reminded the MCN that diabetes is a delegated responsibility to the Lothian Health and Social Care Partnerships who issue directions to NHS Lothian relating to provision of diabetes services. E Brewin indicated the focus of foot work to date has related to new foot ulcers and highlighted an ulcer management tool is being implemented in acute hospital sites and through community podiatrists in Edinburgh supported by circulation of ulcer management guidance. This intervention will support more accurate recording of foot ulcers and in the longer term improve the quality of reporting. It was noted reporting of foot ulcers will initially look worse as recording of ulcers improves. It has been agreed recording of wound classification will relate to the main foot ulcer and will include recording of outcomes. New cards associated with the Check, Protect, Refer (CPR) initiative are being issued with mirrors and it has been agreed Lothian CPR posters will vary to include local guidelines. Risk stratification posters will be available for the Lothian Professional Diabetes Education Conference. J Little indicated with regard to professional education, work is being undertaken to tease out what need to be included and the longer term aspirations within the group. 5
S Ritchie indicated with regard to supporting developments in InPatient Diabetes and the Think, Check, Act initiative, a business case for inpatient diabetes has been developed, however will require a funding decision which will need to be discussed and agreed with the four Lothian Health and Social Care Partnerships who have delegated responsibility for diabetes services. S Wild indicated the first meeting of the PPPP sub group will be organised when M McCallum returns to work. P Collings indicated the activities of the LDRG have focussed on the development of a patient education survey which will be discussed under a separate agenda item. 5. Edinburgh Long Term Conditions Diabetes Workstream Progress Report C Bickler indicated the work stream had not made as much progress as had been hoped. Provision of training is a key area to rolling out the House of Care methodology which has unfortunately been delayed due to issues with employment. It is estimated that the work plan is delayed by approximately three months due to employment issues. 6. Diabetes Quarter 4 (Oct Dec) 2016 Report N Zammitt referred to the national improvement plan quarterly reporting which is a fairly new process. The Red, Amber, Green (RAG) status associated with the reports is outlined at the beginning of each year and going forward there were plans for a more structured process involving key individuals from the MCN. Quarter 1 (Jan March) 2017 data will be available at the end of March 2017 and a meeting has been arranged in early April 2017 involving E Brewin, F Gill, S Wild, D Jolliffe, N Zammitt, M McCallum and A Cumming to ensure collaboration in the reporting process for 2017. It was noted NHS Boards have fed back to the Scottish Government the requirement to submit the report within four weeks of receipt of data was insufficient time to ensure collaboration in reporting therefore submission of reports has been extended to a six weeks. 7. Patient Education Survey I Miller referred to the work of the LDRG in developing a patient education survey given the poor response to uptake of invited to the bi-annual patient education conference which was attended by 80 patients despite circa 4,000 invites mailed to a random selection of individuals from the diabetes register. N Zammitt had approached the LDRG in early 2016 to seek their support in finding out patient wishes for diabetes education, why patients did not wish to attend the conference which appears to be a similar experience for those referred to DESMOND with a large number referred who fail to opt into attending DESMOND. A scoping document and questionnaire has been developed and seeks information relating to what educational opportunities people wish to receive. The questionnaire also seeks information from those offered structured education, why individuals do not engage and what individuals would like in the future to continue to learn more about diabetes. It is planned to distribute the questionnaire via the Diabetes Retinopathy Screening clinics. 6
The LDRG is also seeking support from a medical student, however N Zammitt has reviewed the questionnaire and indicated a student is likely to need supervision to support the LDRG with this exercise. Discussion has taken place with B Hacking who suggested a Short Life Working Group is established to take this exercise forward. It has been suggested to approach Alison Diamond who was previously MCN lead for patient education and B Hacking has offered psychologist support to take forward the survey. B Hacking has also suggested psychological support will assist in providing insights into what inhibits or is a barrier to engagement with education. N Zammitt will provide a further update and feedback regarding opportunities for psychology support. An initial pilot of the questionnaire will be undertaken on paper to ensure there are no difficulties in completion. It is also planned to make the questionnaire available electronically using survey monkey which will assist in analysis of survey results. N Zammitt commented that she had questioned whether the conference was the best use of MCN resource given the low uptake of invites. L McGlynn commented due to a reduction in funding, Diabetes UK are no longer hosting a patient education conference. I Miller confirmed My Diabetes My Way is included on the survey as an educational opportunity for those with diabetes. A Cumming will circulate the project scope and questionnaire to the MCN for information. Action: A Cumming / I Miller 8. AOCB Diabetes Champion L McGlynn referred to communication relating to recruitment of Diabetes Champions. A Cumming confirmed the application process has been circulated via the MCN with a request for further dissemination as appropriate, should anyone wish to receive further information they should contact L McGlynn. Future MCN Meetings N Zammitt indicated the MCN meetings for the remainder of the year will be for two hours and indicated she is keen to have time at each meeting to focus on topic areas. The topic for the next meeting will be Bariatric Surgery which will provide an opportunity to dovetail on work relating to Type 2 diabetes. MCN Budget 2017-18 Given NHS Lothian s financial position, there is the potential the MCN will need to deliver 7% efficiency savings in the next financial year. MCN members were asked to notify A Cumming of any funding requirements for 2017-18 and were asked to bear in mind the MCN annual budget is circa 30,000 per year much of which is supporting DESMOND education. Action: MCN Members 7
9. Schedule of Future Meetings Date Time Meeting Room 31 May 2017 14:00-16:00 Boardroom 1 - RIE 30 August 2017 14:00-16:00 Boardroom 1 - RIE 29 November 2017 14:00-16:00 Boardroom 1 - RIE 8