Background-why this programme?

Background-why this programme? The health burden of diabetes Financial issues/risk to the NHS in LLR Improving quality and cost effectiveness of diabetes services

to 130 billion From 44 billion A real increase of 110%

Financial challenge for the NHS 2001-02: 51 bn 2003-04: 72.1bn 2005-06: 87.2bn 2007-08: 105.6bn 2009-10: 117bn 2011 + inflation only, however must generate efficiency savings? 3-4 % a year.

GP and Consultant increases 2002-2012 43000 41000 39000 37000 35000 33000 31000 GPs Consultants 29000 27000 25000

LLR Diabetes Transformation Project 1 million transformation funding, 2012/13. Remit- Set up an expert reference group investigate and reach a consensus on how LLR can deliver the best diabetes service in the UK OUTPUT- A report for the CCGs on how such diabetes services should be commissioned.

Who is involved in the Programme? East Leicestershire and Rutland CCG Leicester City and County Council West Leicestershire CCG University Hospitals of Leicester Leicester City CCG Leicestershire Partnership Trust

Transformation project Interface Operational Group Representation form all stakeholders CCGs, hospital trust, community trust,public, meets monthly - Subgroups reporting to operational group Type I diabetes, Foot care, pregnancy, renal, patient education, professional development,inpatient, primary care. - Projects- Primary care( City CCG, ELCCG,WLCCG ), EDEN ( city) and county professional education, nursing homes pilot.. Matrix health care ( economic evaluation) - Public consultation events

Key issues Prevention Inequality of care Improved standards to reduce complications More community based care Reducing unplanned care ( hospital admissions) Better inpatient care

Proposed model of diabetes care in LLR The Necessary Nine 1. Screening 2. Preven2on 3. Regular review/ surveillance 4. Prescribing 5. Insulin 6. Pa2ent educa2on 7. Cardiovascular 8. Housebound/care homes 9. Outcomes/audit Primary care se+ng 1.Primary care (core) 2.Primary care (enhanced) 3.Specialist support for Primary care (CDSST) Secondary and ter2ary care se+ng 4.Complex care The Super Seven 1. Inpa2ent care 2. Insulin pumps 3. Renal 4. Foot 5.Children/adolescents 6. Pregnancy 7complex and rare

Commissioning Recommendations: Primary Care 1.Core service provision funded by GMS/PMS/APMS contracts and QoF payments is provided by all practices. CCGs identify outlier practices in terms of QoF achievement, exception reporting and prescribing quality and put in place strategies and support to improve performance. 2.An defined enhanced service provided by appropriately qualified general practices is commissioned by CCG s. 3. CCGs put in place training and development packages to ensure high level delivery of core services and to enable practices to deliver enhanced services 4. Strategies are put in place to ensure housebound patients have improved care, this includes identifying and agreeing the role of GP practices, community nursing, nursing home staff and other services/ agencies to ensure proactive management.

Ensuring practices have the skills required for providing diabetes care in city 300,000 x 3 years investment. Each practice has a PDP for diabetes Post graduate certificate Regular updates Case reviews Msc Diabetes Case reviews & management Journal club Regular updates Behaviour change training Mini modules Mentorship Healthcare Assistant training Patient education Mini modules CPD accredited training Insulin training Nursing home Community Nurse support Mentorship

Specialist support in the community. 5.A locality based, community diabetes specialist support team service (CDSST) is commissioned. Support care of care for complex patients (including those at high risk of unplanned hospital admissions), insulin initiation, GLP1 initiation where this is not provided by practices. In addition, the service will provide support for audit, patient and professional education and research. Typical team DSN, consultant sessions, dietetics, educators

The Super Seven services Insulin Pumps: - MDT Clinics for 300 pump patients and 40 new starts per annum - Assessment of T1DM patients being considered for pumps - Continuous glucose monitoring - Sensor augmented pump therapy - DAFNE Pump Courses

The Super Seven services Renal: - Pre-Dialysis Clinics (CKD 4 / 5) - Haemodialysis Clinics - CAPD Clinics - Transplant Clinics Nephrology - Joint clinics with

Feet: The Super Seven services - Daily Foot Clinics, Monday to Friday, - MDT Foot Care (including Microbiology, Orthopaedics and Vascular Surgery) - Out-Patient Antibiotic Therapy (OPAT) - Telemedicine embedded to support Community Podiatry / DSN led Foot Clinics in the periphery

The Super Seven services Children / Adolescents: - Transition Diabetes Clinics, based upon the Best Practice Tariff criteria - Joint consultations between Children s and Adult Diabetes Teams - 2 clinics per month involving the whole Transition Diabetes Team

The Super Seven services Pregnancy: - Longstanding MDT Diabetes Pregnancy Clinics at both LRI and LGH - Pre-Gestational Care recognised as a priority, particularly in women with T2DM Capacity going to be an on-going challenge (group education / remote monitoring / virtual medicine all likely to emerge)

The Super Seven services Complex and Rare: - Complex T1DM currently the largest group (including Post-Adolescents) - Obese T2DM patients (particularly aged <40 years / NAFLD) - Pancreatic Diabetes (CFRD / Post Pancreatitis or Pancreatectomy) - Neuropathies / Gastroparesis - Medical Andrology - Monogenic Diabetes (MODY / MIDD)

The Super Seven services In-Patient: Daily Consultant-led in-reach - - Daily DSN-led in-reach with increasing Consultant involvement - Further Think Glucose initiative planned, and up-skilling of Diabetes base wards

Specialist services 6. A tariff based service is commissioned for patients seen in the hospital service with new type 1 disease. Those on insulin pumps and patients with rare and complex disease. Other type 1 patients can be seen in hospital or by CDSSTs as deemed appropriate. 7. A tariff based service is commissioned for pregnant patients with diabetes seen in the hospital service, 8. A tariff based service is commissioned for specialist renal patients seen in the hospital service,. 9. A tariff based service is commissioned for children and adolescents in line with best Practice tariff. 10. An Alliance contract for Foot Care encompassing MDT clinics, community podiatry services, and a pilot virtual MDT is commissioned. 11. Hospital based care the standards for in-patient care are explained in the contract with providers as part of the in-patient tariff and encourage the use of CQUIN payments.

Patient Education for greater self management 12. Patient education for prevention An evidenced based patient intervention programme for prevention of type 2 diabetes is commissioned, with coordination of a range of services and options for patient to access, including metformin for suitable high risk patients who do not respond to lifestyle advice. 13. Patient education programmes for Type 1 and Type 2 Diabetes are commissioned.

Timeline for commissioning Convert to commissioning contracts in 13/14 with new service fully commissioned in 14/15

From Recommendations to commissioning a new service 177,000 approved for year 2 of project New services commissioned /developed - Enhanced service for primary care ( insulin initiation, GLP1, active repatriation of patients ) - Procure a CDSST, locality based, led by DSN s include medical specialist input - Potential alliance contract for Foot care to encompass a pathway across the interface - More defined specialist care contract and inpatient Quality.

Site Reconfiguration and Diabetes Transformation merge together Within UHL, a general need to reduce the outpatient foot print at LRI Diabetes out-patient clinics at LRI and LGH are planned to relocate to a renovated LGH Ward 4, mid 2014 Diabetes out-patients will be delivered in the Super Seven Format Consultant support of Community DSNs will be embedded in CDSST and Community Hospitals

The new commissioned services 14/15 Core and enhanced contracts in Primary care Community specialist diabetes support service Super seven contracts for specialist care

Thank you for listening