Shaping Diabetes Services in Southern Derbyshire A vision for Diabetes Services For Southern Derbyshire CCG Vanessa Vale Commissioning Manager September 2013
Contents 1. Introduction 3 2. National Guidance 4 NICE Quality Standards 4 Commissioning Diabetes Without Walls 4 Diabetes Commissioning Guide 5 National Diabetes Inpatient Audit 5 3. Priorities for Improvement 6 4. A vision for diabetes 8 How commissioning diabetes care could be delivered to achieve the vision 8 Flexible support options 10 Diabetic foot care 12 Highly specialist diabetes care 13 Summary of responsibility 14 5. Commissioning 15 Indicators of success 15 Next steps 15 6. Conclusion 16
1. Introduction This document sets out a vision for a model of community diabetes services for Southern Derbyshire CCG and recommendations on how the services for people with Diabetes should be commissioned. It is known that we have 27,000 people diagnosed with Diabetes across Southern Derbyshire and that by 2030 the figures are likely to more than double (World Health Organisation). We also know that in 2011/12 there were a total of 913 admissions with a Primary diagnosis of Diabetes costing 1.9 million and there were 1,508 admissions with a secondary diagnosis of Diabetes costing 4.2 million. For the same period there were 170 admissions for foot care that was attributable to diabetes costing 640,000. There was a total of 24 diabetes related amputations with a total length of stay of 364 days costing a total of 201,000. Amputation is not only devastating in its impact on the person with diabetes and their family, leading to loss of independence and livelihood; it is also expensive for the NHS. Over 119 million is spent each year in England on diabetes-related amputations (Diabetes UK Putting Feet First 2013). Only 50 per cent of people with diabetes who have an amputation survive for two years. Most amputations are preventable where patients have rapid access to multidisciplinary foot care teams. With such a large, increasing population and cost savings to be made it is accepted that the majority of care for this group of patients should be provided in Primary Care. Health professionals working in primary care have a crucial role to play in ensuring that all people with diabetes receive effective care and a responsibility for agreeing with the patient where and how they will receive their care to meet their individual needs. Page 1 of 16
2. National Guidance NICE Quality Standards for Diabetes 2011 The NICE Quality Standards for Diabetes states that services should be commissioned as part of an integrated care pathway ensuring that people affected by Diabetes have access to specialist, condition specific support when indicated. It also states that a key outcome for patients with long term conditions is to provide continuous care coordination within the community, across organisations. This allows care coordination to remain with one health or social care professional throughout the pathway and prevents the transfer of care as a patient moves from one service to another. The NICE Quality Standards define high quality care as follows: 1. Structured education - people with diabetes and/or their carers receive a structured educational programme that fulfills the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education. 2. Nutrition and physical activity advice - people with diabetes receive personalised advice on nutrition and physical activity from an appropriately trained healthcare professional or as part of a structured educational programme. 3. Care planning - people with diabetes participate in annual care planning which leads to documented agreed goals and an action plan. 4. Blood glucose control people with diabetes agree a HbA1c target with their health professional. 5. Medication people with diabetes agree to start, review and stop medications to lower blood glucose, blood pressure and blood lipids. 6. Insulin therapy - trained health professionals initiate and manage insulin therapy. 7. Preconception care women of childbearing age are given information on preconception glycaemic control and those planning a pregnancy are offered preconception advice. 8. Complications people with diabetes receive an annual assessment and the presence of complications are managed accordingly. 9. Psychological problems people with diabetes are assessed for psychological problems which are then managed appropriately. 10. At risk foot people with diabetes at risk of foot ulceration receive a regular review by a foot protection team and those requiring treatment are seen and treated by a foot care team within 24 hours. 11. Inpatient care people with diabetes admitted to hospital are cared for by appropriately trained staff. 12. Diabetic ketoacidosis people with diabetes admitted to hospital with ketoacidosis receive educational and psychological support prior to discharge. 13. Hypoglycaemia people with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist team. Commissioning Diabetes without Walls 2009 Within the document Commissioning Diabetes without Walls it states that it makes sense to integrate diabetes care across all sectors and that services should be flexible as patients move around the different parts of the NHS at different times throughout their diabetic career. Page 2 of 16
It characterises integrated diabetes services as care that offers the experience of seamless services across primary, emergency, specialist, community and social care. The care is designed around each individuals need for long term condition care, regardless of the condition. This requires care to be delivered by skilled, specialist diabetes staff within the multidisciplinary team with services emphasising support for individuals to self-care within their communities. Diabetes Commissioning Guide 2012 The Diabetes Commissioning Guide highlights the importance of designing a whole ideal model of care so that we can design each priority area with the whole picture in mind. This should lead to savings in time and energy as well as a clear plan to achieve the ideal pathway over time, in a sequence of steps. National Diabetes Inpatient Audit 2012 (Sept to Sept) The National Diabetes Inpatient Audit was conducted in September 2012. It provides information on the make-up of teams working in hospitals for people with diabetes, information on the care received and the patient experience at Royal Derby Hospital. The report recommends using the information in the audit to reflect on and improve local service provision. Page 3 of 16
3. Priorities for improvement A number of areas for prioritisation were identified as part of the engagement process that was undertaken by the CCG between September 2012 and June 2013. These areas have helped to highlight where we should focus our attention and inform our priorities for improvement as follows: Integration of care Services should operate from one system whereby they are integral to each other, all health professionals have an understanding of the care each patient is receiving with robust communication links between all health professionals involved in patients care. Standardisation of care and maintained competencies Health professionals working across Primary Care should undertake standardised training in diabetes management to ensure that there is a minimum standard of care delivered to reduce the variation that is currently widespread across SDCCG. On completion of the training there should be support available to help health professionals to implement the new skills on a practical level. Locally based services unless complexity of patient issues requires specialist input Services should be provided as locally as possible for the majority of patients. Patients with complex needs should be seen by specialists within a setting that is appropriate for the level of care to be provided. Flexible services according to locality and patient need A one size fits all approach will not work in SDCCG due to the diverse level of need across patients and local GP surgeries. Services need to be flexible to meet the differing needs of not only patients but health professionals and GP practices across Primary Care. Holistic, co-ordinated care Holistic assessments that take into account the need for physical, psychological, social, spiritual and financial support should be part of every diabetic patients care. Their concerns or problems should initially be identified so that the appropriate support can be provided to address them. Patients should have a named, skilled health professional that will lead their care and coordinate access to all areas of support that each patient needs. Self-care and prevention of complications Patients should have access to information and equipment to enable them to safely monitor and manage their own conditions to prevent complications or address them quickly should they arise. On-going education Education should be available at every stage of the patient pathway to ensure that they are provided with the necessary tools and information about diabetes and selfmanagement. Refresher education should also be available for patients on an annual basis to support them in maintaining their skills and providing updates on medical information. Lifestyle - Patients need to be provided with comprehensive dietary advice at the point of diagnosis and on-going throughout their diabetic journey. Page 4 of 16
- There also needs to be support in helping people with diabetes to access exercise programmes that are suited to their ability and individual needs. Specialist support for health professionals and patients Health professionals should have easy access to responsive specialist support for information and advice relating to diabetes care and management. Page 5 of 16
4. A Vision for Diabetes Diabetes healthcare needs to go beyond disease care. It needs an integrated approach that empowers individuals to make informed choices about their health by shifting from a classical medical model that predominantly deals with the symptoms of the condition to one that is integrative and holistic and utilises functional medicine to address the root causes of the condition, in addition to symptom management. The commissioning of diabetes services needs to be system wide that encompasses the whole pathway from prevention through to highly specialist care to encourage the streamlining of such services. An integrated approach needs to ensure that individual components of care are not commissioned individually, that the service has clearly defined outcomes based on both the prevalence of diabetes in the here and now but also being proactive in preparing for the future increase in incidences. There should be buy in and engagement from all health professionals who are involved in diabetes care and personalised care planning and holistic care should be at its core. This will address the root causes of issues that patients may be experiencing at any one time and will ensure that these issues are dealt with by an appropriate person to support their needs. Whilst there is always a need to focus on mortality and length of life, the vision within this model is based on the overall quality of someone s life which, for an individual living with diabetes day in, day out is one of the most important factors. This will be achieved through developing a Diabetes Care Pathway that has self-care, preventative care and medical care as the key components, as illustrated in figure one. A delivery model for diabetes will need to incorporate all of the aspects of this pathway to be effective and efficient at dealing with the needs of our local diabetes population and the health professionals working across Primary Care. How community diabetes care could be delivered to achieve this vision The model by which care could be provided is one that is jointly led between primary care and specialist care in the community setting. By increasing the capacity within primary care services should be able to deliver high quality diabetes care in a more accessible, appropriate and familiar setting which in turn will free up secondary care to treat appropriate patients. Diabetes care in the community could be provided by health professionals working in general practices with the support of a community based diabetes specialist support team (DSST). Patients could attend their local medical centre to receive the majority of their diabetes care according to their needs. Page 6 of 16
Figure one: Vision for an Integrated diabetes pathway Insulin pumps Foot care Antenatal diabetes Uncontrolled Type 1 Children Low egfr/dialysis patients Inpatient care Awareness raising Be You City 40+ health checks Highly specialist care Prevention Annual review nine care processes Continued education Continued peer support Continued psychological support Continued foot care and education Motivational support Diabetes management Complication management Optimisation of blood glucose control Continuing care Diagnosis Early identification Case finding Screening Initial holistic assessment Initial information, advice and Care Initial education Initial dietary advice Initial psychological support Initial foot care and education Initiation of treatment Initiation of care plan Initial peer support Whole team involvement and standardisation of care across Primary and Secondary care Page 7 of 16
Upon diagnosis patients could be assigned to a diabetic care co-ordinator who could lead their care and coordinate access to all areas of support that they may need. The patient could receive an initial holistic assessment that will take into account their physical, psychological, social, spiritual and financial support needs. Within this assessment they could also be provided with a package of care that provides a menu of options available to support them with any initial concerns or problems and throughout the first 12 months of being diagnosed with the condition. Initial package of care Information and advice Structured education Dietary advice Psychological support Treatment Care plan Living with long term conditions programme Buddy scheme The DSST could be geographically locality based teams that consist of GP leads with an interest in diabetes, specialist nurses, diabetes specialist dieticians, counsellors, diabetes educators, diabetes specialist liaison podiatrists, health trainers and expert patients. Each team could also have additional sessional input from a diabetic consultant who could provide further support to practices. Operating from centralised locality bases, the remit of the DSST could be to provide a range of flexible support options to individual practices, health professionals and patients according to the fluctuating needs. The ethos of this team could be a do with rather than do for approach thus meaning that the main responsibility for diabetes care could lie with general practices and patients themselves. A key element to the role of the DSST could be to act as educators to embed the holistic model across SDCCG ensuring that all health professionals and patients embrace the self-care, preventative care and medical model of diabetes management. They could work to combine clinical care with providing disease specific information, knowledge, self-management education and support. Flexible support options Practice/health professional support As educators the DSST could provide advice, mentorship, support and clinical expertise to health professionals as follows: Point of contact for advice Telephone: Dedicated daily routine and urgent advice could be available to GPs, practice nurses and patients on any aspect of Diabetes care and management. This advice could be provided by a consultant or specialist nurse at designated times. E-mail: Dedicated e-mail address for routine advice available to GP s, practice nurses and patients. Health professional support Dedicated telephone/e-mail advice Combined clinics Education Management guidelines Page 8 of 16
Combined clinics The DSST could offer mentorship and support within clinics held in general practices inclusive of annual reviews, case finding, personalised care planning and problematic patients. They could work alongside practice nurses and/or GP s in practice clinics to support the implementation of the holistic pathway, increase competencies and implement a standardised local diabetes management protocol for the CCG. The focus within these clinics could also be on identifying problems earlier to reduce the onset of complications. Education The DSST could provide a range of rolling; locality based education and training workshops that offer an interactive learning environment with a focus on clinical education, practical case studies and question and answer sessions. Workshops could be inclusive, but not exhaustive of: - Practice diabetes reward scheme - Setting and achieving HbA1c targets - Personalised care planning and self - management - Foot health - Promotion and launch of local diabetes management protocol These workshops could help to support the development of a standardised level of skills and knowledge for staff working in primary care in line with the Integrated Career and Competency Framework for Diabetes Nursing (Trend UK) and The Podiatry Competency Framework for Integrated Diabetes Foot care. The DSST could also undertake an annual peer review to identify practice education needs and ensure that all training undertaken addresses and meets these needs. Standardisation of care The DSST could develop, implement and maintain Diabetes Management Guidelines for the CCG to ensure that all practices are providing diabetic care according to a universal set of standards. Patient support The DSST could help to empower individuals to make informed choices by providing the following: Awareness raising There could be annual diabetes roadshows to communicate key messages to the general public along with two minute diabetes assessment tests. Education There could be education provided at every stage of the pathway from prevention through to specialist care. The programmes could encompass a range of topics inclusive of impaired glucose tolerance, type 2 diabetes management, type 1 diabetes management, blood sugar management, insulin management, cookery classes, menu planning, self-management and emotional well-being. Diet management There could be advice and support available relating to all aspects of dietary management inclusive of practical support relating to cooking and menu planning via interactive diabetic cooking classes. Page 9 of 16
Exercise Individually prescribed exercise could be offered to all patients taking into account the choice of services available and patient s needs. Psychological support There could be dedicated psychological support provided for patients upon diagnosis and on an on-going basis according to individual need. Foot care See specific section on diabetic foot care on pages 12 and 13. Support networks Patient support Awareness raising Education Diet management Exercise Psychological support Foot care Support networks Buddy scheme There could be locality based Diabetes Conversation Café s to offer informal drop in sessions held in a relaxed environment e.g. café s. There could be a health professional present at each drop in to facilitate any issues patients may bring but the focus of these sessions could be predominately to promote peer support amongst patients. There are presently ten patients and carers who are supporting this programme of work who are interested in supporting the development of this initiative. Buddy scheme A buddy scheme could be implemented whereby newly diagnosed patients are offered a buddy to support them through the first few months of being diagnosed with Diabetes and beyond. The buddies could offer support and motivation to patients via the telephone or face to face dependent on need. There are presently ten patients who are interested in supporting the development of this initiative. Should the practice or patients have needs beyond their capabilities the DSST could support them in achieving the desired outcome. For patients presenting with complex diabetic issues the DSST will support practices in managing these patients through the development of an individualised patient treatment plan. After an agreed timeframe should this treatment plan prove to be unsuccessful health professionals may refer patients to the team for short term, focused diabetic interventions if this is deemed appropriate. Diabetic foot care The prevention and management of diabetes foot disease could also be an integral element of the DSST. The specialist diabetes liaison podiatrist role within the DSST could act as the link between Primary Care and the Specialist MDT foot care team within the Acute setting. Considerable effort could be placed and invested in training and supporting primary care health professionals (general practice and community podiatrists) in all elements of diabetes foot care inclusive of annual review foot checks, preventing foot complications and embedding a seamless pathway for patients identified with an increased risk of foot disease. This part of the integrated pathway could maximise the available specialist skills to ensure that there is a proactive focus on prevention with a view to reducing diabetic related amputations for the local population. Page 10 of 16
Rapid access (24 hours) if risk increases The specialist diabetes liaison podiatrists could additionally rotate into the Acute setting to be an active presence on the wards to support facilitation of discharge for patients who have been admitted with diabetes related foot complications. The diagram below details the integrated pathway of care patients could follow for their diabetic foot management. Diabetes foot care pathway PRIMARY CARE ANNUAL REVIEW Fully trained, competent health professionals (via DSST support) COMMUNITY PODIATRY SERVICES LOW RISK (Normal sensations, palpable pulses) Agree foot care plan including education MEDIUM RISK (Neuropathy or absent pulses or other risk factors) Regular review by DSST every 3-6 months HIGH RISK (History of previous foot disease or active foot disease) Frequent review with Secondary Care multi-disciplinary foot care team every 1-3 months (via one stop shop) Highly specialist diabetes care For the ease of commissioning a system wide diabetes pathway there needs to be a clear division of where the care should be provided and by who and where it should not. There are a number of areas of diabetes care that cannot be managed in the community and should be provided in secondary care due to the specialist skills required. These are as follows: Insulin pumps Multi-disciplinary foot care Antenatal diabetes Uncontrolled Type 1 Children Low egfr/dialysis patients Inpatient care Page 11 of 16
The responsibility for the delivery of the above elements of diabetes care should solely lie with the specialists working in the acute setting. This will give greater clarification for their roles as there will be clearly defined areas for staff to work within. Summary of responsibility The information below provides a summary of who could provide elements of the pathway. Primary Care General practice (with DSST support) Disease register maintenance Active case finding Screening of high risk groups Diagnosis Blood glucose monitoring Renal function monitoring Routine foot care Annual reviews (nine care processes) HbA1c >9 Problematic lipids Management of hypertension Erratic glycaemic control Pre-conception awareness & counselling Uncontrolled on maximum medication Erectile dysfunction Insulin initiation & management Severe neuropathy Monitoring and management of mild renal disease Physical activity Personalised care planning DSST Specific Structured education health professionals and patients Treatment plans for problematic patients Dietetics Psychological support Foot care Short term complication management Conversation café s Buddy scheme Secondary care Insulin pumps Foot care Antenatal diabetes Uncontrolled type 1 Children Low egfr/dialysis patients Inpatient care Page 12 of 16
5. COMMISSIONING The commissioning of a co-ordinated, integrated system wide pathway for diabetes care needs to be as uncomplicated as possible to remove the complexities around contractual arrangements with multiple providers. The DSST could form part of an organisation that acts as the connecting, central link between Primary and Secondary Care. It will be responsible for ensuring the full range of support services detailed within this document are provided and could be the single point of responsibility for the entire pathway being accountable for delivery, quality and cost within a fixed budget. By having a single, clinically led pathway with clear accountability for the budget and quality the DSST could be able to use clinical opinion to improve services where it is required to achieve better value. The integrated commissioning system could encourage investment in Primary Care, shared decision making along with supporting self-care as the main driver for patients care, in the right setting to demonstrate best value for money. The CCG should be able to incentivise the provider to deliver high quality services. We should be able to give the provider the responsibility for organising the best delivery model for the different elements of the pathway with other providers and for organising and paying the providers, agreeing an outcome based payment. This approach to commissioning a diabetes pathway could enable the CCG to have one single contract for the diabetic population rather than the multiple contracts for individual elements of it that are currently in place and could enable us to move towards a system that rewards better value across a whole programme of care for our diabetic population. Indicators of Success The indicators for the success of this model will need to be closely aligned to the NICE Quality Standards for Diabetes (2011) and specific indicators within the Atlas of Variation in Healthcare for People with Diabetes (2012). Next steps An essential next step will be to develop a clear understanding of the existing cost of the different elements of the whole pathway to enable the CCG to know how much is actually being spent in order for a new service to be redesigned within the existing cost envelope. Potential organisations could also be offered with an Invitation to Negotiate whereby they will be invited to submit proposals that detail how this vision could be achieved. Page 13 of 16
6. CONCLUSION An integrated system wide approach to diabetes management that is based on self-care, preventative care and medical care should be more cost effective than disease care. It will be a more proactive approach which embeds a robust system of care that will support the predicted rise in diabetes prevalence in the future along with re-organising the present system so that existing patients receive the high quality care they need. Page 14 of 16