health board together for health diabetes delivery … · page 1 of 35 health board together for...

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CARDIFF AND VALE UNIVERSITY HEALTH BOARD

TOGETHER FOR HEALTH – DIABETES DELIVERY PLAN

REFRESH

MARCH 2016

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1. Background and context “Together for Health – a Diabetes Delivery Plan” was published in 2013 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government’s expectations of the NHS in Wales in delivering high quality diabetes services. It therefore focuses on maximising efficiency and effectiveness, tackling variation in access and reducing inequalities in service provision across 7 themes. For each theme it sets out:

Delivery expectations to ensure the right patient, in the right care and the right time

Specific priorities for 2013 – 2016

Responsibility to develop and deliver actions

Assurance measures that will be used to ensure that this plan is delivered and effective outcomes achieved.

What do we want to achieve? The Delivery Plan sets out action to improve outcomes in the following key areas between now and 2016:

Children and young people

Preventing diabetes

Detecting diabetes quickly

Delivering fast, effective treatment and care

Supporting living with diabetes

Improving Information

Targeting research

2. Cardiff and Vale University Health Board’s Delivery Plan Cardiff and Vale Local Health Board produced its first delivery plan in 2013. In our delivery plan we set the following priorities for 2016: Children and Young People Ensure children and young people with diabetes have the best possible start in life and are given the opportunity to fulfil their potential. Preventing Diabetes People are aware how to live a healthy lifestyle, make healthy choices that minimise their risk of developing diabetes and understand the consequences of not doing so.

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Detecting Diabetes Quickly Diabetes is detected quickly where it does occur. Delivering fast, effective treatment and care People receive fast, effective treatment and care so they have the best chance of living a long and healthy life, with patients taking responsibility for lifestyle choices that contribute positively to their treatment and care. Supporting Living with Diabetes People are placed at the heart of diabetes care with their individual needs identified and met and feel supported and informed, able to manage the effects of diabetes. Improving Information Patients, health professionals and service planners will have access to appropriate information to help them make informed decisions about care and treatment. The public, the NHS, the third sector and the Welsh Government will have access to information on the outcomes that result from NHS Care. Targeting Research Access to research can lead to better outcomes for patients. The NHS must promote research and ensure appropriate access to clinical trials.

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Progress against headline priorities Considerable progress has been made against these priorities as highlighted below: Children and Young People Cardiff and Vale UHBs paediatric diabetes services have implemented positive changes to enhance the holistic service provided to children and their families following a peer review. These changes include;-

Additional Consultant sessions, and new diabetes clinics provided at the University Hospital of Wales, and University Hospital Llandough sites

Investment in specialist diabetes nursing service operating across the healthcare system

Investment in a specialist paediatric diabetes dietician

Investment in point of care measurement of HbA1c and new blood glucose download facilities

Additional psychological support to children and their families Preventing Diabetes

During 2015-16, Making Every Contact Count (MECC) training has been delivered to a wide range of staff from the UHB, and also to partner organisations, including third sector and probation services. The training aims to provide public sector workers with the skills to advise, signpost and motivate people to live healthier lives. The training has been adapted following feedback in 2015, and now includes elements of motivational interviewing techniques Podiatry staff have all undertaken MECC and in January and February 2016 all participated in an induction training programme on Motivational interviewing techniques

The Cardiff and Vale Making Every Contact Count Team led the organisation of, and participated in a successful national Making Every Contact Count Conference

A range of action has been delivered within the Cardiff and Vale Food and Physical Activity action plans (see action plan for progress report)

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Nutrition Skills For Life training is provided to partner organisations to support delivery of nutrition education in communities including Get Cooking Courses and Foodwise weight management programme

A Tier 3, multidisciplinary obesity service has been established which provides tailored weight management treatment and therapy. The service commenced in September 2015 and bridges the gap between the tier 2 dietetic led weight management programme delivered via the Eating for Life Programme or 1;1 dietetic clinics, and the Tier 4 specialist bariatric service provided in Swansea .Tier 2 capacity has also been increased as part of implementation of the All Wales Obesity Pathway

Detecting Diabetes Quickly

The Putting Feet First pathway has been delivered to improve awareness and recognition of the foot conditions related to diabetes, and the podiatry department as part of an all Wales initiative are due to provide education and support to Primary care in diabetic foot awareness and foot screening during the forthcoming year, utilising the ‘putting feet first pathway’ to directs patients foot health needs

Community pharmacies are now required through the community

pharmacy contract, to provide opportunistic health promotion advice to

people with diabetes

A Level 3 smoking cessation service has commenced which is delivered through community pharmacies in deprived areas of Cardiff and the Vale of Glamorgan

The All-Wales information booklet for patients with newly diagnosed diabetes have been distributed to all GP practices to provide to patients on diagnosis and training provided by Dietetic Services to practice nurses to support first line education

During 2015-16, the UHB has increased its capacity to deliver structured education (DAFNE and X-PERT)


Working in partnership with Pharma, a training needs analysis of primary care practitioners has been completed and analysed, with a work stream established to plan training to primary care health professionals. Several MERIT training sessions have already been delivered

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A diabetes retinopathy needs assessment has been undertaken, with recommendations developed and subsequent actions to improve equity of access to services

The “Putting Feet First” pathway was introduced over 18 months ago into the primary care setting, and has now been fully implemented. Podiatrists now treat patients presenting with moderate and above risks in relation to diabetes feet complications. Extra support and training has been planned and will be delivered to further enhance and support the primary care to include Nursing homes by the Podiatry service.

A Leading Improvement in Patient Safety project has focussed on the provision of education to prioritised in-patient areas within Cardiff and Vale UHB. Education for professionals (secondary and primary care), has been identified a s a priority area by the Diabetes Service Improvement Group, and is being progressed as part of a formalised programme management approach

Point of Care Testing (POCT) data is now routinely available to the specialist inpatient diabetes team. This will allow the targeting of interventions and specialist support to those individuals and in patient areas of greatest need

The UHB has developed a plan to educate health care professionals across all of our inpatient settings, beginning with prioritised areas identified with POCT data

Diabetic foot awareness has been incorporated into the UHBs Health Care Support Worker induction programme.

Diabetic foot education and introduction to a web based learning tool (FRAME) is now incorporated onto the undergraduate Nursing programme in year 1 and 3.

Insulin pump services for adults and children are provided in line with NICE guidance

Supporting Living with Diabetes

Community Pharmacists are now required through the community pharmacy contract to provide health education and awareness to people living with diabetes

The UHB’s Primary, Community & Intermediate Care Clinical Board has developed "Pacesetter Pathways" in 10 key areas, including diabetes, which have been embedded into General Practice since October 2015. There are many components including promotion of self management and the provision of personal care plans for people living

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with diabetes. These will be audited in June 2016. Nationally provided National Wales Information Service (NWIS) data will support this

Building on the previously established Consultant and GP virtual clinics in all GP practices, as part of the UHBs progress towards a community focussed model of care, GPs now have access to timely advice from Consultants using an e-advice system, to assist effective management of people’s diabetes in the primary care setting, and preventing unnecessary referrals.

Diabetes education and support (XPERT and DAFNE) for people living with diabetes is routinely offered by the UHB. Twenty-seven XPERT and ten DAFNE programmes have been delivered by UHB staff during 2015-16. Dietetic services also offer diabetes awareness sessions for people who are unable to attend a full education programme

The UHBs prudent co-production work delivered a workshop (June 2015) with a range of participants including people living with diabetes. Supported by 1000 lives improvement team, the event aimed to ascertain what living well with diabetes means for people, and what support needs to be in place to support them. The workshop recommended:

Progressing the shift to a community focussed model of care, by prioritising;-

o peer support and professional support/community organizing o structured education/access to a range of education and

support o greater access to physical activity opportunities o an information pathway (information/signposting/social

media options) o use of technology o Training for health professionals, and o A personalised plan and patient record

In response the UHB has done the following:

Established an Education for Patients diabetes self care programme which can be accessed by anyone with type 2 diabetes

A peer support pilot has been established in the North of Cardiff, led by Diabetes UK Cymru .This pilot has been successful in achieving its objectives, and is currently being evaluated

The UHB is developing a web page aimed at education and support for people with Type 2 diabetes– see ‘improving information’

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To support a new Diabetes Specialist Nurse role in City and South cluster, the UHB is are ascertaining what type of education and support might benefit the local population where prevalence of type 2 diabetes is highest . This information will be used to deliver an improved service to meet local needs

Improving Information

The Point of Care Testing system has been developed, and is now supplying real time data to the inpatient diabetes team. This has enabled targeted and timely responses for individuals, and targeting of areas of high risk. The Point of Care Testing Team have recently secured funding to purchase IT equipment to make further improvements in this service, and have developed a plan to use information to improve services in the community

Cardiff and Vale UHB has worked closely with the third sector during 2015-16, to ensure effective signposting to sources of information. This includes collaborating with Diabetes UK Cymru in the successful Living Well with Diabetes Day 2015. Through the UHBs prudent approach and building on the prudent workshop in 2015, a multiagency plan has been implemented to improve education and support for people living with diabetes. Further information is included above in relation to progress on preventing diabetes

Targeting Research

Cardiff and Vale UHB and Cardiff University have a close working relationship, and continue to work together in relation to research into early diagnosis and treatment for type 1 diabetes

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3. The vision: For our population Welsh Government wants:

People of all ages to have a minimised risk of developing diabetes

Where diabetes does occur, an excellent chance of living a long and healthy life, wherever they live in Wales

4. The drivers in Wales:

Spending in Welsh hospitals in 2012-13 on diabetes was almost £90m1, this is an increase of 4% when compared to 2011-12. However NHS expenditure on diabetes related care is almost £500m a year2. In 2013-14; 177,212 people over the age of 17 were registered with their GP as diabetic. This is 3,9133 more people than in 2012-13. There were 1,469 children and young people with diabetes, under the age of 25 in Wales. Almost all have type 1 diabetes. Gestational diabetes is a type of diabetes that some women get during pregnancy. Between 2 and 10% of expectant mothers develop this condition, making it one of the most common health problems of pregnancy. It is widely accepted that Wales is facing a huge increase in the number of people with diabetes. The numbers of adults aged 17 and above registered at a GP practice with diabetes has increased by just over 24,000 people in the last 5 years. Much of the increase is type 2 diabetes due to the aging population and the increases in the numbers of overweight people. There is evidence to show that:

the onset of type 2 diabetes can be delayed, or even prevented

effective management of the condition increases life expectancy and reduces the risk of complications; and

supported self-management is the essential element of effective diabetes care

People with diabetes have a substantially higher risk of serious illness, hospitalisation and premature death compared to those without diabetes.

1 NHS Expenditure Programme Budgets – Wales 2012 -13

2 Together for Health – a Diabetes Delivery Plan

3 Stats Wales

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Outcomes in Wales A number of outcome and assurance measures have been developed, which together, will demonstrate how diabetes services are improving in Wales. Some progress against these measures has been made giving Welsh Government the reassurance that diabetes care in Wales is developing in line with its vision:

Deaths from diabetes is not a common cause of death in Wales. In 2013, 300 people died from diabetes. This has fallen from 420 deaths in 2009

Half of all deaths from diabetes result from cardiovascular disease including heart attacks and strokes. In 2001, in Wales, almost 14,000 people died from cardiovascular disease, by 2011 this had fallen to just over 9,000 deaths

In Wales in 2012-13, 98.9% of patients under the age of 25 years had their HbA1c measured and 97.6% in England. This is considerably improved from 2011-12, where 89.3% of patients in England and Wales had their HbA1c measured

In 2011-12 there has been a decline in the diabetic ketoacidosis (DKA) incidence rates for children and young people from 9,662 in 2010-11 to 5,683

84% of inpatients stated that they were satisfied or very satisfied with the overall care of their diabetes while in hospital

In 2013-14, 93% of patients on the diabetes register had a record of retinal screening, and 91% of patients on the register had a record of a foot examination, in the preceding 15 months

Emergency admissions of people with diabetes have dropped by over 230 patients from 2,815 to 2,584 between 2010 and 2013

Outcomes in Cardiff and Vale of Glamorgan

In 2013/14, in Cardiff and Vale, 93% of patients on the diabetes register had a record of retinal screening in the preceding 15 months4

In 2014/15, in Cardiff and Vale UHB, 91% of patients with diabetes on the register had a record of a foot examination and risk classification within the preceding 15 months5

In 2014/15, in Cardiff and Vale UHB, the percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 64 mmol/mol or less in the preceding 15 months was 79%6

4 Quality and Outcomes Framework (QOF) Statistics for Wales, 2013-14 (Welsh Government

(WG) 5 The classification of risk are: 1) low risk (normal sensation, palpable pulses), 2) increased

risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 15 months. Government (WG)

https://statswales.wales.gov.uk/Catalogue/Health-and-Social-Care/NHS-Primary-and-Community-Activity/GMS-Contract

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In 2014/15, in Cardiff and Vale UHB, 79% of patients with diabetes on the register had a blood pressure reading (measured in the preceding 15 months) of 140/80 mmHg or less6

Challenges We need to continue to improve in these areas as well as ensuring that progress is made where performance has not been as good as anticipated:

Type 2 diabetes is more prevalent among less affluent populations. Those in the most deprived one-fifth of the population are one-and-a-half times more likely than average to have diabetes at any given age7. 9% of those people living in the most deprived areas of Wales report being treated for diabetes compared to 6% of those living in the least deprived - showing the pronounced impact of poverty and the socio-economic determinants of health

A child with HbA1c levels above 9.5%, according to the National Institute for Clinical Excellence, would be at risk of medical complications in the future. In Wales, 27.1% had poor glycaemic control (HbA1c over 9.5%); with 59.5% having moderate control (HbA1c between 7.5 and 9.5%)

Obesity is the top risk factor for type 2 diabetes at all ages. 54% of all adults in Cardiff and Vale UHB in 2013/14 are overweight or obese8. The prevalence of those overweight or obese children aged 4-5 years in Wales (reception year) (26%) was significantly higher than that for England (22%). In Cardiff and Vale UHB, 22% of children aged 4 to 5 are overweight or obese9

Physical activity trends show low rates and a flat lining trend, with 27% of adults in Cardiff and the Vale UHB area meeting physical activity guidelines in 2013/1410

It is estimated that there are around 66,000 people with undiagnosed type 2 diabetes in Wales

High blood pressure is an important risk factor for diabetes, and while 20%11 of adults in Cardiff and Vale UHB are being treated for high blood pressure, it has been estimated that across the UK around half of people with high blood pressure are not receiving treatment12.

Only 4% of newly diagnosed adults in Wales received structured education in 2012-13. In 2014/15, in Cardiff and Vale UHB, 96% of newly diagnosed patients with diabetes had a record of being referred

6 Quality and Outcomes Framework (QOF) Statistics for Wales, 2014-15 (Welsh Government

(WG) Quality and Outcomes Framework (QOF) Statistics for Wales, 2014-15 (Welsh 7 National Diabetes Audit

8 Public Health Wales Observatory 2015, WHS lifestyle trends resource. WHS 2013/14 data

9Child Measurement Programme for Wales, Annual Report 2013/14

10 Public Health Wales Observatory 2015, WHS lifestyle trends resource. WHS 2013/14 data

11 Welsh Health Survey 2013/14, Welsh Government

12 Scarborough P, Bhatnagar P, Wickramasinghe K, Smolina K, Mitchell C, Rayner M (2010).

Coronary heart disease statistics 2010 edition. British Heart Foundation: London

https://statswales.wales.gov.uk/Download/File?fileId=375


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to a structured education programme within 9 months after entry to the diabetes register13.

60% of adults with type 1 diabetes and 33% of adults with type 2 diabetes are not having the annual tests and investigations associated with the national standards. Of those having the annual tests, 86% of type 1 diabetic patients and 65% of adults with type 2 diabetes do not meet the agreed treatment targets

The incidence of diabetes is increasing as the prevalence of obesity is rising. The number of people aged 16 and over predicted to have type 1 or type 2 diabetes in Cardiff and Vale is predicted to rise from 26,021 in 2020 to 32,154 in 203514. Currently there are around 22,200 adults (aged over 17) within Cardiff and Vale UHB who are on a register with their GP with a diagnosis of diabetes (type 1 or type 2), representing about 1 in 20 adults registered within a GP practice in the area15. European age-adjusted percentages of patients who have a diagnosis of diabetes ranges from 5% in Western Vale GP cluster to 9.3% in City and South GP cluster.

The Welsh Health Survey (2013/14) reported that 7% (age-standardised %) of people surveyed in Cardiff and 8% in the Vale of Glamorgan reported being currently treated for diabetes16.

13

Quality and Outcomes Framework (QOF) Statistics for Wales, 2014-15 (Welsh Government (WG) 14

Daffodil projections-Welsh Government. Figures have been taken from the Welsh Health Survey 2012 and prevalence rates have been applied to population projections to give estimated numbers predicted to have diabetes. http://www.daffodilcymru.org.uk/index.php?pageNo=1049&areaID=1&loc=1 15

Public Health Wales Observatory, GP profiles (2015) 16

Welsh Health Survey 2013/14, Welsh Government


http://www.daffodilcymru.org.uk/index.php?pageNo=1049&areaID=1&loc=1

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5. ORGANISATIONAL PROFILE

Cardiff and Vale University Health Board (UHB) was established in October 2009 and is one of the largest NHS organisations in the UK. As a UHB, we have a responsibility for around 475,000 people living in Cardiff and the Vale of Glamorgan (from Trowbridge/St Mellons in the East to Llantwit Major/St Bride’s Major in the West). This includes health promotion and public health functions as well as the provision of local primary care services (GP practices, dentists, optometrists and community pharmacists) and the running of hospitals, health centres, community health teams and mental health services. GP Practices, General Dental Practices, Optometry Services and Community Pharmacies are grouped within primary care clusters and support the UHB in planning and delivering services for local communities.

Together with some services from other Health Boards, and key partners (for example learning disabilities services are provided by Abertawe Bro Morgannwg UHB and Specialist Children and Adolescent Mental Health Services (CAMHS) are provided by Cwm Taf UHB), the UHB provides a full range of health services for local residents. The UHB also provide specialist services such as paediatric intensive care, specialist children's services, renal services, cardiac services, neurology, bone marrow transplantation and medical genetics for people across South Wales, and in some cases the whole of Wales and parts of England . Specialist links with English Community Care Groups (CCGs), Area Teams and other teaching hospitals and Universities have been developed To deliver these highly diverse and complex services, the UHB spends over £1.2 billion every year and employ around 14,000 staff. As a teaching Health Board, Cardiff and Vale University Health Board has close links to Cardiff University, which boasts a high profile teaching, research and development role within the UK and abroad. This is alongside other academic links with Cardiff Metropolitan University and the University of South Wales. The UHB offers under and post graduate medical education and training as part of its agreement with both the Wales Deanery and Cardiff University School of Medicine. training the largest number of Allied Health Professionals, Healthcare Scientists and Nurses of any health board in Wales..

.The importance and value of effective and efficient diabetes services is recognised by the UHB, and has been identified as a key priority within commissioning intentions and Integrated Medium Term Plans for 2016-17 The UHB’s Shaping our Future Wellbeing Strategy (2015-2025) aims to achieve joined up care based on “home first”, avoiding harm, waste and variation, empowering people and delivering outcomes that matter to them. An integrated diabetes model of care delivery is one of several key service models and care pathways highlighted for implementation across the UHB as part of a service transformation programme aimed at delivering its strategic objectives. Much of the diabetes work is seen as an exemplar of how pan-system service transformation can make a tangible difference to outcomes for people living with a long term condition. Diabetes services

http://www.cardiffandvaleuhb.wales.nhs.uk/primary-and-community-services

http://www.cardiffandvaleuhb.wales.nhs.uk/primary-and-community-services

http://www.cardiffandvaleuhb.wales.nhs.uk/our-hospitals

http://www.cardiffandvaleuhb.wales.nhs.uk/health-centres-and-clinics-cardiff-vale

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Responsibility for the delivery of diabetes services crosses a number of Clinical Board areas. In particular, Children and Women, Clinical Diagnostics and Therapies, Medicine and Primary, Community and Intermediate Care, with clinical diabetes’ leads identified for paediatric and adult specialities. Diabetes care in Cardiff and the Vale of Glamorgan is divided into services for children and young people under the age of 18yrs, and those over the age of 18ys. Effective transition protocols exist between services to ensure transition between services are experiences as seamless by those who use them. The governance structure for our diabetes work is provided below.

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Diabetes services – governance structure

Adults Cardiff and Vale UHB’s service model for adults with diabetes is transforming from a hospital centric service, to one which is predominately community focused and patient led, which is based on prudent healthcare principles, and which puts the needs of the person with diabetes, and their families, first. This is our Integrated Community Model for diabetes. The intention is to refocus services around the individual, removing barriers between specialties and organisations and introducing an approach that achieves outcomes for individuals and value for the system. The UHB is working to establish services co-designed with people with diabetes and their carers to enable the best possible health outcomes. To do this, we intend to integrate both the health care system, and the co-ordination of services around the patient, the aim being for the whole health community to join in partnership to own the health outcomes of patients with diabetes in their local area. The UHB’s diabetes service planning is based on the following principles: • The provision of services as close to where people with diabetes live as possible • The provision of coordinated services without duplication or gaps • Working in an integrated way (between primary care and specialists) and in partnership with social care and other providers • Ensuring the workforce is trained (competency based), and care is delivered via multidisciplinary teams

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GENERAL CARE

An individual’s practice includes their GP, practice nurse, community podiatrist, community dietician

Annual care planning cycle including individual care plan

Annual checks and screening

Care bundles

Peer support for people living with diabetes

COMPLEX CARE IN THE COMMUNITY

Community based multidisciplinary Team (MDT) providing support to primary care professionals GPS with managing more complex care

Patient education programmes

Education and training for primary care professionals

Pregnancy advice for women of childbearing age

Foot protection team

Additional support for those with type 2 diabetes and poor glycaemic control

Advice on medication and treatment via e mail

Joint GP and Consultant virtual clinics

MDT includes, Consultant Diabetologist , Diabetes Specialist Nurse, Diabetes Specialist Dietician, Diabetes Specialist Podiatrist

SPECIALIST CARE Specialist care services are multidisciplinary

transition

diabetes foot service

diabetes antenatal services

T1DM service including insulin pump service

Diagnostic service where there is doubt as to type of diabetes

Outpatient service

Diabetes inpatient service

Diabetic kidney disease service

Education and training of secondary care healthcare professionals

PREVENTATIVE

Range of actions at different levels of the obesity pathway; includes physical activity, food, environments, policy

Action to tackle other cardiovascular risk factors e.g. smoking; alcohol misuse

All staff use a Making Every Contact Count approach

• The provision of services that support self management for people with diabetes Cardiff and Vale diabetes Integrated model of care Self management, retinopathy, dietetics, podiatry

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Preventative services Preventing diabetes is central to the UHBs plans. Key risk factors such as obesity, are being tackled through the implementation of specific local and national plans to improve physical activity levels, healthy eating and food environments and wider delivery through the obesity pathway work. The “Making Every Contact Count” programme of work aims to engage a range of professionals to provide General diabetes care The GP is responsible for overseeing management of adults with diabetes, with all patients offered an annual check by their GP, and the GP being responsible for the delivery of diabetes care bundles and care planning and coordination. Practice nurses play a key role in supporting the GP by providing additional support to people with diabetes, and taking responsibility for the provision of information and guidance on self management. Patients also receive clear information about their condition and referral to structured education programmes on diagnosis Complex care in the community GPs are supported to effectively support and treat people with more complex needs by Consultant Diabetologists who are linked to individual GP Practices, and who provide advice by e mail, and through bi-annual virtual clinics held at the Practices. The development of adult diabetic specialist nurse input at a primary care level is being undertaken as part of our service transformation programme, to complement the consultant input. A recent pilot of Diabetes Specialist Nurse support in GP practices has proved that prescribing efficiencies through a greater emphasis on human insulin use in type 2 patients, can release monies that could be used to support primary care with direct access to specialist nurse input. The benefits of this approach are clear. Patients seen in the outpatient department can potentially be discharged back to routine GP care more quickly, as specialist input will continue through the practice. More people with newly diagnosed diabetes can now be started on treatment within the primary care setting. Data from the model to date shows a 35% reduction in new type 2 diabetes referrals to secondary care and a more appropriate reason for referral with fewer referrals because of poor diabetes control. Specialist care People with complex care needs, including all type 1 diabetes patients, are referred to secondary care, and in Cardiff and Vale, around 3,000-4,000 adults with diabetes are seen each year as hospital outpatients. (Roughly one fifth of the people with known diabetes in the area) .Consultants work with individuals, with the support of a specialized multi-disciplinary team, to stabilise their diabetes, and optimise their diabetes care, before discharging back to primary care, with advice to the GP on ongoing diabetes management

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Sometimes, people will need admitting to hospital to receive very specialised treatment. Cardiff and Vale employ specialist therapists and diabetes nurses who work alongside medical colleagues to ensure that people are able to return home as soon as possible. The benefits of the diabetes inpatient team extends to patients admitted whose primary diagnosis for admission was not diabetes but where the presence of diabetes frequently extends and adds to the complexity of the admission and length of stay. Education of inpatient staff across all hospital sites is central due to recognition of the numbers of patient entering hospital care who have diabetes (20% of the in-patient population) and therefore the need to ensure a much greater knowledge of diabetes management and diabetic needs across the health care system The UHB is working to integrate the team should into the wider community so that re-admissions of patients recently discharged can be avoided, and treatment plans set up within hospital are continued seamlessly in the community. Children and Young People

Children and young people with diabetes under the age of 17, all receive their care from specialist (secondary) care. The hospital-based multidisciplinary team co-ordinates the individual’s diabetes care, with the GP taking a holistic overview of the child’s health and prescribing any medication, often in partnership with specialist care. Young people with diabetes move from paediatric to adult medical care at the age of 17. The risk of Diabetic ketoacidosis (DKA) at diagnosis of diabetes in children and young people has not changed in the last 10 years. Some of these children and young people will have had contact with healthcare professionals in the weeks leading up to their emergency presentation, suggesting there may be opportunities to improve diabetes diagnosis and management. A public and healthcare professionals campaign is currently underway by Diabetes UK (the 4 Ts), to raise awareness of the symptoms of diabetes in children and young people to try and avoid this potentially life threatening presentation of the disease. Overview of Local Health Need and Challenges for Diabetes Services Cardiff and Vale University Health Board (UHB) area is the smallest and most densely populated LHB area in Wales, primarily due to Wales’ capital city, Cardiff. 74% and 26% of the Cardiff and Vale UHB area population live within Cardiff and the more rural Vale of Glamorgan respectively. The UHB area includes 16% of Wales’s population, yet it has an age and sex profile with marked differences to that of Wales (figure 1). Figure 1: Percentage of population by age and sex, Cardiff and Vale UHB and Wales, 2014 Source: Public Health Wales Observatory (2014)

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The demographic profile of Cardiff differs from Wales due to the high number of students and young professionals aged 20-34 resident in the area. However, in the Vale of Glamorgan, the population is similar to the population of Wales. Population projections suggest by 2030, the population of over 65 year olds will increase by 44% in Cardiff (19,710 people) and by 53% (12,480 people) in the Vale of Glamorgan. In particular, the numbers of the very elderly (85 yrs +) will increase markedly. The 2011 Census shows that 15.3% of the population of Cardiff described themselves as non-white. In the Vale of Glamorgan this figure was 3.6%. The Welsh average was 4.4%. Figure 2 shows the Welsh Index of Multiple Deprivation by lower super output area across Cardiff and Vale. It shows higher levels of deprivation around the south and east of Cardiff and Barry in the Vale of Glamorgan. Deprivation is known to be associated with poorer health outcomes. There are substantial gaps in life expectancy between people living in the most and least deprived areas and even more stark differences in healthy life expectancy and disability-free life expectancy. Figure 2: LSOA deprivation fifths within Cardiff and Vale UHB area, Welsh Index of Multiple Deprivation (WIMD) 2014, all residents Source: Public Health Wales Observatory (2014)

8 6 4 2 0 2 4 6 8

00-04

05-09

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

90+

Wales Males Cardiff & Vale UHB Males Wales Females Cardiff & Vale UHB Females

Percentage of population by age and sex, Cardiff & Vale UHB and Wales, 2014

Produced by Public Health Wales Observatory, using Mid-year Population Estimates (ONS)

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6. Development of Cardiff and Vale University Health Boards local delivery plan for diabetes

In response to the “Together for Health – A Diabetes Delivery Plan” (2013), health boards are required, together with their partners, to produce and publish a detailed local service delivery plan to identify, monitor and evaluate action needed within timescales. The health board executive leads for diabetes will need to report progress formally to their Boards against milestones in these delivery plans and publish these reports on their websites at least annually. The planning and development of diabetes services in Cardiff and the Vale of Glamorgan is coordinated through a multi agency group (the Diabetes Service Improvement Group), which represents all the different services and organisations working with people with diabetes in Cardiff and the Vale of Glamorgan. The group is supported by Executive sponsors, and views from people living with diabetes and their families are represented by Diabetes UK. The Diabetes Service Improvement Group meets bi-monthly. A Paediatric Diabetes Management Group is also in place to oversee the paediatric component of the plan. The Paediatric group lead consultant attends the Diabetes Service Improvement Group three times a year in order to consider areas requiring joint work across the two groups. Each work area of the delivery plan is sponsored by the relevant Clinical Board Director This group, following assessment of progress against priorities, has reviewed how service provision needs to change, has consulted people living with diabetes for their views on prudent diabetes care, and has drawn up actions to be undertaken during the period of the national delivery plan and in particular actions and outcomes to be delivered this year. These have been incorporated these into an 18 month transformational programme plan to expedite progress towards our goals.

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The project plan is embedded here;-

Copy of Project Plan only.xlsx

In addition to this, lead clinicians have assessed what the UHB is currently doing, to establish what we can do differently or collectively, and to set priorities for 2016-17 within this plan.

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7. Priorities for the coming year The Together for Health Diabetes Delivery Plan sets out action to improve outcomes in key areas between now and 2016. For 2016-17 the following national priorities have been agreed:

Eye Care; Health boards to ensure 100% referral rates to DRSSW Measure times from referral by DRSSW to review by an

ophthalmologist Ensure suitable local infrastructure to support new DRSSW

clinic model

Insulin Pumps; Health boards to provide NICE compliant insulin pump therapy

service by improving expertise and annual training updates, meeting safety standards, providing patients with a choice of devices

Health Care Professional Education; Health boards to ensure all inpatient staff and staff caring for

people living with diabetes have adequate knowledge and training to safely manage diabetes

Pregnancy; A preconception awareness campaign to be developed and

implemented across Wales, supported by a preconception film (various languages) and health care professional on line education module

In addition to these national priorities, Cardiff and Vale University Health Board highlights the following priorities for 2016-17 which reflect the needs of the local population: Children and Young People The priorities for 2016-17 are:

Deliver a 24 hour, 7 days per week out of hours advice line for families and children with diabetes. This will be developed by the All Wales network

Introduce of the first all Wales structured education module for newly diagnosed children and young people

Develop capacity to ensure that every child with diabetes will be offered 4 (30 minute consultation) appointments with a Consultant every year

Enhance the education provided to teachers, families and children about managing diabetes during the school day with the appointment of 0.5 wte band 7 paediatric diabetes clinical nurse specialist.

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Participate in a second cycle of ‘peer review’ (self-assessment) and acting upon outcomes

Preventing Diabetes The priorities for 2016-17 are:

Deliver concerted and widespread action to reduce obesity in the population of Cardiff and the Vale of Glamorgan

Reduce other diabetes key risk factors in the population of Cardiff and the Vale of Glamorgan including smoking and alcohol misuse

Raise the profile of Making Every Contact Count by implementing the communication plan

Detecting Diabetes Quickly The priorities for 2016-17 are:

Work with primary care and allied health professionals to raise awareness of the risks and symptoms of diabetes and explore innovative approaches for early detection

Delivering Fast, Effective Care The priorities for 2016-17 are:

Design and deliver a sustainable diabetes specialist nursing service model to provide specialist interventions, education, and support across all areas of healthcare delivery

Deliver the recommendations of the diabetes retinopathy needs assessment to provide equity of access to services

Ensure that people with diabetes who are admitted to hospital are delivered safe, timely, and effective care.

Ensure that the NICE Diabetes in Pregnancy guidelines are met.

Supporting Living with Diabetes The priorities for 2016-17 are:

Establish peer support across additional areas of Cardiff and the Vale of Glamorgan, prioritised according to need

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Deliver training on effective diabetes diagnosis and treatment to primary care professionals

Increase access to our Education for Patients diabetes self care programme

Design suitable and acceptable education and support provision for highest prevalence local population in City & South cluster

Ensure that all people with diabetes have a personal care plan Improving Research The priorities for 2016-17 are:

Continue with the current research programme Improving information The priorities for 2016-17 are:

Publish a webpage focused on education and support for people living with type 2 diabetes (people living with diabetes have told us that this would be helpful to them). For those without internet access, we will consider other means of providing access to information

Continue to work with the third sector to ensure effective signposting to sources of information and support

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8. PERFORMANCE MEASURES/MANAGEMENT The Welsh Government’s Together for Health – a Diabetes Delivery Plan (2013) contained an outline description of the national metrics that health boards and other organisations will publish:

Outcome indicators which will demonstrate success in delivering positive changes in outcome for the population of Wales.

NHS assurance measures which will quantify an organisation’s progress with implementing key areas of the delivery plan.

Progress with these outcome indicators will form the basis of Cardiff and Vale University Health Board’s annual report on diabetes. The first of these annual reports was published in 2013, and the next one will be published towards the end of 2016. Cardiff and Vale University Health Board also reports progress against the local delivery plan milestones to the Board annually and through its website.

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9. ACTION PLAN 2016 – 2017

Children and Young People

Priority Actions required Lead Due Date Progress

24/7 out of hour’s emergency advice line

Work with the Network to achieve this priority on an All Wales basis

Justin Warner 2017 A proposal will be taken to the DDP implementation group in March 2016.

Create a new paediatric diabetes clinic in Llandough twice per month

Liase with Llandough Out Patients Department

Ambika Shetty April 2016 On target.

Partcipate in the 2016 peer review programme

Complete the assesment and submit a completed operational policy, annual report and workbook.

Justin Warner April 2016 Ongoing

Secure ongoing funding for the PDCNS education post from April 2017

Ensure that the need for funding is captured in the Clinical Board IMTP

Mary Glover/Cath Heath

Dec 2016 Need for funding post April 2017 has been included in the Clinical Boards IMTP

Preventing Diabetes


Reduce population obesity

Implement all levels of the All Wales

Suzanne Wood and Helen Nicholls

March 31st 2017 Level 3 Obesity Service for adults now complete and operational.

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Obesity Pathway

IMTP bid for children’s Level 2 and 3 Obesity Service, in process of development

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Implement the action outlined in the Cardiff and Vale Food and Physical Activity action plans

Susan Toner Lauren Idowu

Director of Public Health Report (2014) focused on obesity and used social media for 5 weeks during the summer of 2015 to engage with professionals and the public on further actions

Action plans refreshed and agreed with partners. Examples of progress include:-

Physical activity and primary care project being piloted with SW Cluster – results expected May 2016

Walking Month (May 2015) promoted using social media

Food Cardiff awarded bronze level within the Sustainable Food Cities Network

Active travel to school project with Sustrans and the Police implemented

Hospital Restaurant Food Standards implemented and restaurants progressing towards achieving full compliance

GP Referrals to the National Exercise Referral Scheme analysed to inform future actions by Clusters

Collate available preventative services for easy

Sian Griffiths Preventative initiatives for key risk factors including lack of physical activity, poor diet, smoking and alcohol misuse are

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signposting signposted through the UHB Making Every Contact Count (MECC) programme. During 2015-16, MECC training has been delivered to a wide range of staff from the UHB (including the podiatry team) and also partner organisations, including third sector and probation services. An external evaluation of the training of the podiatry team is due to report. In addition, training slides have been updated in response to feedback to include elements of motivational interviewing. The Cardiff and Vale Team led the organisation of and participated in a successful All Wales MECC Conference. Opportunities to further extend the reach of the programme will be sought in 2016-17. Further embedding the MECC approach within the UHB and improved communications will be a priority.

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Detecting Diabetes Quickly


Work with primary care and allied health professionals to raise awareness of the risks and symptoms of diabetes and explore innovative approaches for early detection

Progress the provision of POCT testing in peoples home environments

Seetal Sal March 2017

Deliver adapted MERIT training to primary healthcare professionals

Gerry Arthur Sept 2016 Training needs analysis completed and reviewed. Training plan being agreed

Implement outcomes of recent work exploring challenges facing BME communities in accessing preventative health services

Gerry Arthur Sept 2016 Review completed and plan has been developed

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Progress the enhancement of service delivery within the primary and community setting

Design and delivering a sustainable diabetes specialist nursing service model to provide specialist interventions, education , and support across all areas of healthcare delivery

TBC March 2017 Invest to Save funding secured for partial establishment of community service DSN service model and workforce capacity and transformation initiated

Introduce MIQUEST data collection in primary care

Lindsay George July 2016 Work is on-going as per plan in relation to the delivery of this action

Provide training to primary care professionals on diabetes treatment and management

TBC January 2017 A training needs assessment has been conducted and analysed. A work stream has been established to develop and deliver a training plan.

Diabetes care pathway in full use in primary care

Fran Ferner Jan 2017 The care pathway has been introduced in primary care. Use will be audited in June 2016, and any action to ensure full use will be developed as necessary

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Improve timely access to specialist inpatient diabetes services, and ensure diabetes care is delivered effectively and safely on all ward areas

Progress roll out of the Think Glucose Programme across all inpatient areas

Aled Roberts March 2017 A work stream has been established, and a plan developed to deliver Think Glucose. Plan progressing to timescale, commencing with prioritised areas.

Improve and implement foot screening for patients admitted to hospital who have diabetes

Review documentation related to hospital acquired foot damage and develop links with patient safety.

Scott Crawley June 2016 Work is on-going to include foot checks on the ward dashboards

Ward based education and development of a foot screening tool to sit alongside pressure ulcer prevention screening tools and body maps

Scott Cawley March 2017 A service evaluation is currently being carried out through research methodology on two wards in the UHB, which will help direct ward requirements of educational needs to implement diabetic foot screening across whole of the UHB. Funding will be required for Podiatry to undertake the educational support required

Ensure people with diabetes are referred to the specialist diabetes

Aled Roberts March 2017 Continue a schedule of awareness raising and education to ward based staff

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team within 24hrs of admission,

Improve services for pregnant women with diabetes

Medical antenatal service to be developed on the UHW site

Aled Roberts March 2017 A plan has been developed to establish this service

Secure investment to screen and manage positive diabetes results in antenatal clinics

Rachael Burton March 2017 Included in Children and Women Clinical Board IMTP

Supporting living with diabetes


Improve self management of diabetes

Develop alternative delivery of structure diabetes education programmes based on a review of the challenges accessing current programmes experienced by Black and ethnic minority communities

Geri Arthur October 2016 Review of challenges completed City and South GP cluster implementing a pilot to improve access to services for BME communities in the area.

Establish a March 2017 Partial funding secured through Invest to

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specialist diabetes nursing service in the community setting

save bid.

Improving information


Improve the availability of information about diabetes support available locally

Develop a local website Complete consultation, identify a platform, publicise and update as necessary

Lauren Idowu June 2016 One consultation event held with people living with diabetes on the format and content. Another event planned in March

Work with the third sector to ensure effective signposting to sources of information and support

Lauren Idowu March 2017

POCT department to develop online training for home users

Seetal Sal March 2017 Work to be initiated March 2016

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Targeting research


Increase and improve diabetes research

Secure diabetes research and development funding in partnership with the Diabetes Research Network

Colin Dayan March 2017 Active Research programme in place in relation to the early diagnosis and treatment of Type 1 Diabetes.

health board together for health diabetes delivery … · page 1 of 35 health board together for...

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