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Keeping People with Diabetes

Out of Hospital

PCDSPrimary Care Diabetes Society

Supported by:

Keeping People with Diabetes Out of Hospital 32 Primary Care Diabetes Society

Contents

Forewords Lord Rennard MBE, Chair of the Working Group ________________________________________________ 6

Dr Paul Downie, Primary Care Diabetes Society ________________________________________________ 8

Caroline Horwood, Sanofi ________________________________________________________________ 9

Dr Roger Gadsby, Member of the Working Group _______________________________________________ 9

1) Recommendations ________________________________________________________________________ 10

2) Scope of the project _______________________________________________________________________ 11

3) Why do people with diabetes end up in hospital? ________________________________________________ 12

a) Complications _______________________________________________________________________ 12

b) Delayed Diagonsis ____________________________________________________________________ 13

c) Vulnerable Groups ____________________________________________________________________ 13

d) Patient Referral ______________________________________________________________________ 15

e) Access to information __________________________________________________________________ 15

f) Patient confidentiality and consent _________________________________________________________ 15

g) Ways of working in the new NHS __________________________________________________________ 16

4) Financial Burden __________________________________________________________________________ 17

5) How to Keep People With Diabetes Out of Hospital _______________________________________________ 19

6) Sharing & adopting best practice _____________________________________________________________ 22

a) Case Study 1: Care Homes Project ______________________________________________________ 23 South Staffordshire Primary Care Trust

b) Case Study 2: Tackling Diabetes Related Emergency Admissions _________________________________ 26 Nottingham NHS

c) Case Study 3: Local Enhanced Service to target pre-diabetes in Primary Care ________________________ 28 NHS Eastern and Coastal Kent

d) Case Study 4: Integrating Community Care for Diabetes ________________________________________ 30 Berkshire West

e) Case Study 5: New Organisations for New Challenges in Long Term Conditions _______________________ 32 Derby PCT

f) Case Study 6: Reducing Hypoglygaemia & hospital admissions in vulnerable patients ___________________ 34 South Staffordshire PCT

g) Case Study 7: Diabetes Inequalities Outreach Project _________________________________________ 36 Clacton-on-Sea

h) Case Study 8: Prevention in admission in vulnerable peoples ____________________________________ 38 Birmingham and Solihull Mental Health Foundation Trust

7) References ___________________________________________________________________________ 40

8) Contacts ___________________________________________________________________________ 41

Insight Public Affairs were employed by Sanofi by way of a grant

to provide secretariat and administrative assistance for this

Primary Care Diabetes Society policy project.

For more information on this project please contact Katie Russell

on 020 7824 1859 or [email protected]

4 Primary Care Diabetes Society Keeping People with Diabetes Out of Hospital 5

“ How often have you heard about an older patient stuck in hospital

for weeks because there’s nowhere else for them to convalesce? Or

asthmatic and diabetic patients not getting the right support to manage

their condition ending up in A&E before being put on the ward to recover?

We have too many patients, spending too long in hospital, taking too long

to get better.”

Deputy Prime Minister, Rt Hon Nick Clegg MP,

Speech to NHS at University College London Hosptial (May 26 2011)

“ When we are ill, what matters most, is that the NHS is there for us. That

it listens, understands and provides us with the best possible care. The

best outcome. Of course, the best outcome is for people to stay healthy.

But for the many of those who have long-term conditions, the best

outcome is about reducing and minimising the impact of their symptoms,

and wherever possible keeping them out of hospital. For this to happen

there needs to be: a fast and accurate diagnosis; shared decision making

about treatment; and on-going support for self-management.”

Secretary of State for Health, Rt Hon Andrew Lansley CBE MP,

Speech at The Adam Smith Institute, (September 13 2011)

“ We need to help people to manage their diabetes, especially because we

want them to have control over their health care and to spend less time

in hospital.”

Prime Minister, Rt Hon David Cameron MP,

Prime Minister’s Questions (June 15 2011)


Lord Rennard MBEChair of the Working Group

October 2011

Dear Colleague,

It has been my pleasure to Co-Chair this Working Group with my parliamentary colleague, the Lord Harrison, and we are

delighted to launch the findings of the Keeping People With Diabetes out of Hospital Working Group. This report is the

culmination of two ‘deep dive’ roundtables, and a call for evidence from the diabetes clinical community. The Working

Group has scoped out the issue of hospital admissions amongst people with diabetes, proposed a series of practical

recommendations and has strived to identify initiatives that are working to keep people with diabetes out of hospital.

We have been singularly impressed by the innovation and creativity that we have been party to throughout this project;

it is clear that there is a plethora of excellent initiatives taking place across the NHS in England and we hope that this

project will go some way in shining a light on these areas of excellence.

As a member of the All-Party Parliamentary Group on Diabetes, but perhaps more importantly as a person with diabetes,

I am acutely aware of the pressure our diabetes services and clinicians are under in this climate of change in the NHS. Sir

David Nicholson, Chief Executive of the NHS, has set us a challenge – to make £20billlion worth of efficiency savings over

the course of the next three years. This is not just a cost cutting exercise; instead the NHS must continue to improve the

quality of services whilst ensuring that care is delivered in the most efficient way possible. This quality and productivity

challenge is formally embodied in the Department of Health’s QIPP agenda, or Quality, Innovation, Productivity and

Prevention (QIPP).

It is widely understood amongst the diabetes clinical community that people with diabetes are more likely than to be

admitted to hospital than those without the condition. This places a considerable burden on NHS resources, but more

importantly this is often an avoidable and unnecessary worry for the patient, their families and carers. Indeed, Prime

Minister David Cameron himself noted that we need to help people to manage their diabetes better. When addressing the

House of Commons during Prime Minister’s Questions he said, “we want them [people with diabetes] to have control over

their health care and to spend less time in hospital.”2

As a result, the Government is actively encouraging clinicians to find new ways of working to tackle such challenges, whilst

achieving substantial cost savings and utilising existing resources. This project has purposefully taken a solutions focused

approach; bringing together clinical experts to recommend ways to achieve real cost savings whilst improving patient

outcomes.

2 Prime Minister’s Questions, June 15 2011

Critical to meeting this challenge is to break down the barriers between health care professionals and to encourage good, productive dialogue on the ground. What has become clear to us is that doctors, nurses and GPs by their own admission, are not always very good at talking to one another and most importantly, sharing their experiences and insight into their ways of working. This report clearly demonstrates that, in spite of the considerable challenge we face in keeping people with diabetes out of hospital, there is a wealth of expertise on the ground that is driving our diabetes services forward, constantly innovating and consistently striving to deliver and I sincerely hope we can build on this work in the months and years ahead.

I would like to thank my Co-Chair Lord Harrison for his expertise and insight and to Sanofi for their continued support and commitment to improving patient outcomes in diabetes. Finally, I would like to thank the members of the Working Group who have lent their time and expertise to this important project. For our part, we will take these findings to our parliamentary colleagues and continue to speak out for improved diabetes services. We call on you, those on the frontline, to continue to innovate, to continue to share and to continue to strive to attain excellence in diabetes care. Yours faithfully,

Lord Rennard, MBE Chair, Keeping People with Diabetes out of Hospital Working Group


Dr Paul Downie Primary Care Diabetes Society

Caroline HorwoodSanofi

Dr Roger Gadsby MBEProject Working Group

The Primary Care Diabetes Society (PCDS) is delighted to

present this report on behalf of the Keeping People with

Diabetes out of Hospital Working Group. As an organisation

PCDS are constantly striving to support primary care

professionals to deliver high quality clinically effective care, in

order to improve the lives of people living with diabetes. This

project has enabled us to come together with our secondary

and emergency care colleagues and work in partnership on this

critical challenge in diabetes care; how to negate the trend of

high hospital admission rates among those living with diabetes.

This project has presented us with an invaluable opportunity to

assess and reflect on the state of diabetes care, particularly as

we transition into the new NHS. What is clear is that we must

take a holistic, multidisciplinary approach to diabetes care,

striving to provide a fully integrated service.

Jennifer Dixon, director of the Nuffield Trust, noted that

integration is crucial to the future of the NHS and to delivering

the savings that Sir David Nicholson demands. “One of the

areas where there is huge inefficiency is that care is currently

quite fragmented and not proactive enough,” she says. “It

does not reach out to people and there is an enormous divide

between primary and secondary care.” With this project we

have aimed to tackle just this.

The recommendations proposed in this report cover all aspects

of the patient care pathway and are not solely focused on

primary care. Our objective has been to look at the care

pathway in its entirety and identify ways in which we, the

health care professionals, can work with policy makers to

keep people with diabetes healthy and out of hospital. The

revision and improvement of care pathways has proven to be

an effective means of achieving this. Indeed, care pathways

that are less complex, involve fewer appointments or referrals

and are more clearly defined can result in higher quality, more

patient-focused care.

This project has not only set out to review the clinical scenario

in isolation. We have called upon our NHS colleagues to share

any methodology they have followed to tackle admission rates

in their own locality. In our efforts to collate these examples

of best practice we have seen compelling evidence of the

impact that an improved or revised care pathway can have on

patient outcomes. It is imperative that we not only share these

experiences but that we also take these learnings on board and

apply them, where appropriate, in our own settings.

Sanofi are delighted to support the Primary Care Diabetes

Society in this critical area of diabetes care. We are

pleased to work alongside the diabetes clinical community

to assess the diabetes patient care pathway and shine

a light on the plethora of best practice that is currently

taking place in the NHS. This report provides a platform

for health care professionals to learn from their colleagues

across England, and, we hope, will encourage closer ways

of working as we all work to create a more integrated NHS.

At Sanofi, we are committed to working in partnership

with the clinical community and professional associations,

patients and patient groups, managers and policy groups to

facilitate debate, share best practice and improve outcomes

for people with diabetes. In that endeavour, this initiative

under Lord Rennard’s chairmanship is an excellent example

of collaborative working, and I urge for the recommendations

and best practice examples in this publication to be fully

implemented.

On behalf of the members of the Working Group I would

like to thank Lord Rennard and Lord Harrison for their

wholehearted support of this project. We are grateful to them

both for lending their time and expertise, particularly when

both are in such demand. As clinicians with a specialism in

diabetes, we face a considerable challenge in keeping our

patients healthy and out of hospital. In the ever changing

NHS environment we must work together, utilising resources

such as this report, to learn from one another, taking an

innovative eye to the care pathway and consistently striving

for excellence for our patients.


Recommendations Scope of the project

The Primary Care Diabetes Society (PCDS) convened a Working

Group of diabetes clinical experts, including GPs with a Special

Interest (GPSIs), diabetologists, Diabetes Specialist Nurses (DSNs),

public health professionals and patient group representatives

to take a closer look at the rate of hospital admissions amongst

people with diabetes with the following objectives in mind:

The Working Group met on two separate occasions in West-

minster in May and July of 2011. The two policy roundtables

were chaired by Lord Rennard MBE, member of the All-Party

Parliamentary Group on Diabetes, and Lord Harrison, Vice Chair

of the All-Party Parliamentary Group on Diabetes and supported

by Sanofi via an unrestricted educational grant.

Members of the Working Group were as follows:

z Lord Harrison, Vice-Chair,

All-Party Parliamentary Group on Diabetes

z Lord Rennard MBE, Member,


z Adrian Sanders MP, Chair,


z Dr Belinda Allan, Workstream Lead,

Joint British Diabetes Society

z Sarah Astles, Senior Policy Officer,

Juvenile Diabetes Research Foundation

z Dr Charles Bodmer, Consultant Physician & Diabetologist,

Colchester Hospitals University NHS Foundation Trust

z Louise Brant, Government Affairs Manager,

Sanofi

z Dr Richard Brice, GPSI,

Kent

z Dr David Cartwright, Diabetes Lead,

NHS Lincolnshire

z David Davis, NHS Pathways Development Manager,

South East Coast Ambulance Service NHS Foundation Trust/

College of Paramedics

z Dr Paul Downie, GPSI Diabetes,

Primary Care Diabetes Society

z Elizabeth Dunsford, Public Health Specialist,

NHS Ealing

z John Fellows, Senior Policy Officer,

Diabetes UK

z Dr Roger Gadsby MBE, GP & Associate Clinical Professor,

Warwick Medical School

z Patricia Gilliard, PDSN, King’s College Hospital NHS

Foundation Trust

z Dr David Haslam, Chair, National Obesity Forum

z Jill Hill, Nurse Consultant Diabetes, Birmingham Community

Healthcare NHS Trust

z Fiona Kirkland, Diabetes Nurse Consultant,

South Staffordshire PCT

z Dr Stephen Lawrence, GPSI Diabetes,

Medway NHS Trust

z David Newman, Head of Public Affairs,

Juvenile Diabetes Research Foundation

z Michaela Nuttall, CHD co-ordinator for Bromley PCT,

Primary Care Cardiovascular Society

z Dr Paul O’Hare, Director of Quality Assurance,

Warwick Medical School

z Dr Gerry Rayman, Clinical Lead Diabetes In-Patient Care,

Ipswich Hospital NHS Trust

z Rebecca Reeves, Head of Professional Relations,

Sanofi

z Anna Reid, Nurse Consultant,

Guy’s and St. Thomas’ NHS Foundation Trust

z Sheila Smyth, Lead DSN,

North East Essex NHS

z Stella Valerkou, Senior Policy Officer,

Diabetes UK

z Grace Vanterpool MBE, Consultant Nurse,

Hammersmith and Fulham NHS Foundation Trust

z Dr Chris Walton, Chair,

Association of British Clinical Diabetologists

For the purposes of this report, this group of clinical experts will

be referred to as ‘the Working Group’.

Incentivise GPs to target people with pre-diabetes – a register of patients in a pre-diabetic state (IGT/ IFG/ Gestational diabetes) should be included in the Quality Outcomes Framework (QOF). QOF points should be available to GPs who a) put pre-diabetics onto a register, and b) provide these at-risk patients with the necessary management plan to ensure they prevent or delay the onset of diabetes.

Effective patient referral by ambulance services – after an acute episode of hypoglycaemia, the ambulance services must refer the patient to the appropriate primary/secondary healthcare professional. The ambulance services must look at both the short term and long term management of the patient’s condition including risk management, prevention and avoidance.

Appropriate access to treatments – in the new NHS, the clinical community are under increasing pressure to meet the QIPP challenge of making £20billion worth of efficiency savings. It is imperative that clinicians are not forced to jeopardise or compromise the standard of care that they make available to people with diabetes.

GPs to develop strategies to identify and reach vulnerable groups – GPs should develop out-reach strategies to focus on ‘hard to reach’ groups, to support them in the management of their diabetes and keep them out of hospital.

PCTs to invest in the work force – junior doctors and nurses must be educated and trained in the appropriate discharge procedures for patients with diabetes to avoid further complications and possible readmission.

Access to patient records across the NHS – consideration should be given by PCTs and Ambulance Trusts to the challenge of patient consent and clinical access to patient records across the NHS to help the health care professional, be they GP, DSN, paramedic or diabetologist, to administer care whilst fully informed of the patient’s history.

Specialist care to be made available in all PCTs – integral to optimal diabetes service provision is the availability of specialist care.

Integrated, multi-disciplinary teams – closer working relationships across commissioning groups between community health care professionals, such as podiatrists and dieticians, and secondary care specialists, is vital to ensure that the patient receives a comprehensive and consistent service.

1. To identify why people with diabetes are more likely to be admitted into hospital;

2. To assess the impact this trend has on the patient and the NHS;

3. To propose a series of practical recommendations for primary, emergency and secondary care professionals, managers and commissioners to take into consideration;

4. And to identify where successful hospital avoidance strategies are being implemented in diabetes care across England and highlight the initiatives as best practice.


Why do people with diabetes end up in hospital?As Dr Rowan Hillson MBE, National Clinical Director for Diabetes,

observed, “we know what to do, so why aren’t we doing it?”2

National clinical guidance, including a NICE Quality Standard for

Diabetes in Adults, encapsulates the optimal standard of care

that people with diabetes are entitled to. A consensus exists

amongst the diabetes clinical community on what needs to be

done, and yet many people with diabetes are not receiving the

care and support they need to keep them healthy, in control of

their diabetes and out of hospital.

For example, according to the National Institute for Clinical

Excellence (NICE);

“All patients should receive nine crucial tests from their

GP at an annual review of their diabetes management.

These include measurements of weight, blood pressure,

smoking status, a marker for blood glucose called

HbA1c, urinary albumin, serum creatinine, cholesterol,

and tests to assess whether the eyes and feet have been

damaged by diabetes.

These tests are essential to ensure that diabetes is

controlled. If left unchecked, diabetes can lead to

blindness, kidney failure and increase the risk of

developing cardiovascular problems such as heart

attacks and stroke.”3

The National Diabetes Audit for 2009-2010, carried out by NHS

Diabetes, reported that only half of people with Type 2 diabetes,

and less than a third of those with Type 1 diabetes, receive

2 National Diabetes Audit Executive Summary 2009-2010, 2011, NHS Information Centre, p.53 Diabetes care improves, but patients still missing out on key tests, NICE, 2010, www.nice.org.

uk/newsroom/news/DiabetesCareImprovesButPatientsStillMissingOutOnKeyTests.jsp

all nine of the NICE recommended care processes as part of

a complete care bundle. The Audit also reported significant

variation in the individual checks being carried out. For example,

weight measurement and HbA1c checks are carried out most

frequently.4 However, the care processes that check for the

emergence of early complications are not being carried out

to a sufficient level, leaving a large proportion of patients un-

assessed and at risk of developing complications.5

The 2009-2010 Audit also revealed that glucose control levels

in England are not improving. 37% of people with diabetes are

at high risk of future complications due to glucose control above

recommended levels. These results are similar to those found

in the 2006-2007, 2007-2008 and 2008-2009 audits and

therefore demonstrate no improvement.6

What are the key challenges?

The Working Group assessed the current clinical practices and

scoped out the key challenges in keeping people with diabetes

out of hospital. The Working Group discussed the following

issues in detail: complications; delayed diagnosis; social and

demographic circumstances; referral; access to information;

patient confidentiality and consent; and finally the transition into

the new NHS.

a. Complications

Poorly managed diabetes can lead to a range of complications

including amputation, kidney disease, strokes, heart attacks,

depression and blindness. As a result diabetes increases the

chance of a person needing hospital admission by five times.7

This predisposition to complications is further compounded by

the fact that over half of people diagnosed with Type 2 diabetes

already show signs of complications at the point of diagnosis.

This is a widely reported statistic and the Yorkshire and Humber

Public Health Observatory (YHPHO) acknowledge that early

diagnosis and treatment can reduce the risk of complications

that can be found to be well developed at the point of diagnosis.8

However, it was noted by the Working Group that these statistics

4 National Diabetes Audit Executive Summary 2009-2010, 2011, NHS Information Centre, p.115 National Diabetes Audit Executive Summary 2009-2010, 2011, NHS Information Centre, p.116 Ibid, p.147 Turning the Corner: Improving Diabetes Care; A Report from Dr Sue Roberts National Clinical

Director for Diabetes to the Secretary of State for Health, June 2006, Department of Health, p. 138 Diabetes Key Facts, 2006, Yorkshire and Humber Public Health Observatory, p. 15

are dated, and therefore the situation will have almost certainly

improved to an extent, although we lack the evidence to prove it.

The recent National Diabetes Audit noted that the majority of

complications develop after a long period of exposure to high

blood glucose, high blood pressure and high cholesterol. When

coupled with reports that rates of care processes and treatment

target achievement are low, particularly in young people, this

raises concerns for the future. The increasing prevalence of

diabetes will in turn mean that the rate of diabetes related

complications will also increase, negatively impacting on patient

outcomes, and of course on NHS resources.

It is widely acknowledged that a significant proportion of the

NHS diabetes budget is spent on ‘final outcomes of care’,

or complications. Indeed, a report by the NHS Institution for

Innovation and Improvement in 2006 found that diabetic

complications account for almost 20,000 emergency admissions

per year at a cost in excess of £40 million.9

A recent review by NICE of the Clinical Guideline (CG15) – Type

1 Diabetes: diagnosis and management of type 1 diabetes in

children, young people and adults – concluded that the guideline

needs to be updated in order to better reflect the screening

and management of complications such as coeliac disease,

retinopathy, neuropathy and psychosocial aspects.10

b. Delayed diagnosis

Proactive targeting of ‘at-risk’ groups was highlighted by the

Working Group as an important risk management technique.

Such groups might include people who have Impaired Glucose

9 The views of people with diabetes, Key findings from the 2006 survey, 2006, Healthcare Com-mission

10 Review of Clinical Guideline (CG15) – Type 1 Diabetes: diagnosis and management of type 1 diabetes in children, young people and adult, NICE, www.nice.org.uk/nicemedia/live/10944/56133/56133.pdf

Regulation (IGR) or women with gestational diabetes. The

Working Group noted that a high level of resources are currently

concentrated on diabetes registers. It was proposed by the

Working Group that attention should be focused on lifestyle

management of those in a pre-diabetic state (Impaired Glucose

Regulation (IGR) / Impaired Glucose Tolerance (IGT) / Impaired

Fasting Glycaemia (IFG)) to help people avoid developing

diabetes.

It is widely accepted that early diagnosis and treatment can

reduce the risk of complications. The Working Group agreed

that early diagnosis would better enable primary care health

professionals to support patients in avoiding complications, and

ultimately emergency admission.

The Working Group suggested that, as part of the Public Health

Outcomes Framework, a register of people with gestational

diabetes and IGR should be recorded to enable primary care

clinicians to identify those at risk at an early stage in the

development of the condition. The existence of a register alone

is not enough. It must be fully endorsed by the health care

practitioners and those patients on the register must be given

access to the necessary lifestyle management and education

programmes. [See Case Study 2]

c. Vulnerable groups

As part of the process of striving for early diagnosis, it is

important that we identify those groups who are not only

physically at risk of developing diabetes related complications,

but also those whose demography and social circumstances

place them in a vulnerable position. Identification of at-risk

groups by primary and community health care professionals is

part of the solution, however patient awareness and engagement

is also crucial. It was noted that patients need to be aware if they

are at risk, and should be able to identify if they need to visit their

GP and be happy to do so.


BAME Community

When identifying and targeting these ‘at-risk’ groups, the

Working Group noted that any risk management strategies

must be tailored to the demographic and needs of the local

community. For example young people in BAME communities

are particularly at risk of developing Type 2 diabetes, and any

prevention strategies must consider the makeup of the local

patient population and any cultural aspects relevant to care.

For example, it was noted that within the Muslim community

diabetes is a taboo subject, particularly in terms of marriage.

Therefore, to ensure good patient outcomes it is essential that

the patient’s treatment is managed sensitively and appropriately.

The National Diabetes Audit demonstrated that young people in

the BAME community, who also fall in the lower quartile of social

deprivation, are associated with higher risk glucose control.11

The Audit data also clearly demonstrates that all complications

are statistically associated with social deprivation.12

Older People

A report by the Institute of Diabetes for Older People (IDOP)

(2011) noted that the median age of inpatients in more than

200 Acute NHS Trusts was 75 years and the majority had

been admitted as an emergency. This report also found that

factors which increase the likelihood of hospital admission of

older people included care home residency, mis-management

of medication and carer fatigue, among others.13 A report by

Diabetes UK (2010) found that six out of ten care homes in

England, which have residents with diabetes, fail to provide any

training to their staff about the condition. 14 Diabetes UK also

found that only 23% of care homes screen their residents for the

11 National Diabetes Audit Executive Summary 2009-2010, 2011, NHS Information Centre, p.1412 National Diabetes Audit Executive Summary 2009-2010, 2011, NHS Information Centre, p.2113 Keeping Older People with Diabetes out of Hospital – improving outcomes, saving money and

maintaining quality of life and dignity, 2011, Institute of Diabetes for Older People14 Diabetes in care homes – Awareness, screening, training, 2010, Diabetes UK

condition on admission. The report concluded that this missed

screening meant that as many as 13,500 care home residents

could have undiagnosed Type 2 diabetes and were therefore

at increased risk of developing complications.15 All diabetes

complications (excluding Diabetic Ketoacidosis) become more

likely with increasing age and duration of diabetes so it is vital

that this group have their condition closely monitored.

The IDOP report concluded that all older people and their carers

should be educated about the signs and symptoms of diabetes

related complications. The report also recommends that diabetes

care within care homes must be enhanced, with carers supported

in the identification of at-risk patients.16 The Working Group noted

that diabetes care given in care homes is often not appropriate

and that support needs to be available to care workers to ensure

that specialist diabetes care is available where necessary. [See

Case Study 5]

Children & Young People

The Working Group acknowledged that a significant proportion

of children diagnosed with diabetes will have been subject to

a delayed or prolonged diagnosis process. The Working Group

suggested that many of these children present symptoms, which

are sometimes very serious, weeks before they are eventually

diagnosed; and many are only diagnosed after experiencing

complications. The National Diabetes Audit shows that only 4.1%

of children over the age of 12 are receiving all of the NICE key

processes and over 30% of children and young people have

a high risk HbA1c measure, leaving them vulnerable to future

complications.17 The National Diabetes Audit revealed that whilst

social deprivation, gender and the duration of diabetes have

no impact on the likelihood of the nine care processes being

completed, age is a critical variable.

Socio-economic deprivation

Research shows that complications of diabetes such as

retinopathy or cardiovascular disease are more prevalent in areas

of high socio-economic deprivation. Research based on GP

registrations suggests that the prevalence of diabetes in the most

deprived quintile of census output areas was 66% higher than

the most affluent quintile.18 [See Case Study 7]

15 Diabetes in care homes – Awareness, screening, training, 2010, Diabetes UK16 Keeping Older People with Diabetes out of Hospital – improving outcomes, saving money and

maintaining quality of life and dignity, 2011, Institute of Diabetes for Older People17 National Diabetes Audit Executive Summary 2009-2010, 2011, NHS Information Centre, p.2918 Diabetes Key Facts, 2006, Yorkshire and Humber Public Health Observatory (YHPO), p. 11

d. Patient referral

The Working Group noted that the diabetes care pathway can

often be complex and disjointed, and as the patient makes their

way through primary, emergency and secondary care referral

processes, critical information can be miscommunicated,

inaccessible or lost entirely. The Working Group agreed that the

ambulance services and paramedics have a vital role to play in

managing the effective referral of people with diabetes and have

unparalleled access to those most vulnerable to complications.

The National Clinical Quality Improvement Framework for

Ambulance Services have included a pilot marker of “Direct

referral made to an appropriate health professional”, as part of

the Hypoglycaemia Clinical Performance Indicator Audit Cycle

6 – February 2011. This pilot marker has shown wide variation

between ambulance services ranging from 1.9 to 83.9%.

The National Diabetes Support Team (2008) reported that there

are an estimated 100,000 emergency 999 calls every year for

diabetes related emergencies and of them, 35% come from

just 11% of addresses, which clearly points to the existence of

repeat callers.19 The Working Group agreed that the Ambulance

Service is often treated by certain diabetic patients as a

surrogate service, particularly for those patients who are not

good at self management. The Working Group noted that the

Ambulance Service is perhaps ‘too good’ at helping patients with

hypoglycaemia, giving them a short term solution, but not always

facilitating long term management of their condition. Assisting

people with diabetes in the management of their care at home, with

support from community and primary care, would have a significant

impact on patient outcomes and reduce hospital admissions.

One obstacle identified in achieving a consistent referral process,

is that not all patients want to be referred to a secondary care

specialist, or their GP. Crucially though, the Ambulance Service

does have access to hard to reach groups, such as patients with

mental health, drug and alcohol misuse problems i.e. those who

19 Improving emergency and inpatient care for people with diabetes, 2008, National Diabetes Support Team, p.3

may be unable, or choose not to, have a relationship with their

doctor or specialist nurse.

e. Access to information

Limited access to information on what happens to patients

after acute treatment is also very challenging for GPs and poor

communication can effectively hamstring the entire process.

The Working Group cited NICE guidance that states that after a

patient has experienced hypoglycaemia that requires third party

assistance, they ‘ought’ to notify their GP. However, research

shows that this rarely happens. It was agreed that technology

could be used more effectively to manage patient records, and

enable more efficient access to patient information across the

NHS. This would allow GPs, paramedics and specialists to make

informed referral decisions. The introduction of Insulin Passports

was noted by the group but concerns were raised over their

effective implementation.

It was also suggested that stratification of those patients

consistently presenting with hypoglycaemia would enable

clinicians to determine if different treatment regimes or services

would be more appropriate for that patient.

f. Patient Confidentiality and Consent

Patient confidentiality and consent was a recurring area of

contention for the Working Group. The relationship between

the health care professional and the patient is very important,

based on trust and integrity, but there are times when this

can come under strain. If a patient has been admitted due to

hypoglycaemia, they are often reluctant to share this information

with others, for example with the Driver and Vehicle Licensing

Authority (DVLA), as their right to hold a licence can be

withdrawn. This presents health care professionals with a moral

and clinical dilemma.


The Working Group acknowledged that patient confidentiality

must be maintained, however, the system should still allow for the

free flow of information between healthcare professionals, where

appropriate and with patient consent. It was suggested that most

patients expect the communication channels to be in place and

fully functioning, and will rarely say no to offering their consent,

but the reality is that the current system does not lend itself to

this fluid exchange of information. It was concluded that the

fear of confidentiality needs to be challenged, in order for a fully

integrated health service to function. 20

g. Ways of working in the new NHS

The Working Group raised concerns over the consistent

delivery of care in the new NHS. NHS Health Checks were

cited as an example where consistent delivery is by no means

guaranteed. These checks present health care professionals

with an invaluable opportunity to identify those at risk of

developing diabetes and to diagnose the condition. However,

the Working Group noted that in each local health economy

they are administered differently. Such inconsistencies and

inequities could become exacerbated in the new NHS, to the

detriment of the healthcare professional’s ability to identify

those with diabetes.

20 Diabetes Key Facts, 2006, Yorkshire and Humber Public Health Observatory (YHPO), p.3

The issue of re-admissions was also raised, in particular, patients

receiving inconsistent care in the primary and acute setting.

For example, when a patient is admitted into hospital after

experiencing hypoglycaemia they are often given standard oral

treatments that contain higher levels of longer acting insulins,

compared to intravenous insulin. If the patient is receiving

medication with higher levels of insulin than they are used to,

they are at risk of suffering complications which can lead to costly

emergency re-admission.

The Working Group was unanimous about the impact of GPs

and hospital doctors working together to achieve good patient

outcomes. It was also agreed that the barriers to this effective

working relationship, are similar to those barriers that stand in the

way of a good patient-doctor relationship.

It was noted that primary, emergency and secondary care

clinicians must have shared goals, and for this to be achieved,

health care professionals need to get better at networking with

one another. This applies to clinicians across the care spectrum:

specialists, GPs, commissioners, diabetes specialist nurses,

podiatrists and dieticians. Will alone is not sufficient, the means

of communication are also vital. It was agreed that improved

communications structures, incorporating new technologies,

would help with this change. However, concerns were voiced

over the future of this peer-to-peer relationship and diabetes

care in the new NHS. It was noted that GP commissioning will

certainly be an effective way of managing resources for short

term procedures, but commissioning for chronic care could be

at risk. It was concluded that high quality care is not possible

without cooperation, which should be at the heart of the Health

and Social Care Bill. It was also noted that the Diabetes Quality

Standard should ensure that services for long term conditions are

commissioned effectively.

It has been estimated that the NHS spends approximately

£25million a day treating people with diabetes, whilst the

estimated percentage of the NHS’ annual budget dedicated

to the treatment of diabetes ranges from 5-10%, depending

on the source. When assessing the cost of diabetes and

its complications, it is important to consider the financial

implications beyond the acute admission. According to the

YPHO, 1 in 20 people with diabetes incur social services

costs, with more than three quarters of these costs associated

with residential and nursing care, whilst home help services

accounted for a further one-fifth.21 A report by the King’s Fund

further noted that the presence of complications increased

social services costs four-fold.22

When it comes to assessing the financial burden of diabetes

on the NHS, there is a notable lack of recent data on which

to calculate a realistic figure. A report from the Yorkshire and

Humber Public Health Observatory (YHPO) in 2006 suggested

that the total annual cost of diabetes care is £1.3 billion. It is

perhaps most concerning that the YHPO also notes that the

presence of diabetic complications “increases NHS costs five-

fold”.23 It is estimated that acute admissions due to diabetic foot

disease alone costs the NHS £252 million per annum.24

21 Diabetes Key Facts, 2006, Yorkshire and Humber Public Health Observatory (YHPO), p. 722 Type 2 diabetes. Accounting for a major resource demand in society in the UK, 2000, King’s Fund.23 Diabetes Key Facts, 2006, Yorkshire and Humber Public Health Observatory (YHPO), p. 624 Improving emergency and inpatient care for people with diabetes, 2008, National Diabetes

Support Team, p.5

These figures are dated, but in light of the National Diabetes

Audit revealing the increasing prevalence of diabetes, particularly

in young people, it would be prudent to assume that the cost of

diabetes and related complications is set to increase dramatically.

In an interview with BBC Radio 4, Dr Bob Young, clinical lead for

the National Diabetes Information Service, noted that the rising

number of young people with Type 2 diabetes will have “huge

cost implications for the NHS”.25 (N.B whilst the prevalence of

diabetes increases annually, we must also consider increased

screening, diagnosis and reporting.)

A report from the Audit Commission and the Association of

Chartered Certified Accountants (ACCA) (2011) attempted to

cost the diabetes care pathway. It acknowledged that the lack of

quality data made it very difficult to evaluate the financial impact

of care pathways that had been actively improved, and whilst it

is widely understood that simpler, patient focused pathways are

more effective, it is hard to quantify the financial benefits.26

25 Today Programme, 2011, BBC Radio 4, http://news.bbc.co.uk/today/hi/today/news-id_9525000/9525601.stm

26 Costing Care Pathways, 2011, Association of Chartered and Certified Accountants (ACCA) and the Audit Commission, p.5

The Financial Burden

The Cost of Acute Care for Diabetes

The Audit Commission and ACCA costed both elective and emergency acute

care for people with diabetes, using Hospital Episode Statistics (HES) and the

Department of Health National Tarriff. The results were as follows:

zz Treatment specifically for diabetes (diabetes mellitus, diabetes with

lower limb complications, diabetes with hypoglycaemic emergency)

accounts for 54% of spending in inpatient care.

zz Treatment for diabetes related conditions (eyes or vascular

system) accounts for 38% of spending in inpatient care.

Source: Costing Care Pathways, 2011, Association of Chartered and

Certified Accountants (ACCA) and the Audit Commission

The Cost of Emergency Care for Diabetes

Between December 2009 and November 2010 the South Central

Ambulance Service NHS Trust carried out the largest UK survey to describe

the incidence of severe hypoglycaemia requiring an emergency attendance.

zz 398,409 emergency calls were received, of which 4081 (1.02%) were

recorded with hypoglycaemia as the ‘chief complaint’.

zz The study concluded that the estimated annual cost of emergency care

for diabetes in England would be equivalent to £16.9million.

Source: Incidence and costs of severe hypoglycaemia in diabetes requiring

attendance by the emergency service in the United Kingdom, 2011, A.J

Farmer, K.J. Brockbank, M.L. Leech et al.


Whilst it would seem intuitive to address the cost of diabetes

related emergency admissions in order to tackle the cost of

diabetes related inpatient care, the Costing Care Pathways report

revealed some interesting data. PCTs that spend the most on

emergency care were not always those spending the most per

patient on inpatient care. It also shows that those trusts spending

more on elective care tend to spend more per patient. ACCA

and the Audit Commission concluded that although reducing

emergency admissions is beneficial in terms of the patient

experience, ‘the cost savings may be less than expected’. 27

It is also important to look at those patients who are admitted

to hospital where diabetes is an additional complication and not

the primary diagnosis. A report by the National Diabetes Support

Team noted that in patients with diabetes stay in hospital longer,

irrespective of the primary cause of admission.28



Based on the group’s discussions and their clinical experience,

the following recommendations were proposed.

Primary Care

;; It is proposed that as part of the 2012/2013 Quality

Outcomes Framework, an indicator is developed to

incentivise a pre-diabetic register.

;; Further it is proposed that a financial incentive is the most

appropriate course of action.

;; By incentivising GPs, additional resources and capacity

will be made available to maintain a register of pre-

diabetic patients. At-risk patients will be referred on to the

appropriate structured education programmes and provided

with the necessary life-style management techniques.

;; A QOF indicator would not only help incentivise GPs, but

would also raise awareness amongst nurses and other staff

members in the practice on the importance of targeting

these at-risk groups.

The number of people with Type 2 diabetes is increasing

each year, especially in deprived communities.29 Focusing

on those ‘hard to reach groups’ who are more susceptible to

complications as a result of mismanaging their diabetes, will

29 National Diabetes Audit Executive Summary 2009-2010, 2011, NHS Information Centre, p.30

reduce the number of people who are admitted into hospital.

;; ‘Hard to reach’ or ‘vulnerable’ groups could fall into one or

more of the following categories:

• People with diabetes who have a poor or non-existent

relationship with their primary care practitioner (e.g.

patients with mental health, alcohol, drug misuse

problems)

• People with diabetes who are disengaged or unaware of

the risk of complications they could be afflicted with as

a diabetic (e.g. pregnant women)

• People with diabetes who are in care homes, particularly

in the private sector, who do not have access to regular

contact with a diabetes specialist (e.g. older people)

;; It is important to reach these people before they become

unwell. Consideration should be given to a local strategy

whereby healthcare professionals go out into the community

in order to strengthen the relationship between the

healthcare professional and the person with diabetes e.g.

working with ante-natal groups, local pharmacies, private

and public sector care homes.

;; By establishing a level of trust, the person with diabetes is

more likely to engage with their condition; take on board

self-management techniques; and understand when it is

appropriate to seek medical advice.

;; Joint working presents healthcare professionals with an

opportunity to be streamlined and successful in reaching

patients. For example, Diabetes Specialist Nurses working

with Community Psychiatric Specialist Nurses would be

one way of targeting a particularly hard to reach group of

diabetics.

How to keep people with diabetes out of hospital The Working Group’s recommendations

Incentivise GPs to target people with pre-diabetes

- a register of patients in a pre-diabetic state (IGT/ IFG/ Gestational diabetes)

should be included in the Quality Outcomes Framework (QOF). QOF points

should be available to GPs who a) put pre-diabetics onto a register, and

b) provide these at-risk patients with the necessary management plan to

ensure they prevent or delay the onset of diabetes.

GPs to develop strategies to identify and reach vulnerable groups

- GPs should develop out-reach strategies to focus on ‘hard to reach’

groups, to support them in the management of their diabetes and keep

them out of hospital.


General

;; The sharing of specialist knowledge across the clinical

community and across commissioning groups, is critical to

keeping diabetes patients out of hospital.

;; To ensure that this specialist diabetes knowledge in

community, primary and secondary care is fed directly into

the commissioning process, the role of representatives on

Clinical Senates, representing sub-clinical areas, such as

diabetes, should be considered.

95% of diabetes management is self care; therefore patient

education is essential to keeping people with diabetes out of

hospital. According to the Diabetes National Service Framework

educational programmes can prevent or delay the development of

diabetes or its associated complications. Indeed, NICE guidance

suggests that the DAFNE educational programme is associated

with a net cost saving over 10 years of £2679 per patient and a

higher number of quality-adjusted life years.30

;; DESMOND, DAFNE and EXPERT are structured education

programmes already in place, however the volume of places

available to people with diabetes by PCT has yet to be

scoped and in some areas is inadequate.

;; It is important that these programmes are given the

necessary publicity by primary and community healthcare

professionals to ensure people with diabetes are aware of

them and are able to access the resources.

Emergency Care

;; A standardised referral procedure across commissioning

groups would be advisable to establish a continuity of care

in the long-term for patients who are seen by the ambulance

services.

;; It is important that any procedures put in place to

standardise the referral process are kept as simple and

straight forward as possible.

30 Guidance on the use of patient-education models for diabetes, 2003, NICE

;; The issue of consent requires careful planning in order to

protect the patient and maintain an appropriate level of trust

between the patient and the health care professional.

;; Critical to this consideration is consistency – co-ordinating

any access to patient information in primary, emergency and

secondary care must be done across the commissioning

group.

;; Strategies for the sharing of patient information must be

designed to fit the needs of the local health economy.

;; In the early stages of any strategy development, it would

be advisable to pilot any strategy amongst a small group of

vulnerable patients, for example, patients who have poor

self-management of their condition and regularly call on the

ambulance services.

;; Clinical commissioning groups could consider the following:

• Early opt-out consent register – Patients could give their

consent to their GP for information relating to diabetes

episodes to be shared in both directions across the

NHS.

• Voluntary card system – People with diabetes could

be encouraged to carry a small card detailing key

information on their condition, medication, emergency

contact information etc. This would enable paramedics

in particular to make informed decisions about the

patient’s care in an emergency situation.

Secondary Care

;; It is vital that on discharge, both the patient and the clinician

responsible for the ongoing care of that patient are fully

informed as to the type, volume and timing of any treatment

administered.

;; Mechanisms such as a Discharge Checklist are advisable

to ensure that junior doctors and nurses are adhering to a

standardised discharge procedure specifically designed for

patients with diabetes – whether it is the primary cause of

admission, or a secondary condition.

;; The focus must be on patient safety and outcomes, with the

long-term cost benefit of any treatment considered over and

above any short-term gain.

;; Consideration should be given by PCTs, and the emerging

Clinical Commissioning Groups, to the formation of “advisory

hubs” – an informed, multi-disciplinary group of healthcare

professionals who can be referred to for independent advice

and critique on whether seemingly ‘costly’ treatments are

appropriate for patients.

Primary and community healthcare professionals to develop and advertise structured patient education programmes

- GPs to work with community healthcare professionals to provide emotional

and psychological support and self-management techniques, enabling

patients to manage their condition day to day.

Appropriate access to treatments

- in the new NHS, the clinical community are under increasing pressure to

meet the QIPP challenge of making £20billion worth of efficiency savings. It

is imperative that clinicians are not forced to jeopardise or compromise the

standard of care that they make available to people with diabetes.

Specialist care to be made available in all PCTs

- integral to optimal diabetes service provision is the availability of specialist

care. A study into the bed occupancy for in-patients with diabetes before

and after the introduction of a diabetes inpatient specialist nurse service

(DISN) clearly showed that excess bed days can be reduced by 30% when

the correct specialist care is available.Access to patient records across the NHS

- consideration should be given by PCTs and Ambulance Trusts to the

challenge of patient consent and clinical access to patient records across

the NHS to help the health care professional, be they GP, DSN, paramedic or

diabetologist, to administer care whilst fully informed of the patient’s history.

Effective patient referral by ambulance services

- after an acute episode of hypoglycaemia, the ambulance services

must refer the patient to the appropriate primary/secondary healthcare

professional. The ambulance services must look at both the short term

and long term management of the patient’s condition including risk

management, prevention and avoidance.

PCTs to invest in the work force

- junior doctors and nurses must be educated and trained in the

appropriate discharge procedures for patients with diabetes to avoid further

complications and possible readmission.

Integrated, multi-disciplinary teams

- closer working relationships across commissioning groups between

community health care professionals, such as podiatrists and dieticians,

and secondary care specialists, is vital to ensure that the patient receives a

comprehensive and consistent service.

“Diabetes Specialist Nurses preventing acute admission.”

At the University Hospitals of Leicester, a team of diabetes

specialists nurses positioned themselves in A&E and

intervened when a patient presented with a diabetes related

complaint, and where possible, managed to avoid admission

altogether; it was estimated that this exercise saved the

hospital £100,000. This cost saving was then extrapolated

by Diabetes UK, who estimated that this would equate to a

national saving of £100million should the project be rolled

out across the UK.

“ I am aware of [this] excellent beacon of good practice in

Leicester, which is an example that we welcome. It is an

approach that is already being taken in other parts of the

country.”

Earl Howe, Parliamentary Under-Secretary of State for Health, House of Lords (14 July 2011)


The value of sharing best practice

During the discussions of the Working Group, it became clear

that there are many examples of good working across the NHS

that are not receiving the publicity they deserve. The Group noted

that if best practice were more widely shared and adopted, the

inconsistencies in service delivery and the resulting ‘post-code

lottery’ in access to healthcare may, in some way, be addressed.

One initiative that falls under the Government’s QIPP agenda is

the NHS Atlas of Variation. In order to provide greater value to the

existing resources within the NHS, the variations in activity and

spend across the NHS need to be addressed. The Atlas maps

the variations in health spending and outcomes across England,

which in the case of diabetes care is considerable; in particular

the implementation of the nine critical tests, which make up the

Annual Review, as recommended by NICE.

These nine tests include measurements of weight, blood

pressure, smoking status, HbA1c, urinary albumin, serum

creatinine, cholesterol, and tests to assess whether the eyes

and feet have been damaged by diabetes. Treating these risk

factors reduces the development of complications, and the early

identification of complications allows patients to receive treatment

to slow the progression of heart disease, stroke, blindness – and

ultimately hospital admission.

For example, recent figures show that provision of podiatric

services is variable, and that a quarter of people with diabetes

were found to be missing out on vital foot checks. Diabetes

results in about 70 amputations a week in England, 80 per cent

of which are potentially preventable. In the National Diabetes

Audit, 19 PCTs recorded the delivery of all nine care processes in

60% of patients, whilst 2 PCTs reported delivering the complete

care bundle to less than 10% of their patients.31 The Audit also

demonstrates significant variation in rates of complications

at both the SHA and PCT level.32 In order to tackle these

inconsistencies it is imperative that where best practice exists,

with outcomes that can be quantified and evaluated, the detail is

shared.

31 National Diabetes Audit Executive Summary 2009-2010, 2011, NHS Information Centre, p.1132 National Diabetes Audit Executive Summary 2009-2010, 2011, NHS Information Centre, p.21

Sharing & adopting best practice

Overview

A bid was submitted to South Staffordshire PCT requesting

funding for a Diabetes Specialist Nurse (DSN) to work in care

homes. It is well documented that people who live in care

homes receive sub optimal care due to problems with access,

participation and a lower standard of understanding of diabetes

amongst the care home staff. It is recognised that people with

diabetes are admitted to hospital twice as often and remain in

hospital twice as long as people without diabetes. It can be seen

that by far the majority of admissions and re-admissions were

aged over 70 and many of these were from care homes.

The bid was successful and the care home project commenced

in September 2004. A district nurse applied for the job and

after 2 months of increasing her awareness of basic diabetes

management and developing skills in diabetes she began the

project with continued professional support.

Objectives

The service aims to improve the knowledge base and availability

of skills of staff in care homes by deploying a part time diabetes

specialist nurse for care homes to provide clinical leadership to

nursing home staff. Resultant improved management of diabetic

patients in nursing homes will reduce the number and duration of

diabetes related admissions.

;z To increase the knowledge base in the staff of care homes.

To allow them to gain an understanding of the reasons

underpinning the care being given.

;z To encourage the staff to develop empowerment skills

enabling residents with diabetes to continue to manage

diabetes themselves wherever possible.

;z To provide ongoing support and facilitation to both care

home staff and residents in the management of their

diabetes.

;z To identify problem areas within the diabetes management.

;z To agree goals with the person with diabetes and plan

interventions jointly wherever possible.

;z To extend skills of appropriate care home staff members in

the testing of blood sugars and giving of insulin injections.

Strategy

Second or recruit a diabetes specialist nurse for care homes

for one day a week to the project extending existing skills in

diabetes. In summary, the intervention is structured around 3

visits to the care home:

Pre-assessment visit

;z Meet with matron / care manager at the home to introduce

self and explain purpose.

;z Meet with those residents with diabetes and ask permission

to assess their diabetes with an aim of improving

management.

;z Ask residents permission to take blood samples.

;z Send letter to GP explaining purpose of visit.

;z Leave personal questionnaires with residents for completion

before 2nd visit date. Includes symptom status and their

areas of concern.

;z Request any hospital / GP notes to inform next visit.

Assessment visit

;z Where possible a small number of staff could be present

depending on individual residents consent, this allows

experiential learning to take place.

;z Go through diabetes questionnaire with resident where

appropriate.

;z Review blood test results.

Case Study 1 – Care Homes ProjectSouth Staffordshire Primary Care Trust


Outcomes

12 months before intervention12 months after intervention

(6 months real time/ 6 months projected)

Number of admissions (elective) 3 0

Number of admissions (emergency) 39 12

Number of bed days spent in hospital 236 116

TOTAL REDUCED ADMISSIONS 71.5%

TOTAL REDUCED BED DAYS 51%

3 residents had died in the 6 month period, one resident stayed for one visit of 40 days in hospital before death – this is included in the figures above*.

Cost savings

The calculation of cost savings, when looking at cost of

admissions, was impossible to determine as the cause of

admission may not be directly due to diabetes and the audit

demonstrated that diabetes is not always documented even

when present. Causes of admission were variable in this group

and often non-specific. Therefore bed days represented a more

accurate financial perspective.

Data taken from 9 care homes visited 6 months post visit:

zz 120 bed days saved = £30,600 (1 bed day = £255)

zz Proportional increase for the total 14 care homes = £47,600

zz Current cost of DSN for care homes + software assessment

tool = £10,000

SAVING PER ANNUM= £37,600

Recommendations

zz Increase DSN hours to 37.5 hours / week to fund a 2 year

secondment

zz 2 days to be spent in care homes, 3 days education,

facilitation and clinical

zz 2 days in care homes potential cost saving = £95,000

MINUS COST OF DSN = £43,000

COST SAVING PER ANNUM = £52,000

Other potential benefits as role continues to develop:

1. Increase the skills of care home staff to give insulin therefore

saving the cost of district nurse visits. These visits can be up

to 3-4 each morning to each home for insulin delivery and

again in the afternoon.

2. This development will also improve diabetes management as

insulin will be given at the correct time for the resident.

3. Allows more appropriate use of district nurse time.

4. Teaching the care home staff monitoring skills so that

changes in blood sugar levels, which could lead to admission

into hospital, are recognised early so reducing risk of

admission.

5. Begin to address those older people in care homes who are

unable to access the service.

6. Improvement in quality of life, increased ability to participate

in activities of daily living.

Achievement of NSF standards through the implementation

of the East Staffordshire Diabetes Strategy - education and

facilitation.

Contact Fiona Kirkland, Consultant Nurse for Diabetes

[email protected]

;z Assess episodes of hyper / hypoglycaemia.

;z Discuss medications, in particular insulin injections and

develop an agreeable programme on support in this area

in line with the UKCCs Scope of practice aiming for staff to

deliver insulin injections.

;z Discuss appropriateness of meal times.

;z Identify level of activity present. Presence of activity sessions

in the home.

;z Assess foot risk and individual foot care - ability to

participate in foot care.

;z Check eyes examined within the last year. Report should be

present.

;z Demonstrate aspects of care to residents and care home

staff.

Post Assessment visit

;z Compile a report for each person with diabetes visited.

Include agreed goals, how these will be worked towards and

any potential obstacles. Copy to home, resident and GP.

;z Compile an overall report to the home identifying areas of

good practice and areas for improvement.

;z Provide supporting literature.

;z Provide care pathways. These will then support care of

people newly admitted to the home who have diabetes.

After 6 months a care home study day is held to maintain

increased awareness in those homes visited.

Evaluation

June 2005

14 homes were identified by looking at the greatest numbers

of people referred to the diabetes centre from each, thereby

identifying a need. This was then followed by requests from the

homes and GPs as awareness of the project increased.

Prior to intervention:

1. Clinical outcomes are generally poor in this group

2. Chronic hypoglycaemia is common, severely affecting quality

of life

3. Admission rates are high

4. Re-admission rates are also high

Following the intervention an audit was carried out in order to

effectively measure the initiative’s impact. A list of people with

diabetes from each home was obtained. Each of these people

were visited on consent. Hospital admissions for each person

over the year previous to the visit were identified, clarified and

noted as follows:

1. Number of visits

2. Number of days spent in hospital for each visit

3. Number of elective admissions

4. Number of admissions directly due to problems with diabetes

[This information was gained from HISS data by looking into

process reports for each patient and admissions and discharge

data.]

Six months following the intervention the same patients visited

had their hospital records examined for the above criteria in the 6

months following the intervention visit.


3. To ensure all patients with diabetes in Nottingham city

are treated in line with current best practice national (i.e.

National Institute for Health and Clinical Excellence) and

local clinical guidelines.

4. To ensure that all activities are developed and implemented

in a way which improves the quality, efficiency and cost

effectiveness of care in line with national Quality, Innovation,

Productivity and Prevention (QIPP) objectives.

Strategy

A steering committee has been established with formal

partnership agreements and terms of reference to ensure

transparency. The project will be split into 4 broad phases:

1. Understanding the problem via an admissions audit;

2. Data analysis / identifying solutions;

3. Implementation of recommendations and solutions;

4. and evaluation.

Once the results of the audit are analysed and understood it will

allow us to identify areas where changes in practice and current

services could lead to a reduction in hospital admissions and

the steering committee will work collaboratively with all local

stakeholders to devise and implement these.

ImplementationPhase 1: Understanding the problem – The Admissions Audit (July 2010 – January 2011)

Patients with a diabetes related unplanned admission to

Nottingham University Hospitals sites between July 1st 2010 and

December 31st 2010 will have their treatment prior to admission

reviewed and benchmarked against best practice national and

local clinical guidelines. A specialist nurse will review the primary

and secondary care medical records of these patients and

through the use of a personalised questionnaire, patients will also

be given the opportunity to describe their own experience of the

care they received prior to admission.

Phase 2: Data Analysis – Identifying the solutions (February 2011 – April 2011)

The data collected via the audit process will be reviewed by

a multi-stakeholder expert group in order to identify common

factors (around patient management and circumstances leading

to the admission) which, if addressed could have the most

significant impact on admissions and patient outcomes. Local

guidelines and care pathways will be revised accordingly in

consultation with stakeholders across the health economy and

current service provision will be reviewed.

Phase 3: Implementation of Recommendations and solutions (May 2011 – December 2012)

Revised guidelines will be disseminated and new care pathways,

service models and services implemented. These will be

supported by a wide programme of education and support for

clinicians and other healthcare professionals working in the

community.

Phase 4: Evaluation (January 2013 – March 2013)

To evaluate the impact of any changes in practice, including

a re-audit and monitoring levels of unplanned admissions,

approximately 12 months after any necessary changes have been

implemented.

Improving the care pathway

There is significant evidence to suggest that proven care models

can reduce the incidence of: hospital admission, excess length

of stay, acute metabolic complications, diabetic foot disease and

amputation.33 However, when sharing and adopting best practice

it is important that outcomes are clearly presented and evaluated.

The Audit Commission and ACCA noted that “community and

outpatient care data is not good enough” and it is clear that

moving forward, the the quality of data collection needs to be

significantly improved.34

Cost efficient and cost effective diabetes care pathways are a

natural priority in light of the Nicholson challenge. However, the

Working Group noted that the fundamental goal must always

be the improvement of the patient experience. The following

initiatives have been identified by the Working Group as leading

the way in improving the patient care pathway, ensuring that the



person with diabetes receives the right care, at the right time in

the right place, to keep them healthy and out of hospital.

Overview

NIMROD is an innovative collaboration between NHS Nottingham

City, Nottingham University Hospitals NHS Trust, Nottingham

CitiHealth, Diabetes UK and the pharmaceutical industry. The

project is equally funded by NHS Nottingham City and the

pharmaceutical industry and is expected to run for 2 years.

NIMROD will seek to understand why the rates for diabetes

related hospital admissions in Nottingham are higher than

average and then take steps to reduce the rate/number of

avoidable admissions to hospital for people with diabetes and

diabetes related illness.

Objectives

1. To understand why rates for diabetes related hospital

admissions in Nottingham city are higher than the national

average.

2. To reduce the rate/number of avoidable admissions to

hospital for patients with diabetes and diabetes related

illness.

Case Study 2 – Tackling diabetes related emergency admissionsNIMROD: Nottingham NHS and Industry Maximising Resources and Outcomes in Diabetes

The National Diabetes Support Team’s report into improving inpatient and emergency care for people with diabetes, outlines a number of proven

‘best practice’ care models in the UK. These models are cost effective and provide value for money and should therefore for rolled out consistently

across all diabetes care pathways.

These care models are based on specialist diabetes teams commissioned to deliver an enhanced service, which can include:

zz Inpatient diabetic nurse

zz Dietetic and foot care service for high risk patients

zz Educational programmes for all staff

zz Better care pathways between the ambulance service and the specialist diabetes team

Source: National Diabetes Support Team, Improving emergency and inpatient care for people with diabetes, (2008)

The report by the Audit Commission and ACCA notes that “good decisions

cannot be made without knowing how costs will change and whether

value for money will be achieved”. As a result they have developed a

Commissioning Costing tool for PCTs to evaluate spending and to compare

with others. The tool can be found at www.audit-commission.gov.uk/

diabetescostcomparisons.


5. Individual Care Plan. Practices should prepare with the

patient an individual care plan. A comprehensive print-out of

the agreed care plan will be provided for the patient to keep.

6. Record Keeping. Practices are to maintain records

incorporating the fasting sugar levels, blood pressure and

outcomes of cardiac risk assessment.

7. Training. Each practice must ensure that all staff involved

in providing any aspect of care under this service have the

necessary training and skills to do so. Please see ‘Training

and Accreditation’ section for further details.

Contact Dr Richard Brice, GPwSI Diabetes

[email protected]

Overview

The aim of this Local Enhanced Service was to address the

physical healthcare needs of pre-diabetic patients i.e. those with

impaired glucose tolerance (IGT), impaired fasting glycaemia (IFG),

previous gestational diabetes and other relevant type 2 diabetic

patients through recognising and encouraging the development of

the necessary expertise in primary care.

The Quality and Outcomes Framework (QOF) rewards practices

for ensuring that systematic care has been provided for type 2

diabetic patients. However practices are not required to undertake

a regular review for patients identified at risk of developing

diabetes, nor does it incentivise certain critical components of

care to patients with type 2 diabetes.

The specification of this service therefore outlines a more

specialised service to be provided, beyond the scope of essential

services and QOF.

Objectives

By expanding the capacity and skills within primary care this

enhanced service aimed to:

1. Prevent diabetes in those known to be at risk, and where

prevention fails, diagnose early to prevent complications;

2. improve the quality of diabetes care provided in the

community;

3. help deliver the National Service Framework standards; and

4. promote a safe, co-ordinated shift of the delivery of care for

patients from hospital clinics to primary care services.

Strategy Basic Principles

The patient and, where appropriate, their carer should be at the

centre of care and practice staff should support them in self-

management wherever possible.

For patients with IGT, IFG and previous gestational diabetes,

specific responsibilities in delivering this agreement include:

1. The development and maintenance of a register.

Practices must produce up-to-date registers of patients who

are IGT, IFG or who have previous gestational diabetes.

2. Call and recall. Practices will ensure the systematic recall

of all IGT, IFG and previous gestational diabetic patients

using appropriate read codes.

3. Review. Practices will review all patients on the IGT and IFG

registers annually, which must include fasting sugar check,

blood pressure and cardiac risk assessment as a minimum.

Women who have had gestational diabetes and have tested

normal following delivery should be tested 1 year post-

partum and then three-yearly.

A key part of the consultation at review is to emphasise

the message from the DPP (diabetes prevention program)

that the risk of developing diabetes can be reduced by

60% simply by implementing lifestyle changes involving a

better diet and regular exercise. We believe in the positive

reinforcement that patients are “masters of their own

destiny” and they can achieve more by themselves than we

can with drugs.

4. Education of patients. Practices must include education

and lifestyle advice in the annual review.

Case Study 3 – Local Enhanced Service to target pre-diabetes in primary careNHS Eastern and Coastal Kent – Enhanced Service for Diabetes Services


•z The recruitment of Diabetes Specialist Nurses to

cover all the Clinical Commissioning Groups (CCGs)

in Berkshire West would help to support primary care

healthcare professionals in treating complex cases,

reduce variations in care provision and to reduce

inappropriate referrals onto secondary care.

•z The Up-skilling of GP’s and other healthcare

professionals; enhanced capacity of structured

educational programmes for patients [Type 1 & 2]; the

introduction of integrated care; and a dedicated helpline

are other aspects linked to enhanced diabetes nurse

specialist support.

•z Our informatics team are administering a MiQuest audit

in all the GP surgeries, to find out the total numbers of

people actually registered with a diagnosis of diabetes.

•z We are also working with NHS Diabetes and the national

NHS Health Checks team in developing a pre-diabetes

pathway.

•z Locally the Royal Berkshire NHS Foundation Trust

pathology team is trying to identify people with IGT/IFG/

pre-diabetes by proactively following up all those who

have had some type of blood test or screening but who

have not yet been registered on the diabetes registers. A

local GPwSI has been identified to champion the project

including organising road shows in each local area to

raise awareness and lead the WBDC strategy group.

Monitoring

zz Supporting CPD/training and annual validation of skills to

practice diabetes in community.

zz Monitoring the diabetes care through the local strategy

group [WBDC] which has permanent representation from a

patient and Diabetes UK.

zz Monitoring the progress of the pilot through a specialist

sub-group.

Expected Outcomes

Seamless integrated diabetes care pathway across all 4 GP

consortia with high quality, consistent care with reduced variation

in primary care, close to home with multidisciplinary support,

education and self-management.

Contact Dr Onteeru Reddy, Programme Lead – Obesity & Diabetes

[email protected]

Overview

NHS Berkshire West’s Joint Strategic Needs Assessment (JSNA)

demonstrated considerable variation in outpatient and inpatient

referrals to secondary care. The data showed that more patients

were being referred on into secondary care from smaller GP

surgeries located in areas of relative deprivation.

In Berkshire West there are lower rates of people diagnosed

with diabetes (15,517) (QOF) compared to the rates expected

(22,120), in light of a predicted rise to 29,452 by 2020. At any

one time 14% of patients in the Royal Berkshire Hospital have

diabetes, with a further 30% likely to be undiagnosed. It was

also established that whilst 57% of patients with diabetes had

reasonably good control of their condition, the remaining patients

either had poor control (23%) or poor control with complex

needs (15%), with a further 5% of patients requiring referral to

secondary care, but could be managed in primary setting.

In addition, a local GP audit and mapping exercise was used

to identify current capacity and the gaps. This looked at the

recruitment of Diabetes Specialist Nurses (DSNs), identifying

GPwSI/PwSI in each practice and looking at where extra dietetic

and education support was required.

The general consensus from the diabetes strategy group (West

Berkshire Diabetes Care Group, WBDC) and the South Central

SHA was to provide care closer to the patient’s home and to

enhance the patient experience as part of a QIPP pilot.

It was agreed that an integrated care pathway, which links

primary, intermediate and secondary care and ensures the

continuity of a personal care plan, should be established. This

was an opportunity to improve clinical outcomes and financial

efficiency; to reduce the non-elective spend in secondary care;

and help to reinvest in primary care to achieve better patient

outcomes.

Objectives

zz Keep people well and out of hospital via better diabetic

management aiming to avoid unnecessary complications.

zz To improve diabetic management in primary care, looking

to carry out more care in the community, with less hospital

outpatient attendance.

zz To improve the range and quality of care management support

in the community by providing an integrated care system

including specialist support from consultants and nurses.

StrategyPhase 1 – Moving Diabetes Out-Patients (OP) into the Community (StartedOctober 2011)

Moving out of all routine OP diabetes appointments [except

insulin pump patients, pregnant women, teenagers and young

adults] through consultant led community outreach clinics. The

savings from Phase 1 are expected to be reinvested for Phase 2.

Phase 2 – Integrating Community Diabetes Service and Primary Care Diabetes Support (Ongoing)

Phase 2 has several components;

a. Increasing the capacity of diabetes specialist nurse provision;

b. Educational review looking at upskilling GP’s and healthcare

professionals;

c. Therapeutic review looking at the way drugs, including

insulin, are prescribed for each patient;

d. Closely monitoring the provision of personalised care plans

for each patient in primary care, which links with the CQUIN

linked ThinkGlucose project in secondary care;

e. And finally agree on a consistent approach in collecting and

incorporating patient experience feedback into the project.

Case Study 4 – Integrating Community Care for Diabetes-Berkshire WestNHS Berkshire West – QIPP Pilot


Outcomes

QOF data from practices participating in the joint venture show

a 38% improvement in the percentage of patients reducing

their blood sugar glucose levels to target. There was also an

18% increase in the percentage of patients reducing their blood

pressure to target and a 53% improvement in the percentage of

patients achieving their cholesterol target.

Practices served by Integrated Diabetes Services have seen a

15% reduction in new hospital appointments, despite increasing

numbers of diabetics, and a 30% reduction in follow-up

appointments. In contrast, other practices have seen a 15%

increase in new appointments and a 1% increase in follow

ups. 16.4% of new referrals have been not seen directly, but

rather initial advice has been provided to the referrers. To

date, over 85% of practices have been accredited in diabetes

competencies.

There has been a high level of patient satisfaction with the new

organisations created to deliver diabetes care.

Lessons

zz Existing organisational structures of clear divisions into

primary and secondary care may not be suitable to deliver

the proposed government healthcare reforms for integration

of care for long term conditions. However, by GPs and

hospital doctors working together, we demonstrate that

how care for long term conditions is delivered can be

fundamentally restructured, leading to better outcomes at a

lower cost.

zz Shared patient records are a powerful method of speedy

communication between primary and secondary care

clinicians although significant information governance

barriers needed to be overcome. Such communication

is fundamental to saving costs, improving care and the

patient experience.

zz Clinical leadership in primary and secondary care is crucial

to the development of new systems of working. However,

we learnt that clinicians in primary and secondary care

may not fully recognize the different working pressures

experienced by the other clinicians. Time is needed to build

good relationships based on trust, which can then lead to

partnership working.

zz Education of healthcare professionals enables good

professional relationships to develop. This education can be

financially incentivized for practices.

zz Senior managers are key to system change. Often the

data to support the development of services is given a low

priority without senior management support. For instance,

difficulties in obtaining figures to calculate programme

budgeting accurately were helped by senior management

buy in.

Contact Dr Garry Tan

[email protected]

Overview

Without major structural changes to the commissioning and

delivery of care for long term conditions, significant financial

savings cannot be achieved. Fragmenting a patient’s care

pathway by counting and incentivising individual steps will

never be able to provide the efficient continuum of care

needed by patients with long term conditions. This initiative

has redesigned the delivery organisations for a long term

condition (diabetes) to be able to deliver a whole care

pathway for patients, including access to specialist care and

knowledge for all health care professionals and patients.

Patients with long term conditions often attend multiple

locations to see different professionals for their care because

of organizational barriers between primary, community and

secondary care. This project formed integrated multidisciplinary

teams (irrespective of traditional primary or secondary care

barriers) to ensure the patient receives a comprehensive and

consistent service.

Communication between organisations is not optimized, services

are duplicated or are missing, and this fragmentation results in

vulnerable people feeling confused and stranded between care

providers. Current care pathways are generally inefficient which

leads to poor health outcomes. As part of this project, we have

achieved a real-time, unified patient record for our patients (in

both primary and secondary care), based on the patients existing

primary care record.

Objectives

We have removed organizational boundaries and transformed

the structure and delivery of diabetes care to improve clinical

delivery and outcomes. The changes have reduced overall

costs. We have achieved this by forming two new not-for-profit

organisations, each jointly and equally owned by local GPs and

a local NHS Foundation Trust (Derby Hospitals NHS Foundation

Trust) to overcome the financial and governance barriers to

integrated diabetes care. We compared professional and

patient outcomes before and after the implementation of these

partnerships.

Strategy

Consultant clinicians and local GPs drew up a clinical pathway

and defined a diabetes model across primary and secondary

care to deliver this pathway. It included clinical governance,

integrated IT, clinical delivery in GP practices and community

settings, and financial incentives for GP care and healthcare

professional education.

We examined how such “integration” was done elsewhere.

However, it was clear that other models would not remove

traditional “perverse incentives” because the barriers between

primary and secondary care providers would remain. We

therefore developed a novel model to support the clinical

pathway which was predicated on the formation of a new

organization which would deliver diabetes care across

organizational boundaries.

We presented this model to senior management in the PBC

and acute hospital trust to gain support to establish a single

organization to deliver the care pathway. We then bid for, and

won, the contract from the PCT to deliver integrated diabetes

services for the local population in Derby City.

Case Study 5 – New Organisations for New Challenges in Long Term ConditionsDerby Primary Care Trust


Overview

Specific patients have a greatly reduced quality of life due to

severe unpredictability in their blood glucose levels. These

people are unable to prevent dangerous swings in their blood

glucose (BG) levels and suffer from debilitating hyperglycaemia

putting them at risk of admission from Diabetes Ketoacidosis

and very low BG levels. Both can result in coma and death.

Some of the people in this situation through planning,

intelligence and persistence are able to keep themselves out of

hospital by constantly thinking about what their BG levels are

and testing their BG levels up to 20 times a day.

Continuous Glucose Sensors continually measure glucose

levels. Alarms are set at pre-determined levels so that

corrections to high and low glucose levels can be made. This

can significantly improve quality of life and reduce emergency

admissions. In South Staffordshire Primary Care Trust the

Continuous Glucose Sensors are used therapeutically and so

are given to the specific patient who meets set criteria for as

long as it is required and is considered to be of benefit.

Objectives

zz Abolition of severe hypoglycaemia and its potential sequelae

zz Improved quality of life for the person concerned and their

family

zz Reduction in the requirement for ambulance services –

paramedics/A+E/Acute admission

Strategy

The criteria to identify those who were eligible for the pilot were

as follows:

1. People with type 1 diabetes.

Case Study 6 – Reducing hyperglycaemia and hospital admissions in vulnerable patientsSouth Staffordshire Primary Care Trust

2. Lack of awareness of hypoglycaemic episodes.

3. Current or previous repeated hospital admissions for

either hypoglycaemia or Diabetes Ketoacidosis (admission

frequency may have been reduced with intensive input from

specialist services).

4. Significant disruption to lifestyle due to hypoglycaemia or

Diabetes Ketoacidosis

5. Heavy reliance on NHS services, family, friends and

colleagues as they help correct and prevent hypo episodes.

6. Debilitating fear of hypoglycaemia.

7. Finger prick testing of blood sugar levels well above the

normal expected frequency (if normal is above 4 tests a day).

8. Where impact on quality of life is high despite intensification

of treatment options.

9. For use by people with diabetes who are able to offer the

commitment necessary to manage the Continuous Glucose

Sensor and so to develop those skills.

Exclusion criteria: If the person demonstrates any of these

criteria despite the necessary input and support, then cessation

of sensor use is necessary.

If the sensor has no impact on:

z the quality of life,

z number of admissions

z number of hypoglycaemic or Diabetes Ketoacidosis episodes

z safety of the individual in relation to consciousness

Results

After 6 months:

No of hypos per month No of admissions to hospitalNo of paramedic call-outs in addition to the admissions

Is there a positive return on investment

here?Patient Before CGS* After CGS Before CGS After CGS Before CGS After CGS

1 22 0 3 0 2 0 Yes

2 22 0 4 0 2 0 Yes

3 18 0 2 0 4 0 Yes

4 15 0 0 0 2 0 Yes

*Continuous Glucose Sensors (CGS)

Patient Perspective

Heather Aged 53

Type 1 Diabetes since the age of 7. She is blind and has had a

renal replacement. Heather was very frightened of hypos and

wouldn’t let herself fall asleep during the day. Heather has had

over 30 paramedic call outs in the last year, many at night.

Heather has also been admitted to hospital 12 times. After

using the Continuous Glucose Sensor for 5 months she had no

paramedic call outs, no hospital admissions and fewer hypos.

Contact Fiona Kirkland , Consultant Nurse for Diabetes

[email protected]

Annual audit of benefits of continuous glucose sensing using the Sensor:

z To determine progress and reduce inappropriate usage it is

recommended that the benefits are measured 6 monthly.

z To measure hospital admissions in the year before

intensification of treatment began and compare with number

of admissions since use of the Continuous Glucose Sensor.

z To measure the number of hypoglycaemic episodes

recorded by the Continuous Glucose Sensor since its use

commenced and determine reduced rates.

z To record the number of paramedic call-outs.

z To listen to patient experience in relation to impact on their

lifestyle and the impact also on work colleagues and family.

z To determine any improvement in sleep.

z Calculate return on investment.


Overview

Jaywick is ranked as the 3rd most deprived town in England and

Wales whilst the adjacent coastal neighbourhood of Pier Ward is

the 775th (Indices of Deprivation 2007). According to the North

East Essex Local Delivery Plan (2007) Jaywick area has a higher

than average incidence of cardio-vascular disease and low level

of skills and educational attainment. A high number of people of

working age are receiving unemployment benefits. There are a

high number of people on low incomes, a significant number of

unemployed people of working age and widespread indications of

poor physical and mental health.

During 2009, North East Essex had a slightly higher than national

incidence of diabetes at 3.9%. However, one of practices in

Jaywick had a 7.41% prevalence (2009), more than twice the

national average. Furthermore, the local diabetes service reported

poor clinic attendance for their patients from the Jaywick and Pier

Ward.

Objectives

This new initiative aimed to give extra support to people with

diabetes closer to their homes. The project, addressing the

health inequalities in Jaywick and Pier Wards, was set to run

for 18 months and its key performance indicators included the

management of blood pressure, lipids and diabetes. The initiative

involved joint working with primary and secondary care, Public

Health and local authorities. Data was collected and audited, with

a quarterly assessment of key performance indicators.

Strategy

Four practices were contacted within the designated areas and

meetings set up with either the GP or Practice Nurse. These

meetings identified the first 24 patients as meeting a criteria of

HbA1c >over 10% and those who were excluded from QOF due

to non-attendance.

A letter of introduction was sent to the identified patients asking

if they would like an appointment. The letter also indicated that

further contact would be made. Following the initial letter, 10

patients responded and contact was made. At this time, patients

already under the care of the Primary Care Diabetes Service

but who had a poor attendance record were transferred to the

outreach caseload for closer supervision.

A meeting was held with staff from the Emergency Assessment

Unit at the local Acute Hospital to decide the most effective way

to capture patients who had been admitted into hospital from the

project area and to form a weekly contact. The aim was for the

DSN to be informed of identified admissions and discharges from

the specific postcodes.

Patients were also screened using the interrogation of the

PARR++ tool to identify those who have had frequent admissions

to hospital for diabetes. Cross-functional working with other

community agencies enabled the sharing of ideas and experience

of the best ways to engage with the hard-to-reach patients.

Clinics within a local Pharmacy were successful and delivered on

a weekly basis. This enabled patients to be seen closer to home

which has reduced the DNA rate for clinical appointments. Home

visits are also arranged including care homes, non-attendees and

patients who are too unwell to travel.

It was identified that the clinical management of these patients

required a high level of skill and experience. Many of the patients

are young with type 1 diabetes and had complex needs which

would not normally be managed within primary care (GP) or who

have opted out of the secondary care service. Other patients

were those with complex needs and co-morbidities such as renal

disease, mental health problems, COPD and morbid obesity.

Case Study 7 – Diabetes Inequalities Outreach ProjectClacton-on-Sea

Results

The project has had a significant impact on the local population

in terms of improved clinical outcomes and reaching people with

diabetes who previously did not use the services, thus in turn

improving the lifestyle and motivation of people to self-manage

their long term condition and reengaging with health services.

In six months, the project has resulted in:

zz Caseload 49 patients (12 months)

zz Hospital admissions reduction of 33

zz 4 admission avoidances

zz Improvements in 25 patients HbA1c (Diabetes indicator) with

an average drop of 2.2%

zz Improvements in 10 patients’ lipids results

zz 48 non-medication prescriptions initiated

zz 25 referrals to lifestyle interventions

zz 100% of patients feeling more confident in managing their

diabetes

Recommendations

The key to success was the flexibility of appointment times,

locations and home visits as well as the use of alternative

consulting rooms in pharmacies within the local area at times

convenient for the patient. Ideally appointments were made

on the same day of contact. The contact was made by an

experienced Diabetes Specialist Nurse (DSN) who was able to

work autonomously and make instant changes to medication. The

DSN had instant access to GPs, Practices Nurses and Consultants

for information and support. The patients responded well to the

continuity of care, the DSN gained the trust of individuals who

have come back in to the health care system and enabled them

to feel more confident in managing their diabetes.

Patients reported that one of the most important issues for

them was the continuity of care and that the nurse could make

decisions at the time of the appointment. The pilot project has

shown that intervention health outcomes can be positively

affected. Initially the numbers were small, with a caseload of 49

patients.

The project has now been extended across North East Essex

focusing on patients from deprived post codes who have a high

admission record due to diabetes.

Contact Sheila Smyth, Diabetes Service Manger

[email protected]


Overview

It is now well known that people with severe and enduring mental

health problems have a greater risk, than the general population,

of long-term physical health problems, including diabetes, which

can lead to increased hospitalisation and early mortality.

The need to address this problem was recognised by Birmingham

and Solihull Mental Health Foundation Trust, so not only did it

design and implement a physical health strategy, but it also

created a role to dynamically review diabetes outcomes and

related physical health problems this condition can cause. The

diabetes lead was employed within the mental health trust to

support this vulnerable group of patients in our inpatient units,

ensuring that this condition was recognised as a health and

wellbeing need, and to help support discharge.

The improved communication and enhanced ability to support

these people with their physical health led to a speedier recovery

and the prevention of long-term complications; ultimately

reducing the need for acute diabetes/cardiovascular/kidney

admissions.

Objectives

The key priority for this role was to deliver expert advice and

consultation, to include medication management and where

appropriate to prescribe to any inpatient units and home

treatment environments. This was supported by specialist advice

in the overall management of diabetes. Although there was the

ability to prescribe in the community, this was less frequently

done. Instead, close liaison with the GP or community service

were considered a better option to reduce the risk of too many

practitioners providing the same care. This role was created to

enhance support for the service user, not to replace any existing

services.

The diabetes nurse provided assurance that the staff working

with the service users were able to assess care needs, able

to develop, implement and evaluate programmes of care and

provide educational programmes for patients, families/carers and

other health professionals where needed.

The nurse operated in a self-directed mode in developing

guidance, policy and organisational needs appertaining to

diabetes care management.

Guidance included to date:

;z Development of clear referral guidelines for the most

appropriate diabetes care.

;z Development of clinical guidelines on the treatment of hypo

and hyperglycaemia supporting staff in the management

of these issues; therefore preventing unnecessary acute

hospital visits.

;z Distribution of the ‘Safe Use of Insulin’ educational pack (not

presently promoted in mental health trusts) and reducing the

risk of insulin errors.

;z Promotion of the importance of a good physical health

assessment, identifying vital risk factors.

The strategy was also to establish a diabetes network across

secondary, primary and social care, identifying a range of

opportunities around community diabetes services. Providing the

initial baseline assessments of diabetes care in Birmingham and

Solihull mental health foundation trust would allow quicker access

to these services.

Case Study 8 – Preventing Admission of Vulnerable People with Mental Health Problems Birmingham and Solihull Mental Health Foundation Trust

Strategy

The implementation of an expert practitioner supported the

delivery of care with access to improved community services for

people with severe mental health problems.

Having the knowledge of local diabetes, cardiac and lipid services

ensured prompt referral to appropriate services reducing the need

for reactive hospitalisation in emergency situations.

Additionally the local acute inpatient diabetes team had an

awareness of the additional support available to the service user

and had the ability to refer to us patients for acute follow up once

they were discharged; especially those discharged to one of our

inpatient mental health units.

The baseline of staff knowledge and understanding supported

an educational package to be produced for mental health

practitioners. The package varies for the individual teams’

needs ranging from supporting the Consultant Psychiatrists and

pharmacists to the registered mental health nurses and health

care assistances.

The training supported improved understanding of what care

and treatment to provide in individual situations and prevent the

service user from deteriorating in their physical health, ultimately

avoiding the need for paramedics and acute hospital admission.

The service has also included information updates on the intranet,

regular reporting on important news articles and ad hoc diabetes-

related promotion, all supporting the development of an improved

diabetes service for the service user and carer.

Results

Although only preliminary audits against NICE standard have

been commenced, the subjective evidence is starting to become

apparent.

The staff have greater confidence in the management of diabetes

and emergency admissions to A&E for glycaemia control have

been reduced. Wards are far better equipped with treatment

options and the understanding of treatments which cause

hypoglycaemia or hyperglycaemia and have improved care

planning in place for these issues.

The communication between the acute hospitals in the area and

the mental health trust is progressing with acute trusts being

more confident in the care they will receive if discharged back to

our units, supporting an earlier discharge from the acute hospital

beds.

Mental health practitioners have also highlighted that since

diabetes has been more intensely managed, the ability to improve

the acute mental health conditions has also improved over and

above the norm for each individual patient.

Contact Lyndi Wiltshire, Head of Diabetes Care

[email protected]


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References

Supported by:

PCDSPrimary Care Diabetes Society

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