london region national diabetes programme launch … · management of diabetes possible type 2...
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LONDON REGION – NATIONAL
DIABETES PROGRAMME LAUNCH
EVENT
Preventing type 2 diabetes in England
EXPECTED BENEFITS: PHE EVIDENCE
REVIEW
PHE commissioned an evidence review to assess the
effectiveness of ‘real-world’ DPPs:
• 36 included studies
• When compared with usual care:
– On average, 26% lower incidence of diabetes
– Average 1.57kg weight loss
• More intensive interventions were more effective
• 3.24kg in those that adhered to the most NICE guidance
AN EVIDENCE BASED INTERVENTION
• The NHS DPP behavioural intervention will be underpinned by
three core goals:
• Weight loss
• Achievement of dietary recommendations
• Achievement of physical activity recommendations
• The intervention will be long term, made up of at least 13
sessions, spread across a minimum of 9 months.
• Set and achieve goals and make positive changes to their
lifestyle.
• Will be available nationally on roll-out to all adults at risk of
Type 2 diabetes with referral routes through:
– Existing GP Practice registers and opportunistic case
finding
– NHS Health Checks
– Exploring Direct Recruitment
• To be eligible participants will have a blood test indicating Non-
Diabetic Hyperglycaemia within the last 12 months (HbA1c 42-
47mmol/mol (6.0%-6.4%) FPG 5.5-6.9mmol/l)
REFERRAL PATHWAY
GP NHS Health Check or opportunistic
detection
Existing cases of NDH on GP register
External provider NHS Health Check or diabetes
risk assessment
Code Non-diabetic hyperglycaemia
Informs GP and sends data
electronically
Search GP records for range of
hyperglycaemia codes
Generate list of patients for provider /
write to patients asking them to
contact provider / invite patients in for
review
Automated add patient to NDH
register
Inform individual and refer to DPP
Inform individual and refer DPP
Provider invites individual
Annual review of glycaemic status,
weight and CVD risk
Discharge to GP with final clinical data
Does not complete DPP
Progress through DPP
Completes DPP
Provider sends interim clinical data to GP
Automated entry clinical data to EPR
Provider arranges confirmatory blood
test
NHSHC Provider performs or arranges
blood tests
Provider pathway See next slide
Automated add patient to NDH
register
Signpost to NHS choices
HbA1c/FPG in NDH range Place on programme
declined
Diabetes
Referral to GP
Non-diabetic hyperglycaemia HbA1c 42-47mmol/mol (6.0%-
6.4%) FPG 5.5-6.9mmol/l
Management of Diabetes
Possible type 2 diabetes HbA1c ≥ 47mmol/mol (6.5%)
FPG ≥ 7mmol/l
Behavioural Intervention No diabetes
Annual review of glycaemic status, weight and CVD risk
Assessment by provider including
Repeat HbA1c (or FPG) test Weight and height taken
HbA1c/FPG in NDH range Place on programme accepted
Post-intervention assessment
Discharge to GP with final clinical data
Provider invites individual
Referral to DPP
Repeat blood test
• Impact analysis1 (IA) suggests if 390,000 people receive the
NHS DPP intervention over 5 years*
- Approximately £1.1bn of health benefits
- Up to 24,000 cases of Type 2 diabetes prevented or
delayed by Yr 6 (which is on average up to 115 per CCG)
- By year 12, the programme will become cost saving
• Local ROI estimates will be greater with zero intervention
costs
• Visit the new ROI calculator: https://dpp-roi-tool.shef.ac.uk/
BENEFITS AND RETURN ON INVESTMENT
*Based on medium end cost = £270, base rate effectiveness, undiscounted, excluding £10m
estimated implementation and support costs.
Reference: 1NHS England Impact Analysis of implementing NHS Diabetes Prevention Programme,
2016 to 2021 (NHS England, 2016)
NATIONAL PROCUREMENT
• NHS England ran a procurement to appoint four providers to a
national framework. This maximised NHS England's purchasing
power and enabled us to ensure fidelity to the evidence and
national scalability.
• These providers are:
– Reed Momenta
– ICS Health and Wellbeing
– Health Exchange CIC
– Ingeus UK Limited
2016/17 SITES
• Current year one
coverage
• London:
– South London
– North East (New,
TH, C&H, WF)
– Camden, Islington,
Haringey
– CWHHE
• A comprehensive evaluation is being conducted to understand
effectiveness, cost effectiveness and implementation factors
associated with success
• Externally funded evaluation:
• The Department of Health has commissioned evaluation
examining implementation in demonstrator sites and early
learning from in Year 1 undertaken by the NIHR School for
Public Health Research
• The National Institute for Health Research recently
published a call for applications for a longer term
evaluation, outcome due in the Autumn.
EVALUATION
PERFORMANCE – YEAR ONE SITES
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
Apr May Jun Jul Aug Sept
Nu
mb
ers
of
refe
rral
s
Total Referrals - Demos & NDPP YTD (cumulative)
PERFORMANCE – YEAR ONE SITES
21
151
308 390
94.8
161.2
449.2
660
59.25 100.75
280.75
412.5
0
100
200
300
400
500
600
700
Jun-16 Jul-16 Aug-16 Sep-16
In Month Uptake since Go Live for Tranche 1: First 10 Sites against 40% and 25% of Actual Referrals
Uptake Referrals_40Perc Referrals_25Perc
In total, as at the end of September, 870 people have attended
initial assessments. This represents an uptake rate of 34%.
2ND YEAR ROLL OUT
• 13 STP areas have been selected nationally for NDPP
– More areas selected in North and South regions to reflect
lower Year one coverage
• Year two NHS DPP London site:
– Barnet and Enfield
• NHSE looking to make national announcement in December
• STPs not to publicly announce they are involved in the
programme until after this
• STPs can inform internal staff in partnership organisation to work
towards mobilisation
IMPLEMENTATION – MINI COMPETITION
All sites prospectus’ due to be published 6th Dec 2016
• LHEs complete a prospectus detailing local site information
• Providers will submit bids for STPs they are interested in
being the service provider for
• LHEs will evaluate the bids against the nationally provided
evaluation framework
• Panel will include three local STP evaluators, should cover
mix of clinical, commissioning and public heath experience
• Contract will be for 2 years from April 2017
IMPLEMENTATION – DELIVERY GROUP
• The leads from each first wave site in London come together
every 6-8 weeks;
- discuss implementation
- share learning
- problem solve
- reports into London Diabetes Transformation Board
KEEPING IN TOUCH
• For more info and to sign up to our regular e-bulletin
https://www.england.nhs.uk/ndpp
• For any questions email: [email protected]
LONDON REGION – NATIONAL
DIABETES PROGRAMME LAUNCH
EVENT
Regional Event – London December 2016
NHS DIABETES PROGRAMME:
Digital Developments
NHS DIABETES PROGRAMME
Background
• The pace of innovation in digital technologies offers new opportunities to
improve patient experience, and deliver services in a more convenient and
efficient ways and reduce the burden on clinicians and service users.
• The National Diabetes Programme has initiated a digital workstream to
ensure that the programme can harness these opportunities to support its
overall objectives.
NHS DIABETES PROGRAMME
Objectives The objectives of the digital workstream are to achieve improvements in diabetes
outcomes by:
• Improving the provision of information, support and education for individuals
at risk of Type 2 diabetes and those living with both Type 1 and Type 2
diabetes.
• Identifying opportunities for digital innovations to improve self-management
and care for people living with diabetes.
• Furthering the evidence base for innovative approaches to establish the
investment case for adoption in the formal health care sector in England.
• Identifying appropriate routes to market and commissioning arrangements
for proven innovations in this field to support adoption at scale.
NHS DIABETES PROGRAMME
Current Focus
NHS DIABETES PROGRAMME
Type 2 Prevention – Aims and Objectives
• Establish real world evidence of effectiveness of digital interventions
- What potential effect do these DBCI’s have on health inequalities?
- Can any conclusions be drawn about which groups would most benefit
from the introduction of DBCI’s?
- What are the potential costs of implementation and delivery of digital
interventions?
- What lessons can be learnt (positive and negative) about how the
interventions have been implemented?
- What are the characteristics of digital interventions which appear to be
the most effective/to have the most potential?
NHS DIABETES PROGRAMME
Digital Behaviour Change Interventions for T2 Prevention –
Progress to Date
Commission Delivery and
Evaluation Partner
• Responsible for contracting with digital service providers, supporting implementation, evaluation design, supplier management and evaluation.
Identify DBCI
• Open call for digital service providers to take part in evaluation
• Assessment of digital products
Identify Geographies for
piloting
• Digital only Geographies
• Digital as choice at point of offer
• Digital offer for those that have declined F2F referral
• Procurement currently live
• Appoint Service Provider
Feb 2017
• Procurement for 3rd Party
“App Assessor” currently
live
• Expect a Call for Digital
Providers in Feb 2017
• Products assessment in
March 2017
• 3 Digital Only STP’s
identified from Yr 2 EOI
• 3 Digital as choice
identified from EOI call
• EOI requested from Yr 1 sites
NHS DIABETES PROGRAMME
Digital Behaviour Change Interventions for T2 Prevention –
Next Steps
Dialogue with local
geographies
• Communicating intent
• Establishing referral sites
• Governance arrangements
Evaluation Design and Implementation
Planning
• Evaluation Design
• Pathway Design
• Implementation Planning
Service mobilisation and live running
• Referrals Commence
• Data Collection / Qualitative Evaluation
• Interim and final findings report
• December2016 - February
2017
• February 2017- June 2017
• June 2017 - Jan 2019
NHS DIABETES PROGRAMME
Type 1 – Aims and Objectives
• Improve information provision and support for individuals
living with Type 1 diabetes
• Develop a mobile-first website which provides insight,
direction and support all in one place
• Move more T1Ds towards being fully engaged with their
condition, and more knowledgeable and active patients,
in an easy, low friction manner
NHS DIABETES PROGRAMME
• Content and discovery phase nearly complete
• Mock up (“wireframes”) developed
• Initial market sounding with developers
• Proposals for phased agile development and investment
case
Type 1 – Progress to Date
NHS DIABETES PROGRAMME
Questions
LONDON REGION – NATIONAL
DIABETES PROGRAMME LAUNCH
EVENT
30
Diabetes Treatment & Care Programme
Jeff Featherstone, Diabetes Treatment & Care Programme Manager
Treatment & Care transformation
programme
1. Improving uptake of structured education £10m
2. Improving achievement of the NICE recommended treatment targets (HbA1c, cholesterol and blood pressure) and reducing variation £17m
3. Reducing amputations by increasing availability of multidisciplinary footcare teams £8m
4. Reducing lengths of stay for inpatients with diabetes by increasing availability of diabetes inpatient specialist nurses £8m
• Good evidence to suggest that these priorities will: Have the most clinical impact Are most likely to offer the highest return on investment and be sustainable Will lead to improved outcomes for patients
Best Possible Value (BPV)
• Details subject to final confirmation before publication
• Bidding process focused on which identifying bids offer Best Possible Value in terms of Strategic Fit, Value and Risk.
• Bids should be jointly agreed between CCGs and relevant providers with single Senior Responsible Officer
• Application form asks for details of:
Analysis of reasons for local position and actions proposed, with timescales
Planned improved outcomes and expected savings
Mutual commitment to reinvest savings in sustainable services.
Structured education (1)
• Delivery of SE for patients with type 1 diabetes could deliver savings from reduced complications of :
• an estimated £440 average per person after 5 years and £1,800 after 10 years for newly diagnosed patients
• an estimated £880 average per person after 5 years and £3,600 after 10 years for the prevalent population
• Delivery of SE for patients with type 2 diabetes could deliver savings of
• an estimated £93 average per person after 5 years and £129 after 10 years for the prevalent population
• an estimated £77 average per person after 5 years and £118 after 10 years for newly diagnosed patients
Structured education (2) • Understand actual level of attendance at structured education courses-
may well be higher than reported attendance levels. (5.7% reported nationally. Actual levels may be between 15-30%
• Understand why actual structured education attendance is low and agreeing actions to tackle it. Consider:
How clinicians explain structured education to patients
Are providers incentivised to maximise attendance?
Are attendance issues different for differing populations?
Do the time and locations of offer meet patient needs
Do content and cost reflect evidence?
.
Treatment targets (1)
• Treatment target achievement associated with reduced risk of
complications
• Great deal of variation in achievement:
i) > 1 in 2 patients achieving the targets in some CCGs, <1 in 3 in
others.
ii) 40% of type 2 patients achieving targets, but only 20% of type 1.
• Estimated per patient saving (gross):
i. After 5 years, average per patient saving would be £270 due
to reduced risk of complications
ii. After 10 years, average per patient saving would be £600 due
to reduced risk of complications
Treatment targets (2) • Understand reasons for local underachievement of treatment targets
• Is underachievement focussed within specific GP practices,
populations, localities?
• Appropriate achievement of the treatment targets will vary between
different parts of local populations e.g. high elderly population, South
Asian population etc.
• What are positions of comparator CCGs? If in better position, what do
they consider to be reasons for this?
• Actions that have a clear rationale for why they are considered ones to
bring about improvement and are sustainable.
Footcare and Inpatient teams
• Estimated 57 hospital sties do not have a multidisciplinary footcare team and
54 sites do not have diabetes inpatient specialist nurses. Others have teams
but with insufficient capacity for current demand.
• Evidence suggests that, for every £5m invested in Multi-disciplinary
Footcare Teams (MDFTs) or Diabetes Inpatient Specialist Nurses
(DISNs), net savings of around £9m annually can be achieved.
• Bids for funding for footcare and inpatient teams for sites without these in
place, and expansion of capacity in existing services.
• Need to set out how teams will support other professionals also treating the
same patients to promote consistency of care and improved outcomes.
The application forms (1)
38
2 sections:
- Word – qualitative including
written descriptions of plans
and anticipated outcomes
- Excel – quantitate including
key metrics around savings
and expected improvements
in clinical outcomes
Each question clearly labels
which aspect(s) of the
evaluation framework it refers
to
The
application
forms (2)
39
Evaluation criteria: Appraisal dashboards
40
- Clinical
- Cohort size
- Clinical outcomes
- CCG IAF rating (for TT and SE) / Current services in place (for MDFTs and
DISNs)
- Patient experience
- Patient experience measures or improvement plans
- Safety / quality
- High quality service provided
- Sustainability
- Commitment to fund service after transformation funding is withdrawn
- Tracking savings
- Resources
- Per patient cost of service and non-financial costs
- Strategic
- Financial
- Replicability
- Risks – risks around implementation, relationship, targeting, inter-relationship with
other strategic plans
Overall: Must haves
41
Good bids will include details of;
• All partners (CCGs, providers, others) having mutually committed to the bid,
including to costs/savings profiles and to reinvestment of savings for
sustainability of the service developments
• An agreed Senior Responsible Officer, Clinical Lead and an Implementation
Lead across the partnership
• The proposals being in line with local priorities for diabetes e.g. priorities
within STPs
• Engagement (with clinicians, providers and patient groups) and their
support for the proposals
• Governance and oversight arrangements to oversee the delivery of the
interventions
• How participation in the National Diabetes Audit will be increased to ≥ 90%
by 2018/19
As well as the specific details of bids in each priority intervention area.
Bids for funding to improve uptake of structured education
Outcomes/Criteria Importance
(%)
Number of additional patients referred for structured education. Evidence drawn from
National Diabetes Audit. This should be expressed as per X% of population or similar. Also
collect information on current and future referral and attendance rates to support
assessment of bids.
10%
Planned improvement in CCGIAF rating for structured education 5%
Planned increased attendance at structured education and completion of course. 20%
Patient
Experience
Set out local measures of patient experience or use qualitative information about plans for
improvement.10%
Safety/quality Service adheres to NICE guidelines and quality standards. 15%
Total amount of local funding committed in each year 15%
Savings generated locally. 10%
Number of additional patients to attend annually. Total cost of service and details of any
capital requirements upon which successful delivery of the bid is reliant15%
Assessment of identification of implementation risks and mitigating actions 25%
Assessment of identification of degree of support of key partners 25%
Assessment of risk that intervention is not well targeted 25%
Assessment of degree to which inter-relationship with other strategic plans are identified
and addressed.25%
Proportion of new/additional service cost to be funded locally in 2017/18 50%
Degree to which the improvement approach can be replicated elsewhere. 50%STRATEGIC
Sustainability
Value equation
OUTCOMES
Clinical
RESOURCES
RISKS
Bids should clearly set out;
• Percentage of patients with diabetes that achieved the 3 NICE recommended treatment
targets according to the most recent NDA and the expected improvement up to 2020/21
• Understanding of the reasons why treatment targets achievement levels may be lower
than national average (40.2%) including consideration of different segments of the CCG’s
population
• The proposed intervention(s), actions to be taken and the resources required for these
• Local measures of patient experience and/or plans for improvement of patient experience
• Demonstration of how improvements will be sustainable (including whether the bid
requires ongoing funding or describes a short term intervention)
• The profile of anticipated savings and commitment to reinvest these to support long term
sustainability of the service
• Degree to which the approach could be replicated elsewhere
• Any risks to delivery which have been identified and mitigating actions
Bids for funding to enable an increase in
achievement of the 3 NICE recommended treatment
targets
Bids for funding to put in place a new or expanded
multidisciplinary foot care team (MDFT)
Bids should clearly set out;
• Whether the bid is for a new or expanded service
• Current number of patients seen by the MDFT and for each year up to 2020/21 the
planned levels of improvement in;
• Number of patients who will be seen by the MDFT
• Waiting times / accessibility for patients with major / minor foot care needs
• Number of amputations
• Describe how the proposed additional or extended MDFT function will fit into the wider
treatment pathway and interface with other services
• Provide detailed implementation plans including the resources required and the criteria
which will be used to determine which patients are seen by the MDFT
• Local measures of patient experience and/or plans for improvement of patient experience
• Demonstration of how the new/expanded service will be sustainable
• The profile of anticipated savings and commitment to reinvest these to support long term
sustainability of the service
• Any risks to delivery which have been identified and mitigating actions
Bids for funding to put in place a new or expanded
diabetes inpatient specialist nursing (DISN) service
Bids should clearly set out;
• Whether the bid is for a new or expanded service
• Average number of inpatients with diabetes that have needs that would be appropriate
for the DISN to support
• For each year up to 2020/21 set out the planned levels of improvement in average length
of stay for patients with diabetes, reduction in medication errors and reduction in
hypoglycaemic and hyperglycaemic episodes in inpatients
• Describe how the proposed additional or extended DISN function will fit into the wider
treatment pathway and interface with other services
• Provide detailed implementation plans including the resources required and the criteria
which will be used to determine which patients are seen by the DISN
• Local measures of patient experience and/or plans for improvement of patient experience
• Demonstration of how the new/expanded service will be sustainable
• The profile of anticipated savings and commitment to reinvest these to support long term
sustainability of the service
• Any risks to delivery which have been identified and mitigating actions
What to avoid when developing bids
46
• Not including all key partners – ensure you work in an appropriate group of
CCGs and providers
• Failure to ensure that the proposals address all key issues in the appraisal
dashboard
• Submitting many separate bids – an individual CCG may be part of different
partnerships covering differing priorities or providers, but should not submit
multiple bids for the same priorities and providers
• Vague responses – if you don’t have the evidence to back up your
proposals set out how you plan to get it and your best estimate
• Not demonstrating an understanding of the key issues for different parts of
the local population that affect outcomes
• Failure to demonstrate mutual commitment to the proposals across
commissioners and providers
• Failure to confirm mutual support for the cost and savings profiles and for
reinvestment of savings to sustain the improvements
Support available
National support
• Call to bid slide pack which includes;
• The scale of the opportunity for CCGs including what national modelling based
on the evidence suggests in terms of return on investment
• The background and logic models for each of the 4 interventions
• Appraisal dashboard for each of the interventions which will be used in the
assessment of the bids, including the weighting for each criteria
• Various links to supporting information such as a data dashboard which sets out
the available data by CCG to support CCGs developing bids
• A programme of webinars to support organisations developing individual bids (details
TBC)
• Regular webinars with NHS England regional clinical networks
• An email address to direct specific queries to ([email protected])
• A FAQs document to support by answering all the regularly raised questions
Clinical network support
• Support in developing individual bids
• Responding to queries from local commissioners and their partner organisations
Provisional timescales and actions
• Invitation to CCGs to submit funding bids to be issued early
December 2016.
• Funding bids to by submitted by 18 January 2017
• Bids can be by individual or groups of CCGs. Bids should be
jointly agreed with providers
• Successful bidders to be advised by end February 2017
LONDON REGION – NATIONAL
DIABETES PROGRAMME LAUNCH
EVENT
NHS National Diabetes Prevention
Programme
Healthier You- South London
Alison White Interim Programme Director – Diabetes and Stroke Prevention, Health Innovation Network
www.hin-southlondon.org @HINSouthLondon
NATIONAL DIABETES PREVENTION PROGRAMME
NATIONAL DIABETES PREVENTION PROGRAMME
The picture in South London
• Population of just under £3 million
• 430 GP Practices across the 12 boroughs
• 369 Commissioned GP practices provide NHS Health checks
• 10 out of the 12 boroughs commission a community outreach
provider for Heath Checks. 74 pharmacy providers
• Over 140 different languages. The most common non-English languages are Portuguese, Yoruba, Tamil, Polish, Punjabi, Urdu, Guajarati, Bengali, Spanish, Nepalese and Mandarin
• South London has an estimated at risk population of 275,549
NATIONAL DIABETES PREVENTION PROGRAMME
Our approach
Southwark CCG
South-west co-chair
Merton
Merton CCG/LA
Wandsworth CCG/LA
Richmond CCG/LA
Croydon CCG/LA
Kingston CCG/LA
Sutton CCG/LA
South-east co-chair
Lambeth
Lambeth CCG/LA
Southwark CCG/LA
Lewisham CCG/LA
Bexley CCG/LA
Bromley CCG/LA
Greenwich CCG/LA
London Transformation Board Regional NHSE Board
NATIONAL DIABETES PREVENTION PROGRAMME
South London at a glance
• Provider is Reed Momenta with Lloyds pharmacy as a partner
• To date, South London partners have referred over 2000 people onto the programme across 11 boroughs
• Over 28 programmes have started, with lots more planned for the new year
• Partners have localised the offer to suit their populations
• Issues are being resolved quickly and learning is shared across the partnership
NATIONAL DIABETES PREVENTION PROGRAMME
Monthly dashboards (a work in progress)
• Feeds monthly highlight report
• Risk log capture • Review of call off
numbers versus actual numbers
• To include outcome data
NATIONAL DIABETES PREVENTION PROGRAMME
Local success stories Sutton
One of the larger practices sent out 300 letters to patients identified as at risk of developing type 2 diabetes and invited them to attend an open day where they:
• Had their BMI done
• Attended an short information session where they could ask questions
• Filled out referral forms
• Had their blood tests
As a result, 96 people were referred that month.
Southwark
Southwark took the approach of sending out mailshots to their at-risk population.
• Patients received a primer text message alerting them to an important health message being sent by the practice
• Followed up with a letter informing them that they have been identified as at-risk of developing type 2 diabetes- Trial
After the first batch of texts and letters, over 150 people had called the provider, and over 50 had booked onto an individual assessment.
NATIONAL DIABETES PREVENTION PROGRAMME
Local success stories Greenwich
Using the existing local model of Patient Information Clinics, Greenwich are running their own individual assessments for their local population.
• Eligible patients are contacted and invited to a clinic
• At the clinic, they have a blood check and find out more about services for preventing diabetes
Greenwich have found that this model leads to higher quality referrals and patients are more motivated to attend the programme.
Lewisham
Lewisham identified a GP champion who engaged a number of practices to encourage them to send out mailshots inviting eligible patients.
Here the delivery team trialed two different types of mailshot.
• The standard mailshot
• A mailshot including specific demographic information and a follow up text message
The more specifically targeted mailshot leads to higher levels of engagement and an increase in referrals.
NATIONAL DIABETES PREVENTION PROGRAMME
Next steps
• Continue with successful implementation delivery mechanisms and use learning to improve patient experience
• Explore place-based outcomes for each CCG area using data collected by the national team and the provider
• Ensure sustainability of referrals
• Work closely with the provider to start embedding programmes as business-as-usual
LONDON REGION – NATIONAL
DIABETES PROGRAMME LAUNCH
EVENT
NHS Diabetes Prevention Programme
CWHHE
Ibrahim Khan
Senior Public Health Commissioning Manager
CWHHE Collaborative
• Total registered population: 1.4m
• CCGs: 5
• Local authorities: 5
• PH departments: 3
• Total GP practices: 251
Central London
Hounslow
Ealing
West London
Hammersmith & Fulham
Application Process (Jan – March 2016)
• Organisation and partnership working across CWHHE
• 99% of practices use the same clinical system (SystmOne)
Ability of standardise templates and reporting across CWHHE
• Able to demonstrate the need for NDPP i.e. Diabetes, pre-diabetes burden, BME population, areas of deprivation etc
• Non Diabetic Hyperglycaemia (NDH) register
• Out of Hospital contract incentive (managing register, annual reviews and NDPP referrals)
• Successful NHS Health Check programme
• Existing local programmes
• Readiness to refer (templates, reports, identification of eligible patients, incentive)
Pre Diabetes Prevalence
High Risk of Diabetes Register by March 2016
CCG High risk of diabetes register Uncoded high risk of diabetes
Ealing 13421 12774
Hounslow 10709 6083
West London 3101 4711
Hammersmith & Fulham 2219 3921
Central London 2205 4003
CWHHE Total 31655 31492
2 Year Programme Allocation
Central London West London H&F Hounslow Ealing Total
13% 13% 13% 25% 36%
Number of referrals 800 800 800 1538 2214 6152
Upper uptake (40%) 320 320 320 615 886 2461
Pre Mobilisation Phase (April – July 2016)
• CWHHE successful in their bid to join first wave
• Procurement process to choose the provider
• ICS (Independent Clinical Services) announced as the preferred provider in July 2016
• MoU signed between CWHHE and NHSE with H&F CCG as lead organisation
• NDPP steering group set up to meet weekly (teleconference and face to face) led by Hounslow Public Health. Attended by CCG clinical leads, PH managers, CCG managers, comms team, NHSE, provider)
• Links with CWHHE Diabetes Strategy Group
Mobilisation Phase (July – Sep 2016)
• Weekly steering group meetings
• Referral pathway a) Mass invitations
b) Face to face invitations – referrals
c) Active case findings (diabetes risk calculator, NHS Health Check)
• Invitation letter and referral form (available in SystmOne)
• SystmOne crib sheet
• Patient and health professionals leaflets (PPG coordinators engaged)
• Roll out plan (GP engagement, venues, priority areas etc)
• Communication plan
Roll Out (Sep 2016)
• Email communication to all GPs during week commencing 19th of September (led by CCG comms)
• Communication pack with leaflets sent to all practices
• Promotion and presentations at CCG federation/network meetings
• Expression of interest by GPs to conduct initial assessments at practices
• Monthly OOH dashboard
The story so far!
CCG Area Number of referrals
Central London 192
Ealing 588
Hammersmith and Fulham 194
Hounslow 739
West London 322
Total Referrals 2035
Current Position Number
Processing referral 392 Accepted invitation (awaiting IA appointment)
1059
Initial Assessment booked 324 Ready for groups 110
Booked on Group 111 Not Progressing 39
Demand management
• Staggered approach to referrals
• Monitor out of hospital contract performance
• Monitor uptake rate from referrals to initial assessment and from initial assessment to groups
• Most initial assessments in Nov/Dec, majority of groups to start after Christmas
Thank You!
Ibrahim Khan Senior Public Health Commissioning Manager
London Borough of Hounslow
LONDON REGION – NATIONAL
DIABETES PROGRAMME LAUNCH
EVENT
Alice Ehrlich
Public Health Strategist
Camden and Islington Public Health
Diabetes Prevention Programme
Progress and reflections from Camden, Islington
and Haringey
Our partnership
• Members
• Project team
– CCG commissioners x3
– Public Health
– Diabetes clinical lead in Islington
– Practice manager (early days)
Our approach
1. Developing a referral pathway
2. Using NHSE resource
*Specialist Primary Care Diabetic Service, Adult Weight Management and other
NDH= non-diabetic hyperglycaemia; RPG = Random Plasma Glucose; FPG = Fasting Plasma Glucose; (C&I)= relates to Camden and
Islington only; (I)= relates to Islington only; (H) = relates to Haringey only
Community NHS Health Check
GP NHS Health
Check Outreach
(C&I)
Outreach (H)
Pharmacy (C&I)
Other*
HbA1C test
Inform
individual and
get consent
Inform GP
HbA1C test
Inform
individual and
get consent
Add to NDH
register
Referral to DPP
HbA1c/ FPG reading HbA1c/ FPG reading
Inform
individual and
get consent
Add to NDH
register
Invite for
HbA1C test
Add to NDH
register
Inform
individual and
get consent via
text, phone or
letter (letter with
a form for self-
referral counts
as consent)
RPG test
Inform
individual and
get consent
Inform GP
Opportunistic interaction Searches
≤ 12 months > 12 months ≤ 12 months > 12 months
HbA1C test
Inform
individual and
get consent
Add to NDH
register (C&I)
Inform
individual and
get consent
Add to NDH
register (C&I)
Risk stratify
(QDiabetes)
and focus on
high risk groups
first
Our approach
Our approach
1. Developing a referral pathway
• Primary care, Community Health Checks
2. Using NHSE resource
– IT tools
– GP ‘incentive’ for invitations
3. Project planning
4. Implementation…
Our progress
• Referrals 16/17
Aug Sep Oct Nov Dec Jan Feb Mar
Target - 33 68 196 187 232 255 267
Actual 33 68 93
• Challenges
• Primary care engagement
• GP IT
• The pathway in practice
Our next steps
• Getting to ‘business as usual’
• Monitor referrals and patient journeys
• Tackle inequalities
• Practice variation
• Language
• Non-primary care referral routes
LONDON REGION – NATIONAL
DIABETES PROGRAMME LAUNCH
EVENT
NHS Diabetes Prevention Programme
NDPP East London Partnership
NDPP East London Partnership Demographics headlines:
• 866,595 18 yrs and over across the partnership
• 183 GP practices
• All 4 boroughs have very diverse populations:
White British 17% - 38%
White Other 12% - 16%
Asian (Bangladeshi, Indian, Pakistani, other Asian) 29% -36%
Black African & Caribbean 17%-20%
The scale of the ‘Diabetes Challenge’ in NE London
Borough Diagnosed
diabetes
Undiagnosed
diabetes
Non-diabetic
hyperglycaemia
City & Hackney 12,752 2,064 20,322
Newham 21,312 2,998 28,911
Tower Hamlets 14,916 2,252 20,002
Waltham Forest 14,757 2,804 23,397
TOTAL 63,737 10,118 92,632
• 63,737 people diagnosed with Diabetes! • 10,118 estimated undiagnosed diabetes ( local intelligence
suggests this is an under estimate)
• 92,632 estimated as having non-diabetic hyperglycaemia
Referrals and uptake targets Referrals Uptake 40%
Year 1 2,191 876
Year 2 4,080 1,632
Total 6,271 2,508
• Projected Referrals in specification:
• 6,271 over 2 years
• Equates to 1-2 referrals per GP practice per month (2191/136)
• Delivery to-date:
• 337(Nov-ytd) vs 961(Sept-Dec)
Challenges encountered • Mobilisation phase (Do not under-estimate the time required ! )
• Developing relationship with the provider (included personnel changes) • Fully understanding the product being promoted • Partnership working • Engaging general practice teams • Developing and embedding an efficient system of referral
• Competing priorities • 1○ Care Access, CQC, extended services, capacity , organisational
changes , religious/holidays times
• Projected referrals • Not an exact science: attrition along each step of the referral
• Integration with existing services • Assimilation with other similar commissioned community based
services including – exercise on referral / fit for life / community prescription / health trainers / pre-diabetes sessions
• Electronic referral process • Embedded into1○ Care practice systems, search , filtering for exclusion
criteria at the initial call/re-call system-takes time, dashboard for monitoring purposes, refining !
Lessons learned to date
• Clear and consistent communication to all within the practices Cluster/network meetings, 1:1 practice support / TH developed a pack administration staff Robust materials for clinicians with evidence based references for the NDPP Local stakeholder implementation meetings (borough level) often required
• Organising incentives to generate referrals Recognising additional administration cost to be met at a practice level Ensuring it will be on the general practices agenda as many competing priorities Guaranteeing a level of referral
• Requires active engagement to follow up and motivate practice referrals
Having dedicated resources to encourage low referring practices /networks to improve
Organising a robust practice dashboard to regularly monitor the referrals being made
IT guidance and 1:1 support to ensure GP practices know how to use the referral template
• Regular engagement with the Provider
To support the promotion of the NDPP – using materials such as a brief video clip
To fully understand and keep up to date on the referral – initial assessment - group attendance and numbers of
exceptions
• Utilise a local clinical champion - “Call to action”
LONDON REGION – NATIONAL
DIABETES PROGRAMME LAUNCH
EVENT
Date
London Diabetes Clinical Network
Dr Stephen Thomas, Consultant Diabetologist Chair, London Diabetes Clinical Network
Treatment & Care programme priorities
1. Improving uptake of structured education
2. Improving achievement of the NICE recommended treatment targets (HbA1c, cholesterol and blood pressure) and reducing variation
3. Reducing amputations by increasing availability of multidisciplinary footcare teams
4. Reducing lengths of stay for inpatients with diabetes by increasing availability of diabetes inpatient specialist nurses
Priorities reflect evidence as to which interventions best improve outcomes for people with diabetes and show a positive return on investment.
Treatment & Care programme forms core of CCG IAF diabetes support offer
Recent publications…
• Type 1 Diabetes commissioning pack
• Building the right workforce for diabetes care; A toolkit for healthcare professionals
• Best practice renal foot care guidance
• Report | Living with diabetes: What support is needed?
• Infographic | Living with diabetes: What support do people want?
• Improving the management of diabetes care: A toolkit for London clinical commissioning groups
• Commissioning guidance: Foot care service for people with diabetes
• Using HbA1c for better diabetes detection
Date
Structured Education Bid
Draft bid developers - Alison White and Aileen Jackson Health Innovation Network http://www.hin-southlondon.org/
Structured Education Application Questions 1. CCGs?
2. Understanding of reasons for low uptake? ( T1 / T2 / children) - identify which specific populations and GP practices attendance low / reasons why / feedback for reasons of non-attendance / what can help?
3. Funding for Structured Education
4. Plan to improve attendance and completion of courses / accurate recording of attendance / coded reporting of attendance / link payment to attendance
5. Implementation Plan
•Initiatives you plan to put in place to increase uptake( all ages)
•How to support GPs to max attendance
•Focus – newly diagnosed or prevalent diabetes pop across all ages.
•Proposed level of increase in attendance
•Flex numbers attending?
•Plan to develop the workforce so that other clinical services not depleted
6. Specific Actions?
7. Risks – to implementation / arising from relationships / that interventions are not well targeted / interrelationships with other strategic plans
8. Financial
9. Savings/ reductions
10. Service spec for structured education?
11. Will structured education courses be nationally accredited – if so by whom? / non-nationally accredited / internally accredited? Have quality standards to meet?
12. Key learning
Diabetes Structured Education Project
/ Professional Education, Facilitation support for primary care / Mentorship and Training
Contracting , Finance and Value: Strategy, Governance and
Accountability
Outcomes Structured Education:
Inconsistent information
and engagement with patients, leading to variation in take-up
Inequality in structured education delivery for working-age population
Ad hoc provision for additional languages
What is the need/
current situation?
Provide cross-boundary opportunities to access structured education for patients to meet individual needs, leading to increase in attendance.
To design and deliver a Think Diabetes workforce initiative to improve uptake of structured education for working age adults
Outcomes
What will the project
do?
• Commissioning a structured education hub, to include: a
centralised booking system for structured education ready for
digital options, capacity to engage harder to reach patients,
self-referral, signposting to other services and information and
peer to peer support
• To agree cross-charging for structured education courses, to
enable patients to attend the right course at the right time and
in the right location (i.e. to meet personal time and location
commitments, language, cultural needs etc.)
Increased variability, accessibility and availability of Structured Education
Lack of understanding around the value of
structured education leading to low levels or poor quality of referrals.
• Design and deliver an education programme with strong
consideration given to patient-led sessions and/or e-learning
resources to include: Patient impact stories, motivational
techniques, the importance of applying standardised data
coding for referral; attended and completed, strengthening call
and recall in primary care
• Developing diabetes care navigator/champion roles to
maintain and sustain awareness of all of the above
• Commitment to evaluation for spread and adoption of good
practice
Project deliverables
Improve GP practices
knowledge and understanding of the value of structured education to increase referrals into structured education programmes.
• To focus on STP partner organisations to deliver a ‘Think
Diabetes’ initiative and review current HR policies, including:
Awareness education of the importance of employees
with diabetes attending structured education
Addressing gaps in HR policies to facilitate attendance at
structured education
• Provision of tools that can be used to spread and adopt the
‘Think Diabetes’ initiative in any workplace
Patient choice is limited to
what’s available in their place of residence.
There is spare capacity in the system
Lack of understanding in the workplace around
the importance of self-management for diabetes
Increase referrals and attendance at structured education.
Provide proof of concept for the structured education hub for CCGs to sustain
Proposal 1: Increase referrals
• Design and deliver an education programme with strong consideration given to patient-led sessions and/or e-learning resources to include:
o Patient impact stories
o Motivational techniques
o The importance of applying standardised data coding for referral; attended and completed
o Strengthening call and recall in primary care
• Developing diabetes care navigator/champion roles to maintain and sustain awareness of all of the above
• Commitment to evaluation for spread and adoption of good practice
Outcomes
• Increase in GP practice staff understanding SE/diabetes
• Increase in referrals that translate to actual attendance
• E learning resource that can be used for spread and adoption
Proposal 2: Increase attendance • To commission a structured education hub, to enable
adults and children with diabetes to attend the right course
at the right time with language and cultural options :
o A centralised booking system for structured education ready for
digital options
o Capacity to engage harder to reach patients
o Self-referral
o Structured education refreshers
o Signposting to other services and information
o Peer to peer support
o Agreement for a cross-charging for structured education courses
Outcomes
o increased referrals and attendance at structured education
o Opportunity for the evaluation of patients to include treatment
targets/structured education choice
o Evaluation of outcomes between different types of structured
education provided
o Evidence the benefits of a centralised hub
Proposal 3: to increase working age adult attendance
• To focus on STP partner organisations to deliver a ‘Think
Diabetes’ initiative and review current HR policies, to include :
o Awareness education of the importance of employees with diabetes
attending structured education ( links with proposal 1)
o Addressing gaps in HR policies to facilitate attendance at structured
education
• Outcomes o Increased number of HR policies meeting the needs of people with
diabetes to attend structured education
o Provision of tools that can be used to spread and adopt the ‘Think
Diabetes’ initiative in any workplace
Date
NHS Transformation Fund NICE Treatment targets: Lessons learned from NW London Dr Tony Willis, Clinical Lead for Diabetes, CWHHE CCG Collaborative
Treatment Targets Application Questions 1. CCGs involved
2. Current level of HbA1c / BP and Chol - treatment achievement – different cohorts – differential achievements – underachievement- why?
3. Actions Type 1:
Commissioning
Promoting improvement
Incentives and other levers
Actions focused on areas requiring improvement
Actions Type 2:
Commissioning
Promoting improvement
Incentives and other levers
Actions focused on areas requiring improvement
Children and young people: Commissioning T1
Children and young people: Commissioning T2
4. Risks
6. Savings/ reductions
7. Actions short term –/ what necessary to maintain over longer term?
8. Key learning / replicability
Outcomes Treatment Targets project:
Diabetes Treatment Targets Project
Variation: Too many
people with diabetes miss having treatment targets checked and acted upon - leading to excess early complications and death Inequality in care delivery and outcomes around treatment targets
Everyone’ s role to collect NICE treatment targets, little structural, financial or process assistance to do so.
What is the need?
Implement Dashboard (DESP IT /SCI-DC / Iridia) to ensure Programme Manager and
project managers can track achievement and report to STP leads, on variance and intervene
Expand successful London Diabetes Eye Screening Programme to collect NICE care processes
Workplace focus to build choice in NICE Care process collection
Ideas…
Prioritise delivery of improvements based on need – CCG IAF –
know results across London / variation and why / focus on case
management to improve
Highly trained staff doing non cost-effective collection of targets.
Gap between actual and predicted achievement of the NICE
Treatment Targets for diabetes
1.Dashboard of care across London
2. Integrated IT that enables identification of Targets and Outcomes 3. Focus care management on patients not achieving targets - process
Staff Education: Mentoring / coaching / educating / developing / supporting primary care deliver tier 1 and 2 well ( DSN in primary care)
Project Deliverables
Focus on areas with poorer targets (Young Londoners with T1 and T2 diabetes / men / poorer socio-economic areas
Complications could be reduced if caught early.
Improved outcomes for young people / disadvantaged
etc
Get skill-mix right – Lifestyle coaches / HCA in primary care –
foot screening / BP / education etc
Work-placed based screening – public service companies first
London wide Diabetes Programme – linked or based around DESP process
Build capacity and capability
in primary care by reducing burden of aspects of the annual review – focus on upskilling
Implement Type 1 service specification
• Reduced variation in Treatment Targets
• Bust some myths – deprivation not a significant factor 1
• Can be done….examples help (NWL, CEG, etc) 2
• Emphasise the importance of IT 3
• Collaborative working – essential (including patient) 4
Achieving NICE targets
Dia
bet
es r
egis
ter
% D
iab
etes
pre
vale
nce
Dep
riva
tio
n s
core
- IM
D20
15
% 9
key
car
e pr
oce
sses
in 1
5m
% S
tru
ctur
ed e
du
cati
on
in n
ewly
dia
gno
sed
% H
bA
1c,
BP
, Lip
ids
to t
arge
t
% H
bA
1c
≤ 58
% B
P ≤
14
0/8
0
% C
ho
l ≤ 4
393 7.7 43.0 51.7 41.2 22.6 57.3 66.2 45.5
487 4.9 42.2 54.8 72.7 17.2 59.1 63.0 35.9
268 7.8 41.4 41.8 52.9 19.4 59.0 59.7 41.4
188 7.5 41.0 55.3 66.7 13.3 48.9 73.4 31.4
277 9.7 40.1 45.5 22.2 15.5 58.1 69.3 30.3
196 3.8 38.9 23.0 19.2 12.2 46.4 55.1 34.7
204 4.8 38.4 13.2 8.3 17.2 63.2 74.5 31.4
294 6.5 38.2 43.9 10.0 14.6 52.0 50.7 38.1
471 4.9 37.8 33.1 72.9 21.2 59.2 70.1 38.2
115 4.8 37.1 56.5 44.4 20.9 43.5 73.0 53.9
226 10.1 37.0 47.3 54.5 27.0 50.9 67.3 59.7
244 6.1 35.9 34.0 5.6 14.8 48.0 64.8 35.2
287 10.0 35.8 55.4 83.3 19.5 52.6 80.1 35.5
97 4.1 35.4 55.7 28.6 23.7 53.6 68.0 43.3
97 6.0 35.3 66.0 57.1 20.6 62.9 58.8 49.5
234 4.9 35.2 48.7 77.8 20.1 60.3 59.0 47.0
159 5.5 34.8 44.0 42.9 12.6 47.8 62.3 32.7
504 4.7 34.6 33.1 5.3 17.1 50.6 67.7 34.7
88 4.3 34.1 26.1 44.4 15.9 59.1 58.0 35.2
52 1.9 32.0 65.4 42.9 11.5 59.6 57.7 42.3
444 7.5 28.0 46.6 48.4 16.9 47.5 60.8 39.6
180 2.2 27.3 14.4 16.7 22.2 63.3 65.6 37.2
176 4.4 26.7 35.2 16.7 10.8 40.9 62.5 25.0
228 5.4 26.7 68.0 66.7 23.7 61.0 69.3 43.0
338 4.8 26.4 32.0 20.0 20.7 56.8 73.7 42.6
77 1.6 25.9 31.2 37.5 15.6 59.7 55.8 29.9
253 3.2 25.4 26.5 22.2 12.6 56.9 53.8 35.6
145 5.5 25.2 32.4 0.0 15.9 51.7 69.0 33.8
304 2.8 24.5 40.1 24.4 16.4 55.9 61.2 34.5
122 3.4 24.3 40.2 0.0 9.8 49.2 54.9 27.9
109 2.2 23.6 24.8 16.7 13.8 56.0 68.8 33.0
209 2.9 21.8 30.6 52.6 24.4 62.2 78.9 41.6
358 3.5 21.7 46.6 19.4 17.9 59.8 64.2 40.5
188 1.9 21.5 44.7 26.7 20.2 60.6 67.0 35.1
230 2.6 18.5 36.1 23.5 18.3 62.2 69.1 37.0
265 3.2 16.1 43.8 12.0 14.3 51.7 64.2 32.8
128 2.8 16.0 21.9 15.4 15.6 55.5 68.0 31.3
56 3.0 15.7 39.3 0.0 17.9 42.9 66.1 37.5
145 2.3 15.6 62.1 78.9 15.2 63.4 66.2 36.6
73 2.2 15.6 27.4 0.0 16.4 56.2 52.1 32.9
291 2.8 15.1 12.0 25.0 14.1 63.9 50.9 35.1
77 2.8 14.8 6.5 0.0 18.2 50.6 61.0 28.6
180 2.4 14.8 18.9 20.0 15.6 49.4 54.4 35.0
282 2.2 14.2 49.3 33.3 19.1 62.1 70.9 35.8
73 25.2 0.0 5.5 20.0 24.7 69.9 65.8 57.5
Deprivation not a factor in NW London
Vertical axis: percentage of patients achieving target. Horizontal axis: Practice IMD(2015) score.
HbA1c
BP
Lipids
Practice achievement of key targets (ranked by index of multiple deprivation) Inter-practice variability not fully understood but likely to be a factor of various elements including administrative capacity, clinical
expertise, GP workload.
Contractual incentivisation helps mediate change at scale
SOURCE: CWHHE SystmOne
patients with collaboratively developed diabetes care plans in last year
increase in numbers of patients achieving target HbA1c of ≤58 mmol/mol since start of programme (August 2015) – largest single GP network improvement of 15.4%
patients at high risk of developing diabetes received an annual check in last year, with over 12,500 offered referral into the NDPP since 19/9/16
36,123
4.7%
15,291
• Economic impact modelling (IMPACT2, Healthy London Partnership) 1
• Some ROI within 2 years for certain aspects 2
• Contractual incentivisation helps – CCG case for change 3
• Maximise functionality of GP IT systems 4
• Dashboards essential to provide feedback and create change culture 5
• Proactive disease management for poorly controlled patients 6
• Integrated working – use community teams, virtual MDTs 7
• Systematic mental health input and use of self-management tools 8
How to get there
Bed days: part of economic modelling
for diabetes patients with angina
for patients with a myocardial infarction
for patients with heart failure
9,242
10,419
32,162
28.3% of NW London bed days are for people living with diabetes
for patients with a stroke
for patients needing renal replacement therapy
10,967
11,679
2,509 for patients undergoing amputations
NW London diabetes dashboard launching shortly. Incorporates GP, acute, community and social care data. Helps understand population health, spend and outcomes for multiple LTCs. Data shown are for illustration purposes only and are not accurate.
Population health tools important
HbA1c
BP
Cholesterol
BMI
eGFR
Urine ACR
Smoking
Foot risk
Retinal screening
Hypo monitoring
Measured To target
65%
58%
46%
Complications
MI
Stroke
Heart failure
ESRF
Amputation
List of GP practices
Functionality to compare achievement against key metrics across multiple organisations. Drill down to view individual patients not achieving targets or not engaging (dependent on legitimate relationship as care professional)
Use comparative data to drive change
Virtual MDT
Proactive disease management capability through upscaled primary care working with specialist support
Systematic risk stratification and monitoring of patients based on:
1) Current health status (e.g. poor diabetes control)
2) Engagement (attendance at clinics, PAM score)
3) Mental health barriers
4) Social barriers to health
Proactive disease management programme
Clinician Patient
Co-creation of goals
Generalism
Continuity of care
Registered population
Holistic
Coaching / Care navigators
Mental health
Specialist support
Pharmacy
Social prescribing
Key ideas are labelled
Segmentation of care example
Patient Care model
On diabetes register HbA1c controlled Engaging with services
Routine care
HbA1c off target (dependent on disease duration, frailty, etc) AND/OR Not seen in last 3-6 months AND/OR At least one diabetes related admission
Active case management: Care coordinator Regular phone support Health coaching Psychological support Virtual Multi Disciplinary Team review
May be some intermediate stages required. London SCN could create some agreed stratification groups for HbA1c targets and model of care
Importance of mental health – IAPT and psych support
Increase in risk of Type 2 diabetes for individuals exposed to adverse childhood experiences1 (abuse, violence, neglect, parental substance misuse, etc) AND a significant increase in mental health problems (including psychotic illness)2
Increased risk for all cause mortality over a 2 year period for people with diabetes and depression
Average improvement in HbA1c for patients attending the Diabetes Psychological Medicine service in Hammersmith and Fulham at 12-18 months after enrolling
37%
32%
22mmol/mol
SOURCES: 1) http://www.metabolismjournal.com/article/S0026-0495(15)00252-8/abstract 2) http://bjp.rcpsych.org/content/200/2/89
Average results for 165,000 patients participating in the free diabetes.co.uk 10 week online low carb education programme
Systematic use of simple (and free) self management tools
average reduction in waistline measurement
average weight loss
average reduction in HbA1c with around 20% reducing or stopping oral hypoglycaemic medication
10kg
9.4cm
12mmol/mol
Date
MDfT Bid – aspiring to excellence
Draft bid developers – Richard Leigh and Stella Vig
Multi-disciplinary Diabetes foot Team ( MDfT) 1. Name of provider?
2. New or expanded MDfT
3. MDfT current role – criteria / referral process / how enhances staff skills
Current funding arrangements for MDfT
4. Referral/ Assessment time for the MDfT and pathway reflect NICE recommendations
5. Service available for those at risk of developing active foot disease who don’t need MDFT – what is your Foot Protection Team service?
6. a) Gap analysis of the service change required
b) Implementation plan – expected number of staff needed
c) Reasons for considering these actions will close the gap
d) How proposal takes account of the assessment of differing needs and approaches needed to address these
e) How will work with community providers to promote foot-care outcomes
7. Current and planned make-up of MDfT?
8. Saturday and Sunday plans?
9. Recruitment and training plans? / existing employees trained up / LETBs / training arrangements confirmed / actions if delays in recruitment?
10. Risks – to implementation / arising from relationships / that interventions are not well targeted / interrelationships with other strategic plans
11. Financial
12. Patient satisfaction – how and how will improve?
13. How does this extended or improved MDfT fit into wider local diabetes pathways ( inpatient specialist nursing team / primary care) – care plan – actions taken by other professionals
14. Funding of the service over long term / Reduction in LOS and complications are reinvested- self sustaining / How CCG and provider savings will be reinvested?
15. Current service fully or partially adhere to NICE guidelines? Will it conform to this in service spec for 17/18? Peer review / internal assessment / when / formal appraisal of current service? Is assessment planned?
Diabetes Foot Programme (including MDfT)
/ Professional Education, Facilitation support for primary care / Mentorship and Training
Contracting , Finance and Value: Strategy, Governance and
Accountability
Outcomes Diabetes Foot:
MDfT ( Tier 4) in all other diabetes secondary care sites with daily feed into MDfT Tier 5 hub
Local Foot Attack Centre
24/7 access for Diabetes foot issues
What is the need?
Develop “Hot Clinics” manned by rota “Podiatrist of
the week” as part of redesigned foot pathway – Role to include ‘Pathfinder’
for STP.
Implement a Timed London Acute Foot Pathway
Implement extended networked MDfT in each STP;
linked to a Vascular hub centres
What will the
project do?
• Reduced Amputations
• Improved communication
between all parties in pathway
• Self referral throughout pathway
MDfT (Tier 5) in one STP
hub centre Central Foot Attack Centre
MDfT • Baseline of what structure is in each hospital / access
gaps in team in each hospital / Identify new staff and appoint
• Single point of advice and self referral to be in place for each Foot Attack Centre
• 7 day service needed – not just ‘go to A&E’ • Link communication across existing “MDfT” and to all
tier 4 members • Link communication across from “MDfT” to all tier 3
members • Link communication across from “MDfT” to all tier 2
and 1 members - event to launch the service so that primary care understand the pathway
• Develop the MDfT aspects of the pathway
Outcomes:
What will the project deliver?
Foot Protection Team Network for each Local Foot Attack Centre
Making the Case: Variation In CCGs All data relate to the period 1/4/2012 to 31/3/2015 Source: Hospital Episode Statistics and Quality and Outcomes Framework, Health and Social Care Information Centre
Produced by: National Cardiovascular Intelligence Network (NCVIN)
Bid Model 1 – Acute Diabetic Foot (or “where do I send this patient?”)
• To have a single point of contact in the STP footprint
• Appoint two podiatrists (plus support staff) to the single point of
contact
• Alert all HCPs to single point of contact
• Podiatrist duel role o “On call” to A & E; Assessment and Treatment (24/7 or 6 - 7 day working…?)
o Pathfinder
• Liaise on admissions with MDfT and ward
• Liaise with admission to other hospitals
• Liaise with OPD MDfT
• Liaise with discharge to community services
• Audit outcomes – robust data to ensure continuity of service
• Root Cause Analysis for each Major Amputation
Bid Model 2 – Acute Diabetic Foot (or “How to fill the gaps”)
• To remove gaps in current service within the STP footprint
• Appoint two podiatrists (plus support staff) to work across the
STP in secondary care
• Increase Resource for Hot clinics in each Local Foot Attack
Centre
• Podiatrist duel role o Community Support ensuring equality of treatment within the STP
o Pathfinder
• Work across FPTs and MDfTs to ensure equality of care
• Triage to the right MDfT facility eg vascular, renal
• Audit outcomes – robust data to ensure continuity of service
• Root Cause Analysis for each Major Amputation
Date
DISN Bid
Draft bid developer – Paul Trevatt
1. Name of provider? 2. New or existing service? 3. For existing DISN service: current role – criteria/referral process/show service enhances other
staff skills / which other prof support inpatients / current funding? 4. Does service fully or partially adhere to NICE / external or internal review 5. Future role and approach of the DISN service / analysis of staff req per year to 2021 / why this
will be sufficient / knowledge of differing cohorts / criteria for which inpatients ref to DSNs/ ref process in hospital / impact on length of stay / reduction in harms – medication errors / hypo and hyper episodes / audit and review and promote change / How service will enhance the
diabetes skills of other inpatient staff 6. Implementation plan – clinical supervision / recruitment and training of DISNs 7. Specific actions 8. Current and future make-up of diabetes inpatient specialist teams DSNs / Pods / Cons etc 9. Plans for Saturday and Sunday? 10. Finance and metrics
11. Recruitment and training plans? / existing employees trained up / LETBs / training arrangements confirmed / actions if delays in recruitment?
12. Risks – to implementation / arising from relationships / that interventions are not well targeted / inter-relationships with other strategic plans
13. Describe proposed additional or existing DISN service will support wider treatment pathway/ in care plan / follow up to be ensured
14. Funding of the service over long term / Reduction in LOS and complications are reinvested- self sustaining / How CCG and provider savings will be reinvested
15. When will service commence?
Application questions
Diabetes Inpatient Specialist Nurse (DISN) Project
/ Professional Education,
Facilitation support for
primary care / Mentorship
and Training
Contracting , Finance and
Value: Strategy, Governance
and Accountability
Outcomes, DISN:
Evidence shows that
DSNs are cost effective,
improve clinical
outcomes, and reduce
LOS in hospitals
DSNs play a key role in
supporting people to
self manage their
condition with 92%
responsible for
delivering self
management education
to people with diabetes
DSN workload has
increased considerably
in terms of patient
numbers and
complexity
What is the need?
Map the number of DSN &
DISN posts across London.
Identify areas where there
is no DISN / limited DISN
input. Link role to outputs.
Draw together different
partners, from
commissioners to clinical
network, from trusts to
academic providers to
voluntary sector.
What will the project
do?
• Additional DISNs, additional diabetes patients seen, reduction in LOS, improvement in patient experience, reduction in medication errors, reduction in hyperglycaemic / hypoglycaemic episodes, cost savings,
One in six patients
occupying a hospital
bed has diabetes
• Large scale evaluation of the DISN role
across multiple trusts by a academic
provider recognised for workforce
modelling research
• Increase DISN posts in trusts that do not
have any (NaDIA data)
• Improved patient experience
• Finical savings from reduced LOS
• Financial savings from fewer inpatient
harms
• Health benefits / QALYs
• Reduction in inpatient harms including
reduced medication errors and
hypoglycaemic events
• Reduced time requirement of diabetes
patient s on other clinical staff due to
being treated and managed by DISN
• Reduction in length of stay for patients
with diabetes
• Development of commissioning business
case for DISN post
Outcomes:
What will the project deliver?
Support a large scale
regional pilot/ evaluation
of the DISN role (form &
function) across large
and smaller London
providers – the first of is
kind. Develop a business case /
economic modelling for
commissioners on role and
value of DISN post
Regional approach
Multi-partner DISN application could involve the following sites
• Chelsea and Westminster Hospital
• Epsom and St Helier hospitals
• Queen Elizabeth Hospital
• St George’s Hospital
• University College Hospital
• West Middlesex University Hospital
• The bid would be supported by an academic partner with experience in specialist nurse evaluation.
• The bid would require a lead provider / lead CCGs to support funding / governance arrangements.
• The trusts above did not identify a DISN post (NaDIA).
• Trusts / CCGs to approve (or not).
Local bids
• Bids will be expected from individual CCGs or CCG
collaborations. These could, for example, be across
provider footprints or STP footprints.
• Bids should be developed in partnership with
providers, regardless if they are from individual or
multiple CCGs.
• Bids from multiple CCGs should set out the planned
levels of improvement at CCG level and, where
appropriate, at general practice level.
• Bids may be made with academic provider (or not).
Areas for discussion
• Identification of funding is only part of the solution
• Do we have the appropriate qualified workforce
ready to take on the role of a DISN?
• If not, should we train up / mentor / buddy / other?
• Do any models currently exist that we can implement
(London / England / elsewhere)?
• How do we recruit within London?
• How do we avoid pilot trusts recruiting from other
trusts?
• Can we learn from other CNS groups (cancer /
specialist palliative care / neurosciences)?
LONDON REGION – NATIONAL
DIABETES PROGRAMME LAUNCH
EVENT