Summary
The overall aims of the scheme were to improve collaborative care between clinical staff and patients, systems and processes of care and biological outcomes for people living with diabetes by reducing variation between practices and improving the performance of all practices. Practical tools and guidelines supported the scheme. Over the last two years, during a period of unprecedented change in the NHS, care for people with diabetes in Lambeth and Southwark improved significantly.
Results
In 2012/13 around 17% of people with diabetes had agreed a collaborative care plan with their primary care clinician. By March 2014 this had risen to more than 38%, 40% having had their care plan reviewed in the previous 12 months. Of 178 patients surveyed, those who reported having received the three minimum standards also reported being more confident in managing their condition.
The number of people with diabetes on practice registers increased by over 11% between 2011/12 and 2013/14. The number receiving all nine care processes rose by 46% between 2012/13 and 2013/14. Emergency admissions due to diabetes fell from 670 in 2011/12 to 446 in 2013/14.
Challenge
Lambeth and Southwark’s population presents with diabetes at an earlier age and at a more advanced stage than elsewhere in England. Prevalence is lower but people are living longer with diabetes.
In 2011/12, NHS Lambeth and NHS Southwark Clinical commissioning Groups (CCGs) achieved population control for HbA1c < 64mmol/mol of 67.7% and 67.8%, respectively. Despite improvements, both remained in the bottom quartile in England, and variation between practices ranged from 44% to 85%.
The Diabetes Modernisation Initiative (DMI) is a charity-funded initiative to improve diabetes-related health outcomes in Lambeth and Southwark. In early 2012, it developed a focused programme of work in primary care.
Objectives
In 2012, the DMI developed and launched a scheme in partnership with Lambeth and Southwark CCGs. Achievement was linked to a small financial reward equivalent to a maximum of £200k across both CCGs. The overall aim was to improve collaborative care between clinical staff and patients, systems and processes of care and biological outcomes for people living with diabetes, by reducing variation between practices and improving the performance of all practices.
The scheme had the following objectives: to improve patient experience; to develop and improve sustainable systems and processes; and to improve biological outcomes. It was also designed to improve effectiveness of care, reduce the burden on healthcare resources and engage and support primary care staff.
Solution
Four areas were incentivised: clinical engagement, review and development of internal systems and processes, implementing collaborative care planning, and the improvement of blood glucose, blood pressure and cholesterol population control.
All practices were supported to complete the National Diabetes Audit and a practice-level action plan. Local primary and secondary care experts designed prescribing guidelines.
Local IT searches were implemented, providing real-time feedback to clinicians and practice managers. This highlighted areas in need of urgent improvement.
Performance data was shared in a dashboard to enable practices to benchmark their performance. Eight learning events were provided to support primary care clinicians improve diabetes care. These were led by clinical champions using local cases to embed learning into everyday practice and covered local priorities such as care planning, dietetics, medicines management and dose titration.
Local diabetes champions drove improvement, developing, testing and sharing solutions and becoming ambassadors for change.
Learnings
The key learnings from this initiative included: listening to and using the patient voice; using patient advocates to provide patient feedback to practices; and being clear that the level of achievement and variation between practices is not acceptable.
We also learnt to recognise the impact of the external environment without losing focus, to develop a consistent message and to use IT to embed change and provide solutions.
We found that primary care is able to rise to an improvement challenge despite other priorities, and that local clinical champions from all care settings working together can lead change.
Finally, we leant that a few simple clear messages are more easily heard.
Evaluation
The practical guidelines, tools and IT searches that support the system of care can be adapted and adopted by other health economies. We are working with the local Academic Health Science Network/Health Innovation Network to spread this initiative across South London, and beyond.
The programme was recognised in the London Assembly report ‘Blood Sugar Rush – Diabetes Time Bomb in London’, which commended the CCGs for prioritising diabetes locally and for working together. We built links with the London Diabetes Strategic Clinical Network and are developing a website to collate key programme documents.
Results to date show that patient experience has improved through the uptake of collaborative care planning, and an increased number of people are receiving all nine care processes.
