Summary

In November 2011 the community diabetes team at Portsmouth & South East Hampshire expanded to include consultant diabetologists and formed an integrated community, primary and acute care team. The aim was to increase the knowledge and skills in the management of patients with diabetes among carers and clinicians, as well as to improve communications and relationships across the healthcare community.

The new community diabetes team has gone from strength to strength; feedback from both GPs and patients has been excellent. Following a six-month review the team has met its set targets, which include the numbers of clinicians and patients educated and numbers of patients discharged from acute care.

Results

When the community diabetes six-month review meeting took place on April 19, 2012, the following had been achieved:

• 2,171 PWD had undertaken DESMOND training
• 227 clinicians had undertaken MERIT training
• 1,062 individual practice referrals had been seen
• 30 clinicians had undertaken ‘Conversation Map’ training
• 28 of 53 GP practices education visits had taken place or were planned.
• 602 (90 per cent) patients were discharged from Secondary Care – with a follow up appointment costing around £90. This represents an annual saving of £56,000
• The reduction in new outpatient referrals since the team started worked has resulted in cost savings of £30,000
• 57 patients were transferred to Super Six clinics and 15 needed a clinic review pending discharge.

The service also runs an annual patient conference, where a range of professionals volunteers their time and expertise.

Challenge

In 2007 a community diabetes team was commissioned through Practice-based Commissioning locality managers for South East Hampshire residents, to provide a mixture of patient and practice clinical support as well as targeted diabetes-related education. The impact of this initiative along with the diabetes LES was a reduction in diabetes outpatient referrals, however there were still three key issues to tackle and therefore in August 2010 Commissioning Managers along with Dr Partha Kar Consultant Diabetologist at Portsmouth Hospitals NHS Trust developed a proposal for change:

There were three key issues to tackle:

• Inefficiencies in the traditional pathway as long-term follow ups for people with diabetes were conducted in Secondary Care clinics
• Unacceptable variation in the quality of care in primary and community care. This was believed to be contributing to higher-than-expected rates of diabetic emergency admissions and complication rates in the local population
• The disconnect between care services, which resulted in an absence of structured care plans or duplication of effort.

The proposal was developed to resolve the care quality issues, which centred on clinician and patient knowledge. Among clinicians there was inequitable knowledge of diabetes and insulin management. In addition there was no access to prompt specialist advice regarding diabetes management. Patients were also expressing a preference for care management within the Primary Care setting and closer to home.

Drawing on evidence from the NSF for Diabetes, care was shifted from Secondary Care, and education and empowerment of clinicians and patients was pushed to the fore.

Nationally recognised education and training programmes were adopted for patients (DESMOND) and clinicians (MERIT, which meets Local Enhanced Service requirements).

In November 2011 the current diabetes community team comprised two part-time specialist nurses and a GPwSI; it has now increased to two full-time and one part-time specialist nurse, and has full-time administrative support and the input of the local consultant diabetologist team. The service is currently receives annual funding of £152,100. It has capacity for income generation through training programmes for health professionals and healthcare assistants including in care homes.

Objectives

Through integration and collaborative working between community, primary and acute clinicians the initiative aims to improve the knowledge and skills in the management of patients with diabetes, carers and clinicians and improve communications and relationships across the health community.

Specifically it aimed to:

• Reduce diabetes referrals into acute care
• Reduce diabetes admissions to Queen Alexander Hospital (QAH)
• Deliver MERIT training for 50 clinicians each year
• Deliver DESMOND training for 520 patients each year
• Deliver bespoke training to meet identified local need, eg, care homes
• Ensure regular engagement with GP practices, including planned visits from the team (including consultant diabetologist) at least twice a year (can be training sessions if required) and joint caseload review of diabetic patients
• Improve patient reported ability to self-care – 100 per cent patients seen to have personalised care plan
• Deliver seamless care for people with diabetes through complementary working relationships between primary, secondary and community care – including rapid access to specialist support by telephone and email.

The community diabetes team provides the above to all patients with diabetes who are not included in the Super Six, it was agreed these patients would continue to be managed in the Acute Clinics with Portsmouth Hospital’s NHS Trust.

The Super Six

• Pregnancy and pre-pregnancy
• Acute Type 1 diabetes
• Patients suitable for and/or using continuous subcutaneous insulin infusion
• Adolescent (non paediatric) diabetes
• Patients with diabetes and in CKD stage 3
• Patients on dialysis (renal).

Solution

Methodology: 

A change proposal was completed by commissioner and clinical commissioners (GPs) in conjunction with acute and community providers to identify the number of diabetic referrals into Portsmouth Hospital’s Trust. The proposal included the potential outcomes of the change, a cost benefit analysis and a phased approach to the project.

A business case and options appraisal were developed to gain agreement from the South East Clinical Commissioning Committee (GP-led) to ensure they were happy and engaged with the model being proposed.

Once agreement was made the communications plan was put into place and the financial and contractual arrangements finalised and on November 1, 2011 the service started.

A phased approach was agreed for implementation 

Phase 1

GP engagement was vital and began early in the pathway redesign process. Consultants and GPs, with their patients’ agreement, undertook a baseline assessment. This identified patients for discharge to Primary Care and those who would be retained by the Secondary Care team through the Super Six clinics: pregnancy, acute Type 1 diabetes, insulin pumps, adolescents, Type 1 education and renal dialysis.

A diabetologist and specialist nurse reviewed the patients identified for discharge at a series of meetings. These meetings began the process of support and engagement for practices. Through patient reviews the team identified care management issues and education requirements of clinicians in each practice. Open access arrangements for advice and support via telephone or email were put in place with clear and rapid response times. This approach promotes partnership working and joint problem solving between primary and community based clinicians and the team.

Phase 1 of the plan included closing 100 per cent of first15 Clinics in the first six months – a move that would release £120k of funding.

It was also agreed that the community diabetes service would triage all Secondary Care referrals to ensure appropriateness and return patients who were not appropriate for Secondary Care treatment back to the GP with clinical advice. This included people newly diagnosed with Type 2 diabetes.

Phase 2

Following the first six months of the extended service a review meeting was held, following which the remaining five clinics would be closed using the same process as identified in phase 1.

Learnings

The key learning point is that shifting the way care is delivered has a positive impact on the patient experience. The project has moved care closer to the patients’ homes; they no longer have to visit the hospital once or twice a year and can now see their GP or specialist diabetes nurse. This was achieved thanks to engagement from Primary Care and the support of the community diabetes nurse team and the specialist consultants from the Acute Trust.

Another key learning point is to actually reduce the contract with the acute provider, therefore releasing savings against the reduction in income and putting in place a formal contract between the acute consultants and the community provider. This also allows for a true integrated team approach when delivering the service.

GP sign-up and engagement has varied across the Hampshire area. To reduce the variance in engagement the team is taking time to support and explain fully to them how the new service will work, improve outcomes and benefit patients.

The team is now looking for other specialities where it can share this learning to revolutionise the way healthcare is provided to the local population.

Evaluation

Patient feedback is collated as an integral part of the service and is overwhelmingly positive: patients report feeling empowered and in control of their diabetes. They also said that the training is equally useful for their carers/significant others.

Clinicians and other staff across primary and secondary services are consistently positive about the relationships that have formed. Feedback reflects the value placed on gaining a rapid response to any query.  Additionally, MERIT training and update sessions are always oversubscribed.

It is also equally important for the commissioners that the community diabetes team are supported in the development of this service. Feedback from the team has been great.