Summary
In response to the growing prevalence of type 2 diabetes in County Durham and Darlington, a new clinically-led model was developed. A collaboration between local CCGs and Acute NHS Foundation Trusts, with primary care input from local GP Federations and GP practices, the model supports the delivery of diabetes services within primary care, providing specialist resources and developing skills within the primary care workforce to support the provision of high quality patient care..
Innovation
The new County Durham and Darlington diabetes model of care is a complete system-wide transformation that aims to support the shift from hospital care to primary care services, with named specialist resources (Consultant Diabetologists, GPs with a special interest in diabetes (GPwSIs) and Diabetes Specialist Nurses (DSNs)) collaborating with groups of GP practices (based on local GP Federations) in newly formed Locality Diabetes Groups. New monitoring and reporting systems have been developed to ensure robust data collection and oversight of diabetes provision. This innovation built on elements of diabetes transformation nationally and has been implemented as a whole-system change, which we believe to be pioneering in scale and scope for any chronic disease innovation.
Results
The proportion of patients across County Durham and Darlington achieving HbA1C levels of 59mmol/mol increased from 57.0% to 62.4% between June 2016 and April 2017. We knew that better management of blood glucose reduces the number of non-elective admissions related to hypoglycaemia and hyperglycaemia, and have seen corresponding reductions in these admissions across the county. Additionally, admissions related to diabetic comorbidities have been steadily reducing over this period. The business case for the diabetes model identified ‘the cost of inaction’ at an additional £7-9 million in additional prescribing. With the timely transformation of services, the Alliance hopes to manage diabetes across the county better today, and for the future. Any savings generated from efficiencies within the system are ring-fenced for reinvestment in diabetes.
Dissemination and Sustainability
The three commissioning CCGs have committed to a five-year business model for diabetes, in recognition that consistency and stability will be vital to the success of the diabetes model in County Durham and Darlington. This provides assurance to the Alliance that diabetes is a local priority, and facilitates the space for continuous improvement and development. The County Durham and Darlington Alliance model has the potential to be replicated nationally, and indeed, close links with our regional diabetes networks have allowed sharing of good practice and learning across the North East. Strong leadership and a clear vision will be important for other areas wishing to achieve such transformation in diabetes.
Method
Local and national diabetes data was analysed to support a case for change. This highlighted significant variation between localities, and even individual GP practices in terms of diabetic control of the practice populations, and that this was not correlated with spend on diabetes prescribing. The collaboration became aware that there were elements of good diabetes practice within primary care for which there was no mechanism to share good practice. Additionally, many patients were thought to receive a lower standard of care for general diabetes management within primary care. There were no mechanisms in place to support the prevention agenda for the estimated 20,000 undiagnosed type 2 diabetics in our area, and links with health and well-being services were not formalised. The model was implemented in DDES CCG (39 GP Practices) from July 2016, phased out to North Durham CCG (30 GP Practices) from April 2017 and will commence in Darlington CCG (11 GP Practices) from July 2017. Diabetes Specialist Nurses support joint clinics with GP Practice Nurses within primary care, at appropriate frequencies (between monthly and weekly, dependent on practice size and need) to provide care for patients with new complex diabetes needs, achieving individualised targets and managing patients on new or changing therapies. Consultants/GPwSIs attend each practice on a quarterly basis to lead an MDT for a session of focused planning and review for vulnerable patient groups, and provide clinics for the most complex patients. All specialists working into the model have a role of clinical supervision, education and mentorship for practice teams, and provide telephone support out of clinic hours for practice staff. The three CCGs made additional funding available to primary care to enable them to provide enhanced diabetes levels of care, in addition to a separate training budget to facilitate each practice to support at least one designated GP/Practice Nurse diabetes lead to complete an accredited diabetes qualification. Additional opportunities for education and workforce development have been championed locally, including a standardised resource pack for practice nurses, a self-assessment tool based on the TREND career and competency framework, and access to e-learning.
