Summary
This initiative is a single integrated diabetes team across primary, community and hospital diabetes services, employed by different providers, but delivering improved patient and productivity outcomes. Camden CCG invested in value-based commissioning with one pooled programme budget across all sectors: the team is paid from a common budget, allowing savings in high cost areas such as amputations to be reinvested in prevention by having more podiatrists and better-trained staff doing diabetes foot checks. Patients decided the priorities, such as education so they could self-care, and joined-up services supported by IT. Data analytics is used to drive performance across all levels of the health economy, with demonstrable benefits in outcomes and quality of care, including a reduction in deaths due to improvements in elderly care.
Results
Patients are seen in the most appropriate setting by healthcare teams equipped with the appropriate skillset. Well-established workstreams focus on hard to reach and vulnerable groups, facilitating improved person-centred care. Operational and strategic boards meet regularly and experienced diabetes clinicians have worked with all tiers of care to support the development of care pathways and integrated care. Training needs have been identified and a dynamic portfolio of education programmes developed. A competency-based assessment process has been introduced for all clinicians involved in diabetes care. Active screening, register maintenance and accurate coding has resulted in an increased prevalence of diabetes across Camden, with over 600 new cases identified in the last 12 months.
Challenge
The young population of Camden in North London presents a significant opportunity for prevention of ill health as people under 40 are unlikely to have developed many of the complications of diabetes that are the leading cause of death and disability. Camden also has a large minority ethnic population with particularly high proportions of Bangladeshi, Somali and African Caribbean people. Although it is among the most deprived boroughs in London, there is a gap in life expectancy which reflects big differences in wealth and deprivation across the borough. There are also lower than expected levels of diagnosed diabetes and this may reflect Camden’s relatively young population and/or undiagnosed population. A CCG-led scoping exercise found poor control of diabetes, leading to excess early complications and death, and a lack of communication, data and connectivity across services. There was also inconsistent practice amongst providers and insufficient and or inadequate pathways, and a lack of knowledge and confidence in diabetes management amongst GPs, practice nurses, ward staff and community nursing teams.
Objectives
To put in place processes so that staff from different providers work clinically and managerially across the health system to support person-centred care and best practice in primary, community and specialist settings. To improve communication and reduce variation across diabetes services in Camden, using a care planning approach with an emphasis on self-management where possible. To develop an integrated IT platform and ensure all staff have the appropriate competencies.
Solution
The existing diabetes service model was replaced with a new integrated practice unit across all tiers of care as part of a process led by a project manager. An integrated project team was set up, including representatives from the prime contractor, local CCG and multiple provider organisations. A communication strategy was developed to ensure staff remained engaged. A review of skill mix and staffing was undertaken across the IPU, and appropriate staff appointed where necessary. Two senior, highly experienced diabetes specialist nurses were allocated to work with primary care practices and community nurse teams to make a population change in patient diabetes outcomes. A training needs analysis was used to identify gaps in self-reported knowledge, confidence and skills in diabetes in primary care. An electronic diabetes template has been developed to enable care planning and reporting to be consistent and shared with patients. Various specialist workstreams, such as a Bengali diabetes patient education project team and high risk foot group, were established. All practices were incentivised to use a screening tool to identify people at high risk of diabetes or who have undiagnosed diabetes, and a process for clinical audit, outcomes reporting and service monitoring has been established.
Learnings
The secret is to be a system integrator, rather than trying to achieve it all yourself as a provider. Without having a project manager and experienced implementation team at the helm, it would have been difficult to maintain the momentum of the project due to the time constraints experience by all clinical stakeholders. A clear service specification with stated timelines, regularly reviewed at strategic and operational level is required to meet deadlines. On reflection, a task and finish group would have been very helpful in the early stages. Communication and information sharing has been crucial to achieving and maintaining staff engagement. As the new service model replaced the existing model, clear lines of responsibility, line management, accountability and clinical governance were required to ensure best practice and patient safety. Patient engagement at all stages of the project has been invaluable.
Evaluation
Data analysis from October 2013 to March 2015 demonstrates various improvements, including a 50% reduction in the total number of deaths in patients with diabetes and a 42% increase in referrals to Type 2 structured education.
