Summary

First Diabetes is not-for-profit organisation designed as a unique partnership between Primary and Secondary Care for the delivery of comprehensive, integrated, patient centred care for 2,500 patients with diabetes in Derby.

By bringing diabetes care services under a single budget and single clinical governance structure, it has managed to provide care closer to home in a coordinated and safe manner, resulting in improved quality of care and improved patient experience.

Resources used are within the budget that was spent on diabetes care in previous years, while outcomes have been significantly better. In addition, it has strengthened relationships across traditional NHS boundaries and influenced collaborative working for all long-term conditions. Patients were represented from the beginning and continue to be members of the clinical board, which meets monthly.

Results

Quality improvements

• Improvements in QOF targets from August 2009 to January 2011:
• 38 per cent improvement in patients achieving QOF DM 23 (per cent patients with HbA1c <7 per cent rose from 40 per cent to 55 per cent)
• 26 per cent improvement in patients achieving QOF DM 24 (per cent patients with HbA1c <8 per cent rose from 62 per cent to 79 per cent)
• 20 per cent improvement in patients achieving QOF DM 25 (per cent patients with HbA1c <9 per cent rose from 73 per cent to 87 per cent)
• 18 per cent improvement in patients achieving QOF DM 12 (BP < 145/85)
• 53 per cent improvement in patients achieving QOF DM 17 (Chol < 5mmol/L)
• Within one year of the service starting the 91 patients referred to the service with poor diabetes control had lowered their HbA1c with 39 patients having an improvement by >1 per cent. Some 73 were discharged back to their GPs
• The average uptake of retinal screening has risen from 88 per cent to 92 per cent across the five GP practices
• 22 patients were assessed by a consultant ophthalmologist with six referred for sight saving laser treatment in the first year of the service

Patient Education
First Diabetes provides education for patients throughout the whole Diabetes pathway including:

• Pre-Diabetes education to prevent patients progressing from IGT to Diabetes
• Newly Diagnosed Type 2 Diabetes education
• Group education for patients with poorly controlled Diabetes pre-insulin
• Group education for patients on Exenatide
• Group education for patients on multiple daily injections of insulin

In total over 200 patients have attended diabetes education courses.

• Nearly 1000 patients have been screened for diabetes and those newly diagnosed (14 patients) or diagnosed with pre-diabetes (16 patients) offered education
• Professional education – courses for motivational interviewing and care planning have been well attended by professionals from primary and secondary care

Feedback from HCPs and patients

“First Diabetes offers high-quality diabetes care delivered locally by a team of skilled professionals who are committed to providing a patient centered service delivering evidence based practice. They are able to offer speedy appointments for patients needing urgent intervention and to help patients achieve sensible and personally set targets to reduce the long term effects of having diabetes.”  
Dr David Disney, GP

“The FD service from Stoneleigh House is excellent. They give excellent care and advise to any patients I have sent there and have always improved the diabetic measures of control as well as helping the patient with understanding their condition. The patient satisfaction is very high. They have also helped with my own understanding of Diabetes as well as being a considerable support to our nursing team”  
Dr J Cox, GP

“Just a quick note to express my thanks to all who where involved in the IGT event last night in Borrowash. It was an informative evening and provided “some more meat” to the information Dr Bates had already given me. I am pleased to say I am heading in the right direction weight, diet wise. I hope that you are able to run more for other people and areas.”
Patient who had attended an Impaired Glucose Tolerance group meeting that evening

“Top marks for Professionalism of the team.” 
Patient

Challenge

To develop a new collaborative model of working that would provide greater benefit to patients through a more comprehensive and integrated approach to delivering diabetes care.

The new model would need to be based on the formation of a new NHS organisation. The vision was to form a community of diabetes healthcare workers who have a single budget and a single clinical governance structure enabling us to care for the patients safely and effectively.

Objectives

The objective is to provide excellent care to 2,500 patients ‘at the right place, at the right time by the right person’, to ensure that patients are able to see the most appropriate professional at the right time and move between professionals without any financial disincentive or lack of clear ownership of the patient.  The integrated IT system enables a single care record to be kept and all professionals have access to and input into this record.  Ultimately this care would deliver increased patient satisfaction through:

• Patients being seen closer to home (the clinics are largely held in the community)
• Patients having a choice of healthcare professional to see
• Better diabetes control
• Reduction in admissions due to diabetes
• Reduction in long-term complications from diabetes.

Solution

First Diabetes – a joint venture owned by both the Provider arm of the Practice Based Commissioning Consortia (First Provider Group – FPG) and by the local hospital (Derby Hospitals NHS Foundation Trust – DHFT) – was formed to deliver comprehensive, integrated, patient centred Diabetes care to 2500 diabetes patients in Derby.

First Diabetes a Company Limited by Shares jointly and equally owned by the GPs and the hospital. It provides a comprehensive, integrated, patient centred service to the 2500 patients with Diabetes from five GP practices. It was commissioned by Derby City PCT and started delivering the improved service from June 2009.

Clinical partnership was essential to the success of the joint venture. Several meetings between GPs and consultants resulted in an agreed patient pathway and the identification of which patients could be moved safely into the community and who would be seeing them in the joint diabetes clinics.

In the background considerable work was done to understand the financial consequences to the PCT, the hospital and the PBC if a joint venture between the PBC consortia and the hospital was going to be viable.  In the end it was agreed that the most appropriate way of ensuring single financial ownership of the new company was to create a Company limited by Shares in which there were two shares – one held by the PBC group of GP providers and the other by the Hospital.

Two directors were appointed and they hold the Clinical Board to account for the service specification commissioned by the PCT, the financial state of the Company and the quality of the service delivered to patients.  This new arrangement enables the formation of integrated clinical governance, integrated budget across primary and secondary care and integrated clinical pathways.

Patients were represented from the beginning and continue to be members of the Clinical Board, which meets monthly. There is also a separate Patient Board, which meets every two months to discuss how to improve the service.  There are representatives from practice nurses, diabetes nurses (both community and hospital) and dieticians as well as GPs and consultants on the Clinical Board.  This ensures good communication between First Diabetes and the GP practices.

The single IT system used by the 5 GP practices enables the service to see which patients are in need of further education or assistance with their diabetes.  It also provides an easy way of communicating between the healthcare professionals.

Learnings

• Collaboration rather than competition is essential in delivering high-quality care for patients with long term conditions
• An integrated IT system is essential in maintaining good communication between healthcare professionals and seeing quickly who would benefit from the service
• Ongoing ownership of the service is essential and needs time to continue to highlight the benefits of the service to healthcare professionals who may have joined recently and are unaware of the service
• Clear outcome measures are important in defining success and delivering an excellent service.

Evaluation

The success of the project was measured by both the improvement in the outcomes of the patients and also by the improved working relationships between Primary and Secondary Care healthcare professionals involved in delivering diabetes care.

The unified clinical governance structure was seen most clearly in regular meetings of Primary and Secondary Care staff where improvements to the service were discussed, agreed and implemented. New education groups were created and delivered.

Gaps in the service were identified and plans made to fill these. Over the last three years we have grown together as a team and overcome several hurdles including an initial lack of dietician time, developing a reporting structure (financial and clinical) and ensuring ongoing staff development.

Ultimately however our success is not just the improved patient experience and the satisfaction of the healthcare workers; it is the significant achievements that we have made in reducing the risk of long-term complication of patients with diabetes.

The improvements in QOF are higher than those achieved by comparable GP practices in Derby City PCT.  We have already seen small but significant reductions in cardiovascular outcomes, and hope to see the full effect of the service on these complications over the coming 10-15 years.