Summary

Camden in North London is diverse with a large ethnic minority population and is among the most deprived boroughs in London. It has a relatively young population and a life expectancy gap which reflects big differences in wealth and deprivation, with poor diabetes outcomes. A CCG-led scoping exercise found poor control of diabetes, leading to excess complications and death, and a lack of communication, data and connectivity across services. There was also inconsistent practice among providers, insufficient and inadequate pathways, and a lack of knowledge and confidence in diabetes management among health care professionals. Diabetes care in Camden was provided by multiple organisations. In 2015 Camden Diabetes IPU (Integrated Practice Unit) was formed, made up of multiple providers - 36 GP Practices, 2 main acute providers University College London Hospital and Royal Free Hospital, community provider service Central and North West London NHS Trust and Haverstock Health Ltd a GP Federation. The aim is to be responsible for the whole population with diabetes registered to a Camden GP aged over 18 years.

Innovation

This initiative is the first partnership model in England creating a single integrated diabetes team across primary, community and acute diabetes services delivering improved patient and productivity outcomes, with shared IT and budget.

Results

In Year 1 (2015/16) we achieved all outcomes except admissions for DKA. One of the significant improvements was reduction in unplanned admissions for hypoglycaemia: compared to 2014 it has reduced by 21 episodes by Year 1 (2015/6) and by 47 episodes in Year 2 (2016/17). 2016 was the first time that almost 900 people with diabetes in Camden completed the PROM questionnaire; this is significant as it represents approximately 10% of the Camden diabetes population. The majority of questions were answered positively by most respondents. NHS England rated Camden CCG Top performing for Diabetes as part of Improvement and Investment Framework 2016/17. In the National Diabetes Audit 2015/16 – Camden performed overall better than the rest of England –  43.5% patients achieved all 3 treatment targets, 83.8% of Practices took part. There was a significant reduction in unplanned hypo/hyper reductions. Using the average cost of £2,000 per admission, this would be a saving of £42,000 in year 1 and £94,000 in year 2.

Solution

Method

The majority of patients with diabetes are managed in primary care, therefore the focus was in supporting primary care. We implemented annual Practice Visits which included staff from the IPU - Consultant, GP lead, DSN and the staff from the practice. Data from the Local Enhanced Service (LES), QOF and National Diabetes Audit were analysed, identifying areas the practice was performing well and areas not performing well, exploring reasons why, what support required and changes could make. Also as part of visit was increasing awareness of local services, networking between primary care and specialist services. An action plan was agreed following these visits, this may include a MDT to discuss complex patients, education and training, virtual review of notes and supported join clinics. In 2015 only 10 Practices had taken up the visits as this was managed by the CCG. In 2016 the Diabetes IPU took over managing Practice Visits and 34 practices were visited. Our monthly diabetes MDT was established in 2015 and included members of the diabetes team – consultant, psychologist, Diabetes Specialist Nurses (DSN), Dietitian and Podiatrist.  This was extended in 2016 to include clinicians from the mental health service. Patients with poor diabetes control and Serious Mental Illness (SMI) are discussed within our MDT case discussions. The full clinical record which includes GP records through EMIS web are reviewed, discussed as a team and an action plan with follow-up arrangements are agreed. Some of the actions have been joint visits with mental health team and diabetes teams in either patient home or diabetes or mental health service. This joint working had helped us to understand each other’s services and who is best placed to support patient.  It has enabled us to upskilling mental health team staff to feel confident with diabetes to point that they may titrate insulin doses as per action plan. The members of the mental teams have attended our annual three-day diabetes course which included GP, PN and other diabetes related clinicians. Though joint working with the 2 Acute Trusts, resulted in the creation of an innovative system for monitoring, to improve diabetes control in people admitted to hospital.   We have baseline data on inpatient diabetes control for all patients’ diabetes that are registered with a Camden GP. This is part of a Quality Improvement initiative across the both Acute Trusts to improve inpatient diabetes control. It includes an internal audit alert system that identifies and flags to the respective diabetes teams when patient’s blood glucose control is poor. A baseline will now be established which will be used to set targets for improvement in subsequent years.

Service Improvement

Sustainability and Spread

This care model can be easily replicated. NCL Transformation Board is keen to use a similar model for LTC around VBC. Two other CCGs, Islington and Haringey are already in process of implementing a similar initiative for diabetes. Camden CCG is also rolling out a similar care model for their mental health services called the Psychosis IPU.