Summary
The objective was to improve diabetes outcomes across North East Essex from the bottom quartile to the top in five years. The CCG tendered the service, asking the potential new provider to propose a diabetes community-based model under an Integrated Pathway Hub Contract. The contract was to be delivered under the 2012 spend of £2m with no increase in the contract period, with 25% of the value subject to meeting key performance indicators with no exceptions. The service model implemented by Suffolk GP Federation has been clinically led, designed and delivered by the clinical team supporting Primary Care, to deliver an enhanced service therefore building a sustainable future as the demands of growing numbers of diabetes patients continue in a restricted financial environment. The innovative ‘one provider’ approach brought teams from the acute, community and primary care together to deliver as one. All services are delivered within the community/Primary Care setting leaving only the MDT antenatal, MDT vascular foot clinics and inpatients within the hospital building - although all activity remains under Suffolk GP Federation. Objectives have been met within three years.
Innovation
All service activity is managed under one contract. Services are moved out of hospital unless reliant on hospital support services - antenatal and vascular – while Primary Care were engaged through an incentive scheme (PES) supported by a DSN linked to each practice and funding to upskill staff. One team delivers all services from patient education to inpatient care, therefore closing the loop from admissions to discharge and beyond. A data capture system was implemented using NDA and QoF codes to provide monthly reports enabling a proactive approach to case management.
Results
In year one, 70% patients were discharged to Primary Care, including Type 1 patients resulting in less specialist clinics and more facilitation within practice. The referral numbers to the specialist services have continued to fall but patients are more complex. At the end of year three, 37 practices have a GP and PN with advanced training in diabetes, making it a sustainable service managing growth of diabetes. The data allows a proactive rather than reactive service identifying those patients who require intervention to improve results. A NICE-compliant foot pathway was implemented with reduction of waits from 18 weeks to 2-4 weeks. An empowered workforce has resulted in minimal turnover of staff and there has been no loss of service delivery due to sickness. A seven-day inpatient service was implemented with closed loop of follow-up within the specialist service or back to Primary Care. Reviewing patients at weekends has resulted in a reduction of length of stay. There has also been a reduction in readmission for hypo and DKA, and improvements in all three clinical outcomes: HbA1c, cholesterol and blood pressure. The service has been delivered within budget despite the increase in population and prevalence.
Solution
Method
The service has now been running for three years with year one including set-up of service structures with specific focus on further developing Primary Care to manage the change. Many Primary Care clinicians had already completed education for advanced management and insulin initiation, but it had made little difference in reported outcomes. Our aim was to make the Primary Care teams more confident and competent in managing patients by supporting them in their own environment. The PES incentive scheme was offered to the practices with the service KPIs flowed down to reduce the risk. As part of the PES, both GPs and Nurses had to engage with quarterly practice meetings with their link DSN and/or Consultant and attend quarterly leads meetings, which were half clinical and half business. Each practice has used the ‘dashboard’ clinical data capture system: real-time data is available to identify patients requiring intervention in a proactive way. The dashboard is also used for monitoring and reporting for KPIs. Year one involved months of data cleansing, coding rationalisation and alignment. We worked closely with the University of Essex to upskill staff. New pathways and SoP were implemented to support the community specialist service to ensure only appropriate patients were seen and then discharged back to Primary Care with a care plan supported by the link DSN. Specialist clinics such as pumps, young persons and complex patients were set up in community locations and delivered by specialist practitioners, Nurse, Dietitian or Consultant, often running together to enable an MDT approach. Each patient was reviewed face to face, non-face to face or virtually by the specialist team and either discharged to Primary Care with a care plan or kept within service. Year two saw the embedding of a clear focus on clinical outcomes. Consultant and DSN practice visits/virtual clinics used a proactive case finding approach to identify patients not meeting key targets and initiated a plan with follow-up. Year three focused on the diabetes foot pathway, with continued review of ongoing services. A major redesign of the foot pathway has resulted in fewer but more appropriate patients seen in the MDT foot clinics and the diabetes community podiatry clinics, with more training for primary and community care colleagues to ensure patients are being screened appropriately and have and know their risk score.
Service Improvement
Sustainability and Spread
The development of primary care has enabled a service which can cope with the growth of diabetes, look after more complex patients whilst freeing up the specialist team to support them in primary care through a range of activities. The service model can be applied to any disease area and we have been approached to support a CCG in the development of respiratory services and also work across our STP foot print to embed the model in the other two CCGs.
