Summary

The Brent diabetes service worked collaboratively to meet the needs of the local population using data from the Northwest London dashboard and National Audit data. The aims were to improve uptake of structured education for newly diagnosed and ongoing people with Type 2 diabetes and injectable therapy, support care home staff, the clinical pharmacist and people with complex needs, work towards improving national three treatment targets (HbA1c, cholesterol, blood pressure), with an initial focus on HbA1c over 100 mmol/mol to get to an individualised HbA1c target while addressing health inequalities, as well as use of digital continuous glucose monitoring (CGM).

Innovation

Data from the Whole Systems Integrated Care (WSIC) dashboard identified that the national three treatment targets and structured education uptake were not met, plus delivery of injectable therapy education varied. Brent diabetes service worked with local communities in primary care, using data to engage GP practices and focusing on HbA1c over 100 mmol/mol to find an individualised HbA1c target. Ambulance callouts at weekends were greater for the frail, elderly and those with complex needs. The WSIC Dashboard data showed approximately 34,500 people living with diabetes and, of these, 13,800 with moderate to severe frailty. About 1,270 had HbA1c over 100 mmol/mol and the percentage of newly diagnosed people who attended structured education was 3.6% within 12 months. The first step was to collate people with type 2 diabetes with HbA1c over 100 mmol/mol at GP practices. The information was disseminated at a diabetes steering group meeting for the Primary Care Network (PCN). The diabetes specialist nurses (DSN) aligned PCNs with joint GP clinics to improve the three treatment targets and support GP staff. Also, focus was placed on uptake of structured education for newly diagnosed and ongoing people with type 2 diabetes, reducing did not attend (DNA) rates, and addressing variability in injectable therapy education delivered in primary care, health literacy and health inequalities. A pilot with the lead for Integrated Neighbourhood Team Development & Transformation Brent Borough Partnership used population health management tools, WSIC data and the EMIS clinical system. This enabled proactive case finding, a review of people with diabetes with complex needs with the DSN Joint GP clinics and a multidisciplinary team (MDT) meeting with other stakeholders, such as Brent Health Matters. A pilot with the Brent Borough Partnership manager and local government identified staff training needs to reduce London Ambulance Service calls and A&E visits for frail, elderly people in care homes. A care home training programme was run for 10 nursing homes, eight residential homes and 37 learning disability/mental health homes. A prescribing pilot with the medicines optimisation team and ICB pharmacist (Brent Borough) developed a business case to measure the quality and cost-effectiveness of oral hypoglycaemic medication, prescribed for people living with type 2 diabetes, was changed to focus on how to improve the quality of prescribing by optimising medication use and deprescribing if not effective at GP practices. The team worked with pharmacist leads to provide education related to deprescribing for clinical pharmacists.

Equality, Diversity and Variation

MDT meetings identified specific needs as people were discussed. Health literacy issues were identified in some groups. The Integrated Neighbourhood Team Development & Transformation Brent Borough Partnership addressed health inequalities at GP practices with DSN team joint clinics. Following mapping of GP practices per Hba1c, a review of 10% of people with HbA1c over 100 mmol demonstrated improved HbA1c of at least 20% reduction or achieved an individualised HbA1c target within six months. Those who did not meet the target received support from Brent Health Matters to address social needs and housing issues, which had an impact on improving their HbA1c. Joint DSN/GP/PCN clinics reviewed people and deprescribed medication where necessary, enabling ongoing cost savings.

Results

The project was carried out collaboratively with stakeholders in primary care and the diabetes service. Structured education for people newly diagnosed with type 2 diabetes increased from 3.6% to 8.2% in six months. When people were enabled to contact the service to book convenient dates, DNA rates improved, reducing from 55% to 7.3%. People on injectable therapy education improved compliance to self-managing and reduced risks related to hypoglycaemia and hypoglycaemia. Also, the use of CGM enabled people to improve their target time in range. Structured education workshops included patient representation and feedback was used to plan and implement changes. Prescribing team and care home staff feedback was positive. An audit on maximising care of people with type 2 diabetes and HbA1c levels over 100 mmol/mol referred to the Central London Community Healthcare (CLCH) Brent diabetes service demonstrated that people had a 64% reduction in HbA1c (20% in three months and 80% in six months, with 20% not achieving a reduction in six months).

User Feedback

The stakeholders involved were pharmacist leads in primary care, NHS North West London ICB, Integrated Neighbourhood Team, Development & Transformation Brent Borough Partnership, Medicines Management Team, PCN, Brent Health Matters, Complex Patient Management Group, clinical pharmacists, care home staff, carers, GPs/practice staff, endocrinologists and allied health professionals. They collaborated to provide comprehensive diabetes care, address health inequalities, use digital CGM, improve the uptake of diabetes educational sessions while reducing DNA rates, and support care home staff with people who were frail, elderly and with complex needs. Engagement and buy-in were sought at a steering group meeting with CLCH Outer Northwest Division Brent Diabetes team by presenting the mapping of the national three treatment targets. Meetings with the PCN lead mapped a process of joint DSN clinics aligned with MDT meetings. This process enabled complex problems to be reviewed in person with clinicians. Patients were asked for feedback after the joint clinics and educational sessions. GP practice clinicians at joint DSN clinics shared updated EMIS system data. Feedback on the education sessions was obtained after each one. Carers were engaged in the development of injectable therapy sessions and fed back on CGM. The work was presented in a poster at the International Forum London 2024 and at the Transformational meeting with CLCH.