Summary
Women with diabetes are 2-4 times more likely to have a baby with an abnormality and five times as likely to experience a stillbirth as women without diabetes. Effective preconception care (PCC), improves outcomes, but nationally only a third for pregnant women with diabetes access this care. To address this, Derby hospitals piloted PROCEED, a user-centred model for PCC that integrates care vertically across specialities, and horizontally across Primary and Secondary Care. After 12 months, median waiting times reduced from 13 to five weeks and the ‘did-not-attend’ rate from 18 to five per cent. The PCC rate increased to 70 per cent and the stillbirth rate fell from 6 per cent in 2009/10 to 0 per cent. Women valued the flexibility and choice, describing the service as ‘first-class’, while savings to date are £61,000.
Results
PART 1: PRECONCEPTION AWARENESS
In order to reduce the length of this section, the evaluations of the methods used to raise preconception awareness are summarised below, and discussed in detail in Appendix 2.
Group sessions
- Group sessions for young women aged 18-25 ‘Just for Girls’ were a success: 19 women attended. Just over half had failed to attend at least two hospital appointments the previous year. These sessions will continue to be part of routine practice in the Young adult clinic, and may be extended to the paediatric services to include girls 14-18 who are transitioning to the adult service.
- Postnatal pilot groups were set up with the aim of engaging those who did not access preconception care, and respond to users’ views regarding the value of shared experience. Of the 41 women invited, 33 per cent attended, however 66 per cent of these women had accessed preconception care and were not the intended target group. The feasibility of these groups is being explored, and women are individually contacted two weeks after giving birth to ascertain what level of support would be helpful for them. Women who did not access preconception care are given a outpatient appointment four months after giving birth to try to encourage them to access preconception care for future pregnancies
- South Asian women from low socio-economic backgrounds showed little interest in traditional group sessions. However a pilot was set up to assess whether women in this group with gestational diabetes would seek lifestyle advice from their community pharmacist, as they were at high risk of developing diabetes in the future. Eight out of 10 women invited attended: four returned to the pharmacist with relatives. Derby Hospitals NHS Foundation Trust is building on this and has asked by a community pharmacist who works in the area with a high number of these women to engage them through the Medicines Review and New Medication Services to give them preconception advice. This will be evaluated in six months.
Mailing of SAFER leaflets.
- 714 SAFER leaflets (Appendix 1) were mailed to women aged 18-45 with diabetes in Derby and Southern Derbyshire using the Acute Trust and Primary Care databases
- The mailing have resulted in three self-referrals to PROCEED to date
- 19 (76 per cent) recalled receiving the leaflet: a third of whom were considering pregnancy in the next few years
- 95 per cent of women receiving the leaflet were aware of the need for preconception care compared with 5 per cent who did not recall receiving the leaflet (Figure 4).
The exercise will be repeated in 3 years, with the contact information more prominently displayed.
Figure 4 Knowledge as a result of mailing SAFER leaflets.
Community pharmacists
Pharmacists were very interested in the part they could play in raising preconception awareness
One group of six pharmacies audited the advice given over six months. In the period, 25 consultations were carried out in women with diabetes of childbearing age. Eight women were considering pregnancy over the next 1-2 years. The SAFER leaflet was given to them and they were given the PROCEED contact information so that they could self-refer to the service.
Other methods of raising preconception awareness
- Professionals were targeted through update sessions
- Posters were placed in waiting areas in diabetes and retinal screening clinics
- Local papers, radio and television was used to raise preconception awareness
- Information posted on online including through the Acute Trust Twitter feed.
1.1 PROCESS Service efficiency and productivity (Figure 5)
Figure 5 shows service activity in PROCEED (red bars) compared with the last 12 months of the Secondary Care service (blue bars), which represented baseline activities.
Figure 5
Effectiveness of consultations and non- inferiority (Table 1 and Figure 6)
The performance of the new model was determined by ascertaining:
- Whether the components of the consultation that had previously been undertaken in the Secondary Care clinics were undertaken in PROCEED clinics (Table 1)
- The effectiveness of the consultation was gauged by an exit questionnaire (Appendix 3) which looked at knowledge before and after their time in PROCEED. This data was compared with data from 2008 when the knowledge of women attending for preconception care was determined using the same questionnaire (Figure 6).
| Indicator | Target | Q1 | Q2 | Q3 | Q4 |
| Discussion of risk | 100% | 100 | 100 | 95 | 100 |
| Documentation of care plan | 100% | 100 | 100 | 100 | 100 |
| Care plan achieved in six months | 100% | 80 | 75 | 75 | 92 |
| Folic acid prescribed | 100% | 100 | 100 | 100 | 100 |
| Folic acid taken | 100% | 100 | 100 | 100 | 100 |
| Medication started and stopped as planned | 100% | 100 | 100 | 100 | 100 |
Figure 6: User knowledge before and after PCC in PROCEED compared with the knowledge of women who had received PCC in 2008.
These data show that changing the service model from consultant to nurse-led, and increasing the geographical spread did not compromise the components of the consultation undertaken or the knowledge of the women. PROCEED is comparable to to the Secondary Care model in terms of empowering the user.
OUTCOMES
- At the time of presentation with pregnancy, women who accessed PCC were significantly more likely to be taking Folic Acid 5md daily and to have better glucose control compared with those who did not access PCC (Figures 7)
- Compared with those who did not attend PCC, those who had attended PCC had fewer antenatal clinic visits in the first 20 weeks of pregnancy (Figure 7) spent less time in hospital (Figure 8). Their babies were less likely to be admitted to the neonatal unit (Figure 8)
- In 2011, the percentage of women with diabetes who accessed PCC increased from 40% to 70% (Figure 9).
- The congenital abnormality rate was 4 per cent and stillbirth rate reduced from 6 per cent in 2009/10 to 0 per cent (Figure 9).
Figures 7
Figures 8
Figures 9
Challenge
Our challenge was to reduce the number of pregnancies of women with diabetes resulting in stillbirth, infant mortality and congenital defects.
Pregnancy poses additional risks for women with diabetes and their babies. Babies of women with diabetes are:
- Five times as likely to be stillborn
- Three times as likely to die in their first months of life
- Two to four times as likely to have a major congenital anomaly.
The local scenario
The local diabetes in pregnancy service covers Derby and Southern Derbyshire and serves a population of 600,000. The maternity unit handles over 6,000 deliveries a year – 35-50 of cases the mother has diabetes before pregnancy.
Until recently, in common with other centres, Derby Hospitals NHS Foundation Trust provided a multidisciplinary consultant-led Secondary Care preconception service based in an antenatal clinic setting. In 2002/3 local PPC rates and pregnancy outcomes were similar to national data. In 2006, the Trust raised awareness of the importance of PCC among women with diabetes and the professionals involved in their care. As a result of this, the PCC rate rose from 32 per cent in 2002-03 to 68 per cent in 2006-07, and the congenital abnormality rate fell from 11 per cent to 2 per cent and no stillbirths occurred.
From 2009, service capacity reduced as a result of the reconfiguration of diabetes services. Meanwhile service demand remained stable resulting in increased waiting times and an increasing numbers of women becoming pregnant while waiting to be seen. PCC rates started to fall towards baseline levels, and adverse outcomes increased; in particular, the stillbirth rate increased to 6 per cent.
There was considerable variation in the care received ranging from no care or single professional consultations to full multidisciplinary care. Certain populations were not accessing care, particularly teenagers and women from ethnic minority communities from poor socio-economic backgrounds. Furthermore, users reported difficulties accessing a hospital-based clinic and many described attending an antenatal clinic setting as stressful, particularly if they had experienced a miscarriage or were undergoing fertility treatment, contributing to the fact that 18 per cent of appointments were not attended.
The future
Clearly there was the need to redesign the preconception care service to improve capacity, and provide an equitable service that met user needs more effectively. Derby Hospitals NHS Foundation Trust considered whether it could work with specialist colleagues who are now in Primary Care and the organisations they worked for to work as a ‘team without walls’. Derby Hospitals NHS Foundation Trust was fortunate to receive 12 months funding from The Health Foundation’s SHINE programme to pilot PROCEED (Preconception Care in Diabetes in Derby/Derbyshire) the first integrated preconception service, that integrates care not just vertically across diabetes and obstetrics specialties but for the first time horizontally across the boundaries of primary and secondary care. We started the project in April 2011 and report our 12-month data.
Objectives
Derby Hospitals NHS Foundation Trust aims were to improve service quality, and save money by working in partnership with organisations across the boundaries of Primary and Secondary care through:
1. Improving effectiveness and timeliness by
- Redesign the service considering national guidance
- Raise awareness of the need for preconception care among all professionals in contact with women with diabetes as well as women with diabetes to increase the number of referrals into the service
- Increase service capacity by integrating the service across traditional boundaries of Primary and Secondary Care
- Review the adherence to management plans and targets to maximise the clinical quality of the service
- Ensure the lean delivery of the service to reduce waiting times and the total time spent in the service thus reducing the number of women entering pregnancy with suboptimal preparation.
2. Providing a person centred service and equity of care by
- Involve users in the service redesign
- Increasing choice of location – community and hospital settings, and individual or groups sessions of consultations
- Providing flexibility in the time of appointments and method of contact
- Target women from traditionally ‘hard to reach’ groups, in particular young people with diabetes and women from South Asian backgrounds from low socio-economic groups
- Reduce variation through a clearly defined clinical pathway as part of a care bundle.
3. Providing a safe service by
- Ensure all team members had the appropriate competencies as described by Skills for Health
- Compare the service with the previous Secondary Care consultant-led service
- Regular reviews of individual management plans, targets, and adverse events.
Solution
Proceed has two components:
- Raising awareness of the need for preconception care
- Providing preconception care.
PART 1. PRECONCEPTION AWARENESS
- Derby Hospitals Acute Foundation Trust targeted professionals in contact with women with diabetes of childbearing age and the women themselves. Professionals were reminded to ask women about their pregnancy plans and if they were not planning pregnancy advise them to use effective contraception
- Community pharmacists were encouraged to discuss pregnancy plans with women as part of their Medications Review service through presentations at educational meetings organised by the Local Pharmaceutical Committee
- All GP practices were sent information about preconception, user information leaflets and posters
- All women with diabetes aged 18-45 were sent an NHS Diabetes information leaflet about preconception care entitled SAFER (Appendix 1: see Resources)
- User awareness was raised through local media (television, radio and papers), as well as through pages on the Acute Trust website and Twitter.
- Specific groups were targeted who rarely accessed preconception care. Group educational sessions were organised for young women aged 18-25 and South Asian women from low socio-economic backgrounds. Group sessions were also offered to postnatal women with diabetes, so they could share their experiences, and to encourage those who did not access preconception care to do so for future pregnancies.
PART 2. PRECONCEPTION CARE
The vision behind the PROCEED model can be summarised by ‘6 Cs’
THE MODEL-VISION
The key features of PROCEED are:
- Cross-boundary integration: This service not only integrates care vertically across specialties, but for the first time horizontally across the boundaries of Primary and Secondary Care, with clinicians and managers, as well as users working together to achieve the shared vision of improving pregnancy outcomes through preconception care.
- Competent: Derby Hospitals NHS Foundation Trust utilised all specialist resources across Primary and Secondary Care irrespective of the location of the service. All team members have the appropriate competencies as described in Skills for Health and are either currently working or have worked in the diabetes obstetrics service within the last three years
- Choice. Clinics are provided in two community and one hospital-based settings. If necessary, women who work are seen during their lunch breaks and early evening. Telephone and email, as well as face-to-face consultations are undertaken
- Consistency: Consistency of information given during consultations is essential in this emotive area, and also minimises variations in care. This was achieved through close teamwork and regular case discussion.
- Continuity: All people with chronic conditions value continuity of care. In each centre undertaking PROCEED; at least two team members also work in the antenatal service. This ensures continuity of care with clinicians from preconception to the antenatal period.
- Change in consultant role: The role of the consultant physician changed from one of service delivery to one of service overview and clinical mentorship to ensure consistency and ‘lean’ delivery of the clinical pathway. She continues to review women with complex medical problems as well as undertaking an exit care plan for women, before discharging back to their usual provider. Nurse, midwife or dietician-led visits, have replaced the majority of costly consultant-led Secondary Care appointments.
PRECONCEPTION CARE: THE MODEL – CLINICAL PATHWAY (Figure 3)
Following referral, the woman has a multidisciplinary consultation with members of the diabetes and obstetrics team in a location of he choice, where she is signposted to the appropriate resources across Primary and Secondary Care to implement the care plan, which could include:
- Support to facilitate lifestyle changes such as smoking cessation and weight loss.
- Intensification of glucose control.
- Psychological support.
- A prescription of Folic Acid 5mg daily.
- Optimisation other medical problems using drugs that are safe in pregnancy.
- Advice as to how to contact the antenatal service when pregnant.
The clinical pathway and care of each woman in the service is considered at consultant-led monthly team meetings where individual targets were reviewed and inefficiencies in their journey identified and resolved. For example structured education or a trial of insulin pumps could be expedited or the user prioritised for psychological support.
Figure 3: PROCEED clinical pathway
Learnings
Any unit looking after pregnant women with diabetes will have the necessary clinical skills to undertake PROCEED. Having undertaken this transferable project, it is clear that the key challenges involve building the appropriate relationships clinically and managerially to work across traditional boundaries, changing the mind set from a traditional consultant-led service model and obtaining sign up from Acute Trust Management that may perceive the integration of services as a threat in taking away Payment by Results income. It is important for partners to share the same vision.
With this in mind Derby Hospitals NHS Foundation Trust has learnt that:
- It is essential to have support of
- All clinicians who will be part of the service including those in Primary Care
- Service leads in Diabetes and Obstetrics
- Management of the Acute Trust and Partner Organisations
- Commissioners
Derby Hospitals NHS Foundation Trust was fortunate in being to establish this support, with all its partners sharing the same vision of improving pregnancy outcomes in women with diabetes. With an increasing number of organisations moving towards integrated care models for diabetes, these issues may not be as much of a barrier as in the past. To date 11 centres have approached Derby Hospitals NHS Foundation Trust for more information with a view to adopting the model
- Centres should not underestimate the amount of work that needs to be undertaken to raise preconception awareness, which is fundamental to the success of any preconception care service
- Listen to our users: sometimes small changes can make a big difference
- Although any unit providing care for pregnant women with diabetes will be able to implement PROCEED clinically, clinicians who have previously worked in the diabetes antenatal service need to update their skills. The Derby Hospitals NHS Foundation Trust suggested that its Primary Care colleagues attend at least two antenatal clinics a year to familiarise themselves with any changes in practice
- It is essential that the consultant physician reviews the journey of individual users regularly to optimise the lean delivery of the pathway, in addition to providing clinical mentorship to ensure a safe as well as effective service
- Derby Hospitals NHS Foundation Trust found the use of regular clinical team meetings invaluable for reviewing care, allowing staff to express any concern and to implement PDSA cycle, and would recommend these as part of developing this type of service.
- A mechanism for data collection and financial evaluation should be established before starting the project. The cost of the Derby Hospitals NHS Foundation Trust database was £750, a worthwhile investment. It is easy to underestimate the importance of the financial evaluation, and support of a finance manager, and ideally a Health Economist is needed. The financial evaluation was key to producing a robust business case which facilitated the commissioning of PROCEED.
Evaluation
Evaluation processes and key performance indicators were agreed which would reflect service
- Effectiveness
- Efficiency
- Timeliness
- Equity
- Safety
Evaluation was considered in 3 streams:
- Clinical process
- Clinical outcomes, including pregnancy outcomes.
- User and staff experience.
A database was established to
- Collect clinical outcome and process data
- Produce monthly reports to facilitate PDSA cycles
- Generate letters to GPs.
Data entry forms were designed to facilitate prospective data collection in a pressured clinical environment.
The components captured are detailed in Appendix 4:
The PDSA sessions also allowed staff to feedback and therefore refine the service. Full stakeholder meetings were held three times in the 12 months, so that partner organisations could voice their opinion, and also increase the chances of commissioning the project.
