Summary
Solihull has seen an increase in people with diabetes in the last three years of 11%, compared to the national average of 6%. In addition, diabetes has been identified by Heart of England Foundation Trust as an area where savings on current annual spend could be made. Therefore the challenge has been to effect a redesign of the diabetes pathway achieving financial efficiency while providing quality patient care in general practice. Through collaboration between commissioners, community services, primary and secondary care the team has developed a high quality service which has enhanced the skills of the Primary Health Care Team and delivered improved outcomes and satisfaction for patients but without incurring any appreciable increase in costs.
Results
Over the four months the total number of patients discussed at the MDTs was 316. At the end of the four month period 102 patients had had a post pilot HbA1c. Mean change in HbA1c was -1.3% while mean improvement in glycaemic control was -1.8%. There were also significant cost savings in terms of drugs stopped or switched.
Challenge
Solihull has a population of 240,000 and the incidence of diabetes is rising by approximately 3% per year. Diabetes is currently being looked after in primary care both in dedicated GP/Practice Nurse led clinics and in a Community Diabetes Clinic. All GP Practices are signed up to the Locally Enhanced Service although neither the provision nor the quality of this service is audited. Solihull CCG is, like many CCGS across the country, facing increased pressure from cuts in funding. An Effectiveness Review Group (ERG) was set up to review all commissioned services to achieve the financial savings required to maintain statutory requirements. The ERG identified diabetes as an area where savings could be made because of the apparent duplication of expense streams. It was also noted that there was a wide variation in the standard of diabetes management in primary care (the percentage of patients achieving an HbA1c less than 7.5% ranging from 52% to 72%) and that Solihull had a high rate of outpatient appointments for diabetic medicine (ranked 196 out of 211 CCGs). A diabetes working group was therefore set up to look at review and redesign of the whole diabetes pathway. This consisted of members from primary care, secondary care, community care and Public Health as well as Diabetes UK and patient representation. From its inception this group was clear in its desire not to sacrifice patient care in order to achieve savings. It would therefore have to come up with innovative ways to design the pathway which would keep patient outcomes paramount while also being cost effective. The collaboration which resulted has led to the development of a truly integrated diabetes pathway in Solihull, bridging the divide between secondary and primary care and incorporating the patient perspective.
Objectives
To pilot a specialist diabetes service for the population of Solihull that shifts care from hospital and community out-patient clinics to general practice without incurring major cost. To remove the barriers between primary and secondary care allowing collaborative working for the improvement of patient outcomes.
Solution
Interest was expressed by five practices to join this pilot. The diabetes leads and practice nurses met for an exploratory meeting together with the Diabetes Consultant, GP Facilitator, Community DSNs, Pharmacy lead, CCG Project Manager and Patient representative. After discussion, it was agreed that a 'virtual clinic' would take place in each practice monthly for four months. The members would form a community multidisciplinary team. Using the computer patient records the team would together formulate an action plan for each patient discussed. The duration of the pilot was dictated by the requirements of the ERG and this meant that the outcomes needed to be realistic for such a short time frame.
Learnings
Having successfully shown that this model of providing diabetes care is effective and cost efficient it is now the intent of the CCG to role out the model to all practices in Solihull. In fact six more practices have already expressed their interest in joining. The model will continue to be reviewed and it is hoped in the future to add other members to the MDTs including dieticians. By upskilling clinicians in more complex diabetes management, the team can reduce referrals to community and secondary care clinics with no major outlay in cost. This has been largely due to the use of a pharmacy adviser to rationalise and optimise medication at the time of the MDT. This should make the initiative adaptable to all CCGs, including those where other integrated care models already exist, and particularly attractive in this time of financial constraint.
Evaluation
The pilot was evaluated both quantitatively and qualitatively achieved all stated objectives. GPs and PNs taking part in the pilot were asked to complete pre- and post-pilot questionnaires, with responses showing an increase in confidence in all parameters.
