Summary

Starting in November 2011, the existing community diabetes team at South East Hampshire was joined by the local hospital diabetes specialist consultant team to provide regular in-depth educational support to GP practices and locality nursing teams, as well as to provide day-to-day advice via email and telephone.

This was influenced by the need to tackle three key issues:

• Pathway inefficiencies involving secondary care follow-up
• Unacceptable variations in quality of care and knowledge of diabetes and management
• The disconnect between care services resulting in fragmentation and duplication.

Specific objectives included:

• MERIT training for 50 clinicians per year
• DESMOND training for 520 patients per year
• Bespoke training to meet identified local need.

Results

The project has been successful across the range of planned objectives.

Since 2006:

• 2,263 PWD have undertaken DESMOND training
• 227 clinicians have undertaken MERIT training
• 1,354 individual practice referrals have been seen
• 30 clinicians have undertaken ‘Conversation Map’ training.

Since November 2011:

• 642 (90 per cent) patients were discharged from Secondary Care – with a follow up appointment costing around £90. This represents a saving of £54,000 each year
• 57 patients were transferred to Super Six clinics and 15 needed clinic review pending discharge
• 35 of 53 GP practices education visits received or planned.

The service also runs an annual patient conference where a range of professionals give their time and expertise.

Further MERIT and MERIT update courses are now fully booked and follow up visits to GP practices are booked with each of the practices.

Challenge

Commissioners and providers across the health community jointly developed the initiative for people with diabetes. Some Secondary Care services have subsequently been decommissioned and resources reallocated to community-based services.

There were three key issues to tackle:

• Inefficiencies in the traditional pathway as long-term follow ups for people with diabetes were conducted in Secondary Care clinics
• Unacceptable variations in the quality of care provided in primary and community care. This was believed to be contributing to higher than expected rates of diabetic emergency admissions and complication rates in the local population
• Disconnect between care services, which resulted in an absence of structured care plans or duplication of effort.

Care quality issues centred on clinician and patient knowledge.  Among clinicians there was inequitable knowledge of diabetes and insulin management. In addition there was no access to prompt specialist advice regarding diabetes management. Patients were also expressing a preference for care management within the Primary Care setting.

Drawing upon evidence from the NSF for Diabetes, care was shifted from Secondary Care, and education and empowerment of clinicians and patients put to the fore. Nationally recognised education and training programmes are used for patients (DESMOND) and clinicians (MERIT – which meets Local Enhanced Service requirements).

A community diabetes team with two part-time specialist nurses and a GPwSI had been in place since 2006, providing support in diabetes care to Primary Care. This was principally to GP surgeries, but included training in insulin management and healthcare professional education. The team recognised that additional support from consultant diabetologists would bridge the gap between Primary and Secondary Care services and enable more integrated care.

In particular, this would begin to address acute admissions via the local Medical Admissions Unit or A&E department, ambulance service calls, and give longer term potential to reduce amputation rates in the populations served in South East Hampshire by the Hampshire and Portsmouth PCTs.

Starting in November 2011, the existing community team was joined by the local hospital diabetes specialist consultant team to provide regular in-depth educational support to GP practices and locality nursing teams as well as providing day-to-day advice via email and telephone.

In addition to the consultant team support, the service now has two full-time and one part time specialist nurse, a GPwSI and full-time administrative support. The service is receives £152,100 each year in funding. It has capacity for income generation through training programmes for health professionals and health care assistants, including those working in care homes.

Objectives

Through integration the initiative aimed to improve knowledge and skills in management of diabetes among patients, carers and clinicians, and improve communication and relationships across the health community.

Specifically it aimed to:

• Deliver MERIT training for 50 clinicians each year
• Deliver DESMOND training for 520 patients each year
• Deliver bespoke training to meet identified local need, eg, care homes
• Ensure regular engagement with GP practices, including planned visits from the team (including a consultant diabetologist) at least twice a year (can be training sessions if required) and joint caseload review of diabetic patients
• Ensure the consultant diabeteologist is available daily, by phone, to GPs, practice nurses, and community nursing teams Daily mobile phone consultant diabeteologist availability to GPs, Practice Nurses and Community Nursing Teams and provide an email advice line
• Improve patient reported ability to self-care – 100 per cent of patients seen should have a personalised care plan
• Deliver seamless care for PWD through complementary working relationships between Primary, Secondary and community care – including rapid access to specialist support by telephone and email
• Instigate a long-term downward trend in hospital admissions, inappropriate referrals to secondary care and ambulance conveyance rates to secondary care.

Solution

Care pathway development was instigated by a local GP with a special interest in diabetes and agreed by local commissioners. Using policy and best practice guidance, it agreed to aim to discharge 90 per cent of PWD currently receiving Secondary Care-based follow-up back into Primary Care. This required a Local Enhanced Service, appropriate specialist support and education programmes to be in place. Enhanced information sharing was also facilitated by a jointly developed diabetes website.

It was agreed the service would provide triage for Secondary Care referrals to ensure appropriateness and return those deemed inappropriate with clinical advice back to Primary Care. This included people newly diagnosed with Type 2 diabetes.

GP engagement was vital and began early in the pathway redesign process. Consultants and GPs undertook a baseline assessment with the agreement of their with patients. This identified patients for discharge to Primary Care and those who were more appropriate to be retained by the Secondary Care team through the Super Six clinics.
Super Six clinics are:

• Pregnancy
• Renal dialysis
• Insulin pumps
• Acute Type 1 diabetes
• Type 1 education
• Adolescents.

Subsequently, practice meetings were held with a diabetologist and specialist nurse to review patients identified for discharge.

These meetings began the process of support and engagement for practices. Through patient reviews the team identified care management issues and education requirements of clinicians in each practice. Open access arrangements for advice and support via telephone or email were put in place with clear and rapid response times. This approach promotes partnership working and joint problem solving between primary and community-based clinicians and the team.

Learnings

There are four key lessons that have resulted in the success of the project that are applicable to others:

1. Have ‘All Party’ Agreement – hold joint community and consultant team meetings with GP groups to engage GPs and garner their support for the change
2. Promote the quid pro quo – GPs had to recognise that although discharging patients from Secondary Care may seem like more work, the upside is that it releases consultants to provide in-practice education and email/mobile advice support for the GPs. It was also emphasised the reality that patients were being seen in practice in any case for chronic disease management
3. Keep commissioners on board – Hampshire PCT had a diabetes LES which paid practices additional fees for managing more complex patients and initiating injectable therapy. The community team liaised with the PCT to tweak the LES to include education, peer review and admission analysis – all features that could be facilitated by consultant educational visits.
4. Have the right clinical leadership in Primary and Secondary Care – the community team had committed and locally well-known clinicians but it was only the addition of clinical leadership from Secondary Care that enabled the existing service to move forward.

Evaluation

Patient feedback is collated as an integral part of the service and is overwhelmingly positive. Patients report feeling empowered and in control of their diabetes.  They also said that the training is equally useful for their carers/significant others. 
Survey results indicate:

• 89 per cent of patients strongly feel positive benefit of the community diabetes team
• 95 per cent strongly agreed that the diabetes specialist nurses were professional in their manner and a benefit to the patient and their partner/carer.

Relationships with clinicians and other staff across Primary and Secondary services are consistently positive.  GP Survey results indicate:

• 69 per cent of GPs rated their satisfaction as Very Satisfied; the remaining 31 per cent rated their satisfaction as ‘satisfied’ on a scale of 1-5. (1 = very unsatisfied to 5 = very satisfied).
• 91 per cent of GPs surveyed agreed that they would like the service to continue. Of the remaining 9 per cent all responded ‘maybe’ noting that they felt it was too early to see the full impact of the service in improving diabetes care.

Feedback has also reflected the value placed on gaining a rapid response to any query. Additionally, MERIT training and update sessions are continually popular and as a result regularly oversubscribed.

Local commissioners have also congratulated the team for the success of the initiative noting that: “The community diabetes team has gone from strength-to-strength since its launch, and the feedback from both primary care and patients has been excellent.”