Sheffield Primary Care Trust
Service Specification for a Local Enhanced Service:
Initiating Insulin in Primary Care - to be commissioned by Sheffield PCT on behalf of SONIC practices
EIGHTH DRAFT 18/12/08
1. Introduction
All practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This enhanced service specification outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services.
2. Background
It has been identified that early intensive glycaemic control (HBAIc 7%), can result in a significant reduction of microvascular complications of diabetes, compared with less intensive control (HBAIc 7.9%).
Type 2 diabetes is a progressive disease which is associated with insulin resistance and beta cell dysfunction. The majority of patients will require drug treatment to maintain adequate glycaemic control. The National Service Framework for Diabetes delivery strategy (2003), NICE guidelines (2002) and the new GMS contract sets targets and standards that will need to be met to ensure an improvement in diabetes care. Primary care has an important role to play in implementing these and ensuring better health outcomes for patients with diabetes. Patients who are not achieving adequate diabetic control through lifestyle modification and oral hypoglycaemic agents (OHAs) should be considered for insulin therapy.
Locally, the outpatient waiting time for type 2 diabetic patients requiring transfer to insulin is several weeks. The development of primary care based services for initiating insulin will reduce waiting times and provide a more convenient service to patients closer to home.
3. Aims
· To improve the quality of care for patients with diabetes and prevent the onset or worsening of complications and associated symptoms by providing practice based insulin initiation
· To train practice staff in initiation and adjustment of insulin
· To reduce referrals to specialist secondary care diabetic services.
· To encourage patients to take responsibility and empower them with the ability
to make decisions and participate in care and control of their diabetes.
· To reduce emergency admissions for diabetes.
4. Definitions
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5. Service outline
This Local Enhanced Service will provide:
· Assessment. The practice nurse and Diabetic Specialist Nurse will liaise with the referring practice to assess the suitability of the person with diabetes for insulin initiation. This will include:
- checking the capacity of person with diabetes and/or carer to manage insulin treatment
- consulting the wishes of the person with diabetes
- confirmation of sub-optional glycaemic control despite maximum tolerated
doses of oral hypoglycaemic agents
- assessment of the need for better glycaemic control in the light of diabetic complications or symptoms and other biopsychosocial factors.
· Education. Education and support of the person with diabetes , carer and/or partner to enable appropriate self management of insulin, which will include
- using equipment
- injection technique
- blood glucose monitoring
- insulin dose adjusting
- diet
- managing hypoglycaemia
- managing intercurrent illness
- how and when to seek advice
- Support and supervision of the patient until stable glycaemic control is achieved
· Treatment. Patients will be started on insulin.
· Professional links. To work together with other professionals when appropriate. Any health professionals involved in the care of patients in the programme should be appropriately trained.
· Referral policies. When appropriate to refer people with diabetes promptly to other necessary services and to the relevant support agencies using locally agreed guidelines where these exist.
· Record keeping.
Patients will keep their own record of their treatment/medication as this is part of the education process.
The provider will ensure the referring GP receives adequate information including a letter confirming the patients’ acceptance or otherwise on to the programme and a comprehensive ‘discharge’ letter once the patient has completed the programme.
The CAS will keep a record of the referral and the discharge summary.
· Clinical Audit. To carry out clinical audit of the care of patients against criteria specified in Appendix 1.
· Review. All providers involved in the service should meet with the Primary Care Diabetes Leads (Hugh McCullough and the Lead Diabetes Specialist Nurse Sue Beveridge) regularly, with formal reports to SONIC and the Diabetes Network at six monthly intervals.
· Model. Normally, the service will be delivered using a group model (which is recognised as the most appropriate method of starting people on insulin).
A timetable for 2007/08 is attached at Appendix 2.
Where a group start is not possible or is inappropriate because of language, cultural or clinical reasons etc, then insulin starts will be conducted on a one-to-one basis.
The suggested format for each programme will be:
Class 1 Introduction (what is diabetes, why insulin), monitoring, hypoglycaemia
Class 2 Insulin (type, device, injection technique, storage, disposal, dose adjustment, legal issues, prescription for patients’ GP to issue)
Class 3 Diet (this session may be led by a dietitian)
Class 4 Sick day rules, foot care, discussion of any problems
Class 5 Eye care, travel, annual review, discussion of any problems, diabetes knowledge questionnaire
The same education content will be covered where the person with diabetes is started on insulin on an individual basis.
Note 1: The recommendation for providing diabetes education in groups (including the education required around insulin initiation) is according to NICE Technology Appraisal 60 (structured education in diabetes).
Note 2 : prescription for patients’ GP to prescribe will include insulin, pen, meter, sharps bin etc
6 Accreditation and training
· The capability of a practice (or other organisation) to deliver this service will be determined by the Diabetes Network through the Primary Care Diabetes Leads. It is not necessary for the providing staff (e.g. Practice Nurse) to have attended any formal taught courses but they must have been working with the Diabetes Specialist Nurse team and have their confidence.
· By definition the Diabetes Specialist Nurses are trained and accredited to provide this service
· Practice staff will be expected to develop their skills and confidence in managing people on insulin and commencing their treatment. Adequate time has been built into the service level agreement to allow for shadowing and meeting with hospital staff.
· Competencies – is there a checklist we could use Sue?
See also section 10 on ‘eligibility to provide’.
7 Clinical and Corporate Governance
The quality and clinical governance standards are outlined in the Service Specification and must be followed at all times.
At appropriate intervals quality and outcome measures associated with the delivery and performance monitoring of this agreement will be reviewed and where appropriate discussed and altered to meet national requirements and
delivery of agreed key indicators based on local and national priorities.
All commissioned services must comply and demonstrate the ways in which they meet with the relevant standards as outlined by:
· The Standards for Better Health, www.healthcarecommission.org.uk
· The Health Act 2006, Code of Practices for the Prevention and Control of Health Care Associated Infections. www.dh.gov.uk/publications
· The National Health Service Litigation Authority, www.nhsla.com/RiskManagement/PCTStandards
· The Medicine and Healthcare products Regulatory Agency www.mhra.gov.uk
· The National Patient Safety Agency www.mhra.gov.uk
· Accountabilties - Staff providing the service will be clinically responsible to their own organisation (e.g. practice nurses will be responsible to their employing GPs as normal and DSNs will be responsible to their employing Trust as normal). The providing practice may wish to take out additional insurance/indemnity/medical defence cover as appropriate (ask clinical governance for advice, Hugh also checking).
· Untoward incidents – It is a condition of participation in the service that providers will report all near misses, incidents and serious untoward incidents to the PCT that relate to the commissioned service. Providers of the service will also work within the usual governance procedures as per their employing organisation (i.e. recording and reporting of adverse incidents).
· Compliments and Complaints - Patients will be free to complain to or compliment any commissioner or provider as per the usual arrangements. However, because this service is provided by several organisations and because the commissioning arrangements are different this might seem difficult to patients. Therefore a ‘How to complain/compliment’ guide will be included in the education pack.
· Clinical audit and reviews – as described above the providers will regularly review the success of the service and audit patient outcomes and experience. These reports will be presented to SONIC and to the Diabetes Network.
· Risk Management
Fire Safety - providers must familiarise themselves with fire safety procedures for the buildings that the service is provided from and brief patients or visitors accordingly. Non-NHS buildings should be assessed by a PCT officer to ensure they are appropriate.
Venue Safety – all venues will have adequate hand washing facilities and sharps bins
Clinical safety – clinical competency of providing staff is covered in sections 6 and 9.
8 Administrative and management arrangements
In the first year, providers will use the administration centre (CAS) to operate the service. If the provider is unable to provide all the sessions they have been contracted for (e.g. because of unexpected leave) then sufficient notice must be given so that the change can be accommodated if possible. Where no notice can be given (e.g. unplanned sick leave) then the provider must ring the CAS that morning to notify them so that cover can be arranged or groups can be cancelled.
Detailed administrative arrangements have been worked out between the service operator (CAS in the first year) and the providers. These include:
· communications with GPs and patients
· booking providers and patients and ensuring patients are seen within waiting times guarantees
· eligibility criteria for transport, interpreters, home visits, reimbursement of patient travel expenses
· cover arrangements
· how to deal with inappropriate referrals
· ‘discharge procedure’ for patients who have completed the classes
· Arrangements for patients not able to make the classes or who do not respond to invite
· Educational materials
· Room booking and reception
· Referral processes (referral form attached at Appendix 3)
· Financial monitoring
The ‘paper pathway’ is described in Appendix 4.
A format for the ‘Registers’ of which patients and which staff attended the group and 1:1 sessions are attached at Appendix 5 and 6
A discharge summary is attached at Appendix 7
Triage form is attached at Appendix 8
9 Eligibility to provide
Practices eligible to provide this enhanced service must:
· Identify and employ the health care professional who will provide the service.
· Ensure that the health care professional has the capacity (one session weekly for 3 or 4 months in the year) to provide the service.
· Facilitate the release of the HCP for training
· Be able to commit to timetable described in Appendix 2
· Have achieved 75% of diabetes QOF points
Acute Trusts eligible to provide this service must:
· Have existing good arrangements with local practices
· Be able to commit to timetable described in Appendix 2.
Dietetics services eligible to provide this service must:
· Have experience of providing dietary advice to pats starting on insulin
· Have experience of the educational materials already used locally
10 Service Level agreements
This service specification forms the foundation of the service level agreements (contracting arrangements) for the commissioning provision of this new service.
Sheffield PCT, on behalf of SONIC will commission from:
Approximately 3 general practices – for the provision of Practice Nurses, use of premises, support in prescribing drugs and equipment etc
One acute trust - for the provision of Diabetes Specialist Nurses
One provider of dietetics services for the dietitian input
One provider of administrative functions (e.g. CAS) for administration/management support
Names of contributors:
Ayesha Heaton, PBC Manager, Sheffield PCT
Hugh McCullough, Primary Care Diabetes Lead
Sue Beveridge, DSN, STHT
Alison Iliff, Diabetes Network Manager
Contact person : Hugh McCullough or Ayesha Heaton
August 2007
L:\Service Improvement\S I Team\PBC\SONIC\diabetes bus case\fifth draft LES.doc
Acknowledgements:
Wakefield West PCT Insulin Initiation LES
Appendix 1 Clinical Audit and Data collections
1 Clinical Audit
How do we know the service is doing a good job?
A Patients are satisfied – test through programme evaluation at the end of each programme and by tracking DNA rates. Ideally the community service will use the same form as the hospital service for comparison.
B Waiting times are met – track time from receipt of referral to start of programme
C Clinical outcomes improve - Consider testing patients understanding of key points as part of the education programme, test HBA1c control before and after participating in programme (this may be done as part of a follow up)..
2 Data collection for PCT/DoH monitoring purposes
New primary care service
Number of patients that participated in each programme, when, and what type of activity it was - Each patient should attend once a week for 5 weeks if participating in a group programme or may attend 2, 3 or 4 times if attending for 1:1s. The 1:1 activity can be considered similar to first and follow up outpatient attendances as per the definitions used by secondary care. The group classes at hospital are counted as one first and 5 follow up attendances whereas in primary care we can describe the activity more accurately as 5 group attendances. 5 codes could be used:
1:1 first
1:1 follow up
1:1 first – home visit
1:1 follow up – home visit
Group attendance
This is then used to:
· manage demand/capacity of the service,
· make assumptions on hospital savings
· report to DoH (LDP returns)
The CAS will collect data that is useful to help perfect the running of the service, e.g. transport and interpreter useage and costs
Hospital service
Continue to monitor first and follow up diabetes outpatients through usual activity monitoring processes, to test for a reduction. Recognise that insulin initiation is only one aspect of diabetes outpatient care and therefore it may be difficult to measure the impact. This service is unlikely to impact on hospital inpatient activity.
Continue to work with DSNs to track hospital insulin initiation activity for SONIC patients (information only available from them) to indicate proportion of patients considered unsuitable for initiation in primary care or practices not referring into new primary care service.
Eventually this data collection may be covered by the SUS (secondary users service) as per some PCT provided services.
Appendix 2 Model of service/Timetable