Durham and Darlington Diabetes –

Project Overview1st February 2016

Introduction

Anexciting new model of diabetes care will be commencing roll out from April 2016. The model will see the diabetes care currently provided by acute care clinicians at hospital delivered in a primary care setting with a community based approach. During 2016/17 GP Practice Staff across County Durham and Darlington will receive additional training to enable them to provide a higher level of care to patients with both Type 1 and Type 2 Diabetes.

The new model of care was developed, with patients and primary and secondary care clinicians. The business case was presented to the 3 Durham and Darlington CCGs, and agreed, in July 2015.

Rationale

Diabetes mellitus is a complex condition that has a profound impact on the quality of life of people living with it and on the health economy as a whole. From the time of diagnosis to the development of severe complications such as foot amputations, the person with diabetes receives input from a wide spectrum of health and social care professionals. When this care is delivered in a fragmented manner it results in duplication, inefficiency and, worst of all, a poorer health experience.

The costs, both human and financial, are significant and increasing. Whilst there are initiatives in County Durham and Darlington, such as the foot care pathway, that are helping to improve diabetes care, it is evident that a significant rethink about how diabetes care is provided within the community is overdue. Nationally, the focus is on developing truly integrated diabetes care, to close the gaps and reduce fragmentation of services for patients. In 2011 it was identified that, nationally, 80%of NHS spending on diabetes goes into managing potentially preventable complications (State of the Nation 2012 England). This is clearly unsustainable and CCGs are being encouraged to “fundamentally change the way we have historically delivered care for patients with diabetes” (NHS Diabetes, 2013).

Objectives

The new model will deliver an integrated community based model that ensures:

  • A cohesive approach to diabetes care that places the patient at the centre of their care, where the whole health community joins in partnership to own the health outcomes of patients with diabetes in their local area – through Diabetes Locality Groups
  • Joined up and integrated care (between acute, community and primary care) and in partnership with social care, mental health and other health improvement providers, planned around the needs of people with diabetes.
  • A more efficient and less wasteful service, without duplication or gaps, to make best use of the resources available, particularly in view of the known predicted increases in diabetes prevalence.
  • Complications from diabetes are managed effectively within primary care, whilst also ensuring that primary care clinicians are sufficiently trained and supported.
  • Increased skills base within the community, reducing variation in practice to ensure equity of care.
  • Patients have a positive experience of care, ensuring they see the right person, in the right place, at the right time, and where the patient feels there are no boundaries.
  • Provision of services that support self-management for people with diabetes.
  • Compliance against NICE Quality Standards for Diabetes in Adults.

An Integrated and Local Approach

New structures are in the process of being established to support the new model and include:

Training and Education for Primary Care

GP Practices have been asked to complete a Training Assessment Tool for diabetes care. This information will enable a clear understanding of the level of diabetes care already delivered within GP Practices, any variation between GP Practices and a targeted training programme to be developed to upskill Primary Care Staff during 2016/17.

The transition to manage diabetes care within a primary and community setting will be undertaken in a structured, managed and safe way.

A service specification to support the training and education of GP Practice staff, partnership working as part of a locality Based Diabetes Group and responsibilities of GP Practices to deliver increased care and support to patients with both Type 1 and Type 2 diabetes as part of a Diabetes Group is currently in development.

Consultants and Diabetes Specialist Nurses will come and see you in your practice so you don’t need to worry about time away from clinics. This will be at convenient times for you.

Durham and Darlington Diabetes Governance Board

CCGs have agreed to a new contract approach with outcome based contracting and a new commissioning approach where organisations enter into an agreement to work together and establish shared financial accountability for outcomes and resolve disputes without litigation.

This new way of working will see partners across Commissioners and Providers, Primary, Secondary and Social Care working together within an Alliance structure to jointly manage the delivery of a number of agreed outcomes.

The Governance Board will be responsible for working jointly together to achieve the following outcomes for patients with both Type 1 and Type 2 diabetes:

  • Improving patient health outcomes
  • Reducing local variation in the quality of care
  • Ensuring financial sustainability by reducing cost per patient

Diabetes Locality Groups

To support the Governance Board objectives, Diabetes Groups will be established across each locality area with responsibility for managing a defined patient cohort.

•Diabetes Groups manage defined patient cohorts – circa 100,000 population / 6000 Diabetics

•Primary and secondary care clinicians jointly take responsibility for the health outcomes of a defined cohort with a given set of resources

•Local delivery model for Un-controlled patients based on local needs (Geography, patient cohorts, primary care skill base)

•Diabetes groups push a focus on education and prevention

•Diabetes groups co-ordinate the interface with other relevant services (community nursing, podiatry, dietetics, retinal screening)

The benefits of a well-integrated diabetes service include:

  • Improved patient experience
  • Ensuring that all healthcare organisations involved in providing diabetes care, through partnership, clearly own the responsibility for delivering excellent care to their local population
  • Providing clearly defined terms of accountability and responsibility for each health care professional / provider
  • Reducing duplication of time, tests and information

(Best practice for commissioning diabetic services – an integrated care framework, NHS Diabetes, 2013)

Each Diabetes Locality Group will be responsible for reporting on an activity, expenditure and savings dashboard on a regular basis to the Governance Board, to aid them in managing the health and system outcomes of their patient cohort. The dashboard will consist of:

  • Patient measures
  • Performance
  • Achievement against target outcomes
  • Achievement of savings targets

Timetable

It should be noted that year one of the new model is intended to be delivered in a phased way.

The timetable below currently refers to roll out plans for North Durham and DDES CCG’s. Scheduling of delivery in the Darlington CCG will be shared in due course.

In North Durham and DDES CCG’s training and education of GP Practices will commence from April 2016 and will be delivered in throughout 2016/17 in a phased way.

Movement of diabetes patients from current acute based services to having their care delivered within GP Practices, by primary care clinicians will happen in a structured, agreed way and managed in phases through Diabetes Locality Groups throughout 2016/17.

Key Dates / Deliverable / Progress
4th February 2016 / Inaugural Meeting of Durham and Darlington Diabetes Shadow Governance Board. Future meetings 3 weekly initially.
All GP Federations are invited to these meetings / Completed. Future Meeting Schedule on Track
8th February 2016 / GP Practice Diabetes Skills Assessment Completed and Returned / Process in place for following up with outstanding submissions.
March 2016 / GP Practice Training Programme for 2016/17 Confirmed / In development
March 2016 / Service Specification Finalised / In development
April 2016 / Diabetes System Manager in post / In process
April 2016 / Commencement of GP Practice Staff Training – ongoing throughout 2016-17 / In development
April 2016 / Diabetes Groups Phased Implementation April to June 2016 / In development

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