Dr Caz Sayer, Camden CCG chair and Dr Lance Saker, Camden CCG vice chair GP, outline how local health, social care and third party partners worked together to create a diabetes integrated practice unit that is improving patient outcomes, preventing hospital admissions and reducing unnecessary system costs.
Camden, North London, has a diverse population with a large ethnic minority community. One in seven people living in the borough has a long-term condition, of which diabetes is the third most common.
Dr Caz Sayer, Camden CCG chair and Dr Lance Saker, Camden CCG vice chair GP, outline how local health, social care and third party partners worked together to create a diabetes integrated practice unit that is improving patient outcomes, preventing hospital admissions and reducing unnecessary system costs.
Camden, North London, has a diverse population with a large ethnic minority community. One in seven people living in the borough has a long-term condition, of which diabetes is the third most common.
People living with diabetes in Camden reported fragmented care across a complex number of providers and had poor diabetes control, leading to excess early complications. Diabetes prevalence figures in Camden were low, suggesting an undiagnosed population and significant unmet need. The provision and capability of general practice to offer community-based care was also variable, with a reliance on hospital-based care to access specialist advice.
Population health management work undertaken by the CCG, segmenting populations and looking at how to better tailor services to meet the needs of different groups, showed that supporting people to manage their diabetes well through community services not only improved patient outcomes but also reduced unnecessary hospital attendance and admissions. This approach is reflected in national and international evidence showing three key strands to improving outcomes:
- Prevention if possible and early identification to prevent long term complications
- High quality services with clearly defined measurable pathways
- Integration of health care and services with wider systems (social care, third sector support for self-management).
An ambitious multidisciplinary plan for a Diabetes Integrated Practice Unit
To improve diabetes management and outcomes in Camden, clinicians, commissioners, providers (including the voluntary sector), patients and carers came together. The team included representatives from University College London Hospitals NHS Foundation Trust, Royal Free London NHS Foundation Trust, Central and North West London NHS Foundation Trust, Camden and Islington NHS Foundation Trust, Camden general practices and Diabetes UK.
Our goal was to create an integrated service focused around the needs of people with diabetes that would improve outcomes and increase value to the health and wider system. Working together, the team defined the outcomes important to people with diabetes and re-designed services based on best practice pathways.
Metrics and outcomes were jointly developed and agreed. A key element was also to contract in a way that incentivised and enabled delivery. The contract was delivered through a Lead Provider model led by the Royal Free London NHS Foundation Trust.
An important component of the community-based service was supporting and developing general practice to identify and manage patients more effectively. Clinical leads worked with diabetes specialists to help practices identify people with diabetes. Specialists also provided training and education to GPs and practice nurses, which also created stronger relationships and greater confidence in respective roles and capabilities. Pathway and referral information was made available on the Camden CCG GP website.
Reflection and quality improvement was supported by regular peer review and sharing of measurements.
In developing the new service, we worked to ensure key dependencies, such as psychological support, weight management, podiatry etc., were integrated in the pathway. The service was enabled by the Camden Integrated Digital Record (CIDR), allowing record sharing across specialisms.
Built into the new service was recognition of the central role played by the voluntary sector in educating people with diabetes on their condition and supporting self-management , and the role of the wider system (e.g. social care, employment, housing) in keeping people well.
Camden CCG entered into dialogue with local providers and the Integrated Practice Unit was then contracted through a Lead Provider model that included all local partners. Formally contracting the model as an Integrated Practice Unit, while complex to achieve, enabled greater value to be achieved for patients and the system.
Success so far and lessons learnt
Camden’s diabetes services are now rated as top performing nationally. We have seen an improvement in the number of people diagnosed with diabetes, from 7,950 in 2013 to over 9,000 in February 2017. The proportion of patients with good sugar (HbA1c) and blood pressure control (≤140/90mmHg) has improved, both exceeded the contracted targets at 50.2% and 69.4% respectively.
The IPU also exceeded the target reduction in the number of unplanned admissions for people with diabetes experiencing an episode of low blood sugar (hypoglycaemia) and high blood sugar (hyperglycaemia) (target was to reduce to 72, 59 achieved).
The service has seen continued increases in primary care indicators e.g. cholesterol, blood pressure and blood sugar control), coupled with a reduction in the number of cases where patients have attended in emergency care settings for dangerously high levels of blood acids (ketoacidosis) and low/high blood sugar episodes.
Exploring patient-reported outcomes, baselining of PROMS data has been successful with almost 900 people surveyed, and positive themes are emerging. Service users are reporting high satisfaction with the IPU service, with 87% (N=757) agreeing / strongly agreeing they are confident in managing their diabetes. Furthermore, 73% agreeing / strongly agreeing they are confident in accessing people who understand my diabetes when needed and 76% (N=728) found it very or fairly easy to get the care they needed when they needed it.
Camden has seen no diabetes-related major amputations since April 2016 and the cumulative percentage of deaths as a total of register size has reduced from 3.1% in 2014/15 to 2.9% in 2015/16.
The process to develop and contract the Diabetes IPU was lengthy and complex but clearly worthwhile. To ensure we learnt lessons for future Value Based Commissioning contracts the process was independently evaluated, which concluded:
- While clinical leadership would often rapidly align, senior management leadership (at CEO level) was needed to ensure engagement and commitment to the process and provide strategic oversight with a shared focus on improving outcomes for patient
- A clear formal framework is needed to inform and facilitate partnership working and collaborative approaches
- Establishing both a project group with commissioning and contracting expertise and a sub-contracting group of specialist technical contractors is helpful.
