Angela Sharda talks to GP Dr Rahul Thakur about his role as diabetic clinical lead at East Lancashire clinical commissioning group (CCG)
Q. Tell us about your role as CCG clinical lead
A. I joined a practice in East Lancashire as a GP partner in 2015, having comefrom London. I identified a need for a diabetes service in the region and the CCG strategic lead was enthusiastic. There was huge inequity in commissioning arrangements with enormous variation in coding compared to the England average. There was variation in delivery across primary and secondary care, and variation in knowledge, skills and capacity across the providers. Once we identified this we started engaging with protected learning. A diabetes group was set up and we came up with a case for change.
I felt an intense need to start engaging with fellow GPs. We created a WhatsApp group and now have 200 local GPs, from the very experienced to the newly qualified. We talk on a daily basis, leading the peer group.
I started talking about what we needed to do with diabetes and how to upskill. In my own practice, we engaged with the public and patients at an open event. We got an ‘outstanding’ rating from the Care Quality Commission (CQC) and were a finalist in the GP national awards for 2016, which boosted our confidence. We established a new East Lancashire diabetes service model, divided into three parts.
There were core practices, which do most of the stuff that GPs do anyway – prescribing, patient education and cardiovascular care.
We also had enhanced practices, which started doing insulin initiation of complex diabetes and housebound patients. Outcomes and audit were measured. We paid £23 per diabetes patient, quite an incentive. And it encourages more screening. But treatment need not be insulin. We give the practice support and incentivise them to do their best for the patient. We also pay £5 per patient if the practice is delivering structured diabetes education. A lot of practices signed up.
The third category was complex care, which we felt should stay in hospital, like insulin pumps, advanced renal care, inpatient care, foot care, children, pregnancy or antenatal care. We ran an insulin initiation foundation course. A large number of practices in the past year have upskilled. There is still a lot of variation in different areas, and my role is to target those.
I was involved with the NHS England bids, so we have the money and it is time to deliver. We are getting a workforce in place and ensuring there is seamless transition between services. In the enhanced practices, we are trying to support care for housebound patients and those in care and residential homes. There were very few provisions where they would be attended by a skilled healthcare professional. We also support practices in training.
Q. What are you most proud of at your CCG?
A. I am very proud of our GP colleagues. They are so enthusiastic. Some arrange monthly teaching sessions followed by dinner where they talk about what is happening around the area. They are driving the changes here.
Q. What do you think is essential for diabetes care to be improved?
A. It is important to reduce variation. So one practice might have a very skilled healthcare professional who gives great outcomes. The neighbouring practice might not. We have to start from a basic level of education for the patient. I have been engaging with charities and giving talks out of my working hours – such as a group of women who give cooking classes and medical talks. When we talk to the population we also learn about where we are going wrong, the basic questions we are not addressing.
Q. What changes do you want to see the Government make?
A. I think NHS England is doing a tremendous job, especially with the diabetes prevention programme. NHS England, Public Health England and Diabetes UK have come together here. There are a few role models who are driving the changes from the top and that’s showing at the level of individual patients. And it is only the beginning. If NHS England can focus on service provision, variations are likely to improve more.
Q. What problems with the system do patients with diabetes face?
A. Diabetes care could be brought closer to patients’ homes. Patients don’t want to travel 50-100 miles to see a specialist. There is also a delay in appointments. All the services in primary and secondary care are stretched and we need to increase the workforce. Ethnic minorities are a high- risk population, and might not understand much English. If we want to engage them we need to integrate more.
Q. What impact have you made on patients’ lives?
Patients in East Lancashire have welcomed the change. A lot have been waiting for an appointment for a year. When I say I will follow up in three weeks and monitor them on the phone, they are more confident about the service. I make sure I tell them the basics. About 9/10 people who are taking insulin are not aware of how best to treat hypoglycaemia. I check their knowledge at every consultation. A lot of people have said that has really helped.
Q. In terms of sustainability and transformation plans (STPs), what challenges do you see CCGs will face?
The STP is a novel idea. GPs are sceptical. The ideas are good but how will they deliver? My main role as diabetes clinical lead would be to provide clinical leadership for a defined network, providers for a specific task, to improve and safeguard quality, and to communicate with the networks.