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Pulling together


22 April 2016

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Patients with diabetes have to manage the condition themselves most of the time but this can be a challenge if there isn’t a correct clinical pathway for them to be on. In order for this to take shape, primary and secondary care have to join forces

Patients with diabetes have to manage the condition themselves most of the time but this can be a challenge if there isn’t a correct clinical pathway for them to be on. In order for this to take shape, primary and secondary care have to join forces

The soaring prevalence of diabetes, driven by the rise in type 2 diabetes, means that the condition now consumes 10% of NHS budgets. The startling fact can obscure an important truth for those commissioning diabetes care, but the person with diabetes is the one who manages their condition the vast majority of the time. The NHS has to find ways to support their self-management, and integrated care is key to enabling this.
A comprehensive and integrated service, from diagnosis to the management of potentially serious complications such as stroke and amputations, is needed to ensure patient needs are met. With 80% of the NHS diabetes budget spent on managing complications, commissioning a system that can handle them in good time or prevent them altogether can provide a massive boost to the quality of care as well as potential cost savings.
The call for integration is hardly unique to diabetes, but the problems of failing to integrate primary, community and specialist care for people with the condition are acute. Often, someone with type 1 diabetes will receive their treatment from specialist services, while someone with type 2 diabetes is more likely to receive care in their GP practice. However, this division of labour can easily become an overly-rigid divide that can delay someone with type 2 getting quick access to a community podiatrist or specialist diabetologist.
Getting people to the right part of the pathway at the right time is what’s needed. That requires a clearly defined local model of care. Diabetes UK has analysed the most effective examples of integration around the country and we have identified the following five categories as essential to building effective systems.

Aligned finances and responsibility
Too often the financial system drives clinicians apart. Acute trusts are incentivised to keep as many patients on their books as possible, while primary care is pressurised to reduce referrals. But pooling budgets, or at the very least having defined protocols for when people with diabetes are treated in a particular part of the system, can help to get money to where it is needed on the pathway.
Several areas have looked at the role of the consultant diabetologist. They know more about the specialist care of diabetes better than other healthcare professionals, but there are only so many patients they can see directly. Some areas now see them double up as healthcare professional educators to spread that knowledge throughout the system. However, that has required a look at budgets to ensure the right incentives are in place.  
In Portsmouth, the specialist diabetes team is really clear with clinical commissioning groups (CCGs) about the patients who need to be seen in specialist care. This has led to a big fall in the number of patients on their books. They are also contracted to provide support to the rest of the system to look after patients who can be looked after by trained and well-supported primary care. Consultants and diabetes specialist nurses visit GP practices on a six-monthly basis to deliver training and support while providing virtual support the rest of the time. It is also one of many areas to use incentives to encourage primary care attendance at diabetes training courses.

Integrated IT
While cultural change and effective structures matter, the correct behind the scenes processes have to be in place to support clinicians’ work with diabetic patients.
Great strides have been taken in many areas to integrate IT, and the ideal is for all providers in a pathway to use the same system.
In Wolverhampton, a central portal is used to extract data from 49 GP practices and feed it into the trust’s computer systems, giving clinicians a complete record across all care settings.
Diabetic complications are divided into microvascular (due to damage to small blood vessels) and macrovascular (due to damage to larger blood vessels). The system also helps to identify those most at risk of micro and macro vascular complications. That often means earlier treatment than they would otherwise receive, which is removing delays in referral and potentially reducing emergency admissions.

Clinical engagement and leadership
Collaborative approaches can easily become hollow words if clinical staff aren’t fully signed up.
The North West London integrated care pilot (ICP) launched in 2011, covering five hospitals and 104 GP practices. Thousands of staff needed encouraging to work beyond their existing provider boundaries.
At the start of the project, a working group was created with NHS managers, diabetes specialists, GP leads and Diabetes UK attending to flesh out the model of care, clinical pathways and governance structures, so staff were involved in building new systems from day one. After the pilot got off the ground, committees helped to deepen new connections in specialist areas.
Leadership was also enlisted to support the project, with trust chief executives in particular supporting diabetologists spending time away from hospital to support colleagues elsewhere in the pathway.
And the project also made a virtue of using people with diabetes to have a direct role in determining priorities in areas like education and training.

Clinical governance
Incentives are an effective way to ensure plans are put into action. Clinical governance structures should be in place too, removing perverse incentives and creating clear lines of responsibility.
In 2009, Derby Hospitals NHS Foundation Trust, Derby City Primary Care Trust (now Southern Derbyshire CCG) and Derby City GP practices worked together to create a new model revolving around the user. It was a major project that saw a new NHS organisation created, with half the board drawn from the acute trust and half from primary care.
A single clinical governance structure was also created, which meets monthly to review safety, refine pathways and ensure quality of service delivery. The group is accountable to the newly-created board, while patient groups also contribute every other month to the service development.  
Monitoring care processes and outcomes to identify improvements is also key – and taking part in the National Diabetes Audit is a great way to uncover gaps in provision and evidence your successes.

Care planning
As members of the Coalition for Collaborative Care (a coalition of partners set up to help people with long-term illnesses), Diabetes UK is a big supporter of the house of care framework (see Figure 1).

Collaborative care planning is at the heart of the model. Getting people with diabetes to actively take part in the care planning process means a higher chance of having engaged patients who have the information they need to manage their condition better.
Systems and processes are not sufficient to deliver care planned in partnership with patients, but they do provide a starting point. In Wolverhampton, the NHS Trust has worked with the CCG and GP practices for years to deliver an integrated model based on primary care-led diabetes services.
To help put the patients at the centre of the work, they are sent questionnaires prior to their annual review appointment. This includes lists of questions for them to consider and a chance to pick their priorities, as well as the outcomes of their nine care processes of diabetes. This gives them time to think about what would really work for them ahead of their consultation, meaning greater engagement with self-care and education. The whole project is backed up with incentives for training and delivery of care planning. It is popular with patients and clinicians who reported increased patient engagement, shared decision-making and communication.
Exactly what model will work to improve diabetes care in your area will come down to the particulars of your local health economy, but we do know these categories need to be in order to create something that works. Commissioners will need to work closely with people with diabetes to turn these policy aspirations into practice. No one part of the system has all the answers – but rearrange the pathway with the right incentives and support, and better support will be on the cards.

Robin Hewings, head of policy at Diabetes UK.

Resources
House of care framework –  coalitionforcollaborativecare.org.uk/aboutus/house-of-care/.

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