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Tackling diabetes

Tackling diabetes
8 December 2016

A CCG decided it was spending too much on diabetes care so came up with a new way of focusing on preventing and managing the condition

A CCG decided it was spending too much on diabetes care so came up with a new way of focusing on preventing and managing the condition

Diabetes is a significant cause of mortality, healthcare complications and healthcare costs in the UK.  In 2012, the Public Accounts Committee severely criticised the Department of Health (DH) for not managing effectively the performance of primary care trusts (PCTs) in delivering diabetes services.  
Ipswich and East Suffolk clinical commissioning group (CCG) is one of three CCGs in Suffolk, and the majority of acute services are provided by Ipswich Hospital. The other two Suffolk CCGs are West Suffolk, served by West Suffolk Hospital, and Great Yarmouth and Waveney, served by James Paget Hospital.

Examining diabetes data
The geography of the new CCG was smaller than the previous PCT, because it did not contain the western part of the previous Suffolk PCT. This led to the examination of diabetes data in the 42 practices on a more local level for the first time. The first source used was the national general practice profiles, designed to support GPs, CCGs and local authorities in commissioning healthcare including benchmarking indicators in the Quality and Outcomes Framework (QOF). As figure 1 shows in comparison to England, the urban part of Ipswich and East Suffolk CCG in particular had smaller proportions of patients with lower glycosylated haemoglobin levels (HbA1c) and lower blood pressure levels. Of additional concern was that the 2010/11 achievement was less in some areas than that achieved the previous year.
We compared the 2010/11 outpatient activity and follow-up ratios for patients from western and eastern practices in the county. Ipswich and East Suffolk CCG had 62% of the total number of registered patients with diabetes, but accounted for a higher proportion of outpatient appointments – 76%. There were 11 follow-up appointments for every new outpatient appointment in the east, compared with the lower figure of six in West Suffolk CCG, the other CCG form on the breakup of Suffolk PCT.

Examining the spending
The CCG also examined data from the DH’s national exercise on programme budgeting. The DH introduced subcategories of care settings for commissioners to assign expenditure to; as a result, the commissioners were able to benchmark spend per 100,000, not only for diabetes but also for specific parts of the programme.
Locally, compared to national averages, diabetes spending was high in the acute sector, low in the community sector and low in the area of prevention.
We also looked at spending across the CCG compared to the national average. It showed the same pattern: high acute spending, low community spending and low prevention spending.

Views on services
One of the early steps was to share the data – this was done at the CCG’s newly formed clinical executive, which involved a joint workshop with Diabetes UK and 30 attendees, a meeting with the Ipswich hospital diabetes user group and meetings with grassroots GPs and lead GPs for diabetes across three locations. Also, there was a half-day practice-shutdown event for all GPs.
The following four themes were identified:

  • A lack of consistency between different training providers and service providers on how particular patients should be managed – leading to disagreements among GPs and also between different specialists even on basic scenarios, such as the random blood glucose level at which patients might be retested.
  • Differences in attainment between practices.
  • No real ownership of the declining situation. Some pathways were totally outdated, for example glitazones being preferred over gliptins.
  • Poor feedback in the media and politically, including letters from three of the MPs who had constituents in the CCG catchment area.

Solving the problems
Once the scene had been set, the CCG established two groups:

  • An internal task and finish group with six GPs, including the lead GP Dr John Flather, and chief operating officer Melanie Craig.
  • A project board with wider membership including patients, hospital and community clinicians, management, CCG GPs and public health representation.

For the redesign process, the elements of diabetes care were split into five tiers:

  • Inpatients.
  • Complex specialist care.
  • Specialist care.
  • Enhanced primary care.
  • Primary care.

The purpose of the split was not to create divisions or over-engineer the pathway for patients, but to map treatments to the most appropriate professionals and settings. The mapping was significantly aided by Diabetes UK’s Recommendations for the Provision of Services in Primary Care for People with Diabetes, produced in 2005, which included a section on criteria for referral to specialist services.
Various combinations for the provision of different tiers were discussed, which included intermediate providers as used by commissioners in Wandsworth, Enfield, Oxford and Worthing. These intermediate tiers varied from providing enhanced primary care only (such as insulin initiations) to both specialist and enhanced primary care (which would have included traditional hospital activity).
The solution reached by the CCG was to not have a separate service run by separate providers for community specialist and hospital-based specialist diabetes services.The diabetes outpatient activity at the hospital, previously paid for on a pay-per-episode basis, was instead paid for  as a block contract, which was increased to include modest investment in two additional community-based specialist nurses (over and above the funding that was released from the decommissioning and transferred staff) and a £196,000 one-off investment in transition costs.

This was the largest for the purchase
of the hardware required for hospital diabetes staff to review community-based patients (SystmOne units) and the clinical duties of consultants and nurses who needed to be released for a week to complete training.

The new service model
The traditional view of hospital services is that it provides outpatient appointments and inpatient admissions. The main shift the CCG and hospital wanted to achieve was the additional focus on the wider management of diabetes across the population.
To achieve this, the CCG and the hospital agreed a more flexible view of how the integrated diabetes service would act.
The service was not only responsible for seeing specialised cases, but also for providing structured patient education and developing a quality management function. Clinicians in general practice would benefit from an advice service, electronically or via phone, and professional education.
The integrated diabetes service also supports general practice through diabetic specialist nurse review clinics in the community, whether face to face with selected patients or by review of case notes identified by the nurse practitioner or GP. As of the time of writing, the integrated diabetes service has been provided at over 26 locations of the CCG’s 41 member practices.
These changes to the structure of the service were supported by new processes including pathways agreed jointly by primary and secondary care – with specified entry and exit points. These include:

  • Atorvastatin titration before the use of the more expensive ezetemibe, oral anti-diabetic pathways.
  • Improving the consistency between primary and secondary care of lifestyle advice to those diagnosed with type 2 diabetes.
  • Switching patients from different types of gliptin (a particular type of antidiabetic drug) to specifically alogliptin.
  • Reducing the number of blood glucose meter devices (and hence total cost) used by patients across Ipswich and East Suffolk from nineteen to four.

Although many of these service developments have been overtaken by NICE guidance, the Ipswich Hospital Diabetes Centre has identified further projects it is happy to work on with the CCG including reducing the number of blood glucose meter devicess used across Ipswich and East Suffolk from four to one and the review of patients who have been on the more expensive glucagon-like peptide agonists.

The outcome
There are two sources of routine information on intermediate outcomes and care processes – the QOF and the National Diabetes Audit (NDA). The results in relation to QOF, referred to at the beginning of the article, have improved, but the NDA was chosen for the detailed evaluation for the following reasons:

  • It reports Disaggregates type 1 and type 2 diabetes separately in reporting – service predominantly relates to type 2.
  • QOF contains 21 indicators in relation to diabetes, but the data is not linked – for example, 71% of diabetes patients in Ipswich and East Suffolk in 2014/15 had a blood pressure of less than 140/80mmHg, 71% had an HbA1c of less than 64mmol/l – QOF cannot tell us the extent to which these overlap whereas the NDA has a composite measure for patients meeting all treatment targets.
  • QOF is subject to exception reporting – affecting 9.4% of patients in Ipswich and East Suffolk and 10.8% nationally.

At 80% of general practices, participation in the NDA is significantly higher than the national average of 57%. Outcomes are favourable compared to the national average.
The position is favourable in relation to eight key care processes are completed more thoroughly in Ipswich and East Suffolk compared to that of the national average.
These are the checks that healthcare professionals must do to ensure that diabetes complications are caught early. It should be noted that for type 2 diabetes, the percentage of totally completed key care processes fell drastically in England in as a whole between 2013-14 and 2014-15, and this is thought to be due to a more stringent definition in relation to what counts as a test for whether kidneys are leaking protein into the urine as a result of damage diabetes may have done to the small blood vessels.
The National Diabetes Audit showed that in terms of treatment targets, NHS Ipswich and East Suffolk CCG has a higher proportion of patients who meet all three treatment targets than the England average, and that this is unique to the region according to the Healthier Lives website from Public Health England.

1. Alva ML, Gray A, Mihaylova B et al. The impact of diabetes-related complications on healthcare costs: new results from the UKPDS (UKPDS 84) Diabetic Medicine 2015;32:459-66. Epub:07-Jan-2015, PMID:25439048, doi:10.1111/dme.12647
2. Commons Committee of Public Accounts. The management of adult diabetes services in the NHS. 17th report of session 2012-13.
3. Battersby J, Hain D. National General Practice Profiles User Guide. Public Health 2015.

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