Health Service Focus

05.10.16

Improving outcomes through integrated diabetes care

Source: NHE Sep/Oct 16

Ipswich and East Suffolk CCG (IESCCG) won the ‘Innovation in Diabetes Care’ accolade at this year’s Healthcare Transformation Awards. Dr John Flather, diabetes lead for the organisation, explains what has been achieved through an integrated care model.

Over the last three years, Type 2 diabetes care in Ipswich and East Suffolk has been transformed through a collaborative approach developed between IESCCG, Ipswich Hospital Diabetes User Group, Diabetes UK and local GPs. 

Dr John Flather, diabetes lead at IESCCG, told NHE that it was back in 2011 that the local health economy realised there was a problem with Type 2 diabetes care in the area. 

“There was too much being spent on admissions and treating complications, and not enough on education and preventative care,” said Dr Flather. When IESCCG was established in 2013, one of the priorities was to develop improved diabetes services as Ipswich Hospital was dealing with a high number of diabetes-related outpatient appointments, at around 12,000 annually. 

“We wanted to have something that linked the CCG, GPs and acute trust together with equal weight given to all sides,” he said. “We worked from the beginning very closely with the hospital. We looked at national models around the country and tried to distil the best from all of them, and put it together to deliver the desired outcomes. 

“One of the things we realised was that we needed the expertise of the hospital consultants, but we needed to provide the service in primary care. That is what we set out to do.” 

Specialist teams 

Dr Flather noted that Ipswich Hospital’s Diabetes Centre has remained the centre of expertise and knowledge. But a team of diabetic specialist nurses, educated in the Diabetes Centre, was formed to carry out satellite clinics at local practices. 

“In the early days, we went to GP practices across Suffolk and started building satellite clinics on a monthly basis,” he said. “We started small, with three or four. Things really started in 2013 and we increased the number of satellite centres. There are about 40 practices in IESCCG, so 25 out of 40 have their own satellite diabetic clinics that run, generally, on a monthly basis.” 

Shared records 

As well as setting up the specialist teams, the CCG commissioned a shared electronic record between primary and secondary care which enabled hospital consultants to view primary care patients’ diabetes records, including blood glucose, cholesterol, blood pressure and drug history with their consent. There is also a template within the notes so medical professionals can see if any of the eight care processes, as recommended by NICE, have not been completed. 

According to Dr Flather, the electronic record, which uses SystmOne, has been critical to the success of the programme and patient sharing has progressed significantly within Suffolk. 

“We have developed an easy tick-box template saying you are happy for the records to be shared out and shared in. We made it clear that for patients to get the best care the hospital should have access to their past records,” he said. 

“After running for a short period of time, we developed a league table of practices to show who were best at sharing records and we shared that with them. Nobody likes to be bottom of the league and that led to an increase in numbers.

“Also, looking at the data, we started at 58% of patients having all eight care processes complete. We are now up to 72%. It is still not perfect but it is moving in the right direction and is higher than the national average, 59%.” 

DESMOND 

Asked whether he thought the model was replicable across the country, Dr Flather said there is no reason why not because it “doesn’t cause any waves”. Instead, the model focuses on early prevention and education. 

For instance, there has been a lot of work around education, and referring patients to the DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) programme. 

“The number of new diabetics who have gone through DESMOND compared to national [data] is quite staggering,” said Dr Flather, who noted that recent figures from the Diabetes Centre revealed that of 707 newly diagnosed patients, 584 were offered structured education and 71% accepted. He added that the number of people getting structured education was, actually, about 60%, but the national average is only 4%. 

“The whole thing has been turned around,” said Dr Flather, adding that by trying to get the early intervention and education right the local health economy is building a strategy to significantly reduce complications in the long term.

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