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.

Tell us what you think – have your say below or email opinion@nationalhealthexecutive.com

Comments

There are no comments. Why not be the first?

Add your comment

 

national health executive tv

more videos >

latest healthcare news

Cancer Drugs Fund delivered ‘no meaningful value’ to patients

28/04/2017Cancer Drugs Fund delivered ‘no meaningful value’ to patients

The Cancer Drugs Fund (CDF) set up by David Cameron to pay for medicine for over 100,000 people was not good value for money, despite costing the... more >
Health committee urges DH to draw up plan for post-Brexit uncertainty

28/04/2017Health committee urges DH to draw up plan for post-Brexit uncertainty

The Department of Health (DH) have been told to put contingency plans in place to prepare for the effect that Brexit could have on the health and... more >
STPs will not succeed where BCF has failed, warn MPs

28/04/2017STPs will not succeed where BCF has failed, warn MPs

MPs have slammed the government for the failure of the Better Care Fund (BCF) to achieve any of its objectives, arguing that they are unconvinced... more >

editor's comment

22/03/2017New additions and unexpected announcements

As NHE went to press, many of us were still recovering from the chancellor’s unexpected health announcements in his last Spring Budget.   While the sector welcomed Philip Hammond’s revelations, centered on capital funding for advanced sustainability and transformation plans (STPs) and A&E triage schemes (page 24)... read more >

last word

Foreign patient charges are a distraction from the real issues

Foreign patient charges are a distraction from the real issues

Vivek Kotecha, research officer at the Centre for Health and the Public Interest (CHPI), explains why the charging of foreign patients distracts from our home-grown NHS issues.  The Dep... more > more last word articles >
681 149x260 NHE Subscribe button

the scalpel's daily blog

Labour’s pledge to raise wages for ‘underpaid and overworked’ NHS staff

26/04/2017Labour’s pledge to raise wages for ‘underpaid and overworked’ NHS staff

Shadow health secretary Jonathan Ashworth will today outline a major campaign pledge to axe the NHS pay cap, saying that staff are “underpaid and overworked”. The change is predicted to cost the NHS around £1bn, however Labour say that this is the price the government should pay to show hardworking NHS staff that they are being appreciated. Speaking at the Unison Health Conference in Liverpool, Ashworth will say: ... more >
read more blog posts from 'the scalpel' >

comment

A single approach for purchasing HCTEDs

11/04/2017A single approach for purchasing HCTEDs

Andy Leary, finance director of specialised commissioning (National) at NHS England, discusses the new system for buying and supplying high-cost ... more >
Filling the void and standardising security

07/04/2017Filling the void and standardising security

Jayne King, chair of the National Association for Healthcare Security (NAHS) and head of security, portering and reception services at Guy’... more >
Fear barriers to help-seeking in the UK

07/04/2017Fear barriers to help-seeking in the UK

Jon Paxman, 2020health senior researcher, explains why reducing fear barriers may be essential to promoting timely help-seeking, improving health... more >
Considerable scope for improving how local areas tackle smoking

07/04/2017Considerable scope for improving how local areas tackle smoking

Amanda Sandford, information manager at Action on Smoking and Health (ASH), discusses the need to strengthen local relationships in tackling smok... more >
LDRs: a critical part of STPs and sharing cross-border learning

04/04/2017LDRs: a critical part of STPs and sharing cross-border learning

Dr Masood Nazir, national clinical lead – digital transformation of general practice at NHS England and information lead & senior infor... more >

interviews

Tight timetable for nursing associate  regulation

28/03/2017Tight timetable for nursing associate regulation

Jackie Smith, chief executive at the Nursing and Midwifery Council (NMC), talks to NHE’s David Stevenson about the challenges her organisat... more >
Improving the flow

13/02/2017Improving the flow

Glen Burley, chief executive of South Warwickshire NHS FT, explains how his organisation has been able to improve patient flow through its emerge... more >
Leadership development should be for all in health and care

07/12/2016Leadership development should be for all in health and care

Back in August, Stephen Hart joined Health Education England (HEE) as the organisation’s new director of leadership development, which incl... more >
The powerful link between staff and patient satisfaction

03/10/2016The powerful link between staff and patient satisfaction

David Behan CBE, chief executive of the Care Quality Commission (CQC), talks to NHE about the correlation between high rates of staff satisfactio... more >
Dame Fiona Caldicott: We’re not quite ready for sharing back-office function on data security

07/07/2016Dame Fiona Caldicott: We’re not quite ready for sharing back-office function on data security

NHE’s David Stevenson talks to Dame Fiona Caldicott following her much-awaited Review of Data Security, Consent and Opt-Outs. In the f... more >