Excellence in primary care - recognising our strengths and

weaknesses

Patrick Holmes GP

Darlington CCG lead for Diabetes & Obesity

Overview

• Standards of Care – Patient perspective

– NICE / clinical standards

– Government

• How are we doing? – Patients

– NICE/QOF

– Budgets

• Can we do better? How?

Practice Nurse for regular check-ups

GP for regular BP and medication checks

Foot calluses noted by practice nurse

Referred by GP for new patient

education classes

Education course at Health Centre delivered by community

education team

Referred by GP for retinopathy screen

Retinopathy screening at Community Hospital

Referred by practice nurse for podiatry

Bob has obesity issues

Referred by GP to dietitian

Dietitian appointments at

the Walk-in Centre

Bob confesses he has erectile dysfunction

Diabetic Specialist Nurse at the erectile dysfunction clinic at

Hospital

Podiatrist at surgery finds foot

neuropathy

Podiatrist refers to Diabetic foot clinic

Diabetic Foot Clinic seen by Diabetic Specialist Nurse, Podiatrist, and Consultant

at Hospital

Nurse Specialist at GP Surgery has recommended

exenatide

Referred by GP to Hospital

Consultant Diabetologist initiates exenatide

GP eventually thinks Bob

requires insulin

Referred by GP to

LES insulin initiation service

Nurse Specialist at the Surgery decides exenatide is a better option so refers

patient back to GP for referral to specialist team

On direct questioning, Bob has a painful

peripheral neuropathy

Podiatrist refers back to GP

Podiatry Clinic at Community Clinic

Foot neuropathy discovered

Paramedics are called because of an episode of

hypoglycaemia

Taken to A&E and admitted to

hospital BOB

AGE 60

Bob is referred for a hip replacement

Bob has an episode of hypoglycaemia as

an inpatient

Referred by GP to Erectile Dysfunction

Clinic

What do patients want from Primary Care?

What do patients want from Primary Care?

• Free Access

• Competent

• Up to date

• Continuity of care

• Good communicators

• Interested + sympathetic

• Time for care

Adapted from Coulter A. What do patients and the public want from primary care. BMJ 2005;331:1199-1200 Cheragbi-Sobi S et al. What patients want from primary care consultations. Ann Fam Med 2008;6:107-115

NSF Diabetes (2001)

1. Prevention of Type 2 diabetes

2. Identification of people with diabetes

3. Empowering people with diabetes

4. Clinical care of adults with diabetes

5. Clinical care of children and young people with diabetes

6. Management of diabetic emergencies

7. Care of people with diabetes during admission to hospital

8. Diabetes and Pregnancy

9. Detection and management of long-term complications

NICE CG 10, 15, 66, 87 & 119

NICE QS 6

NICE QS 6

1: Structured education

2: Nutrition and physical activity advice

3: Care planning

4: Glycaemic control

5: Medication

6: Insulin therapy

7: Preconception care

8: Complications

9: Psychological problems

10: 'At risk' foot

11: Foot problems requiring urgent medical attention

12: Inpatient care

13: Diabetic ketoacidosis

14: Hypoglycaemia

Government

An end to growth in NHS Budgets

NHS spend UK per year in millions £s

£0

£20,000

£40,000

£60,000

£80,000

£100,000

£120,000

£140,000

£160,000

£180,000

1999/00 2004/05 2009/10e 2014/15e

“Gross” Domestic Product

HOW ARE WE DOING? STRENGTHS & WEAKNESSES

GP Survey 2011/2

Q22. Did you have confidence and trust in the GP you saw or spoke to?

Jul 11 - Mar 12

(1,003,926)

%

Yes, definitely 66

Yes, to some extent 27

No, not at all 4

Don’t know / can’t say 3

Yes (total) 93

Q24. Did you have confidence and trust in the nurse you saw or spoke to?

Jul 11 - Mar 12

(961,185)

%

Yes, definitely 64

Yes, to some extent 22

No, not at all 2

Don’t know / can’t say 11

Yes (total) 86

GP Survey 2011/2

Q32. In the last 6 months, have you had enough support from local services or organisations to help you manage your long term health condition(s)?

Please think about all services and organisations, not just health services

Jul 11 -Mar 12 (471,946) % Yes, definitely 40 Yes, to some extent 24 No 11 I have not needed such support 22 Don’t know / can’t say 3 Yes (total) 64

Q33. How confident are you that you can manage your own health?

Jul 11 - Mar 12

(993,487)

%

Very confident 44

Fairly confident 49

Not very confident 6

Not at all confident 1

Confident (total) 93

National Diabetes Audit 2010/11

Care processes recorded All patients with diabetes T1DM under 55 years

All Care Processes 54.3% 33.1%

Urinary Albumin 75.0% 51.6%

Eye Screening 81.9% 74.8%

Foot Exam 84.4% 66.6%

Smoking Review 84.8% 76.9%

BMI 89.9% 80.9%

Cholesterol 91.6% 73.3%

Blood Creatinine 92.4% 76.2%

HbA1c 92.4% 82.7%

Blood Pressure 95.1% 85.6%

Treatment target Achievement

Target All patients with diabetes T1DM under 55 years

HbA1c < 6.5% (48mmol/mol) 24.8% 6.2%

HbA1c ≤7.5% (58mmol/mol) 63.3% 25.0%

HbA1c≤10.0% (86mmol/mol) 92.1% 79.2%

Cholesterol < 4mmol/l 40.7% 25.2%

Cholesterol < 5mmol/l 77.6% 67.6%

Target BP* 36.4% 56.1%

BP < 140/80 44.8% 58.5%

All** 19.8% 11.4%

*BP target <140/80 without kidney, eye or vascular disease (<130/80 with) **Where patient achieved HbA1c ≤ 7.5%, cholesterol <5mmol/l and BP target

Making better use of resources #2

The majority of people with diabetes fail to

take their tablets as prescribed

Donnan, Diabet Med (2002)

MONEY....

Direct Costs (NHS England)

Diabetes currently accounts for between £3.9b¹ to £10b² (4-10% of NHS expenditure)

• Prescribing - £649m¹ to £857m2

• Primary Care (inc. Ret screening) - £1b¹ to £1.2b²

• Hospital Care - £2.3b¹

• “Complications” - £7.7b²

• PCT Programme Budgets - £1.3b³

1. The management of adult diabetes services in NHS – National Audit Office / DoH – (May 2012) 2. Hex N et al. Diabet. Med. 29, 855-862 (2012) 3. Costing Care Pathways – National Audit Commission (2011)

Distribution of the cost of complications (£7.7 billion)

IHD & AMI

Heart Failure

Stoke

other CVD

Excess Inpatient Days

Renal

Foot Ulcers/Amputation

Neuropathy

other

Hex N et al. Diabet. Med. 29, 855-862 (2012)

Making better use of resources

There are only 3 ways to release money:

– People

– Real estate

– Prescribing

Prescribing Costs

£25

£111

£33

£34

£141

£434

£320

£830

£954

£955

£528

£702

£753

£496

£528

£1,010

£1,022

$0 $200 $400 $600 $800 $1,000 $1,200

Metformin 1g BD

Glucophage SR 1g BD

Glimiprimide 6mg OD

Gliclazide 160mg BD

Diamicon MR 120mg OD

Sitagliptin 100mg OD

Pioglitazone 45mg OD

Exenatide 10mcg BD

Exanetide 2mg QW

Liraglutide 1.2mg OD

Humulin M3 50u BD

Novomix 30 50u BD

Humalog Mix 25

Insulatard 50u BD

Humulin I 50u BD

Glargine 50u BD

Levemir 50u BD

Diabetes Treatments: Annual costs

Costs: BNF, June 2012

NB: Cost of treatment only: Some incur additional costs of counselling, administration and monitoring

£0

£2

£4

£6

£8

£10

£12

£14

NIC

(£

)/d

iab

eti

c p

ati

en

t

PCT

Spend on GLP-1 Analogues per person with diabetes October 2010 - September 2011

17 fold variation

Data: Information Centre Prescribing Support and Primary Care Services Oct 2010– Sept 2011

Spend per patient with diabetes on DPP-4

Oct ‘10 – Sept ‘11

0

2

4

6

8

10

12

NIC

(£)/

Dia

beti

c P

ati

en

t

PCT

22 fold variation

Data: Information Centre Prescribing Support and Primary Care Services Oct 2010– Sept 2011

R² = 0.0027

40

45

50

55

60

65

70

220 240 260 280 300 320 340 360 380

Targ

et

Perc

en

tag

e

NIC (£)/Diabetic Patient

All England PCTs: Weighted Prescribing Costs of Drugs Used in Diabetes October 2010 - September 2011 'v' Percentage of diabetic patients whose HbA1C has been 7 or less in the last 15 months April

2010 - March 2011

Data: Information Centre Prescribing Support and Primary Care Services Oct 2010– Sept 2011

Using drugs

cleverly

Using clever

drugs

• Huge cost of prescribing behaviours

• Unwarranted variation

– Does not reflect evidence

– Does not produce better outcomes

• Major source of waste

• Opportunity for better use of resources

Thinking Big

• Care Planning

• Integrating Care

“The greatest single advance in

medicine will not be some new

drug or procedure but an

increased ability of patients to

care for themselves”

Ivan Illich

Unleashing the largest under-utilised resource in healthcare

• 1% (5% of newly diagnosed) of patients with diabetes offered structured medical education in 2009-10¹

• Only one in three with Type 2 diabetes had adequate adherence to OHDs²

http://www.diabetes.org.uk/Professionals/Service-improvement/Year-of-Care/ 1. National Diabetes Audit 2010-11. 2. Donnan,PT. Diabet Med 2002;19(4):274-84

Care Planning

New models of care.....

Practice Nurse for regular check-ups

GP for regular BP and medication checks

Foot calluses noted by practice nurse

Referred by GP for new patient

education classes

Education course at Health Centre delivered by community

education team

Referred by GP for retinopathy screen

Retinopathy screening at Community Hospital

Referred by practice nurse for podiatry

Bob has obesity issues

Referred by GP to dietitian

Dietitian appointments at

the Walk-in Centre

Bob confesses he has erectile dysfunction

Diabetic Specialist Nurse at the erectile dysfunction clinic at

Hospital

Podiatrist at surgery finds foot

neuropathy

Podiatrist refers to Diabetic foot clinic

Diabetic Foot Clinic seen by Diabetic Specialist Nurse, Podiatrist, and Consultant

at Hospital

Nurse Specialist at GP Surgery has recommended

exenatide

Referred by GP to Hospital

Consultant Diabetologist initiates exenatide

GP eventually thinks Bob

requires insulin

Referred by GP to

LES insulin initiation service

Nurse Specialist at the Surgery decides exenatide is a better option so refers

patient back to GP for referral to specialist team

On direct questioning, Bob has a painful

peripheral neuropathy

Podiatrist refers back to GP

Podiatry Clinic at Community Clinic

Foot neuropathy discovered

Paramedics are called because of an episode of

hypoglycaemia

Taken to A&E and admitted to

hospital BOB

AGE 60

Bob is referred for a hip replacement

Bob has an episode of hypoglycaemia as

an inpatient

Referred by GP to Erectile Dysfunction

Clinic

Current Diabetes Care: Current organisation

GPs

Practice nurses

HCAs

1° care 2° care Intermediate care

Hospital doctors

Hospital DSNs

Hospital dietitians

Hospital podiatrists

GP surgeries Hospital diabetes

service

Community

provider arm

DSN = diabetes specialist nurse

Community DSNs

Community Dieticians

Community Podiatrists

Integrated Diabetes Care

HCAs

1° care 2° care Intermediate care

Specialist podiatrists

Diabetes service

Specialist dietitians

Specialist doctors Specialist DSNs

Practice nurses

GPs

“Ownership of the problem, ownership of the solution”

Integrated diabetes care: Derby

• Single delivery organisation: ‒ Joint venture between local clinicians

‒ Company limited by shares

‒ 50% owned by GPs, 50% owned by local hospital

‒ Holds contract with commissioners (PCT)

• Delivers clinical care along whole patient pathway ‒ Redesign of services in a collaboration between 1 & 2 care

‒ Joint venture working enabled clinical decision making to take priority

‒ Collaborative working enabled commissioning of a comprehensive service

Rea RD, Gregory S, Browne M...Tan GD. Integrated Diabetes Care in Derby. Practical Diabetes 2012;28:312-313.

Integrated diabetes care: levels of integration in Derby

• Governance integration: ‒ eg maintain standards across an organisation with ongoing

training and accreditation based on competencies.

‒ eg transfer of clinical risk from individuals to an organisation.

• Clinical integration:

– maximise efficiency throughout the system (eg IT, care planning).

• Financial integration:

– align financial incentives across the whole patient pathway,

rather than traditional organisational boundaries.

• Outcomes being assessed

• Initial clinical data: (Year 1)

- 19% in unplanned admissions

- 38% in patients with a HbA1c <7%

- 26% in patients with a HbA1c <8%

- 18% in patients with a BP <145/85

- 53% in patients with a cholesterol <5mmol/l

Integrated diabetes care

Integrated diabetes care: Portsmouth ‘Super Six’ Model

• Defined patients who should be managed in a hospital setting – Inpatient diabetes

– Antenatal diabetes

– Diabetic foot care

– Diabetic nephropathy (dialysis & progressive renal disease)

– Insulin Pumps

– Type 1 diabetes (poor control & adolescents)

• Community diabetic team (CDT) – Commissioned to care for all other patients

– Enhanced number of DSN + one GPwSI session per week.

– Consultant diabetologist team working partly for CDT & FT

– Regular contact with practices (visits, email and phone support)

Kar P . The Super Six Model. Diabetes & Primary Care 2012;14:277-283.

Portsmouth ‘Super Six’ Model Outcomes after a year

• 41/52 surgeries covered

• 712 patients discharged

• 6 patients needed to be re-referred back in after complaints

• New referrals from 14 to 2 per month

• Won a “Care Integration Award 2012” from the NHS commissioning board

Summary

• How are we doing? – Patients

• Highly value Medical, Nursing and NHS care in general

• Competence, ‘humaneness’ & continuity of care vaulued

– NICE/QOF • Curate’s egg

• Some patients needs not catered for?

– Budgets • Large, but challenged

• UK Diabetes epidemic

• Can we do better? How? – Service redesign with greater integration

– Working with all providers – dealing with vested interests

– Models out there working

Inspire (or protect) a generation