Integrating diabetes care in Derbyshire

Dr Rustam Rea

Consultant Diabetologist, Royal Derby Hospital

Co-Chair First Diabetes

www.firstdiabetes.co.uk

Person centered integration

BOB AGE 60

Practice Nurse for regular check-ups

GP for regular BP and medication checks

Foot calluses

Podiatry Clinic at Village St Health Centre

Referred by GP for New patient

education classes

DAY course at Coleman St Health Centre delivered by

Nurse Consultant, Dietician and Podiatrist

Referred by GP for retinopathy screen

Retinopathy screening at the London Road

Community Hospital

Referred by GP for Podiatry

Bob has obesity issues

Referred by GP to dietician

Dietician appointments at

the Walk-in Centre

Bob confesses he has erectile dysfunction

Referred by GP to Erectile Dysfunction

Clinic

Diabetic Specialist Nurse at the erectile dysfunction clinic at

RDH

Podiatrist at Village St finds foot neuropathy

Podiatrist refers to Diabetic foot clinic

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

Consultant at RDH

Nurse Specialist at the Osmaston Surgery has

recommended exenatide

Referred by GP to RDH

Consultant Diabetologist initiates exenatide

GP eventually thinks Bob

requires insulin

Referred by GP to

LES2 insulin

initiation service

Nurse Specialist at the Osmaston Surgery decides exenatide is a better option so refers patient back to GP

for referral to Consultant

Foot neuropathy discovered

Integration across a community

‘Bringing together clinicians across the system with legal and financial autonomy to

be responsible for the health outcomes of the community’

Whole system integration

1° care 2° careIntermediate care

Specialist podiatrists

Diabetes service

Specialist dietitians

Specialist doctorsSpecialist DSNs

Practice nurses

GPs

First Diabetes – a very new model

Partnership

Shares held 50% by GPs and 50% by acute trust

Single budget, not-for-profit

Comprehensive

Outcome focused, not process driven

A network including primary care, community and hospital staff

No one directly employed – staff either seconded or sessional

Facilities rented

Pillars of integration in First Diabetes

IT

Financial

Patient participation

Clinical engagement

Clinical governance

SystmOne - the IT solution

Single real-time clinical record

Rapid access to decision making and referrals

Consent and confidentiality

Rolled out into tertiary hospital clinics

Patient access

Programme budgeting – the financial solution

Single budget for diabetes, jointly owned by GPs and hospital

Set by PCT based on previous years spend, scope of specification and efficiency savings

Not-for-profit organisation

Re-invest surplus back into the service

Care planning – the patient engagement solution

Care planning philosophy

Patients informed and educated before clinic appointment

Patient shadow clinical board

Diabetes prevention workshops

Education throughout the patient journey

Clinical engagement

Keeping colleagues engaged – primary care and hospital

New style of leadership – collaborative, shared responsibility, acknowledging historical differences

MSc diabetes module for upskilling primary care

Practice visits, discussing difficult patients – 4 groups

Reporting outcomes and comparing practices

Clinical governance

Underpinned by a legal partnership– Company limited by shares– Equally owned by hospital and GPs– Provides stability and confidence in long term future

Move from silo working to joint ownership– Board of directors– Clinical management board– Wider team working – in hospital, in general practice

Cost of integration

50% lower DNA rate compared to non-integrated service

  Cost per patient 

Year 

First Diabetes £

 National tariff

£2009/10 109 1122010/11 124 1182011/12 121 122

Reduction in prescribing costs

1st Q

uarte

r 200

9/20

10

2nd

Quarte

r 200

9/20

10

1st Q

uarte

r 201

0/20

11

2nd

Quarte

r 201

0/20

11

1st Q

uarte

r 201

1/20

12

2nd

Quarte

r 201

1/20

12

1st Q

uarte

r 201

2/20

13

2nd

Quarte

r 201

2/20

13£0.00

£500.00

£1,000.00

£1,500.00

£2,000.00

£2,500.00

£3,000.00

Total diabetes costs

First Diabetes Act Cost Per standard pu

Derbyshire Act Cost Per standard pu

National Act Cost Per standard pu

Co

st

pe

r P

U

£200M savings if figures were extrapolated nationally

Biochemical outcomes

Sustained QoF improvements for diabetes

Reduction in HbA1c (1-2%) and weight (5-10kg) in patients starting new diabetes drugs

75% reduction in insulin doses and 1.25kg weight loss in patients on complex insulin regimes

Admission with primary code of diabetes

2009/10 2010/11 2011/12 2012/130

20

40

60

80

100

120

140

160

180

County Practices

First Diabetes

Admission with a secondary code of diabetes

2009/10 2010/11 2011/12 2012/130

500

1000

1500

2000

2500

County Practices

First Diabetes

21% reduction in admissions in First Diabetes9% reduction in surrounding county practices

Patient and professional satisfaction

“The FD service from Stoneleigh House is excellent. They give excellent care and advise to any patients I have sent there and have always improved the diabetic measures of

control as well as helping the patient with understanding their condition. The patient satisfaction is very high.

They have also helped with my own understanding of diabetes as well as being a considerable support to our

nursing team”

Recognition

Winner of Quality in Care Awards 2012 for Best Cross Boundary Working and Best Primary and Community Initiative

Finalist in HSJ Awards 2012 in Managing Long Term Conditions category

Finalist in HSJ / Nursing Times Care Integration Awards 2012 in Diabetes Care

Finalist in Health Enterprise East Innovations Awards 2012

Challenges ahead

Providing diabetes care for Southern Derbyshire

Integrating with other long-term conditions

Integrating with social services and mental health

Ongoing clinical engagement

Acknowledgements

Dr Garry Tan

Dr Kyran Farrell

Staff and patients at First Diabetes

GPs, hospital management

PCT / CCG

Thank you

www.firstdiabetes.co.uk

Commissioning for Integrated Diabetes Care

www.tinyurl.com/CommissioningDiabetes