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Type and Title of Submission


Title:

Evidence-based insulin prescribing in type 2 diabetes

Description:

As part of an overall re-design of diabetes services in Northamptonshire, we reviewed the use of insulin in line with NICE CG87.

The diabetes specialist nurses and a medicines management pharmacist ran (and continue to run) regular training sessions for practice nurses to provide them with the skills to initiate human isophane insulin.

The savings we have consequently made on the prescribing budget have been ring-fenced and used to fund a new community-based Diabetes Multidisciplinary Team.

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG 87 - Type 2 diabetes - newer agents (a partial update of CG66)

Is the submission industry-sponsored in any way?

No


Description of submission


Aims and objectives

Our aims and objectives for the new diabetes service are to deliver a best practice care model that provides the best possible outcomes for patients. This will be through the provision of education, information, support and care so that patients can make informed choices and be able to manage their condition and will be delivered primarily via a Multi-Disciplinary Team (MDT) in the community. The MDT will be funded through savings to the prescribing spend that will be realised by implementing the NICE CG87; the main element of our work is encouraging the use of human isophane insulin as the first-line insulin for people with type 2 diabetes.

Prior to this project, human isophane insulin accounted for only 15% of all long- and intermediate-acting insulin in Northamptonshire. This was virtually the opposite of what we would expect to see if CG87 was being followed. CG87 states, "Begin with human NPH insulin taken at bedtime or twice daily according to need" and specifies the use of analogue insulin only in certain circumstances. Our aim was to start to reverse this trend (this is also a national QIPP Medicines Management initiative) and to use the savings made to fund the MDT. The primary aims of the MDT are to:
- Improve the care for people with diabetes across Northamptonshire.
- Maintain and improve the physical and mental health of people with diabetes and hence their quality of life
- Place the emphases for Diabetes care in the county away from the treatment of complications to management of the condition where patients are empowered to work with clinicians such that they may manage their own condition effectively
- Provide care closer to home
- Provide consistent diabetes care across the county to improve quality and reduce inequities
- Minimise the impact of diabetic foot disease on the local population through a tiered, targeted integrated programme of care
- Ensure that 'hard to reach' groups and those with special needs have equal access to services.
- Reduce unnecessary admissions into secondary care
- Reduce length of stay
- Reduce number of outpatient appointments for TYPE 2 Insulin initiation
- Manage outpatient appointments within a primary / community setting following acute care
- Ensure a health economy partnership approach to the care of diabetes in Northamptonshire
- Promote a culture where clinicians learn from each other through exchange of ideas, knowledge and behaviour

Context

Before the project started, human isophane insulin accounted for only 15% of all long- and intermediate-acting insulin in Northamptonshire. This was virtually the opposite of what we would expect to see if CG87 was being followed. CG87 states, "Begin with human NPH insulin taken at bedtime or twice daily according to need" and specifies the use of analogue insulin only in certain circumstances.

In addition, there was a desire amongst key stakeholders to review the overall diabetes service in the county as there was inconsistency of provision of services in different areas and a lot of dependency on secondary care.

We therefore set up a clinical reference group (CRG) which included diabetologists, diabetes specialist nurses, GPs, practice nurses, patients, podiatrists, dietitians and a pharmacist. Over a period of about 4 months the CRG designed their ideal service with the following identified as priorities:
- Multidisciplinary Team (MDT) - A community based multi-disciplinary team of clinicians will be formed. Its purpose will be to provide a link between primary and secondary care and provide more specialist care for patients outside of an acute setting. This team will include a Consultant Diabetologist, Lead Clinicians, Diabetic Specialist Nurses, Dieticians, Multi-Skilled Practitioners and Administrative Support.
- Podiatry
- Mental Health
- Patient Education
- Staff Training
- Pre-Diabetes
- Diabetes prescribing

The CRG acknowledged that there was no new money to fund this 'wish list' and they examined the current areas of spend and discussed how these could be reviewed.
Inappropriate first-line use of analogue insulin was identified as an area which was not in line with NICE guidelines and was costing an estimated extra 1million per year. The CRG agreed that this should be addressed and the consequent savings ring-fenced and used to fund the MDT.

An audit was undertaken in the form of a questionnaire to practice nurses, which established that the majority had previously only received training in how to implement analogue insulin and consequently human insulin was rarely used.

Methods

In order to put the insulin elements of the NICE CG87 into practice we set up a training course for practice nurses.
The one-day course is run by the diabetes specialist nurses and a medicines management pharmacist.
The pharmacist presents the evidence-base behind the NICE guideline and the nurse teaches the practical aspects of initiating human insulin.
After the training the specialist nurse mentors the practice nurses and supervises their first insulin starts.
The training explains the overall context of the project within the diabetes service re-design, explains the appropriate use of both human and analogue insulin and that the costs saved will be directly re-invested into the diabetes service.
The training does not promote switching existing patients' insulin if they are stable as we believe that this is not ethical. The training is aimed at new insulin initiations.
The training commenced in September 2010 and runs approximately every 8 weeks. The training is provided within the current staff's existing 'day job' and we use free NHS venues so the training does not incur extra costs to deliver.

Results and evaluation

When the training started in September 2010 human insulin accounted for 15% of all long- and intermediate-acting insulin. By July 2012 this had grown to 25% and had avoided over 600K of spend (NB costs in this area are not likely to actually fall due to the high increase in prevalence of type 2 diabetes; projected spend has therefore been compared with actual spend).
This money has been used to fund the MDT and the MDT has achieved:
- A 48% reduction in admissions saving 301k (comparing 2010/2011 to 2011/2012)
- Net savings based on the business case are 181k ahead of estimated savings for the year. (Estimated 608,585, actual 790,012).
- Provided mentoring and support for primary care clinicians in the treatment of diabetes to avoid un-necessary referrals.
- Integrated working in 55 primary care practices with clinics involving the range of clinicians including consultant Diabetologist.
- Provided training to 85 practice nurses to initiate human rather than analogue insulin.
- Provided equality of structured patient education across the county.
- Innovation through the use of 'diabetes specialist workers' to support 'hard to reach' patient groups
- Provided psychological support and training to patients and clinicians to identify and avoid depression and anxiety - which can lead onto complications
- Provided a quality service for patients (see appendix 1 for examples of feedback)
- Nominated for the national 'care integration awards'
- The establishment of one of the largest diabetes MDT teams in the county

Key learning points

The key factor has been working as part of a clinical reference group which ensured that everyone was bought into what we were trying to achieve. It was vital for the clinicians on the ground to be able to see that the money saved was ring-fenced and re-invested in diabetes services. The medicines management team had tried to address insulin prescribing in isolation a few years ago and this was not successful.

View the supporting material

Contact Details

Name:Sue Smith
Job Title:Head of Prescribing and Medicines Management
Organisation:Nene and Corby Clinical Commissioning Groups
Address:Francis Crick House, Summerhouse Lane, Moulton Park
Town:Northampton
County:Northants
Postcode:NN3 6BJ
Phone:01604 651360
Email:sue.smith@northants.nhs.uk

 

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This page was last updated: 02 November 2012

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.