The Berkshire West Federation diabetes stakeholder network Diabetes Sans Frontières (DSF) was formed in 2012 with the aim of driving up standards of care for people with diabetes in our community.
DSF was formed to ensure that care for people with diabetes is designed and delivered in the interest of the patients and their carers to achieve the best outcomes possible with the resources available.
The network aims to reduce the burden of diabetes on people in our community with the disorder, to improve outcomes, and to do this whilst reducing the unit cost of care.
This example was originally submitted to demonstrate implementation of NICE guidance CG66. This guideline has now been updated and replaced by NG28. The practice described in the example continues to align with the updated guideline in regard to structured education programmes (Recommendation 1.2.1).
This example was highly commended in the 2014 NICE Shared Learning Awards.
Aims and objectives
The Berkshire West Federation diabetes stakeholder network Diabetes Sans Frontières (DSF) was formed in 2012 with the aim of driving up standards of care for people with diabetes in our community. This was formed from our four federated CCGs: N&W Reading, South Reading, Newbury & District, and Wokingham)
DSF network aims are to:
- Enable patients to receive the right care in the right place at the right time
- Provide a forum where all service development will be presented and agreed
- Ensure that providers give regular reports on performance to all key stakeholders, enabling service issues arising to be addressed
- Create a platform for innovation and service improvement opportunities to be debated and agree upon
- Encourage the promotion of integrated working and sponsorship
- Be a fully representative decision making body for diabetes services
- Ensure patient views are solicited and acted upon when considering service performance and developments
- Improve communication between all stakeholders and in particular, to patients and between providers.
DSF was formed to ensure that care for people with diabetes is designed and delivered in the interest of the patients and their carers to achieve the best outcomes possible with the resources available. The diabetes network board provides the forum where service developments are presented and agreed. Members give regular reports on the key performance indicators, enabling service issues arising to be addressed, creating a platform for innovation and service improvement opportunities to be debated and agreed upon.
The network strives to implement best practice, and to exceed standards of care and outcomes set down by NICE, thus moving our services into the low-cost good-outcome service category as described by the DOVE tool.
The network aims to reduce the burden of diabetes on people in our community with the disorder, to improve outcomes, and to do this whilst reducing the unit cost of care. The network also aims to reduce referral to secondary care, and the use of emergency unplanned care.
Reasons for implementing your project
NICE NG28 Recommendation 1.2.1 outlines key priorities for patients to have structured education, and to achieve their individualised targets for glycaemic control, cholesterol and blood pressure. People with diabetes should also have 9 key clinical processes yearly to identify risk of diabetes complications.
The process that highlighted the need for change in our healthcare community was reports from the National Diabetes Audit of 2009-2010, which showed our community performance in care process and therapeutic target achievement was amongst the worst in England.
These data demonstrated that the implementation of the process of diabetes care as defined by the 8 key processes of diabetes care (retinal screening excluded from 9 NICE measures in this audit) and achievement of therapeutic targets for glycaemic control, hypertension, and lipid management for the 17200 people with diabetes in our community were significantly worse than for matched communities in England. Specifically, glycaemic control was poorer for our community (46.8% vs. 56.8% achieving HbA1c<58mmol/l) and the cost of diabetes care higher at (£548 vs. £517 per person (pp)) than matched communities (2009-10). (See supporting documents).
How did you implement the project
The CCGs engaged an external consultant experienced in process management to guide us, and his help was invaluable. Key to this process was the development of the DSF network board comprising primary and secondary care physicians, healthcare commissioners, patient representatives, diabetes specialist nursing, public health, community nursing, medicines management, communications and community pharmacy - around 20 members.
To do this, the DSF network objective was to improve the skills training of all HCPs, to break down barriers between providers of diabetes care, and to set up robust treatment pathways that would ensure that appropriate care processes and therapeutic interventions occurred in a timely manner without delay.
Our key methods was introduction of
- a community diabetes specialist nurse (DSN) service integrated with secondary care services. The DSN team now works to provide adult education, and directly to support GP practices.
- Nationally approved patient education with DAFNE for type 1 diabetes (4 courses per year) and X-pert for type 2 (60 courses per year).
- HCP education with a Diabetes Foundation course, and an advanced course in injectable therapies, PITstop.
- Care Planning as a consultation tool in primary care. Clinical metrics are collected and posted to the patients 2 weeks ahead of a collaborative consultation focussing on goal setting and action planning.
- a dedicated website for patients, carers and HCPs (www.berkshirewestdiabetes.org.uk)
- a monthly newsletter for HCPs
- a bariatric service with community-based weight loss programmes, and the provision of specialist services including bariatric surgery.
- a web-based system for benchmarking and audit (Eclipse) which enables active case finding within practices.
We have now established a community based diabetes specialist, who provides virtual diabetes clinics, visiting practices and reviewing cases with the practice HCPs, with a capacity of approximately 1500 case reviews per year. Virtual consultation by email or phone for difficult urgent cases and admission avoidance, as well as community based diabetes clinics. These changes are significantly reducing referrals to secondary care and unplanned care.
Care planning is now established in over 20% of our practices and is changing clinical care in those practices.
The web based system Eclipse is installed and 100% of practices are now enrolled. Patients are now able to look up their own records and results thought this system when registered using a smart card.
The most recent National diabetes audit shows that the proportion of people with diabetes receiving all process of diabetes care has increased significantly in those with T2DM from 33.9±2.3% (mean±SEM) (2009-10) to 56.1±1.4% (2011-12) p<0.01. The proportion of people with TIDM diabetes receiving all process of diabetes care has also increased, but from 23.8±3.2 to 42.1±1.5 although this is not statistically significant).
We have been able to control our prescribing costs. The trajectory of increasing cost of diabetes prescribing has been reversed from £294±3 (2009-10) and £313±1 (2011-12) to £283±1per person year (2012-13) (p<0.01).
It is early yet in our project, and as yet, the proportion of people achieving all targets for glycaemic, blood pressure and cholesterol management has not changed at 13.0±0.8% to 15.2±0.8% for T1DM and 20.3 ±0.4% to 20.7±0.5% for T2DM (2009-10 vs. 2011-12).
Establishment of our diabetes network is improving the process of care and is reducing costs. Our new structures make it easier to plan, introduce and monitor care for people with diabetes.
Key learning points
Our key learning points are:
- It is necessary for clinical leaders to fully appreciate the need for change, and the consequences of not doing so.
- Asking for help
- Early appointment of leadership for the programme with generous time provision, and the granting of 'freedom to roam' - the freedom to explore and innovate without the need to constantly refer to CCG boards
- Development of a dynamic stakeholder network to create a platform for joint decision making.
Barriers to change were remarkably few and were overcome relatively easily. There was widespread strong agreement amongst the 4 CCGs that diabetes was a key area where we were underperforming, and a realisation that it would cost us all dear - both in terms of the human cost, and financially - if we did not raise out game. The CCG Federation Chair and Long Term Conditions Chair were both strong advocates of change and fully supported the measures we have introduced. It has been very significant to have commissioning fully on board with the network, and the close collaboration between healthcare commissioners and providers has been powerful - the sense that we are truly working together to create something worthwhile.
The only really significant barrier to change is in implementation. Convincing overworked GPs and Practice Nurses to embrace and implement change is always a challenge. However, 'fast adopter' practices have welcomed many of the changes and the positive signals generated by them are being fed back to encourage other practices to follow suit. There is an expectation by the CCG boards that all practices will fully implement the changes that the stakeholder network is steering.