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Primary Care Working At Scale

North East Essex Diabetes Managed by Suffolk GP Federation

18 June 2015

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Suffolk GP Federation

61 practice members of 65 in Suffolk

Facilitate practices working together Address issues which are optimally solved by collaboration Provide a management infrastructure

Practices remain independent partnerships

Not for profit CIC

Elected Board of GPs, PMs & CEO

Objectives include support and expanding role of primary care

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North East Essex diabetes

Rising demand

North Essex lower quartile outcomes Care processes - below national mean HbA1c <64 – 168th out of 211

‘Hospital model’ seen as unsustainable

Services fragmented – want integration under umbrella of a single provider

Service tendered and won by Suffolk GP Federation

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Diabetes & podiatry, outpatients & education – adult only

Separate agreement for inpatients

£2.5m in Year 1 (then falling) - no additional investment

Fixed budget with 25% contingent on delivering key performance indicators – no exception coding

5 years with possibility of +2 year extension

The contract – managed by Suffolk GP Federation

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The strategy

Diabetes Service Board to manage the services

3 legged model

1. Patient involvement - care planning & service delivery

2. Investment in primary care capacity & expertise

3. Diabetes Specialist Team – working in the community Consultants on secondment 6 specialist nurses, 2 dieticians , 1 specialist midwife

& 3 admin

Underlined by monthly extract of data from practice clinical systems – next slide

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Example monthly data extract summary

Diabetes IPH -Contract Quality and Performance Management (CQPM) SCORECARD 2014/15INDICATORS Baseline Year 1

TargetApr-14 data

(May meeting)

May-14 data (Jun meeting)

Jun-14 data (Jul

meeting)

Jul-14 data (Aug

meeting)

Aug-14 data (Sep meeting)

Sep-14 data (Oct meeting)

Oct-14 data (Nov

meeting)

Nov-14 data (Dec meeting)

Dec-14 data (Jan meeting)

Jan-15 data (Feb

meeting)

Feb-15 data (Mar meeting)

Mar-15 data (Apr meeting)

40.3% 40.4% 40.6% 40.8% 41.0% 41.1% 41.3% 41.5% 41.6% 41.8% 42.0% 42.1%39.1% 38.2% 37.4% 36.7% 45.3% 46.3% 47.0% 48.2% 50.1% 53.8% 55.2% 60.3%

8.2% 16.3% 24.5% 32.7% 40.9% 49.0% 57.2% 65.4% 73.5% 81.7% 89.9% 98.0%0.0% 0.0% 0.0% 0.0% 6.0% 6.5% 7.1% 5.5% 9.3% 15.1% 17.1% 95.0%

8.2% 16.3% 24.5% 32.7% 40.9% 49.0% 57.2% 65.4% 73.5% 81.7% 89.9% 98.0%0.0% 0.0% 0.0% 0.0% 6.0% 6.5% 7.1% 13.2% 16.4% 27.8% 35.7% 96.0%

>32.3% >32.3% >32.3% >32.3%Not due Not due 16.7% Not due Not due 47.2% Not due Not due 37.1% Not due Not due 37.1%

71.4% 71.5% 71.6% 71.7% 71.8% 71.9% 72.0% 72.1% 72.2% 72.3% 72.4% 72.5%68.9% 69.0% 69.0% 69.4% 69.7% 70.1% 70.4% 69.9% 69.1% 67.9% 69.1% 69.5%

79.1% 79.1% 79.2% 79.3% 79.4% 79.4% 79.5% 79.6% 79.6% 79.7% 79.8% 79.8%76.5% 76.7% 77.0% 77.2% 77.1% 76.9% 76.7% 76.7% 76.8% 76.6% 78.9% 79.1%

78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4%77.1% 76.3% 76.3% 76.5% 76.0% 75.5% 74.1% 72.5% 72.1% 72.3% 73.1% 74.7%

63.5% 64.1% 64.6% 65.1% 65.7% 66.2% 66.7% 67.2% 67.8% 68.3% 68.8% 69.4%63.0% 63.0% 61.0% 61.0% 67.0% 65.8% 65.0% 66.1% 67.9% 70.4% 70.8% 75.0%

Patient empowerment change from baseline to 6 weeks following XPERT education

32.3% >=32.3%

Increase the number of type 1 Diabetics who have had a foot check. 63.0%

maintain upper

quartile

Increase in the percentage of patients with diabetes in whom the last blood pressure is 140/80 or less.

78.4%

% of newly diagnosed Type 2 patients OFFERED education within 12 months of diagnosis

0.0% >=98%

% of newly diagnosed Type 1 patients OFFERED education within 24 months of diagnosis

0.0% >=98%

patients receiving all 8 care processes (Weight, BP, Smoking status, HbA1c, urinary albumin, serum creatinine, cholesterol, foot examination)

40.1% 2% increase

percentage of patients with diabetes in whom the last IFCC-HbA1c is 64mmol/mol or less[<8% in DCCT values] in the preceeding 15 months

71.3% 1.17% increase or

69th centileIncrease in the percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5mmol/l or less.

79.0% 0.88% increase or

48th centile

10% increase

Note – this data extract is based on the National Diabetes Audit format which is different to QoF

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Example of the Practice Dashboard

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Primary care responsibility

Governance Practice lead GP & nurse Quarterly meetings with consultant & Link DSN Referrals via Specialist Team

Monthly primary care data extract Case finding e.g. IGR Year of Care training and roll-out Manage wider range of patients – stable T1, T2DM

discharged from hospital Involve partially engaged Focus on KPIs – particularly 8 care processes

£6.44 per list patient over 5 years – Moving to 100% on outcomes from 2015/16

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2014/15 progress

Positive engagement by Colchester Hospital and specialist clinicians – facilitated positive change incl. TUPE, IG and contract issues without a significant detriment to service. Similar joint working with Anglian Community Enterprise

Diabetes Services Board now manages service

Significant investment in engagement events, patient groups and social media

Diabetes Specialist team formed New role for consultants supporting practices and providing governance Positive impact of DSN Link Nurse influencing change in referrals Regular non-clinical visits to improve coding and improve engagement

Most care moved out of hospital 504 (66%) of former hospital patients discharged to practices (142

(44%) T1s and 362 (83%) T2s) – remainder managed in community by Specialist Team – only 2 complaints

Only combined specialist clinics which require input from other specialists or specialist equipment remain at the hospital

Year of Care training rolled out across all practices

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2014/15 outcomes

April 2014 March 2015

Note

Number on diabetes register 17,470 18,400 +5.3%

Patients receiving all 8 care processes

7,00540.1%

11,09560.3%

Percentage receiving all 8 +20.1%

(+58% on 4/15)

Newly diagnosed offered structured education Unclear

T1’s 95% & T2’s 96%

187% increase in patients referred

v 2014/15

1,607 patients referred for structured education, 588

booked (37%) and 462 completed (29%)

HbA1c <=64mmol/mol 11,68766.9%

12,11265.8%

This fell for patients on register >12 months as well

Cholesterol <=5 12,40071.0%

13,65774.2%

Percentage with Chol <5 +3.2%

BP <=140/80 11,77767.4%

12,93970.3%

Percentage with BP <=140/80 +2.9%

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% Patients Receiving all 8 Care Processes at 31/3/15

2013/14 mean

Individual Practices

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Other outcomes

% of Register at

March 2015

% change

T1s receiving a foot check 63% +12.0%

Foot ulcers referred to Podiatry 16% +7.7%

High risk feet referred to Podiatry 26.2% +17.5%

Patients with care plans 16% +7.8%

Admissions for DKA/hypoglycaemia /hyperglycaemia

188 to 177 -7%

Readmissions for DKA/hypoglycaemia /hyperglycaemia

98 to 67 -31%

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Comments

Brave commissioning by CCG

Improving clinical outcomes takes time

Very complex contract to manage with significant risks – not for the faint hearted!

Importance of positive buy-in and engagement from senior clinical team members – both consultants and nurses - changing role of consultant

Including the inpatient work makes a comprehensive and joined up service

Difficult to recruit patients onto peer led empowerment programmes

Importance of real time activity feedback

Not all practices able to fully engage - Hard to reach patients need a separate strategy

We now have increased knowledge of the total cost of diabetes e.g. insulin pumps

Coding is a major issue - foot coding still an issue

Pace of change a challenge