Monday 14th May 2018

13:30 -16:30

Mary Ward House, Conference Centre

Wifi: MaryWardHouse

Password: 8d0da34dfe

London Diabetes Treatment Targets Workshop

London Treatment Targets Workshop

Welcome

• Emergency Exits

• We will not be expecting any fire alarm drills today

• Mobile Phones

• Photography – we anticipate that the slides will be

shared after the meeting, therefore please be mindful when taking pictures of the slides.

London Regional Diabetes Event

Wi-Fi Access:

‘MaryWardHouse’

Password:

8d0da34dfe

Agenda

NHS RightCare – opportunities for

system sustainability

Working together to improve health outcomes

Dr Naheed Rana

NHS RightCare Delivery Partner 14th May 2018

What is RightCare?

NHS RightCare is a programme committed to reducing unwarranted variation to

improve people’s health and outcomes. It ensures that the right person has the

right care, in the right place, at the right time, making the best use of available

resources.

NHS RightCare ensures local health economies

• make the best use of resources to give better value – better value for patients,

the population and the tax payer.

• understand how they are doing – by identifying variation with demographically

similar populations

• get talking about the same stuff - about population healthcare rather than

organisations

• focus on the areas of greatest opportunity by identifying priority programmes

which offer the best opportunities to improve healthcare for populations

• use tried and tested processes to make sustainable change to care pathways to

reduce unwarranted variation 6

7

8

NHS RightCare - Approach

Quality

Spend Outcome

Triangulation of indicators

Identify improvement

opportunities by addressing

unwarranted variation to

create optimal value

9

Principles of value based optimal design

• Shared, common aim

• Shared involvement in defining optimal and

how best to use assets from across the

system to achieve the aim

• Focus on people and the population not the

organisations.

• Focus on those we don’t know as well as

those we do

Population focus

System thinking

Value based

Think of value in two ways:

1. Allocative/Technical/Personal

• Allocative – doing the right things

• Technical – doing them right

• Personal – decisions based on best

current evidence, individuals values

2. Overuse/underuse

• Overuse of lower value interventions

• Underuse of higher value interventions

11

Comprehensive range of Commissioning for Value (CfV) data Intelligence

packs and other products available on RightCare web page:

https://www.england.nhs.uk/rightcare/products/

12

Diabetes Pathway Each indicator is shown as the percentage difference from the average of the 10

CCGs most similar to CCG X

13

Diabetes Pathway Each indicator is shown as the percentage difference from the average of the 10

CCGs most similar to CCG Y

14

Example: North West London STP Diabetes pathway and indicators shown for each CCG within the STP to look for

opportunities to improve at scale

15

Example: North West London STP

16

STP Improvement opportunities

17

Build Storyboards • Prevention, risk factors, primary care, secondary care, prescribing, social

care, public health, outcomes, other co-morbidities and patient journey

18

Build Storyboards • Prevention, risk factors, primary care, secondary care, prescribing, social

care, public health, outcomes, other co-morbidities and patient journey

Quality

Spend Outcome

create optimal

value

patient centred

20

Risk

21

Nine Care Processes

22

Diabetic Complications

23

Good Practice examples

• Effective models of working

between primary and secondary

care to support reduced

unnecessary referrals and

improved outcomes for patients

• Dashboards to drive

improvement

• Joint management plans held

between the consultant and GP

• Access to the clinical record,

shared between the consultant

and GP

• Virtual clinics

• Integrated IT

• Pooled budgets

24

Develop Logic Models

Develop Logic Models

25

• Bringing together pieces of the puzzle to create optimal care pathways and

systems, with patients at the centre

• Adopting Population Health based approach from wellbeing and prevention

through to end of life - shift activity towards prevention

• Working closely with Partners – Diabetes UK, Public Health, National Clinical

Programme, ECTP, NHSI, GIRFT and social care to align priorities and deliver

system wide transformational change & policy at scale.

• Reduce unwarranted variation, workforce retention

whilst using the STP/LHE framework as a vehicle to plan, engage

and improve pathways & deliver opportunities

• Adoption and replication of RightCare initiatives

across system

• Do the right things - i.e. embedding

Shared Decision Making into pathways

26

Opportunity to create a paradigm shift

27

Thank you

Dr Naheed Rana

NHS Right Care - Delivery Partner

(07714 773645

8 Naheed.Rana@nhs.net

DIABETES IN NEL LONDON - ACHIEVING THE TREATMENT TARGETS

Dr B. Huda Consultant Physician

• 7 CCGs • 5 Trusts

– BARTS – BHRUT – ELFT – NELFT – Homerton

• Clinical Effectiveness Group (CEG)

30

NEL

Barking and Dagenham

City and Hackney

Havering

Newham

Redbridge

Tower Hamlets

Waltham Forest

Tower Hamlets – current model

Nominated lead for each practice

Consultant based clinics in the community shared with practice diabetic lead

Specialist diabetic nurse coming out into practices for ‘difficult to manage’ cases and to support insulin starts mentoring practice staff

Monthly multidisciplinary team meetings attended by consultant, DSN, practice leads and extended diabetic team to share and discuss cases and propagate learning, provide local and national updates, share good practice

Role of Community

Diabetologist

Help set up and run diabetes clinics in primary care

Undertake problem patient clinic, cases discussion meetings, educational meetings etc. in primary care

Provide link between primary and secondary care, and support for Community DSN

Secondary care service

Role of Community

DSN

Help practice nurses set up and run diabetes clinic and provide advice / support to practice nurses

Have a case load of patients in with poor control

Undertake education (group and individual) for patients

Education for other health care professionals

Primary Care

Offers routine care (inc annual

review) to all diabetic patients

Patient

Hospital Diabetes Service

Complications, Complex

problems, Pregnancy, Type 1

diabetes

Community DSN

Across the STP

Newham – regular cluster meetings with community DSN support

City & Hackney – similar model to TH with dedicated community/acute DSN working within practices and regular diabetes network meetings

Waltham Forest and BHR – developing similar models

Support from CEG developing across NEL

NDA participation

CCG/LHB Name

Practice

Count

Practices

Submitted

2015-2016

Participation

NHS BARKING AND DAGENHAM CCG 40 36 90.0

NHS CITY AND HACKNEY CCG 43 43 100.0

NHS HAVERING CCG 48 40 83.3

NHS NEWHAM CCG 57 57 100.0

NHS REDBRIDGE CCG 45 41 91.1

NHS TOWER HAMLETS CCG 36 36 100.0

NHS WALTHAM FOREST CCG 44 41 93.2

NHS Right Care Diabetes

Diabetes Transformation Bid

Type 1 Diabetes

Young patients aged 16-25

Preconception

Virtual Case reviews

Type 1 diabetes and young people Enhance structured education capacity across

Barts health

Enhance CSII and technology uptake

Establish true type 1 prevalence , barriers to accessing secondary care, formulate a risk register

Establish MDT models for those with frequent admissions to ED in partnership with RAID, CMHT etc

Preconception

Enhance the EMIS template for annual care review

Develop monthly dashboard for key indicators

Virtual Care reviews

CEG data to provide data at practice level for patients not achieving treatment targets

Practice level review and liaison with community DSN/GP about priority patients

Some direct case note review

What have been the 3 biggest successes/ what are you proud of?

The multi-disciplinary working groups; with membership including a range of clinical and non-clinical staff from a range of organisations across the STP area. Due to the delay in sign-off of the MOU much of the work carried out by this group was carried out in “unfunded time” by staff

Creation of the Education sub-group which scoped current structured education programmes across sites, identified staff training needs to deliver DAFNE.

Close working with the CEG/Clinical Effectiveness Group at QMUL has provided data and the creation of a NEL dashboard to allow benchmarking and audit which will allow in real-time (monthly) oversight of performance and a focus on areas to improve

42

Successes- what has worked?

What have been the top 3 issues and challenges How were these or will these be addressed? What would you do differently? MOU

Significant delay in MOU sign-off which resulted in a delay in appointment to key posts & delivery of milestones

Senior STP buy-in to the bid Governance processes

Partnership working Provider buy-in BHR Working directly with MD in BHR Escalation at an earlier stage

43

Top 3 Issues or Challenges

Summary

Steady progress into Year 2 of DTF

Recruitment/Working groups established

Build MDT/ patient engagement models/dashboards

Setting the direction for Diabetes Transformation -Road Map Approach

Sola Afuape, Workforce Lead for Diabetes, North West London

Initial work across 5 CCGs (CWHHE)

Central

West H&F

Ealing

Hounslow

Brent

Harrow

Hillingdon

Now working across all 8

4 acute providers, 5 community providers, 1 tertiary Central London Community Healthcare NHS Trust Central and North West London NHS Foundation Trust Chelsea and Westminster Hospital NHS Foundation Trust • Chelsea and Westminster Hospital • West Middlesex Hospital Imperial College Healthcare NHS Trust • Charing Cross • Hammersmith • St Mary’s London North West Hospitals NHS Trust • Central Middlesex • Ealing • Northwick Park Royal Brompton and Harefield NHS Trust The Hillingdon Hospitals NHS Foundation Trust West London Mental Health NHS Trust

North West London – a complex landscape

Diabetes is a leading cause of mortality and morbidity in NW London

>142,000 patients in NWL with diabetes (and >190,000 with NDH)

>1000 premature deaths annually

29.4% of emergency admissions

28.3% of NWL bed days

> £340m NWL spend on diabetes (80% spent on complications)

> 25000 living with poor diabetes control (mostly under 65)

North West London Diabetes Transformation Programme

• Achievements so far:

Successful bid for £2.35m share of NHSE Diabetes Transformation Funding

Wave 1 National Diabetes Prevention Programme – largest referrer into the programme

nationally (3 times national average)

Digital Prevention Programme Pilot – since November 2017

Improvements in key metrics

£75k Health Foundation Innovation for Improvement grant to support tailored self-care support

• Awards to date:

Healthcare Transformation Awards: Population health; Diabetes Innovation

Quality in Care Diabetes Awards: Diabetes Team of the Year; Diabetes Prevention and Early

Diagnosis

HSJ Awards: Highly Commended for Primary Care Innovation

2018 – team members are also shortlisted for HSJ and RCNi awards

Key elements of success so far

Patient empowerment

Clinician education

Networks and MDTs

Dashboards

Contracts

Clinical system optimisation

Clinical guidelines

NWL Diabetes Transformation Programme

Project and Subgroup Responsibilities

Updated May 2018

Diabetes Digital Subgroup (All bids + Prevention)

(Co-Chairs –Dr Tony Willis /John Kelly) Project Lead - Will Gilmore -Diabetes Digital Programme Lead Programme support –Deepa Somarchand

Diabetes Commissioning and Contracting Subgroup (All bids + Prevention) Co-Chairs –Dr Raj Chandok / Dr David Gable/ Lesley Robertson Project support – Mark Digby

Project 4. Diabetes Type 2

Prevention Project (incl NDPP) Chair- Lawrence Gibson Implementation Lead

–POST VACANT ( Dr Buchi Reddy Holding)

Programme Support - Manal Adam

Project 3. Diabetes Foot Project

(MDfT bid)

Chair- Dr Wing May Kong Implementation Lead – Catherine Farrer

Programme Support –Manal Adam

Type 1 Diabetes Subgroup (All bids) Co-Chairs :Prof Nick Oliver / Maureen McGinn Programme Lead– Cathrine Farrer Project support – Deepa Somarchand

Project 2.

Reducing unwarranted variation in BP, Cholesterol and HbA1c

(3TTs & DISN bid) Co-Chairs: Dr Koteshwara Muralidhara

Implementation Lead - Kay Dhesi Programme Support – Deepa Somarchand

Project 1. Increasing attendance at Structured

Education (SE bid) Including Diabetes Care Advisory Board

Co-Chairs: Grace Vanterpool & Dr Joan St John

Implementation Leads – Alex Silverstein / Howard Tingle Programme Support– Mark Digby

NWL DIABETES PROGRAMME BOARD SRO – Juliet Brown

Chair – Dr Tony Willis / Deputy Chair - Lesley Robertson Programme Support – PMO Manager ( VACANT)

Diabetes Mental Health Subgroup (All bids + Prevention)

Co-Chairs –Dr Amrit Sachar Programme Manager – Kay Dhesi Project support – Mark Digby

Roadmap - unstructured to structure

Key Themes:

• Programme milestone delivery for the 4 Key programme streams

a) Structured Education

b) 3TTS

c) Multi-disciplinary foot Care

d) Prevention

• Local CCG quarter reporting and future forecasting

• Demonstration of enabling tools:-Dashboard benchmarking and reporting e.g Unify Data collection

• Local examples of best practice and quick wins

• Digital Behavioural change

• Barriers to update of Diabetes Education

Road Map approach

• Quarterly themed Road Map days, to sense-check delivery against outcomes

• Delivery through CCG-level Transformation Groups, chairs meet monthly in our NWLCCCGs Programme Board

• Key change agents in each CCG are

a) GP Transformation Leads (2.5 WTE)

b) Diabetes Nurse consultant (1WTE)

c) Project Support Officer (1WTE)

• Structured implementation through Dashboards cut per CCG / per practice / patient-level

• Teamwork – Collaborative tool for programme management (monitoring and risk management)

• Local sharing of best practice and peer to peer challenge

• Invited speaker - external inspirational, examples of innovation

• Developing underpinning communication plan

• Feedback, evaluation and review

Diabetes Level 1 High risk

Dia

bet

es r

egis

ter

% 9

key

car

e p

roce

sses

in 1

5m

% C

on

tro

lled

NIC

E ta

rget

s

% H

bA

1c

≤ 5

8

% B

P ≤

14

0/8

0

% C

ho

l ≤ 4

% C

are

pla

nn

ing

in 1

5m

% H

ypo

glyc

aem

ia m

on

ito

rin

g

Hig

h r

isk

of

dia

bet

es r

egis

ter

% H

igh

ris

k an

nu

al r

evie

w

Central Central 2186 29.3 16.7 54.7 60.9 36.7 29.2 21.7 539 7.4

North 3204 26.9 17.2 58.8 61.6 37.7 18.3 20.4 1351 8.3

South 2127 43.5 21.4 62.7 71.8 37.6 15.1 29.8 484 20.7

Central Total 7517 32.3 18.3 58.7 64.3 37.4 20.6 23.4 2374 10.6

Ealing South Southall 4453 29.8 15.2 48.3 65.1 38.2 54.1 37.5 2635 57.1

Acton And Chiswick 3114 51.8 19.2 59.7 65.7 39.7 57.9 58.6 2039 61.4

Central Ealing 2270 41.0 20.7 61.8 68.1 40.5 43.5 43.6 1194 37.5

North Southall 6927 35.3 15.2 50.5 57.4 36.0 40.1 44.2 3389 34.4

South Central 1988 37.6 19.2 58.1 65.6 41.3 55.3 27.6 1107 29.2

South North 3591 30.0 18.0 48.8 60.3 37.2 24.8 49.7 2303 20.9

North North 4323 39.4 19.9 58.4 64.8 41.8 41.8 51.0 2536 43.3

Ealing Total 26666 36.9 17.6 53.8 62.7 38.7 44.1 45.2 15203 41.2

H&F Network 1 1760 43.3 19.6 60.6 61.0 44.9 59.3 54.0 622 46.5

Network 2 1552 43.7 20.5 60.9 61.3 40.7 61.2 57.3 580 26.4

Network 3 1040 26.7 20.3 60.3 62.9 39.6 46.3 49.1 602 37.5

Network 4 2453 32.1 16.9 53.3 62.9 38.6 31.3 28.0 305 33.8

Network 5 1287 36.5 14.7 51.3 55.2 34.8 59.8 52.1 572 33.2

H&F Total 8092 36.8 18.3 56.9 60.9 39.9 49.6 45.2 2681 35.8

Hounslow HoH 5031 58.9 20.3 59.3 67.9 41.7 63.2 67.4 3766 42.5

Brentford 3066 32.6 13.5 59.6 61.3 36.9 47.8 38.1 2563 28.9

Feltham 3937 43.9 21.1 56.8 69.1 43.2 61.8 60.6 1688 35.3

Chiswick 1564 45.5 19.9 61.6 68.9 37.1 41.9 54.2 1333 26.6

Great West 4439 43.5 16.1 55.0 64.0 36.9 45.1 33.2 2563 13.3

Hounslow Total 18037 46.2 18.2 58.0 66.2 39.6 54.0 51.4 11913 30.5

West London2 North 3853 42.3 17.6 53.6 66.4 39.2 31.9 29.9 1577 48.1

North Central 2482 38.0 18.2 60.5 66.4 37.3 26.3 26.4 955 20.3

South East 1284 27.0 16.0 57.9 60.5 37.0 13.0 17.4 454 26.4

South West 2069 39.8 17.2 54.2 66.1 36.9 27.9 43.3 812 31.5

West London2 Total 9688 38.6 17.5 56.1 65.6 37.9 27.1 30.3 3798 35.0

Grand Total 70000 39.0 17.9 56.1 64.0 38.8 42.4 42.1 35969 34.6

Dashboards driving change

June 2016 March 2017

Picture example Team works

Structured education and lifestyle change hub

Face to face course

eLearning

Videos

Coaching / Mentoring

Lifestyle change app

NWL Structured education hub

GP Referral

Self referral

Referral from other

Social media Emails Website

management and content

Receive referrals from across NWL

Refer patients to most appropriate intervention

Outgoing communication

SMS messaging

Changing Health

Digital supported self-care: 3 apps pilot to project

Oviva OurPath

Combinations of: App, Website, Goal setting, Coaching/mentoring, Exercise tracking, +/- Peer-peer interactions, +/- 3G Scales, +/- Fitness band

Change in numbers of CWHHE patients with improved care since Q2 2015

22,124 more receiving 9 key care processes

4,884 more with HbA1c 58

3,088 more with NICE targets controlled

5,315 more on NICE recommended statin

20,340 more monitored for hypoglycaemia

46,332 more with collaborative care plan

Iterative learning approach to Road mapping

• Maintaining a focus on our commissioned scope

• Need for ever flexible approaches to engaging with an increasing, diverse and complex stakeholder network

• Clarification of roles and responsibilities both within and outside the programme

• Providing a space to air challenges of local delivery

• Importance of celebrating progress made

The Roadmap events are an evolving and important part of our delivery arm – we incorporate feedback from our stakeholders and as our patient/carer work grows there will have greater involvement in co producing the structure and delivery of the events

Summary

• Road Map events provide focus, clarity and learning

• There is consistent engagement of over 150 stakeholders across NWL health and social landscape (inc 3rd sector)

• A shared understanding, monitoring and use of data is a key part of our success and vital to implementation

• Opportunities for local CCGs to acquire enabling tools, share best practice and hear about the latest innovations

• Patient and Carer contribution is key

Contact details

Sola Afuape Workforce Transformation Lead

Diabetes Transformation Programme

Strategy and Transformation Team

NHS North West London Collaboration of Clinical Commissioning Groups

3rd Floor, 15 Marylebone Road, London, NW1 5JD

Email: nwlccc.diabetes@nhs.net

www.healthiernorthwestlondon.nhs.uk

@HealthierNWL

Haringey diabetes improvement programme

Dr Will Maimaris

Background

• Over 15,000 adults with diabetes in Haringey – diverse population

• Currently only 37% of people with T2 diabetes hitting all three treatment targets – (blood sugar, blood pressure, cholesterol)

• £221.5k in 2017/18 and provisional £202k in 18/19 for programme of work to improve 3-TTs.

• But wider issues in diabetes care beyond 3-TT in Haringey • Variation in primary care (excellent to less than excellent) • Inconsistency in pathway and delivery of care leads to inconsistent

patient experience and outcomes • Lack of integration between physical, lifestyle and mental health

support • No consistent workforce standards for primary care staff

Specialist diabetes cohort

(Super 6)

People with diabetes and

complex needs

Approx 1-2,000 people

Adult diabetic population

25,000 people

At-risk of diabetes (pre-diabetes)

42,000 people

Common outcomes across pathway: (To be finalised) Achieving 3 treatment targets: BP, cholesterol, blood sugar Access to self-management, diabetes education, lifestyle advice Well co-ordinated care for people with diabetes Reduction in anxiety and depression in people with diabetes Increased proportion of people with diabetes in employment Long-term: Reduction in residential care packages Reduction in strokes, heart attacks and amputations

Ongoing specialist care for specific cohorts only: •antenatal and inpatient diabetes, diabetic feet, insulin pumps, type 1 diabetes, diabetic kidney disease, transitions

•Care co-ordination by multi-disciplinary team: Including access to social worker, social prescribing etc

•Standardised high quality management in primary care with links to community support: Regular review and consistent application of evidence based practice •Access to peer support, social prescribing and education to enable self-management and lifestyle change. •Single point of access to diabetes integrated service – e.g. community diabetes nurse, psychological support, dietician, podiatry, specialist advice, social work support

•Community led initiatives to support behaviour change •Identification in primary care and referral to diabetes prevention programme

Enablers: •Integrated IT for direct care

•A care plan visible to all involved in care

•Data and analytics to support quality improvement •Joint programme management and governance •Active involvement of local authorities and voluntary sector •Pathway co-designed with residents and community and voluntary sector input. •Using digital solutions to reduce contact time and paper work for professionals •Hospital and community diabetic team support education, quality improvement and workforce development in primary care

Haringey and Islington Wellbeing Partnership - Proposed Haringey and Islington Diabetes model of care

Some data from latest QOF and NDA (16/17)

CCG name

Diabete

s

Register

Size(17+

)

Prevalen

ce (per

cent)

% of

people

with

diabetes

and

BP<140/

80

% of people

with diabetes

and

Cholesterol<5

% of people

with

diabetes

and

HbA1c<59

% of people

with T2DM

hitting all 3TT

(15/16 NDA)

% of people

with T2DM

hitting all

3TT (16/17

NDA)

NHS BARNET

CCG 20,105 6.2 69.5 71.4 61.4 42 41.1 NHS CAMDEN

CCG 9,057 4.0 73.6 74.0 64.0 44 43.2 NHS ENFIELD

CCG 19,687 7.7 71.1 70.3 59.8 41 39.5 NHS

HARINGEY

CCG 15,213 6.2 68.5 66.1 58.6 34 37.6 NHS

ISLINGTON

CCG 10,368 5.0 67.3 68.9 58.9 38 40.5 NHS CITY

AND

HACKNEY

CCG 14,158 5.7 84.2 75.4 60.3 38 38

NDA – T2DM – 3 treatment targets Haringey and Islington

Haringey 15/16

Haringey 16/17

Islington 15/16

Islington 16/17

% of people with T2 diabetes meeting BP target (140/80)

68.4% 72.7% 70.8 70.3%

% of people with T2 diabetes meeting Hba1C target (58mmol/mol)

60.0% 63.9% 64.7% 66.8%

% of people with T2 diabetes meeting Cholesterol target (<5mmol/L)

74.8% 74.2% 76.6% 77.3%

% of people with T2DM meeting all 3 treatment targets

33.7% 37.6% 38.4% 40.5%

Opportunity to improve diabetes care in Haringey • Exciting times for diabetes improvement in

Haringey – number of projects with accompanying investment

• East Haringey CHIN

• IAPT project for LTCs (diabetes and COPD)

• New locally commissioned service for diabetes

• …and the D-QIST (diabetes quality improvement team)

Diabetes locally commissioned service key features. New LCS in Haringey – roll out from Sept 2017 – offered to all practices.

Never had one before for diabetes – so key driver of improvement, and we need to focus on the roll out.

Key features of the LCS:

• Requirement for audit and peer review of practice NDA outcomes and diabetes pathway

• Practice level Incentives for completion of 8/9 care processes in patients

• Practice level incentives for improvement of 3 TT achievement

• Also case finding element for diabetes

Our process for developing the diabetes quality improvement team

• D-QIST included as part of wider QIST business case – building capacity in the GP federation

• Sept-Oct 2017 – Pathway workshops to look at overall diabetes pathway in Haringey

• November 2017 finalising QIST specification including diabetes QIST project

• December onwards – QIST recruitment place employed by Haringey federation

• Early 2018 – project delivery

What outcomes are we trying to achieve through the diabetes improvement work • Improved quality of care outcomes and reduced

variation in quality • Improved achievement of the three treatment targets • Improved uptake of structured education • Improved experience of care • Improved mental health in people with diabetes

• Development of a skilled local primary care workforce to provide sustainable improvements in diabetes care

• Development of better integration of primary care and community services that support people with diabetes (e.g. IAPT, podiatry, community diabetes service, One You lifestyle services)

• Supports a broader long-term vision for managing long-term conditions

Evidence

• Camden – • integrated practice unit, • focus on skilling up workforce • Joined up IT • outcomes beginning to improve

• Hackney – • Target based incentives (NEL clinical effectiveness group approach) • Plentiful diabetes nursing support – can provide clinics in patients own practice • Pathway for people who are newly diagnosed with T2 diabetes

• Pharmacist led approaches • E.g. Lambeth, Dudley – successful management of hypertension (but not

diabetes specific)

• Haringey medicines management scheme – targeted use of extended consultations with strong motivational interviewing component

What might the diabetes improvement project look like

Specification currently being finalised – in partnership with GP federation

Aspects of the D-QIST project likely to include

1. Supporting delivery of the diabetes aspects of the new locally commissioned service including practice level achievement of the 3 treatment targets

2. Delivery of standardised primary care for people with type 2 diabetes

3. Development of enhanced clinical offer for certain cohorts of people with type 2 diabetes

What might the diabetes improvement project look like

Aspect 1 (Borough wide through QIST team): Supporting delivery of the diabetes aspects of the new locally commissioned service including practice level achievement of the 3 treatment targets This might include visiting practices to • Understanding the diabetes pathway within the practice and

developing simple improvements • Supporting practices (e.g. with data searches) to identify

cohorts of patients who are not meeting the 3 key treatment targets

• Ensuring links are made to pharmacy provision in the QIST where simple pharmacist interventions (e.g adjusting BP meds) can improve achievement of the 3 treatment targets

• Supporting improved call and recall of patients and integration with other services

What might the diabetes improvement project look like Aspect 2 – (borough wide through QIST team) Supporting standardised high quality primary care for people with type 2 diabetes

This might include • Development and systematic use of standardised patient

information/care plans

• Development/implementation of standardised Haringey clinical guidance for management of diabetes

• Development and promotion of systematic use of EMIS/Vision templates to guide clinical review of people with type 2 diabetes

• Development of simple way of sharing information between primary care and intermediate diabetes service and getting clinical advice through EMIS

• Development of a skills and competency framework for clinical staff delivering type 2 diabetes care in Haringey.

• Facilitation and organisation of training and network for front line staff delivering diabetes care.

What might the diabetes improvement project look like Aspect 3: (East Haringey only – delivered through East CHIN) Development of enhanced clinical offer for certain cohorts of people with type 2 diabetes (newly diagnosed and those not managing well)

This might include • Delivery of extended appointments (probably with nurse) as part of

new pathway development • using a consistent framework • using existing clinical staff who are part of wider clinical improvement

network • Care delivered in or close to patient’s own practice

• Testing and learning improvements to diabetes pathway in Haringey • E.g. shared care/links to intermediate diabetes services • Better integration with other services e.g. podiatry, lifestyle support, IAPT

etc • Better and more consistent information for patients • Opportunities for use of phone appointments email/web-based support.

South West London Improving Diabetes in Primary Care event

Clare Elliot, Diabetes Programme Director, South West London Health and Care Partnership

Start well, live well, age well

Background

77 Start well, live well, age well

0

10

20

30

40

50

60

England SWL

Treatment targets and care processes in NDA 2017/18 (%)

All 3 TT All 8 CP

• Treatment target and care process performance in South West London below the national average

• Also wide variation in achievement across SWL

• Individual CCGs unsuccessful in applying for Treatment and Care funding, but good network established from DISN and MDFT projects.

Treatment target variation in SWL

78 Start well, live well, age well

Most deprived practice in SWL (Croydon) is

above national average, [Y VALUE]%.

10

20

30

40

50

60

0 5 10 15 20 25 30 35 40 45

All

3 t

reat

men

t ta

rget

s ac

hie

vem

ent

(%)

Deprivation score

IMD 2015 deprivation score vs treatment target performance

National average = 41.06%

National average =

21.6

The event

• SWL diabetes team invited people with diabetes, practice nurses, GPs, commissioners, public health teams, and diabetes specialists to discuss 4 areas of primary care

Identifying people with diabetes

Care planning and care processes

Achieving treatment targets

Practice and staff development for diabetes

• 69 people attended to give their views with good representation from all groups

• The event was split in to two parts; first a selection of speakers shared examples of good practice / success, and then a workshop exercise took place to identify key themes and needs.

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Speakers

The 4 L’s workshop

Liked is for ideas that we know work well, and that we are currently doing in some areas.

Learned is for things we have tried in the past that worked well, or things that don’t work well. Also for things that have worked well in other areas that we may wish to try.

Lacked is for anything that we don’t have now, but would help us to improve

Longed for is for blue-sky thinking and establishing what ideas we think will really make a difference

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Attendees were invited to give their thoughts for

each of the areas on post it notes which were put

against the 4 L’s for each topic:

The ideas generated from the exercise were then discussed in 4 groups.

Key themes

• Coding and data Accuracy of data and coding needs to improve Use of PRIMIS to support practices Better access to data would be helpful e.g. dashboard

• Practice systems and processes Robust systems help practices to complete care processes – “the magic

template” to prompt for completion and good recall systems. Involving patients in care planning.

• Working together Better access to advice, guidance, and training from specialists. Working more closely together across the healthcare system including mental

health Using the whole team – involving receptionists and HCAs in care for people with

diabetes to reduce load on GPs and nurses.

• Standardised training and competencies • Variation in access to training and in competencies • Lots of support for e-learning options that everyone can use

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Next steps

• SWL team developing a project mandate to work on the areas that can be tackled at STP level

• Suggested actions for practices and CCGs are outlined in the event report

• Spreading e-learning resource that is already available

• Attendees to be involved in future work as it develops

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