this presentation has been developed by boehringer ingelheim ltd. and eli lilly company ltd....

This presentation has been developed by Boehringer Ingelheim Ltd. and Eli Lilly Company Ltd. UK/TRJ/00296a(1). April 2014.This presentation has been developed by Boehringer Ingelheim Ltd. and Eli Lilly Company Ltd. UK/TRJ/00296a(1). April 2014.

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Type 2 diabetes care and the changing NHS

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This presentation has been developed by Boehringer Ingelheim Ltd. and Eli Lilly Company Ltd. UK/TRJ/00296a(1). April 2014.

Overview and objectives

• This module contains an overview of the recent changes in the structure of the NHS and the practical implications for T2D care

• The main learning objectives are to:– Understand the evolution of the NHS prior to the restructure in April 2013

and the challenges the healthcare service is facing– Review the new structure of the NHS, focusing on the role of CCGs in

treatment purchasing and planning, and control of funding– Highlight the need for organised, co-ordinated and structured models of

integrated T2D care delivery– Understand how the NHS Outcomes Framework and the CCGOIS are

used to monitor standards of care on patients with T2D– Review the QOF framework for diabetes and the potential impact of the

NHS changes on diabetes care

NHS: National Health Service; CCGs: Clinical Commissioning Groups; T2D: type 2 diabetes; CCGOIS: Clinical Commissioning Group Outcomes Indicator Set; QOF: Quality and Outcomes Framework.


Evolution of the NHS: the drive for change

1. Adapted from Gorsky, M. Social History of Medicine Vol. 21, No. 3 pp. 437–460. 2. The NHS at 60. Available at: http://www.nhs.uk/NHSEngland/thenhs/nhshistory/Pages/NHShistory1948.aspx. 3. NHS reforms timeline. The Nuffield Trust. Available at http://nhstimeline.nuffieldtrust.org.uk/. 4. National Service Frameworks.2002. Available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4050864.pdf. 5. National Institute for Health and Clinical Excellence. Available at: http://www.nice.org.uk.6. Commissioning Outcomes Framework: Engagement Document. NHS Commissioning Board. 2011. Available at http://www.commissioningboard.nhs.uk/files/2011/11/COF-final1.pdf . All

online resources accessed October 2013.

1948 1960s

‘The Hospital plan (1962)’

District hospitals2

Concept of primary care1

1970s

Regional Health

Authorities1

1980s 1990

‘Working for patients (1989)’3

‘National Health Service and

Community Care Act (1990)’ 2

NHS trusts1

1997

‘The New NHS’ 1

2000 2005 2010 2015

NSFs4

PCTs and Foundation

Trusts2

QOFs5

New NHS structure?

Clinical governance

NICE5

COFs6

1

NHS: National Health Service; NICE: National Institute for Health and Clinical Excellence; NSFs: National Service Frameworks; PCTs: Primary Care Trusts; QOFs: Quality and Outcomes Framework; COFs: Commissioning Outcomes Framework.


NHS structure: pre-April 2013

Department of Health

10 Strategic Health Authorities

152 Primary Care Trusts

Primary care services:

GPs, dentistry, community pharmacy,

opticians etc.

Community health services

e.g. district nursing, health

visitors

Acute hospital trusts

NHS foundation

trusts

Mental health trusts

Ambulance trusts

Commercial providers and

voluntary organisations

Private providers

Care quality commission

Adapted from A junior doctor’s guide to the NHS. NHS medical directorate. 2009. Available at http://group.bmj.com/group/affinity-and-society-publishing/NHS%20Guide.pdf. Accessed October 2013.

Parliament and Secretary of State


Challenges facing the NHS today

• An ageing patient population

• Medical advances– What is possible?– What can the NHS afford?– Will investments deliver long-term value?

• Lifestyle factors

• Rising healthcare costs

• Rising patient expectations around the quality of patient care


Do guidelines keep pace with therapeutic advances?

1920s

Insulin1

1930s

Long acting insulin1

Sulphonylureas4

1960s 1970s

HbA1c

1990s

Metformin4

Human insulin analogue1

T1D: Type 1 diabetes. T2D: Type 2 diabetes. The examples of approved glucose lowering agents is not exhaustive.All online resources accessed October 2013.1. Adapted from History of Diabetes in Timeline. Defeat Diabetes Foundation. Available at http://www.defeatdiabetes.org/about_diabetes/text.asp?id=Diabetes_Timeline. 2. Guidelines from National Institute for Health and Clinical Excellence. Available at http://www.nice.org.uk.3. SmPCs available from http://www.medicines.org.uk/EMC/default.aspx.4. FDA approval for sulphonylureas (tolbutamide as example) and metformin. Available at http://www.accessdata.fda.gov/scripts/cder/drugsatfda/.

Acarbose3

2000

Pioglitazone3

2005 2010 2013/2014

Sitagliptin3

Linagliptin3

Saxagliptin3

Vildagliptin3

Exenatide long-acting3

Meglitinides3Liraglutide3

CG87:T2D management2

CG15:T1D management2

CG63:Diabetes in pregnancy2

CG119:Diabetes foot problems2

Lixisenatide3

Dapagliflozin3

Insulin degludec3

Exenatide3

Alogliptin3

Canagliflozin3


Biggest shake-up of the NHS to date

• This government white paper was developed after the 2010 elections

• It represents the biggest shake-up of the structure of the NHS to date, summarised as follows:

– ‘The Government will devolve power and responsibility for commissioning services to the healthcare professionals closest to patients: GPs and their practice teams working in consortia’

Equity and excellence: Liberating the NHS. July 2010. © Crown Copyright 2010. Available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf. Accessed October 2013.


Proposed NHS structure: post-April 2013

Department of Health

NHS commissioning board

Regional office

27 Local offices

212 Clinical commissioning groups

Public Health England

Local council

Health and wellbeing

board

Regional office

Regional office

Regional office Primary care

Hospital care

Community care

Mental health

Monitor

Adapted from The structure of the NHS in England. NHS Choices. Available at : http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstructure.aspx. Accessed October 2013.

Parliament and Secretary of State

Specialist/ tertiary care


Treatment purchasing and planning

Primary care trust

GPs

NHS hospital

Private hospital

Community

care

Private/charity

community care

GP-led clinical commissioning groups (>200)

NHS hospital

Private hospital

Community care

Private/charity

community care

Private consultancy

Commissioning support group

Pre-April 20131,2 From April 20133,4

All online resources accessed October 2013.1. Delivering primary care. Department of Health (archived content) 2010. Available at http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Aboutus/HowDHworks/DH_074639.2. NHS funding and expenditure. House of Commons Library. 2011. Available at http://www.nhshistory.net/parlymoney.pdf. 3. Adapted from the Health and Social Care Act. 2012. Overview of health and care structures. Available at http://www.dh.gov.uk/health/files/2012/06/A3.-Factsheet-Overview-of-health-

and-care-structures-240412.pdf.4. Adapted from “Commissioning developments: key facts. Available at http://www.commissioningboard.nhs.uk/files/2013/01/com-dev-facts.pdf.

GPsNon-profit

bodies


Control of funding

Pre-April 20131,2 From April 20133,4

Primary care trust

GPs GPs GPs GPs GPs

GPs GPs GPs

GPs GPs GPs

Clinical commissioning groups

All online resources accessed October 2013.1. Delivering primary care. Department of Health (archived content) 2010. Available at http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Aboutus/HowDHworks/

DH_074639.2. NHS funding and expenditure. House of Commons Library. 2011. Available at http://www.nhshistory.net/parlymoney.pdf. 3. Adapted from the Health and Social Care Act. 2012. Overview of health and care structures. Available at http://www.dh.gov.uk/health/files/2012/06/A3.-Factsheet-Overview-of-

health-and-care-structures-240412.pdf. 4. Adapted from ‘Who pays? Determining responsibility for payment to providers.”’ Rules and guidance for clinical commissioning groups. Available at

http://www.commissioningboard.nhs.uk/files/2012/12/who-pays.pdf.

NHS hospital

Private hospital

Community

care

Private/charity

community care

GPs NHS hospital

Private hospital

Community care

Private/charity

community care

Non-profit

bodies


NHS Reform – from April 2013• Wider range of health care

providers

• Clinical commissioning groups (CCGs) of HCPs, which will commission services

• Local healthwatch will give patients/communities a voice in decisions that affect them

• Complex web of care?

Available at: http://healthandcare.dh.gov.uk. Crown copyright © 2011 licensed under the Open Government licence v1.0. Accessed October 2013.

HCPs: healthcare professionals.


Diabetes and the state of care: The need for improvement• In 2010/11 dealing with diabetes cost the NHS £9.8 billion, 10% of the NHS

budget1

– 80% of this was spent on dealing with diabetic complications including blindness and amputations2

• Approximately half of people with T2D and two thirds of people with T1D fail to receive all nine clinically recommended annual tests and investigations2

• Variations in standards of care demonstrate the need for organised, co-ordinated and structured models of integrated care delivery2

• People with diabetes need clear consistent information about:– Which services they need to go to2

– Frequency of monitoring2

1. Hex N, et al. Diabetic Medicine. 2012; 29:855–862.2. Protecting and promoting patients’ interests – licensing providers of NHS services. Diabetes UK response to the consultation. 2012. Available at

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156471/Diabetes-UK-revised.pdf.pdf . Accessed October 2013.


Diabetes care cannot be delivered by one provider alone• Development of effective integrated services requires input from a

range of provider teams

• Primary care, community services, specialist teams and tertiary services, alongside people with diabetes, need to work together to advise on– Local pathways– Commissioning– Co-ordination between providers through effective local diabetes

networks

• “Local primary, community, voluntary and private providers can’t do it on their own and they shouldn’t think they can” – Diabetes UK

Protecting and promoting patients’ interests – licensing providers of NHS services. Diabetes UK response to the consultation. 2012. Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156471/Diabetes-UK-revised.pdf.pdf. Accessed October 2013.


Enhancing quality of life for people with long-term conditions• The 2012 NHS mandate set out measures that are essential to

– Support people living with long-term conditions– Improve the care they receive– Improve their quality of life

• By 2015 it is hoped that:– ‘Far more people will have developed the knowledge, skills and

confidence to manage their own health, so they can live their lives to the full’

• Education for patients and their carers will be essential to provide the necessary skills and information to manage and monitor their medical conditions

Adapted from The mandate. A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015. November 2012. Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/127193/mandate.pdf.pdf. Accessed October 2013.


• Diabetes Education and Self Management for Ongoing and Newly Diagnosed1

• Structured education programme of choice for over 110 healthcare organisations across Great Britain and Ireland, for people with T2D

• Cost-utility analysis2

• Incremental cost of DESMOND = £82• Mean incremental cost/QALY

gained = £2092• Beneficial and cost effective?

• ‘Family’ of patient education modules and related Educator training:1

• Newly Diagnosed• Foundation- (for those who have

established diabetes) • BME- course delivered in Gujarati,

Punjabi, Urdu and Bengali• Walking Away from Diabetes (for those

at high risk of developing Type 2 diabetes)

1. Available at: http://www.desmond-project.org.uk/. Accessed October 2013. Image copyright granted by the DESMOND© team.2. Gillet M, et al. BMJ. 2010; 341:c4093.

Structured education to provide self-management skills – DESMOND


NSF/NICE guidance: Key care processes for diabetes

• Blood glucose level measurement

• BP measurement

• Cholesterol level measurement

• Retinal screening

• Foot and leg check

• Kidney function testing (urine)

• Kidney function testing (blood)

• Weight check

• Smoking status check

NSF: National Service Framework 2001. NICE: National Institute for Health and Clinical Excellence; BP: blood pressure.

Diabetes UK. State of the Nation 2012. England. Available at http://www.diabetes.org.uk/Documents/Reports/State-of-the-Nation-2012.pdf. Accessed October 2013.


The Outcomes Framework identifies the current NHS quality improvement system

Department of Health. The NHS Outcomes Framework 2011/12. December 2011. Crown copyright © 2010 licensed under the Open Government licence v1.0. Available at:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/135554/dh_123138.pdf.pdf. Last accessed October 2013.

Duty of quality

Duty of quality

Du

ty o

f q

ua

lity D

uty o

f qu

ality

Domain 1Preventing people

from dying prematurely

Domain 2Enhancing quality of life for people with

long-term conditions

Domain 3Helping people to

recover from episodes of ill health or following

injury

Domain 4Ensuring that people

have a positive experience of care

Domain 5Treating and caring for

people in a safe environment and

protecting them from avoidable harm

NHS Outcomes Framework

NICE Quality Standards(Building a library of approx 150 over 5 years)

Commissioning OutcomesFramework

Commissioning Guidance

Provider payment mechanisms

tariffStandard contract

CQUIN QOF

Commissioning / ContractingNHS Commissioning Board – certain specialist services and primary care GP consortia – all other health care services

71

2

3 4 5

6


NICE Quality Standards 6: Diabetes in adults

QS6

Structured educationNutrition and

physical activity advice

Care planning

Glycaemic control

Medication

Insulin therapy

Preconception care

Complications

Psychological care

‘At risk’ foot

Foot problems needed urgent

medical attention

Inpatient care

Diabetic ketoacidosis

Hypoglycaemia

QS6: Quality Standard 6.Diabetes in adults quality standard. National Institute for Health and Clinical Excellence. 2011. Available at http://publications.nice.org.uk/diabetes-in-adults-quality-standard-qs6. Accessed October 2013.


Diabetes Outcome Versus Expenditure tool

• Diabetes care expenditure vs clinical outcomes for – A selected CCG– Other CCGs with similar populations– All other CCGs

1. Diabetes Outcomes Versus Expenditure Tool (DOVE). Yorkshire and Humberside Public Health Observatory. Available at http://www.yhpho.org.uk/. Accessed October 2013 Contains public sector information licensed under the Open Government Licence v1.0 available at http://www.nationalarchives.gov.uk/doc/open-government-licence/. Accessed October 2013.

CCGs: Clinical Commissioning Groups.


Clinical Commissioning Group (CCG) Outcomes Indicator Set (CCGOIS) (2012/2013)

• Formerly known as the Commissioning Outcomes Framework (COF)1

• Measuring outcomes of services commissioned by CCGs1

• Indicators do not relate to commissioning itself

• Outcomes indicators have been derived directly from the NHS Outcomes Framework, based on NICE Quality Standards, or from existing data1

Diabetes indicators2

Myocardial infarction, stroke and stage 5 chronic kidney disease

Patients who have received nine care processes

Newly diagnosed patients (<1 year) who are referred to structured education

Patients who have emergency admission for diabetic ketoacidosis

Complications associated with diabetes

Lower limb amputation in diabetes patients

1. About the Clinical Commissioning Group Outcomes Indicator Set (CCGOIS). National Institute for Health and Clinical Excellence. Available at: http://www.nice.org.uk/aboutnice/cof/cof.jsp. Last updated January 2013. Accessed October 2013.

2. Endocrine, nutritional and metabolic indicators. National Institute for Health and Clinical Excellence. Available at: http://www.nice.org.uk/aboutnice/cof/EndocrineNutritionalAndMetabolic.jsp. Last updated September 2012. Accessed October 2013.


Quality and Outcomes Framework for diabetes 2013/2014• Introduced in 2004 as part of the GMSC with annual publication of

practice scores1

Payment for GP

practices

SEPARATE INDICATORS• Blood pressure• Testing foot sensation• Foot examination and risk

classification• HbA1c control• Structured education referral• Dietary review• Records of confirmed diabetes

diagnosis• Erectile dysfunction consultations,

assessment and treatment options• Proteinuria screening

Points

2013/14 menu of indicators2

1. About the Quality and Outcomes Framework (QOF). National Institute for Health and Clinical Excellence. Available at: http://www.nice.org.uk/aboutnice/qof/qof.jsp. Last updated August 2013. Accessed October 2013.

2. NICE menu of indicators. Endocrine nutritional and metabolic. Available at: http://www.nice.org.uk/aboutnice/qof/indicators.jsp. Last updated August 2013. Accessed October 2013..

2012–13: 88 QOF points2013–14: 106 QOF points

QOF: Quality and Outcomes Framework; GMSC: General Medical Services Contract.


A composite QOF indicator for diabetes?

• Joint DoH/NICE initiative to boost routine assessment of patients with diabetes

• National Diabetes Audit (2011) results suggested only half of patients with diabetes received all nine checks

CurrentNine INDIVIDUAL

checks

For 2015 QOF?Bundle individual checks into a SINGLE indicator

Pulse. Revealed: DH plans to bundle diabetes QOF indicators worth over £5000. July 2012. Available at http://www.pulsetoday.co.uk/revealed-dh-plans-to-bundle-diabetes-qof-indicators-worth-over-5000/14224104.article. Accessed October 2013.

Payment for GP

practices

QOF: Quality and Outcomes Framework; DoH: Department of Health.


Implications of the impact of the NHS changes on diabetes care?

Increased GP practice workload

Practice income

Management of complex clinical processes

Performance vs financial reward

Patient-prescriber relationship

Additional practice training needs

Standard of care

QOF monitoring requirements vs patient uptake

Measurement of the integrated care pathway

Competition

QOF: Quality and Outcomes Framework.


Summary and learning points

• Re-structuring of the NHS framework could be one of the most radical and far-reaching reviews in its history

• Potential mid- and long-term implications of these changes include:– Altered patient access to the complex network of diabetes care services – A review of the type and frequency of vital health checks received by

patients– Additional responsibilities for provision of primary care services– A review of/changes to patient-oriented outcomes


Prescribing information