The Hull Integrated Diabetes Care Programme (HIDCaP)

Intended Audience

People with Type 2 diabetes

Health Area

NHS Hull

Background

In the National Diabetes Survey (Healthcare Commission 2007) NHS Hull received a poor rating.  It was found to be under performing and did not attain the minimum standards of care for people with diabetes or reasonable expectations from patients. 

In order to turn this situation around, the PCT decided that diabetes would be one of the ten goal areas for World Class Commissioning. 

A population study by the Yorkshire and Humber Public Health Observatory found that there was a lower than expected prevalence of diabetes in the area. An extensive consultation process was set up involving service users, multidisciplinary representatives from primary care, specialist care, public health and NHS Diabetes alongside managers from the acute and community sectors.

In view of this relatively low known prevalence a key goal of identifying people with diabetes who were not yet diagnosed was identified.  It was recognised that to achieve this goal it would be necessary to:

1. Increase awareness of diabetes in the Hull population
2. Identify high risk groups for screening
3. Increase the capacity to perform oral glucose tolerance tests
4. Improve skills in primary care in screening and accurate diagnosis.

It was also appreciated that it would be inappropriate to diagnose more people with type 2 diabetes without offering appropriate initial management and having sufficient capacity to offer structured education to people who are newly diagnosed.

The Hull Integrated Diabetes Care Programme (HIDCaP) was developed to achieve these and other goals of World Class Commissioning.

Why this service is a good example of shared practice

The programme demonstrates an enlightened approach to integrated commissioning across traditional boundaries.

Working as an integrated team, primary and specialist health care professionals working jointly with service users, public health, service managers and commissioners were able to achieve a common goal leading to improved networking and personal relationships between all partners in the programme.

There was an extensive consultation process which included representatives of the local Diabetes UK branch, other local diabetes support groups and several people with diabetes not affiliated to any support group. A series of meetings were held at a local hotel during which commissioning goals and the framework of the programme were defined.

All of the elements of this programme are sustainable and transferable and it is intended to transfer elements of the programme and lessons learnt into a neighbouring PCT within the same diabetes network.

For the primary care staff involved in the programme feedback suggested that the extra work involved in attending to newly diagnosed people with diabetes was more than offset by the opportunity to discuss the management of individuals and explore areas of care development with specialists at the practice visits.

The software used in the programme was initially commissioned from and supported by an independent company and customised with input from the diabetes consultants and a GP with a specialist interest in diabetes (GPSI) to serve the goals of the PCT programme. A toolkit is being developed using appropriate codes to allow practice or PCT staff to perform the interrogations of practice systems with minimal support.

Objectives

1. Increasing known prevalence of diabetes by early identification and accurate diagnosis of people with type 2 diabetes
2. Ensure sufficient capacity for structured education for newly diagnosed people with type 2 diabetes
3. Strengthen links between primary and specialist care.
   

Service Provided

The PCT subsequently commissioned a programme.  As one element of the programme a team was set up comprising two consultant diabetologists, and a GPSI  to conduct practice visits.  The programme included:

1. Interrogation of practice systems by a customised piece of software to extract (amongst other data relevant to diabetes care) a list of people at risk of diabetes by virtue of BMI exceeding 35 and age exceeding 50 years
2. At a subsequent visit by one of the team to each of 30 practices that had agreed to be involved in the first wave, practice staff were briefed about the aims of the programme; the diagnostic pathway for screening and confirming the diagnosis of diabetes was discussed. Time was also allowed for staff to seek advice regarding organisational issues and the management of individual people with diabetes within the practice
3. Link diabetes specialist nurses maintained contact with the practices after the visits to provide support for any issues arising from the visits
4. Commissioning an increased capacity for oral glucose tolerance tests
5. A major enhancement of commissioning for type 2 diabetes group education.
   

Accountability

The PCT board is ultimately responsible and accountable for ensuring that the programme being undertaken as part of the World Class Commissioning Strategy is robust and effective in leading to the achievement of better health and well-being for the local community and reducing health inequalities.

Evaluation

Increasing known prevalence

There has been a significant increase in the number of diabetes patients registered in primary care across the PCT as a whole. The increase exceeded the trajectory for 2009/10. The rise in prevalence of diabetes in the 30 practices visited between December 2008 and August 2009 was 7.0 % compared with 4.6 % in the 24 practices not yet part of the programme.  This equates to an excess of 133 new diagnoses of diabetes in the practices visited compared with those not visited.

There has been a rise of approximately 50% in the numbers of glucose tolerance tests requested in the PCT.

Ensuring capacity for structured education

The service specification agreed between NHS Hull and Hull and East Yorkshire NHS Trust for 2009/2010 specifies that 1,600 people with diabetes should be offered structured type 2 diabetes education. The total number of people to whom structured diabetes education was delivered in the PCT was 410 in 12 months ending 1 November 2008 and 514 in 12 months ending 1 November 2009.

Recruitment to expand capacity has taken place and training  will be complete in late January 2010 when the monthly capacity to deliver education courses rises to 120 people per month.

 Strengthening links between primary and specialist care

Although not formally evaluated feedback from practice teams suggests that links between primary and secondary care have been enhanced.

Resources

NHS Hull commissioned and funded the data collection process from practices, the time of the two consultant diabetologists and the GPSI to perform the practice visits, the public awareness programme and the enhanced capacity for glucose tolerance tests and education.

The administration of the programme was undertaken by the PCT. Software customisation was funded through a grant from Takeda UK.

Learning

The programme has demonstrated to the PCT, to the specialist team and to primary care staff how powerful joint integrated working can be in using skills in a complementary fashion, and that specialists are welcomed into practices by primary care staff.

There has been an increase in the number of patients with diabetes diagnosed in the practices visited compared with practices not visited within the PCT and practices have made use of the expanded capacity to diagnose accurately with glucose tolerance tests and to refer newly diagnosed people for structured education.

Additional Information

The Hull Integrated Diabetes Care Programme (HIDCaP) is designed to build, on the foundations of the QOF, a service which integrates and utilises the skills of both specialist and primary care staff in a mutually supportive and patient centred fashion. There is an emphasis on strong clinical engagement and leadership within both primary and specialist care.

As well as the practice visits and support programme its elements include a structured education programme for people with diabetes, staff education and a social marketing campaign to increase awareness.

Contact

Dr Chris Walton, Consultant Diabetologist

Team includes:
Dr Jane Patmore,Consultant Diabetologist
Dr Peter Wright ,GPSI
Ms Sue Ward, Commissioning Development Manager NHS HULL

Department of Diabetes, Endocrinology and Metabolism
Hull and East Yorkshire Hospital NHS Trust
Michael White Centre for Diabetes and Endocrinology
Brocklehurst Building
220-230 Anlaby Road
Hull  HU3 2RW

Tel: 01482 675368