Development of a model of care and service specifications for adult patients with diabetes
13 October 2009
Intended Audience
Clinicians and other professionals involved in the provision of care for patients with diabetes or at risk of developing diabetes Commissioners of diabetes care and prevention services
Health Area
NHS Somerset (Somerset PCT)
Background
Diabetes is a major health issue in Somerset affecting more than 19,000 people, with numbers expected to grow to 28,000 by 2017, fuelled by Somerset's aging population and increasing rates of obesity. Standards of services and health outcomes, although above the national average, vary significantly across the county.
It has been estimated that 21% of patients with diabetes in Somerset are undiagnosed and at risk of serious complications, including heart attacks, strokes, blindness, kidney failure and amputation.
The diabetes model of care is the outcome of a strategic review of local diabetes services in Somerset, involving patients, clinicians, commissioners and providers.
The review was informed by a local health needs analysis and a survey of experience elsewhere.
The aim of the model of care to increase the capacity of the healthcare system as a whole to meet the needs of growing numbers of people with diabetes, with care provided in the right place at the right time and with the right amount of expertise.
The planned developments for diabetes care form part of a wider programme to improve the standard of care for people with long-term conditions. They follow on from the South West Darzi review and are expected to evolve in the light of experience and wider developments in the care of long term conditions.
The diabetes model of care is in line with national guidance and best commissioning practice for areas with similar demographics.
How this service improves
The vision is for care to be more integrated and accessible, with an increased focus on:
- preventing illness and helping people stay well
- earlier diagnosis and better care to reduce the risk of complications
- support for patients to manage their own care
Why this service is a good example of shared practice
The model of care for Adult Patients with Diabetes has been developed with widespread involvement of patients, clinicians and healthcare managers and with the support of Diabetes UK and the National Diabetes Support Team.
During the development phase, the experience of patients across their whole care pathway was reviewed by patients and clinicians from all the professional groups contributing to diabetes care and exemplar pathways were identified.
A Steering Group was set up in January 2008, comprising clinicians and managers from local Service Providers and NHS Somerset, the local regional manager for Diabetes UK and a patient representative.
The Steering Group held two stakeholder workshops to develop the model of care, which were attended by members of the Local Implementation Team, together with other stakeholders and patients.
The work of the Steering Group was informed by feedback from the National Diabetes Patient Survey (2006) and a survey undertaken by the Somerset Patient and Public Information Forum, also in 2006.
Six discussion events on the draft model of care were held across Somerset in the Summer of 2008. These events provided an opportunity for patients, their relatives and their carers to ask questions about the proposals and provide feedback in particular on how they might best be supported to manage their own care, and what outcomes they would expect from future services. The discussion events were attended by members of the Steering Group, including clinicians and Diabetes UK representatives and a total of 118 patients relatives and carers.
Patients, the public, and professionals with an interest in the delivery of diabetes care also had the opportunity to comment on two engagement documents, over the period 11 August to 26 September 2008, one for patients and the public and the other for professionals. These documents described the proposed model of care and posed a number of questions about each of the key proposals as well as seeking views on priorities and outcomes.
The engagement document (public version) was widely circulated to stakeholders including 123 voluntary organisations and 80 patient and public involvement contacts. In partnership with diabetes UK, 1,600 people who are members of the charity, were sent copies of the engagement document with a covering letter from the Regional Manager encouraging them to return their feedback. The engagement document was also circulated to healthcare professionals involved in diabetes care, healthcare premises including all 286 residential and nursing homes in Somerset, 75 GP surgeries, 88 pharmacies, 59 opticians, 13 community hospitals, 2 district hospitals and the retinopathy screening clinics.
The engagement document was also available on the trust website for staff and the public to download.
The proposed model of care was presented to the Overview and Scrutiny Committee on 8 September 2008 and to the Professional Executive Committee on 31 October 2008.
A report on feedback from the model of care engagement exercise was submitted to the NHS Somerset Board in December 2008.
The Service Specification was developed from the model of care by a team of Primary Care Trust and Practice Based Commissioning commissioners. Clinical input to the Service Specification was obtained via a task focused group that met once in January 2009. A group of patients who had expressed an interest in continuing to be involved with diabetes service development were invited to comment on the key elements of the Specification at a meeting in January 2009.
The service specification was submitted to the Professional Executive Committee on 26 February 2009.
The focus has been on quality throughout and a range of performance indicators and targets around safety, effectiveness and patient experience are set out in the service specification.
Achievement of these quality outcomes and targets will be monitored by commissioners on a regular basis.
Objectives
- improve the care and health outcomes of adult patients with diabetes in Somerset
- promote partnership working and a shared care approach between providers so patients experience appropriate care, seamlessly, and in a timely manner
- provide accessible services as close to patients? home or work as possible ? optimise resources
The Somerset Diabetes Service will provide care that is personalised, responsive and holistic delivered in the context of how people want to live their lives.
Key deliverables will include:
- community based services
- seamless care provided as close to home or work as possible
- healthy eating and physical activity programmes, accessible through patient choice
- systematic and opportunistic case finding in the community
- support for patients to manage their own condition
- patient education programmes which empower patients to self care
- management plans agreed with patients
- accessible specialist care when needed
- equity of access and choice
A major goal of the Service is to address the differences in the standards of diabetes care that exist across Somerset.
Service Provided
Levels of care required for each stage of the patient's journey have been allocated to the following levels:
- Level 1: core primary care
- Level 2: intermediate care
- Level 3: specialist care
In line with the objective to deliver care as close to the patient as possible, the majority of care for adult patients with diabetes will take place in community settings, with only those elements of specialist care (level 3) that it is not practical to provide in the community being provided in acute care hospitals.
All levels include an emphasis on prevention, early intervention and support for self care.
GP practices will provide core primary care (level 1) to agreed standards with some opting to provide specific aspects of intermediate care (level 2), for example insulin initiation.
Opportunistic case finding for early identification of diabetes will be encouraged in GP practices and through pharmacies, local councils and voluntary groups. Systematic case finding will occur through the Health Checks Programme as well as in primary care.
A county-wide, community based, Diabetes Specialist Nurse Service will provide specified level 2 care, such as insulin initiation and support for patients with sub-optimal glycaemic control. This intermediate service will be delivered by nurse-led teams with medical support from specialist acute care services. The composition of these teams will include as a minimum a Diabetes Specialist Nurse and a Specialist Diabetes Dietician. It is anticipated these teams will also provide training and support for practices, structured education for patients and support for self help groups.
Existing level 2 services, such as podiatry will be enhanced and strengthened to improve access. These services and related specialist care (level 3), wherever possible, will either be at co-located sites in the community, at multidisciplinary clinics or using telemedicine technology.
Acute hospital care will be focused on complex cases and there will be an enhanced level of care for patients admitted to hospital with but not because of diabetes, thus improving the patient experience whilst in hospital and reducing lengths of stay. 3.11 The new arrangements will involve:
- a shift of level 2 services from acute hospitals to the community
- an expansion of nurse-led level 2 services, based in the community
- a strengthening of other existing level 2 services (eg podiatry, dietetics)
- support for GP practices to achieve core standards of primary care and support for those practices opting to provide level 2 care, such as insulin initiation
- freeing up capacity in acute hospitals to focus on most complex cases
- training and support for general ward staff in hospitals to provide improved care for patients admitted with diabetes but not because of their diabetes
The model of care which underpins the planned developments is shown diagrammatically in Appendix 1 attached.
Accountability
A Commissioning Group was established with responsibility for developing the service specification (in consultation with patients, clinicians and other stakeholders), and ensuring safe implementation and the achievement of quality outcomes and targets.
The Commissioning Group will review the service specification at least annually in the light of experience.
The Somerset Diabetes Local Implementation Team, which includes representation from all the services contributing to the diabetes pathway, will enable an integrated approach to pathway management and provide a forum for sharing learning.
Annual learning events are also planned involving front line clinicians, patients and their carers.
The clinical leads will have a key role harnessing and sharing learning across the clinical network.
Learning
Implementation of the diabetes model of care has since been incorporated into the PCT Strategic Framework as a specific priority with regular reports on progress to the Professional Executive Committee.
Patients have been engaged at all stages of the commissioning cycle and will continue to be involved during the implementation phase through patient groups and the Local Implementation Team.