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Improving the delivery of diabetes care

The Diabetes UK report 'Improving the delivery of adult diabetes care through integration' shares key lessons for commissioners and providers to overcome barriers and improve the delivery of diabetes care in their area. Wolverhampton is included as a case study in that report. Information about the model of care being delivered in Wolverhampton is below. For a full explanation of how an integrated model of diabetes care should look please download the report.

The model of care

Organisations involved: The Royal Wolverhampton Hospitals NHS Trust and Wolverhampton CCG and its predecessor, Wolverhampton PCT.

Prevalence: 7.7% - 16,043 people are diagnosed with diabetes.

Delivering diabetes care in Wolverhampton: The model of integrated diabetes care currently provided in Wolverhampton is the result of gradual development over a number of years. The emphasis in development has been to deliver an increased proportion of health care in primary care. This has been done with specialist support through training and ongoing access to advice. Specialist care is delivered in partnership with primary care - according to the clinical needs of the patient.

Supporting the delivery of whole pathway diabetes care

The process of collaborative care planning is supported by the other four enabler of integrated diabetes care: integrated IT, aligned finances and responsibility, clinical engagement and clinical governance.

Integrated IT: The hospital and GP practices have all continued to use their existing IT systems. To provide clinicians with access to a single record of care for each patient (across primary and specialist care) the CCG has introduced an additional IT system which takes information from the existing systems and brings it all together. This central portal extracts data from GP practices in Wolverhampton and feeds these data into the trust's Diabeta3 system. A locally developed algorithm stratifies patients according to risk. Patients are rated against the nine diabetes care processes and based on their risk status for micro and macro vascular complications of diabetes they are flagged as red, amber or green. The results are then used to decide where care should be provided to that person along the pathway and what should be done to improve their care. The system used in Wolverhampton covers all people with diabetes, unless they have opted out of the Summary Care Record or Using data in this way allows the clinicians to lift patient above the system. Both GPs and specialists can see the patients records and see what checks have been completed. Where patients are flagged as red of amber the system enables treatment at an early point and in the right setting, preventing delays in referral and looking to reduce emergency admissions.

The IT system also allows specialists to communicate directly with people with diabetes through a personalised central mailout of people's care process results. This is intended to support self-care, which is a central principle in the delivery of diabetes care in Wolverhampton, by increasing people's knowledge of their condition. Providing people with diabetes with this information prior to their annual review appointment is key to the care planning process.

Aligned finances and responsibility: The Royal Wolverhampton NHS Trust provides community and acute services. Having a single trust immediately means there are no financial barriers between hospital and community based teams. Although Wolverhampton has not introduced a single budget, they have made sure that the way services are financed supports rather than restricts the delivery of care. A block contract is in place to pay for the delivery of specialist care and the IT system in place allows specialists to identify patients who need specialist care without needing a referral from primary care.

To support the increased delivery of diabetes care in primary care, specialists have a key role in contributing to education and training for primary care staff. This is supported by working in a collaborative model, and more formally through educational events and local enhanced service training events. The diabetes specialist nurses also provide training and support for care home workers. In addition, GPs are incentivised to deliver care planning, working in a multidisiciplinary team structure with specialists.

Care planning: The model of care is centred on the need to enable people with diabetes to self-manage their condition. Empowering patients through care planning is central to this. To faciliate the care planning process people with diabetes are sent a questionnaire prior to their annual review appointment, which includes a list of questions for them to consider and identify their priorities. This is discussed at their consultation and an action plan based on this is designed in collaboration with the clinician to inform their ongoing care.  

Clinical engagement and leadership: The Wolverhampton diabetes network is well established and includes the primary care lead, specialist care leads and user and care leads. The following workstreams make up the network, and report back to the diabetes programme board: data governance; patient champions; paediatric diabetes care; education and training; patient and healthcare professional; dependant care in the community and care pathways.

Clinical governance: The network is overseen by 'The Diabetes Programme Board', which has a core membership to include a primary care lead, specialist care lead, user and carer champion, public health consultant, Diabetes UK regional manager and a project manager. The role of the board is to oversee the work of the network in driving improvement and maintaining quality in service delivery. The board will take issues, themes and commissioning priorities to the CCG.

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