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. Derby is included as a case study in that report. Information about the model of care in Derby is provided 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: Derby Hospitals NHS Foundation Trust, Derby City PCT (currently commissioned by Southern Derbyshire CCG) and Derby City GP practices.
Prevalence: 6.3% - 15,000 people diagnosed in Derby City.
Delivering diabetes care in Derby: In 2007, GPs in the community approached the hospital based diabetologist to begin the process of having a community diabetes team commissioned, and discuss the wider delivery of diabetes care. It was agreed that better collaboration between primary and specialist healthcare professionals was needed. It was also recognised that GPs would benefit from education and training from diabetes specialists. Derby introduced a new model of delivering diabetes care in 2009, commissioned by the then PCT. The basis of the new model was the creation of a new NHS organisation: a not for profit joint venture with 50 per cent of shares held by the hospital and 50 per cent by primary care by a group of GP practices.
Supporting the delivery of whole pathway diabetes care
IT: Diabetes specialists and general practices in Derby City both use the IT system, SystmOne. Using a single IT system is the most straightforward means of providing all healthcare professionals with access to a patient's record, regardless of care setting, to provide rapid communication, appropriate referral and holistic care.
Aligned finances and responsibility: The key frustration with the previous system was that people with diabetes were being referred into the hospital based service and not leaving. There were large numbers of people attending hospital clinics for routine review meaning those with complex needs in primary care were unable to access services in a timely manner. Variations in primary care meant discharge was difficult and users felt continuity of care was poor.
This has been addressed in the redesign, so that people with diabetes can be referred either way along the pathway and healthcare professionals in primary care provided with the support and training necessary to delivery more complex diabetes care. This has meant that people with diabetes get ready access to specialist care when they need it, as well as being referred back to primary care for ongoing management as appropriate.
Practically, this has been made possible by the introduction of a single budget and an enhanced service payment, as well as ongoing training and support for GPs from diabetes specialists. The single budget is held by the joint venture organisation and is used to fund the delivery of diabetes care, irrespective of the healthcare professional responsible for delivery. This allows care to be delivered without competition. To manage this nobody is employed directly by the new organisation - GPs are paid an hourly rate and the trust receives an income for the time specialists spend in the joint clinics.
Clinical engagement and leadership: the redesign of the model of diabetes care delivered in Derby was driven by mutual enthusiasm from GPs and the hospital diabetologists. The service is jointly led by a GP and a consultant.
Clinical governance: The Derby model has a single clinical governance structure. The service is jointly led by a GP and consultant and supported by management staff seconded from secondary care. The multidisciplinary clinical team of primary and secondary care clinicians meet monthly to review safety, refine pathways and ensure quality of service delivery. This group is accountable to the board of the joint venture organisations. The joint venture organisations have responsibility for holding the clinical leads to account for the delivery of the commissioned service specification and the financial state of the company. Patient participation groups meet on alternate months to contribute to service development.