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. North West London is included as a case study in that report. Information about the model of care in North West London 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: The redesign in North West London was a pilot project that expanded as it progressed. Eventually it covered three acute hospitals, two community hospitals and 104 GP practices.
Delivering diabetes care in North West London: In 2011 NHS London provided £5.7million for a pilot project to improve the delivery of diabetes care and care for older people in North West London. The Integrated Care Pilot (ICP) did not introduce any new services but focused on better coordinating good practice to enable clinicians to work efficiently across provider boundaries. The revised clinical pathway was based on NICE guidelines and as such, it was agreed that all people with Type 1 diabetes would remain under the care of consultant diabetologists. As part of the development of the ICP, a process for identifying the care needs of people with Type 2 diabetes was devised with the intention being that this would be the best way to ensure people with Type 2 were seen by the most appropriate point in the system to meet their needs. The redesign introduced multidisciplinary group working between specialists and generalists. The ICP partners organised themselves into ten multidisciplinary groups (MDGs). Each group was chaired by a GP and attended by healthcare professionals from primary, community and specialist care. The MDGs were responsible for making sure patients were seen at the appropriate point in the system.
Supporting the delivery of whole pathway diabetes care
To support the work of the MDGs in ensuring people with diabetes are seen at the appropriate point in the system and receive the right care, the ICP introduced the following:
IT: The ICP introduced an IT tool (a secure web based portal). The tool is a support tool for existing clinical IT systems (not a replacement) and was designed for use in conjunction with those. This does require a duplication of data entry for clinicians and GPs are required to take explicit consent from people with diabetes to share information through the IT tool across the system. The intention was that it could be used by the MDGs to stratify patients according to their risk of emergency admissions. This was the first step in deciding where care would most appropriately be provided. Existing arrangements for organisations as data controllers remained in place.
Aligned finances and responsibility: The existing funding arrangements for care delivery remained in place, and the additional work of the ICP - most notably attendance at MDG meetings - was financed through the ICP budget, with the intention that this would be funded through savings generated by the pilot in the longer term. The budget for the ICP is held by the Central London Community Healthcare Trust. The redesign of services has not introduced any additional training for GPs in the delivery of diabetes care, so the MDG meetings are crucial for providing GPs with direct access to specialist knowledge - links that previously not been made - to discuss complex cases and develop their skills.
Clinical engagement and leadership: A working group (equivalent to a diabetes network) was established to design the ICP and attended by NHS managers, diabetes specialists, GP leads and Diabetes UK. The working group determined the model of care, clinical pathways and governance structure for the pilot. Clinician engagement has been maintained through involvement in MDGs, which are an opportunity to discuss and identify ways to work more collaboratively and efficiently across organisations. In addition, committees were established with responsibility for reviewing and improving the delivery of the ICP with specific remits. For example, the clinical care committee's remit was to review the clinical pathways and training and education opportunities. Clinicians from across the pathway were able to feed their experience into discussion at these committees.
Clinical governance: An integrated management board was established to sit above the committee structure. The board was given overall accountability for the pilot with responsibility for driving the strategic agenda and being the main decision making body. The Chair was externally appointed, this helped provide neutrality in the early stages of developing the ICP to bring all the partners together. All the providers in the pilot are represented on the management board and have voting rights with a pre-determined split.