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. Portsmouth is included as a case study in that report. Information about the model of care being delivered in Portsmouth 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: SE Hampshire, Fareham & Gosport and Portsmouth CCGs, Portsmouth Hospitals NHS Trust; Southern Health Foundation Trust and Solent NHS Trust (community trusts), South Central Ambulance Services, all GP practices within the CCG area.
Prevalence: SE Hampshire 6% - 10,271 people are diagnosed with diabetes, Fareham & Gosport 5.7% – 9,347 people are diagnosed with diabetes, Portsmouth 5.3% - 9,255 people are diagnosed with diabetes.
Delivering diabetes care in Portsmouth: In 2010 the diabetes clinical lead at Portsmouth Hospital, a GP with special interest in diabetes and commissioning managers developed a proposal for changing the way diabetes care was being delivered. This was to address the fact that the rate of referral from primary to specialist care was much higher than discharge from specialist care and people were increasingly seen for follow up appointments in specialist care, causing an increase in waiting lists from six to 18 months over a ten year period. The model of care designed to address this defines who does what within the system and is widely known as the 'super six'. The 'super six' are the areas of diabetes care that it was agreed must be managed by consultant specialists in hospital for the purpose of commissioning services. The model of care is based in an increased role for primary care in the delivery of diabetes care. This is supported by the introduction of specialist community based teams, with consultant input, and improved access to professional education and support. The community team provides triage for specialist care referrals and provides 24hour advice for GPs to support their management of diabetes.
Supporting the delivery of whole pathway diabetes care
The main drive behind this redesign was to define roles to increase the ability of primary care to deliver diabetes care, and provide rapid access to specialist care as needed. This is an ongoing process of improvement, and the next steps in the redesign are to reduce the amputation rates in Fareham and Gosport and achieve consistency in the delivery of the 15 healthcare essentials in primary care.
Aligned finances and responsibility: Since 2011, 94 per cent of people with diabetes have been discharged from hospital based care. To support this increased responsibility for primary care, the following have been introduced to clarify roles and responsibilities and ensure the payment system facilitates rather than restricts the appropriate treatment and movement of patients:
- Access to training and ongoing support from diabetes specialists. Each GP surgery gets two visits per year from the community diabetes team - including a consultant and diabetes specialist nurse. There is a 24hour phone and email service for GPs to access specialist support. Professional training is provided on specific issues, to accompany the ongoing support.
- Changes to the payment system. The areas of care that must be delivered in a hospital setting have been defined. Each of these areas has now been commissioned to a distinct service specification - allowing financial alignment with outcomes. In primary care a locally enhanced payment is in use to incentivise attendance at diabetes courses and interaction with the diabetes specialist team to attain endorsement as a GP practice with an interest, and high level of competency, in the delivery of diabetes care.
Clinical engagement and leadership: The process of redefining the care pathway was led by a group that comprised of members of the hospital team, a GP with special interest in diabetes and CCG leads (clinical and non-clinical). Specialists and generalists worked together to identify patients who could be discharged from specialist care for management by GPs with specialist support. Local focus groups were held to seek the opinion of people with diabetes and GP engagement was recognised as crucial and sought early in the process. The clinical lead spoke to healthcare professionals delivering diabetes care across the area and surveyed GP practices with the proposals for improving the service delivery to identify what would support their practice. The 24hour email and phone support were implemented as a result of this process.