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Creating a seamless diabetes service

A redesign of diabetes services will integrate care in Kirklees, West Yorkshire. Lead GP Dr Abdulreham Rajpura and PBC manager Helen Frain explain

A redesign of diabetes services will integrate care in Kirklees, West Yorkshire. Lead GP Dr Abdulreham Rajpura and PBC manager Helen Frain explain

Providing an excellent standard of care closer to home is the key aim of our diabetes service redesign.

There is a high incidence of diabetes in Kirklees, affecting 6.5% of adults in 2006/7. The PCT has a significant Asian population, with 14.5% of residents identified as from ethnic minority backgrounds. So tackling diabetes is a priority, and a commissioning objective shared by all PBC consortiums and stand-alone practices was necessary.

The service redesign via a new local enhanced scheme will help us ensure patients are seen by the most appropriate person in the most appropriate place.

By April next year, GP practices across the north of Kirklees will be working towards treating all but the most complex patients in primary care.

Patients will have access to a truly seamless service. Blood tests, retinal screening and podiatry will all be available in primary care, together with insulin management, so patients will not have to wait for multiple outpatient appointments.

The specialist team of consultants and diabetes specialist nurses will be advising and supporting practices so any concerns about a patient's condition can be dealt with quickly. Stripping out unnecessary hospital referrals means when patients do need to see a consultant or specialist nurse, they will get an appointment more rapidly.

The local picture

Kirklees is a diverse area, with pockets of severe deprivation in the old industrial towns of Huddersfield and Dewsbury in the north – eight of our 23 electoral wards are within the 25% most deprived in England and Wales. In the south, we have the rural areas of the Colne, Holme and Dearne Valleys.

The PCT has a complicated history. It was created from a merger of three former PCTs in north Kirklees and Huddersfield. We have two acute trusts at either end of the patch, the Mid Yorkshire Hospitals trust in the north and the Calderdale and Huddersfield NHS trust in the south.

The project builds on a number of initiatives that have encouraged joint working across primary and secondary care and given us a strong base.

Our diabetes network works closely with the Mid Yorkshire Hospitals trust and Wakefield District PCT. The diabetes network initiated this model and the PBC leads in the North Kirklees consortium have driven it forward. We have created health improvement teams (HITs) with our PCT for long-term condition areas, and the diabetes HIT is a key partner in the redesign process. They are developing structured patient education programmes, improving podiatry services and are involved in a review of dietetic services.

We are one of three national pilot sites for the Diabetes Year of Care, working with our neighbours in Calderdale PCT and the Calderdale and Huddersfield NHS trust. This will offer structured patient education programmes and improved care packages that meet the needs of particular groups of patients and support choice. Three of the Year of Care pilot practices are in Kirklees.

The development of PBC in this area has given us a strong basis to work from. There was 100% sign-up to PBC across the former North Kirklees PCT, with practices forming several locality groups that grew into PBC consortiums. Now there are four PBC consortiums and 11 stand-alone practices in Kirklees, working in seven localities. The PCT was runner up in the national NHS Alliance awards in 2007 for its approach to PBC.

The new service

We decided not to base the new service on GPSIs in diabetes, as we wanted all practices to develop their expertise and run their own services wherever possible.

The specification outlines five levels of provision. Practices will be accredited to deliver care that meets the specification for the level they offer.

Level one and two relate to the QOF, with patients managed by diet alone or diet and metformin, sulphonylurea, thiazolinediones or dipeptidyl peptidase-4 inhibitors. At level three, practices will manage patients on insulin and at level four initiate insulin. Patients will be offered yearly podiatry reviews and retinal screening.

We expect levels three and four to be commissioned under a LES although this is subject to negotiation – we may run a pilot as a LES would commit us across the patch, whereas we are starting the scheme in the north of our area. The aim is to offer equal access for all patients in primary care to level four.

Through consultation with our practices we have established current levels of care provided and their aspirations for the future, using educational needs analysis.

We are now developing an educational package to support primary care practitioners. Almost all practices aspire to move up one level.

Practices that do not wish to provide services at either level three or four are being identified and a commissioning plan will be made. We are talking to stakeholders at the moment, but expect to offer solutions such as services run by the PCT or lead clinicians from neighbouring practices.

This will free up acute services to concentrate on level five:

• gestational diabetes and patients planning a pregnancy
• children and adolescents
• those with renal, cardiac or other complications
• patients requiring specialist treatment such as basal-bolus or Dose Adjustment For Normal Eating (DAFNE) training.

Each practice involved will identify at least one clinician, either a GP or nurse, who can provide enhanced diabetes care. They will be trained to diploma level under a distance-learning package that will be commissioned from the University of Bradford or University of Huddersfield. There will be mandatory study days each year and practices will be supported by secondary care consultants and diabetes specialist nurses offering ongoing training, case reviews and audit.

We are in discussions with the Yorkshire and the Humber strategic health authority to develop a commissioning plan for e-consultations, where consultants provide email and phone support to GPs, agreeing care management plans or referrals.


We believe our redesign will offer improved access to specialist services by allowing them to concentrate on the patients who need that level of support, as well as improving the skills of both primary and specialist care clinicians. It should also:

• improve communication between primary and secondary care
• reduce waiting times
• provide additional services such as care planning and structured education to improve quality of life
• give equitable access across Kirklees to highly skilled professionals
• improve quality of diabetes care in all GP practices with support from the specialist teams.


Our business case was agreed by the PCT in September. Approval was straightforward, largely because so much work had been put into the scheme over the past 18 months, by commissioners from the former North Kirklees PCT, together with the Wakefield District and North Kirklees Diabetes Network and the Kirklees PCT Diabetes HIT.

We had been concerned that our service redesign agenda might get lost in the PCT reconfiguration in 2006. But the new Kirklees PCT agreed to take it on board and allow us to drive the redesign, appointing a subgroup specifically to look at diabetes.

The initial implementation in the north will allow us to learn lessons before the project is rolled out across the PCT. The scheme will be phased, starting with five practices already working at level four and cascading out to practices at three that want to reach four, and level two aiming for three.

Now the challenge is to make detailed commissioning decisions for each level of care, and agree the educational packages, audit and detailed costings.

A key element is workforce planning – identifying which lead clinician each practice will appoint to manage diabetes, whether GP or practice nurse, and developing proposals for accreditation and re-accreditation.

The diabetes and renal programme manager, diabetes specialist nurses and consultant will visit every practice, reviewing patient records and identifying cases that can be treated in primary care and those that require specialist input.


Cost savings are not a key focus of the scheme – our redesign is about providing quality services in the community. Money saved in the acute sector will be reinvested in primary care. We propose that practices will qualify for incentive payments for each patient they take back from secondary care: £50 for managing patients on insulin at level three and £250 for initiating insulin at level four.

We estimate that moving services out of hospital will result in a net saving of about £182,000 in reduced secondary care activity in 2009/10.

This is based on taking 341 first outpatient attendances and 2,132 follow-up attendances into primary care. These savings will cover increased prescribing costs, estimated at £14,000 in 2009/10, as well as the education package for GPs and practice nurses.


The success of the scheme will be judged on improving the quality of patient care and reducing health inequalities by providing enhanced services for all patients, whichever practice they are registered with.

The key measures are:

• all practices meeting the accreditation criteria to deliver the agreed service level that meets the needs of patients
• all practices having access to an educational programme
• patients who require specialist care being seen promptly, meeting 18 week targets
• reduction in first and follow-up outpatient costs
• reduction in non-elective admission costs
• positive feedback from patients.

Our success so far has been based on having a clear project plan, drawing on the expertise and experience of key stakeholders and ensuring that there is clinical representation from the start.

We have benefited from having a multidisciplinary team, including our lead consultant Dr Mark Freeman, diabetes network manager Janet Wilson (who works in Wakefield District and Kirklees PCTs) diabetes and renal programme manager Julie Wood, clinical development manager for Long Term Conditions Joanne Crewe, and the chair of the Long Term Conditions Board, Sheila Dilks. In many parts of the country, networks are based largely on goodwill – having leaders who have been able to dedicate time to this project has made us much stronger.

Dr Abdulreham Rajpura is a senior partner at the Mount Pleasant practice in Dewsbury, West Yorkshire. He is also executive member of the North Kirklees PBC consortium and Kirklees LMC and a member of the Wakefield District and North Kirklees Diabetes Network and the PCT's HIT for diabetes

Helen Frain is commissioning service development manager for Kirklees PCT

Dr Abdulreham Rajpura (right) and Dr Mark Freeman, consultant in diabetes and endocrinology 60-second summary The consultant's opinion

Dr Mark Freeman is consultant in diabetes and endocrinology at the Mid Yorkshire Hospitals Trust and Kirklees PCT's clinical lead for diabetes

‘The whole purpose of the redesign is to allow practices to develop at a level where they are comfortable so patients who require routine care can be discharged back to primary care with an agreement between me and the practice, using a notes review. I will go into practices with the diabetes nurses and offer education and support, such as a notes review or a formal education session.

‘My role has been to put a clinical face on the service redesign and act as a conduit, getting people on board and making sure the service is the best possible from a clinical point of view.

‘I would like to spend more time with patients who need specialist care and this is a way of ensuring a seamless transition between primary care and secondary care.
‘We want a more equitable and well-defined service with
the patient seen by the appropriate person at the appropriate time.'

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