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Delivering a diabetes service closer to home

Diabetes care can be moved closer to patients by a community-based service that is better, faster, cheaper and more convenient than hospital-based care, writes Dr Brian Bates

Diabetes care can be moved closer to patients by a community-based service that is better, faster, cheaper and more convenient than hospital-based care, writes Dr Brian Bates

Our PBC consortium, First Commissioning, was set up in mid-2005 due to the inevitability of PBC and a desire to take control of our own destiny.

With the support of our PCT we have achieved an early breakthrough with a community-based diabetes scheme, which has now been running for more than six months.

Our progress to date has shown that the service can tick all the boxes: faster, cheaper, more convenient, and with as good or better outcomes than those achieved previously. We aim to develop the service even further, under our specialist provider medical services (SPMS) company First Provider, which is due to go live in April.

Four practices initially formed the consortium and some time later we were joined by a fifth practice, taking our total list size to 58,000. All five practices are situated just north of Derby city and have a similar type of population.

Progress

Our consortium's progress was slow at first, despite the support from Derby City PCT, due to vague PBC guidance and the fact our time was precious and in pitifully short supply. Early in 2006 we agreed to spend our PBC directed enhanced service (DES) money on getting a manager and Michael Ryan, our director of business development, joined us in September to drive things forward.

We believe all patients with diabetes should have their condition managed in the community. If they are well controlled then their own practice should be able to do this, regardless of being on insulin or not. If they are poorly controlled then a community-based diabetic network should manage them. Last June we established such a network, based at one surgery, to meet these aims.

Patients are referred into the network by GPs within our consortium if they have problems with their diabetes or an HbA1c of 7.5 or above. The patients are then invited to attend the network within the following 14 days. Patients are seen by a GP with a specialist interest in diabetes or a nurse specialist in long-term conditions.

Patients have six-monthly and annual reviews and three monthly medication and HbA1c reviews between these, so in effect they are having alterations to their treatment every three months. Once they are below the 7.5 HbA1c level they are then returned to their own practice. Information goes back to the practices in a way that is easily understood and suitable for QOF purposes.

The GPSI, who is a practice partner, spends one session a week on this work, and the nurse, who is employed by the same practice, devotes two to three sessions a week. The PCT pays the practice for this time.

There is no doubt that despite being more labour intensive than the hospital-based model, we are substantially cheaper. Our GP specialist earns the network £140 an hour and sees more than two new patients in this time. Our nurse specialist sees a similar number on £70 an hour. By comparison, the tariff cost for every new patient seen at the hospital is £241.

Referrals

Referrals have been steady, at about eight to 10 a month – and we expect them to increase. Our first audit, based on 29 patients seen from June to November 2006, shows high patient satisfaction and excellent clinical outcomes (see box right). At our provider surgery we have free car parking within yards of the building and an atmosphere the patients can more readily relate to than hospital.

Although the patient numbers in the audit are small, the main purpose was to show GPs who were not yet referring of the likely outcomes. We intend to repeat the audit.

Patients who need diabetic support and also the support of other hospital-based specialists, however, should be managed in a hospital setting and they are excluded from our service. These include children, diabetic women who get pregnant, those who develop gestational diabetes and those who have diabetes-related vascular, renal or ophthalmic problems of such a degree that they need joint care with the appropriate specialists.

The scheme has not been established long enough to show savings but these should be identifiable later in the financial year. Should they occur they will be returned to the consortium practices in accordance with national guidance.

To date we have had little contact with our local consultants. As we represent only 10 per cent of the hospital diabetes service and the number of diabetics is increasing almost exponentially, we feel our service will help the hospital to cope with the anticipated increases rather than cause it any problems. However, we would like to have one of our local consultants providing some sessions in our network next year and are currently in talks regarding this.

For 2007/8 we are looking at renegotiating the contract, to be held between First Provider and the PCT, with either a block or cost-per-case arrangement based on current activity.

We are aiming to develop a scheme where patients with impaired glucose tolerance will have access to advice, dietitians and exercise programmes to minimise the conversion rate to full diabetes. This is a very labour intensive programme which is currently very poorly supported but with tremendous potential. More GP and nurse specialist time is planned, as are the services of a dietitian, podiatrist and consultant-run sessions.

These developments will not only allow us to provide an even better service but they also allows us to generate savings that can be used to fund further service developments.

By April all five of our practices will have the same computer system with a central server so the transfer of data between us should be straightforward.

We chose the SPMS route because it allows us to remain part of the NHS family. It makes recruitment of NHS staff – such as consultants or management secondments – much easier. But it is as much about ethos and culture as pay and pensions.

Profits

We envisage most profits made by our company being re-invested into services where investment is currently poor or non-existent.

All partners will have an opportunity to hold an equity stake in the company so no one individual or group has a majority holding that could be detrimental to the organisation's stability. A separate mechanism is planned along the lines of the Lottery Commission, to decide how any surplus is dispersed. This will include input from the general public.

While our service will improve substantially with our proposed developments we are already convinced about it. We see everyone within two weeks and review as required. Patients are very satisfied, we are cheaper than the alternative provider by a significant amount, and our outcomes are excellent.

We are developing similar projects in dermatology and COPD and have established a small but effective carpal tunnel scheme. We have a nursing home project and many other proposals in the pipeline: the future looks busy and exciting.

That said, we realise we are still nearer the beginning of the new world of PBC than we would have liked – but this is the NHS, the super-tanker where change is always slow, painful, tortuous, challenged and never easy. All things considered, we are satisfied with our progress.

Our mantra is that if it can be done quicker, cheaper, as well as or better, closer to home, then it should be. Diabetes is only an example of what can be achieved in a community setting and it should be easy to take the messages from our initiative and apply them elsewhere.

Dr Brian Bates is a GP in Borrowash, Derbyshire, and lead clinician for First Commissioning

60 second summary

  • Initiative: Provision of a community-based diabetes service to five practices within a commissioning consortium
  • Policy link: Shifting a traditionally hospital-based service into the community
  • Set-up time: 12 months
  • Set-up costs: Negligible – unlike substantial ‘time' costs
  • Service staff: GPSI on one session a week; nurse specialist in long-term conditions on two-three sessions a week
  • Cost of service: GPSI sees two new patients an hour at £140 an hour; nurse sees similar number at £70 an hour, versus £241 hospital tariff for every new patient
  • Contract: PCT currently only reimburses practice for GPSI and nurse clinical time – block or cost-per-case contract being renegotiated for 2007/8
  • Outcomes: High patient satisfaction, more convenient location, drop in average HbA1c from 9.72 to 7.4, cheaper than hospital care
  • Savings: To be confirmed once service completes full year. Savings to be reinvested in practices and further service developments
  • Contact: Dr Brian Bates, email bjpbates@aol.comy

Audit of community-based diabetes network care

Patient satisfaction

  • Only one patient waited more than two weeks
  • 87% felt their management was explained fully
  • 91% felt they had enough time with the nurse or GP
  • 91% felt their diabetic care had improved
  • 87% wished to return for further care
  • 91% would recommend the service to friends

Clinical outcomes (mostly insulin conversions)

Average HbA1c fell from 9.72 to 7.4.

This reflects a reduction into the normal range plus a risk reduction of 42% in overall complications, including: 28% of MIs, 74% in microvascular disease and 86% in peripheral vascular disease.

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