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How a GP clinical champion can deliver change in diabetes care

Drive things forward but don’t make it a personal crusade – that is Dr Rebecca Pryse’s advice after two years as diabetes lead for her PBC collaborative.

Drive things forward but don't make it a personal crusade – that is Dr Rebecca Pryse's advice after two years as diabetes lead for her PBC collaborative.

The challenge I faced when I was appointed diabetes lead – later known as clinical champion – was that in 2006/7, 12% of the total spend in secondary care by the PBC collaborative (£6,323,401) was spent on the type 2 diabetes population.

Primary care teams had become deskilled and lacked the confidence to manage routine diabetes. The number of patients seen in secondary care was rising, with a relatively high new-to- follow-up ratio of 1:4.

Each group had their own concerns. The PCT was particularly worried about inefficiencies in diabetes care and the high costs that had resulted from this. Consultants said they were being sent unnecessary referrals, while GP practices and their patients were concerned about long waiting times – around three to four months for outpatient appointments.

41187782My job was to bring about change to address the concerns of all these diabetes stakeholders and keep them on board.

Buckinghamshire PCT funds the collaborative's clinical leads. Payment is £230 for every 3.5-hour session. Initially my post was funded at three sessions a month but then referral triage was reimbursed as an extra role, and this has resulted in an average of two extra sessions a month.

Discharging patients back to primary care

Given that my role was to guide through any changes to services and facilitate discussion of issues that might arise, rejuvenating the diabetes clinical network seemed a good idea. The network had originally been run by the PCT but had drifted off their agenda.

The network invites any clinician or manager involved in diabetes care to attend a meeting every two months, chaired by me, to talk about diabetes issues, such as new protocols and drugs. Usually about 15-20 people attend, including patient group representatives from the local Diabetes UK group.

In addition, I arranged meetings with the key personnel who deliver services, including hospital consultants, community diabetes specialist nurses, podiatrists and dieticians. I also spent time with the diabetes clinic at Stoke Mandeville Hospital to see how this consultant-led service worked.

And I visited some of the 21 GP practices in the PBC group to discuss issues, problems or ideas they might have for improving delivery of services to the 7,000 patients with type 2 diabetes in the locality.

Before the PCT could move forward with service redesign, the high number of hospital follow-ups needed to be addressed. Rather than suggest a mass discharge of patients from secondary care, I worked with the local diabetologist to produce a list for each GP surgery of type 2 diabetes patients that were under hospital follow-up. Lists were sent to the 21 practices in the collaborative, and they were asked which patients their team could manage.

Most practices responded and out of the 689 patients on the secondary care follow-up register, 153 were discharged to GP follow-up. These cases would have cost £88 per follow-up consultation in secondary care, so their discharge to GPs potentially saved at least £13,400. The collaborative will audit the outcome of this process shortly.

Triaging referrals across the PCT

The next step was to look at referrals to the hospital diabetes clinics from 60 practices across the whole PCT. As data collection from the hospital trust was poor, this was a way of keeping track of who was being referred to hospital diabetes services.

All referrals were sent to the PCT's referral support centre, and after administrative checking were sent on to me. I used the PCT referral criteria guidelines drawn up by the diabetes clinical network in early 2006 as a template.

I either passed referrals to the hospital trust or contacted the referring GP to agree an alternative management plan. Urgent and faxed referrals were dealt with by consultants directly but they sent me copies so I could log activity. Each month I fed back a summary to the PCT commissioners.

This was potentially a contentious project. GPs can be sensitive about having their referral letters judged but as a diabetes GP champion I knew a lot of the doctors, which helped to reassure them.

Where possible, I phoned GPs to discuss any referral redirection. Usually I was able to explain that there was a community-based service available for the particular problem the GP was making the referral for, such as community diabetic nurses, a podiatrist, or dieticians.

The referral triage ran from December 2006 to November 2007. Of the 130 referral letters to secondary care, 72 were transferred to community services, which resulted in a cost saving of around £14,000.

Together, the referral triage scheme I helped to establish and the work I did with the diabetologist to reduce secondary care follow-ups have saved the PCT around £28,000. Now we are looking at how this money can be used to benefit diabetes patients.

Right care in the right place

The referral triage process highlighted that some GPs were not sure where to refer patients for the most appropriate tests.

And it was recognised that a joined-up care pathway was needed. In January last year, the PCT asked the collaborative to lead the clinical development of properly commissioned care pathways for diabetes patients so care could be delivered by the right person in the right place, with a seamless transfer between primary and secondary care services where appropriate. It meant taking a good look at where we were and where we needed to be.

The PCT increased my funding to five sessions a month and the pharmaceutical company GlaxoSmithKline employed a consultancy to help analyse data and produce a business model.

Involvement with a drug company on a project was a new experience for the PCT, and partnership working with NHS stakeholders was a novel venture for the company. Core principles were drawn up at the start, as we needed to be clear about why we were doing the work and what we wanted to achieve.

This involved examining such areas as health needs assessment, best practice quality markers, getting feedback from service providers and users, business planning, service specifications and how we could measure new service outcomes.

I helped facilitate three patient participation group evening meetings last summer and at these I explained the concepts of PBC, especially in relation to redesigning diabetes services. We also invited patients to a big stakeholder meeting where, along with clinicians and managers, we looked at current service pathways and how they could be improved.

At the time of writing we are about to present the business case for service redesign to our professional executive committee (PEC) for approval. The two main changes we hope to see are all referrals going through a clinical-based referral triage point, such as a specialist nurse or GP; and the bulk of referrals passed on to a clinical multidisciplinary team led by specialist diabetes nurses.

Lessons learned

It has been good to get doctors, nurses and patients together to talk about diabetes and to listen to each other's views. Health professionals appreciate being involved in redesigning diabetes care, while patients say they feel reassured that there is someone leading diabetes care who understands their needs.

One of my challenges has been keeping the PCT involved. The organisation has also been undergoing change, so keeping up with the different key contacts has been frustrating. People can feel threatened by your ideas but you need to get those people on board, because potentially they could block what you are trying to do.

When going through the service redesign process, find out the PCT's priorities, which will probably be focused on short-term, cash releasing schemes.

But the long-term clinical outcomes are important, so you need to make sure the PCT builds them into any business case. And if you are working with a pharmaceutical company, remember that working around ABPI rules can slow processes down.

It's important for the PBC group and PCT not to rely completely on the GP clinical champion to run the projects. They need to provide project management support because the champion cannot do everything. The role is about driving things forward, so don't get bogged down in detail and administration – delegate instead.

Being a GP clinical champion is hard work but rewarding. Just don't make it a personal crusade and don't take things personally. It is a challenging role, but I would still recommend it.

Dr Rebecca Pryse is Buckinghamshire PCT diabetes GP clinical lead and a part-time GP in Buckingham. She is also school medical officer for Stowe School near Buckingham and Swanbourne House School near Milton Keynes and a private GP at GP Extra Saxon Clinic in Milton Keynes.

Dr Rebecca Pryse: GPs can be sensitive about having their referral letters judged, but it reassures them if they know you Dr Rebecca Pryse 60-second summary

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