The problem
The Royal Docks Medial Practice has been in Newham, for over 20 years.
Newham is one of the most deprived London boroughs in the UK, with 51% of patients from ethnic minorities and a high incidence of type 2 diabetes. The problem we faced was to reach and engage with a cohort of very poorly controlled diabetes patients.
We thought the poor control was due to poor compliance with diet, exercise and medication. Some patients may have found it difficult to book time off work to see the GP or come for blood tests. Many patients are not paid if they miss any time from work. Many are in jobs where they are expected to work long hours and others work two jobs to bring in sufficient income.
For some patients co-morbidities would cause poor compliance from poor mobility or depression.
We decided to reduce the number of times a patient would have to travel for blood tests. This would improve compliance, and so improve management and increase the number of patients with HbA1c below 9%.
The first step was to gather the details of all patients whose HbA1c was above 9% and note those who had not had their blood tests within the last three months. This produced 54 patients in the first cycle of the audit and 52 patients in the second cycle.
What we did
Two methods were employed to improve patient compliance.
First we posted out blood request forms to all 54 patients, with information regarding the times and location of the test and a letter explaining what the test was for. All 54 patients were phoned to inform them that their blood request would be arriving by post. The cost of this was the price of envelopes and stamps for the 54 patients and staff time. It took in total three hours over a week to carry out this process.
After three months, the second part of the audit cycle used another method of engagement to compare with the first approach.
In the second method, we focused on 52 patients who still had an HbA1c above 9%, or had not taken their blood test on the first call.
These people were phoned by the GP or practice nurse (who had received training on the Warwick course) to remind them to have their blood tests done, discuss their diabetes and review their medication. This also allowed a phone consultation, which helped deal with problems or reservations patients might have had.
Challenges
We found that not all patients would answer their mobiles as many are not allowed to when at work. Those patients were phoned in the evenings and if no contact was made a text message was sent and a further letter with their blood test forms.
Outcomes
Through the first method, patient compliance was improved by 57.4%, and 24.07% of the patients had improved their HbA1c to below 9%.
This resulted in the practice diabetes list with HbA1c improving from 81% to 85.4% - only 4.6% below the target.
The key advantages of using the first method are:
· It reduced HbA1c in 25% of patients
· It improved compliance in 55%
· It took three hours to run and cost little
· It could be implemented for many other tests, such as compliance in blood tests for TFTs, LFTs, or U&Es
· It could help reduce hospital admissions of diabetic emergencies and complications
· It could reduce referral costs
· It improved QOF scores and thus practice income (although the costs might offset the potential income)
· Patient satisfaction improved as they took less time off work for tests
With the second method, compliance improved by 32.7%. Some 7.7% of patients reduced their HbA1c to less than 9%.
This resulted in the practice audit score improving from 81% to 82%, though it was still 8% below the QOF target.
Asadullah Naqvi is a fourth-year MBBS at Barts and The London School. He worked with Dr Jim Lawrie at the Royal Docks Practice, east London.
