An attempt to improve diabetes care five years ago in south Hampshire taught us an important lesson – we were going to have to be more ambitious.
We had taken steps to improve diabetes management in primary care by setting up a community diabetes team comprising a GPSI – myself, Dr Goulder – and two diabetes nurses. We would support general practice through education, telephone consultations and visits where necessary. The three problems we were trying to address were:
⦁ the inefficient system of long-term follow-ups being done in hospitals
⦁ unacceptable variation in the quality of care provided in primary and community care, which was contributing to higher than expected rates of diabetic emergency admissions and complication rates
⦁ complete disconnect between services; there was an artificial divide between primary and secondary care, leading to both duplication of work and people falling between the cracks in terms of care planning.
In 2011, our community diabetes team joined forces with a new consultant diabetologist – Dr Partha Kar – who shared our vision for trying something very different from the old way of working.
Our goal was to transfer 90% of patients suitable for discharge from secondary care back into the community, shifting the balance of resources and expertise.
Who could be shifted?
We first had to work out which patients absolutely needed to be under consultant care – creating a clear distinction about what work the acute trust should be doing and what it should not be doing.
For a task we initially thought might be difficult to reach agreement on, when we actually sat down with commissioners to work out who should be doing what, there was a surprising level of agreement. We agreed there was a ‘super six’ that needed to remain under specialist control:
⦁ antenatal diabetes
⦁ diabetic foot care
⦁ renal patients (estimated glomerular filtration rate <30ml/min/1.73m2 or on dialysis)
⦁ insulin pumps
⦁ uncontrolled type 1 diabetes and adolescent diabetes
⦁ inpatient diabetes.
Using practice registers, the community diabetes team identified all patients who did not fall under any of these categories.
This process gave practices more support and identified the care management issues and education requirements of clinicians.
These complex patients fell into a grey area because, of course, they had been sent to see a specialist for a reason. They may not yet have had a complication that required secondary care intervention, but they may well have had poor control or complicating comorbidities.
While clinically identifying which patients could be managed in primary care proved to be relatively easy, the next stage took a long time to get off the ground.
We had to ensure we were not just lumping primary care with hundreds of patients that GPs did not know how to handle.
And consultants, understandably, did not want to discharge patients they felt were not going to be managed properly.
Primary care was fairly keen, but the clear message was GPs absolutely wanted access to a specialist – and the question was how we provided that.
Our idea was for such a radical overhaul of the diabetes care pathway that it took a while for people to understand how it would work.
Old defences between primary and secondary care – which have now largely come down – stopped us for a while putting in place the system we now have.
One issue was that the way hospitals are funded, in particular the tariff system, can be a strong disincentive to agreeing to do less work in the acute sector.
The new model
GPs or practice nurses now manage most patients with diabetes in the community with the community diabetes team.
To give them the support and confidence to do this, we created a direct rapid-response specialist support service that allows GPs and nurses to contact consultants via email or telephone.
The community diabetes team, still a GPSI and two diabetes nurses, manages the service and the specialists have input on a rota system.
The GPs are funded via a LES which is 80% of £2.25 per head of registered diabetes population and £100 for every injectable therapy initiated. The money for the LES came from decommissioning hospital clinics.
The consultants now have two roles – managing the ‘super six’ in hospital and working in the community to provide support for those patients previously seen in the secondary care clinics.
These two roles are reflected in two contracts.
The first contract the two CCGs (South East Hampshire and Fareham and Gosport) have is with Portsmouth Hospitals NHS Foundation Trust for their consultants to manage the ‘super six’.
The second contract is with the community foundation trust, which holds a sessional contract with the consultants who have formed themselves into Southern Diabetes Medical Services LLP to provide this community support and education.
The consultant group holds a sessional contract with Southern Health NHS Foundation Trust, a provider of community care, thus providing an integrated link between the acute and community providers.
Loss of activity for the trust was balanced by a drop in sessional payment for the consultants from the acute trust.
The list of patients thought suitable for discharge was sent to the 49 practices covered by the two CCGs and patients were discharged after joint agreement between the specialists and GP colleagues.
Patients were notified by a letter, jointly signed by Dr Goulder and Dr Kar.
Not every patient was keen to be moved out of secondary care clinics, but the vast majority were happy not to have to travel to hospital and to have support from their practice nurse.
Of the 642 patients discharged, we have registered 13 complaints – four have been reinstated appropriately, while nine were discharged with assurance about the service and care provided in the community.
Since November 2011 when we initiated the ‘super six’ review, 642 patients have been discharged from secondary care and now receive follow-up within general practice.
They are seen closer to home and yet still have access to specialist advice when it is needed.
We have met our target of discharging 90% of those reviewed by the community team.
With a follow-up appointment costing around £90, on this factor alone we have made a recurrent saving of £54,000 a year. The cost of the new service is £76,000 and savings made so far are £91,000 in just under 10 months.
We are on track to have made £50,000 in savings by the 18-month review.
On the other side of the coin, 57 patients whose cases have been reviewed under the new system are now being treated in a ‘super six’ clinic and getting more appropriate care as a result.
New specialist referrals have fallen from around 15 to two per month.
An important part of our work has been to enhance the skills and knowledge of both patients and clinicians in managing diabetes care.
Since 2007 when we first started to ramp up the educational provision in the community:
⦁ 2,263 people with diabetes have undertaken DESMOND training to aid self-management of their condition
⦁ 227 clinicians have undertaken MERIT training to gain the skills to better manage patients on insulin therapy, and courses are continually oversubscribed
⦁ 1,354 individual practice referrals have been seen by the community team
⦁ 30 clinicians have undertaken ‘conversation map’ training as a tool to help drive meaningful behaviour change in patients.
More than 30 practice education visits have been carried out by specialists since November 2011, and one key benefit has been the increasingly positive relationships between GPs, consultants, nurses and other staff involved in diabetes care.
Feedback we have had from primary care has been consistently positive and the vast majority of practices are doing a very good job of managing these patients with the community specialist support.
It is worth pointing out that practices were seeing these patients for QOF anyway, so in effect there was a duplication of work going on.
We expect that emergency admissions will fall and future analysis will look at health outcomes.
Anecdotal feedback from patients has been overwhelmingly positive – many say the education they have received empowers them to take control of their diabetes.
Our model is about making sure secondary care is used in the right way.
The key to convincing commissioners and secondary care that this was the best way forward was to have a clinical champion in the specialist team.
You only need one person to realise that everyone has to be brave and look at a better way of providing care to start the domino effect of convincing everyone
The PCT also took some convincing, with finance managers unable, at least at the beginning, to get their heads around the fact that these patients would no longer need to be seen in hospital at all.
They did fund our initial community diabetes team but moving to the system we have now was by no means an easy feat.
Just common sense?
We hear so much talk about how we need to be radical in redesigning pathways, to think about how you would do it if you were starting from scratch and whether we make the best use of hospitals – but it is not an easy task to convince all parties to take such a leap of faith.
When you think about it, properly defining what should and should not be done in secondary care and ensuring
that the specialist role is about both looking after the ‘high-end’ patients and educating other practitioners is not a particularly far-fetched idea.
We do have plans for further improving the scheme, including making the biannual practice education visits more interactive through use of an audit of practice data and selecting specific areas where work is needed.
At the end of the day, we all want to improve care for patients.
What we knew at the start is that any approach that simply attempted to cut referrals at any cost would not achieve much of anything.
This model of care has recently won the Care Integration Award 2012 for diabetes care, and has also been shortlisted for the HSJ Awards 2012 in the managing long-term conditions category. It has also been recognised nationally in the November bulletin of Sir Bruce Keogh, the NHS Commissioning Board’s medical director.
Dr Tim Goulder is a GPSI in diabetes and Dr Partha Kar is clinical director for diabetes at Portsmouth Hospitals NHS Trust