Diabetes Care Pathway
May 2013
(Updated August 2013 to include additional funnel plot graphs and information on
LiveWell Richmond)
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Executive Summary
PurposeThe purpose of this document is to illustrate the case for change for diabetes services and to put forward recommendations to improve the quality of care in the community.
Background
By 2025 it is estimated that five million people will have diabetes.1 Across England, approximately a third of the projected rise in diabetes prevalence can be attributed to the increasing prevalence of obesity. Diabetes is a major cause of premature mortality with at least 24,000 avoidable deaths each year.2A diagnosis of diabetes approximates to a reduction of life expectancy by about ten years.3National Institute for Health and Care Excellence (NICE) provides comprehensive guidance on prevention, diagnosis, management, and complications of diabetes.
Case for Change
The QOF prevalence of diabetes for adult patients in Richmond was 3.4% in 2011/12 (London: 5.6% and England 5.8%), which is around 5,350 people. Richmond public health analysis (2012/13) shows that there were 5,840 patients of all ages with diabetes. Eighty-five percent were of type 2 (4972 patients), 7% of type 1 (436 patients), and 7% unclassified (432 patients) due to insufficient diagnostic information. There are a number of people living with diabetes who are currently undiagnosed or living with pre-diabetes. Further work around case finding and early prevention is needed to identify these people and provide them with appropriate care in the community.
A low percentage of people in Richmond with diabetes are receiving the nine key tests for diabetes care recommended by NICE, in particular for people with type 1 diabetes (27.7%), with Richmond being in the 2nd lowest quintile nationally for this indicator. Over 50% of people with type 2 diabetes are receiving the nine key tests annually.
Emergency admissions among patients with diabetes vary across practices. After allowing for age and sex distribution, around six practices have significantly higher emergency admissions than the Richmond average for patients with type 2 diabetes.
Ninety percent of people with diabetes have co-morbidities. The National Diabetes Audit (2011/12) shows that in Richmond patients with diabetes, 7.3 per 1000 had had a stroke in the previous year compared to 6.9 per 1000 across England. Similarly, 10 per 1000 of people with diabetes had a myocardial infarction in the previous year compared to 4.8 per 1000 in all PCTs in its cluster group. Current Richmond Diabetes Pathway
The local diabetes pathway sets out levels of care and includes services/activity recommended by NICE for the management of diabetes, in line with the model of care set out in the Diabetes Guide for London.4 The diabetes pathway for Richmond follows a tiered approach.
Level 0 is prevention and lifestyle services for self-care, underpinning all of the other tiers. Level 1 is core primary care services delivered by health care professionals in GP practices. Level 2 is enhanced primary care according to clinical need and is delivered by the practice
or in conjunction with the level 3 Community Based Intermediate Diabetes Service. Level 3 is a consultant led specialist multi-disciplinary service, delivered in a community
setting and aimed at patients with complex needs requiring specialist input.
1 Diabetes UK, Diabetes in the UK 2012: Key Statistics, April 2012 2
National Diabetes Audit Mortality Analysis 2007-2008 – NHS Information Centre, 2011
3 National Service Framework for Diabetes: Standards, 2001 4 Healthcare for London, Diabetes Guide for London, March 2009.
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Level 4 is a consultant led specialist multi-disciplinary service that is delivered in secondary care/hospital settings. Level 4 also includes an inpatient service and emergency
admissions.
There is potential for the Community Ward to case manage diabetes patients who are at very high risk of unplanned hospital admissions, and reduce avoidable emergency admissions.
Cost Savings
In 2012/13, overall total spend on hospital activity for Richmond patients with diabetes, including their co-morbidities, was £12.7 million (including elective procedures, emergency admissions, outpatient appointments, A&E, and community prescriptions).
Treatment for complications and related co-morbidities represents much of the total cost for diabetes.The main possible cost savings are focused on achieving a reduction of avoidable emergency admissions (Ambulatory Care Sensitive Conditions5 (ACS)) due to complications of diabetes and co-morbidities.In 2012/13, there were 141 emergency admissions for ACS conditions for patients with type 2 diabetes that may have been avoided, saving up to £368,388.
Recommendations
A range of stakeholders were identified to consult with (Appendix 1) and their input was used to inform the recommendations:
1) Continue case finding work to identify undiagnosed patients 2) Identification and management of pre-diabetes patients 3) Referral to LiveWell Richmond (lifestyle services) 4) Review Primary Care LES post March 2013 5) Routine implementation of nine key diabetes tests 6) Reduce avoidable emergency hospital admissions
7) Investigate potential to share Diabetes Specialist Nurses (DSNs) across practices 8) Embed NICE Quality Standard in provider contracts
9) Monitor equalities data in provider contracts 10) Offer DESMOND as part of a package of care
11) Provide diabetes education for non-English speaking BME groups
12) Review provision and referral criteria to dietetic services for diabetes patients 13) Offer options for non face-to-face communication for ongoing management
14) Better management of diabetic patients in care homes as they are high risk for emergency hospital admission
15) Review integrated models of care from other CCGs and prioritise the diabetes pathway for the Community Ward
16) Develop an integrated community based diabetes service 17) Develop pathways to address multiple morbidity
18) Ensure a diabetes pathway is embedded in the future Integrated Care Organisation Next Steps
The diabetes pathway will be discussed by the Richmond Clinical Advisory Group (CAG) in June. NHS Richmond CCG will lead on taking recommendations forward, with support from Public Health. Additionally, dependencies in delivering recommendations will be acknowledged and relevant stakeholders will be included to inform planning and delivery of the recommendations. The pathway shall be reviewed every two years as routine and earlier if any national guidance is published that has a great impact. This will be triggered via the Planned Care Group.
5
Ambulatory Care Sensitive (ACS) conditions are common conditions for which timely and effective out of hospital care, including primary care and community care as well as good case-management, can result in a reduction in unnecessary, expensive and unplanned hospital admissions.
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1. Purpose
The purpose of this document is to illustrate the case for change for diabetes services and to put forward recommendations to improve the quality of care in the community.
This document describes diabetes prevalence and outcomes, and maps the existing diabetes prevention, management, and treatment services provided for Richmond patients, including service activity and associated costs where available. The latest NICE guidance for treating diabetes have been referenced and incorporated into the diabetes pathway. Recommendations have been provided for commissioning and implementation in line with best practice from NICE.
An equality impact needs assessment (EINA) has been completed for the diabetes care pathway.
2. Background
Diabetes is one of the biggest health challenges facing the UK today. Since 1996 the number of people diagnosed with diabetes has increased from 1.4 million to 2.9 million. By 2025 it is
estimated that five million people will have diabetes.6 Most of these cases will be Type 2 diabetes, because of the ageing population and rapidly rising numbers of overweight and obese people. Across England, approximately a third of the projected rise in diabetes prevalence can be attributed to the increasing prevalence of obesity. Diabetes is a major cause of premature mortality with at least 24,000 avoidable deaths each year.7A diagnosis of diabetes approximates to a reduction of life expectancy by about ten years.8 It is considered as serious and as damaging as a patient suffering a heart attack.
NHS Richmond Commissioning Collaborative acknowledges that diabetes is a key health issue in the borough. The prevalence of diabetes for adult patients in Richmond was 3.4% in 2011/12 (London: 5.6% and England 5.8%).9 This equals to around 5,350 people in Richmond. As of April 2013, there were a total of 5,840 patients of all ages with diabetes.10
Diabetes is characterised by pancreatic beta cell insufficiency, insulin resistance and chronic hyperglycaemia. It is the chronic raised sugar levels that are thought to cause the series of micro vascular and macro vascular complications, which can affect all the major organs. Diabetes can affect the heart, the kidneys, the peripheral vascular system and the eyes. Patients with diabetes need routine retinal screening, foot care and diabetes management. Diabetes increases the risk of cardiovascular disease (heart attacks, strokes, mini-strokes) by two to four times.11 Diabetes is the
most common reason for renal dialysis and the most common cause of blindness inpeople of working age.12Diabetes results in many planned and unplanned hospital admissions associated with complications, particularly for the specialties of vascular surgery, orthopaedics and
endocrinology. The nature of diabetes means that many health services are involved and these services are commissioned to serve these needs.
6 Diabetes UK, Diabetes in the UK 2012: Key Statistics, April 2012 7
National Diabetes Audit Mortality Analysis 2007-2008 – NHS Information Centre, 2011
8
National Service Framework for Diabetes: Standards, 2001
9 Information Centre, QOF 2011/12. 10 Richmond Data Warehouse, April 2013 11
Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the multiple risk factor intervention trial. Stamler J, Vaccaro O, Neaton J, Wentworth D., Diabetes Care, 1993.
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3. Evidence Based Practice
NICE Guidance describe the following keystones to diabetes prevention and treatment. Prevention of Diabetes
Detection and Diagnosis
Control of Blood Glucose/Blood Pressure/Blood Lipids Weight Control
Screening/treatment of diabetic: eye disease/kidney disease/foot disease Screening/treatment of diabetes in pre-pregnancy/pregnancy
Specific care of children / young adults Psychological care of those with diabetes
Care of those who are housebound or in long-term care facilities
Guidance documents can be accessed from the NICE website at www.nice.org.uk. Additionally, Appendix 2 lists all published NICE Guidance related to Diabetes.
NICE recommends nine key tests for diabetes care. All patients should receive these nine crucial tests from their GP at an annual review of their diabetes management. These include
measurements of weight, blood pressure, smoking status, a marker for blood glucose called HbA1c, urinary albumin, serum creatinine, cholesterol, and tests to assess whether the eyes and feet have been damaged by diabetes.
Additionally, NICE has developed a diabetes pathway, which brings together all relevant NICE guidance, quality standards, and materials to support implementation of diabetes management. The pathways are interactive and designed to be used online. To view the online version of this pathway visit: http://pathways.nice.org.uk/pathways/diabetes.
4. Overview of Diabetes
a) Type 1 Diabetes
13About 10% of diabetes (Type 1) is due to pancreatic beta cell insufficiency resulting in an acute lack of insulin. The onset of type 1 diabetes typically begins in childhood (and continues into adulthood) and is always treated with insulin replacement. Insulin treatment often involves short acting
treatment before mealtimes and longer acting base line treatment at night time. The aim is to achieve tight and optimal glucose control without the occurrence of dangerous hypoglycaemic episodes.
An insulin pump is required only for particular patients who have uncontrolled episodes of hypo or hyperglycaemia. Insulin pumps that are secured subcutaneously to the patient require monitoring and a background insulin injection. This can result in more continual treatment and better glucose control. Blood glucose is recorded according to current glycaemic control. This requires lancets to pierce the skin, a lancing device, testing strips and a blood glucose meter.
b) Type 2 Diabetes
14Type 2 diabetes occurs when the body doesn't produce enough insulin to function properly, or the body’s cells don't react to insulin. This is known as insulin resistance. Type 2 diabetes is far more common than type 1 diabetes. Type 2 diabetes affects people of all ages, and early symptoms are
13
NICE, Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults, Clinical Guideline 15, July 2004 (last updated March 2010)
14 NICE, Type 2 diabetes National clinical guideline for management in primary and secondary care (update), Clinical
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subtle. About 90% of all adults with diabetes have type 2 diabetes. Estimates suggest that around 850,000 people in England are not aware that they have diabetes.15
Type 2 diabetes usually affects people over the age of 40, although increasingly younger people are also being affected. It is more common in people of South Asian, African-Caribbean or Middle Eastern descent.16 The risk factors for type 2 diabetes include:
A close family member has Type 2 diabetes (parent or brother or sister)
Overweight- or if waist is 31.5 inches (80 cm) or over for women; 35 inches (89 cm) or over for Asian men and 37 inches (94 cm) or over for white and black men
Being South Asian or African-Caribbean, these ethnic groups are five times more likely to get type 2 diabetes
High blood pressure or previous heart attack or stroke
Women with polycystic ovary syndrome (PCOS), especially if overweight Having impaired glucose tolerance or impaired fasting glycaemia
Women who have had gestational diabetes Severe mental health problem
The more risk factors that apply, the greater the risk of having diabetes.
Type 2 diabetes is a chronic condition that limits the body's ability to use the carbohydrates in food for energy. The result is elevated blood sugar. Over time, this excess sugar raises the risk for heart disease, loss of vision, nerve and organ damage, and other serious conditions.
Key messages on medicines management for patients with Type 2 diabetes:
Type 2 diabetes occurs due to either reduced insulin secretion or peripheral resistance to its action; patients may be controlled by diet alone, oral antidiabetic drugs and/or insulin. According to the evidence base, the priorities of treatment include: Lifestyle changes
(exercise, diet, smoking cessation etc.), BP control, initiating lipid management/therapy, adding metformin and considering tight glucose control.
Involve the patient in decisions about their individual HbA1c target level, which may be
higher than the 6.5% (48mmol/mol) set for people with type 2 diabetes in general. Highly intensive management should be avoided.
There is evidence that more aggressive treatment of hyperglycaemia early in the disease process produces sustained cardiovascular and microvascular benefits, whereas
aggressive hyperglycaemic lowering later in the disease needs to be individualised
Patients currently taking antihypertensives when diabetes is diagnosed should be reviewed and changed if their blood pressure is poorly controlled or the medication is inappropriate due to microvascular or metabolic problems.
Please refer to ‘Local Agreed Guidance for Anti-diabetic Agents for Type 2 Diabetes’ on the intranet for the locally agreed prescribing pathway. The guidance as of February 2012 is also included in Appendix 3.
c) Impaired fasting glycaemia (IFG)/ Impaired Glucose Tolerance (IGT)
Patients with IFG or IGT have a condition of pre-diabetes and have an increased risk of developing diabetes. However, making lifestyle changes is key to managing or reversing pre-diabetes:
managing weight, keeping active, eating healthily. Treatment may also include management of blood pressure and cholesterol.
15 Diabetes Prevalence Model, Yorkshire and Humber Public Health Observatory 16
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5. Prevalence
Age is a key factor in diabetes prevalence. Type 1 diabetes tends to be diagnosed in childhood but the prevalence of Type 2 diabetes increases steadily after the age of 50 years. Diabetes
prevalence is higher in areas experiencing deprivation. People living in the 20% most deprived neighbourhoods in England are 56% more likely to have diabetes than those living in the least deprived areas.17
a) GP Observed Prevalence (QOF)
In 2011/12, the GP observed prevalence of Diabetes for patients aged 17 and over in Richmond was 3.4%. This equals to around 5,350 patients.18 The London average prevalence was 5.6% and the England average was 5.8%.
The figure below shows that ten practices have a higher prevalence of diabetes than the Richmond average. Two practices have higher diabetes prevalence than the London and England averages.
QOF data can be found on the Information Centre website (www.ic.nhs.uk/qof) as well as the GP Contract website (www.gpcontract.co.uk).
b) Richmond Public Health Analysis
Clinical diagnostic information for diabetes (Type 1 and Type 2) and a set of other diagnostic conditions were derived from GP consultation, community prescription, and hospital inpatient
diagnostic data. Based on data up to April 2013, there were 5,840 diabetic patients in Richmond (all
17 Yorkshire and Humber Public Health Observatory, NHS Richmond CCG Diabetes Community Health Profile,
2010/11.
18
NHS Information Centre. QOF 2011/12. 0% 1% 2% 3% 4% 5% 6% 7% 8% S inh a (Cr an e P ark ) Sar aj lic ( Staines R oad) Boohan (J ubil ee Av enue) Le w is ( Ham pto n) B ha ti a (B roa d La ne ) K ud ra (W oo dl aw n) S ten t (T he G ree n & F ir … W ee k s ( Dean hi ll) Robe rts on ( Cr os s Deep ) P en ny c oo k ( Ham pto n Hi ll) Cr ow ley ( Nor th Road ) P al ac c i (Cas tel na u) O -F ly nn ( Ham pto n W ic k ) Huds on ( S ey m ou r Hous e) Ch ild s ( T h a m e s id e ) J ac k s on ( A c orn) G ri ff iths ( P aradi s e Road ) S m ith (Ri c hm on d L oc k ) B rad ley ( P ark Road ) J ez iers k i ( S he en La ne ) B ate s ( P ag od a A v en ue ) S ay er (Ri c hm on d Gr ee n) Coop er ( Q ue en s ) T ho m as ( Y ork ) J oh al ( T w ic k en ha m P ark ) Da Co s ta (T h e V in e y a rd ) La w ren c e (K ew G ardens ) J oh ns on ( S he en La ne ) F loo d (E s s ex Hous e) B ott ing ( G leb e) F itz m au ri c e (K ew )
Proportion of GP list size on Diabetes Mellitus register, 2011/12
England Richmond London
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ages). Eighty-five percent were of type 2 (4972 patients), and seven percent of type 1 (436
patients), and seven percent unclassified (432 patients) due to insufficient diagnostic information. Six practices had significantly high prevalence and five significantly low prevalence compared to Richmond as a whole. The confidence intervals show how high or low the estimated prevalence could be based on a 5% chance. The high or low diabetes prevalence could be a result of a range of risk factors including ethnicity and deprivation, which are not included in this analysis. A funnel plot shows the same results of high/low prevalence and is included in Appendix 4.
Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013
Type 1 diabetes
The following graph shows prevalence of type 1 diabetes by age and gender. Type 1 diabetes is more prevalent among males, and prevalence rises sharply up to around age 20 for both genders.
0 1000 2000 3000 4000 5000 6000 7000 8000 Rate pe r 10 0,0 00
Age and sex standardised diabetes rate (95% confidence intervals), by practice, NHS Richmond, April 2013
Richmond Average 0.0 1.0 2.0 3.0 4.0 5.0 6.0 P rev al en c e rate pe r 10 00 po pu lati on Females Males
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Type 2 diabetes
The following graph shows the prevalence of type 2 diabetes by age and gender. Type 2 diabetes is more prevalent among males, and increases sharply with age. Prevalence rises steeply from around 50 years old for both genders; the increase is steeper for males.
Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013
c) Modelled Estimate of Diabetes Prevalence
Modelled estimates suggest that the total prevalence of diabetes in Richmond is higher than GP recorded prevalence. This is due to a proportion of patients who are currently undiagnosed. The Diabetes Prevalence Model estimates the total (diagnosed and undiagnosed) number of people aged 16 and over with diabetes. Estimates are adjusted for the age, sex, ethnic group and deprivation pattern of the local population. It is important to note that this statistical model may over-estimate the number of undiagnosed people with diabetes in Richmond.
Estimated total (diagnosed and undiagnosed) diabetes prevalence in adults 16 and over
Source: Yorkshire & Humber Public Health Observatory, Diabetes Prevalence Model http://www.yhpho.org.uk It is estimated that in 2012, 6.2% of people aged 16+ in Richmond had diabetes (vs. 3.4% QOF), which is around 9,850 patients. Across England, approximately a third of the projected rise in diabetes prevalence can be attributed to the increasing prevalence of obesity.
0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0 180.0 P rev al en c e rate pe r 10 00 po pu lati on Females Males
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6. Case Finding
Diabetes is often diagnosed with an incidental finding of raised level of sugar in the blood. For many, the risk of diabetes is well recognised and diabetes is confirmed on a blood test as part of routine primary care. Occasionally diabetes first presents as an acute emergency and coma for example.
There are a number of people living with diabetes who are currently undiagnosed. Further work around case finding is needed to help identify these people and provide them with appropriate care. There is scope to identify undiagnosed diabetes patients and high risk patients in the community through the NHS Health Checks programme, screening in GP Practices, Pharmacies and use of the Diabetes Risk Score.
a) NHS Health Checks
Some of the undiagnosed patients correspond to those patients that cannot access primary care or rarely have the need to attend their doctor. It is these hard to reach population that has been targeted to some extent with the current NHS Health Checks programme, by screening the 40-74 age group. NHS Health Checks are available in primary care, community pharmacies and
community outreach. From April 2011-March 2013, approximately 50 undiagnosed people have been found through the NHS Health Checks Programme. The NHS Health Checks also contributes to preventing diabetes by identifying people with impaired glucose tolerance (IGT). Through the LiveWell programme these individuals can access a group self-management education programme called Walking Away from Diabetes. In 2011/12, GPs referred 50 patients with pre-diabetes (Health Checks and non-health checks patients) to the Walking Away from Diabetes programme and 38 patients completed the programme.
b) Primary Care
Additionally, all patients can be offered screening within primary care. Patients often present and request a test because of symptoms of thirst or fatigue or a family history of diabetes. Likewise a large number of urine or blood tests are offered opportunistically to help with establishing a diagnosis. All pregnant women are screened for diabetes and gestational diabetes.
c) Community Pharmacy
There is also opportunity for patients to be screened through Community Pharmacies. Discussions have taken place across SWL around how pharmacy can contribute within diabetes pathways from a Local Professional Network perspective. Additionally, each year, community pharmacy delivers up to six health promotion campaigns, which is jointly co-ordinated through the LiveWell Richmond Service. Diabetes or related health improvement campaigns (e.g. obesity, physical activity) could contribute to case finding in Richmond.
d) Diabetes Risk Score
The Diabetes Risk Score is an assessment tool which aims to identify individuals with impaired glucose regulation (IGR) and is designed to predict an individual’s risk of developing Type 2 diabetes within the next ten years.
It has been recommended by the 2012 NICE public health guidance, Preventing type 2 diabetes: risk identification and interventions for individuals at high risk, that GPs and other primary
healthcare professionals use the tool for identifying people at risk of developing Type 2 diabetes. The risk assessment is evidenced-based and consists of seven questions. It uses a points system to identity if a person is at low, moderate, or high risk of developing diabetes. Based on this score, appropriate advice is provided in the form of lifestyle changes or a GP referral. The seven
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questions are related to age, gender, waist circumference, BMI, ethnic background, blood pressure and family history.
The tool is particularly useful in assessing people who:
do not fall within the NHS Health Check age range, as anyone over the age of 18 can use it with the exception of pregnant women,
are from Black, Asian and minority ethnic groups (who are at increased risk of diabetes), are from socially deprived groups who are at greater diabetes risk and less likely to access local healthcare services.
GPs, other health professionals, and community practitioners in health and community venues should implement a two-stage strategy to identify people at high risk of type 2 diabetes (and undiagnosed type 2 diabetes). First, a risk assessment should be offered. Second, where needed, a blood test should be offered to confirm whether people have type 2 diabetes or are at high risk.
e) Local Public Health Analysis
Analysing SUS data and GP data extract can contribute to case finding by identifying undiagnosed diabetic patients who have never been to a GP, but were admitted to hospitals for diabetes
emergency care.
7. Outcome Indicators
a) Quality Outcomes Framework (QOF)
Additionally, many of the QOF indicators related to the management of diabetes are also higher or in line with the England average. For example, 71.9% of patients had HbA1c levels <=7.5% in last 15mths (69.9% for England), and 93.4% of patients have had retinal screening in last 15mths (91.9% for England).19 A comprehensive list of primary care indicator results for diabetes for 2011/12 can be found in Appendix 5.
QOF Achievement for practices 2011/12 shows:
Practice achievement for DM31: Last BP is <=140/80 mmHg, ranges from 49% to 85% as of March 2012. The expectation from HfL is that we should aspire to a threshold of 80%. Practice achievement for DM 26: Last HbA1c <= 7.5% ranged from 60% to 90% at March
2012. In 2010/11, an average of 56% of all people with diabetes aged 17 years and older who are not excepted from the Quality and Outcomes Framework have a HbA1c of 7% or less.20 This is statistically significantly higher than PCTs with populations with similar diabetes risk factors and statistically significantly higher than England as a whole.
The exception rate for all Diabetes Indicators was 4.9% for Richmond and 6.9% for England at March 2012. The exception rate for hypertension indicators only was 2% for Richmond and 2.5% for England.
b) NHS Atlas of Variation
The NHS Atlas of Variation in Healthcare21 is a collection of healthcare measures or indicators for
all PCTs. The indicators allow local comparison of performance against the overall performance of all PCTs in England. They are intended to highlight variation, not only in activity and cost, but also in quality, safety and outcome. The following table includes the diabetes indicators from the NHS
19 APHO, National General Practice Profiles 2012. http://www.apho.org.uk/PracProf/ 20
Yorkshire and Humber Public Health Observatory, NHS Richmond CCG Diabetes Community Health Profile, 2010/11.
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Atlas of Variation 2010 and 2011 for NHS SWL Richmond (Richmond CCG) and NHS SWL Kingston (Kingston CCG) (because of similar demographics).22
A low percentage of people in Richmond with diabetes are receiving nine of the key tests for diabetes care recommended by NICE. The nine key tests are: weight, blood pressure, smoking status, HbA1c, urinary albumin, serum creatinine, cholesterol, eye examinations and foot
examinations. This is particularly low for people with type 1 diabetes, with Richmond being in the 2nd lowest quintile nationally for this indicator. Over 50% of people with type 2 diabetes are receiving the nine key tests. Although Richmond is in the middle quintile nationally for type 2 patients, there is still room for improvement. It is recommended that the nine key tests are included as a Key Performance Indicator (KPI) as part of the GP LES for general practice and that GPs are incentivised to achieve all of them. These indicators rely on QOF records, so it is possible that achievement may seem lower than what is actually happening. For example, patients with type 1 diabetes are often seen in hospitals, and their test results may not always be shared with GPs and then entered into QOF. As many type 1 diabetes patients are seen in hospitals for their annual reviews, it is also recommended that acute commissioner’s performance manage the acute trusts. NHS Richmond CCG performs well for people having major lower limb amputations, with the indicator being in the lowest quintile nationally.
c) Variation in Inpatient Activity
23In 2010/2011, there were 7747 observed emergency bed days for patients with diabetes in NHS Richmond CCG. This is 22.5% more than would be expected had those with diabetes had the same lengths of stay as those without diabetes. Across England, patients with diabetes were 39.7% more likely to be re-admitted as an emergency within 28 days of a previous spell of care when compared to patients of a similar age without diabetes. Additionally, in 2010/11 there were 251 emergency readmissions recorded for patients with diabetes in NHS Richmond CCG. This is 21.9% more than would be expected had those with diabetes had the same rates of readmission as those without diabetes. Across England, patients with diabetes having 15.1% more emergency bed days when compared to admissions for patients of a similar age without diabetes. These figures show that the patients with diabetes are more likely to be admitted and re-admitted as an emergency and stay for a longer duration as compared to people without diabetes.
22 The Annual Public Health Report for NHS South West London Richmond Borough Team 2011-2012.
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d) Local Data Analysis on Emergency Admissions
Emergency admissions among patients with diabetes vary across practices. After allowing for age and sex distribution, six practices have significantly higher emergency admissions than the
Richmond average for patients with type 2 diabetes. Five practices have significantly lower emergency admissions. The confidence intervals show how high or low the estimated rates could be based on a 5% chance. A funnel plot shows the same results of high/low emergency admissions and is included in Appendix 6.
The scatter plot below shows that high/low emergency admission among patients with diabetes is positively related/correlated to high/low diabetes prevalence. It cannot be used in statistical testing of the points.
Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013 0 200 400 600 800 1000 1200 0 1000 2000 3000 4000 5000 6000 7000 S tan da rdi s ed ad m is s ion r ate pe r 100,000
Standardised prevalence per 100,000
Age and gender standardised diabetes rates and emergency admission for patients with diabetes, Richmond CCG 2013
0 200 400 600 800 1000 1200 1400 1600 Ra te p e r 1 0 0 ,0 0 0
Age and sex standardised rate for emergency admission, Type 2 diabetes (95% confidence intervals), NHS Richmond, April 2013
Richmond Average
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e) Care Homes
Up to 25% of care home residents have diabetes in the UK.24 National research shows that care home residents with diabetes are at high risk of unplanned emergency hospital admissions.25 Managing these patients well by linking the diabetes pathway to care homes can improve their quality of care and potentially reduce avoidable hospital admissions. Ensuring the existence of a care plan and its communication to all members of the health and social care teams involved in an individual’s care will facilitate high quality diabetes care. Local analysis on care homes admissions does not show any concerns; however this needs to be further looked into and we need to be mindful of this vulnerable group. The proposed CQUIN 2013/14 incentivises community nursing to ensure all patients with common chronic diseases such as diabetes, COPD, congestive heart failure, and falls are identified, appropriately signposted and plans put in place for future illness.
f) Co-morbidities and complications
Of the people with diabetes included in the National Diabetes Audit, in NHS Richmond CCG 7.3 per 1000 had had a stroke in the previous year compared to 6.9 per 1000 across the whole of England. In NHS Richmond CCG 10 per 1000 of people with diabetes had a myocardial infarction in the previous year compared to 4.8 per 1000 in all PCTs in its cluster group.
As diabetes is linked to a number of co-morbidities, it is important to highlight the need to link with other chronic conditions pathways. For example, interdependencies can exist between diabetes and: hypertension, retinopathy, nephropathy, diabetic foot, depression, hyperlipidemia,
cardiovascular disease, COPD, kidney disease, nonalcoholic fatty liver disease, musculoskeletal diseases, neurological diseases, and cancer.
The graph below shows that nearly half of all patients with diabetes have three or more chronic conditions. Less than 10% have no chronic conditions. This highlights that a single pathway to tackle diabetes may not be sufficient to manage all the co-morbidities. Therefore, other pathways for long-term conditions such as CVD, COPD, obesity, and Chronic Kidney disease need to be developed and integrated together.
Number of chronic conditions* for patients with diabetes
Source: Richmond Public Health Analysis using SUS data and GP data extraction April 2013
*Including: congestive heart failure, hypertension, ischemic heart disease, AMI, disorders of lipid metabolism, diabetes, hypothyroidism, asthma, COPD, chronic renal failure, bipolar disorder, schizophrenia, depression, Parkinson's disease, seizure, age related macular degeneration, osteoporosis, rheumatoid arthritis, low back pain, immune-suppression transplant, glaucoma and cancer
24
Diabetes UK, Good Clinical Practice Guidelines for Care Home Residents with Diabetes, 2010
25
The NHS Information Centre, The 2011 National Diabetes Inpatient Audit National Report, 2012 0% 10% 20% 30% 40% 50% 0 1 2 3+
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The following table shows the most common co-morbidities among people with diabetes. Around 70% of people with diabetes have disorders of lipid metabolism and/or hypertension.
Co-morbidity Number
Percent of patients with diabetes
Disorders of lipid metabolism 4264 73%
Hypertension 4165 71%
Depression 1147 20%
Ischemic heart disease (including acute
myocardial infarction) 1029 18%
Asthma 932 16%
Congestive heart failure 746 13%
Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013
g) NICE Quality Standards for Diabetes in Adults
Compliance against NICE Diabetes in Adults Quality Standard (QS6) should be included as a key outcome for diabetes. This quality standard defines clinical best practice, provides specific, concise quality statements, measures and audience descriptors to provide patients and the public, health and social care professionals, commissioners and service providers with definitions of high-quality care. This quality standard covers the clinical management of diabetes in adults, excluding children, young people and pregnant women.
This quality standard describes high-quality, cost-effective care that, when delivered collectively, should improve the effectiveness, safety and experience of care for adults with diabetes in the following ways, linked to the NHS Outcomes Framework 2011/12:26
Preventing people from dying prematurely.
Enhancing quality of life for people with long term conditions.
Helping people to recover from episodes of ill health or following injury. Ensuring that people have a positive experience of care.
Treating and caring for people in a safe environment and protecting them from avoidable harm.
Specifically, it is expected that achieving the high-quality care set out in this quality standard will reduce the complications associated with diabetes.
NICE quality standards need to be embedded in the GP LES, HRCH contract, and acute contracts to improve quality of diabetes care.
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8. Current Local Diabetes Pathway: Levels of Care
The local diabetes pathway sets out levels of care and includes services/activity recommended by NICE for the management of diabetes. The levels of care are in line with the model of care set out in the Diabetes Guide for London.27
The diabetes pathway for Richmond follows a tiered approach:
Level 0 is prevention and lifestyle services for self-care and self-management, underpinning all of the other tiers. Patients with pre-diabetes or lifestyle risk factors can be referred to LiveWell for access to support and assistance with making healthy lifestyle changes. LiveWell Richmond services should be offered to patients throughout the pathway, at each level, when needed. All patients aged 40-74 can receive a Health Check to assess their CVD health, and be referred to LiveWell services to help them take action to reduce their risk of heart disease, stroke, type 2 diabetes and kidney disease.
Level 1 is core primary care services delivered by health care professionals in the patient’s GP practice. Wherever possible, patients with diabetes are treated by their own GP.
27
Healthcare for London, Diabetes Guide for London, March 2009
http://www.londonprogrammes.nhs.uk/wp-content/uploads/2011/03/Diabetes-Guide.pdf Level 4 Secondary Care: Hospital Services Level 3 Specialist Diabetes Management:
Community Based Intermediate Diabetes Service (HRCH and
QMH)
Level 2 Enhanced Services:
Care within General Practice (Primary Care)
(and Community Based Intermediate Diabetes Service when needed)
Level 1 Core Services:
Care within General Practice (Primary Care) Specialist input for new diagnosis or
complex cases, and development of a care plan that allows the patient return to self-management, reducing the need for hospital admission
Many patients manage their diabetes through self-management with support from primary care with routine care and surveillance
Specialist care for patients that have a greater complexity or complications. Input may also be required from other specialities, as clinically appropriate. This level also includes inpatient and emergency care
Level 0 Prevention & Self-care Services:
LiveWell Richmond (HRCH): Health advisor, healthy eating,
physical activity, weight management, stop smoking, safe drinking, Walking Away from Diabetes, Expert Patient Programme
NHS Health Checks (Primary Care, Pharmacies, Outreach): All eligible
patients to receive an NHS Health Check and referred to LiveWell Richmond services as needed
Services for all, for
prevention& self-care, throughout pathway as needed
Care still delivered in primary care, but in conjunction with the Community Based Intermediate Diabetes Service when needed
The Community Ward Service case manages very high risk patients to reduce emergency admissions Patients move up and down the levels as their condition dictates Li v e We ll Ric h m on d Ref e rra l to s e rv ic e s t h ro u g h o u t p a th wa y f o r s e lf -c a re a n d s e lf -m a n a g e m e n t
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Level 2 is enhanced primary care according to clinical need and is delivered by the practice or in conjunction with the level 3 Community Based Intermediate Diabetes Service.
Level 3 is a consultant led specialist multi-disciplinary service, delivered in a community setting and is aimed patients whose clinical need has the complexity requiring specialist input.
Level 4 is a consultant led specialist multi-disciplinary service that is delivered in secondary care/hospital settings. The clinical needs of patients accessing these services have a greater complexity which requires this setting of care. Input may also be required from other specialities. Level 4 also includes an inpatient service and emergency admissions.
Patients with complex symptoms, who are at very high risk of unplanned hospital admissions, are individually case managed by the Community Ward. This is a joint service with health and social care. The aim of the Community Ward service is to reduce avoidable emergency admissions and fits between level 3 and level 4.
Primary care and the intermediate service manage most of the diabetes for NHS Richmond CCG. In practice, direct GP referral to the hospital sector is rare.
The following sections provide further details on diabetes management and activities at each level. Appendix 7: Diabetes Prevention and Management Process, summarises the activity process for each level.
a) Level 0: Prevention and Self-care Services
Prevention and self-care services to support healthy lifestyles are crucial in the prevention and lifestyle management of Diabetes. The main ways to reduce risk of Type 2 diabetes are eating a healthy, balanced diet and doing at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every week. Stopping smoking and drinking sensibly can also lower risk of developing diabetes. Additionally, a healthy lifestyle can help manage diabetes, as well as reduce the risk of developing major diabetes-related
complications. LiveWell Richmond
The LiveWell Richmond Service supports working towards a healthier lifestyle by providing free support and/or services for people over age 16:
Physical Activity e.g. Exercise Referral or Health Walks Healthy Eating
Weight Management Sensible Drinking
Stop Smoking (See Appendix 8 for further details)
Walking Away from Diabetes Programme (for pre-diabetes) Expert Patient Programme
See Appendix 9 for further details on specific LiveWell Services and eligibility criteria.
The dedicated team of LiveWell health coaches provides information and guidance and regularly meets with people who want to make healthy lifestyle changes over two or three months to set and achieve their goals.
Through LiveWell people can also access other structured and supervised programmes tailored to individuals with different health needs, including weight management, exercise, Walking Away from Diabetes, and the Expert Patient Programme. Support in helping patients to find ways to ensure that they are able to comply with their medication regime can also be provided. All patients at risk of diabetes, with pre-diabetes or diabetes should be referred to LiveWell Richmond.
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During 2011/12, GPs referred 50 patients with pre-diabetes to the Walking Away from Diabetes programme and 38 patients completed the programme. In 2012/13, 50 patients completed the Walking Away from Diabetes programme.Discussions with stakeholders highlighted that there is a lack of awareness of the programme amongst clinicians, therefore various marketing methods need to be utilised to raise awareness and improve referral rates.
The contact details for LiveWell Richmond are:
Telephone: 0208 487 1745 (Monday to Friday, 9am to 7pm) Email: [email protected]
Patients can self-refer to the service, or GPs and other healthcare professionals can also refer patients using a LiveWell Referral Form.
NHS Health Checks
The NHS Health Check is a simple, free check which gives patients a clearer picture of their CVD health, and helps them take action to reduce their risk of heart disease, stroke, type 2 diabetes and kidney disease.
The NHS Health Check is available in most GP Practices across Richmond. Some local pharmacists carry out the NHS Health Check. See Appendix 10 for a list of participating
pharmacies. Health Checks are also happening via community outreach events in deprived areas of the borough on a regular basis.
Since 2009, when the programme started, over 30,000 people have been invited for a health check and more 14,000 people have completed a health check.
Following the check, patients are referred to LiveWell Richmond for help setting health-related goals to support making changes to their lifestyle to improve their health. For example, this includes sessions with a Health Advisor, weight management, or referral to the Walking Away from Diabetes programme if patients are identified as having pre-diabetes.
b) Level 1: Core Services within General Practice
Level 1 is care delivered by primary care health care professionals in the GP practice. It includes initial diagnosis and the annual review, based upon the 9 key care processes. Level 1 is supported by the General Medical Services contract, Quality Outcomes Framework.
Key activities occurring at Level 1 include: Screening of high risk individuals
Identification of people with diabetes and pre-diabetes Diagnosis and initial management
Continuing care following agreed protocol
Annual medical review for all patients on the diabetes register, in line with QOF Indicators Referral to lifestyle services through LiveWell e.g. weight management, exercise
programmes, Expert Patient Programme
Referral to relevant self-management programme (e.g. Walking Away from Diabetes, DESMOND, BERTIE)
Referral to Dietetic Services
Referral to counselling/psychology services
Much of the initial diagnosis and routine care of diabetes is performed in primary care. All GPs and practice nurses are familiar with common diabetes management. The majority of patients with diabetes can manage their condition on their own with support from primary care. Much of the day to day management of diabetes is performed by the patient themselves. Primary care clinicians supervise this self management and offer routine care and surveillance. The QOF system guides,
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encourages, and incentivises such activity. GPs can also refer patients with diabetes to LiveWell services for support and assistance with making healthy lifestyle changes.
Immunisations
Practices should ensure that all patients diagnosed with diabetes are offered the seasonal flu vaccine and the one-off pneumococcal vaccination. All healthcare professionals managing diabetes patients should encourage the uptake of appropriate immunisations from their GP. Practice
achievement for QOF DM18: Influenza immunisation given 1 Sep- 31 Mar ranged from 84%-100%. Patient Review
Regular patient reviews are undertaken within the QOF framework, looking at need for insulin, management of blood pressure, cholesterol and blood thinning agents. If a patient has not already accessed LiveWell Richmond this should be considered and a referral generated during the review.
c) Level 2: Enhanced Services within General Practice (and Community Based
Intermediate Diabetes Service when needed)
Level 2 is an enhanced version of level 1. Care is still delivered in the GP practice setting but, according to clinical need, this will be in conjunction with the Community Based Intermediate Diabetes Service. Level 2 is supported by Level 1 is supported by a local enhanced service specification (LES).
Key activities occurring at Level 2 include: Provision of all care for Type 2 patients Oral Glucose Therapy
Hypertension Management Lipid Management
Initiation of Insulin/Injectable treatments in Type 2 (where the skills within the practice exist) Ongoing management with insulin/injectable
Referral to lifestyle services through LiveWell e.g. weight management, exercise programmes, Expert Patient Programme
Referral to relevant self-management programme (e.g. Walking Away from Diabetes, DESMOND, BERTIE)
Referral to Dietetic Services
Referral to counselling/psychology services GP LES
A local enhanced service (LES) is funded and managed by the CCG, and exists to promote GP case finding, core services, and to enable more level 2 enhanced activities within primary care. The LES was set up in April 2010 and has been rolled over for 2013/14. Twenty eight practices have signed up to the LES. There are a remaining 632 patients with diabetes from the two practices who have not signed up to the LES. It is assumed that these patients are still receiving level 2 services from practices in conjunction with community based intermediate diabetes services. The LES will be reviewed this year to reflect any changes to practice and targets (e.g. QOF targets have changed for 2013/14).
Enhanced service requirements of the GP LES include:
Monitor and treat the cardiovascular risk associated with diabetes
Undertake a Mental Health Assessment on all adult patients with diabetes as part of the annual review
Care for patients that are on established insulin and are stable enough to be fully maintained in a primary care setting
Conversion to insulin
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Lipid Management (DM 26, 27, and 28)
Maintain Exception Reporting to equal or below the national averages on QOF indicators. Five practices are able to initiate insulin; the rest of the practices refer their patients to community based diabetes services for insulin initiation. Most GPs prefer that insulin treatment is initiated by specialist teams within the intermediate care team, as specialist skills are needed and DSNs would be an additional cost to employ. Practices would need to have a high enough number of patients needing insulin to justify the need for their own DSN. Other GPs have more involvement with diabetes and they refer patients only when there is a complex case or where sugar control is difficult to achieve. Patients are screened for developing complication of diabetes such as peripheral neuropathy, retinal maculopathy, and depression.
d) Level 3: Specialist Diabetes Management
Level 3 is a consultant led specialist multi-disciplinary service that is usually delivered in a
community setting. The clinical needs of patients referred to this service have the complexity that requires temporary specialist input to formulate and agree a care plan that allows them to return to a self-management situation, reducing the need for hospital admission. The teams work with the patient to agree outcomes and then produce a care-management plan, which the patient’s GP practice can implement between visits to the specialist clinic. This approach means that patients with diabetes are receiving specialised care for their condition at the most appropriate level and do not have to make unnecessary trips to acute hospitals. It is not intended that patients will continue to be seen in this setting in the long term although it is understood that non-compliance and co-morbidities may make it necessary and preferable to advancing them to level 4.
Level 3 Specialist Diabetes Management services are provided at Teddington Memorial Hospital and Queen Mary’s Hospital.
Key activities occurring at Level 3 include: Specialist input
Dietetics
DESMOND (Type 2)- Newly Diagnosed and Foundation Programme (patients who have had diagnosis for >12 months for ongoing management)
BERTIE (Type 1)- currently through Kingston Hospital or QMH (there are plans to also offer an in-house education programme this through HRCH)
Podiatry
Retinal Screening
Develop individual care plan with patient Insulin initiation* for Type 2 patients
Insulin initiation* for BD & basal bolus regimens Titration of insulin regimens for both Type 1 and 2 Telephone liaison and support for Level 1 & 2 practices Ongoing management of Type 1 patients
Referral to lifestyle services through LiveWell e.g. weight management, exercise programmes, Expert Patient Programme
Referral to counselling/psychology services
*for those practices not commissioned to undertake this themselves
Appendix 11 includes the sub-pathway for referring adult patients with type 2 diabetes to Intermediate care, as well as Secondary care.
Teddington Memorial Hospital (TMH)- Community Based Intermediate Diabetes Service Hounslow and Richmond Community Healthcare NHS Trust (HRCH) are commissioned to provide the intermediate diabetes service at TMH. The consultant led intermediate care team comprises an
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endocrine consultant, a GP with a Special Interest (GPwSI), two specialist diabetes nurses, a podiatrist, and dietitian. The team accept referrals and triages them, directing them towards which service level they need. DSN Helen Church leads the service with consultant Dr. Oldfield.
The number of patients referred to the service with type 1 diabetes has increased. This may be due to GPs referring some patients for clarification on whether the patient has type 1 or type 2 diabetes. A new in-house education programme for type 1 patients is development to ensure complete care and is awaiting to be agreed by commisioners.
The total cost of the service for 2012/13 is around £250,000. In 2011/12 there were a total of 2025 attendances to the Diabetes service. Targets as specified in the HRCH Service Specification:
Performance Indicator Threshold (Patients seen) Method of Measurement
Initial Contact 400 Patients attending
Follow Up Contact 1,600 Patients attending
Formal Advice and Guidance responses
New service Recorded activity on choose
and book DESMOND Programme 90% new patients = 360
Requires minimum 36 DESMOND programmes in 2010/11
90% of new patients attend programme
DESMOND referrals for the Newly Diagnose programme have decreased significantly between 2011/12 and 2012/13. Referrals for the Foundation programme have also reduced.It could be useful to include the DESMOND programme in the package of care for patients for a better uptake.
2011/12 Referrals 2012/13 Referrals
DESMOND Newly diagnosed programme 300 206
DESMOND Foundation programme 129 105
DNA DESMOND 20
Cancelled DESMOND 22
Other referral patients either declined attendance or seen 1-1 in clinic as they were not suitable for attending. The following table shows the attendance for the diabetes sub-services (excluding DESMOND). The majority of new referrals are for the DSN or Dietitian, with the DSN seeing the vast majority of follow up attendances. Diabetes Sub-service New referrals attendance 2012/13 Follow up attendance 2012/13 DSN 110 1200 GPwSI 13 142 Dr. Oldfield (Consultant) 3 109 Dietitain 75 137
The DNA rate has been improved thereby improving productivity and reduction of waiting times. DNA rates are currently running at 8.4%.
Wait times:
Medical review depending on clinician- from 4 weeks
DSN- same day access for urgent cases, 2 weeks for routine cases Dietitian- 4-6 weeks for new and follow up appointments
Podiatry- 24-48 hours for urgent cases, 2 weeks for routine cases
Contact details for the Teddington Community Based Intermediate Diabetes Service:
Specialist Nurse Support:
The Diabetes Specialist Nurse team is based at Teddington Memorial Hospital and is available for clinic appointments, telephone advice and support and home visits for housebound patients.
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Multi-Disciplinary Team:
Multi-disciplinary team clinics are held on Thursday, all day, and nurse led clinics are held on Mondays, Thursdays, and Fridays each week at Teddington Memorial Hospital.
Referral information:
Clinic assessment- referrals can be made by GP practices only.
Desmond Education Programme- can be made by self referral or referral by GP/Practice Nurse, or any other allied health care professional for both Newly Diagnosed and
Foundation sessions. The referral form is included in Appendix 12
Walking Away Programme- referrals can be made from a GP/Practice Nurse, other health care professional, LiveWell Richmond, or self-referral Nurse.
Queen Mary’s Hospital, Roehampton (QMH) - Diabetes Outpatient Service
Patients in the Richmond and Barnes locality have been historically referred to community-based intermediate diabetes services provided by Queen Mary’s Hospital in Roehampton. This is often chosen by GPs based on proximity.
The beta cell unit at QMH is structured similarly to the intermediate diabetes service at TMH. Historically this has been referred to by Richmond and Barnes locality doctors as well as Wandsworth GPs. This service is consultant led by Dr Oldfield. The service provides a comprehensive diabetes outpatient service for adults (age 16+) with a confirmed diagnosis of diabetes. It doesn’t include Diabetes Paediatric service or pregnancy and diabetes service (usually referred to Kingston Diaban unit for duration of pregnancy).
When patients are discharged back home from QMH, if follow up is needed, they are referred to the HRCH Community DSN team.
Activity and cost for the QMH Outpatient Diabetes Service is detailed below. The total cost for the service is around £238,000. From the activity and costing data available, it seems that the service at TMH may be less expensive compared to QMH. However, more information is required to draw any conclusions. There may be potential to provide community based diabetes services across Richmond by GP clusters. Service Forecast Outturn Activity (2012/13) Forecast Outturn Value (2012/13)
Diabetic Medicine (Multi-practitioner, First) 52 £ 20,431 Diabetic Medicine (Multi-practitioner, Followup) 107 £ 19,137 Diabetic Medicine (Single-practitioner, First) 111 £ 32,556 Diabetic Medicine (Single-practitioner, Followup) 1382 £ 166,258
Total 1652 £ 238,381
Contact details for the QMH Diabetes Outpatient Service: Opening hours: Monday to Friday 8.30am – 4.30pm Telephone advice: 020 8487 6447
Secretaries: 020 8487 6441 or 020 8487 6987 Outpatients main number: 020 8487 6449 Fax: 020 8487 6535
Specialist Diabetes Dietitian
Up until September 2012, the TMH Community Based Diabetes Service included dietetic input on a clinic per week basis (0.10 WTE). Since September, carbohydrate counting sessions were
introduced for suitable type 1 patients (2 sessions per month), and now the total dietetic input is 0.15 WTE. There has been a 43% increase in dietetic face-face encounters from 2011/12- 2012/13.
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As the complexity of patients and subsequent email communication (non face-face contacts) has increased, there is a need to increase dietetic time.
Currently, the TMH Community Based Diabetes Service has no dietetic referral criteria and referrals can be made from any level in the diabetes pathway. As there is very limited community dietetic capacity, this possibly causes more referrals from levels 1 and 2 in the pathway. QMH also has no referral criteria, but is working on having one in place soon to optimise the use of their specialist diabetes dietician resources (1.0 WTE).
It is recommended that the provision, access to, and referral criteria for dietetic services for diabetes patients are reviewed.
Retinal Screening
People with diabetes are at risk of developing a complication called retinopathy. Keeping blood glucose, blood pressure and blood lipid levels under control will help to reduce the risk of
developing retinopathy.For protection against retinopathy, it is best to have eyes screened with a digital camera when first diagnosed and then every year, to identify and then treat eye problems early.
Retinal screening is offered on an annual basis to patients in Richmond. QOF data for DM 21: Retinal screening in the last 15 months, show that 93.4% of patients have been screened in 2011-2012. Two practices achieved less than 90%. Performance data for Quarter 3 for 2012/13 shows that 4492 received retinal screening, out of 4947 that were referred (rolling data for a 12 month period). This is just over 90% achievement at Quarter 3.
There have been some quality issues at Kingston Retinal Eye Unit (KREU), as the unit struggled to offer appointments for patients with significant diabetic retinopathy within the recommended
national time scales. Since November 2012, KREU stopped providing Wandsworth and Richmond Diabetic Eye Screening (DES) with patient outcomes/audit reports to the national programme to complete KPI data. The issue has been taken up at Kingston Clinical Quality Reference Group and is being resolved.
There was a serious incident (SI) at Wandsworth, which highlighted the importance of correctly identifying patients with diabetic retinopathy and updating their QOF registers. A letter was sent to practices to this effect.
Foot Care
Foot problems can affect anyone who has diabetes. Diabetes, particularly if it is poorly controlled, can damage nerves, muscles, sweat glands and circulation in the feet and legs leading to
amputations. Reviewing the feet of people with diabetes at time of diagnosis and annually, and keeping blood glucose, blood fats and blood pressure under control can prevent some of the complications associated with the feet.
Routine podiatric foot care is offered to patients in Richmond to reduce the risk of lower limb
ulceration and early amputation. HRCH are commissioned to see urgent cases within 72 hours and routine cases within 4 weeks. HRCH are currently meeting these targets. The HRCH podiatry service at TMH has the capacity to see up to 9 patients within a fortnightly session, depending on complexity of the cases. Historically the clinic was not always fully utilised by direct referrals to the clinic via TMH. In order to make good use of this clinic time, the HRCH community podiatry service has filled vacant slots within the clinics with patients on current caseload, with complex wounds, or wounds that are non healing. Most if not all of these patients are diabetic.
Diabetic patients who would qualify to be seen by podiatry under Any Qualified Provider (AQP) are those classified as low risk and who have no other co morbidities that would place them at
increased risk. The AQP contract does not cover provision for:
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anyone with a wound grade 2-5 on wagner scale, or wound non healing within 4 weeks Anyone with Neuropathy of lower limbs
Anyone with significantly impaired circulation to lower limbs
The care for these patients will remain within block contract of HRCH specialist podiatry service. AQP does not cover annual diabetic foot screening, as this is commissioned from primary care. Self- management (e.g. DESMOND, BERTIE)
Self management of diabetes is key to a good prognosis. Accordingly, all newly diagnosed patients/carers with diabetes are offered an appropriate education programme to teach them self management of their diabetes. BERTIE education is offered for type 1 diabetes. DESMOND is offered for type 2 diabetes. There is also ‘Walking Away from Diabetes’ offered to those with IFG/IGT, who are at risk of developing diabetes (Level 0 LiveWell Richmond Service). Patient self management and support is also available through the Diabetes Network and Diabetes UK charity.
There is potential for more ongoing management through non face-to-face communication. The HRCH Intermediate Diabetes service now offers non face-to-face follow ups as an alternative to clinic appointments, which has increased activity above target. This has also led to improved patient outcomes and joint working with the patient to encourage/support self-management. There were 384 non face-to-face contacts in 2012-13, which has included telephone contact, SMS, and email. There is a place for alternative forms of communication (e.g. email, text, telecare) and other options for ongoing management should be considered, as this can reduce clinic visits.
Non-English Speakers
Currently, non-English speakers are offered one-one sessions with a translator with the intermediate care team. The team also use Diabetes UK literature, which is available in many languages. There is a BME DESMOND for South Asian communities, but this it is not delivered in Richmond. This area has been highlighted within the recommendations and mentioned within the Equality Impact Needs Assessment.
e) Community Ward
Patients with complex symptoms, who are at very high risk of unplanned hospital admissions, are individually case managed by the community ward. This is a joint service with health and social care. The aim of the service is to reduce avoidable emergency admissions and fits between level 3 and level 4.
Patients at very high risk of hospital admission are identified through risk stratification of data from GP Practices and Hospitals. Identified patients are discussed at a multi-disciplinary team meeting, which is composed of a social worker, community matron, care navigator, and a GP. A home care plan may be developed with the patient and carer (with specialist input as needed), and
telecare/telehealth may be offered. Care delivery at home is co-ordinated by a Community Matron, supported by a Care Navigator. Patients can be on the community ward for a maximum of 12 weeks and patients are discharged following progress against their care and support plan. Appendix 13 describes the process of the community ward.
The Community Ward service is being rolled out in four waves across the borough, beginning with Teddington and Hampton in January-March 2013 for a pilot feasibility study. Wave 2 covers East Sheen and Barnes (mid May 2013); Wave 3 covers Twickenham, Whitton and Heathfield (June 2013); and Wave 4 covers Richmond, Kew, and Ham (July 2013). The waves were grouped to be in line with health and social care services provided in the areas.
Wandsworth and Hounslow CCGs have developed Virtual/Community Wards with their diabetes pathways and have moved acute care activity to community. There is a need to further explore their models of care and apply learning locally.
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f) Level 4: Secondary Care
Level 4 is a consultant led specialist multi-disciplinary service that is delivered in hospital settings. The clinical needs of patients referred to this service have a greater complexity or complications. Input may also be required from other specialities, as clinically appropriate. Level 4 also includes inpatient and emergency services.
GPs can refer directly to diabetes services at Kingston, West Middlesex, St Georges and Charing Cross hospitals in the main, although GP referrals to level 4 hospital care is rare. The referrals are triaged by the Richmond Clinical Assessment Service (RCAS) and appointments are arranged using the choose and book system. Some referrals to Level 4 services are made from the
intermediate diabetes care to level 4 services. A review of RCAS shows that referrals for diabetic medicine (as a main speciality) have increased by 5.2% and consultant-to-consultant referrals have risen by 57% since 2009.
Key activities occurring at Level 4 include (referrals for the following): Newly diagnosed/ registered type 1 patients
Existing/ newly registered females with diabetes who are pregnant Newly diagnosed/registered adolescents and young people
Self-management programme, BERTIE (Kingston Hospital or QMH) Management of severe and acute complications
Inpatient care and diabetic emergencies Renal Unit
X-ray
Psychological support Psychological Support
Mental health problems are more common in people with physical illness. People with diabetes may have emotional or psychological support needs resulting from living with diabetes or due to causes external to the condition. Based on Richmond Public Health analysis, 20% of patients (1147 patients) with diabetes had depression in 2012/13.
Psychological support therapies are offered to patients with diabetes in Richmond. Patients are referred through their GP or self-referred the Richmond Wellbeing Service. The service is based at Richmond Royal and also in a number of practices in the borough. The Richmond Wellbeing Service offers group workshops, counselling, self help courses, a range of talking therapies and computer-based therapies. Activity data for diabetes patients accessing psychological support is not available.
Address: Richmond Royal Hospital, Kew Foot Road, Richmond, TW9 2TE Telephone: 020 8548 5550
