Guidelines in Practice Award joint runner up, Newham GP Dr Clare Davison, describes her team’s project to support practices in raising local standards in diabetes care


 

Newham PCT covers the same area as the London Borough of Newham. The 2001 census found that Newham was one of only two boroughs nationwide with the majority of the population made up of ethnic minorities. Most come originally from the Indian subcontinent or are of Afro-Caribbean origin. As a result of this demographic profile there are above average levels of diabetes in Newham.

In the late 1990s, practices noticed significant increases in diabetes diagnoses as well as long waiting times for the diabetes outpatient service. Inpatient numbers were rising, to the extent that 40% of admissions to the local coronary care unit were patients with established or newly diagnosed diabetes. Patient outcomes were poor, with high rates of admission for ketoacidosis and lower limb amputation twice the national average.

Newham had below national average practice nursing hours and 36 of the 64 practice premises were class 4 or 5. It also has an extremely mobile population, with practices reporting annual patient list turnover of between 25 and 33%.

It was clear that Newham general practices would need considerable support to meet increasing demand and raise clinical standards.

UKPDS trials provided strong evidence regarding prevention of complications in type 2 diabetes,1,2 and the National Service Framework for Coronary Heart Disease enabled us to anticipate what might be expected from primary care in the proposed National Service Framework for Diabetes.3,4

Setting up the scheme

In 1999, we put forward a successful proposal to use some of the pooled savings from the multi-fund we belonged to at the time. Subsequently we gained funding through the primary care directorate and the clinical governance directorate of Newham PCT.

A model of diabetes care was proposed and agreed by the GP Forum, Diabetes Working Group and the multi-fund (Figure 1, below). A Newham GP led the project, and through the Clinical Effectiveness Group at the local department of general practice, at Queen Mary and Westfield College, we were able to recruit and train an auditor.

Figure 1: Pathway of care

We planned to effect change by providing practices with administrative, educational and financial support. Practices were given incentive payments linked to increasing the numbers of patients with diabetes they were caring for and carrying out more, and better quality, annual reviews. Payments were graded according to a three-level ‘ladder’ (Table 1, below).

Table 1: Targets of the three-level ladder
  2001 2002 2003
Level 1 Minimum prevalence identified 2% Minimum prevalence identified 2.5% Minimum prevalence identified 2.5%
Level 2 Patients with type 2 diabetes who did not require insulin:
Caring for 70%
Annual reviews 50%
Patients with type 2 diabetes who did not require insulin:
Caring for 75%
Annual reviews 60%
Patients with type 2 diabetes who did not require insulin:
Caring for 75%
Annual reviews 60%
Level 3 Patients with type 1 or type 2 diabetes:
Caring for 75%
Annual reviews 60%
Patients with type 1 or type 2 diabetes:
Caring for 75%
Annual reviews 65%
Patients with type 1 or type 2 diabetes:
Caring for 75%
Annual reviews 65%

Initial survey

In January 2000, a baseline survey was undertaken of 60 practices. The survey consisted of a manual audit, which was designed to discover how many patients had diabetes, where they lived and whether they were being cared for by a GP or by the hospital. This information would be used to plan service development.

Establishing a disease register

Our first step was to establish that all practices had a disease register. Standard Read codes were applied and a computer template was used to record clinical data.

The disease register was validated through annual audits; for example, we identified patients with type 2 diabetes taking insulin who were incorrectly coded as having type 1 diabetes, or those taking diabetes medication who were not on the register.

Educational events

In 2000, a series of three workshops was held for GPs and practice nurses in four localities. In 2001, education was provided through the PCT’s scheme for protected learning time, and this was successful in encouraging more staff to attend.

In 2002 and 2003, the lead GP and a diabetes specialist nurse set up a University of Warwick Certificate in Diabetes Care course locally. So far, 48 GPs and practice nurses have participated in the course.

Recently, the ‘Insulin 4 Life’ course has been organised in our area with the support of one of the local consultants. All practices that have completed the Warwick Certificate are invited to participate in the course.

Support for practices

Each year, the auditor completed an audit in each practice and gave feedback to staff on their practice’s performance. The lead GP also visited practices to give advice where needed on management, referrals and education.

Information and resources

Newly diagnosed patients are given an information and resource pack, My Diabetes, which includes details of foot care, healthy diet, retinal screening, local leisure facilities and voluntary agencies, including the local patient support group Diabetes Newham, and Diabetes UK.

Structured educational sessions are also organised for patients. They are conducted in English, Asian or minority languages, when information from dieticians, a podiatrist and specialist diabetes nurses is available.

Incentivising improvement

Table 2 (below) gives details of payments made through the Newham Diabetes Incentive Scheme from 2001 to 2003.

Table 2: Newham Diabetes Incentive Scheme, payments 2001-2003
  2001 2002 2003
Level 1 £200 per GP* £400 per GP* £400 per GP*
Level 2 £400 per GP* £30 per annual review £30 per annual review
Level 3 £400 per GP* £40 per annual review £40 per annual review
* = whole-time-equivalent GPs, excluding salaried GPs and GP assistants

As the project progressed, more practices took part in the scheme and moved up the levels ladder (Figure 2, below). By 2003, the number of practices achieving level three audit standards had almost doubled, to 27.

Figure 2: Practices participating in scheme and levels achieved, 2001-2003

As we have a varied mix of practices, most of which are small,we analysed the data for participation in the scheme by whole-time-equivalent GP principals (Figure 3, below) as well as by practice. This also showed an improvement, so that by 2003 more than half were working in practices providing level three care.

Figure 3: Whole-time-equivalent GPs participating in scheme and levels achieved, 2001-2003

We hope that staff in these practices will train in the initiation and management of insulin.

Measuring success

Over the 3 years since the project began, significant improvements have been made.

The proportion of patients being looked after in the community has increased, with a corresponding decrease in those under the care of the hospital service.

The percentage of diabetes patients who have undergone annual review in primary care has increased from 50% in 2001 to 67% in 2003.

There has also been an improvement in the percentage of patients who have been assessed for 10-year CHD risk, BMI level and smoking status and have undergone cholesterol, creatinine, glycaemia, proteinuria and blood pressure measurement as well as eye examination and foot examination (Figure 4, below).

Figure 4: Newham Diabetes Incentive Scheme audit results, 2001-2003

The results shown in Figure 4 are averages across Newham practices. This masks the fact that many practices have made great strides in improving diabetes services in accordance with NICE guidelines 5,8 and the NSF for Diabetes.

Audit inevitably emphasises process and outcome criteria. However, achieving the Warwick Certificate in Diabetes Care has helped healthcare professionals to improve their approach to management and make care more ‘patient centred’ as well as raise clinical standards.

We are fortunate in having two supportive patient representatives who share their experiences, and a cognitive behavioural therapist, all of whom contribute to providing the Warwick Certificate course locally.

Plans for the future

It seems we have now reached a state of equilibrium. Although some practices are still moving up the levels ladder, some have slipped down as a result of staff changes. However, we hope that by the autumn of 2006 more than half of Newham’s GPs will be working in practices where high quality services, including the initiation of insulin, will be provided.We are also aiming to reduce the proportion of patients with diabetes under the care of the hospital services to the suggested level of 15%.

Approximately 20% of patients are registered with practices that do not provide structured care, so we are in the process of developing locality clinics for these patients, staffed by GPs with a special interest.

Rolling out the project

Our scheme was posted on the Audit Commission website as an example of good practice before the publication of the NSF for Diabetes.

We have put forward a proposal to set up a local enhanced service for diabetes under the new GMS contract because we have been disappointed by the funding formula and resulting level of resources available through the new contract’s diabetes indicators, particularly as it appears to disadvantage inner-city areas of high prevalence.

Other PCTs have expressed an interest in our work, and neighbouring City and Hackney PCT has obtained funding to develop a similar scheme as an enhanced service.

References

  1. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. Br Med J 1998; 317: 703- 13.
  2. Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40. UK Prospective Diabetes Study Group. Br Med J 1998; 317: 720- 6.
  3. Department of Health. National Service Framework for Coronary Heart Disease: Modern Standards and Service Models. London: DoH, 2000.
  4. Department of Health. National Service Framework for Diabetes: Standards. London, DoH, 2001.
  5. National Institute for Clinical Excellence. Inherited Clinical Guideline E – Management of type 2 diabetes: Retinopathy screening and early management. London: NICE, 2002.
  6. National Institute for Clinical Excellence. Inherited Clinical Guideline F – Management of type 2 diabetes: Renal disease prevention and early management. London: NICE, 2002.
  7. National Institute for Clinical Excellence. Inherited Clinical Guideline G – Management of Type 2 diabetes: management of blood glucose. London: NICE, 2002.
  8. National Institute for Clinical Excellence. Inherited Clinical Guideline H – Management of Type 2 diabetes: Management of blood pressure and blood lipids. London: NICE, 2002.

Guidelines in Practice, November 2004, Volume 7(11)
© 2004 MGP Ltd
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