Dr Rustam Rea describes the development of First Diabetes, an integrated diabetes organisation jointly owned by Derby GPs and Derby Hospitals NHS Foundation Trust
Diabetes is a devastating condition, affecting a rapidly increasing number of people in the UK and worldwide. The complications of diabetes occur from childhood through to old age and affect both individuals with diabetes and their families.
Recently published statistics on diabetes make for sobering reading:
- for the first time, the number of people in the UK who have been diagnosed with diabetes has reached 3 million, equivalent to 4.6% of the UK’s population1
- a further 850,000 people are thought to have undiagnosed type 2 diabetes1
- every year in England and Wales, 24,000 people with diabetes die earlier than expected (i.e. compared with the expected mortality rate for people without diabetes)2
- although the vast majority of people with diabetes have type 2, over 250,000 people in the UK have type 13
- the increase in the number of people with diabetes and in those with the condition who have related complications, has resulted in increased hospital admissions4
- in 2010/2011, NHS direct spending on diabetes was almost £10 billion, or £1 million per hour. Eighty percent of NHS spending on diabetes is on managing potentially preventable complications5
- only 54% of people in England with diabetes are receiving the nine key health checks6
- only 19.9 % of people with diabetes (all types) in England meet the recommended targets for blood glucose, blood pressure, and cholesterol.6
In light of this, primary and secondary care clinicians in Derby met together in 2008 to address the rising prevalence of diabetes and its complications in their local area. Recognising the need for every part of the NHS to work together, they identified several factors that hindered best care for people with diabetes. These are summarised in Table 1 and reflected in a recent NHS Diabetes publication.2
A number of options were considered to address these problems in Derby, including:
- buying sessions of consultant diabetologist time to see patients in the community
- discharging all patients who do not attend the multidisciplinary clinics (e.g. foot clinic, antenatal clinic, insulin pump clinic, diabetes/renal clinic) back to primary care
- arranging for GPs to work within the hospital.
However, each of these three possible solutions fell short of true clinical integration based around the needs of patients and so were rejected in favour of a more patient-centred approach.
After extensive discussions, local clinicians agreed that the most effective way of integrating services would be to have a single organisation responsible for all diabetes care and health outcomes. This would be owned, governed, and run both by GPs and the local acute hospital, in equal partnership. In this way, two traditionally separate parts of the NHS would have a stake in making sure that services were delivered effectively, efficiently, and equitably. A new service, First Diabetes, was formed in 2009 (see www.firstdiabetes.co.uk). There were a number of challenges in setting up this unique arrangement, as outlined below.
|Several IT systems were in use within primary care. In secondary care, completely separate IT systems were used, which did not communicate with the primary care systems||Single IT system in use between primary and secondary care—majority of primary care have now moved to this system|
|There was a financial hurdle to refer patients into secondary care and discharge back into primary care||Single budget covering primary and secondary care for people with diabetes|
|Ongoing education and support for clinicians in primary and secondary care was required||Development of a partnership organisation jointly and equally owned by primary and secondary care clinicians|
|There was a need to engage people with diabetes in understanding and controlling their illness||Introduction of care planning, with patients receiving test results prior to their appointment|
|Responsibility for and oversight of the diabetes outcomes of the local population was fragmented||Joint ownership of the outcomes with GPs and consultants working together to reduce prevalence and complications|
The challenges of setting up First Diabetes
Setting up a partnership
The first challenge was to join two separate NHS organisations into a legal partnership. The arrangement was made possible by the acute trust being a Foundation Trust, and the local GPs having a provider body separate from the local commissioning body. Careful thought had to be given to:
- how the organisation would be governed
- the resolution of any possible future conflict.
Legal advice confirmed that a company limited by shares (with one share being owned by the GP provider consortium, and one by the acute trust) would be the most effective way of setting up the single organisation.
Scope of care of the service and budget
The second challenge was to define a single budget that would cover both primary and secondary care diabetes services. The details of this budget became clearer when the scope of the new service was defined. The primary care trust (PCT) (as it was then) made it clear when it commissioned the service that it did not intend First Diabetes to provide services delivered under the General Medical Services contract. Neither would First Diabetes provide care for end-stage complications (e.g. dialysis, angioplasty, amputations). First Diabetes serves a population of just over 60,000 people, of whom 2300 have diabetes, so even a few additional people requiring treatment for end-stage complications would have had a significant impact on annual expenditure.
Both retinal screening and monitoring, provided by a consultant ophthalmologist, were included in the service, and commissioned to be delivered in the community. Originally, podiatry care was to be included as part of the service, but because of historical reciprocal arrangements between provider arms of local PCTs, and the difficulty of separating out diabetes podiatry from non-diabetes podiatry, this part of the service was not in the end commissioned within First Diabetes.
Thirdly, there was the challenge for clinicians to work differently. Derby is fortunate in having diabetes clinics in the community. The proposed new service, however, was much more than just a community clinic: it was aimed at managing people who would always be looked after in primary care, as well as those people who received care in traditional hospital clinics. As a result of this challenge, secondary care clinicians have spent a lot of time building relationships with GPs, practice nurses, and other healthcare professionals who look after the majority of the people with diabetes in the five GP practices covered by First Diabetes. There has also been a challenge for GPs to learn to:
- share IT records
- discuss and refer patients to the new service, when appropriate
- compare clinical outcomes between practices.
Addressing the above issues has led to the development of a healthcare diabetes community with improved communication, joint training, and relationships based on an appreciation of the different jobs done by each professional in trying to achieve a common goal.
Meeting the QIPP agenda
After it was commissioned in 2009, First Diabetes was able to provide a comprehensive diabetes service to the local population of Derby for the first time. This included:
- systematic screening for people with diabetes
- structured education for people:
- at high risk of developing diabetes
- newly diagnosed with diabetes
- taking oral agents and who did not achieve their glycaemic targets
- receiving complex insulin regimens and who did not achieve their glycaemic targets
- regular healthcare professional education
- retinal screening for diabetic retinopathy in the community
- retinal monitoring of diabetic retinopathy by a consultant ophthalmologist in the community.
These services were provided within a budget set by the PCT, with annual savings either being reinvested into the service, or reimbursed to the PCT.
Improved patient experience
We have continued to see a significant improvement in the experience of patients attending First Diabetes clinics in the community over the past 4 years. In particular:
- patients have commented on how easy it is to attend the clinic because it is local, and the parking is free
- the joint budget allows the service to be more responsive to patients’ needs.
As a result, clinics run by a combination of primary and secondary care professionals have been set up in GP surgeries (either jointly with practice nurses or in parallel) for patients who are unable or unwilling to travel to hospital or community clinics. This movement of clinicians across primary and secondary care has been helpful in improving working relationships and communication across the diabetes healthcare community.
Prioritisation of case finding and education
Local GPs have prioritised the need to identify people who are at high risk of developing diabetes and to provide education for them. In the past 4 years we have systematically:
- screened GP registers for patients who are at high risk of developing diabetes
- offered tests to diagnose diabetes
- run group education sessions for people at high risk of diabetes, and their relatives.
Nearly 50% of people identified as being at high risk of diabetes who have attended the educational sessions have reduced their risk of diabetes to normal after 12 months.
Impact on hospital admissions
Over the past few years, First Diabetes has been able to invest in a diabetes specialist nurse with the specific role of helping to reduce the number of hospital admissions and duration of stay of patients with diabetes. Initial data have shown a low but stable number of people being admitted to hospital for diabetes, a reduction in lengths of stay, and a significant fall in the number of people admitted for another reason but also having diabetes (secondary code). This suggests that providing effective care for people with diabetes not only improves their diabetes-related outcomes but also helps them with the management of other long-term conditions.
Current and future costs
At the time the service was commissioned, there were considerable cost pressures within the NHS. Despite this, First Diabetes continues to provide an innovative and high-quality service within budget. The focus of the service is to reduce long-term complications for the local diabetes community, bringing significant cost savings in the future. However, in the short term there has also been a reduction in the cost of drug prescribing within the GP practices of First Diabetes, in contrast to the increasing pharmacological costs for diabetes nationally.8
Insights and future developments
The development of integrated services relies on good working relationships between clinicians across different sections of the healthcare system. Traditional boundaries need to be challenged:
- Secondary care clinicians need to:
- take responsibility for the health outcomes of the local population, not just the patients they see
- GPs and practice nurses need to:
- share patient data
- offer open access to patients who are struggling with their condition
- compare patient outcomes between practices
- Commissioners need to create healthcare systems that:
- allow patients to move in and out of primary and secondary care without financial penalties
- ensure that IT systems in the local area share data between providers and with patients, allowing patients to regain control of their care
- offer a good patient-centred experience to motivate people to care for themselves and to engage with education.
Following the development of First Diabetes, a sister partnership organisation, InterCare Health, was launched in 2010, which delivers diabetes care for the remaining GP practices in Derby (over 10,000 people with diabetes). In the near future, Southern Derbyshire clinical commissioning group will be commissioning diabetes care for the whole of southern Derbyshire, a population of over 500,000, and we await the model of care that has been chosen.
Diabetes is a complex, serious, and increasingly prevalent condition, which affects more than 3 million people in the UK. By integrating services between primary and secondary care through shared IT systems, single programme budgeting, and joint ownership of the outcomes of these patients, we can begin to reduce the complications and improve patients’ experience of care.
- Integrated models like this, which organise care around the patient and bring specialist and generalists together in one provider organisation, could be of interest to all CCGs and seem likely to improve patient care
- However, this pilot does not include podiatry, GMS, and QOF-related diabetes care, demonstrating the complexities involved
- Bringing the GMS and QOF elements of diabetes into a care scheme like this would dramatically broaden its scope, but would need careful planning around distribution of finance and reward
- When commissioning services like these, CCGs must be wary of competition legislation and also conflict of interest between CCG board members and their provider roles
- In general practice, diabetes often co-exists with several other long-term conditions and is managed with these, so focusing the care scheme around the diabetes-specific care elements seems sensible
- Prevention of diabetes in high-risk patients is covered by NICE public health guidance, so public health departments in local authorities may also wish to commission care from organisations like these.
CCG=clinical commissioning group; GMS=general medical services; QOF=quality and outcomes framework
- Diabetes UK website. Statistics. Diabetes prevalence 2012. March 2013. Available at: www.diabetes.org.uk/About_us/What-we-say/Statistics/Diabetes-prevalence-2012/ (accessed 6 November 2013).
- NHS Health and Social Care Information Centre. National diabetes audit mortality analysis 2007–2008. London: HSCIC, 2011. Available at: www.hqip.org.uk/assets/NCAPOP-Library/Diabetes-Audit-Mortality-Audit-Report-2011-Final.pdf
- Association of British Clinical Diabetologists. Lost tribe campaign. Adult Type 1 patients have distinct needs but are ‘lost’ in the diabetes epidemic. Call for specific commissioning to ensure specialist care. Press release, 9 November 2012. Available at: www.diabetologists-abcd.org.uk/Type1_Campaign/Press_Release.pdf
- NHS Health and Social Care Information Centre. National Diabetes Audit 2010–11. Report 2: complications and mortality. London: HSCIC, 2012. Available at: www.hqip.org.uk/assets/NCAPOP-Library/NCAPOP-2012-13/Diabetes-Audit-Report-10-11-ComplicationsMortality-pub-2012.pdf
- Hex N, Bartlett C, Wright D et al. Estimating the current and future costs of type 1 and type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabet Med 2012; 29 (7): 855–862.
- NHS Health and Social Care Information Centre. National Diabetes Audit 2010–11. Report 1: care processes and treatment targets. London: HSCIC, 2012. Available at: www.hscic.gov.uk/searchcatalogue?productid=7331&q=%22National+diabetes
- NHS Diabetes. Best practice for commissioning diabetes services—an integrated care framework. NHS Diabetes, 2013. Available at: www.diabetes.org.uk/Documents/nhs-diabetes/commissioning/best-practice-commissioning-diabetes-services-integrated-care-framework-0313.pdf
- NHS Health and Social Care Information Centre website. Prescribing for diabetes in England: 2005–2006 to 2011–2012. London: HSCIC, 2012. Available at: www.hscic.gov.uk/article/2021/Website-Search?productid=7988&q=prescribing+for+diabetes&sort=Relevance&size=10&page=1&area=both (accessed 22 October 2013). G