Dr Azhar Farooqi discusses how practices could use practice-based commissioning to redesign services and provide extra specialist treatments for patients with diabetes


An organised and structured primary care framework for diabetes has long been recognised as delivering a high standard of care for patients with type 2 diabetes.1 By contrast, primary care with a less well developed support structure tends to deliver worse outcomes than those achieved for patients with a similar condition who attend hospital follow-up.1 The key to success in primary care seems to be regular, prompted call and recall by willing and able primary care teams led by the GP.

Such characteristics of a primary care diabetes service have been acknowledged in the quality and outcomes framework (QOF).2 The QOF clinical indicators for diabetes recognise the importance of diabetes registers, regular review of patients, and the importance of process and outcome targets. The success of this approach is demonstrated by the fact that general practice in the UK has been able to deliver year on year improvements in care for people with diabetes.3

However welcome the QOF has been, it is only a start in ensuring the universal achievement of the highest standards of diabetes service provision. The QOF points totals that trigger payments, for example, fall short of evidence-based targets such as those suggested by the National Institute of Health and Clinical Excellence.1 Each individual’s HbA1c target (for glycaemic control) should be set between 6.5% and 7.5%, based on the risk of microvascular and macrovascular complications. In general, the lower target is preferred for people at significant risk of macrovascular complications, but a higher target may be necessary for those at risk of iatrogenic hypoglycaemia. Future developments prompted by practice-based commissioning (PBC) promise further verifiable improvements in provision of diabetes care; depending on service specification, these may be delivered increasingly in the primary care setting. With this in mind, Diabetes UK issued its revised Recommendations for the provision of services in primary care for people with diabetes in August 2006.5

This article will discuss the likely components of a service specification for diabetes that could be commissioned under PBC. Far from being an abstract concept, such a specification will allow all practices to plan developments that allow them to deliver high quality for those components of the service they feel they may be able to provide.

Aims of diabetes care

There are several overall aims of diabetes care.5 These are to:

  • ensure life expectancy/quality of life for patients with diabetes is similar to that of the general population
  • provide equal access for all patients to high quality diabetes care and prevention—particularly for vulnerable groups such as people living in institutions, the socially deprived, and black and minority ethnic groups
  • reduce prevalence of type 2 diabetes by prevention of obesity and promotion of a healthy diet and physical activity
  • achieve early diagnosis and treatment of people with type 2 diabetes to reduce likelihood of developing long-term complications and associated costs—diabetes services should offer screening for those at increased risk of developing the disease
  • maintain near-normal blood glucose levels to prevent microvascular complications, such as diabetic retinopathy, diabetic renal disease, and diabetic neuropathy; and to alleviate symptoms and avoid acute metabolic crises, such as hypoglycaemia and ketoacidosis
  • monitor cardiovascular risk factors—patients should be advised to reduce these risks by healthy weight management and by undertaking physical activity, and they should receive smoking cessation advice and treatment for dyslipidaemia and hypertension
  • encourage the active involvement of people with diabetes in the provision of their own care by providing ongoing education and support at a level that each person can understand.

Service specification for diabetes care

In order for PBC to be a success, service specifications will have to be developed. This is analogous to an individual planning refurbishment of his or her home. The specification for such a scheme would be expected to be developed in consultation with family, the bank manager, local authorities, and specialists such as architects. Only then would builders be invited to tender for the contract.

Similarly, services in the NHS need a specification; commissioners need to consult with patients, finance departments, and specialists in primary and secondary care. Only after this consultation process is complete should decisions be made on inviting providers to tender for services. Currently, such scenarios are an exception rather than the rule in the NHS.

Three tiers of service

The provision of services for patients with diabetes could be divided into three types, or tiers, of care. These are:

  • tier 1—a specification for diabetes services should address the minimum level of care that all general practices will need to provide for their patients with diabetes (although, in theory, under PBC this could be delegated to another practice)
  • tier 2—certain aspects of service provision for diabetes, while remaining specialist (i.e. expected to be delivered by healthcare professionals with specialist or enhanced skills), could be delivered by providers in practices offering enhanced services, by an intermediate care service (e.g. led by specialist nurses), or by specialists in a secondary care setting. In fact, it should be possible for any suitable providers who could meet the service specifications, to tender for and provide such services under PBC
  • tier 3—the specification will also have to define which elements of the service can only be provided by a specialist centre (usually in a hospital environment).

The Department of Health has published a diabetes commissioning toolkit, which provides guidance to commissioners who wish to develop a service specification suitable for their locality.6 My view of the key elements of service specification at each of the three possible tiers described above is given in Box 1.

Box 1: Suggested key elements of the three tiers of a diabetes service

Tier 1 (to be provided by all general practices)

  • identify/diagnose people with diabetes
  • establish a diabetes disease register
  • initiate management of type 2 diabetes
  • provide access to patient education according to national guidance
  • offer at least annual review/surveillance of patients with type 2 diabetes and ongoing management, referral of complex patients and those with complications, according to local guidelines
  • refer patients with type 1 diabetes and participate in shared care as agreed
  • offer pre-pregnancy counselling and referral, according to local guidelines
  • recognise, treat, and initiate appropriate referral of diabetic emergencies

Tier 2 (a ‘specialist’ service not needing to be based in hospital)

  • offer educational support to primary care professionals
  • provide educational programmes for people with diabetes
  • triage referrals to specialist services (other than acute admissions)
  • provide patient/professional helpline
  • give initial and ongoing treatment for type 1 diabetes other than children and adolescents and those with complex complications as agreed locally
  • initiate insulin treatment for type 2 diabetes, insulin titration, and care for complex patients

Tier 3 (hospital-based care)

  • acute admissions
  • paediatric care
  • diabetes in pregnancy
  • complex complications
  • other categories as agreed locally
 

Practical implications for general practice of a tiered service

Provision of a tier 1 service

It is inconceivable that general practice in any future service model would not be expected to provide this level of care for people with diabetes. The reimbursement for this is already part of the GMS contract global sum and QOF payments. Practices may increasingly be monitored on the quality of their provision, and will need to ensure that they have appropriately trained practice nursing and GP staff to deliver a tier 1 service. This will need to include regular clinical updates and demonstrate awareness and implementation of local and national evidence-based guidelines for diabetes. Practices will also need to be aware of how to access appropriate diagnostic tests (e.g. the glucose tolerance test), and services such as dietetic, podiatry, and patient education, as well as retinal screening.

Practices will need to maintain up-to-date patient registers and have appropriate computer facilities for call and recall. They will probably also need to be able to offer dedicated diabetes clinics for their patients. Quality assurance will need at least QOF type data to be available for PCT-led practice visits, which may also require information on referral patterns for diabetes, prevalence rates, and training undertaken by the practice team.

Under PBC, it would be possible for practices to delegate such a service to a neighbouring practice offering the service, although this would have financial implications.

Provision of a tier 2 service

Practices that aspire to provide any aspect of a tier 2 service would need to be already providing a high level of achievement at tier 1. As a tier 2 service would be beyond the minimum required of a practice, an explicit and costed service level agreement would need to be confirmed with the commissioner (usually the PCT). Practices, therefore, will need to be clear on the true costs of providing the service; these would include costs of administration, premises, and ongoing training and service costs for relevant healthcare professionals. It is apparent, therefore, that a proper business planning exercise would need to be undertaken by a practice before it could contemplate offering such a service.

It is, of course, true that some practices may already be providing such types of services, however a formal service agreement involves commitment to achieving explicit quality standards in return for payment. An important element of such quality assurance would be the provision of enhanced clinical skills in primary care.7

It is likely that healthcare professionals will be required to certify their accredited training, such as through a postgraduate diploma or specialist training course, or by providing evidence of a significant attachment or work with a specialist. Other important quality issues will involve ensuring the suitability of premises and administrative support. Practices that wish to provide such services will need to include such issues in their business planning well in advance of any proposal to their PCT.

Conclusions

Practice-based commissioning is likely to result in the development of a local service specification for diabetes. Inevitably, this will result in a clearer definition of the minimum that each practice should provide for its patients, but will also offer opportunities for service redesign, with more diabetes specialist services being delivered in the community.

The prospect of a wider range of providers will create chances for practices to provide higher levels of care, providing that they can meet the challenge of quality assurance, and that they can also demonstrate a higher level of clinical expertise.

 

  1. Griffin S. Diabetes care in general practice: meta-analysis of randomised control trials. Br Med J 1998; 317 (7155): 390–395.
  2. Department of Health. Quality and outcomes framework. Guidance—Updated August 2004. London: DH, 2004.
  3. York and Humber Public Health Observatory. Quality indicators for diabetes, QOF tables 2004-2006. www.yhpho.org.uk/viewResource.aspx?id=721
  4. National Institute for Clinical Excellence. Management of type 2 diabetes—management of blood glucose. Inherited clinical guideline G. London: NICE, 2002.
  5. www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/The_provision_of_services_in_primary_care/
  6. Department of Health. Diabetes commissioning toolkit. London: DH, 2006.
  7. Department of Health. Implementing care closer to home: convenient quality care for patients—Part 3: the accreditation of GPs and Pharmacists with special interests. London: DH, 2007.G