Sandwell and West Birmingham (SWB) CCG has a substantial ethnic minority, a socially deprived, non-compliant population and high rates of diabetes. Traditionally, individualised diabetes management has been disjointed, with gaps and duplication in service and no seamless care between the community and hospitals. The aim was to address unmet needs and help devolve diabetes care into the community, train and give ownership to patients and carers, increasing hospital clinic capacity for more complex patients and improving overall care for every diabetes patient. SWB CCG, in collaboration with secondary care providers Sandwell and West Birmingham Hospital Trust (SWBH) and Birmingham Community Healthcare (BCHC), commissioned a community diabetes service in all 111 practices. This model was named Diabetes in Community Extension (DICE). The CCG also commissioned a Diabetes Local Improvement Scheme (LIS) in 2014-15 to complement the DICE service in primary care. The financial model was based on block contract and sessional payment. In the last three years, nearly 5,000 patients have been seen in DICE clinics, resulting in 2,500 fewer outpatient appointments. The DICE model has upskilled primary care staff, delivered effective care closer to the patient’s home, improved satisfaction and brought significant cost savings.
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A previous service, the Smethwick Pathfinder Project, involved nine GP practices and was successful, but needed redesign to cover the entire SWB CCG. The aims for the DICE model were: to reduce hospital outpatient attendances, devolve care closer to patients’ homes, to educate and upskill primary care staff, including use of evidence-based clinical guidelines and formulary-based medicines management, and also reduce emergency hospital attendances from hypoglycaemia, diabetic ketoacidosis (DKA) and amputations. The model is an innovative and pioneering project because: it is one of the first such projects to be initiated in the country which has successfully evolved over time; it puts the patient at the centre with a ‘Right Care, Right Here’ approach to diabetes management; it improves the diabetes service through upskilling; it offers a novel concept of disease management and delivering care, with specialists going out to patients rather than traditional hospital-based care, allowing primary and secondary care to improve capacity and develop specialist services, respectively; it is a cost-effective way of delivering care for chronic disease, reducing long-term complications, outpatient follow-ups and hospital admissions; it brings joined-up, collaborative working with definite evidence of improvement in clinical parameters (QOF results), and is liked by stakeholders for its innovative, cost-saving and effective model of care delivery, which could change how chronic disease is managed in future. The model can be easily adopted by any other CCG.
The DICE model covered all the 111 practices in the CCG. Consultations and joint meetings with GPs, nurses, patients, specialists and commissioners were held prior to commissioning, to set criteria for which patients would be seen, the pathway, frequency of practice visits, methods of training through joint consultations and education, continuing audits, follow-up query and contact with specialists and detailed evaluation plan. It launched on 1 April 2014. The typical model entailed joint diabetes clinics within GP practices every eight weeks, offering a one-off advice and management plan by a consultant and diabetes specialist nurse visiting GP practices on a prearranged basis. Options to suit individual practices included virtual clinics, joint consultations, a case notes review and advice and guidance in the presence of the GP/practice nurse (PN) to ensure constant and consistent upskilling. A Diabetes LIS and Primary Care Commissioning Framework (PCCF) was also commissioned to complement the DICE service in primary care. Provision was made for telephone and email enquiries, with a maximum turnaround for non-urgent enquiries of two working days. Yearly detailed evaluation of both qualitative and quantitative outcomes including user feedback was gathered by the CCG and discussed at the CCG steering group meetings to learn and make recommendations.
In 2014-2015 data from 53 practices showed that 3,060 patients were seen and 595 fewer outpatient appointments were made. A total of 31 practices reported positive engagement. Outpatient attendances reduced by 1,016 in 2015 and by a further 733 in 2016, representing a decrease in outpatient costs from £1.2 million in 2013/14 to £838,703 in 2016/17. Regarding hypoglycaemia, there were 38 fewer admissions in 2016 than in 2015 (yearly comparisons). Inpatient elective and non-elective/emergency data sets showed a clear reduction in the total number of admissions relating to diabetes (2016/17 compared to 2015/16) by 105 admissions with a cost saving of £186,385. DKA-related admissions remained stable (43 and 44 in the last two years, respectively). Blood glucose testing strip prescribing levels remained low and in line with local guidance. Use of cost-effective NPH insulins increased and the use of long-acting analogues reduced. Practices have seen significantly improved HbA1c levels and QOF parameters.
Sustainability and Spread
The DICE model’s 111 GP practices cover a population of more than half a million people. It has been so successful and popular with GPs and PNs that the CCG has assured funding for the foreseeable future. Interest has been expressed across the region and other places in the country want to implement a similar model, including Walsall, Dudley, Staffordshire, Coventry and Lancaster. There has been interest from Hong Kong as well. The project was published as a case study in the RCP Future Hospitals programme. After winning the QiC award 2014 in the best Primary Care Initiative for the pilot Smethwick Pathfinder Project, the DICE model was a finalist in the PSCA awards 2016, HSJ awards 2016 and Healthcare Transformation award in 2017. It also won the RCP Excellence in Care award in June 2018.
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