Commissioning an integrated Community Diabetes Team

Summary

In November 2011 the community diabetes team at Portsmouth & South East Hampshire expanded to include consultant diabetologists and formed an integrated community, primary and acute care team. The aim was to increase the knowledge and skills in the management of patients with diabetes among carers and clinicians, as well as to improve communications and relationships across the healthcare community. 

The new community diabetes team has gone from strength to strength; feedback from both GPs and patients has been excellent. Following a six-month review the team has met its set targets, which include the numbers of clinicians and patients educated and numbers of patients discharged from acute care.

Challenge

In 2007 a community diabetes team was commissioned through Practice-based Commissioning locality managers for South East Hampshire residents, to provide a mixture of patient and practice clinical support as well as targeted diabetes-related education. The impact of this initiative along with the diabetes LES was a reduction in diabetes outpatient referrals, however there were still three key issues to tackle and therefore in August 2010 Commissioning Managers along with Dr Partha Kar Consultant Diabetologist at Portsmouth Hospitals NHS Trust developed a proposal for change:  

There were three key issues to tackle:  

  • Inefficiencies in the traditional pathway as long-term follow ups for people with diabetes were conducted in Secondary Care clinics
  • Unacceptable variation in the quality of care in primary and community care. This was believed to be contributing to higher-than-expected rates of diabetic emergency admissions and complication rates in the local population
  • The disconnect between care services, which resulted in an absence of structured care plans or duplication of effort.  
The proposal was developed to resolve the care quality issues, which centred on clinician and patient knowledge. Among clinicians there was inequitable knowledge of diabetes and insulin management. In addition there was no access to prompt specialist advice regarding diabetes management. Patients were also expressing a preference for care management within the Primary Care setting and closer to home. 

Drawing on evidence from the NSF for Diabetes, care was shifted from Secondary Care, and education and empowerment of clinicians and patients was pushed to the fore.  

Nationally recognised education and training programmes were adopted for patients (DESMOND) and clinicians (MERIT, which meets Local Enhanced Service requirements). 

In November 2011 the current diabetes community team comprised two part-time specialist nurses and a GPwSI; it has now increased to two full-time and one part-time specialist nurse, and has full-time administrative support and the input of the local consultant diabetologist team. The service is currently receives annual funding of £152,100. It has capacity for income generation through training programmes for health professionals and healthcare assistants including in care homes.

Objectives

Through integration and collaborative working between community, primary and acute clinicians the initiative aims to improve the knowledge and skills in the management of patients with diabetes, carers and clinicians and improve communications and relationships across the health community.  

Specifically it aimed to:

  • Reduce diabetes referrals into acute care
  • Reduce diabetes admissions to Queen Alexander Hospital (QAH)
  • Deliver MERIT training for 50 clinicians each year
  • Deliver DESMOND training for 520 patients each year
  • Deliver bespoke training to meet identified local need, eg, care homes
  • Ensure regular engagement with GP practices, including planned visits from the team (including consultant diabetologist) at least twice a year (can be training sessions if required) and joint caseload review of diabetic patients
  • Improve patient reported ability to self-care – 100 per cent patients seen to have personalised care plan
  • Deliver seamless care for people with diabetes through complementary working relationships between primary, secondary and community care – including rapid access to specialist support by telephone and email. 
The community diabetes team provides the above to all patients with diabetes who are not included in the Super Six, it was agreed these patients would continue to be managed in the Acute Clinics with Portsmouth Hospital’s NHS Trust. 

The Super Six

  • Pregnancy and pre-pregnancy 
  • Acute Type 1 diabetes
  • Patients suitable for and/or using continuous subcutaneous insulin infusion
  • Adolescent (non paediatric) diabetes
  • Patients with diabetes and in CKD stage 3 
  • Patients on dialysis (renal).

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QiC Diabetes Winner 2012
Best innovative commissioning initiative
Commissioning an integrated Community Diabetes Team
by Portsmouth & South East Hampshire

Contacts

Melissa Way

Job title:
Senior Commissioning Manager
Place of work:
Portsmouth & South East Hampshire
Email:
Melissa.way@hampshire.nhs.uk

Resources

CDT Flow chart - 219.8 KB

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