This initiative is a single integrated diabetes team across
primary, community and hospital diabetes services, employed by different
providers, but delivering improved patient and productivity outcomes. Camden
CCG invested in value-based commissioning with one pooled programme budget
across all sectors: the team is paid from a common budget, allowing savings in
high cost areas such as amputations to be reinvested in prevention by having
more podiatrists and better-trained staff doing diabetes foot checks. Patients
decided the priorities, such as education so they could self-care, and
joined-up services supported by IT. Data analytics is used to drive performance
across all levels of the health economy, with demonstrable benefits in outcomes
and quality of care, including a reduction in deaths due to improvements in
The young population of Camden in North London presents a significant opportunity for prevention of ill health as people under 40 are unlikely to have developed many of the complications of diabetes that are the leading cause of death and disability. Camden also has a large minority ethnic population with particularly high proportions of Bangladeshi, Somali and African Caribbean people. Although it is among the most deprived boroughs in London, there is a gap in life expectancy which reflects big differences in wealth and deprivation across the borough. There are also lower than expected levels of diagnosed diabetes and this may reflect Camden’s relatively young population and/or undiagnosed population. A CCG-led scoping exercise found poor control of diabetes, leading to excess early complications and death, and a lack of communication, data and connectivity across services. There was also inconsistent practice amongst providers and insufficient and or inadequate pathways, and a lack of knowledge and confidence in diabetes management amongst GPs, practice nurses, ward staff and community nursing teams.
To put in place processes so that staff from different providers work clinically and managerially across the health system to support person-centred care and best practice in primary, community and specialist settings. To improve communication and reduce variation across diabetes services in Camden, using a care planning approach with an emphasis on self-management where possible. To develop an integrated IT platform and ensure all staff have the appropriate competencies.
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