The Pathfinder Diabetes Project launched 15 years ago to address some of the unmet needs of people with diabetes. In this model, GP practices identify cohorts of difficult diabetes patients with poor HbA1c control for a one-off advice and management plan by the consultant/diabetes specialist nurse every two to three months. This model fits with the Right care, Right here model of care advocated by the SWBH Trust in devolving care into the community, giving ownership to patients and carers. Recent audits show a 50% to 62% reduction in HbA1c levels and the model is now being rolled out to 80 practices.
The Sandwell and West Birmingham catchment population has a high prevalence of diabetes, leading to significant morbidity and mortality. Challenges included a lack of clinical engagement and partnership, and inadequate care planning, with poor levels of joined-up care and insufficiently engaged patients.
Diabetes care was also hampered by an absence of of integrated IT systems, poor clarity regarding finances and responsibility and a lack of robust clinical governance structure.
As a result, diabetes care was full of gaps and duplication in service. This eventually resulted in an inability to build capacity and capability in primary care and to progress towards better management of diabetes patients.
The project had a long list of goals, among them: to upskill GPs and practice nurses (PNs); to reduce ‘do not attends’ (DNAs); to increase patient satisfaction; and to improve diabetes control by reducing HbA1c.
It also aimed to provide care without financial boundaries, to build capacity within primary care, to improve appropriate referrals to secondary care and to improve communication between GPs/PNs and specialists.
Finally, the project hoped to improve formulary compliance and value for money prescribing, reduce hospital and A&E admissions with hypos and DKA, and to increase the uptake of structured education programmes.
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