WISDOM (West Hampshire Improving Shared Diabetes Outcome Measures) was developed in September 2017 in response to below average CCG NDA outcomes for the three treatment targets for type 2 diabetes. The project evolved from a blueprint for Primary Care Network (PCN) management of diabetes to a sustainable component of the new community service contract (April 2020). It focuses on professional culture change, rapid clinical results and wider adoption across the locality. It illustrates how a large, population-level intervention can deliver measurable results within two years, change existing commissioned activity and influence neighbouring Dorset and Southampton CCGs to adopt it.
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Emerging PCN clusters were mapped with stakeholders and offered quarterly cluster meetings facilitated by a GP with a special interest (GPSI) and Diabetes Specialist Nurse (DSN). Patient feedback was gathered to develop the curriculum for a new structured education refresher session titled ‘WISER’. In terms of staffing, funded backfill enabled each practice to release one GP and one Practice Nurse. Practices also received additional funding for a monthly in-house meeting to discuss 15% of their complex cases identified from audit data. WISDOM project staff were in place from December 2017, with a go-live date planned for March 2018. Staff were relied upon to be flexible and willing to take up short-term contracts and backfill other roles so the project roles could be filled. A GPSI was appointed to peer-lead the PCN cluster meetings. The project team included the GPSI lead, DSNs (1.0 WTE), Consultant Diabetologist, CCG and Medicines Management lead.
During 2018/19 (Year 1), a total of 46/49 practices in nine PCNs participated in 36 PCN cluster meetings. Each quarter the ‘live’ data was extracted anonymously using the PRIMIS GRASP DM Diabetes Audit tool. Discussion of metrics and appropriate solutions was actively encouraged. Through discussion and a review of best practice, upper targets were set for the Amber Treatment Target criteria (and, by default, the Red criteria warranting a potential referral to the specialist service). Patients identified a need for refresher Type 2 diabetes education and contributed to shaping the curriculum, resulting in the inclusion of a psychological component. Process mapping was also offered to surgeries where a need or variation was identified.
Participation in the WISDOM project provides GP surgeries with quarterly feedback about the numbers of patients who are achieving all three treatment targets (Risk rated GREEN) so they can stratify patients for further intervention. PRIMIS GRASP DM audit data extracts the results from the preceding 12 months, while the National Diabetes Audit (NDA) extracts data from the preceding 18 months. Over the course of the project it has been reassuring to note that the figures generated by PRIMIS GRASP DM and NDA (as they become available) are closely analogous, but not identical. Importantly, PRIMIS GRASP DM data enable closer tracking of improvements than is possible with NDA data. PRIMIS GRASP DM data demonstrate the success of WISDOM over two years from December 2017 to December 2019. Measured by Treatment Target achievement alone, WISDOM outperformed the national rate of improvement more than twice over. In addition to population level improvements in the 3TTs, the team delivered: WISER three-hour patient education refresher sessions, including a psychology presentation; process mapping visits (n=25) producing summary reports with recommendations for improvement; a WISDOM conference in June 2019; motivational interviewing workshops (n=8); a Big Team Meeting leadership event that included teams in Dorset and Southampton CCG, secondary care colleagues, CCG partners and community teams; a qualitative review in January 2019, which identified these themes: process improvements, cultural change and learning and knowledge. Since April 2020 WISDOM has been commissioned into the community contract, replacing, and improving on, the previous Consultant Outreach project.
Sustainability and Spread
An ambitious vision has been launched to target ‘Amber’ risk patient groups in a large Type 2 population in order to improve outcomes and reduce complications. The project set out to drive improvement through culture change while explicitly targeting investment in primary care. In June 2019 the first Wessex WISDOM conference was held, giving a platform to national and local speakers and being well attended by all stakeholders. A Toolkit was developed for members of Gloucester CCG who attended a one-day WISDOM workshop in January 2020. The Twitter handle @WISDOMDiabetes has enabled wider dissemination of progress. WISDOM has continued, uninterrupted, using Zoom cluster meetings during the COVID-19 pandemic. It is suitable for COVID-19 recovery plans and travel costs, room hire and primary care costs will be reduced significantly.
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