A new diabetes model was planned in County Durham and Darlington (CD&D) in 2014, in response to the growing prevalence of Type 2 diabetes, which was increasing faster than the national average. The model is clinically led, and is a collaboration between three local Clinical Commissioning Groups (CCGs), namely North Durham CCG, Durham Dales, Easington and Sedgefield (DDES) CCG, Darlington CCG, and three Acute NHS Foundation Trusts (FTs), (CD&D FT, North Tees and Hartlepool FT, City Hospitals Sunderland FT), with primary care input from seven local GP Federations and 78 GP practices across the county. The integrated model commenced in DDES CCG in July 2016, was adopted across North Durham CCG in April 2017 and was rolled out to Darlington CCG in October 2017. The model, focused on integration, patient-centredness and sustainability, aims to reduce the variation in the quality of care and patient outcomes for the population of 43 000 people with diabetes across CD&D. It supports the delivery of diabetes services within primary care, providing specialist resources and skills in all GP practices.
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The project team included specialist and primary care clinicians, commissioners, finance managers, business intelligence teams, medicines optimisation teams and project managers. Extensive engagement was conducted with stakeholders to develop a series of ‘Bold Steps’ to demonstrate improvements in diabetes services. Data dashboards were created to capture progress against a range of process, patient quality, prescribing and finance outcomes, monitored monthly at practice, locality, CCG and county level. This data allowed diabetes groups, the Board and individual practices to benchmark performance, reduce variation and drive improvements. Local and national diabetes data highlighted significant variation between and within localities. A clinical model was developed over 18 months, driven by the clinical leads for the three CCGs and three Foundation Trusts. This included new patient pathways and a commitment to shared working to improve diabetes services across the county. Diabetes specialists working in the community took on new roles and the levels of diabetes skills and experience in each practice were investigated to highlight where further support was needed. Work was focused on training and development and diabetes prescribing, with new recommendations for the diabetes formulary and guidance to support primary care decision making around therapies, in line with NICE guidance. A new commissioning model shaped service delivery, including the introduction of an Alliance agreement, in which all providers and commissioners agreed to take joint responsibility for diabetes care in CD&D, a risk and gain share agreement, and a commitment to reinvest any savings generated. New roles were developed to manage the implementation, coordinate clinical activity and support people with diabetes to navigate local health and support services.
Patients’ diabetes education and support services have been transformed, supported by access to NHS England’s Diabetes Treatment and Care Transformation Fund, and a seven-day diabetes inpatient specialist nursing service has been implemented across the region’s two acute hospitals. County Durham has seen significant changes in clinical and patient engagement, as well as in patient outcomes. Monthly reporting at whole system, provider, CCG, locality and practice level has shown improvements in a range of patient indicators, such as the rising proportion of patients across CD&D achieving HbA1C levels of 59mmol/mol. Improvements have been seen across most areas in relation to diabetes care and outcomes, with a significant reduction (20%) in non-elective activity, plus reduced outpatient activity as primary care teams have been able to manage more complex diabetes. In relation to blood glucose achievement, this equates to 1,600 additional patients achieving <59mmol/mol in April 2019, compared with August 2016. Practices are able to view benchmarking reports and 87.2% have achieved Care ++ status, demonstrating the skills and commitment to manage patients with complex diabetes, including maintaining and initiating patients on injectable therapies, and safe management of patients discharged from secondary care.
Sustainability and Spread
The CD&D integrated diabetes model commenced in DDES CCG in July 2016, was adopted across North Durham CCG in April 2017 and rolled out to Darlington CCG in October 2017. The service won a Quality in Care award in 2017. Since then, the model has demonstrated true integration. Learning from the first CCG rollout was considered and recommendations adopted, as the next two CCGs joined. Notable developments included rationalising prescribing, supporting education and training in primary care, and Type 2 diabetes structured education transformation. A mid-point evaluation by the CD&D Diabetes Governance Board, which is responsible for overseeing all diabetes care across the three CCGs, captured the patient experience, surveyed healthcare professionals in primary care and produced in-depth reports into diabetes quality, finance, prevention, plus communications and engagement. Members of each locality diabetes group (diabetes specialist service, practice nurses and GPs and GP Federation leads) were invited to share their views on the integrated diabetes work. The three commissioning CCGs have committed to a five-year business model for diabetes, recognising that consistency and stability are vital to the success of the diabetes model in CD&D. This provides assurance to the Alliance that diabetes is a local priority and facilitates continuous improvement. The first two years of the model focused on developing the necessary infrastructure, in particular cementing relationships and trust between partners, to enable true collaboration. Years three to five will continue to focus on improving outcomes for people with diabetes in the area. New priorities include further support for vulnerable groups, such as frail, elderly people with diabetes, and a system-wide review of costs and savings related to diabetes across the county. The CD&D diabetes model has the potential to be replicated nationally and good practice and learning have been shared across the North East, thanks to close links with regional diabetes networks. Transformation at this scale requires a climate of collaboration, with partners supported to put aside their own agendas at times to achieve wider system change. Strong leadership and a clear vision will be important.
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