There are over 19,000 people with diabetes in North East Essex, with prevalence 5.6% higher than the national average. The traditional hospital model was unsustainable. Multiple providers created a confusing system and duplication of care led to rising costs and increased pressure. Suffolk GP Federation won a competitive tender to deliver a new, clinically led integrated model of care under the North East Essex Diabetes Service (NEEDS). Launched in 2014, the aim was to improve diabetes outcomes, moving the region from the bottom to the top quartile within five years. The contract was to be delivered under the 2012 spend of £2 million, with 25% of the value subject to meeting key performance indicators. Suffolk GP Federation implemented a framework acceptable to GPs which led to full dissemination. The model has seen diabetes care transferred away from hospitals into a community setting, including a new role for consultants, supporting GP practices and providing governance. Services are now easier to access and understand for patients, which has led to better outcomes and improved self-management.
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In 2014/15 service structures were established, with a focus on making primary care teams more confident and competent in managing patients by supporting them in their own environment. A diabetes specialist nurse (DSN) was linked to each GP practice and the service worked with the University of Essex to train staff. New pathways and standard operating procedures were implemented to ensure only appropriate patients were seen. Specialist clinics were set up in community locations and delivered by specialist practitioners, a nurse, dietitian or consultant, often with a multidisciplinary team (MDT) approach. The single specialist team provided care for inpatients at the local hospital, providing continuity of care which increased to seven-day working. The plan was to transfer all patients out of hospital specialist clinics. Using clear criteria, each patient was reviewed and either discharged to primary care with a care plan (1,000 patients) or kept within service. To measure patient outcomes each practice implemented a ‘Year of Care’ approach and a real-time data capture system providing monthly reports that allowed clinicians to identify patients in need of intervention. The same system monitored and reported KPIs. In 2015/16, there was a clear focus on clinical outcomes. Consultant and DSN practice visits/virtual clinics (to manage insulin-dependent patients under the care of community nursing teams) identified patients not meeting key targets and initiated a plan with follow-up. Integrated working was developed with social services for care home and domiciliary carer training, alongside Improving Access to Psychological Therapies (IAPT) pathways and joint working to increase and improve access to psychological support. Setting up additional education groups helped patients self-manage and filled gaps. The team built on existing patient forums, supported Diabetes UK T2T programmes and increased patient engagement. In 2016/17, focus was on redesigning the diabetes foot pathway, resulting in fewer, but more appropriate, patients seen in MDT foot clinics and community podiatry clinics. There was more training for primary and community care colleagues to ensure patients were appropriately screened and knew their risk scores. Patients and HCPs were given a hotline for 'hot' feet and advice.In 2017/18 the renal pathway was improved and a dedicated practitioner was put in place to develop severe mental health pathways.The 2018/19 focus is on learning disability and improving maternity care. ‘Care Navigators’ improve awareness of structured education, plus well-being programmes support self-management. The management of type 1 diabetes patients is also being reviewed against the RightCare Pathway.
It is now easier for patients to access and understand services, which has led to better outcomes and people feeling more confident and in control. Up to March 2018: 72.3% (14,247) of type 1 and type 2 patients received all eight care processes; 75.7% (1,614) of type 1 patients were referred to specialist podiatry services; 71.6% (14,054) of patients had total cholesterol within the recommended range; 71.4% (14,075) patients’ blood pressure was within target levels; 71.3% (14,054) patients had an HbA1c level within the recommended range; 75.1% (11,870 extra) patients were offered a tailored care plan, with all GP practices showing better outcomes in 2018 compared to 2014. A total of 37 out of 38 GP practices engaged. By the end of year three, all practices had a GP and practice nurse with advanced training in diabetes. The NICE-compliant foot pathway was implemented, reducing an 18-week wait to 2-4 weeks (high risk) and 4-8 weeks (moderate risk).
Sustainability and Spread
The initial length of contract was five years (2014-19) but the success of the service has led to its extension until 2021. The model was delivered on a fixed budget of £2 million – 20% less than the previous contract and with no additional income for an increase in diabetes patients (5% per annum) or a rise in NHS inflation (typically 6% per annum). Funding for the service was provided by North East Essex CCG. Consultation with stakeholders was important. This included North East Essex CCG, Colchester Hospital, diabetes specialist teams, Anglian Community Enterprise, GP practices and a Diabetes Service Board to influence service delivery and ensure effective governance, management and improvement. Having only one provider enabled much tighter financial control and the freedom to be creative with delivery. The service can cope with the growing numbers with diabetes and looks after more complex patients, freeing specialist teams to support primary care. There has been reinvestment from savings each year. Redesign of the diabetes foot pathway enabled an increase in vascular consultant, orthopaedic and orthotics time in MDT foot clinics. The design of a pump database reduced spend, allowing funds to be used for flash monitoring and continuous blood glucose monitoring. There was also reinvestment in mental health, psychological therapies (IAPT) and care home initiatives.
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