The North West London (NWL) Diabetes Improvement Programme began in 2014 in five Clinical Commissioning Groups (CCGs) and has now spread to eight. It has achieved continued quality improvement in key diabetes metrics, including: improvements in nine key care processes; a 12% improvement in treatment target achievement (HbA1c ≤ 58, BP ≤ 140/80, Cholesterol ≤ 4); a 30% increase in structured education attendance in the past year, reaching almost 10% of the prevalent diabetes population; plus a total of 11,473 NHS Diabetes Prevention Programme (NDPP) referrals in 2018/19. The programme operates a large-scale, ongoing clinician education initiative, including 10-point training in secondary care. The Know Diabetes information and support service is about to relaunch, providing a single point of referral, diabetes education and multi-channel campaigns to all patients with diabetes and Non-diabetic hyperglycaemia (NDH) in NWL. The programme is beginning to show impact on diabetes outcomes, including an 8% reduction in diabetes foot admissions in 2018/19 and reductions in myocardial infarction (MI), acute kidney injury and renal failure. The NWL Diabetes Quality, Innovation, Productivity and Prevention (QIPP) scheme this year aimed to show prescribing savings through lifestyle change and complications savings.
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Needs identified included: poor achievement against National Diabetes Audit Three Treatment Targets (NDA 3TT) in NWL, compared with many CCGs in London in 2015/6 data; fragmentation of services; poor outcomes; spiralling costs in hospitals, with over 7% annual growth in diabetes complications costs; diabetes admissions accounting for 41% of all admissions and 63% of bed days; continued growth in diabetes registry and NDH numbers (Harrow CCG has the highest predicted NDH population in the UK); low levels of structured education and self-management support, plus no integration of mental health. Initiatives to meet these needs included a structured education programme, helping commissioners and existing providers to maximise existing capacity and referrals, assisting with QISMET accreditation for some locally designed/developed courses to increase capacity, as well as continuing with Phase 2 of the remote structured education services (Changing Health, OurPath and Oviva), enabling an additional 2,200 patient licences. The Know Diabetes platform was specified and procured. MyWay Digital Systems and Dynamic Health Systems were granted the contract to provide up to 300,000 patients with support through personalised, targeted communication and behaviour change and education nudges at low cost. In addition, treatment targets were assisted via a CCG implementation team comprising a GP, project support officer and nurse consultant visiting the practices requiring most improvement. The NWL Clinical Guidelines were updated, EMISweb clinical templates were developed and a pan-NWL Diabetes quality improvement dashboard was actioned. A liaison psychiatrist and two mental health nurses were employed to train primary care and run virtual clinics/multidisciplinary teams. Local best practice examples were shared across NWL. Over 630 diabetes professional education places were provided. For the multi-disciplinary footcare team (MDFT) more podiatrists were employed to provide additional weekend working and reduce wait time for ulcers/foot lesions at weekends and there was additional clinical training and awareness-raising for clinicians. For in-patients there was a wide rollout of 10-point training (Ruth Miller) in hospitals, care homes and renal dialysis units. Further digital developments included a diabetes data set comprising a READ2/CTV3/SNOMED-aligned primary care data set and an acute hospital complications data set. The programme also worked with the One London Local Health and Care Record Exemplar programme and London Diabetes Strategic Clinical Network to ensure that diabetes was adopted as a first-of-type proof of concept for the One London Discovery Programme.
There have been substantial improvements in key patient outcomes over the last three years, with increases in: diabetes case finding (12,000 more patients on the diabetes register since 2015); patients receiving nine key care processes (up from 25.4% to 69.5%); achievement of three treatment targets (from 17.9% to 25.6%); collaborative care planning (from 5.5% to 83.4%); monitoring of hypoglycaemia in patients on sulphonylureas or insulin (from 6.5% to 94.4%); the NDH register (an increase of over 100,000); referrals into the National Diabetes Prevention Programme (over 25,000 referrals and over 11,000 initial assessments); annual numbers attending structured education programmes (up from 5,461 to 8,386 since 2017/8). There have been significant reductions in some key metrics: incidence of Type 2 diabetes; growth rate of acute admissions with diabetes complications (from 8.3% to 4.9%); in-patient diabetes foot admissions (reduction in average annual growth rate from 13.2% to -2.3%); admissions with MI, acute kidney injury and renal failure. Primary care is now mobilised, educated and engaged in improving diabetes care through communication and professional education, and over 1,800 clinicians involved in in-patient care have received the award-winning 10-point training. The team has developed, and is implementing, a unified integrated outcomes-based service specification across NWL, supported by population health dashboards. The ‘Know Diabetes’ service is about to launch, consisting of a website, eLearning platform and patient portal, offering a single point of referral and contact centre plus a personalised, proactive multichannel communication system.
Sustainability and Spread
There was evidence of reduced hospital activity in 2018/19 (compared with annual changes over the last four years) for all complications when combined; there was also evidence of reductions in foot activity, MI and renal failure. In 2019/20 QIPP will continue to monitor the effectiveness of the programme and support cash savings. One main area is to support Type 2 diabetes remission at scale, aiming to support over 6,200 patients to attend remission programmes in 2019/20. Dissemination about the programme has taken place through multiple channels, including talks at Diabetes UK, Diabetes Professional Care (DPC) and a paper in Practical Diabetes.
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