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Diabetes in Scotland. “Is integrated care achievable?”. Lewis Ritchie Andrew Morris 14 th March , 2001. Priority Clinical Issues : NHSiS. Increasing Patient Involvement Health Priorities : heart disease, cancer, mental health, (diabetes) Professional Isolation

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Diabetes

in Scotland

“Is integrated care achievable?”

Lewis Ritchie

Andrew Morris

14th March , 2001


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Priority Clinical Issues : NHSiS

  • Increasing Patient Involvement

  • Health Priorities : heart

    disease, cancer, mental health,

    (diabetes)

  • Professional Isolation

  • Integration of Care

  • Enhance Professional Education

  • Reconfiguration of Services:

    Managed Clinical Networks


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Clinical Governance

  • Setting standards

  • External peer review

  • Reporting findings


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Pressures on the System

  • Limited resource

  • Limited time

  • Fragmentation/inefficiencies

  • Conflict between service delivery & training

  • Increased demands/expectations

  • Increased number of clinical priorities

  • Aging population

  • Low morale


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Teamwork

How do we meet the diabetes challenge?


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Clinical IM&T:

Underpins the solution

  • Patient care

  • Teamwork

  • Clinical networks

  • Audit

  • Governance

  • Research

Communication!


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GP

Lab Data

Screening

Nursing

HospitalCare

Investigations

PAMS

Social

Services

Pharmacy

The Health Care Family


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Nursing

Lab Data

PAMS

GP

Pharmacy

Hospital

Care

Social

Services

Screening

Investigations

Working togetherVital for Seamless Care


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Community Health Number

07 10 64 02 50

Date of Birth

Sex

Check


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Characteristics of Tayside

  • Population 400,000

  • Dundee United 2 Rangers 0

  • Rural and inner city

  • Static population

  • Unique patient identifier


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Community Health Number

07 10 64 02 50

Date of Birth

Sex

Check


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Data Sources

  • Encashed prescriptions

  • Diabetic Clinics

  • Discharge Diagnoses

  • Regional biochemistry

  • Diabetic Eye Van

  • Primary care


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Diabetes in Tayside9003 patients in 1997; prevalence 2.26%

Morris et al, BMJ, 1997


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DARTS and general practices

  • Automated returns for chronic disease management

  • Identification of high risk patients

  • Anonymised audit of monitoring targets

  • “Seamless” diabetes care


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St Vincent Endpoints -Eyes

Percent patients

B’ground Prolif LaserBlind


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St Vincent Cardiovascular

Percent patients

Hypertension IHD MI CABG/PTCA


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DARTS aggregate summary report


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The Core Structure


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Regional Diabetes Managed Clinical Network

TDAG

Specialist Nurses

Training and

education

Network

Development/IT

Clinical

Governance &

guidelines

Acute Trust

Register

SIGN 25

DARTS/MEMO

Steering

Group

LHCC’s/Trusts

THB

Facilitator

Clinical Network

Co-ordinator


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What Are We Achieving?

  • annual audit

  • agreed regional protocols

  • multi-speciality collaboration

  • patient involvement

  • professional education & training

  • quality research programme


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Key aspects of development

  • Guidelines/governance

    (Perth and Kinross LHCC)

  • Clinical effectiveness (Angus/Dundee LHCCs)

  • Pilot IT system (Arbroath LHCC)

  • Educational package - Warwick

  • Electronic Communication


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DARTS 2000 Communications

General Practice

Hospitals / Clinics


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www.diabetes-healthnet.ac.uk


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The DARTS / MEMO Collaboration


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The DARTS / MEMO Collaboration


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Each practice / clinic has it’s own secure home page


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The DARTS / MEMO Collaboration


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The DARTS / MEMO Collaboration


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Improved Clinical Outcomes?

  • On-going evaluation a priority

  • Locality evidence growing


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Clinical Networks

Network Co-ordination

Clinical IM&T

Multi-specialty teamwork

Health Board/Trust/LHCC support


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Clinical Network Development in Tayside

Risk Areas

  • Competition vs Collaboration

  • Personal fiefdoms!

  • Technology and change is a “painful disorder”

  • Underestimating the Commitment!

  • “Not invented here”should not be the excuse to avoid change

Let’s remember - Scotland is a small place!


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Summary

  • Levers in the system

  • We need to work as a team

  • Managed clinical networks work

  • If we can’t do it for diabetes, who can?

  • Will 2001 be the year of delivery?


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Thank you

for

listening!

Comments Please


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Thank you for

listening!


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