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“Is integrated care achievable?”

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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“Is integrated care achievable?”

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  1. Diabetes in Scotland “Is integrated care achievable?” Lewis Ritchie Andrew Morris 14th March , 2001

  2. 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

  3. Clinical Governance • Setting standards • External peer review • Reporting findings

  4. 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

  5. Teamwork How do we meet the diabetes challenge?

  6. Clinical IM&T: Underpins the solution • Patient care • Teamwork • Clinical networks • Audit • Governance • Research Communication!

  7. GP Lab Data Screening Nursing HospitalCare Investigations PAMS Social Services Pharmacy The Health Care Family

  8. Nursing Lab Data PAMS GP Pharmacy Hospital Care Social Services Screening Investigations Working togetherVital for Seamless Care

  9. Community Health Number 07 10 64 02 50 Date of Birth Sex Check

  10. Characteristics of Tayside • Population 400,000 • Dundee United 2 Rangers 0 • Rural and inner city • Static population • Unique patient identifier

  11. Community Health Number 07 10 64 02 50 Date of Birth Sex Check

  12. Data Sources • Encashed prescriptions • Diabetic Clinics • Discharge Diagnoses • Regional biochemistry • Diabetic Eye Van • Primary care

  13. Diabetes in Tayside9003 patients in 1997; prevalence 2.26% Morris et al, BMJ, 1997

  14. DARTS and general practices • Automated returns for chronic disease management • Identification of high risk patients • Anonymised audit of monitoring targets • “Seamless” diabetes care

  15. St Vincent Endpoints -Eyes Percent patients B’ground Prolif Laser Blind

  16. St Vincent Cardiovascular Percent patients Hypertension IHD MI CABG/PTCA

  17. DARTS aggregate summary report

  18. The Core Structure

  19. 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

  20. What Are We Achieving? • annual audit • agreed regional protocols • multi-speciality collaboration • patient involvement • professional education & training • quality research programme

  21. 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

  22. DARTS 2000 Communications General Practice Hospitals / Clinics

  23. www.diabetes-healthnet.ac.uk

  24. The DARTS / MEMO Collaboration

  25. The DARTS / MEMO Collaboration

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

  27. The DARTS / MEMO Collaboration

  28. The DARTS / MEMO Collaboration

  29. Improved Clinical Outcomes? • On-going evaluation a priority • Locality evidence growing

  30. Clinical Networks Network Co-ordination Clinical IM&T Multi-specialty teamwork Health Board/Trust/LHCC support

  31. 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!

  32. 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?

  33. Thank you for listening! Comments Please

  34. Thank you for listening!

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