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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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Presentation Transcript
slide1

Diabetes

in Scotland

“Is integrated care achievable?”

Lewis Ritchie

Andrew Morris

14th March , 2001

priority clinical issues nhsis
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

clinical governance
Clinical Governance
  • Setting standards
  • External peer review
  • Reporting findings
pressures on the system
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
slide6

Clinical IM&T:

Underpins the solution

  • Patient care
  • Teamwork
  • Clinical networks
  • Audit
  • Governance
  • Research

Communication!

slide7

GP

Lab Data

Screening

Nursing

HospitalCare

Investigations

PAMS

Social

Services

Pharmacy

The Health Care Family

slide8

Nursing

Lab Data

PAMS

GP

Pharmacy

Hospital

Care

Social

Services

Screening

Investigations

Working togetherVital for Seamless Care

community health number
Community Health Number

07 10 64 02 50

Date of Birth

Sex

Check

slide11

Characteristics of Tayside

  • Population 400,000
  • Dundee United 2 Rangers 0
  • Rural and inner city
  • Static population
  • Unique patient identifier
community health number12
Community Health Number

07 10 64 02 50

Date of Birth

Sex

Check

data sources
Data Sources
  • Encashed prescriptions
  • Diabetic Clinics
  • Discharge Diagnoses
  • Regional biochemistry
  • Diabetic Eye Van
  • Primary care
slide15

DARTS and general practices

  • Automated returns for chronic disease management
  • Identification of high risk patients
  • Anonymised audit of monitoring targets
  • “Seamless” diabetes care
st vincent endpoints eyes
St Vincent Endpoints -Eyes

Percent patients

B’ground Prolif Laser Blind

slide17

St Vincent Cardiovascular

Percent patients

Hypertension IHD MI CABG/PTCA

slide21

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

what are we achieving
What Are We Achieving?
  • annual audit
  • agreed regional protocols
  • multi-speciality collaboration
  • patient involvement
  • professional education & training
  • quality research programme
key aspects of development
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
slide24

DARTS 2000 Communications

General Practice

Hospitals / Clinics

improved clinical outcomes
Improved Clinical Outcomes?
  • On-going evaluation a priority
  • Locality evidence growing
slide39

Clinical Networks

Network Co-ordination

Clinical IM&T

Multi-specialty teamwork

Health Board/Trust/LHCC support

clinical network development in tayside
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!

summary
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?
slide42

Thank you

for

listening!

Comments Please

slide43

Thank you for

listening!

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