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PROGRESS ON COMMISSIONING A DIABETES SERVICE. Developing a Model of Care for Adult Patients with Diabetes January 2009. What do we know about current and future service demands? . Growth in obesity to continue Growth in new diabetics to continue Somerset: 19,200 in 2007 to 28,000 by 2017

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PROGRESS ON COMMISSIONING A DIABETES SERVICE

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PROGRESS ON COMMISSIONING A DIABETES SERVICE

Developing a Model of Care for Adult Patients with Diabetes

January 2009


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What do we know about current and future service demands?

  • Growth in obesity to continue

  • Growth in new diabetics to continue

  • Somerset: 19,200 in 2007 to 28,000 by 2017

  • Sizeable number of undiagnosed diabetics

  • Need to invest in services to meet demand

  • Need to increase emphasis on prevention

  • Need to ensure optimal use is made of specialist services


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What do patients want?

  • Better information at diagnosis

  • Improved access to information

  • More control over their condition

  • Better integration of care

  • More services closer to home

  • Better access to related services (dietetics, podiatry)

  • More focus on prevention


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What do GPs want?

  • To continue to provide best possible services from in-house skills

  • More training for members of primary healthcare team

  • Better access to Dietitians and Podiatrists

  • Better access to Diabetic Nurse Specialists

  • Access to timely advice

  • Optimise diabetes QOF scores

  • To have the option of providing services over and above ‘core’ diabetic care (e.g. insulin initiation)


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What does Somerset PCT want?

  • Ensure new service has the capacity to meet expected demand

  • Improved services for diabetics

  • Equitable access to services

  • Uptake from hard to reach groups

  • Measure improvements in meaningful terms (outcomes based specification)

  • Implement health care record (eventually electronic)

  • Affordable service


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What are the key elements of the new service?

  • Increased availability of structured education (Desmond/Dafne courses)

  • Expansion in capacity of Diabetic Specialist Nurses, Dieticians, Podiatrists

  • DSN run countywide community clinics

  • Clinics to co-locate Dietitians, Podiatrists (Psychologists) according to need


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What are the key elements of the new service? (Continued)

  • DSN service to focus on:

    glycaemic controlinsulin initiations

    complex patientspre-pregnancy advice

    8-8 advice line

  • DSN service to deliver training to primary care teams

  • DSN service to be monitored through specialist supervision

  • Specialist care to focus on patients with complex care needs


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Proposed Model of Care

  • The proposed delivery model is based on levels of care:

    • Level 1 providing core basic care

    • Level 2 an intermediate level of care

    • Level 3 specialist level of care

    • It is proposed to deliver all of Level 1 and Level 2 and as much of Level 3 as possible in the community as close to the patient’s home or work as possible.

    • Level 1 care will normally be delivered at GP practices but with input from pharmacists, local councils, voluntary groups particularly in relation to opportunistic screening.


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Proposed Model of Care (Continued)

  • GP practices may also opt to provide some of intermediate care.

  • A new community based service will be introduced, managed by multidisciplinary teams. This will deliver specified intermediate services and related Level 3 services, as well as training and ongoing support for practices.

  • Hospital care will be focused on the most complex cases with an enhanced level of care for patients admitted with but not because of diabetes.

  • A key theme running through all levels of care will be supporting patients to self manage through structured education programmes and agreement of care management plans.


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Next Steps

January 2009

  • Clinicians finalise Care Pathways

  • Patient involvement – 21 January

  • Information Packs available

    Feb 2009

  • PEC approval of final specification

  • Year of Care Project continues

    April 2009

  • Commission Service – details of provision still to be confirmed.


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Diabetes UK information packs

  • 2000 packs have been purchased from Diabetes UK for issuing to patients when the diagnosis of Type 2 Diabetes has been confirmed in order to provide them with consistent, quality assured information about their condition.


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Year of Care Project

  • Creating integrated care planner

  • Delivering self-care training

  • Results sharing documentation

  • Identifying clinical champions

  • Further details from MaggieAyre@somerset.nhs.uk


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Yeovil area only

Current Community Service

  • GP referrals directly to:

  • Su Down

    Diabetes Nurse Consultant

    su.down@somerset.nhs.uk

    Tel: 01935 848281

    Clinics held in Crewkerne, Wincanton and Yeovil.


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