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Welcome to the Brent Intermediate Diabetes Care Services Launch. 10th May 2006 Clay Oven , Wembley. Brent Diabetes Services. Dr. Senan Devendra MD MRCP Consultant in Endocrinology & Integrated Diabetes Care Brent tPCT & Central Middlesex Hospital. The Team. Claire Lawler

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Welcome to the Brent Intermediate Diabetes Care Services Launch

10th May 2006

Clay Oven , Wembley

brent diabetes services

Brent Diabetes Services

Dr. Senan Devendra MD MRCP

Consultant in Endocrinology & Integrated Diabetes Care

Brent tPCT & Central Middlesex Hospital

the team
The Team
  • Claire Lawler
  • Nina Patel, Julia Anthony & Lucy Ogida (DSN’s)
  • Sala Salih & Camelia Kirollos (Diabetes Edu. Network)
  • Salma Butt, Helen Davies & Farhat Hamid (dietetics)
  • Rakhee, Gaytree & E. Shillingford (podiatry)
  • Leena Sevak & Maggie McClelland (pathway managers)
  • Rowland Hughes (DPAG chair)
  • Silvia Sedeghian & G.Vafidis(retinal screening)
  • Ricky Banarsee & Azeem Majid (Imperial - research)
  • Kirsten Darylmple (Imperial – education faculty)
  • JKC – too many to mention
Diabetes SPA total referrals per locality (according to GP post code)20.02.06 – 26.04.06 total = 207 x £241= £50,000
brent diabetes services8
Brent Diabetes Services
  • Clinical support: MDT approach

- Intermediate care clinics

- Email consultations

- Liaising with District Nurses/out of hours

- Up-skilling Primary Care colleagues

- Telephone support clinics for patients

brent diabetes services9
Brent Diabetes Services
  • Education: MDT approach

- patient education

- health care professional education

  • Research & Audit

100 years of hormones

Photo Courtesy of Prof. G.Williams

Dean of Medicine, Univ. of Bristol

expected standard of care microalbuminuria pathway
Expected Standard of Care& Microalbuminuria Pathway

Dr Encarna Fernandez

Diabetes GPWSI – Kilburn Locality

weight management in diabetes intermediate care

Weight Management in Diabetes Intermediate Care

By Helen Davies & Salma Butt

Specialist Diabetes Dietitians

the business case
The business case !
  • Type 2 DM – overweight at diagnosis
  • Av. BMI = 28-29
  • Relationship with macrovascular disease
  • Weight loss associated with survival
  • Does weight need to be managed “differently” in DM
current services
Current services
  • Diabetes education sessions
  • MDT intermediate care clinics
  • Fit for Life programme
  • Obesity clinic at Central Middx
mdt intermediate care clinic
MDT intermediate care clinic
  • Initial assessment
  • Readiness to change
  • Brent options
  • Refer to pathway

(enclosed in conference pack)

fit for life
Fit for Life
  • 12 week weight management programme
  • Nutrition education + exercise
  • Group support
  • Referral through Diabetes SPA
obesity clinic at cmh
Obesity clinic at CMH
  • Patients with complications/poor control + maximum oral therapy
  • Failed at Intermediate care clinic
  • Intensive weight management advice
  • Long term support if necessary
  • Bariatric surgery
new package of care for improving glycaemic control in primary care

New package of care for improving Glycaemic control in primary care

Nina Patel

DSN Brent tPCT

  • To provide focused intensive input to improve HbA1c with a clear supportive plan and exit strategy
referral criteria
Referral criteria
  • Patient on maximum doses of oral hypoglycaemic

(see protocol for the use of oral hypoglycaemic agents*)

  • HbA1c > 8 % (age < 75)


where will the patient be seen
Where will the patient be seen?

DSN clinic in own locality

  • Kilburn Kilburn Square clinic
  • Wembley WembleyWCHC
  • Willesden Willesden CHC
  • Kingsbury Chalkhill Health Centre
  • Harlesden Monks Park CHC
first review consultation 1
First Review – Consultation 1
  • Patient considered for education session
  • Medication review – address compliance
  • Dietetic assessment – weight management pathway
  • Assessment of motivation, health beliefs, readiness to change
  • Set realistic goals
  • Obtain a contract with agreed roles of DSN and patient (minimum 1.5% HbA1c reduction by 3 months)
  • Start Blood glucose monitoring
  • Insulin discussed or started
consultation 2 2 to 3 wks post visit 1
Consultation 2:(2 to 3 wks post visit 1)
  • Assess blood glucose results
  • If not started, start insulin e.g. once daily long-acting or twice daily mix. Insulin

(this can be done with practice nurse/ district nurse)

  • Given algorithm to follow
  • Address weight gain issue with insulin

Titration of insulin doses over telephone with daily or weekly contact.

consultation 3 4 to 6 weeks post visit 1
Weight check/ WC

Blood glucose control


Injection sites

Management of pen device.


Consider prandial insulin

Titration of insulin doses over telephone with daily or weekly contact.

Also consider


Weight management clinic

Exercise classes

Patient support group

Expert patient course

Consultation 3: (4 to 6 weeks post visit 1)
consultation 4 3 month review
Consultation 4: 3 month review
  • Check HbA1c (1 week before appointment)
  • Further titration of insulin
  • Add pre-meal soluble insulin
  • Check weight gain/WC & dietitian review
  • Titration of insulin doses over telephone with daily or weekly contact.
exit strategy
Exit strategy
  • Hba1c less than 7.5% (or desired goal achieved) return to the care of GP and Practice nurse.
  • Maintain regular contact (telephone of link DSN or Diabetes SPA given)
  • If HbA1c goal not achieved – consider other options (eg. restart package of care, JKC - insulin pump therapy, novel therapeutic agents)

Joint British Societies Guidelines 2 on prevention of Cardiovascular Disease in Clinical Practice (JBS2):implications for Brent

Dr. Joan St John

Gpwsi Diabetes

Wembley Locality

  • How will the new guidelines affect the management of people with diabetes in Brent
  • What are the workforce and cost implications
  • What is the most effective way to implement the new guidelines ?
jbs 2 2005
JBS – 2 2005

High risk patients

  • Established athero-sclerotic disease
  • 1ry prevention CVD risk >20%
  • Diabetics

ALSO elevated risk due to a single risk factor

BP >160/ >100 (or less if target organ damage)

Elevated TC: HDL >6 or FH of hyperlipidaemia

jbs 2 targets for high risk patients
JBS-2 targets for high risk patients

Total cholesterol <4

(25% reduction)

LDL-cholesterol <2

(30% reduction)

next steps
Next Steps
  • What is the most effective way to implement the new guidelines ? In Primary care or Intermediary care
  • Guidelines for Titration of Simvastatin or
  • Trying to treat to target with one drug one visit
highest risk group diabetes one of the following
“Highest” Risk Group ( Diabetes + one of the following)
  • Previous CV event
  • Peripheral Vascular disease
  • Family history of Premature (<60yrs) death from IHD
  • Renal Impairment (eGFR < 60)
  • Micro-albuminuric patients
treatment pathway for high risk group
Treatment Pathway for High Risk Group


Start Simvastatin 20mg Start Atorvastatin 20mg (titrate to 80mg)

to 40mg if needed to achieve target or Rosuvastatin 10mg od


T. Cholesterol = 4

LDL = 2

Law, BMJ 2003

diabetes education network dr camelia kirollos associate specialist central middlesex hospital
Diabetes Education


Dr Camelia Kirollos

Associate Specialist

Central Middlesex Hospital

* Please refer to handout for details

diabetes education network
Diabetes Education Network
  • Professionals’ Education
  • Nurses: Practice nurses, District nurses, Twilight nurses, Residential homes, Nursing Homes
  • Doctors: GPs, GPwSI, Hospital Doctors
  • Health care Assistants
diabetes education network43
Diabetes Education Network
  • Patients’ Education

Short courses - 2 days

Long courses 6 weeks

Tailored Ethnic or Cultural courses

Eg. For Pakistani, Gujarati Communities

patients self management courses
Patients’ self-management courses
  • DAFNE: For Type 1 Diabetes (since 2002)

Alternate Months at JKDC (CMH)

Available soon in intermediate care

  • DESMOND: For newly diagnosed Type 2 Diabetes (NSF requirement)
dafne improvement lasts
DAFNE Improvement lasts




HbA1c (%)



Severe hypoglycemia

per 100 pt y












Years of follow-up

certificate in diabetes care warwick courses
Certificate in Diabetes Care: Warwick Courses
  • Warwick Diabetes care
    • Run twice a year: February and September
  • Includes 4 units (Each is a whole day)
      • Understanding Diabetes
      • Therapeutic Options
      • Preventing & Managing Complications
      • Life Times
consultant led seminars
Consultant led seminars
  • Insulin for life programme (Insulin initiation)
  • MERIT (Insulin initiation)
  • Consultant notes review service

(eg. HbA1c >7.5%)

educational needs
Educational Needs
  • The network needs to extend and invite the front line workers:
    • Eg: Health care assistants
    • Twilight nurses
    • Pharmacist in the community and hospitals
    • Local initiatives for day release education.
    • Courses for Hospital staff.
    • Junior Doctors programmed trained.
competency skills a mandatory requirement

Competency & Skills“A Mandatory Requirement ”

Ram Dhillon FRCS

Consultant Surgeon, Northwick Park Hospital, Harrow

Hon. Professor, Middlesex University, London

National Clinical Lead, Elective Care Team

(m): 07 958 450 544


no mans land locus of demand need for capacity competency skills
2nd OpinionNo Mans Land(Locus of Demand & Need for Capacity, Competency & Skills)

No Mans Land

Intermediate Tier Level Care

Home to: (PwSIs) GPwSIs, NwSIs, AHPwSIs

what is fundamental for acquisition of competency skills
What is Fundamentalfor Acquisition of Competency & Skills
  • Knowledge & Skills
  • Knowledge & Skills
  • Knowledge & Skills
  • Knowledge & Skills

Adequate Training & Accreditation


Clinical activity *

Local mentoring *

Directed learning *







Middlesex University, London

Royal College of General Practitioners (RCGP)

Clinical Case Studies *

Seminars #

(lectures, practical skills)



A Model for Competency/Skills Training & Accreditation in Respiratory Medicine for Primary Care ( Dr Vincent Mak & Prof. Ram Dhillon)
  • NB. Further details on Postgraduate Training for Special Interests :





pwsis with special interests competent skilled potential effects




Integrate 1*/2*


Clinical Pathways

Clinical Governance

Community Care

Cost-Effective Care

PwSIswithSpecial Interests ( competent & skilled)Potential effects