Lothian Diabetes Managed Clinical Network Nicola Zammitt Secondary care clinical lead MCN CD ECED

1. Lothian Diabetes Managed Clinical Network Nicola Zammitt Secondary care clinical lead MCN CD ECED MCN meeting 24/11/16

2. Outline Context Diabetes Improvement Plan Quarterly reporting Refreshed MCN Staff Subgroups/workstreams Meetings Recent challenges T2D LES

3. Diabetes Improvement Plan 2014: Context In last 10 yrs, 1o care contacts for diabetes risen by 25%. Diabetes: 10% of total heath resource expenditure in UK. NHS Scotland Quality Strategy: Put people at the heart of everything NHS does Provide best possible care Improvement in quality of care involves all staff/levels/roles Route map to the 2020 Vision for health and Social Care: Builds on quality strategy Aim for safe, effective and person-centred care. Focus on 12 priority areas of action Diabetes improvement plan priorities are anchored to those of the route map

4. 2020 Vision for Health and Social Care

5. Diabetes Improvement Plan (2014): 8 priorities

6. Diabetes Improvement Plan: 8 priorities

7. Diabetes Improvement Plan: 12 measures 12 Initial measures • % people with DM who receive all 9 key indicator measurements: • Weight/BMI • Urine albumin creatinine ratio • Serum creatinine • BP • HbA1c • Cholesterol • Retinopathy screening • Foot risk stratification • Smoking status

8. National Diabetes Improvement Plan 2014 12 Initial measures • J • % persons with an HbA1c <58mmol/mol at 1 year post diagnosis • % persons with an HbA1c <58 mmol/mol and >75 mmol/mol • % current smokers • % people aged 50-80 with total chol <5mmol/l AND SBP <140 mmHg • % of new foot ulcers • % of eligible people who got retinopathy screening in last 15 months • % of people with diabetes with end stage renal disease or on dialysis • % people on insulin pumps • % people with BMI ≥ 30 who have lost ≥ 5% body weight in last year • % persons who have attended structured education • % disengaged from care (no HbA1c or retinal screening in last 15/12)

9. Quarterly reporting • From Jan 2016: NHS Boards (through MCNs) provide quarterly report outlining progress against the 12 diabetes quality measures. Section 1 Baseline and Self-Assessment • Use RAG rating to indicate baseline performance for the start of quarter 1 • Self-assessment: consider where focussed action is needed, where current activity will support continued improvement or where no action is required. • Section 1 only completed once at start of reporting year. • Overview and some examples:

10. 1. % people with DM who get 9 key measurements • Recording of smoking status is done particularly badly • SCI only “counts” smoking status recorded within last 15 months • Discussion with public health: ? Change request in to trak Similar to Scottish average

11. 1. % people with DM who get 9 key measurements • Urine ACR and foot risk scores also done badly • Recent focus on 9 key measurements at FM questions • SG considers <80% to be “low”: all require local attention. • Foot screening for adults with type 1 diabetes needs early attention, particularly as these patients should be attending hospital • ? disengaged from other follow-up • <5% Lothian pts disengaged (no HbA1c, no DRS in 15/12)

12. 2. % with HbA1c <58mmol/l 1 yr post Dx • Above Scottish average for type 1’s over 18 (59.1% Lothian vs 49%) • Similar to Scottish average for adult type 2’s (70.9% Lothian vs 71%)

13. Measures 5-9

14. Measures 10-12 • How do we get input from subgroups for quarterly reports? • Timelines are tight • 4 weeks from data available to sending in and board sign-off • How do we feedback info from quarterly reports to clusters/IJBs?

15. Refreshed MCN

16. Refreshed MCN • Clinical lead role shared 1o/2o care (David Jolliffe, Nicola Zammitt) • 2o care clinical lead is also Diabetes CD • New strategic programme manager (Paul Currie → Alyson Cumming) • New MCN coordinator (Bonnie Thomson → Marie McCallum) • HSCPS – IJBs. • LTCs – House of Care, multimorbidity hubs, cDSNs • New public health liaison • Joy Tomlinson → Sarah Wild. Duncan McCormick to lead DRS • New sub-groups aligned to improvement plan • Time is precious. Need room for new players. • Other autonomous groups link to MCN but not formal sub-groups. SLWGs as necessary • Leaner MCN. Meet quarterly.

17. Refreshed MCN • New sub-groups aligned to improvement plan • Prevention & early detection (plus public health and ? Prescribing) • T1DM • Innovation • In patient diabetes • Education (improving info and supporting/developing staff) • Feet • Threads run thro all groups: Person-centred care, equality of access.

18. Refreshed MCN

19. Background to LES 2012 Diabetes MCN reviewed T2 pathway Pathway presented to LMC: T2 LES to support pathway 2015-16: 1o care investment £1M (non recurring) to support key strategic priorities incl LES. Approved by NHSL Board. From July 2015: LES funding to GPs to:- Assess and manage new onset patients Help reflect the rise in prevalence and complexity 118/125 practices signed up (95%) engagement fee £300 per practice - £35,400 Practices paid £120 per newly diagnosed patient managed Total cost of LES for 9 months - £229,320

20. LES going forward 31/3/16: non-extension of LES funding After extensive discussions, decision on 14/6/16 to reinstate. Risk sharing approach with IJBs: £220k for rest of financial year Challenge to identify future funds(?£5M for 1o care over 5 years) CMT agreed on 14/11/16 to support LES but IJBs to discuss funding. LES Service outcomes: Named practice lead (GP or Practice nurse) is required to: 1. Keep up to date with current MCN and LJF recommendations on diabetes care, incl indications for referral. 2. Liaise with the Community Diabetes Specialist Nurses (DSN). 3. Ensure that relevant practice staff remain abreast of service developments and referral pathways (incl annual educational update)

21. LES: what does it cover? Work included in LES (£120 per new patient): Correct coding at diagnosis: populates SCI Diabetes In house education on diet and lifestyle (GP, nurse, pharmacist, AHP) Refer to DESMOND or other suitable structured education CV risk score Foot assessment +/- referral Review of all the standard diabetes QoFindicators Work of initial assessment Identify complications (retinopathy screening automatically triggered) Initiate diet and medical therapy +/- referral Establish FU in line with guidelines and MCN recommendations LES needs refreshing (QOF removed, new T2 Dxpathway – HbA1c). Opportunity to build quality into refresh Eg aim HbA1c<58mmol/mol at 1yr post-Dx (measure 2 on improvement plan)