Welcome to the Brent Intermediate Diabetes Care Services Launch

2. Brent Diabetes Services Dr. Senan Devendra MD MRCP Consultant in Endocrinology & Integrated Diabetes Care Brent tPCT & Central Middlesex Hospital

3. 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

7. Diabetes SPA total referrals per locality (according to GP post code) 20.02.06 – 26.04.06 total = 207 x £241= £50,000

8. 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

9. Brent Diabetes Services Education: MDT approach - patient education - health care professional education Research & Audit

11. Expected Standard of Care& Microalbuminuria Pathway Dr Encarna Fernandez Diabetes GPWSI – Kilburn Locality

13. Weight Management in Diabetes Intermediate Care By Helen Davies & Salma Butt Specialist Diabetes Dietitians

14. 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 Weight gain in adulthood is a major risk factor for type 2 diabetes – in fact most people with Type 2 diabetes are overweight at diagnosis (the average BMI is 28-29). In absolute terms the greatest burden of diabetes and of its cardiovascular complications are with BMI 25-30. Each KG weight lost at 12 months after diagnosis is associated with 3-4 months increased survival in overweight patients with Type 2 diabetes. THIS IS GREATER THAN CAN BE ACHIEVED BY GLUCOSE, LIPID OR BLOOD PRESSURE LOWERING ALONE. Having diabetes means that there are clear health benefits to losing weight and having diabetes makes no difference to the approach; but diabetes must be managed whilst making lifestyle changes I.e. monitoring HBA1c and making necessary adjustments to medications – needs to have a TEAM APPROACH. Weight gain in adulthood is a major risk factor for type 2 diabetes – in fact most people with Type 2 diabetes are overweight at diagnosis (the average BMI is 28-29). In absolute terms the greatest burden of diabetes and of its cardiovascular complications are with BMI 25-30. Each KG weight lost at 12 months after diagnosis is associated with 3-4 months increased survival in overweight patients with Type 2 diabetes. THIS IS GREATER THAN CAN BE ACHIEVED BY GLUCOSE, LIPID OR BLOOD PRESSURE LOWERING ALONE. Having diabetes means that there are clear health benefits to losing weight and having diabetes makes no difference to the approach; but diabetes must be managed whilst making lifestyle changes I.e. monitoring HBA1c and making necessary adjustments to medications – needs to have a TEAM APPROACH.

15. Current services Diabetes education sessions MDT intermediate care clinics Fit for Life programme Obesity clinic at Central Middx So what’s on offer for patients in Brent. MDT clinic – team approach, most effective way to tackle weight management. Specific package of care to be implemented. FFL – group programme. Patient would choose one to one or group. 12 weeks in duration, includes exercise sessions. Diabetes education sessions – introduction to diabetes but mentions weight management and its importance. All patients that will be assessed for weight management should also attend education. Health promotion – Salma to talk more about this later. Obesity clinic at Central Middx – again talk more about this later.So what’s on offer for patients in Brent. MDT clinic – team approach, most effective way to tackle weight management. Specific package of care to be implemented. FFL – group programme. Patient would choose one to one or group. 12 weeks in duration, includes exercise sessions. Diabetes education sessions – introduction to diabetes but mentions weight management and its importance. All patients that will be assessed for weight management should also attend education. Health promotion – Salma to talk more about this later. Obesity clinic at Central Middx – again talk more about this later.

16. MDT intermediate care clinic Initial assessment Readiness to change Brent options Refer to pathway (enclosed in conference pack)

17. Fit for Life 12 week weight management programme Nutrition education + exercise Group support Referral through Diabetes SPA

18. 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 Clinic that will focus on HIGH RISK patients I.e. those patients who are on maximum therapy prior to starting insulin. Also patients who have tried and failed to lose weight, perhaps consider surgery as final approach. Clinic offers weekly support from clinician and Dietitian. Will also be support from DSN. Experienced with use of anti-obesity medications. Long term support and structured approach.Clinic that will focus on HIGH RISK patients I.e. those patients who are on maximum therapy prior to starting insulin. Also patients who have tried and failed to lose weight, perhaps consider surgery as final approach. Clinic offers weekly support from clinician and Dietitian. Will also be support from DSN. Experienced with use of anti-obesity medications. Long term support and structured approach.

20. New package of care for improving Glycaemic control in primary care Nina Patel DSN Brent tPCT

21. AIM To provide focused intensive input to improve HbA1c with a clear supportive plan and exit strategy

22. Referral criteria Patient on maximum doses of oral hypoglycaemic (see protocol for the use of oral hypoglycaemic agents*) HbA1c > 8 % (age < 75) *www.brentpct.nhs.uk

23. 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

24. 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

25. 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.

26. Consultation 3: (4 to 6 weeks post visit 1) Weight check/ WC Blood glucose control BP Injection sites Management of pen device. Hypo’s Consider prandial insulin Titration of insulin doses over telephone with daily or weekly contact. Also consider Orlistat/Sibutramine Weight management clinic Exercise classes Patient support group Expert patient course

27. 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.

28. 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)

30. 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

31. Introduction 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 ?

33. 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 Lifestyle advice +Lifestyle advice +

34. JBS-2 targets for high risk patients Total cholesterol <4 (25% reduction) LDL-cholesterol <2 (30% reduction)

36. 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

37. “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

38. Treatment Pathway for High Risk Group

40.  Diabetes Education Network Dr Camelia Kirollos Associate Specialist Central Middlesex Hospital

41. Brent Diabetes Education Network

42. Diabetes Education Network Professionals’ Education Nurses: Practice nurses, District nurses, Twilight nurses, Residential homes, Nursing Homes Doctors: GPs, GPwSI, Hospital Doctors Health care Assistants

43. Diabetes Education Network Patients’ Education Short courses - 2 days Long courses 6 weeks Tailored Ethnic or Cultural courses Eg. For Pakistani, Gujarati Communities

44. Attendants of diabetes patient education courses between July 2004 and March 2006

45. 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)

46. DAFNE Improvement lasts We now think that the improvement may last even longer. This chart is from Dusseldorf again showing the improvement in both HBA1c and hypos lasts at least 3 years and possibly as long as 6We now think that the improvement may last even longer. This chart is from Dusseldorf again showing the improvement in both HBA1c and hypos lasts at least 3 years and possibly as long as 6

47. 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

48. Consultant led seminars Insulin for life programme (Insulin initiation) MERIT (Insulin initiation) Consultant notes review service (eg. HbA1c >7.5%)

49. 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.

51. 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 (e): ram.dhillon@talk21.com

52. No Mans Land(Locus of Demand & Need for Capacity, Competency & Skills) 2nd Opinion

53. What is Fundamentalfor  Acquisition of Competency & Skills Knowledge & Skills Knowledge & Skills Knowledge & Skills Knowledge & Skills Adequate Training & Accreditation

54. 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 : www.pgdip.com

55. PwSIswith Special Interests ( competent & skilled )Potential effects NSFs Demand Capacity Access Integrate 1*/2* Retention/Recruitment Clinical Pathways Clinical Governance Community Care Cost-Effective Care

57. Questions? gm.e.diabetes.bre-pct@nhs.net www.brentpct.nhs.uk