A new look for diabetes services

Involving patients in taking a good hard look at diabetes services in North East Essex helped convince commissioners that change was needed. Feedback suggested that while some had a great experience, that was far from universal.

“There was a lot of variation,” explains public health consultant Jo Broadbent. “There were so many areas where we felt we could make improvements that we decided what we needed was to recommission it as a managed pathway.”

The work began when Dr Broadbent was lead for long term conditions in the former North East Essex Primary Care Trust – she now works for Essex County Council and North East Essex Clinical Commissioning Group. Diabetes was one of three long term conditions targeted for improvement by the PCT (along with stroke and chronic obstructive pulmonary disease), a process that began with setting up patient groups.

“The patient forum was instrumental to the improvement process,” she explains. Patients would talk to each other and find out that their experiences of services could be very different. “They were asking things like ‘why am I going to hospital when other patients aren’t?’. We were also an outlier on diabetic amputations – we needed to reduce variability there too.”

Although the decision to rethink services had been made by the PCT, the transition to CCGs meant that the case had to be made again to a fresh organisation.

Poor benchmarking

But, says Dr Broadbent, the new processes helped with clinical ownership, and the case was convincing. “We had a lot of evidence that some of our outcomes didn’t benchmark well,” she says. “The patient experience feedback showed us that some people were getting a great service, and some weren’t. The case for change was easy to make.”

The CCG decided to adopt a prime contractor model and looked to see if anyone had followed a similar path. “There was a lot of talk about it but we couldn’t find where someone had procured a managed pathway,” she says, adding that the CCG did learn from work done in Bromley on an integrated managed pathway.

When they opened up the process to bidders they were delighted that there was a lot of interest. “We took several bidders through to [invitation to tender] and several were appointable, which was reassuring,” she says.

The CCG chose the Suffolk GP Federation, which had good experience in delivering a range of community services. The contract essentially involves responsibility for primary care services (delivered by GP practices), community and hospital outpatients.

A quarter of the value of the £10m contract (over five years) is tied to achieving upper quartile national performance for HbA1c, cholesterol and annual checks. There is an element of shared risk, Dr Broadbent explains, because the GP practices have to achieve certain standards under a specific enhanced service for diabetes care.

Patient education

Patient education is an important element, she explains, as is primary care development. Feedback from the federation suggests that primary care engagement, upskilling and joint working have been key achievements so far.

“The contract has been in place just over a year and we’ve seen improvements across most of the measures,” she says.

Performance on diabetes foot care has exceeded agreed targets, with, for example, 75 per cent of people with type 1 diabetes having had a foot check in the year to March 2015, compared to 63 per cent the previous year – the service target was 69.4 per cent.

The number of patients with care plans has also beaten targets – almost a quarter (23.8 per cent) now have a care plan (against a target of 17.6 per cent).

Almost all (96 per cent) of the patients with type 2 diabetes had been offered structured education within 24 months of diagnosis and the number of people taking up the offer also increased.

Further audit work is ongoing to test the impact on patient complications.

Although the scheme has won national recognition – including being highly commended in the 2014 HSJ Awards in the procurement category – it is going down well locally too. While 94.5 per cent of patients surveyed say they are satisfied with the overall service, an overwhelming 100 per cent say they would be likely or very likely to recommend it to others.

The CCG is now looking to build on the experience of the diabetes re-procurement in other areas of community health services, including nursing and home care response. “It’s a similar approach but on a bigger scale,” she says. “This really works for patients and for us.”