Collaborate and integrate to improve diabetes care

Diabetes is a serious condition. Treating its complications – blindness, amputation and stroke – accounts for the bulk of the £10bn the NHS spends annually on the condition. And the number of people with diabetes is increasing at an alarming rate.

With these worrying facts in mind, how should health leaders and commissioners best support people with diabetes, who often fall through the gaps between different NHS care settings?

‘They often get stuck in one part of the system’

Those with type 1 are mainly looked after in specialist care and people with type 2 receive care based in GP practices. But the rigid divide between primary and secondary care means they often get “stuck” in one part of the system.

If they have foot problems, they may need to see a community podiatrist. Stubbornly high blood glucose levels can benefit from the expertise of a specialist diabetologist. Some people are seen in hospital unnecessarily.

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‘Artificial boundaries’

As the NHS Five Year Forward View says, we need to break out of the “artificial boundaries between hospitals and primary care, between health and social care, between generalists and specialists – all of which get in the way of care that is genuinely coordinated around what people need and want”.

No one has all the answers, but the five health economies explored in the report Improving the Delivery of Adult Diabetes Care through Integration help show how to do just that.

‘We need to break out of the artificial boundaries between hospitals and primary care’

The five elements that enable integrated care have been identified by the diabetes community as care planning, integrated IT, clinical engagement, leadership, and aligned finances and responsibility.

Alongside Derby, Leicester, north west London and Portsmouth, the NHS in Wolverhampton has made striking progress for people with diabetes in all of these areas. It has worked as a whole, whether it is the trust that delivers hospital and community care, or the clinical commissioning group and the primary care trust before it.

Clinical engagement and leadership

To maximise the chances of success, all relevant stakeholders should be engaged collaboratively in discussion about how to maintain and improve standards of diabetes care.

For example, Wolverhampton CCG has an established diabetes network, which consists of people with diabetes, clinicians and commissioners, who meet to ensure the service is meeting the needs of people with diabetes. In addition, the CCG has diabetes groups for specific work streams, including user involvement, care pathways, education and training.

‘Some areas have been able to overcome the rigid financial divide between primary, community and specialist care’  

Wolverhampton and the other areas discussed in the report looked at see the role of specialists in a relatively new way. Individual patient care remains important, but their role is increasingly about leadership to help develop a diabetes service across an area, while using their expertise to help train and work with other healthcare professionals.

Some areas have been able to overcome the rigid financial divide between primary, community and specialist care by pooling budgets or having clear protocols for when people with diabetes are treated by a particular part of the system.

In the case of Wolverhampton, the single trust for hospital and community services reduces boundaries between specialists and community based teams. Having a single organisation immediately means there are lower financial barriers between hospital and community based teams. Although Wolverhampton has not introduced a single budget, it has made sure that the way services are financed supports, rather than restricts, the delivery of care.

The IT system allows specialists to identify patients who need specialist care without needing a referral from primary care – a so-called “no referral, referral”. This stops money getting in the way of people being seen in the right place.

‘There has been a radical reduction in the number of people being seen in specialist care’

To support the increased delivery of diabetes care in primary care, specialists have a key role in contributing to education and training for primary care staff. This is supported by working in a collaborative model, and more formally through educational events and local enhanced service training events.

The diabetes specialist nurses also provide training and support for care home workers. In addition, GPs are incentivised to deliver care planning, working in a multidisciplinary team structure with specialists.

This has led to a radical reduction in the number of people being seen in specialist care.

Care planning

In collaborative care planning, clinicians and people with diabetes work together to agree goals and identify needs personal to the patient. To be effective, it must not be a tick-box exercise. It is about giving the person with diabetes the opportunity to work together with their healthcare team to play a bigger role in deciding their care.

Wolverhampton is facilitating care planning by mailing the patients an individualised structured diabetes report containing their outcomes of nine care processes of diabetes, with a clinical comment to guide them to interpret these outcomes, prior to their annual review appointment.

This report encourages patients to identify and prioritise their key concerns around their own care. This is discussed at their consultation and an action plan designed in collaboration with the clinician informs their ongoing care. There are also local incentives for training and delivery of care planning.

‘Patients flagged as red or amber get treatment at an earlier point and in the right setting’

Integrated IT systems enable GPs and specialists in Wolverhampton to see the same records and identify patients. Using IT systems this way means that referrals can be triaged and reduces duplication. A central portal extracts data from 49 general practices and feeds it into the trust’s system.

A locally developed formula groups patients according to risk. Patients are rated against the nine diabetes care processes, and based on their risk status for micro and macro vascular complications of diabetes - they are flagged as red, amber or green.

The results are then used to decide where care should be provided to that person along the pathway and what should be done to improve their care. The system used in Wolverhampton covers all people with diabetes, unless they have opted out of the Summary Care Record or care.data.

Using data in this way allows clinicians to track patients through the system. Both GPs and specialists can see the patient’s records and see what checks have been completed. Patients flagged as red or amber get treatment at an earlier point and in the right setting. This prevents delays in referral so that more severe problems can be avoided and costly emergency admissions are reduced.

Board oversight

Wolverhampton CCG has a diabetes programme board to oversee the work of the diabetes network to drive service improvements. It includes representatives from across the service.

The achievements of Wolverhampton have been hard won and it has had to continue to fight in order to sustain them. Knitting services together is painstaking and often slow work, and until recently, the CCG has often had to swim against the tide of national policy. Many diabetes and other clinical networks have struggled to keep going as funding is withdrawn.

‘Healthcare providers are not behaving as profit makers for their particular organisation’

Fear of competition rules, that are at best translucent, makes commissioners fearful of collaborating with their providers as providers maximise income through payment by results.

But in Wolverhampton, payment by results was replaced by an annual contract with a service level agreement around the core needs of integrated co-working. This disincentivises “keeping hold” of patients in the wrong place. Healthcare providers are not behaving as profit makers for their particular organisation. Instead they are partners for the whole NHS.

The lessons learned from Wolverhampton’s successes fit with the new models of care set out in the forward view. We look forward to more people with diabetes benefiting from a more integrated service.

Robin Hewings is head of policy and Barbara Young is chief executive at Diabetes UK