Welcome to the Brent Intermediate Diabetes Care Services Launch

1. Welcome to the Brent Intermediate Diabetes Care Services Launch 10th May 2006 Clay Oven , Wembley

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

4. www.brentpct.nhs.uk

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

10. 100 years of hormones Photo Courtesy of Prof. G.Williams Dean of Medicine, Univ. of Bristol

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

15. Current services • Diabetes education sessions • MDT intermediate care clinics • Fit for Life programme • Obesity clinic at Central Middx

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

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. 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 Consultation 3: (4 to 6 weeks post visit 1)

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

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 CHOLESTEROL < 5.5 OR LDL < 3.8 CHOLESTEROL > 5.5 OR LDL >3.8 Start Simvastatin 20mg Start Atorvastatin 20mg (titrate to 80mg) to 40mg if needed to achieve target or Rosuvastatin 10mg od Target: T. Cholesterol = 4 LDL = 2 Law, BMJ 2003

39. Education

40. Diabetes Education Network Dr Camelia Kirollos Associate Specialist Central Middlesex Hospital * Please refer to handout for details

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 Total = 550

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 30 9 25 HbA1c (%) 20 8 Severe hypoglycemia per 100 pt y 15 10 7 5 6 0 0 1 2 3 6 Years of follow-up

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.