DIABETES CARE PATHWAY

1. WEST HERTS IiYH SERVICE REDESIGN IMC/LTC WORKSTREAM DIABETES CARE PATHWAY For presentation at clinical reference group September/October DRAFT SUMMARY Version 2

2. Diabetes care pathway Redesign Introduction As part of ‘Investing in Your Health’ the health care system in Bedfordshire and Hertfordshire has committed to reducing the use of major hospital services by delivering more proactive care to people, especially those with Diabetes. Background The incidence of diabetes has been estimated to be approximately 4.5% of the population (including undiagnosed) and is estimated due to age and increasing obesity to increase to 5.5% by 20101. Diabetes has been calculated to account for 5% of al NHS expenditure most of the spend dealing with avoidable diabetic complications. Pathway redesign to promote proactive management and services more appropriate to the needs of these individuals preventing unnecessary complications will be key to delivering ‘Investing in Your Health’ and ‘Commissioning a Patient led NHS’ as well as improving the health and well being of this population. • PBS Diabetes Prevalence model • Williams et al The true Costs of Type 2 diabetes in the UK-Findings from T2ARDIS and CODE-2 UK

3. Objectives of pathway redesign Objectives • Available data of current pathway and comparison to national trends • Current pathway and current gaps in pathway delivery • Evidence for change – (appendix) • Potential future pathway and potential for delivery in out of hospital facilities • The estimated potential of key initiatives to facilitate shifts of care out of hospital • Benefits of new pathway • Cost analysis of new pathway in comparison to current pathway

4. Diabetes Data for West Herts – 2005/06 Inclusive of 2nd,3rd & 4th reasons for admission Outpatient data to be reviewed by C Johnston, Unscheduled care and emergency admission data ??? to review against national figures

5. Estimated prevalence of diabetes Type 1 and 2 across West Herts(York PBS model)

6. Current Pathway • Fragmented services between professional groups – no multidisciplinary team approach • Outpatient secondary care provision instead of a disease management approach • Fragmented services between primary care organisations and acute care • Lack of coordination between professionals and services • Inequity of service provision across local health economy • Lack of education and information resources The following table charts provision of diabetes services across PCTS

7. Summary of potential provision of care for diabetics by provider OUT OF HOSPITAL 2º CARE OUT OF HOSPITAL Public health Outpatients Inpatients Intermediate care Primary Care Community Inpatient care • School • Programmes • Community • diabetes • prevention • & education • generic public health programmes eg smoking cessation • Initial presentation • Diabetic register • Sub groups • Annual review Types1 + 2 • Management of • Type 2 without • Complications • Initial diagnosis • Specialist MDT clinics • for diabetic patients • Management & monitoring of all diabetic • patients on sub groups of register via integrated care plans • Provision of Education programmes for all diabetic patients and support for general practice staff & other care providers to educate patients • Help line & open access for all registered diabetics to MDT • Co-ordination of care of diabetic patients across providers by care co-ordinator • Specialist clinics • or other community disease specific services • Paeds Acute crisis- DKA Infection Hypo-glceamia Acute illnesses Foot ulcers Charcoats Surgical patients Bed based and non bed based intermediate care for : Foot conditions With support from podiatry and specialist nurse for IV antibiotics Hypo-glyceamics With support from podiatry and specialist nurse for IV antibiotics Approximately 85% of register 15-20% of register(& all retinopathy care 35% of register) Care –co-ordination – community matron Discharge facilitation 2-3% register

8. Summary of potential provision of care for diabetics by workforce OUT OF HOSPITAL 2º CARE OUT OF HOSPITAL Public health Outpatients Inpatients Intermediate care Primary Care Community Inpatient care Out reach from community specialist team Voluntary sector Diabetes UK • GP • Practice nurse • Diabetic facilitator • Diabetologist • GPwSI • Speciaist diabetic nurse • Podiatrist • Dietician • Orthotist • Optometrist • Psycologist • Diabetic educator • Voluntary sector • Clinical pharmacology • Obstetrician/midwife • Specialist physicians & surgeons • Specialist • physicians & • Surgeons • In reach from • community • specialist team • IMC medical nursing & therapy teams • In reach from • community • specialist team Care –co-ordination – community matron Hospital discharge team & community team & community matron

9. Functions of Diabetes Multi-disciplinary team • Open access to clinic via helpline to support early management of unscheduled events • Assure provision of integrated care management plans for all diabetes patients • Coordinate care of diabetes patients between public health primary care, acute care • Early assessment of all suspected type 1 diabetes patients and assessment and management of unstable type 2 patients • Education programmes for Type 1 and 2 diabetes • Follow up and co-ordinate care of diabetes patients on discharge

10. Benefits of new patient Journey • Patients have access to services when needed • Increase independence and empowerment • Reduced unscheduled events 10% reduction in A&E • Reduce outpatient attendance within acute care by 100% • attendances and emergency admissions • Improved team working – inter-professional support • and development and patient centred care • Improved quality of life for the diabetes population • Improved demand and capacity management as a result of the provision of more proactive care

11. Estimated population requiring management by a specialist diabetic team based on a population of 150,000 (retinopathy and paediatric care provision is excluded from this model) This is the percentage that proportion overall that would be managed by a specialist team are you all happy with this ratio

12. Cost of service for a population of 150,000 (diabetic population of 4500) estimated diabetic prevalence of 3% with  23 % of diabetic population requiring management beyond general practice.

13. Cost model of Diabetes pathway across West Herts