Community Diabetes Carethe hospital view

Dr Prakash Abraham

• How many practices here?

• How many run diabetes clinics?

• What proportion of patients with diabetes come there?

• What are the barriers for taking this on?

Projected Prevalence of Diabetes Mellitus in UK

2001 2010 2030

1.5m

3.0m

6.0m

Grampian Prevalance

• Approaching 4%

• Over 19,500 patients with diabetes (April 2006)

• 12000 in April 2002

• 10,000 attendances at diabetes clinic

Need for integrated care

• Two 30 minute review appointments for 19,500 patients per year. 19,500hours

• 44 weeks work/year: 444 hours per week• Each clinic ~4 hours: 110 clinics a week

supervised by 3 WTE consultant diabetologists (Associate Specialists/Clinical assistants/SPRs).

• 10 clinics per week by permanent staff• ~10 Trainee run clinics

Treatment Distributions

Insulin On Insulin 694 23Not on Insulin 2157 77

Type Type I 427 15Type II - Insulin 282 10Type II - Tablets 815 22Type II - Diet 803 29Type II - Tablets & Diet 520 25

Over 75% not on insulin Initial & realistic target for transfer of care

Diabetic Population: Banff & Buchan

• 1999 1678

–1.9% of population

• 2005 2876–3.6% of population

Place of Care

Practice Only Care

34

5565

76

0

10

20

30

40

50

60

70

80

%

2001 2003 2004 2005

Place of Care

Hospital Only Care

30

24

18

11

0

10

20

30

40

%

2001 2003 2004 2005

Care Parameters Improved

8.37.6

9399

47

62

9598

70

89

0

10

20

30

40

50

60

70

80

90

100

percent

HbA1c HbCheck BP<140/80

BP check PN Foot

2001

2005

Patients and Staff FeedbackWhat are the benefits of being seen at your Practice?

Total %Convenience 156 89Accessibility 90 51Continuity 77 44Familiarity 112 64Other 5 3

Total %1 4 32 73 493 18 124 46 31More than 4 7 5

How often do you attend your Practice for Diabetic Care in one year?

Which professionals did you see at your diabetic review today?

Total %Practice Nurse 152 88Practice Nurse and GP 14 8GP 1 1Other 5 3

Total %Yes 148 87No 22 13

Did you attend your Practice to have bloods taken before today’s diabetes review?

With all this patient exchange what does the hospital doctor

do?

What does the hospital Dr do?

• Golf• Hill walking• But still

– about 10000 patients attending annually– More complex patients (higher proportion of

the 25% that need more time)– To see with same time as in practice clinics– 28 clinics per week (still running at > twice the

capacity)

Woolmanhill attendances

0

2000

4000

6000

8000

10000

12000

14000

16000

1999 2000 2001 2002 2003 2004

New

Return

What does the hospital Dr do?

• Release of hospital resources to focus on complicated cases

• Develop services– Adolescent care– Pregnancy care– Foot/Renal– Insulin Pump

• Guidelines & Protocol development

• Teaching/Training/Research

Integrated care: Building blocks 1

• Enthusiastic team• Multidisciplinary leadership

– GP– DSN– Dietitian– Podiatry– Patient– Management Representative– Secondary care link

Building blocks 2

• Agreed Criteria• Agreed standards• Empowerment: Staff/Patients• IT Support/Audit• Education at all levels

– GPs: Lilly course– All(Warwick, Shipley, Insulin for life)– Ongoing education/ Courses /Conferences /

Network days

Incentives for transfer

• Better patient care

• Satisfied patient and staff

• Easier access & better service for the 25% who need more input

• Higher GP contract Quality points

• Clinical Accord

GP contract

GP Contract 2004/5~90/99 Points (including

all 56 previous points)LHCC AVERAGES - Q & O FRAMEWORK

Diabetes Q & O Framework

1 100% 10 84%

2 94% 11 97%

3 98% 12 62%

4 79% 13 77%

5 98% 14 77%

6 54% 15 51%

7 85% 16 88%

8 82% 17 50%

9 84% 18 74%

Wishlist

• Dedicated time for– Telephone session with practices– Teleconferencing

• Practice education visits

• Redesign of secondary care to deliver better care of diabetes complications

Primary & secondary care work in partnership with the

patient at the centre