Coin Street Conference Centre 5 th March 2015 Date Wifi Network - - PowerPoint PPT Presentation

London Diabetes Strategic Clinical Network Date

London Foot Care Network

Coin Street Conference Centre 5th March 2015

Wifi Network name: CSNC1 Password: Event293

Agenda for the Day

Time Item Speaker 8.30am Registration and Coffee 9.15am Chairs’ Welcome  Outline for day  Update on work of the London Footcare Network Ms Stella Vig Vascular and General Surgeon, Croydon Hospital Richard Leigh Head of Podiatry, Royal Free Hospital Session 1- Commissioning for Excellence 10.00am Presentation Renal and Footcare Services Working Together Dr Neil Ashman, Renal Consultant, Barts and the Royal London Hospital 10.15am Presentation Update on Vascular Services in London Mr Obi Agu Vascular Surgeon, University College Hospital 10.30am Presentation Commissioning Diabetic Footcare Services Lesley Roberts Programme Lead, Camden Diabetes Integrated Practice Unit 10.30am Panel question and answer session 11.00am Tea and coffee 11.30am Participant Workshop Developing a Footcare Service Specification 12.30pm Lunch

Agenda for the day cont…

Session 2 – Challenges and Opportunities for Excellence 1.30pm Presentation Diabetes in London Dr Stephen Thomas Chair, Diabetes Strategic Clinical Network 1.45pm Presentation Audit of Local Footcare Services in London Richard Leigh Head of Podiatry, Royal Free Hospital 2.15pm Presentation National Diabetes Footcare Audit Professor William Jeffcoate Steering Group Chair, National Diabetes Footcare Audit 2.30pm Participant Workshop Setting cluster priorities Session 3 – Forward Planning 3.30pm Presentation Feedback on the Footcare Service Specification Ms Stella Vig Vascular and General Surgeon, Croydon Hospital Richard Leigh Head of Podiatry, Royal Free Hospital 4.00pm Presentation Forward Planning and next meeting Ms Stella Vig Vascular and General Surgeon, Croydon Hospital Richard Leigh Head of Podiatry, Royal Free Hospital 4.30pm Close

Chairs Welcome

Chairs’ Welcome

Ms Stella Vig & Richard Leigh

Session 1 - Commissioning for Excellence

Renal and Footcare Services Working Together

Dr Neil Ashman

Renal and Footcare Services Working Together Neil Ashman CD, London Renal Network

London Renal Network 2015 Priorities

• Understand & reduce variation
• Improve AKI outcomes
• Improve shared decision making, patient autonomy & experience

Work closely with Diabetes Network to improve ‘small vessel’ disease outcomes Work with CV & Stroke Networks to improve case-finding & secondary prevention Understanding & reducing variation project aims:

• 1. To apply community-based existing experience & CKD tools across London
• Integrated single care pathway
• eGFR reporting using CCG-based IT
• (Virtual) cluster-based MDT management decision-making
• 2. Earlier identification of at-risk rapid progression CKD to prevent ESRD
• Joint working with Diabetes Network
• Intervene and prevent other co-morbidities through ‘at-risk’ kidney patients

• 1. What can you as a foot care community do to help people with kidney failure?
• 2. What can we as a kidney community do to help with foot care for people with diabetes?

100 amputations/week in England, at 0.25/100 pat years (23-fold non- diabetics) 15/week in London?

% OR Prevalent foot ulcer 21% 5.1 Prior amputation 15% 2.6 Neuropathy 79% 2 Routine podiatry clinic 44% 0.3 Daily foot inspection 29% 0.2

Consistent message across other (small) studies – major increase in ulceration, amputation Dialysis couches, haemodynamic shifts, microcirculatory impairment 59% 2-yr mortality after amputation on dialysis HD amputations at 2/100 pat years 2/week in London?

5,946 adults treated for ESRD by dialysis in London Growth ranges from 3.8 – 6.8% over 5 years

• 1. What can you as a foot care community do to help people with kidney failure?

Three times a week, for four hours 156 hospital visits per year Teach us to do foot care

• Foot care checklist?
• Foot care link nurse?
• On-site podiatry clinics

Put this into Commissioning as a quality marker

London Renal Network Proposal, priority 1: Understand & reduce variation Apply community-based existing experience & CKD tools across London to identify at risk people with diabetes with rapid eGFR decline

• Five-year plan
• Cluster-based, risk-stratified, joint primary/secondary integrated care teams
• Third sector involvement, personalise care where possible
• ? Target diabetes as our population health emergency?

Outcomes – measurables TBC as a joint project with Diabetes Network:

• Reduce complications of microvascular disease
• Integrated heart failure case finding & management
• Integrated retinal screening and intervention (Steve Thomas, St Thomas’s)
• Improve secondary prevention
• AF identification and anticoagulation
• Peripheral vascular disease

Proposed state 2015/16

Borough-based, virtual CKD Hub Nephrology, GIPSI, nursing, CEG All referrals & advice done in EMIS. Able to link to Trust software. Proforma EMIS template (Clinical Effectiveness Group) Patient demographics Variables to include interval eGFR, uPCR, dipstix, BP & DM, diabetic control, medication GP-triggered ‘other’ referral

• utside CKDG

GP-triggered CKD stage- based referral At risk patients > 10 ml/min/yr automated referral FA at CKD Clinic Borough-based Investigate, diagnose, treat, communicate Clinical advice Discharge with forward

• plan. Offer annual e-

review? Clinical advice Discharge with forward

• plan. Offer annual e-

review? Lifelong FUP Other C2C referral CEG-defined clear & pragmatic guidelines

>75 yrs v < 75 yrs Stage I – II CKD Audit of referral practices Education package

Kidney Institute

This is just not a predictor of renal outcome It is a predictor of diabetes outcomes as well

• Sight & retinopathy
• Neuropathy
• Foot care & ulcer risk

How do we use community-based Renal Clinics & surveillance to improve diabetes care? Most at-risk people with nephropathy seen in 1-stops to include:

• Foot care checklists for every diabetic patient
• Record risks, document short foot examination
• Podiatry
• As ever, better diabetic control
• 2. What can we as a kidney community do to help with

foot care for people with diabetes?

An opportunity through Networks to define best practice

• Who is doing foot care well for patients with nephropathy?
• How do we get the message out?

We are waiting for events in at-risk groups Do we need a standardised PIL for dialysis patients?

Session 1 - Commissioning for Excellence

Update on Vascular Services In London

Mr Obi Agu

London Cardiac and Vascular Strategic Clinical Network Date

Update on vascular services Mr Obi Agu

Vascular Surgeon, Royal Free London Trust Chair, London Vascular Advisory Group

London Cardiac and Vascular Strategic Clinical Network Date

• The prevalence of PVD in the UK population over 60 is

20% (2.3 million)

• Of these, 25% claudicate (500-600,000)
• 20% of these will develop critical limb ischaemia (115,000)
• 11,500 will undergo amputation annually with 12.4%

mortality

• (HSE 2010-13)

Improving vascular services in London

• A wide range of key reports and recommendations have sought to improve the organisation and

delivery of acute vascular services in the UK including:

• Vascular Society (VSGBI) Provision of Vascular Service
• Case for Change 2009
• All Party Parliamentary Group for Vascular Disease
• NICE
• NCEPOD/VSGBI ‘Lower Limb Amputation: Working together’ Nov 2014
• Recommendations focus on improving outcomes and quality of care through:
• Improved early detection and screening
• Better management and secondary prevention
• Integration of care and use of MDTs
• Improve quality and efficiency through centralisation of services and expertise
• Focus on outcomes

London 07/08 - 20 hospitals performing LL arterial bypass

London 2007/08: 25 hospitals performing LL angioplasties

‘Our primary objective is to provide ALL vascular patients with the lowest possible elective and emergency morbidity and mortality rates in the world. To achieve this we will need to modernise

• ur service and deliver world class care

from a smaller number of higher volume hospital sites

Vascular Society – Provision of Services 2012 Recommendations

• Revised to reflect the changes in service provision which accompany the specialty

status of services and reflects a multidisciplinary service with vascular patients at its centre

• Key recommendations focus on provision of timely and appropriate care and

include:

• All patients with disorders of arteries, veins and lymphatics should receive care

from vascular specialist teams

• Stop vascular interventions by general surgeons and improve and increase use of

endovascular procedures

• 24/7 access to specialist vascular team for both elective and emergency care
• Emergency patients should receive rapid treatment from a vascular specialist

team and may need to travel beyond their local hospital to receive high quality care

• A designated site for arterial interventions providing 24/7 on site care is essential

and should form centre of a clinical network

• Arterial centres should provide support and outreach to non-arterial centres within

their network.

NICE Guidance – Lower limb PAD

• NICE guidance for Lower Limb Peripheral Arterial Disease was published in August 2012
• Key priorities for implementation:
• Improving information for patients and helping them to understand the progression of the

disease

• Offering secondary prevention of CVD in people with PAD
• Smoking cessation
• Diet, weight management and exercise
• Lipid, diabetes and high blood pressure management
• Diagnosis
• Assess for presence of PAD if symptomatic, have diabetes, are having an intervention on leg
• Assess and examine
• Measure ankle brachial pressure
• Imaging for revascularisation following duplex ultrasound
• Management of intermittent claudication
• Management of critical limb ischaemia
• Assessed through MDT
• Amputation as last resort

The All Party Parliamentary Group on Vascular Disease

• Report in response to the Department of Health’s Cardiovascular Disease Outcomes Strategy
• Contains key recommendations that cover prevention, diagnosis and treatment:
• Prevention
• Improve uptake of NHS AAA Screening Programme
• Improve reporting and uptake of health checks
• Improve use of vascular care plans
• Awareness campaigns and early intervention, sharing best practice
• Diagnosis
• Improve quality and involvement of primary care in diagnosis of PAD
• Improve diagnosis and treatment of diabetes
• Treatment
• Improve use of MDT in vascular networks
• Improve and increase provisions of nurse led foot care protection teams in the community
• Publish amputation rates and outcomes for transparency
• Establish vascular centres of excellence that can provide 24/7 care

Amputation should be considered a failure

Clear Pathway for all patients at risk of PVD and diabetic foot Modern technology to link centres to optimise local delivery and avoid unnecessary travelling Key recommendations March 2014

MDT for all PVD and DF patients Balance centralisation for complex with need to maintain equity of patient access for PVD Pathway coordinators and named contact person 24/7 Sub-24 hour referral policy for CLI to MDT QOF for referral for preventative podiatry and education

VSGBI Provision of Services 2014 – Non-Arterial Centres Recommendations

• Minimum of 2 surgeons, increasing according to need and size of unit
• Outpatient clinics will be main components of the service at NA sites
• The role of Vascular Specialist Nurses will become increasingly important,

proactive and vital clinical link for patient care within the network

• Interventional radiology should continue at NA centres to improve capacity

across the network

• Suggested timelines for less urgent cases treated at the NA centres are:
• NA diabetic foot team assessment within 24 hours (NICE guidance)
• Vascular input and imaging within 48 hours (72 hours over weekends)
• NA centre Endovascular Revascularisation within 10 days.
• Repatriation to and from arterial centres will be key

Vascular Society – Provision of Services 2014 Recommendations cont…

• The recommendations also include service provision for the following conditions:
• Diabetic foot service
• It is vital that diabetic foot care in the vascular network is organised to enable equal access

to vascular expertise for the diabetic patient at both the arterial and non-arterial centres.

• When assessment by the NA centre diabetic foot team makes a diagnosis of acute infection,

without significant ischaemia, and surgical intervention to drain and debride the foot is necessary, an emergency referral should be made.

• Critical limb ischaemia
• Assessment, imaging, MDT and timelines for treatment
• Amputations
• Toe, ray and transmetatarsal amputations can be performed at the NA centre providing there is

local surgical expertise.

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Overall assessment of care

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Principal recommendations

Best practice clinical care pathway to support QIF

A ‘best practice’ clinical care pathway, supporting the aims of the Vascular Society’s Quality Improvement Framework for Major Amputation Surgery, and covering all aspects of the management of patients requiring amputation should be developed. This should include protocols for transfer, the development of a dedicated multidisciplinary team (MDT) for care planning of amputees and access to other medical specialists and health professionals both pre- and post operatively to reflect the standards of the Vascular Society of Great Britain and Ireland, the British Association of Chartered Physiotherapists in Amputee Rehabilitation and the British Society of Rehabilitation Medicine. It should promote greater use of dedicated vascular lists for surgery and the use of multidisciplinary records.

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Principal recommendations

Vascular review within 24 hours if admitted under another specialty

When patients are admitted to hospital as an emergency with limb-threatening ischaemia, including acute diabetic foot problems, they should be assessed by a relevant consultant within 12 hours of the decision to admit or a maximum of 14 hours from the time of arrival at the hospital, in line with current guidance. If this is not a consultant vascular surgeon then one should be asked to review the patient within 24 hours of admission.

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Principal recommendations

Commence planning for rehabilitation and discharge as early as possible

For patients undergoing major limb amputation, planning for rehabilitation and subsequent discharge should commence as soon as the requirement for amputation is identified. All patients should have access to a suitably qualified amputation/discharge co-ordinator.

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Principal recommendations

Surgery on planned operating lists within 48 hours

As recommended in the Quality Improvement Framework for Major Amputation Surgery (VSGBI), amputations should be done on a planned operating list during normal working hours and within 48 hours of the decision to operate. Any case waiting longer than this should be the subject of local case review to identify reasons for delay and improve subsequent

• rganisation of care.

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Vascular services in London

• London has led the reorganisation of services in the UK.
• Providers and commissioners have worked together to establish vascular networks

in London centred around specialist arterial vascular centres.

• Most non-arterial centres have established outpatient and vascular cover rotas
• There is continued increased uptake and use of the AAA screening programme
• Health Checks Programme has launched and been established in London
• The London Vascular Advisory Group, part of the London CVD Strategic Clinical

Network has been established to support strategic improvement of vascular services for patients

London Arterial Centres

• South West
• St George’s Hospital
• South East
• St Thomas’ Hospital
• Kings College Hospital*
• North East
• Royal London Hospital
• Queens Hospital, Romford
• North Central
• Royal Free Hospital
• University College London Hospital*
• North West
• St Mary’s Hospital
• Northwick Park Hospital

Vascular services in London

• London has led the reorganisation of services in the UK.
• Providers and commissioners have worked together to establish vascular networks

in London centred around specialist arterial vascular centres.

• Most non-arterial centres have established outpatient and vascular cover rotas
• There is continued increased uptake and use of the AAA screening programme
• Health Checks Programme has launched and been established in London
• The London Vascular Advisory Group, part of the London CVD Strategic Clinical

Network has been established to support strategic improvement of vascular services for patients

Next steps for vascular services in London

• London continues with the centralisation of vascular services.
• Establishing high quality and safe services at non-arterial centres will be a continued focus
• Development of services and best practice is needed for diabetic foot services, critical limb

ischaemia and amputation rates

• Continued development of footcare service specification is welcomed
• There is a continued need for data to improve outcomes – National Diabetic Foot Audit, NCEPOD

Lower Limp Amputation report, and National Vascular Registry

• The London Vascular Advisory Group is looking to improve outcomes at a pan-London level:
• Providing a forum for leading specialists to thrash out best practice and pathways for London
• Establish a triage system for patients with a AAA in conjunction with London Ambulance Service
• Improve outcomes for critical limb ischaemia in London
• Respond to the recommendations of the NCEPOD Lower Limb Amputation report
• Working closely with the London Foot Network to continuously improve services in the capital

Session 1 - Commissioning for Excellence

Commissioning Diabetes Footcare Services in London

Lesley Roberts

Commissioning Diabetes Foot Care

Lesley Roberts, RGN, PGCertHSM, PGDip.Mgmt, MBA Programme Lead, Camden Diabetes IPU,

Haverstock Healthcare

Camden Diabetes Integrated Practice Unit

• Patient Education
• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

Why integrated care?

Integrated care should be seen as a complex strategy to INNOVATE and implement LONG-LASTING

CHANGE in the way services in the

health and social-care sectors are delivered.

European Observatory on Health Systems and Policies

What is different?

• Camden Diabetes IPU began on April 2014
• Royal Free Hospitals London are accountable

for a POPULATION CHANGE in outcomes

• Everyone working as ONE TEAM
• Everyone is patient focused.
• We have agreed standards, pathways,
• utcomes
• We use the clinical model from Diabetes Guide

for London

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Our patients developed key priorities….

• Patient Education
• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

Camden IPU Vision

A service that:

• Delivers outcomes that matter to patients
• Works across organisational boundaries
• Considers a whole population – prevent and

treat

• Patients leading their own care
• Provides the best value for Camden taxpayers

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• Patient Education
• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

Camden Diabetes Integrated Practice Unit Implementation

Aims?

Too many people with diabetes have poorly controlled and managed diabetes, leading to excess early complications and death Inequality in care delivery and

• utcomes

Disjointed service have been commissioned : integrated clinical and social care services planned that addresses poor control of diabetes, to prevent complications

What is the need?

Provide High Quality Integrated diabetes care, sharing data to reduce duplication and improve communication across service. Improve the Health and wellbeing of people living with diabetes in Camden. Support the Prevention of type 2 diabetes, through raising awareness and education. Equitable and patient-centred services that enable people to achieve good control, thereby reducing complications. Well informed, engaged patients and healthcare professionals committed to working in partnership to achieve best

• utcomes possible.

What will the programme do? What will the programme deliver?

Patient-Focused:

• Structured Patient Education / Patient Involvement and Experience

AIM: Integrate around the patient / outcomes that matter to patients / Easier for patients and carers to understand and navigate all services / Promote self-care / More structured patient education and involvement.

• A year on year improvement in number of undiagnosed patients with diabetes in Camden
• Improved management of patients with uncontrolled diabetes.
• Improved patient experience and quality of life
• Reduced mortality and morbidity from diabetes-related causes
• Reduction in the numbers of unscheduled attendances and admissions to hospitals

Diabetes services that are not always cost-effective. Gaps between actual and predicted prevalence of diabetes: Half of people are undiagnosed. Strong Clinical Services:

• Review and amend : Skill mix and Staffing / Pathways / Tiers of Diabetes /

Clinical IT Templates / Referral Forms / Care planning / Diabetes Foot Health / Kidney disease/ Heart Disease / Eye disease. AIM: Equitable and of consistent high quality, accessible, provided as close to home as possible

Commissioned across a population

• Working together across organisational boundaries sharing best practice,

delivering value, breaking down barriers and improving outcomes by considering a whole population – prevent and treat AIM: Value Based Commissioning will be implemented.

Highly competent staff at all Tiers of diabetes care

• Providing timely access to appropriately skilled healthcare professionals

responsive to the individual, including those with special needs, e.g. housebound.

• Build capacity and capability in primary care

AIM: Increased competencies at all levels

• Patient Education
• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

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TIER 1

ESSENTIAL CARE Delivered by General Practices in primary care, community settings and the patient’s home - all Practices will deliver Tier 1 care

• Annual review
• Follow up of patients with Type 2

diabetes

• Medications reviews
• Complications Screening &

Management e.g BP, HbA1c, weight, lifestyle factors

• Patient education (excluding

Structured Patient Education on diagnosis)

• Telephone support for patients
• Referring appropriately to other

Tiers/specialist services

• Care planning
• Family planning advice and

referral for pre-conception advice

• Care for housebound patients

(including maintenance of a register of housebound patients)

• Maintenance of a register of

patients with Diabetes, indicating place of care

• Testing “at risk of diabetes”

patients and maintaining register

• Referral to IAPT

TIER 2

ENHANCED ESSENTIAL CARE Delivered by General Practices in primary care, community settings and the patient’s home. As Tier 1, plus:

• Injectable therapies
• GLP-1 agonists

GP Practices may choose to deliver these services for their own patients

• nly or as a ‘hub’ service

for a number of Practices. Note: There will be a process to identify the Tier 2 practices in Camden.

TIER 3

INTERMEDIATE CARE Delivered by Consultant-Led Multidisciplinary team(s) in community settings

• Structured Patient Education for patients

newly diagnosed with diabetes (Type 2)

• Access to “At Risk” foot clinic
• Access to specialist diabetes dieticians
• Assessment, specialist advice and

individual interventions for patients *, especially:

• Hypo-unawareness
• Recurrent Hypoglycaemia
• Peripheral Neuropathy
• Insulin & GLP-1 analogue initiation and

management for Type 2

• Pregnancy planning & pre-conception

advice clinic – in development

• Referral to Specialist Diabetes IAPT team
• Joint clinics where competency is known

e.g CKD and Diabetes Clinic at Mary Rankin

• Same day diabetes clinic – self referral

(to avoid A&E attendance) – TO BE DEVELOPED

• Persistent BP>130/80 despite having 3

maximum tolerated antihypertensive agents

• Persistent total cholesterol>4;LDL>2

despite maximum tolerated statins

• Mentoring and coaching support for

primary care

TIER 4

HOSPITAL BASED CARE Delivered by Consultant-Led specialist teams in secondary care

• Assessment of patients newly

diagnosed with Type 1 diabetes

• On-going management of Type 1
• Type 1 Structured Education
• Review of complex/atypical patients
• Review of patients with suspected

secondary diabetes

• Management of active foot disease
• Assessment of Autonomic

Neuropathy

• Joint clinics (e.g. Diabetes and CKD

/CHD / CVD clinics)

• Initiation of CSII/Pump therapy
• Assessment and management of all

pregnant women with diabetes

• Review and management of patients

with severe and/or unstable and/or new complications of diabetes*, especially: Abnormal LFTs Malignant Hypertension

• Access to Clinical Psychologists
• Genetic causes of diabetes
• Young adult clinics (18 – 25)
• Inpatient services

Retinal Screening

Camden Diabetes Integrated Practice Unit (ADULTS ONLY) - Tiers of Care Version 0.6

• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

20 Objectives….

1. The objectives of the project are as follows: 2. Identify gaps in staffing and agree additional clinical and admin staffing required and appoint staff by March 2014. 3. Develop outcomes by March 2014. 4. Agree minimum level of knowledge necessary for competency at Tier 1 level. Develop competencies in all practices (by DSN led visits for case-note review and management plan creation / facilitation clinics and mentoring of staff) 5. Agree, assess and improve clinical competencies for district nursing staff dealing with diabetes patients thereby providing safer high quality care for some of the most vulnerable people with diabetes by December 2014. 6. Develop support for District nurses: A review of diabetes protocols/ Assessment sheets / DN care plans / Blood glucose records /creation of Aide memoir for staff /updated policy and implementation

• f Hypo boxes / MDT Home visits with GP and

Diabetes Specialist staff and Consultant if appropriate. 7. Deliver accredited Foundation Course in Diabetes from July 2014. 8. Develop clinical governance arrangements across and between all providers by July 2014. 9. For very complex and vulnerable people with diabetes develop High risk MDTs in clinic settings, homes and/or practices by July 2014 10. Develop process to monitor outcomes by July 2014. 11. Review and streamline all pathways by end August 2014. 12. Standardise all patient-held and staff communication care plans by August 2014. 13. Implement Diabetes Foot work-stream that ensures all patients are risk stratified and seen in appropriate tier of podiatry by March 2016. 14. Improve diabetes care in hospital by March 2016 15. Develop PIT-stop training for Tier 2 practices who can deliver a higher level of diabetes care including insulin and GLP-1 agonist management with 3-6 Tier 2 practices in place by March 2016. 16. Implement Mental Health work-stream by January 2015. 17. Year on year improve and standardise quality of diabetes care at all Tiers by March 2016. 18. Ensure each patient with diabetes is seen in appropriate Tier of Care (or at home if housebound) by March 2016. 19. Ensure all staff dealing with diabetes patients meet TREND competencies by March 2016. 20. Promote the use of QDiabetes to Improve prevalence to meet expected prevalence by March 2016. 52

• Patient Education
• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

Coordinated Care - Clinical Model

Diabetes Guide for London Aims

Tier 4 – used more appropriately Tier 3 – expanded to support primary care at Tiers 2 and 1. Tier 2 – set up Hub practices (3) Tier 1 – Better essential care in practices

Patients seen in correct tier Move unobstructed through tiers http://www.londonprogrammes.nhs.uk/wp- content/uploads/2011/03/Diabetes-Guide.pdf

Commissioning Diabetic Footcare Services

• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

Minimizing Complications Diabetes Foot Work-stream

• Review staffing – new Band 7 Podiatrist added
• Lead Diabetes podiatrist role created in Tier 3
• Improved internal referral process between

podiatrists;

• Different SLAs don’t help integration / Perverse

incentives not patient focused.

• Discharge back to GP
• Standardised Care Plan etc.
• Foot Check Training;

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• Patient Education
• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

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Minimizing Complications Diabetes Foot Work-stream

• Implement Risk Stratification Tool;
• Practice Nurse and District Nurse Support;
• co-created training
• Move appropriate patients to clinics dependent on

foot risk; ongoing

• Pathways; all tiers pathways now clear and patient

focused.

• Standardised Patient Leaflets;

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• Patient Education
• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

Minimizing Complications Diabetes Foot Work-stream

• Developed Foot Protection team in Community T3;
• MDT Diabetes Foot team in T4 – UCLH and RF;
• QOF Foot Data reported to diabetes board;
• Standardising data to deliver Outcome Metrics;
• National Diabetic Foot audit 2014;
• CIDR - Camden Integrated Digital record

– use podiatry as exemplar

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• Patient Education
• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

QUOTES FROM GPs

• “It has engaged some of the most hard to

reach patients.”

• “Patients who previously declined to attend

appointments have been willing to attend because there was specialist input.”

• “The practice will have managed to complete

YOC reviews on all but one patient, and of those completed to date 100% have had all 9 care processes done.”

Have we achieved what people with diabetes want?

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• Patient Education
• Coordinated care
• Minimising complications
• One stop visit
• Better quality of life

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Session 1 - Commissioning for Excellence

Panel Question and Answer Session

Dr Neil Ashman Mr Obi Agu Lesley Roberts

London Diabetes Strategic Clinical Network Date

Tea and Coffee

Wifi Network name: CSNC1 Password: Event293

Session 1 - Commissioning for Excellence

Participant Workshop

Developing a Footcare Service Specification

Workshop 1 – Service Specification The London Footcare Network has been asked to develop a gold-standard footcare service specification. Questions

• 1. What are the key components of an integrated diabetic

footcare service? – 10 min

• 2. What needs to be included in a service specification to ensure

that an integrated service is commissioned? - 20 min

• 3. What components are missing from the draft service

specification on your tables? – 10 min

• 4. Feedback - 20 min

London Diabetes Strategic Clinical Network Date

Lunch

Wifi Network name: CSNC1 Password: Event293

Agenda for the afternoon

Session 2 – Challenges and Opportunities for Excellence 1.30pm Presentation Diabetes in London Dr Stephen Thomas Chair, Diabetes Strategic Clinical Network 1.45pm Presentation Audit of Local Footcare Services in London Richard Leigh Head of Podiatry, Royal Free Hospital 2.15pm Presentation National Diabetes Footcare Audit Professor William Jeffcoate Steering Group Chair, National Diabetes Footcare Audit 2.30pm Participant Workshop Setting local priorities Session 3 – Forward Planning 3.30pm Presentation Feedback on the Footcare Service Specification Ms Stella Vig Vascular and General Surgeon, Croydon Hospital Richard Leigh Head of Podiatry, Royal Free Hospital 4.00pm Presentation Forward Planning and next meeting Ms Stella Vig Vascular and General Surgeon, Croydon Hospital Richard Leigh Head of Podiatry, Royal Free Hospital 4.30pm Close

Session 2 - Challenges and Opportunities for Excellence

Diabetes in London

Dr Stephen Thomas

Dr Stephen Thomas Chair, London Diabetes Strategic Clinical Network

Population age demographics of a London borough – young population. Scale potential diabetes problem concealed.

7

Prevalence of chronic kidney disease in persons (18 +) 2006-2007

Mortality from chronic renal failure in persons (all ages) 2004-2006

Impact of Diabetes

78

London Diabetes Strategic Clinical Leadership Group membership

Name Job title Dr Stephen Thomas Consultant Diabetologist & Clinical Lead (Chair) Dr Natasha Patel Consultant Diabetologist & South London Academic Health Science Network Lead Dr Stella Vig Consultant Vascular and General Surgeon Jo Reed Diabetes Specialist Nurse (Renal) Vacant (Nurse) Miranda Greg Dietician (Diabetes) Efa Mortty Deputy Head of Medicines Management (Pharmacist) Anna Hodgkinson Pharmacist (Diabetes & CVD) Dr Samantha Mann Consultant Ophthalmologist & Retinal Screening Lead Lewisham, Southwark and Lambeth Dr Dipesh Patel Consultant diabetes & Endocrinology ABCD London Representative Dr Karen Anthony Consultant in Diabetes and Endocrinology Dr Anne Dornhorst Consultant Physician in Diabetes and Internal medicine Dr Rajashree Baburaj Consultant Physician and Endocrinologist Richard Leigh Diabetes Specialist Podiatrist & Head of Podiatry Zabeer Rashid Specialist Podiatrist - Diabetes

London Diabetes Strategic Clinical Network

Applying clinical advice to commissioning to ensure value for money with excellent clinical

• utcomes across complex pathways and systems

London Diabetes Strategic Clinical Network SCLG Clinical Director: Dr Stephen Thomas

Equity of access Education Management of care Detection of diabetes

Patient experience

Priority areas

• Detection of Diabetes
• Management of care
• Foot care
• Insulin pumps
• Education
• Patient Experience
• Type 1 diabetes and eating disorders
• DESP Reprocurement
• Diabetes Prevention Programme

London Diabetes Strategic Clinical Network: Improving patient

• utcomes

Detection of Diabetes

• 20 of 32 CCGs currently use HbA1c
• Recommending the use of HbA1c across London
• Aim is to pick up more people with type 2 and ‘at high risk of diabetes’
• Decision tree with advice to start intensive lifestyle interventions to reduce risk of

developing diabetes and related complications.

Diabetes Prevention Programme

• London SCN currently seeking to partnership with London AHSNs and interested

CCGs to get involved in the national programme.

• Imperial AHSN have evaluated the Westminster MyAction programme
• Health Innovation Network wrote Patient Education Toolkit with SCN
• Aiming to build on current programmes running locally in CCGs.

Dialysis

Case 5

• Mr TS Latin American origin
• Diagnosed with T2DM in 2002 at the age of 41 years
• Seen for the first time in our clinic in 2009 aged 48

years

• Diabetic retinopathy and neuropathy
• BP 166/97 mmHg poor compliance with ACE-I and

amlodipine

• Proteinuria, eGFR 86 ml/min BMI 27.1 kg/m2

86 81 71 57 36 38 31 8 8 23 45 68 90 113 2009 2010 2011 2012 2014 eGFR ml/min

eGFR (MDRD)

Renal Biopsy

2.6 4.2 5. 3.6 4. 0. 1.3 2.5 3.8 5. 6.3 2009 2010 2010 2011 2012 g/24hrs

Proteinuria

Education

• Patient education
• Toolkit has been downloaded far and wide.
• Available at the Health Innovation Network
• Healthcare Professionals education:
• Currently looking at: ‘Essential skills and competencies’, ‘programmes currently

available’ and ‘Continuing Education’

Session 2 - Challenges and Opportunities for Excellence

Audit of Local Footcare Services In London

Richard Leigh

London Diabetic Foot Audit 2015 Acute Services survey results

London Footcare Network Meeting NHS England - London Strategic Clinical Networks Thursday, 5 March 2015

Acute Survey 2015

https://www.surveymonkey.com/r/acutefootcare

7 Responses

• Queen Elizabeth

Hospital

• King’s College Hospital
• Mile End Hospital
• Homerton Hospital
• Croydon University

Hospital

• University Hospital

Lewisham

• Royal Free Hospital

In 2013 Survey 18 Responses:

• Central Middlesex Hospital
• Charring Cross Hospital
• Croydon University Hospital
• Hillingdon Hospital
• Homerton Hospital
• King George Hospital
• Kings College Hospital
• Lewisham Hospital
• Mile End Hospital
• Newham University Hospital
• North Middlesex Hospital
• Northwick Park Hospital
• Queens Hospital
• Royal Free Hospital
• Royal London Hospital
• St Helier Hospital
• West Middlesex University Hospital
• Whipps Cross University Hospital

Number of podiatry chairs on site

1 2 3 1 2 3 4 5 6 7 8 Number of Chairs Acute Survey 2015

When does podiatry operate Mon – Fri?

1 2 3 4 5 6 All day 4 mornings, 1 afternoon 4 all day, 1 afternoon Acute Survey 2015

Who provides podiatry

1 2 3 4 In house Community Both Acute Survey 2015

WTE of service

2 1 6 2 1 1 1 1 3 1 2 3 4 5 6 7 Podiatrist Band 8b Podiatrist Band 8a Podiatrist Band 7 Podiatrist Band 6 Podiatrist Band 5 Diabetes Nurse Specialists Nurse Band 8a Nurse Band 7 Nurse Band 6 Nurse Band 5 HCA Admin Support Acute Survey 2015

Is there 24/7 cover for acute diabetic foot?

4 3 Yes No

Acute Survey 2015

Is the 24/7 cover provided by A&E?

6 1 Yes No

Acute Survey 2015

Is there a dedicated multidisciplinary foot care service provided?

5 2 Yes No

Acute Survey 2015

Is there a pathway from A&E to the foot care MDT?

6 1 Yes No

Acute Survey 2015

Are all hospital in-patients with an active foot ulcer discharged back to the MDT?

5 2 Yes No

Acute Survey 2015

What staff are involved during scheduled 'clinics/meetings' of the MDT?

7 7 2 1 5 1 3 1 1 1 1 1 2 3 4 5 6 7 8 Podiatrist Diabetoligist Orthapeadic Surgeon Plastic Surgeon Vascular Surgeon TVN Diabetes Nurse Specialist Radiologist Vascular Nurse Specialist Renal Physicians Infectious Disease Acute Survey 2015

What other health care professionals are available other than in the MDT

1 3 1 3 1 3 7 4 5 3 5 1 2 3 4 5 6 7 8 Acute Survey 2015

What tests and results do podiatry have direct access to?

6 7 7 5 6 1 2 3 4 5 6 7 8 Blood tests Radiology Microbiology Duplex Histology Acute Survey 2015

Is there a dedicated clinical session for the treatment of painful neuropathy?

1 6 Yes No

Acute Survey 2015

What proportion of patients with the following conditions, are seen by vascular services within the following time frames?

1 2 3 4 5 25% 50% 75% 100% Acute Survey 2015

Number of sites

Are you able to admit patients for surgical debridement?

5 2 Yes No

Acute Survey 2015

Is outpatient parenteral antibiotic therapy available?

6 1 Yes No

Acute Survey 2015

Is an orthotist available in the podiatry clinic?

6 1 Yes No

Acute Survey 2015

Are 'off the shelf offloading devices' available?

1 2 3 4 5 6 7 8 Surgical Shoe Darco Shoe (pegassist) Derby Boot Aircast Prevalon (heel protectors) AFO PRAFO Acute Survey 2015

Is access to total contact casting and scotch casting available?

6 1 Yes No

Acute Survey 2015

Is there an agreed structured, tailored diabetes education programme for foot care offered to all patients with diabetes?

6 1 Yes No

Acute Survey 2015

Do you have a policy in place that requires all patients with diabetes admitted to hospital to have a foot examination recorded

4 2 Yes No

Acute Survey 2015

Is your organisation taking part in the National Diabetic Footcare Audit?

6 1 Yes No

Acute Survey 2015

100% ‘YES’ and ‘No’

YES

• Is rapid access to the

MDT available to GPs? – 100% Yes

• Is Topical Negative

Pressure eg VAC available on the ward? – 100% Yes

• ‘Offloading’ is available

NO

• None

Acute Survey 2015

Summary of main findings

From the 7 responding acute sites:

• Only three questions had 100% ‘yes’ answers: GP rapid access, TNP availability,

Offloading

• Most acute sites operate a clinic 5 days a week
• More than a third of Trusts running both acute and community facilities
• The majority of acute care provided at Band 7 or above
• Lack of administrative support
• Nearly half acute sites do not have 24/7 cover for acute diabetic foot
• Two acute sites have no dedicated MDT
• Podiatry generally has good access to various tests and results
• Podiatry generally has good access to offloading devices and casting
• One acute site has no link from A & E to the Foot MDT
• Only one acute site is not signed up to the NDFA
• The majority of MDTs comprise Podiatrists, Diabetologists and vascular surgeons

but lack other specialties. These tend to be available outside the MDT.

• Only one acute site has a dedicate clinical session for treatment painful of

neuropathy

• There is major variation in the timeframe for patients seeing a vascular surgeon
• Two acute sites unable to admit patients for surgical debridement
• Two acute sites have no policy for foot examination of all patients with diabetes

admitted to the ward

Community Survey 2015

https://www.surveymonkey.com/r/acutefootcare

Community Survey 2015

London Diabetic Foot Audit 2015 Community Services survey results

London Footcare Network Meeting NHS England - London Strategic Clinical Networks Thursday, 5 March 2015

Community Survey 2015

https://www.surveymonkey.com/r/communityfootcare

7 Responses

Providers CCGs

• Haringey
• Bexley
• Greenwich
• City & Hackney
• Harrow
• Croydon
• Newham
• Whittington Health
• Oxleas Adult Community

Health Services

• Oxleas NHS Foundation Trust
• Homerton University Hospital

NHS Trust

• London North West

Healthcare NHS Trust

• Croydon Health Services
• North East London Foundation

Trust

What are the Whole Time Equivalent (WTE) staffing levels of the service?

5 7 8 4 5 1 2 3 4 5 6 7 8 9 Podiatrist Band 8a Podiatrist Band 7 Podiatrist Band 6 Podiatrist Band 5 Diabetes Nurse Specilaist Nurse Band 8a Nurse Band 7 Nurse Band 6 Nurse Band 5 Admin Support Community Survey 2015

How many podiatry patient chairs does the service have on site?

2 3 1 1 1 1 2 3 4 7 8 13 16 18 Services with chairs Number of chairs Community Survey 2015

What other health care professionals are available to the community podiatry service

5 6 5 1 6 3 8 2 8 1 2 3 4 5 6 7 8 9 Community Survey 2015

What tests and results does the community podiatry service have direct access to?

4 5 7 2 2 1 2 3 4 5 6 7 8 Blood tests Radiology Microbiology Duplex Histology Community Survey 2015

Is rapid access to the community podiatry service available for GPs?

7 1 Yes No

Community Survey 2015

Is an orthotist available to the community podiatry service if needed?

4 4 Yes No

Community Survey 2015

Are 'off the shelf offloading devices' available?

3 7 1 4 4 2 1 2 3 4 5 6 7 8 Surgical Shoe Darco Shoe (pegassist) Derby Boot Aircast Prevalon (heel protectors) AFO PRAFO Community Survey 2015

What are the Whole Time Equivalent (WTE) staffing levels of the Foot Protection Team?

4 5 5 3 1 3 1 2 3 4 5 6 Podiatrist Band 8a Podiatrist Band 7 Podiatrist Band 6 Podiatrist Band 5 Diabetes Nurse Specilaist Nurse Band 8a Nurse Band 7 Nurse Band 6 Nurse Band 5 Admin Support Community Survey 2015

What other health care professionals are available other than in the Foot Protection Team

6 6 6 1 3 1 7 5 7 2 6 1 2 3 4 5 6 7 8 Community Survey 2015

Is there a published pathway agreed with your local acute Trusts for the referral of patients with an active foot ulcer for use across both primary and secondary care?

5 2 Yes No

Community Survey 2015

Is there a published pathway agreed with local Trusts for the prevention, early detection and management of diabetic foot disease?

5 2 Yes No

Community Survey 2015

Is there an emergency service available for local clinicians to refer in to?

6 1 Yes No

Community Survey 2015

Is there a dedicated clinical session for the treatment of painful neuropathy available through the Foot Protection Team?

2 5 Yes No

Community Survey 2015

Is there an agreed structured, tailored diabetes education programme for foot care offered to all patients with diabetes through the Foot Protection Team?

2 5 Yes No

Community Survey 2015

Is Topical Negative Pressure available through the Foot Protection Team?

4 3 Yes No

Community Survey 2015

The 100% ‘Yes’ and ‘No’

YES

• What days do the community

podiatry service operate (including any meetings of Foot Protection Team)? - 100% 5 days per week

• What days does the Foot

Protection Team operate? – 100% said all day

• Is there shared care between the

Foot Protection Team and the local acute MDT? – 100% yes

• Is continuing education in

diabetes care available to Foot Protection Team staff regarding diabetic foot? – 100% Yes NO

• Does the community service
• perate seven day working? –

100% no

• Are patients with potential foot

problems supplied with a 24 hour a day, 7 days a week nominated clinician /person including telephone numbers? – 100% No

Community Survey 2015

Summary of main findings

From the 7 responding providers:

• Only four questions had 100% ‘yes’ answers: Operate 5 days a week, All day access, Shared

Care, Staff training available.

• Two questions had 100% ‘no’ answers: 7 day working, 24/7 named contact and phone

number.

• Majority of podiatrists Band 6 or above
• Majority have administrative support
• A wide range of other services are available to community podiatry
• A wide range of tests are available to community podiatry, but lack in several areas eg Duplex
• One service has no rapid access for GPs
• Half community teams have no orthotist
• Half community teams only have basic offloading devices
• FPTs podiatry care provided at Band 6 or above. Only 1 service had a DSN
• A wide range of services are available outside the FPT
• Two services had no published agreed pathways between acute and community Trusts
• Two services had no published agreed pathway with the local Trust for prevention, early

detection and management of diabetic foot pathology

• One service had no emergency care
• Five services had no dedicated clinical session for treatment of painful neuropathy
• Five services had no structured education programme for foot care
• Four services had access to TNP

Community Survey 2015

https://www.surveymonkey.com/r/communityfootcare

Community Survey 2015

Session 2 - Challenges and Opportunities for Excellence

National Diabetes Footcare Audit

• Prof. William Jeffcoate

Session 2 - Challenges and Opportunities for Excellence

Participant Workshop

Setting local priorities

Workshop 2 – Setting local priorities Questions

• 1. What three local priorities are you going to take away to

improve on and report back at the next meeting? – 10 min

• 2. How are you going to implement these priorities? – 10 min
• 3. How are you going to engage stakeholders to provide

integrated care and deliver on these local priorities?–15 min

• 4. Feedback – 20 min

Session 3 - Forward Planning

Feedback on the Footcare Service Specification

Ms Stella Vig & Richard Leigh

Feedback on service specification – Need to include the following

• Commissioning of the support of Psychology of

diabetes impacting on the diabetic foot.

• Commissioning of Rehabilitation
• Commissioning of Charcot services
• Holistic and integrated care – every contact counts
• Role and funding of named clinical leads and

coordinators across specialisms

Feedback on service specification – Need to include the following

• Integrated diabetes budgets
• Focus on prevention
• Flexible working
• 7 day working
• Outreach into community
• Need for ongoing CPD across professional boundaries
• Inclusion of allied health staff – dieticians,

pharmacists, care providers

Feedback on service specification – Need to include the following

• Quality measures to aspire to essential outcomes
• Eg QOF and referral
• Quality assurance function for primary care
• Need to be more specific on staff and competencies
• Training and education needs
• Care settings for diverse communities
• Understanding the hard to reach people and

alternative care settings

• Develop stakeholders within community leaders
• References to existing documents and competencies

Session 3 - Forward Planning

Forward Planning

Ms Stella Vig & Richard Leigh

• Next Steps:
• Mandatory:
• Audit registration: Pan London and National DFA
• Membership of a Task and Delivery Group
• Work towards implementation of the local priorities
• Engagement of stakeholders
• Prepare three minute presentation on what achieved
• Proposed dates:
• Friday 18th September
• Friday 2nd October

London Diabetes Strategic Clinical Network Date

Close and thank you

Further information: jaynairn@nhs.net