LONDON REGION NATIONAL DIABETES PROGRAMME LAUNCH EVENT Preventing - - PowerPoint PPT Presentation

LONDON REGION – NATIONAL DIABETES PROGRAMME LAUNCH EVENT

Preventing type 2 diabetes in England

EXPECTED BENEFITS: PHE EVIDENCE REVIEW

PHE commissioned an evidence review to assess the effectiveness of ‘real-world’ DPPs:

• 36 included studies
• When compared with usual care:

– On average, 26% lower incidence of diabetes – Average 1.57kg weight loss

• More intensive interventions were more effective
• 3.24kg in those that adhered to the most NICE guidance

AN EVIDENCE BASED INTERVENTION

• The NHS DPP behavioural intervention will be underpinned by

three core goals:

• Weight loss
• Achievement of dietary recommendations
• Achievement of physical activity recommendations
• The intervention will be long term, made up of at least 13

sessions, spread across a minimum of 9 months.

• Set and achieve goals and make positive changes to their

lifestyle.

• Will be available nationally on roll-out to all adults at risk of

Type 2 diabetes with referral routes through: – Existing GP Practice registers and opportunistic case finding – NHS Health Checks – Exploring Direct Recruitment

• To be eligible participants will have a blood test indicating Non-

Diabetic Hyperglycaemia within the last 12 months (HbA1c 42- 47mmol/mol (6.0%-6.4%) FPG 5.5-6.9mmol/l)

REFERRAL PATHWAY

• r opportunistic

• n GP register

• f Diabetes

• Impact analysis1 (IA) suggests if 390,000 people receive the

NHS DPP intervention over 5 years*

• Approximately £1.1bn of health benefits
• Up to 24,000 cases of Type 2 diabetes prevented or

delayed by Yr 6 (which is on average up to 115 per CCG)

• By year 12, the programme will become cost saving
• Local ROI estimates will be greater with zero intervention

costs

• Visit the new ROI calculator: https://dpp-roi-tool.shef.ac.uk/

BENEFITS AND RETURN ON INVESTMENT

NATIONAL PROCUREMENT

• NHS England ran a procurement to appoint four providers to a

national framework. This maximised NHS England's purchasing power and enabled us to ensure fidelity to the evidence and national scalability.

• These providers are:

– Reed Momenta – ICS Health and Wellbeing – Health Exchange CIC – Ingeus UK Limited

2016/17 SITES

• Current year one

coverage

• London:

– South London – North East (New, TH, C&H, WF) – Camden, Islington, Haringey – CWHHE

• A comprehensive evaluation is being conducted to understand

effectiveness, cost effectiveness and implementation factors associated with success

• Externally funded evaluation:
• The Department of Health has commissioned evaluation

examining implementation in demonstrator sites and early learning from in Year 1 undertaken by the NIHR School for Public Health Research

• The National Institute for Health Research recently

published a call for applications for a longer term evaluation, outcome due in the Autumn.

EVALUATION

PERFORMANCE – YEAR ONE SITES

Total Referrals - Demos & NDPP YTD (cumulative)

PERFORMANCE – YEAR ONE SITES

In total, as at the end of September, 870 people have attended initial assessments. This represents an uptake rate of 34%.

2ND YEAR ROLL OUT

• 13 STP areas have been selected nationally for NDPP

– More areas selected in North and South regions to reflect lower Year one coverage

• Year two NHS DPP London site:

– Barnet and Enfield

• NHSE looking to make national announcement in December
• STPs not to publicly announce they are involved in the

programme until after this

• STPs can inform internal staff in partnership organisation to work

towards mobilisation

IMPLEMENTATION – MINI COMPETITION

All sites prospectus’ due to be published 6th Dec 2016

• LHEs complete a prospectus detailing local site information
• Providers will submit bids for STPs they are interested in

being the service provider for

• LHEs will evaluate the bids against the nationally provided

evaluation framework

• Panel will include three local STP evaluators, should cover

mix of clinical, commissioning and public heath experience

• Contract will be for 2 years from April 2017

IMPLEMENTATION – DELIVERY GROUP

• The leads from each first wave site in London come together

every 6-8 weeks;

• discuss implementation
• share learning
• problem solve
• reports into London Diabetes Transformation Board

KEEPING IN TOUCH

• For more info and to sign up to our regular e-bulletin

https://www.england.nhs.uk/ndpp

• For any questions email: diabetesprevention@phe.gov.uk

LONDON REGION – NATIONAL DIABETES PROGRAMME LAUNCH EVENT

Regional Event – London December 2016

NHS DIABETES PROGRAMME: Digital Developments

NHS DIABETES PROGRAMME

Background

• The pace of innovation in digital technologies offers new opportunities to

improve patient experience, and deliver services in a more convenient and efficient ways and reduce the burden on clinicians and service users.

• The National Diabetes Programme has initiated a digital workstream to

ensure that the programme can harness these opportunities to support its

• verall objectives.

NHS DIABETES PROGRAMME

Objectives

The objectives of the digital workstream are to achieve improvements in diabetes

• utcomes by:
• Improving the provision of information, support and education for individuals

at risk of Type 2 diabetes and those living with both Type 1 and Type 2 diabetes.

• Identifying opportunities for digital innovations to improve self-management

and care for people living with diabetes.

• Furthering the evidence base for innovative approaches to establish the

investment case for adoption in the formal health care sector in England.

• Identifying appropriate routes to market and commissioning arrangements

for proven innovations in this field to support adoption at scale.

NHS DIABETES PROGRAMME

Current Focus

NHS DIABETES PROGRAMME

Type 2 Prevention – Aims and Objectives

• Establish real world evidence of effectiveness of digital interventions
• What potential effect do these DBCI’s have on health inequalities?
• Can any conclusions be drawn about which groups would most benefit

from the introduction of DBCI’s?

• What are the potential costs of implementation and delivery of digital

interventions?

• What lessons can be learnt (positive and negative) about how the

interventions have been implemented?

• What are the characteristics of digital interventions which appear to be

the most effective/to have the most potential?

NHS DIABETES PROGRAMME

Digital Behaviour Change Interventions for T2 Prevention – Progress to Date

• Responsible for contracting with digital service

providers, supporting implementation, evaluation design, supplier management and evaluation.

• Open call for digital service providers to take part in

evaluation

• Assessment of digital products

• Digital only Geographies
• Digital as choice at point of offer
• Digital offer for those that have declined F2F referral
• Procurement currently live
• Appoint Service Provider

Feb 2017

• Procurement for 3rd Party

“App Assessor” currently live

• Expect a Call for Digital

Providers in Feb 2017

• Products assessment in

March 2017

• 3 Digital Only STP’s

identified from Yr 2 EOI

• 3 Digital as choice

identified from EOI call

• EOI requested from Yr 1

sites

NHS DIABETES PROGRAMME

Digital Behaviour Change Interventions for T2 Prevention – Next Steps

• Communicating intent
• Establishing referral sites
• Governance arrangements

• Evaluation Design
• Pathway Design
• Implementation Planning

• Referrals Commence
• Data Collection / Qualitative Evaluation
• Interim and final findings report
• December2016 - February

2017

• February 2017- June 2017
• June 2017 - Jan 2019

NHS DIABETES PROGRAMME

Type 1 – Aims and Objectives

• Improve information provision and support for individuals

living with Type 1 diabetes

• Develop a mobile-first website which provides insight,

direction and support all in one place

• Move more T1Ds towards being fully engaged with their

condition, and more knowledgeable and active patients, in an easy, low friction manner

NHS DIABETES PROGRAMME

• Content and discovery phase nearly complete
• Mock up (“wireframes”) developed
• Initial market sounding with developers
• Proposals for phased agile development and investment

case

Type 1 – Progress to Date

NHS DIABETES PROGRAMME

Questions

LONDON REGION – NATIONAL DIABETES PROGRAMME LAUNCH EVENT

30

Diabetes Treatment & Care Programme

Jeff Featherstone, Diabetes Treatment & Care Programme Manager

Treatment & Care transformation programme

1. Improving uptake of structured education £10m 2. Improving achievement of the NICE recommended treatment targets (HbA1c, cholesterol and blood pressure) and reducing variation £17m 3. Reducing amputations by increasing availability of multidisciplinary footcare teams £8m 4. Reducing lengths of stay for inpatients with diabetes by increasing availability of diabetes inpatient specialist nurses £8m

• Good evidence to suggest that these priorities will:

 Have the most clinical impact  Are most likely to offer the highest return on investment and be sustainable  Will lead to improved outcomes for patients

Best Possible Value (BPV)

• Details subject to final confirmation before publication
• Bidding process focused on which identifying bids offer Best Possible Value

in terms of Strategic Fit, Value and Risk.

• Bids should be jointly agreed between CCGs and relevant providers with

single Senior Responsible Officer

• Application form asks for details of:
• Analysis of reasons for local position and actions proposed, with timescales
• Planned improved outcomes and expected savings
• Mutual commitment to reinvest savings in sustainable services.

Structured education (1)

• Delivery of SE for patients with type 1 diabetes could deliver savings

from reduced complications of :

• an estimated £440 average per person after 5 years and

£1,800 after 10 years for newly diagnosed patients

• an estimated £880 average per person after 5 years and

£3,600 after 10 years for the prevalent population

• Delivery of SE for patients with type 2 diabetes could deliver savings
• f
• an estimated £93 average per person after 5 years and

£129 after 10 years for the prevalent population

• an estimated £77 average per person after 5 years and

£118 after 10 years for newly diagnosed patients

Structured education (2)

• Understand actual level of attendance at structured education courses-

may well be higher than reported attendance levels. (5.7% reported

• nationally. Actual levels may be between 15-30%
• Understand why actual structured education attendance is low and

agreeing actions to tackle it. Consider:

• How clinicians explain structured education to patients
• Are providers incentivised to maximise attendance?
• Are attendance issues different for differing populations?
• Do the time and locations of offer meet patient needs
• Do content and cost reflect evidence?

Treatment targets (1)

• Treatment target achievement associated with reduced risk of

complications

• Great deal of variation in achievement:

i) > 1 in 2 patients achieving the targets in some CCGs, <1 in 3 in

• thers.

ii) 40% of type 2 patients achieving targets, but only 20% of type 1.

• Estimated per patient saving (gross):
• i. After 5 years, average per patient saving would be £270 due

to reduced risk of complications

• ii. After 10 years, average per patient saving would be £600 due

to reduced risk of complications

Treatment targets (2)

• Understand reasons for local underachievement of treatment targets
• Is underachievement focussed within specific GP practices,

populations, localities?

• Appropriate achievement of the treatment targets will vary between

different parts of local populations e.g. high elderly population, South Asian population etc.

• What are positions of comparator CCGs? If in better position, what do

they consider to be reasons for this?

• Actions that have a clear rationale for why they are considered ones to

bring about improvement and are sustainable.

Footcare and Inpatient teams

• Estimated 57 hospital sties do not have a multidisciplinary footcare team and

54 sites do not have diabetes inpatient specialist nurses. Others have teams but with insufficient capacity for current demand.

• Evidence suggests that, for every £5m invested in Multi-disciplinary

Footcare Teams (MDFTs) or Diabetes Inpatient Specialist Nurses (DISNs), net savings of around £9m annually can be achieved.

• Bids for funding for footcare and inpatient teams for sites without these in

place, and expansion of capacity in existing services.

• Need to set out how teams will support other professionals also treating the

same patients to promote consistency of care and improved outcomes.

The application forms (1)

38

2 sections:

• Word – qualitative including

written descriptions of plans and anticipated outcomes

• Excel – quantitate including

key metrics around savings and expected improvements in clinical outcomes Each question clearly labels which aspect(s) of the evaluation framework it refers to

The application forms (2)

39

Evaluation criteria: Appraisal dashboards

40

• Clinical
• Cohort size
• Clinical outcomes
• CCG IAF rating (for TT and SE) / Current services in place (for MDFTs and

DISNs)

• Patient experience
• Patient experience measures or improvement plans
• Safety / quality
• High quality service provided
• Sustainability
• Commitment to fund service after transformation funding is withdrawn
• Tracking savings
• Resources
• Per patient cost of service and non-financial costs
• Strategic
• Financial
• Replicability
• Risks – risks around implementation, relationship, targeting, inter-relationship with
• ther strategic plans

Overall: Must haves

41

Good bids will include details of;

• All partners (CCGs, providers, others) having mutually committed to the bid,

including to costs/savings profiles and to reinvestment of savings for sustainability of the service developments

• An agreed Senior Responsible Officer, Clinical Lead and an Implementation

Lead across the partnership

• The proposals being in line with local priorities for diabetes e.g. priorities

within STPs

• Engagement (with clinicians, providers and patient groups) and their

support for the proposals

• Governance and oversight arrangements to oversee the delivery of the

interventions

• How participation in the National Diabetes Audit will be increased to ≥ 90%

by 2018/19 As well as the specific details of bids in each priority intervention area.

Bids for funding to improve uptake of structured education

Outcomes/Criteria Importance (%) Number of additional patients referred for structured education. Evidence drawn from National Diabetes Audit. This should be expressed as per X% of population or similar. Also collect information on current and future referral and attendance rates to support assessment of bids. 10% Planned improvement in CCGIAF rating for structured education 5% Planned increased attendance at structured education and completion of course. 20% Patient Experience Set out local measures of patient experience or use qualitative information about plans for improvement. 10% Safety/quality Service adheres to NICE guidelines and quality standards. 15% Total amount of local funding committed in each year 15% Savings generated locally. 10% Number of additional patients to attend annually. Total cost of service and details of any capital requirements upon which successful delivery of the bid is reliant 15% Assessment of identification of implementation risks and mitigating actions 25% Assessment of identification of degree of support of key partners 25% Assessment of risk that intervention is not well targeted 25% Assessment of degree to which inter-relationship with other strategic plans are identified and addressed. 25% Proportion of new/additional service cost to be funded locally in 2017/18 50% Degree to which the improvement approach can be replicated elsewhere. 50% STRATEGIC Sustainability Value equation OUTCOMES Clinical RESOURCES RISKS

Bids should clearly set out;

• Percentage of patients with diabetes that achieved the 3 NICE recommended treatment

targets according to the most recent NDA and the expected improvement up to 2020/21

• Understanding of the reasons why treatment targets achievement levels may be lower

than national average (40.2%) including consideration of different segments of the CCG’s population

• The proposed intervention(s), actions to be taken and the resources required for these
• Local measures of patient experience and/or plans for improvement of patient experience
• Demonstration of how improvements will be sustainable (including whether the bid

requires ongoing funding or describes a short term intervention)

• The profile of anticipated savings and commitment to reinvest these to support long term

sustainability of the service

• Degree to which the approach could be replicated elsewhere
• Any risks to delivery which have been identified and mitigating actions

Bids for funding to enable an increase in achievement of the 3 NICE recommended treatment targets

Bids for funding to put in place a new or expanded multidisciplinary foot care team (MDFT)

Bids should clearly set out;

• Whether the bid is for a new or expanded service
• Current number of patients seen by the MDFT and for each year up to 2020/21 the

planned levels of improvement in;

• Number of patients who will be seen by the MDFT
• Waiting times / accessibility for patients with major / minor foot care needs
• Number of amputations
• Describe how the proposed additional or extended MDFT function will fit into the wider

treatment pathway and interface with other services

• Provide detailed implementation plans including the resources required and the criteria

which will be used to determine which patients are seen by the MDFT

• Local measures of patient experience and/or plans for improvement of patient experience
• Demonstration of how the new/expanded service will be sustainable
• The profile of anticipated savings and commitment to reinvest these to support long term

sustainability of the service

• Any risks to delivery which have been identified and mitigating actions

Bids for funding to put in place a new or expanded diabetes inpatient specialist nursing (DISN) service

Bids should clearly set out;

• Whether the bid is for a new or expanded service
• Average number of inpatients with diabetes that have needs that would be appropriate

for the DISN to support

• For each year up to 2020/21 set out the planned levels of improvement in average length
• f stay for patients with diabetes, reduction in medication errors and reduction in

hypoglycaemic and hyperglycaemic episodes in inpatients

• Describe how the proposed additional or extended DISN function will fit into the wider

treatment pathway and interface with other services

• Provide detailed implementation plans including the resources required and the criteria

which will be used to determine which patients are seen by the DISN

• Local measures of patient experience and/or plans for improvement of patient experience
• Demonstration of how the new/expanded service will be sustainable
• The profile of anticipated savings and commitment to reinvest these to support long term

sustainability of the service

• Any risks to delivery which have been identified and mitigating actions

What to avoid when developing bids

• Not including all key partners – ensure you work in an appropriate group of

CCGs and providers

• Failure to ensure that the proposals address all key issues in the appraisal

dashboard

• Submitting many separate bids – an individual CCG may be part of different

partnerships covering differing priorities or providers, but should not submit multiple bids for the same priorities and providers

• Vague responses – if you don’t have the evidence to back up your

proposals set out how you plan to get it and your best estimate

• Not demonstrating an understanding of the key issues for different parts of

the local population that affect outcomes

• Failure to demonstrate mutual commitment to the proposals across

commissioners and providers

• Failure to confirm mutual support for the cost and savings profiles and for

reinvestment of savings to sustain the improvements

Support available

National support

• Call to bid slide pack which includes;
• The scale of the opportunity for CCGs including what national modelling based
• n the evidence suggests in terms of return on investment
• The background and logic models for each of the 4 interventions
• Appraisal dashboard for each of the interventions which will be used in the

assessment of the bids, including the weighting for each criteria

• Various links to supporting information such as a data dashboard which sets out

the available data by CCG to support CCGs developing bids

• A programme of webinars to support organisations developing individual bids (details

TBC)

• Regular webinars with NHS England regional clinical networks
• An email address to direct specific queries to (england.diabetestreatment@nhs.net)
• A FAQs document to support by answering all the regularly raised questions

Clinical network support

• Support in developing individual bids
• Responding to queries from local commissioners and their partner organisations

Provisional timescales and actions

• Invitation to CCGs to submit funding bids to be issued early

December 2016.

• Funding bids to by submitted by 18 January 2017
• Bids can be by individual or groups of CCGs. Bids should be

jointly agreed with providers

• Successful bidders to be advised by end February 2017

LONDON REGION – NATIONAL DIABETES PROGRAMME LAUNCH EVENT

NHS National

• nal Diabetes

betes Preventi ention n Prog

• gramme

amme Healt althier ier You- South th London

• n

Alison White Interim Programme Director – Diabetes and Stroke Prevention, Health Innovation Network

www.hin-southlondon.org @HINSouthLondon

NATIONAL DIABETES PREVENTION PROGRAMME

NATIONAL DIABETES PREVENTION PROGRAMME

The he pic ictur ture e in in Sou South th Lo Lond ndon

• n
• Population of just under £3 million
• 430 GP Practices across the 12 boroughs
• 369 Commissioned GP practices provide NHS Health checks
• 10 out of the 12 boroughs commission a community outreach

provider for Heath Checks. 74 pharmacy providers

• Over 140 different languages. The most common non-English languages

are Portuguese, Yoruba, Tamil, Polish, Punjabi, Urdu, Guajarati, Bengali, Spanish, Nepalese and Mandarin

• South London has an estimated at risk population of 275,549

NATIONAL DIABETES PREVENTION PROGRAMME

Our approach

Southwark CCG

South-west co-chair Merton

South-east co-chair Lambeth

London Transformation Board Regional NHSE Board

NATIONAL DIABETES PREVENTION PROGRAMME

South London at a glance

• Provider is Reed Momenta with Lloyds pharmacy as a partner
• To date, South London partners have referred over 2000

people onto the programme across 11 boroughs

• Over 28 programmes have started, with lots more planned for

the new year

• Partners have localised the offer to suit their populations
• Issues are being resolved quickly and learning is shared

across the partnership

NATIONAL DIABETES PREVENTION PROGRAMME

Monthly dashboards (a work in progress)

• Feeds monthly

highlight report

• Risk log capture
• Review of call off

numbers versus actual numbers

• To include
• utcome data

NATIONAL DIABETES PREVENTION PROGRAMME

Local success stories

Sutton One of the larger practices sent out 300 letters to patients identified as at risk of developing type 2 diabetes and invited them to attend an open day where they:

• Had their BMI done
• Attended an short information

session where they could ask questions

• Filled out referral forms
• Had their blood tests

As a result, 96 people were referred that month. Southwark Southwark took the approach of sending out mailshots to their at-risk population.

• Patients received a primer text

message alerting them to an important health message being sent by the practice

• Followed up with a letter informing

them that they have been identified as at-risk of developing type 2 diabetes- Trial After the first batch of texts and letters, over 150 people had called the provider, and over 50 had booked

• nto an individual assessment.

NATIONAL DIABETES PREVENTION PROGRAMME

Local success stories

Greenwich Using the existing local model of Patient Information Clinics, Greenwich are running their own individual assessments for their local population.

• Eligible patients are contacted and

invited to a clinic

• At the clinic, they have a blood

check and find out more about services for preventing diabetes Greenwich have found that this model leads to higher quality referrals and patients are more motivated to attend the programme.

Lewisham Lewisham identified a GP champion who engaged a number of practices to encourage them to send out mailshots inviting eligible patients. Here the delivery team trialed two different types of mailshot.

• The standard mailshot
• A mailshot including specific

demographic information and a follow up text message The more specifically targeted mailshot leads to higher levels of engagement and an increase in referrals.

NATIONAL DIABETES PREVENTION PROGRAMME

Next steps

• Continue with successful implementation delivery

mechanisms and use learning to improve patient experience

• Explore place-based outcomes for each CCG area using data

collected by the national team and the provider

• Ensure sustainability of referrals
• Work closely with the provider to start embedding

programmes as business-as-usual

LONDON REGION – NATIONAL DIABETES PROGRAMME LAUNCH EVENT

NHS Diabetes Prevention Programme CWHHE

Ibrahim Khan Senior Public Health Commissioning Manager

CWHHE Collaborative

• Total registered population: 1.4m
• CCGs: 5
• Local authorities: 5
• PH departments: 3
• Total GP practices: 251

Central London Hounslow Ealing West London Hammersmith & Fulham

Application Process (Jan – March 2016)

• Organisation and partnership working across CWHHE
• 99% of practices use the same clinical system (SystmOne)

Ability of standardise templates and reporting across CWHHE

• Able to demonstrate the need for NDPP i.e. Diabetes, pre-diabetes

burden, BME population, areas of deprivation etc

• Non Diabetic Hyperglycaemia (NDH) register
• Out of Hospital contract incentive (managing register, annual reviews

and NDPP referrals)

• Successful NHS Health Check programme
• Existing local programmes
• Readiness to refer (templates, reports, identification of eligible

patients, incentive)

Pre Diabetes Prevalence

High Risk of Diabetes Register by March 2016

CCG High risk of diabetes register Uncoded high risk of diabetes Ealing 13421 12774 Hounslow 10709 6083 West London 3101 4711 Hammersmith & Fulham 2219 3921 Central London 2205 4003 CWHHE Total 31655 31492

2 Year Programme Allocation

Central London West London H&F Hounslow Ealing Total 13% 13% 13% 25% 36% Number of referrals 800 800 800 1538 2214 6152 Upper uptake (40%) 320 320 320 615 886 2461

Pre Mobilisation Phase (April – July 2016)

• CWHHE successful in their bid to join first wave
• Procurement process to choose the provider
• ICS (Independent Clinical Services) announced as the preferred

provider in July 2016

• MoU signed between CWHHE and NHSE with H&F CCG as lead
• rganisation
• NDPP steering group set up to meet weekly (teleconference and

face to face) led by Hounslow Public Health. Attended by CCG clinical leads, PH managers, CCG managers, comms team, NHSE, provider)

• Links with CWHHE Diabetes Strategy Group

Mobilisation Phase (July – Sep 2016)

• Weekly steering group meetings
• Referral pathway

a) Mass invitations b) Face to face invitations – referrals c) Active case findings (diabetes risk calculator, NHS Health Check)

• Invitation letter and referral form (available in SystmOne)
• SystmOne crib sheet
• Patient and health professionals leaflets (PPG coordinators engaged)
• Roll out plan (GP engagement, venues, priority areas etc)
• Communication plan

Roll Out (Sep 2016)

• Email communication to all GPs during week commencing 19th of

September (led by CCG comms)

• Communication pack with leaflets sent to all practices
• Promotion and presentations at CCG federation/network meetings
• Expression of interest by GPs to conduct initial assessments at

practices

• Monthly OOH dashboard

The story so far!

CCG Area Number of referrals Central London 192 Ealing 588 Hammersmith and Fulham 194 Hounslow 739 West London 322 Total Referrals 2035

Current Position Number Processing referral 392 Accepted invitation (awaiting IA appointment) 1059 Initial Assessment booked 324 Ready for groups 110 Booked on Group 111 Not Progressing 39

Demand management

• Staggered approach to referrals
• Monitor out of hospital contract performance
• Monitor uptake rate from referrals to initial assessment and from

initial assessment to groups

• Most initial assessments in Nov/Dec, majority of groups to start

after Christmas

Thank You!

Ibrahim Khan

Senior Public Health Commissioning Manager London Borough of Hounslow Ibrahim.khan@hounslow.gov.uk

LONDON REGION – NATIONAL DIABETES PROGRAMME LAUNCH EVENT

Alice Ehrlich Public Health Strategist Camden and Islington Public Health

Diabetes Prevention Programme Progress and reflections from Camden, Islington and Haringey

Our partnership

• Members
• Project team

– CCG commissioners x3 – Public Health – Diabetes clinical lead in Islington – Practice manager (early days)

Our approach

• 1. Developing a referral pathway
• 2. Using NHSE resource

Our approach

Our approach

• 1. Developing a referral pathway
• Primary care, Community Health Checks
• 2. Using NHSE resource

– IT tools – GP ‘incentive’ for invitations

• 3. Project planning
• 4. Implementation…

Our progress

• Referrals 16/17

Aug Sep Oct Nov Dec Jan Feb Mar Target

• 33

68 196 187 232 255 267 Actual 33 68 93

• Challenges
• Primary care engagement
• GP IT
• The pathway in practice

Our next steps

• Getting to ‘business as usual’
• Monitor referrals and patient journeys
• Tackle inequalities
• Practice variation
• Language
• Non-primary care referral routes

LONDON REGION – NATIONAL DIABETES PROGRAMME LAUNCH EVENT

NHS Diabetes Prevention Programme

NDPP East London Partnership

NDPP East London Partnership

Demographics headlines:

• 866,595 18 yrs and over across the partnership
• 183 GP practices
• All 4 boroughs have very diverse populations:

White British 17% - 38% White Other 12% - 16% Asian (Bangladeshi, Indian, Pakistani, other Asian) 29% -36% Black African & Caribbean 17%-20%

The scale of the ‘Diabetes Challenge’ in NE London

Borough Diagnosed diabetes Undiagnosed diabetes Non-diabetic hyperglycaemia City & Hackney 12,752 2,064 20,322 Newham 21,312 2,998 28,911 Tower Hamlets 14,916 2,252 20,002 Waltham Forest 14,757 2,804 23,397 TOTAL 63,737 10,118 92,632

• 63,737 people diagnosed with Diabetes!
• 10,118 estimated undiagnosed diabetes ( local intelligence

suggests this is an under estimate)

• 92,632 estimated as having non-diabetic

hyperglycaemia

Referrals and uptake targets

Referrals Uptake 40%

Year 1 2,191 876 Year 2 4,080 1,632 Total 6,271 2,508

• Projected Referrals in specification:
• 6,271 over 2 years
• Equates to 1-2 referrals per GP practice per month

(2191/136)

• Delivery to-date:
• 337(Nov-ytd) vs 961(Sept-Dec)

Challenges encountered

• Mobilisation phase (Do not under-estimate the time required ! )
• Developing relationship with the provider (included personnel changes)
• Fully understanding the product being promoted
• Partnership working
• Engaging general practice teams
• Developing and embedding an efficient system of referral
• Competing priorities
• 1○ Care Access, CQC, extended services, capacity , organisational

changes , religious/holidays times

• Projected referrals
• Not an exact science: attrition along each step of the referral
• Integration with existing services
• Assimilation with other similar commissioned community based

services including – exercise on referral / fit for life / community prescription / health trainers / pre-diabetes sessions

• Electronic referral process
• Embedded into1○ Care practice systems, search , filtering for exclusion

criteria at the initial call/re-call system-takes time, dashboard for monitoring purposes, refining !

Lessons learned to date

• Clear and consistent communication to all within the practices

Cluster/network meetings, 1:1 practice support / TH developed a pack administration staff Robust materials for clinicians with evidence based references for the NDPP Local stakeholder implementation meetings (borough level) often required

• Organising incentives to generate referrals

Recognising additional administration cost to be met at a practice level Ensuring it will be on the general practices agenda as many competing priorities Guaranteeing a level of referral

• Requires active engagement to follow up and motivate practice referrals

Having dedicated resources to encourage low referring practices /networks to improve Organising a robust practice dashboard to regularly monitor the referrals being made

IT guidance and 1:1 support to ensure GP practices know how to use the referral

template

• Regular engagement with the Provider

To support the promotion of the NDPP – using materials such as a brief video clip To fully understand and keep up to date on the referral – initial assessment - group attendance and numbers of exceptions

• Utilise a local clinical champion - “Call to action”

LONDON REGION – NATIONAL DIABETES PROGRAMME LAUNCH EVENT

Date

London Diabetes Clinical Network

Dr Stephen Thomas, Consultant Diabetologist

Chair, London Diabetes Clinical Network

Treatment & Care programme priorities

1. Improving uptake of structured education 2. Improving achievement of the NICE recommended treatment targets (HbA1c, cholesterol and blood pressure) and reducing variation 3. Reducing amputations by increasing availability of multidisciplinary footcare teams 4. Reducing lengths of stay for inpatients with diabetes by increasing availability of diabetes inpatient specialist nurses Priorities reflect evidence as to which interventions best improve outcomes for people with diabetes and show a positive return on investment. Treatment & Care programme forms core of CCG IAF diabetes support offer

Recent publications…

• Type 1 Diabetes commissioning pack
• Building the right workforce for diabetes care; A

toolkit for healthcare professionals

• Best practice renal foot care guidance
• Report | Living with diabetes: What support is

needed?

• Infographic | Living with diabetes: What support do

people want?

• Improving the management of diabetes care: A

toolkit for London clinical commissioning groups

• Commissioning guidance: Foot care service for

people with diabetes

• Using HbA1c for better diabetes detection

Date

Structured Education Bid

Draft bid developers - Alison White and Aileen Jackson

Health Innovation Network http://www.hin-southlondon.org/

Structured Education Application Questions

• 1. CCGs?
• 2. Understanding of reasons for low uptake? ( T1 / T2 / children) - identify which specific populations and GP practices

attendance low / reasons why / feedback for reasons of non-attendance / what can help?

• 3. Funding for Structured Education
• 4. Plan to improve attendance and completion of courses / accurate recording of attendance / coded reporting of attendance /

link payment to attendance

• 5. Implementation Plan
• Initiatives you plan to put in place to increase uptake( all ages)
• How to support GPs to max attendance
• Focus – newly diagnosed or prevalent diabetes pop across all ages.
• Proposed level of increase in attendance
• Flex numbers attending?
• Plan to develop the workforce so that other clinical services not depleted
• 6. Specific Actions?
• 7. Risks – to implementation / arising from relationships / that interventions are not well targeted / interrelationships with
• ther strategic plans
• 8. Financial
• 9. Savings/ reductions
• 10. Service spec for structured education?
• 11. Will structured education courses be nationally accredited – if so by whom? / non-nationally accredited / internally

accredited? Have quality standards to meet?

• 12. Key learning

Diabetes Structured Education Project

/ Professional Education, Facilitation support for primary care / Mentorship and Training Contracting , Finance and Value: Strategy, Governance and Accountability Outcomes Structured Education:

What is the need/ current situation?

• pportunities to access

Outcomes What will the project do?

• Commissioning a structured education hub, to include: a

• To agree cross-charging for structured education courses, to

Increased variability, accessibility and availability of Structured Education

• Design and deliver an education programme with strong

• Developing diabetes care navigator/champion roles to

• Commitment to evaluation for spread and adoption of good

Project deliverables

• To focus on STP partner organisations to deliver a ‘Think

• Provision of tools that can be used to spread and adopt the

Proposal 1: Increase referrals

• Design and deliver an education programme with strong

consideration given to patient-led sessions and/or e- learning resources to include:

• Patient impact stories
• Motivational techniques
• The importance of applying standardised data coding for referral;

attended and completed

• Strengthening call and recall in primary care
• Developing diabetes care navigator/champion roles to

maintain and sustain awareness of all of the above

• Commitment to evaluation for spread and adoption of good

practice Outcomes

• Increase in GP practice staff understanding SE/diabetes
• Increase in referrals that translate to actual attendance
• E learning resource that can be used for spread and adoption

Proposal 2: Increase attendance

• To commission a structured education hub, to enable

adults and children with diabetes to attend the right course at the right time with language and cultural options :

• A centralised booking system for structured education ready for

digital options

• Capacity to engage harder to reach patients
• Self-referral
• Structured education refreshers
• Signposting to other services and information
• Peer to peer support
• Agreement for a cross-charging for structured education courses

Outcomes

• increased referrals and attendance at structured education
• Opportunity for the evaluation of patients to include treatment

targets/structured education choice

• Evaluation of outcomes between different types of structured

education provided

• Evidence the benefits of a centralised hub

Proposal 3: to increase working age adult attendance

• To focus on STP partner organisations to deliver a ‘Think

Diabetes’ initiative and review current HR policies, to include :

• Awareness education of the importance of employees with diabetes

attending structured education ( links with proposal 1)

• Addressing gaps in HR policies to facilitate attendance at structured

education

• Outcomes
• Increased number of HR policies meeting the needs of people with

diabetes to attend structured education

• Provision of tools that can be used to spread and adopt the ‘Think

Diabetes’ initiative in any workplace

Date

NHS Transformation Fund NICE Treatment targets: Lessons learned from NW London

Dr Tony Willis, Clinical Lead for Diabetes, CWHHE CCG Collaborative

Treatment Targets Application Questions

• 1. CCGs involved
• 2. Current level of HbA1c / BP and Chol - treatment achievement – different cohorts – differential achievements –

underachievement- why?

• 3. Actions Type 1:

Commissioning Promoting improvement Incentives and other levers Actions focused on areas requiring improvement Actions Type 2: Commissioning Promoting improvement Incentives and other levers Actions focused on areas requiring improvement Children and young people: Commissioning T1 Children and young people: Commissioning T2

• 4. Risks
• 6. Savings/ reductions
• 7. Actions short term –/ what necessary to maintain over longer term?
• 8. Key learning / replicability

Outcomes Treatment Targets project:

Diabetes Treatment Targets Project

What is the need?

Ideas…

• 2. Integrated IT that enables identification of Targets and

• 3. Focus care management on patients not achieving

Project Deliverables

• Reduced variation in Treatment Targets

• Bust some myths – deprivation not a significant factor

1

• Can be done….examples help (NWL, CEG, etc)

2

• Emphasise the importance of IT

3

• Collaborative working – essential (including patient)

4

Achieving NICE targets

Deprivation not a factor in NW London

Vertical axis: percentage of patients achieving

• target. Horizontal axis: Practice IMD(2015) score.

HbA1 c BP Lipids Practice achievement of key targets (ranked by index of multiple deprivation)

Inter-practice variability not fully understood but likely to be a factor

• f various elements including

administrative capacity, clinical expertise, GP workload.

Contractual incentivisation helps mediate change at scale

patients with collaboratively developed diabetes care plans in last year increase in numbers of patients achieving target HbA1c of ≤58 mmol/mol since start of programme (August 2015) – largest single GP network improvement of 15.4% patients at high risk of developing diabetes received an annual check in last year, with over 12,500 offered referral into the NDPP since 19/9/16

36,123 4.7% 15,291

• Economic impact modelling (IMPACT2, Healthy London Partnership)

1

• Some ROI within 2 years for certain aspects

2

• Contractual incentivisation helps – CCG case for change

3

• Maximise functionality of GP IT systems

4

• Dashboards essential to provide feedback and create change culture

5

• Proactive disease management for poorly controlled patients

6

• Integrated working – use community teams, virtual MDTs

7

• Systematic mental health input and use of self-management tools

8

How to get there

Bed days: part of economic modelling

for diabetes patients with angina for patients with a myocardial infarction for patients with heart failure

9,242 10,419 32,162

28.3% of NW London bed days are for people living with diabetes

for patients with a stroke for patients needing renal replacement therapy

10,967 11,679 2,509

for patients undergoing amputations

NW London diabetes dashboard launching shortly. Incorporates GP, acute, community and social care data. Helps understand population health, spend and outcomes for multiple LTCs. Data shown are for illustration purposes only and are not accurate.

Population health tools important

List of GP practices

Functionality to compare achievement against key metrics across multiple organisations. Drill down to view individual patients not achieving targets or not engaging (dependent on legitimate relationship as care professional)

Use comparative data to drive change

Virtual MDT Proactive disease management capability through upscaled primary care working with specialist support

Systematic risk stratification and monitoring of patients based on: 1) Current health status (e.g. poor diabetes control) 2) Engagement (attendance at clinics, PAM score) 3) Mental health barriers 4) Social barriers to health

Proactive disease management programme

Clinician Patient

Co-creation

• f goals

Generalism Continuity of care Registered population Holistic Coaching / Care navigators Mental health Specialist support Pharmacy Social prescribing

Key ideas are labelled

Segmentation of care example

Patient Care model On diabetes register HbA1c controlled Engaging with services Routine care HbA1c off target (dependent on disease duration, frailty, etc) AND/OR Not seen in last 3-6 months AND/OR At least one diabetes related admission Active case management: Care coordinator Regular phone support Health coaching Psychological support Virtual Multi Disciplinary Team review May be some intermediate stages required. London SCN could create some agreed stratification groups for HbA1c targets and model of care

Importance of mental health – IAPT and psych support

Increase in risk of Type 2 diabetes for individuals exposed to adverse childhood experiences1 (abuse, violence, neglect, parental substance misuse, etc) AND a significant increase in mental health problems (including psychotic illness)2 Increased risk for all cause mortality

• ver a 2 year period for people with

diabetes and depression Average improvement in HbA1c for patients attending the Diabetes Psychological Medicine service in Hammersmith and Fulham at 12-18 months after enrolling

37% 32% 22mmol/mol

Average results for 165,000 patients participating in the free diabetes.co.uk 10 week online low carb education programme

Systematic use of simple (and free) self management tools

average reduction in waistline measurement average weight loss average reduction in HbA1c with around 20% reducing or stopping oral hypoglycaemic medication

10kg 9.4cm 12mmol/mol

Date

MDfT Bid – aspiring to excellence

Draft bid developers – Richard Leigh and Stella Vig

Multi-disciplinary Diabetes foot Team ( MDfT)

• 1. Name of provider?
• 2. New or expanded MDfT
• 3. MDfT current role – criteria / referral process / how enhances staff skills

Current funding arrangements for MDfT

• 4. Referral/ Assessment time for the MDfT and pathway reflect NICE recommendations
• 5. Service available for those at risk of developing active foot disease who don’t need MDFT – what is your Foot Protection Team

service?

• 6. a) Gap analysis of the service change required

b) Implementation plan – expected number of staff needed c) Reasons for considering these actions will close the gap d) How proposal takes account of the assessment of differing needs and approaches needed to address these e) How will work with community providers to promote foot-care outcomes

• 7. Current and planned make-up of MDfT?
• 8. Saturday and Sunday plans?
• 9. Recruitment and training plans? / existing employees trained up / LETBs / training arrangements confirmed / actions if delays in

recruitment?

• 10. Risks – to implementation / arising from relationships / that interventions are not well targeted / interrelationships with other

strategic plans

• 11. Financial
• 12. Patient satisfaction – how and how will improve?
• 13. How does this extended or improved MDfT fit into wider local diabetes pathways ( inpatient specialist nursing team / primary

care) – care plan – actions taken by other professionals

• 14. Funding of the service over long term / Reduction in LOS and complications are reinvested- self sustaining / How CCG and

provider savings will be reinvested?

• 15. Current service fully or partially adhere to NICE guidelines? Will it conform to this in service spec for 17/18? Peer review /

internal assessment / when / formal appraisal of current service? Is assessment planned?

Diabetes Foot Programme (including MDfT)

/ Professional Education, Facilitation support for primary care / Mentorship and Training Contracting , Finance and Value: Strategy, Governance and Accountability Outcomes Diabetes Foot:

What is the need?

What will the project do?

• Reduced Amputations
• Improved communication

between all parties in pathway

• Self referral throughout pathway

• Baseline of what structure is in each hospital / access

• Single point of advice and self referral to be in place

• 7 day service needed – not just ‘go to A&E’
• Link communication across existing “MDfT” and to all

• Link communication across from “MDfT” to all tier 3

• Link communication across from “MDfT” to all tier 2

• Develop the MDfT aspects of the pathway

Outcomes: What will the project deliver?

Making the Case: Variation In CCGs

All data relate to the period 1/4/2012 to 31/3/2015 Source: Hospital Episode Statistics and Quality and Outcomes Framework, Health and Social Care Information Centre Produced by: National Cardiovascular Intelligence Network (NCVIN)

Bid Model 1 – Acute Diabetic Foot (or “where do I send this patient?”)

• To have a single point of contact in the STP footprint
• Appoint two podiatrists (plus support staff) to the single point of

contact

• Alert all HCPs to single point of contact
• Podiatrist duel role
• “On call” to A & E; Assessment and Treatment (24/7 or 6 - 7 day working…?)
• Pathfinder
• Liaise on admissions with MDfT and ward
• Liaise with admission to other hospitals
• Liaise with OPD MDfT
• Liaise with discharge to community services
• Audit outcomes – robust data to ensure continuity of service
• Root Cause Analysis for each Major Amputation

Bid Model 2 – Acute Diabetic Foot (or “How to fill the gaps”)

• To remove gaps in current service within the STP footprint
• Appoint two podiatrists (plus support staff) to work across the

STP in secondary care

• Increase Resource for Hot clinics in each Local Foot Attack

Centre

• Podiatrist duel role
• Community Support ensuring equality of treatment within the STP
• Pathfinder
• Work across FPTs and MDfTs to ensure equality of care
• Triage to the right MDfT facility eg vascular, renal
• Audit outcomes – robust data to ensure continuity of service
• Root Cause Analysis for each Major Amputation

Date

DISN Bid

Draft bid developer – Paul Trevatt

1. Name of provider? 2. New or existing service? 3. For existing DISN service: current role – criteria/referral process/show service enhances other staff skills / which other prof support inpatients / current funding? 4. Does service fully or partially adhere to NICE / external or internal review 5. Future role and approach of the DISN service / analysis of staff req per year to 2021 / why this will be sufficient / knowledge of differing cohorts / criteria for which inpatients ref to DSNs/ ref process in hospital / impact on length of stay / reduction in harms – medication errors / hypo and hyper episodes / audit and review and promote change / How service will enhance the diabetes skills of other inpatient staff 6. Implementation plan – clinical supervision / recruitment and training of DISNs 7. Specific actions 8. Current and future make-up of diabetes inpatient specialist teams DSNs / Pods / Cons etc 9. Plans for Saturday and Sunday?

• 10. Finance and metrics
• 11. Recruitment and training plans? / existing employees trained up / LETBs / training

arrangements confirmed / actions if delays in recruitment?

• 12. Risks – to implementation / arising from relationships / that interventions are not well targeted /

inter-relationships with other strategic plans

• 13. Describe proposed additional or existing DISN service will support wider treatment pathway/

in care plan / follow up to be ensured

• 14. Funding of the service over long term / Reduction in LOS and complications are reinvested-

self sustaining / How CCG and provider savings will be reinvested

• 15. When will service commence?

Application questions

Diabetes Inpatient Specialist Nurse (DISN) Project

/ Professional Education, Facilitation support for primary care / Mentorship and Training Contracting , Finance and Value: Strategy, Governance and Accountability Outcomes, DISN:

DSNs are cost effective, improve clinical

• utcomes, and reduce

LOS in hospitals DSNs play a key role in supporting people to self manage their condition with 92% responsible for delivering self management education to people with diabetes DSN workload has increased considerably in terms of patient numbers and complexity

What is the need?

Map the number of DSN & DISN posts across London. Identify areas where there is no DISN / limited DISN

• input. Link role to outputs.

Draw together different partners, from commissioners to clinical network, from trusts to academic providers to voluntary sector.

What will the project do?

• Additional DISNs, additional diabetes patients seen, reduction in LOS,

improvement in patient experience, reduction in medication errors, reduction in hyperglycaemic / hypoglycaemic episodes, cost savings,

One in six patients

• ccupying a hospital

bed has diabetes

• Large scale evaluation of the DISN role

across multiple trusts by a academic provider recognised for workforce modelling research

• Increase DISN posts in trusts that do not

have any (NaDIA data)

• Improved patient experience
• Finical savings from reduced LOS
• Financial savings from fewer inpatient

harms

• Health benefits / QALYs
• Reduction in inpatient harms including

reduced medication errors and hypoglycaemic events

• Reduced time requirement of diabetes

patient s on other clinical staff due to being treated and managed by DISN

• Reduction in length of stay for patients

with diabetes

• Development of commissioning business

case for DISN post

Outcomes: What will the project deliver?

Support a large scale regional pilot/ evaluation

• f the DISN role (form &

function) across large and smaller London providers – the first of is kind. Develop a business case / economic modelling for commissioners on role and value of DISN post

Regional approach

Multi-partner DISN application could involve the following sites

• Chelsea and Westminster Hospital
• Epsom and St Helier hospitals
• Queen Elizabeth Hospital
• St George’s Hospital
• University College Hospital
• West Middlesex University Hospital
• The bid would be supported by an academic partner with

experience in specialist nurse evaluation.

• The bid would require a lead provider / lead CCGs to support

funding / governance arrangements.

• The trusts above did not identify a DISN post (NaDIA).
• Trusts / CCGs to approve (or not).

Local bids

• Bids will be expected from individual CCGs or CCG
• collaborations. These could, for example, be across

provider footprints or STP footprints.

• Bids should be developed in partnership with

providers, regardless if they are from individual or multiple CCGs.

• Bids from multiple CCGs should set out the planned

levels of improvement at CCG level and, where appropriate, at general practice level.

• Bids may be made with academic provider (or not).

Areas for discussion

• Identification of funding is only part of the solution
• Do we have the appropriate qualified workforce

ready to take on the role of a DISN?

• If not, should we train up / mentor / buddy / other?
• Do any models currently exist that we can implement

(London / England / elsewhere)?

• How do we recruit within London?
• How do we avoid pilot trusts recruiting from other

trusts?

• Can we learn from other CNS groups (cancer /

specialist palliative care / neurosciences)?

LONDON REGION – NATIONAL DIABETES PROGRAMME LAUNCH EVENT