An Exploration of the Transition of An Adult Diabetes Service in England Transition from a hospital based model to a community based model of care (Type 2 – Diabetes) Impact of an ageing population & long-term conditions on health care systems Over 2.7 million people with Diabetes in England Challenges – health maintenance, cost-effective provision whilst maintaining service quality & patient experience

Research Study Background Research findings part of a larger study 3 year project focusing on patient and public involvement in the commissioning of long term conditions services Funded by the National Institute of Health Research Phases – National scoping exercise, 3 case study sites in England Peckham, S; Wilson P.M; Williams.L; Smiddy.J; Reay.J;, Bloomfield.L; Kendall. S; Brook.F & Smallwood.D. 2014. Commissioning for long-term conditions: hearing the voice of and engaging users – a qualitative multiple case study, Health Services and Delivery Research Volume: 2 Issue: 44 DOI: 10.3310/hsdr02440

Case Study Site 18 month case study analysis (2011-13) Diverse in terms of geographical location & demographic profiling Exemplar Development Tracking & evaluating a diabetes service re-design (hospital to community-based) Approximately 21,600 patients with Type 2 Diabetes Data collection methods focused on field work; documentary analysis; non-participant observation and interviews with key stakeholder including patients; clinicians and service managers

Location Profile One of England’s largest cities with industrial roots Located centrally in Britain Population approximately 550,000 Age profile – Under 5 years (6.1%), under 20 years (24.4%) 75 + years (7.5%), 85+ years (2.1%), 95+ years (0.8%) 2 Universities – 50,000 students By 2017 increase of 8.4% in 75+ years Ethnically diverse – approximately 14% population from black or minority ethnic groups Deprivation higher than national average Life expectancy for men and women lower than national average Higher rates of mortality and morbidity than the national average

Local Health Services Time of Transition – Primary Care Trusts & Strategic Health Authorities abolished Practice based commissioning groups became Clinical Commissioning Groups (CCGs) Three main hospitals, children’s hospital Single Clinical Commissioning Group Comprises all health clinics/general practices within the city (89) 99% of population registered with GP practices

Factors Influencing Service Re-design Disease Projections Number of patients with Type 2 Diabetes projected to increase from 21,600 to 30,000 by 2020 Demands on hospital-based care (secondary care) Before service redesign all patients with requirements above routine management referred to hospital irrespective of need Stakeholder Feedback Public consultations identified the need for improved communication between primary and secondary care, care nearer to home and at a single location Key Policy Drives and Service Gaps Health policy drives for care closer to home, locally overall rise in admissions

Community Diabetes Services (Type 2 – Diabetes) Levels of Care Level 1 – Routine Level 2 – Enhanced Level 3 – Specialized Level 4 – Complex Level 1 & 2 to take place within primary care

Main Objectives & Outcomes To improve quality of care & clinical effectiveness, ensuring patient safety, ensuring patient satisfaction The same if not better clinical outcomes Clinical Target: At least 56.5% of patients will have an HbAlc level at or below 7.5% Patient supported via care planning approach Good patient experience An increased number of patients cared for outside of the hospital setting

Benefits & Performance Specification Financial Benefits Central (service based in one area of the city) expected net savings YR 1 - £17k YR 2 - £78K YR3 - £ 93K City-wide (roll out of service to all areas of the city) expected net savings YR 1 - £95K YR 2 - £111K YR£ - £113K

Community Service Comprised a multi-disciplinary team Consultant & diabetic nurse specialists Service focus: to ensure that patients were cared for at most appropriate level & reduce burden on specialist provider (hospital setting) Level 1 & 2 care to take place within primary care The majority of T2DM patients on oral agents, daily insulin regimens to managed in primary care

Getting Started Main aim to assist primary care teams to deliver more complex care (Commencing 2009) Diabetic Nurse Specialists bridging primary and secondary care Diabetes Planning and Commissioning Group – supported transition process – patient/public involvement (Diabetes UK) Required up skilling of practice nurses: nurse specialist – led education General practitioners Consultant-led education – mentorship, joint consulting, educational events, case-note discussion

Specialist Community Team

On-Going Initiatives Support & expertise relating to: - Self management Diet & Lifestyle New Therapies Initiation of Insulin Therapy Short term interventions – insulin initiation referral – management plans jointly agreed with patients

Service Examples Support clinics for patients – increased understanding of condition and it’s management, independent living Training provision for practice nurses, district nurses, care homes – aim to offer on-going care for diabetic patients Training provision for patients – structured education courses (DESMOND & Expert Patient Programme) Commenced clinics within Leisure/Sports centres Liaison with Ambulance services – acute admissions are followed up by the team

Service Time Line & Achievements Year 2009 – 1250 patient follow up appointments for diabetes took place in the community Year 2010/11 – diabetes services at hospital re-commissioned focusing on Level 3 specialist care Year 2012 – Community Diabetes Service rolled out citywide – key role for nurse practitioners in education and support, patient and professional feedback mechanisms reflected positive response to new service Almost 3,000 patients with Type 2 diabetes discharged to secondary care Financial projections realised – savings re-invested in community service

Some Key Enablers Professional support for service change Consultant flexibility Diabetes Nurse Specialist – role development Practice nurse and General Practitioner buy-in & upskilling Education & Training Patient Acceptance – care closer to home, nurse support through transition Changes in Tariff Based Services

Conclusions & Future Applications Central role of community nurses in service re-design Active Patient & Public involvement Role flexibility & Upskilling Proactive working relationships Template for service transition from hospital based care to community (diabetes) Potential template for other long-term services

Questions Contributors Dr Jane Smiddy (University of Hertfordshire) Ms Joanne Reay (NHS North East Clinical Commissioning Group) Ms Lorraine Williams (London School of Hygiene and Tropical Medicine) Professor Stephen Peckham (University of Kent) Professor Patricia Wilson (University of Kent) Contact - j.e.smiddy@herts.ac.uk HS&DR Funding Acknowledgement This project was funded by the National Institute for Health Research Health Services & Delivery Research programme (project number 08/1806/261). Department of Health Disclaimer The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health.