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

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

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

Diabetes Data for West Herts – 2005/06 Inclusive of 2nd,3rd & 4th reasons for admission PCT Population Diabetes Register QMAS data Diabetes out patient attendances Podiatry clinics for Diabetic patients Unscheduled care attendances Emergency admissions Average LOS NP FU Watford & 3 Rivers 180,000 5163 168 791 357 2702 30 429 10.4 Dacorum 149,000 4147 206 1347 282 2598 21 301 8.1 St Albans & Harpenden 136,000 3447 157 679 154 2584 12 227 7.9 Hertsmere 93,000 2750 22 92 216 1195 2 52 11.4 West Herts 558,000 15707 553 2909 1009 9079 65 9.2 Outpatient data to be reviewed by C Johnston, Unscheduled care and emergency admission data ??? to review against national figures

Estimated prevalence of diabetes Type 1 and 2 across West Herts (York PBS model) Qmas data type 1 (estimated prevalence York PBS model) type 2 (estimated prevalence York PBS model) male female total % Watford & 3 Rivers 180,000 5163 322 237 559 9% 2241 3374 5615 91% 6174 Dacorum 149,000 4147 273 198 471 10% 1695 2604 4299 90% 4770 St Albans & Harpenden 136,000 3422 257 166 423 1599 2403 4002 4425 Hertsmere 93,000 2750 181 137 318 1268 2024 3292 3610 15482 1033 738 1771 6803 10405 17208 18979

Current Pathway Fragmented services between professional groups – no multidisciplinary team approach Outpatient secondary care provision instead of a disease management approach Fragmented services between primary care organisations and acute care Lack of coordination between professionals and services Inequity of service provision across local health economy Lack of education and information resources The following table charts provision of diabetes services across PCTS PCT Podiatry Dietetics Diabetes specialist nurses Education Retinopathy services Provider 1º 2º Watford & 3 Rivers Dacorum St Albans & Harpenden Hertsmere

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

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

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

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

Estimated population requiring management by a specialist diabetic team based on a population of 150,000 (retinopathy and paediatric care provision is excluded from this model) prevalence Estimated diabetes population Proportion to be managed in general practice Proportion to be managed by specialist care Diabetes  3% 4,500 77% 23% 1057 Type 1  10% 450 0% 100% Type 2  90% 4050 85% 15% 607 This is the percentage that proportion overall that would be managed by a specialist team are you all happy with this ratio

Cost of service in Primary Care Cost of service for a population of 150,000 (diabetic population of 4500) estimated diabetic prevalence of 3% with  23 % of diabetic population requiring management beyond general practice.   Gross unit Total Cost of service in Primary Care Qty Unit cost p.a. £k GPwSI/Consultant diabetologist Sessions 100 DSN wte 35 Podiatrist Dietician Orthotist Administrator 20 Diabetic educator clinical pharmacology Obstetric consultant  100 Midwife Staff cost 0.00 Non-pay on-cost at 42% Total service cost Based on condition population of 5,184 Cost/ patient (£ p.a.)

Cost model of Diabetes pathway across West Herts Scheme: Dac W3R St Albans & Harpenden Hertsmere St albans Herts   Savings in Secondary Care % Reduction Activity Unit Cost /unit Saved £k saved Annual activity Non-elective admissions 10% Spells Outpatients - FS (WHHT)  100% Appointments Outpatients - FU (WHHT) 100% A&E attendances Attendances Saved trust activity Condition prevalence Service cost per PCT Current PCT spend diabetes community services Net saving £k p.a.