1. Reforms: Diabetes West 2012-2016
Neil Black MD FRCP (Edin.)
Consultant Physician
Lead Clinician Diabetes Network
Western Health & Social Care Trust
Reforms: Diabetes West

2. Reforms Identify a problem
Those at the sharp end come up with the solutions
Take it from the patient perspective
Evaluate and adjust

3. Themes of reform
1. Stratification 2. Care integration & Communication

4. Care types/levels
Hospital MDT: T1 n ~1300, T2 ~3,000 Modified Portsmouth Model (‘Super Six’)
Acute inpatient
Pregnancy / Pre-Pregnancy
Active Foot disease
Advancing CKD/RRT
Type 1 (including insulin pumps)
Complex T2
Care delivered as close as possible to ‘one stop shop’

5. Care types/levels Primary Care: n=6,500 At risk of diabetes
Hospital MDT: T1 n ~1300, T2 ~3,000 Modified Portsmouth Model (‘Super Six’)
Acute inpatient, Pregnancy/PrePregnancy, Active Foot,
Advancing CKD/RRT, Type 1 (incl. insulin pumps), Complex T2
Care delivered as close as possible to ‘one stop shop’
Primary Care: n=6,500
At risk of diabetes
Controlled T2
Uncontrolled T2 with guidelines and advice

6. Care types/levels
Hospital MDT: T1 n ~1300, T2 ~3,000 Modified Portsmouth Model (‘Super Six’)
Acute inpatient, Pregnancy/PrePregnancy, Active Foot,
Advancing CKD/RRT, Type 1 (incl. insulin pumps), Complex T2
Care delivered as close as possible to ‘one stop shop’
Primary Care & Diabetes Support Team: n=3,000
‘Uncontrolled’ T2
T1 DNA: to be invited to #Type1West online community
Primary Care: n=6,500
At risk of diabetes
Controlled T2
Uncontrolled T2 with guidelines and advice

7. Care types/levels
Hospital MDT: T1 n ~1300, T2 ~2,000 (↓ from 3,000) Modified Portsmouth Model (‘Super Six’)
Acute inpatient, Pregnancy/PrePregnancy, Active Foot,
Advancing CKD/RRT, Type 1 (incl. insulin pumps), Complex T2
Care delivered as close as possible to ‘one stop shop’
Primary Care & Diabetes Support Team: n=4,000 (↑ from 3,000)
‘Uncontrolled’ T2
T1 DNA: to be invited to #Type1West online community
Primary Care: n=6,500 (↔)
At risk of diabetes
Controlled T2
Uncontrolled T2 with guidelines and advice
Refer to the ‘shaft left’

8. DiabetesWest care integration
Open / shared records
Education
Guidance
Accessibility for advice

9. DiabetesWest care integration
Consultants with Primary Care
Systematic Practice visits: organisation, audit, education, support, case discussions
Regular Diabetes slot at Primary Care Practice Learning Days
Reorganisation of diabetes community team
Equity of access across WHSCT area, professionals in specialty hubs
Coordinated working as active MDTs rather than independent professionals
Guidelines and pathways
NI Electronic Care Record Diabetes Pathway
Open, transparent, patient-centred
Western adoption June 2016
Diabetes Service single point of referral
NIECR e-referral triage: referral from GP desktop system

10. Communication: futures
NIECR Patient Portal Electronic Document Transfer Podcast GP / Practice nurse education (Public Health Agency collaboration) Project ECHO (PHA /e-health collaboration)

11. When the case doesn’t fit…..
Self-Management Education:
DESMOND
Diabetes Updates (Diabetes CHAT)
CHOICE (Insulin flexible dose adjustment: BERTIE)
CHOICE refreshers
Divert Diabetes (prevention)

12. Diabetes West: IHI Triple Aim
Improving the patient experience of care (including quality and satisfaction);

13. Diabetes West: IHI Triple Aim
Improving the patient experience of care (including quality and satisfaction);
Continuity
Common, simple messages
Empowered patient making decisions together with their team
Reducing waits for reviews
Reducing waits at clinic attendance
Clearer pathways for specialty access and urgent referral
Bring care closer to people: diabetes support hubs

14. Diabetes West: IHI Triple Aim
Improving the patient experience of care (including quality and satisfaction);
Improving the health of populations;
Systematic practice visits targeting low A1c on SU, high A1c
Auditing achievement of essential points of care
Quality improvement initiative with GP QI leader on 5 point critical care component initiative
Increase direct communication, support and education for: GPs, Practice Nurses, Community Pharmacy

15. Diabetes West: IHI Triple Aim
Improving the patient experience of care (including quality and satisfaction);
Improving the health of populations;
Reducing the per capita cost of health care.
Reducing duplication of effort
Reducing repeat testing by open access to common records
Decomissioning Diamond system
Reducing complications?

16. Neil Black
Diabetes West 2016