1. 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

2. 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 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: /hsdr02440

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Specialist Community Team

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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 -
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.