1. The Role of Clinical Networks in Supporting Improvement
Dr David Lipscomb and Abigail Kitt

2. Questions to consider for your presentation are:
1.   Which forms of variation are most serious?
2.   What are the barriers to a better diabetes system?
3.   What would enable a better local diabetes system?
4.  Are there changes to incentives and measurement that would support improvement?
5.  What role does integration have to play in improvement? What would enable it?

3. million
1-2 Clinical Sessions per week
2 days a week as lead organisation for NDPP
4 days a week “interim” programme manager

4. The Role of the Clinical Network
Non Statutory & Support
Not Performance Management
We support commissioners and providers to implement improved care for diabetes
Strategic overview and identification of gaps
Objective independent advice and expertise
We have a Clinical Advisory Group to provide a forum for providers and commissioners to share information, shared practice and provide advice.
We work to simplify, provide expertise and understanding of local context to enable progress
Allows space for interaction and sharing
Provided input to national to support and shape projects i.e NAO
Our work is about relationships and trust

5. South East Diabetes Programme - Plan on a Page 2016-17
Delivered through a network of patients, carers, the public, clinicians and commissioners in order to improve diabetes related health care outcomes across Kent, Surrey and Sussex
Aligned with South Region Diabetes Programme
NHS Diabetes Prevention Programme (NDPP)
To lead and coordinate the Wave One NDPP implementation across the South East following successful Expression of Interest (March 2017)
To provide specific project support and leadership to commissioners and GP practices for effective implementation and roll out (March 2017)
To support selection of preferred provider through national procurement across the South East (May 2016)
Patient Education
To improve the standardised data capture and reporting of patient activity from the providers (March 2017)
To support improvements in data capture in primary care systems (March 2017)
To encourage improved access and uptake to patient education and support empowering patients with diabetes to manage their own condition (March 2017)
To support assessment of all education programmes against NICE criteria through use of QISMET certification process (March 2017)
To work with South programme teams and programme lead to ensure sharing of best practice in relation to patient education provision across the South (March 2017)
Footcare
To encourage and support full participation in the national foot care audit in order to target key issues and ensure the implementation of the NICE Guidance for foot care, including the establishment of MDT and linking with vascular networks (March 2017)
To work with South programme teams and programme lead to ensure sharing of be4st practice in relation to foot care services across the South (March 2017)
Commissioning Support
 To encourage increased participation in National Diabetes Audit (NDA) and produce updated briefing (September 2016)
To provide ad hoc advice and commissioning guidance as required (March 2017)
Continue to provide clinical advice and oversight in partnership with the ASHN on the Hypo pathway (March 2017)
To review rating of diabetes component of CCG assessment framework and develop related action plan (March 2017)
Provide communication links between local diabetes CAG and the South East/London Diabetes Paediatric Network

6. Our talk
We are going to share 3 key challenges we have identified as a network and how we are trying to support address them

7. Challenges – CCG Management Capacity & Capability & Engagement
The rapid turn over of CCG diabetes commissioners.
Varying capability and priority given to diabetes
The lack of capacity in commissioning and providers to have space to engage with the CN and space to develop – constantly impressed by how much does get achieved
Slowness of change
Variation in engagement. Diabetes not necessarily priority

8. CCG – A random example CCG “x” has a population of 480,000
It represents 250 GPs
It has a budget of £609.8million
If we accept that 10% of their budget is spend on diabetes that is £60millon of the budget
Yet there is only 1 CCG manager and 1 lead GP and they cover a number of conditions and yet a significant influence on the budget
If this was a business with a turnover of £60m you would have more than one commission/project lead

9. To address:
It is extremely helpful to have the 2 indicators in the CCGIAF and the Diabetes Aide Memoire (certainly supported improvement in NDA take up)
We are a constant place of support, expertise, history
We provide information/guidance/shared learning that is locally specific
Trusted source of support – NDPP example – trusted relationships formed

10. Clinical Leadership/HCP Training
Issues of recruitment gaps
Issues of capacity to take up leadership roles
The capacity to undertake leadership training to improve leadership skills
The complexity of the system to lead with potential for miscommunication
Better relationships and appreciation of skill mix between clinical leads and commissioners/managers Commissioning across CCG boundaries
Potentially our best clinicians have had enough?
HCP training – we are working to ensure “quality” of patient structured education but are struggling to find ways to ensure quality of education/training for HCPs.

11. To address:
We have a CAG that is inclusive not exclusive. We try and provide webexs, etc to enable wide participation
We have a consultants forum which will be joined with HEKSS Deanery
We try and provide locally specific information and support
We continue to flag up HCP education with HEKSS and nationally
We are proud to have 2 DUK clinical champions

12. Complexity of Commissioning & Incentives
Public Health, NHS England (GP, Specialist, NDPP), CCGs, Social Services
The long term nature of diabetes and the need for CCGs to demonstrate “in year” improvements, particularly around finance
BPT, PRB, CQUINS, LES/LIS, Quality Premiums, STP Fund, GMS
There isn’t the facility for commissioning across the whole patient pathway and the Sharing of clinical and financial responsibility.

13. To address: As an example Foot Care – a complex commissioning pathway
We had to briefing paper to try and demonstrate why we should look at diabetic foot care at all
We worked with the vascular reconfiguration networks
We run the South East Foot Care Network as a shared forum
We have just finished our 3rd yearly gaps analysis for every MDFT across KSS
We provide an annual, locally specific foot care data briefing to support business planning
We are conducting an RCA process
All our MDFTs were supported to participate in the NDFA

14. To address: Simplification of incentives as levers
Significant variation in LES payments and content.
Should be the same from Lincolnshire to Lancaster?
Transparency
LES guidance on appropriate content for LES and payment?

15. Patient Education Identified issue of quality.
Capitalising on our biggest wasted resource – people affected by diabetes
We now have 5 locally developed programmes QISMET certified as meeting the NICE criteria:
SADIE
BHITE
STEPH
MINT1E
SITE
(4 more in the pipeline)
And 2 gaps analysis

16. Ambulance Hypo Pathway
Improved capitalising on third sector and industry resources and support where appropriate

17. Challenges - CN The insecurity of the Clinical Network
Issue of nimbleness, particularly for task and finish work: Smith Review, difficult to recruit staff on short term basis, budgets, interim staffing
The rapid change of CCG diabetes commissioners.
Varying capability and priority given to diabetes
The lack of capacity in commissioning and providers to have space to engage with the CN and space to develop – constantly impressed by how much does get achieved