1. Integrated Diabetes Service (HvIDS)
Information Evening
19th June 2018
Thomas Galliford
Clinical Lead

2. Our Vision - Integrated Diabetes Model
Providing a joined up end to end pathway (enabling a smooth transition across services for patients) including single point of access
Shorter waiting times for structure education and to see diabetes consultants and podiatry
More support for primary care
Primary care up-skilling
Psychiatry support as part of the diabetic pathway
Outcomes bases contract

3. Service Specification
Tier 1
Primary Care
Tier 2
Consultant led Community diabetes care
Tier 3
Hospital based diabetes services

4. Primary care upskilling (and support)
HERTS VALLEYS INTEGRATED DIABETES SERVICE
KEY ISSUES
Primary care upskilling (and support)
Patient education
Foot health
Mental health
IM&T
HertsOne
GP Federation

5. Primary care upskilling (and support)
HERTS VALLEYS INTEGRATED DIABETES SERVICE
KEY ISSUES
Primary care upskilling (and support)
Patient education
Foot health
Mental health
IM&T
HertsOne
GP Federation

8. Enhanced clinical triage

9. Suggested Virtual Review cases:
Clinical management discussions
Second opinions in diabetes management or that relate to patient diabetes care
Case reviews incl. non-engaged patients/serial DNAs therefore for specialist oversight +/- advice
Medication
Renal
Lipids
Hypertension

10. Enhanced clinical triage
Greater Consultant presence in the community setting
Greater support for Community part of HvIDS (Tier 2) by Consultants

13. Treatment targets
Glycaemic control
Insulin management (Foundation and Advanced)
Footcare
Type 1 Diabetes
Diabetes in the Elderly
Diet and Obesity
Clinical Presentation
eLearning modules: Pre-conception, hypoglycaemia

14. GP Practice visits
Questionnaire – to be circulated and completed prior to PV date and returned to HCT
QoF data
NDA data
PH data
EDEN Gap analysis data
EDEN attendance data
PDP

15. GPPV – suggested timetable
Update regarding service and local initiatives (15 mins)
Questionnaire review (30 mins)
Case Review / case based Q&A CPD (45 mins) – 5 cases of each sub-speciality (e.g. renal/foot/oral meds/ANC/engagement/hyperglycaemia or insulin management)
Feedback regarding particular patients in HvIDS from the IDS team (cDSN lead) – (30 mins)
Discussion re: QoF/NDA/Skills gap analysis (25 mins)
Discussion re: PDP (5 mins)

16. GP Enhanced Commissioning Framework
1 GPPV
Engagement with diabetes-related education
= 6 hours of diabetes related CPD
Attendance at Herts Diabetes Conference
Attendance at Primary Care Diabetes Society Conference
Participation in Webinars
Completion of e-learning modules e.g. CDEP
Attendance at EDEN modules
PLUS incentivisation for:
GLP-1 initiation
Insulin initiation

17. Primary care upskilling (and support)
HERTS VALLEYS INTEGRATED DIABETES SERVICE
KEY ISSUES
Primary care upskilling (and support)
Patient education
Foot health
Mental health
IM&T
HertsOne
GP Federation