1. “ Delivering results to you ” Share information. Facilitate diabetes care planning. Dr Pete Davies; p.davies@nhs.netp.davies@nhs.net Sandwell & West Birmingham NHS Trust

2. The Problem: Diabetes care: often passive –Are we surprised if appointments & tests are forgotten or missed? Cards stacked against patients –Professionals have the power & knowledge and can prepare –Patients cannot easily be prepared We lack shared understanding –which tests matter? –What do the results mean?

3. “Breaking bad news” in diabetes consultations e.g. HbA1c blood test results Similar to hearing negative feedback at performance review/appraisal Can’t take it in Don’t hear anything else that is said There has to be a better way!

4. To achieve better outcomes in Long-term Conditions You need all these components Engaged empowered patient Organised proactive system Partnership = Better outcomes

5. Patients & Partnerships Overlooked Engaged empowered patient Organised proactive system Partnership = Better outcomes Service redesign; QoF, etc. Lots of focus, attention and investment “Cinderella”

6. The average person with diabetes: spends three hours each year with a professional The remaining 8,757 hours, they care for themselves. 3 8,760 = 0.03 %

7. Historical Diabetes Care Passive –Nurse/doctor agenda –Telling e.g. results of tests, examination etc. –Judging –Prescribing & proscribing “thou shalt not” –Often time-constrained

8. To support Self Care Get Active! –Patient-led agenda –Share information before the care plan meeting –Allow time for reflection –Patient is better prepared Engaged An active partner

9. Understanding Glucose control- HbA1c Test We do not make it easy for patients! …a surrogate for glucose control …useful clinically BUT abstract, not easy to explain, or understand Units of measurement have changed! –7%  53mol/mol

10. Solution: When blood tests processed Send HbA1c result –direct to person with diabetes –Do so for everyone –Make it timely (before the care- planning review) –Do so in a format that communicates meaning promotes reflection & care planning

11. Lean Six-sigma Methodology Key Moments Force-field analysis Voice of the Customer Survey Root Cause Analysis Inventive problem solving Helped identify key enablers; helped us ‘manage’ resistors Game-changer! Demand high original idea (text message) NOT popular Understanding of HbA1c is poor Identified low health literacy Product design would be critical Incorporate low cost AND high quality- The ‘Personal Mailer’

13. Health Literacy & patient/user views Patient group consultation Online communities: DAFNE-online (UK) & Tu-Diabetes (international) –Feedback on idea & options for graphics and text via online survey tool

14. Professional Help One member of patient group was a graphic designer! Artwork ideas discussed with 2 independent graphic designers

15. Descriptor text Aim for a low reading age –Calculated reading age =‘easy to read’ for a 13-15 or 11 year old, respectively Not bad for an abstract concept

19. Design Features Trend present and previous results Number and arrow Scale Coloured ruler 3 categories linked to NICE & QoF targets Clear advice “what next” ‘pause, reflect.. bring to consultation’ Goal setting & individualised targets Signpost to lifestyle services Simple descriptors

20. Design Features Trend present and previous results Number and arrow Scale Coloured ruler 3 categories linked to NICE & QoF targets Clear advice “what next” ‘pause, reflect.. bring to consultation’ Goal setting & individualised targets Signpost to lifestyle services Simple descriptors

21. Design Features Trend present and previous results Number and arrow Scale Coloured ruler 3 categories linked to NICE & QoF targets Clear advice “what next” ‘pause, reflect.. bring to consultation’ Goal setting & individualised targets Signpost to lifestyle services Simple descriptors

22. Outcomes of Design Work The result is meaningful –You don’t have to‘get it’ (i.e. understand A1c) in order to know how your diabetes treatment plan is doing Now you have the meaning, you might just assimilate this into –positive health behaviours, –Engagement in care planning

23. Does it work? Pilot Evaluation n=1800 –8 general practices recruited –1 specialist practice (PHD) Evaluated by paired questionnaire Administered at time of consultation Patient and HCP gave their views We could match the responses

24. Results to Patients: patient benefits Statement % Agreeing/ Strongly agreeing* “Getting my HbA1c result before my appointment helped me” 73% “having my HbA1c result made it easier to talk to my doctor and/or nurse” 76% “I would like to receive my HbA1c result in this way in future” 89% “The fact my patient had their HbA1c result made the consultation easier” 74% People with diabetes Healthcareprofessionals *n=178 questionnaires returned for analysis

25. Results to Patients: patient’s behaviour DomainPatient comment Medication adherence (concordance) “getting my result made me take my tablets” Dietary adherence “I’ve been trying hard with my diet, so this really gave me a boost” Empowerment “I will go back to my nurse and ask to go on a diabetes course” Confidence “I can now see that my treatment plan is really working!” People with diabetes *n=178 questionnaires returned for analysis

26. Results to Patients: benefits to diabetes team DomainHCP comment* Understanding diabetes “they wanted to know more about their result” Engagement “before this it was difficult to get her to come” Partnership working “after we’d discussed their result, they could see its value and were all for it” Did this create time pressures? No extra time pressures *n=17 professionals across 8 practices Healthcare professionals

27. Present State Successful roll-out –December 2011, all Sandwell GP practices –Available to 20,000 people with diabetes Safeguard –exclude screening for diabetes High level of interest, other PCTs/CCGs and patients Support from my Trust –Sustainable & may be extended

28. Summary & Conclusions Patient involvement enabled product quality Sharing information in this way –Led to positive changes in health behaviours –Enhanced consultations/care planning, suggesting partnerships were strengthened Suggesting people have understood & taken greater control of their diabetes   

29. Summary & Conclusions (2) We recommend Lean Six-Sigma methods for Quality improvement work Many other applications of this technology are feasible Easily transferable to other areas Lots of options for moving this into the digital health domain    

30. Acknowledgements Mr Stuart Davis, type 2 diabetes 15 yrs, podiatrist 37 years, Sandwell PCT Ms Dottie Tipton, Service Improvement Manager, SWBH Dr Jenny Harding, pharmacist, Director of Clinical Governance Sandwell PCT Thanks to Lilly UK for providing project support. Thanks to Sandwell Diabetes Support Group for financial support for the pilot

31. Understand diabetes. Take control p.davies@nhs.net Maybe initiatives like ours can help achieve that