1. 1 Primary Care Working At Scale North East Essex Diabetes Managed by Suffolk GP Federation 18 June 2015

2. 2 Suffolk GP Federation  61 practice members of 65 in Suffolk  Facilitate practices working together  Address issues which are optimally solved by collaboration  Provide a management infrastructure  Practices remain independent partnerships  Not for profit CIC  Elected Board of GPs, PMs & CEO  Objectives include support and expanding role of primary care

3. 3 North East Essex diabetes  Rising demand  North Essex lower quartile outcomes  Care processes - below national mean  HbA1c <64 – 168th out of 211  ‘Hospital model’ seen as unsustainable  Services fragmented – want integration under umbrella of a single provider  Service tendered and won by Suffolk GP Federation

4. 4  Diabetes & podiatry, outpatients & education – adult only  Separate agreement for inpatients  £2.5m in Year 1 (then falling) - no additional investment  Fixed budget with 25% contingent on delivering key performance indicators – no exception coding  5 years with possibility of +2 year extension The contract – managed by Suffolk GP Federation

5. 5 The strategy  Diabetes Service Board to manage the services  3 legged model 1.Patient involvement - care planning & service delivery 2.Investment in primary care capacity & expertise 3.Diabetes Specialist Team – working in the community  Consultants on secondment  6 specialist nurses, 2 dieticians, 1 specialist midwife & 3 admin  Underlined by monthly extract of data from practice clinical systems – next slide

6. 6 Example monthly data extract summary Note – this data extract is based on the National Diabetes Audit format which is different to QoF

7. 7 Example of the Practice Dashboard

8. 8 Primary care responsibility  Governance  Practice lead GP & nurse  Quarterly meetings with consultant & Link DSN  Referrals via Specialist Team  Monthly primary care data extract  Case finding e.g. IGR  Year of Care training and roll-out  Manage wider range of patients – stable T1, T2DM discharged from hospital  Involve partially engaged  Focus on KPIs – particularly 8 care processes  £6.44 per list patient over 5 years – Moving to 100% on outcomes from 2015/16

9. 9 2014/15 progress  Positive engagement by Colchester Hospital and specialist clinicians – facilitated positive change incl. TUPE, IG and contract issues without a significant detriment to service. Similar joint working with Anglian Community Enterprise  Diabetes Services Board now manages service  Significant investment in engagement events, patient groups and social media  Diabetes Specialist team formed  New role for consultants supporting practices and providing governance  Positive impact of DSN Link Nurse influencing change in referrals  Regular non-clinical visits to improve coding and improve engagement  Most care moved out of hospital  504 (66%) of former hospital patients discharged to practices (142 (44%) T1s and 362 (83%) T2s) – remainder managed in community by Specialist Team – only 2 complaints  Only combined specialist clinics which require input from other specialists or specialist equipment remain at the hospital  Year of Care training rolled out across all practices

10. 10 2014/15 outcomes April 2014March 2015Note Number on diabetes register 17,47018,400+5.3% Patients receiving all 8 care processes 7,005 40.1% 11,095 60.3% Percentage receiving all 8 +20.1% (+58% on 4/15) Newly diagnosed offered structured education Unclear T1’s 95% & T2’s 96% 187% increase in patients referred v 2014/15 1,607 patients referred for structured education, 588 booked (37%) and 462 completed (29%) HbA1c <=64mmol/mol 11,687 66.9% 12,112 65.8% This fell for patients on register >12 months as well Cholesterol <=5 12,400 71.0% 13,657 74.2% Percentage with Chol <5 +3.2% BP <=140/80 11,777 67.4% 12,939 70.3% Percentage with BP <=140/80 +2.9%

11. 11 % Patients Receiving all 8 Care Processes at 31/3/15 2013/14 mean Individual Practices

12. 12 Other outcomes % of Register at March 2015 % change T1s receiving a foot check 63%+12.0% Foot ulcers referred to Podiatry 16%+7.7% High risk feet referred to Podiatry 26.2%+17.5% Patients with care plans 16% +7.8% Admissions for DKA/hypoglycaemia /hyperglycaemia 188 to 177 -7% Readmissions for DKA/hypoglycaemia /hyperglycaemia 98 to 67 -31%

13. 13 Comments  Brave commissioning by CCG  Improving clinical outcomes takes time  Very complex contract to manage with significant risks – not for the faint hearted!  Importance of positive buy-in and engagement from senior clinical team members – both consultants and nurses - changing role of consultant  Including the inpatient work makes a comprehensive and joined up service  Difficult to recruit patients onto peer led empowerment programmes  Importance of real time activity feedback  Not all practices able to fully engage - Hard to reach patients need a separate strategy  We now have increased knowledge of the total cost of diabetes e.g. insulin pumps  Coding is a major issue - foot coding still an issue  Pace of change a challenge