Health Committee work programme Appendix 1

Appendix Diabetes Modernisation Initiative Site Visit BRIEFING PACK 17th October 2013 Gracefield Gardens Health and Social Care Centre 2-8 Gracefield Gardens Streatham SW16 2ST Contents Itinerary Biographies Lambeth and Southwark – overview of the area .5 The Diabetes Modernisation Initiative .6 The DMI’s Local Partners and providers Poster - A Network of Excellence for Paediatric Diabetes: Young Diabetes Connections .8 Media Releases .9 Diabetes Community Champions tackle diabetes in Lambeth and Southwark Lambeth and Southwark Diabetes UK Voluntary Group: Working in partnership with patients to transform diabetes care 11 Care Planning Advocates: A case study of successful community empowerment 13 Tackling Unwarranted Variation: Levering change in primary care .14 17 October 2013 – From 1.30pm - 3.30pm Gracefield Gardens Health and Social Care Centre 2-8 Gracefield Gardens, Streatham, SW16 2ST Itinerary 1.25pm Arrive at Gracefield Gardens 1.30pm Welcome Meet diabetes specialist nurses who deliver self management education to patients Participate in some of the activities carried out on the DESMOND programme (a structured education programme for people with type diabetes) 2.00pm Opening presentation Tackling unwarranted variation in diabetes outcomes across Lambeth and Southwark 2.20 pm Case studies 1) Starting young: Tackling variation in paediatric care 2) Arming our community: How we're using patient advocates to spread the word about care planning and quality assure how it is done 3) Reaching the harder to reach: Hear from a community champion about how she is working on raising awareness of diabetes in her community 2.50 pm Q&A with panel members Barry Coker – Chair of Lambeth and Southwark Diabetes Voluntary Group Jane Doherty – DMI Clinical Lead/ Southwark GP Sonia Winnifred – Community Champion John O’Leary – Patient Advocate Rebecca Dallmeyer – DMI Clinical Lead Dawn Edwards – Patient Advocate 3.05 pm Facilitated discussion Learning from the DMI, what principles and approaches can be used to reduce unwarranted variation across London? 3.30 pm Close Biographies Barry Coker: Chair of Lambeth and Southwark Diabetes UK Voluntary Group Barry is the chair of our patient forum He was born and raised in Southwark and has been living with Type diabetes for the last eight years Sonia Winnifred: Vice-Chair of Lambeth and Southwark Diabetes UK Voluntary Group Sonia has been vice chair of the patient forum for around 18 months She is active in the Lambeth local community and has a personal interest in improving diabetes care in the borough Andrew Eyres: Chief Officer, NHS Lambeth CCG Andrew is an experienced NHS leader in Lambeth and has worked across the NHS in inner-south east London for 23 years He is currently the Chief Officer, NHS Lambeth CCG and the Senior Responsible Officer for the DMI Jean Young: Head of Primary and Community Care Development, Southwark CCG Jean works with clinical leads to commission out of hospital services for patients in Southwark, contributing to and translating a programme of pathway/service redesign into contracts with providers She also leads on developing the role of primary care to deliver agreed pathway improvements, including the commissioning of both extended arrangements for primary care services Rebecca Dallmeyer: Clinical Lead, DMI Rebecca has worked in south east London as a pharmacist and healthcare manager for more than 20 years in hospital, primary care and urgent care settings She has been a member of the Southwark Professional Executive Committee for the PCT and led the programme of work for long term conditions, and in particular diabetes, at Southwark CCG She is currently a clinical lead at the DMI and undertaking project work to support the development of consistent, evidence based provision of diabetes care in general practice John O'Leary, MBE: Patient Advocate John is a retired Police Officer and was diagnosed with Type diabetes about 10 years ago He attended a DESMOND and Self Management Program (SMP) and as a result dispensed with medication Following this he decided to become a Lay Tutor and was involved in delivering the SMP and is currently part of the team involved in training Health Care Professionals Dawn Edwards: Patient Advocate Is a patient who has been living with Type diabetes for nearly 10 years and is an active member of the DMI patient forum Jane Doherty: Southwark GP and DMI Clinical Lead Jane has been a GP in Southwark for 23 years and has been running the diabetic clinic at her practice since 1997 In addition to her clinical work, Jane has been a member of the Southwark Professional Executive Committee for the PCT and the lead for long term conditions at Southwark CCG She has been a GP trainer for the Guy's and St Thomas' GP training scheme since 2000 She is now a clinical lead at the DMI and co-chair of the Clinical Reference Group for the DMI Rosarie Atkinson: Diabetes Specialist Nurse, Lambeth Rosarie is a nurse working in the Lambeth Community Team The team supports the development of primary care, the delivery of clinics and structured education Caroline Rook: Practice Nurse, Lambeth Caroline also works as a nurse in the Lambeth Community Team Jane Stopher: DMI Programme Director Jane is Director of the DMI Dual trained as a general and mental health nurse, she has practiced clinically in the UK, US and Australia She specialises in leading complex change across organisational boundaries Jennifer George: DMI Transformation Lead – Self Management Jennifer is the Transformation Lead for the DMI self management workstream She has eight years of service improvement and change management experience and has worked at a local and national level to improve services for people living with long term conditions She has a Masters in Health Psychology and has used her theoretical knowledge to suggest and implement practical solutions to support behaviour change Alex Manya: DMI Head of Service Design and Analysis Alex leads the analysis and evaluation elements of the DMI He has worked in change management and service improvement for over nine years He worked on the redesign of Haringey Council’s Children’s Service and designed the NSPCC’s performance systems and service evaluation tools Lambeth and Southwark – an overview Lambeth and Southwark are large, inner-London boroughs with diverse, highly transient populations Their combined population of 600,000 has an average density of around 28,000 per square mile and an average population churn of around 27% annually, presenting challenges for the detection and treatment of long term health conditions Lambeth is one of the most densely populated inner London boroughs and has the highest proportion in the country of: Portuguese, South American and Mixed race white and black African people; people from multiple mixed ethnic backgrounds and people from non-Caribbean and non-African black backgrounds There are high levels of social deprivation, with 15% of the working-age population on out-of-work benefits Over 150 languages are spoken across the boroughs After English the main languages are Portuguese, Yoruba, French, Spanish and Twi The area is served by Guy’s and St Thomas’ NHS Foundation Trust and Kings College Hospital NHS Foundation Trust and there are currently 93 GP practices operating across the two boroughs Nationally, person in 24 is diagnosed with diabetes Across Lambeth and Southwark, the figure is in 21 The latest estimate of diabetes prevalence across the two boroughs suggests that we have detected around 79% of cases This represents a substantial improvement in the number of people whose diabetes has been detected, (an additional 4,500 people between 2009/10 and 2012/13) but there remain an estimated 7,500 people with undiagnosed diabetes across Lambeth and Southwark The Diabetes Modernisation Initiative The Diabetes Modernisation Initiative is a three year change programme, funded by Guys and St Thomas' Charity with a £4.5million grant The programme works with commissioners and acute, community and primary care providers across the boroughs of Lambeth and Southwark Three strategic priorities have remained throughout:  Improving care for children and young people;  Improving people’s ability to self manage;  Improving diabetes care in primary and community care settings Our vision is for Lambeth and Southwark to be two of the best boroughs in which to receive diabetes care, measured through improving outcomes for our population We operate across the health economy, accountable to all the partners A clinical reference group and thriving patient forum oversee our programme, ensuring our work is clinically robust and tackles what matters to patients Our principles of working are to:  deliver change above and beyond the mainstream  for change to be sustainable and not cost increasing  delivered through partnerships with patients at the heart  change to be scaleable across the health economy Following successful Foundations and Transformation phases, the programme is in its final phase: Legacy, ending in June 2014 The DMI’s Local Partners and providers The DMI’s Partner Organisations and provider landscape The DMI has partners from multiple organisations and is part of a wide and varied provider landscape Our key partners and stakeholders are: King’s Health Partners, which is comprised of three foundation trusts and a university They have 3.6 million patient contacts a year between them, are comprised of 31,000 staff and have an annual turnover of £2.8 billion The three NHS founders comprise Guy's and St Thomas', King's College Hospital and South London and Maudsley NHS Foundation Trusts Together they serve a local population that is among the most ethnically, socially and economically diverse in the world and are amongst the highest rated and financially strong Foundation Trusts in the country They provide the full range of medical and healthcare services, from acute and specialist medical care through to mental healthcare and services that promote physical and psychological well-being Lewisham and Greenwich NHS Trust provides services across Lewisham, Greenwich and Bexley The trusts are recently merged and provide acute and community services Lambeth Diabetes Intermediate Care Team provides community-based diabetes services, including diabetes clinics and structured education, to people with diabetes in Lambeth The service is comprised of Diabetes Specialist Nurses, a dietician, a GP with a special interest in diabetes and consultant diabetologists from the local acute trusts and is managed by Crowndale Medical Centre A key part of their remit is to support and improve primary care management of diabetes Southwark Community Diabetes Service is provided by the Community Services Directorate of Guy’s and St Thomas’s NHS Foundation Trust Similarly to the Lambeth community service, they offer a range of services to people with diabetes in Southwark, and work closely with primary care to improve management of diabetes in general practice General Practice We work with all of the 93 practices across Lambeth and Southwark, engaging GPs and Practice Nurses Together they have 28,000 people with diabetes on their registers We work with Lambeth and Southwark CCGs who together have a budget of nearly £800 million and serve a population of almost 600,000 Poster - A Network of Excellence for Paediatric Diabetes: Young Diabetes Connections Media Releases Diabetes Community Champions tackle diabetes in Lambeth and Southwark A team of Diabetes Community Champions is to spearhead a new campaign to tackle a growing diabetes crisis in the London Boroughs of Lambeth and Southwark New figures show there are now 35,500 people with diabetes in the two London boroughs – with one in five unaware they have the condition That is expected to soar to 42,500 people with diabetes in the boroughs by the end of the decade The 15 local Diabetes Community Champions will help people spot the signs of diabetes and encourage them to go for health checks They will tell them how to change their lifestyles and where to get services to stop diabetes from leading to disability or early death The champions all come from Black, Asian and minority ethnic communities, where diabetes is more common than in the white population They include a bishop, psychotherapist and practitioner working with drug users Diabetes UK is running the project to deliver 30 community events by the end of October It is one of three schemes they are delivering across London The Diabetes Modernisation Initiative – a local programme to help people with diabetes live well – is funding the work in Lambeth and Southwark The champions will organise coffee mornings, give talks in community centres, attend tenant meetings, and run stands at fun days and events They will explain what diabetes is and what puts people at risk - like high blood pressure, being overweight, or having relatives with diabetes The champions will tell people about the local services available, including five specialist community clinics, self-management courses, and how to get their feet and eyes checked They will help people understand that diabetes, if left unmanaged, can lead to blindness, amputated limbs, strokes and kidney failure Sandra Tomlinson volunteered as a Diabetes Community Champion because her partner has Type diabetes Ms Tomlinson said: “Five years ago he was drinking five to ten 10 litres of water a night and his feet were swelling up But our GP didn’t recognise the symptoms It was two years before another doctor tested him for diabetes.” Ms Tomlinson will run workshops for African Caribbean communities in Southwark She says: “I come from an African Caribbean background and understand the culture I can help dispel some misunderstandings about diabetes, such as the false belief that it only affects older people The programme is a great way of getting the message out.” Juliet O’Brien, Diabetes UK Diverse Communities Officer, said: “Raising awareness of diabetes in minority communities is vital; people from an African or African Caribbean community are three times more likely to develop Type diabetes and people from a South Asian background are six times more likely to develop the condition Getting the word out into the local community is a crucial step to tackling the rising tide of diabetes.” Jennifer George, Transformation Lead at the Diabetes Modernisation Initiative, said: “This small band of champions will make a huge difference They will reach into their communities at an early stage to stop diabetes playing havoc with people’s lives later on They will let people with diabetes know what care to expect, how to get it and how to look after themselves We hope the Champions will continue to spread the word about diabetes, and how it can destroy lives, after the campaign finishes in October.” To find out more, email juliet.o’brien@diabetes.org.uk or visit www.diabetes.org.uk 10 Lambeth and Southwark Diabetes UK Voluntary Group: Working in partnership with patients to transform diabetes care Two years ago, the DMI wanted to give people living with diabetes in Lambeth and Southwark more of a say in their health services It set up the Diabetes Patients Forum to help people with diabetes talk to health professionals about better ways to design and develop the best services for them Since then, the Forum has met every other month It now has 80 members – all over 40 years old - who come from different local and ethnic communities across the two boroughs People come along to support each other and discuss their care At the Forum they meet other patients, learn about their condition, share their stories, and talk about what help they can get Medical professionals also attend to give information and advice on various diabetes topics The Forum has worked closely with the DMI to help improve local services For example, its members have said what kind of support people want when they are diagnosed with diabetes They’ve also helped design patient information packs and fed-back their experiences of GP care and local diabetes services One common complaint was the poor quality of foot care for patients with diabetes Bad foot care can lead to problems ranging from cracked skin and calluses to ulcers, gangrene and - in extreme cases - amputation The Forum took its concerns to the DMI who, in turn, worked with GPs and practice nurses to improve local foot care services It held education events and sent out leaflets with information on how to carry out foot checks and identify potential problems It helped primary practice professionals know how to recognise signs of damage and when and where to refer patients on The DMI also helped the Forum feedback its concerns to community podiatry services which responded by introducing a programme of foot health improvement As a result of these joint activities, more patients now get regular foot checks, greatly reducing their risk of discomfort, disfigurement and disability Many participants also say the Forum has helped them to become more confident in managing their own diabetes and keeping themselves healthy They’ve become more aware about the treatment they should receive and better able to talk to their GPs about what needs to be done Some have gone on short education and training courses to learn more about their condition and how to control it 11 The Forum will launch as a stand-alone voluntary group dedicated to improving the lives of people with diabetes in Lambeth and Southwark The charity Diabetes UK is helping the volunteers to set up and run the group It will link them in to a network of nearly 400 similar groups across the UK, all run by volunteers The group will continue to campaign to improve diabetes services when the DMI programme winds up in 2014 A top priority is to take forward the DMI’s work in tackling the variation in the quality of diabetes care across the two boroughs 12 Care Planning Advocates: A case study of successful community empowerment Care planning advocates: supporting quality care planning What did we want to achieve? To use patient advocates to ensure delivery of high quality care planning What did we do? A call to action was circulated to recruit people to act as care planning advocates Those interested were invited to a day-long training workshop This involved a comprehensive selection process and group training programme to learn more about care planning and to understand the expectations of a care planning advocate The successful advocates attended local Diabetes Eye Complication Screening clinics (DECS) to collect patient experience of care planning Here, patients were asked a series of questions to determine what they understood by care planning, whether they were receiving care planning and to identify whether care planning was associated with increased confidence in managing their diabetes What did we find? 22 patients expressed an interest to become care planning advocates Following the selection and training workshop, 10 people were trained 240 patients have been interviewed whilst attending their DECS appointment The feedback collected represents 67% of GP practices in Lambeth and Southwark 28% of patients interviewed are receiving the minimum standards of care planning1 People receiving care planning report significantly greater confidence in managing their condition than those who are not involved in the care planning process What does this mean? Care planning is a difficult concept to understand and can often be a tick box exercise Using advocates to collect patient experience of care planning is an innovative way to assure the quality of the process It facilitates knowledge transfer between advocate and patient, so while experience is being collected, the patient is also being informed about care planning This reinforces care planning it as an integral part of their care Furthermore, the information is fed back to general practice as an ongoing way to assess and embed quality care planning Minimum standards of care planning were defined as a way to explain and measure the care planning process In every consultation the patient must have the opportunity to set a goal, agree a way to follow up the goal and have a documented care plan 13 Tackling Unwarranted Variation: Levering change in primary care The key indicators for success in the primary care are:  Improvement in the detection of diabetes  Improvement in the percentage of the diabetes population with an HbA1c < 64 mmol/mol  Reduction in variation between the best and the worst performing practices for both measures above Analysis of the local picture highlighted unwarranted variation in both boroughs, with only two practices in each achieving HbA1c control above the national upper quartile, i.e performing in the top 25% of practices nationally In Lambeth, 19 practices, and in Southwark, 22 practices were below the national lower quartile In Lambeth, in 2011/12, (grey markers) the percentage of patients on the register achieving HbA1c of < 64mmol ranges from 57% to 85% across practices, with a mean of 68% In Southwark (orange markers) the range is from 43% to 83%, with a mean of 68% 14 Further analysis demonstrated that there is no single answer to variation Geography and deprivation did not affect outcomes, nor did the availability of any single clinic or extended appointment times However, local data from Changing Diabetes@KHP indicated a link to processes and systems as there is significant delay in: – – initiating insulin titrating insulin to target HbA1c Focusing our efforts To ensure we were targeting support most effectively, we took a two pronged approach Working with existing Local Incentive Schemes, we developed a DMI reward scheme that supports all practices to make improvements in diabetes care We identified practices that would benefit most from our support, based on their performance on the three main QOF outcomes in 2012/13 Building momentum for change Since early 2012, we engaged with PCT / CCG commissioners, Local Medical Committees (LMCs), local practices and patients We used local diabetes practice and commissioning champions alongside patient representatives to build a momentum for change Joint NHS Lambeth and Southwark ‘reward scheme’ A ‘reward scheme’ designed by clinicians and supported by CCGs that supports practices to make improvements in diabetes care Prescribing guidelines and treatment algorithms Local experts, across primary and secondary care, designed prescribing guidelines to drive initiation, review and timely titration of anti-diabetic medicines These were launched at learning events in April and May using local clinical cases to embed the treatment algorithms in everyday practice Support tools IT support tools were developed and piloted in several practices to test their effectiveness and usability before dissemination across all general practices These tools provide practical support to practices to complete online ‘systems audit’ and individual improvement plan Practices are being supported to implement effective and efficient systems 15 Education Education events were developed for primary care clinicians, covering local priorities such as care planning, new tests at diagnosis, dietetics, medicines management and titration Proactively target practices below the national QOF median in biological outcome measures with a bespoke package of support Progress to date 89 practices (96%) across Lambeth and Southwark reviewed their diabetes care and completed action plans for improvement - an unprecedented level of engagement Care planning improved substantially in 2012 (28% of patients sampled now report having received all three of our minimum standards) Diagnosis guidance was available a year ahead of other boroughs and practice registers soared in 2012/13, increasing by an additional 1,146 patients – an 8% improvement on the previous year Focus for the legacy Improving systems and processes of diabetes care According to data collected from 82 (87%) practices and 23,945 people with diabetes in Lambeth and Southwark, only 7,714 (32%) of people with diabetes had received all nine of the NICE recommended care processes in the previous 12 months Improvements can be made across all nine care processes with particular focus on smoking status, urinary albumin and foot checks having the greatest impact Percentage of diabetic patients in Lambeth and Southwark receiving each of the care processes: 16 Improving diabetes control This initiative means that healthcare professionals that treat people with diabetes in Lambeth and Southwark CCGs are working to a common algorithm based on rigorous initiation, review and timely titration of antidiabetic medicines The key treatment and prescribing messages are reinforced by every healthcare professional that interacts with a person with diabetes making every contact count Medication / Prescribing We have developed practice IT system searches to identify the number of people with diabetes and with an HbA1c greater than 64mmol/mol who were on no medication, first line, second or third line treatment options as defined by NICE, and also those that have not had their blood glucose tested in the last 12 months Based on data from 82 (87%) practices and 23,945 people with diabetes in NHS Lambeth and NHS Southwark, we have a clear picture of the proportions of patients at each stage of the blood glucose control management pathway: Practices, working with the community team, are identifying strategies for responding to each cohort by developing practice level plans identifying the resources required to implement change Practical examples include using these lists of patients to prioritise how they re-call patients, make changes to their systems and track their progress Improvements can be made at each stage of the NICE prescribing algorithm Optimising first and second line therapy could increase the proportion of people with HbA1c less than 64mmol/mol by 9% 17 ... care .14 17 October 2 013 – From 1. 30pm - 3.30pm Gracefield Gardens Health and Social Care Centre 2-8 Gracefield Gardens, Streatham, SW16 2ST Itinerary 1. 25pm Arrive at Gracefield Gardens 1. 30pm... Voluntary Group: Working in partnership with patients to transform diabetes care 11 Care Planning Advocates: A case study of successful community empowerment 13 Tackling Unwarranted... black backgrounds There are high levels of social deprivation, with 15 % of the working-age population on out-of -work benefits Over 15 0 languages are spoken across the boroughs After English the main