Vinod Patel and John Davies

2. PIP: Focus on Diabetes Vinod Patel and John Davies

3. A Guide to the NHS Choice in Elective Surgery: Free Choice Choice in Elective Surgery: at 6 Months Choice in Primary Care Choice in Elective Surgery: at Referral Choice for Long Term Conditions Commercial Policy Choice, Equity and Responsiveness Foundation Trusts Patient Experience NHS Treatment Centres Workforce New Independent Providers Primary Medical Care Contracting IM&T / NPfIT Fee for Service Modernisation Agency SLA Payment by Results Roles & Responsibilities Finance Regime PCT Development Social Care Regime Addressing Failure Standards, Accreditation & Inspection Planning, Performance & Assessment Behaviours & Relationships RSU Capacity Planning 2008 21) Incentives for Choice (other than PbR) 3) Support patient’s choosing 27) Deployment and Take Up of new IT systems 1) Deliver 4 or 5 choices 11) Incentives must combine to provide right overall levers 24) PCT Commissioning 2) ICRS eBooking & Infrastructure 13) Right workforce 12) Shaping the workforce through contracts & incentives 6) Ability to move the money using Tariff 5) Support patient’s choosing 4) PCT Commissioning 26) Planning Information 9) Evolution of Secondary to Primary Care 17) Market Entry & Market Exit policy 8) Data to set tariff 15) Systems integrate with independent sector 29) Support for patients in the community 16) Choice offered is fair to independent providers 10) Data and transactional systems 25) Business and Data requirements for PbR 28) “Playing Field” regulation 23) PCT Training & Rollout 7) PCT Commissioning 14) Commercially viable tariff 18) Implementation & Training 20) Info on impact of shift to primary care 19) Contracts to support standards 22) Required behavioural change

4. A World Class NHS: Our Vision • Fair– equally available to all, taking full account of personal circumstances and diversity • Personalised – tailored to the needs and wants of each individual, especially the most vulnerable and those in greatest need, providing access to services at the time and place of their choice • Effective – focused on delivering outcomes for patients that are among the best in the world • Safe – as safe as it possibly can be,giving patients and the public the confidence they need in the care they receive.

5. Key Initiatives Strategic Leadership Workforce Development Support for Service Users and carers Tele-healthcare Metrics : QoF to individualised QoF Navigator Role Sharing Best Practice: Tube Map of LTC

6. Diabetes in the Young! Meeting of DSN, Doctors, Dietitians, Managers n = 8 Main Aim: Advise on the service for Diabetes for the young across Coventry and Warwickshire

7. Diabetes in the Young!Main Themes Consultant-led Service Dietician Support Paediatric Diabetes Specialist Nurse support Insulin Pumps eg 50 vs 5 in local areas Psychiatry and Psychology Support Transition Care

8. Diabetes in the Young!Main Themes: The Information for Commissioning The Needs assessment by Public Health The Who of the teams, locations, WTE Clinical Service: the What Clinics, In-patient, Emergency, non-electives, throughput, Transition, Psychology NICE Guidelines: 10 key areas, self-assessment Sharing Best Practice; stop reinvention, share! Commissioning Template

9. Diabetes in the Young!Main Themes: The Information for Commisioning The Needs assessment by Public Health The Who of the teams, locations, WTE Clinical Service: the What Clinics, In-patient, Emergency, non-electives, throughput, Transition, Psychology NICE Guidelines: 10 key areas, self-assessment Sharing Best Practice; stop reinvention, share! Commissioning Template Tea and Biscuits Philosophy of Care!

10. 129 3 We do not always help patients to navigate the system: ASTHMA Issues with providing joined-up care for asthma… … are serious and result in high emergency admissions rates Standardised emergency hospital admissions for asthma, 2004. Average admission rate = 100 • In England • 1 in 4 do not have a routine asthma review • ≤ 75% adults and children with asthma do not have written personal asthma action plans • 12% do not know what to do during an asthma attack • People without a written personal asthma action plan are 4 x more likely to have an asthma attack requiring hospital treatment than those with a plan * * * * * * * Yorkshire andHumberside * Source: The Asthma Divide, Asthma UK, 2007

11. The Towards 2010 Agency Vision-“long-term redevelopment of local health services” Improve health and reduce health inequalities Provide care closer to home Provide quality care in quality places Waqar Malik:

12. The Future: Integrated & Community-based ? Cost Tertiary Prevent £ Secondary Primary Self -care Encourage and Fund P Patient Axis Individual self -care Cost P Friends and Family Encouraged Self-help networks Professionals as partners Professionals as facilitators Professionals as authorities £ Discouraged Adapted from Ferguson T 1995 Cited by Emslie-Smith A 2007 Commissioning Axis

18. “ Excellence requires that important, simple things are done right all the time . ” NSF Coronary Heart Disease

19. A POETIC Vision of Healthcare Integrated: Across all services, sectors and agencies The main determinants of health

20. A POETIC Vision of Healthcare Integrated: Across all services, sectors and agencies: councils, schools, employers, voluntary groups, social sector, health, private enterprise, community centres Diabetes Chronic Disease Management

21. A POETIC Vision of Healthcare • Patient-centred, Public health driven, Professionally inspired • Outcome-based: benefits desired must be clear • Evidence-based: ideally randomised clinical trials • Team delivered: joint training and accreditation • Integrated: across all sectors in the community • Cost-effective and clinically governed Unpublished: Patel V and Morrissey JR 2007

22. NHS West Midlands: Key Initiatives Strategic Leadership Workforce Development Support for Service Users and carers Tele-healthcare Metrics : QoF to individualised QoF Navigator Role Sharing Best Practice: Tube Map of LTC

23. A World Class NHS: Our Vision Fair– equally available to all, taking full account of personal circumstances and diversity Personalised – tailored to the needs and wants of each individual, especially the most vulnerable and those in greatest need, providing access to services at the time and place of their choice Effective – focused on delivering outcomes for patients that are among the best in the world Safe – as safe as it possibly can be,giving patients and the public the confidence they need in the care they receive.

24. Hypertension (36%), Arthritis (24%), Diabetes 15%, depression 10%, COPD 4%, Stroke 4%, BMJ 22 Sept 2007

25. 2 Long term conditions are a significant cause of death in the region Mortality per 100,000 European-standardised population, West Midlands, 2003/05 We forget: CVD 25% have diabetes, 20% COPD Stroke 25% have diabetes, 15% COPD Cancer Coronary heart disease Stroke COPD Diabetes Epilepsy Hyper-tension Asthma Source: NCHOD

26. 90 2 There remains an unjustifiable variability in the quality and safety of services and individual care STROKE EXAMPLE Equal to or above national average Below national average 2006 audit Emergency brain scan within 24 hours of stroke, % Patients treated in a stroke unit, % Screening for swallowing disorders within 24 hrs of admission, % Trust (Site) * * * Stroke Unit Treatment: 31% to 100% Emergency Brain Scan: 5% to 58% Screening for Swallow: 14% to 99% * * * * * * * * * * N/A * * * * * * * * * * National average* * International evidence indicates maximum of 3 hours is preferred * England, Wales and Northern Ireland Source: The National Sentinel Audit of Stroke 2006, February 2007

27. Birmingham OwnHealth • Oscott & Kingstanding, • Washwood Heath, • Bordesley Green

28. Goals Goals Eight care management priorities Know how and when to get help 1 Learn about the condition and set treatment goals 2 Take medicines correctly 3 4 Get recommended tests and services Act to keep the condition in good control 5 6 Make lifestyle changes and reduce risks Build on strengths and overcome obstacles 7 Follow-up with specialists and appointments 8

29. Toward 2010: Diabetes Care Model Acute Care Community hospital Heart of Birmingham Smethwick The Diabetes Centre Rowley Regis ‘Intermediate-care’ Greater care needs, e.g. diabetes with target-organ damage, optimisation of risk factor management, intensifying treatment ‘Specialist-care’ Complex cases (e.g. renal), diabetes complications, co-morbidities, pumps, pregnancy, transition care Wednesbury Podiatrist Admin &HCA Oldbury Diabetologist GPSI ~30-40% total West Bromwich Tipton Dietician ~10% total Diabetes Specialist Nurses General Practice Wider Primary Care/Self-care Self-care/Primary Care Prevention of Diabetes through Healthy Lifestyles; early recognition of IGT/diabetes; monitoring and treatment in community Everyone with or at risk of diabetes HOBt PCT includes the wards of Aston, Bordesley Green , Handsworth Wood, Ladywood, Lozells and East Handsworth, Nechells, Soho, Sparkbrook and Springfield

30. Cost Tertiary Encouraged £ Secondary Primary Discouraged Pennies Self -care Industrial age medicine Ferguson T 1995 Cited by Emslie-Smith A 2007

31. Health care 10% Environmental exposure Genetic 5% predisposition 30% social circumstances 15% Determinants of health and their contribution to premature death Adapted from McGinnis et al 2002 Behavioral patterns 40% Proportional contribution to premature death

32. Cost Individual self -care P Encouraged Friends and Family Self-help networks Professionals as partners Professionals as facilitators Professionals as authorities £ Discouraged Information age health care: Now and the Future Diabetes Patient: 3 hours vs 8757 hours in year! D Kerr in Building a Health Service Fit for the Future 2006 Ferguson T 1995 Cited by Emslie-Smith A 2007

33. Steno-2 Targets Achieved

34. 67% 70 61% 58% 53 % 60 50 40 Number of events 30 20 10 0 nephropathy retinopathy autonomic cardiovascular disease neuropathy Steno 2: Event Reduction

35. Steno-2 : CVD Event Reduction

36. Steno-2 : 13 years follow up data

37. Steno-2 : Conclusion “ A target driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50%.”

38. A POETIC Vision of Healthcare Team delivered: Multi-disciplinary, professionally inspired and fit for purpose

39. Policy Levels for Tackling Inequalities in Health

40. Individualised Risk Evaluation and Action Plan …individualised to people and communities The main determinants of health

41. One approach to diabetes is to tackle it alongside other linked conditions Joint ‘alphabet’ approach to the treatment of diabetes and other conditions 25% of patients with stroke or CHD conditions also have diabetes, suggesting need for a joint approach Source: Dr Vinod Patel, Warwick Medical School/George Eliot Hospital NHS Trust

42. A World Class NHS: Our VisionDoes Apply to Long Term Conditions • Fair– equally available to all, taking full account of personal circumstances and diversity • Personalised – tailored to the needs and wants of each individual, especially the most vulnerable and those in greatest need, providing access to services at the time and place of their choice • Effective – focused on delivering outcomes for patients that are among the best in the world • Safe – as safe as it possibly can be,giving patients and the public the confidence they need in the care they receive.

44. Prevention Diagnosis Ongoingmanage-ment Outpatientcare Acute episode Intermediate care Current evidence-based practice in the COPD pathway • Screening to identify those at risk • Smoking cessation and public health initiatives/ campaigns • Screening to identify those likely to have COPD • Mobile clinics to identify patients • Diagnostic testing with GPwSI specialist nurse • Triage call centre and patient database • Exercise in referral and other ‘healthy living’ care • Telephone supported self-care • Pulmonary rehabilitation • Care manage-ment for severe patients • Clinics in the community • Forces on moderate/severe patients • Emergency care ‘gatekeeper’ • Reduced LOS via developing links to GPwSIs, intermediate care and social care • Facilitated discharge • Intermediate care nurses trained in COPD Source: Clinical evidence review; team analysis

45. Prevention Diagnosis Ongoingmanage-ment Outpatientcare Acute episode Intermediate care Current COPD prevention and treatment is some way from this practice • Limited specific screening • Variable success at smoking cessation programmes • Limited specific screening • Limited but developing mobile clinics • Testing carried out in both GP surgeries and acute centres • No single comprehensive database available • Exercise on referral not always taken up • Limited provision for self-care • Limited care management for severe patients • Mostly offered in acute centres • Limited clear database to patient members treated • Patients present to A&E and sometimes inappropria-tely referred • Often COPD-specific skills Source: Clinical evidence review; team analysis

47. Diabetes Passport

50. The service model • Proactive • Outbound calls at agreed times, with scope for inbound • Supportive not directive care management • Stage based approach tailored to the needs of individuals • Patients set their own goals • Handing over control and responsibility to the patient • Motivational coaching and support • To build confidence and motivation • Systematic approach • Software platform provides decision support and captures data on progress • Robust clinical background • Ensures appropriate outcomes and governance • Builds on existing care provision • Service as a complement to current patient-professional relationships • Integrates with other local services • Enables patients to access the right support when needed