Diabetes in Scotland: A time of transition in primary care

Since I last wrote in this Journal with regard to diabetes care in Scotland (Quigley, 2015), there have been significant developments in primary care. The next 12 months will see the birth of an entirely new contract for general practice. In this commentary, I discuss the landscape of quality care in diabetes with respect to this and the complete dismantling of the Quality and Outcomes Framework (QOF) that has recently occurred. In addition, I provide an update on the use of the My Diabetes My Way platform.

Farewell to QOF
Most readers will be aware that QOF was dropped entirely in Scotland on 1 April 2016, with funding being moved to the Global Sum. Consequently, QOF data are no longer extracted for payment purposes, although the understanding is that practices will endeavour to use the data for their continuing internal quality agendas.

The myriad reasons for the demise of QOF in Scotland are covered better elsewhere. In summary, however, the Scottish Government was persuaded by the argument that QOF, across almost all clinical domains, including diabetes, was in essence a short-term success but a long-term failure. The framework, of course, was introduced as part of the drive to improve clinical standards across the incentivised areas. It appeared to reach a quality ceiling, however, within 4 years of its introduction.

With the clawing back of overall funding from general practice and a QOF programme that relentlessly pursued the biomedical model, GPs and practice nurses became increasingly disillusioned with the prospects of improving patient care. More specifically, we all remember troublesome patient-care issues (such as altering glycaemic targets) and pointless clinical exercises (such as the keeping of an obesity register with no incentive to tackle the issue clinically). There were also a number of unforeseen consequences of the technology itself; for example, there was no read code for unspecified diabetes, leading to loss of follow-up and worsening care in this small but important patient group.

So, driven by a proactive Scottish General Practitioners Committee and a willingness by Holyrood to listen to our legitimate concerns, Transitional Quality Arrangements (TQAs) were put in place, and Scotland (following the example of our Welsh colleagues) introduced GP practice clusters within the context of the integration of health and social care.

GPs within a cluster have responsibility for supporting the delivery and monitoring the quality of care provided (Information Services Division, 2017). Although QOF has been dropped, there remains a contractual commitment to maintain disease registers, use diagnostic coding and provide lifestyle advice. The concept of Local and Direct Enhanced Services also remains unchanged.

The impact of clusters
What does this mean for diabetes care in Scotland? The challenge increases with time. With just under 300 000 people diagnosed and over half a million at risk of developing type 2 diabetes (Scottish Diabetes Survey Monitoring Group, 2017), the role of primary care is more pivotal than ever. As a result, primary care needs to become ever more engaged in the development of and progress in diabetes care.

Our experience so far (and it is very early days) confirms that clusters have taken on the role of driving forward the quality agenda for our patients. In a refreshing change, no explicit “top-down” demands, or indeed instructions, have been given to the cluster quality leads and their committees, who are solely charged with developing the quality agenda, with an emphasis on local priorities. Given the enormous range of challenges within the service, it is now perfectly possible for a particular cluster to focus on issues across the health and social care spectrum that may entirely exclude diabetes care.

For example, there was universal agreement in my local cluster, of which I am the quality lead, that our relationship with secondary care and “interface” problems were a greater threat to patient care than anything else. By way of addressing this issue, our quality agenda this year has focused entirely on meeting with colleagues from a range of services, including child and adolescent mental health services, physiotherapy, community psychiatry and palliative care, and has eschewed data crunching entirely. Although our colleagues in secondary care diabetes are attending a cluster meeting shortly in order to discuss service improvements, we are aware of other clusters that have not chosen diabetes as a priority at all.

With this relative lack of top-down control, professionalism is a key driving force for clinic improvement. The Scottish healthcare community is a very data-rich environment, and it is hard to imagine that any practice (through its practice quality lead) or cluster (through its cluster quality committee) would not address any material decline in its relative performance in diabetes care that was identified in the regularly published and updated comparative data. We shall see whether professionalism trumps cash incentivisation!

The new GP contract
There may be other opportunities on the horizon for improving the quality of care for people with diabetes. We will get a first glimpse of the new contract for general practice in November 2017. It envisions the transformation of the GP’s role from that of “gatekeeper” to “expert generalist”. This new role will focus mainly on leadership, undifferentiated presentations and complex care, while practice support pharmacists, advanced nurse practitioners and other healthcare professionals will have expanded roles. If this contract is successful and the primary care team is released from its current constraints and armed with more time, we might return to the days when we were better able to deliver diabetes care rather than treatment.

My Diabetes My Way
For some years, we have sought in Scotland to harness the potential of technology to improve patient experience, quality of care and outcomes. In 2010, the University of Dundee developed a web-based module to access NHS records called My Diabetes My Way. This service, through its advanced data-integration capability, harvests information from patients, primary care, secondary care and laboratory services. Whilst uptake from patients has been slower than many stakeholders would have wished, it is now sitting at over 28 000 registrants. Recent observational research has shown that use of the platform can improve clinical outcomes, including glycaemic control (Wake et al, 2016).

The website is an accessible, interactive resource for patients, family, carers and friends, and provides functionality across the spectrum, from key elements of the individualised patient care record to education, support and information on local NHS services, all with the primary aim of supporting self-management. In addition to the main website, My Diabetes My Way has a social media presence on both Twitter and Facebook.

Winner of several international awards, the My Diabetes My Way service has stimulated interest across the UK. Somerset and Norfolk are leading the way in England, and 20% of English Trusts have expressed an interest. The service has also come to the notice of other countries, including Kuwait and the United Arab Emirates, and the commercial spin-off company, now launched, harbours global ambitions.

Useful resources
– My Diabetes My Way: www.mydiabetesmyway.scot.nhs.uk
– Improving together: a national framework for quality and GP clusters in Scotland: https://is.gd/ScotGPframework