Improving services for people with diabetes

The recent Healthcare Commission review Managing Diabetes: Improving Services for People with Diabetes looked at how the healthcare system supports people with diabetes in managing their own care (The Healthcare Commission, 2007). The review concluded that the performance of the majority (73%) of PCTs was ‘fair’, with 16% being assessed as ‘good’ or ‘excellent’ and 12% as weak.

The Healthcare Commission highlighted continued weaknesses in the management of people with diabetes particularly when  involving individuals in their own care. The targets for self-management are not new: in 1989, the St Vincent Declaration highlighted the need for people with diabetes to be managed proactively and the important health consequences if this was not done (St Vincent Declaration, 1989). Included as a 5-year target of the St Vincent Declaration was the need to ‘organise training and teaching in diabetes management and care for people of all ages with diabetes, for their families, friends and working associates and for the health care team’. Twenty years on, some progress has been made, but not nearly enough.

Findings of the Healthcare Commission review
The 2007 Healthcare Commission report listed the outcomes of a review of services commissioned by PCTs to assess how well they were supporting adults (those aged 17 years and over) with diabetes to care for themselves.

All PCTs were assessed against the following criteria.

• Are adults with diabetes looking after their condition?
• Do adults with diabetes feel supported to self-care through care planning, information and education?
• Do adults with diabetes have key tests and measurements carried out?

To answer these questions, the Healthcare Commission carried out a national survey of people with diabetes, reviewed information from the QOF (DoH, 2006a) and looked at hospital episode statistics.

The Healthcare Commission found that most people with diabetes have regular check-ups; reported knowing enough about taking their medication; reported having the easily recognisable key tests carried out; and, where necessary, were offered advice about stopping smoking.

However, several areas of the review demonstrated that the support offered in many PCTs was in great need of improvement. Required in particular were the following.

• Better partnerships between people with diabetes and their healthcare professionals when planning and agreeing care.
• Increases in the number of people with diabetes attending education courses and actively working to improve their knowledge of diabetes.
• A higher degree of close working between all organisations providing and commissioning diabetes services.
• Increases in the number of people with diabetes with an HbA_1c <7.4%.
• Reduction in the variation between general practices’ achievements.

Responding to the results of the Healthcare Commission report
Diabetes is a major priority for a large number of PCTs and, given that the number of people with diabetes is increasing steadily, it will remain a priority that will need to be tackled. Based on the NHS’s previous track record, there is no reason for optimism that improvement will be made rapidly. However, there are now opportunities available that will enable progress, such as practice-based commissioning (PBC), payment-by-results and the Year of Care project.

Practice-based commissioning
PBC will provide a powerful mechanism for engaging local GPs in the management of people with diabetes (DoH, 2004b). PBC consortia will be able to promote better care by bringing together a multidisciplinary team to work with people with diabetes and encourage self-management.

PCTs, in conjunction with practice-based commissioning groups, have been charged with the responsibility of commissioning local services, including those to improve care for people with diabetes. In commissioning services, it will be important to include performance metrics and indicator targets, which measure such areas as the involvement of service users, as part of the overall contract.

Payment-by-results
Under payment-by-results, there is a specific tariff for episodes of care such as out-patient appointments and in-patient stays. This has helped to identify overall costs in the healthcare system and has supported the shift of care from the secondary to primary setting by releasing resources and allowing investment in primary care, such as payment for GPSIs. The focus on costs has helped identify more efficient ways of providing care and the cost of providing care in different settings. A negative impact has been that payment-by-results has encouraged a competitive relationship with secondary care – this goes against the current management approach of using a multidisciplinary team.

Year of Care
The Year of Care for diabetes pilot project is a partnership between Diabetes UK, the DoH and the NDST (Diabetes UK, 2007). The Year of Care describes all the planned care that a person with diabetes should expect to receive over a year, including self-management support.

The pilot project is about empowering people through greater choice and involvement, enhancing self-management and improving health outcomes. The idea is to develop the annual review discussion from a tick-box exercise of measuring biomedical variables to a care-planning discussion. This means giving people more time to consider information, providing more care options, supporting self-management, assisting people when they are thinking through management options and allowing individuals to jointly decide with their healthcare professional on the right options for them. The plan they arrive at will form the basis of their individual Year of Care.

Kensington and Chelsea PCT
Overall, Kensington and Chelsea PCT was rated as ‘fair’ in this national audit. The patient survey was based on a sample size of 861 individuals from the patient lists of nine practices in the borough, of which 310 questionnaires were completed. Thirty-nine per cent of eligible individuals responded; this was lower than the national response rate of 55%.

Kensington and Chelsea PCT performed better than the London average. London PCTs performed worse than the national average, in keeping with most historical patient satisfaction surveys.

Locally, Kensington and Chelsea PCT have the benefit of working with a single PBC group that covers the whole of the PCT, is well developed and rates diabetes as a major priority. This has allowed the PCT to invest in services locally and ensure general practice buy in.

Furthermore, Kensington and Chelsea PCT have invested £200 000 in a nurse- and dietician-led community diabetes service with clinical support coming from secondary care. As part of the newly established community diabetes service, patient education forms a central component of care. As well as one-to-one education, this will also include implementing the X-PERT group education programme accredited by NICE (Deakin et al, 2006).

Conclusion
Healthcare trusts need to work collaboratively with partners to improve services and pool resources for people with diabetes.

To achieve this, PCTs will need to:

• ensure that diabetes remains or becomes a local priority
• work closely with the PBC groups to ensure general practice support to the local development of diabetes services and reduce variation in general practice achievements
• use lessons from elsewhere when commissioning services and also use approaches recommended in the diabetes commissioning toolkit (DoH, 2006b)
• ensure that all diabetes services commissioned include performance metrics and indicators that measure patient experience
• implement the NICE health technology appraisal on structured education for patients (NICE, 2003)
• review local approach to care planning and look at the results from the Year of Care planning approach.