In June, NHS England, in partnership with the Healthier You: NHS Diabetes Prevention Programme, published the NHS RightCare: Diabetes pathway, which aims to support commissioners to review local diabetes pathways and identify where potential improvements could be delivered.
The pathway was developed by the NHS England diabetes team, in collaboration with the NHS Diabetes Prevention Programme, Public Health England, Diabetes UK and a range of patient groups and other stakeholders. It defines the core components of an optimal diabetes service for people with or at risk of developing type 1 and type 2 diabetes, in order to deliver better value in terms of outcomes and cost. It also provides commissioners with guidance that will allow them to think through their existing diabetes service and compare it with an optimal service, as well as guidance about the scale of improvements that could be delivered through optimisation of local pathways.
NHS RightCare has been rolled out across all 207 local health economies in England, and all Clinical Commissioning Groups have been provided with a dedicated Delivery Partner to help support and implement the RightCare approach. Local health economies can use the product to structure their local improvement discussions.
There are seven key areas of focus, represented by the columns in Figure 1, which align with the Five Year Forward View (NHS England, 2014) and the NHS RightCare cardiovascular disease prevention pathway (NHS England, 2016). The diabetes pathway aims to provide local health economies with:
- A high-level, overarching national case for change.
- Priorities for improvement and key high-impact interventions along a pathway.
- Underpinning guidance and evidence.
- Implementation resources to help make change on the ground.
- Practice examples that show the potential of population health approaches.
What does this mean for primary care specifically?
Primary care has an important role to play in a number of the RightCare pathway’s key focus areas, although, appreciably in the context of modern NHS pressures, it is paramount that any new tools or systems do not add to the workload. Prevention of type 2 diabetes links with the NHS Diabetes Prevention Programme, which is due to be rolled out all across the country. The aim will be to identify high-risk individuals and refer them to the appropriate local programme. Diagnosis, in any eventuality, is done in primary care, but the focus of this work is more about ensuring that type 1 diabetes is not missed (thus hopefully reducing hospital admissions for diabetic ketoacidosis), and that genetic variations of diabetes – which have implications regarding the specific treatment needed – are identified.
The goal of reducing amputations correlates strongly with regular foot checks: again, a core feature of primary care diabetes delivery. This is more about helping to raise the issue of self-management, as well as awareness of early referrals for appropriate individuals. With the majority of amputations being preventable, the role of primary care is critical.
Increasing uptake of structured education is an area of contention as, although referral rates have gone up, the uptake rates have not matched them. Is there anything else primary care can actually do? Would better encouragement help, or is it also about ensuring that the education programmes are more fit for purpose in the 21st century, and being appreciative of patients’ needs rather than those of the healthcare professionals? NHS England is exploring digital options, which may act as a useful adjunct to face-to-face education sessions.
Improving inpatient safety is likely to sit squarely with the hospital specialist team; however, better linkage between specialist and primary care teams would help improve communication, increase awareness of those who need to be admitted and even help with admission prevention.
The final two priorities – improving type 1 diabetes services and meeting care process targets – are perhaps the two that need a more joined-up approach. Appreciably, the specialists have a major role here, with support and access being key features. The old buzzword “integration” reappears but, as the quest for the holy grail continues, it is perhaps worth noting that before integration comes collaboration. Without sign-up from both parties, an integrated care model is barely worth the paper it’s printed on.
New system changes offer us an opportunity to perhaps ditch terms such as “community diabetologist”, which is little else but a tautology: a hospital is part of the community and specialists have a role across the whole system, irrespective of buildings, providing support to primary care where needed. Indeed, improving type 1 diabetes care and treatment targets hinges on this philosophy, and my request to primary care would be to open the doors wide to those specialists who are willing to try to work differently.
In summary, the seven priorities in the NHS RightCare pathway have been based on input from multiple stakeholders, evidence review and the principles of return on investment. Focus is needed to deliver them and, as much as primary care has an important role to play, so too does the whole diabetes profession. We stand, yet again, at a set of crossroads. The question is whether, this time, we choose the right path – together.
NHS RightCare is a national programme supported by NHS England, committed to delivering the best care to patients, making the NHS’s money go as far as possible and improving patient outcomes.
The new Diabetes Pathway was published in June 2017 and can be accessed at: www.england.nhs.uk/rightcare/products/pathways/diabetes-pathway
Increasing daily step count reduces mortality and morbidity up to around 10 000 steps, with no minimum step count for benefits.
20 Mar 2023