Sandwell and West Birmingham Clinical Commissioning Group (CCG) has a substantial ethnic minority population. Diabetes is more prevalent (10.1%) than the national average (7%), social deprivation is high and compliance is a major stumbling block. The impact on primary care is significant. We aimed to empower, up-skill and support primary care to manage diabetes locally, refer appropriately, improve capacity, and provide value-for-money prescribing and a holistic and sustainable approach to chronic disease management.
Integrated working
The CCG, in collaboration with Sandwell and West Birmingham Hospital Trust and Birmingham Community Healthcare, asked us to redesign the diabetes service model based on the Smethwick Pathfinder Project (http://bit.ly/2u3ToXW), which won a national Quality in Care award in 2014 (http://bit.ly/2uIP8eB). They commissioned us to deliver a similar model to all 89 practices in the CCG from 1 April 2014. We named this model Diabetes in Community Extension (DiCE). The financial model was based on block contract and sessional payment.
The typical model centred on providing joint diabetes clinics within GP practices for 4 hours every 8 weeks. Practices identified difficult diabetes patients, including those with HbA1c >69 mmol/mol (8.5%), for a one-off advice and management plan by an assigned team of consultant and diabetes specialist nurse (DSN), who ran parallel clinics, for implementation by the primary care team.
GPs sat with the consultant and practice nurses (PN) with the DSN. The DSN and consultant often discussed common or problem patients. DSNs started insulin and GLP-1, educated PNs about HCA1c on blood glucose monitoring and oversaw insulin starts and follow-up.
Options to suit individual practices were:
- Virtual clinics
- Joint consultations
- Case note review
- Advice and guidance.
The service was provided via telephone or email during normal working hours. Telephone and email enquiries were dealt with on the same day, with a maximum turnaround time for non-urgent enquiries of 2 working days.
Initially, engaging practices and convincing them about the rationale for joint working was a challenge. There was also some initial resistance from GPs and PNs to sitting in a joint clinic. Although this is still an occasional issue, most practices now follow this rule, as it is fundamental to up-skilling and the core principle behind DICE.
Results
In summary, there were:
- 5000 patients were seen in primary care, resulting in 2500 fewer secondary care outpatient appointments.
- 1214 fewer outpatient attendances in 2015; 1330 fewer in 2016.
- 8 fewer hypoglycaemic admissions in 2015; 22 fewer in 2016.
- 35 fewer admissions related to hypoglycaemia.
- No increase in diabetic ketoacidosis admissions (cost savings of nearly 150k).
More and more practices are engaging in structured education and can initiate insulin/GLP-1 therapy independently. The quality of referrals to the DiCE team has improved significantly.
Conclusion
The DiCE model has been praised for its simplicity and effectiveness and can be adopted by any CCG. The patient is at the heart of service delivery, with GP/PN up-skilling as the key aim. There has been excellent year-on-year feedback. It is cost-effective, liked by stakeholders and could change how chronic disease is managed in future.
