Transforming Diabetes Programme
Update November 2015
In the last two months the work to be included within the programme has been defined in greater detail and received agreement from NHS Aylesbury Vale and NHS Chiltern Clinical Commissioning Groups (CCGs) to progress to the next level.
The Transforming Diabetes Programme has three clinical priority areas of:
· Early diagnosis / prevention
· Management of Type 2 diabetes to insulin initiation
· The patient with complex patient and HbA1c>100
With two overarching supporting areas of:
· Patient and healthcare professional education
· Technology
In September a workshop was held at which health care professionals, Public Health members and patient representatives were invited to develop the pathways for patients around those priorities. Out of this workshop came a number of projects which supported those priority areas; these were presented to the CCGs Long-Term Conditions Joint Executive Team (LTC JET) in October and approved for development.
The projects are defined below along with the expected completion date
Description of the initiative
In place by or from
Preventing diabetes to include:
· Communicate the rationale for identifying individuals at risk of developing diabetes to the public and clinicians
· Develop a model to identify patients at risk (could be practice based or a centrally managed model)
· Provision of appropriate services to support patients in making lifestyle changes to include psychological interventions, web based education and weight management options
By 31/3/16
Development of a pathway and protocols for the management of patients with Type two diabetes up to and including Insulin initiation to include:
· diagnosis and treatment with oral therapies and injectable therapies
· referral criteria for DSN and secondary care to OPA and DSN services.
By 31/3/16
Identification and management of patients with complex needs (HbA1c> 100) who have Type 1 or Type 2 diabetes
By 31/3/16
Development of a real time ‘Advice and Guidance’ network pathway between BHT consultant Service, DSNs and Primary Care
By 31/3/16
Development of an HCP programme of education, to include:
· Training needs analysis (see access details at end)
· Foundation level education available for all HCAs, practice nurses and GPs
By 11/12/15
From 1/4/16
Development of a Patient Education Programme, to include:
· Patient information sheets for pre diabetes and point of diagnosis with key messages and signposting to websites and education options
· 5 – 10 minute videos of key messages available on BHT and CCG plus local Diabetes websites
· Pro-active follow up from Education provider of patients referred at time of diagnosis with feedback on attendance to practices
· Provision of web based education as an alternative to group education
By 31/3/16
From 1/4/16
From 1/4/16
From 1/4/16
Development of a website to support local HCPs and patients:
· HCPs – details of HCP education events including relevance to HCP depending on role, signposting to national sites such as NICE, DUK and potentially an interactive clinical forum?
· Patients – details of education events and how to book on, copies of the handout sheets, signposting to DUK and potentially an interactive forum.
By 31/1/16
Development of a service model and education for care home staff:
· Guidance/training? on the management of patients with diabetes
· Access to short education modules such as videos, information sheets on the website
By 30/9/16
Development of an appropriately funded model for insulin initiation and management. Process will include:
· Mapping of who/which service is currently delivering insulin initiation/titration for each practice in Bucks
· Clear guidance on when to introduce insulin and how to titrate
· Education programme for HCPs
· Education programme for patients
By 30/9/16
Technological support to include:
· Shared patient records with read / write access accessible by any clinician seeing a patient with diabetes in Bucks irrespective of provider
· Centralised data searches identifying individuals &/or communities of patients at risk of developing complications allowing appropriate services to be targeted at those individuals or practices were greatest need is identified.
· A practice level diabetes data dashboard including key indicators/outcome measures.
· Pathways and protocols embedded within the practice and other clinical systems providing immediate and consistent clinical decision support information regardless of location and organisation.
From 30/9/16
The group of initiatives described below will be explored in greater depth for feasibility in January – March 2016 after which a decision will be made by the Diabetes Steering group on those to be further scoped.
· Explore with primary, community and secondary care providers’ alternative models of diabetes service provision taking into account the current workforce and the funding/training implications of new ways of working. Proposed new model to include:
· Community pharmacists and other Allied Health Professionals
· A multidisciplinary team approach for complex patients
· Patient support such as patient ambassador/champions
· Patient access to the online resource hub – how is this different from the website?
From 1/4/17
In early November GPs and practice nurses with a specific interest in diabetes were invited to an event to hear about the plans for diabetes, to provide input to those plans and to identify any further opportunities or challenges to be addressed.
Attendees were also invited to sign up to the project groups listed above. The meeting was very well attended with good and attendees gave clear support and endorsement of the following:
· Embedding the concept of prevention of diabetes within all practices with positive interest in the idea of centralised case finding.
· The idea of the first consultation being about ‘breaking bad news’ and the implications re support / education opportunities for patients.
· The beginnings of a debate on the place and quality of diet / lifestyle advice in the prevention / early diagnosis pathway.
· The concept that Type 2 diabetes up to and including insulin initiation is best delivered in primary care.
· The wider use of technology particularly with regard to shared records
· The move to a multidisciplinary approach to patients with poorly controlled diabetes.
· That to deliver change we need to work very differently and that, at times, this requires us all to feel uncomfortable as roles and relationships change.
In the next few weeks the newly formed groups will develop each project in much greater depth, reviewing existing pathways and protocols, developing service specifications and business cases as required and making recommendations for changes to ways of working.
Progress reports will be issued on a regular basis through this newsletter.
For anyone wanting more detailed information there is the opportunity to join our Diabetes professional group on line on the Lets Talk Health Bucks.
For an invitation to access the group please contact:
Jackie Lonsdale –
Scott Riley –
Dr Kathy Hoffman
GP Diabetes Facilitator, Thames Valley Cardiovascular Strategic Clinical Network;
Bucks CCGs Diabetes Clinical Lead
November 2015