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East Midlands Diabetes Conference

Integrated Diabetes Care - Delivering Better Outcomes for All - 17 October 2013

(27th October 2013)
 

View and review presentations from the conference!
 

An Overview


The East Midlands Diabetes Conference took place in Grantham on 17th October 2013.  The conference was organised by the East Midlands Diabetes Clinical Advisory Group and supported by funding from the Association of British Clinical Diabetologists( ABCD)
 

The conference was a great success and was attended by over 70 delegates ranging from patients, diabetes specialists in hospital and community services, general practitioners, and commissioning managers and clinical leads from Clinical Commissioning Groups.   
 

The conference was opened by Professor Melanie Davies who is clinical lead for the East Midlands Diabetes Clinical Advisory Group. Melanie described the role of the Clinical Advisory Group as part of the East Midlands Cardiovascular Strategic Clinical Network and shared the initial priorities for diabetes for 2013-14 which are cardiovascular disease prevention, foot health and peripheral arterial disease and type 1 diabetes.



Professor Jonathan Valabhji provided an update on current national policy on diabetes.  Jonathan commented that the level of CCG attendance at the conference was a demonstration that the Strategic Clinical Network were focusing on aspects that were relevant and of use to CCGs.  Jonathan referred to the diabetes parameters that are part of the Outcome Indicators for Clinical Commissioning Groups.  He stated that the national priorities were as follows:
 

  • Tackle obesity through a multi-agency approach
  • Prevention / early diagnosis / finding the undiagnosed
  • Manage people well / self-care through people empowerment and care planning and the 9 care processes and 3 targets
  • Effective management of those with complications through integrated care, pro-actively manage CVD risk and multi-morbidity.  He specifically raised the issue of high premature mortality and reduced 5 year survival rate due to diabetic foot ulcer. 
  • Transition services
  • Inpatient Diabetes Care in the light of the Francis & Keogh reviews
  • Type 1 diabetes care.  Jonathan referred to the need for patients with type 1 diabetes to have access to specialist diabetes care and that primary care did not have sufficient number of patients to develop their expertise in management.
  • Psychology services and ‘parity of esteem’ of mental health and physical health problems
     

Presentations - these can be viewed and downloaded from the subsection opposite


This was followed by a series of presentations focusing on the major themes of the conference.
 

  1. Cardiovascular Disease Prevention – Kamlesh Khunti provided an overview of the link between diabetes management and cardiovascular disease prevention and presented evidence from recent trials. He stated that diabetes is not CHD risk equivalent at diagnosis but lifetime risk is high.  He stated that improvements in cardiovascular management for people with diabetes have reduced premature death due to CVD.  Several studies have investigated the impact of tight glycaemic control on outcomes in type 2 diabetes, with mixed results and with few trials showing a benefit. Only the UKPDS trial showed reductions in CV outcomes and mortality.  He highlighted the need for early management of cardiovascular disease in people with diabetes as this is where the greatest gains are to be had.  Bad glycaemic legacy drives the risk of complications for diabetic patients in early years after diagnosis.  Clinical inertia was a major problem in type 2 patients with delays in time to treatment intensification from first HbA1c above 7.5%, by number of OADs and type of intensification.  He summarised by saying that tight glycaemic control should be targeted from the day of diagnosis and that intensive glycaemic control reduces risk of microvascular complications and has some benefit in reducing cardiovascular events.  Kamlesh finished by outlining the research programme which East Midlands CLAHRC were undertaking around diabetes which will contribute to improving outcomes for patients for people with diabetes.
     

  2. Integrated Care – Mo Roshan & Rustam Rea highlighted the importance of integrated care in ensuring that the needs of diabetic patients are met particularly as they will have multiple long term conditions as they get older.  Mo stated that there was a need for new thinking and a new system of commissioning for integrated care.  Rustam using a patient case study demonstrated how integrated care could offer a person with poor control of their diabetes by having ownership of the patient outcomes, sharing information that this person has not accessed appointments in primary or secondary care, by being responsive to the patient’s needs and constantly looking for those people falling through the gaps. Rustam described the pillars of integration and highlighted the potential for integrated IT systems to support improving the delivery of care for example by ensuring that the 9 key care processes were delivered for all patients.
     

  3. Type 1 Diabetes – Anne Kilvert presented a number of patient case studies to outline the issues faced by people with type 1 diabetes during the different ages of man. She highlighted that patients with type 1 diabetes are not receiving the care they need and that they could be seen as the lost tribe.  She stated that people with type 1 diabetes needed input from specialists in managing type 1 diabetes either in hospital or in the community.  Patients with type 1 diabetes are missing out on 9 key care processes and 3 targets, are more likely to have amputations, CKD and diabetic retinopathy.  Admissions from DKA are rising admissions and mortality is 135% greater than the general population.  Achieving patient engagement with specialists was seen as the first step to providing better care.
     
  4. Foot Health & PAD – Fran Game highlighted that there is a 10 fold variation in foot amputations nationally.  She stated that more effort was required to move patients off the current stairway to amputation and premature death.  People with foot ulceration had poorer 5 year survival rates than some common cancers. There was a need for patients to have their feet properly and regularly screened in primary care and for immediate referral to a multi-disciplinary foot clinic. It was essential for the MDT to have the appropriate staff composition and a particular issue was restricted access to vascular surgeons.  Fran raised the need to improve foot examinations within 24 hours of admission to hospital. The national audit has recommended steps to improve structure, process and outcomes for foot care which will be considered as part of the east Midlands priority project on Foot Health and Peripheral Arterial Disease.
     

The morning speakers joined Melanie Davies in a Question Time session with questions from the audience.
 

Over lunchtime there were 'Newsround Updates from health communities and Diabetes UK on the current development areas and challenges around diabetes care. This was helpful in understanding the current issues and in sharing work areas to support sharing of good practice. Copies of the Newsround Updates are available on the webpage.
 

  1. Integrated Care in Leicester, Leicestershire and Rutland - Azhar Farooqi, Ian Lawrence, Bernie Stribling presented the work in leicester to commission integrated care for diabetes.  Azhar emphasised the need for commissioners to improve care for people with diabetes to impact on expected costs in the future and tightening NHS budget.  He described the development of the diabetes transformation programme and the proposed model for diabetes care.  GP practices were being asked to define the level of diabetes care they wished to provide and were being supported through the EDEN diabetes education programme to ensure that they have the competencies to deliver the proposed level of diabetes care.  Ian Lawrence described the Super Seven services which would be provided by secondary care this included deliver of these services in community outreach areas to improve patient access and specification of inpatient services. Bernie outlined how they had specified the services and were in the process of commissioning for 20140-15 the core and enhanced services in primary care, community specialist diabetes support service and super 7 hospital service and were in the process of commissioning these services.
     
  2. Hypoglycaemia Pathway – June James provided an update on the implementation of the EMAS hypoglycaemia pathway in Leicestershire & Rutland. Patients were referred by EMAS to the service via the single point of access this was as an alternative to being taken to hospital.  Patients were contacted by the community diabetes service within 48 hours of referral.  June commented that an audit of what happened to patients post call-out of the ambulance service to a hypo had shown that 5 patients had died within 30 days of call-out with the hypoglycaemia being an indication of other health problems. A patient satisfaction survey found that patients valued the service.  June commented that nearly half of the HbA1cs were below target demonstrating that their diabetes control was too tight and that this included frail and older people.  The service has had a positive impact in terms of admission avoidance and reducing 2nd call outs.   The service has now been extended to include patients who have been conveyed to hospital to ensure appropriate follow-up. 
     
  3. Paediatric Diabetes and Best Practice Tariff – Tabitha Randell stated that there was still a wide variation in outcomes by diabetes centre for patients with type 1 diabetes and that HBa1C levels are still high at a median of HbA1c of 8.7% (National Paediatric Diabetes Audit 2010-11).  She described the implementation of the outpatient paediatric diabetes tariff from April 2012 which aims to improve the quality of care for children and young people with diabetes. The diabetes tariff will provide additional funding to diabetes centres if 14 standards of care were met.  Centres that do not meet the standards in 2014-15 will see a reduction in funding. There is a planned peer review of all centres starting in Autumn 2013. There are plans to include inpatient admissions with a primary diagnosis of diabetes from 2014-15 with plans to reward centres with low admission rates.  Tabitha spoke about the lost tribe of people aged between 16 and 25 in transition from paediatric to adult services and asked if the Best Practice Tariff should be extended to aged 25.  People aged 16-25 account for 25% of all DKA admissions at an annual cost of £5.3m.
     

 

Conference Evaluation and Key Learning Points


The conference evaluated well with all attendees scoring the conference as either Excellent or Good. Attendees were asked to comment on what were the key learning points from the conference. The main points are captured below:
 

  • What everyone else is doing on development of diabetes services in East Midlands
  • Impact of the many co-morbidities associated with diabetes
  • Paediatric Best Practice Tariff and paediatric/transition services
  • The specific needs of Type 1 diabetes – lost tribe and importance of commissioning an effective type 1 service and l]=not losing them to follow-up
  • The importance of CVD review along with diabetes
  • Glycaemic control and risk in Type 2 diabetes
  • Individualised HbA1c targets
  • Need to broaden remit of integrated service to screen for CVD more fully
  • Focus on patients who have most to gain in relation to reduction in HbA1c
  • Potential for IT to support integrated care
  • How other trusts are dealing with the challenges and lessons learned
  • Diabetes management clinical computer templates for key processes of care (Derby)
  • Examples of good practice
  • Foot care - need for better provision and whole standards have to be achieved
  • Disease burden for elderly patients who will have multiple long term conditions
  • Integrated models and interface between primary and secondary care
  • The importance of working in a more integrated manner
  • Diabetes education for staff – EDEN project in Leicester
  • Hypoglycaemic pathway – how is this being implemented locally?
     

Martin Cassidy

Senior Quality Improvement Lead

East Midlands Strategic Clinical Network

Email - martin.cassidy@nhs.net