Health CommitteeWritten evidence from Sanofi Diabetes (LTC 34)

Sanofi Diabetes works closely with healthcare professionals from across the diabetes care pathway, including diabetologists, diabetes specialist nurses and GPs with a special interest as well as allied and public health professionals. Through its support of the Diabetes Parliamentary Think Tank,1 chaired by Adrian Sanders MP, and its work with the Primary Care Diabetes Society (PCDS),2 Sanofi has developed a picture of the current management of diabetes in the NHS and the concerns of those working to deliver diabetes care. The following written submission draws on discussion and consultation with these individual groups, but is representative of Sanofi’s position only.

Executive Summary

Moving more diabetes care into the community must be a priority. However, primary and community healthcare professionals must be supported with the necessary specialist input in order to improve patient outcomes.

To ensure that local NHS and social care services are ready to treat people with diabetes in the community it is imperative that specialist knowledge is retained and developed. Access to patient outcomes and service performance data is also vital in the commissioning and provision of services in the community.

Support is available to commissioners at a local level, however there is an acute need for national leadership in this area and we look forward to the publication of the Diabetes Action Plan; Long Term Conditions Outcomes Strategy and the Diabetes Companion Document.

Integrated care across the diabetes care pathway is desirable. However, there are significant barriers to this becoming a reality, including the perverse incentives that are built into the current system that prevent healthcare professionals from working together.

Response

1. It is widely understood that keeping people with diabetes out of hospital must be a priority when designing and commissioning diabetes services. Strengthening the provision of care in the community will be integral to tackling this acknowledged over-reliance on hospital care. However, in order to guarantee the delivery of high-quality care in the community, health-care professionals working in the community will require support from specialists. In July 2012, the Keeping People with Diabetes out of Hospital (KPDOH) Expert Working Group recommended that GPs should have regular contact with specialists in a community setting in order to review more complex cases; prevent unnecessary referrals into secondary care; and enable GPs to develop disease specific knowledge. This may not require extensive service re-design, but simply take the form of a regular multi-disciplinary team meeting held in the GP practice.

Local professional networks are also valuable in engendering the flow of information, skills and knowledge across the pathway. At a time when professional education budgets are severely restricted, professional clinical networks can play a significant role in improving levels of specialist knowledge in the community.

2. There are two issues to be addressed when assessing the “readiness” of local health and social care systems to treat and support people with long-term conditions. Firstly the workforce and level of specialist expertise in the system has a significant impact on “readiness” and indeed the responsiveness of the care system. The wholesale re-organisation of the NHS and the move towards a more “generic” approach to system structures (preventing mortality; chronic disease management; recovery from episodes of ill health; patient safety; and quality) have prompted debate on the “dilution” of disease-specific skills in the commissioning and delivery of diabetes services in both primary and secondary care. The role of Diabetes Specialist Nurses (DSNs) has been the headline discussion topic at two Diabetes Think Tank meetings, and the retention and development of this sector of the diabetes clinical profession has pervaded all discussions. Concerns have been raised that as financial constraints take hold, investment in training, recruiting and retaining DSNs has been de-prioritised. Evidence shows that DSNs have a significant impact on the quality of patient outcomes and if the strength of the workforce is corroded, patients will be negatively impacted.

Secondly it is vital that commissioners and providers have access to data relating to individual patients, local health outcomes and service performance from across the pathway, both nationally and from within their own locality. The KPDOH Expert Working Group recommended that strategies for sharing patient information should be explored, specifically taking on the challenge of patient consent. Patients expect healthcare professionals to have all of the information necessary to make informed decisions about their care, yet barriers remain that prevent the necessary transparency.

3. The Diabetes Action Plan; Long Term Conditions Outcomes Strategy; and the Diabetes Companion Document have all been delayed and it is our understanding that they will now be published by NHS England, and not the Department of Health. A timeline for the publication of these long anticipated documents is still not clear. At the most recent meeting of the Diabetes Think Tank (1 May 2013) it was clear that without a national strategy the diabetes clinical community is in a state of flux. Whilst it is understood that NHS England are looking for change to be driven locally, there is a desire for national leadership to guide this change at a service-specific level.

We welcome the publication of Best practice for commissioning diabetes services: An integrated care framework, a document co-produced by NHS Diabetes, the Department of Health and leading patient and professional associations.

4. Integrated care is widely acknowledged as a desirable outcome in the re-organisation of the NHS and would enhance the quality of service received by people with multiple chronic diseases. However, members of the Diabetes Think Tank strongly believe that the present payment system poses a major barrier to achieving it. In particular it was noted that the purchaser-provider split at the centre of the health system and the resulting competition between healthcare providers fails to adequately incentivise healthcare professionals to work together to provide joined-up care for people with diabetes.

It was further observed that the present system of tariff payments provides secondary care diabetes specialists with a perverse incentive, encouraging them to treat simpler cases to maximise profit for their Trust, rather than focus on the more complex patients who require more attention and therefore more resource.

The Think Tank agreed that in order to enable greater integration of care, the financial model needs to match the model of care that it is meant to deliver. It was suggested that if healthcare professionals were placed within an incentive system which encouraged joint working, the service would transform itself accordingly. Furthermore, there needs to be greater clarity as to the exact size of local diabetes budgets, and who is responsible for the allocation of funds across the entire integrated pathway.

In addition to redressing the balance of incentives, it is imperative that Health and Wellbeing Boards place emphasis on the importance of integrated diabetes service provision in their Joint Strategic Needs Assessments (JSNAs).

There are a number of integrated diabetes care models working successfully in the NHS including models in Derby, Portsmouth and North West London. However, it is important to note that there is no “one-size fits all” model which commissioners should seek to deliver in every locality. The availability of a choice of models will be greatly desirable in providing a service tailored to the specific needs of the local health economy.

5. The KPDOH Expert Working Group identified a number of integrated care models in its report. These models particularly focused on reducing avoidable hospital admissions amongst people with diabetes.

Full details of these case studies are available here (pp.23—39): http://www.pcdsociety.org/media/Keeping_People_with_Diabetes_out_of_Hosptial_-_A_report_by_the_Primary_Care_Diabetes_Society.pdf

6. Research by the Institute of Diabetes for Older People (IDOP) shows that the median age of inpatients in more than 200 Acute NHS Trusts is 75 years and the majority have been admitted as an emergency. This report also found that factors which increase the likelihood of hospital admission of older people included care home residency, mis-management of medication and carer fatigue, among others.3 Diabetes UK (2010) found that six out of ten care homes in England which have residents with diabetes, fail to provide any training to their staff about the condition. Diabetes UK also found that only 23% of care homes screen their residents for the condition on admission. The report concluded that this missed screening could mean that as many as 13,500 care home residents could have undiagnosed Type 2 diabetes and could be at increased risk of developing complications.4 All diabetes complications (excluding Diabetic Ketoacidosis) become more likely with increasing age and duration of diabetes and it is vital that this group have their condition closely monitored. The KDPOH Expert Working Group noted that diabetes care delivered in care homes is often not appropriate and that support needs to be available to care workers to ensure that specialist diabetes care is available where necessary.

7. It is known that people with severe and enduring mental health problems have a greater risk of long-term physical health problems, including diabetes, which can lead to increased hospitalisation and early mortality.

Birmingham and Solihull Mental Health Foundation Trust has developed a model for managing and treating people with diabetes in their care. A diabetes lead has been appointed within the Trust to support this vulnerable group of patients. Early evidence demonstrates a positive impact on patient outcomes. More details of this model are available in the KPDOH Expert Working Group’s report.

9 May 2013