Health CommitteeWritten evidence from the Association of British Clinical Diabetologists (LTC 35)

SERVICES PROVIDED FOR PATIENTS WITH DIABETES

Summary

This document provides evidence from the Association of British Clinical Diabetologists (ABCD), commenting on long term conditions from the viewpoint of people with diabetes.

Diabetes care in the UK is principally delivered by primary care teams, usually by the Practice Nurse.

Incentives and penalties limit contact of people with diabetes with the specialist teams until late in their disease process.

There is an urgent need for pilot work which would explore the best means and value of true integration between the specialty teams and primary care.

The team structure required to treat people with multiple morbidities in the community does not currently exist in the NHS.

There is a considerable amount of published information and advice for those who commission services for people with diabetes and this should be incorporated in service specifications.

The care pathways for people with diabetes centres entirely upon the general practitioner. The resulting pathway, while notionally attractive, remains difficult for people with diabetes and hampers integrated care.

The concept of an integrated care organisation for people with diabetes should be explored.

1. The scope for varying the current mix of service responsibilities so that more people with diabetes are treated outside hospital and the consequences of such service re-design for costs and effectiveness.

(a)Since the 1990s there has been a drift away from providing routine diabetes care within the hospital sector. This has been driven by a number of changes, most significantly the willingness of specialist diabetes teams to work outside the hospital setting. More recently, diabetes figured significantly in the QOF payment incentives. This, more than anything, persuaded primary care that they should manage diabetes in-house to ensure that their income was maximised. The Payment by Results system put a tariff on all referrals to specialist care which has also limited the flow of patients to the hospital sector. Unfortunately these changes have come about due to financial incentives and penalties, but any financial gains have not been ploughed back into diabetes care. The bill for diabetes care continues to grow, but this is largely made up of increases in the medicines budget with increases in the medical and social costs due to disability.1

(b)The end result has been that the percentage of patients seen in the hospital sector is already limited. This would probably range from a figure of 10–30% of patients being seen in a hospital setting, although that figure will vary according to local arrangements, and will usually be at the lower end of that range. People with diabetes now tend to be referred later in their disease process at which point they already have diabetes complications which may not be amenable to treatment at that stage.2

(c)It is argued, therefore, that the UK has a practice nurse delivered diabetes system. With a few notable exceptions, it is the practice nurses who will deliver routine diabetes care. There are many reasons why this is inappropriate. However, the main problem is that although the practices nurses are well motivated and dedicated, they do not have the appropriate training for this role given the various other calls upon their time and generally work in isolation.

(d)To allow diabetes care to be adequately delivered in primary care there will need to be a considerable expansion in staffing in that sector to allow for adequate care planning for the 5–6% of patients within the population who have diabetes. At the same time there is a requirement to design and commission an interface between the specialist team and primary care to allow the two sectors to work together. Diabetes specialist teams remain keen to work across the interface but the hardening of the organisational and financial barriers in the modern NHS make this increasingly difficult.

2. The readiness of local NHS and social care services to treat with long term conditions (including multiple conditions) within the community.

(a)The NHS is not optimally structured to treat patients with multiple morbidities in the community. Notionally, this would be the role of the GP, but the concept is now outdated due to increasing complexity of treatment and the increasingly pressurised role of primary care.

(b)At its simplest, the healthcare system can be divided into primary care, secondary care and social services. In recent years, the concept of multiple providers has fragmented this system further by introducing new organisations which duplicate activity rather than innovate. Communication between organisations is poor and budgetary allocations harden divisions.

(c)To be able to manage complex conditions in the community, there needs to be a team of healthcare professionals who can work within a common organisation which bridges all of the current functions. This team would include a senior doctor. In the context of diabetes, this would be a Consultant in diabetes given that the specialty remains wedded to the concept of general medicine rather than single organ systems. Patients with diabetes commonly have multiple morbidities, most commonly ischaemic heart disease, heart failure, kidney failure, peripheral vascular disease, advanced eye disease and amputation. As a result of these co-morbidities, they are often poorly mobile with high social care needs. The wider team therefore needs connections with social services and the therapies on the one hand, but as this patient group is extremely vulnerable medically, there also needs to be a bridge with the acute hospital to organise complex investigations and to provide in-reach in the event that the patient is transported to hospital.

(d)Ideally this team would operate within the same organisation, with shared management, a single budget and shared IT systems. Alternatively it would need to be set up as a virtual organisation with cooperation between the different providers.

3. The practical assistance offered to commissioners to support the design of services which promote community-based care and provide for the integration of health and social care in the management of long-term conditions:

(a)The Association of British Clinical Diabetologists (ABCD) , as the national association representing Consultants in diabetes within the UK, has had input into a variety of documents to guide those who commission services for people with diabetes.3 The major message has been integration of care. Patients with diabetes require access to multiple services at different times in their lives, ranging from a diabetes pregnancy clinic to a wheelchair service to social services. The advice provided outlines practical steps to integration of care.

4. The ability of NHS and social care providers to treat multi-morbidities and the patient as a person rather than focusing on individual conditions:

(a)While GPs may remain as generalists, specialist care is increasingly organ or system specific. The practical result of this is that an individual with multiple morbidities, using their GP as a central point of referral, is sent to multiple appointments and locations and back to their GP with little communication between each of the services. The care pathway therefore resembles a cricket batsman’s stroke pattern rather than a smooth continuum. While Consultants in diabetes maintain one of the few specialties with an ongoing commitment to generalism rather than a single organ system, their work pattern is constrained by the current geography of the healthcare system.

(b)From the perspective of an individual with diabetes, the care pathway must be made simpler.4 They wish to be referred to a single point of reference where all of their various problems can be managed. The NHS is currently not set up to do this. The system needs to be changed towards a model of integrated care organisations with a team which operates freely between primary care, social services and secondary care

5. Current examples of effective integration of services across health, social care and other services which treat and manage long-term conditions:

(a)Examples of integration of care within diabetes extend only to limited integration of medical services. There have, for example, been social enterprises set up between primary and secondary care to manage diabetes. In other examples, secondary care teams have gained the contract for community care of diabetes by forming separate companies outside the acute Trust. Such examples do not extend to true integration of care as an integrated care organisation.

Current examples of integration of care include:

A social enterprise for diabetes care in Derby.

Consultants in diabetes bidding for the community diabetes service in Portsmouth and running this as a limited liability company in conjunction with a community provider.

A joint initiative between primary and secondary care in Hull to improve diabetes screening with education sessions for those newly diagnosed.5

A joint initiative to improve diabetes care through care planning in North West London.6

9 May 2013