The Super Six model of DIABETES care

Dr Partha Kar

Portsmouth Hospitals NHS Trust

Southern Health NHS FT

Solent NHS Trust

Challenges 2017..world of 5YFV

• Finances

• Multiple providers

• Different priorities of acute & community providers

• Resistance to change

• Moving care in community

• 7 day service for acute care

Challenges for locality 2009/2010

• Wage bill, financial envelope of acute Trust (PFI)

• What does a chronic disease specialist ACTUALLY do in an acute Trust?

• Continued activity in spite of not being commissioned i.e. outside agreed N/F ratio/ demand management

• Variability in pathways to same hospital

• Different/Conflicting KPI / financial drivers for both teams

2009…

Portsmouth City PCT, SE Hampshire PCT

Catchment ~605,000

Register ~31,000

Mixed socio-economic group

Specialty Diabetes Team (SDT) based in Acute Trust

(Portsmouth Hospitals NHS Trust)

SE Hampshire PCT

1.6 WTE Nurse

1 session/week with GPs with a special interest

(Southern Health NHS Foundation Trust)

Portsmouth PCT

No intermediate team

Too much…..too many?

83 GP surgeries

3 CCGs

1 Acute NHS Trust

2 community NHS Trust

1 private provider

1 ambulance Trust

And many many individuals….

Time for a rethink!

• Discussion amongst local GPs and PNs

• Discussion with PCTs/ CCGs

• Patient groups

• Diabetes UK

• Trust Executives

• Consultant colleagues

• GPsWI (Dr Tim Goulder) / CCG lead (Dr Jim Hogan)

Re-defining the role of a specialist…

• Specialist

• Educator

• Leader

• Accountability

Specialist diabetes: The Super Six

(WITHIN ACUTE TRUST)

1. A) Patients in hospital (20% of population pa)

In-patient care

Peri-operative care

B) MDT services:

• 2. Antenatal diabetes

• 3. Foot diabetes

• 4. Pumps

• 5. Adolescent/Type 1 Diabetes (poor control)

• 6. Renal (eGFR between 20-40 and less-in joint

conjunction with Renal)

Situation locally..

• The “Super Six” model…

• Activities for acute Trust- using specialist skills

• Release activity for Commissioners to use

• Reduce workforce for acute Trusts – Consultants, as a group, drop PA sessions.

• Activities for Community Trust – using educator role

• Join existing Community Diabetes team

FUNDAMENTAL?

SAME team across hospital/community

Situation locally…

• 52 week cover (Consultants)

• Phone service 5:30 – 7 pm Mon-Fri (based on GP advise)

• Nhs. Net email (24 hour response time)

• Visits to GP surgeries ( service at GP discretion)- 2/ year

• No case holding

• Key Performance indicators: short term / long term

Situation locally..

Patients were discharged-

BUT with GP consent AND patient consent- in an agreed step wise manner with CCGs and GPs

Visits:

◦ Virtual clinics (case-based discussions)

◦ Audit

◦ Educational session on area(s) of diabetes management of surgeries choice

◦ Patient review

◦ Review of database to discuss patients regards QoF targets

Since November 2011…

• 1483 (96%) patients discharged from general diabetes

secondary care.

• 59 patients transferred to “super six” clinics and 15

needed clinic review pending discharge.

• General diabetes referral down from 15/month to

0/month

Since November 2011…

Telephone calls:

• Nurses: 4394

• Doctors: 511

Emails:

• Nurses: 2534

• Consultants: 417

• Total referrals to specialist care: 17

Response rate within 24 hours: 99.4%

• Portsmouth PCT / CCG agrees to Community diabetes tender: August 2012

• Same model of care

• No post code lottery

• Solent NHS Trust

• Same format, discharges started

• 3 providers in region- contracts with all 3, Consultant body integrated link between all organisations

Recognition:

Shortlisted: BMJ Awards 2015 (Clinical Leadership)

Highly commended: HSJ Awards 2014 (Acute sector innovation)

Runner Up: Guardian Healthcare Innovations Awards 2013

Shortlisted: HSJ Awards 2013

Shortlisted: Nursing Times Award 2013 (Young Persons service)

Shortlisted: BMJ Awards 2013 (Diabetes Team of the Year)

Shortlisted: HSJ Awards 2012 in Management of LTC

Winner: Care Integration Awards, 2012

Winner: Quality in Care Award, 2012 (Best Network Initiative)

Silver Award: Quality in Care Award, 2011 (Team of the Year)

Winner: HealthCare & Social Awards , 2010

Feedback 2015

• Patient feedback:

• On a scale of 0-10, the average rating was 9.5 (0

was poor, 10 was excellent)

• Primary care feedback:

• On a scale of 0-10 (0 was poor, 10 was excellent)

96.6% scored between 8-10 on “Satisfaction”

• On a scale of 0-3, (0 was No; Yes was absolutely),

100% scored 3 on “Continue the services”

Hard outcomes…

Difference in number of events between no intervention scenario and current intervention scenario

2010/11 2011/12 2012/13 2013/14 2014/15

DKA 0 8 51 77 92

Hypos 0 15 44 69 67

HHS 0 -2 4 -1 2

MI 0 29 58 53 65

CVA 0 -13 -1 47 59

AMP 0 38 37 28 73

Economy…

Concentrate on specialty work

• 3/371 (0.8%) babies with a weight greater than 4.5 kg

• 1/371 (0.3%) intra-uterine deaths

• 0% neonatal deaths

• 2/371 (0.6%) congenital abnormalities

• 16/371 (4.3%) intra-uterine growth retardation

• 284/371 (76.5%) mothers were breast feeding

• A progressive increase in mothers receiving pre-

pregnancy counselling (1.8 fold increase)

• The international St Vincent’s Declaration of 1989 for Diabetes declared that health care

professionals should achieve pregnancy outcomes in women with diabetes that approximate

that of women without diabetes.

Further developments…

7 day diabetes service started from July 2014

Rota covered by DSNs and Consultants

Online (free)module to help 15 essential checks to be rolled out (NDA focus)

182 CCGs visited so far with ideas- adapted in other areas e.g.:

Leicester

Southampton

Gateshead

Camden

Super Six diabetes model

• Re-defines role of specialists

• Moves care in community but with support

• 7 day service

• Outcomes

• Financial savings

• Longest standing model of care in diabetes- 5 years

• Evidence of leadership making change happen for patients

Thank you!