1. Diabetes CCWHE OOH Contracts
Dr Raquel Delgado
Diabetes GP Lead

2. Aims and Objectives
Address variation of care across CCGs and practices
Early identification and prevention
Better management of the 9 care processes
Reward and promote specialist services in the community
Up skill practices and clinicians

3. Tools to support the contracts
NWL Diabetes Education Programme
System1 OOH Diabetes Templates
CCWHE Diabetes guidelines available from Hounslow CCG website
Diabetes Dashboards
New Diabetes Community Service

4. Systm1 OOH Templates

5. CCG Dashboards

6. OOH Diabetes contracts
High risk diabetes
Diabetes Level 1
Diabetes Level 2 - injectables

7. Requirements for all the contracts
No exception reporting
All practices submitting data to the National Diabetes Audit (NDA)
Provide the data set requirement to secure payments and monitor improvements
Engagement with local diabetes education programme
Named lead GP/Clinician
Peer review and clinical audit
Payment based on KPIs achievement

8. High Risk Diabetes
Identify high risk patients Register of high risk patients XaZLG: gestational diabetes and abnormal glucose test Annual BP, HbA1c , lipids , smoking, BMI and lifestyle interventions/referral

9. Level 1 Diabetes Contract
Referral to structured education and provide patients with information at diagnoses
Annual 9 care processes including ACR and retinal screening
Annual review with ½ hour appointment
Hypoglycaemia recording frequency and management
CCWHE Diabetes guidelines for BP, lipids, HBa1c, insulin and glucometers + glucose strips
Care plans including housebound and care home patients
Copy of care plans given to patients with individualised targets
Patient satisfaction survey
Discharge from secondary care suitable patients

10. Level 2 Diabetes Contract
Insulin and GLP-1 initiation and optimisation and insulin education
Two ccredited clinicians
Only accredited clinicians can carry out the service
Annual accredited re-fresher courses
Adhere to prescribing guidelines for insulin
Face to face appointments , telephone, , Skype
Dietician and DSN support from the community service
Referral to insulin education programmes
Minimum network population of 30,000

11. New Diabetes Service
Named diabetologist , dietician, DSN and podiatrist per locality
Clinical psychologist
Diabetes podiatry
Flexible service to meet the needs of localities and patients
and telephone access to all clinicians within the service
Joint clinics with diabetologist , DSN and dieticians
Joint visits to housebound patients
Larger choice of education programmes for Type 1 and Type 2 (newly diagnosed, insulin and established diabetes)