1. Managed Clinical Network
Lothian Diabetes
Managed Clinical Network
Nicola Zammitt
Secondary care clinical lead MCN
CD ECED
MCN meeting 24/11/16

2. Outline Context Refreshed MCN Recent challenges
Diabetes Improvement Plan
Quarterly reporting
Refreshed MCN
Staff
Subgroups/workstreams
Meetings
Recent challenges
T2D LES 2

3. Diabetes Improvement Plan 2014: Context
In last 10 yrs, 1o care contacts for diabetes risen by 25%.
Diabetes: 10% of total heath resource expenditure in UK.
NHS Scotland Quality Strategy:
Put people at the heart of everything NHS does
Provide best possible care
Improvement in quality of care involves all staff/levels/roles
Route map to the 2020 Vision for health and Social Care:
Builds on quality strategy
Aim for safe, effective and person-centred care.
Focus on 12 priority areas of action
Diabetes improvement plan priorities are anchored to those of the route map
ScotPHO (Scottish Public Health Observatory)
Over last 10 yrs, no. of 1o care contacts for diabetes risen by 25% to ~800,000 contacts per year.
Diabetes accounts for 10% of total heath resource expenditure in UK and is projected to account for 17% by 2035. 3

4. 2020 Vision for Health and Social Care

5. Diabetes Improvement Plan (2014): 8 priorities

6. Diabetes Improvement Plan: 8 priorities

7. Diabetes Improvement Plan: 12 measures
12 Initial measures
% people with DM who receive all 9 key indicator measurements:
Weight/BMI
Urine albumin creatinine ratio
Serum creatinine BP
HbA1c
Cholesterol
Retinopathy screening
Foot risk stratification
Smoking status

8. National Diabetes Improvement Plan 2014
12 Initial measures J
% persons with an HbA1c <58mmol/mol at 1 year post diagnosis
% persons with an HbA1c <58 mmol/mol and >75 mmol/mol
% current smokers
% people aged with total chol <5mmol/l AND SBP <140 mmHg
% of new foot ulcers
% of eligible people who got retinopathy screening in last 15 months
% of people with diabetes with end stage renal disease or on dialysis
% people on insulin pumps
% people with BMI ≥ 30 who have lost ≥ 5% body weight in last year
% persons who have attended structured education
% disengaged from care (no HbA1c or retinal screening in last 15/12)

9. Quarterly reporting
From Jan 2016: NHS Boards (through MCNs) provide quarterly report outlining progress against the 12 diabetes quality measures.
Section 1 Baseline and Self-Assessment
Use RAG rating to indicate baseline performance for the start of quarter 1
Self-assessment: consider where focussed action is needed, where current activity will support continued improvement or where no action is required.
Section 1 only completed once at start of reporting year.
Overview and some examples:

10. 1. % people with DM who get 9 key measurements
Recording of smoking status is done particularly badly
SCI only “counts” smoking status recorded within last 15 months
Discussion with public health: ? Change request in to trak
Similar to Scottish average
1b. Improve documentation of smoking status from 75% to at least 80% by end of Currently exploring why documentation of smoking status is so low. Possibly a data entry issue as QOF pages suggest that smoking data are 95% complete for people diabetes. Source of SCI smoking data for patients seen in primary care is currently being explored with SCI Diabetes Team and MCN public health lead Dr Duncan McCormack

11. 1. % people with DM who get 9 key measurements
Urine ACR and foot risk scores also done badly
Recent focus on 9 key measurements at FM questions
SG considers <80% to be “low”: all require local attention.
Foot screening for adults with type 1 diabetes needs early attention, particularly as these patients should be attending hospital
? disengaged from other follow-up
<5% Lothian pts disengaged (no HbA1c, no DRS in 15/12)
% patients receiving this measure
Type 1 adult
Type 2 adult
Scotland
NHSL
Urine ACR
63%
75%
69%
Foot risk score
65%

12. 2. % with HbA1c <58mmol/l 1 yr post Dx
Above Scottish average for type 1’s over 18 (59.1% Lothian vs 49%)
Similar to Scottish average for adult type 2’s (70.9% Lothian vs 71%)

13. Measures 5-9 Similar to the Scottish average (47% T1; 54% T2)
5. % age 50-70: TC<5 & SBP <140
Similar to the Scottish average (47% T1; 54% T2)
LES for T2DM
6. % of new foot ulcers
Figures for new foot ulcers v. low. Likely under-reporting. SDS 2015: 5.7% people with diabetes in Lothian had foot ulcer. Q’erly data: 5 new ulcers in last 3/4.
Liaise with foot group and SCI to review how data is recorded. Foot ulcer management tool on SCI
7. % people with DRS in last 15/12
DRS standards: >80% screened in last 15/12. Lothian 84.5%; Scotland 84%
Maintain current level of retinopathy screening
8. % reaching ESRF or RRT
1.2% T1DM and 0.7% T2DM, in line with rest of Scotland.
Maintain
9. % of people on CSII therapy
NHS Lothian performs well vs rest of Scotland, but not vs international data. SNP aim for 20% on CSII
Continue to increase pump provision to appropriate patients with type 1 diabetes

14. Measures 10-12
10. % of persons with a BMI ≥ 30 who lost ≥ 5% wt in the last year
Similar to Scottish average but room for improvement, with just 14% of obese individuals with type 2 diabetes losing at least 5% body weight over 12 months.
Changes to referral criteria into LWMS should help. Midlothian launched new Wt Mx pathway in Sept 2016
11. % persons who have attended structured education
Similar to Scottish average but significant room for improvement. Participation in DESMOND is not systematically recorded on SCI so the data for type 2 diabetes is not reliable.
Establish systems for accurately recording how many people have been offered structured education – by end of 2016
12. % disengaged
<5% of patients disengaged
Maintain <5%
How do we get input from subgroups for quarterly reports?
Timelines are tight
4 weeks from data available to sending in and board sign-off
How do we feedback info from quarterly reports to clusters/IJBs?

15. Refreshed MCN

16. Refreshed MCN
Clinical lead role shared 1o/2o care (David Jolliffe, Nicola Zammitt)
2o care clinical lead is also Diabetes CD
New strategic programme manager (Paul Currie → Alyson Cumming)
New MCN coordinator (Bonnie Thomson → Marie McCallum)
HSCPS – IJBs.
LTCs – House of Care, multimorbidity hubs, cDSNs
New public health liaison
Joy Tomlinson → Sarah Wild. Duncan McCormick to lead DRS
New sub-groups aligned to improvement plan
Time is precious. Need room for new players.
Other autonomous groups link to MCN but not formal sub-groups. SLWGs as necessary
Leaner MCN. Meet quarterly.

17. Refreshed MCN New sub-groups aligned to improvement plan
Prevention & early detection (plus public health and ? Prescribing)
T1DM
Innovation
In patient diabetes
Education (improving info and supporting/developing staff)
Feet
Threads run thro all groups: Person-centred care, equality of access.

18. Refreshed MCN

19. Background to LES 2012 Diabetes MCN reviewed T2 pathway
Pathway presented to LMC: T2 LES to support pathway
: 1o care investment £1M (non recurring) to support key strategic priorities incl LES. Approved by NHSL Board.
From July 2015: LES funding to GPs to:-
Assess and manage new onset patients
Help reflect the rise in prevalence and complexity
118/125 practices signed up (95%)
engagement fee £300 per practice - £35,400
Practices paid £120 per newly diagnosed patient managed
Total cost of LES for 9 months - £229,320
Lothian Local Medical Committee represent interest of all general medical practitioners within Lothian within matters affecting T&C of service. It liaises with and supports the UK GP committee and its sub-committee. Provides representation, guidance and support to GPs and practices. 19

20. LES going forward 31/3/16: non-extension of LES funding
After extensive discussions, decision on 14/6/16 to reinstate. Risk sharing approach with IJBs: £220k for rest of financial year
Challenge to identify future funds (?£5M for 1o care over 5 years)
CMT agreed on 14/11/16 to support LES but IJBs to discuss funding.
LES Service outcomes:
Named practice lead (GP or Practice nurse) is required to:
1. Keep up to date with current MCN and LJF recommendations on diabetes care, incl indications for referral.
2. Liaise with the Community Diabetes Specialist Nurses (DSN).
3. Ensure that relevant practice staff remain abreast of service developments and referral pathways (incl annual educational update) 20

21. LES: what does it cover? Work included in LES (£120 per new patient):
Correct coding at diagnosis: populates SCI Diabetes
In house education on diet and lifestyle (GP, nurse, pharmacist, AHP)
Refer to DESMOND or other suitable structured education
CV risk score
Foot assessment +/- referral
Review of all the standard diabetes QoF indicators
Work of initial assessment
Identify complications (retinopathy screening automatically triggered)
Initiate diet and medical therapy +/- referral
Establish FU in line with guidelines and MCN recommendations
LES needs refreshing (QOF removed, new T2 Dx pathway – HbA1c).
Opportunity to build quality into refresh Eg aim HbA1c<58mmol/mol at 1yr post-Dx (measure 2 on improvement plan) 21