Transcript New Developments in Diabetes

Community Diabetes Care
the hospital view
Dr Prakash Abraham
• How many practices here?
• How many run diabetes clinics?
• What proportion of patients with diabetes
come there?
• What are the barriers for taking this on?
Projected Prevalence of Diabetes Mellitus in UK
6.0m
3.0m
1.5m
2001
2010
2030
Grampian Prevalance
• Approaching 4%
• Over 19,500 patients with diabetes (April
2006)
• 12000 in April 2002
• 10,000 attendances at diabetes clinic
Need for integrated care
• Two 30 minute review appointments for
19,500 patients per year.
19,500hours
• 44 weeks work/year: 444 hours per week
• Each clinic ~4 hours: 110 clinics a week
supervised by 3 WTE consultant
diabetologists (Associate
Specialists/Clinical assistants/SPRs).
• 10 clinics per week by permanent staff
• ~10 Trainee run clinics
Treatment Distributions
Insulin
Type
On Insulin
Not on Insulin
Type I
Type II - Insulin
Type II - Tablets
Type II - Diet
Type II - Tablets & Diet
694
2157
427
282
815
803
520
Over 75% not on insulin
Initial & realistic target for transfer of care
23
77
15
10
22
29
25
Diabetic Population:
Banff & Buchan
• 1999 1678
–1.9% of population
• 2005 2876
–3.6% of population
Place of Care
Practice Only Care
76
80
65
70
55
60
50
% 40
34
30
20
10
0
2001
2003
2004
2005
Place of Care
Hospital Only Care
40
30
30
24
18
% 20
11
10
0
2001
2003
2004
2005
Care Parameters Improved
100
90
80
70
60
percent 50
40
30
20
10
0
93
99
95 98
89
70
62
47
8.37.6
HbA1c
HbCheck
BP
BP check PN Foot
<140/80
2001
2005
Patients and Staff Feedback
What are the benefits of being seen at your Practice?
Convenience
Accessibility
Continuity
Familiarity
Other
Total
156
90
77
112
5
%
89
51
44
64
3
How often do you attend your Practice for Diabetic Care in one year?
1
2
3
4
More than 4
Total
4
73
18
46
7
%
3
49
12
31
5
Which professionals did you see at your diabetic review today?
Practice Nurse
Practice Nurse and GP
GP
Other
Total
152
14
1
5
%
88
8
1
3
Did you attend your Practice to have bloods taken before today’s
diabetes review?
Yes
No
Total
148
22
%
87
13
With all this patient
exchange what does
the hospital doctor
do?
What does the hospital Dr do?
• Golf
• Hill walking
• But still
– about 10000 patients attending annually
– More complex patients (higher proportion of
the 25% that need more time)
– To see with same time as in practice clinics
– 28 clinics per week (still running at > twice the
capacity)
Woolmanhill attendances
16000
14000
12000
10000
New
8000
Return
6000
4000
2000
0
1999
2000
2001
2002
2003
2004
What does the hospital Dr do?
• Release of hospital resources to focus on
complicated cases
• Develop services
– Adolescent care
– Pregnancy care
– Foot/Renal
– Insulin Pump
• Guidelines & Protocol development
• Teaching/Training/Research
Integrated care: Building blocks 1
• Enthusiastic team
• Multidisciplinary leadership
– GP
– DSN
– Dietitian
– Podiatry
– Patient
– Management Representative
– Secondary care link
Building blocks 2
•
•
•
•
•
Agreed Criteria
Agreed standards
Empowerment: Staff/Patients
IT Support/Audit
Education at all levels
– GPs: Lilly course
– All(Warwick, Shipley, Insulin for life)
– Ongoing education/ Courses /Conferences /
Network days
Incentives for transfer
• Better patient care
• Satisfied patient and staff
• Easier access & better service for the 25%
who need more input
• Higher GP contract Quality points
• Clinical Accord
GP contract
GP Contract 2004/5
~90/99 Points (including
allAVERAGES
56 previous
points)
LHCC
- Q & O FRAMEWORK
Diabetes Q & O Framework
1
100%
10
84%
2
94%
11
97%
3
98%
12
62%
4
79%
13
77%
5
98%
14
77%
6
54%
15
51%
7
85%
16
88%
8
82%
17
50%
9
84%
18
74%
Wishlist
• Dedicated time for
– Telephone session with practices
– Teleconferencing
• Practice education visits
• Redesign of secondary care to deliver
better care of diabetes complications
Primary & secondary care
work in partnership with the
patient at the centre