Focus UK: Commissioning, prevention, and integrated care
Wednesday 8th–Thursday 9th March
The first 2 days of the Diabetes UK Professional Conference featured a number of sessions focused on diabetes care within the UK healthcare system.
Commissioning trials and tribulations
One of these sessions was the first-ever workshop exploring the commissioning of services for diabetes care, with four presenters sharing their very different real-world experiences. In commissioning services for Northumbria, Nick Lewis-Barned is responsible for some of the least population-dense areas of the UK, whereas population density is at the other end of the spectrum for Tony Willis and Raquel Delgado, reporting their experiences for North-West London and Hounslow, respectively. And Kate Fayers presented a different scenario again, being responsible for the West Hampshire community diabetes service.
Fayers’ service was launched in 2010 and recommissioned in 2015, making them “one of the very few services that has been through the complete washing machine cycle twice.” But she added that “it was a pretty painful experience if I’m honest,” saying that putting the bid together took over 100 hours of time of the two people involved, and was an isolating experience.
The presenters highlighted themes including creating patient-centered services that are convenient for them, the need for effective project management, fostering excellent communication between primary, specialist, and community care, creating a shared vision, and the need to allow time for changes to bed in and clinical results to become apparent.
Willis also advised the audience to learn how to speak the commissioners’ language. “Commissioners understand bed–days as a currency,” he observed.
Continuing the commissioning theme, a session on Thursday morning covered the funding of new technologies, beginning with representatives of INPUT, the charity that exists to help diabetes patients access funding for technology, outlining the sorts of issues with which patients approach them.
Nick Oliver (Imperial College London) then shed light on the process that led to the current NICE guidance on continuous glucose monitoring (CGM). He outlined the research considered and the cost-effectiveness analyses used, which resulted in the current recommendations that CGM be used only in patients who struggle with hypoglycemia, and in those who remain hyperglycemic despite self-monitoring their glucose at least 10 times a day.
Oliver used these recommendations as the basis for a business case, which he presented to the CCG to secure funding for CGM. He provided the CCG with supporting evidence from scientific literature, and also used data on local hypoglycemia rates, obtained from the London ambulance service, which he stressed should always be included in a business case.
However, not all patients who might benefit from technologies meet the NICE requirements, as outlined by Pratik Choudhary (King’s College London), who presented several recent cases of patients he felt would benefit, but for whom there was no “box to tick” to apply for funding. These included a woman for whom CGM would reduce the burden of self-care, an anesthetist who wanted a monitor with an alarm as a safety measure, and a man who had achieved major improvements in his glycated hemoglobin level while self-funding CGM, but lacked the money to continue it further.
Giving the point of view of NHS England, Partha Kar (Portsmouth Hospitals NHS Trust) questioned why people should struggle to gain funding for NICE-recommended technologies, saying, “if Nick Oliver can do it, why can’t anyone else?” and asking Oliver if he had received many requests for advice from other clinicians (he had not).
“There is a NICE guideline and people have a responsibility to follow the NICE guidelines,” he said, and invited people to contact him if they had continued problems gaining funding despite taking advice from clinicians who have successfully done so.
Kar did not directly address the case studies raised by Choudhary, but did stress that funding for technologies cannot be opened out too freely until more healthcare professionals are fully trained in their use. Indeed, lack of relevant healthcare provider expertise was one reason cited by patients contacting INPUT for being unable to access technologies.
He concluded by reiterating that clinical leaders need to decide where diabetes technologies lie among their funding priorities, and need to fully train diabetes professionals so they can support patients to use these technologies safely. “So that’s my challenge back to the whole community,” he said.
Stopping Type 2 diabetes at source
In a Wednesday session, representatives of NHS England outlined the aims of the Diabetes Prevention Programme, “Healthier You,” and reported on its early progress. The program, which began 2 and half years ago, represented a major shift for the NHS, and a large part of the early work involved simply convincing people that prevention could be an important part of NHS care. Diabetes was selected for the first systematic preventive strategy because, by targeting people with non-diabetic hyperglycemia – or prediabetes – for lifestyle interventions to prevent or delay diabetes, the program could demonstrate results far faster than one that aimed to prevent, for example, cardiovascular outcomes.
The first wave of sites to join the program did so from April 2017, and by the end of January this year 25,687 at-risk people had been referred to the program, with 7232 choosing to take up the service. Allowing for an increasing referral rate and a lag between referral and attendance at first session, the program directors believe that around 30% of people referred are at least starting on the program. By the end of roll-out in 2020, they anticipate that the program, which is run by four providers nationwide, will be delivering 100,000 interventions per year.
The early data also indicate that the program is acceptable to people of ethnic minorities and low-income groups, and the directors plan to assess its acceptability for people with learning difficulties. In addition, they aim to develop digital interventions to meet the needs of people who decline participation in the program because of time constraints.
There followed a more in-depth presentation of the experiences of implementing the program in a first-wave site: the East Midlands. Martin Cassidy, the lead program coordinator for the area, revealed that, 7 months into the program, they are now hitting their monthly referral targets, with a total of 3308 referrals so far. Of these patients, 54.5% agreed to join the program, 24.3% declined, and 21.2% were discharged because the provider was unable to contact them.
Once on the program, 83% of patients attended the first session and around three-quarters attended sessions 2 to 4. These first four sessions are delivered within the first month, with the other four spread over a further 8 months. Cassidy emphasized the importance of describing the program as four sessions in a month, with later top-up sessions also available, rather than putting patients off by describing an intervention lasting 9 months.
Attendance remained high for the maintenance sessions, at between 68% and 81%, with the latter value being for the last session; patients appeared to miss sporadic sessions due to other commitments, rather than their attendance tailing off over time.
Cassidy outlined a number of additional lessons learned, including the benefits of incentivizing practices to refer (including acknowledging high-referring practices in a newsletter), the importance of good communication with the program provider, and that summer is a bad time to launch the program.
But the most important thing, he said, was making the program a clinical commissioning group (CCG) priority and having sufficient CCG resources to engage and regularly communicate with practices, chase up non-referring practices, and communicate the benefits of the program.
PROCEEDing from Derby
For the Mary MacKinnon lecture, Paru King outlined the genesis and achievements of the award-winning Derby model of integrated diabetes care project, for which she is the clinical lead, and which was launched, coincidentally, in the same year as the Lonely Planet Guide named Derby as a top 10 place to visit worldwide.
The model is based on “seamless pathways centered around the user,” ie, the diabetes patient. It fully integrates financial, information technology, organizational, and clinical aspects, and has a single clinical governance structure. So for example, patients have a single, shared electronic record that is accessible by all their care providers, whether they are primary or specialist providers, and facilities rapid communication between them. And there is a single budget “so that specialist and primary care team members together own problems as well as solutions.” Patients’ care can be escalated and de-escalated between the primary and specialist providers as needed; when specialist care is required, the team can come into the community and sees patients in a clinic local to them. The patients are also able to contact their care providers for help by means that can include telephone, email, and Skype.
The models’ achievements included a 50% reduction in non-attended appointments, an average glycated hemoglobin reduction from 10.2% to 7.9%, and significant cost-savings. And King showed many videos of diabetes care professionals and patients discussing the professional and personal benefits of integrated care.
With such positive results, King applied the integrated care principles to preconception care for diabetes patients: the PROCEED model. This produced similar encouraging outcomes, doubling the proportion of women receiving preconception care from 32% to 70%, and reducing non-attendance from 18% to 5% and average glycated hemoglobin from 9.1% to 7.1%. Furthermore, the congenital abnormality rate was 4% during the first 12 months of PROCEED, compared with 10% in the preceding 12 months, and the stillbirth rate was 0% versus 6%, although King stressed the difficulty of drawing conclusions from such small numbers. And, again, the integrated care approach saved money, and is now a commissioned service.
Surprisingly, despite being “a strong clinical model that was nationally recognized and evidence based,” the Derby integrated care model fell afoul of commissioning changes, and, for some years, struggled to obtain contracts. But a new chair for the commissioning group proved supportive of the approach, and the team is now poised to roll its services out to Derbyshire as whole.