NHS RightCare Pathway: Diabetes: The Magnificent Seven

NHS RightCare is a programme committed to reducing unwarranted variation to improve population health. NHS RightCare is about delivering the best care to patients, making the NHS’s money go as far as possible and improving patient outcomes. All 207 local health economies are now using the RightCare approach and the programme is working at both a national and local level, through a team of NHS RightCare Delivery Partners to implement this approach. Dr Partha Kar, Associate National Clinical Director for Diabetes, at NHS England explains how this works in practice when it comes to diabetes.

The NHS RightCare Pathway: Diabetes looks at specific areas of intervention where the return on investment is likely to have the biggest benefit beyond the financial benefits. It also looks at clinical areas which need to be tackled in order to benefit the population living with, or at risk of developing, diabetes.

There are seven key areas which are the point of focus. These align with the Five Year Forward View and the cardiovascular prevention optimal value pathway. Identification of those at high risk of developing Type 2 diabetes and increasing attendance in the Healthier You: the National Diabetes Prevention programme (NDPP) are both priorities.

Identifying people with Type 2 diabetes earlier is understandably a key focus with emphasis on the correct diagnosis and prioritisation at an earlier stage to help prevent future complications. This also touches upon the importance of correctly diagnosing Type 1 diabetes, to prevent diagnosis at admission, as well as genetic subtypes, all of which have significantly different treatment paradigms compared to Type 2 diabetes.

Safety within hospitals continues to be an issue as per the National Diabetes Inpatient Audit. With about 4% of patients with Type 1 diabetes going into Diabetic Ketoacidosis or two out of five drug charts having errors related to diabetes, the focus is on safety.  The NHS RightCare Pathway: Diabetes has made this a priority for acute trusts. Inpatient diabetes care is now an issue which all trusts have a responsibility to tackle, especially in light of the fact that 17-20% of inpatients at any given time have diabetes as a co-morbidity.

The majority of diabetes foot amputations are preventable, yet we continue to experience issues in this area but there is a real drive to reduce this across the country. We’re starting that journey by raising awareness amongst patients and professionals, self-management and access to multidisciplinary clinics as well as other opportunities.

According to the National Diabetes Audit, attendance at structured education programmes continues to be poor.  This has to change and we have to understand and overcome the barriers which contribute to poor and low attendance. A significant number of patients still report not being offered or provided diabetes care education. We need to understand whether it’s timing or the modes of delivery and there should also be focus areas for improvement, along with increasing awareness amongst professionals about the benefits education can bring in a long-term condition.

In line with the Five Year Forward View, another major focus is on variation of care. The national audits show a huge degree of variation in markers and the onus is on all policymakers and professionals to help reduce this level of variation.  The CCG Improvement & Assessment Framework (IAF) shows starkly the variation in care across the country and the hope is that with support from NHS RightCare this will improve over time.

Finally, NHS RightCare Pathway: Diabetes also brings to the fore the importance of highlighting Type 1 diabetes care as a priority area. The needs, training and fundamentals of Type 1 diabetes care do differ from Type 2 diabetes care. It’s important to focus on this area, especially when looking at the data from the national diabetes audits.

The publication of this document highlights what’s needed for a Type 1 diabetes service, the need for commissioners and Sustainability and Transformation Partnerships (STPs) to recognise this as a part, yet a distinct entity from Type 2 diabetes, keeping in mind the role of access to technology in Type 1 diabetes e.g. Insulin pump use, continuous glucose monitoring use, as per NICE guidelines.

Transitional services also need to be embedded, with smooth handover from paediatric departments, again, an area of huge variation in the country.

The theme that runs throughout is the need to reduce variation, base interventions on evidence and gain maximal benefit, clinically as well as on a financial basis. These are exciting times for diabetes care with availability of the transformation funds and digital interventions from NHS England also focussing on these areas with NHS Improvement also looking at reducing variation as part of their GIRFT work.

Only time will tell how successful these priorities are but it certainly helps set the tone for areas to focus on. The challenge now is for all systems to dovetail into delivering these seven priorities with support from all stakeholders including clinical networks, the NHS RightCare team and of course the NHS England diabetes team.

Partha Kar

Professor Partha Kar is National Specialty Advisor, Diabetes with NHS England and co-lead of Diabetes GIRFT with NHS Improvement.

He has led and delivered so far on (April 2016- till date):

  • Freestyle Libre being available on NHS -across country
  • NHS Right Care Diabetes pathway
  • Diabetes “Language Matters” document
  • Type 1 diabetes NHS England web-resource – on NHS choices
  • Introduction of Frailty into QoF treatment targets for diabetes care in NHS
  • Availability of CGM to all T1D pregnant patients
  • Diabetes Technology pathway development with multiple stakeholders
  • Setting up pilot projects for diabulimia treatment in London & Wessex
  • Introduction of Low Carbohydrate App into NHS Apps Library

Other work has involved input in updating of driving guidelines in relation to use of technology in those living with diabetes, helping to develop a virtual reality programme to improve hospital safety and starting work on increased mental health access for diabetes patients across the NHS

Professor Partha Kar has been a Consultant in Diabetes & Endocrinology at Portsmouth Hospitals NHS Trust since 2008. He has been the Clinical Director of Diabetes from 2009-2015, being part of a multiple national award-winning department (HSJ Awards / BMJ Awards) due to its services and care provided.

He is the pioneer of the Super Six Diabetes Model which aims to deliver diabetes care differently and is recognised as one of the good examples of integrated care.

An avid user of social media such as twitter (@parthaskar) to engage with patients – and been recognised as a “Social media Pioneer” by HSJ in 2014.

He also writes a monthly blog for the BMJ, has a personal blog (“Sugar and Spice: Wish all things were nice”) and a podcast (“Sweet Talking”)

He has also been:

  • Co-creator of TAD (Talking About Diabetes) – TED talks from those with T1Diabetes
  • Co- creator of Type 1 Diabetes comic (Volume 1 and 2)
  • Setting up Type 1 Diabetes: Rise of the Machines – event on Closed Loops/DIY tech

Follow Partha on Twitter: @parthaskar

One comment

  1. Rob F says:

    But isn’t the right patient mindset the most important thing? And that goes some way beyond just offering DESMOND or similar.

    Staff training on patient activation and application of nudge techniques etc don’t look very important based on the article above. Which is a shame.