Improving Diabetes Treatment Targets in Bedfordshire Delivering Personalised Care Planning as a key part of Diabetes Annual Review

Over 24,000 people are known to have diabetes across Bedfordshire CCG.  According to the National Diabetes Audits (NDA) 2016/17 only 19% of Type 1 and 38.1% of Type 2 patients with diabetes were achieving all three NICE recommended treatment targets; HbA1C, blood pressure and cholesterol.  For Type 2 this was below the national average and we were ranked 8 out of 11 CCGs in our RightCare peer group.  Furthermore, there had been little improvement from the 2015/16 NDA.  Practice level analysis of all three treatment targets for Type 2 diabetes showed a wide range of performance from 22% to 59%.  The NDA also highlighted significant improvement in both referrals to and attendance at Structured Education.

To incentivise improvement in performance across our 48 general practices, Bedfordshire CCG submitted a successful bid to NHS England’s Treatment and Care Programme.  We were awarded two year’s funding of £170,000 in 2017/18 and £237,000 in 2018/19 to implement a Locally Commissioned Service (LCS) incentivisation scheme to deliver personalised care planning as part of the diabetes annual review.  Our aims were first, to ensure that the patient was an active participant in shared decisions making and secondly, that all care processes were completed and active steps taken to help patients achieve the treatment targets.  Practices are paid per individual care plan delivered.  Updating the care plan can be done throughout the year; however incentivisation is specifically earmarked for care planning delivered at the annual review.

Building on the care planning approach that had already been implemented by Milton Keynes CCG, we implemented a three step process for the Diabetes annual review:

Step 1 – HCA or practice nurse appointment to carry out blood and urine tests, weight and waist measurement, blood pressure and heart rate and foot examination

Step 2 – Test results letter sent to patient.   Patient asked to think about any questions they may wish to ask, or things they would like to discuss, at their annual review

Step 3 – Patient annual review appointment with practice nurse or GP to discuss test and examination results, find out how they are coping generally and consider ways to help the patient manage their diabetes.  At the end of this appointment the patient is given a copy of their jointly agreed care plan.

To underpin this process the clinical lead GP for diabetes and the Consultant Nurse lead for the Integrated Community Diabetes Service designed a new SystmOne diabetes long term conditions template based on best practice.  This is a key tool to support practices in delivering each stage of the annual review process and ensure consistency of coding.   Both the patient’s ‘test results’ letter and the individualised care plan are populated via the template and referral forms to a range of other services can be downloaded, for example structured education programmes, mental health and wellbeing, weight management and smoking cessation.

To raise awareness, prior to implementation of the LCS and the new diabetes template, we undertook extensive communication with primary care including meetings with Locality Boards, education events (supported by Consultant Diabetologists and the GP clinical lead), direct contact with individual practices and regular updates in the GP newsletter.

In addition, at least one health professional in the practice was required to attend half-day ’Introduction to Personalised Care Planning’ training delivered by Bedfordshire CCG and ‘Successful Diabetes’.  This included practical guidance on how to use the diabetes template coupled with an introduction to care planning, the underlying evidence base and tips to ensure effective shared decision making.

When submitting quarterly claims for completed care plans, practices are also required to complete an audit form with their latest position for delivery of care processes, treatment targets and structured education referrals. This enables changes in performance to be tracked at CCG, locality and practice level and is shared with each locality board.

Almost all our practices have signed up to the LCS.  The first care plans were delivered in Quarter 3 2017/18;   the number of completed care plans has increased each quarter, rising from 1,000 in Quarter 4 2017/18 to 2,300 in Quarter 2 2018/19.  We aim to achieve our ambitious target of delivering at least 10,000 care plans by March 2019.

By Quarter 1 2018/19 we were already starting to see some improvements in delivery of treatment targets in practices, together with a 68% increase in foot checks, a 44% increase in referrals to Structured Education and a 17% reduction in outpatient attendances.   As many patients may not have any further tests until their next annual review it will be a few more months before we have substantial evidence to demonstrate the outcomes of this initiative; however we are confident that by the end of 2018/19 there will be significant improvement in achievement of all three treatment targets.

Informal feedback from patients who have been engaged in care planning has been very positive and we are currently developing a mechanism for more formal feedback.  The diabetes template has been well received by practices and we have used their feedback to further improve the template and care planning documentation.

Wendy Pearson
Commissioning lead
Bedfordshire CCG

Dr Sanhita Chakrabarti
Clinical Lead
Bedfordshire CCG