Since April 2017, NHS England has made £105 million of diabetes transformation funding to improve treatment and care for the 2.8 million adults and children diagnosed with Type 1 or Type 2 diabetes across England.

For Sheffield Clinical Commissioning Group (CCG), this funding has enabled:

• Improved uptake of structured education
• Improved achievement of treatment targets
• An expanded Multi-Disciplinary Footcare Team (MDFT)
• An expanded Diabetes Inpatient Specialist Nursing team (DISN)

Ceri James, Diabetes Commissioning Manager at Sheffield CCG, and Rajiv Gandhi, Diabetes Clinical Director and Anna Hescott, Diabetes Service Manager at Sheffield Teaching Hospital, explain how the diabetes transformation funding is improving outcomes for people with diabetes in Sheffield and beyond.

Structured education

The diabetes transformation funding from NHS England has supported an increase in the provision of both Type 1 and Type 2 structured education in Sheffield and in-reaching support to develop Type 1 structured education in Barnsley, Doncaster and Bassetlaw.

Anna Hescott, Diabetes Service Manager at Sheffield Teaching Hospital tells us about the improved structured education service: “We have been able to focus on increasing appropriate and informed referrals, as well as working towards specialised sessions to be delivered to specific groups who have previously been ‘hard to reach’ or are likely to benefit from additional input.

“For Type 1 patients in Sheffield, the team have developed a ‘BOOST’ offer for patients who have previously attended DAFNE but have not optimised this control. This has evaluated really well in terms of patient confidence, glycaemic control and positive initial signs of reductions in HbA1C.

“For patients with Type 2 diabetes in Sheffield, the CCG has expanded the offer of DESMOND to include more sessions in new locations across the city, as well as developing an offer to specific groups of people spread over four days. These tailored courses have evaluated really well and attendance has improved. The dieticians have also created a ‘Look Ahead’ session with is a shorter session aimed at providing some key dietetic messages and a ‘taster’ to entice people to come to DESMOND.”

Improved achievement of treatment targets

The work to increase treatment targets has been carried out by Primary Care Development Nurses (PCDNs). They have been working with practices to raise awareness of the importance of their patients achieving the three treatment targets through:

• Education and upskilling with practice nurses, HCAs and GPs
• Neighbourhood and locality meetings
• Producing a range of materials and collateral to assist clinicians and patients in achieving targets
• Running regular reports form PRIMIS GRASP
• Providing practices with named patient data of those out of range

In 2018-19, some of the funding was used to recruit practice nurses who could devote some time to the project (i.e. diabetes nurses who did not work full time but wanted to work some extra hours on this project).

During the same period, the work by the Primary Care Development Nurses (PCDNs) and the practice nurses resulted in 1,237 patients being reviewed and the following number of additional patients meeting the treatment targets at the end of 2018-19:

• BP – 217
• HbA1c – 76
• Statin – 100

Ceri James, Diabetes Commissioning Manager at Sheffield CCG explains: “These figures reflect an increase in the diabetes population in Sheffield of 700 patients over the same period. It is also important to note that there will also be patients whose treatment targets have improved because of this work but have not actually reached NICE targets, but this is still a significant and worthwhile achievement, but a difficult one to measure.

“In 2019-20, we intend to continue working with the PCDNs and recruit an extra PCDN and practice nurses to continue the work. The team have been focussing on all three targets with a focus in 2018-19 on blood pressure. For 2019-20, we intend to have a particular emphasis on HbA1c and making sure that as many patients as possible are on an appropriate statin, whilst continuing to raise awareness of maintaining a healthy blood pressure.”

Diabetes inpatient specialist nurses

As a result of rising prevalence of inpatients with diabetes at Sheffield Hospitals (to around 20%), inpatients with diabetes seen by the Diabetes Inpatient Specialist Nurse (DISN) team had fallen from 43.2% (2011) to 27.7% (2015); the national average is 35.8%.

Rajiv Gandhi, Diabetes Clinical Director and Consultant Physician at Sheffield Teaching Hospital tells us: “As a result of diabetes transformation funding from NHS England, we expanded our DISN team and undertook an ambitious programme of change to improve the experience of all inpatients with diabetes, reduce harm and ensure sustainability through these improvements and reducing Length of Stay (LoS).  Key to this was a pro-active approach to timely review of patients and it was a multipronged, multi-interventional approach”.

Some examples of the key interventions are:

• Seven-day DISN team cover until 8pm
• Detailed granular dashboards derived from multiple databases, point of care testing, etc, to allow for daily alerts of all new admissions with diabetes, “virtual wards” and proactive review of high-risk patients e.g. T1DM and renal
• Detailed care plans highlighted on e-whiteboards
• Dedicated inpatient consultant to review the large amounts of remote intelligence on all inpatients and co-ordinate the DISN team response, senior support for daily MDTs and enhanced “front door” presence
• Enhanced discharge plans, communication with community teams and post-discharge contact to improve post-discharge care (especially to vulnerable groups) and reduce re-admissions
• Inpatient peripatetic diabetes pharmacy service to improve medicines safety
• Enhanced training of all staff
• Senior project board to monitor progress, provide clinical governance and identify further service improvement
• As a result of these interventions, there has been a doubling of the number of patients reviewed by the DISN team. After just 12 months, we have seen a substantial reduction in adverse events like hypoglycaemia and a rise in “good diabetes days”. In addition, excess LoS in diabetes patients fell by 0.5 days, representing 5500 bed days and a saving of £1.6million per annum.

Multi-disciplinary footcare team

The Diabetes and Podiatry team successfully bid for £112,000 in 2017/18 and £185,000 in 2018/19 of diabetes transformation funding from NHS England to invest across the pathway.

Rajiv Gandhi added: “This has funded additional podiatrists (working across inpatients, outpatients and community), a Foot Service Co-ordinator, administrative support and some additional kit (including a cast cutter to enable some casting to be done at our ‘cold site’), attendance at casting courses and targeted project work.”

This has enabled the service to develop in the following key areas:

• Prevention: Increased community Podiatry capacity to improve compliance with NICE recommendations for moderate and high-risk care
• Education: Increased training for primary care screeners and launch of an e-learning package. A Band 7 podiatrist has also qualified as an independent prescriber
• Timely intervention: Increased hospital-based Podiatry to support people with active foot disease and inpatients with foot disease, including enhanced support for dialysis patients (a very high-risk group)
• Equity: Introduction of a domiciliary Podiatry service for immobile/vulnerable patients with active foot disease

Although much of the benefit of the enhanced investment will take a number of years to be realised (e.g. complications such as recurrent ulceration and amputation), there are several early indicators of positive outcomes:

• Earlier intervention: Pressures on the foot service in recent years have meant that patients with foot ulcers were not receiving timely care and greater proportions were presenting with more severe ulcers. Data from 2018 suggests that there has been a reversal of this trend, likely due to the enhanced service offered as a direct result of NHS England diabetes transformation funding. As a result, substantially fewer people are presenting with severe ulcers and average healing times have fallen substantially. In addition to increased community capacity and education to support early intervention, as part of the expanded DISN team programme, health care support workers have been undertaking foot checks following hospital admission of people with diabetes resulting in early identification of foot problems and ensuring that the vast majority of inpatients are now undergoing foot checks
• Reduction in average ulcer healing times: The National Diabetes Foot Ulcer Audit has recently shown that Sheffield was among the top 15% for the proportion of patients with severe ulcers who were alive and ulcer free at 12 weeks. Correspondingly, ulcer healing times have improved substantially
• Cost reduction across primary, community and outpatient services: Despite a growth in people with active foot disease, the cost of ulcer management is reducing in Sheffield. We estimate that, to date, this represents a saving in the region of £180,000.

For more information about Sheffield CCG’s work to improve treatment and care for patients with diabetes in Sheffield, contact SHECCG.LTCportfolio@nhs.net.