Diabetes Programme Progress ReportDr Charles Gostling, Joint Diabetes Clinical Director

October 2013

1. Supporting self-management including patient education and care planning

2. Adopting new technologies

3. Enabling an integrated care system for diabetes

(new models of care and working across organisational boundaries)

Work group meetings were held over the summer with a wide range of attendees from across south London including service providers, service users, commissioners and representatives from industry.

We have now developed a project plan that outlines the key programmes we will be developing.

Diabetes high level themes

9 July: workshop on self management was attended by over 30 participants from across health and social care

Key priorities and emerging themes: • Improve systems and processes for encouraging people with diabetes to

participate in education and training programmes to support self-management.

• Work with commissioners and providers to increase the choice of education programmes available, including development of online courses, culturally sensitive methods of delivery and “short taster” courses.

• Looking to adopt and defuse IT solutions to help people improve their ability to monitor and manage their routine care

• Improve care planning by promoting direct patient access to GP records including personal medicines information, blood glucose and other important test results.

Clinical problems scoped in planning workshops

Key priorities and emerging themes:

• Work with teams in primary care to identify the cohort of people with type 1 diabetes, being managed by their GP, community service or other, whose condition might be improved if they had improved access to care and self management technologies.

• Improve self management in people with type 1 diabetes through the adoption of appropriate technologies such as insulin pumps and continuous blood glucose monitors.

31 July: workshop on the adoption of new technologies attended by over 30 participants from across health and social care

Clinical problems scoped in planning workshops

Clinical problems scoped

Enabling an integrated care system for diabetes, new models of care and working across organisational boundaries

Issues CausesPotential solutions/

innovationsPrioritisation

11 September: information fed into major stakeholder workshop

Planning workshop

Key priorities and emerging themes: • Working across the network to develop and defuse the LAS community

response hypoglycemia urgent care pathway.

• Working with providers, area prescribing teams, London Procurement and pharmaceutical companies to identify current uptake and usage of therapeutic agents to ensure good compliance with NICE guidance.

• Working with industry to develop tools to start to identify high and low risk patients who would most benefit form having care delivered in new ways - such as being managed via phone clinics or via tier three multidisciplinary teams.

11 September: over 70 participants from across health and social care and representatives from industry

1. Improving self-management of insulin therapy through better access to appropriate use of technologies

2. Improving the management of unscheduled care by developing pathways for the management of hypoglycaemia care in the community

3. Improving access to Structured education and related support for self-management

4. Review the use of insulin management for people with Type 2 diabetes to optimise care and support the effective use of resources.

5. Improving the prevention care and treatment of diabetic retinopathy by sharing test information across care settings

Projects being taken forward in 2013-14

Organisational Processes

Feedback from working group participants

“Everyone was open to ideas”

“Opportunity for active input

form all delegates”

Diagnostics Company representative

Pharma representatives

Best thing was “Table discussions and

information sharing especially when ones ideas and comments

get highlighted”

Service user

“Excellent and motivational speakers

giving succinct presentations”

Commissioner

“Clear process for decision-

making with a large number

of stakeholders”

Best thing was “Broadness of discussions”

Clinician

Organisational Processes

Key milestones and delivery dates

February to April

Completed

Wide engagement with expert groups and

stakeholders to identify priority workstreams.

Identify areas of good practice

locally and nationally.

Identify NICE guidance best

practice standards and current delivery performance against quality

measures.

July to early September

Completed

Planning workshops with wide range of

stakeholders to identify key

themes and issues in workstream as

part of project planning.

Continue to collect detailed data on areas of good practice locally and nationally. Conduct further analysis of and

base line service provision and

delivery performance against quality

measures.

September October In progress

Scope 5-6 potential

projects for feasibility and

impact on care.

Identify volunteers for task and finish

groups with membership

from all sectors.

October In progress

Present Project Initiation

proposals to AHSN Board on

10th October.

Fully develop the priority

project work plans and task

and finish groups to deliver

priority project aims and

objectives

October to March 14

Started October 2013

Work with stakeholders and

task and finish groups to

implement and monitor agreed objectives as outlined in the

project work plan.

Work with stakeholders to develop further proposals for

follow on project or new priorities

for taking forward in 2014-15

And yet more

Develop the HIN website to support

information exchange

Be a focus for innovative ideas

Cross cutting themes:

CLARHC HESL Research networks Patient experience London Connect

Support NHS England strategic clinical networks

Work with other HIN workstreams

– Musculoskeletal,

Dementia, Alcohol and Cancer