CCG develops a range of initiatives to improve outcomes for patients suffering from diabetes, resulting in nearly 50,000 patients registering for the non-diabetic hyperglycaemia

* Please describe the challenges or problems your solution set out to solve.

5 CWHHE CCG clinical diabetes leads began working in 2014 to address common key issues:

• Unwarranted variability in the quality of diabetes care and achievement of NICE indicators

• Poor achievement relative to other London areas

• Lack of joined up pathways across care settings

• Variability in referral, uptake and completion of structured education

• Little patient involvement in decisions about own care or support for self-management

• No easily accessible up to date comprehensive diabetes guidance for clinicians

• Non-existent intervention for pre-diabetes

• High levels of prescribing expenditure vs outcomes

• High admission rates for hypoglycaemia

We drew inspiration from Tower Hamlets, Bradford and Leicester

* Please describe the actions you took to achieve your result

We have initially commissioned the CWHHE Diabetes Out Of Hospital Services (OOHS). The aim was to improve care and outcomes for patients by initially addressing some of the inter-practice differences in monitoring of the 9 key care processes and achievement of NICE targets using performance related payment across GP networks against the following Key Performance Indicators:

• % of patients with record of 9 key care processes

• % of patients reaching all 3 NICE treatment targets (HbA1c ≤ 58, blood pressure ≤ 140/80, cholesterol ≤ 4)

• % of patients with record of care planning consultation (requires results shared with patient prior to appointment, collaborative goal setting and care plan development with the offer of a printed care plan to patient at the end of the consultation)

• % of patients on sulphonylureas and/or insulin who have been asked about the presence of symptoms of hypoglycaemia

• % of newly diagnosed patients referred to structured education (since 2016/7)

• % prescribing of cost effective glucometer strips vs total strip prescriptions

Targets were based on average achievement across GP network populations of 30,000 minimum and contracts were agreed with the GP federations with a payment for full achievement of the diabetes targets of £37.42 per patient with diabetes. A substantial part of the improvement in diabetes care across CWHHE has been due to the widespread use of basic analytics at patient and population level, i.e. clinical reports from the GP systems and manual export into Excel spreadsheets.

Whilst these approaches required some manual processes, we have seen significant improvement already in key diabetes measures. In parallel, we have been developing the Whole Systems Integrated Care data warehouse in North West London containing linked primary, community, acute and social care data, and have just introduced the first set of diabetes dashboards which have automated previously manual processes and allowed linkage of key data sets.

Diabetes users and user groups were engaged from before design began and have been involved since:

• providing significant input into the design of the contract

• attending CWHHE Collaborative diabetes strategy groups

• co-designing patient invitation letters and care plans

• selection of glucometers

* Please list the most significant results

Collaborative work across 1.4m citizens, over 70,000 diabetes patients, 5 CCGs and 235 GP practices to achieve:

• Significant improvements in achievement of the 9 key care processes, hypoglycaemia monitoring and collaborative care planning

• 3088 additional patients achieving all 3 NICE treatment targets since June 2016

• Establishment of Non-Diabetic Hyperglycaemia register of nearly 50,000

• 3165 NDPP initial assessments

• Widespread use of diabetes dashboards to promote quality improvement and improve patient care

• Clinical IT system optimisation to standardise clinical guidance, coding and reporting

• Production of printable care plans and invitation letters for patients

• Introduction of digital supported self-care apps for patients

* Describe how your project has spread to other teams, departments or organisations

• Approach is highly reproducible for other LTCs (similar approach now starting for AF/hypertension pathway in NWL) and other areas

• Achievements so far brought together nearly 200 stakeholders from across North West London including patients and user group facilitators, public health teams, clinicians from all 4 acute hospital trusts, community teams, GP federations, commissioners and senior management teams to provide input into the successful NWL STP bid for diabetes transformation funding (£2.35m plus further local investment)

• Now launching next phase of diabetes transformation focussing on integrated outcomes based commissioning across entire diabetes pathway and further support for patient self-management