Health Needs Assessment for Diabetes in Dudley
Document metadata Title
Diabetes Health Needs Assessment for Dudley
Authors
Karen Jackson, Consultant in Public Health Joanne Gutteridge, Commissioning Manager, Long-term Conditions. NHS Dudley
External Consultant
Professor Jammi N Rao Director, Gorway Global Consulting.
Organisational ownership
NHS Dudley
Publication date
June 2012
Key words
Diabetes, Needs Assessment, Dudley, Chronic disease, Long-term condition,
Availability
Paper (limited) and web.
Updates
None proposed.
Target audience
General practitioners, health service commissioners, hospital consultants, specialist nurses
Citing this document
Jackson K, Gutteridge J, Rao JN. Health Needs Assessment for Diabetes in Dudley. June 2012. NHS Dudley.
Related publications
None.
Superseded documents
None.
Contact for enquiries
Karen Jackson, NHS Dudley
For recipient’s use
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Diabetes Health Needs Assessment, NHS Dudley
Contents
Executive summary .......................................................................................................... 5 Introduction ..................................................................................................................... 6 Purpose and objectives................................................................................................ 6 Our brief ....................................................................................................................... 6 Process of health needs assessment ........................................................................... 6 Background and context ................................................................................................... 8 About diabetes............................................................................................................. 8 Why diabetes matters ................................................................................................. 8 National and policy context ......................................................................................... 9 Wider NHS context .................................................................................................... 12 Health and wellbeing of the people of Dudley................................................................. 13 Public health in Dudley .............................................................................................. 13 Demographics ............................................................................................................ 13 Deprivation ................................................................................................................ 14 Health inequalities ..................................................................................................... 15 Area Classifications .................................................................................................... 15 Epidemiology of diabetes ............................................................................................... 16 General epidemiology................................................................................................ 16 Diabetes in young people .......................................................................................... 16 Complications of diabetes ......................................................................................... 17 Diabetes prevalence in Dudley .................................................................................. 18 Modelled and projected prevalence of diabetes ...................................................... 19 Diabetes mortality in Dudley ..................................................................................... 22 Variations in diabetes prevalence ............................................................................. 26 Variations in clinical treatment ................................................................................. 28 Resources deployed for diabetes .................................................................................... 32 Costs of diabetes care in Dudley ............................................................................... 32 Efficiency of resource use in Dudley ................................................................................ 33 Variation in hospital inpatient activity ...................................................................... 36
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Interaction between primary care and hospital services .......................................... 38 Prescribing in primary care – trends and costs. ........................................................ 39 Growth in prescribing for diabetes in Dudley ........................................................... 42 Locally enhanced services in primary care ................................................................ 43 Prevention of diabetes and NHS Health Checks ........................................................ 45 Quality of services in Dudley ........................................................................................... 46 DiabetesE ................................................................................................................... 46 National diabetes audit ............................................................................................. 48 National diabetes in-patient audit - NaDIA .............................................................. 49 Corporate needs assessment .......................................................................................... 51 Effectiveness of diabetes care ......................................................................................... 57 Effectiveness of preventative interventions.............................................................. 58 New models of care ................................................................................................... 59 Recommendations ......................................................................................................... 61 List of Figures ................................................................................................................. 62 List of Tables .................................................................................................................. 64 References ..................................................................................................................... 65
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Diabetes Health Needs Assessment, NHS Dudley
EXECUTIVE SUMMARY
An estimated 15,000 people in Dudley, 5.7% of the over-17 population are known to have diabetes. The data suggest that the recorded cases represent about 75% of the estimated number of prevalent cases. 90% of known cases are type 2 diabetes. Diabetes prevalence is growing. The best evidence we have is that the number of people with diabetes in Dudley is likely to grow to 21,000 by 2015; 24,000 by 2025; and to 25,700 by 2030. Dudley is not atypical compared to England. The prevalence of diabetes in Dudley is slightly higher than the England figure but lower than the West Midlands average. There is a twofold variation in the recorded crude prevalence of diabetes among general practices in Dudley – from under 3% to just over 7%. Diabetes is a major cause of complications that lead to considerable ill-health, mortality and healthcare resource expenditure. One in 12 deaths is due to diabetes. If national research based estimates apply then Dudley could be spending an estimated £48 million on healthcare for diabetes and its complications. The quality of care delivered in primary care as measured by QoF scores is generally good in Dudley but varies among practices. The extent of exception reporting for diabetes QoF indicators varies from 7.2% to 13.4%. There is also variation among practices. The efficiency with which resources are deployed in Dudley is similar to other comparable districts. Hospital in-patient bed use is just above the England average. The main specialist hospital service for Dudley has a slightly higher than regional average number of follow-up attendances in out-patients for the number of new cases seen. National trends in prescribing show a sharp rise in costs due to newer insulins. 84% of diabetes prescription items in Dudley are for 1st and 2nd line drugs. Many PCTs have a higher rate. Dudley’s services score well in the national DiabetesE self assessment. For almost all indicators of quality of services, Dudley and Dudley Group Hospitals are in the best 25% of organisations. Dudley is in the bottom 25% for kidney screening and management. In the National Diabetes Audit in 2011 Dudley practices scored in the middle 50% for most indicators, the best 25% for 9 and the worst 25% for only 1 (urinary albumin). In the 2011 National Diabetes In-Patient Audit (NaDIA) Dudley Group Hospital compares well with other hospitals. Staff working in provider units thought that there was scope for service quality and scope to be further enhanced. Training, better integration of services and funding were often cited as key factors. There is a great deal of evidence in the form of systematic reviews and clinical guidelines from authoritative sources that would adequately inform clinical decisions. Similarly there is a great deal of evidence of what works in prevention of diabetes. New models of care such as integrated care programmes, ‘expert’ patients, and telehealth and telecare are emerging but existing evaluations do not show sufficiently clear-cut and convincing benefit. They do hold promise as cost-efficient alternatives but implementation needs careful management and monitoring.
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INTRODUCTION PURPOSE AND OBJECTIVES 1
NHS Dudley commissioned this health needs assessment (HNA) for diabetes with the following objectives:
To estimate the current prevalence of diagnosed and hidden diabetes in Dudley To estimate the projected increase in the prevalence and number of people with diabetes To assess the current state of services with respect to effectiveness, cost-effectiveness, and the use of innovative models of care To make a comparative assessment of the quality and effectiveness of diabetes care in Dudley in comparison with the rest of the region and with similar districts To summarise the state of knowledge of what works in diabetes To identify gaps in services currently available for Dudley residents To take account of the views of key stakeholders involved in providing diabetes services To make recommendations for the short and medium-term future.
OUR BRIEF 2
Our brief to carry out this HNA encompasses the above purpose and objectives. Specifically the brief required us to: collate available statistical information on the epidemiology of diabetes, including the analysis of general practice, hospital and community service data; carry out predictive modelling of future growth in need for diabetes care; summarise effective models of care as reported in the published literature; assess the current state of provision of services in Dudley; summarise newer treatments available and current and likely future uptake; produce a report setting out the findings and recommendations; and present these findings to key partners involved in the delivery of diabetes care in Dudley.
PROCESS OF HEALTH NEEDS ASSESSMENT 3
HNA is a formal and structured method to understand the need for health care and related services and support in a defined population, usually in respect of a specified health or disease based topic. While individuals can also go through a process of assessment as to their health and/or healthcare needs, HNA is usually applied to whole populations or large subgroups thereof. HNA makes a distinction between need, demand and supply1. 3.1 Need is defined as the capacity to benefit. It therefore follows that need can exist only when there is an effective intervention to ameliorate the condition and resources are available with which to procure the intervention. This is a purist definition and differs from the more common understanding of the term. 3.2 Demand is what patients ask for, based on their lived experiences, what they know and understand of their condition, and their knowledge and experience of the services and treatments they expect to be available. It can be more or less than normative need, and is often influenced by many factors including the media, advertising by suppliers and anecdotal accounts of their peers.
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Diabetes Health Needs Assessment, NHS Dudley
3.3 Supply refers to the health care that is provided; it is determined by the interests and priorities of professionals, the political process and the resources that are made available. Newer treatments are often supplied with the expectation that it will lead generate its own demand and before the need for them has been fully and unarguably established by high quality research. 4
HNA, when carried out well, has the potential to tease out these conflicting and overlapping concepts and make explicit the choices available to commissioners together with a clearer understanding of likely impacts of their decisions. Seen in this light, HNA is not an isolated activity but an integral part of the process of commissioning health care.
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The traditional model of HNA is a composite of 3 separate but interlinked exercises: 


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Epidemiological needs assessment consists of the use of available data and information from whatever sources may be available to draw a picture of the scale of the condition or disease in question; its distribution among segments of the population defined by age, gender, ethnicity, social class, deprivation, and geographic location. Comparative needs assessment sets the local findings in the context of the region and the country. Comparisons are also possible with other areas of the country that share the same or similar socio-demographic, economic and cultural characteristics. Corporate needs assessment takes account of the views of key stakeholders involved in the provision of current services.
A distinction is also often drawn between healthcare needs and health needs assessment. In practice the term HNA is often loosely used to include both; it is helpful however to be clear of the distinction. Healthcare needs assessment confines itself to the clinical and other curative and/or professionally delivered support and services that can be delivered. Health needs assessment takes a broader, more holistic approach and considers also the wider determinants of health2 that can often make a big difference to the outcomes that people and communities experience and value. However, with good reason3 this report does not make such a clear distinction.
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BACKGROUND AND CONTEXT ABOUT DIABETES 7
Diabetes is not a single pathological disease entity. Rather it is the term used to denote a group of conditions characterised by higher than ‘normal’ levels of blood glucose resulting from a deficiency of insulin production, or a reduction in the effectiveness of the insulin that is produced by the body, or a combination of these two defects. This metabolic abnormality is also accompanied by vascular changes that lead to most of the complications that are the major cause of the health burden of diabetes4,5. Leaving aside rare conditions, there are in the main four types of diabetes:
Type 1 diabetes used to be called insulin dependent diabetes mellitus (IDDM) or juvenile onset diabetes, but those terms are no longer in use. Type 1 diabetes occurs when the insulin producing cells are destroyed and the body becomes dependent upon externally administered insulin. The onset is sudden and unpredictable with ill-understood causes and risk factors that include genetic, infection, auto-immune or environmental conditions. Type 2 diabetes accounts for the vast majority of cases. It was previously called Non-insulin dependent diabetes mellitus (NIDDM), but that term is now out of favour. Type 2 diabetes starts as insulin resistance when the insulin that is produced by the body, often in greater than normal quantities, loses its effectiveness at the level of the tissues that need to metabolise glucose. After a period of excess insulin production, the pancreas gets exhausted and insulin production falls leading to elevated blood glucose levels. Risk factors include ethnicity, age, body weight, body fat distribution, sedentary lifestyle, history of gestational diabetes, and family history of diabetes. Though usually a disease of later years, increasingly Type 2 diabetes is being reported in adolescents and young adults especially in high risk ethnic groups. Type 2 diabetes is important for the health service because of the number of people affected and the heightened cardiovascular risk that it carries. Gestational diabetes is the term used to describe glucose intolerance during pregnancy. It is associated with obesity and a family history of diabetes. It is important to recognise and manage gestational diabetes because of the adverse effects on the baby. Gestational diabetes is also associated with an enhanced risk of developing Type 2 diabetes years later. Secondary diabetes can arise as a complication of pancreatic damage, liver cirrhosis, and endocrinological disease or treatment, and rarely due to anti-viral or anti-psychotic therapy.
WHY DIABETES MATTERS
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Diabetes matters because it results in a wide range of complications. These are important for the individual of course, but in this needs assessment the primary focus is on the effect of these complications on the health of the population; and, closely linked to this, the economic impact on the health service.
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The macro vascular complications of Type 2 diabetes lead to an increased risk of coronary artery disease (angina, myocardial infarction), peripheral artery disease (lower limb ischaemic pain, gangrene) and carotid artery disease (strokes and dementia). Management of type 2 diabetes therefore involves a heavy emphasis on measures and treatments to lower the risk of these Diabetes Health Needs Assessment, NHS Dudley
cardiovascular complications. Indeed Type 2 diabetes can be said to be a cardiovascular condition with changes in blood glucose metabolism. 10 The duration and extent of elevated blood glucose determine the risk of micro vascular complications in which changes in the small blood vessels in specific organs lead to retinal damage and potentially blindness, chronic kidney disease leading potentially to end-stage renal disease, and nerve damage, especially in the lower limbs, leading to pain, foot disease and amputations, and erectile dysfunction. These complications are related to both severity and duration of hyperglycaemia. The UK Prospective Diabetes Study6 found that In Type 2 diabetes the development of retinopathy was related also to the presence of hypertension. Most patients with Type 1 diabetes develop evidence of retinopathy within 20 years of diagnosis. In Type 2 diabetes retinopathy may begin to develop even before the diagnosis of diabetes7 . 11 At the population and public health level diabetes matters because of its impact on health, mortality and morbidity. These consequences are described more fully in the section on epidemiology and costs.
NATIONAL AND POLICY CONTEXT 12 Diabetes has enjoyed a prominent place in the NHS planning, service improvement, and quality development initiatives since many years. The following table is a list of key papers and policy documents from official sources that set out the importance of diabetes and the imperatives for NHS organisations to carry out local needs assessments, develop and implement local commissioning plans, specify and monitor quality standards, improve outcomes and reduce inequalities – and to do all this with the active inclusion and involvement of local people and communities.
No.
Document
1.
National Service Framework for Diabetes, 2001. Department of Health8.
2.
National Service Framework for Diabetes: delivery strategy. 2003. Department of health9.
3
Diabetes Commissioning toolkit, 2006. Department of Health10.
Summary One of the first of the national frameworks, this was a national level needs assessment for diabetes services, made the case for quality improvement and proposed 12 quality standards for the service to aspire to and to be achieved in the next 10 years. This was the delivery plan. It proposed local diabetes networks with local leaders to champion the service; local assessments and plans to achieve the standards; national audits; local workforce development. Guidance issued by the then National Clinical Director for Diabetes and Primary Care Diabetes Society, this report outlines the key questions for commissioners, and provides a generic specification for diabetes services.
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No. 4.
5.
10
Document Department of Health. The way ahead. The local challenge. Improving diabetes services, the National Service Framework four years on. 200711. Five years on. Delivering the diabetes national service framework. 200812.
6.
Commissioning diabetes without walls. NHS Diabetes. 200913.
7.
Six years on. Delivering the Diabetes National Service Framework. Feb. 201014.
8.
The NHS Outcomes Framework 2011/1215.
9
Diabetes in Adults quality standard. National Institute for Health and Clinical Excellence. March 201116.
Summary This report from the National Clinical Lead for diabetes took stock of progress 4 years after the delivery strategy was published.
This was a stock take of the strategy half way through the original 10 year plan. It noted considerable progress but also observed variations in quality of care, and relatively slower progress in the care of children with diabetes and the involvement of people in their own care. NHS Diabetes was the successor to the National Diabetes Support Team organisation, and brought together professional bodies and the Dept of Health and voluntary bodies such as Diabetes UK to develop a commissioning tool kit. This guidance was targeted at commissioners and urged them to use their powers to commission truly integrated care (TWW – teams without walls) by engaging better with providers, patients and other stakeholders, regard diabetes as a long term condition, and to innovate and commission new models of care. This was a further stock take of progress, 6 years after the original NSF delivery strategy had appeared. Highlighted the role of NHS Diabetes in developing toolkits for commissioners and providers and national audits. It called for a clearer focus on prevention both of diabetes and of its complications especially of retinal disease by a comprehensive screening programme. This document sets out the key outcomes by which the NHS will be held to account. It was the second such outcomes framework to be published after the Coalition Government came to power in 2010. As such it is in keeping with the new philosophy of fewer ‘targets’, replaced by high level outcomes measured by a few well specified indicators shared as much as practicable by other organisations, e.g. social care. As part of the new arrangements for holding the NHS to account for quality of care, NICE developed this guidance on evidence-based standards with clear definitions for each together with a measurement process. See box on next page.
Diabetes Health Needs Assessment, NHS Dudley
1. People with diabetes and/or their carers receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education. 2. People with diabetes receive personalised advice on nutrition and physical activity from an appropriately trained healthcare professional or as part of a structured educational programme. 3. People with diabetes participate in annual care planning which leads to documented agreed goals and an action plan. 4. People with diabetes agree with their healthcare professional a documented personalised HbA1c target, usually between 48 mmol/mol and 58 mmol/mol (6.5% and 7.5%), and receive an ongoing review of treatment to minimise hypoglycaemia. 5. People with diabetes agree with their healthcare professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance. 6. Trained healthcare professionals initiate and manage therapy with insulin within a structured programme that includes dose titration by the person with diabetes. 7. Women of childbearing age with diabetes are regularly informed of the benefits of preconception glycaemic control and of any risks, including medication that may harm an unborn child. Women with diabetes planning a pregnancy are offered preconception care and those not planning a pregnancy are offered advice on contraception. 8. People with diabetes receive an annual assessment for the risk and presence of the complications of diabetes, and these are managed appropriately. 9. People with diabetes are assessed for psychological problems, which are then managed appropriately. 10. People with diabetes with or at risk of foot ulceration receive regular review by a foot protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours. 11. People with diabetes admitted to hospital are cared for by appropriately trained staff, provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing their own insulin. 12. People admitted to hospital with diabetic ketoacidosis receive educational and psychological support prior to discharge and are followed up by a specialist diabetes team. 13. People with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist diabetes team. Box: The 13 quality standards proposed by NICE.
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WIDER NHS CONTEXT 13 Healthcare expenditure (15% private and 85% public, i.e. NHS) measured in current prices grew from £55 billion in 1997 to £ 140.8 billion in 2010 – an annual average growth of 7.5% in nominal terms17. Since the economic crisis of 2007-8, it became clear that the NHS could not expect its funding growth to continue at these levels. In 2010 the health service got what was considered a good settlement – a commitment ‘that NHS spending will rise in line with inflation between 2011-12 and 2012-13’18. NHS Chief Executive David Nicholson identified in his 2008/9 annual report the need for the NHS to improve the efficiency with which it did its business so that savings of £20 billion19 could be made by the end of 2013/1420. The major initiative by which these goals were to be achieved was the Quality Innovation, Productivity and Prevention (QIPP) programme. 14 A year later, in the 2011-12 Operating Framework for the NHS, the £20bn savings goal was confirmed with an extension of the time frame for these savings to 2014/15. This took into account other measures put in place by the Coalition Government such as a 2 year pay freeze, and provided further time for longer term changes in the service to feed through21. 15 In the most recent operating framework for 2012-1322, the emphasis was on putting in place the transition arrangements to the NHS reforms signalled in the NHS white Paper (and that subsequently became law with the passage of the Health and Social Care Bill). The stated goals of the 2012-13 Operating Framework were to improve services for patients by
putting patients at the centre of decision making successfully completing the last year of transition to the new system and building CCG capacity increasing the pace of delivery of the quality and productivity (QIPP) challenge maintaining strong control over service and financial performance 16 The key outcome mandated in the 2012-13 Operating Framework that relates specifically to diabetes is included under Domain 1. Outcomes Framework Domain 1: Preventing people from dying prematurely The NHS is to support clinical strategies aimed at reducing early mortality from cardiovascular disease, including heart disease, stroke, kidney disease and diabetes. Commissioners and providers need to work together to ensure earlier diagnosis and treatment. 17 In summary therefore, the national policy context and the wider NHS context requires commissioners and providers of diabetes services to deliver quality and to do so while taking account of the views of patients and communities, and with a clear focus on improving the efficiency with which resources are deployed.
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Diabetes Health Needs Assessment, NHS Dudley
HEALTH AND WELLBEING OF THE PEOPLE OF DUDLEY PUBLIC HEALTH IN DUDLEY 18 The 2011 health profile for Dudley23 shows a mixed picture for the health of the people of Dudley. Some indicators are better than the England average while many are worse but not by much. Deprivation levels are higher, with just under 15,000 children living in poverty. Mortality rates have declined in the last 10 years. Premature deaths from cancer and heart disease and stroke are similar to the England average; but this hides a gap in life expectancy between the most deprived areas within Dudley and the least deprived parts of 9.4 years for men and 5.2 years for women. Obesity rates and alcohol harm are marginally higher.
DEMOGRAPHICS 19 In 2009 the mid-year estimated resident population of Dudley was 306,600. The distribution of the population by age group and gender is shown in the Chart below
Figure 1. Population structure in Dudley (Source: ONS data, chart taken from ‘Unequal Dudley, Annual Report of the Director of Public Health – 2010, NHS Dudley24
20 Of course, the age distribution of the population is not uniform in all areas within Dudley. Affluent wards in the periphery of the borough tend to have a generally older population with more than 25% over 60, while the more central deprived wards tend to have a younger age profile – more than 60% are under 45 years in age. 21 Besides age and deprivation another key demographic determinant of diabetes is ethnicity. In the 2001 census, when Dudley had a population of 305,155 the ethnic make-up was as shown below:
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Ethnic category
% age of population
White Asian or Asian British Black or Black British Mixed Others inc Chinese
93.68 3.97 0.95 1.01 0.38 Total BME population 6.32%
Table 1. Ethnic background of the population of Dudley
22 The 2007 estimate from the Office of National Statistics put the proportion of the population belonging to Black and Minority Ethnic groups at 8.7%, an increase of approximately 9,000 people. Dudley has less ethnic diversity than the rest of the country but within Dudley there are wards where upwards of 12% of the population come from a BME background.
DEPRIVATION 23 Deprivation in Dudley is well documented in the DPH’s annual report for 2010 from which the following figure is presented
Figure 2. Distribution of deprivation in Dudley by Lower Super Output Area. Source: Unequal Dudley. DPH Annual Public Health Report for 2010.
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Diabetes Health Needs Assessment, NHS Dudley
HEALTH INEQUALITIES 24 There are many ways to demonstrate health inequalities and in later sections of this report data will be presented that show variations in outcomes and treatment processes that pertain more specifically to diabetes. Here we present life expectancy at birth in geographical units known as lower super output areas (LSOAs) in Dudley after they have been put into 5 groups according to the level of deprivation.
Figure 3. Life expectancy in males and females by deprivation quintile – Quintile 1 is the least deprived 20% of LSOAs and Quintile 5 is the most deprived 20% of LSOAs. Source: APHO Local Health Profiles 2011 (http://www.apho.org.uk/default.aspx?RID=49802
AREA CLASSIFICATIONS 25 To allow meaningful comparisons between areas The Office for national Statistics has developed a system of classification25 of areas into groups or clusters that share similar socio-demographic, educational and economic characteristics. The area classification exists at three hierarchical levels, supergroup, group and subgroup. For most purposes the 13 groups are sufficient for comparative purposes. Dudley, alone among local authorities in the West Midlands, comes within the Manufacturing Towns group. 26 For diabetes specifically, the Yorkshire and Humber Public Health Observatory has developed the diabetes area classification for Primary Care Trusts26. The 152 PCTs (this number is not fixed and PCTs will soon cease to exist anyway) are grouped into 19 ‘Blue’, 10 ‘Indigo’, 46 ‘Orange’, 25 ‘Purple’, and 52 ‘Yellow’ clusters. Dudley is included in the Orange Cluster. Telford and Wrekin is the only other West Midlands PCT in this cluster.
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EPIDEMIOLOGY OF DIABETES GENERAL EPIDEMIOLOGY 28 In the United Kingdom in 201127, based on data from the Quality and Outcomes Framework data from general practices, there were an estimated 2.9 million people with diagnosed diabetes. Diabetes UK also estimates that there are likely another 850,000 people with as yet undiagnosed diabetes. The general population prevalence in the 4 countries varies between 4.3% in Scotland and 5.5% in England28. Age and ethnic origin are the most important determinants of the prevalence. The table below shows the prevalence by age and ethnicity. Age Group29
Prevalence
Ethnic group30
16-34 35-54 55-64 65-74 75+
1.8% 9.4% 11.1% 15.2% 15.9%
Bangladeshi Black Caribbean Black African Indian Pakistani
Prevalence Men Women 8.2 5.2 10.0 8.4 5.0 2.1 10.1 5.9 7.3 8.6
Table 2. Prevalence of diabetes by age and by ethnic origin, national data.
29 It is widely accepted that the rise in diabetes prevalence seen in the past decade will continue into the foreseeable future. The continuing rise in obesity, and increasingly sedentary lifestyles combined with a population that will grow older are the main factors. But an important driver is also a combination of greater awareness, readiness to test for the condition, better recording of data due to the incentives in the Quality and Outcomes Framework, and the changes in the diagnostic criteria towards a lower biochemical threshold for the diagnosis of diabetes. A 2011 WHO report31 recommended the use of a HbA1c level of 6.5% as cut off level for the diagnosis of diabetes to be made. HbA1c levels below that level do not exclude the presence of diabetes diagnosed on the standard glucose tolerance tests. 30 Diabetes UK estimates that by 2025, 5 million people in the UK will have diabetes. This projected number is itself a million more than the projection they made a year earlier in the 2010 report.
DIABETES IN YOUNG PEOPLE 31 The vast majority of diabetes in young people is Type 1 diabetes. A 2009 survey by the Royal College of Paediatrics and Child Health32 established that there were 22,783 children and young people under the age of 17 with diabetes, giving a prevalence of 207 per 100,000. Of these 97% (20,488) have Type 1 diabetes and 1.5% (328) were recorded as Type 2 diabetes. The all England 0-17 prevalence of Type 1 diabetes is 186.3/100,000.
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Diabetes Health Needs Assessment, NHS Dudley
COMPLICATIONS OF DIABETES 32 The health burden of diabetes can be estimated in several ways, none of them perfect and all of them subject to the underlying assumptions. Taking mortality as a measure, in 2008 the National Collaborating Centre for Chronic33 Conditions estimated that diabetes was the cause in 4.2% of deaths in men and 7.7% of deaths in women. This is almost certainly an underestimate since deaths due to the myriad complications of diabetes such as chronic kidney disease and cardiovascular diseases are often not recorded as due to the underlying condition of diabetes. Cohort follow up studies show for example that a 609 year old man with newly diagnosed diabetes and without existing arterial disease can lose up to 8-10 years of life without proper management. 33 Figures compiled by Diabetes UK from various official sources and research studies present a more detailed picture of the health burden of diabetes as measured by the risk and incidence of serious life threatening or disabling complications. These data are presented in the following table. Complications of diabetes Cardiovascular disease
Kidney disease
Eye disease
Lower limb ischaemic vascular disease
Neuropathy
Sexual dysfunction
Risk, incidence or other measure of burden Risk increased at least two fold. 44 percent of deaths in people with Type 1 and 52 % of deaths in people with Type 2 diabetes. Risk of a stroke within first 5 years of diagnosis increased two fold. 30% of people with Type 2 diabetes develop overt kidney disease. Diabetes now the single biggest cause of end-stage renal disease. Renal disease accounts for 21% of deaths in people with Type 1 and 11% of deaths in people with Type 2 diabetes. Risk of blindness increased in diabetes by 10 to 20 fold. Diabetes is now the leading cause of blindness under 65. Within 20 years of diagnosis, all patients with Type 1 diabetes and 65% of people with Type 2 diabetes have some degree of retinopathy. Cataracts and glaucoma risk increased 2 fold in people with diabetes. Diabetes is now the commonest single cause of lower limb amputations in adults. In 2006/7 there were 1,445 such amputations out of a total of 5,574 in the UK 34. Risk of Neuropathic foot ulceration in diabetes in 1 year is 5%; with 10% of such ulcers resulting in an amputation. An amputation is itself a risk marker for mortality with 70% of people dying within 5 years of an amputation. Some degree of neuropathy may be present in 50% of people with diabetes. Chronic painful neuropathy affects 16% of people with diabetes – a 3-fold increase compared to the general population. Relatively under-researched area but reported prevalence of erectile dysfunction in men varies between 35 and 90% of men with diabetes; and of sexual dysfunction in women estimated at 27%.
Table 3. The health burden of diabetes. Data source: Diabetes UK, see Reference 8
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DIABETES PREVALENCE IN DUDLEY 34 With the advent of the general practice Quality and Outcomes Framework in 2003 the quality of data on those conditions that are included is excellent. The Quality Management Analysis System (QMAS), a national IT system, uses data from general practices to calculate the QoF achievements of individual practices against national indicators. The Information Centre for Health and Social Care (NHS IC) makes this data widely available. In March 201235 the NHS IC published diabetes prevalence data according to which there were in Dudley in 2010-11, 14,961 people with diagnosed diabetes aged 17 years or more. The relevant underlying denominator population is the registered population, aged 17 and over, of 253,552, giving a prevalence estimate of 5.9% with a 95% CI ranging from 5.81 to 5.99. 35 A good starting estimate therefore is that the health services in Dudley currently need to provide services for between 14,730 and 15,190 people with diabetes. 36 The chart below compares the prevalence in Dudley with the prevalence in the other primary care trusts in the West Midlands. Most of these are co-terminous with the relevant local authorities and so the comparison should remain valid even after 2013 when PCTs no longer exist. It should be remembered though that the denominator for the QoF derived prevalence estimate is not the resident population of a geographically defined areal unit but the registered population of a defined list of general practices.
QoF Prevalence of diabetes Heart Of Birmingham Teaching PCT Walsall Teaching PCT Wolverhampton City PCT Sandwell PCT Stoke On Trent PCT Birmingham East and North PCT North Staffordshire PCT WEST MIDLANDS Dudley PCT Telford and Wrekin PCT Solihull PCT Worcestershire PCT South Staffordshire PCT Coventry Teaching PCT ENGLAND South Birmingham PCT Shropshire County PCT Warwickshire PCT
8.89
6.16 5.9
5.54 5.23 0
1
2
3
4
5
6
7
8
9
10
% age of registered popn. aged 17+, 2010-11 Figure 4. QoF based prevalence of GP recorded diabetes in West Midlands PCTs. Actual figures are shown for the highest and lowest prevalence PCTs and for England, West Midlands, and for Dudley. The denominator used is the general practice registered population aged 17and over. Source: NHS Information Centre for Health and Social care, March 2012
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Diabetes Health Needs Assessment, NHS Dudley
37 Clearly Dudley has a prevalence that is somewhat higher than the figure for England and slightly lower than the West Midlands average. There are almost certainly errors and biases in this estimate since they are based on recorded and reported data. If there is a subset of the population that is not registered with a general practice and this subset is a relatively young and healthy group then the figure is likely to be an overestimate. If some practices under-record their cases then we have an underestimate. This figure also does not take into account children and young people with diabetes; but since that is a special group whose diagnosis is unlikely to be missed and who will be in receipt of specialised care they will be counted elsewhere. Locally available information from general practices provide another source of data that estimate the number of people with diabetes, currently known to the service. NHS Dudley has access to data held on general practice registers through MSD Informatics. The following table is based on data extracted from this source through a query run 0n 20 Dec 2011. Note that these data are for all ages and are based on general practice registrations regardless of where patients live.
Total registered population People with Type 1 diabetes People with Type 2 diabetes Type unrecorded Diabetes under 65 Diabetes 65 and above Total No. of people with diabetes
Number 301,456 1235 13018 241 6722 7772 14494
%age of total diabetes 8.5 89.8 46.4 53.6
Table 4. Recorded number of people with diabetes from MSD Informatics system
38 There are potential errors and biases in all data recording systems. It should be no surprise therefore that estimates from different sources of data However accounting for these potential biases, the figure of 5.9% of people aged 17 and over, and around 15,000 people with diabetes is a useful working figure on which to base the current provision of services.
MODELLED AND PROJECTED PREVALENCE OF DIABETES 39 We know from national studies that most people who are diagnosed as having diabetes have had the condition for some years prior to the diagnosis. There is thus a pool of undiagnosed diabetes in any population. For England, Diabetes UK estimates that there are 850,000 people with un-recognised diabetes. Various attempts have been made to estimate the true prevalence of diabetes in the population. These are based on sophisticated models that take account the characteristics of a defined population in respect of ethnicity, age distribution, deprivation levels, social class structure, and obesity prevalence. The model then uses the risk of diabetes in these subsets of the population to derive synthetic estimates of the prevalence of diabetes. 40 All such models are necessarily based on a set of assumptions and are prone to error; however they are useful as a pointer of what we may be missing. The APHO model36 bases its results on adjusting for a combination of age, sex, ethnicity and deprivation. It too estimates diabetes
Diabetes Health Needs Assessment, NHS Dudley
19
prevalence both as a number of cases and as a prevalence rate (%) on the 17 + population. A fuller explanation of the methods used is available on the YHPHO website (www.yhpho.org.uk). 41 The modelled estimates for the 3 years 2009, 2010 and 2011 are as follows Year
2009
Estimated No. with diabetes 19,085
Estimated prevalence
2010
19,386
7.89%
5.76%
11.31%
--
--
2011
19,715
8.01%
5.74%
11.62%
14,961
75.9%
7.79%
95% Confidence Interval for estimated prevalence Lower limit Upper limit 5.60% 11.27%
QoF reported figure 13,541
%age recognised diabetes 70.95%
Table 5. Comparison of modelled prevalence against known prevalence of diabetes. The QoF reported number of prevalent cases for 2009 is taken from the APHO spreadsheet model referred to, the figure for 2011 comes from the March 2012 publication from the Information Centre ( Figure 4 above)35.
42 The data in Table 4 (known prevalence) and in Table 5 (modelled estimate) need cautious interpretation. Firstly, we need to note that the known prevalence is based on registered population. The modelled estimate is based on a geographically defined population. There is good reason to believe that in the case of some districts, including Dudley, there may be a good overlap between the two denominators, but to the extent that they differ, there may be a problem with a direct comparison between the two numbers. Nevertheless, the %age of modelled prevalence that is recognised, at around 25% is not dissimilar to the figure for many other areas. For 2009, for instance the percentage ‘true’ diabetes recognised was 73% for England and 74% for the West Midlands. The 2011 data are based on more recent QoF data than were published in the original APHO model, and if they are right then they do show an improvement in the recognition rate. 43 The APHO model is also a predictive tool that projects the prevalence of diabetes in years to come. Of course, any such attempt at predicting the future has to deal with even more variables that have to do with the underlying population, changes in risk factor prevalence, and availability and effectiveness of preventive strategies in the future. As the number of assumptions increases our willingness to accept literally and at face value the results of such modelling should decline. With that caveat out of the way, the following chart shows the projected number of cases between 2009 and 2030.
20
Diabetes Health Needs Assessment, NHS Dudley
160 151.7 150 Dudley
140
146.8
West Mids
134.9
130 England 120 110 100 90
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
80
Figure 5. Projected prevalence of diabetes in England, West Midlands, and Dudley to the year 2030. The estimated figure for 2009 has been rebased to 100.
44
The table below shows the actual numbers of people with diabetes that Dudley can expect to have, together with a range representing 95% confidence limits on the central estimate. Year
Number
Prevalence
Lower limit
Upper limit
2009 2010 2011 2012 2013 2014 2015 2020 2025 2030
19,085 19,386 19,715 20,102 20,411 20,791 21,095 22,703 24,145 25,754
7.79% 7.89% 8.01% 8.14% 8.26% 8.39% 8.51% 9.04% 9.49% 9.99%
13,727 14,149 14,143 14,407 14,609 14,865 15,297 16,353 17,276 18,306
27,633 27,797 28,614 29,199 29,683 30,265 30,416 32,920 35,208 37,751
Table 6. Projected number of people with diabetes in Dudley to 2030. Based on APHO predictive model. The lower and upper limits are at the 95% confidence level.
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DIABETES MORTALITY IN DUDLEY 45 Deaths due to diabetes is an indirect means of assessing the level of need for effective services to manage diabetes well and prevent complications and prevent or postpone morbidity and mortality. The point was made earlier that though diabetes is a major risk factor for cardiovascular disease (itself the case of 25% of all deaths), the fact that diabetes may not be mentioned in death certificates means that these deaths are not ascribed in the official statistics to diabetes. A recent report from the National Diabetes Audit37 presented reliable data on mortality among people with diabetes using a retrospective cohort study method. 46 The cohort defined for the mortality analysis was all those people with diabetes registered to GP practices in England and covering a 15 month period from 1 Jan 2007 to 31 March 2008 (as defined by the 2007-8 National Diabetes Audit) and who were alive at 1 Nov 2008. These cases were followed up until 31 Oct 2010, a variety of means being used to ascertain all deaths in this period. 47 The outcome data are reported and presented for Primary care Trusts in several ways: as actual number of deaths, crude mortality rate, and as Standardises Mortality Ratios (SMRs) using one of 3 different comparator or reference populations. These details are set out in the following table for ease of reference and to aid understanding the data for Dudley set against other comparator districts. Statistical measure Actual number of deaths Crude Mortality Rate
SMR against England background population
SMR against all England Type 2 diabetes patients included in the NDA
Background population SMR against England background population
Units
Notes
Counts
--
Deaths per 100,000 population years at risk
This is a more precise measure than a simple ratio of deaths to the population alive at the start of the study Gives a measure of the burden of diabetes compared to the national mortality experience if diabetes was not present Gives a measure of the diabetes burden in the PCT in comparison with the rest of the country. Thus this is a comparative measure of the relative success of the local service for people with diabetes. This is the usual overall population level SMR. Gives a broad measure of the ‘health’ of a local population relative to the country.
Ratio of observed to expected deaths, with the expected deaths calculation based on the background England population Ratio of observed to expected deaths, with the expected deaths calculation based on the England NDA cohort
Ratio of observed to expected deaths for the PCT’s overall population with the expected deaths calculation based on the England background population
Table 7. Measures of mortality used in the National Diabetes Audit Mortality Analysis 2007-08
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Diabetes Health Needs Assessment, NHS Dudley
Measure of mortality
Dudley
England
362
46,142
4,081
3760
160
145
(95% CI: 144-178) 110
(95% CI: 144-147) 100
(95% CI: 99-122) 102
(by definition) 100
(95% CI: 98-105)
(by definition)
Deaths Crude rate Type 2 cohort SMR compared to England background population (=100) Type 2 cohort SMR compared to England NDA cohort Background population SMR
Table 8. Data for Dudley from the National Diabetes Audit Mortality Analysis 2007-8.
48 The figures in Table 8 need careful interpretation. Overall the population level mortality in Dudley, as shown by the general SMR of 102, is little different from the England average. The mortality experienced by people with diabetes in Dudley is seemingly higher than that of similarly affected people in England, but the 95% confidence interval of 99-122 spans 100, suggesting that the observed SMR of 110 might be statistically non-significant, a result of the smaller number of cases in the Dudley cohort. The mortality experienced by people with diabetes in Dudley is clearly higher than the background (non-diabetic) England population, as shown by an SMR of 160. This is higher also than the comparable measure for the England diabetes cohort but here again there is considerable overlap of the two confidence intervals, suggesting that the difference may not be statistically significant. 49 These data on mortality can also be presented as comparisons with health districts that share characteristics similar to Dudley. Dudley is in the Orange cluster in the Diabetes Area Classification. The following three figures show how Dudley compares with other PCTs in its cluster (Figure 6), with other PCTs in England relative to the general health of its population (Figure 7) and finally as a funnel plot that compares PCTs against each other to identify outliers in relation to diabetes mortality taking account of the size of each PCT as measured by the expected number of deaths. All three charts are reproduced from the National Diabetes Audit Mortality Analysis 2007-2008 published in Nov 2011.
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Figure 6. SMRs for NDA cohort by PCTs arranged by Diabetes Area Classification cluster. Dudley is in the Orange Cluster with an SMR of 160 (95% CI: 144-178). Chart taken from National Diabetes Audit Mortality Analysis 2007-2008
Figure 7. Scatter plot of PCT SMRs for diabetes cohort (v England general population) against all cause SMRs for the general population. Dudley’s position is at x=102, y=160.
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Diabetes Health Needs Assessment, NHS Dudley
Figure 8. Statistical process Control (SPC) Funnel plot of PCTs Each PCT is represented by a dot that plots its position with reference to the expected number of deaths (Dudley’s is 329) on the X-axis, and the SMR (Dudley’s is 110)
50 An estimate of the excess mortality due to diabetes was presented in a 2008 publication from the YHPHO38 on behalf of the National Diabetes Information Service. Using a methodology for identifying deaths attributable to diabetes developed first by the World Health Organisation in 2005, the study combined data on the additional risk of dying among people with diabetes, prevalence data and background mortality figures to arrive at an estimate by of ‘excess deaths’. This figure is not the same as the actual deaths; it represents in a sense the deaths that are potentially avoidable if diabetes services could (theoretically) reduce the mortality risk due to diabetes down to nil. 51 This study showed that:
In England there were 26,300 deaths (11.6% of all deaths) between 20 and 79 that can be attributed to diabetes. At PCT level the percentage of all deaths that could be attributed to diabetes varies from 9.25% to 17.08% In Dudley there were 179 diabetes-attributable deaths, accounting for 11.56% of all deaths. This figure, like many other indicators, is almost identical to the England average.
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VARIATIONS IN DIABETES PREVALENCE 52 Within Dudley there are variations in the prevalence of diabetes with some areas having greater needs than others. The areas can be defined in geographical terms (electoral wards, census super output areas) or as service level aggregations (general practices being the most obvious). In terms of service planning, as well as availability of data, the latter is the more pragmatic choice to make. The need for services can be measured as a) the number of people with diabetes; and b) the success with which these known cases of diabetes are treated. For all of these purposes the QoF data provides an excellent and reliable source of information. 53 The national Quality Management and Analysis System (QMAS) collects, analyses and presents QoF data returned by general practices. Based on the data in April 2011, recorded diabetes prevalence rates for general practices in Dudley are shown in the chart in Figure 10. These prevalence rates are crude rates, i.e. they are simply the ratio of the number of people with recorded diabetes to the total number of patients registered who are 17 or over; no account is taken for the age and ethnic composition of the practice’s registered population. There is a big variation in the recorded prevalence from as low as 3.6% to just over 9%. This variation is almost certainly the result of a composite of factors including variability in recording of data, propensity to test and therefore diagnose diabetes, variation in age structure of practice registered populations and real differences in the true (but unknown) prevalence of diabetes due to demographic and other factors. 54 The precision of prevalence rates by practice are subject to the size of the practice population. Large practices can be expected to have a relatively more precise estimate of the true prevalence. By plotting the excess of recorded over expected prevalence against the expected prevalence, we can generate what is known as a ‘funnel plot’ with confidence limits around the expected prevalence. Practices that fall outside these confidence limits are statistical ‘outliers’, i.e. they have either a larger or smaller number of recorded cases of diabetes than would have been expected from the age and ethnic group distribution of their practice populations. This is shown in Figure 9. Clearly some are within the standard 95% confidence limits where as for others fewer cases are recorded than would be expected. Observed relative to expected (%)
40
Diabetes Mellitus: 00CR, Dudley MCD
20 0 -20 -40 -60 -80 0
200
400
600
800
1000
1200
1400
Expected No. of Patients
Figure 9. Statistical process control chart (Funnel plot) of Dudley practices showing excess of recorded prevalence against expected prevalence.
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Diabetes Health Needs Assessment, NHS Dudley
M87628 M87614 M87610 M87018 M87026 Y02653 M87623 M87025 M87625 M87617 M87032 M87634 M87010 M87005 M87021 M87605 M87034 M87030 M87024 M87601 M87015 M87006 M87036 M87027 Y02212 M87007 M87028 M87012 M87017 M87612 M87016 00CR M87019 M87041 M87023 M87014 M87638 M87009 M87602 Y02955 M87037 M87011 M87621 Y01756 M87003 M87001 M87008 M87020 M87002 M87619 M87606 M87629 M87040 M87620 M87618
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
Figure 10. Diabetes prevalence (crude rates) by general practice in Dudley. The average for Dudley (code 00CR) is 5.9%
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VARIATIONS IN CLINICAL TREATMENT 55 The QoF data also serve as a valuable source of information to examine variation among general practices in the extent to which effective treatment outcomes are achieved. There are 6 QoF indicators that measure clinically relevant treatment targets. While these are not final health outcomes they serve as valuable proxies for the effectiveness with which services are delivered to people with diabetes. These QoF indicators are as shown in the Table below. DM 15 however was introduced for 2011 12 and data for this are not included in the dataset published for 201011 by the NHS Information Centre. These data are available by practice and are presented as a percentage achievement which is worked out as a proportion of the number of patients who achieve the relevant target divided by the number of patients with diabetes. DM12 DM15 DM17 DM23
DM24
DM25
The percentage of patients with diabetes in whom the last blood pressure reading is 145/85 or less The percentage of patients with diabetes with a diagnosis of proteinuria or microalbuminuria who are treated with ACE inhibitors (or A2 antagonists) The percentage of patients with diabetes whose last measured total cholesterol within the previous 15 months is 5mmol/l or less The percentage of patients with diabetes in whom the last HbA1c is 7 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months The percentage of patients with diabetes in whom the last HbA1c is 8 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months The percentage of patients with diabetes in whom the last HbA1c is 9 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months
Table 9. QoF indictors that are target measures for diabetes. In addition there are another 9 Indicators that are process measures
56 The individual achievements of practices are not of immediate relevance here. What is important is the variation and the opportunity presented by such variation to improve outcomes at the population level by targeting areas in greatest need and ‘levelling up. An additional factor to take into account is that the QoF indicators were developed as a reward system to encourage high quality care. For that reason, patients who do not engage with the service or opt out of the care processes may legitimately be regarded as exceptions and discounted for the purpose of calculating the achievement of the target. It is possible therefore that the achievement figures may not reflect fully in the effectiveness of care. The best way to show this complex information is as scatter plots that charts claimed achievement percentages against the percentage of patients counted as ‘exceptions’. The chart for DM 25 is omitted since the spread of practices is very similar to that in the scatter plot for DM24. Ideally one would expect high achieving practices to not also have high rates of exception reporting.
28
Diabetes Health Needs Assessment, NHS Dudley
DM 12 achievement v exception reporting
Exception reported patients,%
25% 20% 15% 10% 5% 0% 45%
55%
65%
75% Achievement
85%
95%
105%
Figure 11. Scatter plot showing Dudley practices QoF achievement against exception reporting for DM12 – The %age of patients with diabetes in whom last recorded blood pressure was 145/85 or lower. Within any given 10% achievement band there is considerable variation in the proportion of patients who are ‘exception reported’.
DM17 achievement vs exception reporting
Exception reported patients, %
35% 30% 25% 20% 15% 10% 5% 0% 60.0%
70.0%
80.0%
90.0%
100.0%
110.0%
Achievement
Figure 12. Scatter plot showing Dudley practices’ QoF achievement against exception reporting for DM 17 – the percentage of people with diabetes whose last measured blood cholesterol as 5 mmol/L or lower. Within any given 10% achievement band there is considerable variation in the proportion of patients who are exception reported.
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DM23 achievement v exception reporting Exception reported patients, %
70% 60% 50% 40% 30% 20% 10% 0% 0%
20%
40%
60%
80%
100%
120%
Achievement
Figure 13. Scatter plot showing Dudley practices’ QoF achievement against exception reporting for DM 23 – the percentage of patients with diabetes whose last HbA1c was 7% or lower. Exception reporting seems to be between 0 and 20% for most practices within a wider range of achievement of the target. The one practice with a 100% achievement and 67% exceptions could well be an error.
DM24 achievement v exception reporting
Exception reported patients,%
60% 50% 40% 30% 20% 10% 0% 40%
50%
60%
70% 80% Achievement
90%
100%
110%
Figure 14. Scatter plot showing Dudley practices’ QoF achievement against exception reporting for DM 24 – the percentage of patients with diabetes whose last HbA1c was 8% or lower. There is variation both in achievement and in exception reporting. As in the previous figure one practice is an outlier and could be a data error.
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Diabetes Health Needs Assessment, NHS Dudley
QoF Indicator
DM 12
Total exceptions reported across all Dudley practices 688
Exception reporting %age across all Dudley practices 7.2
DM 17
979
10.5
DM 23
1274
13.4
DM 24
939
10.0
DM 25
722
7.6
Table 10. Exceptions reported for QoF outcome targets for diabetes, numbers and percentages for all Dudley practices combined.
57 The data in the Table above show the number and percentage of exception reporting for QoF outcome targets. What we do not know is the extent of overlap between the exceptions reported for each of the QoF targets. However, experience would suggest that very often it is the same patients who for one reason or another disengage from the service and are reported as exceptions. It remains unclear, however, why there should be such a discrepancy between the number of exceptions for DM 23, 24 and 25. All three are based on the last reported HbA1c measurement, the difference being the level of HbA1c that is used to denote achievement of the target. Ideally the number should be the approximately the same, with any variation being due to data errors. Assuming complete overlap of the figures then we have at least 1274 patients (approximately 8.5%) in Dudley who are not engaging with the services with respect to HbA1c measurement and almost 700 patients about whose blood pressure control we can say very little.
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RESOURCES DEPLOYED FOR DIABETES 58 There has been a great deal of national research on the costs of treating diabetes. A NICE assessment in March 201139 showed that the cost of treating diabetes rose at an average rate of 9% year on year between 2006/7 and 2009/10. Expenditure item Healthcare (excluding community care) Primary care prescriptions (excl hospital prescribing) Total costs increase in expenditure
2006/7 (£ billion) 1.04
2007/8 (£ billion) 1.15
2008/9 (£ billion) 1.26
2009/10 (£ billion) 1.43
0.57
0.59
0.60
0.65
1.61
1.74
1.86
2.08
-
8.1%
6.9%
11.8%
Table 11. Health care costs for diabetes, Figures relate to England form 2006/7 to 2009/10. Source: NICE cost impact and commissioning assessment, March 2011. Figures exclude the costs of treating children 17 and under.
59 Calculating costs is always difficult and much influenced by decisions on which costs to count and how to measure them. More recent estimates would suggest that 10% of the NHS budget could be taken up by services that treat diabetes and its complications. Though more than 5 years old now one of the most comprehensive national reports on diabetes was from Professor Sue Roberts, then National Clinical Director for Diabetes40. The report concluded that in England:
Diabetes accounted for 5% of all NHS expenditure in 2002. Recent estimates say it could now be as high as 10%. The first Wanless report of 2002 estimated the total annual cost of diabetes to the NHS to be £1.3 billion. The presence of diabetic complications increases NHS costs for a patient by more than fivefold. In 1997 diabetes accounted for 9% of hospital costs. Diabetes increases by five times the chance of a person needing hospital admission 1 in 20 people with diabetes incurs social services costs. More than three-quarters of these costs were associated with residential and nursing care, while home help services accounted for a further one-fifth. The presence of complications increased social services costs four-fold.
COSTS OF DIABETES CARE IN DUDLEY 60 Prescriptions of drugs used in the treatment of diabetes accounted for £4.66 million each year. This estimate is based on data from the electronic prescribing and cost analysis system (ePACT) for the Quarter Jul-Sep 2011 (Q2 of 2011-12) and published by the NHS Information Centre41. If 32
Diabetes Health Needs Assessment, NHS Dudley
we assume that the primary care prescribing costs bear the same relationship to total healthcare costs as that reported in the NICE assessment above, we may extrapolate to calculate the total direct health care costs of treating diabetes in Dudley to be £14.88 million. However this does not take into account the costs of treating the consequences of diabetes such as heart eye and kidney disease. If we take as given the estimate that 10% of the total health care costs a big enough population to be accounted for by diabetes and its consequences, and given that NHS Dudley spent £ 488.3 million on health care in 2011-1242 then it would be a safe estimate that diabetes could accounts for as much as £48 million each year. This figure is considerably greater than the figure quoted in the Programme Budgeting returns43 to the Department of Health of £9.53 million as the expenditure attributable directly to programme budgeting category 4a. This huge difference highlights the difficulties in apportioning costs incurred by the health service to disease categories. Much depends on what costs are counted, how fixed costs are apportioned and how items of expenditure are categorised.
EFFICIENCY OF RESOURCE USE IN DUDLEY 61 It is a germane question to ask whether the resource that is currently expended on diabetes is being deployed in the most efficient manner. What outcomes are we getting for the inputs? And how does Dudley compare with other commissioning organisations? The National Diabetes Information Service (NHS Diabetes) provides the Diabetes Expenditure Versus Outcome (DOVE) tool 44 that shows a PCTs position relative to others with respect to a selected outcome. The latest edition of this tool uses data from 2010-11, and allows spending to be compared to outcomes. It is also possible to show how the change in spending between 2009-10 and 2010-11 is related to changes in outcome – in other words, are we using resources more efficiently. 62 In using the DOVE tool, a range of definitions of ‘expenditure’ on diabetes can be selected and for each we can select one of a range of outcomes. For each combination of expenditure and outcome a quadrant plot of PCTs is generated that shows where each PCT falls in relation to expenditure along the horizontal axis and outcome along the vertical axis. A PCT can thus fall into one of 4 categories: Expenditure Low
High
Outcome Good
Low cost, good outcome
High cost, good outcome
Poor
Low cost, poor outcome
High cost, poor outcome
63 The possible expenditure and outcome choices available in the DOVE tool are shown below. Each expenditure category can be combined with each outcome measure to generate a separate quadrant analysis. Thus there are 72 possible combinations; some of course do not make logical sense. For example there is no a priori reason to expect that expenditure on blood glucose testing items should bear any relationship to blood pressure outcomes. For the purposes of this report we present quadrant diagrams only for total expenditure on diabetes and for only two outcomes: HbA1c< 7 and blood pressure < 145/85, since these are the outcomes that most directly determine clinical health outcomes. It should also be noted that
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33
since the scale of measurement for expenditure and outcomes are different the only way to represent both on the same quadrant diagram (essentially a scatter plot) is to express each as a z-score. Expenditure choices Programme budgeting total spend on diabetes Total spend on prescribing Spend on non-insulin anti-diabetic drugs Spend on insulin items Spend on blood glucose testing items Average spend per item on all diabetic items Average spend per item on non-insulin antidiabetic drugs Average spend per item on insulin items
Outcome choices People with diabetes with a HbA1C of 7% or less People with diabetes with a HbA1c of 7% or less including exceptions People with diabetes with a blood pressure <145/85 People with diabetes with a blood pressure < 145/85 including exceptions People with diabetes with cholesterol lower than 5 People with diabetes with cholesterol lower than 5 including exceptions Clinical outcomes index for people with diabetes Clinical outcomes index for people with diabetes including exceptions
Average spend per item on blood glucose testing items Table 12. Expenditure items and outcome measures that can be chosen in the DOVE tool
Figure 15. Programme budgeting total spend compared to HbA1c < 7% for Dudley. Scatter plots shows Z-scores for spend (X-axis) vs. outcome (y-axis) for all PCTs, Orange group PCT and for Dudley (large blue square). Dudley comes in the high spend (ÂŁ660 per person with diabetes) poor outcome (HbA1c < 7% in 52.9%) quadrant but is well within the 95% CI box.
34
Diabetes Health Needs Assessment, NHS Dudley
Figure 16. Programme budgeting total spend compared to blood pressure < 145/85 for Dudley. Scatter plots shows Z-scores for spend (X-axis) vs. outcome (y-axis) for all PCTs, Orange group PCT and for Dudley (large blue square). Dudley comes in the high spend (ÂŁ660 per person with diabetes) poor outcome (BP < 145/85 in 78.4%) quadrant but is well within the 95% CI box.
64 Dudleyâ&#x20AC;&#x2122;s position on the quadrant diagram for these same two outcomes is little different when the expenditure is set to the total prescribing cost per person with diabetes. In both cases Dudley falls in the lower right quadrant signifying a less good outcome than the average given the level of expenditure. These charts are therefore not presented. It should also be noted that though Dudley comes in the high cost/poor outcomes quadrant, the fact that it is also within the 95% confidence interval box means that Dudley is not statistically significantly different from other health districts. 65 There is a great deal of information in this tool and the analysis raises questions for further exploration. It is not possible to present all the information in printed format as part of this needs assessment. The Excel file is available via this link.
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VARIATION IN HOSPITAL INPATIENT ACTIVITY 66 Another way of looking at the efficiency with which health care resources are deployed in looking after people with diabetes is to consider hospital admissions. We accept that people with diabetes will need greater use of hospital inpatient facilities but how does NHS Dudley compare with other PCTs in England? The Variation in Inpatient Activity (VIA) tool from the National Diabetes Information service provides an elegant way of answering this question. The tool uses the Hospital Episode Statistics (HES) database to calculate first the expected use of hospital beds (day case, emergency, elective admissions or length of stay for each of these admission categories) by people with diabetes if we assumed that they would have the same rate of use as people without diabetes. The actual usage by people with diabetes is then presented as a %age excess (or deficit.) The data are presented as funnel plots with the expected rates shown as 95% confidence lines and each PCT plotted on the graph with expected bed use on the X-axis and the excess on the y-axis.
Figure 17. Hospital in patient resource use in Dudley in comparison with England PCT, and Orange group PCTs. The dashed blue line is the 95% Confidence Interval for the expected bed use for people without diabetes. This chart uses 2009-10 data and measures bed use for all HRGs combined and for all categories of admissions. NHS Dudley patients with diabetes used 28976 bed-days against an expected 23,796 bed-days â&#x20AC;&#x201C; an excess of 21.8%. The excess bed-days for England was 19.4%.
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Diabetes Health Needs Assessment, NHS Dudley
Figure 18. Hospital in patient resource use in Dudley in comparison with England PCTs, and Orange group PCTs. The dashed blue line is the 95% Confidence Interval for the expected emergency bed use for people without diabetes. This chart uses 2009-10 data and measures bed use for all HRGs combined, but for emergency admissions only. NHS Dudley patients with diabetes used 21,249 emergency bed-days against an expected 17,790 bed-days â&#x20AC;&#x201C; an excess of 19.4%. The excess bed-days for England were 17.7%.
67 A similar analysis is available in the VIA tool for provider hospital Trusts. The graphs for The Dudley Group of Hospitals Trust (the acute hospital provider that would be expected to cater to the needs of the majority of NHS Dudley patients with diabetes) show a broadly similar picture to the above. The following table shows the figures
Total bed-days Emergency bed days
Actual bed-days 32,707
Expected bed-days 26,547
Excess in Dudley 23.2%
England excess 20.8%
25,700
21,341
20.4%
18.7%
Table 13. Data from Variation in Inpatient Activity tool for The Dudley Group of Hospitals. 2009/10 data. See text for explanation.
68 The broad conclusion from this data is that the service in Dudley is using the hospital inpatient resource with average efficiency. There is of course room for making improvement but Dudley is not an outlier.
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INTERACTION BETWEEN PRIMARY CARE AND HOSPITAL SERVICES 69 The current conventional model of providing clinical care for diabetes is based on a split between primary care delivered through general practices and more expensive specialist care provided by consultant led teams based in hospitals. The efficiency with which the latter is used is often seen as a quick way to improve the overall efficiency of the service. One measure is provided by the number of referrals made to hospital consultants and frequency with which patients are followed up in hospital clinics. The figures that are routinely collected and monitored for this purpose is based on definitions and codes developed for the Payment by Results (PbR) tariff system of remunerating care providers. A distinction is made firstly between consultant-led clinics and clinics where patients are seen by specialists other than medical consultants, and secondly, whether the visit by the patient is a first attendance or a follow-up attendance. 70 The following chart shows the figures for new and follow-up out-patient visits to consultant-led clinics in Dudley Group Hospitals each month from April 2011 to March 2012. The ratio of follow-up to first attendances is compared with the ratio for all West Midlands hospitals. Over this 12 month period there were 746 first visits and 5,358 follow-up visits to Dudley Hospitals, giving an overall ratio of follow-up to new cases of 7.18. In West Midlands hospitals as a whole, the ratio was 5.35. The reasons for this slightly higher ratio in Dudley have not been investigated in this needs assessment but clearly the finding raises questions for commissioners to explore further with the hospital specialist team.
600
Follow-up attendance
First attendance
Dudley 1st to FUp Ratio
WM 1st to FUp Ratio
10.00 9.00
400
300
200
100
8.00 7.00 6.00 5.00 4.00 3.00
Ratio of Fup / First
Outpatient Attendances
500
2.00 1.00 -
Figure 19. Monthly out-patient face-to-face attendances in the specialty of Diabetic Medicine from Apr 2011 through to March 2012, split between new (dark blue bars) and follow-ups (light blue bars). The line graphs show the follow-up to new ratio for Dudley (green line) and West Midlands (purple line). Cases where a procedure was carried out are not included. This chart shows only cases seen in consultant led clinics. Source: West Midlands Healthcare Commissioning Services, May 2012.
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Diabetes Health Needs Assessment, NHS Dudley
71 The following chart shows similar data for clinics that are not consultant-led but run by other specialists, mainly nurses. The data presented in the chart are for the two year period April 2010 to March 2012. As in the chart for consultant led clinics, the ratio of follow-up to first attendances is compared with the ratio for all West Midlands hospitals. Over the 12 month period April 2011 to March 2012, there were 323 first visits and 4,909 follow-up visits to Dudley Hospitals, giving an overall ratio of follow-up to new cases of 15.2. In West Midlands hospitals as a whole, the ratio was 7.5. The reasons for this clearly higher ratio in Dudley have not been investigated in this needs assessment but clearly the finding raises questions for commissioners to explore further with the hospital specialist team. It is also important to note that in both these charts we have looked only at the inputs as measured by clinic visits; what we have not been able to do is analyse the value gained from these visits – the outputs – in terms of health gain.
600
First attendance
First attendance
Dudley 1st to FUp Ratio
WM 1st to FUp Ratio
45.00 40.00
500
400
30.00 25.00
300 20.00 200
15.00
Ratio of Fup / First
Outpatient Attendances
35.00
10.00 100 5.00 -
Figure 20. Monthly out-patient face-to-face attendances in the specialty of Diabetic Medicine from Apr 2010 through to March 2012, split between new (dark blue bars) and follow-ups (light blue bars). The line graphs show the follow-up to new ratio for Dudley (green line) and West Midlands (purple line). Cases where a procedure was carried out are not included. This chart shows only cases seen in clinics that are not consultant-led. Source: West Midlands Healthcare Commissioning Services, May 2012.
PRESCRIBING IN PRIMARY CARE – TRENDS AND COSTS. 72 The mainstay of the medical management of diabetes is prescribing drugs that control blood glucose (anti-diabetic drugs), and other drugs that control blood pressure and cholesterol, as these are the main risk factors for the secondary complications in diabetes of heart, retinal and kidney disease. However the data that is collected on prescribing does not include the diagnosis and so within the prescribing database it is not possible to distinguish, in respect of these other drugs, whether the patient has diabetes. In respect of the anti-diabetic drugs however, they are
Diabetes Health Needs Assessment, NHS Dudley
39
used exclusively in diabetes and so the diagnosis is immaterial, and the expenditure can confidently be attributed to diabetes. 73 The ‘Drugs for diabetes’ is the section of the British National Formulary (BNF) of highest cost and greatest increase in cost of prescribing over the year to 2010/11. In 2010/11 there were 38.3 million items prescribed at a net ingredient cost of £725.1 million. This accounted for 4.1% of items prescribed and 8.4% of the total cost of prescribing in 201145. 74 There are extensive guidelines from NICE and other bodies that should guide the choice and use of drugs. The prescribing data provide a good source of information to judge the extent to which prescribers follow recommended good practice. The national picture on the growth and trends in anti-diabetic drug prescribing is shown below
Figure 21. National trends in costs for anti-diabetic drug prescribing. Note the sharp growth in prescribing of human insulin analogues and the relative flat line for biguanides and suphonylureas
75 The chart needs to be interpreted in light of the NICE guidance. First line treatment consists of metformin. If HbA1c cannot be kept below 6.5% then the second line treatment is to add a sulphonylurea. If HbA1c remains above 7.5% then there may be a case for the use of human NPH insulin as well. The chart shows only a modest rise in biguanide (metformin) prescribing cost but that is because it is a relatively cheap, though highly effective first line drug that is available in generic form. Metformin prescribing actually rose dramatically from 8.6 million items in 2005/6 to 14.6 million items in 2010/11 45. This follows NICE’s recommendation that this drug should be the first choice oral therapy. 76 The picture is different for insulin products. The evidence base on the benefits and costs of using one of the newer human insulin analogues is such that only selected patients would meet the criteria suggested in NICE guidance46. However the data show a steady increase in the use
40
Diabetes Health Needs Assessment, NHS Dudley
of human analogue insulin. More work needs to be done to establish whether this trend is justified by patient factors such as age and inability to cope with the twice daily injections of human NPH insulin. The National Prescribing Centre believes that
Long-acting insulin analogues have few advantages over human NPH insulin in type 2 diabetes and are expensive long-acting insulin analogues should be targeted for use in specific individual patients the widespread use of long-acting insulin analogues for type 2 diabetes may not represent the best use of resources
An important driver for the escalation in the costs of treating diabetes is the almost relentless drive by pharmaceutical companies to develop novel drugs and drug delivery systems. A Thomson Reuters business analysis of trends in drug development forecast that worldwide sales of insulin and insulin analogues alone would increase from USD 15,006.6 billion in 2010 to USD 23,433.2billion in 2016 – a year on year growth of 7.6% 47.
% metformin and sulfonylureas
77 The NHS Business Services Authority provides useful comparative data on QIPP comparators across Primary care Trusts. One such comparator is the proportion of antidiabetic prescription items that are for either metformin or a sulphonylurea – first and second line drugs. The chart below shows the value of this indicator for all the PCTs in England. The value of the indicator in Dudley is 84%.
Hypoglycaemic agents (Quarter to December 2011)
100 95 90 85 80 75 70
NORTH TYNESIDE NORTHUMBERLAND CARE TRUST DERBYSHIRE COUNTY DEVON BUCKINGHAMSHIRE CROYDON MILTON KEYNES NEWCASTLE BRISTOL TORBAY CARE TRUST CAMDEN WALSALL TEACHING NORTHAMPTONSHIRE TEACHING WESTMINSTER LEICESTERSHIRE COUNTY & RUTLAND WANDSWORTH TEACHING BATH & NORTH EAST SOMERSET REDCAR & CLEVELAND LEICESTER CITY DARLINGTON SOUTH STAFFORDSHIRE ROTHERHAM EALING GATESHEAD GREENWICH TEACHING BROMLEY COUNTY DURHAM HERTFORDSHIRE NORFOLK NORTH SOMERSET SOUTHAMPTON CITY COVENTRY TEACHING NORTH YORKSHIRE & YORK SOMERSET HARTLEPOOL HARINGEY TEACHING BEXLEY CARE TRUST BERKSHIRE WEST WEST KENT WARRINGTON SWINDON BLACKPOOL EAST SUSSEX DOWNS & WEALD BARNSLEY BEDFORDSHIRE WOLVERHAMPTON CITY NORTH EAST ESSEX WAKEFIELD DISTRICT LEWISHAM HAMMERSMITH & FULHAM HEREFORDSHIRE CENTRAL LANCASHIRE DUDLEY WESTERN CHESHIRE KIRKLEES BERKSHIRE EAST DONCASTER WARWICKSHIRE LIVERPOOL NORTH LANCASHIRE TEACHING SHROPSHIRE COUNTY TELFORD & WREKIN BARNET BASSETLAW ENFIELD BRADFORD & AIREDALE TEACHING CORNWALL & ISLES OF SCILLY WALTHAM FOREST OLDHAM HEART OF BIRMINGHAM WIRRAL LUTON WEST SUSSEX SALFORD BARKING & DAGENHAM SANDWELL
65
© Copyright NHSBSA 2012
Figure 22. Percentage of prescription items that are first or second line drugs. Dudley is shown in red. Other West Midlands PCTs are shown in light blue. A high value is considered economical prescribing – though this needs careful interpretation in the context of other information. Source data: ePACT. Chart taken from NHS Business Services Authority website. (http://www.nhsbsa.nhs.uk/PrescriptionServices/3332.aspx).
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41
GROWTH IN PRESCRIBING FOR DIABETES IN DUDLEY 78 An extensive analysis of prescribing patterns and costs at PCT level is provided by the Department of Medicines Management at Keele University48. The general trend as shown in the chart below is one of continued growth especially in the use of newer drugs.
Figure 23. Quarterly prescribing data for Dudley. Newer drugs are being increasingly used. Source: Keele University Dept of Medicines Management.
42
Diabetes Health Needs Assessment, NHS Dudley
LOCALLY ENHANCED SERVICES IN PRIMARY CARE 79 Changes introduced in the last decade to the General Medical Services contract49 allow primary care organisations and general practices to develop locally enhanced services (LES) contracts as an incentive to practices to provide additional services. NHS Dudley has developed a LES for diabetes that has been taken up in the current year by 40 of 51 practices. The data from the LES for 2011-12 are presented below.
9 practices did not meet the criterion of a minimum QoF score of 85% across all indicators to undertake the LES this year. These practices received a visit by the clinical and commissioning lead to identify issues and develop a practice action plan for implementation and improvement next year. Submissions were received from 38 practices covering 85 % of the total diabetes population in Dudley. Total cost of LES for 2012/13 was £319,765 which was a reduction of £180,235 from the previous year. A further 2 practices did not submit data this year and therefore received no payment. All 38 practices were delivering Tier 1 services which resulted in 78 patients being discharged back from Secondary Care 1281 Patients identified and put on an ‘At Risk of diabetes Register’ Of the ‘at risk’ 752 (59%) had an annual review 8212 (62%) of diabetes patients had at least an additional 6 month review In addition all these practice were undertaking personalised care planning (a national priority for all long term conditions) with patients whose control was poor defined as HbA1c >9 and/or complications of diabetes Tier 2 services: 29 practices covering 68.3 % of total diabetes population were undertaking commencement of insulin within the practice setting. Across the economy this resulted in 134 insulin commencements (88.2% in these practices) within primary care. An audit of results showed that the HbA1c was reduced on average by 4.54 (range 0.2-7.54). If this activity had been undertaken in secondary care then the associated cost in OPD activity would have been £72226 therefore producing a return on investment of £12226. Tier 3 services: In addition 20 practices (covering 52.5% of total diabetes population) were delivering commencement of treatment with GLP-1 drugs in primary care. An audit of the results achieved showed an average HbA1c reduction of 1.51 (range 0.6-3.6) and average weight reduction of 3.56Kg (range -5 to 9.1Kg). If this activity had been undertaken within secondary care and paid for under PbR tariffs the cost in OPD activity would have been £51,205 producing a saving of £11205.
Diabetes Health Needs Assessment, NHS Dudley
43
80 The LES contract also generated useful data of the prevalence of complications of diabetes. These are shown in the following table. Complication
total number of patients
% of total diabetes population
Type 1 diabetes mellitus with retinopathy
369
3.29
Type 2 diabetes mellitus with retinopathy
2410
21.5
Chronic painful diabetic neuropathy
252
2.25
Diabetic Charcot arthropathy
23
0.21
Diabetic foot at moderate risk (right /left)
1300
11.6
Diabetic foot at high risk (right /left)
212
1.89
Ulcerated foot ( right / left)
110
0.98
Chronic Kidney Disease 3
2013
17.96
Chronic Kidney Disease 4
208
1.86
Chronic Kidney Disease 5
60
0.54
Chronic Kidney Disease 5 dialysis
79
0.7
Stroke
396
3.53
Transient Ischaemic Attack
451
4.02
Myocardial Infarction
870
7.76
Coronary Heart Disease
2290
20.43
37
0.33
Hypoglycaemic attack requiring 3rd party assistance
Table 14. Data returned from practices that signed up to tier 1 of the LES contract 2011-12
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Diabetes Health Needs Assessment, NHS Dudley
PREVENTION OF DIABETES AND NHS HEALTH CHECKS 81 Prevention of diabetes is included in the general public health strategies being implemented across the borough – specifically the Obesity Strategy which aims to increase opportunities for physical activity and improve access to healthy food, the Alcohol Reduction Strategy and the Health Inequalities Strategy. All strategies include action on the wider determinants of health as well as lifestyle, behaviour and awareness. 82 There are a full range of lifestyle services in the Dudley borough which are available to the public generally as well as those with a long term condition including diabetes. The lifestyle pathways link into the diabetes pathway and include Exercise on Prescription, Weight Management, Smoking Cessation, Get Cooking!, and Alcohol Counselling. All pathways are detailed in the ‘Lifestyle Pathways Guidance’ for primary care. It is not known how many people with diabetes access these services. 83 The NHS Health Checks programme is a national scheme launched in 2009. It is targeted at all adults between 40 and 74 without existing vascular disease. People are invited for a health check every 5 years from the age of 40 and are screened for diabetes, CVD risk, hypertension, obesity, CKD and lifestyle risk in Dudley. The programme began in July 2010 and is delivered by general practices and community pharmacies under a LES contract, and by community outreach provision. In 2011-12 16,705 people were invited and 7,365 checks were completed. 43 (0.6%) people were identified and diagnosed with diabetes as a result of an NHS health check.
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QUALITY OF SERVICES IN DUDLEY 84 Quality in the health services can be defined and measured in many different ways; and there is a large body of literature on the subject, including official commitment to ensuring quality services50. The three dimensions of quality are clinical effectiveness of services, processes and procedures that ensure patient safety, and systems that improve the patient experience. For the purposes of this needs assessment we need a summary high level measure of the service at an organisational level that allows a comparative judgement to be made of the service quality. The DiabetesE self-assessment system provides just such a summary.
DIABETESE 85 DiabetesE is an online self assessment tool which ‘measures and benchmarks the quality of diabetes service provision and is a mechanism for capturing service strengths and gaps in primary, secondary and community care and commissioning in one place. It is one of a suite of complementary information tools which operate under the auspices of the National Diabetes Information Service.51. There are a total of 344 questions in the PCT and specialist diabetes provider modules covering all aspects of commissioning and providing diabetes services. The responses to these questions result in summary scores for each of 15 modules – 3 for PCTs and 12 for specialist diabetes providers. Organisations are free to choose which modules to complete and they are scored only for those modules that apply to them and they elect to complete. The modules are shown in the Table below Modules
Code
PCT Questionnaire Leadership, Policy and Strategy LPS Productivity and Contracting PC Prevention and Health promotion PHP Specialist Diabetes Provider Questionnaire Clinical Leadership CL Staff Development SD Patient Experience PE Children and Young People CYP Adults with diabetes AD Inpatient care –Adults IP Prevention and Management of Diabetic Foot PMF Disease Inpatient Management of Active Foot Disease IMF Kidney Screening and management KSM Pre-Pregnancy PP Diabetes in pregnancy DP
No. of organisations that completed the module 121 119 119 162 140 141 77 117 82 98 70 57 72 76
Table 15. Modules and number of organisations that completed each in the DiabetesE self assessment tool. This data is taken from the 7th National Report of DiabetesE dated January 2012 and the figures may well be out of date by the time this Needs Assessment is published. Readers should follow the link in the reference52 for the latest data.
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Diabetes Health Needs Assessment, NHS Dudley
86 The results of the latest DiabetesE quality assessments are presented below; the results are from the publicly available results pages of DiabetesE53.These data change frequently as commissioners and providers update their scores. They are up to date as of 23 May 2012. PCT Modules LPS PC
Specialist Provider Modules CL SD
HPP
Number of Clin providers Leadership
NHS Dudley
90
90
90
2
CYP
Staff Pat development Experience
85
top 25% of scores nationally
PE
85
AWD
IP
Children & Adults with Young people Diabetes
82
74
PMF
IMF
KSM
Kidney In-patient Prev / Mngm In-pat care of screening & care - adults foot disease foot disease Mngmnt
77
81
middle 50% of scores nationally
76
72
PP
DP
Pre pregnancy care
Diabetes in pregnancy
32
82
94
bottom 25% of scores nationally
Figure 24. Combined DiabetesE scores for Dudley commissioner and providers organisations. The commissioner is NHS Dudley and the 2 main providers are The Dudley Group of Hospitals and Dudley Primary care Specialist Team. For the latter two the combined score is an average weighted by the number of patients that use each service. CL Clinical Leadership
SD Staff development
Dudley Community Services 80 Russells Hall Hospital 87 Sandwell &West Bham Hosp 58 Sandwell & WB Community Walsall Manor 84 New Cross 87 For comparison NHS West Midlands (n=23) 76 National summary (n=206) 68 top 25% of scores nationally
PE
CYP
Pat Experience
Children & Young people
AWD
78 90
77 85 x
74
78
66
90
90
70 79
x
79 79
Adults with Diabetes
x 82 X 67
IC
PMFD
IMFD
KSM
PP
DP
In-patient care - adults
Prev / Mngm foot disease
In-pat care of foot disease
Kidney screening & Mngmnt
Pre pregnancy care
Diabetes in pregnancy
X
X
82 X 93
64 X 84
81
83
67 x x X
90
75
71 75 77 72 74 72 middle 50% of scores nationally
65 62
x 70 x 79 x 84
X 72 x 27 x
82
94
90
90
x
x 42 83
88 90
64 51 50 74 62 49 59 73 bottom 25% of scores nationally
87 85
70
39 71
Figure 25. Provider Scores for domains that apply to them for a selected range of organisations to which Dudley patients might be referred. The first 2 organisations are the most relevant and they are included in the composite provider score in the earlier Figure.
Diabetes Health Needs Assessment, NHS Dudley
47
NATIONAL DIABETES AUDIT 87 Information on the clinical effectiveness of services in Dudley and how it compares with other areas comes from the National Diabetes Audit. The results of the 2010/11 audit were not available at the time of preparing this report but the data from the 2009/10 audit54 may still be relevant to determine which areas to focus on. The following Table provides a summary snapshot of Dudleyâ&#x20AC;&#x2122;s performance Audit Indicator
Dudley score
Notes
Practice participation
74.55% (41 out of Middle 50% , up from 55 practices) 70% in 2008/09 Complication prevalence over 1 year (% of patients included in audit) Ketoacidosis 0.47 Angina 3.22 Myocardial infarction 0.44 Best 25% Cardiac failure 1.5 Stroke 0.53 Diabetic retinopathy treatments 0.11 Renal failure 0.39 Amputation minor 0.08 Best 25% Amputation major 0.03 Best 25% Care Processes (%age achieved) BMI 90.46 HbA1c 93.48 Blood Pressure 95.52 Best 25% Urinary albumin 60.82 Worst 25% Blood creatinine 93.16 Cholesterol 91.89 Best 25% Eye screening 74.68 Foot exam 84.79 Best 25% Smoking review 89.38 Best 25% All care processes 44.56 Worst 25% Treatment targets NICE HbA1c<6.5% 24.03 NICE HbA1c<=7.5 66.67 Best 25% NICE Cholesterol < 4.0 mmol/l 43.59 Best 25% Targeted BP 48.77 Table 16. Dudleyâ&#x20AC;&#x2122;s results from the National Diabetes Audit 2009/10. All results fall in the middle 50% of the distribution of English PCTs except where otherwise stated. Note: The complication prevalence rate is measured as the percentage of patients included in the audit who had one or more relevant admissions recorded in the Hospital Episode Statistics (HES) database in the preceding one year. It is therefore strictly speaking a 0ne year prevalence rate.
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Diabetes Health Needs Assessment, NHS Dudley
NATIONAL DIABETES IN-PATIENT AUDIT - NADIA 88 This audit programme, run by the Healthcare Quality Improvement Partnership (HQIP) and Diabetes UK together with the NHS Information Centre provides a nationally benchmarked indicator of the quality of care that people with diabetes receive when they are admitted to hospital for whatever reason55 . The audit is based on a detailed survey carried out by hospital teams in England and Wales on a nominated day in the first two weeks of October. Full details of the audit methodology are available in the report and hospital level results and comparative analysis are also available through the NHS Information centreâ&#x20AC;&#x2122;s website56. A total of 230 hospitals contributed to the audit, 212 in England and 18 in Wales. 89 There is a wealth of information available and the tools on the NHS IC website allow interactive charts to explore the results. For the purposes of this needs analysis the following table shows the key results for Russellâ&#x20AC;&#x2122;s Hall Hospital, contrasted with the national figures for England.
Diabetic Patients surveyed Prevalence of diabetes Percentage White Percentage emergency Percentage Management of diabetes Percentage other medical Percentage Non Medical Percentage Diabetes Type 1 Percentage Diabetes Type 2 Insulin Percentage Diabetes Type 2 Non insulin Percentage Diabetes Type 2 Diet only Percentage Diabetes Type Other Nursing hours per patient Consultant hours per patient Visited by specialist diabetes team Medication errors prescription errors management errors of pts on insulin Admitted with foot disease Seen by the foot MDT within 24 hours % Severe Hypo % Minor Hypo
Russells England Max Upper Median Lower Min Hall Hosp Mean value quartile value Quartile value 77 11.6 25.8% 17.3% 15.2% 13.1% 5.9% 100.0% 98.8% 95.0% 85.0% 26.7% 90.5 84.5% 100.0% 91.2% 86.9% 81.8% 0.0% 15.8 9.0% 23.1% 11.6% 8.1% 5.9% 0.0% 65.8 18.4 5.3 35.5
66.6% 24.4% 7% 34%
92.1% 61.5% 24.1% 68.4%
73.6% 27.4% 9.0% 39.4%
67.2% 22.9% 5.9% 33.3%
62.4% 33.3% 18.4% 2.6% 3.9% 0.0% 29.4% 8.3%
38.2
39%
72.7%
45.6%
39.3%
32.8% 12.5%
19.7
18%
46.7%
23.2%
17.6%
13.4%
0.0%
1.3
1%
7.3%
1.6%
0.0%
0.0%
0.0%
3.02 1.88 95%
0.85 0.29 38%
0.58 0.17 28%
0.37 0.09 20%
0.00 0.00 0%
32.4% 20.7% 18.4%
69% 44% 56%
38% 26% 23%
31% 19% 18%
25% 14% 11%
6% 0% 0%
11.6%
27% 100%
12% 89%
9% 67%
5% 33%
0% 0%
9.6% 21.8%
28% 48%
12% 26%
9% 21%
6% 16%
0% 5%
1.20 0.20 51%
20.30% 7.80% 16.1 88.9 -13
Diabetes Health Needs Assessment, NHS Dudley
49
Staff Knowledge - Answer Qs Staff Knowledge - Emotional support Staff Knowledge - Work together Overall Satisfaction Patient reported unexpected high Patient reported unexpected low Patient felt Involved in treatment plan Able to take control of diabetes care Staff aware of diabetes Some, all or most staff know enough about diabetes Percentage renal replacement therapy Foot Risk Assessment completed within 24 hours Foot Risk Assessment completed during the hospital stay
Russells England Max Upper Median Lower Min Hall Hosp Mean value quartile value Quartile value 48.60% 100% 69% 58% 47% 0% 90.60% 100% 92% 87% 80% 0% 42.40%
100%
55%
46%
37%
0%
86.40% 18.6
100% 71%
92% 31%
87% 25%
82% 18%
29% 0%
27.1
80%
32%
24%
18%
0%
40.8
100%
43%
33%
23%
0%
64.7
100%
76%
70%
59%
20%
71.70% 62.70%
100% 100%
94% 77%
88% 69%
83% 60%
58% 14%
34%
3%
0%
0%
0%
28%
100%
32%
16%
8%
0%
30%
100%
38%
20%
12%
0%
5.3
3.1%
Table 17. Main results of NaDIA 2011 for Russells Hall Hospital. Results are compared with England figures and with the hospitals using the min and max values reported and the 25th and 75th centile values (lower and upper quartiles) and the median value. Note that there were 77 patients identified in RHH on the audit day and so some indicators may not be appropriate to calculate due to small numbers, e.g. severe hypos
90 These data show that the level of service provided to NHS Dudley residents in Russells Hall Hospital is of a quality that compares well with other hospitals and with England as a whole. For most indicators RHH values are above the median and some are close to or above the 3rd quartile value. It is acknowledged that a proportion of NHS Dudley patients use other hospitals but a detailed presentation of results from the 3 other main hospitals would be unmanageably complex. 91 A pdf version of the full report from NaDIA for Russells Hall Hospital will be attached to this Needs Assessment Report as an Appendix and a copy is embedded here in the electronic version of this report.
NADIA results and charts for Russells Hall Hospital May 2012.p
50
Diabetes Health Needs Assessment, NHS Dudley
CORPORATE NEEDS ASSESSMENT 92 Corporate needs assessment is the means by which we take into account the experience and wisdom of the service providers and funders and use this intelligence to inform our final conclusions and recommendations. In this instance we decided to do this semi-formally by means of a brief questionnaire that went out to range of service providers in Dudley. A copy of our survey tool is attached in an appendix to this report. 93 We received 18 responses grouped as follows Community Diabetes Teams - 2 (1 for the adult service and 1 for the children’s service) Virtual Ward service – 2 District Nurse teams - 6 Dietician service – 1 Dudley Group Hospital - 6 ( Pre-pregnancy service, diabetes in pregnancy service, diabetes inpatient team, outpatient diabetes centre, adults pump service, foot care service) General practice Local enhanced service – 1 94 The intelligence gleaned from these responses is described briefly below:
Service
Activity
Strengths Weaknesses / opportunities
District Nursing Teams There are 15 District nursing teams across Dudley; the responses we received are probably representative. The main role is to deliver specific interventions such as insulin injections and blood glucose testing to housebound, mainly elderly patients with diabetes. In addition, as district nurses, other care is also delivered such as pressure sores prevention. Difficult to ascertain precisely. One response quoted an annual figure of 4,500 visits to administer insulin and/or check blood glucose. Another gave a point prevalence caseload figure of 7 patients needing insulin injections, some of them twice a day. Another had a caseload of 9 housebound patients (of which 2 were taken on in the past year). Another team made 10 home visits each day (7 morning and 3 in the afternoon) Across the 15 teams a scoping exercise identified 84 patients needing nurse visits for insulin injections (DPH Annual report 2010) Personalised care; holistic assessment; good team working; high levels of patient satisfaction Limited information from GPs and hospital at time of referral, ongoing training in diabetes advances; co-ordination when a patient is discharged back home, distance to travel; allocation of teams could be better with reference to geographical spread, need to review use of twice daily insulin, maybe a case for better co-ordination of care across teams with greater consistency of what is done and how.
Diabetes Health Needs Assessment, NHS Dudley
51
Service
Activity Strengths Weaknesses / opportunities
Service
Activity
Strengths
Weaknesses / opportunities
52
Virtual Ward There are 6 teams (working with assigned practices) of nurses and case managers who provide the virtual ward service for people with long-term conditions (diabetes is just one of them). They aim to support care at home, avoid admissions and enable early discharge responses received from 2 of the teams (teams 3 and 4) One team had an active case load of 244 (point prevalence) â&#x20AC;&#x201C; only some of these will have diabetes No information provided No information provided
Community Diabetes Team Childrenâ&#x20AC;&#x2122;s service Responsible for all aspects of nursing care for children and young people (CYP) with diabetes from Dudley, including education and training for other staff, insulin pump service, CYP when inpatients. Total case load 140 from Dudley, 10 from adjacent districts, run 10 hospital clinics a month: 4 insulin pump clinics (average 3 patients seen), 1 adolescents clinic (average 8 patients), 5 general clinics (average 8 in each clinic). Currently there are 24 CYP on an insulin pump. 1645 nurse contacts annually (based on 11 months data of 1508). Only 46 DNAs over 11 months. Service well integrated with community services, prim care and hospital. Insulin pumps are started at home or in a community clinic Good relationships with professional staff in primary and secondary care Take part in regional and national networks Handover between adolescent and adult services and loss of engagement Input of dietetics and psychology in clinics could be improved. Training commitment of ward staff on a regular basis. Better deployment of technology (24-hour telephone advice, HbA1c analysis in clinic, continuous glucose monitoring for complex cases) An agreed and funded insulin pump strategy Increased dietetic support
Diabetes Health Needs Assessment, NHS Dudley
Service
Activity
Strengths
Weaknesses / opportunities
Community Diabetes Team Adults A multi-disciplinary team (nurses, podiatrists, dietician, BME worker) that runs clinics in general practices or Brierly Hill Centre, offers to see patients at home in an emergency, podiatry clinics and home visiting, podiatry input into hospital service twice a week. Service also offers structured education for patients and other clinical staff Monthly Diabetes Specialist Nurse (DSN) clinics not taken up by 9 practices (ad-hoc clinics in 3 of these) 1021 referrals (including referrals to nurse, podiatrist or dietician) in 2011-12, plus another 228 referrals for diabetes education. Total patient contacts annually approx: Nurse contacts: 2509 (2300 over 11 months) Podiatry contacts: 2348 (2153 over 11 months) Dietician: 404 (202 over 6 months) Training and education: 173 staff attended (courses cover a range of levels) Patients: 138 (plus 37 partners) Integration of care between community and hospital. Range of training courses for patients and for clinician staff from arrange of backgrounds. Specialist clinics in general practices much valued. One referral route to the entire service. Care homes to be involved soon, work in progress. Podiatry offers rapid access â&#x20AC;&#x201C; 24 hours if urgent (Mon-Fri 9-5 service). Closely integrated with rest of diabetes service in community and in hospital. Clear clinical pathway for diabetic foot management. Education Facilitator enables an efficient programme of training to be run. Lack of nurses able to work better with BME communities. Still further opportunities exist for integration of specialist staff with hospital counterparts. Podiatry service not available in Halesowen due to lack of a suitable location and some patients have to travel to clinics elsewhere. Clinicians' time not best used doing secretarial work. Further investment in Xpert Patient education for patients and families. Further training for other staff that look after people with diabetes. More work needs to be done with care homes on Think Glucose and Putting Feet First. Scope to expand joint modality clinics in community to reduce hospital appointments.
Diabetes Health Needs Assessment, NHS Dudley
53
Service
Activity
Strengths Weaknesses / Opportunities
Service Activity Strengths
Weaknesses / Opportunities
Service
Activity
Strengths
Weaknesses / Opportunities
54
Dietetics Not a separate service as such but part of the community and hospital diabetic teams, But also have other areas of work; All dieticians see people with diabetes in all these settings. Activity or diabetes already listed as part of community and hospital teams. 2.1 wte deal solely with diabetes. Present in 10 clinical sessions a week; often see diabetes patients in clinics jointly with other professionals Contacts per year total: 626 in diabetes centre; 208 CHO counting weekdays + Saturday, 144 in paediatric clinics and 60 inpatients. Team working as part of a multi-disciplinary team. Able to offer CHO counting, educational programmes for staff, one to one consultations. Cover over holiday periods, limited support for CYP (only 1 session a week) Limited educational sessions for type 2 diabetes Staffing levels below the British Dietetic Assn recommended levels of 6 dieticians and 3 support staff for a population of 300,000.
Diabetes in Pre-pregnancy service, DGH A pre-conception clinic that runs once a month 12 new and 55 follow ups in a year, 3 patients fitted with insulin pumps preconception Accessible staff. Good Patient feedback. Better outcomes from pregnancy for those who attend Need better referral routes as some women do not access service at present. Need to work closely with infertility services Consider open access route Need to better educate clinicians treating patients likely to get pregnant re use of drugs that might be harmful (ACEIs, statins)
Diabetes in Pregnancy service, DGH A weekly diabetes antenatal clinic jointly run by Cons Obstetrician + Cons Diabetes physician, diabetes specialist nurse and midwife + dietician. Supported by a weekly nurse led education clinic. Follow NICE guidelines. Led on hand held diabetes antenatal records, work with WMPI 2010/11 169 new patients and 914 FUs â&#x20AC;&#x201C; a 15% increase over previous year. Telephone consultations also used. 5 patients fitted with insulin pumps each year. CGMS offered to all Type1 diabetes once in each trimester. Clear patient pathway, excellent team working, good outcomes. Handheld notes dev in Dudley now in use across UK improves communication between patients and their health care professionals. Leading on National diabetes in pregnancy audit Screening for gestational diabetes not in place. Problems getting data on outcomes of pregnancy complicated by diabetes. Need our own local database. Sustainability of present service if numbers increase. Need to ensure that women with diabetes are not referred to infertility services without also being seen in diabetes pre-pregnancy clinic.
Diabetes Health Needs Assessment, NHS Dudley
Service
Activity
Strengths
Weaknesses / Opportunities
Service
Activity
Strengths Weaknesses / Opportunities
Diabetes Inpatient team Part of the Think Glucose initiative, a service to enhance the care of all inpatients that have diabetes whatever the reason or specialty of admission. Focuses on Staff education; protocols to ensure safe practice, influence the care and management of diabetes in all inpatients by offering specialist advice. Service runs 7 to 7 Mon-Fri, 9-5 Sat. Consultant round 4 times a week. 10 calls a day for advice 324 referrals a month. Improved outcomes. 0.5 days aver reduction in LOS. Prescribing errors cut from 24.6% to 6.4%, better management of hypos (up from 26% to 65%); and HbA1c reduction of 1% 3 months after discharge. Won 2 National Awards in 2011. Outcomes in top quartile (National Diabetes Inpatient Audit, 2011). Patient satisfaction 86.4%. Engaging non-specialist staff is challenging. Investment needed to expand in-patient podiatry service. Opportunities exist to avoid admissions. Need to develop better links and trust with primary care so that stable patients can be discharged soon to make room for others more in need of specialist care.
Diabetes Outpatient Centre A Mon-Fri service providing ambulatory clinic care in a purpose built diabetes centre. A full range of speciality clinics, staffed by doctors, nurses, podiatrists, psychologists. 2011/12 first 10 months activity data show New Follow up Consultant 1168 7974 Nurse 326 4489 Nurse telephone 475 357 Good patient feedback Robust clinical processes Lack joint clinics for renal, eye disease and vascular disease, and joint preoperative assessment. Some referrals come in after patient has been (potentially avoidably) admitted. Need better links with primary and secondary care to aid communication â&#x20AC;&#x201C; a database would help. Need to consider consultant community diabetic clinics.
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Service Activity Strengths
Weaknesses / Opportunities
Service
Activity Strengths
Weaknesses / Opportunities
Adult Insulin Pump Service 4 consultant led pump clinics a month; NICE criteria followed Since 2006 60 patients have been started on a pump. National CSII audit put the service in top quartile Positive feedback from patients An active pump users group Database and an EPR would help with documentation. Need referral guidelines jointly with primary care. Need to agree funding for continuous glucose monitors and closed loop devices.
Diabetes Foot care service A twice a week consultant led multi-disciplinary foot clinic with seamless referral for those needing urgent vascular or orthotic input. Twice weekly inpatient consultant and podiatrist ward rounds to implement the Putting Feet First initiative NA Good feedback from patient. Number of foot ulcers in inpatients has declined. National award – Highly commended category Need enhanced links with primary and sec care. Need to increase to a daily inpatient podiatry service to deal with acute foot problems and reduce risk of new ulcers Plan to develop step down iv antibiotic therapy in community for osteomyelitis to reduce hospital bed use.
95 The broad conclusions we may draw from this exercise can be summarised as follows:
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There are a lot of enthusiasm and commitment on the party of the clinical teams and their leaders and managers to provide a high quality service. The hospital inpatient and outpatient service is proud of its national prominence and its patient satisfaction scores. All the respondents have identified areas for improvement. Common to these ideas is the need for better co-ordination, and more responsive real time information flows. Some of the respondents are aware of the challenge yet to come in terms of greater numbers of patients that might come their way in the near to medium term future. But the proposals to meet this challenge seem to be predicated upon additional funding to expand the service. The specialist services are engaged in training and skilling up other health care professionals who are not primarily diabetes professionals but upon whom rests the responsibility for day to day management patients. Of course there has to be a strong foundation of self management but that in turn depends upon patient education programmes.
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EFFECTIVENESS OF DIABETES CARE 96 There is a large volume of literature on the effectiveness of the various interventions and treatments available for the management of diabetes. These treatments and interventions comprise
pharmacological agents to improve glucose metabolism and control blood glucose control, drugs or other treatments to control risk markers and risk factors such as cholesterol, smoking, hypertension and obesity programmes aimed at educating patients and/or their families to better manage their lives around diabetes service delivery improvements that aim to make the service maximally efficient
97 It is not the intention of this needs assessment report to document this evidence in detail. Rather the aim is to draw attention by reference to a few key publications and guidelines that summarise the most important features that should be considered when specifying a diabetes service to be commissioned. Many of these publications are from national bodies such as NICE and the National Prescribing Centre (on sensible and cost-effective use of drugs). No
Title and brief summary
Reference
1
Preventing type 2 diabetes: population and community-level interventions. PH 35. May 2012. 92 page detailed guidance with 11 key recommendation for Government and other public bodies and health agencies as well as communities and individuals
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2
Diabetic foot problems – inpatient management. CG 119. March 2011, updated with a correction in Jan 2012. Intended for hospital staff that care for people with diabetic foot problems.
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3
Liraglutide for the treatment of type 2 diabetes mellitus. TA203. Oct 2010. Provides guidance on this new glucagon-like peptide (GLP-1) analogue drug and specifies criteria that would limit its use to a few well selected patients.
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4
Type 2 diabetes: The management of type 2 diabetes. CG 87. This is a partial update of CG 66. This is the main NICE guidance on the management of type 2 diabetes; it focuses mainly on the rational and evidence based use of drugs for the control of blood glucose, self monitoring of glucose and drug and other treatment for the control of blood pressure, lipids, antithrombotic therapy, eye, renal and nerve damage . It has been updated on line in March 2010, Sep 2010 and July 2011 to take account of recent developments and regulatory pronouncements on rosiglitazone and pioglitazone. Also some recommendations in this guideline to do with the management of neuropathic pain have been updated and replaced by CG 96.
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5
Continuous subcutaneous insulin infusion (CSII) for the treatment of diabetes mellitus. TA 151. This is the main technology appraisal and guidance of the use of insulin pumps. It was issued in July 2008 and is a review and an update of the earlier technology appraisal of insulin pumps â&#x20AC;&#x201C; TA 57. It endorsed the use of CSII therapy and laid down the criteria for patient selection and the conditions under which CSII use should be supported.
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6
Diabetes in pregnancy: Management of diabetes and its complications from preconception to the postnatal period. CG 63. First published March 2008 and modified in July 2008
62
7
Type 1 diabetes in children, young people and adults. CG 15. Updated 26 October 2011.
63
8
Guidance on the use of patient education models for diabetes (Types 1 and 2). TA 60.
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9
Guidance on the use of long-acting insulin analogues for the treatment of diabetes â&#x20AC;&#x201C; insulin glargine. TA 53; issued 2002. Recommended this type of insulin as an option for people with type 1 diabetes. The recommendations for people with type 2 diabetes have been replaced by the May 2008 CG 87.
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10
Exenatide prolonged-release suspension for injection in combination with oral antidiabetic therapy for the treatment of type 2 diabetes. TA 248 February 2012. Exenatide is an expensive new drug, a GLP-1 analogue similar to liraglutide (see TA 203). This guidance provides criteria for its use that would ensure that it is used in accordance with the evidence of where it offers the most clinical benefit.
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Table 18. Key clinical guidelines and technology assessments from NICE.
EFFECTIVENESS OF PREVENTATIVE INTERVENTIONS 98 Much of the advance made in the pharmacological management of diabetes in reality constitutes not treatment in the sense of a cure but effective secondary prevention of complications due to diabetes. In the case of type 1 diabetes insulin represents a replacement therapy for what the body is unable to provide, and much of the recent advance in technology has been concerned with ever more sophisticated means of delivery of the insulin while seeking to make the exogenous drug identical to human insulin. In type 2 diabetes the therapeutic advances have come from better understanding of cardiovascular risk reduction and achieving tighter blood glucose control with a combination of drugs including insulin while minimising the risk of hypoglycaemia. 99 The first convincing demonstration of the possibility that type 2 diabetes can be reversed and effectively cured came from a small study67 in Newcastle of 11 middle-aged obese people with type 3 diabetes, in whom extreme calorie restriction over a period of 8 weeks led to a complete reversal of diabetes with normalisation of beta cell function and liver insulin sensitivity. This study, though small and preliminary, convincingly shows the link between obesity and diabetes as well as the potential of primary prevention.
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100 The possibility of primary prevention of type 2 diabetes using non-pharmacological means by focusing on individuals with impaired glucose metabolism has also been convincingly shown in a series of randomised controlled trials. These have been brought together and systematically reviewed in a meta-analysis68 that showed that lifestyle interventions are as effective as pharmacological interventions and can reduce the rate of progression to clinical type 2 diabetes. The number needed to treat (NNT) for benefit is 7.
NEW MODELS OF CARE 101 The current conventional model of providing clinical care for diabetes is based on a historical separation between primary care delivered through general practices and specialist care provided by consultant led teams based in hospitals. This model, at least in the context of the NHS as it is currently structured, is characterised by:
people with diabetes belonging to a named general practice that is relatively free to organise its services for diabetes as it chooses Diabetes consultants in hospitals supported by teams of specialist nurses Other specialists such as optometrists, chiropodists, dieticians and clinical psychologists working in a range of hospital, specialist clinic or community settings Variable arrangements for commissioning these services with payments based on activity levels. 102 Developments in the NHS over the last few years that have impacted on diabetes services significantly include
The establishment of the Quality and Outcomes Framework (QoF) as a means for measuring and rewarding general practices for better quality care; the development of diabetes centres usually in hospital to bring together all the services that people might need under one roof; The expansion of the range of services in some larger general practices with some doctors developing a special interest in diabetes and thereby reducing the need for referrals to hospital outpatient services. Chronic disease management programmes Expert Patient Programmes that aim to devolve as much responsibility as feasible to the individual with diabetes. 103 None of these developments however altered the basis of commissioning of services. There is no a priori reason to believe that alternative models of care will not deliver better results or be more efficient. A review69 of the different models of care in diabetes was undertaken by the London Health Observatory in 2008 and provides a useful summary of developments in the field. One innovative proposal to emerge is the ‘year of care approach’ which would require a specification of a care pathway that includes all the services that the ‘average’ patient might need or use over a national 1 year period and monitor the contract against this pathway rather than on aggregate activity levels. This would leave the provider with the freedom to determine how and where the care is delivered.
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104 Many PCTs and hospitals have collaborated to set up integrated care programmes. However the view is widespread that organisational boundaries have got in the way of truly integrated care despite the rhetoric. There have been few robust and well designed evaluations of integrated care programmes on which to base future commissioning decisions. One such evaluation is the RAND / Ernst & Young evaluation of the Department of Healthâ&#x20AC;&#x2122;s Integrated care pilot programme70. Of the 16 pilot sites diabetes was chosen only by Tower Hamlets. This was not set up as a randomised trial and the evaluation was a mix of qualitative findings from questionnaire surveys and clinical outcome data with little or no possibility of direct attribution to the input intervention of integration. Thus in the case of diabetes one improvement noted was that the percentage of patients with controlled HbA1c and controlled blood pressure increased from 24% to 28%. Across the 16 areas a disappointing result was that patients did not share the sense of improvement that staff reported in response to questionnaires. 105 One of the most exciting developments in recent times has been tele-health and tele-care. The possibility that healthcare, including the monitoring of the results of treatment and clinical and other health-related advice, can be delivered remotely through information technology enabled systems holds great promise, especially when linked to the idea that for a lifelong condition like diabetes success depends a great deal on the individual taking control and responsibility for the quality of outcomes. The Department of Health funded a large randomised controlled trial71 of tele-health and telecare in 3 chronic conditions (diabetes, chronic lung disease and heart failure) across and 238 general practices in three districts, Kent, Newham and Cornwall, involving 6,191 patients. 106 Early results from this trial are promising: striking falls in mortality (45%), reductions in emergency room attendance (15%), decline in both emergency (20%) and elective (14%) admissions, and a drop in both bed-days (14%) and tariff costs (8%). The Department of Health launched the â&#x20AC;&#x153;Three million livesâ&#x20AC;? campaign to extend the idea to the estimated 3 million people with long term conditions who could potentially benefit; a large number of these would be people with diabetes. 107 These early results need to be replicated more widely and confirmed on longer term follow up before commissioners will feel encouraged to make the necessary investment. There has also been critical comment in the general and trade press about the poor take up of tele-health programmes especially by general practices72. Other reports suggest that the critical factor for success is not the technology, nor even securing acceptance by patients who appear surprisingly enthusiastic73 , but rather it is managing the culture change needed to embed new ways of working among staff 74.
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RECOMMENDATIONS
Healthcare commissioners, clinical practitioners as well as service providers should have a shared understanding that future developments in diabetes care will need to occur in the context of increasing prevalence, rising demand and reduced financial resources. Dudley should develop and implement an agreed strategy to identify people with undiagnosed diabetes and manage their care. Dudley needs to develop and implement an agreed strategy to slow the rise in obesity and the associated predicted rise in the prevalence of diabetes Commissioners, clinical practitioners and service providers need to consider how best they can make the care pathway more efficient in order to be able to cope with rising demand. Any strategy must include the elements of self care, better education through the life course, focus on disease management in primary care, and must exploit new technologies and models of care. NHS Dudley and the successor commissioning bodies should review the extent to which general practices rely on exception reporting in respect of QoF. Healthcare commissioners should review the use of hospital specialist services and agree a model of care that would use specialist skills and knowledge appropriately and efficiently to maximise the value gained in terms of outcomes and reduced variation among practices. Healthcare commissioners and finance staff should review the programme budgeting analysis and gain a better understanding of how resources are deployed in the care of people with diabetes in order to identify opportunities for improvements in efficiency. General practices should consider the available evidence to explore the scope for further improvements in the cost effectiveness of prescribing for diabetes. Healthcare commissioners and providers should consider and implement newer and innovative models of care that hold the promise of more efficient use of resources while delivering better quality.
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LIST OF FIGURES Figure 1. Population structure in Dudley .............................................................................................. 13 Figure 2. Distribution of deprivation in Dudley by Lower Super Output Area.. ................................... 14 Figure 3. Life expectancy in males and females by deprivation quintile .............................................. 15 Figure 4. QoF based prevalence of GP recorded diabetes in West Midlands PCTs. ............................ 18 Figure 5. Projected prevalence of diabetes in England, West Midlands, and Dudley. ......................... 21 Figure 6. SMRs for NDA cohort by PCTs arranged by Diabetes Area Classification cluster.................. 24 Figure 7. Scatter plot of PCT SMRs for diabetes cohort (v England general population) against all cause SMRs for the general population. ............................................................................................... 24 Figure 8. Statistical process Control (SPC) Funnel plot of diabetes mortality ...................................... 25 Figure 9. Statistical process control chart (Funnel plot) of Dudley practices showing excess of recorded prevalence against expected prevalence. ............................................................................. 26 Figure 10. Diabetes prevalence (crude rates) by general practice in Dudley. ...................................... 27 Figure 11. Scatter plot showing Dudley practices QoF achievement against exception reporting for DM12 – The %age of patients with diabetes in whom last recorded blood pressure was 145/85 or lower. .................................................................................................................................................. 29 Figure 12. Scatter plot showing Dudley practices’ QoF achievement against exception reporting for DM 17 – the percentage of people with diabetes whose last measured blood cholesterol as 5 mmol/L or lower. .................................................................................................................................. 29 Figure 13. Scatter plot showing Dudley practices’ QoF achievement against exception reporting for DM 23 – the percentage of patients with diabetes whose last HbA1c was 7% or lower ..................... 30 Figure 14. Scatter plot showing Dudley practices’ QoF achievement against exception reporting for DM 24 – the percentage of patients with diabetes whose last HbA1c was 8% or lower. .................... 30 Figure 15. Programme budgeting total spend compared to HbA1c < 7% for Dudley. ......................... 34 Figure 16. Programme budgeting total spend compared to blood pressure < 145/85 for Dudley...... 35 Figure 17. Hospital in patient resource use in Dudley in comparison with England PCT, and Orange group PCTs.. .......................................................................................................................................... 36
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Figure 18. Hospital in patient resource use in Dudley in comparison with England PCTs, and Orange group PCTs ............................................................................................................................................ 37 Figure 19. Monthly out-patient face-to-face attendances in the specialty of Diabetic Medicine from Apr 2011 through to March 2012. ........................................................................................................ 38 Figure 20. Monthly out-patient face-to-face attendances in the specialty of Diabetic Medicine from Apr 2010 through to March 2012. ........................................................................................................ 39 Figure 21. National trends in costs for anti-diabetic drug prescribing. ................................................ 40 Figure 22. Percentage of prescription items that are first or second line drugs. ................................. 41 Figure 23. Quarterly prescribing data for Dudley. ................................................................................ 42 Figure 24. Combined DiabetesE scores for Dudley commissioner and providers organisations. ....... 47 Figure 25. Provider Scores for domains that apply to them for a selected range of organisations to which Dudley patients might be referred. ............................................................................................ 47
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LIST OF TABLES Table 1. Ethnic background of the population of Dudley .................................................................... 14 Table 2. Prevalence of diabetes by age and by ethnic origin, national data. ....................................... 16 Table 3. The health burden of diabetes. Data source: Diabetes UK, see Reference 8 ......................... 17 Table 4. Recorded number of people with diabetes from MSD Informatics system ........................... 19 Table 5. Comparison of modelled prevalence against known prevalence of diabetes.. ...................... 20 Table 6. Projected number of people with diabetes in Dudley to 2030. Based on APHO predictive model. The lower and upper limits are at the 95% confidence level. .................................................. 21 Table 7. Measures of mortality used in the National Diabetes Audit Mortality Analysis 2007-08 ...... 22 Table 8. Data for Dudley from the National Diabetes Audit Mortality Analysis 2007-8. .................... 23 Table 9. QoF indictors that are target measures for diabetes. In addition there are another 9 Indicators that are process measures ................................................................................................... 28 Table 10. Exceptions reported for QoF outcome targets for diabetes, numbers and percentages for all Dudley practices combined. ............................................................................................................. 31 Table 11. Health care costs for diabetes, Figures relate to England form 2006/7 to 2009/10. Source: NICE cost impact and commissioning assessment, March 2011. Figures exclude the costs of treating children 17 and under. .......................................................................................................................... 32 Table 12. Expenditure items and outcome measures that can be chosen in the DOVE tool............... 34 Table 13. Data from Variation in Inpatient Activity tool for The Dudley Group of Hospitals. 2009/10 data. See text for explanation. ............................................................................................................. 37 Table 14. Data returned from practices that signed up to tier 1 of the LES contract 2011-12 ............ 44 Table 15. Modules and number of organisations that completed each in the DiabetesE self assessment tool. .................................................................................................................................. 46 Table 16. Dudleyâ&#x20AC;&#x2122;s results from the National Diabetes Audit 2009/10. All results fall in the middle 50% of the distribution of English PCTs except where otherwise stated. ............................................ 48 Table 17. Main results of NaDIA 2011 for Russells Hall Hospital. ........................................................ 50 Table 18. Key clinical guidelines and technology assessments from NICE. .......................................... 58
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REFERENCES (1) Wright J, Wilkinson JR. Development and importance of health needs assessment. BMJ 316:1310. (2) Wilkinson J, Marmot M. Social determinants of Health: the solid facts. 2nd ed. WHO; 2003. (3) This report focuses mainly on healthcare needs. The general improvements that need to be achieved in the sphere of wider determiants are firstly, of a generic nature and therefore common to many chronic conditions; and secondly, are likely to be well understood by those responsible for commissioning services. Healthcare on the other hand is more directly amenable to change and improvement in the short to medium term, and more capable of being changed by the process of commissioning. (4) What is diabetes? Diabete UK website; http://www.diabetes.org.uk/Guide-todiabetes/Introduction-to-diabetes/What_is_diabetes/?gclid=CJrk6rr-hK8CFUEMfAodhj2q3w. accessed 26 March 2012 (5) Diabetes Fact Sheet 2011. National Centre for Chronic Disease Prevention and Health promotion. Centres for Disease Control, Atlanta GA; http://www.cdc.gov/diabetes/pubs/factsheet11.htm. accessed 12 March 2012. (6) UK Prospective Diabetes Sudy Group. Intensive blood nglucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352(9131):837-53. (7) Fowler MJ. Microvascular and macrovascular complications of diabetes. Clinical Diabetes 26(2):77-82. (8) NSF Diabetes. Department of Health 2001. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid ance/Browsable/DH_4096591. accessed 20 March 2012. (9) Department of Health. National Service Framework for Diabetes, Delivery Strategy. Jan 2003. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid ance/DH_4003246. accessed 20 March 2012. (10) Diabetes Commissioning toolkit. Department of Health, November 2006. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/di gitalasset/dh_4140285.pdf. accessed 20 March 2012. (11) Department of Health. Improving diabetes services. The NSF four years on. 2007. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/d h_072779.pdf. accessed 20 March 2012. (12) Five years on. Delivering the diabetes National Service Framework, August 2008. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/di gitalasset/dh_087122.pdf. accessed 20 March 2012 (13) Commissioning Diabetes Without Walls. NHS Diabetes. 2009. http://www.diabetes.nhs.uk/document.php?o=28. accessed 21 March 2012.
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(14) Six Years On. Delivering the Diabetes National Service Framework. Department of Health. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docume nts/digitalasset/dh_112511.pdf. accessed 02 April 2012. (15) The NHS Outcomes Framework 2012/13. Department of Health. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/d h_131724.pdf. accessed 08 April 2012. (16) Diabetes in Adults Quality Standard. NICE, March 2011. http://www.nice.org.uk/media/FCF/87/DiabetesInAdultsQualityStandard.pdf. accessed 08 April 2012 (17) Expenditure on health care in the UK 1997-2010. Jurd, A 2 May 2012. http://www.ons.gov.uk/ons/dcp171766_264293.pdf accessed on 10 July 2012. (18) The Operating framework for the NHS in England 2010-11. Dec 2010. http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/links/operatingframe work2010-2011.pdf accessed 08 April 2012. (19) The potential for the NHS to make efficiency savings of this magnitude first emerged in a March 2009 powerpoint briefing by McKinsey commissioned by the Department of Health in February of that year. (20) David Nicholson. The Year, NHS Chief Executive's Annual Report, 2008/09. p 47. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/d h_099700.pdf. accessed 09 April 2012. (21) The Operating Framework for the NHS in England 2011/12. Department of Health, 15 Dec 2010. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/docume nts/digitalasset/dh_122736.pdf. accesed 09 April 2012. (22) The Operating Framework for the NHS in England 2012-13. Department of Health, 24 Nov 2011. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/d h_131428.pdf. accessed 09 April 2012. (23) Local Authority health profiles. Association of Public Health Observatories, 2012. See http://www.apho.org.uk/resource/view.aspx?RID=50215&SEARCH=dudley&SPEAR=. Accessed 30 March 2012/ (24) Unequal Dudley. Annual Report of the Director of Public Health - 2010. http://issuu.com/curiousecho/docs/unequal_dudley_web?mode=window&backgroundColo r=%23222222. accessed 30 March 2012 (25) National Statistics 2001 Area Classification. http://www.ons.gov.uk/ons/guidemethod/geography/products/area-classifications/ns-area-classifications/index/clustersummaries/local-authorities/index.html. accessed 31 March 2012. (26) Diabetes Area Classification for PCTs. Yorks and Humber Public Health Observatory. http://www.yhpho.org.uk/resource/item.aspx?RID=9950. accessed 31 March 2012.
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(27) Diabetes UK. Diabetes in the UK 2011-12. Key Statistics on diabetes. http://www.diabetes.org.uk/Documents/Reports/Diabetes-in-the-UK-2011-12.pdf. Accessed 30 March 2012. (28) The prevalence in Wales is 4.6% and in Northern Ireland is 4.5% of the general adult population. (29) The age group specific prevalence is taken from Diabetes UK; the data are from the Information Centre's 2010 Health Survey for England. (30) The ethnicty prevalence data are based on self reported doctor diagnoses diabetes and are taken from the Information Centre's Health Survey for England 2004: health of ethnic minorities. http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestylesrelated-surveys/health-survey-for-england/health-survey-for-england-2004:-health-ofethnic-minorities--full-report. accessed 30 March 2012. (31) World Health Organisation. Use of glycated Haemoglobin (HbA1c) in the diagnosis of diabetes mellitus. Abbreviated report of a WHO Consultation. WHO 2011. http://www.who.int/diabetes/publications/report-hba1c_2011.pdf. accessed 30 March 2012. (32) Gowing up with diabetes: children and young people with diabetes in England. Royal College of Paediatrics and Child Health. London March 2009. http://www.rcpch.ac.uk/sites/default/files/Growing_up_with_Diabetes_Report.pdf. accessed 30 March 2012. (33) National Collaborating Centre for Chronic Conditions. Type 2 diabetes: national clinical guideline for management in primary and secondary care (update). London: Royal College of Physicians; 2012. (34) The amputee statistical database for the United Kingdon, 2006/07. Information Services Division, NHS Scotland. Edinburgh, 2009 (35) Compendium of Population Health Indicators, Diabetes Prevalence 2010-11. NHS Information Centre for Health and Social Care March 2012. https://indicators.ic.nhs.uk/download/NCHOD/Data/27D_621PC_11_V1_D.xls accessed on 30 March 2012. (36) APHO diabetes prevalence model, 2009-2030. Yorkshire and Humber Public Health Observatory. http://www.yhpho.org.uk/resource/view.aspx?RID=81123. accessed 16 Dec 2011. (37) National Diabetes Audit Mortality Analysis 2007-08. NHS Information Centre for Health and Social Care 1 November 2011. http://www.ic.nhs.uk/webfiles/Services/NCASP/Diabetes/New%20web%20documents/NHS _Diabetes_Audit_Mortality_Report_2011_V3_0_2_.pdf accessed on 30 March 2012. (38) Diabetes Attributable deaths: Estimating the excess detahs among people with diabetes. Yorks and Humber Public Health Observatory, June 2008. for the PCT data see http://www.yhpho.org.uk/resource/item.aspx?RID=9941; for a summary report see http://www.yhpho.org.uk/resource/view.aspx?RID=9909. Accessed on 4th April 2012.
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(39) Cost Impact and commissioning assessment for diabetes in adults. National Institute for health and clinical excellence. March 2011. http://www.nice.org.uk/media/109/95/CostingCommissioningImpactAssessmentFinal.pdf. accessed 04 April 2012. (40) Turning the corner: Improving diabetes care. Department of Health, June 2006, London. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/di gitalasset/dh_4136011.pdf. accessed 4 April 2012. (41) Quarterly Prescribing cost analysis, England July-September 2011. NHS Information Centre. http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/prescriptions/quarterlyprescription-cost-analysis-england-july--september-2011. accessed 03 April 2012. (42) Data provided by NHS Dudley Finance Department, 27 May 2012. (43) Department of Health, February 2012. http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Programmebudg eting/DH_075743#_1 accessed 28 May 2012. (44) NHS Diabetes and Yorkshire and Humber Public Health Observatory. Diabetes Outcome versus expenditure tool. http://www.yhpho.org.uk/default.aspx?RID=88739. accessed 04 April 2012. (45) Prescribing for Diabetes in England 2005/06 to 2010/11. The health and social care Information centre 24 August 2011. http://www.ic.nhs.uk/statistics-and-datacollections/primary-care/prescriptions/prescribing-for-diabetes-in-england-2005-06-to2010-11 accessed on 21 March 2012. (46) National Institute for Clinical Excellence. NICE Clinical Guideline 87. The management of Type 2 diabetes. National Collaborating Centre for Chronic Conditions and the Centre for Clinical Practice, NICE; 2009 May. (47) Spotlight on diabetes - A Pharma Matters Report. Thomson Reuters; 2012 Jan. (48) Prescribing information to support QIPP, Dudley PCT. Dept of Medicines Management, Keele University. http://www.keele.ac.uk/pharmacy/mm/pctsla/reports/. Note however that access to the full report is password protected and available only to PCT staff. (49) General Medical Services Contract was introduced in 2003. See http://www.nhsemployers.org/payandcontracts/generalmedicalservicescontract/pages/con tract.aspx for details. Accessed 07 June 2012. (50) Department of Health. High quality care for all: NHS next stage review final report. 2008. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/D H_085825. accessed 04 April 2012 (51) DiabetesE Self-assessment system. National Diabetes Information Service. http://www.innove.co.uk/Pages/Services/DiabetesE/ accessed 08 April 2012 (52) DiabetesE Seventh National Report: Executive Summary. Jan 2012. http://www.innove.co.uk/Assets/Files/Services/DiabetesE/Seventh-National-ReportSingles.pdf accessed on 23 May 2012
68
Diabetes Health Needs Assessment, NHS Dudley
(53) DiabetesE. Combined Commissioner / Provider dashboard. https://www.diabetese.net/Public/HowDoICompare.aspx?pt=CombinedCommissionerProvi derView. accessed 23 May 2012. (54) National Diabetes Audit 2009/10 PCT level results. The Information Centre for Health and Social Care. http://www.ic.nhs.uk/webfiles/Services/NCASP/Diabetes/200910%20annual%20report%20 documents/NDA_2009_2010_Dashboard_v2_3_10.xls. Accessed on 11 April 2012. (55) Healthcare Quality Improvement Partnership, Diabetes UK and NHS Information Centre. National Diabetes Inpatient Audit 2011. Published on 17 May 2012. http://www.ic.nhs.uk/webfiles/Services/NCASP/audits%20and%20reports/7.National_Diabe tes_Inpatient_Audit_2011_FINAL_INTERACTIVE_PDF.pdf accessed on 23 May 2012. (56) National Diabetes Inpatient Audit (NaDIA) Comparative Hospital Level Analysis for England 2010-11. http://www.ic.nhs.uk/webfiles/Services/NCASP/audits%20and%20reports/2.NaDIA_Provide r_Level_Analysis_Comp_DataReport_values_v2.xls accessed 23 May 2012. (57) Preventing type 2 diabetes: population and community-level interventions. National Institute for Health and Clinical Excellence (NICE) May 2012. http://publications.nice.org.uk/preventing-type-2-diabetes-population-and-communitylevel-interventions-ph35 (58) Diabetic Foot Problems - inpatient management. CG 119. National Institute for Health and Clinical Excellence (NICE) March 2011. http://guidance.nice.org.uk/CG119/Guidance (59) TA203 Diabetes (type 2) - liraglutide: full guidance. National Institute for Health and Clinical Excellence (NICE) October 2010. http://guidance.nice.org.uk/TA203/Guidance/pdf/English (60) Type 2 diabetes. The management of type 2 diabetes. CG 87. Updates and replaces CG 66. updated in July 2011. National Institute for Health and Clinical Excellence (NICE) May 2009. (61) Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus. Technology appraisal guidance (TAG)151. Review of TAG 57 . National Institute for Health and Clinical Excellence (NICE) July 2008. http://www.nice.org.uk/nicemedia/live/12014/41300/41300.pdf (62) Diabetes in pregnancy. management of diabetes and its complications from pre-conception to the postnatal period. re-issued JUly 2008. National Institute for Health and Clinical Excellence (NICE) March 2008. http://www.nice.org.uk/guidance/CG63/NICEGuidance (63) Type 1 diabetes in children, young people and adults. CG 15. first published 2004; updated October 2011. National Institute for Health and Clinical Excellence (NICE) October 2011. http://www.nice.org.uk/guidance/CG15/NICEGuidance (64) TA60 Diabetes (types 1 and 2) - patient education models: guidance. National Institute for Health and Clinical Excellence (NICE) May 2003. http://www.nice.org.uk/guidance/TA60/Guidance/pdf (65) Guidance on the use of long-acting insulin analogues for the treatment of diabetes â&#x20AC;&#x201C; insulin glargine. TA 53. National Institute for Health and Clinical Excellence (NICE) December 2002.
Diabetes Health Needs Assessment, NHS Dudley
69
http://publications.nice.org.uk/guidance-on-the-use-of-long-acting-insulin-analogues-forthe-treatment-of-diabetes-insulin-ta53/evidence (66) Exenatide prolonged-release suspension for injection in combination with oral antidiabetic therapy for the treatment of type 2 diabetes. TA 248. National Institute for Health and Clinical Excellence (NICE) February 2012. http://publications.nice.org.uk/exenatideprolonged-release-suspension-for-injection-in-combination-with-oral-antidiabetic-therapyta248/guidance (67) Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia 54(10):2506-14. (68) Gillies CL, Abrams KR, Lambert PC, Cooper NJ, Sutton AJ, Hsu RT, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ 334(7588):299. (69) Diabetes models of care: a briefing on models of diabetes management practice. Arowobusoye, N. and Furlong, C October 2008. http://www.lho.org.uk/Download/Public/14164/1/Diabetes%20models%20of%20care%20br iefing%20final%20171108.pdf accessed on 26 May 2012. (70) National Evaluation of the Department of Health's Integrated Care Pilots. Final report. RAND Europe and Ernst & Young LLP March 2012. http://www.rand.org/content/dam/rand/pubs/technical_reports/2012/RAND_TR1164.pdf accessed on 26 May 2012. (71) Whole System Demonstrator Programme - Headline Findings December 2011. Department of Health December 2011. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/d h_131689.pdf accessed on 26 May 2012. (72) Stirling A. GPs urge minister to rethink telehealth pilots as low takeup in pilot area revealed. PULSE 26 May 2012. http://www.pulsetoday.co.uk/newsarticle-content//article_display_list/13313760/gps-urge-ministers-to-rethink-telehealth-drive-as-lowtakeup-in-pilot-area-revealed. accessed on 26 May 2012 (73) Telecare:what's happened to the whole system demonstrators. Vinegar, D. 2012. http://www.guardian.co.uk/healthcare-network/2012/apr/10/telecare-whole-systemdemonstrators-wsd accessed on 26 May 2012. (74) Perspectives on telehealth and telecare. Learning from the 12 Whole System Demonstrator Action Network (WSDAN) Sites. WSDAN briefing paper. Giordano, R., Clark, M., and Goodwin, N. 2012. www.kingsfund.org.uk/document.rm?id=9341 accessed on 26 May 2012.
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Diabetes Health Needs Assessment, NHS Dudley