Dr Rustam Rea, Associate Clinical Director and Consultant in Diabetes, Derby Hospitals NHS Foundation Trust, talks about First Diabetes - an integrated diabetes service, delivering care in one place, closer to patients’ homes.  The health care professionals in the team are drawn from both the hospital and the community and include consultants, GPs, specialist nurses, health care assistants and dieticians. The team are able to communicate easily among themselves through a shared electronic patient record and work closely with the practices who are part of the First Diabetes service. As well as providing individual appointments for patients, team members also provide group education along the whole patient pathway, from prevention of diabetes to complex insulin regimes. They also go out to practices to see patients and provide professional training and advice.

1. Integrating diabetes care in Derbyshire
Dr Rustam Rea
Consultant Diabetologist, Royal Derby Hospital
Co-Chair First Diabetes
www.firstdiabetes.co.uk

2. Person centered integration
BOB
AGE 60
Practice Nurse for
regular check-ups
GP for regular BP and
medication checks
Foot calluses
Podiatry Clinic at Village
St Health Centre
Referred by GP
for New patient
education
classes
DAY course at Coleman St
Health Centre delivered by
Nurse Consultant, Dietician and
Podiatrist
Referred by GP for
retinopathy screen
Retinopathy screening at
the London Road
Community Hospital
Referred by GP
for Podiatry
Bob has obesity
issues
Referred by GP to
dietician
Dietician
appointments at
the Walk-in
Centre
Bob confesses he
has erectile
dysfunction
Referred by GP to
Erectile Dysfunction
Clinic
Diabetic Specialist
Nurse at the erectile
dysfunction clinic at
RDH
Podiatrist at
Village St finds
foot neuropathy
Podiatrist refers to
Diabetic foot clinic
Diabetic Foot Clinic seen
by Diabetic Specialist
Nurse, Podiatrist, and
Consultant at RDH
Nurse Specialist at the
Osmaston Surgery has
recommended exenatide
Referred by GP to
RDH
Consultant Diabetologist
initiates exenatide
GP
eventually
thinks Bob
requires
insulin
Referred
by GP to
LES2
insulin
initiation
service
Nurse Specialist at the
Osmaston Surgery decides
exenatide is a better option
so refers patient back to GP
for referral to Consultant
Foot neuropathy
discovered

4. Integration across a community
„Bringing together clinicians across the
system with legal and financial autonomy to
be responsible for the health outcomes of the
community‟

6. Whole system integration
1 care 2 careIntermediate care
Specialist podiatrists
Diabetes service
Specialist dietitians
Specialist doctorsSpecialist DSNs
Practice nurses
GPs

7. First Diabetes – a very new model
 Partnership
 Shares held 50% by GPs
and 50% by acute trust
 Single budget, not-for-profit
 Comprehensive
 Outcome focused, not
process driven
 A network including primary
care, community and
hospital staff
 No one directly employed –
staff either seconded or
sessional
 Facilities rented

8. Pillars of integration in First Diabetes
 IT
 Financial
 Patient participation
 Clinical engagement
 Clinical governance

9. SystmOne - the IT solution
 Single real-time clinical record
 Rapid access to decision making and referrals
 Consent and confidentiality
 Rolled out into tertiary hospital clinics
 Patient access

10. Programme budgeting – the
financial solution
 Single budget for diabetes, jointly owned by GPs and
hospital
 Set by PCT based on previous years spend, scope of
specification and efficiency savings
 Not-for-profit organisation
 Re-invest surplus back into the service

11. Care planning – the patient
engagement solution
 Care planning philosophy
 Patients informed and educated before clinic appointment
 Patient shadow clinical board
 Diabetes prevention workshops
 Education throughout the patient journey

12. Clinical engagement
 Keeping colleagues engaged – primary care and hospital
 New style of leadership – collaborative, shared
responsibility, acknowledging historical differences
 MSc diabetes module for upskilling primary care
 Practice visits, discussing difficult patients – 4 groups
 Reporting outcomes and comparing practices

13. Clinical governance
 Underpinned by a legal partnership
– Company limited by shares
– Equally owned by hospital and GPs
– Provides stability and confidence in long term future
 Move from silo working to joint ownership
– Board of directors
– Clinical management board
– Wider team working – in hospital, in general practice

14. Cost of integration
 50% lower DNA rate compared to non-integrated service
Cost per patient
Year First Diabetes
£
National tariff
£
2009/10 109 112
2010/11 124 118
2011/12 121 122

15. Reduction in prescribing costs
£0.00
£500.00
£1,000.00
£1,500.00
£2,000.00
£2,500.00
£3,000.00
CostperPU
Total diabetes costs
First Diabetes Act Cost Per
standard pu
Derbyshire Act Cost Per
standard pu
National Act Cost Per
standard pu
£200M savings if
figures were
extrapolated nationally

16. Biochemical outcomes
 Sustained QoF improvements for diabetes
 Reduction in HbA1c (1-2%) and weight (5-10kg) in
patients starting new diabetes drugs
 75% reduction in insulin doses and 1.25kg weight loss in
patients on complex insulin regimes

17. Admission with primary code of diabetes
0
20
40
60
80
100
120
140
160
180
2009/10 2010/11 2011/12 2012/13
County Practices
First Diabetes

18. Admission with a secondary
code of diabetes
0
500
1000
1500
2000
2500
2009/10 2010/11 2011/12 2012/13
County Practices
First Diabetes
21% reduction in admissions in First Diabetes
9% reduction in surrounding county practices

19. Patient and professional satisfaction
“The FD service from Stoneleigh House is excellent. They
give excellent care and advise to any patients I have sent
there and have always improved the diabetic measures of
control as well as helping the patient with understanding
their condition. The patient satisfaction is very high.
They have also helped with my own understanding of
diabetes as well as being a considerable support to our
nursing team”

20. Recognition
 Winner of Quality in Care Awards 2012 for Best Cross
Boundary Working and Best Primary and Community
Initiative
 Finalist in HSJ Awards 2012 in Managing Long Term
Conditions category
 Finalist in HSJ / Nursing Times Care Integration Awards 2012
in Diabetes Care
 Finalist in Health Enterprise East Innovations Awards 2012

21. Challenges ahead
 Providing diabetes care for Southern Derbyshire
 Integrating with other long-term conditions
 Integrating with social services and mental health
 Ongoing clinical engagement

22. Acknowledgements
 Dr Garry Tan
 Dr Kyran Farrell
 Staff and patients at First Diabetes
 GPs, hospital management
 PCT / CCG

23. Thank you
www.firstdiabetes.co.uk
Commissioning for Integrated Diabetes Care
www.tinyurl.com/CommissioningDiabetes