New Diabetic Service for Hounslow CCG

Dr Delgado Raquel, diabetic lead for Hounslow CCG presented to new diabetic service commissioned and it’s impact on the locality. DM

3 types of services will be commissioned for practices. This can be delivered either by the practice or locality level. If necessary, neighboring localities can provide services. There may be flexible delivery of service, where resources within the locality. Eg delivery of level 2 requires 2 clinicians, and premises. If one practice cannot deliver this, we may be able to clinicians from 2 practices and run the service from where there is clinical space available. We will also be supported to explore new ways provide consultations eg email, phone and online. The key outcomes are improved diabetic care, identifying diabetic care, improving access and upskilling primary care and patients.

3 types of service will be commissioned.

  • High risk of diabetes
  • Level 1 – managing type 2 diabetics
  • Level 2 – Initiating insulin.

Key Outcomes

  • Address variation of care across CCG and practices.
  • Early identification and prevention. Reduces the consequent complications.
  • Better management of 9 care processes,
  • NWL diabetes education programme
  • Diabetes dashboard, will be available which allows comparing across practice, locality, CCG and NWL.
  • New diabetes community service.
  • Systm One OOH templates (yellow means that you have to input data).
  • Local diabetes education courses for clinicians. Doctors and nurses. These will be available, more information will be available shortly.

High Risk

  • Register, XaZLG code. Gestational diabetes and abnormal glucose test.
  • Annual BP, HbA1c, Lipids, smoking, BMI, Lifesytle intervention / referral.
  • High risk

Level 1 diabetes.

  • Refer to structured education programme
  • Annual 9 care processes including ACR and retinal screening (which are not included in QoF)
  • Annual review with 30m appointment.
  • Hypoglycaemia recording frequency and management.
  • Following CCWHE guidelines Diabetes for BP, Lipids, HbA1c insulin and glucose strips.
  • Care planning including housebound patients.
  • Copy of care plan given to patient.
  • Patient satisfaction survey.
  • Discharge from secondary care suitable patients.

Level 2

  • Insulin and GLP-1 Initiation and optimization and insulin education.
  • Need to have 2 accredited clinicians.
  • Annual accredited re-fresher course.
  • Adhere to prescribing guidelines.
  • Face to face appointments, telephone, email.
  • Dietician and DSN from the community service.
  • Referral to insulin education programme.
  • Min network population of 30,000.
  • Can have up to 3 sites for a locality.
  • Patient will be seen 11 times.

New diabetic service will have:

  • New diabetic service has dieticians, DSN, podiatrist, clinical psychologist linked to each locality.
  • It will be a flexible service.
  • Email and telephone access to all clinicians.
  • Joint clinics with diabetologist, Diabetic specialist nurse and dieticians.
  • Joint visits for housebound patients.
  • Larger choice of education programmes for patients and clinicians.