25 working days – Ready, Steady, Go!

I’m going to keep this blog short and sweet because I know how busy every manager who has diabetes in their portfolio, is going to be.

The much anticipated opportunity to bid for £44m, an extra £4m than originally announced in the NHS England Operations and Contracting Guidance in September. 

Follow this link to find all the information.  The deadline for submitting your bid is the 18th of January 2017 – 25 working days.  Challenging over the Christmas period.

The funding is:

“To support the implementation of the Five Year Forward View vision of better health, better patient care and improved NHS efficiency, NHS England has created a transformation fund. This funding will enable local areas to deliver on key ambitions identified by the independent cancer and mental health taskforces. Additionally we will continue to build on the Transforming Care priority for those with learning disabilities and kick start, at scale, revolutions for diabetes treatment and prevention”.

“Revolutions”!  Not only have you got to get these bids in fast but there is a clear steer that the bids have to engender “Revolution”.

NHS England want to support bids for the following 4 areas:

·         Structured education £10m

·         Treatment targets £17m

·         Multi-Disciplinary Footcare Teams (MDFTs)  £8m

·         Diabetes Inpatient Specialist Nursing Teams (DISNs)  £8m  

It is worth noting the breakdown of how much funding NHS England want to put into each of the 4 priority areas.  This might influence your bid focus.

Another point of note is that bids need to reference and be submitted via STPs:

 “Sustainability and Transformation Plans (STPs) are central to this process and all bids should be explicitly linked to the relevant local STP plans. This process is open to any STP, although individual organisations or alliances may bid on behalf of an STP for this funding; submission of applications must be via STPs.”

There is one thing I think that this less clear:

“It is also to give an indicative sense of any modelling assumptions of transformation funding beyond 2018/19, should this be available”.

My understanding of this statement is that if you do not bid or are unsuccessful in your bid this automatically means that, if there is any further funding in 2018/19, you will not be eligible.

So it is well worth putting aside your turkey to get your bid in.

I have a feeling that despite the challenging deadline over Christmas and getting agreements.  I am very optimistic that CCGs/Collaborative of CCGs/STPs will bid for this funding in their droves. 

25 days – Ready, Steady, GO!!

It’s the small things

A couple of small things before I start.

I am learning about blogging all the time.  Recently I have learnt that you can get an email notification when I publish a blog (isn’t technology clever).  So if you want to register just scroll down and on the right and there is a little box that looks like this:

Follow by Email

Top of

Bottom ofAnother small thing is that in my last blog I mentioned that there might be a 5th area for the Diabetes Funding from NHS England called “Enhancing Pathways”.  This is not correct.  Serves me right for being impatient and not waiting till the actual bidding guidance comes out.

The Diabetes Funding bidding process announcement has been delayed so we all a wait with eager anticipation.

So with those small things tidied up I wanted to write about another small thing.

If you’ve read my blog before you will probably have noted that I am particularly passionate about diabetes patient education.  See my previous blogs – Brick Dust and Diabetes Patient Education – A Moral Imperative?

There are so many things in diabetes care to feel strongly about. I wonder why this one continues to bubble to the top of my personal interest?

I think it is partly because whilst working for NHS Diabetes I was given this as my key lead area so that exposed me to a more detailed understanding and it easy to be interested in something you get to learn quite a lot about.  Another reason is the people I meet.  The people who are so dedicated to good quality patient education.  They are just so flipping inspirational that I can’t help but be infected by them.   Also meeting patients who say how patient education has made such an enormous difference, is so powerful. 

But mostly - it just makes sense.  When we know that diabetes patients only see a health care professional for an average of 3 hours a year;  how else do we expect to manage the rising need without enabling, supporting, encouraging and allowing people with diabetes the opportunity to help themselves?

So, no one is more delighted than me that the CCG Improvement and Assessment Framework Indicators for Diabetes and the funding bids strongly focus on ATTENDING education.  Yes I know.  It’s not for everyone. I know it can be a struggle for people with diabetes and health care professionals to attend and provide courses.  I also know that education is a complement to everything else and not the panacea.  But when patients do attend a well-run, quality course it can be transformational.

Currently the data for ‘attendance’ is not being captured correctly.  A smashing piece of work was done by York and Humber Diabetes Clinical Network shows that 25% to 30% of people with diabetes do attend education which is 5 times higher than the nationally reported figure. 

It’s sad where services are getting good attendance rates at patient education that this is not being shown in national statistics.  It’s hard to justify, sustain, get a pat on the back, and show what an amazing job is being done by diabetes teams without good quality data. 

That is why I am delighted that Diabetes UK, with the support of the 11 national Clinical Networks, education providers and many others have produced some guidance on improving data capture for “attendance” at patient education so that we properly capture and recognise the work that is going on out there and also can have a more informed understanding of where gaps need to be addressed.

The guidance has 4 simple Read Codes (The explanation of Read Codes can be found here)

If Diabetes Structured Education Providers can ensure that they let Primary Care practices know these codes further to their referral then this can be entered into the patient record and then captured through the annual National Diabetes Audit. Simple.

I know that little bit of guidance won’t change the world.  It is such a very small thing.  But it is a baby step in the right direction.

Beyond Money

I’ve not said this before but I should say that all opinions in my blogs are my own.  For some reason I particularly feel obliged to say this before I go on and write.  I welcome challenge to my thoughts.  It is where I get my learning from.  The NHS is so big and complex that no individual person can possibly have a completely confident overview and for a middle manager like me that is certainly true.

So with my disclaimer said, I will carry on.

As we continue to wait for more detail on the process to access the £40m announced in the NHS England Operating and Contracting Framework it is giving rise to some interesting observations.

We are expecting bids for be for the following 4 areas:

1.       improving uptake of structured education

2.       improving access to specialist inpatient support to reduce length of stay for people with diabetes

3.       improving access to a multi-disciplinary foot team for people with diabetic foot disease to reduce amputations

4.       improving the achievement of the NICE recommended treatment targets.

 But also potentially a 5th category will be included called:

5.       Enhancing Pathways

The expectation of the need to quickly mobilise to submit robust bids has given rise to lots of interesting discussion.

During one such discussion it was agreed that clinical time would be needed to support the implementation of the planned work should a bid be approved.  In response one of the group said: “You can give me £1million, £2million, £3million but we still will not have the capacity; the available staff or the trainees in the pipeline to implement the work and increase capacity”. 

It made me pause.

Has the NHS gone beyond money?  We may have money to give to diabetes, which is a wonderful and exciting opportunity at this time of austerity but are there the people out there with the right skills and training?  With the potential implications of Brexit; the removal of grants for student nurses and no significant rise in NHS funding are we likely to see a dramatic increase in the wider pool of clinicians currently available to us?

These are competitive bids.  There is potential that not everywhere will receive funding.  We know, for example, that we have shortages of nurses and podiatrists in general.  In proposals looking to hire staff, even in the short term, could we end up just pinching staff from each other potentially de-fleecing other departments or neighbouring services who did not win funding? 

There certainly is a weight of responsibility for those who will be reviewing and approving bids and although tricky to ascertain, it may be reviewers need to check that they are not robbing Peter to pay Paul.  Just a thought.

A bit like Sir David Attenborough, sitting in the jungle and observing interesting behaviours, I have also witnessed other phenomena arising from the funding bids.

I recently attended a meeting where GP diabetes leads were introducing themselves, for the first time, to their neighbouring GP diabetes leads.  It was delightful to see.  There was a huge richness and shared learning in the conversations had.

So maybe there is something else this funding provokes beyond just money.  Something just as valuable as pounds and pence.  The opportunity to review where services are at; across boundary discussions; galvanising shared learning and new relationships.

All of value - beyond money.

The Horse’s Mouth

We are all eagerly awaiting the NHS England bidding process for the diabetes transformation fund announced in the 2017-19 NHS Operational and Planning Guidance (page 22)

There is a huge amount of speculation and diabetes managers have been bombarded, since the announcement on the 22nd of September, with questions from providers, commissioners and businesses, about how to get their hands on some of the funding.

There are questions about who can bid; how much; how many bids can be submitted; what’s the evaluation process, etc, etc.

It is also believed that the bidding process will be one bite of the cherry.  That the funding bids will be for a portion of £80m across 2 years (£40m in 2017/18 and £40m in 2018/19).  That the bids will be the one and only opportunity.  However, this is probably incautious speculation. 

Much better to get information from the horse’s mouth.  So this week my action for Diabetes Managers is to sign up for the “Diabetes Programme E-Bulletin”.  It was formally called the “Diabetes Prevention Programme E-Bulletin” but now there is a national “Diabetes Treatment and Care Programme” it has expanded to include information on this as well.

Please follow this LINK to sign up.

This month’s bulletin has the following information regarding the bids which you may find helpful:

National Diabetes Treatment and Care Programme Update

• As announced in the 2017-19 Planning Guidance, NHS England will be launching a wider programme of investment to support the treatment and care of people who already have diabetes.
• CCGs and CCG-led partnerships will have the opportunity to bid for additional national funding of approximately £40m in 2017/18 to promote access to evidence based interventions which will improve:
• uptake of structured education;
• access to specialist inpatient support
• access to a multi-disciplinary foot team for people with diabetic foot disease; and
• the achievement of the NICE recommended treatment targets whilst driving down variation between CCGs.
• Using a Best Possible Value approach, the national team have reviewed the evidence base and identified key initiatives which will result in the highest return on investment in these four areas.

The bidding process

• The bidding process for the diabetes transformation fund will form part of a wider process alongside several other clinical priority areas, such as maternity, cancer and mental health.
• CCGs and CCG-led partnerships will be invited to submit bids including details of their current services for patients with diabetes and outline delivery plans for proposed new or expanded services/initiatives. The nature of who participates in the partnership, and the roles of each partner, will be for local determination.
• It is expected that the bidding documentation will be published during early November. This timeline should enable successful areas to be informed of their allocation ahead of the start of the 2017/18 financial year.

Ahead of the publication of bidding documentation, and throughout the bidding period, we will be holding webinars with the Clinical Network, Diabetes UK and CCG colleagues (dates to follow) to inform of progress, encourage feedback and respond to queries.

No doubt the official notification regarding the bid process will ensure that Diabetes Managers will be kept very busy in the weeks before Christmas but hopefully the effort put in will reap a nice post festive bonus for diabetes care.

WW2

Don’t worry I’m not about to start a history lesson.  In fact history is not my strongest subject, partly because I was too busy sending love notes to the cute boy in my history classes at school.  But I digress.

“Welcome Wave 2”

The Expressions of Interest for the National Diabetes Prevention Programme Wave Two sites have been submitted. 

The anecdotal evidence suggests  interest is very high and that there will be a healthy cohort of wave 2 sites ready to start work by the end of the year.

So here are some initial top tips from a Wave one site to Wave two sites.

1.       Get the LMC involved:

Primary care is stretched to breaking.  However, I haven’t met anyone in primary care who doesn’t feel frustrated that they will see patients on a daily basis that are at risk of diabetes and there is very little they can offer.  The Diabetes Prevention Programme is directly funded by NHS England. But the identification and referral of patients is not. CCGs need to identify ways to reduce workload for primary care and look for solutions for incentivisation and support.  Some of the Demonstrator sites and Wave one sites are coming up  with creative ideas, i.e. auto populated referrals; hiring of someone to identify and discuss risk and referral with patients; text messages, review of local enhanced diabetes services/agreements etc, etc

2.       CCGs don’t need do any “Contract Management” with the provider:

NHS England is funding the service provision and has hired the South, Central and West CSU to do the contract management. You might want to get someone from the South Central and West CSU at one of your first Steering Group meetings to share how this will work and what reports you will get locally

3.       Stakeholder Communication:   

Make sure you have regular steering group meetings that include, GPs, Diabetes specialists, Commissioners, Public Health – PHE and Local Authority, Diabetes UK, Biochemists, Communications, Service users and the Provider (once confirmed).  Remember that one size does not fit all.  Holding clinical Webinars might be useful.

4.       Lead Organisation:

There is not getting around it the project takes a minimum of 3 days a week project management time, probably irrespective of site size.  There is a lot to do.  It is also helpful to have a lead clinician.  The Lead Organisation needs to develop good relationships with all the partner organisations and the provider and be prepared to share learning.

5.       Sign up:

The Memorandum of Understanding (MOU) will need to be signed by the lead organisation and NHS England.  Although not a requirement, it is really helpful to get all partner organisations (CCG and LA) to have high level physical sign off on the MOU as well.

6.       Alignment with other programmes: 

It is important to identify any existing diabetes prevention programmes and consider alignment with NHS Healthcheck and weight management programmes.  NHS England can provide 2 very helpful documents one of which is published here:

7.       Champions:

Start working with CCGs about how to identify “Champion Practices” who would be willing to be early referrers.

8.       And Finally:

Don’t forget to subscribe to the NHS England Diabetes Prevention Programme newsletter:  ndpp.england@nhs.net

We know that the NHS Diabetes Prevention Programme is not the panacea.  We all eagerly await more information about the CCG Improvement & Assessment Framework, “Improvement Offer” which we know will include £40m for treatment and care for people with existing diabetes. 

Sticking with the theme I started with - we know we have a battle on our hands but we will know that we will have several things in our armoury to support the fight for improvement in diabetes.  

Don’t Lose Heart

Did anyone notice?  I had a bit of a Summer break but I am now back on the blogging wagon.  And certainly the world did not stop while I was away.  There has been lots going on to keep us all on our toes.

The main news for my fellow diabetes managers was that on the 7th of September the CCG Assessment for the six clinical priority areas was published.  You can see how your CCG was rated here.

The CCG Improve and Assessment Framework (CCGIAF) was published on the 26th of March 2016.  The data to provide the 2015/16 CCGIAF ratings, is from the National Diabetes Audit (NDA) submission we all uploaded back in the Summer of 2015. We didn’t know that CCGIAF was on its way at that point so there is acknowledged acceptance that this year’s data is just a baseline.

Its worth pointing out that the data for the 2017/18 CCGIAF results was uploaded, through the National Diabetes Audit, in July & August this year.   Therefore, we may not see what change in the CCG ratings for diabetes in the CCGIAF results next year either.

But, if you are one of the 71% of CCGs in the country who are rated as “Needing Improvement”, don’t lose heart.

We had to start somewhere.  The point of having an “improvement” framework is that the indicators are something we are not good at now and can actually “improve” on.  It is meant to be something that we can get our teeth stuck into.

In fact, I am hoping that we are about to see an improvement as a direct result of the CCGIAF. I am extremely hopeful that the NDA participation rates nationwide will have dramatically improved.  I certainly hope so.  I know lots of people put a huge amount of effort into it.

Another reason to be cheerful is contained in the covering letter of the CCGIAF “Methodologies for initial baseline clinical ratings for dementia, diabetes, learning disabilities”

It says ; “ (Information on the improvement offers available to CCGs in the six clinical priority areas will also be made available on the NHS England pages in the coming weeks. A link to these offers will be published on the CCGIAF page (https://www.england.nhs.uk/commissioning/ccg-auth)”.   I love an “offer”.  I wonder what the “offer” will be?

It also goes on to say:

“ Other key elements in the diabetes treatment pathway include timely access to multidisciplinary footcare teams and specialist diabetes inpatient teams. Consideration will be given to the potential for reflecting local access to these services in ratings for future years”.  Diabetes Mangers are certainly going to be busy. 

And then, even more excitingly, this has then been followed up with the 2017-2019 NHS Operational Planning and Contracting document published on the 22nd of September.   Page 17 says:

·         Diabetes: The NHS Diabetes Prevention Programme will be scaled up in 2017/18 and 2018/19 in two further phases of expansion, with appropriate national funding to support this.  Additionally, we intend to launch a wider programme of investment in supporting the treatment and care of people who already have diabetes, for which CCGs will have the opportunity to bid for additional national funding of approximately £40m per year to promote access to evidence based interventions – improving uptake of structured education; improving access to specialist inpatient support and to a multi-disciplinary foot team for people with diabetic foot disease; and improving the achievement of the NICE recommended treatment targets whilst driving down variation between CCGs.

Ooooooooooooooo.  Did you spot it?  £40m. Now that’s something to make your ears prick up.

We need to get going with improvement so that when we upload data to the National Diabetes Audit in the Summer of 2017 we will see some change for 2018/19.  But we have been given some clear direction on where we should be heading and a few sweeteners are heading our way to help us move forward.  Don’t lose heart.  Get cracking. 

MyNHS - Waiting

I am naïve.  Writing a blog is hard work.  I have no idea how Roy Lilley, my favourite NHS blogger, does it every day.  I had no idea of the commitment needed to keep it up.  One of the issues is that my blog is a little bit niche.  Trying to find the time and something to say every week about Diabetes from a managers perspective, was always going to be tricky.

My saving grace is that diabetes is in the NHS Mandate, NHS Business Plan and Five Year Forward View.  Diabetes is high profile for the NHS and therefore, luckily, there is a plethora of stuff being churned out to provide rich fodder for me to try and understand and reflect back each week.

However, this week I am focused on what hasn’t been published rather than what has.

A bit of history.

The CCG Assurance Framework 2015/16 published on the 26th March 2015 announced that:

 “It is our intention to publish the CCG scorecard which will inform several of these components on MyNHS, through the NHS Choices website.  Our performance and delivery commitments will be described in relation to five population groups: the generally well, people with long term conditions, people with mental health problems or learning disabilities, children and young people, and the frail elderly, with an additional focus on planning.  The outcome measures in the scorecard will be derived from, and assessed in line with, the NHS Outcomes Framework. 

We will also publish a more detailed operational manual as well as technical guidance on the metrics used in the scorecard.  Key sources of information for assurance will be thoroughly scrutinised so that everyone has full confidence in the facts.”

The “CCG Scorecard” has now morphed into the “CCG Improvement and Assessment Framework” which includes six clinical priorities matching those set out in the Five Year Forward View.  One of these clinical priorities is diabetes. 

Considering there are only 2 indicators for each of the six clinical priorities the wording of the diabetes indicators certainly squeezes a lot in:

1.       Diabetes patients that have achieved all the NICE-recommended treatment targets: HbA1c<+58mmol/mol (7.5%), cholesterol<5mmol/L and blood pressure<+140/80mmHg and for children: HbA1c<=58mmol/mol (7.5%)

2.       The percentage of people with diabetes diagnosed for less than one year who have a record of attendance at a structured education course.

Look at the technical guidance.  It relies on participation in the National Diabetes Audit and also the indicators, rightly, include adults and children which in some respects have different needs, funding, services, etc, etc.  Certainly lots to get ones teeth in to.

So, as promised back in March 2015 we now have the Operational Manual and the Technical Guidance and, as of last Monday the 25th of July we have the performance against the 2 diabetes indicators on MyNHS.  Click on the link.  Have a look.

MyNHS: “enables users easily to see how their local health and care services compares to similar services round the country”. 

Putting the information on MyNHS is deliberately to demonstrate transparency to the public although, at the moment, you can tell whether the percentages published for each CCG on each indicator or considered good or not.

So are you wondering what hasn’t been published? 

Well, by the end of June, we were meant to have had CCGs performance ranked by each of the six clinical areas.  However, there has been a delay.  According to the Health Service Journal (27th of July) there are wrangles about how the ratings should be described (good, bad, ugly, etc) and also whether the information being collected on performance for these indicators are really reflective of a CCG’s performance in these clinical areas.

I can understand it.  Diabetes is complicated.  Care is delivered across so many NHS departments.  Distilling a rating for “better care” just in to 2 indicators must be tricky if neigh on impossible.  The indicators also needed to be an area that needed improvement and therefore, by its nature, will not look good initially.  It will be in 5 years time when people can really make a judgement.  Not now.

I can imagine the public wondering why their CCG is looking poor for diabetes.  You can imagine CCGs wondering whether those 2 indicators can really provide an assessment of diabetes care.  

Some heads have rolled after the announcement of 26 CCGs being classed as “Inadequate” further to the publication of the CCG Assurance Annual Assessment 2015/16 last week.  Such tricky stuff.  No wonder people are in knots.  No wonder there is a delay.

However, you have to start somewhere.  This is all new.  Anything new has teething problems.  I see it as a huge opportunity to keep diabetes very much on the NHS radar and I think the 2 indicators selected for diabetes are a really good starting point and certainly key areas for improvement.

Plus………………………………………………….. it gives me something to write about.

The skinny bell curve

One size does not fit all.

We know that it is the combination of achieving the 3 treatment targets that has the best benefit for people with diabetes. Achieving the combination will keep people with diabetes healthier for longer and reduce complications.

This is why the 3 treatment targets are one of the two diabetes indicators in the CCG Improvement and Outcomes Framework that was published on the 31st of March.

“Diabetes patients that have achieved all the NICE-recommended treatment targets: Three (HbA1C, cholesterol and blood pressure) for adults and one (HbA1C) for children.”

As a manager, I am getting perilously close to talking about things that are for trained clinicians.  However, it is important that managers have a rudimentary understanding in order to have a reasonable level of conversation with clinicians.

What is imperative to tackling this CCGIAF indicator is the absolute necessity for clinicians and managers to unpack, understand what this indicator is trying to achieve.

What this discussion will reveal is that that everyone is different.  What treatment targets might be right for one might not be right for another. NICE Guidance and CCGIAF indicators cannot possibly accommodate the richness of the individual.

NICE Guidance is very clear that the first consideration is: “1.1 Individualised Care”.  The first sentence in the guidance states:

“Adopt an individualised approach to diabetes care that is tailored to the needs and circumstances of adults with type 2 diabetes, taking into account their personal preferences, comorbidities, risks from polypharmacy, and their ability to benefit from long‑term interventions because of reduced life expectancy.”

In particular, if this indicator is not discussed robustly there is the potential of misunderstanding what needs to be achieved.   Driving people’s treatment targets down en-masse without considering the individualised needs will have detrimental affects.

In particular, treatment targets may need to be varied for older people with diabetes.

The International Diabetes Federation Guidance for older people with type 2 diabetes is very clear (Page 31):

The different HbA1C treatment targets recognise the different, individualised needs of older people with diabetes in particular to prevent hypoglycaemia.

Okay, okay.  I’ll shut up now.  I am out of my depth.  My point is that discussion with you clinical teams is imperative.  It will show that what is required is the narrowing of the bell curve.  A subtle but important distinction to ensure the indicator improves care and outcomes rather than worsen them.

I love a plan

You might want to stop reading my blog for a while (please don’t!).  I am definitely in danger of boring you to tears with banging on about the Diabetes Aide Memoire.  I have one in my bag at all times. It’s because I’m excited about it.  

Personally I love a plan. 

I might be alone -  but for me, the last 3 years, since April 2013, have been “The Wilderness Years”.  There has been a sense of anarchy, tearing up the rule book.  It has felt like the NHS has become a frontier town.  Yes, there has been a sense of excitement, mania, creativity.  But also a sense of lawlessness and chaos. 

In April 2013, we were told it was all about local ownership, local decisions.  Decide your priorities based on local intelligence and in consultation with local people.  We had a pick list of things that CCGs could look at called the CCG Outcomes Indicator Set to help choose priorities and track improvement.  Local things for local people.  It was a good philosophy and one that must never be lost. 

However, I found it difficult to work out:

1)      Who was focused on what?

2)      The rationale for selection?

3)      How to galvanise across boundary approach when we are all doing different things?

It was difficult to understand whether things were improving.  I’d be at meetings hearing some good shared practice but be thinking, that’s nice but that’s not what we are working on locally.

It was difficult to get the collective transformational push at “pace and scale” that the national rhetoric is increasingly shouting about.

So I love the STP “Diabetes Aide Memoire”.  It is one of the 6 “Aides” for the 6 clinical areas of focus in the CCG Improvement and Assessment Framework.  The 6 clinical areas were picked as the areas that could provide the most impactful, transformational change.

It’s only 2 pages long. Love it.

It’s not to replace locally identified needs and locally developed solutions.  Please don’t let that be the unintended consequence but it does provide some areas where we can have a collective approach, across boundaries and push together.

So this week I want to set you all a little task.  Share the Diabetes Aide Memoire widely.  Keep one in your bag.  Whip it out and quote at meetings. Hand out copies to your next Network, Board, PLT, etc meetings and ask how the objectives are going to be tackled.  Get some ideas.

Does Size Matter?

This week I went to the beautiful Taunton to join in a meeting about preparation for Wave 2 of the Healthier You NHS Diabetes Prevention Programme.  It is anticipated by the end of 2018/19 that the whole of the country will have access to the Programme. 

One of the key questions for Wave 2 and Wave 3 sites will be: What is the optimal programme size?

The Five Year Forward Vision ambition is that: “Support delivery of the STP process which states that by 2020 local health economies should have developed comprehensive strategies to tackle obesity and diabetes prevention locally, with the aim of referring 500 people per 100,000 population annually to an evidence based Type 2 diabetes prevention programme.”

The word “referring” is important because a referral does not mean that the referred person will actually turn up at the course.  The way the person is referred will impact on the chances of attendance.  For example, we already know from the “Demonstrator Sites”, that a mailshot to patients identified as “at risk” and asking them to call to book a place has a lower uptake rate than referral further to a one to one discussion with the local GP practice.

Wave one sites are providing the opportunity to test the “Optimal” programme size.  Some Wave one NDPP sites have less than 200,000 population and the biggest site (South East) has a catchment size of 4,628,531!

Let’s be optimistic.  Let say that for every person referred 50% turn up.  That would mean that if programme catchment area was 100,000 population you would see 250 people attend courses.  That would mean 17 courses (or 15 people her course) per year when the programme was fully up and running.  It’s not enough.  That’s 1 course every 3 weeks that has to be sited somewhere convenient and accommodate any special needs, hearing loops, wheel chair access, interpreters, etc. To get good availability and convenience you need to go bigger.

The South East has the biggest catchment for a Wave One site.  The population is 4,628,531 and covers 3 counties across 20 CCGs and 6 local authorities.  Based on 50% attendance that would mean 767 courses were needed per year.  There is less pressure to have the programme delivering lots of referrals from the start of the programme to ensure that enough courses can be filled and a lot more courses offered to provide a variety of places.  However, the South East site is very big geographically.  You can imagine, trying to match course location to where referrals will be popping up from, particularly in the early days, will be extremely tricky.

So what is too big, what is too small and what is just right?  Are STP Footprints just the right size?

Well again, STP Footprints cover a population size of 300,000 in West, North & East Cumbria to 2,800,000 in Greater Manchester. 

Size is important.  But maybe equally important is who is going to lead and coordinate the implementation of the programme?  STP Footprints are definitely an appealing option but they will need some infrastructure and a project lead identified to lead the work.

So 2 key questions to consider for future sites for the Diabetes Prevention Programme:

1)      Think size

2)      Think lead coordination

Oh – and don’t forget to check that diabetes prevention is definitely in your STP plans. 

Certainty in Uncertainty

Mathematics is not my strongest skill.  I find NHS finance and incentives extremely complicated.  The following paragraph will confirm my ignorance and make NHS finance gurus laugh.

We have GMS/PMS/APMS Contracts, DES, QOF and Locally Commissioned/Enhanced/Integrated Service Agreements.  We have Standard Contracts/Block Contracts/Lead Provider Contracts.  There is PBR, BPT, Quality Premiums, CQUINS.  We have various pots of funds for Pilot, Vanguard, Demonstrator, Test beds, Innovation sites and the lately the Sustainability and Transformation Fund access through the STP Planning process.  What a lot of acronyms!  (Please note I have worked hard to put links to help describe them all!)

I can’t pretend for a minute I understand it all.  I do try because I am always trying to spot funding that could be capitalised on to support diabetes.

To add the complexity of funding flows through the enormous NHS organisation.  We now can add uncertainty.

Simon Stevens could not have been clearer in his interview with Andrew Marr prior to the country’s decision to leave the European Union. He made clear that the uncertainty of leaving the EU would create uncertainty for the NHS.   

Only time will tell.  I’ll admit I am not great with uncertainty.  I felt things were just beginning to come together after all the cards were thrown in the air further to the Langsley debacle in April 2013.  In particular I like the “Diabetes Aide Memoire” to support Sustainability and Transformation Planning.  I like how, in 2 pages, we have a clear job list that we can work on together, collaboratively.

No one will be more delighted, when I am laughed at for being a worry-pot this time next year.  But I am concerned.  I am concerned about whether the funding required to underpin the improvement work outlined in the “Diabetes Aide Memoire” is still going to be available come April 2017 and beyond.

However, in a time of uncertainty let me give you some certainty.

Unless obesity rates decline, physical activity rates increase and the diabetes prevention programme succeeds, then the 3.2million people with diabetes in the UK, will rise to 5million by 2025 and the current 10% of the NHS budget will need to rise to 17% by 2035. 

The other thing I am certain about is the commitment of all NHS staff.

Diabetes Managers – We Need You

I get this type of phone call from a manager every week:

“Hello, my colleague suggested I call you.  I’m on a short term contract and have been asked to cover diabetes.  I haven’t been given much of a hand over”.

I’m thinking:  “Crikey.  The last manager didn’t last long”.

“I’ve never done diabetes before.  I need to know how many Type 1 diabetes cases will be avoided by the diabetes prevention programme for the business plan I am writing”.

I’m thinking: “Oh dear!!”

“I cover Long Term Conditions and Cancer.”

I’m thinking: “Well no wonder you don’t know the difference between Type 1 and Type 2 diabetes when you covering so many conditions”.

Diabetes affects people from head (retinopathy) to toe (neuropathy).  People with diabetes account for at least 17% of all hospital beds.  Diabetes cuts across and impacts every patient pathway and care is commissioned from social care; to public health; to primary care; to community care to hospital care.  It is a complicated condition.  It is complicated to commission.

In England there are 209 CCGs (too many in some areas, if you ask me, but I’m hoping STPs will sort this out).  Each CCG has a manager who supports a CCG GP Lead for diabetes.  The turnover of CCG GP and Manager Diabetes Leads seems excessive and sometimes a change of person leads to planning, rather than getting on with implementation, starting all over again.

CCGs hold a third of the £76bn of the NHS budget and we know that at least 10% is spent on diabetes.

Yet many managers are being asked to squeeze diabetes in on top of a myriad of other conditions that they have to provide management support for.

Managers like everyone in the NHS are extremely busy.  They go from a meeting about cancer straight into a meeting about diabetes.  It doesn’t matter how much support, simplification, tools that are provided - there are only so many hours in a day. 

We now have a “Diabetes Aide Memoire” to support the Sustainability and Transformation Planning process.  For a document that is only 2 pages long there is a lot to achieve.  We need management capacity to support the team/network/STP approach to getting it right.

Given the lack of management capacity to support diabetes care.  I am constantly in awe of how much managers, as part of a team, achieve.  But more management support, particularly to support “the doing” rather than just the planning, are needed to make the seismic shift in preventing diabetes and preventing the complications of diabetes.

The Right Honourable Stephen Dorrell, in his opening address last week at the NHS Confederation Conference said:

 “It is important to begin this conference by restating yet again the vital role played in by the management community.  Managers are not a cost born by the healthcare team, they are part of the team an indispensable part of the team and part of its success “.

Managers are needed.  More management support for team/network approaches to diabetes improvement is needed.  Managers working in diabetes are amazing.

A Broken Record

Anyone who knows me will probably be rolling their eyes at this blog.  Not this again!   Honestly can she not have a conversation without asking how things are going in planning and supporting this year’s participation in the National Diabetes Audit.  She’s like a broken record!

I hope they are saying this.  I hope it is with an indulgent smile.

So this year’s audit upload period has arrived.  From the 20th of June to the 12th of August CCGs will be working hard to support their practices to upload information to the National Diabetes Audit.

There is lots of easy to read information on what practices have to do on the NDA website.

From what practices tell me, it takes about 10 – 20 minutes to participate and this year the process has been made much easier for practices using Vision.

I get questions from CCGs and Practices about “consent”.   A letter that went out to all practices in May makes the position very clear – “The NDA has approval from the Health Research Authority Confidentiality Advisory Group, to collect patient identifiable data under Section 251."; “This means there are no legal obstacles to services participating in the NDA”.  Therefore patients do not have to be individually consented but posters should be placed in surgeries and these can be downloaded from the NDA website.

Anyone can see which practices uploaded data for last year’s audit by looking at the CVD Primary Intelligence Packs produced by the National Cardiovascular Intelligence Network.
The NDA provides an essential overview of diabetes care in England and enables high quality commissioning.  if we didn't have it we'd all end up trying to invent it.  Diabetes is one of the six priority clinical areas of the CCG Improvement and Assessment Framework (CCG IAF) and CCGs with less than 25% GP practice participation will be categorised as ‘greatest need for improvement’ due to an inability to make a reliable assessment.

I was talking to a CCG who has had 100% participation for the last 2 years.  They were excitedly telling me how impactful and helpful having robust data was to their local diabetes improvement plans but until then had not realised the value. 

I am really looking forward to having this conversation with more CCGs and Health Care Professionals.  This audit and all the tools are funded. It is so valuable. So go for it. 

Diabetes Networks – I shouldn’t have given up

I am realising that writing a blog is an opportunity for self-reflection.

In Diabetes UK’s publication: “Improving the Delivery of Adult Diabetes Care Through Integration” it says, “The need to join up health services to centre around patients rather than the needs of the system is increasingly recognised in national policy.” 

The key enabler for supporting an “integrated” approach to diabetes care is through robust Diabetes Networks.  A clinically led diabetes network, involving people with diabetes, provides the means to integrate care, improve clinical outcomes, cost-effective services, improved patient experience, and equity of service provision.

I absolutely fundamentally believe this.  And there is a plethora of documents, evidence, policies, and guides, to support this belief.

In 2004, one of my tasks as South East Regional Manager for the National Diabetes Support Team (later to become NHS Diabetes and disbanded in April 2013) was to support the development of Diabetes Networks.

The “The National Diabetes Service Framework Delivery Strategy” (2003) definition of: “An effective network should cover ‘a natural population’ – usually determined by the population served by a specialist diabetes service based within an NHS trust".  I’d like to see a map of how many diabetes networks there are in the UK that meet that definition and with the name of the managerial and clinical lead.  Very, very few I suspect.

I believe in the necessity and the power of Diabetes Networks to support integrated diabetes care and yet why have I stopped trying to support, cajole, thump the table to encourage more Diabetes Networks being developed?  Why did I give up?

Some of the reasons, off the top of my head:

·       No one else seems bothered.  No one seems that interested in talking about diabetes networks.  I speak to a lot of Trusts and CCGs each week, not a single one has initiated a conversation about starting a Diabetes Network to support integrated care.  Some have CCG based groups – not the same I’m afraid.

·        Who pays for the Network support?  As there is often more than 1 CCG, a hospital trust, may be a community trust and other organisations that are all part of the network then it is in the interest of everyone to support a network but can you imagine how many board papers have to be written to get agreements through all these different NHS/PH organisations for them to toss it in few quid each to make it happen.  I know a “few quid” is easy for me to say.  Getting any funding for anything is extremely difficult but it is a “few quid” in comparison to 10% of the NHS budget spent on diabetes.

·        Diabetes networks are difficult to pin down.  I’ve had the most ridiculous conversations about what office and computer a Diabetes Network Manager would sit at, if they aren’t really “owned” by any one organisation. 

·        Shouldn’t it be a local CVD Network? – maybe, in a utopian world but going to a CVD Network meeting can be extremely long and I found that those interested in Renal walked out when the diabetes stuff was discussed and then those interested in cardiology walked in only when their agenda items were on.  Unless it is a network built around mutual interest it just won’t work.   However, that is not to say, that a Diabetes Network should not strongly interlink with other pathways and networks.

·       Diabetes Networks are not like Cardiac, Stroke and Cancer Networks.  No they are not. There should be more of them because; barring Vascular hubs (non arterial centres) Diabetes Networks should be centred on the local patient pathway.  For example the county of Kent should have 4 diabetes networks by the NSF definition.

·       Diabetes Networks also stumble across the same issues as all changes to models of care, namely, money flows, PBR, contracting, mandate, IT integration.

Whatever the reason, I sniff change in the wind.  There may be a new opportunity to get back to Diabetes Networks as the conduit for radical and robust transformation of integrated diabetes care – Sustainability and Transformation Plans (STPs) or 5 Year Forward View Plans (5YFV plans).

Now I might be wrong but when I am reading information about the STPs it says things like:  “health and care organisations within these geographic footprints are working together to develop STPs” and “footprints should be locally defined, based on natural communities, existing working relationships, patient flows” and “STPs footprints are not statutory bodies, but collective discussion forums which aim to bring health and care leaders to support the delivery of improved health and care based on the needs of the local populations.  They do not replace existing local bodies or change local accountabilities”.  Well you could be reading the very good guide from Diabetes UK on “How to: Delivery a successful local network”.  If we are developing an environment that supports STP principles, which are so akin to the principles of Diabetes Networks then surely there is a much bigger hope for Diabetes Networks to be understood and supported?

I shouldn’t have given up.   My Diabetes Week resolution is to capitalise on the opportunity that the “footprint” or “Network” approach to STPs has presented to bang the drum for establishing a networked, integrated approach to robust and safe transformation of diabetes care.