Hooray for the NDA

Before you read this I should admit that I am completely biased.  I think the National Diabetes Audit (NDA) is fantastic.  I’m not sure anyone could persuade me otherwise.  I believe that this is the 12th year.  That’s impressive.
“The National Diabetes Audit (NDA) is the largest annual clinical audit in the world”
We are incredibly lucky.
Unlike QOF, which was designed as a financial reward mechanism, the NDA integrates data from both primary and secondary care sources, making a comprehensive audit across the patient pathway.
This year’s audit upload period is between the 20th June to 29th July 2016. 
In 2015, The NDA moved to an opt-in model to allow practices more control on what happens to their data.   It requires about 20 minutes to upload the data in each practice once a year.  Please don’t throw tomatoes at me.  I know Practices are so overwhelmed that even 20 minutes feels like a big ask.  Therefore, it is really important that CCG diabetes leads, communicate and support NDA participation. 

I don’t think the NDA should be mandated but let me see if I can give you some important reasons to make the effort:

1)      The NDA data supports ensuring that your locally defined diabetes pathway is sustaining and hopefully improving outcomes

2)      It helps to monitor the impact of any changes to your diabetes model of care on patient outcomes

3)      Include participation in your local enhanced service agreements to demonstrate the impact of investment on patient outcomes

4)      The NDA is used to support the Right Care Diabetes pathway and Atlases of Variation

More information and lots of support for CCGs and Practices can be found on the NDA website.

This year there is one more reason to encourage and support participation. 

The CCG Improvement and Outcomes Framework was published on the 31st of March and the Technical Guidance was published last week.  It clearly states that the source for the 2 diabetes indicators will be the National Diabetes Audit and that any CCG that has less than 25% of practice participation will be automatically placed on the lowest rating for diabetes.   The performance against the 60 indicators will be published at the end of this month and will use the NDA data submitted last year (2014/15) so you can already see how your local CCG will fare.  However, the performance for next year, 2017, will be collected in this month’s NDA upload period. 

Have I persuaded you?

Working with Industry – I’m an advocate – Maybe

I am an advocate of working with industry.

When I worked in the NHS I did not work with industry.  Frankly I was intimidated.  They had posh cars and smart suits.  In the office, if someone from the NHS went to work for industry they would say they had gone to the “dark side”.  Reps would use words I didn’t understand.  “Hello, I’m part of the Market Access Team and I would like to show you some slides (on my very modern looking tablet) about our value proposition”.  Ummmmmm.  No idea what you just said but I’m pretty sure you are trying to and pull the wool over my eyes.  Plus I’m a manager; I am definitely not allowed to be near a prescription pad so why do you want to talk to me?

I then worked for a pharmaceutical company for 2 years on their diabetes portfolio. 

I loved it.  What a brilliant experience to see the NHS from the outside. I learnt a huge amount.  I learnt how to work with industry.

In fact if you want to work in the pharmaceutical industry you have to take an examination in the Associate of British Pharmaceutical Industry (ABPI) Code of Practice.  Here’s my certificate. 

I’m proud of it.  It was hard work.  There were 4 components: Code of Practice; Human Body Systems; Development of Use of Medicines and a condition area of the students choosing – guess what mine was!

Yes there are people in industry whose integrity I would question but when a surgeon in the NHS tells me that he wants a long waiting list because then he sees more people in his private clinic - well I guess you get all sorts in any organisation.
The ABPI, in an effort to continue to improve the reputation of the pharmaceutical industry, will also be launching a central portal for the “Public disclosure of transfers of value to healthcare professionals and healthcare organisations” on the 30th of June 2016.

It is also worth noting that the medical technology companies have a different Association of British Healthcare Industries Code of Conduct.  Hence why on a stand with blood glucose monitors, you can grab up some post it notes and pens which you can no longer stock up on from Pharmaceutical company stands.

My favourite example of working with industry was a Cardiac Network I worked with.  The manger would agree the next actions at the Network meeting then meet with a “Network Industry Group” directly after.  The manager would share what the Cardiac Network wanted to achieve; ask industry what they could potentially help with and then walk out and let the group discuss what they might be able to offer.  It was open, it was transparent and it was inclusive not exclusive.  It also saved that manager a lot of time in seeing reps individually (Yes. I know.  Not everyone in industry is a “Rep” (A Sales Representative) but the variety of industry job titles makes it very difficult to make any distinction).

However, working with a collaborative industry group is getting harder.  Increasingly Medical and Educational Grants (MEGs) are being discouraged in preference for a legally binding “Joint Partnership Agreements” to support projects. Getting a “Joint Partnership Agreement” with several companies is a, form filling, nightmare.  Personally, particularly in diabetes, I wouldn’t want an exclusive relationship with one company.  Industry, understandably, are fed up of being seen as a “cash cow”, particularly as budgets get tighter.  They want to be seen as partners that can offer expertise, project manager support, data support, etc.  They want a “win win”. They are also extremely weary of any accusation of bribery.  Therefore the ABPI rules have got much more stringent. Almost to the point of the ridiculous.  I recently was involved in organising a conference at a rather run down, but good value, manor house. However, at the last minute industry were not sure they could provide sponsorship because there was an outdoor pool, and therefore could be considered a spa venue which is not allowable by the ABPI code.  The pool was, frankly, was more like a pond and was used to wash the owner’s dog.  Certainly, I wasn’t going to get my swimming costume out!

A few years back the Department of Health and the ABPI did produce a tool kit to try and get better “Joint working” with industry but the rules of engagement to enable “safely” working with industry are getting more complicated.  After all, I very much doubt many NHS managers have done an exam or any training on how to work with industry?  In fact, I think most of managers would struggle to find their local organisation industry policy?

Actually working with industry is a lot of work hard and I think, while writing this I have changed my mind.  I am an advocate of working with industry they have a lot to offer but the complexity of the rules of engagement on both sides can ultimately lead to confusion, a lot of paperwork and ample opportunity for misunderstandings that can ruin relationships.

Brick Dust

I used to work for a company who produced and sold a very popular blood thinning drug.  At the time there was a sudden flood of counterfeit product which had mixed in brick dust! Horrifying!  A lifesaving drug, padded out with brick dust. I don’t think anyone would question that perhaps the patient getting the counterfeit drug may not be getting optimal treatment.

The NICE Diabetes Quality Standards, Statement 2 says:

“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.” 

The NICE criteria for structured education has 6 of components/ingredients:

1.       It is evidence‑based, and suits the needs of the person.

2.       It has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self‑manage diabetes.

3.       It has a structured curriculum that is theory‑driven, evidence‑based and resource‑effective, has supporting materials, and is written down.

4.       It is delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the person, and who are trained and competent to deliver the principles and content of the programme.

5.       It is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency.

6.       The outcomes are audited regularly.

NICE “Technology appraisals” are recommendations on the use of new and existing medicines and treatments within the NHS.  Structured education is a NICE technology appraisal recommendation. It is a treatment.  It is a very important part of diabetes care.  Like with a drug, nationally available structured education programmes such as, DAFNE, DESMOND and XPERT have been through rigorous Randomised Controlled Trials (RTC) to evidence that the ‘treatment’ improves patient outcomes.

The CCG Improvement and Outcomes Framework challenges us to significantly increase the attendance of people attending structured education. 

Denying that commissioners aren’t struggling with balancing the books would be like denying that Jeremy Hunt is having trouble over the Junior Doctor contract.

There might be a massive temptation to dilute the content/ingredients of structured education.  Is there a utilitarian argument that by diluting we could do the greatest good for the greatest number of people?  After all, it is a treatment, like a pill. And some pills, for some people, are hard to swallow.  Certainly for those that cannot swallow the treatment we should do our best to offer an alternative option but surely you would first offer the best recommended treatment?  Surely you would offer structured education that meets the NICE criteria.

Otherwise might we be offering – brick dust?

Diabetes Prevention – Such Fun

I’m not being sarcastic.

I am having such a good time.  I’m not saying it’s not hard work but as a manager I love getting my teeth stuck into something and the NHS Diabetes Prevention Programme (NDPP) certainly provides that.

The NDPP is the first Diabetes Prevention programme to be rolled out at national scale in the world!

The aim is to provide a behavioural intervention which delays or prevents people in England, who are at high risk, of getting type 2 diabetes.  

There is a lot of scepticism. 

A significant number of people at risk of diabetes feel well; are working age and are juggling families and aging parents.  An, intervention that is at least a nine month commitment, with a minimum of 13 education and exercise sessions of one to two hours per session; mostly in groups – may not be that appealing.

After all if only under 10% of people, who have already been diagnosed with diabetes attend patient education, (see earlier blog) then are people going to attend who have not been diagnosed with a condition? 

However, currently there are nearly 6 million people at risk of diabetes in England (a prevalence of 11.2%).  There is an expectation that 100,000 people per year will go through the programme by 2020 which is (and I’m stretching my mathematical ability here, so shout if I’m wrong) only about 1.7% of the at risk population.  Put like that it sounds more achievable?

Some helpful things for managers to know are:

·       The NDPP behavioral intervention is being commissioned and funded directly by NHS England (Yes – that is unusual. Normally NHS England only directly commission things like specialist services and prisons).

·        Four organisations have been invited to join the national framework; Reed Momenta; Pulse Healthcare Limited trading as ICS Health and Wellbeing; Health Exchange CIC and Ingeus UK Limited; and the contract management has been awarded to South Coast and Western Commissioning Support Unit.

·        You can see your local prevalence in the recently published, National Cardiovascular Intelligence Network (NCVIN) CVD: Primary care Intelligence packs.

·        It is for CCGs/LAs to work locally to provide the support, incentives, funding to primary care to help identify and refer to the programme.  The letter on the 16th of February providing CCGs with more information on the content for local Sustainability and Transformation Plans says:

“as a minimum, we expect that all plans will: describe a local cross-partner prevention plan, with particular action on national priorities of obesity and diabetes” and that “access to sustainability and transformation funding will be linked to successful STP work”. 

When I speak to any primary care clinicians they all see, nearly every day, someone who is overweight; has familial history of diabetes; had gestational diabetes; etc, and find it difficult because they have little they can offer to divert the potential progression to diabetes. 

But we have something now.

Yes it is going to be a huge challenge but with 700 people a day receiving the life changing diagnosis of diabetes - haven’t we got to try?

As a manager I love a challenge and I am certainly going to enjoy supporting this one.

Diabetes Patient Education – A moral imperative?

The NICE Diabetes Quality Standards, “defines clinical best practice”.   Statement 2 of the 15 NICE Diabetes Quality Standards says:

“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.”  The guidance goes into detail about what “structured” means.

On average people with diabetes spend only 3 hours with a healthcare professional per year.  The rest of the 8,757 hours per year (or 8,781 hours per leap year) people are managing their condition for themselves.

Diabetes prevalence has increased by nearly 60% in the past 10 years and potentially this trend will continue at an alarming rate. I can only imagine that the time that people spend with a health care professional will go down?

Are we missing a trick?  At a time when resources are stretched it is a crashing shame not to harness our most under used and powerful resource – the person or carer themselves.

There are 57 new indicators in the CCG Improvement and Assessment Framework

One of the 57 reads: “Number of people with diabetes diagnosed less than a year who attend a structured education course”

Look again.  It says “attend”.  That’s a big deal. 

It’s not a coincidence that, with the introduction of 11 QOF points to refer patients to education, there was an enormous leap in referrals from 15.9% in 2012/13 to 75.8% in 2014/15.  However, despite a dramatic upturn in referrals, only 5.9% of people with Type 2 diabetes and 1.9% of people with Type 1 diabetes “attended” patient education. (National Diabetes Audit 2014-2015)

That’s a bit dispiriting for providers working hard to run courses.  We know that more people attend education than is being reported.  So what’s going on?  I’ll tell you where I think we should start.  Look at how we get data on “attendance” into GP clinical systems.  If that data isn’t being captured; then it is not being submitted annually to the National Diabetes Audit and your CCG IAF is indicator is not going to improve.

However, even if we get the data capture right and we double or treble recorded attendance at structured education we still have a mountain to climb.  Having this as a CCG IAF indicator will certainly focus the mind.

But more importantly, we know that people with diabetes are likely to spend less time with a healthcare professional in the future.  Surely we should be ensuring that we tool people with diabetes and their carers with quality education and information to support themselves.  I would go as far to say it may be a moral imperative.

Don't say I didn't warn you!

The CCG Improvement and Outcomes Framework was published on the 31st of March.

The stated goal is: “to bring clarity, simplicity and balance to the conversation between NHS England and CCGs about what matters to both sides”.  (I thought we were all on the same “side”?)

Two of the set indicators are focused on diabetes.

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

·        People with diabetes diagnosed less than a year who attend a structured education course”

 (NB: “attended” – structured education – not “referred” – more in tomorrow's blog)

The most important thing to know is that it is expected that the data source for the assessment of the CCG performance on these indicators is the NATIONAL DIABETES AUDIT

The initial assessment in expected in June (although the HSJ is speculating that this may be delayed).  You can already see how your CCG will look for these two indicators by going to the NDA website.  I can tell you…………. It won’t look pretty.

The NDA last year changed into an opt-in audit so national participation dropped to 57%.  The participation, by CCG, varied between 3% to 100%. 

I wonder what will be done about assessing those with as little as 3% data?

The next upload period for the National Diabetes Audit is expected to start in June 2016.  It requires each Primary care practice to opt in and submit data once a year and takes approximately 20 minutes depending on your clinical system.

There are loads of reasons to ensure robust participation in the NDA but the CCGIAF may be another really good one.

June is next month!   It only happens once a year.  Communicate, prepare and support your practices to participate in the National Diabetes Audit. 

Don't say I didn't warn you.

What I call – “The Black Market”

Local Enhanced Services, Locally Commissioned Services, Local Integrated Service Agreements for diabetes.  Whatever we call them, these agreements are being taken up with gusto by primary care services who wish to support patients with diabetes to be managed in their local surgery rather than having patients traipse into their local hospital (with a tariff charge for each appointment). 

Do we know how much CCGs spend to fund primary care to take on more advanced levels of diabetes care for patients above and beyond what is funded in their standard contract/QOF?

The answer is no. 

In fact, generally CCGs next door to each other probably don’t know the content of their local service agreement or the payment.  It tends to be a closely guarded secret – what I call “The Black Market”.  You can imagine the potential fall out if GPs at the neighbouring CCG find out that they are being paid less for a very similar service.

I often get asked what should be in a good LES/LCS/LIS and it’s difficult to share examples, because, as I said, they are a closely guarded secret.

However, there are two things that I do ask CCG diabetes leads:

·         How do you know whether the local payment is sustaining or improving patient outcomes?  

·         Where do you advertise your local, structured, primary care diabetes healthcare professional (GP, Practice Nurse, Health Care Assistant) education annual programme?

Without these two things how can you be sure that the additional funding is making the blindest bit of difference to patient outcomes and is in fact safe and not detrimental to patient outcomes?  You don’t.

So make sure that all local agreements include:

·         Thou shalt submit data to the National Diabetes Audit once a year

·         Thou shalt evidence attendance at quality diabetes healthcare professional education

Oh, and how about a robust Local Diabetes Clinical Network to support monitoring and suggesting tweaks to support continuous improvement? 

I will be coming back to these points in later blogs.  Here endth the lesson for now.

Why all the fuss?

An NHS manager recently said "I am fed up of talking about diabetes". 

Certainly diabetes and diabetes prevention are hot topics in healthcare at the moment and why shouldn't it be?

There are currently 3.9 million people with diabetes (6.2% of the country).  700 people are diagnosed with the condition every single day and 590,000 have diabetes but don't know it yet. 12% of the country are at risk high of diabetes.

Diabetes is responsible for:

• 20,000 premature deaths
• 1/5th of hospital admissions for heart failure, heart attacks and strokes
• 135 amputations per week
• Most common cause of kidney failure

Diabetes accounts for around 10% of the annual NHS budget.  This is nearly £10 billion a year or £1 million every hour.  Compare that with the cost of cancer £5.86 billion on cancer care, which is 5.6% of the UK’s total health spend. 

These figures are mostly taken from Diabetes UK "State of the Nation - Challenges for 2015 and beyond" which is a publication I strongly recommend.  The next update in due in July/August 2016.

https://www.diabetes.org.uk/About_us/What-we-say/Statistics/State-of-the-nation-challenges-for-2015-and-beyond/

A report published in the Journal Diabetic Medicine has projected that the NHS’s annual spending on diabetes in the UK will increase from "£9.8 billion to £16.9 billion over the next 25 years, a rise that means the NHS would be spending 17% of its entire budget on the condition".  Will NHS funding be increased to accommodate this? It doesn't look likely.

Below is one of my favourite charts from the Diabetes UK report.  It shows what great strides have been made to improve Coronary Heart Disease (CHD) and Strokes/Mini Strokes (TIAs) in particular.  However, the slide I would like to see is this data projected over the next 10 -20 years.  Will all the amazing achievements in these conditions get eroded by the increase burden of diabetes?

There are lot more reasons why diabetes is worth talking about as a diabetes manager. 

You might be fed up with talking about it, but diabetes isn't going away.  So get used to it. 

The Difference between Type 1 and Type 2 Diabetes - For Managers

Managers working in diabetes don't have to be gurus in diabetes but it is important for managers to know that Type 1 and Type 2 Diabetes are very different.  Sometimes I wish they were called something different so that commissioners did not lump them together.

"In type 1 diabetes, the body's immune system attacks and destroys the cells that produce insulin. As no insulin is produced, your glucose levels increase, which can seriously damage the body's organs.  If you're diagnosed with type 1 diabetes, you'll need insulin injections for the rest of your life. It usually develops before the age of 40, often during the teenage years.

Type 2 diabetes is where the body doesn't produce enough insulin, or the body's cells don't react to insulin. This is known as insulin resistance.
If you're diagnosed with type 2 diabetes, you may be able to control your symptoms simply by eating a healthy diet, exercising regularly, and monitoring your blood glucose levels.
However, as type 2 diabetes is a progressive condition, you may eventually need medication, usually in the form of tablets/injections."

http://www.nhs.uk/Conditions/Diabetes/Pages/Diabetes.aspx

For me, as a non clinician, the most useful things to know as a Manager are:

· It’s not you.  Commissioning Diabetes is complicated.  The pathway covers public health, prevention, primary care, community care, specialist care in DGHs and sometimes tertiary care (i.e. Islet transplants for type)

· In the UK, around 90% of all adults with diabetes have type 2

· You cannot prevent or delay type 1 diabetes (so the new NHS Diabetes Prevention Programme is for the prevention or delay of type 2 diabetes) https://www.england.nhs.uk/ourwork/qual-clin-lead/diabetes-prevention/

· A person with type 2 diabetes does not become a type 1 if they move on to insulin injections.

· Many commissioners are redesigning diabetes patient pathways so that patients can "safely" be discharged from secondary care services to primary care services. (Care Closer to Home).   In my personal opinion don't discharge your Type 1 patients.  The reason being that, type 1 only accounts for 10% of your diabetic population and is managed very differently.  Get your Type 2 diabetes patient pathway right first.  By right, I mean that the redesigned pathway has evidenced that patient outcomes have been at least sustained and hopefully improved.  Then you can get more ambitious and look at discharging stable type 1 diabetics.

There are many other things I could probably add (and please send me ideas and I can edit) but I hope this is a good starting point.

The Diabetes Manager

Welcome to "The Diabetes Manager".  This is my first ever attempt at a "blog".  IT savvy, I am not but I am trying to keep up with the kids.

This blog is for any managers working in diabetes, whether in the NHS, charity or private sectors - or anyone interested.

When asking my husband whether I should start a blog for managers working in diabetes, he said, "No. It would be boring".

And the truth is, he is probably right but I get really excited about how diabetes NHS policy can be translated into improving outcomes for people affected by diabetes or the risk of diabetes.  Ask my friends.  I could prattle on about my passion all day long!

So rather than bore my husband and my friends I thought a blog would be a good outlet.

And you never know, there maybe others out there that loves this stuff too.