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.