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.

Finger on the Pulse

I am often asked how I keep updated.  Unfortunately, I don’t think they mean my fashion sense!  I’m pretty sure that they are referring to how to keep on top of the latest information on diabetes for managers.

I am in a very privileged position.  I almost, exclusively work in diabetes which is a luxury that few managers have.  We have Diabetologist and Specialist Diabetes Nurses and I often wonder whether there is a place for the Specialist Diabetes Manager.  I suppose we do have a few Diabetes Network Managers across the country but they are few and far between.

Lots of reading is the answer, which is tricky because I am dyslexic.  Yes – expect my blogs to be littered with spelling mistakes.  So I am discerning about my reading sources.   But knowing how very busy managers working in diabetes are, I’ll try and give you my list of top sources short.

So here’s my essential list:

1)      I subscribe to NHS Networks daily news stories as it is really easy to flick through the list

2)      I subscribe to the fortnightly newsletter and regularly browse The Diabetes Times website

3)      Diabetes UK have just launched a Diabetes Commissioners Network monthly newsletter

4)      I get "Practical Diabetes" delivered to my home – for free

If I can, I also go to 2 conferences:

Diabetes UK Professional Conference which is in Manchester next year and
Diabetes Professional Care Conference at Olympia, London in November and is FREE.  I  am also happen to be helping with a workshop this year so do pop in and say hello.

And of course you could always subscribe to this blog by putting your email address into the box on the right hand of my blog page.  Happy Reading.