Running a cost-effective diabetes local enhanced service

GP partner Dr Pipin Singh offers advice on how to set up and run a cost-effective diabetes enhanced service

One in ten people over 40 in the UK are now living with a diagnosis of Type 2 diabetes, according to recent data. The new figures show that there are 3.8 million people living with a diagnosis of diabetes in the UK, and 90% of these have Type 2.

In addition, it’s estimated there are almost 1 million more people living with Type 2 diabetes who haven’t been diagnosed, bringing the total number up to 4.7 million. By 2030 it’s predicted this number will rise to 5.5 million.¹

In order to deal with the increasing burden of diabetes on the NHS, GP practices are increasingly managing diabetes in the community and much of this is through locally designed and commissioned services.

Signing up to your local service

Before starting, ensure you have a lead GP and nurse for the diabetes work at your practice. All clinicians involved need to read the service specification laid out by the CCG, so your templates can be adjusted accordingly and appropriate codes added for data extraction and payment.

Have a clear understanding of what the service aims to achieve. This will ensure that all aspects of diabetes care are covered and will typically include:

• Maintenance of a diabetes register
• Ensuring referral to structured education takes place (DESMOND or equivalent)
• Promotion of self-care and self-management, which will involve gathering information and sharing it prior to the care planning consultation.
• Prevention of complications by ensuring appropriate screening is in place
• Sharing outcomes with neighbouring practices and the specialist service
• Contributing to the National Diabetes Audit
• Care planning consistent with a year of care standard, eg, including 20-minute appointments as minimum.

Setting up your service

Most practices will have been running diabetes clinics in house successfully for a long time, but how each practice runs their service will differ and it is always worth reviewing your set-up, sharing ideas with colleagues and learning new methods.

Whatever system you adopt it’s vital to ensure you know how many patients are on your list and how many are Type 2 and how many non-Type 2 diabetes patients, including how many are under hospital care. This will be key to determining your staff and procedural requirements.

Choosing team members

Decide who you would like to be part of your in-house clinic, for example:

• GP
• Practice Nurse
• Dietitian
• Pharmacist
• Healthcare assistant
• Dedicated admin team including IT support

How you staff your clinic will obviously depend to an extent on your patients and service requirements. But as an example, to manage nine patients booked into our diabetes clinic each week, our practice employs a team of one GP, one nurse and one healthcare assistant to run this clinic effectively.

Defining your processes

• Review your register
• Decide how many patients you plan to see per diabetes clinic session and aim for a minimum 20-minute appointment
• Re-call is best done in the patient’s birthday month
• Your re-call should be carried out by dedicated administrative staff using appropriate invitations. This can be done via letter, text or email depending on your surgery’s policies.

The review

This should consist of two appointments. The first will be used to collate the appropriate data via trained healthcare assistants (HCAs). Your HCAs can be trained to carry out the appropriate foot pulse assessment and 10g monofilament check

First appointment – information to collect:

• Blood work consisting of Hba1c, UEs, LFTs, FBC and non-fasting lipids.
• Height
• Weight
• Body mass index
• Pulse and blood pressure
• Smoking data
• Alcohol data
• Foot screening
• Urine for ACR

These results should then be attached to a results sheet and sent to the patient. The attachment of these results could be an administrative task, or nurse task if the nursing team has appropriate time dedicated to do this.

What you decide to put on the results sheet will depend on your clinical lead but could include:

• Asking the patients to document what is important to them
• Documenting what they would like to talk about at their review appointment.

You should book the patient’s formal review to discuss their results during that first appointment. This is more efficient than sending out a separate appointment inviting them in for a second time –and should reduce your DNA rate.

At the second appointment ensure that all the appropriate information required (as set out by QOF and your local service specification) are collated and documented using the appropriate codes to ensure that you are paid appropriately for the work that you have done. Above all, however, ensure the patient’s agenda takes priority.

How to encourage uptake

Arrange your appointment times to help increase uptake. For example, for people in work we offer general GP appointments for the main annual review appointment and appointments for bloods and biometric foot checks with the HCA at 8 am. This approach is still cost effective – the 8 am appointment fits into the HCA’s hours and while a GP appointment is more costly than a clinic appointment, the payments for achieving QOF and enhanced service targets outweighs the expense.

How to handle DNAs

By booking patients’ review appointments at their first data gathering appointment, your DNA rate should fall but undoubtedly you will still have some DNAs.

• Are they a ‘serial non-attender?’ If so, why? Is it the timing of your appointments? Could they be offered an evening clinic appointment or early morning appointment? Could the second appointment be carried out over the phone?
• Are they housebound? If so, think about who will need to carry out the review and how this may happen? For example via district nurses, a community matron, yourself, the practice nurse?
• Ensure they are coded as ‘Did not attend diabetes clinic’ to help minimize the impact on performance related payments.
• Send them an appropriate reminder letter or text.

Summary tips

• Consider training up your HCAs to do the foot checks and basic data gathering, for example smoking, alcohol data at the initial appointment
• Ensure your templates include the appropriate codes and all the information required by QOF and your local service
• Having a lead GP will help maximize your achievement, for example it allows your service to deal with more complicated cases such as steroid induced diabetes, or diagnostic uncertainty around Type 2 or Type 1, as well as to assist with administrative uncertainties such as coding.
• A lead GP will also be able to manage any pre-diabetes protocols and clinical uncertainty that may arise with this.
• Schedule a weekly clinic de-brief to ensure any complex cases are discussed.
• Consider inviting the retinal screening team to your surgery to carry out their reviews 
• Does your structured education programme offer self-referral or online courses? If not, is it a possibility? This is likely to increase uptake.
• Get help from diabetes.org.uk – they provide useful patient information leaflets that they are often willing to post out along with booklets around initial diagnosis.
• Can you up-skill to initiate newer treatments such as SGLT2s, GLP-1s or even insulin? This will help in reducing your referrals.
• Consider research trials that patients may be suitable for; these can have indirect benefits for your achievement and medicines costs as well as benefits for patients. (See: https://www.directclinicaltrial.org.uk)
• If available, attend your locality meetings with specialist services present to maintain good working relationships and keep your knowledge updated with the condition. Management of diabetes is developing continuously.

References

1. Number of people with diabetes reaches 4.7 million. Diabetes UK. February 2019.