Slides from opening plenary at Diabetes UK, 14th March 2018, London: "Cardiovascular risk reduction in diabetes: Maximising patient benefits" This is some of the output over the last few years of the North West London Diabetes Transformation Team, demonstrating that urban deprivation doesn't need to be a barrier to improvements in care (as shown elsewhere including Tower Hamlets).

1. Making cardiovascular disease risk
reduction happen in primary care
Dr Tony Willis, Clinical Director for Diabetes, North West London

2. 142,713 patients in NWL with diabetes
41% of all NWL admissions
63% of bed days (36% have a coded complication)
£598m NWL spend on diabetes patients (~22%)
377additional beds by 2028 – a medium size hospital
Background: NWL data

3. £500,000,000
£550,000,000
£600,000,000
£650,000,000
£700,000,000
£750,000,000
17/18 18/19 19/20 20/21 21/22 22/23 23/24 24/25 25/26 26/27 27/28
Do nothing
Transformation Programme
Background: NWL diabetes cost projections
Finance team
convinced!!
Transformation plan: integrated care/MDTs, psychological
support, education, digital – reduce complications

4. Super Six

5. Reduce variability in experience and outcomes
Provide care planning resources
Easy access to trusted diabetes information
Put bigger emphasis on prevention
Background: Clinician and user wish list

6. Practicename
Listsize
Diabetesregister
%Diabetesprevalence
%9keycareprocessesin15m
%HbA1c,BP,Lipidstotarget
%HbA1c≤58
%BP≤140/80
%Chol≤4
%patientsonAtorvastatin20mg+
%Careplanningin15m
%Hypoglycaemiamonitoring
%Structurededucationinnewlydiagnosed
St Quintin Health Centre 2383 96 4.0 85.4 33.3 70.8 88.5 49.0 41.7 90.6 93.5 60.0
Dr Srikrishnamurthy 2222 239 10.8 74.1 30.5 57.7 69.5 63.2 64.9 76.6 79.8 100.0
Dr H Dathi - Golborne Medical Centre 2502 193 7.7 64.8 30.1 60.1 77.7 46.6 70.5 72.0 87.8 100.0
The Golborne Medical Centre 5114 419 8.2 74.9 24.8 62.8 73.3 47.3 70.6 79.7 94.7 100.0
North Kensington Medical Centre 4764 229 4.8 78.2 24.5 64.2 68.1 51.1 51.5 93.9 97.1 100.0
Barlby Surgery 9791 483 4.9 64.0 23.8 61.1 77.0 41.6 46.2 76.8 86.3 100.0
Queens Park Health Centre 2837 280 9.9 56.8 23.2 57.1 84.3 40.0 27.5 17.9 57.7 63.2
Key standards included:
• 9 key care processes
• NICE 3 treatment targets
(cholesterol  4)
• Care planning
• Structured education
• Hypoglycaemia monitoring
• Non-diabetic hyperglycaemia
Background: Local incentive scheme in Primary Care

7. 1.46m citizens
229 GP practices
> 75,000 people with diabetes
> 63,000 people at high risk of diabetes
Background: Initial work across 5 CCGs (CWHHE)

8. Case studies

9. No drop in achievement with increasing deprivation levels
Other factors responsible: admin, knowledge
Data analysis: Effects of deprivation
Scatter plot of GP practices:
Index of Multiple Deprivation (x) vs Achievement of treatment targets (y)
3TT HbA1c  58 BP  140/80 Cholesterol  4

10. 352patients with diabetes
High levels of deprivation
69% from Black and Minority Ethnic (BME) backgrounds
What happened?
• Virtual clinics with diabetes consultant
• Focussed on patients with HbA1c > 100 mmol/mol
• Agreed management plan per patient
• GP implemented during subsequent face-to-face consultation
Mean HbA1c reduction after 8 months: 36.5 mmol/mol
Case study 1: Virtual clinics, White City Estate

11. Golborne ward is most deprived in London, 12 yr life expectancy gap between north and south
Case study 2: Clinical leadership, North Kensington
Map of Index of Multiple Deprivation (IMD) 2015

12. 15 practices
4087patients with diabetes
High levels of deprivation
Large North African population
What happened?
• Clinical leadership by local GP
• Dashboard discussion during clinical network meetings
• Bespoke GP education sessions
Golborne Medical: 3 treatments targets increased by 16.7%
Case study 2: Clinical leadership, North Kensington

13. CCG
Network
Practicename
Listsize
Diabetesregister
%Diabetesprevalence
%9keycareprocessesin15m
%HbA1c,BP,Lipidstotarget
%HbA1c≤58
%BP≤140/80
%Chol≤4
%patientsonAtorvastatin20mg+
%Careplanningin15m
%Hypoglycaemiamonitoring
%Structurededucationinnewlydiagnosed
West London North St Quintin Health Centre 2383 96 4.0 85.4 33.3 70.8 88.5 49.0 41.7 90.6 93.5 60.0
Dr Srikrishnamurthy 2222 239 10.8 74.1 30.5 57.7 69.5 63.2 64.9 76.6 79.8 100.0
Dr H Dathi - Golborne Medical Centre 2502 193 7.7 64.8 30.1 60.1 77.7 46.6 70.5 72.0 87.8 100.0
The Golborne Medical Centre 5114 419 8.2 74.9 24.8 62.8 73.3 47.3 70.6 79.7 94.7 100.0
North Kensington Medical Centre 4764 229 4.8 78.2 24.5 64.2 68.1 51.1 51.5 93.9 97.1 100.0
Barlby Surgery 9791 483 4.9 64.0 23.8 61.1 77.0 41.6 46.2 76.8 86.3 100.0
Queens Park Health Centre 2837 280 9.9 56.8 23.2 57.1 84.3 40.0 27.5 17.9 57.7 63.2
Dr Ahmed - Queens Park Health Centre 2523 123 4.9 72.4 21.1 47.2 78.9 56.1 72.4 82.1 95.0 91.7
The Exmoor Surgery 3568 276 7.7 58.7 20.7 59.4 70.7 41.3 55.1 68.1 75.0 81.8
Shirland Road Medical Centre 3920 244 6.2 59.0 20.5 51.6 70.5 37.3 49.2 66.8 70.7 100.0
Meanwhile Garden Medical Centre 2835 279 9.8 57.3 19.7 61.6 72.0 35.8 47.3 29.0 52.2 100.0
Dr Pauline Lai Chung Fong - Queens Park Health Centre 1574 92 5.8 72.8 19.6 68.5 51.1 41.3 48.9 53.3 91.1 100.0
Grand Union Health Centre 10122 512 5.1 56.8 18.4 58.2 64.1 41.4 41.8 45.9 73.9 98.2
The Elgin Clinic 4380 295 6.7 45.8 14.9 54.6 58.3 40.3 40.7 52.9 44.9 42.9
Half Penny Steps Health Centre 5170 201 3.9 24.9 8.5 50.2 53.2 28.9 33.8 4.0 27.0 57.1
North Total 63705 3961 6.2 61.7 21.8 58.8 70.5 43.3 50.1 59.6 73.8 85.1
Listsize
Diabetesregister
%Diabetesprevalence
%9keycareprocessesin15m
%HbA1c,BP,Lipidstotarget
%HbA1c≤58
%BP≤140/80
%Chol≤4
%patientsonAtorvastatin20mg+
%Careplanningin15m
%Hypoglycaemiamonitoring
%Structurededucationinnewlydiagnosed
2355 96 4.1 56.3 24.0 58.3 68.8 46.9 35.4 50.0 60.4 33.3
5118 393 7.7 49.1 23.4 57.3 67.9 44.5 67.2 68.2 69.4 45.9
2246 226 10.1 38.5 23.0 49.1 65.0 57.1 54.9 37.6 9.6 30.8
9500 459 4.8 30.9 19.4 58.6 69.3 37.7 34.4 35.5 53.5 35.1
2364 114 4.8 59.6 19.3 42.1 75.4 50.0 72.8 71.1 79.7 33.3
2926 290 9.9 62.1 19.0 52.8 81.4 35.9 24.5 1.4 8.1 70.8
4795 231 4.8 39.8 18.6 58.9 49.8 45.9 38.5 22.9 2.6 73.7
4537 291 6.4 43.6 16.5 56.4 56.0 38.1 31.3 14.1 3.2 25.0
10745 504 4.7 36.3 16.5 48.8 69.6 34.7 38.9 23.6 34.2 8.1
3412 262 7.7 37.8 14.9 54.6 61.8 39.7 41.6 50.8 19.7 20.0
2892 277 9.6 39.7 14.1 58.1 71.5 28.5 29.6 32.9 7.6 23.8
3957 240 6.1 40.0 13.8 52.9 67.5 33.8 45.8 12.9 0.9 0.0
1615 96 5.9 69.8 13.5 60.4 52.1 50.0 42.7 2.1 55.4 53.8
2517 187 7.4 43.9 13.4 47.1 70.6 29.9 46.0 56.1 59.5 36.4
5050 187 3.7 26.2 12.3 43.3 55.6 35.8 30.5 2.1 11.8 19.2
64029 3853 6.0 42.3 17.6 53.6 66.4 39.2 41.4 31.9 29.9 33.1
June 2016 March 2017
13.4
30.1
Case study 2: Clinical leadership, North Kensington
Golborne

14. “…Having a consistent GP and specialist Diabetes nurse
at the practice has helped my journey...I feel more
motivated. I now know a lot more than I did before. I
can even advise my family members who have
diabetes. I feel more able to make healthy choices and
more upbeat…”
Patient with Type 2 DM and Serious mental illness living in Golborne Ward, North
Kensington
Case study 2: Patient feedback

15. 22 practices, historically many single-handed, near retirement
12,077patients with diabetes (10.2%)
43% born outside UK, 48% Asian
What happened?
• Community diabetes team provided education
• Administrative support from GP federation
• Saluja clinic (~ 1000 diabetes patients): new practice manager,
new culture of positivity, reception training
4.3% improvement in NDA 3TT in past year
Case study 3: Community team and GP federation, Southall

16. Network
Diabetesregister
%Diabetesprevalence
%9keycareprocessesin15m
%HbA1c,BP,Lipidstotarget
%NDA3TreatmentTargets
%HbA1c≤58
%BP≤140/80
%Chol≤4
%patientsonAtorvastatin20mg+
%Careplanningin15m
%Hypoglycaemiamonitoring
North Southall 219 9.8 71.7 49.8 62.5 70.8 89.0 68.9 79.9 94.1 98.9
292 10.9 41.8 27.1 43.6 57.9 76.7 49.7 55.8 11.0 90.3
268 8.6 72.0 25.7 42.2 60.1 78.0 48.9 41.4 82.5 94.4
985 10.3 66.8 24.2 41.3 63.5 71.2 42.8 59.9 90.5 94.9
380 12.6 75.8 22.4 36.8 60.3 72.1 46.3 50.0 81.6 99.2
793 11.2 54.4 21.3 37.6 51.5 72.3 43.9 44.4 76.4 84.1
196 9.7 61.2 20.4 47.7 58.7 77.6 39.3 34.7 91.3 97.7
724 12.6 72.4 20.3 36.0 66.6 61.2 42.8 36.5 96.8 98.9
565 10.9 36.8 19.8 34.0 54.5 68.8 42.5 48.8 34.3 48.4
768 10.0 50.4 19.8 39.3 55.9 77.7 40.8 55.1 79.3 91.0
437 6.6 60.4 19.0 35.1 61.8 54.2 42.1 40.5 78.9 93.2
828 10.2 63.6 18.1 35.0 55.9 65.3 41.9 40.2 81.4 95.2
480 16.0 51.0 16.0 34.4 54.6 59.6 34.4 41.5 84.0 94.5
225 14.2 40.0 12.9 30.4 46.7 53.8 32.9 36.0 75.1 96.1
North Southall Total 7160 10.6 58.9 21.5 38.5 58.4 69.0 43.1 47.5 77.4 90.0
South Southall 517 13.5 61.9 22.4 42.3 54.5 72.5 43.9 38.5 86.3 98.4
475 11.1 53.5 21.3 39.5 51.2 66.7 42.5 35.6 75.8 88.8
308 9.4 72.1 20.1 37.8 51.0 69.2 42.2 45.8 76.9 89.8
792 9.5 57.8 20.1 40.0 54.7 68.1 39.3 37.9 82.7 96.4
698 10.0 61.7 19.5 35.1 56.7 60.9 46.8 59.9 87.4 92.7
612 7.4 49.8 16.8 27.6 54.4 56.4 43.1 51.0 95.1 97.4
1080 9.3 56.6 16.3 35.1 54.6 63.4 40.4 44.2 88.9 98.2
444 9.4 37.2 14.6 34.1 53.6 61.5 35.1 35.6 64.6 81.8
South Southall Total 4926 9.6 56.2 18.6 36.1 54.2 64.4 41.7 44.1 84.0 94.1
12086 10.2 57.8 20.3 37.5 56.7 67.1 42.5 46.1 80.1 91.7
Network
Listsize
Diabetesregister
%Diabetesprevalence
%9keycareprocessesin15m
%HbA1c,BP,Lipidstotarget
%NDA3TreatmentTargets
%HbA1c≤58
%BP≤140/80
%Chol≤4
%patientsonAtorvastatin20mg+
%Careplanningin15m
%Hypoglycaemiamonitoring
North Southall 2452 209 8.5 79.9 41.6 53.5 65.6 87.6 67.0 81.3 61.7 96.6
1815 180 9.9 71.7 21.1 47.9 63.3 76.7 38.9 30.0 75.0 77.0
3208 389 12.1 76.9 20.3 37.0 63.5 67.9 40.9 46.3 90.7 96.5
5229 679 13.0 76.4 20.0 37.6 63.5 64.1 39.8 30.3 49.3 97.3
7046 420 6.0 49.8 20.0 40.2 63.3 64.3 40.7 37.1 65.5 73.8
3122 254 8.1 39.4 18.9 42.5 51.2 82.7 35.4 32.3 89.8 22.2
2494 283 11.3 50.5 16.3 33.1 54.4 65.0 35.3 43.5 84.5 94.2
7403 723 9.8 22.7 15.4 27.5 42.9 57.1 39.7 38.3 45.5 32.6
4878 530 10.9 2.8 15.1 29.4 52.1 66.2 38.7 37.7 1.7 10.6
7289 726 10.0 62.9 15.0 29.7 52.1 59.2 36.5 34.7 83.1 82.9
7686 735 9.6 23.8 14.1 30.4 50.7 64.9 34.4 51.2 51.3 58.8
9517 971 10.2 18.8 13.9 32.0 57.4 57.8 32.9 40.9 13.9 61.6
3138 474 15.1 34.6 12.7 29.1 51.7 55.7 27.2 34.6 50.8 60.0
1616 211 13.1 43.6 10.4 25.0 46.9 52.6 27.5 25.1 67.8 75.6
North Southall Total 66893 6784 10.1 41.5 16.8 33.6 54.8 63.3 37.1 39.7 52.0 62.8
South Southall 3631 502 13.8 51.6 18.5 35.5 48.8 78.1 41.6 35.1 69.3 79.4
4542 422 9.3 12.1 17.8 32.9 56.2 60.9 36.3 32.9 43.8 47.4
3083 289 9.4 73.0 17.0 34.3 42.2 73.0 38.1 38.8 80.6 41.4
6493 629 9.7 34.8 16.7 33.1 54.4 59.9 41.2 53.7 52.3 57.4
8242 748 9.1 57.1 15.0 35.2 54.1 65.5 34.6 32.1 77.7 81.7
11303 1007 8.9 42.5 14.7 32.5 49.3 68.8 35.2 39.7 78.1 92.2
5334 558 10.5 31.2 13.3 31.2 45.0 54.3 34.2 32.4 59.0 55.4
8132 554 6.8 47.3 13.0 26.3 40.4 63.2 32.9 40.1 28.7 50.9
South Southall Total 50760 4709 9.3 43.1 15.5 32.6 49.3 65.3 36.5 38.4 62.6 68.0
117653 11493 9.8 42.2 16.2 33.2 52.5 64.1 36.8 39.1 56.4 64.9
Case study 3: Community team and GP federation, Southall
January 2017 February 2018
Saluja
9.3% increase in
National Diabetes
Audit 3TT
achievement

17. 43 practices
19,858people with diabetes, 48.6% from BME backgrounds
What happened?
• Locality meetings shared achievements and learning
• Whole CCG education events
• Practices used a patient level dashboard
3mmol/molmean reduction in HbA1c
10.3% increase in patients with HbA1c  58 (50.6% to 60.9%)
Case study 4: Whole CCG improvement, Hounslow

18. Spotlight 1: NICE recommended statin prescribing
June 2016
7.7% increase
in NICE
recommended statin
prescribing
4.3%
increase in patients
achieving target
cholesterol
8.0
70.4
62% variability in
prescribing to NICE
recommendations
between practices

19. Spotlight 2: Early intensification (HbA1c  53 in first 2 yrs)
2.6%
increase in patients
achieving target
HbA1c
7.9%
increase in most
deprived locality
S.K. Paul, K. Klein, B.L. Thorsted, et al., Delay in treatment
intensification increases the risks of cardiovascular
events in patients with type 2 diabetes Cardiovasc.
Diabetol. 14 (2015) 100
62%
increased
risk of CV
events at 5
years

20. Impact

21. 24,843 more receiving 9 key care processes
4,254 more with HbA1c  58 since 1/15
3,039 more achieving NICE 3TT targets since 6/16
5,315 more on NICE recommended statin
> 52,000 more with collaborative care plan
11,161 have accepted referral to NDPP
Impact: Significant improvements in diabetes care

22. Diabetesregister
%9keycareprocessesin15m
%ControlledNICEtargets(HbA1c,BP,lipids)
%HbA1c≤58
%BP≤140/80
%Chol≤4
%Careplanningin15m
%Hypoglycaemiamonitoring
Non-diabetichyperglycaemiaregister
%NDHannualreviewandreferral
2362 59.3 21.8 61.1 65.9 40.1 71.9 83.0 1923 36.8
3398 54.9 20.5 58.8 62.2 41.5 65.5 78.3 2818 22.1
2307 70.9 20.8 62.7 69.4 39.2 74.0 85.0 2022 29.5
8067 60.8 20.9 60.6 65.3 40.4 69.8 81.5 6763 28.5
4926 56.2 18.6 54.2 64.4 41.7 84.0 94.1 3978 35.9
3222 65.8 23.2 63.0 68.7 43.1 81.3 92.2 2915 54.2
2438 59.3 28.3 65.8 71.9 46.3 81.8 92.6 2127 43.7
7741 58.2 19.9 58.6 69.6 42.5 78.1 84.8 4924 30.4
2100 44.9 23.9 62.2 66.4 42.8 65.3 81.3 1545 15.7
3824 60.1 21.8 61.4 68.8 46.7 76.2 77.4 3342 24.4
4664 66.0 23.2 59.8 70.0 45.7 80.8 90.2 4530 36.8
28915 59.3 21.8 59.8 68.5 43.8 79.0 87.4 23361 34.9
3800 54.0 22.4 61.3 61.2 45.8 71.3 87.0 3027 35.1
2453 56.1 19.0 55.4 68.3 38.7 74.8 86.7 1509 48.2
2526 42.8 19.5 59.7 61.7 40.7 65.5 81.6 2031 36.8
8779 51.4 20.6 59.2 63.3 42.4 70.6 85.3 6567 38.6
5662 71.1 25.0 61.6 71.5 47.0 81.9 96.0 6059 54.7
3280 55.9 20.8 63.3 60.4 41.9 73.0 84.1 3334 42.5
4505 67.4 24.4 59.6 72.7 44.2 84.9 92.6 3337 42.9
1630 66.1 25.2 64.9 75.0 43.4 82.1 93.9 1849 39.5
4856 63.8 19.2 59.2 64.6 40.7 76.7 90.5 4491 32.4
19933 65.6 22.8 61.1 68.5 43.7 79.8 91.8 19070 43.7
3972 65.8 22.3 60.2 67.8 44.5 78.4 88.7 3585 46.1
2455 55.9 20.9 58.3 69.8 40.7 73.1 87.2 1119 34.2
1422 52.5 21.9 64.3 65.6 42.3 71.0 89.1 814 31.7
2431 64.7 22.5 59.4 68.4 42.2 82.2 90.8 1929 45.7
10280 61.3 22.0 60.1 68.1 42.8 77.0 88.9 7447 42.7
75974 60.5 21.9 60.2 67.5 43.1 77.0 87.8 63208 38.2
Diabetesregister
%9keycareprocessesin15m
%HbA1c≤58
%BP≤140/80
%Chol≤4
%Careplanningin15m
%Hypoglycaemiamonitoring
Highriskofdiabetesregister
%Highriskannualreview
Central Central 1997 23.6 60.5 62.0 36.6 5.7 3.2 7 0.0
North 2802 35.3 66.4 66.8 40.4 15.4 4.0 2 0.0
South 2002 31.1 66.9 67.9 37.8 3.2 2.5 1 0.0
Central Total 6801 30.6 64.8 65.7 38.5 9.0 3.3 10 0.0
Ealing South Southall 3268 29.0 40.1 62.1 39.7 8.1 7.9 0 0.0
Acton And Chiswick 2931 38.2 62.2 64.1 39.8 13.1 7.4 0 0.0
Central Ealing 1760 29.8 56.4 67.2 41.4 12.8 5.9 0 0.0
North Southall 5755 23.4 49.9 59.3 40.9 4.1 5.6 4 0.0
South Central 1861 24.2 53.0 63.5 43.8 10.2 3.9 0 0.0
South North 2344 21.9 50.8 63.8 44.5 0.9 9.3 1 0.0
North North 3412 24.4 50.9 60.5 44.9 3.8 14.1 0 0.0
Ealing Total 21331 26.9 51.2 62.1 41.9 6.8 7.8 5 0.0
H&F Network 1 1689 33.7 63.5 67.7 43.6 36.5 14.2 1 0.0
Network 2 1589 33.3 63.9 62.7 38.1 6.5 4.6 3 0.0
Network 3 974 18.5 63.2 66.9 37.6 7.6 9.3 0 0.0
Network 4 2275 19.6 52.1 62.3 36.8 10.1 2.1 1 0.0
Network 5 1175 29.3 58.3 57.4 34.8 10.0 8.3 2 0.0
H&F Total 7702 26.9 59.4 63.4 38.4 14.8 7.0 7 0.0
Hounslow HoH 4382 27.3 48.1 64.3 39.4 8.7 1.1 2 0.0
Brentford 2249 31.7 57.0 60.2 38.5 10.2 1.5 2 0.0
Feltham 3675 26.1 49.6 70.5 40.8 6.9 4.2 20 0.0
Chiswick 1448 30.0 55.0 64.2 39.4 11.1 1.0 72 1.4
Great West 3704 28.7 48.8 57.5 37.0 3.7 0.5 11 0.0
Hounslow Total 15458 28.2 50.6 63.5 39.0 7.5 1.7 107 0.9
West London2 North Central 1757 30.2 58.2 61.1 36.8 7.9 2.1 2 0.0
North East 2193 30.8 57.4 61.8 37.5 6.9 1.5 0 0.0
North West 2198 29.3 60.6 61.5 34.8 6.7 1.8 8 0.0
South East 1129 27.5 60.9 59.8 32.6 4.4 3.0 1 0.0
South West 1894 21.8 53.2 61.6 34.9 3.1 0.5 0 0.0
West London2 Total 9171 28.0 57.9 61.3 35.6 6.0 1.6 11 0.0
Grand Total 60463 27.8 54.6 62.9 39.4 8.1 4.8 140 0.7
Diabetes Level 1 High risk
Diabetesregister
%9keycareprocessesin15m
%ControlledNICEtargets
%HbA1c≤58
%BP≤140/80
%Chol≤4
%Careplanningin15m
%Hypoglycaemiamonitoring
Highriskofdiabetesregister
%Highriskannualreview
Central Central 2186 29.3 16.7 54.7 60.9 36.7 29.2 21.7 539 7.4
North 3204 26.9 17.2 58.8 61.6 37.7 18.3 20.4 1351 8.3
South 2127 43.5 21.4 62.7 71.8 37.6 15.1 29.8 484 20.7
Central Total 7517 32.3 18.3 58.7 64.3 37.4 20.6 23.4 2374 10.6
Ealing South Southall 4453 29.8 15.2 48.3 65.1 38.2 54.1 37.5 2635 57.1
Acton And Chiswick 3114 51.8 19.2 59.7 65.7 39.7 57.9 58.6 2039 61.4
Central Ealing 2270 41.0 20.7 61.8 68.1 40.5 43.5 43.6 1194 37.5
North Southall 6927 35.3 15.2 50.5 57.4 36.0 40.1 44.2 3389 34.4
South Central 1988 37.6 19.2 58.1 65.6 41.3 55.3 27.6 1107 29.2
South North 3591 30.0 18.0 48.8 60.3 37.2 24.8 49.7 2303 20.9
North North 4323 39.4 19.9 58.4 64.8 41.8 41.8 51.0 2536 43.3
Ealing Total 26666 36.9 17.6 53.8 62.7 38.7 44.1 45.2 15203 41.2
H&F Network 1 1760 43.3 19.6 60.6 61.0 44.9 59.3 54.0 622 46.5
Network 2 1552 43.7 20.5 60.9 61.3 40.7 61.2 57.3 580 26.4
Network 3 1040 26.7 20.3 60.3 62.9 39.6 46.3 49.1 602 37.5
Network 4 2453 32.1 16.9 53.3 62.9 38.6 31.3 28.0 305 33.8
Network 5 1287 36.5 14.7 51.3 55.2 34.8 59.8 52.1 572 33.2
H&F Total 8092 36.8 18.3 56.9 60.9 39.9 49.6 45.2 2681 35.8
Hounslow HoH 5031 58.9 20.3 59.3 67.9 41.7 63.2 67.4 3766 42.5
Brentford 3066 32.6 13.5 59.6 61.3 36.9 47.8 38.1 2563 28.9
Feltham 3937 43.9 21.1 56.8 69.1 43.2 61.8 60.6 1688 35.3
Chiswick 1564 45.5 19.9 61.6 68.9 37.1 41.9 54.2 1333 26.6
Great West 4439 43.5 16.1 55.0 64.0 36.9 45.1 33.2 2563 13.3
Hounslow Total 18037 46.2 18.2 58.0 66.2 39.6 54.0 51.4 11913 30.5
West London2 North 3853 42.3 17.6 53.6 66.4 39.2 31.9 29.9 1577 48.1
North Central 2482 38.0 18.2 60.5 66.4 37.3 26.3 26.4 955 20.3
South East 1284 27.0 16.0 57.9 60.5 37.0 13.0 17.4 454 26.4
South West 2069 39.8 17.2 54.2 66.1 36.9 27.9 43.3 812 31.5
West London2 Total 9688 38.6 17.5 56.1 65.6 37.9 27.1 30.3 3798 35.0
Grand Total 70000 39.0 17.9 56.1 64.0 38.8 42.4 42.1 35969 34.6
June 2016
Impact: Dashboards effectively driving change
January 2015 February 2018

23. Patient empowerment: collaborative care planning
Clinician education
Networks and MDTs
Dashboards
Contracts
Clinical system optimisation
Clinical guidelines
Impact: Ingredients needed for success

24. Contracts

25. GP Federations
NHSE
Imperial
Chelwest
CLCH
Hillingdon CNWL
WLMHT
LNWHNT
CCGCCGCCGCCGCCGCCGCCGCCGCCGs x8
OOHS
Specialist
PBR
Block
PBR
PBR
?
? ?
Different
performance
measures, mostly
activity rather than
outcomes focussed
GP
GP
GP
GP
GP
QOF
Diabetes
mentor
programme
Public
health
Patient
??
Contracts: Simplified view of current contract complexity

26. Digital

27. Clinical System Optimisation
Integrated Records
Supported Self-Care Apps
Know Diabetes Information Hub
Digital Initiatives

28. Templates
Reports
Alerts
Guidelines
Letters and care plans
Digital: Clinical systems optimisation

29. CapabilitiesSources
Clinical record
Per patient costing
LTC dashboards
Population health
Risk stratification
Community
Social care
Primary care
Integrated
Record
Secondary care
Mental health
Digital: Whole Systems Integrated Care
Over 2 million patient records: linked by NHS number
An integrated care record including primary, secondary and social care data: NHS-owned

30. Integrated Records: Individual and population dashboards

31. Inner city app pilot: 430 patients with Type 2 diabetes
Digital: Supported self-care apps
Oviva OurPath Changing Health

32. Digital: App feedback
“I have lost
weight”
“This app has changed
my life. It keeps me
motivated”
“I found it really useful to have a friendly 'voice' on hand.
I loved the little tips and advice I was sent and it kept
me motivated”

33. 6.9mmol/mol
reduction in mean HbA1c
2.5kg
reduction in mean weight
Digital: App evaluation
Most deprived deciles over-represented vs diabetes register

34. 60,000people to receive
structured education by 2021
Needs massively scalable and longer term solution
Digital: Ongoing education / behaviour change support
>350,000 need to receive
support in a sustainable way

35. Face to face course
eLearning
Videos
Coaching / Mentoring
Lifestyle change app
GP Referral
Self referral
Referral from other
Social media Emails
Website
management
and content
Receive referrals from
across NWL
Triage patients to most
appropriate intervention
Proactive life-long personalised support
SMS
messaging
Digital: Know Diabetes single point of referral / call centre
Single point of referral /
Call centre
Dynamic Health Systems

36. Pathway automation
Landing page
Person with Type 2 DM, Age 67, Female, HbA1c 64, BMI 34
Health Foundation Innovating for Improvement Grant
Follow up
Keep going!
Change in
weight
Motivational
videosEmail
Digital: Personalised self-care support
Personalised
support
Wait 4 days
Measuring
response from
linked clinical data

37. Digital: Diabetes learning health system
Timeline
Clinical analysis
Engagement analysis
NudgesIterative
design
Invite

38. Summary

39. Rollercoaster ride
2013 2014 2015 2016 20182017
Clinical
leads meet
LIS starts
Signs of
improvement
Agree to
work across
STP
NHSE bid
writing
CCGs fail to
support
investment
Updated
financial
model shows
bigger
opportunity
Threat of
losing NHSE
funding CCG funding
still not
released
Encounter
opposition
Win
NHSE
funding
Retain NHSE
funding
Win
awards
Visit
to DUK
conference

40. Eventually the door gives way…

41. Learn
from
others
Key components are
key components
Think
digital
Demonstrate
small wins
Maximise
scale
YOU
Work with local
clinical champions
Tenacity –
“stuck record”

42. • Programme director (Lesley Robertson)
• GP Leads (esp. Raquel Delgado, Raj Chandok, Yasmin Razak)
• Commissioning colleagues across NWL
• Programme team (Deepa, Sola, Buchi, Manal, Amrit and others)
• Primary care teams
• NWL Self care team (Aran Porter, Abeer Itrakjy)
• Informatics team (esp Ian Riley, Jess Murray, Rachel Meadows)
• Diabetes user groups
• Senior team: CCG chairs (esp Mohini Parmar), SRO (Clare Parker)
• Diabetes UK
Thanks
My family