This document discusses new models of primary care for diabetes management. It describes how a federation of 61 practices in Suffolk, England established a community interest company to provide diabetes services to 580,000 patients. Key aspects of their model include patient involvement, investing in primary care services, and establishing a diabetes specialist team in the community. The model has improved diabetes outcomes across practices and helped increase the percentage of patients receiving all eight diabetes care processes from 40.1% to 60.3% over one year. Lessons learned include the importance of clinical leadership, ability to monitor progress, and using peer pressure and financial incentives to facilitate practice changes.

2. New Models of Working
MCP - What Does Primary Care Need
to Do?
David Pannell
30 June 2015

3. How to find us

4. Suffolk Federation
 61 of 65 practices – 580,000 patients
 Practices remain independent partnerships
 Not for profit Community Interest Company
 Portfolio services – 60 staff + turnover £6m

5. Whose afraid of their hospital?

6.  Diabetes, podiatry, outpatients & education +
inpatients
 £2.5m per annum
 Model
1.Patient involvement
2.Investment in primary care
3.Diabetes Specialist Team in community
Diabetes – Primary care at scale

7. Primary care’s role
 Working at population level – no exception
coding!
 Manage wider range patients e.g. stable T1s
 Managed to deliver outcomes
 Monthly data extract
 £6.44 per list patient over 5 years

8. Monthly data extract from all practices
Diabetes IPH -Contract Quality and Performance Management (CQPM) SCORECARD 2014/15
INDICATORS Baseline Year 1
Target
Apr-14 data
(May
meeting)
May-14
data (Jun
meeting)
Jun-14 data
(Jul
meeting)
Jul-14 data
(Aug
meeting)
Aug-14
data (Sep
meeting)
Sep-14
data (Oct
meeting)
Oct-14 data
(Nov
meeting)
Nov-14
data (Dec
meeting)
Dec-14
data (Jan
meeting)
Jan-15 data
(Feb
meeting)
Feb-15
data (Mar
meeting)
Mar-15
data (Apr
meeting)
40.3% 40.4% 40.6% 40.8% 41.0% 41.1% 41.3% 41.5% 41.6% 41.8% 42.0% 42.1%
39.1% 38.2% 37.4% 36.7% 45.3% 46.3% 47.0% 48.2% 50.1% 53.8% 55.2% 60.3%
8.2% 16.3% 24.5% 32.7% 40.9% 49.0% 57.2% 65.4% 73.5% 81.7% 89.9% 98.0%
0.0% 0.0% 0.0% 0.0% 6.0% 6.5% 7.1% 5.5% 9.3% 15.1% 17.1% 95.0%
8.2% 16.3% 24.5% 32.7% 40.9% 49.0% 57.2% 65.4% 73.5% 81.7% 89.9% 98.0%
0.0% 0.0% 0.0% 0.0% 6.0% 6.5% 7.1% 13.2% 16.4% 27.8% 35.7% 96.0%
>32.3% >32.3% >32.3% >32.3%
Not due Not due 16.7% Not due Not due 47.2% Not due Not due 37.1% Not due Not due 37.1%
71.4% 71.5% 71.6% 71.7% 71.8% 71.9% 72.0% 72.1% 72.2% 72.3% 72.4% 72.5%
68.9% 69.0% 69.0% 69.4% 69.7% 70.1% 70.4% 69.9% 69.1% 67.9% 69.1% 69.5%
79.1% 79.1% 79.2% 79.3% 79.4% 79.4% 79.5% 79.6% 79.6% 79.7% 79.8% 79.8%
76.5% 76.7% 77.0% 77.2% 77.1% 76.9% 76.7% 76.7% 76.8% 76.6% 78.9% 79.1%
78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4% 78.4%
77.1% 76.3% 76.3% 76.5% 76.0% 75.5% 74.1% 72.5% 72.1% 72.3% 73.1% 74.7%
63.5% 64.1% 64.6% 65.1% 65.7% 66.2% 66.7% 67.2% 67.8% 68.3% 68.8% 69.4%
63.0% 63.0% 61.0% 61.0% 67.0% 65.8% 65.0% 66.1% 67.9% 70.4% 70.8% 75.0%
Patient empowerment change from baseline to 6 weeks following XPERT
education
32.3% >=32.3%
Increase the number of type 1 Diabetics who have had a foot check. 63.0%
maintain
upper
quartile
Increase in the percentage of patients with diabetes in whom the last
blood pressure is 140/80 or less.
78.4%
% of newly diagnosed Type 2 patients OFFERED education within 12
months of diagnosis
0.0% >=98%
% of newly diagnosed Type 1 patients OFFERED education within 24
months of diagnosis
0.0% >=98%
patients receiving all 8 care processes
(Weight, BP, Smoking status, HbA1c, urinary albumin, serum creatinine,
cholesterol, foot examination)
40.1% 2% increase
percentage of patients with diabetes in whom the last IFCC-HbA1c is
64mmol/mol or less[<8% in DCCT values] in the preceeding 15 months
71.3% 1.17%
increase or
69th centile
Increase in the percentage of patients with diabetes whose last measured
total cholesterol within the previous 15 months is 5mmol/l or less.
79.0% 0.88%
increase or
48th centile
10%
increase
Note – this data extract is based on the National Diabetes Audit format which is different to QoF

9. Practice Dashboard

10. Peer pressure to drive change
2013/14 mean
Individual Practices

11. 2014/15 outcomes
April 2014 March 2015
Number on register 17,470 18,400 +5%
Received all 8 processes 7,005
40.1%
11,095
60.3%
Newly diagnosed offered
structured education Unclear
T1’s 95% &
T2’s 96%
HbA1c <=64mmol/mol 11,687
66.9%
12,112
65.8%
Cholesterol <=5 12,400
71.0%
13,657
74.2%
BP <=140/80 11,777
67.4%
12,939
70.3%

12. Lessons
 Clinical leadership and clinical model
 Ability to get practice agreement quickly
 Peer pressure and money to facilitate change
 Be able to monitor progress
 Management