New joined-up service to improve diabetes care

This week - 12 to 18 June 2017 – marks Diabetes Awareness Week. Diabetes is a growing challenge to the NHS.  Public Health England Health Profiles report that there are around 73,750 patients registered with diabetes in Essex, with Castle Point and Rochford and Southend residents having the highest reported rates of hypoglycaemia in the East of England region.  With this in mind local health and care organisations have launched a new Integrated Diabetes Service to improve services, patient experience and reduce ill health. 

The new Integrated Diabetes Service has been commissioned by local Clinical Commissioning Groups (CCGs) and is being delivered through a partnership arrangement with Southend University Hospital Trust and Essex Partnership Trust.  The new service brings all elements of the previous community and hospital services together under a single budget, single contract and single clinical governance structure. 

The aims of the service are to improve patient experience and reduce ill health and complications due to diabetes through:

  • Single point of contact and triage for all diabetes referrals
  • Consultant-led Multi-disciplinary Team (MDT) one stop clinic to develop a collaborative care plan
  • Support with dietary needs
  • Dedicated podiatry service
  • Increased patient education
  • Robust support & education in Primary Care
  • Repatriation of Insulin Pump service

Each person with diabetes is constantly managing their condition. The new service helps support self-management – by delivering care and support centred and coordinated around their needs. The comprehensive service delivers care from diagnosis to management of complications.   The new local model of care ensures all parts of the system work together throughout a patient’s diabetes journey.

Collaborative care planning means that clinicians and patients work together to agree goals, identify support needs and develop and implement action plans.

The ultimate goal is improved health outcomes for the diabetic population i.e. reducing amputations, retinopathy, kidney disease, cardiac complications, risk of stroke.

Dr Sami Ozturk, GP Clinical Lead for the new Integrated Diabetes Service said: “People living with diabetes face daily challenges including diet and exercise, treatment-taking, psychological stress, education, illness and disability. The input and skills of healthcare professionals across primary, community and specialist care is essential to provide high quality care.   It’s important that we meet individual needs and empower patients to be engaged in their own care.

Historically, diabetes services worked in silos, the community teams and hospital teams weren’t working together as well as they could. The aim of integrating diabetes care is to refocus services around the individual, removing barriers between specialties and organisations and introducing an approach that achieves better outcomes.”

Diabetes UK was very active in helping to design the new service, which saw its first patients on Tuesday 3 January 2017.  It is estimated that 80 per cent of previous diabetes hospital outpatient appointments will now take place in the community.

Multidisciplinary clinics are being held in Benfleet, Westcliff and Rochford with a fourth site towards the Shoebury area soon to be introduced. These clinics include the Consultant, Diabetes Nurse Specialists, Podiatrists and Dietitians.  Individual clinics continue across the south east Essex area.

A local insulin pump service has also been introduced and the first eight patients have received their pumps with the support and guidance of the service without needing to travel out of the local area.

All community diabetes patients have been automatically transferred to the service, and patients currently under the care of the hospital will be reviewed and transferred to the service as appropriate.

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