Making a difference to people with diabetes - A joint working programme WMAHSN, HEE, Daiichi-Sankyo, Lilly & Novo Nordisk

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Case Study Summary
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Overview summary:
Making a difference to people with diabetes aims to make 1,000 positive differences for people with diabetes with 500 difference makers, developing a self-motivating network of change agents to give people the confidence, tools, know-how and enthusiasm to make a change to what they do what they do and improve patient experience and care.
Challenge identified and actions taken :
Diabetes expenditure is approximately 10% of the NHS budget, with the West Midlands spending £94million on diabetes prescriptions between April 2012 and March 2013. There is also a wide variation in the achievement of good clinical outcomes. Only 16% of patients who are prescribed a new medicine take it as prescribed, experience no problems and receive as much information as they need. In primary care, around £300million per year of medicines are wasted (likely to be a conservative estimate), of which £150 million is avoidable. NHS England has a priority on medicines optimisation, which aims to deliver improved patient outcomes through a patient-centred approach.
Impacts / outcomes:
Difference maker: Emma Innes, Matron in Diabetes, in conjunction with the In-Patient Diabetes Nurses
Project outline: Redesigned the in-patient pathway at Worcestershire Royal Hospital by proactively seeing all patients on the Acute Medical Unit who were high risk: newly diagnosed diabetes, admitted with hypoglycaemia <4 or hyperglycaemia >11 mmols or use Insulin. The aim was to be able to review and intervene in diabetes management before the effects of acute illness, poor oral intake and non-specialist management could cause any adverse events with the diabetes control.
Difference made:
  • Over nine months after the service change, the diabetes errors on the Acute Medical Unit reduced to 0 from 10 errors recorded over the nine months prior
  • Increased number of patients seen by the DSN team initially, but this is balanced by the fact that patients on the medical wards are more stable due to the early intervention.

Difference maker: Dr Andrew Askey, GP, Walsall CCG
Project outline: To improve screening for renal complications in people with diabetes by ensuring they have annual urinary albumen:creatinine ratio performed. An EMIS prompt was designed to alert clinicians when ACR screening was due, and further refined to advise on READ coding microalbuminuria or proteinuria and prescribing appropriate medication (ACEi, or AiiR blocker).
Difference made: In 2014, 469 people with diabetes had ACR screen in my practice, increasing to 613 in 2015 with an increase of 144 people screened. In addition, 55 patients were coded with microalbuminuria or proteinuria, and 28 were started on ACEi medication.


Difference maker: Sat Kotecha, community pharmacist and Chair, Local Pharmacy Network, West Midlands
Supporters:I involved my pharmacy team, patients and the Health Trainer that works from my pharmacy. I also engaged with other pharmacies, a consultant and the company that make the disposable HBA1c tests - the LPC is currently putting a business case together for commissioners to consider.
Project outline: I believe that the person who can make the biggest difference to their diabetes is the patient themselves. However, as diabetes is a 'silent condition', people have no idea if the changes they make are making a difference. I wanted to give people an objective measure to motivate them to make a difference for themselves by measuring HBA1c at baseline and the patient receiving advice on medicines adherence, diet and exercise. There was then a series of follow ups to measure the impact and motivate the individual.
Difference made:
  • 18 patients participated in the service, 10 completed all four consultations, while the rest stopped at various intervals.
  • A range of HBA1c reduction from 3mmol/mol to 14mmol/mol
  • All 18 patients reported changes to diet and increases in physical activity
  • 11 patients reported improved adherence to medication/changes to timing etc
  • Eight patients stopped home BGT as they felt it was unnecessary
  • All 18 patients would recommend to friends and family.

Difference maker: Julie Taylor, Diabetes Specialist Podiatrist, Staffordshire and Stoke-on-Trent Partnership NHS Trust
Supporters:podiatry line manager, professional leads for podiatry and physiotherapy, statistical support, non-medical prescribing lead, West Midlands Diabetic Foot Network, four GPs in four practices and diabetes consultant, Staffordshire University
Project outline: I wanted to improve timeliness of access to prescriptions for individuals with diabetic foot problems. Current processes cause delays that can have a negative impact on patient and carer experience and clinical outcomes. I wanted to make supplementary prescribing work in my community setting.
Difference made:
  • My supplementary prescribing increased from 0 to 50 prescriptions, by developing clinical management plans with five independent prescribers (four co-located GP practices who had not experienced supplementary prescribing previously and diabetes consultant)
  • On these 50 occasions, times to prescription improved from minutes to 1 -14 days (from the GP practice)
  • My prescribing prevented at least one hospital admission
  • Nine prescriptions for antibiotics were provided during consultation (commonly delayed by days with existing process and often not in line with local guidance for foot infection)
  • 19 prescriptions for wound dressings/offloading devices that are often incorrectly prescribed due to similar names of products (which require additional prescriptions and associated delayed commencement of appropriate care plans) with a potential saving of >£150 and associated frustrations
  • More importantly, the patient and carer feedback has been very positive, notably regarding convenience and reducing anxiety.
Supporting quote for the innovation from key stakeholders:
“WMAHSN are really good at promoting these great things, and the medicines optimisation programme has this drive behind it that engages people".
Which local or national clinical or policy priorities does this innovation address:
Long Term Conditions, Quality improvement
Plans for the future:
The initial group of people that made a difference have since gone on to do other joint working projects together and have created an energy and enthusiasm for having a go to make positive change happen. The legacy of the programme is that the individuals involved have continued to pursue further changes and have made significant achievements at a personal and organisational level.
Tips for adoption:
This programme is about driving improvement in diabetes and medicines optimisation without dictating how the difference makers achieve their goals. Instead, it has given people time to think and a framework to think differently, with some projects having wide impacts. There were some challenges during the programme which provide constructive lessons for the future. While the aim of identifying 500 difference makers to make 1000 differences was not achieved, the programme showed a rich experience of how a few people can make changes which impact the lives of many thousands of people with diabetes.

Support for the difference makers included:
  • Two days training around change thinking
  • follow up half day
  • Teleconferences
  • Half day training on ‘Measurement for Improvement’
  • ‘Buddy system to provide support, challenge thinking and identify resources needed.
Contact for further information:
For more information, contact Lucy Chatwin, Business Manager at WMAHSN, on 0121 371 8061 or email lucy.chatwin@wmahsn.org
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