Abstract
Aims: Meeting the complex needs of growing population of patients with diabetes requires new ways of delivering specialist care in community. We report on population-based project developed and delivered to improve diabetes care.
Methods: Collaborative working between primary, secondary and community care was introduced in seven practices in the North East Locality caring for more than 82,000 patients with about 2900 diagnosed with diabetes 4.2%. This work required a synchronised central and practice-based effort to reach all patients in the population. Diabetes specialists provided guidelines on how to assess pre-defined searches and address risks in the population, primary care hosted the multidisciplinary virtual clinics, and commissioners invested in the diabetes dashboard to monitor quality of care.
Results: Eighteen clinics took place between March and July 2017 with each practices holding at least two clinics. Each clinic was attended by at least one GP, one practice nurse, one specialist diabetes nurse, and one consultant in diabetes. Approximately 150 patients were discussed: eight patients per 60 minute clinic on average. The issues identified as responsible for poor clinical outcomes fell into four main domains: pharmacological, psychological, social and technological. The outputs included changes in clinical and non-clinical treatments, better linking with services, improved continuity of care, and time savings to patients and secondary care clinics. The feedback from primary care was positive with improved care for patients and growing confidence in managing complex patients with diabetes in primary care.
Conclusions: Bringing high quality care to all patients with diabetes questions the traditional ways of working across diabetes services. The pilot conducted in NEL is an example of planning, organising, delivering and monitoring care to specific requirements of working within the population-based approach