Agenda item
Diabetes Services in Brent
The report covers services currently provided, including; healthy eating and physical programmes, awareness and health checks, primary care measures through the Quality and Outcomes Framework; GP insulin scheme, community and secondary care provisions and diabetic eye screening services.
Minutes:
Melanie Smith (Director of Public Health) presented the report that had been jointly produced by the council’s Public Health Team, Brent Clinical Commissioning Group (CCG) and NHS England. Members were aware that diabetes was of particular concern in the borough and noted that 22,097 people were on GP diabetes registers in Brent. Diabetes UK had estimated a diabetes prevalence rate of 10.5% overall in Brent in October 2013, although rates varied across the borough. It is estimated that one in four people with diabetes in London are undiagnosed and are at high risk of developing long term complications. The committee heard that there had been a 38% increase in diabetes rates for NHS Brent between 2008/09 and 2012/13. Melanie Smith informed members that those with diabetes in Brent were more likely to develop complications arising from their condition than the general population, including heart disease, stroke, foot disease that may necessitate amputation, kidney disease and loss of sight. However, early diagnosis, good diabetic care and self management could all be effective in preventing complications from arising. Melanie Smith referred to the findings from the 2011/12 National Diabetes Audit that identified that people with diabetes in Brent were less likely to suffer complications than the national average of those with diabetes, despite the borough’s relatively high levels of deprivation. This served as evidence that both health services and residents were responding well once diabetes was diagnosed.
Isha Coombes (Manager, Brent CCG) then summarised the current diabetes services currently operating in the borough. A total budget of £9.493m had been set for diabetes services for 2013/14 and it included a range of services. This included health promotion and prevention of diabetes schemes run in conjunction with the CCG and the council, including physical activity programmes, healthy eating, diabetes awareness raising, risk assessment and health checks and the Moving Away from the Pre-diabetes programme. The council commissions the NHS Health Check programme offered by Brent GPs aimed to prevent diabetes as well as heart disease, stroke, kidney disease and certain types of dementia. The council was also working with Diabetes UK through a community engagement programme, using community champions to promote awareness of diabetes for the high risk groups in the borough. Isha Coombes advised that diabetic patients were currently managed in primary care under the standard General Medical Services (GMS)/Personal Medical Services (PMS) contract, including additional health checks under the Quality and Outcomes Framework (QOF), a voluntary scheme which all Brent practices participated in. Other schemes to tackle diabetes included the Brent GP insulin initiation scheme, which had been rolled out across Brent in April 2012 and the Ealing Integrated Care (ICO) Organisation service that helped patients with type II diabetes, secondary care services and the Brent diabetic eye screening service. The latter is commissioned by NHS England from Ealing ICO. Those patients with positive screening tests would subsequently be referred to ophthalmology services at Central Middlesex Hospital (CMH).
Isha Coombes then outlined the proposals for the diabetes service redesign commencing in April 2014. The committee heard that Brent CCG recognised the need to invest in diabetes services, particularly as diabetes was expected to continue to rise in the borough. A redesigned integrated pathway community based service would realise a number of benefits, including:
· Providing a consultant led service where patients were seen by a multi-disciplinary team and treated in one appointment rather than a series of appointments
· Achieving value for money, ensuring patients were treated in the most appropriate environment according their needs at the right cost
· Opportunities to upskill GPs and practice nurses in diabetes care
· Facilitate early discharge back to GP care
· Develop a clinical network of care to provide tiers 1 and 2 care within localities.
Isha Coombes advised than Brent CCG had agreed an additional £693K of funding to enhance and further develop the community based integrated diabetes pathway, including increasing clinical capacity through additional specialist staff. Members heard that the redesigned service would improve health outcomes through:
· Providing early detection and identification of diabetes
· Involving patients in the decisions around personalised care planning
· Developing patient knowledge, skills and confidence for better self-management
· Demonstrating robust and clinical outcomes
· Targeting high risk populations
During members’ discussions, Councillor Colwill stated that the report lacked any reference to the task group on diabetes that he had chaired, including the recommendations it had made and he asked what progress had been made on these. A member acknowledged that overall most Brent GP practices were achieving a high number of points for the diabetes domain of QOF, however they enquired what steps were being undertaken to improve the small number that were underachieving. Surprise was expressed that the Wembley site was unable to cope with demand for diabetic eye screening and why had there not been extra clinics laid on or staff redistributed accordingly. Further information was also sought in respect of initiatives to support healthy eating in Brent. A member commented that the report needed more detail in order for the committee to fully scrutinise the matter and the report focused too much on providing an overview, whilst he felt the section on diabetes service redesign was also too brief. He suggested that there could be more details, for example, on plans for diabetes services in the Kingsbury locality as it had the highest diabetes prevalence in the borough.
The committee enquired whether the £9.493m designated for diabetes services was inclusive of the council’s public health spend. In noting that the QOF was optional, clarity was sought as to whether it was included as part of NHS Brent contracts and what was the total spend on GPs participating in the scheme. Details of NHS England funding for commissioning of diabetic eye screening services for Brent and funding for the Brent GP insulin initiation scheme and the Ealing integrated care pathway programme was sought. Clarity was sought as to whether the ophthalmology services commissioned by Brent CCG at CMH were different from community based services and on community screening services in Brent. It was also enquired whether an interpretation service was available for patients whose first language was not English and what was the total number of diabetic consultants in the borough.
In reply to the issues raised, Melanie Smith stated that the report explained the current position in respect of diabetes services, so some initiatives such as healthy eating were still in the process of being developed. She acknowledged the role played by the diabetes task group and the recommendations that it had made and the task group would be referred to in future reports. Members noted that all of the task group recommendations had been referenced, however those relating to schools would be more difficult to achieve, whilst there were also resource limitations in respect of the recommendations relating to green gyms. However, a number of methods were being considered in respect of awareness raising, including working with Diabetes UK and using community champions as an outreach. Melanie Smith advised that the high demand for diabetic screening in the borough was very welcome and exceeded that in other areas and consideration of how to reconfigure the service to cope with this demand was being undertaken. She advised the committee that there were practical difficulties in identifying the exact public health funding allocated for addressing diabetes as resources were allocated to address risk factors for a range of conditions, for example promotion of physical activity might reduce diabetic risk but would also improve mental wellbeing. The committee noted that Ealing ICO operated community diabetic eye screening in the borough at Wembley, the Jeffery Kelson Centre at CMH and Willesden Community Hospital and Melanie Smith added that in some cases, it was more useful to monitor and screen patients rather than refer them to the ophthalmology service.
Isha Coombes confirmed that the funding allocated by Brent CCG for diabetes service included both primary, community and acute care. For the Ealing ICO integrated pathway, the funding would increase from £391K in 2013-14 to nearly £1m in 2014-15. Members noted that Brent CCG commissioned an interpreters service for all services, including diabetes, and liaised with the service providers to put in place the appropriate arrangements. The committee also heard that there was presently one full time diabetes nurse consultant and five diabetes specialist nurses and the new model would include additional staff as set out in section 10.6 of the report.
Jo Ohlson (Chief Operating Officer, Brent CCG) acknowledged that diabetes prevalence was highest in the Kingsbury locality, however it was also a significant issue across the whole of the borough and early diagnosis was critical in achieving positive outcomes. In respect of Brent CCG commissioned services at CMH, Jo Ohlson clarified that although diabetic clinical services were not part of out of hospital care, some eye conditions may be unrelated to diabetes and so the service covered a range of possible conditions. She added that future reports could include more information on pathways, staff and intervention.
Dr Sarah Basham (Co-Clinical Director, Brent CCG) acknowledged that the Wembley site was underperforming, however this was partly attributable to both it being a small centre and because it operated on a walk-in basis. Steps were being taken to ensure practices were up to speed through investment in training and through staff cascading their skills, such as those qualified in the Brent GP insulin initiation scheme, and through peer pressure to raise standards, however most practices were scoring above the national average. Dr Sarah Basham advised that many GPs in the borough were already insulin initiation scheme trained, however the process of initiating a patient was a lengthy one and required regular contact with the patient. Where practices could not provide a particular service, they could facilitate access to those that could.
Rachel Donovan (NHS England) added that those practices that were underperforming would be assessed to identify the underlying reasons for this and then given the appropriate tools to be able to improve. She confirmed that GP practices were remunerated for providing diabetes services under the QOF and that the total spend on this could be provided.
The Chair stated that the committee had felt that more information in future reports was necessary in order for effective scrutiny to be able to take place, including financial details. The Chair added that a description of the type of information that members wished to be provided at future meetings would be sent to the council’s Public Health Team and Brent CCG. She also requested further details in respect of the diabetes service redesign from April 2014.
Supporting documents:
- 1-Diabetes - covering report - covering report, item 4. PDF 55 KB
- 1-Diabetes_HOSC V1 Jan 2013, item 4. PDF 501 KB