SYMPOSIUM REPORT BY:
Dr Milan K Piya
Academic Clinical Fellow
WISDEM, University Hospitals Coventry and Warwickshire NHS Trust
& Division of Metabolic and Vascular Health
Warwick Medical School, University of Warwick
TACKLING GRAND CHALLENGES OF DIABETES 2012:
“HIGH QUALITY, COST-EFFECTIVE SPECIALIST DIABETES CARE
IN THE COMMUNITY”
This is a meeting report from the WISDEM and Warwick Medical School Annual
Clinical Symposia Series held on 27th September, 2012. This meeting is part of a
series of annual meetings held to try and tackle grand challenges in diabetes care,
and is an independent series of meetings supported and organised by the
Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism
(WISDEM) in University Hospitals Coventry and Warwickshire NHS Trust in
partnership with Warwick Medical School, University of Warwick. The theme this
year in these times of austerity and changing NHS structure, was the provision of
high quality, cost-effective diabetes care in the community.
This symposium aimed to bring together a collection of leading experts in the field
from around the country to talk about their experiences using various models of
specialist diabetes care in the community, and discuss examples of success and
hurdles in achieving this success. There was an opportunity for the panel to weigh
the pros and cons of some of the models discussed and for the audience to ask
questions to help the delegates design or modify the diabetes service provision in
their local community to make it high quality and cost-effective.
Chair of the meeting, Professor Sudhesh Kumar, Pro Dean (Research) of Warwick
Medical School welcomed the delegates to the symposium and explained the scope
and purpose of this symposium. Professor Peter Winstanley, Dean of Warwick
Medical School, described the challenges with the rising diabetes population, as well
as the importance of high quality cost effective care.
Dr Roger Gadsby, associate clinical professor at Warwick Medical School was
invited to give a plenary lecture on Models of specialist care in the community:
Priorities for community aspects of diabetes care. Dr Gadsby illustrated his first
point by talking about one of his mentors, Professor Malins, who had worked in the
General Hospital in Birmingham and had seen around 12,000 new cases of diabetes
over a 24 year period - around 500 a year! He also visited various GP practices and
had built a rapport with the local GPs as well as practice nurses. However, as Dr
Gadsby pointed out, looking after all patients with diabetes in secondary care is
neither feasible nor cost effective, especially with the hugely increasing number of
patients with diabetes. Equally, the care of patients with diabetes was quite
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challenging in the community, given the large number of GPs and practice nurses
and wide variation in care, as well as a poor interface between primary and
secondary care in many regions. The initiation of insulin and GLP-1 therapy in
primary care had created a huge shift in practice from a previous culture where all
insulin starts were done in secondary care. He also discussed the impact of
incentivising improvements in care, like the Quality Outcomes Framework (QOF),
and increased training of primary care staff in the management of diabetes,
acknowledging the difficulties with the cuts in staff education budgets in primary as
well as secondary care being the most vulnerable when it came to cost cutting.
Various models of care he discussed, included a model that Prof Malins had used
whereby the consultant diabetologist employed by secondary care visited GP
practices and built relationships with healthcare professionals in primary care. He
saw patients as well as provided educational support to staff. Another model was for
primary care to employ the consultant diabetologist. A further model was the use of
GPs with specialist interest (GPSI) to lead the service, and this could be coupled
with employing diabetes specialist nurses to work in the community. The final model
was the use of intermediate care clinics with the use of diabetes specialist nurses,
podiatrists, dieticians and GPSIs with or without consultant diabetologists but the
cost effectiveness would depend upon the number of people seen as well as the
length of the consultations. Each model has its own merits and drawbacks and
different ones may be appropriate in different regions.
Dr Gadsby also highlighted the important role of NHS Diabetes in providing national
leadership for diabetes care, tackling unacceptable variation in care, supporting local
improvement, and championing audit into action. Key priorities for community care of
diabetes were the need for integration of primary and secondary care, high quality
care from GPs, annual retinal screening, appropriate foot care and a seamless
pathway for referral to secondary care. In conclusion, a person with diabetes should
see the right healthcare professional at the right time, overcoming NHS barriers, and
that healthcare professionals should respect each other’s expertise and work
together in partnership to develop a suitable model of care that was cost effective in
their local area.
Professor Andrew Boulton, from the University of Manchester and Miami, was then
invited to give the Jeff Goulder Memorial Lecture on The Diabetic Foot in 2012.
Prof Boulton started by highlighting the increased mortality in patients with diabetes
a foot ulcer, and talked about the importance of Prevention, Identification, Treatment
and Service (PITS) in the management of the diabetic foot. He also discussed the
Eurodiale study which is a multicentre trial across 14 European sites across 10
countries where 49% had peripheral vascular disease, 58% had foot infection and
31% had both. In diabetic foot ulcers, >80% of ulcers were preventable. However, a
recent study showed no reduction in amputations in England between 2004 and
2008 (Vamos et al 2010 Diabetes Care).
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He stressed the importance of screening in the prevention of foot ulcers, and how
there was no need for an expensive test to diagnose an ‘at risk neuropathic foot’.
The American Diabetes Association (ADA) produced recommendations for
assessment of neuropathy which Prof Boulton had been involved in writing, which
advises the use of a 10 gram monofilament test at 4 sites in addition to one of tuning
fork sensation, pinprick sensation, ankle reflex or use of a biothesiometer. Other
more recently proposed assessments included the Ipswich Touch Test which was
found to be as good as the 10 gram monofilament, and also free of cost and quick
(Rayman et al 2011 Diabetes Care). The vibratip was portable and reliable, and the
neuropad which tested for loss of sweating which is known to be a predictor of foot
ulceration. The importance of foot care on a dialysis unit was stressed, given that
patients with end stage renal disease on dialysis were four times as likely to have a
foot ulcer, and those with a foot ulcer had a higher mortality than those without.
In the management of the diabetic foot, Prof Boulton reiterated the importance of a
multidisciplinary foot team, and gave the example of Ipswich where there had been a
62% reduction in amputation over the course of 11 years after an introduction of a
foot team. He highlighted the importance of off loading and debridement in wound
healing. He questioned the evidence of hyperbaric oxygen, and thought it may be
useful in an adjunct in chronic ischaemic feet not amenable to vascular surgery.
Other adjuncts in wound healing he discussed included negative pressure wound
healing (VAC therapy) and larvae therapy, although he felt that the type of dressing
didn’t affect wound healing. He stressed the importance of hand washing to reduce
infection, especially MRSA infection and ended by reemphasising the importance of
a multidisciplinary foot team working to prevent and treat diabetic feet.
Professor Norman Waugh then enlightened the audience on how Cost Effective
Care in Diabetes was determined. He set the scene by quoting recent data that
diabetes accounted for 10% of the healthcare budget, with 2010/2011 estimates
around £9.8 billion in the UK (Hex et al Diabetic Medicine 2012). 78% of that cost
was for treating complications and 21% was for the treatment and management of
diabetes. The Health Technology Assessment (HTA) has an important role where
there is a limited health care budget coupled with the fact that there are more
clinically effective interventions than could be afforded. HTA has a role in helping
decide whether a treatment works, at what cost and whether it is cost-effective.
Finally for NHS policy makers, the most important answer to the question - should
we provide it?
Prof Waugh then described postcode prescribing prior to 1995 which improved
slightly with the development of regional HTA units in Trent, West Midlands, Wessex
and Scotland, and further improved with the arrival of the National Institute for Health
and Clinical Excellence (NICE) in 1999. He then talked about Warwick Evidence,
which is an academic group based in Warwick Medical School consisting of a
multidisciplinary team of systematic reviewers, information scientists, health
economists, statisticians, public health consultants and access to clinical experts as
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required. The interest areas of Warwick Evidence were diabetes, screening and
prostate disease. The difficulties associated with a technology assessment report
include the intensity of scrutiny, corporate tantrums, orchestrated campaigns as well
as lack of evidence. He cited examples of inhaled insulin, insulin pump therapy and
GLP-1 therapy as case studies of technology appraisals, and stressed the
importance of quality of life data to support certain interventions that may not have a
huge benefit when assessed clinically, for example insulin pump therapy.
Therapies in diabetes known to be cost-effective were discussed including bariatric
surgery, prevention of diabetes in people with IGT, retinal screening and
photocoagulation. He stressed that the biggest challenge in diabetes care was ‘How
to persuade people to reduce weight and increase activity’ citing the strong evidence
linking Type 2 diabetes and weight/lifestyle. In summary, Health Technology
Assessments involved making a decision as to whether or not an intervention was
cost effective, and that the greatest problem arose when an intervention was
clinically effective but not cost effective. Prof Waugh stated that the goal of health
technology appraisals were to improve health, by facilitating the prompt uptake of
beneficial new treatments, and inhibiting the introduction of new treatments that are
not cost effective, so allowing the funds to be better allocated.
The next session was a series of case studies on models of care, chaired by Dr
Richard Hancox, Programme Director, Sustainable Specialities and Transformation.
The following models were discussed Jill Hill, Diabetes Nurse Consultant described the Birmingham Community
Diabetes Service. Difficulties in East Birmingham PCT in 2003 were
discussed including a high South Asian population, very high level of
deprivation and 32 of the 59 GP practices being single handed with a huge
variation in standard of care. The Kaiser Permanante model from California
had been adopted to tackle this by providing patient and healthcare
professional education, agreeing on local diabetes guidelines, producing
collaborative referral criteria, creating a local enhanced service, delivering
community clinics by healthcare professionals fluent in South Asian
languages, and employing practice nurses with a special interest in diabetes
to try and improve standard of diabetes care and reduce variation.
 Dr Gillian Hawthorne, Consultant Diabetologist described the Newcastle
model with initial difficulties similar to Birmingham with high social deprivation
and a large ethnic minority population in 2001. The main goal was to stratify
patients so that annual reviews and uncomplicated patients with type 2
diabetes were cared for by primary care, and referral criteria were agreed to a
community assessment clinic. Clinical guidelines were agreed for all aspects
of diabetes care, and there was a fast track for pregnancy, foot ulcers and
newly diagnosed type 1 diabetes. An example of their success was the retinal
screening program in Newcastle where 100% patients were invited and 82%
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attended. Diabetes was no longer found to be the commonest cause of
blindness in the working age population in Newcastle (Arun et al 2009
Diabetic Med). The caseload of the podiatry had changed drastically from
2001 to 2009, with an increasing complexity in cases thought to be because
the practice nurses were assessing the low risk feet during annual reviews.
The introduction of SystmOne, a paperless electronic record system that
allowed communications between podiatry, community nursing, walk in centre
and 40% of GP practices was another aid to streamlined services. 85% of
patients with type 2 diabetes are now managed in primary care, and the
strengths of the model were that it was based in the community with good
relationships with primary care and commissioner buy in, a block contract and
stability between 2001 and 2009.
 Professor David Simmons described the Diabetes Integrated Care Initiative in
North Cambridgeshire and Fenland. The goal of the intervention was to
reduce hospital admissions in people with diabetes by identifying high risk
patients and managing them, and at the same time providing broad care to all
patients with diabetes and training staff. The local area was an area with poor
outcomes, and no single responsible hospital. The three year intervention
started in 2007, and there was funding for extra healthcare professional time
so that there was better coverage of GP practices with dietetic and podiatry
services, as well as multidisciplinary team meetings in various practices
including Doddington and Ely. He described a drop in HbA1c from 9.7% to
8.4% as well as a reduction in weight from 95 to 90kgs in 6 months (Hollern,
Simmons 2001 Primary Care Diabetes). However, there was no reduction in
hospital admissions following this intervention.
 Professor Andrew Wilson from the University of Leicester then described the
cluster randomised trials of Intermediate Care Clinics for Diabetes (ICCD)
study in Leicester and Warwickshire. This was run across 3 PCTs with a short
term nurse led and consultant supported input focussing on glycaemic and
cardiovascular risk factor control, and the aim was to compare GP practices
that had access to ICCD with those that provided normal care. Over an 18
month period in 49 GP practices, there was no significant difference in HbA1c
and no obvious cost benefit of running ICCD. Dr Paul O’Hare from Warwick
Medical School then discussed the ICCD sub-studies which showed that there
were small benefits in each area but no major difference overall.
This session was followed by a panel discussion where the apparent success of the
Birmingham and Newcastle model was compared to the lack of clear benefits in the
Cambridgeshire and ICCD models which were a lot shorter in duration. The
speakers agreed that it was probably too short to assess the outcomes that were
studied and further work was required in this area.
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Dr Amanda Adler, consultant physician in Addenbrooke’s Hospital as well as chair of
the NICE technology appraisal committee, was then invited to deliver her keynote
lecture: What is NICE doing to inspire good diabetes care, and is it working?
She discussed 8 aspects of the role of NICE on the impact of diabetes in the UK.
The first aspect was that NICE was inspiring lower drug prices through the role of
technology appraisals as well as the Pharmaceutical Price Regulation Scheme
(PPRS). She cited a recent example where the drug Ranibizumab (Lucentis) for the
treatment of diabetic macular oedema had been agreed at a lower cost to the NHS
following a technology appraisal and negotiation with the maker of the drug. The
second aspect was the use of NICE guidelines when recommended practice differs
from actual practice. The NICE guidelines on newer agents shows how the cost per
QALY of the insulins Lantus and Detemir compared to NPH were not cost effective,
and therefore NICE had not recommended them as a cost effective treatment,
although there is current widespread use of these two insulins costing the NHS
billions. The third role of NICE discussed was the NICE Quality Standard for
diabetes care that was inspiring collection of data nationally. DiabetesE is a web
based, self assessment, diabetes care performance improvement tool to support the
implementation of the Quality Standard.
Dr Adler then talked about Quality Outcomes Framework (QOF) which had been
under the remit of NICE since 2009 and how this had led to improvements in
diabetes care. The net benefit of QOF was the monetary benefit from which the
delivery cost and QOF payment was subtracted and certain QOF clinical targets
were under review for their cost effectiveness. The fifth aspect was the Scientific
Advice Programme which is the ‘fee for advice’ service that NICE advises
manufacturers jointly with the European Medicines Agency. The next aspect was
helping clinicians learn about drugs on the horizon via the NICE Medicines and
Prescribing Centre, formerly the National Prescribing Centre which is now under the
remit of NICE. The seventh aspect was the Topic Selection Consideration Panel
which avoided the commitment of resources to diabetes therapies of low priority. The
final role of NICE was a measure of how well the NICE guidelines were being
implemented using a tool called ERNIE (Evaluation and review of NICE
implementation evidence). Dr Adler concluded that NICE had helped improve the
cost-effectiveness of diabetes care through its various roles.
This was followed by a lively debate on Hospital Specialists are not essential for
good community diabetes care. Dr Vinod Patel, Associate Professor in Warwick
Medical School argued FOR the motion and Dr Wasim Hanif, Consultant Physician
and Honorary Senior Lecturer in University of Birmingham argued AGAINST the
motion. With good humour and arguments for both sides of the case, it was an
entertaining draw.
Kate Lynch, NHS Project Manager for Healthcare at Home Ltd started the final
session by talking about Diabetes Service Review South Warwickshire. Phase 1 had
recently been completed where there had been a review of the cost of 36 patient
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journeys into A&E, inpatients, outpatients and diagnostics. There had also been case
studies of patient journeys in primary care along with qualitative interviews of 12 GP
surgeries and quantitative data extraction from GP databases. The plan of Phase 2
was to assess the cost effectiveness of four streams: education, care planning,
prevention of long term complications as well as systems before further steps to
provide cost effective healthcare at home.
Professor Robert Istepanian, Professor of Data Communications from Kingston
University London then talked about the role of mobile healthcare (m-health)
technology in improving diabetes and obesity management. Advances in mobile
technology now allowed improvements in the proposed m-health interventions, with
specific advantages of sending timely reminders and informing patients of their
results in real time. This could improve patient compliance and help change lifestyle
and behaviour through patient empowerment. Recent publications from his research
group had demonstrated a reduction in HbA1c and blood pressure in patients with
diabetes using m-health technology compared to control. He also discussed the
results of a meta-analysis of the effect of mobile phone intervention for diabetes and
glycaemic control (Liang et al 2011 Diabetic Medicine). Of the 22 trials selected with
over 16,000 patients, 9 trials were for Type 1 diabetes and 10 were for Type 2
diabetes. He concluded that the results provided strong evidence that mobile phone
intervention resulted in statistically significant improvement in glycaemic control and
self management, especially in Type 2 diabetes patients.
Professor Jeremy Wyatt, Professor of eHealth Innovation in The University of
Warwick highlighted the importance of sharing data records with patients and
between health and social care services to support integrated care. The Power of
Information published by the Department of Health in May 2012 had a 10 year
framework to integrate health and social care and inform patients, with a statement
‘No decision about me without me’. The SCI-DC was a successful example of
electronic health records which holds records of over 250,000 patients with diabetes
in Scotland. This information is accessible to secondary care clinics as well as
podiatrists, dieticians, retinal screeners and researchers. My Diabetes My Way, was
a portal for patients with diabetes in Scotland but the uptake had been less than
anticipated. The Veterans Affairs (VA) systematic review of patient electronic health
records, published in July 2012 showed low grade evidence that patient access to
own records may improve health outcomes in long term conditions like diabetes. He
concluded by emphasising that there was strong NHS pressure for data sharing, and
that diabetes care involved multiple agencies making it more important to share data.
Patient electronic health records may help patients with diabetes and it was
important to formulate what data needed to be shared, with whom and in what
format.
The final talk of the day was delivered by Dr Partha Kar, Consultant Diabetologist at
Portsmouth. He discussed the Super Six Model that had been adopted for diabetes
care delivery in Portsmouth. The specialist in the Acute Trust looks after six aspects
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of diabetes care- inpatients and perioperative patients, antenatal diabetes, foot care,
insulin pumps, renal clinics and adolescent/type 1 diabetes patients with poor
control. The community diabetes team included an evening telephone service and an
email account with a 24 hour response time to support the care of diabetes in
primary care. The community diabetes team also visited each GP surgery twice a
year to hold virtual clinics (case discussions), in addition to providing education in
diabetes management based on topics requested by the surgeries. This model had
been recognised by national awards including the Care Integration Awards 2012.
Professor Sudhesh Kumar concluded the meeting by emphasising that patients with
diabetes needed access to better standards of care in the community including
specialist care, and that various models discussed during the meeting could be used
or improved to develop a locally suitable integrated model of care, tailored to local
needs. The need for more research to explore efficacy and benefits in terms of
health outcomes and costs was also highlighted.
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