Systematically Addressing
Health Inequalities in Diabetes
Care
The ‘Christmas Tree’ Diagnostic
Model
National Support Team Health Inequalities
Commissioning for Best Outcomes
Population Focus
Optimal
Population
Outcome
Challenge to Providers
The diagnostic model will support the systematic
delivery of the best health outcomes from a
given set of interventions.
It is based on the assumption that the aim is to
achieve optimal health improvement at
population level, embracing minimal health
inequalities.
Commissioning for Best Outcomes
Population Focus
10. Supported selfmanagement
This side of
diagram
9. the
Responsive
Services
shows aspects
of service
provision that
7. Expressed
Demand
will influence
achievement
of best service
Optimal
Population
Outcome
Challenge to Providers
13.Networks,leadership
and coordination
4. Accessibility
2. Local Clinical
Effectiveness
outcomes
from a
6.Known
particular set
Population
of
Health
Needs
interventions
5. Engaging the
public
12. Balanced Service Portfolio
8. Equitable Resourcing
11.Adequate Service Volumes
1.Known
Intervention
Efficacy
3.Cost Effectiveness
Commissioning for Best Outcomes
Optimal
Population
Outcome
13. Networks, Leadership
and Co-ordination
Services should be based where
possible on strong evidence.
However, efficacy, based on
experimental trials must
translate into effective local
intervention.
This must be constantly
checked through local audit and
systems of governance.
Challenge to Providers
5. Engaging
the public
4. Accessibility
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
3.Cost Effectiveness
Commissioning for Best Outcomes
Challenge to Providers
To have the maximum impact on mortality
and morbidity, as many patients with diabetes
should be assessed and managed for the
following:
•Still smoking
•Raised BP
•Raised cholesterol
•Raised HbA1c
•possible benefit from low-dose aspirin
Attention should be given to ensuring that
patients have been assessed and controlled
for all, not just one or two
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
Commissioning for Best Outcomes
Challenge to Providers
Are diabetes registers being used to identify
potential for multiplicative risk reduction in
relation to:
•Smoking cessation support?
•Alcohol harm reduction?
•Physical activity?
•Cold/damp housing; fuel poverty in the
elderly?
Is there a focus on outcome, rather than
referral; is professional support assertive; is
there a menu of support options based on
social marketing/insight research?
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
F840
F84004
F84006
F84009
F84010
F84014
F84017
F84022
F84032
F84047
F84050
F84052
F84053
F84070
F84074
F84077
F84086
F84088
F84089
F84090
F84091
F84092
F84093
F84197
F84121
F84624
F84631
F84641
F84642
F84654
F84657
F84658
F84660
F84661
F84662
F84666
F84669
F84670
F84671
F84672
F84673
F84677
F84679
F84681
F84799
F84700
F84706
F84707
F84708
F84713
F84717
F84722
F84724
F84727
F84728
F84729
F84730
F84734
F84735
F84736
F84739
F84740
F84741
F84742
Y00 2 49
25
A PCT with problems
DM 6 - % patients whose HbA1C <= 7.4 (measured in last 15 months)
100%
80%
60%
40%
20%
0%
Practice code
Target Met
Target Missed
Exception coded
Target Met
Target Missed
Practice code
Exception coded
A88 0
18
A88 6
15
A88 6
14
A88 6
13
A88 6
11
A88 6
08
A88 6
03
A88 6
01
A88 0
25
A88 0
24
A88 0
23
A88 0
22
A88 0
20
A88 0
16
A88 0
15
A88 0
14
A88 0
13
A88 0
12
A88 0
11
A88 0
10
A88 0
09
A88 0
08
A88 0
07
A88 0
06
A88 0
05
A88 0
04
A88 0
03
A88 0
02
A88 0
01
South Tyneside
DM 20 - % patients whose HbA1C <= 7.4 (measured in last 15 months)
100%
80%
60%
40%
20%
0%
N820
N82001
N82002
N82003
N82004
N82009
N82011
N82014
N82018
N82019
N82021
N82022
N82024
N82026
N82033
N82034
N82035
N82036
N82037
N82039
N82041
N82046
N82048
N82049
N82050
N82051
N82052
N82053
N82054
N82058
N82059
N82060
N82062
N82065
N82066
N82067
N82070
N82073
N82074
N82076
N82077
N82078
N82079
N82081
N82082
N82083
N82084
N82086
N82087
N82089
N82090
N82091
N82092
N82093
N82094
N82095
N82097
N82199
N82100
N82101
N82103
N82104
N82105
N82106
N82107
N82108
N82109
N82110
N82113
N82115
N82116
N82617
N82617
N82619
N82621
N82623
N82633
N82641
N82642
N82645
N82646
N82647
N82648
N82649
N82650
N82651
N82655
N82657
N82659
N82662
N82663
N82664
N82665
N82668
N82669
N82670
N82671
N82676
N 78
Y08021679
10
Spearhead PCT where insufficient focus on BP management
in patients with Diabetes
DM 12 - % patients whose BP <= 145/85
100%
80%
60%
40%
20%
0%
Practice Code
Target Met
Target Missed
Exception coded
Commissioning for Best Outcomes
Challenge to Providers
Is there a strong focus on
performance management of
QOF outcomes, with
verification sampling where
maximum points are
claimed, and recovery plans
where outcomes are suboptimal?
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
Commissioning for Best Outcomes
Challenge to Providers
Is there a diabetes
‘dashboard’ of key
information by practice
bringing together actual v
expected register numbers,
QOF outcomes data,
prescribing data, and
selected hospital admission
data, all compared with the
district averages (z-score), is
seen to be an effective tool
for change
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
Commissioning for Best Outcomes
Challenge to Providers
Are there teams of specialist
professionals working in the
community to support improved
management of diabetes by
primary care, maintaining
updated manuals, guidelines and
protocols; ongoing induction and
professional development
training; action planning
support; evaluation and audit;
assistance on procurement ,
maintenance and effective use of
equipment?
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
Commissioning for Best Outcomes
Challenge to Providers
Where standards are patchy, best practice engages
primary and secondary care together as a
compensatory system:
• Where primary care cannot offer fully effective
care for all patients, this is recognised in a
scaled accreditation system eg L1 L5.Intermediate/ secondary services then
provide the missing elements proactively.
• All patients can therefore receive effective and
comprehensive care. Incentives should support
development up the competency scale, which is
supported by primary and secondary care
practitioners working closely together providing
shared care in the community.
• The whole system should share responsibility
for population level outcomes eg in QOF. This
information should be available to all involved.
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
CHD Equity Audit 2006
Selected measures by z scores
Example of a good practice
2.5
4.6
4.3
3.9
3.3
2.0
1.5
Z SCORE
1.0
0.5
0.0
-0.5
-1.0
-1.5
A3
A4(a)
Measures of Need
B1
B2
B3
B4
Primary Care
Indicator
C1
C2
C3
C4
Secondary care
CABG/PTCA
Cardiac
Outpatients
Acute MI
Heart Failure
Angina
ACE Inhibitor
Statin
Beta Blocker
A4(c)
Aspirin
A4(b)
who smoke
CHD Register
Crude Rate
CHD Mortality
% aged 75+
A2
% CHD patients
A1(b)
CHD Register
Standard Ratio
A1(a)
IMD
2004
20% deprived
-2.0
D1
Tertiary
Care
Commissioning for Best Outcomes
Challenge to Providers
2. Local Clinical
Effectiveness
Interventions need to be affordable
to treat all those who could benefit,
and cost beneficial , justifying the
opportunity cost against alternative
ways to spend
1.Known
Intervention
Efficacy
3.Cost Effectiveness
Commissioning for Best Outcomes
Challenge to Providers
2. Local Clinical
Effectiveness
Has there been for diabetes, a
prescribing cost-versus-QOF
outcomes analysis by practice
with tailored support to change
for poor performers
1.Known
Intervention
Efficacy
3.Cost Effectiveness
Fig 7a - Prescribing Costs per Diabetic Pt (Apr 06-Mar 07) v Percentage of diabetic patients whose HbA1C
has been 7.4 or less in the last 15 months (Apr 06-Mar 07)
80
75
Higher % pts at target - Low prescribing
25
Higher % pts at target - High prescribing
70
% target met
21
17
65
13
1
14306
60
28
5
26
22
55
32
33
50
4
20
15 8
45
23
29
19
16
107
2
24
27
12
31
40
11
9
3
18
35
Low er % pts at target - Low prescribing
30
£150
£200
Low er % pts at target - High prescribing
£250
£300
NIC (£) per diabetic patient
£350
£400
£450
Commissioning for Best Outcomes
Challenge to Providers
Bringing services closer to
patients and communities may
substantially improve uptake,
presentation and utilisation.
Patient pathways should be
designed with this in mind.
However, there will possibly be
tradeoffs between effectiveness,
as interventions are moved
away from specialists and
specialist facilities, and cost
effectiveness if the efficiencies
of centralisation are lost.
4. Accessibility
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
3.Cost Effectiveness
Commissioning for Best Outcomes
Challenge to Providers
5. Engaging the
Public
Appropriate
Utilisaion
4. Accessibility
Delivery systems for interventions should be
based around, and directly respond to, the
needs and wants of the person, rather than the
person having to fit around the needs of the
service.
Patient and community inputs should be drawn
in systematically, not as a tokenistic add-on.
Addressing Diabetes Inequalities through
Community Engagement
Support patient selfmanagement and
empowerment, targeting
those not achieving treatment
goals. Facilitating links to
other supports where
necessary
Raising community awareness
of key health messages about
prevention/early identification.
Case finding and linking to
life-style and primary care
services
Coordination of inputs and
output with strategic
approach to Community
Engagement
Improve the skills of primary
and specialist care
professionals to better meet
the needs of patients and
make the links to lifestyle
change support resources
Outreach to identify reasons
for non-engagement with
services. Advocacy to improve
accessibility of clinical care
and ongoing quality of
services
Commissioning for Best Outcomes
Population Focus
Challenge to Providers
5. Engaging the
Public
10. Supported selfmanagement
9. Responsive Services
13.Networks, Leadership
and Coordination
7. Expressed Demand
Attention given to this array of
provider-side aspects of delivery
6.Known
should
produce good health service
Populationoutcomes.
Health Needs
However, good population health
outcomes will not be achieved
also
addressing the way
8.without
Equitable
Resourcing
communities use the service.
4. Accessibility
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
3.Cost Effectiveness
Commissioning for Best Outcomes
Population Focus
10. Supported SelfManagement
9. Responsive Services
7. Expressed Demand
6.Known
Population
Health Needs
8. Equitable Resourcing
13. Networks, Leadership
And Co-ordination
It is now possible to get good estimates
of health need, either from census, local
survey, extrapolation from national
surveys or, increasingly, from local
clinical systems. Geographical systems
can map down to tailored
neighbourhoods, census output areas
and population quintiles.
There are still problems of obtaining
good intelligence by ethnicity and other
social groupings.
Commissioning for Best Outcomes
Population Focus
a) Neighbourhood Cluster Types eg:
• Older large estates
• New estates
• Rural and small towns
• Ex-Coalfields communities
• Mixed young families
6.Known
Population
Health Needs
• Established non-caucasian ethnic
• Mobile young
b) Segmentation Groups
Commissioning for Best Outcomes
Population Focus
7. Expressed Demand
6.Known
Population
Health Needs
One of the major problems of
obtaining optimal population
health outcomes from service
delivery is that people in
deprived circumstances often do
not present with major health
problems until too late.
Barriers to presentation include
structural issues such as poor
access and transport; language
and literacy problems; poor
knowledge; low expectation of
health and health services; fear
and denial , and low self esteem.
Commissioning for Best Outcomes
Population Focus
7. Expressed Demand
6.Known
Population
Health Needs
Is there a systematic and ongoing
strategy to include as many
people as possible with
established disease onto Diabetes
registers?
Actual numbers compared to
estimates of expected numbers
by practice
Systematic strategies to ‘sweat
the asset’ of practice records to
identify patients with disease
Variety of ‘segmented’ options to
identify patients in the
community, scaled up
appropriately
Spearhead PCT – Registration Gaps for Major Conditions
Expected v Registered Prevalence of major QOF conditions
PCT Registered
PCT Expected
25%
22.4%
20%
15%
10%
5.1%
4.95%
12.5%
5%
4.2%
3.6%
0%
Coronary Heart Disease
Hypertension
Diabetes
Blackburn with Darwen
This PCT has been able to to close the register gaps for CVD and Diabetes
Expected v Registered Prevalence of major QOF conditions
35%
PCT Registered 16+
PCT Expected
30%
28.7%
25%
20%
15.0%
15%
10%
5.5% 5.5%
4.6% 4.6%
5%
2.5% 3.1%
0%
Coronary Heart
Disease
Hypertension
Diabetes*
COPD
Diabetes Prevalence
GP Practice prevalence compared to locally expected prevalence by ward
7%
% prevalence
6%
5%
4%
3%
2%
1%
0%
Amber
Valley
Bolsover
Chesterfiel
d
Derbyshire
Dales
Erew ash
High Peak
Practices by district
QOF Prevalence
Expected Diabetes Prevalence
North East
Derbyshire
South
Derbyshire
Expected v Registered Prevalence of major QOF conditions
25%
22.9%
20%
15%
PCT Registered
PCT Expected
10%
5.2%
4.5%
11.9%
5%
4.2%
3.7%
0%
Coronary Heart
Disease
Hypertension
Diabetes
National Support Teams
NHS Bolton
Dr.S.Liversedge
Bolton 2008/09
Expected v Registered Prevalence of major QOF conditions
35%
PCT Registered 16+
31.0%
PCT Expected
30%
National Support Teams
25%
20%
16.4%
15%
10%
5%
4.6%
6.1%
4.8% 4.7%
4.8%
2.5%
0%
Coronary Heart
Disease
Hypertension
Diabetes*
COPD
National Support Teams
The activity has continued, with the latest figures, for January,
continuing the trend.
It is estimated that 83-85% of all patients would have been assessed
by end March 2009
The figures also show that practices in the more deprived
neighbourhoods have been supported to achieve the best results:
Deprivation Score No. Practices % Assessed
>40
14
79.4
30-39
18
73.7
20-29
12
75.2
<20
11
74.3
It
Commissioning for Best Outcomes
Population Focus
7. Expressed Demand
6.Known
Population
Health Needs
8. Equitable Resourcing
In order to achieve equitable outcomes
for deprived populations, resources
applied need , firstly, to be proportionate
to need . But they also need
disproportionate supplements to reflect
the extra effort and support required.
Commissioning for Best Outcomes
Population Focus
6.Known
Population
Health Needs
8. Equitable Resourcing
Is there a local mechanism to
‘raise the bar’ beyond QOF
maximum for target outcomes, for
Diabetes measures. Where extra
incentives are used, do they
recognise the disproportionate
effort/resource to achieve
outcomes in disadvantaged
elements of the register
population ( e.g. using
exponential incentives )
Commissioning for Best Outcomes
Population Focus
9. Responsive Services
7. Expressed Demand
6.Known
Population
Health Needs
8. Equitable Resourcing
When patients do express demand
and present for service
appropriately, and with resources
targeted and available, services
should respond actively to channel
them effectively to interventions
they will benefit from.
This should happen regardless of
entry point chosen.
Patients should receive culturally
sensitive help to navigate to
relevant service, and should be
followed up to ensure arrival and
engagement.
F840
F84004
F84006
F84009
F84010
F84014
F84017
F84022
F84032
F84047
F84050
F84052
F84053
F84070
F84074
F84077
F84086
F84088
F84089
F84090
F84091
F84092
F84093
F84197
F84121
F84624
F84631
F84641
F84642
F84654
F84657
F84658
F84660
F84661
F84662
F84666
F84669
F84670
F84671
F84672
F84673
F84677
F84679
F84681
F84799
F84700
F84706
F84707
F84708
F84713
F84717
F84722
F84724
F84727
F84728
F84729
F84730
F84734
F84735
F84736
F84739
F84740
F84741
F84742
Y00 2 49
25
A PCT with problems
DM 6 - % patients whose HbA1C <= 7.4 (measured in last 15 months)
100%
80%
60%
40%
20%
0%
Practice code
Target Met
Target Missed
Exception coded
Commissioning for Best Outcomes
Population Focus
9. Responsive Services
7. Expressed Demand
6.Known
Population
Health Needs
8. Equitable Resourcing
Is there a Diabetes QOF
Exception Strategy, with clear
transparent interpretation of
criteria, regular monitoring of
outlier levels, and a strongly
enforced validation process,
including notes audit?
Gateshead - Total QOF Scores by Practice
N820
N82001
N82002
N82003
N82004
N82009
N82011
N82014
N82018
N82019
N82021
N82022
N82024
N82026
N82033
N82034
N82035
N82036
N82037
N82039
N82041
N82046
N82048
N82049
N82050
N82051
N82052
N82053
N82054
N82058
N82059
N82060
N82062
N82065
N82066
N82067
N82070
N82073
N82074
N82076
N82077
N82078
N82079
N82081
N82082
N82083
N82084
N82086
N82087
N82089
N82090
N82091
N82092
N82093
N82094
N82095
N82097
N82199
N82100
N82101
N82103
N82104
N82105
N82106
N82107
N82108
N82109
N82110
N82113
N82115
N82116
N82617
N82617
N82619
N82621
N82623
N82633
N82641
N82642
N82645
N82646
N82647
N82648
N82649
N82650
N82651
N82655
N82657
N82659
N82662
N82663
N82664
N82665
N82668
N82669
N82670
N82671
N82676
78
N
Y08021679
10
Another Spearhead PCT - QOF Scores by Practice
Analysis of QOF Non-Clinical Points earned by GP Practice
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Practice Code
Points Earned
Points Missed
Liverpool
QOF % non-clinical points
achieved
QOF non-clinical score by GP practice and deprivation
100.0
95.0
90.0
85.0
80.0
75.0
70.0
65.0
60.0
55.0
50.0
0.0
20.0
40.0
60.0
Ward deprivation score (2004)
80.0
Commissioning for Best Outcomes
Population Focus
10 Supported Selfmanagement
9. Responsive Services
Appropriate
Utilisation
7. Expressed Demand
Commissioners
and providers should ensure
6.Known
that patients are empowered to make
Population
informed choices about their treatment, and
Health Needs
are educated and supported to utilise
treatments and therapies to best effect.
This should take into account factors such as
8. Equitable Resourcing
literacy, language, culture and IQ.
Commissioning for Best Outcomes
Population Focus
10. Supported Selfmanagement
9. Responsive Services
Appropriate
Utilisation
Is the provision of self-management
training scaled-up so as to be able to offer
support to all newly diagnosed patients
with diabetes? Is there a menu of quality
assured options, designed with insight
into the preferences of the main range of
segmental groups?
Commissioning for Best Outcomes
Challenge to Providers
Population Focus
5. Engaging the
Public
10. Supported Selfmanagement
9. Responsive Services
Appropriate
Utilisation
2. Local Clinical
Effectiveness
7. Expressed Demand
6.Known
Population
Health Needs
8. Equitable Resourcing
4. Accessibility
Appropriate utilisation of
service by the
population may require
adjustments to supply.
1.Known
Intervention
Efficacy
3.Cost Effectiveness
Commissioning for Best Outcomes
Population Focus
Challenge to Providers
Capacity of services needs to be
commissioned to accommodate appropriate
demand while meeting national standards.
Service pathways should be balanced to
avoid bottlenecks and engineered to
allow smooth and efficient progress.
12. Balanced Service Portfolio
8. Equitable Resourcing
11.Adequate Service Volumes
3.Cost Effectiveness
Workforce planning
• Is there PCT support to practices in developing a
sustainable workforce, with appropriate skill mix to
maintain effective, efficient and affordable register
management, recognising the industrial scale of activity
– Modelling of person-hours of activity necessary by
practice per annum
– Modelling of necessary workforce, with skill-mix
review
– PCT/PBC alliance commissions training eg of NVQ3
Care Technicians, for subsequent employment by
practice/practice cluste
Commissioning for Best Outcomes
Population Focus
Challenge to Providers
13.Networks,leadership
and coordination
6.Known
Population
Health Needs
1.Known
Intervention
Efficacy
Commissioning for Best Outcomes
Population Focus
10. Supported Selfmanagement
9. Responsive Services
7. Expressed Demand
6.Known
Population
Health Needs
=
Optimal
Population
Outcome
Challenge to Providers
+
+
+
13. Networks, Leadership
and Co-ordination
+
12. Balanced Service Portfolio
8. Equitable Resourcing
11.Adequate Service Volumes
5. Engaging the
Public
4. Accessibility
2. Local Clinical
Effectiveness
1.Known
Intervention
Efficacy
3.Cost Effectiveness