Local Enhanced Service
Integrated Community Diabetes
Service 2011-12
Offered to Cam Health Local Commissioning Group Practices
The aim of the Cam Health commissioned Integrated Community Diabetes Service is
to deliver high quality and cost effective care closer to home. The Service will be
responsive to patient need, enabling them to have equitable access to a range of
professionals to support better self management and resulting in improved long term
outcomes. Timely intervention and improved awareness by patients aims to reduce
the numbers who require hospital referral and follow up, elective and non-elective
admissions and the numbers developing complications.
The model is an Integrated Community Diabetes Service, commissioned by Cam
Health, and has a number of interrelated components:
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A monthly community consultant-led multi-disciplinary clinic to support the
process of moving the care of diabetic patients from the hospital to the
community and the practices
Enhanced support to all practices with strengthened regular input from
Community Diabetic Specialist nurses and dieticians, and the community
Diabetologist, using virtual case discussions particularly of patients with poor
control and/or complications, consultations within the practices and where
needed home visits
The Barriers Framework will be implemented and patients will have access to
personal health planning and enhanced education programmes
Primary care will provide the majority of care for patients with Type 2 Diabetes
and support the care for patients with Type 1 Diabetes. The LES is intended
to support Cam Health practices to engage in the initial implementation of the
Integrated Community Service, and to encourage all Cam Health practices to
fulfil the primary care element of the integrated service to ensure that a
stepped improvement is achieved in management of diabetes patients,
particularly those at most risk.
All the elements formed part of the Cam Health Diabetes Business Case
Contents:
1.
Purpose of Agreement
2.
Duration of Agreement
3.
Introduction – New Policy
4.
Aims
5.
Review / Audit / Evaluation
6.
Health Record
7.
Pricing & Payment Arrangements
8.
Payment Verification
9.
Performance
10.
Protection of Vulnerable Adults (POVA)
11.
Care quality Commission (CQC)
12.
Period of LES, Future Commissioning Intentions and Termination
13.
Signature to the Agreement
Local Enhanced Service (LES)
For Cam Health Integrated Diabetes Service
1. Purpose of Agreement
This Agreement outlines the service to be provided by the Provider, called Integrated
Community Diabetes Service, as a Local Enhanced Service.
2. Duration of Agreement
This agreement is for a period of eighteen months commencing 1st October 2011
and ending on 31st March 2013.
3. Introduction
The service is proposed in the context of the standards set out in the National
Service Framework (NSF) for Diabetes 2002 and National Institute for Clinical
Excellence (NICE) guidance on Diabetes 2008 which set out the clinical targets,
treatment pathways and goals for secondary and primary care.
The model of care is based on the pilot work done in partnership by Cambridgeshire
Community Services NHS Trust and Cambridge University Hospitals NHS FT.
Findings from the evaluation of the service piloted in East Cambs & Fenland
published as “It’s time for integrated care for people with diabetes”, Diabetes
Integrated Care Initiative in East Cambs and Fenland 1 April 2009 – 31 March 2010.
D.Simmons, H.Hollern.
CAM HEALTH GP local commissioning group seek the roll out of the model
described in the Cambridgeshire Diabetes Service Specification (February 2011),
tailored to fit the needs of the people with diabetes within the 8 member practices.
CAM HEALTH cluster of practices has a population of 73,863 (at June 2011) and
2580 people registered with diabetes (at March 2011). The number has increased
over the last three years and is projected to continue increasing due to a growing
population and increased longevity. The cost of treating this cohort of patients in
secondary care in 2010/11 was £3m. There is significant deprivation within the
population served by Cam Health, and it is well known that deprivation is associated
with poorer health outcomes for patients with long term conditions.
Better control of diabetes leads to better health outcomes. The local commissioning
group believes that some of the resources invested in treating the consequences of
diabetes would be better invested in minimising the harmful effects of the disease.
4. Aims
The aim of this LES is to support the provision of a quality integrated community
based diabetes service. The care will be provided closer to home and aims to reduce
the cost of secondary care treatment by providing care within the practices,
community clinic or at home.
The scheme will provide a consistent and quality service through a patient-centred
and collegiate-based approach. Support will be provided for effective selfmanagement of glucose levels, weight and lifestyle changes through education and
personal health plans.
Cam Health intends to put in place robust evaluation. It will be necessary to collect
and analyse data that will aim to support future commissioning decisions, both within
Cam Health and at future Clinical Commissioning Group level. Diabetic patients will
be tracked over time using both hospital data for admissions, practice data with
regard to Emergency Department and Outpatient attendances, and Community Trust
data. There is an assurance that the highest standards of Information Governance
will be introduced and maintained.
The LES would require GP practices offering the service to deliver quality and
consistent care, and to support the evaluation of the programme:
(i)
Diabetic clinical leads to continue with their professional development
in Diabetes of up to 8 hours per practice per annum. This could include
completion of the credentialing framework if Diabetes Manager is
adopted.
(ii)
Review the Practice Diabetes Register to identify patients for who
enhanced assessment and/or support is indicated. This would include
patients with poor control, (including all those with Hba1 of 9% or more)
or who are at higher than average risk or have complications. Patients
will also be identified at their routine reviews.
(iii)
Review these patients in practice virtual review clinics with DSN and
Diabetologist
(iv)
Consider referral of these patients to the community service after doing
all that is normally expected including the development of an action
plan, and record those referrals made at the Virtual Review Clinics
(v)
Provide the facilities for weekly/fortnightly DSN clinics
(vi)
Provide annual fasting glucose tests and weight and blood pressure
checks for patients with IFG, IGT and history of GDM.
(vii)
Offer and support the pilot and evaluation of Co-creating Health’s
Personal Health Plans (PHP) for a small group of high risk patients.
CCH will provide the PHP introduction consultation with the patient and
offer training for a member of your staff.
(viii)
Provide Cam Health with NHS numbers of Diabetic patients registered at
the practice. Such data to be obtained and managed in line with local
Information Governance Standards, and BMA guidance.
In addition, the practices will be fulfilling their obligations that are considered to be
part of essential services according to advice given to the PCT
(ix)
Provide appropriate pre-conceptual advice for females with diabetes of
child-bearing age
(x)
Provide appropriate referrals to patient education programmes such as
DEP or DESMOND
(xi)
Provide support for patients with a BMI over 35 and referrals to
appropriate programmes such as CHIP, Weigh2Go, healthy walking,
gym or other exercise programmes
(xii)
Aim to provide a Diabetes Management Plan for at least 50% of the
Diabetic patients managed by the practice. This will normally be
provided at the Annual Diabetic Review. Such a plan should be agreed
jointly with the patient and identify short and long term goals and where
appropriate, priorities of care.
5. Review / Audit / Evaluation
All practices involved in the scheme will be required to:
(i)
Keep a record of the number of patients reviewed in the virtual clinics,
and the outcomes in terms of changes to management or referral
onwards
(ii)
Support the conduct of agreed audits of patients e.g. those being
prescribed glipitins, exenatide and pioglitazone
(iii)
Keep a record of the numbers of Diabetes patients who have a Diabetes
Management Plan in place.
(iv)
Keep a record of the numbers of patients who have been referred for
exercise or weight management
(v)
Keep a record of the numbers of patients of patients receiving preconceptual counselling
(vi)
Keep a record of the numbers of patients referred for patient education
(such as DEP or Desmond)
Cam Health is able to directly access hospital data for admissions for patients given
a Diabetes code. This is not the case for outpatient or emergency department
attendances, or some community services, so Cam Health will track patients using
the NHS numbers provided by Cam Health practices. In this way, a robust evaluation
process can be set up to monitor this new model over the coming years, and help
future evaluation by commissioners.
6. Health Record
It is expected that the practice will record the care of Diabetic patients in line with
good practice, in the Electronic Health record
Practices need to ensure that the agreed coding is used to record the provision of a
Diabetes Management Plan, and weight management and exercise referral.
Practices must ensure that details of the patients’ monitoring as part of the LES is included
in their life-long record.
7. Pricing and Payment Arrangements
Payment
Credentialing
 Professional
development/educat
ion
Price
£
Payment Process
End of year return
Monitored by
Community Clinical
Systems
CCS reports
 Joint virtual clinics
 Joint practice clinics
with DSNs
Pre-conception care
£ per patient
End of year return
DM prevention work
£ per GP
End of year return
DM Management
Plans
CCH PHP pilot
Data extraction
£ per practice
End of year return
£ per practice
End of year return
Practice clinical
systems
Meeting reports
Practice clinical
systems
Practice clinical
systems
Practice clinical
systems
3 returns annually
8. Payment Verification
Practices entering into this contract agree to participate fully in the post payment verification
/validation process determined by the PCT and LMC. Practices should ensure that they keep
accurate records to ensure a full and proper audit trail is available. Practices are
encouraged to utilise Practice computer systems to enable this condition to be met.
9. Performance
The PCT reserves the right to utilise the GPSIF (GP Service Improvement Framework) to
help inform Enhanced Services Commissioning Intensions from practices. Therefore
evidence of poor performance may result in withdrawal of the ability to provide Enhanced
Services until satisfactory performance can be demonstrated.
10. Protection of Vulnerable Adults (POVA)
It is important that practices must comply with National guidance on the Protection of
vulnerable adults. A POVA lead should therefore be identified for each practice
11. Care Quality Commission (CQC)
The provider must meet CQC standards and where appropriate be registered with the Care
Quality Commission (CQC). The standards and the relevant services are contained in the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care
Quality Commission (Registration) Regulations 2009.
12. Time Period of LES, Future Commissioning Intentions and Termination
It is anticipated that the LES will run from 1st October 2010 until 31st March 2013. There will
be a review at 6 and 12 months in order to give sufficient notice of commissioning intentions,
if any, for the period, 1st April 2013 and onwards.
Should either party wish to terminate this agreement, a minimum period of 3 months notice
must be provided in writing. However in the event that the Contractor breaches the
requirements of this service level agreement and/or the PCT or Contractor terminates the
PMS/GMS Contract, this Service Level Agreement will also be terminated.
13. Signatories to the Agreement
Practices wishing to provide this service are required to complete and sign the
application form, and return to Cam Health Integrated Care Office
Name of Practice……………………………………………………………………………..
Signed on behalf of the practice (GP or Practice Manager) by………………………….
Signature……………………………………………….Date………………………………..