North Central London Care Pathway
Review
Proposed NCL Intermediate
Diabetes Contracting Model
Final Report
25th November 2010
Commissioning
Support for London
Introduction
Stephenson House, 75 Hampstead Rd, London NW1 2PL
Introduction
As part of the NCL Care Pathway Project review, CSL have undertaken a finance
and activity analysis to support the decision making by the NCL team. The output
from CSL consists of two elements:

A generic operational pathway for the Intermediate Diabetes service (attached
as Appendix 2). This pathway supplements the Diabetes Pathway designed
in June 2010 by the NCL Diabetes Pathway Group and has enabled CSL
Project Finance to cost a generic service offering for the NCL. It is solely
based on the Diabetes Pathway produced by the NCL Diabetes Pathway
Group (attached as Appendix 1) to this report;

A full report to NCL on the work undertaken.
NCL have initiated a service redesign in order to introduce a community based
Intermediate Diabetes Service for patients with ‘challenging’ management problems,
where it is deemed that they can be seen by an expert multidisciplinary team. The
aim of this Service is to provide integrated support within the community, between
primary care management and secondary care services. The service is intended to
provide a local, more accessible and cost effective service in line with the model of
care proposed by Healthcare for London in its ‘Diabetes Guide for London’ paper.
The Intermediate Diabetes Service is also intended to offer advice and education
regarding Diabetes to Primary Care clinicians and patients.
As part of the NCL Care Pathway Project review, we have documented the
Proposed NCL Intermediate Diabetes Contracting Model. This has been based
upon the NCL clinically-led commissioning model, written in June 2010, by the NCL
Diabetes Pathway Group and described above. The Contracting Model is intended
to supplement the commissioning model with a costed generic service offering for
NCL.
Attached to appendices to this report are:

Appendix 1 - The Diabetes Commissioning Pathway produced by the NCL
Diabetes Pathway Group;

Appendix 2 - The proposed NCL Intermediate Diabetes Contracting Model
produced by CSL Project Finance;

Appendix 3 - The CSL Project Finance COPD Contracting Model Proposal.
3
Scope of the Review
The CSL project brief specified that the scope of our review was to determine and
document each stage of the "patient journey", against the newly designed care
pathway, to enable costings to be developed. In order to do this the project team
worked with NCL to agree the Diabetes Model (Appendix 2).
Diabetes (medicine) Acute Outpatient attendances for 09/10 were 49k with
expenditure of £4.4m. NHS Camden has costed their intermediate diabetic services
(pilot) at £181k. Were we to apply the NHS Camden cost base to the diabetic
registers within NCL, this would indicate an estimated out of hospital cost for diabetic
services in NCL at £1.39m, split as follows:

Barnet £0.4m;

Camden £0.2m;

Enfield £0.3m;

Haringey £0.3m;

Islington £0.2m.
The above estimation excludes Primary Care costs, including general district nurse
costs related to diabetic care. We also appreciate that other PCT’s do not use the
NHS Camden model. Therefore, the above costs are theoretical.
The NCL aims for the redesigned service to provide:









An Intermediate Service for patients with challenging management problems,
that do not warrant a secondary care referral, where they can be seen by a
multidisciplinary team;
Work in partnership with patients with Diabetes, supporting patients with
diabetes to self manage;
Structured education;
Short term interventions to support improvements in Diabetes related health
outcomes;
Better Diabetic control within the community;
Support to GP Practices with mentorship, education and skills training;
Advice and support to Social Services, and Residential & Nursing Homes;
Reduced referrals and emergency admissions into secondary care;
Evaluate, audit and monitor the service to achieve quality improvement.
In collaboration with NCL it was agreed that this review would not include any capital
expenditure. It is recognised that buildings may require adaption for new use, and
also that certain equipment may be required. These costs are very localised and,
therefore, difficult to include within a generic cost model. We appreciate that there
may be a way of including indicative costings for hard and soft facilities services,
which would need subsequent agreement.
The review has not included planned activity increases due to population growth and
demographics. We have also not considered the acute unit potential pricing
reductions (2011/2012, 4%).
Summary Findings & Conclusions
The proposed Contracting Model has been based upon the NCL clinically-led
commissioning model written in June 2010, by the NCL Diabetes Pathway Group.
The parameters for service inclusion in the Contracting Model have been endorsed
by the stakeholders consulted.
The proposed innovative new service is not directly comparable with the existing
model and, therefore, direct cost comparisons may be validly challenged. However,
the above indicates that for a service of 801 patients and having a total of 3,406
attendances would cost £0.2m per annum. This cost excludes local overheads,
including property and IM&T costs, but does include pharmaceuticals and
consumables. We consider there are savings to be made against an existing
Diabetic service under PbR.
It is recommended that any new contracting model introduced is shadow
implemented for a minimum twelve months, for further testing, refinement and
review.
The Intermediate Care Service is transformational, and would be expected to
experience significant variance in use, form and function during the initial years.
The proposed Intermediate Care Service should be capable of delivery in the most
appropriate setting for a given health economy (e.g. Acute, Polysystem, etc), given
the local skills and resources available.
Primary Care Education costs have been included within the costing and are driven
by an assumed percentage of relevant service staff’s time. For the purposes of this
summary, these have been based upon the availability of 1 WTE from each
professional group.
Key Aims and Objectives of Review
It is intended that the final Diabetes model will be consistent with the direction of
travel for commissioning in the NHS and aim to provide a sustainable format capable
of adaptation to future increases in activity and changes in practice.
The final Diabetes intermediate health services contracting model will:




Articulate fair and transparent currencies and tariffs, that appropriately reflect
the resources dedicated to Diabetes community health services;
Recognise the full costs involved in providing the service;
Provide a means for fair and equitable commissioning of services;
Build in sustainability through recognition of the financial implications of future
growth and improvements in outcomes.
5
Secondary criteria will look to the model:
 Promoting good practice;
 Promoting greater consistency and efficiency;
 Avoiding perverse incentives in the overall payment structure.
Detailed Findings and Conclusions
General
Registered Patient and new patient referral numbers used are those provided by
commissioning officers at NHS Camden. These have been benchmarked against
SUS data, 0809 QOF PCT data and epidemiological studies. There are
approximately 52k registered patients within diabetes in NCL.
Diabetic Medicine Outpatient appointments for the NCL are shown below;
Total tariff activity
Barnet PCT
9,281
Camden PCT
7,719
Haringey Teaching PCT
9,868
Islington PCT
11,312
Enfield PCT
10,376
NCL sector
48,556
Tariff First / FU
Total cost ratio
4.2
£540,568
5.2
£529,995
5.2
£815,341
3.2
£1,240,374
2.2
£1,266,413
3.6
£4,392,691
Diabetes (medicine) Acute Outpatient attendances for 09/10 were 49k with
expenditure of £4.4m. NHS Camden has costed their intermediate diabetic services
(pilot) at £0.18m. Were we to apply the NHS Camden cost base to the diabetic
registers within NCL, this would indicate an estimated out of hospital cost for diabetic
services in NCL at £1.39m, split as follows:

Barnet £0.4m;

Camden £0.18m;

Enfield £0.34m;

Haringey £0.27mk;

Islington £0.2m.
The above estimation excludes Primary Care costs, including general district nurse
costs related to diabetic care. We also appreciate that other PCT’s do not use the
NHS Camden model and that activity varies between PCT’s. Therefore, the above
costs are theoretical.
We understand that diabetes prevalence ranges from 3.9% (Camden) to 5%
(Islington). However, diagnosed prevalence in all PCTs is lower, ranging from 3.4%
(Camden) to 4% (Islington):
– 7k registered in Camden (17+ registered population)
– 7k registered in Islington (15+ registered population)
– 10k registered in Haringey
– 13k registered in Enfield (17+ registered population)
– 15k registered in Barnet
The admission rates for patients on diabetic registers vary from 1.6% (Barnet) to
3.9% (Enfield)
Patient Flow Assumptions
Patient flow assumptions into the Intermediate Care Services are derived from
working with NHS Camden and using their activity, and also feedback from Haringey
PCT as a response to the circulation of draft documents.
Patient numbers referred to the Intermediate Diabetes (Intermediate Care) Service
and have been assumed at 13% of Primary Care supported patients. This indicates
a total of 801 patients.
It has been assumed that each referral will result in one Helpline call.
Professional inputs to patient ratios, via the Intermediate Service, are based upon six
months actual data drawn from the Crowndale Intermediate Diabetes pilot in
Camden.
Average numbers of patient visits, shown within the “Proposed NCL Intermediate
Diabetes Contracting Model” by professional input, have been calculated initially
from first to follow-up ratios provided by NHS Camden and then later revised at the
NCL workshop, through wider clinical input.
Primary Care Education resource is driven by an assumed percentage of relevant
service staff’s dedicated time (provided by NHS Camden), and for the purposes of
this model has been based upon the availability of 1 wte from each professional
group.
Costing Assumptions
It has been assumed that:
 The proposed new community diabetes service is not directly comparable with
the existing model;
 An indicative service that is for 801 patients would have a total of 3,406
attendances and would cost £0.2m per annum;
7
 This cost excludes local overheads, including property and IM&T costs, but
does include pharmaceuticals and consumables.
The existing Diabetic service under PbR (excluding MFF) and being treated by a
multi disciplinary team would cost notably higher than £0.2m. However, differences
in service specification, as stated above, means services are not directly
comparable. We also assume that a provider would be able to provide a full service
on these activity levels.
Staffing costs have been calculated at scale mid-points (including employer oncosts) based upon estimated productive time. We recognise that staff salaries,
bandings and also staff utilisation may vary dependant upon location and also local
provider decision. Our cost model is indicative, with the flexibility that will assist local
planning.
An administration overhead has been added at 20% of pay to include IM&T and
Managerial Overhead, but excludes any assumption to account for the costs of Land
and Buildings.
Pharmaceutical professional support is provided via the PCT, and the Intermediate
Care Services would work to protocols and guidance issued.
We understand that best practise may also require the use of DESMOND. This has
been excluded from our cost model, as costs may vary depend on activity and
deployment. Local consideration for this cost would be required and included within
the commissioners cost model.
Average hours of professional time, ratios of professional input, and the regularity of
visits are derived from working with NHS Camden, and feedback from Haringey PCT
as a response to the circulation of draft documents.
Primary Care Education costs are driven by an assumed percentage of relevant
service staff’s dedicated time (provided by NHS Camden), and for the purposes of
this summary have been based upon the availability of 1 WTE from each staff group.
The table below provides a summarised Intermediate Diabetes Contracting Model,
based upon Registered Patient numbers within NHS Camden. This uses tested
assumptions around patient flows, detailed in Appendix 3;
Proposed NCL Sector Intermediate Diabetes Contracting Model (based upon the produced NCL clinically-led
commissioning model)
Assumed Annual
Total Annual
Per
Consultation
Patient
Cost per
Service Cost patient
Numbers
Numbers Patient (£)
(£)
Cost (£)
Community Diabetes Helpline
801.39
£7.72
Community Diabetes Service
First & Follow-Up Consultant consultations
First & Follow-Up Specialist Diabetes consultations
First & Follow-Up Dietician consultations
First & Follow-Up Podiatrist consultations
Total Patient Numbers / Appointments
Total Service Costs
240.42
304.53
152.26
104.18
801.39
£73.96
£24.62
£19.91
£19.91
Primary Care Education
£6,189
4.00
5.00
4.00
4.00
£7.72
£71,124
£37,492
£12,126
£8,297
£129,038
£161.02
£45,591
Total Community Diabetes Service (Intermediate Care) Costs
£180,818
Market Forces Factor (MFF)
The purpose of the MFF is to estimate the unavoidable cost differences of providing
healthcare in different geographic areas. As such, it is difficult to argue that it should
not be used in relation to any Community Care based Contracting Model.
It is accepted that certain costs falling on Providers in relation to the service (e.g.
drugs, consumables etc) are not subject to geographic variation. However, the way
in which the MFF is constructed is intended to take such issues into account.
The indices that are used to compile the MFF include:




Staff index;
Medical and Dental London Weighting;
Buildings index’;
Land index.
The proportion of national HCHS expenditure attributable to each element of
operational costs determines the weighting that each index receives within the
overall MFF. For 2009-10, the weightings used are as follows:
%
Staff
M&D London Weighting
Buildings
Land
56.10%
13.80%
3.00%
0.60%
eg. Equipment,
Not considered to vary
Total
26.50% consumables, drugs
100.00%
9
Appendix 1 NCL Diabetes Pathway
11
Appendix 2 Proposed NCL Intermediate Diabetes Contracting Model (based
upon the produced NCL clinically-led commissioning model)
Elements not forming part of/leaving the proposed contracting model
Controlled Patient Management within Primary Care
Intermediate Care Diabetes Service
Identification and
formal diagnosis
Initial Contact
Formal Diagnosis
Entry on Diabetes Register
Patient meets referral criteria
Retinal Screening
Service
Secondary Care
Management
Support Services
Psychological Support (IAPT)
Smoking Cessation (Level 2 or 3)
Group Structured Education
Weight Management Service
Community Pharmacy
Podiatry
Primary Care Patient Management
Community
Matrons/Nurses
Home visit(s)
Care Planning & Annual
Review
Continuing Education
Examination
Tests
H
Primary Care Patient Management
Patient meets
referral criteria
Referral
Community Diabetes
Helpline
Primary Care
Education
Community Diabetes Service
(Intermediate Care)
Consultant consultation
Specialist Diabetes Nurse
Consultation
Dietician consultation
Podiatrist consultation
(Short Term Intervention)
Increased Access
to Psychological
Therapies (IAPT)
(Level 3)
Appendix 3 - Proposed NCL Community Diabetes Contracting Model
(based upon the produced NCL clinically-led commissioning model)
Community Diabetes Service (Intermediate Care)
Assumed
Patient
Numbers
Annual
Cost per
Patient
£
Community Diabetes Helpline
801
£7.72
Community Diabetes Service
First & Follow-Up Consultant consultations
First & Follow-Up Specialist Diabetes consultations
First & Follow-Up Dietician consultations
First & Follow-Up Podiatrist consultations
Total Service Costs
240
305
152
104
801
£73.96
£24.62
£19.91
£19.91
Primary Care Education
Total Community Diabetes Service (Intermediate Care) Costs
Consultation
Numbers
4.00
5.00
4.00
4.00
Total
Annual
Service
Cost
£
Per
Patient
Cost
£
£6,189
£7.72
£71,124
£37,492
£12,126
£8,297
£129,038
£161.02
£45,591
£180,818
13
Appendix 3 - Proposed NCL Intermediate Diabetes Contracting Model - Activity Assumptions
Total New Patient Referrals
Continuing Registered Patients
485
7,258
0809 QOF PCT Registered Patient Data
Barnet
14,785
Enfield
12,589
Haringey
10,263
Islington
7,502
Camden
6,765
Community Matrons/Nurses
2.00% Require Home Visit
154.86
Initial Contact
Newly Diagnosed
485
Primary Care Patient Management
Retinal Screening Service
100.00% Retinal Screening (Newly Diagnosed)
100.00% Retinal Screening (Period Review)
485
7,258
Community Diabetes Service (Intermediate Care)
Care Planning & Annual Review
80.00% Newly Diagnosed
80.00% Continuing Patients
388
5,806
Examination
80.00% Newly Diagnosed
80.00% Continuing Patients
388
5,806
Continuing Education
80.00% Newly Diagnosed
80.00% Continuing Patients
388
5,806
Tests
80.00% Newly Diagnosed
80.00% Continuing Patients
388
5,806
Assumed 80% of Diabetes care provided in Primary
Care
Community Diabetes Service
Newly Diagnosed
12.00% Primary Care managed referred to Service
30.00% Consultant Consultation
38.00% Specialist Diabetes Nurse Consultation
19.00% Dietician Consultation
13.00% Podiatrist Consultation
Continuing Patients
13.00% Primary Care managed referred to Service
30.00% Consultant Consultation
38.00% Specialist Diabetes Nurse Consultation
19.00% Dietician Consultation
13.00% Podiatrist Consultation
47
14
18
9
6
755
226
287
143
98
Assumed 13% of Primary Care supported patients referred to service
Professional input % based on 6 month data from Crowndale
Intermediate Diabetes pilot
Community Diabetes Helpline
100.00% of referrals to service
Average Number of visits =
Consultant
Specialist Diabetes Nurse
Dietician
Podiatrist
Time devoted to Primary Care Education
801
4
5
4
4
0.15
Appendix 3 - Proposed NCL Intermediate Diabetes Contracting Model – Costings Assumptions
Staffing resource costings at identified grade and per table at worksheet 3 ('tables'). Administrative Overheads (incl IM&T, Travel & Managerial overheads, but excl Building costs, set at 20% of pay
Pharmaceutical Professional Support is provided via the PCT and Primary Care and the Community Diabetes Service work to protocols and guidance issued
Incomplete/unverified data
Grade
Hours
Annual
Regularity
Total
£
Pay
£
Admin
Support
+20%
£
Pharmaceuticals
£
Consumables
£
SubHardware Contract
£
£
Tariff
£
Admin
Overhead
@ 20% of Pay
£
Primary care
Initial Contact
Diabetic Induction
Diabetic Testing
Formal Diagnosis
Total Currency
Care Planning & Annual Review
Newly Diagnosed Patients
GP Consultation
Practice Nurse Consultation
Total Currency
Continuing Patients
GP Consultation
Practice Nurse Consultation
Total Currency
Examination
Newly Diagnosed Patients
Practice Nurse Consultation
Total Currency
Continuing Patients
Practice Nurse Consultation
Total Currency
Practice Nurse AfC6
Practice Nurse AfC6
GP
0.50
0.50
0.50
£16.04
£17.54
£46.64
£80.22
£13.36
£13.36
£38.87
GP Prescribing
£2.67
£2.67
£7.77
GP
Practice Nurse AfC6
0.50
0.50
£46.64
£16.04
£62.68
£38.87
£13.36
GP Prescribing
£7.77
£2.67
GP
Practice Nurse AfC6
0.50
0.50
£46.64
£16.04
£62.68
£38.87
£13.36
GP Prescribing
£7.77
£2.67
Practice Nurse AfC6
0.50
£17.54
£17.54
£13.36
£1.50
£2.67
Practice Nurse AfC6
0.50
£17.54
£17.54
£13.36
£1.50
£2.67
£1.50
15
Appendix 3 - Proposed NCL Intermediate Diabetes Contracting Model – Costings Assumptions
Incomplete/unverified data
Grade
Hours
Annual
Regularity
Total
£
Pay
£
Admin
Support
+20%
£
Pharmaceuticals
£
Consumables
£
SubHardware Contract
£
£
Tariff
£
Admin
Overhead
@ 20% of Pay
£
Continuing Education
Forms part of consultation under 'Care Planning & Annual Review', 'Examination', and 'Tests'
Tests
Newly Diagnosed Patients
Practice Nurse Testing
Total Currency
Continuing Patients
Practice Nurse Testing
Total Currency
Practice Nurse AfC6
0.50
£17.54
£17.54
£13.36
GP Prescribing
£1.50
£2.67
Practice Nurse AfC6
0.50
£17.54
£17.54
£13.36
GP Prescribing
£1.50
£2.67
1.00
£39.82
£39.82
£33.18
Community Matrons/Nurses
Home Visit
AfC7
Total Currency
£6.64
Appendix 3 - Proposed NCL Intermediate Diabetes Contracting Model – Costings Assumptions
Incomplete/unverified data
Grade
Hours
Annual
Regularity
Total
£
Pay
£
Admin
Support
+20%
£
Pharmaceutical Consumable
£
£
SubHardware Contract
£
£
Tariff
£
Admin
Overhead
@ 20% of Pay
£
Community Diabetes Service (Intermediate Care)
Staff grading levels may reduce from application of greater skill mix should service expansion occur
Community Diabetes Service
All Patients
Consultant Consultation
Consultant
0.50
£73.96
£44.97
Specialist Diabetes Nurse Consultation
Dietician Consultation
Podiatrist Consultation
Total Currency
AfC8a
AfC7
AfC7
0.50
0.50
0.50
£24.62
£19.91
£19.91
£138.40
£19.27
£16.59
£16.59
AfC8a
0.17
£7.72
£7.72
£5.78
Consultant
Specialist Diabetes
Nurse AfC8a
Dietician AfC7
Podiatrist AfC7
0.15
Community Diabetes Helpline
All Patients
Helpline Calls
Total Currency
Primary Care Education
Developmental Education
Developmental Education
Developmental Education
Developmental Education
Total Currency
0.15
0.15
0.15
per annum
£21,043.80
£9,017.85
£7,764.75
£7,764.75
£45,591.15
£20.00
£16 to £23 28day pack
(injectables)
8.99
£1.50
3.85
3.32
3.32
1.16
£21,043.80
£9,017.85
£7,764.75
£7,764.75
17
18