January 2009
Doncaster Primary Care Trust
Local Enhanced Service for Diabetes Mellitus: Insulin Initiation.
All practices are expected to provide essential and those additional services
they are contracted to provide to all their patients. This enhanced service
specification for Diabetes Mellitus: Initiation outlines more specialised services
to be provided which are beyond the scope of essential services. No part of
the specification by commission, omission or implication defines or redefines
essential or additional services.
Background
Currently few practices initiate insulin within the practice. Most of this work is
done by diabetes specialist nurses. Many diabetics are on suboptimal
treatment despite maximum oral therapy. By reducing Hba1c, control of
diabetes is improved and therefore leading to a reduction in immediate
complications, long-term complications hospital admissions and outpatient
referrals.
The Enhanced Service should help to improve the quality of life for patients
with Diabetes Mellitus: and improve the patient’s understanding of his or her
condition and reduce referrals to secondary care which will make the service
more local and accessible to patients.
Diabetes NICE guidance on lowering blood glucose in type 2 diabetes,
recommends use of insulin where other therapies and lifestyle modification
have failed to adequately control the sugar levels.
Aims
To improve the quality of care provided in the community to patients with Type
2 Diabetes by making the service more accessible and responsive
To reduce HbA1c
To reduce the long term complications of Diabetes
To reduce non-elective hospital admissions in patients with diabetes.
To work towards the PCT objectives of delivering care closer to home
Service Outline
The service detailed in this LES must have a one designated lead within the
practice; this can be a GP or practice nurse. Insulin Initiation must be provided
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by the practice and its employed nursing staff and not by community or
specialist nurses.
This locally enhanced service will fund practices to identify patients suitable
for Insulin initiation, (Hba1c>8)
Provide patients with Education around lifestyle and titrate insulin dose
The Frequency of appointments is agreed on an individual basis with the
patient:
The service will include the –
Initial Assessment of patient for Insulin Initiation (appendix 1)
Agree Treatment Plan
Dosing and titration of Insulin through the below regimes as clinically
appropriate:
Once daily
Twice daily
Basal Bolus
Education
• Education should be given as per Community Insulin Education Protocol
(appendix 2)
The aim is to encourage all patients to self adjust their insulin dosage
According to blood glucose levels, activity and dietary intake
Continuing Care
• Healthcare Professionals initiating insulin are to monitor the effect of
treatment and potential side effects and establish a plan for review. Initially
regular contact by telephone may be required for support and guidance.
• When blood glucose levels are stable and education checklist completed the
Patient can then maintain telephone contact with there, Practice Nurse or
General practitioner.
If involved District Nurses to contact the insulin initiator with any problems by
fax or by telephone or through local community services.
• If in the future the glycaemic control is not acceptable or the patient
develops complex needs, then referral to the Community Diabetes Specialist
Nurse or Consultant can be made either by the patient themselves or the
healthcare professional managing their diabetes.
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Standards/Accreditation
Staff involved in the delivery of this service will be appropriately trained and
competent in the provision of the services offered.
The services delivered by this LES will be subject to clinical audit.
Practitioners involved in insulin initiation must receive a certificate from an
accredited course or similar which they will be required to submit to the PCT.
Doncaster Primary Care Trust will run an accredited Insulin Initiation course
locally to be funded by the PCT, (available to GP’s or practice nurses).
Practitioners who have been carrying out insulin initiation for some years
without accreditation will continue to be able to do so upon demonstration of
the core competencies contained within an accredited insulin initiation course.
(See appendix 3 and 4). Practitioners must also be able to demonstrate a
level of activity sufficient to have maintained their skills.
Doncaster Primary Care Trust will be offering any practitioner already trained
in Insulin Initiation the opportunity to attend an update if they so wish.
Practitioners will be expected to provide evidence of continuing clinical
competency around the delivery of insulin initiation, which is to include
evidence of 2 hours of CPD education and the continuing delivery of insulin
initiation, this should be demonstrated on an annual basis.
Performance management
Yearly audit of patients on insulin with diabetes mellitus type2. To include
reduction in Hba1c as a result of insulin initiation.
This LES will be subject to annual review and can be cancelled with three
months notice by the PCT or the contractor. The PCT will review numbers of
admissions and readmissions when undertaking its evaluation of this LES.
Read Coding
XaP63
Insulin treatment initiated (5 Byte Read code)
66Ap
Insulin treatment initiated (CTV3 Read Code)
Costing and Payment mechanism
This LES attracts a fee of £200 per patient initiated and will be paid over a 12
month period as follows:
£120 at 4 weeks
£20 at 12 Weeks
£20 quarterly for next 3 quarters
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Practices should claim payment using claim form supplied by PCT.
Appendix 1 – Baseline Assessment
Appendix 2 – Education protocol
Appendix 3 – Core Competencies: Insulin Initiation
Appendix 4 – Competency for life
Appendix 5 – Annual Audit
Audit Please return by end of December 2009 to:
Public Health
White Rose House
Ten Pound Walk
Doncaster
DN4 5DJ
MM
05/01/09
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