Sutton and Merton Boroughs
PERFORMANCE REQUIREMENTS
SPECIFICATION, QUALITY AND PERFORMANCE
SPECIFICATION
Care Pathway/Service
Diabetes specific Expert Patients Programme Pilot
Commissioner Lead
Annette Bunka
Provider Lead
Period
Applicability of Module E
(Acute Services Requirements)
1. Purpose
1.1 Aims
To support the provision of lay led self management courses to patients living with Type 2
diabetes registered with a Sutton or Merton GP.
The Expert Patient Programme (EPP) is about creating a partnership between professionals
and patients to become equal partners. This will create a new generation of people who are
empowered to take action in partnership with the health professional working with them, for
example, to reduce pain, improve the use of medication and enhance their overall quality of
life. The EPP is part of wider self care agenda to help people with chronic health conditions
self manage more effectively.
Please note: The term ‘Provider’ here is taken to mean, the organisation/consultant awarded
the contract who will be providing expert assistance; support and guidance to the Pilot
Coordinator (see 3.2 for more information on roles).
1.2 Evidence Base
In Great Britain, at any one time, as many as 17.5m adults may be living with a chronic
disease. Older people suffer more with up to three quarters of adults aged 75 and over
falling in this category. (DH The Expert Patient: A new approach to chronic disease
management for the 21st Century 2001).
Estimates published by the Department of Health for England indicate that: 80% of GP consultations relate to chronic disease
 70% of primary care budgets are consumed by chronic disease
 60% of people admitted as medical emergencies have an exacerbation of chronic
disease or have a chronic disease
 For patients with more than one condition, costs are six times higher than those with
only one.
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Evidence shows that people who attend the Expert Patients Programme (EPP) have
reduced hospital admissions and have fewer outpatient attendances as a result of the
techniques that are learned, including how to:
 Reduce pain and fatigue
 Improve communication with family, friends, doctors and other healthcare providers
 Action plan
 Problem solve
 Understand exercising and healthy eating
 Manage daily activities
 Manage difficult emotions
 Plan for the future
 Relieve stress on carers
 Reduce demand on GPs and other HealthCare Professionals
The Department of Health (DH) 1999 White Paper, “Saving Lives: Our Healthier Nation”,
specifically recognised that more needed to be done to support people with long term
conditions and pointed to the value of self-management training courses
The NHS Improvement Plan (June 2004) stated that “The Expert Patients Programme will
be rolled out throughout the NHS by 2008 to enable thousands more people with long term
conditions to take more control of their health”.
‘Your health, your care, your say’ public consultation document has made it clear that the
public want to be supported to live more independently, have greater choice in their
treatment and be empowered to take control of their long term condition through properly
supported self care.
NHS Sutton and Merton Strategic Plan (2007) have eight priorities, of which two can be linked
to EPP. Priority 4, improving self-management of diabetes to support better health outcomes
for people living with the disease. Priority 5, supporting people with coronary heart disease to
best manage their condition.
NHS Sutton and Merton GP registers show that from a population of around 400,000 there
are approximately 16,000 people living with diabetes.
Ethnic profile of Merton and Sutton
It is known that people of South Asian, African, African-Caribbean and Middle Eastern
descent have a higher than average risk of Type 2 diabetes so it would be expected that
differences in the ethnic profile of Merton and Sutton would have an impact on prevalence
and mortality from diabetes.
The NSF for diabetes notes that Type 2 diabetes is up to six times more common in people of
South Asian descent and up to three times more common in those of African and AfricanCaribbean descent compared with the white population.
The ethnic profile of Merton and Sutton is shown below: (Source: 2001 Census)
White
Mixed
Asian
Black
Chinese or other
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Merton
Number
%
140,883
75
5,869
3
20,807
11
14,626
8
5,723
3
Sutton
Number
%
160,351
89
3,725
2
8,500
5
4,601
3
2,591
1
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All people
187,908
100
179,768
100
This shows that Merton has a more ethnically diverse population than Sutton with 11% of the
population in the Asian census category, as compared with 5% in Sutton, and 8% Black
compared with 3% in Sutton. Therefore it could be expected that there will be higher
prevalence of diabetes in line with known risk factors.
1.3 General Overview
The Department of Health established the EPP Community Interest Company as a social
enterprise organisation in April 2007, after its success in demonstrating how the courses
enable individuals to better self-manage their condition and thereby reduce health
consultations and hospital visits.
The EPP is a self-management course for adults with long term health conditions. Groups
of up to 16 participants meet over six weekly 2.5 hour sessions and are led through a
structured course by trained tutors who themselves live with a long term condition. The
course is aimed at anyone with any long-term condition and does not exclude people for any
reason inclusive of age, sex, ethnicity or religion. EPP does not take the place of post
diagnosis education delivered by the appropriate healthcare professional(s), but is designed
to complement it, should a patient need further support having lived with the condition for a
period of time.
EPP can deliver generic courses which both complement and support other disease specific
educational courses available to individuals living with a long term condition. The programme
delivers self-care support and aims to improve the quality of life of people with long term
conditions by developing generic self-management skills, and improving participant’s
confidence and motivation to take more effective control over their lives and condition, thus
improving overall quality of life. The course covers the following topics:
 Goal Setting
 Problem Solving
 Pain & Fatigue Management
 Dealing with Anger, Frustration & Fear
 Cognitive Symptom Management
 Healthy Eating
 Exercise
 Communication
 Working with your Health Care Professional
 Relaxation Techniques
 Depression Management
NHS SWL Sutton and Merton Borough EPP Pilot will be a disease specific programme.
Diabetes has been chosen as improvement in patient education in diabetes has been
identified as an area for action within NHS Sutton and Merton’s current Strategic Plan, given
the evidence for the benefits of patient education and involvement programmes in supporting
improved self care thereby reducing GP and outpatient visits, and A&E attendances.
An assessment of the effectiveness of the pilot programme will inform the potential future
commissioning of an EPP for other long term conditions.
1.4 Policy Overview
NHS SWL Sutton and Merton Borough team aim to commission local services for local people
and expect the provider to ensure delivery is in a setting that is appropriate in terms of
timeliness and effectiveness of response as well as safe and convenient to the participant.
NHS SWL Sutton and Merton Borough team are committed to providing an accessible
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education care pathway for all.
The following documents influence the delivery of the service:
 The NHS Improvement Plan (2004)
 The Operating Framework for the NHS in England 2010/11
 Our Health, Our Care, Our Say (2006)
 NHS 2010-2015: from good to great. Preventative, people centred, productive. DH
(2009)
 Carers Strategy DH (June 2008)
 Healthier People, Excellent Care SEC SHA (2007)
 Expert Patient Programme DH (2006)
 Stepping Stones to Success - An Implementation, Training and Support Framework for
Lay Led Self Management (June 2005)
 Stepping Stones to Quality (March 2007)
The project will work within the commissioning framework for health and wellbeing (DH
2007) by:
 Putting people at the centre of commissioning
 Understanding the needs of populations and individuals
 Sharing and using information more effectively
 Assuring high quality providers for all services
 Recognising the interdependence between work, health and well-being
 Developing incentives for commissioning for health and well-being
 Making it happen – local accountability
 Making it happen – capability and leadership
1.5 Objectives
Objectives of the overall programme are:
 To provide quality assured lay led self management courses to patients with Type 2
diabetes in the community
 To provide appropriate information and sign posting to other services which may be of
benefit to patients with Type 2 diabetes
 To empower people to manage their condition effectively, thus improving quality of life
 To equip people with the tools & skills to implement ongoing self care
 To effectively support volunteer tutors to deliver course content to the best of their ability
 To work in partnership with health professionals, particularly GPs and Practice Nurses, to
promote courses and refer appropriate people
 To provide people with ongoing self management support via post course
meetings/activities within the pilot timelines
Specific course objectives include educating individuals on how to:
 Manage medication usage
 Manage daily activities
 Understand the importance of exercising and healthy eating
 Manage difficult emotions
 Relieve stress on carers
 Use problem solving techniques
 Use action planning
 Improve communication with family, friends, doctors and other healthcare providers
 Reduce demand on GPs and other HCPs
 Reduce pain and fatigue
 Plan for the future
1.6 Expected Outcomes
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Outcomes of the overall programme are:
 Improved health care through improvement of self-management skills
 Improvement in medicines management
 Reduction in admissions, outpatient and GP appointments by helping individuals to
communicate more effectively with healthcare professionals.
 Local trained qualified and experienced tutors
 Sustainability via a transferable toolkit
There will be an assessment of the effectiveness of the pilot programme which will support
any future delivery of EPP including the potential commissioning for other long term
conditions.
Individual outcomes for course participants:
 Feel confident and more in control of their life
 Improved ability to self manage the condition(s), including feelings which may be
exacerbated by the condition such as depression, anxiety and stress, as well as levels of
pain and fatigue
 Manage their condition and treatment together with healthcare professionals
 Be realistic about the impact of the condition on themselves and their family
 Use their new skills and knowledge to improve their quality of life
 Improved medicines management and reduced wastage
 Contribute towards reductions in unplanned admissions, A&E attendances and
outpatient appointments
 Working from self management plans, improved independence and awareness of
services
 Improved knowledge of where to access information, services and support available
2. Scope
2.1 Service Description
The provider is to support the provision of a chronic disease self management course
specifically aimed at people with Type 2 diabetes, which is underpinned by the following
assumptions:
 People with diabetes have similar concerns and problems
 People with diabetes have to not only deal with their disease(s) but the impact on their
lives
 Lay people who themselves have diabetes, when given training and a detailed manual,
can deliver the course as effectively, if not more so, than health professionals.
The course will be 7 weeks in length, one 2.5 hour session a week, and delivered to up to 16
participants. The tutors are trained volunteers who themselves live with one or more long
term health condition; tutors living with diabetes would be preferred for this pilot.
2.2 The Provider Requirements
NHS SWL Sutton and Merton Borough Team are looking to commission an appropriately
experienced and qualified organisation/provider to support the delivery of the EPP pilot to
support Sutton and Merton patients with Type 2 diabetes to manage their condition better to
improve their health and wellbeing.
The provider will be required to:
 Recruit volunteer tutors
 Develop and distribute marketing materials for the courses
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Provide administrative support to the tutors
Provide support to the tutors during the course
Ensure the programme is developed within best practice guidelines
Participate in meetings and training days
Keep up-to-date records of tutors' details and courses delivered
Keep staff and trustees within the organisation briefed
Work to raise the profile of self-management within Sutton and Merton
Access local networks and the support that can be gained from them
Explore joint working across agencies
Increase access for people from BAME communities
Demonstrate a robust knowledge of the EPP, its governance framework and evaluation
processes
Support NHS SWL Sutton and Merton Borough team to set up a quality assurance
process and mechanisms to monitor the programme as outlined in Stepping Stones to
Success
Deliver 3 EPP courses and 1 re-union event
Develop a survey and evaluation form that will be used to identify the number outcomes
achieved and gather patients experience data
Ensure monitoring and evaluation forms are completed and analysed
Train, assess, supervise and support tutors to deliver sessions/courses
Design an EPP tool kit for future use by NHS colleagues
The organisation/provider is required to comply with all relevant national and local policies,
including (but not limited to):
 Safeguarding Vulnerable Adults
 Management and Control of Medicine
 NHS Confidentiality Code of Practice
 Equal Opportunities
 Data Protection Act 1998
 Access to Health Records Act 1990
 SUI and incident reporting
The EPP pilot will require the successful organisation/provider to link to a number of existing
groups, networks, services and health professionals currently operating within Sutton and
Merton.
As stated in 1.2, Type 2 diabetes is up to six times more common in people of South Asian
descent, and up to three times more common in those of African and African-Caribbean
descent, compared with the white population. Merton has a more ethnically diverse
population than Sutton with a higher percentage of the population in the Asian and Black
census categories than Sutton. The provider will be expected to work with the NHS SWL
Sutton and Merton Borough Team to identify where community groups are most at risk/need
is greater and provide targeted engagement, including marketing the programme to ethnic
minorities in appropriate language if sufficient need is identified.
2.3 Accessibility/acceptability
Provider:
The provider will ensure that they comply with the provisions of the Single Equality Scheme
Consultation Document 2010 - 2011 as set out here.
All courses are to run in accessible venues with good public transport links and/or parking.
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Individuals:
 It is expected that patients will commit to the entire seven sessions, barring ill health or
other unforeseen circumstances.
 It is expected that patients taking part in the pilot programme are able to independently
look after their own needs (including personal care) whilst in attendance. If there is
sufficient need for carers to attend an additional course will be provided for these patients.
2.4 Whole System Relationships
The provider will be working within a context of health in its widest sense by encouraging
individuals to take more control of their health by learning new life skills to manage their
condition on a daily basis.
The provider will connect with local people through disease specific support groups and
disability forums, and with other stakeholders within the health economy (e.g. GP Practices,
Community Matrons, Specialist Nurses, Intermediate Care teams and other NHS
professionals) to encourage patient referrals.
It is also important for the EPP to have ongoing working relationships with other groups such
as not for profit and voluntary sector organisations and other providers of EPP or similar self
care courses, to raise awareness and generate support for the programme.
The whole system relationships, therefore, include:
 Health and Social Care, Commissioners
 Community based nurses
 Public Health (including Health Promotion)
 Local Authority, Health Trainers, Healthy Workplace projects
 Voluntary organisations, Volunteer Centres, local branches of Charitable Organisations
(e.g.Diabetes UK)
 Carers organisations
 Community groups and support centres,
 Private sectors.
2.5 Interdependencies
The success of Sutton and Merton EPP is dependent upon the awareness, support and
referrals from the following Health Professionals and groups:
 GPs
 Support Groups
 Specialist nurses
 Practice nurses/ District Nurses
 Acute Trusts
 Carer Groups
 Voluntary organisations
The provider will link into patients, public and client groups and should:
 Undertake active engagement with patients and local communities to develop and
improve services
 Evidence that systematic feedback is being used to shape and improve the program
2.6 Relevant networks and screening programmes
Sutton and Merton EPP Team will link into Long Term Conditions networks such as:
 NHS Sutton and Merton Diabetes Network
 Diabetes UK
 Diabetes Centre at St Helier Hospital
 South East London EPP Leads Network
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St Georges Healthcare NHS Trust
3. Service Delivery
3.1 Roles and Responsibilities
The EPP pilot team will consist of the following roles:
 Commissioned Provider
Will provide expert assistance; support and guidance to the Pilot Coordinator and EPP
Team to set up and deliver the EPP.
 SWL NHS Representative
Will take the strategic lead and overall management
 Pilot Coordinator
Will lead on day to day management of the programme.
 Administrative support
To support the EPP team with administrative duties, and lead on enquiries and course
enrolment
 Volunteer tutors
Will support tutors to deliver courses
The team will be responsible for:
 Delivery of 3 courses, consisting of 7 week programme
 1 reunion event
 Organising dates and appropriate venues
 Providing materials and equipment
 Provide qualified experienced tutors and organise tutor cover
 Designing and disseminating publicity
 Course promotion
 Relationship building with internal and external partners and wider health professionals
 Recruitment of participants and ensuring courses are full
 Participant support
 Evaluation of courses
 Evaluating the impact of courses on participants
 Training, assessing and accreditation of 3 tutors
 1 tutor supervision session
For full provider requirements, please refer back to section 2.2
3.2 Quality Assurance
The Ss2Q (the national Quality Assurance Framework for EPP), states the EPP Lead should
be someone who lives with a long term condition and an Accredited Tutor for the programme.
Where possible, to ensure autonomy of the service and oversee quality assurance, the Lead
would also be an Accredited Assessor and Lead Trainer who can train new tutors and
undertake assessments, supervision and support to existing tutors. Tutors living with
Diabetes would be preferred for this pilot.
4. Scheduling
4.1 Activities Required
Between November 2011 and July 2012 the following activities will need to be in progress or
completed:
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Delivery of 3 courses, consisting of 7 week programme, first of which to commence
January 2012
Organising dates and appropriate venues
Providing materials and equipment
Provide qualified experienced tutors and organise tutor cover
Designing and disseminating publicity
Course promotion
Relationship building with internal and external partners and wider health professionals
Recruitment of participants and ensuring courses are full
Participant support
Training, assessing and accreditation of 3 tutors
During July and August 2012 the following activities will need to be in progress:
 Evaluation of courses
 1 reunion event
 Evaluating the impact of courses on participants
 Training, assessing and accreditation of 3 tutors
 1 tutor supervision session
 Promote project outcomes and next steps
4.2 Timelines
Preparation
Preparation for project delivery
November and
December 2011
Delivery
Promote, recruit to and deliver 3 EPP, 35 or
more participants completing course
January 2012 to
July 2012
Evaluation
Evaluation of outcomes, promotion of
outcomes, agree next steps
August 2012
5. Referral, Access and Acceptance Criteria
5.1 Geographic coverage/boundaries
The pilot programme is for patients living in the boroughs of Sutton or Merton who are
registered with an NHS Sutton and Merton GP.
5.2 Location(s) of Service Delivery
Courses will be provided in accessible community venues across the both boroughs, such as:
 Community Venues i.e. Halls, Community and Leisure Centres, Libraries etc
 Local Support Centres/Organisations
 Schools and Colleges
 Health Centres, GP Surgeries and Hospitals
All possible venues will comply with the Disability Discrimination Act and be fully accessible to
include accessible toilet facilities and ample space for those who have limited mobility.
Venues should also have excellent public transport links and/or parking on site or close by
where possible.
5.3 Days/Hours of operation
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Aim to provide 7 week course on weekdays and weekends for 2.5 hours per session,
morning, afternoon and/or evening in conjunction with venue and tutor availability. Should
consider delivering an evening course if a need is identified.
5.4 Referral Pathways
Self Referral
The service is available to adults (18+) who live in Sutton or Merton. Patients should self
refer to the EPP as this is seen as the first step in self management. GPs, support workers,
Carers and other healthcare professionals may enquire on a person’s behalf but ultimately,
the patient must contact the EPP team directly in order that their suitability for the programme
can be ascertained.
The EPP team would be the first point of contact for patients accessing the service to ensure
efficiency. This will include the following tasks:
 Receive enquiry via telephone from patient
 Undertake screening of patient to ascertain suitability for the course – this includes
identifying long term condition(s) and assessing readiness to take on behaviour change
 Explain course content and commitment to every session to patient
 Discuss available course dates and book patient onto course
 Record patient contact details and other relevant information on a database
 Send patient confirmation letter and Participant Agreement Form
 Add patient to course register
 Contact patient 14 days prior to course starting to remind them of course start
5.5 Referral criteria & sources
Patients attending an EPP course must meet the following criteria:
 Have been living with Type 2 diabetes for a minimum of 12 months
 Have completed the Structured Patient Education programme provided for patients newly
diagnosed with Type 2 diabetes
 Can independently travel to the venue
 Are ready and willing to take on behaviour change
 Are able to independently look after themselves whilst attending the course
 Feel comfortable in a group setting
 Are able to commit to the entire seven week course (barring illness or other unforeseen
circumstances)
5.6 Care Pathway(s)
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Patient learns about EPP via GP, Practice or Specialist Nurse, Poster or Leaflet
Patient self refers by phoning the EPP team
Patient screened & if suitable, booked onto appropriate course
Patient attends seven week course
Patient kept on database & invited to EPP Reunion(s)
5.7 Referral route
 Patients can self refer to the service.
 Patients can contact NHS Sutton and Merton. Patients will be screened for their suitability
for the course and then offered a place on the next available course.
Patients will remain on an EPP database for future activities such as reunions and to raise the
awareness of possible future consultation / engagement opportunities. (Patients can be
removed from the database at their request.)
5.8 Exclusion criteria
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Patients who have lived with their condition for less than 12 months
Patients under 19 years of age
Patients requiring personal care
Patients not ready for self management and /or behaviour change (all referrals will be
screened by tutors)
Patients wanting to attend the course with a Carer or Partner (Carer/Partner can be on
site but not in the room when course is taking place)
Must not have attended an EPP course within the last 2 years
6. Future Planning and Tutors
After completing a seven week course, patients will remain on the EPP database to be invited
to post course support events. Involvement in post course activities is voluntary and patients
can be removed from the database at their request.
To maintain a pool of volunteer tutors, patients who have completed a course have the
opportunity to apply to become a volunteer tutor for the programme. This would be subject to
funding and a successful interview.
7. Equalities Information
The EPP team should ensure access to interpreting services for those whom English is a
second language.
Publicity materials will be distributed across Sutton and Merton using a range of different
formats, targeting at Black and Asian Minority Ethnic groups which are clinically most at risk
of developing Diabetes. JSNA evidence indicates that south Asians are 6 times more likely to
get diabetes and onset is generally 10 years earlier than the general population. In addition,
there are higher reported rates of diabetes in Merton, and there is a higher Asian population
in Merton.
Diversity monitoring will be part of the enrolment and evaluation process. The following data
will be collected, status, gender, age, ethnicity, Religion and disability.
8. Continual Service Improvement/Innovation Plan
EPP is a licensed course, therefore changes to the content and tutor manual cannot be made
- irrespective of any patient feedback. However, alternative courses to EPP are available,
and these are more adaptable.
NHS Sutton and Merton should also be aware of guidance or developments from Department
of Health, EPP CIC and the Local Health Economy that may involve development of the
programme to meet quality assurance guidelines and/or local patient need.
9. Finance Information
The contract for this programme will be for pilot period only, and is subject to the standard
terms and conditions of the NHS.
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The programme budget is £18,000. This figure is to include all costs incurred by EPP Team,
including admin support, materials, room hire, travel costs, carer and childcare costs for
participants etc.
10. Quality and Performance Indicators
Quality Performance Indicator
Threshold
Service User Profile Data
100% of data
collected
Service User Experience
90% patient
satisfaction
Ss2Q
Appropriate
level achieved
Quality Performance Indicator
Threshold
Method of
Measurement
Pre and Post
course questionnaire
Evaluation session /
form covering seven
week course period
Ss2Q Self
Assessment tool
used
Method of
Measurement
Frequency of
Monitoring
Each course
Week 1
and
Week 7
Each Course
Frequency of
Monitoring
Participant ability to manage
their condition better
90% patient
satisfaction
Participant survey
End of each
course and end of
program
Estimated reduction in GP
consultations relating to
Diabetes
Reduction of
50%
Participant survey
End of each
course and end of
program
Estimated reduction in
hospital admissions for
Diabetes
Reduction of
75%
Participant survey
End of each
course and end of
program
Estimated reduction in A& E
attendances for Diabetes
Reduction of
75%
Participant survey
Quality Performance Indicator
Threshold
Method of
Measurement
End of each
course and end of
program
Frequency of
Monitoring
Total number of courses
delivered
3
Course Registers
Quarterly
Number of participants
enrolling in courses
18
Application Forms
and Course
Registers
Pre course
delivery
Number of participants
completing courses
14
Course Registers
and Evaluation
Forms
End of course
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Number of participants
attending reunion event
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30
Acceptance Forms
and Participant
Survey
End of program
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12. Competence Criteria
A clear understanding of the purpose/objective of EPP and its importance.
Adequate qualifications and experience in delivering EPP and access to qualified experienced
tutors.
Experience of:
 Undertaking similar work in the health or health related sectors.
 Working with other public sector organisations.
 Have an understanding of the local population or able to explain how they will get that
knowledge.
A clear and workable plan to mobilise EPP in Sutton and Merton
Proposals for:
 How the programme will be delivered across Sutton and Merton boroughs.
 Reporting and evaluation mechanism for feeding back to NHS SWL Sutton and Merton
Borough team on quality and performance indicators (as per section 10)
 An engagement plan detailing methods of engaging residents, ensuring that the
programme reflects the age/sex/and ethnic profile of the underlying population.
Demonstrate the ability to engage with NHS SWL Sutton and Merton Borough Team partners
and stakeholders
Demonstration of added value/innovation
Price
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