Wandworth Local Health and Care Plan - October 2019

54 Live Well - Chronic disease management – Diabetes -what we will do Summary Description of the programme What will be different about our approach There is an increasing prevalence of diabetes in Wandsworth and the current service model will not be able to provide sufficient proactive and holistic support. The new model of care enhances the ability of primary care and community services to support patients outside of acute hospital settings, thus managing their disease more proactively and reducing the likelihood of complications. The new service model will result in;: ¨• Prevention of Type 2 diabetes through increased screening and annual recall of patients at risk of developing diabetes • Early identification, improvement in treatment of and prevention of the complications of diabetes • Improved access through patients can access diabetes care closer to home, in the right place and at the right time. • Reduced attendances in acute settings as more patients will be supported in primary and community settings. • Improved patient experience and outcomes • Patients to be better supported to self manage • Improved sustainability and reduction in variation in quality of care for people living with diabetes • Upskilling of primary care workforce and enhanced collaborative working across all providers What will we do Description of initiative What will be the impact How will we measure success New Model of Diabetes Care The new diabetes service model will deliver the following: a) A Primary Care Local Incentive Scheme (LIS) which will support primary care to offer consistent care for diabetic and pre-diabetic patients b) Consultant deep-dives in primary care b) Additional clinical capacity in community settings to enable more patients to be supported closer to home • Improved prevention and management approaches of patients at an earlier stage, with pre-diabetic registers established in all GP practices • Improved detection and diagnosis of non-diabetic hyper-glycemia and Type 2 diabetes • Reduced hospital admissions and lengths of stay • Reduction in prevalence of Type 2 diabetes • Reduction in hospital admission and length of stay • Improvements in quality of life indicators/ patient experience and reduction in diabetes-related complications National Diabetes Prevention Programme (NDPP) A free education programme for those who are at risk of developing Type 2 diabetes or have Non-diabetic Hyperglycaemia. NDPP is a tailored, personalised support including education on healthy eating and lifestyle, help to lose weight and physical exercise programmes • Reduction in the number of patients at risk of developing diabetes • Increased notification of patients with NDH • Increase the number of patients accessing NDPP programme Diabetes Book & Learn An on-line booking service for patient diabetes education courses. The service accessible to both patients and GPs across south London for both Type 1&2 The Diabetes Book & Learn Service also holds a directory of lifestyle and community services including mental health services and patients may be signposted to services available in their own local areas • Improve access and take up of diabetes structured education • Improve choice for patients • Standardise processes across south London which will reduce and streamline administration • Increase in the number of referrals for diabetes structured via both GPs and self-referrals Diabetes Structured Education Diabetes Structured Education for patients with both Type 1 &2 Diabetes. The accredited structured education covers traditional education, on- line/digital education which is accessible via the Diabetes Book & Learn Hub, extra capacity during evenings & weekends and sessions targeting primarily BAME patients • Increase in referrals and attendances at diabetes education courses • Improved glycemic control and quality of life • Year in year increase in attendance at structured education courses and improvement in patient reported confidence to self-manage