This case study was developed prior to the NHS Listening Exercise. The outcomes of this exercise have led to some changes to the policy, and this case study may not reflect the current policy position. More information can be found in our detailed response to the NHS Future Forum.
This case study sets out how Sentinel Healthcare Community Interest Company, clinical commissioners in Plymouth, are working with partner organisations to improve care for diabetes patients.
- What’s being done?
- Working in partnership
- How is clinical-led commissioning helping?
Plymouth has around 11,600 patients with diabetes and around 1,200 new patients enter the system each year. Currently the majority of diabetic patients receive their care and monitoring from specialists at the acute hospital, Plymouth Hospitals NHS Trust (PHNT). This means the secondary care specialists are not always able to focus their attention on the most complex and least stable patients for example Type 1, Pump patients and antenatal patients.
What’s being done?
The proposal is to create a central hub, based at PHNT, to manage the more complex specialised diabetic patients. All other diabetic patients will be managed in the community. Initially this will be through virtual clinics held in GP practices. A virtual clinic will be held in each GP practice and will involve one of the PHNT diabetic consultants working with the practice GPs to help them manage the ongoing care of their less complex diabetic patients. The clinics will also include education and training from the consultant to the GP to help them continue the ongoing management of their diabetic patients within the practice.
Following on from these virtual clinics locality clinics are being developed in community settings, where more complex patients can be seen in an outpatient setting by diabetic consultants. This will then free up capacity at PHNT to see the most specialist diabetic cases.
Working in partnership
In addition to this, Sentinel are working with the County Council to develop links with the county’s commissioning boards, They want to develop a campaign aimed at developing a partnership approach to supporting patients in the community to take ownership of their diabetes.
There is also work taking place across Plymouth to put in place an expert patient service where patients will support each other to manage their condition more effectively. A number of stakeholders are working together to empower patients and ensure that they aware of the long term health risks associated with diabetes. This will involve social services, local schools, health leads, public health, employers and community groups, all actively taking part in developing robust links across the city to ensure that people actively take ownership of their health.
How is clinical-led commissioning helping?
Clinical-led commissioning is supporting the development and creation of a diabetes team which works across all care settings. Commissioners are working with clinicians to develop a seamless service which identifies more patients who can be treated optimally in a primary care setting without the need for additional referral to specialised secondary care.
How are patients benefiting?
There are a number of benefits for the patient and the healthcare staff, including:
- Diabetes care is being delivered closer to the patient’s home
- The team are able to identify diabetes earlier in the disease progression, reducing the risk of escalation to cardiovascular events
- There is a reduction in unnecessary referrals to secondary care
- Patients are optimally treated by a named and familiar GP with support from a specialist secondary care diabetes clinician
- GPs and practice nurses are supported at practice level by the consultant. This also supports personal development in the area of diabetes
- Each patient’s treatment plans are developed at practice level, ensuring optimal care and appropriate treatments.
To date the new service has led to 54 avoided referrals to secondary care.
The virtual clinics have also seen 66 new referrals that would have normally been sent to secondary care.