Diabetes Care Pathway

Diabetes Care Pathway May 2013 (Updated August 2013 to include additional funnel plot graphs and information on LiveWell Richmond)

Executive Summary Purpose The purpose of this document is to illustrate the case for change for diabetes services and to put forward recommendations to improve the quality of care in the community. Background By 2025 it is estimated that five million people will have diabetes. 1 Across England, approximately a third of the projected rise in diabetes prevalence can be attributed to the increasing prevalence of obesity. Diabetes is a major cause of premature mortality with at least 24,000 avoidable deaths each year. 2 A diagnosis of diabetes approximates to a reduction of life expectancy by about ten years. 3 National Institute for Health and Care Excellence (NICE) provides comprehensive guidance on prevention, diagnosis, management, and complications of diabetes. Case for Change The QOF prevalence of diabetes for adult patients in Richmond was 3.4% in 2011/12 (London: 5.6% and England 5.8%), which is around 5,350 people. Richmond public health analysis (2012/13) shows that there were 5,840 patients of all ages with diabetes. Eighty-five percent were of type 2 (4972 patients), 7% of type 1 (436 patients), and 7% unclassified (432 patients) due to insufficient diagnostic information. There are a number of people living with diabetes who are currently undiagnosed or living with pre-diabetes. Further work around case finding and early prevention is needed to identify these people and provide them with appropriate care in the community. A low percentage of people in Richmond with diabetes are receiving the nine key tests for diabetes care recommended by NICE, in particular for people with type 1 diabetes (27.7%), with Richmond being in the 2 nd lowest quintile nationally for this indicator. Over 50% of people with type 2 diabetes are receiving the nine key tests annually. Emergency admissions among patients with diabetes vary across practices. After allowing for age and sex distribution, around six practices have significantly higher emergency admissions than the Richmond average for patients with type 2 diabetes. Ninety percent of people with diabetes have co-morbidities. The National Diabetes Audit (2011/12) shows that in Richmond patients with diabetes, 7.3 per 1000 had had a stroke in the previous year compared to 6.9 per 1000 across England. Similarly, 10 per 1000 of people with diabetes had a myocardial infarction in the previous year compared to 4.8 per 1000 in all PCTs in its cluster group. Current Richmond Diabetes Pathway The local diabetes pathway sets out levels of care and includes services/activity recommended by NICE for the management of diabetes, in line with the model of care set out in the Diabetes Guide for London. 4 The diabetes pathway for Richmond follows a tiered approach. Level 0 is prevention and lifestyle services for self-care, underpinning all of the other tiers. Level 1 is core primary care services delivered by health care professionals in GP practices. Level 2 is enhanced primary care according to clinical need and is delivered by the practice or in conjunction with the level 3 Community Based Intermediate Diabetes Service. Level 3 is a consultant led specialist multi-disciplinary service, delivered in a community setting and aimed at patients with complex needs requiring specialist input. 1 Diabetes UK, Diabetes in the UK 2012: Key Statistics, April 2012 2 National Diabetes Audit Mortality Analysis 2007-2008 NHS Information Centre, 2011 3 National Service Framework for Diabetes: Standards, 2001 4 Healthcare for London, Diabetes Guide for London, March 2009. Page 2 of 47

Level 4 is a consultant led specialist multi-disciplinary service that is delivered in secondary care/hospital settings. Level 4 also includes an inpatient service and emergency admissions. There is potential for the Community Ward to case manage diabetes patients who are at very high risk of unplanned hospital admissions, and reduce avoidable emergency admissions. Cost Savings In 2012/13, overall total spend on hospital activity for Richmond patients with diabetes, including their co-morbidities, was 12.7 million (including elective procedures, emergency admissions, outpatient appointments, A&E, and community prescriptions). Treatment for complications and related co-morbidities represents much of the total cost for diabetes. The main possible cost savings are focused on achieving a reduction of avoidable emergency admissions (Ambulatory Care Sensitive Conditions 5 (ACS)) due to complications of diabetes and co-morbidities. In 2012/13, there were 141 emergency admissions for ACS conditions for patients with type 2 diabetes that may have been avoided, saving up to 368,388. Recommendations A range of stakeholders were identified to consult with (Appendix 1) and their input was used to inform the recommendations: 1) Continue case finding work to identify undiagnosed patients 2) Identification and management of pre-diabetes patients 3) Referral to LiveWell Richmond (lifestyle services) 4) Review Primary Care LES post March 2013 5) Routine implementation of nine key diabetes tests 6) Reduce avoidable emergency hospital admissions 7) Investigate potential to share Diabetes Specialist Nurses (DSNs) across practices 8) Embed NICE Quality Standard in provider contracts 9) Monitor equalities data in provider contracts 10) Offer DESMOND as part of a package of care 11) Provide diabetes education for non-english speaking BME groups 12) Review provision and referral criteria to dietetic services for diabetes patients 13) Offer options for non face-to-face communication for ongoing management 14) Better management of diabetic patients in care homes as they are high risk for emergency hospital admission 15) Review integrated models of care from other CCGs and prioritise the diabetes pathway for the Community Ward 16) Develop an integrated community based diabetes service 17) Develop pathways to address multiple morbidity 18) Ensure a diabetes pathway is embedded in the future Integrated Care Organisation Next Steps The diabetes pathway will be discussed by the Richmond Clinical Advisory Group (CAG) in June. NHS Richmond CCG will lead on taking recommendations forward, with support from Public Health. Additionally, dependencies in delivering recommendations will be acknowledged and relevant stakeholders will be included to inform planning and delivery of the recommendations. The pathway shall be reviewed every two years as routine and earlier if any national guidance is published that has a great impact. This will be triggered via the Planned Care Group. 5 Ambulatory Care Sensitive (ACS) conditions are common conditions for which timely and effective out of hospital care, including primary care and community care as well as good case-management, can result in a reduction in unnecessary, expensive and unplanned hospital admissions. Page 3 of 47

1. Purpose The purpose of this document is to illustrate the case for change for diabetes services and to put forward recommendations to improve the quality of care in the community. This document describes diabetes prevalence and outcomes, and maps the existing diabetes prevention, management, and treatment services provided for Richmond patients, including service activity and associated costs where available. The latest NICE guidance for treating diabetes have been referenced and incorporated into the diabetes pathway. Recommendations have been provided for commissioning and implementation in line with best practice from NICE. An equality impact needs assessment (EINA) has been completed for the diabetes care pathway. 2. Background Diabetes is one of the biggest health challenges facing the UK today. Since 1996 the number of people diagnosed with diabetes has increased from 1.4 million to 2.9 million. By 2025 it is estimated that five million people will have diabetes. 6 Most of these cases will be Type 2 diabetes, because of the ageing population and rapidly rising numbers of overweight and obese people. Across England, approximately a third of the projected rise in diabetes prevalence can be attributed to the increasing prevalence of obesity. Diabetes is a major cause of premature mortality with at least 24,000 avoidable deaths each year. 7 A diagnosis of diabetes approximates to a reduction of life expectancy by about ten years. 8 It is considered as serious and as damaging as a patient suffering a heart attack. NHS Richmond Commissioning Collaborative acknowledges that diabetes is a key health issue in the borough. The prevalence of diabetes for adult patients in Richmond was 3.4% in 2011/12 (London: 5.6% and England 5.8%). 9 This equals to around 5,350 people in Richmond. As of April 2013, there were a total of 5,840 patients of all ages with diabetes. 10 Diabetes is characterised by pancreatic beta cell insufficiency, insulin resistance and chronic hyperglycaemia. It is the chronic raised sugar levels that are thought to cause the series of micro vascular and macro vascular complications, which can affect all the major organs. Diabetes can affect the heart, the kidneys, the peripheral vascular system and the eyes. Patients with diabetes need routine retinal screening, foot care and diabetes management. Diabetes increases the risk of cardiovascular disease (heart attacks, strokes, mini-strokes) by two to four times. 11 Diabetes is the most common reason for renal dialysis and the most common cause of blindness in people of working age. 12 Diabetes results in many planned and unplanned hospital admissions associated with complications, particularly for the specialties of vascular surgery, orthopaedics and endocrinology. The nature of diabetes means that many health services are involved and these services are commissioned to serve these needs. 6 Diabetes UK, Diabetes in the UK 2012: Key Statistics, April 2012 7 National Diabetes Audit Mortality Analysis 2007-2008 NHS Information Centre, 2011 8 National Service Framework for Diabetes: Standards, 2001 9 Information Centre, QOF 2011/12. 10 Richmond Data Warehouse, April 2013 11 Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the multiple risk factor intervention trial. Stamler J, Vaccaro O, Neaton J, Wentworth D., Diabetes Care, 1993. 12 State of the Nation, England - Diabetes UK, 2012. Page 4 of 47

3. Evidence Based Practice NICE Guidance describe the following keystones to diabetes prevention and treatment. Prevention of Diabetes Detection and Diagnosis Control of Blood Glucose/Blood Pressure/Blood Lipids Weight Control Screening/treatment of diabetic: eye disease/kidney disease/foot disease Screening/treatment of diabetes in pre-pregnancy/pregnancy Specific care of children / young adults Psychological care of those with diabetes Care of those who are housebound or in long-term care facilities Guidance documents can be accessed from the NICE website at www.nice.org.uk. Additionally, Appendix 2 lists all published NICE Guidance related to Diabetes. NICE recommends nine key tests for diabetes care. All patients should receive these nine crucial tests from their GP at an annual review of their diabetes management. These include measurements of weight, blood pressure, smoking status, a marker for blood glucose called HbA1c, urinary albumin, serum creatinine, cholesterol, and tests to assess whether the eyes and feet have been damaged by diabetes. Additionally, NICE has developed a diabetes pathway, which brings together all relevant NICE guidance, quality standards, and materials to support implementation of diabetes management. The pathways are interactive and designed to be used online. To view the online version of this pathway visit: http://pathways.nice.org.uk/pathways/diabetes. 4. Overview of Diabetes a) Type 1 Diabetes 13 About 10% of diabetes (Type 1) is due to pancreatic beta cell insufficiency resulting in an acute lack of insulin. The onset of type 1 diabetes typically begins in childhood (and continues into adulthood) and is always treated with insulin replacement. Insulin treatment often involves short acting treatment before mealtimes and longer acting base line treatment at night time. The aim is to achieve tight and optimal glucose control without the occurrence of dangerous hypoglycaemic episodes. An insulin pump is required only for particular patients who have uncontrolled episodes of hypo or hyperglycaemia. Insulin pumps that are secured subcutaneously to the patient require monitoring and a background insulin injection. This can result in more continual treatment and better glucose control. Blood glucose is recorded according to current glycaemic control. This requires lancets to pierce the skin, a lancing device, testing strips and a blood glucose meter. b) Type 2 Diabetes 14 Type 2 diabetes occurs when the body doesn't produce enough insulin to function properly, or the body s cells don't react to insulin. This is known as insulin resistance. Type 2 diabetes is far more common than type 1 diabetes. Type 2 diabetes affects people of all ages, and early symptoms are 13 NICE, Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults, Clinical Guideline 15, July 2004 (last updated March 2010) 14 NICE, Type 2 diabetes National clinical guideline for management in primary and secondary care (update), Clinical Guideline 66, 2008. Page 5 of 47

subtle. About 90% of all adults with diabetes have type 2 diabetes. Estimates suggest that around 850,000 people in England are not aware that they have diabetes. 15 Type 2 diabetes usually affects people over the age of 40, although increasingly younger people are also being affected. It is more common in people of South Asian, African-Caribbean or Middle Eastern descent. 16 The risk factors for type 2 diabetes include: A close family member has Type 2 diabetes (parent or brother or sister) Overweight- or if waist is 31.5 inches (80 cm) or over for women; 35 inches (89 cm) or over for Asian men and 37 inches (94 cm) or over for white and black men Being South Asian or African-Caribbean, these ethnic groups are five times more likely to get type 2 diabetes High blood pressure or previous heart attack or stroke Women with polycystic ovary syndrome (PCOS), especially if overweight Having impaired glucose tolerance or impaired fasting glycaemia Women who have had gestational diabetes Severe mental health problem The more risk factors that apply, the greater the risk of having diabetes. Type 2 diabetes is a chronic condition that limits the body's ability to use the carbohydrates in food for energy. The result is elevated blood sugar. Over time, this excess sugar raises the risk for heart disease, loss of vision, nerve and organ damage, and other serious conditions. Key messages on medicines management for patients with Type 2 diabetes: Type 2 diabetes occurs due to either reduced insulin secretion or peripheral resistance to its action; patients may be controlled by diet alone, oral antidiabetic drugs and/or insulin. According to the evidence base, the priorities of treatment include: Lifestyle changes (exercise, diet, smoking cessation etc.), BP control, initiating lipid management/therapy, adding metformin and considering tight glucose control. Involve the patient in decisions about their individual HbA 1c target level, which may be higher than the 6.5% (48mmol/mol) set for people with type 2 diabetes in general. Highly intensive management should be avoided. There is evidence that more aggressive treatment of hyperglycaemia early in the disease process produces sustained cardiovascular and microvascular benefits, whereas aggressive hyperglycaemic lowering later in the disease needs to be individualised Patients currently taking antihypertensives when diabetes is diagnosed should be reviewed and changed if their blood pressure is poorly controlled or the medication is inappropriate due to microvascular or metabolic problems. Please refer to Local Agreed Guidance for Anti-diabetic Agents for Type 2 Diabetes on the intranet for the locally agreed prescribing pathway. The guidance as of February 2012 is also included in Appendix 3. c) Impaired fasting glycaemia (IFG)/ Impaired Glucose Tolerance (IGT) Patients with IFG or IGT have a condition of pre-diabetes and have an increased risk of developing diabetes. However, making lifestyle changes is key to managing or reversing pre-diabetes: managing weight, keeping active, eating healthily. Treatment may also include management of blood pressure and cholesterol. 15 Diabetes Prevalence Model, Yorkshire and Humber Public Health Observatory 16 http://www.nhs.uk/conditions/diabetes-type2/pages/introduction.aspx Page 6 of 47

Sinha (Crane Park) Sarajlic (Staines Road) Boohan (Jubilee Avenue) Lewis (Hampton) Bhatia (Broad Lane) Kudra (Woodlawn) Stent (The Green & Fir Weeks (Deanhill) Robertson (Cross Deep) Pennycook (Hampton Hill) Crowley (North Road) Palacci (Castelnau) O-Flynn (Hampton Wick) Hudson (Seymour House) Childs (Thameside) Jackson (Acorn) Griffiths (Paradise Road) Smith (Richmond Lock) Bradley (Park Road) Jezierski (Sheen Lane) Bates (Pagoda Avenue) Sayer (Richmond Green) Cooper (Queens) Thomas (York) Johal (Twickenham Park) Da Costa (The Vineyard) Lawrence (Kew Gardens) Johnson (Sheen Lane) Flood (Essex House) Botting (Glebe) Fitzmaurice (Kew) 5. Prevalence Age is a key factor in diabetes prevalence. Type 1 diabetes tends to be diagnosed in childhood but the prevalence of Type 2 diabetes increases steadily after the age of 50 years. Diabetes prevalence is higher in areas experiencing deprivation. People living in the 20% most deprived neighbourhoods in England are 56% more likely to have diabetes than those living in the least deprived areas. 17 a) GP Observed Prevalence (QOF) In 2011/12, the GP observed prevalence of Diabetes for patients aged 17 and over in Richmond was 3.4%. This equals to around 5,350 patients. 18 The London average prevalence was 5.6% and the England average was 5.8%. The figure below shows that ten practices have a higher prevalence of diabetes than the Richmond average. Two practices have higher diabetes prevalence than the London and England averages. 8% 7% 6% 5% 4% 3% 2% 1% 0% Proportion of GP list size on Diabetes Mellitus register, 2011/12 England Richmond London Source: www.ic.nhs.uk/qof QOF data can be found on the Information Centre website (www.ic.nhs.uk/qof) as well as the GP Contract website (www.gpcontract.co.uk). b) Richmond Public Health Analysis Clinical diagnostic information for diabetes (Type 1 and Type 2) and a set of other diagnostic conditions were derived from GP consultation, community prescription, and hospital inpatient diagnostic data. Based on data up to April 2013, there were 5,840 diabetic patients in Richmond (all 17 Yorkshire and Humber Public Health Observatory, NHS Richmond CCG Diabetes Community Health Profile, 2010/11. 18 NHS Information Centre. QOF 2011/12. Page 7 of 47

Prevalence rate per 1000 population Rate per 100,000 ages). Eighty-five percent were of type 2 (4972 patients), and seven percent of type 1 (436 patients), and seven percent unclassified (432 patients) due to insufficient diagnostic information. Six practices had significantly high prevalence and five significantly low prevalence compared to Richmond as a whole. The confidence intervals show how high or low the estimated prevalence could be based on a 5% chance. The high or low diabetes prevalence could be a result of a range of risk factors including ethnicity and deprivation, which are not included in this analysis. A funnel plot shows the same results of high/low prevalence and is included in Appendix 4. Age and sex standardised diabetes rate (95% confidence intervals), by practice, NHS Richmond, April 2013 8000 7000 6000 5000 4000 3000 2000 1000 0 Richmond Average Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013 Type 1 diabetes The following graph shows prevalence of type 1 diabetes by age and gender. Type 1 diabetes is more prevalent among males, and prevalence rises sharply up to around age 20 for both genders. 6.0 5.0 4.0 3.0 2.0 Females Males 1.0 0.0 Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013 Page 8 of 47

Prevalence rate per 1000 population Type 2 diabetes The following graph shows the prevalence of type 2 diabetes by age and gender. Type 2 diabetes is more prevalent among males, and increases sharply with age. Prevalence rises steeply from around 50 years old for both genders; the increase is steeper for males. 180.0 160.0 140.0 120.0 100.0 80.0 60.0 Females Males 40.0 20.0 0.0 Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013 c) Modelled Estimate of Diabetes Prevalence Modelled estimates suggest that the total prevalence of diabetes in Richmond is higher than GP recorded prevalence. This is due to a proportion of patients who are currently undiagnosed. The Diabetes Prevalence Model estimates the total (diagnosed and undiagnosed) number of people aged 16 and over with diabetes. Estimates are adjusted for the age, sex, ethnic group and deprivation pattern of the local population. It is important to note that this statistical model may over-estimate the number of undiagnosed people with diabetes in Richmond. Estimated total (diagnosed and undiagnosed) diabetes prevalence in adults 16 and over Source: Yorkshire & Humber Public Health Observatory, Diabetes Prevalence Model http://www.yhpho.org.uk It is estimated that in 2012, 6.2% of people aged 16+ in Richmond had diabetes (vs. 3.4% QOF), which is around 9,850 patients. Across England, approximately a third of the projected rise in diabetes prevalence can be attributed to the increasing prevalence of obesity. Page 9 of 47

6. Case Finding Diabetes is often diagnosed with an incidental finding of raised level of sugar in the blood. For many, the risk of diabetes is well recognised and diabetes is confirmed on a blood test as part of routine primary care. Occasionally diabetes first presents as an acute emergency and coma for example. There are a number of people living with diabetes who are currently undiagnosed. Further work around case finding is needed to help identify these people and provide them with appropriate care. There is scope to identify undiagnosed diabetes patients and high risk patients in the community through the NHS Health Checks programme, screening in GP Practices, Pharmacies and use of the Diabetes Risk Score. a) NHS Health Checks Some of the undiagnosed patients correspond to those patients that cannot access primary care or rarely have the need to attend their doctor. It is these hard to reach population that has been targeted to some extent with the current NHS Health Checks programme, by screening the 40-74 age group. NHS Health Checks are available in primary care, community pharmacies and community outreach. From April 2011-March 2013, approximately 50 undiagnosed people have been found through the NHS Health Checks Programme. The NHS Health Checks also contributes to preventing diabetes by identifying people with impaired glucose tolerance (IGT). Through the LiveWell programme these individuals can access a group self-management education programme called Walking Away from Diabetes. In 2011/12, GPs referred 50 patients with pre-diabetes (Health Checks and non-health checks patients) to the Walking Away from Diabetes programme and 38 patients completed the programme. b) Primary Care Additionally, all patients can be offered screening within primary care. Patients often present and request a test because of symptoms of thirst or fatigue or a family history of diabetes. Likewise a large number of urine or blood tests are offered opportunistically to help with establishing a diagnosis. All pregnant women are screened for diabetes and gestational diabetes. c) Community Pharmacy There is also opportunity for patients to be screened through Community Pharmacies. Discussions have taken place across SWL around how pharmacy can contribute within diabetes pathways from a Local Professional Network perspective. Additionally, each year, community pharmacy delivers up to six health promotion campaigns, which is jointly co-ordinated through the LiveWell Richmond Service. Diabetes or related health improvement campaigns (e.g. obesity, physical activity) could contribute to case finding in Richmond. d) Diabetes Risk Score The Diabetes Risk Score is an assessment tool which aims to identify individuals with impaired glucose regulation (IGR) and is designed to predict an individual s risk of developing Type 2 diabetes within the next ten years. It has been recommended by the 2012 NICE public health guidance, Preventing type 2 diabetes: risk identification and interventions for individuals at high risk, that GPs and other primary healthcare professionals use the tool for identifying people at risk of developing Type 2 diabetes. The risk assessment is evidenced-based and consists of seven questions. It uses a points system to identity if a person is at low, moderate, or high risk of developing diabetes. Based on this score, appropriate advice is provided in the form of lifestyle changes or a GP referral. The seven Page 10 of 47

questions are related to age, gender, waist circumference, BMI, ethnic background, blood pressure and family history. The tool is particularly useful in assessing people who: do not fall within the NHS Health Check age range, as anyone over the age of 18 can use it with the exception of pregnant women, are from Black, Asian and minority ethnic groups (who are at increased risk of diabetes), are from socially deprived groups who are at greater diabetes risk and less likely to access local healthcare services. GPs, other health professionals, and community practitioners in health and community venues should implement a two-stage strategy to identify people at high risk of type 2 diabetes (and undiagnosed type 2 diabetes). First, a risk assessment should be offered. Second, where needed, a blood test should be offered to confirm whether people have type 2 diabetes or are at high risk. e) Local Public Health Analysis Analysing SUS data and GP data extract can contribute to case finding by identifying undiagnosed diabetic patients who have never been to a GP, but were admitted to hospitals for diabetes emergency care. 7. Outcome Indicators a) Quality Outcomes Framework (QOF) Additionally, many of the QOF indicators related to the management of diabetes are also higher or in line with the England average. For example, 71.9% of patients had HbA1c levels <=7.5% in last 15mths (69.9% for England), and 93.4% of patients have had retinal screening in last 15mths (91.9% for England). 19 A comprehensive list of primary care indicator results for diabetes for 2011/12 can be found in Appendix 5. QOF Achievement for practices 2011/12 shows: Practice achievement for DM31: Last BP is <=140/80 mmhg, ranges from 49% to 85% as of March 2012. The expectation from HfL is that we should aspire to a threshold of 80%. Practice achievement for DM 26: Last HbA1c <= 7.5% ranged from 60% to 90% at March 2012. In 2010/11, an average of 56% of all people with diabetes aged 17 years and older who are not excepted from the Quality and Outcomes Framework have a HbA1c of 7% or less. 20 This is statistically significantly higher than PCTs with populations with similar diabetes risk factors and statistically significantly higher than England as a whole. The exception rate for all Diabetes Indicators was 4.9% for Richmond and 6.9% for England at March 2012. The exception rate for hypertension indicators only was 2% for Richmond and 2.5% for England. b) NHS Atlas of Variation The NHS Atlas of Variation in Healthcare 21 is a collection of healthcare measures or indicators for all PCTs. The indicators allow local comparison of performance against the overall performance of all PCTs in England. They are intended to highlight variation, not only in activity and cost, but also in quality, safety and outcome. The following table includes the diabetes indicators from the NHS 19 APHO, National General Practice Profiles 2012. http://www.apho.org.uk/pracprof/ 20 Yorkshire and Humber Public Health Observatory, NHS Richmond CCG Diabetes Community Health Profile, 2010/11. 21 RightCare www.rightcare.nhs.uk Page 11 of 47

Atlas of Variation 2010 and 2011 for NHS SWL Richmond (Richmond CCG) and NHS SWL Kingston (Kingston CCG) (because of similar demographics). 22 A low percentage of people in Richmond with diabetes are receiving nine of the key tests for diabetes care recommended by NICE. The nine key tests are: weight, blood pressure, smoking status, HbA1c, urinary albumin, serum creatinine, cholesterol, eye examinations and foot examinations. This is particularly low for people with type 1 diabetes, with Richmond being in the 2 nd lowest quintile nationally for this indicator. Over 50% of people with type 2 diabetes are receiving the nine key tests. Although Richmond is in the middle quintile nationally for type 2 patients, there is still room for improvement. It is recommended that the nine key tests are included as a Key Performance Indicator (KPI) as part of the GP LES for general practice and that GPs are incentivised to achieve all of them. These indicators rely on QOF records, so it is possible that achievement may seem lower than what is actually happening. For example, patients with type 1 diabetes are often seen in hospitals, and their test results may not always be shared with GPs and then entered into QOF. As many type 1 diabetes patients are seen in hospitals for their annual reviews, it is also recommended that acute commissioner s performance manage the acute trusts. NHS Richmond CCG performs well for people having major lower limb amputations, with the indicator being in the lowest quintile nationally. c) Variation in Inpatient Activity 23 In 2010/2011, there were 7747 observed emergency bed days for patients with diabetes in NHS Richmond CCG. This is 22.5% more than would be expected had those with diabetes had the same lengths of stay as those without diabetes. Across England, patients with diabetes were 39.7% more likely to be re-admitted as an emergency within 28 days of a previous spell of care when compared to patients of a similar age without diabetes. Additionally, in 2010/11 there were 251 emergency readmissions recorded for patients with diabetes in NHS Richmond CCG. This is 21.9% more than would be expected had those with diabetes had the same rates of readmission as those without diabetes. Across England, patients with diabetes having 15.1% more emergency bed days when compared to admissions for patients of a similar age without diabetes. These figures show that the patients with diabetes are more likely to be admitted and re-admitted as an emergency and stay for a longer duration as compared to people without diabetes. 22 The Annual Public Health Report for NHS South West London Richmond Borough Team 2011-2012. 23 Yorkshire and Humber Public Health Observatory, Variation in Inpatient Activity: Diabetes 2009/10 and 2010/2011. Page 12 of 47

Standardised admission rate per 100,000 Rate per 100,000 d) Local Data Analysis on Emergency Admissions Emergency admissions among patients with diabetes vary across practices. After allowing for age and sex distribution, six practices have significantly higher emergency admissions than the Richmond average for patients with type 2 diabetes. Five practices have significantly lower emergency admissions. The confidence intervals show how high or low the estimated rates could be based on a 5% chance. A funnel plot shows the same results of high/low emergency admissions and is included in Appendix 6. 1600 1400 1200 Age and sex standardised rate for emergency admission, Type 2 diabetes (95% confidence intervals), NHS Richmond, April 2013 1000 800 600 400 200 0 Richmond Average Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013 The scatter plot below shows that high/low emergency admission among patients with diabetes is positively related/correlated to high/low diabetes prevalence. It cannot be used in statistical testing of the points. 1200 Age and gender standardised diabetes rates and emergency admission for patients with diabetes, Richmond CCG 2013 1000 800 600 400 200 0 0 1000 2000 3000 4000 5000 6000 7000 Standardised prevalence per 100,000 Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013 Page 13 of 47

e) Care Homes Up to 25% of care home residents have diabetes in the UK. 24 National research shows that care home residents with diabetes are at high risk of unplanned emergency hospital admissions. 25 Managing these patients well by linking the diabetes pathway to care homes can improve their quality of care and potentially reduce avoidable hospital admissions. Ensuring the existence of a care plan and its communication to all members of the health and social care teams involved in an individual s care will facilitate high quality diabetes care. Local analysis on care homes admissions does not show any concerns; however this needs to be further looked into and we need to be mindful of this vulnerable group. The proposed CQUIN 2013/14 incentivises community nursing to ensure all patients with common chronic diseases such as diabetes, COPD, congestive heart failure, and falls are identified, appropriately signposted and plans put in place for future illness. f) Co-morbidities and complications Of the people with diabetes included in the National Diabetes Audit, in NHS Richmond CCG 7.3 per 1000 had had a stroke in the previous year compared to 6.9 per 1000 across the whole of England. In NHS Richmond CCG 10 per 1000 of people with diabetes had a myocardial infarction in the previous year compared to 4.8 per 1000 in all PCTs in its cluster group. As diabetes is linked to a number of co-morbidities, it is important to highlight the need to link with other chronic conditions pathways. For example, interdependencies can exist between diabetes and: hypertension, retinopathy, nephropathy, diabetic foot, depression, hyperlipidemia, cardiovascular disease, COPD, kidney disease, nonalcoholic fatty liver disease, musculoskeletal diseases, neurological diseases, and cancer. The graph below shows that nearly half of all patients with diabetes have three or more chronic conditions. Less than 10% have no chronic conditions. This highlights that a single pathway to tackle diabetes may not be sufficient to manage all the co-morbidities. Therefore, other pathways for long-term conditions such as CVD, COPD, obesity, and Chronic Kidney disease need to be developed and integrated together. Number of chronic conditions* for patients with diabetes 50% 40% 30% 20% 10% 0% 0 1 2 3+ Source: Richmond Public Health Analysis using SUS data and GP data extraction April 2013 *Including: congestive heart failure, hypertension, ischemic heart disease, AMI, disorders of lipid metabolism, diabetes, hypothyroidism, asthma, COPD, chronic renal failure, bipolar disorder, schizophrenia, depression, Parkinson's disease, seizure, age related macular degeneration, osteoporosis, rheumatoid arthritis, low back pain, immune-suppression transplant, glaucoma and cancer 24 Diabetes UK, Good Clinical Practice Guidelines for Care Home Residents with Diabetes, 2010 25 The NHS Information Centre, The 2011 National Diabetes Inpatient Audit National Report, 2012 Page 14 of 47

The following table shows the most common co-morbidities among people with diabetes. Around 70% of people with diabetes have disorders of lipid metabolism and/or hypertension. Percent of patients Co-morbidity Number with diabetes Disorders of lipid metabolism 4264 73% Hypertension 4165 71% Depression 1147 20% Ischemic heart disease (including acute myocardial infarction) 1029 18% Asthma 932 16% Congestive heart failure 746 13% Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013 g) NICE Quality Standards for Diabetes in Adults Compliance against NICE Diabetes in Adults Quality Standard (QS6) should be included as a key outcome for diabetes. This quality standard defines clinical best practice, provides specific, concise quality statements, measures and audience descriptors to provide patients and the public, health and social care professionals, commissioners and service providers with definitions of high-quality care. This quality standard covers the clinical management of diabetes in adults, excluding children, young people and pregnant women. This quality standard describes high-quality, cost-effective care that, when delivered collectively, should improve the effectiveness, safety and experience of care for adults with diabetes in the following ways, linked to the NHS Outcomes Framework 2011/12: 26 Preventing people from dying prematurely. Enhancing quality of life for people with long term conditions. Helping people to recover from episodes of ill health or following injury. Ensuring that people have a positive experience of care. Treating and caring for people in a safe environment and protecting them from avoidable harm. Specifically, it is expected that achieving the high-quality care set out in this quality standard will reduce the complications associated with diabetes. NICE quality standards need to be embedded in the GP LES, HRCH contract, and acute contracts to improve quality of diabetes care. 26 https://www.gov.uk/government/publications/nhs-outcomes-framework-2011-to-2012 Page 15 of 47

LiveWell Richmond Referral to services throughout pathway for self-care and self-management 8. Current Local Diabetes Pathway: Levels of Care Specialist care for patients that have a greater complexity or complications. Input may also be required from other specialities, as clinically appropriate. This level also includes inpatient and emergency care Specialist input for new diagnosis or complex cases, and development of a care plan that allows the patient return to self-management, reducing the need for hospital admission Care still delivered in primary care, but in conjunction with the Community Based Intermediate Diabetes Service when needed Level 4 Secondary Care: Hospital Services Level 3 Specialist Diabetes Management: Community Based Intermediate Diabetes Service (HRCH and QMH) Level 2 Enhanced Services: Care within General Practice (Primary Care) (and Community Based Intermediate Diabetes Service when needed) The Community Ward Service case manages very high risk patients to reduce emergency admissions Patients move up and down the levels as their condition dictates Many patients manage their diabetes through selfmanagement with support from primary care with routine care and surveillance Level 1 Core Services: Care within General Practice (Primary Care) Services for all, for prevention & selfcare, throughout pathway as needed Level 0 Prevention & Self-care Services: LiveWell Richmond (HRCH): Health advisor, healthy eating, physical activity, weight management, stop smoking, safe drinking, Walking Away from Diabetes, Expert Patient Programme NHS Health Checks (Primary Care, Pharmacies, Outreach): All eligible patients to receive an NHS Health Check and referred to LiveWell Richmond services as needed The local diabetes pathway sets out levels of care and includes services/activity recommended by NICE for the management of diabetes. The levels of care are in line with the model of care set out in the Diabetes Guide for London. 27 The diabetes pathway for Richmond follows a tiered approach: Level 0 is prevention and lifestyle services for self-care and self-management, underpinning all of the other tiers. Patients with pre-diabetes or lifestyle risk factors can be referred to LiveWell for access to support and assistance with making healthy lifestyle changes. LiveWell Richmond services should be offered to patients throughout the pathway, at each level, when needed. All patients aged 40-74 can receive a Health Check to assess their CVD health, and be referred to LiveWell services to help them take action to reduce their risk of heart disease, stroke, type 2 diabetes and kidney disease. Level 1 is core primary care services delivered by health care professionals in the patient s GP practice. Wherever possible, patients with diabetes are treated by their own GP. 27 Healthcare for London, Diabetes Guide for London, March 2009 http://www.londonprogrammes.nhs.uk/wp-content/uploads/2011/03/diabetes-guide.pdf Page 16 of 47

Level 2 is enhanced primary care according to clinical need and is delivered by the practice or in conjunction with the level 3 Community Based Intermediate Diabetes Service. Level 3 is a consultant led specialist multi-disciplinary service, delivered in a community setting and is aimed patients whose clinical need has the complexity requiring specialist input. Level 4 is a consultant led specialist multi-disciplinary service that is delivered in secondary care/hospital settings. The clinical needs of patients accessing these services have a greater complexity which requires this setting of care. Input may also be required from other specialities. Level 4 also includes an inpatient service and emergency admissions. Patients with complex symptoms, who are at very high risk of unplanned hospital admissions, are individually case managed by the Community Ward. This is a joint service with health and social care. The aim of the Community Ward service is to reduce avoidable emergency admissions and fits between level 3 and level 4. Primary care and the intermediate service manage most of the diabetes for NHS Richmond CCG. In practice, direct GP referral to the hospital sector is rare. The following sections provide further details on diabetes management and activities at each level. Appendix 7: Diabetes Prevention and Management Process, summarises the activity process for each level. a) Level 0: Prevention and Self-care Services Prevention and self-care services to support healthy lifestyles are crucial in the prevention and lifestyle management of Diabetes. The main ways to reduce risk of Type 2 diabetes are eating a healthy, balanced diet and doing at least 150 minutes (2 hours and 30 minutes) of moderateintensity aerobic activity, such as cycling or fast walking, every week. Stopping smoking and drinking sensibly can also lower risk of developing diabetes. Additionally, a healthy lifestyle can help manage diabetes, as well as reduce the risk of developing major diabetes-related complications. LiveWell Richmond The LiveWell Richmond Service supports working towards a healthier lifestyle by providing free support and/or services for people over age 16: Physical Activity e.g. Exercise Referral or Health Walks Healthy Eating Weight Management Sensible Drinking Stop Smoking (See Appendix 8 for further details) Walking Away from Diabetes Programme (for pre-diabetes) Expert Patient Programme See Appendix 9 for further details on specific LiveWell Services and eligibility criteria. The dedicated team of LiveWell health coaches provides information and guidance and regularly meets with people who want to make healthy lifestyle changes over two or three months to set and achieve their goals. Through LiveWell people can also access other structured and supervised programmes tailored to individuals with different health needs, including weight management, exercise, Walking Away from Diabetes, and the Expert Patient Programme. Support in helping patients to find ways to ensure that they are able to comply with their medication regime can also be provided. All patients at risk of diabetes, with pre-diabetes or diabetes should be referred to LiveWell Richmond. Page 17 of 47

During 2011/12, GPs referred 50 patients with pre-diabetes to the Walking Away from Diabetes programme and 38 patients completed the programme. In 2012/13, 50 patients completed the Walking Away from Diabetes programme. Discussions with stakeholders highlighted that there is a lack of awareness of the programme amongst clinicians, therefore various marketing methods need to be utilised to raise awareness and improve referral rates. The contact details for LiveWell Richmond are: Telephone: 0208 487 1745 (Monday to Friday, 9am to 7pm) Email: info@livewellrichmond.org.uk Patients can self-refer to the service, or GPs and other healthcare professionals can also refer patients using a LiveWell Referral Form. NHS Health Checks The NHS Health Check is a simple, free check which gives patients a clearer picture of their CVD health, and helps them take action to reduce their risk of heart disease, stroke, type 2 diabetes and kidney disease. The NHS Health Check is available in most GP Practices across Richmond. Some local pharmacists carry out the NHS Health Check. See Appendix 10 for a list of participating pharmacies. Health Checks are also happening via community outreach events in deprived areas of the borough on a regular basis. Since 2009, when the programme started, over 30,000 people have been invited for a health check and more 14,000 people have completed a health check. Following the check, patients are referred to LiveWell Richmond for help setting health-related goals to support making changes to their lifestyle to improve their health. For example, this includes sessions with a Health Advisor, weight management, or referral to the Walking Away from Diabetes programme if patients are identified as having pre-diabetes. b) Level 1: Core Services within General Practice Level 1 is care delivered by primary care health care professionals in the GP practice. It includes initial diagnosis and the annual review, based upon the 9 key care processes. Level 1 is supported by the General Medical Services contract, Quality Outcomes Framework. Key activities occurring at Level 1 include: Screening of high risk individuals Identification of people with diabetes and pre-diabetes Diagnosis and initial management Continuing care following agreed protocol Annual medical review for all patients on the diabetes register, in line with QOF Indicators Referral to lifestyle services through LiveWell e.g. weight management, exercise programmes, Expert Patient Programme Referral to relevant self-management programme (e.g. Walking Away from Diabetes, DESMOND, BERTIE) Referral to Dietetic Services Referral to counselling/psychology services Much of the initial diagnosis and routine care of diabetes is performed in primary care. All GPs and practice nurses are familiar with common diabetes management. The majority of patients with diabetes can manage their condition on their own with support from primary care. Much of the day to day management of diabetes is performed by the patient themselves. Primary care clinicians supervise this self management and offer routine care and surveillance. The QOF system guides, Page 18 of 47

encourages, and incentivises such activity. GPs can also refer patients with diabetes to LiveWell services for support and assistance with making healthy lifestyle changes. Immunisations Practices should ensure that all patients diagnosed with diabetes are offered the seasonal flu vaccine and the one-off pneumococcal vaccination. All healthcare professionals managing diabetes patients should encourage the uptake of appropriate immunisations from their GP. Practice achievement for QOF DM18: Influenza immunisation given 1 Sep- 31 Mar ranged from 84%-100%. Patient Review Regular patient reviews are undertaken within the QOF framework, looking at need for insulin, management of blood pressure, cholesterol and blood thinning agents. If a patient has not already accessed LiveWell Richmond this should be considered and a referral generated during the review. c) Level 2: Enhanced Services within General Practice (and Community Based Intermediate Diabetes Service when needed) Level 2 is an enhanced version of level 1. Care is still delivered in the GP practice setting but, according to clinical need, this will be in conjunction with the Community Based Intermediate Diabetes Service. Level 2 is supported by Level 1 is supported by a local enhanced service specification (LES). Key activities occurring at Level 2 include: Provision of all care for Type 2 patients Oral Glucose Therapy Hypertension Management Lipid Management Initiation of Insulin/Injectable treatments in Type 2 (where the skills within the practice exist) Ongoing management with insulin/injectable Referral to lifestyle services through LiveWell e.g. weight management, exercise programmes, Expert Patient Programme Referral to relevant self-management programme (e.g. Walking Away from Diabetes, DESMOND, BERTIE) Referral to Dietetic Services Referral to counselling/psychology services GP LES A local enhanced service (LES) is funded and managed by the CCG, and exists to promote GP case finding, core services, and to enable more level 2 enhanced activities within primary care. The LES was set up in April 2010 and has been rolled over for 2013/14. Twenty eight practices have signed up to the LES. There are a remaining 632 patients with diabetes from the two practices who have not signed up to the LES. It is assumed that these patients are still receiving level 2 services from practices in conjunction with community based intermediate diabetes services. The LES will be reviewed this year to reflect any changes to practice and targets (e.g. QOF targets have changed for 2013/14). Enhanced service requirements of the GP LES include: Monitor and treat the cardiovascular risk associated with diabetes Undertake a Mental Health Assessment on all adult patients with diabetes as part of the annual review Care for patients that are on established insulin and are stable enough to be fully maintained in a primary care setting Conversion to insulin Hypertension Management (DM 30 and 31) Page 19 of 47

Lipid Management (DM 26, 27, and 28) Maintain Exception Reporting to equal or below the national averages on QOF indicators. Five practices are able to initiate insulin; the rest of the practices refer their patients to community based diabetes services for insulin initiation. Most GPs prefer that insulin treatment is initiated by specialist teams within the intermediate care team, as specialist skills are needed and DSNs would be an additional cost to employ. Practices would need to have a high enough number of patients needing insulin to justify the need for their own DSN. Other GPs have more involvement with diabetes and they refer patients only when there is a complex case or where sugar control is difficult to achieve. Patients are screened for developing complication of diabetes such as peripheral neuropathy, retinal maculopathy, and depression. d) Level 3: Specialist Diabetes Management Level 3 is a consultant led specialist multi-disciplinary service that is usually delivered in a community setting. The clinical needs of patients referred to this service have the complexity that requires temporary specialist input to formulate and agree a care plan that allows them to return to a self-management situation, reducing the need for hospital admission. The teams work with the patient to agree outcomes and then produce a care-management plan, which the patient s GP practice can implement between visits to the specialist clinic. This approach means that patients with diabetes are receiving specialised care for their condition at the most appropriate level and do not have to make unnecessary trips to acute hospitals. It is not intended that patients will continue to be seen in this setting in the long term although it is understood that non-compliance and comorbidities may make it necessary and preferable to advancing them to level 4. Level 3 Specialist Diabetes Management services are provided at Teddington Memorial Hospital and Queen Mary s Hospital. Key activities occurring at Level 3 include: Specialist input Dietetics DESMOND (Type 2)- Newly Diagnosed and Foundation Programme (patients who have had diagnosis for >12 months for ongoing management) BERTIE (Type 1)- currently through Kingston Hospital or QMH (there are plans to also offer an in-house education programme this through HRCH) Podiatry Retinal Screening Develop individual care plan with patient Insulin initiation* for Type 2 patients Insulin initiation* for BD & basal bolus regimens Titration of insulin regimens for both Type 1 and 2 Telephone liaison and support for Level 1 & 2 practices Ongoing management of Type 1 patients Referral to lifestyle services through LiveWell e.g. weight management, exercise programmes, Expert Patient Programme Referral to counselling/psychology services *for those practices not commissioned to undertake this themselves Appendix 11 includes the sub-pathway for referring adult patients with type 2 diabetes to Intermediate care, as well as Secondary care. Teddington Memorial Hospital (TMH)- Community Based Intermediate Diabetes Service Hounslow and Richmond Community Healthcare NHS Trust (HRCH) are commissioned to provide the intermediate diabetes service at TMH. The consultant led intermediate care team comprises an Page 20 of 47

endocrine consultant, a GP with a Special Interest (GPwSI), two specialist diabetes nurses, a podiatrist, and dietitian. The team accept referrals and triages them, directing them towards which service level they need. DSN Helen Church leads the service with consultant Dr. Oldfield. The number of patients referred to the service with type 1 diabetes has increased. This may be due to GPs referring some patients for clarification on whether the patient has type 1 or type 2 diabetes. A new in-house education programme for type 1 patients is development to ensure complete care and is awaiting to be agreed by commisioners. The total cost of the service for 2012/13 is around 250,000. In 2011/12 there were a total of 2025 attendances to the Diabetes service. Targets as specified in the HRCH Service Specification: Performance Indicator Threshold (Patients seen) Method of Measurement Initial Contact 400 Patients attending Follow Up Contact 1,600 Patients attending Formal Advice and Guidance New service Recorded activity on choose responses DESMOND Programme 90% new patients = 360 Requires minimum 36 DESMOND programmes in 2010/11 Page 21 of 47 and book 90% of new patients attend programme DESMOND referrals for the Newly Diagnose programme have decreased significantly between 2011/12 and 2012/13. Referrals for the Foundation programme have also reduced. It could be useful to include the DESMOND programme in the package of care for patients for a better uptake. 2011/12 Referrals 2012/13 Referrals DESMOND Newly diagnosed programme 300 206 DESMOND Foundation programme 129 105 DNA DESMOND 20 Cancelled DESMOND 22 Other referral patients either declined attendance or seen 1-1 in clinic as they were not suitable for attending. The following table shows the attendance for the diabetes sub-services (excluding DESMOND). The majority of new referrals are for the DSN or Dietitian, with the DSN seeing the vast majority of follow up attendances. New referrals attendance 2012/13 Follow up attendance 2012/13 Diabetes Sub-service DSN 110 1200 GPwSI 13 142 Dr. Oldfield (Consultant) 3 109 Dietitain 75 137 The DNA rate has been improved thereby improving productivity and reduction of waiting times. DNA rates are currently running at 8.4%. Wait times: Medical review depending on clinician- from 4 weeks DSN- same day access for urgent cases, 2 weeks for routine cases Dietitian- 4-6 weeks for new and follow up appointments Podiatry- 24-48 hours for urgent cases, 2 weeks for routine cases Contact details for the Teddington Community Based Intermediate Diabetes Service: Specialist Nurse Support: The Diabetes Specialist Nurse team is based at Teddington Memorial Hospital and is available for clinic appointments, telephone advice and support and home visits for housebound patients. Tel: 020 8714 4070

Multi-Disciplinary Team: Multi-disciplinary team clinics are held on Thursday, all day, and nurse led clinics are held on Mondays, Thursdays, and Fridays each week at Teddington Memorial Hospital. Referral information: Clinic assessment- referrals can be made by GP practices only. Desmond Education Programme- can be made by self referral or referral by GP/Practice Nurse, or any other allied health care professional for both Newly Diagnosed and Foundation sessions. The referral form is included in Appendix 12 Walking Away Programme- referrals can be made from a GP/Practice Nurse, other health care professional, LiveWell Richmond, or self-referral Nurse. Queen Mary s Hospital, Roehampton (QMH) - Diabetes Outpatient Service Patients in the Richmond and Barnes locality have been historically referred to community-based intermediate diabetes services provided by Queen Mary s Hospital in Roehampton. This is often chosen by GPs based on proximity. The beta cell unit at QMH is structured similarly to the intermediate diabetes service at TMH. Historically this has been referred to by Richmond and Barnes locality doctors as well as Wandsworth GPs. This service is consultant led by Dr Oldfield. The service provides a comprehensive diabetes outpatient service for adults (age 16+) with a confirmed diagnosis of diabetes. It doesn t include Diabetes Paediatric service or pregnancy and diabetes service (usually referred to Kingston Diaban unit for duration of pregnancy). When patients are discharged back home from QMH, if follow up is needed, they are referred to the HRCH Community DSN team. Activity and cost for the QMH Outpatient Diabetes Service is detailed below. The total cost for the service is around 238,000. From the activity and costing data available, it seems that the service at TMH may be less expensive compared to QMH. However, more information is required to draw any conclusions. There may be potential to provide community based diabetes services across Richmond by GP clusters. Service Forecast Outturn Activity (2012/13) Forecast Outturn Value (2012/13) Diabetic Medicine (Multi-practitioner, First) 52 20,431 Diabetic Medicine (Multi-practitioner, Followup) 107 19,137 Diabetic Medicine (Single-practitioner, First) 111 32,556 Diabetic Medicine (Single-practitioner, Followup) 1382 166,258 Total 1652 238,381 Contact details for the QMH Diabetes Outpatient Service: Opening hours: Monday to Friday 8.30am 4.30pm Telephone advice: 020 8487 6447 Secretaries: 020 8487 6441 or 020 8487 6987 Outpatients main number: 020 8487 6449 Fax: 020 8487 6535 Specialist Diabetes Dietitian Up until September 2012, the TMH Community Based Diabetes Service included dietetic input on a clinic per week basis (0.10 WTE). Since September, carbohydrate counting sessions were introduced for suitable type 1 patients (2 sessions per month), and now the total dietetic input is 0.15 WTE. There has been a 43% increase in dietetic face-face encounters from 2011/12-2012/13. Page 22 of 47

As the complexity of patients and subsequent email communication (non face-face contacts) has increased, there is a need to increase dietetic time. Currently, the TMH Community Based Diabetes Service has no dietetic referral criteria and referrals can be made from any level in the diabetes pathway. As there is very limited community dietetic capacity, this possibly causes more referrals from levels 1 and 2 in the pathway. QMH also has no referral criteria, but is working on having one in place soon to optimise the use of their specialist diabetes dietician resources (1.0 WTE). It is recommended that the provision, access to, and referral criteria for dietetic services for diabetes patients are reviewed. Retinal Screening People with diabetes are at risk of developing a complication called retinopathy. Keeping blood glucose, blood pressure and blood lipid levels under control will help to reduce the risk of developing retinopathy. For protection against retinopathy, it is best to have eyes screened with a digital camera when first diagnosed and then every year, to identify and then treat eye problems early. Retinal screening is offered on an annual basis to patients in Richmond. QOF data for DM 21: Retinal screening in the last 15 months, show that 93.4% of patients have been screened in 2011-2012. Two practices achieved less than 90%. Performance data for Quarter 3 for 2012/13 shows that 4492 received retinal screening, out of 4947 that were referred (rolling data for a 12 month period). This is just over 90% achievement at Quarter 3. There have been some quality issues at Kingston Retinal Eye Unit (KREU), as the unit struggled to offer appointments for patients with significant diabetic retinopathy within the recommended national time scales. Since November 2012, KREU stopped providing Wandsworth and Richmond Diabetic Eye Screening (DES) with patient outcomes/audit reports to the national programme to complete KPI data. The issue has been taken up at Kingston Clinical Quality Reference Group and is being resolved. There was a serious incident (SI) at Wandsworth, which highlighted the importance of correctly identifying patients with diabetic retinopathy and updating their QOF registers. A letter was sent to practices to this effect. Foot Care Foot problems can affect anyone who has diabetes. Diabetes, particularly if it is poorly controlled, can damage nerves, muscles, sweat glands and circulation in the feet and legs leading to amputations. Reviewing the feet of people with diabetes at time of diagnosis and annually, and keeping blood glucose, blood fats and blood pressure under control can prevent some of the complications associated with the feet. Routine podiatric foot care is offered to patients in Richmond to reduce the risk of lower limb ulceration and early amputation. HRCH are commissioned to see urgent cases within 72 hours and routine cases within 4 weeks. HRCH are currently meeting these targets. The HRCH podiatry service at TMH has the capacity to see up to 9 patients within a fortnightly session, depending on complexity of the cases. Historically the clinic was not always fully utilised by direct referrals to the clinic via TMH. In order to make good use of this clinic time, the HRCH community podiatry service has filled vacant slots within the clinics with patients on current caseload, with complex wounds, or wounds that are non healing. Most if not all of these patients are diabetic. Diabetic patients who would qualify to be seen by podiatry under Any Qualified Provider (AQP) are those classified as low risk and who have no other co morbidities that would place them at increased risk. The AQP contract does not cover provision for: diabetic patients identified as at increased risk or above (nice CG 10) Page 23 of 47

anyone with a wound grade 2-5 on wagner scale, or wound non healing within 4 weeks Anyone with Neuropathy of lower limbs Anyone with significantly impaired circulation to lower limbs The care for these patients will remain within block contract of HRCH specialist podiatry service. AQP does not cover annual diabetic foot screening, as this is commissioned from primary care. Self- management (e.g. DESMOND, BERTIE) Self management of diabetes is key to a good prognosis. Accordingly, all newly diagnosed patients/carers with diabetes are offered an appropriate education programme to teach them self management of their diabetes. BERTIE education is offered for type 1 diabetes. DESMOND is offered for type 2 diabetes. There is also Walking Away from Diabetes offered to those with IFG/IGT, who are at risk of developing diabetes (Level 0 LiveWell Richmond Service). Patient self management and support is also available through the Diabetes Network and Diabetes UK charity. There is potential for more ongoing management through non face-to-face communication. The HRCH Intermediate Diabetes service now offers non face-to-face follow ups as an alternative to clinic appointments, which has increased activity above target. This has also led to improved patient outcomes and joint working with the patient to encourage/support self-management. There were 384 non face-to-face contacts in 2012-13, which has included telephone contact, SMS, and email. There is a place for alternative forms of communication (e.g. email, text, telecare) and other options for ongoing management should be considered, as this can reduce clinic visits. Non-English Speakers Currently, non-english speakers are offered one-one sessions with a translator with the intermediate care team. The team also use Diabetes UK literature, which is available in many languages. There is a BME DESMOND for South Asian communities, but this it is not delivered in Richmond. This area has been highlighted within the recommendations and mentioned within the Equality Impact Needs Assessment. e) Community Ward Patients with complex symptoms, who are at very high risk of unplanned hospital admissions, are individually case managed by the community ward. This is a joint service with health and social care. The aim of the service is to reduce avoidable emergency admissions and fits between level 3 and level 4. Patients at very high risk of hospital admission are identified through risk stratification of data from GP Practices and Hospitals. Identified patients are discussed at a multi-disciplinary team meeting, which is composed of a social worker, community matron, care navigator, and a GP. A home care plan may be developed with the patient and carer (with specialist input as needed), and telecare/telehealth may be offered. Care delivery at home is co-ordinated by a Community Matron, supported by a Care Navigator. Patients can be on the community ward for a maximum of 12 weeks and patients are discharged following progress against their care and support plan. Appendix 13 describes the process of the community ward. The Community Ward service is being rolled out in four waves across the borough, beginning with Teddington and Hampton in January-March 2013 for a pilot feasibility study. Wave 2 covers East Sheen and Barnes (mid May 2013); Wave 3 covers Twickenham, Whitton and Heathfield (June 2013); and Wave 4 covers Richmond, Kew, and Ham (July 2013). The waves were grouped to be in line with health and social care services provided in the areas. Wandsworth and Hounslow CCGs have developed Virtual/Community Wards with their diabetes pathways and have moved acute care activity to community. There is a need to further explore their models of care and apply learning locally. Page 24 of 47

f) Level 4: Secondary Care Level 4 is a consultant led specialist multi-disciplinary service that is delivered in hospital settings. The clinical needs of patients referred to this service have a greater complexity or complications. Input may also be required from other specialities, as clinically appropriate. Level 4 also includes inpatient and emergency services. GPs can refer directly to diabetes services at Kingston, West Middlesex, St Georges and Charing Cross hospitals in the main, although GP referrals to level 4 hospital care is rare. The referrals are triaged by the Richmond Clinical Assessment Service (RCAS) and appointments are arranged using the choose and book system. Some referrals to Level 4 services are made from the intermediate diabetes care to level 4 services. A review of RCAS shows that referrals for diabetic medicine (as a main speciality) have increased by 5.2% and consultant-to-consultant referrals have risen by 57% since 2009. Key activities occurring at Level 4 include (referrals for the following): Newly diagnosed/ registered type 1 patients Existing/ newly registered females with diabetes who are pregnant Newly diagnosed/registered adolescents and young people Self-management programme, BERTIE (Kingston Hospital or QMH) Management of severe and acute complications Inpatient care and diabetic emergencies Renal Unit X-ray Psychological support Psychological Support Mental health problems are more common in people with physical illness. People with diabetes may have emotional or psychological support needs resulting from living with diabetes or due to causes external to the condition. Based on Richmond Public Health analysis, 20% of patients (1147 patients) with diabetes had depression in 2012/13. Psychological support therapies are offered to patients with diabetes in Richmond. Patients are referred through their GP or self-referred the Richmond Wellbeing Service. The service is based at Richmond Royal and also in a number of practices in the borough. The Richmond Wellbeing Service offers group workshops, counselling, self help courses, a range of talking therapies and computer-based therapies. Activity data for diabetes patients accessing psychological support is not available. Address: Richmond Royal Hospital, Kew Foot Road, Richmond, TW9 2TE Telephone: 020 8548 5550 Page 25 of 47

9. Cost of Diabetes a) Current Costs Diabetes accounts for approximately a tenth of the NHS budget each year, a total exceeding 9 billion, for direct patient care (treatment, intervention and complications). 28 The following table* shows the number and cost for hospital admissions for Richmond patients with diabetes, including their co-morbidities, for 2012/13. Total spend was 12,766,382 for patients with diabetes. Number Cost Elective Procedure (planned) 1,883 2,226,861 Emergency admission 1,199 2,779,722 First outpatient appointment 5,815 789,466 Follow up outpatient appointment 19,595 1,182,568 A&E 2,619 306,901 Community prescriptions 544,102 5,480,864 Total 12,766,382 Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013 * Current SUS data access issues for obtaining costs for hospital admissions due to diabetes as the main reason for non-elective admission. Outpatient data due to diabetes is not available, as there is no diagnosis data at outpatient clinics for diabetes. a) Possible Cost Savings Treatment for complications and related co-morbidities represents much of the total cost for diabetes. The main possible cost savings are focused on achieving a reduction of avoidable emergency admissions (Ambulatory Care Sensitive Conditions 29 (ACS)) due to complications of diabetes and co-morbidities. The Community Ward service is aimed particularly at reducing emergency hospital admissions. In 2012/13, there were a total of 141 emergency admissions for ACS conditions in Richmond for patients with type 2 diabetes (including their co-morbidities) that may have been avoided, saving up to 368,388. The table in Appendix 14 shows the number and cost for these emergency admissions by primary diagnosis for patients with type 2 diabetes. 10. Pathway Indicators Performance Indicators provide a baseline level of diabetes management in Richmond and a point from which to measure performance as a result of the services put in place. The table in Appendix 15 summarises indicators for the diabetes patient pathway that can be used as a dashboard of diabetes service performance. It would be useful to select which indicators should be included and monitored annually. 28 Hex, N., Bartlett, C., Wright, D., Taylor, M. and Varley, D. (2012), Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabetic Medicine, 29: 855 862. doi: 10.1111/j.1464-5491.2012.03698.x 29 Ambulatory Care Sensitive (ACS) conditions are common conditions for which timely and effective out of hospital care, including primary care and community care as well as good case-management, can result in a reduction in unnecessary, expensive and unplanned hospital admissions. Page 26 of 47

11. Recommendations 1) Continue case finding work to identify undiagnosed patients There is scope to further identify undiagnosed pre-diabetes (people with IFG or IGT) and diabetes patients through the NHS Health Checks programme, screening in GP Practices, and use of the Diabetes Risk Score. Additionally, discussions have taken place across SWL around how pharmacy can contribute within diabetes pathways from a Local Professional Network perspective. There is scope to be involved with these discussions and identify how the Local Pharmaceutical Committee can support the diabetes pathway. 2) Identification and management of pre-diabetes patients Patients with pre-diabetes have an increased risk of developing diabetes. Further work is needed to better understand the prevalence of pre-diabetes in the borough. GP Practice data can be analysed to obtain the number of people who have IFG. It would also be useful to identify these patients and invite them to attend the Walking Away from Diabetes programme (part of LiveWell Richmond), as lifestyle changes are key to managing or reversing prediabetes. This could be included as an activity in the updated GP LES. 3) Referral to LiveWell Richmond services (lifestyle services) Prevention and self-care services to support healthy lifestyles are crucial in the prevention and lifestyle management of Diabetes. All patients at risk of diabetes, with pre-diabetes, or diabetes should be offered LiveWell Richmond to help support lifestyle changes. GPs should refer to the service using the LiveWell Referral form. LiveWell services need to be well marketed and advertised widely. LiveWell services need to also be included in the Directory of Services for Planned Care. 4) Review Primary Care LES post March 2013 A LES is funded and enables more level 2 activities within primary care. The LES was set up in April 2010 and has been rolled over for 2013/2014. The LES should be reviewed this year to reflect any changes in practice and targets (e.g. QOF targets have changed for 2013/14). Additionally, components from the NICE Quality Standards for Diabetes in Adults could be included in the LES as key outcomes for diabetes. Activity around IFG/IGT patients and referral to the Walking Away from Diabetes programme could also be included in an updated LES. Furthermore, the LES could incentivise high risk patients (e.g. those with high blood pressure) to have more checks with GPs in the year. 5) Routine implementation of nine key diabetes tests A low percentage of people in Richmond with diabetes are receiving nine of the key tests for diabetes care recommended by NICE. This is particularly low for people with type 1 diabetes. There is room for improvement for Type 2 patients as well. It is recommended that the nine key tests are included as a KPI as part of the LES for General Practice, and that GPs are incentivised to achieve them. This possibly could also be improved by more complete QOF records. As many type 1 diabetes patients are seen in hospitals for their annual reviews, it is also recommended that acute commissioners performance manage the acute trusts. 6) Reduce avoidable emergency hospital admissions Some of the emergency admissions are Ambulatory Care Sensitive Conditions and are avoidable. There is potential to avoid 140 emergency admissions for diabetes patients, saving over 350,000 through the Community Ward. 7) Investigate the potential to share Diabetes Specialist Nurses (DSNs) across practices Very few GP practices employ DSNs. Five practices are able to initiate insulin. Most GPs prefer that insulin treatment is initiated by specialist teams within the intermediate care team, Page 27 of 47

as specialist skills are needed and DSNs would be an additional cost to employ. Practices would need to have a high enough number of patients needing insulin to justify the need for their own DSN. It is recommended that the potential to share DSNs across practices in order to extend specialist skills and services within primary care is investigated. It will need to be considered how the Community based diabetes service at TMH and QMH works with practices with DSNs. 8) Embed NICE Quality Standard in provider contracts The NICE Diabetes in adults quality standard (QS6) needs to be embedded in the GP LES, Hounslow & Richmond Community Healthcare NHS Trust (HRCH) contract, and acute contracts to improve quality of diabetes care. Achieving the high-quality care set out in this quality standard will improve the effectiveness, safety, and experience of care for adults with diabetes, as well as reduce the complications associated with diabetes. 9) Monitor equalities data in provider contracts There are currently gaps in equality data for commissioned services. Contracts do not currently include a requirement to obtain and monitor equality data. As referenced in the EINA, it is recommended to include a requirement in contracts for service providers to monitor and routinely report on equality data for protected groups. 10) Offer DESMOND as part of a package of care DESMOND attendances have decreased in the past year. DESMOND should be offered as a key component of a package of care (not offered as optional) by GPs. This would help to increase attendances again if patients and carers feel that DESMOND is a main part of their care package. The new QOF measure for referral to a structured education may also help to increase referrals to DESMOND. 11) Provide diabetes group education for non-english speaking BME groups Currently, non-english speakers are offered one-one sessions with a translator with the intermediate care team. The team also use Diabetes UK literature, which is available in many languages. It is recommended that diabetes education for South Asian communities be provided for Richmond patients. This gap in service provision is highlighted in the EINA. 12) Review provision and referral criteria to dietetic services for diabetes patients Currently, there are no dietetic referral criteria and referrals can be made from any level in the diabetes pathway. As there is very limited community dietetic input, this possibly causes more referrals from levels 1 and 2 in the pathway. As the complexity of patients and subsequent email communication (non face-face contacts) has increased, there is a need to increase dietetic time. It is recommended that the provision, access to, and referral criteria for dietetic services for diabetes patients are reviewed. 13) Offer options for non face-to-face communication for ongoing management There is potential for more ongoing management through non face-to-face communication. This can reduce clinic visits. Options for this can include emails, texts, or telecare/telehealth. Options for ongoing management should be considered. 14) Better management of diabetic patients in care homes as they are high risk for emergency hospital admission Best practice for commissioning diabetes services, published in 2013, shows that nationally, up to 25% of care home residents have diabetes and are at high risk for emergency hospital admissions. Managing these patients well by linking the diabetes pathway to care homes can improve their quality of care and potentially reduce avoidable hospital admissions. Ensuring the existence of a care plan and its communication to all members of the health and social care teams involved in an individual s care will facilitate high quality diabetes care. Local analysis on care homes admissions does not show any concerns; however this needs to be further looked Page 28 of 47

into and we need to be mindful of this vulnerable group. The proposed CQUIN 2013/14 incentivises community nursing to ensure all patients with common chronic diseases such as diabetes, COPD, congestive heart failure, and falls are identified, appropriately signposted and plans put in place for future illness. 15) Review integrated models of care from other Clinical Commissioning Groups (CCGs) and prioritise the diabetes pathway for the Community Ward Wandsworth and Hounslow CCGs have developed Virtual/Community Wards with their diabetes pathway and have moved acute care activity to the community. There is a need to explore their models of care and apply learning locally. It is recommended to adopt a similar model to prioritise the diabetes pathway within the Richmond Community Ward. 16) Develop an integrated community based diabetes service In the Richmond and Barnes area, the intermediate community diabetes services are usually obtained from the nearby QMH in Roehampton. There is a lack of clarity around service activity and associated costs for QMH. This service is being managed by the Commissioning Support Unit (previously Acute Commissioning Unit-ACU). From the initial data and costings received, it seems that QMH may be more expensive as a provider as compared to TMH. But further information is required to reach conclusions. There may be potential to provide community based diabetes services by GP clusters. 17) Develop pathways to address multiple morbidity Local analysis shows that 90% of patients with diabetes have co-morbidities such as CVD, hypertension, Depression, Asthma, Chronic kidney disease and disorders of lipid metabolism. There is a possibility to develop a pathway for diabetes and related multi-morbidities to reduce emergency hospital admissions significantly. Future services should be able to manage patients with multi-morbidities such as CVD, heart failure, and COPD as very few patients only have diabetes. Likewise, work on CVD, COPD, Stroke and AF should address diabetes. 18) Ensure a diabetes pathway is embedded in the future Integrated Care Organisation Richmond and Hounslow Councils, along with Hounslow and Richmond Community Healthcare NHS Trust and the CCGs in both boroughs are working together to develop an integrated organisation for health and social care. In the future, it is recommended that a diabetes pathway is embedded in the future Integrated Care Organisation. Next Steps The diabetes pathway document will be reviewed and discussed by the Richmond Clinical Advisory Group (CAG) in June. NHS Richmond CCG will lead on taking recommendations forward, with support from Public Health. Additionally, dependencies in delivering recommendations will be acknowledged and relevant stakeholders will be included to inform planning and delivery of the recommendations as needed. The pathway shall be reviewed every two years as routine and earlier if any national guidance is published that has a great impact. This will be triggered via the Planned Care Group. Page 29 of 47

12. Conclusion Diabetes is a key disease concern for Richmond, all London boroughs, and nationally. It is a continuing and growing problem in Richmond. It is a life shortening condition; it is very common, and therefore it is hugely expensive. Good disease management can make a significant difference to the clinical outcomes and patient s experience of diabetes. This management can reduce the need for emergency hospital admission, reduce the risk of lower limb amputation, and enhance the life quality of those with diabetes. Currently in Richmond, diabetes prevalence is increasing and more work needs to be done around preventing diabetes and identifying undiagnosed and high risk patients. Many patients are able to self-manage their condition with support from primary care, however, all of the nine key tests for diabetes need to be routinely implemented in order to identify and prevent potential complications. Community based Intermediate diabetes services provide specialist support and an integrated diabetes service for the borough would improve access and potentially reduce costs from QMH. The Community Ward has great potential in reducing avoidable emergency admissions for diabetes patients. Mapping available services already commissioned contributes to increasing awareness of the various services available to support clinicians in identifying and managing patients with diabetes. Additionally, focusing on outcome indicators and quality measures will ensure quality of care at all levels of the patient pathway. Page 30 of 47

Appendix 1: Stakeholders Name Title Organisation Planned Care Group NHS Richmond Clinical Commissioning Group (CCG) Dr. Nicholas Jackman GP Clinical Lead for Diabetes NHS Richmond CCG and GP with Special Interest in Diabetes Dr. Nicola Bignell Richmond CCG Governing NHS Richmond CCG Body member and GP Helen Church Diabetes Specialist Nurse Hounslow & Richmond Community Healthcare NHS Trust (HRCH) Alun Willis Dietetics and Diabetes Clinical HRCH Service Manager Annie Roberts Diabetes Dietitian Kingston Hospital NHS Foundation Trust Carlin Conradie Dietetic Services Manager Kingston Hospital NHS Foundation Trust Alastair Mackinlay Chair of Diabetes UK Richmond and Twickenham Diabetes UK Richmond and Twickenham Voluntary Group Voluntary Group Dr. Neil Browning Darzi Fellow 2011 NHS Richmond CCG Peter Yuen Public Health Analyst London Borough of Richmond upon Thames (LBRuT) Caoimhe O Sullivan Public Health Principal- Public LBRuT Health Intelligence Anna Raleigh Consultant in Public Health LBRuT Dr. Usman Khan Public Health Principal LBRuT Katherine Thompson Public Health Principal LBRuT Jane Bailey Public Health Lead LBRuT Michael Hughes Health Improvement Manager- HRCH LiveWell Richmond JJ Nadicksbernd Lead Facilitator, End of Life NHS Richmond CCG Care, Cancer, Care Homes Stephen Broderick Information and Performance NHS Richmond CCG Manager Tara Bahri Senior Practice Pharmacist NHS Richmond CCG Denise Madden Head of Service Development HRCH Jane Nicoli-Jones Specialist Group Services HRCH Manager and Lead Nurse Users and carers Leona Patel Public Health Lead LBRuT Diabetes UK Richmond and Twickenham Voluntary Group Page 31 of 47

Appendix 2: Related NICE guidance Published Preventing type 2 diabetes - risk identification and interventions for individuals at high risk. NICE Public Health Guidance 38 (2012). Preventing type 2 diabetes - population and community interventions. NICE Public Health Guidance 35 (2011). Diabetic foot problems - inpatient management. NICE clinical guideline 119 (2011). Diabetes in Adults Quality Standard. NICE Quality Standard 6 (2011). Weight management before, during and after pregnancy. NICE public health guidance 27 (2010). Prevention of cardiovascular disease. NICE public health guidance 25 (2010). Type 2 diabetes newer agents. NICE clinical guideline 87 (2009). Autologous pancreatic islet cell transplantation for improved glycaemic control after pancreatectomy. NICE interventional procedure guidance 274 (2008). Diabetes: insulin pump therapy. NICE technology appraisal guidance 151 (2008). Type 2 diabetes: the management of type 2 diabetes (update). NICE clinical guideline 66 (2008). Diabetes in pregnancy. NICE clinical guideline 63 (2008). Maternal and child nutrition. NICE public health guidance 11 (2008). Physical activity and the environment. NICE public health guidance 8 (2008). Behaviour change. NICE public health guidance 6 (2007). Diabetes (type 1 and 2) inhaled insulin. NICE technology appraisal guidance 113 (2006). Obesity. NICE clinical guideline 43 (2006). Type 1 diabetes. NICE clinical guideline 15 (2004). Type 2 diabetes: footcare. NICE clinical guideline 10 (2004). Allogeneic pancreatic islet cell transplantation for type 1 diabetes mellitus. NICE interventional procedure guidance 257 (2003). Diabetes (type 1 and 2) patient education models. NICE technology appraisal guidance 60 (2003). Diabetes (type 1 and 2) long acting insulin analogues. NICE technology appraisal guidance 53 (2002). Under Development Diabetes in children and young people: diagnosis and management of type 1 and type 2 diabetes in children and young people. NICE clinical guideline (publication date tbc). Overweight and obese adults - lifestyle weight management. NICE Public Health Guidance (publication expected May 2014) Page 32 of 47

Appendix 3: Local Agreed Guidance for Anti-diabetic Agents for Type 2 Diabetes (February 2012) Page 33 of 47

Appendix 4: Funnel Plot showing Diabetes Prevalence by Practice Page 34 of 47

Appendix 5: Primary Care Indicators for Diabetes, 2011-12 Indicator PCT Value England Average England Lowest England Highest Diabetes: QOF prevalence (17+) 3.4% 5.8% 0.0% 18.0% Exception rate for diabetes indicators 4.9% 6.9% 0.0% 36.9% Hypertension: QOF prevalence (all ages) 10.5% 13.6% 0.0% 60.1% Exception rate for hypertension indicators 2.0% 2.5% 0.0% 31.5% Exception rate for smoking indicators 0.7% 0.7% 0.0% 16.5% Obesity: QOF prevalence (16+) 6.1% 10.7% 0.0% 41.8% Diabetes admissions (per 1000) 0.700 1.15 0.0 11.5 Ratio of recorded vs expected diabetes prevalence 0.577 0.883 0.0 12.0 DM 2: Record of BMI in the last 15mths 93.7% 94.9% 38.1% 100% DM 26: Last HbA1c is <=7.5% in last 15mths 71.9% 69.9% 0.0% 100% DM 27: Last HbA1c is <=8% in last 15mths 80.9% 78.7% 0.0% 100% DM 28: Last HbA1c is <=9% in last 15mths 89.6% 88.6% 39.1% 100% DM 21: Retinal screening in last 15mths 93.4% 91.9% 0.0% 100% DM 29: Record of peripheral pulses last 15mths 89.7% 89.6% 0.0% 100% DM 10: Record of neuropathy test last 15mths 91.0% 91.9% 0.0% 100% DM 30: Last BP is <=150/90 89.6% 89.9% 15.0% 100% DM 31: Last BP is <=140/80 65.9% 70.7% 0.0% 100% DM 13: Record of micro-albuminuria test last 15mths 88.9% 88.9% 0.0% 100% DM 22: egfr or serum creatinin testing in last 15mths 96.8% 96.9% 40.0% 100% DM 15: Proteinuria/micro-album. treated w inhibitors 91.4% 87.4% 0.0% 100% DM 17: Measured total chol (last 15mths) <=5mmol/l 78.5% 81.7% 0.0% 100% DM 18: Influenza immunisation given 1 Sep - 31 Mar 91.2% 90.7% 32.0% 100% Dep 1: Depression case finding in CHD and/or diabetes patients 90.9% 88.6% 0.0% 100% Smoking 3: status recorded in last 15mths (certain conditions) 94.5% 95.6% 13.6% 100% Smoking 4: cessation advice/referral offered (certain conditions) 94.1% 92.9% 8.8% 100% Page 35 of 47

Appendix 6: Funnel plot showing Emergency Admissions for patients with diabetes by practice Page 36 of 47

Appendix 7: Diabetes Prevention and Management Process Prevention & Self-care Services All patients at risk of diabetes, with pre-diabetes, or diabetes offered referral to LiveWell Richmond services to support with lifestyle changes and self-care: Health Advisor, healthy eating, physical activity, weight management, Expert Patient Programme, Walking Away from Diabetes, stop smoking, safe drinking All eligible patients to be offered an NHS Health Check and referred to LiveWell Richmond services as needed a Level 1 Level 2 Level 3 Level 4 Core Services Screening of High Risk Individuals Identification of people with diabetes and pre-diabetes Diagnosis and initial management Continuing care following agreed protocol Annual Medical Review for all patients on the diabetes register, in line with QOF Quality Indicators Referral to lifestyle services through LiveWell Richmond Referral to self-management programme Referral to dietetic services Referral to counselling/psychology services Enhanced Services Achieving all parameters outlined at Level 1 Provision of all care for Type 2 patients Oral Glucose Therapy Hypertension Management Lipid Management Initiation of Insulin/Injectable treatments in Type 2* Ongoing management with insulin/injectable Referral to lifestyle services through LiveWell Richmond Referral to self-management programme Referral to dietetic services Referral to counselling/psychology services * Where the skills within the practice exist Specialist Diabetes Management Consultant & Nurse Led General MDT management and advice and/or access to therapies Specialist input Dietetics DESMOND Group education Podiatry Retinal Screening Patients with poor glycaemia control Insulin Initiation (for those practices not commissioned to undertake this themselves) Accept referrals from Level 2 Practices Develop Individual care plan with patient Insulin initiation for Type 2 patients Insulin initiation for BD & basal bolus regimens Titration of insulin regimens for both Type 1 and 2 Telephone liaison and support for Level 1 & 2 practices Ongoing management of Type 1 patients Referral to lifestyle services through LiveWell Richmond Referral to counselling/psychology services Secondary Care Urgent Referral direct to consultant of choice: Newly diagnosed/ registered type 1 patients Self-management programme, BERTIE (Kingston Hospital or QMH) Existing/ newly registered females with Diabetes who are pregnant Newly diagnosed/registered adolescents and young people Psychological support Management of severe and acute complications Inpatient care and diabetic emergencies Urgent Specialist Referral for X-ray and Renal Unit Page 37 of 47 Patients will move across levels as their condition dictates

Appendix 8: Stop Smoking It is NICE guidance that all patients diagnosed with Diabetes should be referred for smoking cessation advice. This referral should be re-offered at every opportunity by all health care professionals until smoking ceases. There are two QOF indicators for smoking related to diabetes for 2013-2014. Smoking 2: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses whose notes record smoking status in the preceding 12 months Smoking 5: The percentage of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder or other psychoses who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 12 months Smoking cessation services are available through community pharmacies, GPs, secondary care and the dedicated smoking cessation service Smoke Free. The Smokefree contact number is 0800 085 2903 and the latest information can be found at: http://www.smokefreekingstonandrichmond.nhs.uk/ Page 38 of 47

Appendix 9: LiveWell Richmond Services and Eligibility Criteria Taking Care of Yourself: Telephone help and advice in finding support to achieve a healthier lifestyle Web Page Mobile phone application for android and iphone Volunteer Health Champions Eligibility Everyone who lives in LBRuT or has a Richmond GP Supporting Change: Eligibility Health Trainer Service 1-2-1 health Everyone who lives in LBRuT or has a coaching in line with NICE PH6 Richmond GP, aged >16 Including smoking cessation Must be able to consent, and set and work towards personal goals Specialist Help: Eligibility Exercise on referral Any adult who lives in LBRuT or has a Richmond GP. Suitability for the programme is assessed by a fitness instructor, and data from practice required. Those with mental health problems and CVD are not excluded. Weigh2loose BMI >25 Telephone befriending Adults aged 50+ who live in LBRuT or have a Richmond GP. Expert Patient Programme Adults who are living with a chronic long-term condition and lives in LBRuT or has a Richmond GP. Walking away from diabetes Health walks Those with pre-diabetes who live in LBRuT or have a Richmond GP. Fasting blood sugar between 6 and 6.9 mmol/l. No exclusions for adults; children would need to be accompanied Expert Patients Programme (EPP) The EPP is a self-management programme for people who are living with a chronic long-term condition. It is supports people by improving their confidence and quality of life, helping them manage their condition more effectively. The course covers: dealing with pain and extreme tiredness; coping with feelings of depression; relaxation techniques and exercises; healthy eating; communicating with family, friends and healthcare professionals; planning for the future. The course is free, with six weekly sessions, each lasting around 2.5 hours. It is particularly helpful for those living with diabetes. http://www.nhs.uk/nhsengland/aboutnhsservices/doctors/pages/expert-patientsprogramme.aspx Walking Away From Diabetes Part of the DESMOND programme, this is a specific programme for those with pre-diabetes, who are at risk of developing Type 2 diabetes. It is 3 hours of structured self management education delivered in groups of up to 10 participants by trained Walking Away Educators. Partners are welcome. Contents covered include: Understanding more about diabetes and blood glucose, how being at risk can affect long term health and how to reduce risk by increasing physical activity and eating healthily. http://www.desmond-project.org.uk/ Page 39 of 47

Referral criteria to Exercise on Referral Fast Track to Level 3 Qualified Details instructors Obese BMI > 30 (South Asians > 27.5), or BMI > 25 and high waist circumference: o Male: > 94 cm or > 90 cm for South Asians o Female: > 80 cm (all females) Without co-morbidity or complex need High normal blood pressure Not medication controlled (130-139/85-89) Type 2 diabetes Diet controlled Osteoarthritis mild to moderate Mild, where physical activity will provide symptomatic relief, or Clinical diagnosis- with no history of previous low trauma fractures Mild stress/anxiety/depression Mild Intermittent claudication No symptoms of cardiac dysfunction Mild bone density No history of low trauma fractures changes/osteoporosis Refer to Exercise Referral Details Instructor Level 4 Obese BMI >35kg/m 2 or BMI >30kg/m 2 with co-morbidity or complex need Hypertension Stage 1 Medication controlled (140-159/90-90) Type 2 diabetes Medication controlled Type 1 diabetes With adequate instructions regarding modification of insulin dosage depending on timing of exercise, and warning signs Severe osteoarthritis/ With intermittent /severe mobility problems Rheumatoid arthritis (RA) Stroke/TIA >1 year ago. Stable CV symptoms. Mobile, no assistance required. COPD/ emphysema Without ventilatory limitation but would benefit from optimisation of respiratory system mechanics and correction of physical deconditioning. Neurological conditions E.g. Early onset Parkinsons disease (stable); multiple sclerosis Depression Moderate Psychiatric illness Mental health classes with specialist supervision only. Refer to Exercise Referral Details Instructor Level 4 BACR A GP or other designated Health Professional can refer to Phase qualified IV but only if it is 6/12 since the cardiac event or 6/12 since discharge from Phase III or CHD history but no recent acute event Post myocardial infarct Post angioplasty Claudication with cardiac dysfunction Clinically stable and without any of the contraindications to exercise as listed below Exclusion criteria and absolute contra-indications to exercise: Patients under the age of 18 New or uncontrolled arrhythmias A recent significant change in a resting ECG Other rapidly progressing terminal illness A recent myocardial infarction (within 2 days) Experiences significant drop in BP during Any other acute cardiac event exercise Symptomatic severe aortic stenosis Uncontrolled resting tachycardia > 100bpm Acute pulmonary embolus or pulmonary infarction Febrile illness Acute myocarditis or pericarditis Experiences pain, dizziness or excessive Suspected or known dissecting aneurysm breathlessness during exertion Resting systolic BP > 180 / DBP > 100 A blood pressure drop of > 20mmHg Uncontrolled/unstable angina demonstrated during ETT Acute uncontrolled psychiatric illness Unstable diabetes Unstable or acute heart failure Uncontrolled arterial or ventricular arrhythmias Page 40 of 47

Appendix 10: Local pharmacies offering the NHS Health Check C. Goode Pharmacy 22 London Road, Twickenham Tel: 020 8892 1614 Health On The Hill 62 High Street, Hampton Hill Tel: 020 8977 2539 Minal Pharmacy 9 High Street, Whitton Tel: 020 8894 7933 Pharmacare 12 Back Lane, Ham Tel: 020 8940 7918 Kanset Pharmacy 177 Ashburnham Road, Ham Tel: 020 8948 0601 Lloyds Pharmacy Teddington Memorial Hospital, 60 Hampton Road, Teddington Tel: 020 8977 0630 Springfield Pharmacy 124 Sheen Road, Richmond Tel: 020 8940 2304 Richmond Pharmacy 82-86 Sheen Road, Richmond Tel: 020 8940 3930 Page 41 of 47

Appendix 11: NHS Richmond CCG Referral Pathway for Adult Patients with Type 2 Diabetes to Intermediate or Secondary Care Access to Psychological Therapies by referral to Richmond Wellbeing Service Page 42 of 47

Appendix 12: DESMOND Education Referral Form Page 43 of 47

Appendix 13: Community Ward Page 44 of 47

Appendix 14: Emergency Admissions for Ambulatory Care Sensitive Conditions in Richmond for Patients with Type 2 Diabetes (April 2013) Primary diagnosis Number of emergency admission Tariff cost Lobar pneumonia, unspecified 25 95,901 Non-insulin-dependent diabetes mellitus 1 3,184 Non-insulin-dependent diabetes mellitus 4 14,985 Non-insulin-dependent diabetes mellitus 1 2,647 Other iron deficiency anaemias 1 3,145 Iron deficiency anaemia, unspecified 3 7,566 Essential (primary) hypertension 2 1,519 Congestive heart failure 17 53,496 Left ventricular failure 3 14,178 Unstable angina 10 11,029 Other forms of angina pectoris 2 1,604 Angina pectoris, unspecified 4 5,900 Other forms of acute ischaemic heart disease 1 3,658 Acute ischaemic heart disease, unspecified 1 1,067 Chronic obstructive pulmonary disease with acute lower respiratory infection 15 39,629 Chronic obstructive pulmonary disease with acute exacerbation, unspecified 6 15,128 Chronic obstructive pulmonary disease, unspecified 2 1,371 Bronchiectasis 1 3,557 Asthma, unspecified 3 3,735 Volume depletion 3 6,772 Noninfective gastroenteritis and colitis, unspecified 1 2,903 Epilepsy, unspecified 1 540 Other and unspecified convulsions 3 5,478 Acute pharyngitis, unspecified 3 2,335 Acute upper respiratory infection, unspecified 2 1,470 Duodenal ulcer 1 2,914 Tubulo-interstitial nephritis, not specified as acute or chronic 1 2,334 Pyonephrosis 1 2,706 Cellulitis of other parts of limb 22 56,704 Pyogenic granuloma 1 933 Total 141 368,388 Source: Richmond Public Health Analysis using SUS data and GP data extraction, April 2013 Page 45 of 47

Appendix 15: Performance Indicators Indicator Benchmarking diabetes prevalence between CCG, London, and National Benchmarking diabetes prevalence in GP Practices against CCG average QOF Diabetes Indicators DM32: The practice can produce a register of all patients aged 17 years and over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed DM 26: The percentage of patients with diabetes in whom the last IFCC- HbA 1c is 59 mmol/mol or less in the preceding 15 months DM 27: The percentage of patients with diabetes in whom the last IFCC- HbA 1c is 64 mmol/mol or less in the preceding 15 months DM 28: The percentage of patients with diabetes in whom the last IFCC- HbA 1c is 75 mmol/mol or less in the preceding 15 months DM 21: The percentage of patients with diabetes who have a record of retinal screening in the preceding 15 months DM 29: The percentage of patients with diabetes with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer) or 4) ulcerated foot within the preceding 15 months DM 30: The percentage of patients with diabetes in whom the last blood pressure is 150/90 mmhg in the preceding 15 months DM 31: The percentage of patients with diabetes in whom the last blood pressure is 140/80 mmhg in the preceding 15 months DM 13: The percentage of patients with diabetes who have a record of micro-albuminuria testing in the preceding 15 months (exception reporting for patients with proteinuria) DM 15: The percentage of patients with diabetes with a diagnosis of proteinuria or micro-albuminuria who are treated with ACE inhibitors (or ARBs) DM 17: The percentage of patients with diabetes whose last measured total cholesterol within the preceding 15 months is 5 mmol/l DM 18: The percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March NEW for 13/14: The percentage of patients with diabetes, on the register, who have a record of a dietary review by a suitably competent professional in the preceding 12 months NEW for 13/14: The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register Baseline Figure PCT 3.4%, SHA 5.6% National 5.8% (11/12) PCT range: 6.9% to 1.7% (11/12) PCT average: 3.4% (11/12) 3.4% (11/12) 71.9% (11/12) 80.9% (11/12) 89.6% (11/12) 93.4% (11/12) 89.7% (11/12) 89.6% (11/12) 65.9% (11/12) 88.9% (11/12) 91.4% (11/12) 78.5% (11/12) 91.2% (11/12) No baseline figure yet No baseline figure yet Page 46 of 47

NEW for 13/14: The percentage of male patients with diabetes, on the register, with a record of being asked about erectile dysfunction in the preceding 12 months NEW for 13/14: The percentage of male patients with diabetes, on the register, who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 12 months National Diabetes Audit Percentage of people in the National Diabetes Audit (NDA) with Type 1 diabetes receiving all nine key care processes Percentage of people in the NDA with Type 2 diabetes receiving all nine key care processes Percentage of people in the NDA having major lower limb amputation five years prior to the end of the audit period Excess length of stay (%) in hospital among people with diabetes when compared with people without diabetes No baseline figure yet No baseline figure yet 27.7% (1 Jan 2009-31 Mar) 54.3% (1 Jan 2009- Mar 2010) 0.09% (1 Jan 2009- Mar 2010) 9.2% (09/10) Insulin total net ingredient cost ( ) per patient on GP diabetes registers 129.5 (10/11) Non-insulin anti-diabetic drugs total net ingredient cost ( ) per patient on GP diabetes registers Hospital admissions Avoidable emergency admissions for patients with diabetes per 100,000 population (age and sex standardised) Other QOF indicators relevant to diabetes Smoking 3: The percentage of patients with one of or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder and other psychoses whose notes record smoking status in the previous 15 months. Smoking 4: The percentage of patients with any or any combination of the following conditions: coronary heart disease, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder and other psychoses who smoke whose notes contain a record that smoking cessation advice or referral to a specialist service, where available, has been offered within the previous 15 months. Prevention and Self-care Number and percentage of patients with IFG/IGT attending Walking Away from Diabetes Programme Number and percentage of patients with diabetes who are case managed through the Community Ward 66.8 (10/11) 377 (2012/13) (Richmond Public Health Analysis using SUS data and GP data extraction) 94.5% (11/12) 94.1% (11/12) 50 attendances (2012/13) No current percent as IFG/IGT is not available yet No current figure as in pilot phase Page 47 of 47