Delivering specialist diabetes care in a GP practice in Stockport

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The challenge 

Dr Seabrook and Partners is a GP practice in Stockport. About 530 of its patients have diabetes. Patient stories showed a ‘one size fits all’ approach to diabetes care could lead to poor communication, unmet needs and poor compliance with treatments. Furthermore care needed to be efficient and cost effective. The team wanted to find innovative ways of working and providing high quality specialist care closer to home. Specifically, they wanted to improve the quality of care for hard to reach diabetes patients who had three or more uncontrolled risk factors outside recommended targets. 

The aim 

The aim of the project was to provide specialist care, at the practice, to patients at high risk of diabetes-related complications who had been unable to engage with current systems of care, and to modify their risk factors. The practice wanted to provide patient-centred care, and to streamline the patient journey, resulting in higher efficiency and lower costs to the patient, practice and health service. 

What did they do? 

In February 2009 a diabetes specialist nurse (DSN) and GP with special interest (GPSI) in diabetes joined the practice team to undertake a pilot study targeting patients at high risk of developing diabetes related complications, who had previously found it difficult to engage with conventional models of care. The team defined patients with the highest level of risk as those with HbA1c greater than 7.5% and any two or more of the following:

• BP>130/80
  
• total cholesterol>4mmol/l and LDL-c>2mmol/l
  
• established cardiovascular disease (CVA, angina, MI, PVD)
  
• established micro-vascular complications (retinopathy, nephropathy, neuropathy)
  

These patients attended a 40 minute appointment with the DSN and GPSI. A person-centred approach gives patients the opportunity to set the agenda for the consultation and promotes shared decision making, personal care planning and SMART goal setting. Motivational interviewing strategies are used to facilitate behaviour modification and adherence to existing and new treatments. Follow up appointments are planned according to the patients individual needs and care plan. Patients are also offered and encouraged to utilise services outside the practice including podiatry, dietitians, physical exercise scheme, weight management services, XPERT diabetes and expert patient programmes. Those patients requiring expertise outside that of the specialist team are referred to the diabetes team in secondary care. The practice has different levels of care so should a patient's risk factors change they can step up or down to the next level on the care pathway to receive the right care from them at the right time. 

What happened? 

In the initial cohort of patients at higher risk of diabetes related complications, mean HbA1c fell by 1.1% and blood pressure by 16/4 mm Hg. Those meeting cholesterol targets rose from 42% to 70% and LDL-C from 31% to 51%. In addition, there was a mean weight loss of 0.7kg. On average patients attended two joint and two single appointments before stepping down to regular care. Structured patient feedback showed high levels of satisfaction particularly with consultation time, care close to home and joint consultations. On average a patient episode in the higher level of care cost £272 compared with £672 from the secondary care provider based on the average two joint and two single appointments per patient.

Key outcomes

• Improvements in diabetes risk factors including reduction HbA1c of 1.1% and BP by 16/4 mm Hg
  
• Patient able to ‘step down’ to regular care after receiving specialist input from DSN and GPSI
  
• Care provided in GP practice cost £272 compared to £672 in secondary care
  
• High levels of patient satisfaction