DR RAQUEL DELGADODIABETES GP LEAD

Diabetes CCWHE OOH Contracts

Aims and Objectives

Address variation of care across CCGs and practices

Early identification and preventionBetter management of the 9 care processesReward and promote specialist services in

the communityUp skill practices and clinicians

Tools to support the contracts

NWL Diabetes Education ProgrammeSystem1 OOH Diabetes TemplatesCCWHE Diabetes guidelines available from

Hounslow CCG websiteDiabetes Dashboards New Diabetes Community Service

Systm1 OOH Templates

CCG Dashboards

OOH Diabetes contracts

High risk diabetesDiabetes Level 1Diabetes Level 2 - injectables

Requirements for all the contracts

No exception reportingAll practices submitting data to the National

Diabetes Audit (NDA)Provide the data set requirement to secure

payments and monitor improvementsEngagement with local diabetes education

programme Named lead GP/ClinicianPeer review and clinical auditPayment based on KPIs achievement

High Risk Diabetes

Identify high risk patientsRegister of high risk patients XaZLG: gestational diabetes and abnormal glucose test Annual BP, HbA1c , lipids , smoking, BMI and lifestyle interventions/referral

Level 1 Diabetes Contract

Referral to structured education and provide patients with information at diagnoses

Annual 9 care processes including ACR and retinal screening

Annual review with ½ hour appointmentHypoglycaemia recording frequency and managementCCWHE Diabetes guidelines for BP, lipids, HBa1c, insulin

and glucometers + glucose stripsCare plans including housebound and care home patientsCopy of care plans given to patients with individualised

targets Patient satisfaction survey Discharge from secondary care suitable patients

Level 2 Diabetes Contract

Insulin and GLP-1 initiation and optimisation and insulin education

Two ccredited clinicians Only accredited clinicians can carry out the serviceAnnual accredited re-fresher courses Adhere to prescribing guidelines for insulinFace to face appointments , telephone, email, SkypeDietician and DSN support from the community

serviceReferral to insulin education programmesMinimum network population of 30,000

New Diabetes Service

Named diabetologist , dietician, DSN and podiatrist per locality

Clinical psychologistDiabetes podiatryFlexible service to meet the needs of localities and

patientsEmail and telephone access to all clinicians within the

serviceJoint clinics with diabetologist , DSN and dieticians Joint visits to housebound patients Larger choice of education programmes for Type 1 and

Type 2 (newly diagnosed, insulin and established diabetes)