Brent Diabetes Services

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Welcome to the Brent Intermediate Diabetes Care
Services Launch
10th May 2006 Clay Oven , Wembley
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Brent Diabetes Services

• Dr. Senan Devendra MD MRCP
• Consultant in Endocrinology Integrated Diabetes
  Care
• Brent tPCT Central Middlesex Hospital

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The Team

• Claire Lawler
• Nina Patel, Julia Anthony Lucy Ogida (DSNs)
• Sala Salih Camelia Kirollos (Diabetes Edu.
  Network)
• Salma Butt, Helen Davies Farhat Hamid
  (dietetics)
• Rakhee, Gaytree E. Shillingford (podiatry)
• Leena Sevak Maggie McClelland (pathway
  managers)
• Rowland Hughes (DPAG chair)
• Silvia Sedeghian G.Vafidis(retinal screening)
• Ricky Banarsee Azeem Majid (Imperial -
  research)
• Kirsten Darylmple (Imperial education faculty)
• JKC too many to mention

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www.brentpct.nhs.uk
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Diabetes SPA total referrals per locality
(according to GP post code) 20.02.06 26.04.06
total 207 x 241 50,000
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Brent Diabetes Services

• Clinical support MDT approach
• - Intermediate care clinics
• - Email consultations
• - Liaising with District Nurses/out of hours
• - Up-skilling Primary Care colleagues
• - Telephone support clinics for patients

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Brent Diabetes Services

• Education MDT approach
• - patient education
• - health care professional education
• Research Audit

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100 years of hormones
Photo Courtesy of Prof. G.Williams Dean of
Medicine, Univ. of Bristol
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Expected Standard of Care Microalbuminuria
Pathway

• Dr Encarna Fernandez
• Diabetes GPWSI Kilburn Locality

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Weight Management in Diabetes Intermediate Care

• By Helen Davies Salma Butt
• Specialist Diabetes Dietitians

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The business case !

• Type 2 DM overweight at diagnosis
• Av. BMI 28-29
• Relationship with macrovascular disease
• Weight loss associated with survival
• Does weight need to be managed differently in DM

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Current services

• Diabetes education sessions
• MDT intermediate care clinics
• Fit for Life programme
• Obesity clinic at Central Middx

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MDT intermediate care clinic

• Initial assessment
• Readiness to change
• Brent options
• Refer to pathway
• (enclosed in conference pack)

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Fit for Life

• 12 week weight management programme
• Nutrition education exercise
• Group support
• Referral through Diabetes SPA

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Obesity clinic at CMH

• Patients with complications/poor control
  maximum oral therapy
• Failed at Intermediate care clinic
• Intensive weight management advice
• Long term support if necessary
• Bariatric surgery

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New package of care for improving Glycaemic
control in primary care

• Nina Patel
• DSN Brent tPCT

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AIM

• To provide focused intensive input to improve
  HbA1c with a clear supportive plan and exit
  strategy

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Referral criteria

• Patient on maximum doses of oral hypoglycaemic
• (see protocol for the use of oral
  hypoglycaemic agents)
• HbA1c gt 8 (age lt 75)
• 
  www.brentpct.nhs.uk

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Where will the patient be seen?

• DSN clinic in own locality
• Kilburn Kilburn Square clinic
• Wembley WembleyWCHC
• Willesden Willesden CHC
• Kingsbury Chalkhill Health Centre
• Harlesden Monks Park CHC

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First Review Consultation 1

• Patient considered for education session
• Medication review address compliance
• Dietetic assessment weight management pathway
• Assessment of motivation, health beliefs,
  readiness to change
• Set realistic goals
• Obtain a contract with agreed roles of DSN and
  patient (minimum 1.5 HbA1c reduction by 3
  months)
• Start Blood glucose monitoring
• Insulin discussed or started

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Consultation 2 (2 to 3 wks post visit 1)

• Assess blood glucose results
• If not started, start insulin e.g. once daily
  long-acting or twice daily mix. Insulin
• (this can be done with practice nurse/
  district nurse)
• Given algorithm to follow
• Address weight gain issue with insulin
• Titration of insulin doses over telephone
  with daily or weekly contact.

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Consultation 3 (4 to 6 weeks post visit 1)

• Weight check/ WC
• Blood glucose control
• BP
• Injection sites
• Management of pen device.
• Hypos
• Consider prandial insulin
• Titration of insulin doses over telephone with
  daily or weekly contact.

• Also consider
• Orlistat/Sibutramine
• Weight management clinic
• Exercise classes
• Patient support group
• Expert patient course

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Consultation 4 3 month review

• Check HbA1c (1 week before appointment)
• Further titration of insulin
• Add pre-meal soluble insulin
• Check weight gain/WC dietitian review
• Titration of insulin doses over telephone with
  daily or weekly contact.

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Exit strategy

• Hba1c less than 7.5 (or desired goal achieved)
  return to the care of GP and Practice nurse.
• Maintain regular contact (telephone of link DSN
  or Diabetes SPA given)
• If HbA1c goal not achieved consider other
  options (eg. restart package of care, JKC -
  insulin pump therapy, novel therapeutic agents)

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Joint British Societies Guidelines 2 on
prevention of Cardiovascular Disease in Clinical
Practice (JBS2)implications for Brent

• Dr. Joan St John
• Gpwsi Diabetes
• Wembley Locality

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Introduction

• How will the new guidelines affect the management
  of people with diabetes in Brent
• What are the workforce and cost implications
• What is the most effective way to implement the
  new guidelines ?

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JBS 2 2005

• High risk patients
• Established athero-sclerotic disease
• 1ry prevention CVD risk gt20
• Diabetics
• ALSO elevated risk due to a single risk factor
• BP gt160/ gt100 (or less if target organ damage)
• Elevated TC HDL gt6 or FH of hyperlipidaemia

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JBS-2 targets for high risk patients

• Total cholesterol lt4
• (25 reduction)
• LDL-cholesterol lt2
• (30 reduction)

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Next Steps

• What is the most effective way to implement the
  new guidelines ? In Primary care
  or Intermediary care
• Guidelines for Titration of Simvastatin or
• Trying to treat to target with one drug one visit

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Highest Risk Group ( Diabetes one of the
following)

• Previous CV event
• Peripheral Vascular disease
• Family history of Premature (lt60yrs) death from
  IHD
• Renal Impairment (eGFR lt 60)
• Micro-albuminuric patients

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Treatment Pathway for High Risk Group
CHOLESTEROL lt 5.5 OR LDL lt 3.8
CHOLESTEROL gt 5.5 OR LDL
gt3.8 Start Simvastatin
20mg Start
Atorvastatin 20mg (titrate to 80mg) to
40mg if needed to achieve target
or Rosuvastatin 10mg
od
Target T. Cholesterol 4 LDL 2
Law, BMJ 2003
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Education
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• Diabetes Education
• Network
• Dr Camelia Kirollos
• Associate Specialist
• Central Middlesex Hospital

Please refer to handout for details
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Brent Diabetes Education Network
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Diabetes Education Network

• Professionals Education
• Nurses Practice nurses, District nurses,
  Twilight nurses, Residential homes, Nursing Homes
• Doctors GPs, GPwSI, Hospital Doctors
• Health care Assistants

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Diabetes Education Network

• Patients Education
• Short courses - 2 days
• Long courses 6 weeks
• Tailored Ethnic or Cultural courses
• Eg. For Pakistani, Gujarati Communities

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Attendants of diabetes patient education courses
between July 2004 and March 2006
Total 550
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Patients self-management courses

• DAFNE For Type 1 Diabetes (since 2002)
• Alternate Months at JKDC (CMH)
• Available soon in intermediate care
• DESMOND For newly diagnosed Type 2 Diabetes (NSF
  requirement)

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DAFNE Improvement lasts
30
9
25
HbA1c ()
20
8
Severe hypoglycemia per 100 pt y
15
10
7
5
6
0
0
1
2
3
6
Years of follow-up
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Certificate in Diabetes Care Warwick Courses

• Warwick Diabetes care
• Run twice a year February and September
• Includes 4 units (Each is a whole day)
• Understanding Diabetes
• Therapeutic Options
• Preventing Managing Complications
• Life Times

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Consultant led seminars

• Insulin for life programme (Insulin initiation)
• MERIT (Insulin initiation)
• Consultant notes review service
• (eg. HbA1c gt7.5)

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Educational Needs

• The network needs to extend and invite the front
  line workers
• Eg Health care assistants
• Twilight nurses
• Pharmacist in the community and hospitals
• Local initiatives for day release education.
• Courses for Hospital staff.
• Junior Doctors programmed trained.

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Competency SkillsA Mandatory Requirement

• Ram Dhillon FRCS
• Consultant Surgeon, Northwick Park Hospital,
  Harrow
• Hon. Professor, Middlesex University, London
• National Clinical Lead, Elective Care Team
• (m) 07 958 450 544
• (e) ram.dhillon_at_talk21.com

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No Mans Land(Locus of Demand Need for
Capacity, Competency Skills)

• 2nd Opinion

No Mans Land Intermediate Tier Level Care Home
to (PwSIs) GPwSIs, NwSIs, AHPwSIs
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What is Fundamentalfor Acquisition of
Competency Skills

• Knowledge Skills
• Knowledge Skills
• Knowledge Skills
• Knowledge Skills
• Adequate Training Accreditation

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A Model for Competency/Skills Training
Accreditation in Respiratory Medicine for Primary
Care ( Dr Vincent Mak Prof. Ram Dhillon)
PGCert
REGn

CPD

• NB. Further details on Postgraduate Training for
  Special Interests www.pgdip.com

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PwSIswith Special Interests ( competent
skilled )Potential effects

• Retention/Recruitment
• Clinical Pathways
• Clinical Governance
• Community Care
• Cost-Effective Care

• NSFs
• Demand
• Capacity
• Access
• Integrate 1/2

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Questions?

• gm.e.diabetes.bre-pct_at_nhs.net
• www.brentpct.nhs.uk