South Tees Diabetes Programme

1
South Tees Diabetes Programme
Programme Aims
Development of an agreed and costed model of
care which describes how the must have
components of the diabetes service are to be
delivered locally and how national specifications
for diabetes services are to be met.
South Tees Diabetes Programme
Commissioners Middlesbrough PCT, Redcar and
Cleveland PCT Providers South Tees Hospitals NHS
Trust, Middlesbrough PCT, Redcar and Cleveland
PCT Population 280,000
Outcomes Network Wide

• Defined levels of care within primary care and
  plans to develop this further
• Integrated primary and secondary care diabetes
  service
• Patient education and self-care skills training
  in place
• Defined roles for specialist teams
• Defined skills and workforce training plans in
  place
• Reduction in hospital outpatient appointments as
  care can be effectively managed in a primary care
  setting
• Reduced unscheduled admissions and length of stay
  for diabetes patients through effective case
  management and efficient discharge co-ordination

Benefits

• People with diabetes are supported, where
  appropriate, to manage their condition as best
  they can themselves. Quality of life is improved
  and people are empowered to manage their
  condition
• Improved patient experience as patients
  experience a seamless, co-ordinated journey
  through the healthcare system
• Proactive case management systems are in place
  across the care delivery system

Measures

• Reduction of the gap between numbers of people
  diagnosed with diabetes and projected diabetes
  prevalence
• Number and type of new referrals to specialist
  services for newly diagnosed diabetes patients
• Numbers of unscheduled admissions where diabetes
  is a primary cause of admission
• Numbers of occupied bed days for patients with
  diabetes
• Numbers of patients being actively managed in
  primary care
• Capacity and uptake of patient education on
  self-care skills training

2
South Tees Diabetes Programme

• August 07 Progress to date
• Needs Assessment exercise carried out in line
  with NDST commissioning toolkit and supplemented
  by local data sources
• Stakeholder events held to develop high level
  vision of future model of care and review that
  model in light of needs assessment
• Diabetes Retinal Screening Service review
  undertaken and recommendations presented to
  commissioning organisations
• Diabetes dietetic service review underway
• Costing of existing and future models of care in
  progress

• April 07 Milestones
• Diabetes retinal screening service review
  completed and recommendations presented to PCTs
  for implementation
• Dietetics service/structured education review
  commences

• June 07 Milestones
• PCT restructures in place
• Development of action plans and briefings to
  ensure transition of responsibility and
  governance for the project shifts from current
  Network structure to new commissioning structures
  is as smooth as possible
• Costing workshop bottom-up costing of primary
  and community based interventions

• September 07 Milestones
• Costed current and future models of care are
  completed
• Prioritised and costed implementation
  recommendations are in place for each
  commissioning organisation

Local Contacts Anne Greenley, Senior Service
Reform Manager, Middlesbrough PCT/Redcar and
Cleveland PCT Anne.Greenley_at_middlesbroughpct.nhs.
uk