WIG_Summary_5.0 by huanghengdong

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									   the    Wig
   Wandsworth NSF Diabetes Implementation Group
                                                                                                                                                                    April 2006
   c/o The Earlsfield Practice, 2-4 Steerforth Street, SW18 4HH




   Executive Summary

   Workgroups and areas. Also related work streams that have been presented to and ratified by the WIG.

Area                     Code           Date to           Date        Future Cost                    Notes                                           Lead/contact
                                        start or          finished    Implications
                                        started           or target
Implementation           WIG            1/8/01            ongoing     Clinical lead sessional fees
group                                                                 PCT admin costs                                                                jo.butler@swlondon.nhs.uk

                                                                                                                                                     Neil.Bamford@nhs.net
Agreeing Terms of        TOR1
                         TOR2           Aug 2004                                                     Revised TOR accepted Aug 2004                   Neil.Bamford@nhs.net
reference

Health Needs             HNA1           1/8/02            1/2/04                                     List of resources                               Neil.Bamford@nhs.net
Assessment               HNA2           14/7/05           1/2/06                                     Public Health Survey                            charlotte.ashton@swlondon.nh
                                                                                                                                                     s.uk

Clinical Audit           Audit          1/7/04            1/9/04                                     Wandsworth wide collection of EMIS data         Ken.Earle@stgeorges.nhs.uk
                                        1/11/05           ongoing                                    Review of EMIS data
Long Term                LTG            1/6/05            ongoing                                                                                    Claire.Hurrell@wpct.nhs.uk
Conditions Group                                                                                     Pathway Mapping                                 stephen.warren@swlondon.nh
                                                                                                                                                     s.uk
Clinical                 CEG            1/5/05            ongoing     PCT funded                     Review of evidence, local guidelines and NICE   Lyndsay.Forbes@swlondon.nh
Effectiveness                                                                                                                                        s.uk
Group
PCT Lead,                PCT             1/8/01           ongoing     PCT admin funding                                                              Claire.Hurrell@wpct.nhs.uk
Minutes, Mailings                                                                                                                                    stephen.warren@swlondon.nh
and Links.                                                                                                                                           s.uk




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Prevention of         Standard 1                                                The NHS will develop, implement and monitor
Type 2 diabetes                                                                 strategies to reduce the risk of developing Type
                                                                                2 diabetes in the population as a whole and to
                                                                                reduce the inequalities in the risk of developing
                                                                                Type 2 diabetes.

Wandsworth South      WSX          1/7/02    1/7/04           Locality budget   Facilitator led programme linking home exercise
Exercise Initiative                                                             routines, primary care education and local gyms
                                                                                and health centres

Tooting Healthy       THL          1/4/04    ongoing          Grant funded      Healthy living area initiative focusing on BP, diet,   Deb.James@swlondon.nhs.uk
Living Programme                                                                mental health

Battersea Healthy     BHL          1/5/05    ongoing          Grant funded      Range of programmes in Battersea on healthy            Judith.Nelson@gstt.nhs.uk
Living Programme                                                                eating, exercise, smoking cessation, health
                                                                                education                                              Direct Line - 020 7585 0977

School meals          SMI          1/4/02    1/5/05           Grant funded      Improving school meals                                 Judith.Nelson@gstt.nhs.uk
initiative

Footsteps             Fsteps       1/5/05    Under threat     Locality budget   Referral pathway for exercise, healthy eating,         Deb.James@swlondon.nhs.uk
                                                                                weight loss, smoking cessation, diabetes
                                                                                education

Wandsworth            WSP          17/3/06   17/3/07          Grant Funded      Public Health pilot to identify people at risk and
Screening                                                                       refer to lifestyle and exercise programme              jo.butler@swlondon.nhs.uk
Programme

Identification of     Standard 2                                                The NHS will develop, implement and monitor
people with                                                                     strategies to identify people who do not know
diabetes                                                                        they have diabetes.

High risk             HRS          1/3/05    First 3 areas                      Work group to identify diabetes in high risk           jo.butler@swlondon.nhs.uk
                                             identified and                     groups; gestational diabetes, impaired fasting
Screening                                    screening                          glycaemia, schizophrenia.
                                             programmes
                                             set up, Jan
                                             2007
Hidden Diabetes       GD           Funding                    Grant funded      Public Health Department initiative to set up a
                                   sought                                       Wandsworth Wide programme                              jo.butler@swlondon.nhs.uk

Empowering            Standard 3                                                All children, young people and adults with
people with                                                                     diabetes will receive a service which encourages
                                                                                partnership in decision-making, supports them in
                                                                                managing their diabetes and helps them to

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diabetes                                                                               adopt and maintain a healthy lifestyle. This will
                                                                                       be reflected in an agreed and shared care plan
                                                                                       in an appropriate format and language. Where
                                                                                       appropriate, parents and carers should be fully
                                                                                       engaged in this process.
                                                                                        st             nd
Wandsworth PCT      G1           1/6/02      1/2/06     Drug company funding           1 Edition & 2        Edition                         Zeena.Wilson@stgeorges.nhs.
                    G2           1/2/06      ongoing                                                                                        uk
Diabetes
Guidelines                                                                             Wandsworth-wide agreed guidelines for the
                                                                                       management of diabetes and complications             Ken.Earle@stgeorges.nhs.uk

Handheld Records    HHR1         1/9/05      1/9/06     Pilot and audit fully funded   Patient held record and information booklet
                                                        from PCT, a full roll out      piloted with full audit.
                                                        would require more funds
                    HHR2         1/6/07      ongoing                                   Revised record using specially developed My
                                                        Drug Company Funding           Diabetes handbooks                                   Judith.Nelson@wpct.nhs.uk

Housebound Help     HBP 1        1/6/03      1/2/06                                    Help pack and guidelines for DNs and care            Neil.Bamford@nhs.net
Pack                                                                                   homes. Includes a compendium of resources for
                    HBP2         1/2/06      ongoing                                   the housebound

Diabetes for        DFB          1/6/09      To be      Drug company funding           Information handbook offered to all newly            Neil.Bamford@nhs.net
                                             repeated                                  diagnosed Type 2. Distributed to all practices.
Beginners                                    annually


Patient Education   PEG          To 1/9/09   ongoing    Funding required to upgrade    Nurse facilitator and nurse specialist led groups    jo.butler@swlondon.nhs.uk
Groups (type 2)                                         to recommended DESMOND         in primary and secondary care. Will be replaced
                                                        scheme or similar              by Desmond
                                                        programme of structured
                                                        education with resources,
                                                        training and nationally
                                                        auditable results

Desmond             desmond      1/9/09      To be      Funding agreed from PCT        Nationally recognised patient education              jo.butler@swlondon.nhs.uk
                                             ongoing                                   programme offered to all newly diagnosed with
                                                                                       type 2 diabetes.

DAFNE               dafne        1/5/05      ongoing    This will require annual fee   Educational programme for type 1 diabetes with       Zeena.Wilson@stgeorges.nhs.
                                                        for training, resources and    national training, guidelines and audit              uk
                                                        audit


Clinical care of    Standard 4                                                         All adults with diabetes will receive high-quality
adults with                                                                            care throughout their lifetime, including support


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diabetes                                                                                       to optimise the control of their blood glucose,
                                                                                               blood pressure and other risk factors for
                                                                                               developing the complications of diabetes

                        G2, HBP2                                                               These areas summarised above are also                Ken.Earle@stgeorges.nhs.uk
                        PEG,                                                                   relevant to this standard. For further information
                        Dafne,                                                                 contact Dr Earle, SDU lead at St Georges
                        desmond,
                        WRiiTE
Wandsworth              RSP         1/3/03     ongoing         Ring fenced Strategic Health    Wandsworth wide retinal screening programme          susanne.sorensen@stgeorges
Retinal Screening                                              Authority funds and                                                                  .nhs.uk
Programme                                                      secondary care


Minimum Data Set        MDS         1/3/03     1/6/06                                          Common agreement on data recording,                  fiona.hicks@swlondon.nhs.
                                                                                               templates and EMIS coding throughout
                                                                                               Wandsworth

Blood glucose           BGM1        1/3/03     1/7/06          Testing strips from             Supply, training and calibration of capillary        jo.butler@swlondon.nhs.uk
                        BGM2        1/7/06     ongoing         prescribing budget. Meters      meters. Supplier switched to Bayer for BGM2
monitoring policy
                                                               supplied free. External
                                                               calibration for bgm2 by St
                                                               Georges lab will incur a cost

Rolling Education       CDRep       1/1/05     1/10/06         Funded from ““pump priming      Ongoing professional education cycles linked to      Ken.Earle@stgeorges.nhs.uk
Programme                                                      funds””, future cycles may      outreach and teleclinics. Major programme
                                                               require PCT funding             offering, training, assessment, audit and
                                                                                               refreshing skills for all GPs and practice nurses

Wandsworth              WRiiTE      1/9/07     To be           PCT and Practice based          Continuation of the CDRep but geared to              Ken.Earle@stgeorges.nhs.uk
                                               ongoing         commissioning                   supporting PBC practices and local issues
Rolling Initiative in
Training and                                                                                   identified by HSC report
Education

Practice Based          PBC         1/4/08     1/4/09 To       From PBC savings                Programme to provide more diabetes care in GP        Nicola.Jones2@nhs.net
                                    Wandle     expand to all                                   practices, supported by outreach clinic from St
Commissioning of                    Valley     Wandsworth
Diabetes Care                                                                                  Georges. Skills, training and evaluation through
                                    Cluster
                                                                                               WRiiTE course

GPs with special                    Proposed                   To be agreed                    Introduction of GPSI clinics in Wandsworth           andrew.dicks@nhs.net.uk
interest

Clinical care of        Standards                                                              All children and young people with diabetes will
children and                                                                                   receive consistently high-quality care and they,


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young people        5&6                                          with their families and others involved in their     Murray.Bain@stgeorges.nhs.u
with diabetes                                                    day-to-day care, will be supported to optimise       k (Paediatric Consultant)
                                                                 the control of their blood glucose and their
                                                                 physical, psychological, intellectual, educational   sarah.foulger@stgeorges.nhs.
                                                                 and social development.                              uk (Specialist nurse)

                                                                 All young people with diabetes will experience a
                                                                 smooth transition of care from paediatric
                                                                 diabetes services to adult diabetes services,        Ken.Earle@stgeorges.nhs.uk
                                                                 whether hospital or community-based, either          (Adult services consultant)
                                                                 directly or via a young people’s clinic. The
                                                                 transition will be organised in partnership with
                                                                 each individual and at an age appropriate to and
                                                                 agreed with them.

                    G2, dafne,                                   These areas summarised above are also
                    CDRep,                                       relevant to this standard. For further information
                    BGM2,                                        contact Dr Bain, Consultant Paediatrician at St
                    MDS
                                                                 Georges or Dr Earle, SDU lead at St Georges

Management of       Standard 7                                   The NHS will develop, implement and monitor
diabetic                                                         agreed protocols for rapid and effective
emergencies                                                      treatment of diabetic emergencies by
                                                                 appropriately trained health care professionals.
                                                                 Protocols will include the management of acute
                                                                 complications and procedures to minimise the
                                                                 risk of recurrence.


A&E diabetologist   A&E          1/4/07   ongoing   St Georges   Creation of specialist consultant post. Info from    Paul.Chandler@stgeorges.nhs
                                                                 Paul Chandler, business manager                      .uk

                    G2, HBP2                                     These areas summarised above are also                Ken.Earle@stgeorges.nhs.uk
                    CDRep,                                       relevant to this standard. For further information
                    BGM2,                                        contact Dr Earle, SDU lead at St Georges
                    MDS

Care of people      Standard 8                                   All children, young people and adults with
with diabetes                                                    diabetes admitted to hospital, for whatever
during admission                                                 reason, will receive effective care of their
to hospital                                                      diabetes. Wherever possible, they will continue
                                                                 to be involved in decisions concerning the
                                                                 management of their diabetes.




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                    G2, HBP2                                                                   These areas summarised above are also                Ken.Earle@stgeorges.nhs.uk
                    CDRep,                                                                     relevant to this standard. For further information
                    BGM2,                                                                      contact Dr Earle SDU lead at St Georges
                    MDS,
                    LDSAG
Diabetes and        Standard 9                                                                 The NHS will develop, implement and monitor
pregnancy                                                                                      policies that seek to empower and support
                                                                                               women with pre-existing diabetes and those who
                                                                                               develop diabetes during pregnancy to optimise
                                                                                               the outcomes of their pregnancy.


                    BGM2, G2                                                                   These areas summarised above are also                arshia.panahloo@stgeorges.n
                                                                                               relevant to this standard. For further information   hs.uk
                                                                                               contact Dr Panahloo at St Georges

Detection and       Standards                                                                  All young people and adults with diabetes will
                    10&11                                                                      receive regular surveillance for the long-term
management of
long-term                                                                                      complications of diabetes.
complications
                                                                                               The NHS will develop, implement and monitor
                                                                                               agreed protocols and systems of care to ensure
                                                                                               that all people who develop long-term
                                                                                               complications of diabetes receive timely,
                                                                                               appropriate and effective investigation and
                                                                                               treatment to reduce their risk of disability and
                                                                                               premature death.

Diabetes Nurse      DNF          1/3/01        Ceased 1/4/06   Diabetes nurse facilitators     Programme in Wands Sth and Battersea to train
Facilitators                                                   salary (Grade 4/5). Option to   and support practice nurses, GPs and other staff
                                                               extend this in Wandsworth       in data collection and coding, registers,
                                                               though there is crossover       templates, annual review and use of guidelines.
                                                               support from CHD nurse
                                                               facilitators

Clinical                         1/3/03        ongoing         Facilitator Salary              Similar system to above, but based at Queen          fiona.hicks@swlondon.nhs.uk
Governance                                                                                     Mary’s Roehampton
Facilitator

Community                        1/2/04        ongoing         Specialist nurse salary         Specialist nursing input for insulin conversion,     lucy.chadder@gstt.sthames.nh
                                 (Battersea)                   (grade 5)                       shared clinics, housebound, training and audit       s.uk
Diabetes
                                 1/7/05                                                                                                             Judith.Nelson@wpct.nhs.uk
Specialist Nurses                (Wands Sth)
                                                                                                                                                    yvonne.bornemann@swlondo
                                 1/9/05
                                 (Putney)                                                                                                           n.nhs.uk



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Podiatry                           Existing       ongoing      Born by secondary care      Rapid referral, guidelines and advice for diabetic   Mark.Greenhill@stgeorges.nhs
                                   service                                                 foot conditions                                      .uk
                                   reconfigured
                                                                                                                                                Robert.Harrison@swlondon.nh
                                                                                                                                                s.uk

Community                          Existing       ongoing      PCT Community Trust         Wandsworth wide primary care and domiciliary         shamsie.simpson@swlondon.n
                                   service                                                 care for persons with diabetes                       hs.uk
Podiatry
                                   reconfigured

Dietics                            Existing       ongoing      PCT Community Trust         Wandsworth wide primary care and domiciliary         shamsie.simpson@swlondon.n
                                   service                                                 care for persons with diabetes                       hs.uk
                                   reconfigured

Integrated health    Standard                                                              All people with diabetes requiring multi-agency
                     12                                                                    support will receive integrated health and social
and social care
                                                                                           care
                     Fstps, THL,                                                           These areas summarised above are also
                     BHL,                                                                  relevant to this standard
                     Desmond
Tooting Advocacy                                               Grant funded                User group for support, information and              Michael.Nayagam@swlondon.
Service                                                                                    education                                            nhs.uk

Ramadan leaflets                                               Wandsworth South Locality   Leaflets distributed through all primary care        asmat.nisa@swlondon.nhs.uk
and advice                                                                                 centres and hospitals, advice sessions, press
                                                                                           releases
St Georges Local     LDSAG                        Ceased       Born by secondary care      Forum for patients, carers and professionals to      Paul.Chandler@stgeorges.nhs
                                                  11/11/06                                 advice on hospital diabetes services. Info on        .uk
Diabetes Services
Advisory Group                                                                             future plans from Paul Chandler,

Expert Patient       EPP           1/4/04         ongoing      NHS central funding         The national expert patients programme               Colin.Smith@swlondon.nhs.uk
Programme                                                                                  providing training, support and facilitation

Wimbledon            WVDG          Longstanding   ongoing      Self funded                 Support Group, Speakers, Events and                  Maureen Ball
Voluntary Diabetes                                                                         Awareness
Group                                                                                                                                           0208 789 1756

Service Provision    SPG           Dec 2005       April 2006                               Examining care closer to home, GP                    Ken.Earle@stgeorges.nhs.uk
Group                                                                                      commissioning and clinical care pathways



                                                                                                                        Executive Summary 5.0,       August 2007. NJB


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