Integrated care is a policy imperative, but exactly how integration happens is left to local service providers and commissioners. The initiation and management of change depends on a variety of contextual factors. Here, we outline some factors that we consider to be essential in shaping the processes involved in transforming diabetes services.
Integrating diabetes care in Derby and Oxfordshire
Over last ten years I have been involved in developing two integrated diabetes care programmes, First Diabetes in Derby from 2008 and then more recently in Oxford since 2013. Both programmes were underpinned with recommendations from Diabetes UK’s Best practice for commissioning diabetes services: An integrated care framework. My role on both programmes was to catalyse and co-lead the change process with colleagues in secondary, community and primary care. In Oxfordshire, my consultant colleagues Dr Garry Tan and Dr Alistair Lumb, from OUH, provided clinical leadership.
Although the integration programmes in Derby and Oxfordshire were similar in principle, working on them has felt very different. Specifically, the Derby programme happened quickly, at a time when many services were being moved out of the hospital into the community. The management team at the acute trust provided significant administrative and project management support which enabled the change to happen over a period of months, rather than years. During that programme, we started with a group of five practices and limited the scope of the service to diabetes. We initially excluded podiatry and inpatient care in order to quickly get the service off the ground.
In contrast, the Oxfordshire programme is more comprehensive and far-reaching. For example, stakeholder organisations include a community NHS trust which employs diabetes specialist nurses (DSNs), podiatrists, dieticians and mental health professionals (Improving Access to Psychological Therapy service). The inclusion of mental health is crucial to the long-term success of caring for people with diabetes.
In retrospect, there were differences in how the programmes started, for example the speed and degree of involvement of leadership from the executive boards, the scale of integration, leadership in primary care, and one less controllable factor: personnel turnover.
The drivers for integration
The stories of the Derby and Oxfordshire integration programmes started very differently. In Derby, the integration process was initiated by primary care, while in Oxfordshire it has largely been driven by the consultants in diabetes in secondary care.
In Derby, I was approached by a GP who was concerned that the continuity of care of patients seen in hospital was not ideal and felt that many patients could be seen in the community, closer to their homes. Working together, we developed a model of shared ownership of the local diabetes population.
In Oxfordshire the integration process was driven by the need to manage a growing population of people with diabetes without increasing the number of referrals, some of which were late or inappropriate. One of the biggest challenges we have experienced in Oxfordshire has been securing buy-in from primary care. The focus in primary care was very much on the lack of resources (for example community DSNs), and understandably, at times it was difficult to change the focus to thinking about a complex transformation of services. In my opinion, the difference between who was driving the change in Derby and Oxfordshire influenced the dynamic and ensuing speed of the integration programmes right from the start.
Working with senior management in secondary care
The practical support provided by senior management for both integration programmes varied across the two acute trusts. The idea of the integrated diabetes service was welcomed by senior management at both trusts, but the leadership and resources allocated to develop and implement the new model of care differed.
In Derby, we were encouraged work on the model we thought would be most appropriate, and our activity was supported by the allocation of time, money, proactive executive support and a project manager from the trust. The trust was demonstrably proud of our work, and we felt the initiative was recognised and promoted both locally and nationally.
In Oxford, seven years later, the resources allocated to the integration programme were much tighter. We were asked to produce a detailed proposal indicating how the new model of care would deliver significant changes, and to outline the implications for the trust. Without dedicated project management support, this task was a challenge. Also, the trust made clear that both the transformation and delivery of the new service would need to be within the current financial envelope.
The scale and complexity of integration
The integration process also varied in terms of our approach to implementation. In Derby, we started smaller. We worked with one locality covering five practices and had a clear aim to develop a joint venture organisation, in partnership with those practices, which would become one legal entity. The scale of the integrated service was smaller in Derby, and included only primary care and secondary diabetes care, as the community provider had been taken over by the acute trust. The joint venture organisation, First Diabetes, was solely focused on Diabetes.
In Oxfordshire, the initial idea was to work across the county and involve all six localities, covering approximately 70 practices. The new service needed to include the community trust, Oxford Health, which was responsible for the community DSN service, podiatry, dietetics, and the IAPT mental health services. In our exploratory work, we concluded that the integrated service needed to cover mental health, which meant engaging with additional services within and outside of the acute trust. Another way the two integration programmes differed was that the Oxfordshire programme involved patients right from the beginning. This patient involvement made it stronger. In the future we hope that social care services will also be included.
A major lesson for us as clinical leaders was learning that starting with a smaller number of providers gave the service transformation greater momentum in Derby. This is increasingly the approach we are taking in Oxfordshire, where we are now piloting the new model of care in one locality with an add-on approach regarding other services and localities.
Leadership in primary care
In both Derby and Oxfordshire, the consultants in diabetes were committed to transformation and working with primary care. In Derby however, the impetus to integrate came from the GPs and therefore, primary care buy-in was already secured. Importantly, there was a shared understanding, across primary and secondary care, that investment and rethinking of the ways of working was needed and that risk was a necessary component of that process. In contrast, in Oxfordshire, the driver for change initially arose from secondary care, and it was harder to engage primary care. However, we have seen that over time, there has been a significant increase in primary care buy-in, at the CCG level as well as at locality and individual practice level.
Personnel turnover
It is debatable whether personnel turnover is a controllable factor since people continually move to different roles and organisations. In Derby, we were very fortunate that all those involved in transformation stayed throughout the initial integration process. This was aided by the speed of the process. In Oxfordshire, however, there was a turnover of commissioners, project managers from the CCG and clinicians on the programme team, which at times meant there was little continuity of work and time was needed to bring new people up to speed a number of times. . This was somewhat frustrating as it felt like an unnecessary interruption. However, on the upside, it did mean that we had to revisit the vision time and time again, which in the end may turn out to be an advantage in making sure that everyone is signed up and committed to the ongoing implementation of the programme.
Further reading
Best practice for commissioning diabetes services. An integrated care framework Link