“Delivering results to you”

Share information. Facilitate diabetes care planning.

Dr Pete Davies; p.davies@nhs.netSandwell & West Birmingham NHS Trust

The Problem:• Diabetes care: often passive

– Are we surprised if appointments & tests are forgotten or missed?

• Cards stacked against patients– Professionals have the power & knowledge

and can prepare– Patients cannot easily be prepared

• We lack shared understanding– which tests matter? – What do the results mean?

“Breaking bad news” in diabetes consultationse.g. HbA1c blood test results

• Similar to hearing negative feedback at performance review/appraisal

• Can’t take it in• Don’t hear anything else

that is said

There has to be a better way!

To achieve better outcomes in Long-term ConditionsYou need all these components

Engaged empowered

patient

Organised proactive

system

Partnership

= Better outcomes

Patients & Partnerships Overlooked

Engaged empowered

patient

Organised proactive

system

Partnership

= Better outcomes

Service redesign; QoF, etc.

Lots of focus, attention and investment“Cinderella”

The average person with diabetes:

spends three hours each year with a professional

The remaining 8,757 hours, they care for themselves.

3

8,760

= 0.03 %

Historical Diabetes Care

• Passive– Nurse/doctor agenda– Telling e.g. results of

tests, examination etc.– Judging– Prescribing &

proscribing • “thou shalt not”

– Often time-constrained

To support Self Care

Get Active!– Patient-led agenda– Share information before the

care plan meeting– Allow time for reflection– Patient is

• better prepared

• Engaged

• An active partner

Understanding Glucose control- HbA1c TestWe do not make it easy for patients!

• …a surrogate for glucose control

• …useful clinically

• BUT abstract, not easy to explain, or understand

• Units of measurement have changed!– 7% 53mol/mol

Solution: When blood tests processed

• Send HbA1c result – direct to person with diabetes– Do so for everyone – Make it timely (before the care-

planning review)– Do so in a format that

• communicates meaning• promotes reflection & care planning

Lean Six-sigma MethodologyKey Moments

Force-field analysis

Voice of the Customer Survey

Root Cause Analysis

Inventive

problem solving

Helped identify key enablers; helped us ‘manage’ resistors

Game-changer!Demand high

original idea (text message) NOT popular

Understanding of HbA1c is poor

Identified low health literacy

Product design would be critical

Incorporate low cost AND high quality-

The ‘Personal Mailer’

Health Literacy & patient/user views

• Patient group consultation

• Online communities: DAFNE-online (UK) & Tu-Diabetes (international)– Feedback on idea & options for graphics and

text via online survey tool

Professional Help

• One member of patient group was a graphic designer!

• Artwork ideas discussed with 2 independent graphic designers

Descriptor text

Aim for a low reading age

– Calculated reading age =‘easy to read’ for a 13-15 or 11 year old, respectively

Not bad for an abstract concept

Design FeaturesTrendpresent and previous results

Number and arrow

ScaleColoured ruler

3 categorieslinked to NICE & QoF targets

Clear advice “what next” ‘pause, reflect.. bring to consultation’

Goal setting & individualised targets

Signpost to lifestyle services

Simple descriptors

Design FeaturesTrendpresent and previous results

Number and arrow

ScaleColoured ruler

3 categorieslinked to NICE & QoF targets

Clear advice “what next” ‘pause, reflect.. bring to consultation’

Goal setting & individualised targets

Signpost to lifestyle services

Simple descriptors

Design FeaturesTrendpresent and previous results

Number and arrow

ScaleColoured ruler

3 categorieslinked to NICE & QoF targets

Clear advice “what next” ‘pause, reflect.. bring to consultation’

Goal setting & individualised targets

Signpost to lifestyle services

Simple descriptors

Outcomes of Design Work

• The result is meaningful– You don’t have to‘get it’ (i.e. understand A1c)

in order to know how your diabetes treatment plan is doing

• Now you have the meaning, you might just assimilate this into– positive health behaviours, – Engagement in care planning

Does it work?Pilot Evaluation

• n=1800– 8 general practices recruited– 1 specialist practice (PHD)

• Evaluated by paired questionnaire• Administered at time of consultation• Patient and HCP gave their views• We could match the responses

Results to Patients: patient benefits

Statement % Agreeing/ Strongly agreeing*

“Getting my HbA1c result before my appointment

helped me”

73%

“having my HbA1c result made it easier to talk to my

doctor and/or nurse”

76%

“I would like to receive my HbA1c result in this way in

future”

89%

“The fact my patient had their HbA1c result made the

consultation easier”

74%

Peo

ple

with

di

abet

es

Hea

lthca

repr

ofes

sion

als

*n=178 questionnaires returned for analysis

Results to Patients: patient’s behaviour

Domain Patient comment

Medication adherence (concordance)

“getting my result made me take my tablets”

Dietary adherence “I’ve been trying hard with my diet, so this really gave me a boost”

Empowerment “I will go back to my nurse and ask to go on a diabetes course”

Confidence “I can now see that my treatment plan is really working!”

Peo

ple

with

di

abet

es

*n=178 questionnaires returned for analysis

Results to Patients: benefits to diabetes team

Domain HCP comment*

Understanding diabetes “they wanted to know more about their result”

Engagement “before this it was difficult to get her to come”

Partnership working “after we’d discussed their result, they could see its value and were all for it”

Did this create time pressures? No extra time pressures

*n=17 professionals across 8 practices

Hea

lthca

re p

rofe

ssio

nals

Present State• Successful roll-out

– December 2011, all Sandwell GP practices– Available to 20,000 people with diabetes

• Safeguard – exclude screening for diabetes

• High level of interest, other PCTs/CCGs and patients

• Support from my Trust– Sustainable & may be extended

Summary & Conclusions• Patient involvement enabled product quality

• Sharing information in this way– Led to positive changes in health behaviours– Enhanced consultations/care planning,

suggesting partnerships were strengthened

• Suggesting people have understood & taken greater control of their diabetes

Summary & Conclusions (2)

• We recommend Lean Six-Sigma methods for Quality improvement work

• Many other applications of this technology are feasible

• Easily transferable to other areas

• Lots of options for moving this into the digital health domain

Acknowledgements

Mr Stuart Davis, type 2 diabetes 15 yrs, podiatrist 37 years, Sandwell PCTMs Dottie Tipton, Service Improvement Manager, SWBHDr Jenny Harding, pharmacist, Director of Clinical Governance Sandwell PCT

Thanks to Lilly UK for providing project support.Thanks to Sandwell Diabetes Support Group for financial support for the pilot

Understand diabetes. Take control

p.davies@nhs.net

Maybe initiatives like ours can help achieve that