“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. Too often a passive affair.

– 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– So many tests: which are important? – What does all the data 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

All eggs in one basket?

Engaged empowered

patient

Organised proactive

system

Partnership

= Better outcomes

Service redesign; QoF, etc.

Lots of focus, attention and investment“Cinderella”

Self-careThe 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

The solution

• When blood tests are processed

• Send HbA1c result direct to person with diabetes– For everyone – Within 5 days (before the care-

planning review)– In a form 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’

Product Design is everything

• Give the result meaning– You don’t have to‘get it’ (i.e. understand A1c)

in order to know how your diabetes treatment plan is doing

• makes the result easier to understand assimilate into– positive health behaviours, – Engagement in care planning

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

ScaleColoured ruler

Number and arrow

3 categorieslinked to NICE & QoF targets

Simple descriptors

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

Goal setting & individualised targets

Design FeaturesTrendpresent and previous results

ScaleColoured ruler

Number and arrow

3 categorieslinked to NICE & QoF targets

Simple descriptors

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

Goal setting & individualised targets

Design FeaturesTrendpresent and previous results

ScaleColoured ruler

Number and arrow

3 categorieslinked to NICE & QoF targets

Simple descriptors

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

Goal setting & individualised targets

Design FeaturesTrendpresent and previous results

ScaleColoured ruler

Number and arrow

3 categorieslinked to NICE & QoF targets

Simple descriptors

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

Goal setting & individualised targets

Design FeaturesTrendpresent and previous results

ScaleColoured ruler

Number and arrow

3 categorieslinked to NICE & QoF targets

Simple descriptors

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

Goal setting & individualised targets

Design FeaturesTrendpresent and previous results

ScaleColoured ruler

Number and arrow

3 categorieslinked to NICE & QoF targets

Simple descriptors

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

Goal setting & individualised targets

Design FeaturesTrendpresent and previous results

ScaleColoured ruler

Number and arrow

3 categorieslinked to NICE & QoF targets

Simple descriptors

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

Goal setting & individualised targets

Pilot Evaluation 2011

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

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

Quantitative analysis of Results to Patients

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

Qualitative analysis of Results to Patients

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

Qualitative analysis of Results to Patients (2)

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 from December 2011,

all Sandwell GP practices

• Safeguard excluding screening for diabetes

• National interest high, other PCTs/CCGs and patients

• Support from my Trust’s CEO = sustainable

Summary & Conclusions• Patient involvement shaped product quality

– enabling better understanding

• Sharing information in this way– Was welcomed– Led to positive health behaviours, suggesting

people have taken greater control of their diabetes

– Enhanced consultations with doctors & nurses, suggesting partnerships were strengthened

Summary & Conclusions (2)

• The project team are firm advocates of Lean and Six-Sigma methodologies

• 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