The National Diabetes Audit (NDA) for 2017/18 has found that London based AT Medics was the best performing primary care organisation for Type 2 diabetes care across England and Wales. AT Medics is the largest primary care provider in London managing 35 GP surgeries and caring for over 270,000 patients. Many of the practices that we manage will have historically experienced significant organisational and clinical challenges.
Last week, the 2017/18 NDA was published, and revealed that AT Medics practices have some of the best outcomes in Type 2 Diabetic patient care in England and Wales.
- The national average for completed Diabetes reviews (8 care processes) was 57.3% compared to an AT Medics average of 86.9%
- The national average for Diabetes control (3 treatment targets) was 40.4 % compared to an AT Medics average of 48.2%.
- These achievements exceeded those of any CCG in the country for 2017/18.
- AT Medics have exceeded achievements of the highest performing CCGs in the UK on both outcome measures.
The following data visualisation is from EZ Analytics, utilising NDA data for London:
These unprecedented achievements come just before Word Diabetes Day, and have enabled a step-change improvement for our Type 2 diabetic patients in:
- Diagnosis rates
- Care process completion
- Blood pressure control
- Appropriate lipid management
- 3 treatment target control (blood pressure, cholesterol and blood sugar control)
- Medicines safety in diabetes
All of the above will over time contribute to a reduction in diabetic complications including amputation rates, heart disease, strokes, blindness and kidney failure. There is also evidence that patients receiving all 8 care processes will have reduced mortality rates.
Dr Tarek Radwan, AT Medics Medical Director & Founder, said “We are very grateful to our teams across London who have contributed to this landmark achievement in Diabetic patient care, which we have seen further improved in 2018/19. We are beginning to share our methodology with practices outside of our group, starting with NHS Lambeth CCG practices this week, and our ambition is to share our learning and tools across the country as we have with other interventions that have resulted in better patient care and outcomes.”
Type 2 Diabetes affects 3.7 million people in the UK and is a leading cause of morbidity and mortality. The condition accounts for 10% of the total NHS budget and costs the NHS £10 billion a year, with 80% of this due to its complications. With prevalence rates increasing significantly year to year Diabetes is a key public health priority.
In 2016/17 there was an 82% variation between the highest and lowest performing practices achieving their 8 care processes across London. Around 40% of patients with Type 2 Diabetes had received all 8 care processes and, a similar percentage were achieving all three treatment targets. These results were just below London average and it was clear that improvement was needed.
AT Medics developed a Diabetes Improvement Project in 2017, recognising a significant variation in the monitoring and management of our Type 2 diabetic population of approximately 13,000 patients, as measured by the 8 care processes and 3 treatment targets which form part of the National Diabetes Audit, one of the largest annual clinical audits in the world, integrating data from both primary and secondary care sources, making it the most comprehensive audit of its kind.
Recognising this area for improvement, AT Medics planned a multi-factorial quality improvement approach to ensuring a sustained, replicable and scalable step-change in the care delivered to our diabetic patients. Led by our Medical Director, Dr Tarek Radwan, and supported by an experienced senior management team, we implemented an organisation-wide quality improvement programme comprising of:
- Data analytics to identify the issues, peer-comparison of performance and evaluating the effectiveness of the programme as it progressed (ezanalytics.co.uk)
- A comprehensive and bespoke educational programme for 45 clinical pharmacists, delivered at-scale by AT Learning (atlearning.co.uk)
- Senior clinical leadership and mentorship to develop the workforce, create a sense of urgency and to ensure improvement, satisfaction and continuity in patient care
What we did
AT Medics decided to implement a nine-month quality improvement programme named “The AT Medics Diabetes Improvement Project (DIP)”. The challenges and aims we identified for this programme are as follows:
- Ineffective recalling
- Variable clinical knowledge regarding components of annual reviews
- Variation in completeness of care during annual reviews
- Inconsistent clinical management of BP, Cholesterol and Hba1c
- Streamline recall systems for patients with Type 2 diabetes
- Achieve a target of 75% for all 8 Diabetic care processes.
- Systematically improve triple target (BP, Cholesterol, and Hba1c) control through a standardised approach to care management aiming for a target of 50%.
- Reduce variation between highest and lowest performers within AT Medics
- Encourage a culture of opportunistic reviews and interventions within the organisation
A set of interventions and a model of improvement were implemented to achieve these aims.
What were the results?
A significant step change in National Diabetes Audit targets was achieved in the space of 9 months. The nature of our QI approach has meant that the programme can continue in a sustainable manner with less intensive oversight needed in 2018/19. It is our aim to maintain and improve these outcomes going forwards such that patients will benefit from reduced risk of morbidity and mortality in relation to Diabetes.
As a result of this intervention we have been able to improve the uptake of 8CP from 40% to 88.60% and improved treatment targets from 39% to over 48.40% across the whole organisation. In addition the variation between highest and lowest performers has been dramatically reduced, and this change has been sustained (and in many cases further improved) in 2018/19.
As a result of more frequent in-depth personalised follow ups, patients feel that they are receiving an enhanced level of care. They have often anecdotally commented how pleased they are that we are taking the time to proactively address their health issues in a more organised way. There is now a streamlined process for recalls. Practices are aware of the trajectories and methods needed to achieve optimal Diabetes outcomes.
What were the results?
A step change in National Diabetes Audit targets was achieved in the space of just 9 months. The nature of our QI approach has meant that the programme can continue in a sustainable manner with less intensive oversight needed in 2018/19. It is our aim to maintain and improve these outcomes going forwards such that patients will benefit from reduced risk of morbidity and mortality in relation to Diabetes.
As a result of this intervention we have been able to improve the uptake of 8CP from 40% to 86.9% and improved treatment targets from 39% to over 48.2% across the whole organisation. In addition the variation between highest and lowest performers has been dramatically reduced, and this change has been sustained (and in many cases further improved) in 2018/19.
What were the key elements to success in this project?
- Working as a large organisation with a streamlined management structure meant that this at-scale intervention could be rapidly mobilised.
- Training of our pharmacist workforce through a pan-London education programme has been a key positive outcome and given great job satisfaction.
- Our bespoke training programme for clinical pharmacists is delivered in a practical way, enabling rapid application of theory into practice.
- Our bespoke business intelligence tool EZ Analytics has allowed us to monitor, analyse and act upon key metrics to support the care of people with Diabetes.
- We have developed a replicable and scalable programme that has been proven across a diverse patient population, across 16 CCGs and a wide spectrum of staff arrangements
Omar Din – Director of Digital Health & Learning | firstname.lastname@example.org | 07966 032 942