Health Committee work programme Appendix 1

Itinerary...2 Biographies...3 Lambeth and Southwark – overview of the area...5 The Diabetes Modernisation Initiative...6 The DMI’s Local Partners and providers...7 Poster - A Network of

BRIEFING PACK

Gracefield Gardens Health and

Social Care Centre

2-8 Gracefield Gardens

Streatham SW16 2ST

Diabetes Modernisation Initiative

Site Visit

Appendix 1

Itinerary 2

Biographies 3

Lambeth and Southwark – overview of the area 5

The Diabetes Modernisation Initiative 6

The DMI’s Local Partners and providers 7

Poster - A Network of Excellence for Paediatric Diabetes: Young Diabetes Connections 8

Media Releases 9

Diabetes Community Champions tackle diabetes in Lambeth and Southwark 9

Lambeth and Southwark Diabetes UK Voluntary Group: Working in partnership with patients to transform diabetes care 11

Care Planning Advocates: A case study of successful community empowerment 13

Tackling Unwarranted Variation: Levering change in primary care 14

17 October 2013 – From 1.30pm - 3.30pm

Gracefield Gardens Health and Social Care Centre

2-8 Gracefield Gardens, Streatham, SW16 2ST

Itinerary

1.25pm Arrive at Gracefield Gardens

1.30pm Welcome

Meet diabetes specialist nurses who deliver self management

education to patients Participate in some of the activities carried

out on the DESMOND programme (a structured education

programme for people with type 2 diabetes)

2.00pm Opening presentation

Tackling unwarranted variation in diabetes outcomes across

Lambeth and Southwark

2.20 pm Case studies

1) Starting young: Tackling variation in paediatric care

2) Arming our community: How we're using patient advocates to

spread the word about care planning and quality assure how it is

done

3) Reaching the harder to reach: Hear from a community champion

about how she is working on raising awareness of diabetes in her

community

2.50 pm Q&A with panel members

Barry Coker – Chair of Lambeth and Southwark

Diabetes Voluntary Group Jane Doherty – DMI Clinical Lead/ Southwark GP Sonia Winnifred – Community Champion John O’Leary – Patient Advocate Rebecca Dallmeyer – DMI Clinical Lead Dawn Edwards – Patient Advocate

3.05 pm Facilitated discussion

Learning from the DMI, what principles and approaches can be

used to reduce unwarranted variation across London?

3.30 pm Close

2

Barry Coker: Chair of Lambeth and Southwark Diabetes UK Voluntary Group

Barry is the chair of our patient forum He was born and raised in Southwark and has been living with Type 2 diabetes for the last eight years

Sonia Winnifred: Vice-Chair of Lambeth and Southwark Diabetes UK Voluntary Group

Sonia has been vice chair of the patient forum for around 18 months She is active in the Lambeth local community and has a personal interest in

improving diabetes care in the borough

Andrew Eyres: Chief Officer, NHS Lambeth CCG

Andrew is an experienced NHS leader in Lambeth and has worked across the NHS in inner-south east London for 23 years He is currently the Chief Officer, NHS Lambeth CCG and the Senior Responsible Officer for the DMI

Jean Young: Head of Primary and Community Care Development,

Southwark CCG

Jean works with clinical leads to commission out of hospital services for patients in Southwark, contributing to and translating a programme of

pathway/service redesign into contracts with providers She also leads on developing the role of primary care to deliver agreed pathway improvements, including the commissioning of both extended arrangements for primary care services

Rebecca Dallmeyer: Clinical Lead, DMI

Rebecca has worked in south east London as a pharmacist and healthcare manager for more than 20 years in hospital, primary care and urgent care settings She has been a member of the Southwark Professional Executive Committee for the PCT and led the programme of work for long term

conditions, and in particular diabetes, at Southwark CCG She is currently a clinical lead at the DMI and undertaking project work to support the

development of consistent, evidence based provision of diabetes care in general practice

John O'Leary, MBE: Patient Advocate

John is a retired Police Officer and was diagnosed with Type 2 diabetes about

10 years ago He attended a DESMOND and Self Management

Program (SMP) and as a result dispensed with medication Following this he decided to become a Lay Tutor and was involved in delivering the SMP and is currently part of the team involved in training Health Care Professionals

Dawn Edwards: Patient Advocate

Is a patient who has been living with Type 2 diabetes for nearly 10 years and

is an active member of the DMI patient forum

Jane Doherty: Southwark GP and DMI Clinical Lead

Jane has been a GP in Southwark for 23 years and has been running the diabetic clinic at her practice since 1997 In addition to her clinical work, Jane has been a member of the Southwark Professional Executive Committee for the PCT and the lead for long term conditions at Southwark CCG She has been a GP trainer for the Guy's and St Thomas' GP training scheme since

2000 She is now a clinical lead at the DMI and co-chair of the Clinical

Reference Group for the DMI

Rosarie Atkinson: Diabetes Specialist Nurse, Lambeth

Rosarie is a nurse working in the Lambeth Community Team The team supports the development of primary care, the delivery of clinics and

structured education

Caroline Rook: Practice Nurse, Lambeth

Caroline also works as a nurse in the Lambeth Community Team

Jane Stopher: DMI Programme Director

Jane is Director of the DMI Dual trained as a general and mental health nurse, she has practiced clinically in the UK, US and Australia She

specialises in leading complex change across organisational boundaries

Jennifer George: DMI Transformation Lead – Self Management

Jennifer is the Transformation Lead for the DMI self management

workstream She has eight years of service improvement and change

management experience and has worked at a local and national level to improve services for people living with long term conditions She has a

Masters in Health Psychology and has used her theoretical knowledge to suggest and implement practical solutions to support behaviour change

Alex Manya: DMI Head of Service Design and Analysis

Alex leads the analysis and evaluation elements of the DMI He has worked in change management and service improvement for over nine years He

worked on the redesign of Haringey Council’s Children’s Service and

designed the NSPCC’s performance systems and service evaluation tools

4

Lambeth and Southwark – an overview

Lambeth and Southwark are large, inner-London boroughs with diverse, highly transient populations Their combined population of 600,000 has an average density of around 28,000 per square mile and an average population churn of around 27% annually, presenting challenges for the detection and treatment of long term health conditions

Lambeth is one of the most densely populated inner London boroughs and has the highest proportion in the country of: Portuguese, South American and Mixed race white and black African people; people from multiple mixed ethnic backgrounds and people from non-Caribbean and non-African black

backgrounds There are high levels of social deprivation, with 15% of the working-age population on out-of-work benefits

Over 150 languages are spoken across the boroughs After English the main languages are Portuguese, Yoruba, French, Spanish and Twi

The area is served by Guy’s and St Thomas’ NHS Foundation Trust and Kings College Hospital NHS Foundation Trust and there are currently 93 GP practices operating across the two boroughs

Nationally, 1 person in 24 is diagnosed with diabetes Across Lambeth and Southwark, the figure is 1 in 21

The latest estimate of diabetes prevalence across the two boroughs suggests that we have detected around 79% of cases

This represents a substantial improvement in the number of people whose diabetes has been detected, (an additional 4,500 people between 2009/10 and 2012/13) but there remain an estimated 7,500 people with undiagnosed diabetes across Lambeth and Southwark

The Diabetes Modernisation Initiative

The Diabetes Modernisation Initiative is a three year change programme, funded by Guys and St Thomas' Charity with a £4.5million grant

The programme works with commissioners and acute, community and

primary care providers across the boroughs of Lambeth and Southwark

Three strategic priorities have remained throughout:

 Improving care for children and young people;

 Improving people’s ability to self manage;

 Improving diabetes care in primary and community care settings

Our vision is for Lambeth and Southwark to be two of the best boroughs in which to receive diabetes care, measured through improving outcomes for our population

We operate across the health economy, accountable to all the partners A clinical reference group and thriving patient forum oversee our programme, ensuring our work is clinically robust and tackles what matters to patients Our principles of working are to:

 deliver change above and beyond the mainstream

 for change to be sustainable and not cost increasing

 delivered through partnerships with patients at the heart

 change to be scaleable across the health economy

Following successful Foundations and Transformation phases, the

programme is in its final phase: Legacy, ending in June 2014

6

The DMI’s Local Partners and providers

The DMI’s Partner Organisations and provider landscape

The DMI has partners from multiple organisations and is part of a wide and varied provider landscape Our key partners and stakeholders are:

King’s Health Partners, which is comprised of three foundation trusts and a

university They have 3.6 million patient contacts a year between them, are comprised of 31,000 staff and have an annual turnover of £2.8 billion

The three NHS founders comprise Guy's and St Thomas', King's College

Hospital and South London and Maudsley NHS Foundation Trusts

Together they serve a local population that is among the most ethnically, socially and economically diverse in the world and are amongst the highest rated and financially strong Foundation Trusts in the country They provide the full range of medical and healthcare services, from acute and specialist

medical care through to mental healthcare and services that promote physical and psychological well-being

Lewisham and Greenwich NHS Trust provides services across Lewisham,

Greenwich and Bexley The trusts are recently merged and provide acute and community services

Lambeth Diabetes Intermediate Care Team provides community-based

diabetes services, including diabetes clinics and structured education, to people with diabetes in Lambeth The service is comprised of Diabetes

Specialist Nurses, a dietician, a GP with a special interest in diabetes and consultant diabetologists from the local acute trusts and is managed by

Crowndale Medical Centre A key part of their remit is to support and improve primary care management of diabetes

Southwark Community Diabetes Service is provided by the Community

Services Directorate of Guy’s and St Thomas’s NHS Foundation Trust

Similarly to the Lambeth community service, they offer a range of services to people with diabetes in Southwark, and work closely with primary care to improve management of diabetes in general practice

General Practice We work with all of the 93 practices across Lambeth and

Southwark, engaging GPs and Practice Nurses Together they have 28,000 people with diabetes on their registers

We work with Lambeth and Southwark CCGs who together have a budget

of nearly £800 million and serve a population of almost 600,000

Poster - A Network of Excellence for Paediatric

Diabetes: Young Diabetes Connections

8

Media Releases

Diabetes Community Champions tackle diabetes in Lambeth and Southwark

A team of Diabetes Community Champions is to spearhead a new campaign to tackle a growing diabetes crisis in the London Boroughs of Lambeth and Southwark New figures show there are now 35,500 people with diabetes in the two London boroughs – with one in five unaware they have the condition That is expected to soar to 42,500 people with diabetes in the boroughs by the end of the decade.

The 15 local Diabetes Community Champions will help people spot the signs of diabetes and encourage them to go for health checks They will tell them how to change their lifestyles and where to get services to stop diabetes from leading to disability or early death

The champions all come from Black, Asian and minority ethnic communities, where diabetes is more common than in the white population They include a bishop, psychotherapist and practitioner working with drug users.

Diabetes UK is running the project to deliver 30 community events by the end of October It is one of three schemes they are delivering across London The Diabetes Modernisation Initiative – a local programme to help people with diabetes live well –

is funding the work in Lambeth and Southwark.

The champions will organise coffee mornings, give talks in community centres, attend tenant meetings, and run stands at fun days and events They will explain what diabetes is and what puts people at risk - like high blood pressure, being

overweight, or having relatives with diabetes

The champions will tell people about the local services available, including five specialist community clinics, self-management courses, and how to get their feet and eyes checked They will help people understand that diabetes, if left unmanaged, can lead to blindness, amputated limbs, strokes and kidney failure.

Sandra Tomlinson volunteered as a Diabetes Community Champion because her partner has Type 2 diabetes Ms Tomlinson said: “Five years ago he was drinking five to ten 10 litres of water a night and his feet were swelling up But our GP didn’t recognise the symptoms It was two years before another doctor tested him for diabetes.”

Ms Tomlinson will run workshops for African Caribbean communities in Southwark She says: “I come from an African Caribbean background and understand the

culture I can help dispel some misunderstandings about diabetes, such as the false belief that it only affects older people The programme is a great way of getting the message out.”

Juliet O’Brien, Diabetes UK Diverse Communities Officer, said: “Raising awareness

of diabetes in minority communities is vital; people from an African or African

Caribbean community are three times more likely to develop Type 2 diabetes and people from a

South Asian background are six times more likely to develop the condition Getting the word out into the local community is a crucial step to tackling the rising tide of diabetes.”

Jennifer George, Transformation Lead at the Diabetes Modernisation Initiative, said:

“This small band of champions will make a huge difference They will reach into their communities at an early stage to stop diabetes playing havoc with people’s lives later

on They will let people with diabetes know what care to expect, how to get it and how to look after themselves We hope the Champions will continue to spread the word about diabetes, and how it can destroy lives, after the campaign finishes in October.”

To find out more, email juliet.o’brien@diabetes.org.uk or visit www.diabetes.org.uk

10