Super Six Model of Diabetes Care: Integration in Diabetes

The Super Six model of diabetes care in South East Hampshire and Portsmouth based itself on defining clearly with local GPs, Commissioners and specialists as to which services needed to exist within the confines of an acute Trust, due to its MDT setting or higher expertise involved.

The 6 services were:

• Inpatient diabetes
• Foot diabetes (with predefined criteria)
• Poorly controlled Type 1 diabetes, including adolescents
• Insulin Pump services
• Low eGFR or patients on renal dialysis
• Antenatal diabetes

This involved any other patients with diabetes being managed in the community by a combination of virtual means (emails/phones) and GP surgery visits.

The GP surgery visits were used primarily for education with options given to GPs and practice nurses such as: Virtual clinics (case-based discussions) Review of database to discuss patients in regard to Quality and Outcomes Framework targets Review of audits completed by surgery on diabetes care Educational session on area(s) of diabetes management of surgery's choice Patient review (in conjunction with GP or practice nurse.

So far, this model of care, based on the crux of redefining specialist's roles has met with approval from primary care and patients and is also starting to show improvement in outcome measures, along with recognition in the form of awards such as: Shortlisted for BMJ Awards 2013 (Diabetes Team of the Year, Clinical Leadership Team of the Year) Shortlisted for HSJ Awards 2012 in Management of Long Term Conditions Winner Care Integration Awards, 2012 Winner, Quality in Care Awards 2012 Quality in Care Award, 2011 (Silver Award in NHS Diabetes Team of the Year).

This model of care has also involved 3 different providers in the local health economy (Southern Health NHS Foundation Trust, Solent NHS Trust and Portsmouth Hospitals NHS Trust) working together in an integrated care model. Further info: http://www.kingsfund.org.uk/publications/specialists-out-hospital-settings.