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Creating effective shared care for patients with diabetes in Salford

Why was the initiative launched?
What happened?
Chosen approach
Resources deployed
Assessment and Review
Does it work?
Tips for success
To find out more contact

Why was the initiative launched?


In 1994 Salford Royal Hospitals NHS Trust started to use the EFQM Excellence Model® as a framework for developing excellence in its services. The work by the Diabetes Clinical Team reflected their concern about co-ordination between primary and secondary care. Patients were complaining about delays in referral, about the information available and about the care provided in the community.

What happened?


The Diabetes Clinical Team agreed that the overall result required was an improvement in quality of care of patients across the primary/secondary divide. To be clinically effective care had to be multidisciplinary. In particular the team sought an increase in the percentage of diabetic patients having a structured preventative care review because this would increase early detection and treatment of potential complications of diabetes. The clinical result would be an increase the percentage of diabetic patients with total cholesterol below 5.5 mmol/L and LDL Cholesterol below 3.5 mmol/L, with a reduced diabetes complication rate.

Chosen approach


The approach chosen by the Diabetes Clinical Team was to promote 100% shared care. This required significant improvements in the quality of information available. Action was taken to build on a local diabetes register and create a district-wide diabetes information system.

The new system provides information about all aspects of patients' history and management. It builds on the principle that people putting information into an information system should get out more than they put in. The system prompts users to follow the district protocol for preventative care and to keep it updated. When patients are seen at hospital new information is added directly. When patients are seen in primary care, new information is sent by post, though systems to enable direct access for primary care are being explored. After new information has been added, an updated summary is sent to the GP and to the patient . GPs also receive quarterly summaries about their patients.

All patients in the district now have an annual nurse review. The review creates a contract between the nurse and the patient to ensure clarity about what patient needs to know and do. Problems occurring between reviews are referred directly to the specialist nurse for assessment. Patient education is a feature of all reviews provided in hospital. Non insulin dependent patients, whose reviews are undertaken in primary care, are offered educational sessions at the hospital.

Since the initiative was launched, communications and the development of good working relationships have been given priority. Care has been taken to ensure that messages have been consistent and the messenger heard. Peer links are encouraged, for example between nurses in secondary and primary care and between non-clinical staff (such as IT and practice managers). Regular sessions are arranged to allow staff from primary and secondary care to get together and discuss current issues: what have been the problems this month? The sessions are proving popular and attracting many GPs and practice nurses.

Resources deployed


The local Consultant, Dr Bob Young, led the initiative working with the Diabetes Clinical Team. Systems have been put in place to identify and deliver training to enable staff to play their part in the new service. Staff are encouraged to challenge current skill mixes. The use of Individual Performance Review (IPR) and Personal Development Plans (PDPs) have been given particular prominence. All hospital staff have IPRs and PDPs. This is being extended to primary care, with PDPs in place for practice nurses. The role of practice nurses in diabetes management is now reflected in a specific English Nursing Board course offered through the Diabetes Centre and accredited by Salford University.

Assessment and Review


A District Diabetes Steering Group has regular educational meetings and uses data from the district-wide diabetes information system to review practice. The shared-care guideline is continually updated to reflect findings of reviews of evidence undertaken by the multidisciplinary diabetes team. The local guideline places emphasis on enabling patients to get to the right part of the system at the right time.

Does it work?


Shared care for patient with diabetes in Salford was achieved, on time, by January 1998. Specific local service improvements were:


The Table illustrates the improved quality of service being provided. The improvements have been achieved within existing resources, but problems are emerging. For example, patients have direct access to the specialist (hospital-based) nurses: they can self-refer. Over 6,000 telephone questions have been asked of the four specialist nurses, and accommodating this within other clinical work is difficult.

Key performance indicator 1993 1998
Number of Salford residents with diagnosed diabetes 4780 5352
Patients screened in last 18 months 55% 73%
Patients with total cholesterol <5.5 mmol/L 32% 74%
Patients with total LDL cholesterol < 3.5 mmol/L 15% 54%
Complications Rate 1995 1998
Diabetes-related amputations (knee) 9 4
Diabetes-related amputations (toes) 15 8
Complications Rate UK Salford
Blindness due to diabetes < 50 years 1- 4% 0.04%

The district-wide diabetes information system that supports the service has been a particular success and now allows rapid audits, virtually at a keystroke, to assess all aspects of care. It provides reliable monthly and quarterly analyses to allow monitoring of the service. This IT system in now in use in about 40 diabetes services in other UK hospitals.

Tips for success



To find out more contact


Henry Stahr
Corporate Development Manager
Salford Royal Hospitals NHS Trust.
Stott Lane, Salford M6 8HD

Tel 0161 787 4212 Email hstahr@mcmail.com

The following materials are available:

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