Diabetes is a major health priority for the East Midlands. Following an Innovation Exchange event, which focused on diabetes prevention and treatment, the East Midlands AHSN launched a call for proposals seeking innovative solutions.
As a result, the East Midlands AHSN worked with the University Hospitals of Derby and Burton NHS Foundation Trust, Derbyshire Community Health Services NHS Foundation Trust and industry partners Entec Health Ltd and Aranz Medical Ltd to implement a new 3D wound imaging and information system called Silhouette® within their diabetic foot ulcer pathway. Using this technology enabled them to deliver routine diabetic foot ulcer treatments in the community rather than in the acute outpatient setting.
Across Derbyshire the previous system meant that multidisciplinary team pathways resulted in the majority of patients attending outpatient clinics at acute hospitals for all their diabetic foot ulcer appointments. This was costly and in many cases the outpatient capacity could not keep up with increases in demand.
By introducing this technology, the Derbyshire health and care teams saw increased efficiency, were able to provide more joined up care and a better patient experience. Over the course of the intervention an average of 19% of patient appointments for foot ulcers were delivered in the community, compared to all appointments being delivered in an acute setting prior to the intervention.
There are more than 61,000 people with a diabetic foot ulcer at any given time, including 6,000 people with diabetes having leg, foot or toe amputations each year in England – many of which are avoidable. In total the NHS spends on average £1.3bn (Diabetes UK 2012) on treating ulceration and, where needed, undertaking amputations. This places a heavy burden on the health and care system.
Across Derbyshire the multidisciplinary team pathways meant that most patients attended outpatient clinics at acute hospitals for their diabetic foot ulcer appointments. This was costly and in many cases the outpatient capacity couldn’t keep up with continuing increases in demand.
Many patients were required to travel significant distances on a weekly or fortnightly basis to attend outpatient clinics at acute hospitals. Providing improved access to correctly resourced multidisciplinary teams, diagnostics and clinical advice was identified as an effective way to improve patient care and create greater health and care efficiencies.
The East Midlands AHSN supported the development and delivery of a demonstrator project in South Derbyshire in order to develop a new technology-enabled model of care for diabetic foot ulcer patients. The demonstrator ran from 2016 until March 2020, predominantly supported by short-term transformation funding.
The collaboration involved the University Hospitals of Derby and Burton NHS Foundation Trust, Derbyshire Community Health Services NHS Foundation Trust and industry partners Entec Health Ltd and Aranz Medical Ltd. Together the team successfully implemented the Silhouette® 3D wound imaging system as part of a targeted integrated pathway across both primary and secondary care in South Derbyshire.
The East Midlands AHSN coordinated with all partners to implement the new pathway, while also providing communications, patient and public involvement, planning and procurement support to facilitate wider adoption and spread across the region and nationally. For example, the AHSN ensured that the system can be readily procured from a framework available to all NHS organisations.
They also established a health economic model and supporting evaluation to monitor and report on the impact of the demonstrator and offered support for the additional two years of transformation funding for further sustainability and adoption across North Derbyshire, Nottingham and Nottinghamshire.
Additionally work has commenced in Nottingham to implement a community-based model following the successful bid for funding from the Nottingham University Hospitals charity. This model is being piloted alongside the development of a business case to support longer term sustainability.
Initial evaluation of the programme in Derbyshire in collaboration with University Hospitals of Derby and Burton NHS Foundation Trust and Derbyshire Community Health Services NHS Foundation Trust found:
- Prior to the intervention, the New to Follow up Appointment ratio for outpatient appointments for the service within an acute setting was 1:10 (for every one new appointment there were 10 follow up appointments). This has since decreased to a ratio of 1:6 due to increased capability to deliver care in the community.
- Over the course of the intervention an average of 19% of patient appointments were delivered in community relative to all appointments delivered in an acute setting in September 2016.
- There was an improved access to clinical data and co-ordination of patient cases, with associated time savings through a centralised portal linking to acute patient records.
- As a result of the changes and increased capacity the outpatient appointment clinic can manage higher risk patients at a faster rate due to the reduced bottleneck in the hospital clinics.
Service user feedback
- 72% of patients were seen within 30 minutes of their planned appointment time, compared to only 3% prior to the intervention
- 85% of patients advised that the technology increased their confidence in the care that they receive
- 71% of patients felt better informed about their foot care.
Since the service came into effect in South Derbyshire in September 2016 there has been a demonstrable increase in the number of community outpatient appointments shifted from the acute hospital, resulting in care closer to home for many patients.
Since the end of the first 12-month demonstrator the deployment of the innovation has been supported by temporary transformation funding, which has limited the impact and longer term sustainability of the innovation. However, commissioners, primary and secondary care are currently working collaboratively to embed the learning from the demonstrator into a system-wide integrated pathway for diabetic foot care. A pathway, which will include elements of best practice established during the demonstrator, will be implemented across North and South Derbyshire.
In recognition of the work undertaken to date, the service was recently the highest scoring poster abstract in the Evidence-Based Practice category at the Symposium of Advanced Wound Care.
Following a pilot of the innovation supported by funding secured from Nottingham University Hospitals Charity, Nottingham University Hospitals NHS Trust are also developing a business case to implement this innovation to support a shift of activity from acute services to community based practice, bringing care closer to home with only the most complex of cases being referred to acute services.
September 2016 – March 2020.