Developing a Regional Integrated Pathway for Diabetes in Northern Ireland

Executive Summary: Northern Ireland Diabetes Network sets the strategic direction for diabetes treatment and care in Northern Ireland (NI) to deliver against A Diabetes Strategic Framework. This Regional Pathway will standardise access and provide equity through integration of diabetes services, supporting treatment and care now, and within an Integrated Care System (ICS) in NI from April 2024 and beyond. This paper outlines work, methodology and findings to support system considerations through to key principles, proposed model and recommendations for implementation. Background: Diabetes affects nearly 112,000 people in NI. An integrated response is required for an increasing population presenting with multi-morbidities, utilising all existing assets across workforce, infrastructure, technology, finance and Community Voluntary Sector. Methodology: The Network undertook qualitative and quantitative research with key stakeholders, using a three-strand approach of Primary Care, Hospital Services and citizen strand involving people living with diabetes (PLWD) facilitated by Diabetes UK. A Citizen Poll, (365 responses), provided a pulse check on current and proposed service provision. Together this informed a Regional Integrated Pathway for Diabetes, approved for implementation. Regional Integrated Pathway for Diabetes and Community Care Model The pathway outlines a high-level integrated approach across Primary and Secondary care creating a Community Care model. This model will support people living with diabetes (PLWD) who are not T1/2 complex or on Super 6 pathways, who are unable to manage or control their condition. Through support appropriate to current environment and pressures, outcomes can be optimised with the right care, at the right time, in the right place under the right HCP within Community Care Model. Risk stratification is the overarching process supporting treatment and management of conditions, facilitating self-management and effective use of all available resources. This model will improve equity and access to treatment and care for all PLWD across NI, upskill Primary Care and support new ways of working. Benchmarking: Existing community models, locally, nationally and internationally, were reviewed for key evidence and learning. Current and developing workforce, technology, digital systems and available data have been considered. Quality Assurance: Key principles (4C’s) for the delivery of care were identified through insights across service development exercises - Capacity, Capability, Culture and Configuration. These key principles underpin service design, quality assuring the final model. ICS: This work adds considerable value to ICS progression and will enable Network to share, subject to ability to deliver, a regional approach to diabetes treatment and care for localisation by AIPB’s, to consider appropriate use and application of existing assets to support -the ICS vision. This pathway will support and demonstrate enhanced patient outcomes within an integrated health ecosystem. Forward Plan: This work is a key enabler to ICS model implantation in NI. The pathway sets an integrated direction for a long-term condition; a template for other conditions. Our 3-year journey demonstrates the value of effective partnership with service users and HCP’s in response to challenges faced in diabetes; concluding an integrated, stratified approach which provides a person-centred solution can support all PLWD appropriately. A lesson for other conditions and services.