The Big Interview – Dr Parijat De

Dr Parijat De has been a consultant physician in diabetes and endocrinology for 13 years. During his tenure at the Sandwell and West Birmingham NHS Trust he has introduced nurse-led diabetic renal review clinics and was also named Healthcare Professional of the Year at the annual QiC Awards.

Here he tells The Diabetes Times how some of his pioneering ideas have helped revolutionise diabetes care.

What made you want to specialise in diabetes and endocrinology?

I trained in this speciality and became a consultant in diabetes and endocrinology in 2003. I have always felt that this is one of the few sub-specialities within general medicine that encompasses and allows one to think and analyse general internal medicine in its entirety in the truest possible sense given the multi-system involvement in diabetes.

Specialising in diabetes allows you to deal with an ever-growing challenge of both prevention and chronic management of a potentially serious long term condition including the exciting avenue of latest research into newer and ever-growing therapy area to treat diabetes.

Endocrinology gives you the opportunity to critically analyse and differentiate diagnostic conundrums and come up with a sensible investigation and management plan for patients and I find this quite stimulating.

Why did you introduce nurse-led diabetic renal review clinics and what are the main benefits?

Diabetes is more prevalent in the Sandwell and West Birmingham area compared to the national and regional average. Diabetic Nephropathy (DN) is a major cause of premature death in patients with all types of diabetes. Although nurse-led clinics are generally believed to be successful, there is very little data on impact of specific nurse-led clinics in patients with DN.

With the growing prevalence and unmet needs of this high-risk cohort, we set up a protocol-driven, diabetic renal nurse-led review clinic to specifically target education and adopt an “ABC” approach – improve HbA1c, Blood Pressure BP and Cholesterol.

We evaluated results over three different time periods between 2003 and 2014 in our mixed ethnic population and found significant reductions in HbA1c, blood pressure, cholesterol and proteinuria. Patient satisfaction scores were high and medication compliance improved significantly.

These results suggested that our nurse-led clinic is highly effective in this cohort of patients. The ABC strategy, together with the increased use of cardio-protective agents has improved renal outcomes and hopefully will result in further long-term cardiovascular improvements.

You have been behind several community-based integrated diabetes clinics in Sandwell and West Birmingham CCG, which ones have been the most effective and why?

Traditionally, diabetes management has been somewhat disjointed with gaps and duplication in service when it comes to seamless care between the community and hospitals for a variety of reasons. The impact of bludgeoning diabetes prevalence in Sandwell and West Birmingham CCG is huge and primary care has significant difficulty in managing increasing numbers, reducing HbA1c, diabetes complications and maintaining skills in diabetes.

The Smethwick Pathfinder Diabetes Project (initiated 15 years ago) started off with three to four practices initially, which were then expanded to seven GP practices in 2010, to address some of these unmet needs. In this model, GP practices identified cohorts of difficult diabetes patients with poor HbA1c control (69 mmol/mol and above) for a one-off for advice and management plan by the consultant/diabetes specialist nurse every two to three months.

This model fitted very nicely with the Right Care Right Here model of care advocated by our SWBH Trust in devolving care into the community, giving ownership to patients and carers, thereby increasing hospital clinic capacity and reducing costs. In-house, diabetes management in GP surgeries became much better as a result of upskilling of knowledge, patient satisfaction improved and routine hospital referrals decreased significantly.

Audits showed a 50 per cent to 62 per cent reduction in HbA1c levels (2010-2012).  This innovative model of community working was praised by GPs, practice nurses and patients as being an ‘excellent service, innovative and wish such clinics were more frequent’.

Following on the success of the above, Sandwell and West Birmingham CCG commissioned us to deliver a community diabetes service in all the 89 practices from April 1st 2014. We named this model, DiCE – Diabetes in Community Extension. These were joint diabetes clinics within GP practices which took place every eight weeks. Practices identified the difficult diabetes patients for a one-off advice and management plan by an assigned team of consultant and diabetes specialist nurse. Options included virtual clinics, case notes review and advice and guidance. The financial model was based on block contract.

DiCE results:

Year 1 – 3060 patients (53 practices)

Year 2 – 1985 patients seen (61 practices).  595 less outpatient appointments made, 25/53 practices (50 per cent) have decreased their outpatient activity.

All practices gave extremely positive feedback for DiCE, especially – care closer to home, up skilling as extremely beneficial for staff, joint consultations helping to educate patients and thus becoming more responsive, access to support and team work.

It has been an eventful journey from our initial Smethwick Pathfinder Project to the recent DiCE model of care. Our model of diabetes care is innovative because it is one of the first projects delivered on such a scale in the country where patients are at the heart of the service. It provides a unique service delivery with specialists going out, it is cost-effective and liked by stakeholders and could change how chronic disease is managed in future.

We won a national QiC award in 2014 and our model has been praised for its simplicity and effectiveness and can be adapted by any CCG.

It is hoped that through wider dissemination of the above approach, closer working with every GP practice will become a norm. This is exciting work in progress in a difficult financial climate but hopefully, a great step towards providing first class care for every diabetes patient.

What has been your biggest career achievement so far?

I have been a consultant physician in diabetes, endocrinology, and lipid metabolism in City Hospital, Birmingham since January 2003. I was the trust clinical governance lead 2006-2010, Royal College tutor 2010-2014 and now a clinical lead in diabetes, endocrinology and nephrology since April 2015.

Within a span of one year as clinical lead, I have brought about numerous changes within the diabetes team and the way diabetes patients are managed both within the hospital and out in the community.

I have led the in-patient diabetes team, as a THINK GLUCOSE Lead and champion, focusing particularly on patient safety and safe use of insulin, through numerous simple innovations in delivering safe and efficient diabetes care for every patient in the hospital. I have led many of these interventions pretty much from the front and hands-on, through effective co-ordination and team work with a multi-disciplinary bunch of health care professionals within the trust.

I have also worked with the CCG to forward and continue to develop the successful and award-winning community-integrated diabetes project DiCE.

I remain a staunch clinical governance protagonist and oversee risk and governance within the department including constantly auditing and updating protocols, new guidelines and incorporating new research into day to day clinical practice.

From the financial point of view, I have helped make justifiable and evidence based changes to the structure and working of the diabetes team to generate substantial savings within the directorate (both pathology and radiology investigations cost trimmings) and continue to lead the way forward maintaining a balance between clinical effectiveness and cost efficiency.

For all the dedication and passion in my work with diabetes, I suppose being recognised and awarded the Diabetes Healthcare Professional of the Year at the National Quality in Care Awards 2016 would be classed as my most humbling and biggest career achievement so far.

After winning the award, can you explain some of the other initiatives you have introduced?

Specific new IN-PATIENT diabetes initiatives successfully introduced are as follows:

• In August 2015, I introduced a new abbreviated diabetic ketoacidosis (DKA) management protocol (incorporating national guidance but shortened from 10 to two pages) and a new iDKA App to make DKA diagnosis and management pathway easier to follow. It received excellent uptake and review by junior doctors and nurses so far with improving DKA audit results and crucially, this has resulted in reduction in length of stay of in-patients with DKA by 3.2 days.
• Propagating and promoting a new stand-alone insulin prescription chart (with pre-prescribed insulin units) – introduced May 2015. This has reduced insulin errors significantly (from 60 a year before to 37 a year after introduction) with no serious harm or never event so far. This work was recognised and shortlisted in the Health Service Journal and Nursing Patient Safety Awards in May 2016.
• I have also introduced a novel daily hypoglycaemia email alert through our IT system which identifies recurrent hypoglycaemia by wards in the hospital. It also prioritises those needing immediate action through our Think Glucose champions and educates problem clinical areas. This is working well and as a result a number of changes have been made already to in-hospital hypoglycaemia management.
• To improve basic diabetes education and improve insulin knowledge within the hospital, I have introduced a free online module – 6 steps to insulin safety – via the hospital E-learning website. This is now essential training for all junior doctors and registered nurses in the trust and staff are being encouraged to complete this module. Following this introduction, our CCG has recently introduced the same module for all residential and nursing care home staff.
• I have also rolled out a unique, monthly notification of individual insulin and other prescription error alerts for all junior doctors within our hospital. It is endorsed by college and clinical tutors, through our hospital SAFEGUARD reporting system. This allows them to further discuss with their educational supervisors, and thus help reflect and learn from incidents and errors. This will hopefully prevent and reduce prescription errors of all forms in the future.

How have you brought about positive changes to diabetes services overall within the hospital and in the CCG?

I introduced a post myocardial infarction in-patient diabetes detection alert system in collaboration with cardiology in 2014. Through this simple, yet innovative tweaking of the hospital THINK GLUCOSE IT system and iCM, last year, we have detected new onset diabetes in 10.6 per cent patients in one year (national diabetes prevalence 5-7 per cent), who would otherwise have been missed – with potential implications.

All of them receive counselling, management plan and are enrolled into X-PERT diabetes education (fits in with the new CCG and National drive towards screening and detecting new onset diabetes in high-risk population.

I also introduced and championed the FLORENCE digital tele-healthcare for diabetes within the trust. It is an  innovative and practical new mobile phone texting service which uses remote BP monitoring and helps with medication, insulin, and blood glucose reminders. This also improves adherence to treatment plans by engaging patients. FLO has improved BP and medication compliance with no additional hospital visits, saved vital specialist resource and money with high patient satisfaction (98 per cent).

Are you working on any research projects currently and if so what are the priorities?

I am a jobbing diabetes clinician and work very much hands-on dealing with day to day diabetes and endocrine clinical problems. Understanding the evolution and progression of type 2 diabetes is essential in order to better manage the disease process. To this effect I am involved in a research project currently called CDRC which is looking into the natural history of diabetes and its complications. This is to provide a repository of information for future analysis to help determine potential biomarkers of chronic diseases related to diabetes.

What are some of the biggest challenges healthcare professionals are faced with when treating diabetes?

As far as I can see, significant unmet needs and challenges still faced by healthcare professionals are as follows:

• The high prevalence and significant morbidity and mortality associated with diabetes in the mainly ethnic minority population who, by and large, have high social deprivation, lack of knowledge, education and self-management skills and are non-complaint and frequently default attendance.
• Lack of clinical engagement and partnership between primary and secondary care and lack of clear-cut guidelines for which patients to be managed by whom and where.
• Lack of care planning, joined-up care and engaged patients. Lack of clarity among patients to learn, engage and self-manage, partly because of lack of knowledge, skill base and partly due to poor uptake of structured diabetes education programmes (DAFNE and X-PERT).
• Lack of integrated IT systems. Patient information is not universally accessible or shared between primary and secondary care with resultant delays in accessing appropriate and safe care, delays in communication and referrals and invariable duplication of services.
• Lack of clarity regarding finances and responsibility. Financial boundaries are not clearly demarcated leading to divisions between primary and secondary care – there is a tendency to hold onto complex diabetes patients for financial reasons in the community with the result of worsening of metabolic control, and similarly for hospitals to endlessly follow-up relatively routine diabetes patients.
• Lack of robust clinical governance structure. General lack of ownership and fragmented approach to patient care with no robust clinical governance structure in place leading to risky and unsatisfactory service provision.
• Lack of training and knowledge within primary care to deal with day to day diabetes related issues.
• Financial restraints on specialists to prescribe the right medication for the right patient at the right time.

As a result, diabetes care is still full of gaps and duplication. This eventually results in an inability to build capacity and capability in primary care and to progress towards better management of diabetes patients.

You are keen to reduce insulin errors and basic management of hypo and hyperglycemia when in hospital, how do you think these problems could be reduced?

Our hospital (SWBH) employs 7,500 people and has 38,000 admissions each year. One in three admitted patients have diabetes and a third are insulin treated. Insulin is the top five high-risk medications worldwide.

A total of 42 insulin incidents occurred in our trust in 2014 and two consecutive national NaDIA audits (2013 and 2015) highlighted poor hypoglycemia management. Subsequent root cause analysis revealed numerous insulin errors, hyperglycemia mismanagement and highlighted significant deficits in diabetes knowledge, especially related to safe insulin use. Two pharmacy-led insulin audits highlighted similar problems in March 2016.

We have tried to tackle some of these issues within our hospital and have made some progress and implemented quite a few changes which I think is the way forward:

• The introduction and use of a new stand-alone insulin prescription chart (with pre-prescribed insulin units), introduced May’15 has seen insulin incidents (prescribing errors and missed insulin) decrease from 60 (Apr’14 – May’15) to 37 (June’15 – Apr’16).
•  A new, abbreviated diabetes ketoacidosis (DKA) protocol (national guidance, but shortened from 10 to 2 pages) and DKA App launched Aug’15 has made it much easier for staff to understand, follow, and implement management.  Audit has shown significant improvements in basal insulin continuation, use of 10 per cent Dextrose when glucose drops < 14mmol/l and referral to Think Glucose diabetes team. Additionally, there has been significantly earlier use of saline/insulin and crucially, reduction in LOS and early discharge by 3.2 days.
• The introduction of a new free, mandatory new “6 steps to insulin safety online module” for all junior doctors and nurses. Over 100 staff have already completed the module successfully in the last six months. Currently pharmacists are being encouraged to complete this module in our trust and this has been recently introduced for care home staff in our CCG.
• the introduction of a new daily hypoglycemia email alert to identify hypoglycaemia by wards in the hospital which allows us to prioritise those needing immediate action and educate them. PRECISION (Abbott) hypoglycaemia database and a new Think Glucose hypoglycaemia prompt tick box check caused by Sulphonylurea and insulin has also been developed for hypoglycaemia detection and action.
•  Ulysses SAFEGUARD IT system now reports all insulin incidents monthly – discussed in Quality Improvement meetings and lessons learnt have been shared in THINK GLUCOSE champions updates and with other directorates (elderly medicine, intensive care).
• The introduction of a monthly junior doctor insulin/prescription error alert (Aug’15) now mandates all error discussions with their educational supervisors helping them reflect and learn from mistakes. We have seen a reduction in number of incidents already.

You have been a Diabetes UK Clinical Champion, what has the role involved and how has it helped improve diabetes care?

What attracted me to the Diabetes UK Clinical Champion programme was the chance to be able to deliver tangible improvements and make a real difference for people with diabetes by shifting our impact on patients and focusing on the broader system with able support from Diabetes UK and a leadership development programme delivered by an internationally renowned business school.

The support I have received (Ashridge sessions, Action Learning Sets, Diabetes UK support) as a Clinical Champion has helped me gain important leverage into addressing ongoing in-patient issues within our trust with regards to diabetes management.

I have hopefully made some positive impact on the need to better in-patient diabetes management by being able to influence people at the correct level within the trust – to continue to improve education and reduce insulin errors in our hospital.

This wonderful Clinical Champions programme has helped networking with like-minded colleagues, learn new things to help make a difference, share experiences and realise common problems and themes exist almost everywhere. More importantly, this programme has helped bring diabetes issues to the forefront in my trust and executives and senior management now look up and take notice!

What does the future of diabetes care in the UK hold?

Although the epidemic of diabetes continues, I feel exciting times are ahead of us. Diabetes prevention is the key and national programmes are in place to address this. Healthy lifestyle adoption and educating both public and school children is going to be crucial.

Integrated community working is essential in diabetes if we are to resource allocate effectively and this will only happen through on-going upskilling of health care professionals in primary care.

We will need to embrace new technologies to diagnose, monitor and treat a chronic condition like diabetes. To this effect and beyond, investment is important, including in specific areas like clinical management and research. Diabetes specialist training and recruitment needs to continue as well.

In-patient diabetes care needs to be improved through education utilising pharmacists and our diabetes specialist nurses and training more Think Glucose champions who need to take more ownership and drive diabetes related issues in hospitals to the forefront.

DUK is doing a stellar job through raising diabetes profile, research and various patient and public initiatives including the successful DUK Clinical Champion programme.

I am excited and confident that even further strides can be made into dealing and tackling diabetes issues in UK. Through the continuing efforts of so many dedicated professionals, UK will no doubt continue to lead the way globally.