Doing diabetes differently – a new commissioning approach

Diabetes treatment represents one of the fastest growing costs in health care, predicted to account for around 17% of the total NHS budget by 2035. We take a look at how one pioneering project has trialled a new model of health service contracting. But is their bid to ‘do diabetes differently’ proving too different to be adopted by commissioners on an ongoing basis?

Diabetes is a big problem for the UK health service, with one recent study estimating that the annual cost of directly treating diabetes will rise from £9.8bn to £16.9bn over the next 25 years.

It’s common for patients with diabetes to experience associated mental health problems, linked to poor treatment adherence and dietary control. This increases the risk of further complications and in some cases doubles the eventual cost of treatment. Yet despite NICE recommendations, effective psychological care for diabetes patients is scarce. Milton Keynes Hospital NHS Foundation Trust attempted to address this stalemate by introducing psychological therapy for diabetes patients, with great results.

An innovative partnership

Funded by the Health Foundation’s annual Shine programme, the Doing diabetes differently project was a partnership between the Trust and social enterprise Evolving Families (set up by LifePsychol Ltd, a company offering clinical psychology). Together they aimed to make diabetes treatment more effective by adding psychological screening to routine medical appointments and providing psychotherapeutic interventions where needed.

The project tested a new model of outcome-based contracting using a ‘social impact bond’, an innovative contract between commissioners and providers. The Trust agreed to pay for psychological therapy services in arrears, contingent on results – in this case a significant improvement in patients’ blood glucose scores, with a premium for any reduction in inpatient admissions.

This unique approach enabled the hospital to ‘save to spend’ rather than ‘spend to save’, thereby breaking the funding deadlock.

The project

When arriving for a clinic appointment, diabetes patients were asked to complete a questionnaire about their mental health and their commitment to keeping to their treatment. Consultants referred patients that they were most concerned about to Evolving Families for a brief psychological intervention. This could include help overcoming negative thoughts or behaviour, or help changing negative perceptions of experiences.

Questionnaires were repeated when the intervention came to an end, along with satisfaction questionnaires for patients, families, carers and staff. Blood glucose results and inpatient admissions were also measured before and after therapy.

Outcomes from the pilot

The project’s findings highlighted valuable trends in diabetes care, showing the effect that anxiety, depression and distress has on a patient’s control of their condition, as well as their quality of life.

Patients exhibited post-therapy improvements across the board, with the majority ‘strongly valuing’ the service they received. One said it was the ‘best service I have used in 38 years of diabetes care’. The project was also popular with hospital staff. Dr Asif Ali, the hospital’s Lead Diabetes Consultant, states that patients derived ‘immense benefits from this collaborative venture’.

Highly commended

Last September, the project was highly commended in the ‘Efficiency in outsourcing’ category of the HSJ Efficiency Awards.

Project lead Dr Miriam Silver, Consultant Clinical Psychologist from LifePsychol, says it’s been an amazing project to be part of:

‘We've been able to operate a service that isn't hampered by the current divisions between mental and physical health, adult and child services, outside of defensive service boundaries that are inevitable in a time of austerity.

‘In our model people can be offered therapy if their mental health is impacting on their physical health or treatment adherence, even where they don't meet the criteria for IAPT, adult mental health or CAMH services. And psychological therapy can consider each patient’s problems more holistically, allowing us to explore issues related to school, work, family relationships and past experiences, making a huge difference to people's lives.’

Next steps

So, what next for the project? The pilot ended in December 2013 and despite its obvious successes, at present the team is still uncertain whether it will become an ongoing service come the new financial year. Dr Silver describes hitting ‘a number of barriers’ persuading commissioners to take up the social impact bond model; encountering a preference for fixed budget costs, and a general opinion that variable costs in arrears appear confusing.

Dr Silver says: ‘We'd love to be commissioned on the basis of our outcomes, because that’s the strongest test of value for public money. However, although there’s a lot of talk about payment by results, at the moment the reality is still payment by throughput.

‘It’s very difficult to be innovative in a conservative commissioning environment. However we’re determined to continue to explore the model of social impact bonds, as well as more traditionally commissioned services.’