Implementation Project

NTAC project implementation sites in partnership with their PCTs are implementing insulin pump therapy into their clinical practice as a result of following the NTAC project implementation process. This process has involved introducing significant changes to the way that services have been structured and the way in which healthcare has been delivered within these Trusts.

On this page, you will have unprecedented access to the learning gathered from the teams and there are NTAC project implementation sites so you can make contact and hear from them directly about what really happened and the challenges they encountered. In addition there are support tools and resources for you to download, adapt and use, which all stem from the work completed at each participating Trust.

To explore this section please click on the headings below:

  •  - gives an overview of the NTAC insulin pump therapy project, where you will be able to gain access to the data we collected as part of this process.
  •  - gives an overview of the three NHS Trusts who were involved in the project and what their biggest achievement was following their robust implementation processes.
  • - provides you with a step by step checklist of the essential questions that need to be answered to enable and plan for a change to clinical practice.
  • - provides all of the information and resources that you may find useful when planning the implementation process for insulin pump therapy at a local level.
  • - has been designed to help Trusts understand what implementation will mean locally and what needs to be put in place in order to make it happen.
  • - provides full and complete patient pathway diagrams that can be tailored as appropriate. These are currently being followed in the three NHS Trusts that we worked with on this project.
  •  - this section explores the training and education that may be required for clinicians and patients in order to successfully implement insulin pump therapy.
  • - provides a number of questions around evaluating success and advocates the need to continually monitor and maintain progress being made as implementation filters through.
  • - details what Trusts need to put in place to ensure that a sustainable insulin pump therapy service can remain in place for future years.

Project Background

NTAC project implementation sites across England are implementing insulin pump therapy into their routine clinical practice. The teams agreed and secured the funding for this service improvement on the basis of the NICE Guidance. Teams also drove implementation forward on the foundation of improving quality of life for patients whilst reducing the number of diabetes and non-diabetes related admissions to hospital. A robust was followed to allow a greater number of patients to optimise their glucose control and therefore reduce the risk and costs of long term complications associated with poorly controlled diabetes.

After following this , patient outcomes and the effect on local health economies (clinical and non clinical) were measured in a total of 85 patients across all three sites. Impact on service, financial consequences and the required clinical and patient support needed within the first three months of pump initiation was evaluated.

The evaluation measures and values were subjected to independent analysis undertaken by the NHS Technology Adoption Centre and the NHS Information Centre for Health and Social Care.

  • Click here to access summary data presentation in a pdf file.
  • Click here to access the full project data report.

Project Sites

Birmingham Children's Hospital NHS Foundation Trust
Clinical Implementation Lead: Professor Timothy Barrett

Birmingham Children's Hospital provides a comprehensive service to children, young people and their families. Facilities include: an emergency department dealing with over 45,000 patients a year, 20 beds in PICU, 9 theatres, 280 in-patient and day-case beds including child and adolescent mental health services and 38 specialties and supporting departments.

The biggest achievement of going through a robust implementation process for this Trust was that it gained agreement from its lead PCT (Heart of Birmingham) on behalf of all Birmingham PCTs to support the implementation of NICE guidance on insulin pump therapy for up to 15% of its patients.

The approach to implementation, according to Prof Barrett was to "appoint a pump implementation lead…" which "should be a consultant (paediatrician or nurse) with sufficient seniority to move [implementation] forward". Prof Barrett advocates that "early involvement of [your] PCT commissioning manager" is crucial and letting "them know what you are trying to do at an early point in the commissioning cycle (which can be up to 10 months before the start of the next financial year)" is critical. It is also important to "involve [your] business manager early to help write the business case" and to "involve finance officers…to cost out the service" according to Prof Barrett.

The Whittington Hospital NHS Trust
Clinical Implementation Lead: Dr Karen Anthony

Whittington Hospital NHS Trust is an acute general hospital in Archway, North London, which serves a diverse local population of approximately 250,000 and has 467 inpatient beds. The Whittington is one of the teaching hospitals for University College London.

The biggest achievement of going through a robust implementation process for this Trust was that it successfully sought agreement on funding an insulin pump therapy service from its leading Primary Care Trust (PCT). This was a significant development because there are multiple PCTs that commission services for the Whittington and overcoming the barrier of navigating around this complex landscape was a considerable achievement.

East Lancashire Hospitals NHS Trust
Clinical Implementation Lead: Dr Shenaz Ramtoola

East Lanashire Hospitals NHS Trust provides high quality medical and surgical care to patients in the North West of England. Specialist services are available throughout the Trust's hospitals for a vast range of health care provision for the people of East Lancashire and further afield.

The biggest achievement of going through a robust implementation process for this Trust was that it successfully sought agreement on funding an insulin pump therapy service without the need for a business case. Funding was secured through direct consultations and agreement with the Trusts two Primary Care Trusts for the entire health economy.

The implementation team collaborated with all stakeholders, including commissioners, head of policy and technology analyss and finance representatives. This collaboration played a significant role in the achievements made.

The Trusts success, according to Dr Ramtoola was achieved because of the "project members' efforts and motivation, and increased mutual understanding" of what needed to change and why. "Collaborative working across organisations in respect of funding and procurement" enabled and provided "a growing and sustainable insulin pump therapy service" according to Dr Ramtoola. The "findings from the [service] audit, being able to reflect on current practice" and having regular and in-depth "discussions with other implementation sites" also contributed to the outputs of the NTAC insulin pump therapy project at the Trust.

Mandate for Change

The Quality and Outcomes Framework stated that 2.6 million people have been diagnosed with diabetes in the UK, with the Yorkshire and Humber Public Health Observatory claiming that by 2025, there will be more than four million people with diabetes in the UK. All Primary Care Trusts (PCTs) have a duty to work with provider organisations to ensure that an appropriate infrastructure is in place which will allow the delivery of effective treatment pathways for patients. As the demand on diabetes services increases, service improvement and the implementation of technological advances such as insulin pump therapy will require a strong mandate for change.

The existing diabetes set up and infrastructure within provider organisations is going to shift as a result of implementation of an insulin pump therapy service. Building a mandate for change will be important if Trusts are to secure funding for this service, and the NTAC project implementation sites found that engagement with all of the relevant stakeholders early on in the implementation process was an essential component to achieving success.

There are three underlying principles that underpinned the mandate for change in the NTAC implementation sites, which included:

  1. The speed of adoption (e.g. how quickly can this change be achieved),
  2. Ultimate utilisation (e.g. how many people within the organisation need to be involved to see the technology successfully embraced) and
  3. Proficiency (e.g. are the relevant skills in place to deliver this service).

In order to formulate the mandate for change, the NTAC project implementation sites and subsequent implementation project data from the How To Why To Guide to Insulin Pump Therapy Technology Implementation Project (Click here) supported the notion that carrying out an analysis of your patient population (which must include a baseline measurement calculated using the NICE guidance for insulin pump therapy is an important first step. Some Trusts for example, may have a large number of patients with Type 1 diabetes in their catchment area who could benefit from insulin pump therapy and as a result, engagement with more than one PCT provider may be required. If more than one PCT provider needs to be involved, this will undoubtedly expand the overall scale of change locally. This was the case at the Whittington Hospital NHS Trust which had to navigate around seven PCT organisations before implementation discussions could begin. A strong and clear mandate for change sets the precedent for the entire implementation process.

Planning for Implementation

A systematic and team based approach to implementation is essential if insulin pump therapy is to be successfully adopted, and part of this approach involves establishing a core implementation team representative of all stakeholders who can drive forward the changes required and fulfil the . 'Buy in' from the entire Multidisciplinary Team (MDT) from the outset must be a long-term commitment and only then can improved patient outcomes be achieved. Once an implementation team has been formed, the following questions need to be answered:

  1. Does the Trust understanding the technology and how it will impact on the local health economy?
  2. Can the Trust identify its own potential adoption barriers and benefits at this early stage?
  3. Is it possible to overcome these barriers and resolve them quickly and can opportunities be harnessed?

The long term sustainability of this service improvement will stem from understanding these issues. Having an awareness of what adoption 'on the ground' will look like in order to work towards a detailed implementation plan is an important step in the planning process.

Understanding the technology and its impact on the local health economy is not always straight forward but it will be the precedent for moving forward. Click here to see that carrying out an analysis of your patient population before implementation is essential, as in the Whittington Hospital NHS Trust for example, the diverse and transient population demands a very different service model compared to more static patient populations such as those found in Birmingham and East Lancashire. If you are not aware of your local health economy and how it will be impacted by insulin pump therapy, implementation will prove to be difficult.

The audit proforma (which compliments and follows similar principles as set out in the NICE audit tool) has been developed and utilised by the NTAC project implementation sites to help you to understand where gaps in your service may lie. The outcome of completing this audit will provide you with useful information that can then be shared with your implementation team in preparation for the implementation phase.

Implementation

Trusts and their respective PCTs will have to continually re-think and revise local objectives, priorities, and strategies in order to effectively implement insulin pump therapy. The experience of the NTAC project implementation sites suggests that the initiation, implementation and 'go live' process will take approximately 6-8 months. The following questions were explored in the NTAC project implementation sites which facilitated a successful implementation phase:

  1. Has a clinical and board level champion been identified?
  2. implementation team which will initiate, oversee and ?
  3. Can the team understand the dynamics of what is required to take the plan forward, and has it experience of similar benefits?
  4. Have the key tasks been identified?
  5. Have the been identified?
  6. Do the cost pressures (time, money, people, equipment,) appear reasonable and consistent with existing best practice?
  7. Have the key risks of each of the main components been identified and managed (designed out, shared, and mitigated)?
  8. Has the revised  been agreed?
  9. Has the team got a review mechanism in place for managing and communicating delivery against the implementation plan and for identifying and managing risk?

Once implementation begins, the service demands will be real and the new infrastructure surrounding financial agreements and clinical time will be in place - there is no going back.

Click here for an example that diabetes specialist nurse and dietitian time played a significant part in the delivery of an effective insulin pump therapy service. Nursing and dietitian time accounted for 20% of the overall support given at Birmingham Children's Hospital, 78% of the overall support given at East Lanashire Hospitals NHS Trust and 34% of the overall support given at the Whittington Hospital NHS Trust.

Nursing and dietetic time is essential in the delivery of an effective insulin pump therapy service and carefully planning workload capacity for these personnel is fundamental when implementing a pump service. Ensuring that a sustainable and practical support infrastructure is in place before and during the initiation of an insulin pump therapy service is crucial. If support is not thought about when drawing up resource requirements and agreeing patient pathways, the rate and success of adoption will be hampered. Birmingham Children's Hospitaland East Lanashire Hospitals NHS Trust incorporated the recruitment of dedicated 'pump nurse(s)' into their respective implementation programme to ensure the effective delivery of this service.

Procurement is also an essential part to implementation, and the purchasing of pump technology can be daunting, complex and time consuming - but it does not need to be. The procurement section of this How to Why to Guide will explain what processes need to be followed for purchasing this technology, which should be discussed as an implementation team. The protocols that underpin procurement will also impact on the speed at which implementation can take place locally.

The Patient Pathway: how will it change?

The experience from the NTAC project implementation sites suggests that there are five core areas of consideration when thinking about how the patient pathway will change:

  1. Method of referral into pump clinic - does one exist? Is it efficient? How could it be better?
  2. Patient assessment and selection per NICE criteria integrating opportunities for patient choice.
  3. Provision of appropriate structured
  4. Dealing with emergency scenarios and provision of out-of-hours support. What local plans are currently in place locally?
  5. Training, education and increased awareness of the available technology for other front line health care professionals -

Each Trust will have different needs and demands from what it wants its pump service to deliver, which is going to be important when pulling together an analysis of the current pump pathway locally. However, it is hoped that the patient pathway documents which have been formulated as part of the NTAC implementation project will provide Trusts with a clear insight into what needs to change and why.

Each pathway provides guidance and thoughts as to how you might structure your service - but it is for local implementation team to decide on which pathway (or which parts of the pathways provided) is right for them and the local health economy they serve. Discussing these pathways as an implementation team to assess their impact at a local Trust level is crucial.

Click here for an example that introducing a mobile phone rota into the overall pathway of care was an effective way of ensuring support for patients and their families. Strengthening telephone support services may result in further efficiency savings because there is potential for the number of face to face interventions to be further reduced. This option must however be discussed as an implementation team.

The audit proforma that NTAC project implementation sites developed will help with understanding your current service status. For those Trusts who are already implementing insulin pump therapy in large numbers, a Quality Assurance document is provided in the section of this How to Why to Guide.

The that developed will help with understanding your current service status. For those Trusts who are already implementing insulin pump therapy in large numbers, a Quality Assurance document is provided in the of this How to Why to Guide.

Training and Education

Successful management of insulin pump therapy requires patients to understand how insulin works both in theory and in practice. Skills in insulin management need to be transferred to patients from health care professionals and this requires appropriate training for both the patient and the healthcare professional(s) delivering this training.

Structured education in flexible insulin pump therapy may address problems of diabetes control for many patients and such a robust understanding is essential for maximising the benefits that this technology can bring. Ensuring patients have access to high quality training in insulin use will ensure that insulin pump therapy is offered first to the patients most likely to gain greatest benefit and will also increase the potential benefit they may achieve from conversion to insulin pump therapy.

It should not be underemphasised how important a patients understanding of how to use insulin is before it is decided that they need a pump. Ensuring this understanding contributes to the delivery of an efficient insulin pump therapy service because it ensures that patients with greatest need are prioritised for insulin pump therapy accordingly.

The NICE Health Technology Approaisal on patient-education models for diabetes defines structured education as "a planned and graded programme that is comprehensive in scope, flexible in content, responsive to an individual's clinical and psychological needs, and adaptable to his or her educational and cultural background." The International Diabetes Federation stated in 2004 that:

  • All people with diabetes, no matter where they live, have the right to learn about their disease.
  • Healthcare professionals must be educated to be responsible for prevention and provision of diabetes care.

A joint Department of Health and Diabetes UK Toolkit entitled 'Structured Patient Education in Diabetes' was developed in 2005, should be viewed in order to understand the task ahead for developing and/or refining the educational set-up in your Trust / local area.

NTAC project implementation sites have further developed an education pump checklist, which is useful for understanding education issues pre and post implementation. NTAC project implementation sites have also developed an education pathway document which highlights how education has been approached week by week, session by session, patient by patient. These are only example models and should be applied and tailored to local need.

Education should be aligned to all of the other aspects of implementing this technology - it must not 'stand alone' in the overall service improvement pathway. There may be cost pressures associated with education, which must be factored in when completing the economic impact calculations. There may be infrastructural changes that need to be factored into the implementation plan. Each implementation team will need to assess individual service requirements in terms of education.

Evaluation of Effectiveness

The NICE Guidance sets out that insulin pump therapy should be offered by a trained specialist team which should include a doctor, specialist diabetes nurse and a dietitian. Therefore as numbers of patients treated with insulin pump therapy increase, attention will need to be given to the model of care within the clinical environment required to provide adequate follow up for these patients. Considerations and being able to successfully overcome these evaluation matrices include the need for:

  • Continuing education including dietetic support (see ).
  • Early identification for problems.
  • Provision of support to deal with above.

A proportion of patients will continue to have problems on insulin pump therapy, for example:

  • Psychological issues.
  • Continued or recurrent problems with severe hypoglycemia.
  • Not achieving or maintain biomedical benefit and will require further intensive intervention.

When evaluating success and assessing how a sustainable infrastructure can remain in place, the following questions should be addressed:

  1. How and when will you evaluate the impact that implementation has had on patient care, service efficiency and service costs?
  2. Who will be responsible for collecting ongoing data to assess the effectiveness of the plan and its implementation?
  3. How will accountability for implementation be assessed?
  4. What Trust-wide mechanism will be created to allow changes in the implementation of the technology and the plan itself?

Initially, as team members gain experience it may be valuable to have all the health care professionals together, seeing patients either jointly or in close succession. As numbers grow, it may not be possible or necessary for all patients to see all members of the team and it may be more appropriate for follow-up to be targeted and for the patient to see the most appropriate member(s) of the team as required.

For the many patients who achieve good control on insulin pump therapy, follow up requirements may be quite low and routine visits may not be necessary apart from annual review, educational support and regular self review of HbA1c (e.g. obtained from primary or routine appointment) and hypoglycemia experience. Patients should be able to access support when concerned about their diabetes control. With increasing use of data downloads, particularly in patients using bolus advisors which capture blood glucose levels, carbohydrate intake and bolus doses remote electronic review may reduce the need for face to face contact. It should be noted however that the degree of follow up should be individually tailored to individual patient need, as for some people, a standard annual follow up may not be sufficient. Services need to be able to provide an appropriate level of follow up should patients require it as part of their overall management of care.

An overview of different models on maintaining insulin pump therapy services which are used accross the country was written by the NTAC mentor sites may find useful in ensuring long term effectiveness of your insulin pump therapy service.

A quality assurance document for Maintaining a Pump Service has also been developed by NTAC project implementation sites. This includes details on service delivery, multidisciplinary team involvement, out-of-hours cover for pump patients, criteria for starting pump therapy and many other core components to developing your service.

Measurements of success

The primary task of this implementing insulin pump therapy is to reduce the number of overall hospital admissions and provide a higher quality services and support for patients.

A fundamental goal within this is to measure the impact insulin pump therapy and to identify the potential benefits, costs and practical issues associated with the routine implementation of the technology.

We undertook the following measurements to assess patient outcomes and impact on productivity and the use of resources so that we could provide relevant information to help providers and commissioners make informed choices about how the adoption of this technology could make a positive difference to NHS performance and the well being of patients:

  • Contributing factors to insulin pump therapy initiation,
  • Patient support requirements,
  • Impact of varying patient populations,
  • The effect of new referrals on service delivery,
  • Training and educational needs of patients and healthcare professionals,
  • Utilisation of existing clinical expertise.

Three success stories from the NTAC project implementation sites can be found below:

  • "We now run the training over 2 days, we run a pre pump saline trial routinely. We can offer training in tandem (2 families together). We have developed structured education materials to use" - Birmingham Children's Hospital
  • "Pre project we had a service developed historically over more than 10 years with very small numbers of new patients annually and a minority of the team involved. Since…we have employed a part time specialist pump nurse, we have trained up most members of the team, we have audited our service, developed a structured pump pathway, and instituted dedicated multidisciplinary insulin pump therapy clinics" - East Lancashire Hospitals NHS Trust
  • "We now have a separate pump clinic…currently two monthly but this may increase. Previously [we] held a pump clinic every three months. We have been able to arrange sufficient clinic space to run adult and paediatric pump clinics in parallel - one adult and one paediatric consultant, one adult and one paediatric pump-trained DSN and one dietitian who supports both services" - The Whittington Hospital NHS Trust
  • Click here to access the implementation project summary data

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