BaNES CCG Community Diabetes Specialist Nurse Service

Tender description

NHS Bath & North East Somerset Clinical Commissioning Group (BaNES CCG) seeks to commission a Community Diabetes Specialist Nursing service. The successful provider would need to develop the service in line with the development of the overall diabetes care pathway in BaNES. The objectives are to: • To provide consistent, evidence-based community diabetes clinics (with home visits for housebound patients) that are tailored to meet individual patient’s needs and optimise both access and sustainability of service. • Proactively case-manage patients in community settings when acute exacerbations of a co-morbidity impact upon diabetes management. • Provide support in specialist areas of diabetes care, transitional and young person’s care, structured education programmes, foot and renal services. • Liaise with primary care and community based health care professionals, including care homes, to develop and provide individual personalised care plans. • To provide education to other health care professionals involved in caring for people with diabetes, offering mentorship and competency sign off where appropriate. • Lead regular educational sessions/virtual wards (the community multidisciplinary diabetes team sessions) with an RUH Diabetic Consultant across all BaNES practices. • Provide telephone/email support to other health care professionals, including care homes. • To offer a single point of access to health care professionals and patients for both routine and urgent cases. • Delivery of effective group education programmes (for patients with type 1 and 2 diabetes) to empower patients with diabetes to maintain independence and for greater self-management. Locally there were 7600 people (aged 17+) diagnosed with either Type 1 or Type 2 diabetes on GP registers in 2013-/14 (4.6% of the CCG 17+ population). The national prevalence is 6.2%. With the expected increase in population and obesity trends, the prevalence of diagnosed and undiagnosed diabetes in BaNES in patients aged over 16 years, is projected to increase to 7.4% by 2030. Referrals to consultant-led outpatient diabetes clinics are rising at 7% per annum. Diabetes patients are also getting older and increasingly have other comorbidities which add to the complexity of caring for these patients. There is variation in the number of patients with Type 1 and Type 2 diabetes who receive the nine recommended care processes with 49.2% of patients with Type 1 diabetes receiving eight out of the nine processes and 66.0% of patients with Type 2 diabetes receiving them (National Diabetes Audit 2011/12 – eight processes as retinal screening omitted due to unreliable data). Furthermore, only 13.6% of patients with Type 1 diabetes and 22.9% of patients with Type 2 diabetes were meeting their treatment targets for HbA1c, cholesterol and blood pressure (National Diabetes Audit 2011/12). There are 27 GP practices in NHS Bath and North East Somerset CCG (k...