Do managed clinical networks improve quality of diabetes care? Evidence from a retrospective mixed methods evaluation.

PROBLEM System-wide improvement of chronic disease care is challenging because it requires collaboration and communication across organisational and professional boundaries. Managed clinical networks are one potential solution, but there is little evidence of their effectiveness. DESIGN AND SETTING Retrospective, mixed-methods evaluation of the form and impact of quality improvement in the Tayside Diabetes Managed Clinical Network (MCN) 1998-2005. STRATEGIES FOR CHANGE Progressive implementation of multiple quality improvement strategies predominately directed at individuals and clinical teams (guideline development and dissemination, education, clinical audit, encouragement of multidisciplinary team working, task redesign). Information technology played an important role in supporting QI activity, but participants identified it as facilitative rather than delivering QI by itself. More important was achieving widespread clinical engagement through persuasion and appeal to shared professional values by clinical leaders. EFFECTS OF CHANGE Simple process measures such as glycated haemoglobin measurement rapidly improved. More complex process measures such as eye screening improved more slowly, and were more dependent on redesign of the care pathway. Improvement was greater for type 2 than type 1 diabetes. Significant shifts of care for type 2 diabetes into primary care were achieved, but were harder to achieve without additional resources. LESSONS LEARNT Delivering better care to whole populations across organisational and professional boundaries required sustained work over long periods, and at all levels of the system of care. Past network focus on clinical collaboration has been effective at improving clinical process and outcome, and the network is now prioritising work with managers and patients to support future redesign.