We are testing a new beta website for gov.scot go to new site

Diabetes Action Plan 2010: Quality Care for Diabetes in Scotland

Listen

LIST OF ACTIONS

CHAPTER

ISSUE

ACTION

TIMESCALE

RESPONSIBILITY

QUALITY STRATEGY

2.1

Primary prevention of type 2 diabetes

NHS Boards should take account of the Obesity Strategy Route Map in their work with Community Health Partnerships ( CHPs) and NHS Boards' planning partners.

SGHD

NHS Boards

Effective

Equitable

2.2

Screening for type 2 diabetes

The Scottish Public Health Network recommendations on screening will be considered through further discussions with:

  • Scottish Government Health Directorates;
  • NHS Boards; and,
  • Key stake holders such as the clinical biochemistry community.

SGHD

Directors of Public Health

Effective

Efficient

3.1

Self Management

The Scottish Diabetes Group ( SDG), with the diabetes MCNs, and working with local patient representatives and relevant voluntary sector organisations, will seek to identify and promote appropriate self management tools for diabetes

SDG

NHS Boards through their diabetes MCNs

Person-centred

Effective

Safe

3.1

Self Management

SDG, through its Diabetes Care Focus Group, will monitor and review provision of information for people living with diabetes, including local and national annual overviews

SDG

Person-centred

Effective

Safe

3.1

Self Management

SDG, with NHS Health Scotland and other agencies, will improve the information available, for example on cardiovascular disease, on www.mydiabetesmyway.scot.nhs.uk, and increase use of the website by people with diabetes.

SDG

NHS Health Scotland

Person-centred

Effective

Safe

3.1

People with diabetes at the centre

SCI-DC will work to increase the availability of web-based access by people with diabetes to their own diabetes clinical data. Information should be available in formats to meet different educational and language needs, and in formats for those with sensory and other disabilities.

SCIDC Steering Group

Person-centred

Effective

Safe

3.2

Maintaining vascular health

The Scottish Diabetes Group will support initiatives to improve vascular health, including continuing to monitor cardiovascular risk factors and the prevalence of cardiovascular disease in the annual Scottish Diabetes Survey and sharing this with all stakeholders.

Safe

Effective

3.2

Maintaining vascular health

The Scottish Diabetes Group will support implementation of SIGN 116 by supporting SCI-DC initiatives to integrate information on vascular risk.

Safe

Effective

3.3

Foot care

A series of initiatives will be undertaken to promote prevention of foot problems including:

Safe

Person-centred

Effective

  • Within the previous 15 months, in line with the NHSQIS clinical standards, 80% of people with diabetes should have an allocated foot risk score which should be electronically communicated to all healthcare professionals involved in the care of the patient. This score should be communicated effectively and clearly to patients.

NHS Boards through their diabetes MCNs

  • All patients with low risk feet should have access to education for self management of foot care. This should be supported by the national foot care leaflets which will be available online for healthcare staff in a variety of languages.

SDG, NHS Boards through their diabetes MCNs

  • The national foot care leaflets should be evaluated through patient feedback.

Foot Action Group

  • IT links are required to allow transfer of foot related information (and other information) between the national diabetes database and the main four GP systems with particular reference to transfer of foot screening information.

SCI-DC, NHS Boards through their diabetes MCNs

3.3

Foot care

Through the SDG resources that have been allocated, each NHS Board will designate an existing individual whose responsibility will be to:

Safe

Person-centred

Effective

educate and support podiatrists and other relevant healthcare professionals delivering diabetes care in the community and to organise up-skilling and maintenance of competencies and practical skills;

NHS Boards, through their diabetes MCNs

ensure access to the national foot care leaflets, patient education programmes, including electronic learning opportunities, to support people with diabetes in managing their foot care.

NHS Boards, through their diabetes MCNs

3.4

Eye care

SDG will continue to support the development of the DRS collaborative and encourage links between DRS and all other stakeholders in the diabetes community.

SDG

Safe

Person-centred

Effective

Efficient

Equitable

Timely

3.4

Eye care

NHS Boards will consider the benefits of adopting the approach taken by the community optometry DRS pilots in NHS Highland and NHS Borders.

NHS Boards

Safe

Person-centred

Effective

Efficient

Equitable

Timely

3.5

Preventing renal disease

A series of initiatives will be undertaken to promote optimal kidney function:

September 2011

Timely

Safe

Efficient

Identify and provide information on the prevention and progression of diabetes complications for people with diabetes and renal disease/chronic kidney disease

SDG

Scottish Renal Registry

The annual Scottish Diabetes Survey will report on eGFR rates through better data linkage. Target 80% by 2011.

Survey Monitoring Group

SCI-DC

There should be clear pathways for referral between diabetes services and the local nephrology service.

NHS Boards through their diabetes MCNs

As part of its patient access programme, SCI-DC will work with the Renal Patient View to promote self management and ensure people with diabetes understand the significance of results.

SCI-DC

3.6

Positive pregnancy experiences

NHS Boards, through their Diabetes MCNs, will ensure:

NHS Boards through their diabetes MCNs

Safe

Person-centred

  • awareness raising sessions on diabetic pregnancy are promoted in both primary and secondary care for healthcare professionals to improve pre-pregnancy and ante-natal diabetes care and glycaemic control in women with diabetes

April 2012

  • collaboration between multidisciplinary pregnancy care teams and the local Diabetic Retinopathy Screening so that systems are in place for appropriate retinal screening during pregnancy

September 2011

  • programmes are in place to detect and treat gestational diabetes during pregnancy.

May 2012

Following delivery those with gestational diabetes mellitus should have:

  • lifestyle advice with the aim of reducing type 2 diabetes mellitus
  • regular screening with the aim of early detection of type 2 diabetes mellitus.

September 2012

3.6

Positive pregnancy experiences

SDG, along with NHS Quality Improvement Scotland and other national organisations, will investigate the feasibility of repeating in 2012 the national pregnancy audit in light of SIGN Guideline 116.

SDG

NHSQIS

Safe

Person-centred

3.7

Care for people from black and minority ethnic communities

Diabetes outcomes specific to minority ethnic communities will be reported:

Equitable

Effective

Person-centred

  • The Scottish Diabetes Survey will produce a report on clinical outcomes for people from minority ethnic groups.

Scottish Diabetes Survey Group

  • The Scottish Diabetes Retinopathy Screening Collaborative will report to SDG through the annual Scottish Diabetes Survey with information on DRS uptake across different ethnic groups in Board areas.

SDRSC/ SDSG

3.7

Care for people from black and minority ethnic communities

Learning from current and planned activities in supporting minority ethnic communities will inform the Action Plan over its lifetime

Equitable

Effective

Person-centred

  • The Diabetes Minority Ethnic Sub Group of the SDG will consider and scope the benefits of collating and reporting on best practice across NHS Boards on working cross-culturally, ensuring quality patient education and self management support and monitoring the training and support provided to healthcare professionals.

Minority Ethnic Sub Group

  • From this the Diabetes Minority Ethnic Sub Group will report to the SDG with recommendations on taking this work forward and its value in supporting NHS Boards.

Minority Ethnic Sub Group

  • The outcomes of the Diabetes UK Scotland Asian Community Project, funded from the Self Management Fund, will be considered in support of providing, strengthening and maintaining links between communities and the NHS.

  • Through their local contacts, the diabetes MCNs will revise and update their needs analysis and review of services for minority ethnic communities.

January 2013

NHS Boards through their diabetes MCNs

3.8

Children, young people and families

Initiatives to improve self management skills within families and communities include:

September 2010

Person-centred

Timely

Safe

  • A new DVD for children with type 1 diabetes will be commissioned;

SDG

  • A symposium on diabetes in schools as part of a wider review of existing arrangements for diabetes in schools will be held by September 2010 following which a set of action points will be published.

SDG

3.8

Children, young people and families

Organisation of paediatric care will be reviewed at national and local levels, and:

April 2011

Person-centred

Timely

Safe

  • A paediatrician will be appointed to the SDG.

SDG

  • Each NHS Board, through its diabetes MCN, will develop, publish and show evidence of implementation of a transitional care plan with measurable outcomes identified and reported through SDG by June 2011.

NHS Boards through their diabetes MCNs

  • NHSQIS will commission an audit of glycaemic control in children and adolescents.

NHSQIS

3.9

The spectrum of emotional and psychological support

To ensure adequate training of staff in psychological skills:

Person-centred

Safe

  • The diabetes MCNs should report to the Scottish Diabetes Group the number of diabetes specialist staff who have undergone training in behaviour change and/or psychological and emotional support.

September 2010 ongoing

NHS Boards through their diabetes MCNs/ SDG

  • All existing staff programmes will take account of cultural differences, in the type and presentation of psychological consequences of diabetes.

May 2011

NHS Boards through their diabetes MCNs

  • Patient feedback on the support and signposting received in relation to emotional support should be collected to inform the development of staff training and to measure the impact such training delivers.

October 2011

NHS Boards through their diabetes MCNs

3.9

The spectrum of emotional and psychological support

To develop and share effective national initiatives:

Person-centred

Safe

  • Three meetings a year of the new psychology appointees will be supported to ensure coordinated developments and best practice is shared (responsibility: Diabetes Psychology Working Group; SGHD);

Diabetes MCNs

Psychology Working Group

  • The Diabetes Psychology Working Group will share learning gained with the Living Better Project and the Long Term Conditions Unit.

April 2013

Psychology Working Group

  • Lessons from the PIDPAD pilot, including patient feedback, should be acted upon by NHS Boards through diabetes MCNs.

April 2012

SGHD

  • MCNs, with local voluntary and other agencies, will carry out analysis of resources for emotional support for people with diabetes. Diabetes UK Scotland will work with the Network Managers to develop a mechanism for recording emotional support resources in their areas.

NHS Boards through their Diabetes MCNs

  • Further development of the buddy service nationally will be considered.

Diabetes UK Scotland

MCNs

SDG

  • Ways of underpinning the financial sustainability of a national emotional support service will be explored, and links developed with NHS 24, to ensure that people who would benefit from Careline Scotland will be referred.

Diabetes UK Scotland

NHS 24

3.10

Structured education

All patients should have access to structured education programmes that are quality assured, in line with NICE criteria, within three months of diagnosis. National initiatives on education will support local provision by:

Person-centred

Effective

  • A national education coordinator will be appointed to work with the diabetes MCNs in the implementation of the patient and professional diabetes education frameworks.

NHSNES

SDG

Diabetes Education Advisory Group

  • The Diabetes Education Network ( DEN) Scotland will have a representative on SDG and will become a subgroup of the Diabetes Education Advisory Group ( DEAG). DEN will have responsibility for developing the national framework for diabetes patient education.

DEN

DEAG

  • After the first year of reviewing structured education provision the SDG, in consultation with DEN and the Diabetes Care Focus Group ( DCFG), will set milestone targets for subsequent years.

SDG

DEN

DCFG

3.10

Structured education

The national education co-ordinator will work with the diabetes MCNs in the implementation of a training and education strategy, including:

  • Reviewing structured education for people with type 2 diabetes and complete the national framework for the education of people with type 1 diabetes;
  • Supporting the diabetes MCNs to identify and promote effective educational tools, programmes and modules.

3.10

Structured education

Education will be improved at a local level, through:

Person-centred

Effective

  • Each diabetes MCN identifying an individual who will have responsibility and the skills for ensuring delivery of local patient education programmes.

April 2011

  • Each diabetes MCN ensuring the provision of a range of education solutions, including quality assured structured education programmes to all people with diabetes.

December 2011

NHS Boards through their diabetes MCNs

  • Each diabetes MCN undertaking/commissioning user impact and/or experience measures in relation to patient education.

June 2012

  • Clinical records documenting participation levels in self management programmes. This information will also be recorded in the electronic record.

April 2011

NHS Boards through their diabetes MCNs SDSG

  • Reporting for the Scottish Diabetes Survey the percentage of people in each level of self management programmes.

3.11

Insulin therapy

The SDG will prioritise the recommendations from the type 1 diabetes SLWG report as part of developing services for those with type 1 diabetes.

SDG

Safe

Timely

3.11

Insulin therapy

Local insulin strategies will be reviewed for people with type 1 and 2 diabetes.

June 2011

NHS Boards through their diabetes MCNs

Safe

Timely

3.11.1

Intensive insulin therapy in people with type 1 diabetes

People with diabetes who could benefit from intensive insulin therapy should have access to structured education programmes as documented in section 3.10. In particular:

Safe

Timely

  • Patients will receive carbohydrate counting instruction prior to initiation of intensive insulin regimens.

  • Mydiabetesmyway.scot.nhs.uk will include a section on intensive insulin therapy.

SDG

3.11.1

Intensive insulin therapy in people with type 1 diabetes

The availability of insulin pump therapy for those who would benefit from it will be promoted by:

Safe

Timely

  • Including in the Scottish Diabetes Survey figures on pump usage;

SDSG

  • Arranging further national pump awareness days;

SDG

  • The SDG commissioning waiting times criteria for insulin pump therapy in line with national criteria and make recommendations for a consistent approach across the country.

October 2010

SDG

  • Scottish Government Health Directorates scoping the implications of putting pumps and associated consumables onto the National Drug Tariff.

October 2010

SGHD

3.12.1

Out-of-hours care

The Scottish Diabetes Group will work with NHS 24 to improve NHS 24's services for people with diabetes, in particular by exploring the possibility of NHS 24 developing a dedicated diabetes pathway.

SDG

NHS 24

Timely

Safe

Effective

3.12.1

Out-of-hours care

The Scottish Diabetes Group will explore with other organisations optimal use of the Emergency Care Summary.

SDG

Timely

Safe

Effective

3.12.3

Diabetic ketoacidosis

The incidence of hypoglycaemia that result in emergency admissions will be reduced by:

Safe

Timely

  • supporting the development of interventions to improve post-hypoglycaemia patient support through enhanced communication.

SAS

SDG

  • NHS Boards, through their diabetes Managed Clinical Networks, reviewing the care pathway of people who experience severe hypoglycaemia.

December 2010

NHS Boards, through their diabetes MCNs

3.12.3

Diabetic ketoacidosis

Incidence and care of diabetic ketoacidosis will be improved by:

Safe

Timely

  • The SDG and SGHD exploring the roll-out of a diabetic ketoacidosis awareness campaign for children with undiagnosed diabetes;

SDG

SGHD

  • NHS Boards, through their diabetes Managed Clinical Networks, reviewing care pathways for the presentation and management of DKA throughout the whole episode;

December 2010

NHS Boards, through their diabetes MCNs

NHSQIS

  • NHSQIS commissioning a national audit of Diabetic Ketoacidosis; and

  • The Diabetes Education Advisory Group overseeing the roll out of care bundles for Diabetic ketoacidosis.

Diabetes Education Advisory Group

3.13.1

Safe and effective management of diabetes in hospital

The Diabetes Education Advisory Group and the Inpatient Working Group will coordinate several initiatives to improve care for inpatients:

Safe

Effective

  • They will consider, for implementation in Scotland, UK documents produced by Joint British Diabetes Societies e.g. on the hospital management of hypoglycaemia in adults with diabetes and the standards of care for people with diabetes undergoing surgery and elective procedures.

  • They will consider the suitability of the Think Glucose programme for implementation in Scotland.

  • The diabetes MCNs will develop foot protection programmes for patients with diabetes on general hospital wards.

NHS Boards through their diabetes MCNs

3.13.1

Safe and effective management of diabetes in hospital

The diabetes Managed Clinical Networks will development mechanisms to record the number of inpatient wards in general hospitals with specific guidelines for the management of hypoglycaemia.

June 2012

NHS Boards through their diabetes MCNs

Safe

Effective

3.13.2

Care homes and non- NHS settings

NHS Boards, through their diabetes Managed Clinical Networks, will take steps to improve the local provision of education to the wider community, voluntary and independent sector staff working in day care and institutional settings. This will include:

Equitable

Person-centred

  • Undertaking an assessment of educational needs of staff in non- NHS care settings;

  • Giving day care, home care and care staff access to educational events.

December 2010

DEAG

4.1

Ensuring quality care

Implementation of research-based high quality clinical practice will be supported by:

Equitable

Effective

Efficient

Safe

Timely

Person-centred

NHS Boards, through their diabetes Managed Clinical Networks, updating their local clinical guidelines in the context of SIGN Guideline 116;

December 2010

NHS Boards, through their diabetes MCNs

  • The diabetes Managed Clinical Networks actively promoting and reporting the number of patients registered on the SDRN research register as part of the annual Scottish Diabetes Survey to support the SDRN target of increasing recruitment to trials by 12.5% each year;

September 2010

diabetes MCNs

  • NHS Quality Improvement Scotland implementing a diabetes improvement programme based on SIGN Guideline 116, using the diabetes Managed Clinical Networks as the mechanism;

NHSQIS

  • Diabetes UK Scotland, in consultation with the Diabetes Care Focus Group, asking the 'Better Together' Team to ensure appropriate representation of people with diabetes in taking forward its long term conditions module;

Diabetes UK Scotland

Diabetes Care Focus Group

  • The Chief Scientist Office, through its Experimental and Translational Medicine Research Committee, continuing to support diabetes research..

Chief Scientist Office

4.1

Ensuring quality care

To ensure the SDG and linked organisations such as the SDRN, as well as diabetes Managed Clinical Networks, are able to communicate effectively, a communications strategy will be developed, including:

SDG

Equitable

Effective

Efficient

Safe

Timely

Person-centred

  • The DiS (Diabetesinscotland.org.uk) website communicating progress of the implementation of the Diabetes Action Plan through an annual report from the Scottish Diabetes Group;

August 2011

SDG

  • Each diabetes Managed Clinical Network hosting an event for people living with diabetes to raise awareness of local services and research. This could be done in partnership with the local voluntary sector;

April 2011

diabetes MCNs

  • SDG and the diabetes Managed Clinical Networks considering how existing diabetes care information/resources can be effectively disseminated amongst other agencies/third party organisations. These resources will be developed and evaluated through effective patient engagement.

SDG

diabetes MCNs

4.2

Professional development

Each diabetes Managed Clinical Network will identify an individual with responsibility for coordinating diabetes education. That person will:

January 2011

NHS Boards through their diabetes MCNs

Safe

Effective

  • review the specific diabetes learning needs of staff;

  • promote educational initiatives to suit all staff across primary and secondary care;

  • compile a database of staff training, linking to the long term conditions education database maintained by NES;

NHSNES

  • ensure training programmes recognise the differences between different cultural and social groups.

4.2

Professional development

The SDG and the diabetes Managed Clinical Networks will consider how to share best practice, such as the CARE measure, in delivering person-centred consultations. This should link to the wider long-term conditions environment to promote the spread and sustainability of best practice.

January 2013

SDG, NHS Boards through their diabetes MCNs

Safe

Effective

4.2

Professional development

The SDG, through its Diabetes Education Advisory Group, will ensure that healthcare professionals have access to the training and support required to deliver high quality patient-centred care.

SDG

Diabetes Education Advisory Group

Safe

Effective

5.1.2

Involving people living with diabetes

Diabetes MCNs should ensure that people living with diabetes are fully engaged in the MCN's activities by:

Person-centred

Effective

  • demonstrating, in their annual reports, the impact of patient involvement on how local services have been developed and/or improved;

April 2011

NHS Boards through their diabetes MCNs

  • recording and reporting in their annual reports the number of people who have attended a Diabetes Voices course.

June 2011

NHS Boards through their diabetes MCNs

5.1.2

Involving people living with diabetes

The Diabetes Voices programme will be reviewed, updated and rolled out further.

Diabetes UK Scotland

Person-centred

Effective

5.1.3

Diabetes Managed Clinical Networks

NHS Boards will maintain the effectiveness of the diabetes MCNs, in particular by ensuring proper engagement of the MCNs in Boards' planning of future patient-centred service developments.

NHS Boards

Equitable

Effective

Efficient

5.1.3

Diabetes Managed Clinical Networks

NHSQIS will work with diabetes MCNs on developing a quality improvement programme and on the continuous review of diabetes care.

NHSQIS

NHS Boards through their diabetes MCNs

Equitable

Effective

Efficient

5.1.3

Diabetes Managed Clinical Networks

The MCN Lead Clinicians' group and MCN Managers' groups will continue to meet regularly to:

MCN Lead Clinicians' group

Equitable

Effective

Efficient

  • share expertise and best practice

MCN Managers' group

  • advise SDG in strategy development

  • collaborate with other members of SDG, including Diabetes UK Scotland and the Diabetes Care Focus Group.

5.1.3

Diabetes Managed Clinical Networks

NHS Boards will accredit their diabetes MCN where this has not already been done.

September 2012

NHS Boards

Equitable

Effective

Efficient

5.1.4

Remote and rural care

Diabetes MCNs will explore telehealth opportunities and consider how teleheathcare solutions can be embedded into the pathways of people with diabetes.

January 2013

NHS Boards through their diabetes MCNs

5.1.4

Remote and rural care

Diabetes MCNs will develop effective links with community pharmacy services. NHS Boards, through their diabetes MCNs and CHPs, will ensure that people with diabetes and their carers get access to a range of support at local level, including voluntary groups, peer support and events.

December 2010

August 2012

NHS Boards through their diabetes MCNs

5.1.5

Optimal use of information technology

Optimal sharing of clinical information will be promoted through the increased use of NHS Boards' diabetes databases during routine clinical care.

NHS Boards

Effective

Efficient

Person-centred

5.1.5

Optimal use of information technology

Ensure that the electronic diabetes systems meet the needs of users and record and store clinical data in 70% of clinical encounters relating to foot ulcer, paediatric diabetes, dietetic and DSN reviews.

NHS Boards

Effective

Efficient

Person-centred

5.1.5

Optimal use of information technology

To maximise the use of the diabetes care system by patients to enhance self management and improve patient/professional communication:

  • The Scottish Diabetes Group will support the development of a Patient Held Record Project in partnership with Diabetes UK to start in 2010.
  • There will be an increase in the number of patients directly accessing their own data electronically.

SDG

Diabetes UK

Effective

Efficient

Person-centred

5.1.5

Optimal use of information technology

To ensure current existing diabetes system functionality is maintained within each NHS Board and integrated into existing and future systems:

  • further integration will be encouraged between NHS Boards' diabetes databases, non-diabetes registers and currently operating relevant systems such as primary care and emergency care summary.

NHS Boards

Effective

Efficient

Person-centred