This Action Plan is a continuation of the range of work set out in the Scottish Diabetes Action Plan published in 2006. The importance of continuity of effort was one of the main messages to emerge from the consultation process undertaken between June and August 2009. The Better Diabetes Care consultation document ( www.scotland.gov.uk/diabetes) was widely distributed and made available online. The Scottish Diabetes Group ( SDG), also provided funding to Diabetes UK Scotland to drive the consultation process through a national survey of people living with diabetes and a series of local and national events.
Over 85 organisations and many individuals responded to the consultation with a range of thoughtful and valuable views. All responses were analysed and collated by the most relevant sub group of the SDG. All sub groups are multidisciplinary and include representation by people living with diabetes. In addition the SDG had access to and advice from reports produced by the Scottish Public Health Network ( www.scotphn.net), the diabetes Managed Clinical Networks ( www.diabetesinscotland.org.uk) the SIGN Guideline development group ( www.sign.ac.uk/guidelines/fulltext/116/index.html) and the Type 1 Diabetes Short Life Working Group. Grateful thanks are due to the individuals and organisations who contributed over the last few months. They are listed in Appendix 1. The organisational and individual responses are available on the Scottish Government website ( www.scotland.gov.uk) and provide the basis for this Action Plan.
In this Action Plan, we have suggested the use of the expression 'the diabetes community' as a convenient way of indicating the interests uniting people living with diabetes, healthcare professionals and voluntary sector organisations. When the word 'we' is used later in the Action Plan, it should be understood as meaning 'the diabetes community'. Implementation of this Action Plan depends on continued collaboration between all groups within the diabetes community and interactions with other national and international organisations.
Diabetes mellitus, recognised by a raised blood glucose level, is the most common disorder of metabolism. Over 228,000 people, or one in twenty-five of the Scottish population, have been diagnosed with the condition, and an estimated 20,000 remain undiagnosed ( www.scotpho.org.uk).
There are two main types of diabetes. About 13%, or over 27,000 people in Scotland, have type 1 diabetes. This develops when there is a severe lack of insulin in the body because most or all of the cells in the pancreas that produce insulin have been destroyed. People with type 1 diabetes therefore need to inject insulin from the time of diagnosis. Type 1 diabetes is one of the commonest long term conditions affecting children and adolescents in Scotland, which has one of the highest prevalence rates of type 1 diabetes in Europe.
Type 2 diabetes develops when the body can still produce some insulin, though not enough for its needs, or when the insulin that the body produces does not work properly. Type 2 diabetes usually appears in people over the age of 40 and its rise in prevalence is closely linked to rising obesity levels, the aging population and reduced activity. Most people with type 2 diabetes manage to control blood glucose levels with lifestyle changes and oral medication, but some may also require insulin therapy.
Since the previous Action Plan was published in 2006, Scotland has continued to see a steady increase in the prevalence of diabetes (Fig. 1). Although much of the rise can be attributed to better monitoring and data collection, it still represents a serious concern. This undesirable trend reflects what is happening in the rest of the UK and in other parts of the world. The number of people with type 2 diabetes in Scotland is currently increasing at a rate of 4% per year.
Fig. 1. Prevalence of diabetes in Scotland
Source: SDS 2009 ( www.diabetesinscotland.org.uk/publications)
Diabetes has been recognised for at least the last 10 years as an exemplar long term condition, both in terms of the growing number of people with type 2 diabetes and in terms of the serious and expensive complications it can bring in its train. Maintaining and improving the quality of diabetes services against a backdrop of increased incidence and prevalence, and the consequent pressure on those services, forms the key challenge facing NHSScotland.
Diabetes care is thought to account for some 10% of all NHS expenditure; this high level of investment emphasises the importance of ensuring care is in line with cost-effective and evidence-based treatment.
Some of type 2 diabetes can be prevented or its onset delayed. Prevention of type 2 diabetes, and the avoidance of complications in those with the condition would be extremely cost-effective, but even more importantly would contribute greatly to quality of life.
The Scottish Diabetes Research Network ( SDRN) epidemiology group has found that between 2001 and 2007, mortality was higher among people with diabetes than the general population by about 10% for men and about 25% for women. The excess risk of diabetes appears to have fallen in recent years and is at least partly explained by more effective treatment of diabetes, hypertension and dyslipidaemia.
The prevalence of both types of diabetes here, compared with rates in other countries, suggests the need for even stronger action in Scotland. The publication of the Quality Strategy, with its ambition for world-class healthcare, encourages us to aim for services for people with diabetes that at least match the best that can be found anywhere else in the world.
The Quality Strategy for NHSScotland
This Diabetes Action Plan contributes to the Scottish Government's Quality Strategy, which sets out the measureable and achievable actions that relate to the key drivers of healthcare quality.
The Institute of Medicine's six 'dimensions of quality' are the key foundation of systems-based healthcare quality improvement:
- Person-centred: providing care that is responsive to individual personal preferences, needs and values and assuring that patient values guide all clinical decisions
- Safe: avoiding injuries to patients from care that is intended to help them
- Effective: providing services based on scientific knowledge
- Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy
- Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location or socio-economic status
- Timely: reducing waits and sometimes harmful delays for both those who receive care and those who give care.
Each of the actions set out within this Plan contains an indication of the 'dimensions of quality' to which it relates, in terms of the care of people with diabetes.
Other drivers of improvements in services specific to diabetes are:
- the diabetes clinical standards published by NHS Quality Improvement Scotland in October 2002;
- the criteria in the diabetes domain of the Quality and Outcomes Framework ( QOF) in the new GMS contract; and
- the SIGN Guideline 116 on the management of diabetes.
A key aspect of achieving the aim of world-class diabetes services will be the creation of a properly mutual NHS, one in which people living with diabetes feel able to take a leading role in their healthcare. Healthcare professionals have a vital role in encouraging confidence and enabling self management in every interaction. This requires an ability to communicate well in consultations, using words that are easy to understand.