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Diabetes Action Plan 2010: Quality Care for Diabetes in Scotland

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5. INTEGRATION

Integrating health, care and other services

5.1 Organisation of care

5.1.1 Scottish Diabetes Group

The Scottish Diabetes Group ( SDG) advises on all aspects of diabetes care across Scotland. It has representation from people with diabetes, voluntary sector organisations, researchers, a broad range of healthcare professionals and suppliers, and those involved in planning healthcare services at local, regional and national level.

The SDG will continue its role of overseeing, on behalf of the Scottish Government Health Directorates, the implementation of this Action Plan, with an emphasis on the development of person-centred quality care. Monitoring will be on the basis of regular reports from each Board's diabetes Managed Clinical Network.

5.1.2 Involving people living with diabetes

Where we want to be:

We want diabetes services to be developed through the full involvement and engagement of people living with diabetes, so that they are truly person-centred.

Why we want to be there:

In its survey, Diabetes UK Scotland found that six out of ten people would like to have a say in their local diabetes services. People said that they would fill in surveys, take part in local consultations and would complete satisfaction surveys at clinics. The role of patient representatives on NHS committees was also widely supported.

The move towards person-centred care is about the transformation of the relationship between healthcare professionals and people living with long term conditions such as diabetes. It recognises that the majority of care is self care and that patients need to be empowered to manage their care, including what they need from healthcare professionals. That change of relationship needs to be built in to how services are planned and how we drive quality forward. The Criteria for a Participation Standard produced by the Scottish Health Council refer to 'supported and effective involvement of people in service planning and improvement'. For diabetes services, this means: having methods to identify and encourage people to be involved; assessing their support needs so that they can participate fully; creating mechanisms and opportunities to participate in decision making; and ensuring feedback on decisions.

Diabetes Voices

Diabetes services are already committed to involving and engaging people living with diabetes through MCNs, the SDG and its various sub groups. In support, Diabetes UK Scotland, with Scottish Government funding, provides Diabetes Voices training for patient representatives and this is currently being rolled out across the diabetes MCNs. However, the move towards a 'mutual NHS' means that the focus on patient involvement and engagement needs to be strengthened. This includes reviewing the content and delivery of Diabetes Voices and considering, at MCN and SDG levels, improving standards of participation. The Scottish Government Health Directorates are also funding an extension of the programme to carers, and those caring for people with diabetes should be included.

The Scottish Government Health Directorates are further extending the Voices programmes so that those who undergo the training are encouraged to promote the importance of self management. That approach will also be reflected in the Diabetes Voices programme.

Actions we will take:

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

  • The diabetes MCNs should, in their annual reports, demonstrate the impact of patient involvement on how local services have been developed and/or improved ( MCNs).
  • NHS Boards through their MCNs will record and report in their annual reports the number of people who have attended a Diabetes Voices course.

2. Diabetes Voices to be reviewed, updated and rolled out further (Diabetes UK Scotland).

Healthcare Quality Dimensions: patient-centred; effective.

5.1.3 Diabetes Managed Clinical Networks ( MCNs)

Where we want to be:

We want to ensure that the diabetes MCNs are strong and effective in developing and integrating diabetes care within NHS Boards and their local planning partners.

Why we want to be there:

The diabetes MCNs have played a crucial role in the continued development of structures and services to help support and influence the quality improvement of diabetes care. This was made clear in the national overview follow-up report of NHS Boards' performance against the diabetes clinical standards published by NHSQIS and Diabetes UK Scotland in March 2008. The diabetes MCNs remain the prime vehicle for delivery of the aspirations in the Action Plan, and for the improvement programme being developed by NHSQIS to support implementation of SIGN 116, including any revision of the diabetes clinical standards needed to bring them into line with the revised Guideline. Each NHS Board must therefore ensure that, in line with HDL (2007) 21 on Strengthening the Role of MCNs, its diabetes MCN is fit for purpose, with a lead clinician, working with a Network manager, to provide strong clinical leadership.

Within each NHS Board, the diabetes MCN will be the main mechanism for integrating diabetes care. Strong links to the Board's senior management teams are essential. This can be provided through the Long Term Conditions Executive Sponsor who has been identified through the work of the Long Term Conditions Collaborative. The diabetes MCN should ensure that the regular reports which it produces for the Scottish Diabetes Group on progress against the NHS Board actions in this Action Plan are cleared with senior management within the Board before submission to the SDG. Where they have not already done so, NHS Boards should also take steps to accredit their diabetes MCN, in line with guidance from NHS Quality Improvement Scotland.

The best way of enhancing the effectiveness of the diabetes MCNs is by making sure there is strong participation on the part of people living with diabetes and the voluntary sector organisations which support them. This issue is dealt with in section 5.1.2.

It is also essential that Primary Care should play a full role in the work of the MCNs, given that that is the setting in which the majority of diabetes professional care is delivered. There is a role for the Primary Care Diabetes Society in promoting primary care teams' participation in the work of the diabetes MCNs.

The diabetes MCNs should continue to evolve and adapt in the light of implementation of the Action Plan and other developments, with the overall aim of providing fully integrated services that address the totality of the needs of people living with diabetes. One possible development that the Scottish Diabetes Group will wish to keep in mind is the transformation of diabetes MCNs into diabetes Managed Care Networks, the difference being that Managed Care Networks would be more clearly understood as embracing people's social and other care needs in addition to their healthcare needs.

Actions we will take:

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

2. NHSQIS will work with diabetes MCNs to develop a quality improvement programme.

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

  • share expertise and best practice;
  • advise SDG on strategy development;
  • collaborate with other members of SDG including Diabetes UK Scotland and the Diabetes Care Focus Group.

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

Healthcare Quality Dimensions: equitable; effective; efficient.

5.1.4 Rural and remote care

Where we want to be:

We want to develop initiatives and programmes which ensure that people have access to robust services wherever they live in Scotland.

Why we want to be there:

One of the defining characteristics of care provision in Scotland is the challenge of geography. Island, rural and remote communities need to have access to diabetes care which provides optimal support for their condition. This Action Plan needs to deliver practical support to those initiatives and programmes which tackle the geographical spread of Scotland and the need for around the clock care.

Remote and rural areas pose specific challenges to the delivery of care. Telehealth can help diabetes services overcome these obstacles, by allowing clinicians to consult with patients remotely. At the moment live video conference clinics are available for people with diabetes in Orkney. This includes links to a computer for patient monitor readings. These are supported locally by nursing staff and a consultant based in Aberdeen. Telehealth can also allow GPs to consult with specialists thereby reducing the need for referrals.

Telehealth will also have a role to play in supporting self management.

Chronic Medication Services

Through the Chronic Medication Service and the public health aspects of the new pharmacy contract, community pharmacists are well placed to assist diabetes services in providing support for people with diabetes, especially those who, for whatever reason, are finding it difficult to maintain control or access services.

The Chronic Medication Service which formalises the contribution of community pharmacists to the management of people with long term conditions will be rolled out from April 2010. This service will assist in improving people's understanding of their medication and optimising the clinical benefits from their therapy. This highlights the importance of having effective community pharmacist representation on diabetes MCNs.

Actions we will take:

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

2. 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 (responsibility: diabetes MCNs).

An Orkney to Grampian diabetes clinic via video conference

An Orkney to Grampian diabetes clinic via video conference

5.1.5 Optimal use of information technology

Where we want to be:

We want to ensure that there is a comprehensive register and clinical database supporting the integrated care of everyone with diabetes in Scotland.

Why we want to be there:

High quality care requires high quality patient data, whether for clinical activities relating to an individual's care or epidemiological activities that enable the diabetes community to understand diabetes and its effects in order to design better care. Good clinical data enable both healthcare professionals and people with diabetes to understand an individual's diabetes care requirements.

The Scottish Government recognises the importance of information sharing, particularly in view of the multi-disciplinary nature of diabetes care. The Scottish Diabetes Group will continue to monitor the progress made, to ensure that the current momentum with the project is maintained.

SCI-DC acts as a comprehensive disease register and clinical database supporting the integrated care of over 220,000 people with diabetes in Scotland.

By February 2009, the SCI-DC Network had been rolled-out across all NHS Board areas in Scotland. It is linked to and extracts relevant diabetes-related data from almost all GP practices and the specialist diabetes clinics across Scotland.

In addition, SCI-DC provides comprehensive support for:

  • The NHSScotland Diabetes Retinopathy Screening Programme
  • Structured foot ulcer risk assessment
  • The annual Scottish Diabetes Survey

Patient access to their health data is a key part in supporting better self management. SCI-DC will continue to develop that access and the SDG will support initiatives which help deliver access. The SCI-DC developments mentioned in this action plan are subject to approval of a business case. Lessons emerging from the Patient Held Record Project will be actively incorporated in diabetes care more generally through diabetes MCNs and individual healthcare professionals.

Consideration should also be given to making sure people living with diabetes who also have chronic kidney disease are able to benefit from the Renal PatientView Initiative, supported by the Scottish Government, which allows people to see the results of their blood tests on their home computer.

Actions we will take:

1. Optimise sharing of clinical information through the increased use of the NHS Boards' diabetes databases during routine clinical care.

2. 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.

3. Maximise the use of the diabetes care system by patients to enhance their own 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.
  • Increase the number of patients directly accessing their own data electronically.

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

  • Encourage further integration between the NHS Board diabetes database, non-diabetes registers and currently operating relevant systems such as primary care and emergency care summary.

Healthcare Quality Indicators: effective; efficient; person-centred.