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Diabetes Action Plan 2010: Quality Care for Diabetes in Scotland



Improving the quality of healthcare and healthcare experience and developing a mutual NHS - offering the people with diabetes in Scotland a world-class service and a stronger voice in service improvement

We recognise that people's experience of the NHS is about more than speedy treatment: it is the quality of care they get that matters most to them. It will be important to measure the experience of patients and use the information to drive up standards. Patients will be encouraged to be partners in their own care and can expect to experience improvements in the things people have said they want from their health service:

  • Caring and compassionate treatment
  • Clear communication and explanation
  • Effective collaboration with the clinician
  • Clean and safe care environment
  • Continuity of care
  • Clinical excellence

These principles are integral to diabetes care across Scotland.

3.1 Putting people with diabetes at the centre

Where we want to be:

We want people living with diabetes to be regarded as leading partners in their care, and to be supported to manage their own condition effectively.

Quality of care will be measured by the degree of person-centredness achieved.

Why we want to be there:

People with diabetes manage their own condition for at least 95% of the time. The key to putting people with diabetes at the centre is ensuring a partnership approach between people with diabetes and their healthcare teams.

Creating diabetes services with good, effective communication between people with diabetes and healthcare professionals, and which promotes self management, is a core element of this action plan.

Effective self management is dependent on access to easily understood information, quality education and access to psychological and emotional support. We also need to recognise the contribution of unpaid carers in developing self management skills. In its survey, Diabetes UK Scotland found that over 22% of all carers said they did not have enough support in place.

Over the next three years, we expect to see improvements for people with diabetes arising from long term conditions work generally and, in particular, implementation of the principles of self management as set out in Gaun Yersel' ( www.ltcas.org.uk/self_man_gaun.html), the self management strategy for Scotland, and the actions on self management in the Long Term Conditions Action Plan ( www.sehd.scot.nhs.uk/mels/CEL2009_23.pdf) (June 2009). We will encourage the diabetes community to share their experience by contributing to the generic self management programmes associated with long term conditions while at the same time supporting diabetes-specific work on self management.

Self management cannot be supported by the NHS alone. The third sector provides support to people with long term conditions and has a key part to play in supporting self management strategies.

People with diabetes need to be able to find local sources of support to help them manage. The Scottish Government's self management work includes an initiative, Access to Local Information to Support Self Management ( ALISS). This innovative project is developing an electronic means for people to contribute and support each other in their communities. This can include, for instance, sharing details of support groups, self management programmes, patient education provision, emotional support, carer and family support and telehealth resources. The ALISS methodology will have clear benefits for people with diabetes, given the degree to which they have to manage their own condition.

Information for people living with diabetes

Access to relevant and timely information is essential to support people with diabetes to manage their condition successfully. This Action Plan is committed to ensuring that this happens. Attention should be paid to the level of understanding of each person with diabetes, in particular whether they have adjusted to their diagnosis. Literacy and numeracy are especially important in self managing the technical aspects of monitoring and understanding the medicines used in diabetes. People with poor literacy levels generally have poorer health status and are 1.5 to 3 times more likely to experience poor health outcomes, as they have less knowledge of self management and health-promoting behaviours.

We need to see a consistent approach to the development of high quality patient information across NHS Boards. This approach can involve partner organisations like Diabetes UK Scotland and the Juvenile Diabetes Research Foundation. Key priorities are:

  • making information available to patients and their families and carers in language they can understand;
  • the need to develop links with NHS Inform;
  • developing links with NHS Carer Information Strategies;
  • the development of the My Diabetes My Way website to become a key resource for people with diabetes; and
  • a particular focus on meeting the needs of those communities and individuals who have traditionally found it harder to engage with health services.

Actions we will take:

The Scottish Diabetes Group will support initiatives to improve self management:

  • SDG, will work with the diabetes MCNs, local patient representatives and relevant voluntary sector organisations to identify and promote appropriate self management tools for diabetes (responsibility: SDG/ MCNs)
  • 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, 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
  • 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.

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

3.2 Maintaining vascular health

Where we want to be:

We want to promote an increase in the numbers of people with diabetes who achieve recommended targets for glycaemic control, blood pressure and cholesterol (Fig. 3) and a reduction in the incidence of cardiovascular events.

Figure 3. Percentage of patients reaching targets for HbA 1c, BP and total cholesterol - type 2 - by NHS Board

Figure 3. Percentage of patients reaching targets for HbA1c, BP and total cholesterol - type 2 - by NHS Board

Why we want to be there:

Morbidity and mortality from cardiovascular disease ( CVD) are thought to be between 1.52 to 4.33 times higher in people with diabetes compared to the general population. The relative risk of cardiovascular disease is particularly high in women with type 1 diabetes diagnosed under the age of 40.

Scotland is able to capture important research information through effective use of information technology. The Scottish Diabetes Research Network Epidemiology Group found that, between 2001 and 2007, mortality was higher among people with type 2 diabetes than the general population by about 10% for men and 25% for women.

The excess risk of diabetes appears to have fallen in recent years, and is probably explained, at least in part, by more effective treatment of diabetes, hypertension and dyslipidaemia. This trend should, and needs to, continue.

Cardiovascular risk factors in diabetes include dyslipidaemia, hypertension, hyperglycaemia and smoking. Patients with diabetes who have one or more risk factors should have the relevant information to help them recognise and manage their risk factors. SIGN Guideline 116 emphasises the importance of aggressive treatment of hypertension with lifestyle modification and drug therapy and recommends a target of less than 130/80. Care systems need to ensure assessment of lipid status and introduction of statins for appropriate groups.

People with diabetes who have established vascular disease need careful assessment and regular review to ensure that they benefit from the measures described in SIGN Guideline 116 (diabetes), SIGN Guideline 108 (acute stroke) and SIGN Guideline 89 (Peripheral Vascular Disease). It is incumbent on the Scottish Diabetes Group to support implementation of these Guidelines.

Actions we will take:

The Scottish Diabetes Group will support initiatives to improve vascular health including:

  • Continue to monitor cardiovascular risk factors and the prevalence of cardiovascular disease in the annual Scottish Diabetes Survey and share this with all stakeholders.

The Scottish Diabetes Group will support implementation of SIGN Guideline 116 by:

  • Supporting SCI-DC initiatives to integrate information on vascular risk.

Quality Healthcare Indicators: safe; effective.

3.3 Foot care

Where we want to be:

We wish to see a progressive reduction in the incidence of ulcers and amputations in people with diabetes as recorded in the Scottish Diabetes Survey.

Why we want to be there:

Foot disease risk has recently been the subject of a campaign by the Scottish Diabetes Group's Foot Action Group. This is against a backdrop, established in the Diabetes UK Scotland survey, that just over a quarter knew their foot risk score. However, many other people said that they did not know what their risk score was but would like to know.

High quality and accessible foot care is seen by people with diabetes as a real priority. Work over the past few years, including the launch of the National Foot Screening Programme, has started to deliver this priority.

Over the lifetime of this Action Plan we need to see this priority embedded in the delivery of diabetes care across NHS Board areas and to see this evidenced in new programmes, clinical outcomes and patient feedback. The Foot Action Group and others are considering the training and skill mix required to deliver a quality foot service. Quality foot care should include timely access to an orthotist with diabetes competencies.

People with diabetes should have access to specialist multi-disciplinary services, delivered by healthcare professionals with the appropriate competencies, when they have active foot disease and access to a podiatry treatment/management plan, including reinforcement of education, formulated in consultation with the patient and tailored to suit the patient's needs.

Actions we will take:

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

  • 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 (responsibility: 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 (responsibility: SDG, NHS Boards through their diabetes MCNs).
  • The national foot care leaflets should be evaluated through patient feedback (responsibility: Foot Action Group).
  • IT links are required to allow transfer of diabetes information between the national diabetes database and the main four GP systems with particular reference to transfer of foot screening information (responsibility: SCI-DC, NHS Boards through their diabetes MCNs).

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

  • 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 (responsibility: NHS Boards, through their diabetes MCNs).
  • Ensure access to the national foot care leaflets and patient education programmes, including electronic learning opportunities, to support people with diabetes in managing their foot care (responsibility: NHS Boards, through their diabetes MCNs).

Quality Healthcare Dimensions: safe; person-centred; effective.

3.4 Eye care

Where we want to be:

Scotland should have a world-class retinopathy screening programme which identifies eye problems at early stages with a view to reducing significant visual loss in people with diabetes.

Why we want to be there:

The diabetic retinopathy screening service in Scotland has been implemented in all NHS Boards since 2006 and has made major strides in recent years. Scotland has a quality-assured service based on digital imaging. Most eligible people with diabetes have now been assessed at least twice and new versions of the software have been introduced. National study days have allowed multidisciplinary teams from across Scotland to share expertise and encourage innovation. The experience of the Scottish Diabetic Retinal Screening ( DRS) service has been shared with other UK and European countries in the planning and development of their programmes. It is important that the level of quality achieved by this service is maintained.

The vision of the DRS collaborative is to offer a safe, effective, efficient, equitable and quality assured service to all people with diabetes, to detect diabetic retinopathy in a timely manner and to ensure that treatment is offered to reduce visual impairment and blindness. Feedback from the consultation process by people with diabetes recognised the improved service for retinal screening.

DRSScreening 'at home' in the Western Isles

DRS Screening 'at home' in the Western Isles

From April 2009, optometrists are obliged to offer retinal photography to everyone aged 60 and over, whether they have diabetes or not. Optometrists and the DRS programme therefore need to work together so that people with diabetes can benefit from a cohesive and first-class service delivered locally. Pilot studies of optometrist image capture are being undertaken in NHS Borders and Highland to determine the benefits that increased partnership between optometrists and the DRS programme would bring to people with diabetes. The early results appear promising.

Integration of the retinal screening programme with other eye services will be improved by the chairman of Optometry Scotland forming part of the DRS collaborative executive.

A robust and effective DRS service has facilitated the redesign of diabetes services, allowing more aspects of care to be delivered by community teams. The SCI-DC network linkage to the DRS software encourages optimal integrated clinical care. Clinicians can demonstrate retinal images to people with diabetes and consider interventions to reduce progression of retinopathy. Joint initiatives by the SDRN epidemiology subgroup and the DRS collaborative provide a platform for world-class clinical research.

Actions we will take:

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

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

Healthcare Quality Indicators: all six.

DRSscreening image

DRS screening image

3.5 Preventing renal disease

Where we want to be:

We want to be able to prevent the progression from chronic kidney disease ( CKD) to end-stage renal failure in people with diabetes to an extent that is comparable with the best outcomes worldwide.

Why we want to get there:

Approximately 30% of people with type 1 diabetes and 20% of people with type 2 diabetes develop diabetic nephropathy. Renal vascular disease is also a common cause of renal failure particularly in people with type 2 diabetes. Accelerated cardiovascular disease in people with diabetes and renal disease is well recognised.

Diabetes is now the commonest reason for people starting renal replacement therapy in Scotland.

Identification of chronic kidney disease in someone with diabetes should result in treatment that slows the progression of renal disease, and improves cardiovascular risk factor management.

The earlier we can identify chronic kidney disease, the sooner we can implement the recommendations from SIGN Guideline 116 to delay its progression and support people with diabetes to manage their condition. There are limited Scottish national data on the prevalence of kidney disease in people with diabetes. The SDRN is working with the Scottish Renal Registry, maintained by the Scottish Renal Association, to identify trends and outcomes by linking to the data held by the Registry.

Actions we will take:

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

  • Identify and provide information on the prevention and progression of diabetes complications for people with diabetes and renal disease/chronic kidney disease (responsibility: SDG/Scottish Renal Registry).
  • The annual Scottish Diabetes Survey will report on eGFR rates through better data linkage. Target 80% by 2011 (responsibility: Survey Monitoring Group/ SCI-DC).
  • There should be clear pathways for referral between diabetes services and the local nephrology service (responsibility: NHS Boards through their diabetes MCNs).
  • As part of its patient access programme, SCI-DC will work with Renal PatientView to promote self management and ensure people with diabetes understand the significance of results (responsibility: SCI-DC).

Healthcare Quality Dimensions: timely; safe; efficient.

3.6 Positive pregnancy experiences

Where we want to be:

We want to ensure that women with pre-existing diabetes, and those who develop gestational diabetes, have pregnancy outcomes comparable with the best population outcomes worldwide.

Why we want to get there:

National audits in Scotland, England and Wales have highlighted the risks of pregnancy in women with diabetes. Critical findings of the audits are an increase in birth weight, rates of caesarean section, congenital anomalies and perinatal mortality in children born to women with diabetes. The feedback from the Better Diabetes Care consultation emphasised the continuing challenges.

SIGN Guideline 116 reviews the evidence base for the management of pre-existing (type 1 and type 2) diabetes as well as for the screening, diagnosis and management of gestational diabetes. The Guideline provides clear recommendations for optimal management of diabetes and stresses the importance of excellent blood glucose control before and during pregnancy.

In women with established diabetes, pregnancy should be planned and women during their fertile years should have access to contraceptive advice and pre-pregnancy counselling. An experienced multiprofessional team, led by a named obstetrician and physician, should provide comprehensive maternity care prior to and during pregnancy.

Type 1 diabetes

Type 1 diabetes is a high risk state for both the woman and her foetus because of increased risks of spontaneous abortion, ketoacidosis, severe hypoglycaemia, pre-eclampsia, premature labour, polyhydramnios, late intrauterine death, foetal distress, obstructed labour and congenital malformation. Infants of mothers with diabetes need careful monitoring after birth. Complications of diabetes such as retinopathy can worsen during pregnancy.

Type 2 diabetes

In the national audits the number of pregnancies in women with type 2 diabetes was fewer than in women with type 1 diabetes, but during the consultation several groups commented on an increasing proportion of pregnancies in type 2 diabetes. Contributing factors could include the increasing prevalence of obesity, the increasing age and a change in ethnic composition of the pregnant population. Management prior to and during pregnancy should follow the same intensive programme of metabolic, obstetric and neonatal supervision as for women with type 1 diabetes, since similar adverse outcomes are recognised in type 2 diabetes.

Gestational diabetes

SIGN Guideline 116 emphasises the need to recognise women with gestational diabetes, the prevalence of which is increasing, in order to optimise pregnancy outcomes by evidence-based management interventions. Screening for gestational diabetes identifies a higher risk group for future type 2 diabetes. Lifestyle interventions could prevent metabolic progression to established diabetes.

Actions we will take:

1. NHS Boards, through their diabetes MCNs, will ensure

  • 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
  • collaboration between multidisciplinary pregnancy care teams and the local Diabetic Retinopathy Screening programme so that systems are in place for appropriate retinal screening during pregnancy
  • programmes are in place to detect and treat gestational diabetes during pregnancy
  • 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.

2. 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.

Quality Healthcare Indicators: safe; person-centred.

3.7 Care for people from black and minority ethnic communities

Where we want to be:

In keeping with the Scottish Government's strong commitment to addressing health inequalities, we want to ensure that diabetes outcomes for people from black and minority ethnic ( BME) communities are comparable to general Scottish outcomes.

Why we want to be there:

Progress has been made over the past few years in relation to improving our understanding of the needs of people from BME communities who have diabetes or are at risk of developing it. Their risk is reflected in the cardiovascular risk assessment tool recommended by SIGN Guideline 97, ASSIGN, which has been developed for maximum accuracy in Scotland by including factors such as family history. Work has been undertaken to develop culturally appropriate patient education, and a conference on diabetes care for minority ethnic groups was held in Glasgow in November 2009. Collaborative work between the NHS, voluntary and community sectors and industry has also started to make inroads. We remain at the initial stages of real improvement and need to find better ways to deliver substantial improvement over the next three years.

BME communities should have clear lines of communication with diabetes MCNs. Through their local contacts, the MCNs will revise and update their needs analysis and review of services for minority ethnic communities. This may include the use of trained clinical or community link workers working alongside diabetes professionals and/or long-term conditions teams. This could play a valuable role in helping patients and their families understand and manage their diabetes in their cultural context and help avoid hospital admission. At all times patient and family information should be in appropriate languages and formats and communication problems bridged. The Scottish Diabetes Group will work with its Diabetes Minority Ethnic Sub Group and voluntary sector organisations to deliver substantial improvements over the next three years.

Actions we will take:

1. Diabetes outcomes specific to minority ethnic communities will be reported

  • The Scottish Diabetes Survey will produce a report on clinical outcomes for people from minority ethnic groups (responsibility: 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 (responsibility: SDRSC/ SDSG).

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

  • The Diabetes Minority Ethnic Sub Group of the SDG will collate and report on best practice across NHS Boards on working cross-culturally, including quality patient education and self management support and the training and support provided to healthcare professionals.
  • 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.
  • 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, diabetes MCNs will revise and update their needs analysis and review of services for minority ethnic communities.

Healthcare Quality Dimensions: equitable; effective; person-centred.

3.8 Children, young people and families

Where we want to be:

In keeping with the Scottish Government's aim of giving all children the best possible start in life, we want to ensure that children with diabetes and their families can lead full and active lives.

Why we want to be there:

The needs of children with diabetes and their families are a priority for improved diabetes care. Support and work over the lifetime of the previous Action Plan has provided a good platform for delivering the necessary improvements.

Children need to be supported not just in the NHS but in their communities and in their schools. The involvement of children and their families is integral to developing this support.

Children and families living with diabetes also tell us that greater public awareness of type 1 diabetes is necessary to remove any likely stigma and misunderstanding.

Diabetes health

Work carried out by the Scottish Study Group for the Care of Diabetes in the Young and the Scottish Diabetes Survey indicates that, overall, glycaemic control in children under the age of 15 is poor and only a small percentage achieve optimal blood glucose control. Good control of diabetes in childhood and adolescence can reduce complications in later life, but management is challenging. Families need considerable support to optimise blood glucose control and quality of life, at diagnosis and on a regular basis after diagnosis.

Transition from child to adult services

Evidence also suggests that good transition programmes improve health outcomes and quality of life. Poor clinic attendance is linked to inappropriate transition. Those lost to follow-up have poorer diabetes control. Medical crises can be averted through regular follow-up and education. Every child with diabetes should have access to transitional clinics which fully support them in their adolescent years, in line with the Scottish Government Guidance Hospital Services for Young People in Scotland published in May 2009, which emphasises the need for good transition arrangements for young people moving into the adult care sector across all specialties.

Service redesign initiatives and developments should show evidence of consultation with young people with diabetes and their families.


Information from Diabetes UK Scotland, local family support groups and individual families around Scotland suggests that children with diabetes can face unnecessary problems at school, such as exclusion from trips, access to essential snacks and issues around injections. While there is good practice in some schools across Scotland, action is needed to ensure that no child with diabetes is, in any way, disadvantaged as a result of the condition. In order for a child fully to participate in education, health services, schools and the family should work together effectively. Guidance on the Administration of Medicines in Schools was published by the Scottish Government in 2001. It requires NHS Boards and education authorities to draw up policies on managing healthcare in schools and to develop effective management systems to support individual pupils with such need, to enable them to play a full part at school. As well as emphasising that it is for NHS Boards to ensure arrangements are in place with education authorities, the guidance makes clear that it is essential that NHS Boards and education authorities work together on appropriate arrangements.

Actions we will take:

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

  • A new DVD for children with type 1 diabetes will be commissioned (responsibility: 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 (responsibility: SDG).

2. Organisation of paediatric care will be reviewed at national and local levels

  • A paediatrician will be appointed to the SDG (responsibility: 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 (responsibility: NHS Boards through their diabetes MCNs).
  • NHSQIS will commission an audit of glycaemic control in children and adolescents (responsibility: NHSQIS).

Healthcare Quality Indicators: person-centred; timely; safe.

3.9 The spectrum of emotional and psychological support

Where we want to be:

We want to improve the spectrum of emotional and psychological support for people living with diabetes in Scotland through enhancing the skills of clinical staff and valuing the contribution of voluntary sector support, including peer support. We must build on progress and at the same time speed up improvements where we are in the strongest position to do so.

Why we want to be there:

Part of the benefit of providing emotional and psychological support is to help people with diabetes to make choices, actively self manage their condition on a day-to-day basis and minimise the risks of the long term damage that diabetes can cause. In addition, by recognising and addressing emotional issues, interventions can reduce more serious psychological issues.

The importance of psychological support is underlined by evidence that suggests between 20% and 30% of people with diabetes will suffer from depression at some point. We need to ensure that emotional support - local voluntary groups, peer support projects, etc - is fully recognised in local strategies and programmes. Networks of local support will become increasingly important over the lifetime of this Action Plan as the number of people with diabetes continues to grow. NHS Boards will need to identify and plan how they will support these services and work in partnership with them. For example, Careline Scotland provides emotional support through telephone and email counselling and provision of tailored information to people living with diabetes. The Scottish Government already provides support to the Diabetes UK Scotland Careline service and consideration needs to be given to a range of support initiatives including peer-to-peer support such as the buddy service.


The Scottish Diabetes Group has committed £450k to funding the Psychology in Diabetes, Psychology and Diabetes ( PIDPAD) project, which will run within six Boards over the next three years. The project will aim to implant psychological care within diabetes services through training NHS staff to improve their skills in behaviour change and psychological support. This initiative provides the opportunity for:

  • increased psychological support to people with diabetes;
  • integrated care across medical and psychological issues; and
  • building a skill base in diabetes within the psychology professions.

SIGN Guideline 116 sets out the evidence base on psychological interventions to help people achieve better control of their diabetes.

In December 2008, NES published a guide to developing evidence-based psychological therapies in Scotland: 'The Matrix'. It contains a section on heart disease, but not one on diabetes. The Scottish Diabetes Group will consider whether a diabetes section should be developed.

The 'Living Better' initiative organised by the Royal College of General Practitioners, with Scottish Government funding, aims to improve the mental health and well-being of people with diabetes and coronary heart disease. It runs until November 2010 and aims to improve the detection, assessment and management of depression, anxiety and stress through the development and implementation of local care pathways. NHS Boards, through their diabetes MCNs, should roll out the lessons from the pilots.

Actions we will take:

1. Ensure adequate training of staff in psychological skills

  • 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 (responsibility: MCNs/ SDG. September 2010 ongoing).
  • All existing staff programmes will take account of cultural differences in the type and presentation of psychological consequences of diabetes.
  • 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, (responsibility: NHS Boards through their diabetes MCNs).

2. Develop and share effective national initiatives

  • Three meetings a year of the new psychology appointees will be supported to ensure coordinated developments and that best practice is shared (responsibility: 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 (responsibility: Psychology Working Group/ SGHD).
  • Lessons from the PIDPAD pilot, including patient feedback, should be acted upon by NHS Boards through diabetes MCNs (responsibility: NHS Boards through their diabetes MCNs.
  • Diabetes 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.
  • Further development of the buddy service nationally will be considered (responsibility: Scottish Diabetes Group).
  • Explore ways of underpinning the financial sustainability of a national emotional support service and develop links with NHS 24 to ensure that people who would benefit from Careline Scotland will be referred (responsibility: Diabetes UK Scotland, NHS 24).

Healthcare Quality Dimensions: person-centred; safe.

3.10 Structured education

Where we want to be:

We want to increase the number of people with type 1 and type 2 diabetes who have been invited to participate in and have attended a quality assured structured education programme.

Why we want to be there:

Since the 2006 Action Plan was published, structured education has become recognised as central to diabetes care and to the self management of long term conditions generally. In Diabetes UK Scotland's survey of people living with diabetes, structured education was the most valued type of education. This should underpin our actions over the next three years.

Effective self management of diabetes is the cornerstone of quality care and individual patient education is essential to optimise self management. A range of education programmes for patients and staff is available. A healthcare professional, funded by SDG, will be seconded to NES for two years to ensure patient and staff education programmes are complementary and effective. The need for this role was identified after discussions between the voluntary sector, patients, staff, QIS, NES and SDG.

Progress has been made, including the initial roll out of DAFNE and DESMOND and the emergence of localised courses like TIM (Tayside Insulin Management programme). However, the next three years needs to see a significant increase in access and quality. The recommendations on structured education in SIGN Guidance 116 will help promote this work.

Actions we will take:

1. 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:

  • A national education co-ordinator will be appointed to work with the diabetes MCNs in the implementation of the patient and professional diabetes education frameworks (responsibility: NES, Scottish Diabetes Group, Diabetes Education Advisory Group ( DEAG)).
  • The Diabetes Education Network ( DEN) Scotland will have a representative on SDG and will become a subgroup of the DEAG. DEN will have responsibility for developing the national framework for diabetes patient education.
  • After the first year of reviewing structured education provision, the SDG, in consultation with DEN and Diabetes Care Focus Group ( DCFG), will set milestone targets for subsequent years.

2. The national education co-ordinator will work with the diabetes MCNs in the implementation of a training and education strategy. This will include:

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

(responsibility: NHSQIS/ NES, DEAG).

3. Education will be improved at a local level:

  • Each diabetes MCN will identify an individual who will have responsibility and the skills for ensuring delivery of local patient education programmes.
  • Each diabetes MCN will ensure the provision of a range of education solutions, including quality assured structured education programmes to all people with diabetes.
  • Each diabetes MCN will undertake/commission user impact and/or experience measures in relation to patient education.
  • Clinical records will document participation in the level of self management programmes as defined by DENS. This information will also be recorded in the electronic record.
  • The percentage of people in each level of self management programmes will be reported for the Scottish Diabetes Survey.

Responsibility: NHS Boards through their diabetes MCNs.

Healthcare Quality Dimensions: person-centred; effective.

3.11 Insulin therapy

Where we want to be:

We need to ensure that people living with diabetes can safely manage their insulin therapy to maximise their quality of life.

Why we want to get there:

Type 1 diabetes affects 0.4 to 0.5% of the population. A 70% increase in prevalent cases of type 1 diabetes in those aged under 15 is predicted in Europe between 2005 and 2020 3. Despite advances in the care of people with type 1 diabetes, the condition continues to be associated with substantial mortality and morbidity with an estimated shortening of lifespan on average of 15 years. Rates of cardiovascular disease are increased 3.6 fold in men and 7.7 fold in women.

Supporting those with type 1 diabetes to manage insulin from diagnosis and those with type 2 diabetes who move to insulin therapy requires a team effort with nurses, dietitians, doctors, pharmacists and others working in partnership with the individuals with diabetes and their carers.

Actions we will take:

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

2. Local insulin strategies will be reviewed for people with type 1 and 2 diabetes (responsibility: diabetes MCNs).

Healthcare Quality Dimensions: safe; timely.

3.11.1 Intensive insulin therapy for people with type 1 diabetes

Where we want to be:

Over the next three years we want to see significant progress in patient access to intensive insulin therapy. For example, the provision of insulin pumps needs to reflect guidance on eligibility.

Why we want to be there:

Intensive insulin therapy 4 aims to resemble as much as possible the natural pattern of insulin release from the pancreas in order to keep blood glucose levels at near normal rates. It is not necessarily about more insulin but about changing how insulin is taken. There is unequivocal evidence that intensive insulin treatment reduces microvascular complications in type 1 diabetes. For most people this involves mutiple dose injection.

Up to 4,000 people with type 1 diabetes in Scotland could benefit from access to insulin pump therapy. The current uptake, however, is between 500-600 people. Patient and professional knowledge of the value of insulin pumps has increased greatly over the last three years and has brought with it increased expectation on the NHS to deliver pump services. Pump therapy should now be considered as a mainstream therapy, though the importance of multiple dose insulin treatment as an alternative to pumps should also be borne in mind. Provision should be evidence-based and take account of patient choice. Access to pump therapy should be boosted significantly across NHS Board areas over the lifetime of this Action Plan.

NHS Boards are aware of the need to invest in insulin pumps and the structured education associated with them, as the table in Appendix 2 indicates.

NHS Boards will find it helpful to assess their investment plans against the thinking on pumps and structured education set out in the clinical and resource impact report produced by SIGN to accompany Guideline 116.

Work will also be commissioned on identifying guidance on the point of initial referral and best practice models in order to deliver waiting times criteria based on the 18-week referral to treatment guarantee.

This work will take account of any future legislation or guidance such as the Patients' Rights Bill currently going through the Scottish Parliament. This will ensure that criteria can be agreed for the point of initial referral and the start of any treatment necessary, to ensure consistency in care across Scotland.

Actions we will take:

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

  • Patients should receive carbohydrate counting instruction prior to initiation of intensive insulin regimens.
  • Mydiabetesmyway.scot.nhs.uk will include a section on intensive insulin therapy (responsibility SDG).

2. Insulin pump therapy is available for those patients who would benefit from it.

  • The Scottish Diabetes Survey will include figures on pump usage and it is expected that by the end of the three years, NHS Boards will have made significant and sustained progress in increasing access to insulin pump therapy in line with the latest clinical guidance (responsibility: SDSG).
  • A national pump awareness day will be arranged (responsibility: SDG by October 2012).
  • The SDG will commission waiting times criteria for insulin pump therapy in line with national criteria and make recommendations for a consistent approach across the country (responsibility: SDG by December 2010).
  • Scottish Government Health Directorates will scope the implications of putting pumps and associated consumables onto the National Drug Tariff.


On 18 November 2009 the Minister of Health and Wellbeing launched Scotland's first Islet Transplant Programme at the Scottish National Blood Transfusion Service in Edinburgh. The Scottish Islet Isolation Laboratory is the only one in the UK which will operate 24 hours a day, and offers a lifeline to, initially, a small number of patients who, until now, have had to live with constant blood sugar monitoring and the fear of coma due to low blood glucose. The new treatment involves extracting islets (the cells which produce insulin) from a donated pancreas by a complex and labour intensive laboratory process. They are then injected into the liver of recipients under local anaesthetic. People who will benefit from this new treatment are those with type 1, or insulin dependent diabetes, and also kidney transplant recipients. This treatment is made possible by the close collaboration between the pancreas transplant programme at the Royal Infirmary of Edinburgh, the Scottish National Blood Transfusion Service and the Scottish Centre for Regenerative Medicine.

3.12 Reducing emergency admissions

3.12.1 Out-of-hours care

Where we want to be:

We want people with diabetes to have access to robust out-of-hours diabetes care.

Why we want to be there:

People with diabetes need access to consistent, co-ordinated and high quality care at all times. Effective out-of-hours care is fundamental to reducing the number of unplanned admissions for metabolic emergencies.

The Type 1 Diabetes Short Life Working Group report explores out-of-hours care services for people with diabetes and looks at the rationale for introducing a dedicated NHS 24 diabetes service. It is expected that this work could provide a viable alternative to further rolling out the DiabNet scheme.

Actions we will take:

1. The Scottish Diabetes Group will work with NHS 24 to improve NHS 24's services for people with diabetes and develop a dedicated diabetes pathway (responsibility: Scottish Diabetes Group and NHS 24).

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

Healthcare Quality Indicators: timely; safe; effective.

3.12.2 Diabetes emergencies

Where we want to be:

We want to reduce or prevent the number of diabetes emergencies.

Why we want to be there:

Diabetic ketoacidosis ( DKA) and hypoglycaemia are major causes of emergency situations in the community and in hospital.

Reducing hospital admissions of people with diabetes will help NHS Boards achieve the trajectories they have developed in line with HEAT target T6:

'to achieve agreed reductions in the rates of hospital admissions and bed days of patients with primary diagnosis of COPD, Asthma, Diabetes or CHD, from 2006-07 to 2010-11.'

Current initiatives that will help address this target include the growing availability of structured education programmes for people with established diabetes to help them manage the condition more effectively and ongoing discussions with NHS 24 on developing its services for people with diabetes. The Scottish Ambulance Service is considering a revision of its guidelines to reduce episodes of repeat severe hypoglycaemia.


Hypoglycaemia (hypo) occurs when blood glucose levels drop below normal levels and is a common complication of injecting insulin. It can also occur in people with type 2 diabetes who are taking insulin or certain oral medication. It can be classified as mild, moderate or severe; severe hypoglycaemia needs third party help with recovery. The Scottish Ambulance Service ( SAS) has adopted 'See and Treat' Guidelines which recommend that in most cases it is preferable for people with hypoglycaemia to remain at home. Evidence from a research project under way in Stirling University suggests that around 7,000 diabetes calls to the SAS relate to hypos including a significant number of repeat callers. It is thought that as the number of people with type 2 diabetes taking insulin increases, there may well be a corresponding increase in severe hypoglycaemia.

3.12.3 Diabetic ketoacidosis ( DKA)

Data on the incidence of DKA over the past five years shows an upward trend, though this may be due to more accurate reporting and coding. The Type 1 Diabetes Short Life Working Group recommended that an audit take place in 2010-11, and this is expected to eliminate uncertainties around current data.

The Type 1 Diabetes Short Life Working Group report recommended the introduction of a DKA awareness campaign, modeled on the Vanelli campaign 5 that is understood, at one point, to have virtually eliminated DKA in newly diagnosed patients in Parma.

Care bundles for DKA have also been developed for use by Accident and Emergency and medical ward-based staff. These are currently being piloted before being considered for further roll out.

Primary Care is expected to have a central role in reducing diabetic hospital admissions through early recognition and management of diabetic presentations, complications, and potential emergencies such as diabetic ketoacidosis ( DKA) and hypoglycaemia.

Actions we will take:

1. We will reduce the incidence of hypoglycaemia that result in emergency admissions by:

  • supporting the development of interventions to improve post-hypoglycaemia patient support through enhanced communication (responsibility SAS and Scottish Diabetes Group).
  • NHS Boards, through their diabetes Managed Clinical Networks, will review the care pathway of people who experience severe hypoglycaemia.

2. Incidence and care of diabetic ketoacidosis ( DKA) will be improved by:

  • The SDG and SGHD will explore the roll out of a DKA awareness campaign for children with undiagnosed diabetes.
  • NHS Boards, through their diabetes MCN, will review care pathways for the presentation and management of DKA throughout the whole episode.
  • NHSQIS will commission a national audit of DKA.
  • The Diabetes Education Advisory Group will oversee the roll out of care bundles for DKA.

Healthcare Quality Indicators: safe; timely.

3.13 Quality in-patient care

3.13.1 Safe and effective management of diabetes in hospital

Where we want to be:

We want people with diabetes to be supported wherever possible to live independently in the community. Diabetes services should be provided locally wherever possible, in keeping with the 'Shifting the Balance of Care' agenda. Where admission to hospital is unavoidable, we want to harness for people with diabetes the benefits of the work of the highly successful Scottish Patient Safety Programme, through improvements in knowledge of diabetes among hospital staff, with an increased commitment to supporting people with diabetes to self manage where possible.

Why we want to be there:

Diabetes was included in HEAT target T6, in recognition of the fact that people with diabetes stay an extra two to three days in hospital compared to other conditions, whatever the diagnosis, and around 10% of people in hospital, at any one time, have diabetes. Interventions such as foot care in the community, with additional inpatient support for patients with diabetes, can reduce admissions and bed occupancy for people with this condition.


The Think Glucose Programme was designed by the NHS Institute for Innovation to improve the management of people with diabetes when they are admitted to hospital. It achieves this through the introduction of an awareness campaign as to the importance of glucose control combined with a system of audits. Think Glucose has reported considerable success in reducing bed days and diabetic complications at those hospitals in England where it has been rolled out.

Actions we will take:

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

  • 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 ( MCNs).

2. The diabetes MCNs will develop mechanisms to record the number of inpatient wards in general hospitals with specific guidelines for the management of hypoglycaemia.

Healthcare Quality Dimensions: safe; effective.

3.13.2 Care homes and non- NHS settings

Where we want to be:

People with diabetes living in non- NHS care settings must have timely access to appropriate diabetes services.

Why we want to be there:

We are much more aware now of the need to provide information, advice, care and support to people with diabetes outside of hospital and general practice. Settings such as care homes for older people, children's residential units and prisons require specific approaches in terms of both information and delivery of care. Over the lifetime of this Action Plan, diabetes care services should become more flexible and effective in their capacity to reach people in all care settings and to provide training and mentoring for non-specialist community care partners. This relates to action 4.8 in the Long Term Conditions Action Plan, which seeks to link NHS staff training to the Continuous Learning Framework for social care staff.

Actions we will take:

1. 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.

  • Undertake an assessment of educational needs of staff in non- NHS care settings.
  • Day care, home care and care staff should have access to educational events.

Healthcare Quality Dimensions: equitable; person-centred.