Diabetes care - Diabetes improvement plan: commitments - 2021 to 2026

The Improvement Plan

Diabetes care is continually evolving and the landscape has changed in response to the COVID-19 pandemic identifying some new areas of focus. Significant progress has been made in response to the priorities and actions identified in the Diabetes Improvement Plan 2014 and much of this activity will continue.

Following consultation with the diabetes community and stakeholders a number of commitments linked to the existing priority areas have been agreed which build on the progress to date and support continued improvements in diabetes care. For 2021 – 2026, Priority 4 will change to Equity of Access.

The Scottish Government, through the Scottish Diabetes Group, and NHS Boards will commit themselves to implementing a programme of work to improve the quality of care and outcomes within the identified priority areas. Progress will be evidenced through a number of measurable standards which will be reported at both health board and national level. We will report delivery against each commitment annually and continue to review the Diabetes Improvement Plan on a five year cycle.

There are eight Priority areas and under each of these are a number of specific commitments we are making to work towards improving care outcomes and experiences for people living with Diabetes in Scotland.

1. Prevention and Early Detection of Diabetes and its Complications

2. Type 1 Diabetes

3. Person-Centred Care

4. Equity of Access

5. Supporting and Developing Staff

6. Inpatient Diabetes

7. Improving Information

8. Innovation

Diabetes Improvement 2021 – 2026: Commitments & Priorities

Priority 1 - Prevention and Early Detection of Diabetes and its Complications

To establish and implement approaches to support the prevention and earl detection of type 2 diabetes, rapid diagnosis of type 1 and to implement measures to promptly detect and prevent the complications of diabetes

Commitment 1.1 We will continue to support the implementation of the Framework for the Prevention, Early Detection and Early Intervention of Type 2 Diabetes

The Framework for the Prevention, Early Detection and Early Intervention of Type 2 Diabetes is a 5 year programme supporting Boards to implement strategies to reduce the number of people developing type 2 diabetes and support early identification of people with type 2 diabetes. The implementation of this framework is being monitored by Scottish Government's Diet and Healthy Weight Team and the success of this programme will be monitored through their evaluation framework.

We will continue to develop SCI-Diabetes to ensure that it meets the needs of this work stream and support the implementation of the framework where we can.

To ensure progress against this commitment we will review the:

• % of adults with type 2 diabetes who are newly diagnosed with type 2 diabetes
• % of adults with type 2 who achieve optimal glycaemic (<58mmol/mol) control at 1 year post diagnosis
• % of adults with type 2 who complete structured education within 6 months of diagnosis
• % of adults with type 2 diabetes where this is now in remission

Commitment 1.2 We will work collaboratively with generalist care colleagues to raise further awareness of type 1 diabetes and relaunch an extended DKA prevention campaign

Diabetic ketoacidosis (DKA) on diagnosis of type 1 diabetes continues to be an issue. In addition, the recent evidence that deaths under the age of 50 can be partly related to DKA^[4] highlights the importance of reducing DKA in those with existing type 1 diabetes. To minimise these risks, we will work collaboratively with generalist care colleagues, third sector and people living with diabetes to relaunch the national education campaign, Think, Test, Telephone, to support the early detection and urgent referral for those with new onset type 1 diabetes as well as targeting those with pre-existing type 1 diabetes. The diagnostic information pages on SCI-Diabetes will be promoted to diabetes teams to ensure capture of DKA status at diagnosis and the type 1 summary pages will be further enhanced to capture all DKA events. This will help assess the impact of this activity.

To ensure progress against this commitment we will review the:

• % of people with type 1 diabetes who are recorded as having DKA at diagnosis
• % of people with type 1 diabetes who are recorded as having a DKA episode within the last 12 months

Commitment 1.3 We will ensure care pathways support individuals to have their processes of care completed while considering the principles of realistic medicine

The COVID-19 recovery phase is providing diabetes teams with the opportunity to revise care pathways to further ensure robust approaches to screening and the surveillance of diabetes. Changes to the regularity of some of the processes of care have been agreed (retinal screening and foot screening for lower risk individuals). Further consideration is required to ensure that there care pathways are tailored around the person and a more personalised approach to care is taken. For example inclusion of a frailty score and the need for screening for cholesterol when the person living with diabetes is using a statin.

Developing care models aligned to the 'House of Care' philosophy and utilising community hubs affords the opportunity for the processes of care to be completed in a pre-care planning appointment and this information can then be used to inform the care planning consultation between the person and their healthcare team.

In recognition that foot screening and screening for microalbuminuria has in recent years been the process of care measures least likely to be completed, performance around this will be closely monitored.

One of the key aspects of the Diabetic Retinopathy Screening programme is to reduce the incidence of vision loss in people living with diabetes. We will work with the Diabetic Retinopathy Screening programme and SCI-Diabetes to monitor progress against this outcome.

Promotion of the value of the processes of care being undertaken will take place with health professionals and people living with diabetes, and examples of good practice shared.

To ensure progress against this commitment we will review the:

• % of people with diabetes who have all nine processes of care recorded
• % of people with diabetes who have had foot screening
• % of people with diabetes who have had screening for microalbuminuria

Priority 2 - Type 1 Diabetes

To improve the care and outcomes of all people living with type 1 diabetes

Commitment 2.1 We will support early optimisation of glycaemic control in new onset type 1 diabetes

We will continue to support optimisation of glycaemic control in new onset type 1 diabetes through early intensification of therapy and timely access to high quality education.

To ensure progress against this commitment we will review the:

• % of people living with diabetes who are recorded as having attended structured education within six months of diagnosis
• % of people who achieve optimal glycaemic control (<58mmol/mol in adults and <48mmol/mol in children) at one year post diagnosis with the aim of 58% of people achieving this.

Commitment 2.2 We will support appropriate and timely access to technologies to improve glycaemic control and quality of life for people living with type 1 diabetes

Diabetes technologies can significantly benefit people with type 1 diabetes through optimising glycaemic control and improving quality of life. We will build upon the progress that has been made to further increase access to existing and emerging diabetes technologies in a timely manner.

This is a rapidly evolving area with the ongoing development of life changing technologies. The development of Closed Loop (linked insulin pump and CGM) is the biggest advance in management of type 1 diabetes since the advent of insulin therapy. In line with best practice and analysis from health economists, we should aim to ensure all people that would benefit from these therapies have access at the earliest opportunity.

We will also continue to monitor and target equity of access to technologies, as we know that currently people from the most deprived groups are less likely to use them^[5]. We will work to identify and understand the reasons for this to ensure that services are designed specifically with these issues in mind. We will also review access to diabetes technologies for women who are planning pregnancy and during their pregnancy.

Key to progressing this commitment will be working with relevant stakeholders including the Scottish Health Technologies Group, National Planning Board and SIGN to develop the clinical and health economic case for adopting and implementing the latest diabetes technologies. This will include closed loop systems and single/dual hormone APS as well as other innovative technologies as they become available.

To ensure progress against this commitment we will review the:

• % of people with type 1 diabetes who have access to flash glucose monitoring
• % of people with type 1 diabetes who have access to insulin pump therapy
• % of people with type 1 diabetes starting on insulin pump therapy within six months of referral
• % of people with type 1 diabetes who have access to continuous glucose monitoring
• % of women with type 1 diabetes who have access to continuous glucose monitoring during pregnancy
• % of people with type 1 diabetes who have access to closed loop/Artificial Pancreas Systems (both single and dual hormone)
• % of people with type 1 diabetes in SIMD1 vs SIMD5 with access to diabetes technologies
• Data from international health services to benchmark against the most advanced diabetes services

Commitment 2.3 We will continue to support improvements in care and outcomes for children with particular emphasis on their needs when attending early year’s services, school and out of school services

The Supporting Children and Young People in Education guidance will be relaunched and extended to include children living with diabetes who are attending pre-school, school and out of school care. The revised guidance will be developed in collaboration with the education, childcare and diabetes communities with representation from relevant stakeholders, people living with diabetes and their families as well as third sector organisations.

To ensure progress against this commitment we will work with paediatric teams to assess the use of this document and support any activity needed to ensure access and awareness of the guidance.

Commitment 2.4 We will ensure children and young people transitioning to adult services for diabetes are supported in line with the National Standards for Transition

We will review and if needed update the National Standards for Transition and the suite of supporting tools. This work stream will be led by the type 1 subgroup of the SDG. Paediatric and Adolescent diabetes teams should use the transition standards self-reflection tool to highlight areas that are working well and identify where improvements may be required. Examples of best practice will be shared.

To ensure progress against this commitment we will review the:

• % of 18 - 25 with diabetes with optimal glycaemic control
• % of 18 - 25 with diabetes who are engaged with diabetes services

Commitment 2.5 We will continue to support improvements in care and outcomes for adults living with Type 1 diabetes

"Time trends in deaths before age 50 years in people with type 1 diabetes: a nationwide analysis from Scotland 2004–2017" reports that while mortality has fallen, the relative impact of type 1 diabetes on mortality before the age of 50 has not improved. This highlights the need to improve premature circulatory diseases and DKA and coma and to develop effective strategies to enable people with type 1 diabetes to avoid clinically significant hyper or hypoglycaemia.

We will revise and expand on the previous initiative to reduce DKA at initial presentation of type 1 diabetes to include those with existing type 1 diabetes. This will focus on supporting people living with type 1 diabetes to better understand the risks of DKA and how to avoid it with the aim of reducing the number of people with diabetes developing DKA.

Recording of when DKA happens allows support to be tailored and offered on an individual basis to prevent future occurrences and identifies areas where further targeted activity around DKA would be helpful. Examples of local activity taking place and areas of good practice will be shared with diabetes teams.

To ensure progress against this commitment we will review the:

• % of people with type 1 diabetes who are recorded as having one or more episodes of DKA in one year
• % of people with type 1 diabetes with optimal glycaemic control
• % of people with type 1 diabetes with a BP <= 130/80mmHg
• % of people with type 1 diabetes with HbA_1c >75mmol/l and a systolic BP > over 130 mmHg

Priority 3 - Person-Centred Care

People living with diabetes are enabled and empowered to safely and effectively self-manage their condition by accessing consistent, high quality education and by creating mutually agreed individualised care plans

Commitment 3.1 We will ensure timely and appropriate access to structured education and support for people living with diabetes

People living with diabetes with have timely access to a variety of person centred educational and support resources, including online learning, remote health pathways to enable and empower them to self-manage their condition. People living with diabetes, care providers and third sector will support the development and review of these resources to ensure they are fit for purpose and help to ascertain any potential gaps. Any resources developed will include a focus on wellbeing, emotional support and mental health and be in a range of formats and languages.

To ensure progress against this commitment we will review the:

• % of people living with diabetes who are recorded as having attended structured education
• % of people living with diabetes who are recorded as having attended structured education within six months of diagnosis
• % of people living with diabetes who are recorded as having attended structured with HbA_1c >75mmol/l

Commitment 3.2 We will work collaboratively with partner agencies to support improvements in out of hours care for people living with diabetes

We will build on the success of the Scottish Ambulance Service and NHS Fife project^[6] to identify and support people living diabetes who have had a hypoglycaemic event which resulted in an ambulance call out. To support roll out of this programme nationally, clinical systems will be developed between the Scottish Ambulance Service and health board to enable glucose results to be reported and shared. This will alert diabetes teams of people who may benefit from follow up support to reduce the number of future hypoglycaemic events.

The diabetes algorithms and triage tools used by NHS24 will also be reviewed to ensure people are directed to appropriate services in a timely manner. Self-directed support will be increased through patient education materials and help guides to support self-management out of hours.

Upskilling of staff who work out of hours to increase their knowledge of diabetes care will also be core to supporting improvements in this area.

To ensure progress against this commitment we will work with the Scottish Ambulance Service and NHS24 to assess the patient pathways out of hours and support any subsequent activity that may be required as a result.

Commitment 3.3 We will work with NHS Boards, clinicians and third sector to promote good practice and reduce variation in access to mental health support across the country, so that everyone has the opportunity to live well with diabetes

We will work with a wide range of stakeholders to ensure that people living with diabetes have equitable and timely access to mental health and emotional wellbeing support. A review of the existing support for people living with diabetes across Scotland will take place and areas of good practice and available resources for people living with diabetes will be investigated further. We will ensure that health care professionals are supported to recognise and have conversations about mental health and wellbeing and can signpost people to the right services and support where required.

To ensure progress against this commitment we will work with wider Mental Health policy teams and clinical leaders within the NHS. Alongside Diabetes Scotland, we will engage with people living with diabetes to establish where additional support is required and how best this could be delivered. We will encourage NHS boards to include patient reported outcomes as part of their clinical consultations so that mental health and wellbeing can be discussed and the right support put in place.

We will establish a Short Life Working Group of key stakeholders to progress this commitment. The group will focus on identifying a Patient Reported Outcomes Measure (PROM) for mental health and wellbeing that can be incorporated into routine clinical care. The Group will also work with boards to ensure they have a robust pathway from screening to support for those who need it, dependent on local resources. This will include utilisation of digital solutions and signposting to existing resources to help individuals live well with diabetes.

Commitment 3.4 We will support ongoing work to improve outcomes in pregnancy

We will continue to improve outcomes for women with diabetes planning for pregnancy and during their pregnancy. We will do this by:

• Improving linkages between diabetes and pregnancy clinical systems and developing pregnancy specific quality improvement measures within the diabetes dashboard.
• Collaborate with other stakeholders to ensure structured patient education is available for all women living with diabetes during pregnancy and for those planning pregnancy.
• Ensuring women with gestational diabetes have access to information, support and follow-up to help prevent development of type 2 diabetes.
• Improving rates of pre-pregnancy counselling particularly in women with type 2 diabetes.
• Improving pregnancy outcomes for women with type 1 and type 2 diabetes (rates of caesarean section, still birth, neonatal admission)

Commitment 3.5 We will support ongoing work to improve outcomes for people with foot disease

We will continue to improve outcomes for people with foot disease. We will do this by:

• Ensuring all episodes of foot ulcers are recorded on the electronic diabetes clinical systems will allow us to determine if interventions result in improved outcomes such as ulcer healing and reduced amputations.
• Improving timely input for people with foot ulcers; with a particular focus on people living in areas of deprivation
• Improving healing rates, reducing rates of major amputations

Priority 4 - Equity of Access

To reduce the impact of deprivation, ethnicity and other factors which can disadvantage diabetes care and outcomes for people

Commitment 4.1 We will work collaboratively with NHS Boards and Health and Social Care Partnerships to ensure diabetes is at the forefront of developing, delivering and embedding alternative care models within everyday clinical practice and considered within workforce planning

We will work with diabetes care providers across all settings and services to develop sustainable person centred care models to improve outcomes for everyone living with diabetes. We will work to ensure that evolving care models address existing health inequalities by integrating pathways with existing services and resources such as social work, mental health services, education and third sector.

To ensure progress against this commitment we will work with NHS Boards and Health & Social Care Partnerships, Diabetes Scotland, My Diabetes, My Way and people living with diabetes to ensure that services evolve to meet the needs of everyone within the populations we care for. We will also continue to engage with our communities and enhance our data capture to understand the various needs to the populations we care for to ensure no one is disadvantaged from the services that are being delivered. Where required we will implement outreach models to support vulnerable and high risk groups.

Commitment 4.2 We will ensure that the outcomes for people living with diabetes are not disadvantaged as a result of digital exclusion

As diabetes services evolve, and respond to the COVID-19 pandemic, they are increasingly moving to more virtual models of care and so there is a need to consider the impact of this type of healthcare on people who are currently digitally excluded. This will be considered through undertaking an Equality Impact Assessment (EQIA) and Fairer Scotland Assessment.

To ensure progress against this commitment we will work with key partners including Diabetes Scotland, My Diabetes, My Way and Digital Health and Care Institute to understand the scope of digital exclusion amongst people living with diabetes and the barriers to inclusion. We will seek input from frontline diabetes services to determine what challenges they face in delivering care virtually. We will consider age, deprivation, ethnicity, and geographical location of people to help inform our approach to improving digital inclusion and mitigate against the risks of further digital exclusion.

We will also consider the Rapid Response Evidence Review on Digital Exclusion/Digital Participation in Scotland published by Healthcare Improvement Scotland. This examines published information on access to and attitudes towards the use of digital technologies to access healthcare for people living with chronic health conditions, and in particular diabetes.

We will continue to create close links with the Technology Enabled Care programme, the Scottish Access Collaborative and the Modernising Patient Pathway Programmes within Scottish Government to ensure evolving care models are appropriately aligned.

Priority 5 - Supporting and Developing Staff

To ensure healthcare professionals have access to consistent, high quality diabetes education to equip them with the knowledge, skills and confidence to deliver safe and effective diabetes care

Commitment 5.1 We will upskill diabetes teams to support the mental health and wellbeing of people living with diabetes, including the use of motivational interviewing and signposting to additional support where required

Scottish Diabetes Education Action Group will conduct a national training needs analysis. This will include consideration of knowledge, practical skills, behaviour change methodology, educational theory, new technologies, IT and emotional support that are necessary for the health care professionals working in NHS Scotland.

To ensure progress against this commitment we will review the diabetes training opportunities available to health care professionals and the levels of participation. We will undertake a follow up training needs analysis Scotland-wide to determine areas of improvement or where further support is required. We will work with health care professionals to ensure that care and support planning considers the emotional wellbeing of the person living with diabetes and appropriate person reported outcome measures.

Commitment 5.2 We will support training and education on diabetes and ensure it is delivered and available to all healthcare professionals

We will continue to work in partnership with patient groups, third sector, Health Boards, NHS Education for Scotland, Universities and Higher Education authorities to optimise education opportunities for healthcare professionals. As the professional roles and responsibilities continue to evolve within the health and social care system we remain committed to supporting the delivery of high quality diabetes teaching, learning and continued professional development. There will be increased focus on virtual learning and we will work to address information governance challenges to ensure widespread roll out and adoption.

To ensure progress against this commitment we will review the diabetes training opportunities available to all existing and future diabetes health care professionals, monitor uptake of these, and develop additional support as required.

Priority 6 - Inpatient Diabetes

To improve the quality of care for people when admitted to hospital by improving their glucose management and reducing the risk of complications during admission

Commitment 6.1 We will support boards to optimise diabetes inpatient care in hospitals across Scotland and reduce avoidable adverse events

The key to delivering this commitment will be ensuring hospitals have an appropriately resourced specialist service^[7], that is consultant led, with inpatient specific resource for each multidisciplinary team (MDT) group to ensure timely MDT specialist referral and proactive review for all aspects of specialist inpatient care.

To support improvement to inpatient care provided to people living with diabetes we will, in collaboration with Diabetes Scotland, develop a self-assessment in-patient checklist to support hospitals teams to consider the areas of care needed, what is currently provided and what areas of care that require further development.

Use of effective e-health and close collaboration with e-health teams will also be crucial. This will include the ongoing development of:

• SCI Diabetes in-patient domain
• Linked blood glucose (ketone) meter data – improving prioritisation of specialist review and quality through automated data collection
• Linkage of SCI Diabetes, Patient Administration Systems (PAS) and Connected meters
• Development of in-patient dashboard for local, regional and national reporting of inpatient demography, performance and outcomes
• Reporting and collating critical incidents including inpatient DKA, inpatient Hyperosmolar Hyperglycaemic State, technology failures, insulin errors and hypoglycaemia.

Optimising diabetes in-patient care will also require effective processes to be in place to avoid unnecessary admissions and delays to discharge due to diabetes related issues. Key areas to consider would be:

• Admission – whether elective or emergency. Preadmission clinics can help optimise diabetes prior to elective surgery as can appropriate referral pathways for those who require urgent input pre admission/on admission
• Effective safe discharge planning

To ensure progress against this commitment we will review the:

• Number of NHS Boards where there is secure data capture between their relevant IT systems and industry providers of blood glucose systems.
• % of in-hospital hypoglycaemia and timely resolution of this
• % of DKA developing while in hospital
• % of hospital acquired foot ulceration

Commitment 6.2 We will work with non-diabetes leads at health board level on patient safety through the further roll out of Diabetes Think, Check, Act focusing on reducing insulin prescription errors and DKA

We will work with non-diabetes specialist inpatient teams to upskill them in supporting people with diabetes and encourage the roll out of 'diabetes champions' to support quality improvement in diabetes inpatient care.

We will continue to embed the national in-patient diabetes improvement initiative, Diabetes, Think, Check, Act and work with key stakeholders to ensure all healthcare professionals and undergraduate medical and nursing students complete the online modules. This will support improvements in inpatient care for people with diabetes in acute hospitals in particular around the safe use of insulin.

To ensure progress against this commitment we will review the:

• Uptake ofDiabetes, Think, Check, Act modules
• % of in-hospital hypoglycaemia and timely resolution of this
• % of DKA developing while in hospital
• Number of critical incidents

Commitment 6.3 We will work with non-diabetes leads at health board level on patient safety through the further roll out of CPR for Feet leading a reduction in iatrogenic foot harm

We will continue to embed the national in-patient diabetes improvement initiative Check, Protect and Refer (CPR) for feet campaign on admission to hospital; raise awareness of risk and; introduce appropriate pressure relief and education to prevent avoidable foot ulcers.

To ensure progress against this commitment we will review the:

• Uptake ofCPR for Feet modules
• % of hospital acquired foot ulceration

Priority 7 - Improving Information

To ensure appropriate and accurate information is available in a suitable format for effective and reliable use by all those involved in diabetes care

Commitment 7.1 We will ensure ongoing support and development of SCIdiabetes to further enhance its capability to enhance clinical care and assist in driving improvement

We will continue to enhance SCI-Diabetes to support clinicians and governance teams to identify areas for improvement at an individual patient, practice, specialist -care clinic, regional and national level, and monitor the impact of any changes that have been implemented.

We will continue to identify metrics and develop visualisations to identify progress against each of the priority areas in the Diabetes Improvement Plan and the commitments.

Work continues to strengthen the extensive data linkages that SCI-Diabetes has, for example with diabetes technologies and pregnancy services to increase the support provided to people with diabetes.

To ensure progress against this commitment we will ensure that health care professionals, SCI-Diabetes and e-health teams work collaboratively to ensure that changes implemented in SCI-Diabetes support clinical care and drive improvements in diabetes care.

Commitment 7.2 We will support national, regional and local health improvement strategies through refinement to the diabetes dashboard and the Scottish Diabetes Survey

We will continue to develop the diabetes dashboard within SCI-Diabetes to allow health care professionals to monitor the outcomes for the populations they care for, support identification of areas where improvement is required and allow for sharing of best practice. Particular areas of focus will be around inpatient care and diabetes in pregnancy.

The diabetes dashboard in tandem with the Scottish Diabetes Survey will continue to provide information on key diabetes related measures and outcomes and will be used to inform progress against the priority areas within the Diabetes Improvement Plan and drive health improvement initiatives.

To ensure progress against this commitment we will continue to promote and review the usage of the diabetes dashboard across Scotland. We will identify and share examples of quality improvement initiatives as a result of information highlighted in the diabetes dashboard.

Priority 8 - Innovation

To accelerate the development and roll-out of innovative solutions to improve treatment, care and quality of life of people living with diabetes

Commitment 8.1 We will support the development and roll-out of innovative solutions to improve treatment, care and quality of life of people living with diabetes

In collaboration with the Chief Scientist Office, the National Planning Board and NHS Scotland's wider innovation work streams we will continue to maximise the opportunities around data, technologies and innovation to improve diabetes care and outcomes in Scotland.

One key area of focus will be the evaluation, adoption and widespread implementation of existing technologies such as hybrid closed loop systems and also emerging technologies such as single and dual hormone Artificial Pancreas Systems. We will work with key stakeholders including the Scottish Health Technologies Group and NHS National Services Scotland Procurement to ensure Scotland is well placed to ensure timely and affordable access to such technologies.

Other key areas we are looking to develop will be innovative solutions to improve in-patient diabetes care and foot ulcer prevention. In addition we will work with key Scottish based groups developing health informatics and artificial intelligence solutions to improve risk stratification, communication and improve person centred care models.

While most diabetes technologies are used for people living with type 1 diabetes, consideration will also be given to the use of appropriate technology for people living with other types of diabetes.

To ensure progress against this commitment we will continue to promote networking opportunities and mechanisms to increase the pace of adoption of proven innovations.