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NEWS FLASH:

How to Deliver a Modern Diabetes Service (DoH Drivers and Evidence Base)

The NHS has undergone more radical change over the last five years than at any other time in its 60-year history. The NHS Plan, published in 2000, which set out the Government’s core health policies and reforms, has driven these changes. The Government is now embarking on its ‘second phase’ of health reform, highlighted in the recently published five-year plan. The changes taking place over the next five years aim to:

• Improve the management of long-term conditions (for example diabetes)
• Reduce risk (evidence based treatments)
• Improve financial performance
• Increase patient choice (drive quality agenda)
• Reduce overall health care costs
• Minimise unplanned changes (financial stability)

There can be little doubt now, that for nurses who form the core of the workforce involved with the care of the person with diabetes, that these changes will have an impact on their roles in the future. Not least on the growing influence of Diabetes Specialist Nurses within an increasingly Primary Care based service.

It is clear that the Government considers diabetes to be a major priority. Consequently, a great deal of energy has been expended on developing a National Service Framework (NSF) for diabetes and an accelerated process of improvements in services and outcomes. This report highlights current national policy frameworks, which are influencing and shaping the future of diabetes care. (For comprehensive information visit http://www.dh.gov.uk/ and http://www.diabetes.nhs.uk/).

The local diabetes network will give front line care staff the opportunity to define the service they want for their patients and thus allow service providers such as the diabetes service and independent providers to respond. This will facilitate quality services that meet patient’s needs and offer value both to patients and commissioners.

National Service Framework for Diabetes

Diabetes services are expected to develop and improve to meet the needs of people with diabetes. In order to achieve this, the government has developed a range of targets set out within a number of policy frameworks, both specific to diabetes (e.g. the NSF for Diabetes), and those focussing on wider NHS issues.

A report Improving Diabetes Services – The NSF 2 Years on, by Dr Sue Roberts, National Clinical Director for Diabetes to the Secretary of State for Health, describes the progress made during the second year of implementation of this programme. It is structured to reflect the three key themes behind the diabetes NSF:

• Patient-centred care
• Working together
• Support for service delivery

According to the report, the first year of the programme produced considerable local and national improvements in diabetes care. The National Diabetes Support Team (NDST) is up and running and providing support to frontline diabetes service. The NDST identify best practice and evidence and share this with health care professionals involved in diabetes services nationally.

There are now 158 diabetes networks in England, with 89% of Primary Care Trusts (PCT’s) being part of a diabetes network. In addition, 82% of PCT’s have identified user champions for diabetes who are involved in influencing diabetes service delivery. Improvements have also been made in patient education. This has been primarily in the form of Structured Education Programmes.

However, despite this significant progress much still needs to be done. The author of the report, Dr Sue Roberts, states that “It demonstrates that real action to tackle some of the existing challenges has been taken…However, I am aware that the service provided to people with diabetes is, on the whole, still patchy and piecemeal. The coming years will have to witness measurable progress in working towards the NSF standards”.

The Cochrane Review

Specialist nurses in diabetes mellitus (Cochrane Review)

People with diabetes have multiple learning needs relating to their diet, monitoring, and treatments. In most healthcare systems in England Diabetes Specialist Nurses (DSN’s) provide much of these needs, usually aiming to empower patients to self-manage their diabetes. The Cochrane Review 2003 aimed to assess the effects of the involvement of specialist nurse care on outcomes for people with diabetes, compared to usual care in hospital clinics or primary care with no input from specialist nurses. A total of six trials including 1382 participants who were followed up for 6-12 months were included. The main results showed that glycated haemoglobin (HbA1c a fundamental marker which demonstrates how well blood glucose is controlled in a person with diabetes) in the intervention groups was not found to be significantly different from the control groups over a 12 month follow up period. Furthermore, where reported, emergency admissions and quality of life were not found to be significantly different between groups. No information was found regarding BMI, mortality, long-term diabetic complications, adverse effects, or cost. (http://www.cochrane.org/reviews/en/ab003286.html).

Patient-Centred Care

Patient-centred care is central to the NSF and is needed to ensure that individual care matches individual needs and nurses will be fundamental in this process. Nationally major progress has been achieved in involving users and encouraging partnership working.

Health Minister Rosie Winterton at Diabetes UK’s annual parliamentary reception (2005) announced plans to put patient education programmes at the heart of diabetes services. A joint report by Department of Health and Diabetes UK provides guidance to give people with diabetes the knowledge they need to manage their condition effectively.

NICE guidance on patient education is to be reinstated and PCT’s will need to implement NICE recommendations by providing all people with diabetes high-quality, structured education from January 2006.

In the forward to the Department of Health, Structured Patient Education in Diabetes, Report from the Patient Education Working Group (2005), Rosie Winterton states “One of the explicit aims of the Diabetes NSF is to ‘make best practice the norm’ and reduce variance between services. Apart from the clinical improvements that this requires, there is also a need to ensure that all patient education is based on sound education principles and is quality assured”. (http://www.dh.gov.uk/assetRoot/04/11/31/97/04113197.pdf)

NICE Technology Appraisal

NICE Health Technology Appraisal #60 – Guidance on the use of patient-education models for diabetes recommends that: “structured patient education is made available to all people with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need”.

The usual 3-month funding direction that accompanies NICE Technology Appraisals was waived when the guidance on patient-education models was published in April 2003. However, Ministers agreed to its reinstatement from January 2006, at which point the NHS will need to make funds available for patients to be treated in line with this guidance. (http://www.nice.org.uk/page.aspx?o=TA060guidance)

Supporting people with long term conditions

Supporting self-care is an essential part of diabetes care. The diabetes NSF advocates the use of structured patient education programmes in order to achieve this.

Two national patient education programmes have been developed that meet the NICE Technology Appraisal for Patient Education criteria:

• Dose Adjustment For Normal Eating (DAFNE) for people with type 1 diabetes (http://www.dafne.uk.com/)
• Diabetes, Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) for people with type 2 diabetes. (http://www.desmond-project.org.uk/)

PCT’s are at liberty to commission these programmes for local health services. Or as in many case develop their own programmes as long as they meet the standards set out by NICE.

Self-care – A real choice: Self-care support – A practical option; was published in January 2005, and is aimed at PCT, NHS Trust, SHA and social care management teams as well as health and social care professionals and practitioners. (http://www.dh.gov.uk/assetRoot/04/10/17/02/04101702.pdf) Its purpose is to:

• Provide information on the developing policy on support for self-care and the reasons why it is important (the why)
• Suggest what practical action can be taken by those delivering health and social care (the what)
• Provide some ideas on how to support self-care (the how)

Supporting People with Long Term Conditions aims to embed into local health and social care communities an effective, systematic approach to the care and management of patients with a long-term condition.

The key criteria agreed by the Patient Education Working Group are underpinned by the philosophy that the programme will be evidence based, dynamic, and flexible to the needs of the individual and users should be involved in its ongoing development. The programme should have specific aims and learning objectives, which are shared with patients, carers and family. The programme should support self-management attitudes, beliefs and knowledge and skills for the learner, their family and their carers.

There are four key criteria headings, which state that education programmes should:

• Have a structured written curriculum
• Have trained educators
• Be quality assured
• Be audited

Doing things differently

Many areas of the country are exploring new approaches to diabetes care delivery in order to ensure better accessibility, consistency and choice for patients. This has included switching routine outpatient work, traditionally performed in specialist clinics, to the community under the supervision of trained primary care staff. Several initiatives have tested the introduction of specialist support for diabetes in primary care. Diabetes care requires partnership between many different healthcare professionals to provide an integrated service. Consequently, the best model adopts a multidisciplinary approach that places greater emphasis on collaboration between primary and secondary care, with specialists providing support and training to GP practices.

Each practice is ideally linked to a consultant and one or more diabetes nurse specialists. Most patients with diabetes visit their primary care team. Immediate specialist advice is usually only a phone call away so it is generally not necessary for most patients to attend outpatient’s clinics. This allows specialist teams to concentrate on managing patients with complex problems and focus on structured education programmes. Practice and specialist teams should meet regularly to discuss patient care, management issues and team development.

Joining things up

The development of local diabetes networks has been identified as an essential part of NSF standard delivery. Currently, 158 diabetes networks have been, or are in the process of being set up across England. Development and assessment support is available from the NDST’s eight new Regional Programme Managers. In addition, a network self-assessment tool will soon be available.

Government bodies working together

Several areas of government are working together to support local diabetes services:

• The Vascular Programme Board forms an alliance between the diabetes, CHD, elderly and renal teams to provide strategic direction
• Work on long-term conditions – a common approach has been adopted for the long-term conditions NSF, diabetes NSF and the developing long-term conditions strategy
• Work on self-care – The Expert Patient Programme (EPP) has been pivotal to encouraging self-care management skills in people with long-term conditions, including diabetes.

Support for service delivery

2005 has seen local support delivery initiatives created, many revolving around the NDST. The NDST works in collaboration with diabetes care co-ordinators in Strategic Health Authorities (SHA), PCT’s and NHS Trusts throughout England to ensure the NSF and Diabetes Delivery Strategy are as fully implemented as possible. The eight Regional Programme Managers are now in place and provide local support for networks, PCT’s and other service providers.

The main functions of the NDST are:

• Network development – provide funding and support for 158 local networks
• Knowledge management and communications – systems and processes have been established to facilitate information capture and exchange, including a website, on line forums, email-based briefings and fact sheets

Retinal screening

Diabetic retinopathy screening is one of the Priorities and Planning Framework (PPF) targets in the diabetes NSF. Local delivery of this target has been developed by the UK National Screening Committee’s national screening programme for sight threatening retinopathy. Without a clear idea of the current situation, it is impossible to ensure that people with diabetes are getting the care deserve. People with diabetes could be going blind as a result.

Funding has already been set aside to enable PCT’s to meet the NSF target on retinal screening. 

Workforce

Phase 1 of the Diabetes Competence Framework has proved extremely useful in supporting workforce development. It is a practical tool focussing on the routine management of people with diabetes (i.e. aimed primarily at Practice Nurses and diabetes care assistants). It has already been used to establish job descriptions and training requirements for diabetes healthcare assistants.

http://www.skillsforhealth.org.uk/

http://www.escriber.com/Assets/EscriberDownloads/Images/A%20Professional%20Toolkit
%20for%20Nurses%20Working%20in%20Diabetes%20Care.pdf

http://www.diabetesnurse.org.uk/Downloads/Competency-Framework.pdf

Measuring improvements

Measuring improvements in service delivery and the impact the changes are having is crucial to successfully implementing the diabetes NSF and Diabetes Delivery Strategy.

Several products are now available to help analyse and support service development, including:

• National Diabetes Audit – a voluntary national system for routine data collection, analysis and feedback that can show if long-term outcomes for people with diabetes are improving http://www.icservices.nhs.uk/ncasp/pages/audit_topics/diabetes/
  default-new.asp
• Diabetes E – a nationally procured, web-based service that enables PCT’s, GP practices, and diabetes networks to perform the diabetes service assessments necessary to ensure NSF delivery (244 PCT’s have signed up) www.diabetesE.net/demo
• PBS (Public Health Observatory, Brent, SchArr) diabetes prevalence model – provides an evidence – based approach for determining diabetes prevalence (diagnosed and undiagnosed) at SHA, local Authority and PCT level. http://www.lho.org.uk/HIL/Disease_Groups/Diabetes.aspx
• Better Metrics Project – a joint venture between the SHA and National Clinical Directors has defined 13 indicators to measure how successfully the NSF standards are being implemented http://www.diabetes.nhs.uk/Reading_room/Factsheets.asp

The Department of Health acknowledges that much work is being done to implement the NSF for Diabetes and highlights several areas for encouragement.

There is now:

• Greater emphasis on patient involvement to influence and tailor service delivery
• Recognition that working practices need to evolve in order to meet the needs of people with diabetes
• Greater awareness of cultural issues and the need to work within the community to address these issues
• Evidence to suggest that diabetes networks are enhancing service delivery

The Department of Health warns, however, that there are still unacceptable differences in care and treatment for people with diabetes and although there are grounds for optimism, there is no room for complacency.

The Diabetes Continuing Care Reference Dataset brings together into one dataset the combined clinical data requirements of the National Diabetes Audit, the Diabetes chapter of the new GMS Quality and Outcomes Framework (QoF), the Diabetes E performance management tool, and the diabetes indicators for Better Metrics Performance Indicator Project.

The dataset was approved as a national standard by the Information Standards Board in March 2005, and includes the following three data items on patient education:

• The date on which a review of the patient’s diabetes education requirements took place
• The date on which a diabetes structured education programme was offered to the patient
• The date it was recorded that a patient has completed/attended a patient structured education programme

Supporting people with long-term conditions

An NHS and social care model to support local innovation and integration

Supporting people with long-term conditions: An NHS and social care model to support local innovation and integration was published in January 2005 and is aimed at PCT, NHS Trust, SHA and social care management teams as well as health and social care professionals and practitioners. Its purpose is to:

• Provide information on the developing policy on support for self-care – the reasons why it is important (the why)
• Suggest what practical action can be taken by those delivering health and social care (the what)
• Provide some ideas on how to support self-care (the how)

Supporting people with long-term conditions aims to embed into local health and social care communities an effective, systematic approach to care and the management of patients with a long-term condition. The NHS and social care long-term conditions model involves matching care with need, and patient education will run through all levels of care. The model highlights the need for supported self-care in order to ensure that patients are empowered and informed. Education will have an important role in delivering these objectives.

Long-term conditions National Service Framework

The department of Health has subsequently published The long-term conditions NSF in March 2005. The NSF primarily aims to transform the way health and social services support people to live with long-term neurological conditions.

Key themes are independent living, care planned around the needs and choices of the individual, easier, timely access to services and joint working across all agencies and disciplines involved.

The principles of the NSF are therefore also relevant to service development for other long-term conditions. This NSF is a key tool for delivering the Government’s strategy to support people with long-term conditions outlines in the NHS Improvement Plan: Putting People at the Heart of Public Services. It applies to health and social services working with local agencies involved in supporting people to live independently, such as providers of transport, housing, employment, education, benefits and pensions.

Medicines management

Practical support will be provided to PCT’s and NHS hospital Trusts to help implement the medicines management aspects of the NSF for Diabetes. Guidance will be provided on the clinical, cost-effective and safe use of diabetes, medicines to ensure that patients receive the right drugs and doses, and are involved in the treatment decision-making process.

Workforce development

The training, recruitment and retention of medical staff are the biggest challenges to improving the quality and responsiveness of the NHS. The emphasis is on increasing retention via a range of initiatives aimed at improving the quality of the working life for NHS staff and making health service careers more attractive, including:

• The Agenda for Change – employment and career conditions for all NHS, except doctors and dentists
• The National GMS Contract – GP practices will be contracted to provide a core range of services including monitoring of diabetic patients. Diabetes care is a high priority within the contract
• The Consultant Contract

Planning framework 2005-08

This initiative sets out the planning framework for all NHS organisations and social service authorities over the next three financial years. It looks to PCT’s and Local Authorities to forge even closer local partnerships in order to take forward the NHS Improvement Plan. Building on the Local Strategic Partnerships, they will need to work closely with other NHS organisations to prepare Local Delivery Plans for the period 2005-06 to 2007-08. The framework is very clear on its expectations stating, “Meeting the core standards is not optional”. Healthcare organisations must comply from the date of publication of this document.

New contractual framework for pharmacy

A vision for pharmacy in the new NHS (July 2003) set out the continuing programme of reform for pharmacy services. The proposed new contractual framework for community pharmacy, published recently is key to delivering the vision of community pharmacy in the future. Benefits for patients and the NHS include:

• Improved patient choice and convenience in accessing medicines
• Management of long-term conditions e.g. diabetes, through pharmacist medication reviews
• Reducing health inequalities
• Improved patient safety through advice to patients and other professionals
• Sustained achievement of the 24/48 –hour access target
• Supporting GP’s and other primary care staff
• Helping GP’s meet quality targets for prescribing
• Improved prescribing and reduced wastage of medicines

Chronic disease management

Chronic disease management (CDM) is emerging as a high priority for the Government. The failure to manage chronic diseases effectively on a day-to-day basis results in patients developing unnecessary complications and can lead to premature death.

The intention is to offer tailored services that encourage long-term self-care and effective and appropriate interventions. A key aim is to avoid hospital admissions for the chronically ill. Several pilot projects focusing on care of the elderly and coronary heart disease are currently underway. The Dudley Model of Care is a superb example of new ways of managing chronic disease and is often cited by the Secretary of Health Patricia Hewitt. http://news.bbc.co.uk/1/hi/health/4921872.stm

To work well, CDM systems require effective information management, patient education/support and responsive and adaptable services. Private sector involvement in supporting CDM is now inevitable with a number of private providers already positioning themselves to take advantage of the potential new market in health care provision for the chronically ill. Perhaps the most notable example at the moment is Richard Branson’s ‘Virgin Health Care’. There is little doubt that in the next few years privately run treatment centres will play a key role in long-term condition health care provision. The management of diabetes is acknowledged as a key issue, and diabetes is one of the 11 chronic diseases recognised by the Government as being a priority.

Funding for Diabetes Services

Payment by Results

A fundamental change in the way money flows around the NHS (‘Reforming NHS Financial Flows’) has been implemented. The costs of secondary care are fixed across the country. PCT’s will be able to commission services (e.g. retinopathy treatment) at a fixed price (the national tariff) and be free to negotiate around patient numbers. Most secondary care services will be covered by 2007-2008. Private providers matching the tariff can also be commissioned to provide services.

The Department of Health is committed to a tariff-based system to support new service development for long-term conditions. It will be possible to ‘unbundle’ existing tariffs into smaller parts, enabling individual service costs to reallocated to new ways of working and to different settings. This will be enhanced as policies on CDM are further developed and as policies on these long-term conditions become consistent/complementary across primary and secondary care.

The payment by results system and practice-based commissioning is set up to allow for an ‘unbundling of the tariff’ for each of elements of the care pathway, such as insulin starts.

Note: If an insulin start is done by the GP surgery with a protocol in place and following an integrated care pathway then there is no need to make the payment. The person is then managed within primary care.

In theory, any diabetes service can then be accessed from different sources with lower provider costs leading to an overall cost saving in the pathway. Within the UK we currently have ‘scan in a van’ in operation, which is a mobile screening service that visits GP surgeries and takes referrals, in the same way as a static service, but for a lower cost. Of course there is nothing stop an independent provider conducting insulin starts in the patients home at price which undercuts the tariff and offers safe effective care at better value to the GP than engaging his own staff to carry out the process or referring to secondary care.

With this in mind those providing diabetes services should have a clear understanding of the way services are developing within their own health economy, identify any opportunities or threats and agree a plan to meet the challenges of shifting service models.

Patient choice

By 2008 there should be a maximum of 18-week wait between referral and treatment for all conditions. Within this, patients should be offered a choice of where they receive treatment including potentially the private sector. This initiative is linked closely to the ‘Payment by Results’ agenda, and overall is designed to drive up efficiency and quality of NHS providers. Currently, patient choice is restricted to treatment venue; however, this is expected to be extended to care pathways, especially for chronic diseases such as diabetes.

Practice-based commissioning

In April 2005, practice-based commissioning was introduced. Participating GP practices are allocated a commissioning budget and take responsibility for commissioning the full range of services. Practice-based commissioning will assume greater importance and should:

• Increase patient choice and drive up quality
• Allow practices to secure a wider range of services, more responsive to patients needs
• Increase the importance of supporting people with long-term conditions e.g. diabetes
• Allow funding to be directed into packages of care that best meet patients needs

Practice-led commissioning provides a new structure within which care can be managed proactively at the level at which patients generally enter the health care system. It provides incentives for clinicians to take responsibility for care, with any savings resulting from service improvement remaining within the practice.

Structure of diabetes services

Nationally diabetes services will strategically link together the Department of Health, the National Diabetes Support Team (NDST), the Strategic Health Authority, PCT’s and NHS Trusts, front line staff, and users and carers. This will be underpinned by the work co-ordinated by Diabetes UK.

The National Diabetes Support Team

The NDST (www.cgsupport.nhs.uk/diabtetes/The_NDST/The_team.asp) was established to support local healthcare services. It has already established a national diabetes network of healthcare professionals, which facilitates the sharing of information and good practice (www.cgsupport.nhs.uk/diabetes). It is also closely involved in a number of initiatives looking at service improvement including:

• A national Diabetes Workforce Group established to develop diabetes workforce planning and development, under the umbrella of the Long Term Conditions care Group Workforce (CGWT)
• Occupational standards for diabetes (e.g. retinopathy), commissioned by CGWT
• Diabetes Information Strategy Diabetes Datasets that define minimum standards that should be recorded and maintained within clinical systems
• The National Clinical Audit Support Programme, which has put a technical infrastructure in place to collect comparative diabetes clinical audit data
• Five new research projects defining groups at high risk of diabetes
• The Diabetes Heart Disease and Stroke Prevention Project, a primary care study designed to identify the prevalence of diagnosed Type 2 diabetes and coronary heart disease, and to screen for undiagnosed diabetes (www.nelh.nhs.uk/screening/diabetes/project/home.htm)
• The Expert Patient Programme (EPP), which runs national training courses to help people with long-term conditions develop new skills to manage their illness. By 2008, the EPP will be extended to all of the NHS

The programme of change in diabetes care delivery is supported by the Modernisation Agency through the NDST, which will play a pivotal role in strategy implementation over the next five years and influence policy relating to all aspects of diabetes care delivery. The NDST is responsible for ensuring the NSF standards are delivered. Their vision of how local services will underpin the national strategy.

The White Paper: ‘Our health, our care, our say: a new direction for community services’

The White Paper (WP) published in March 2006 provides great opportunities for people with diabetes and those who care for them. The principles at the heart of the WP go right back to the NHS plan and are aimed to ‘accelerate the move into a new era where the service is designed around the patient rather the needs of the patient being forced to fit around the service already provided’. The emphasis is on supporting self-care, promoting well-being and community engagement, as well as prevention and early intervention.

For the diabetes community none of this new. These are the principles that were outlines in the Diabetes NSF and the Delivery Strategy. But whereas it has sometimes seemed hard to move in the direction of greater self-management for patients, more care close to home, and more joined up working for staff, this is now being actively promoted as the central direction for NHS, and there will be incentives and new support both locally and centrally to help it happen.

The WP had a unique public consultation at the heart of its development, and it is good to know that the public felt that services for Long Term Conditions (LTC) like diabetes had improved considerably and the benefits of structured care are really appreciated. Obviously more needs to be done but there are now real opportunities to improve. The emphasis throughout this WP is on concentrating effort to improve services most in areas of greatest deprivation, these are the areas where diabetes is most common, where outcomes are worst and where people need most support, new resources and new ideas.

The WP is 230 pages long and packed with proposals and ideas. Many of these need to be worked out in detail and in pilots, so there are opportunities for the diabetes community to contribute to new thinking and evaluate new ways of working. Below are some of the many ideas, which will have a significant effect for people with diabetes and those who work with them.

http://www.dh.gov.uk/assetRoot/04/12/74/59/04127459.pdf

People with diabetes

People with diabetes will benefit from the initiatives to improve access to services and greater range of options for care and support for health improvement closer to where they live. There will also be better access to specialist advice, and up to date information, perhaps by seeing a specialist in the community but also because primary care teams will be working and training more closely with the specialists themselves. The important role of GP’s and primary care team in providing consistency of care is recognised and there will be many more opportunities for people to shape the sort of services available. For the first time some of what GP’s earn will depend on the results of patient surveys.

Support for self-care will be promoted by a document on ‘how to do it’ for PCT’s to be published imminently. The GP contract will increasingly contain requirements to support people in self care and the commissioners (those who decide what care should be available for people locally) will be monitored on how well they do this and how well they begin to move resources towards prevention, well being and community resources. Where primary care is not providing good care Primary Care Trusts (PCT’s) will have a duty to look for others to do it better, especially in areas of disadvantage.

The Diabetes NSF supported care planning and group education (structured education programmes for example) specifically designed for people with diabetes and there is currently huge demand for these both nationally and locally. The WP supports patient education in general and will treble the funding for the Expert Patient Programme (EPP), supporting its move to a community interest company, which will enable it to diversify, market and deliver self-management courses. Everyone will get an ‘information prescription’ containing details about diabetes and local services, and there will be more schemes in which GP’s can ‘prescribe’ exercise and other healthy activities. Care planning, already an important part of the diabetes NSF gets support, so that everyone can expect to be offered real involvement in planning their own care by 2010 ahead of the Diabetes NSF date of 2013. Those with both health and social care needs will be offered a Health and Social Care Plan by 2008. The WP recognises the importance of developing training for health care professionals to ensure that they have a greater understanding about how to help people who want to take a bigger part in their own self-care.

Type 2 diabetes may be prevented in two thirds of people by improved physical activity and diet. The WP team will develop a self-assessment ‘Life Check’ for everyone at key points in life. This will support individuals and communities at high risk of developing diabetes to get involved in more healthy lifestyles and environments.

Those who work with people with diabetes

A structured systematic approach to care for diabetes already practiced in the community is supported and promoted. Diabetes care teams will find that they are increasingly expected to include support for self-management and promoting well-being as part of routine care, and this will be included in future versions of the Quality and Outcomes Framework (QoF). This may also lead to better physical health and reduced demands on acute care.

The WP specifically supports multidisciplinary teamwork. There will be a higher profile for nurses and allied health care professionals (AHP) and pilot areas to look at direct referral, initially for physiotherapists but later for others. The role of pharmacists is emphasised. There will be more work on new skills and opportunities for staff including further thinking around Practitioners with a Special Interest (PwSI).

The value of specialist care is underlined in a substantial section, which describes ways in specialist care, and advice can be made more readily available to patients closer to home. This is the group of professionals who may be most affected in their day-to-day practice by these recommendations. The WP concentrates on surgical specialities. But diabetes specialists are already defining the challenges of working in this way, and developing solutions that go beyond simply changing the site of care to developing new ways to work in support of colleagues right across the community (e.g. Dudley Model). This white paper is an opportunity both to get these issues more widely understood, but also contributes to changes in practice that may improve the quality of services in the community. This will only come about if local diabetes networks grasp the opportunities in this WP and everyone, specialists and generalists alike, really work together with people with diabetes to design the services that local practices want to buy and that will genuinely improve health and patients experience.

Those organise and coordinate care

There are important new initiatives, which will underpin better services. Most of these relate to improved commissioning, joint work with social services and better use of information to guide these decisions. The central role for general practice (practice based commissioning (PBC)) in deciding what services to buy for their local population is emphasised.

There will be a new National Reference Group for Health and Well-being to guide decisions, and practices will be expected to take local QoF findings into account with other local information, and use tested methods to focus care on the local areas where it is most needed. A framework for Commissioning for Health and Well-being will be developed. To support joined up working and joint commissioning more PCT’s will work in alignment with social services and there will be new Directors of Social Services, Directors of Children’s Services and a greater role for the Director of Public Health. The ‘nuts and bolts’ of commissioning will become clearer over the next few months, including further thinking about how Payment by Results (PbR) can work better for LTC.

While much of the detail of the WP is around partnership work between health and social services, the WP makes clear that to reap the benefits for people with LTC commissioners will need to work with local providers to develop comprehensive, integrated and more effective packages of care. Cooperation and coordination between all providers is key, and diabetes networks can capitalise on this. This is a critical time for local networks to redesign services for everyone with diabetes. These need to include specialist services for children, pregnant women and those in hospital but also to ensure that there are really sound local schemes for prevention, to support well-being and self-care, and to engage people with diabetes in living healthy lifestyles within their communities.

Local commissioners will be looking for this now! Specific initiatives where the national diabetes team will be working with the diabetes community are in commissioning for diabetes, the ‘Year of Care approach’ and further development of the tariff.

Other organisations

The WP specifically mentions ‘The Third Sector’. This relatively new phrase recognises that there is much good work and huge potential for care to be delivered outside the ‘public and private’ sectors. Diabetes UK gets a mention as an example in Paragraph 7.94.

The WP encourages people to think of a whole new range of initiatives, such as cooperatives and other ‘social enterprise’ organisations. The ‘community interest’ initiative for EPP is an example. Some of this may sound quite daunting to people in the diabetes communities but there are opportunities for partnerships and joint working. The Department of Health will set up a Social Enterprise Unit and a Fund to coordinate support and encourage this.

Summary of the Governments agenda, pulling all the stands together

The NHS Plan was published in 2000. It was the first policy document on health to make quality as important as value for money.

http://www.dh.gov.uk/assetRoot/04/05/57/83/04055783.pdf

In 2002, the Wanless Report stated that the only way that health services can be afforded in the future is by people being fully engaged in their own health before and during times of sickness. Following this, the NHS received the largest injection of money in its history and subsequently there has been a steady stream of changes all designed to grasp opportunities to make the NHS fit for purpose in the 21^st century. The final important building block is now in place. This is the new White Paper that covers all aspects of the care people need in the community and in their own homes.

These changes have come out one by one and for clinicians they have sometimes not made much sense and felt like change for change’s sake. However, they have all been linked and the way they fit together has now been made clear in an important document published in March 2005 – Creating a patient-led NHS.

http://www.dh.gov.uk/assetRoot/04/10/65/07/04106507.pdf

Taken together these changes provide a foundation for the sort of service each of us would want for our families and ourselves. Healthcare professionals need to get actively involved for this to come about. They need to help shape it on the ground and take advantage of the benefits, working both on behalf of and with people with diabetes.

Up until now, most of the changes have been focussed on hospitals and people with acute illnesses. There are difficulties in transferring lessons to long-term conditions like diabetes, but also major opportunities. The Diabetes National Service Framework (NSF) supports the principles of self-management and systematic working across the whole diabetes community through diabetes networks. These are also core principles of the new NHS, meaning there are real opportunities to radically improve services. Getting it right now for diabetes could create a model for the management of long-term conditions in general.

The world has changed since the creation of the NHS. Although there is still national involvement in setting the quality framework for health services, the majority of health service funding has been devolved to local commissioners because they are seen as best placed to understand how services should be matched to local needs. This was described in Shifting the Balance of Power

http://www.dh.gov.uk/assetRoot/04/07/35/54/04073554.pdf

Before this was published in 2002, local services were expected to respond uniformly to national targets, which produced real improvements in areas such as waiting times and heart disease. However, some healthcare professionals and managers felt that these were not the priority in their local area.

This difficulty is being addressed by reducing the number of national targets in 2005/06, and ensuring that local services set and are monitored on their own targets. These are agreed with their Strategic Health Authority (SHA) in the annual Local Delivery Plan (LDP’s). These local targets should be based on national standards like those in the Diabetes NSF and NICE guidelines. All PCT’s are still expected to make the best the ‘norm’ as outlined in the Diabetes NSF, but they now have the opportunity to decide how best to go about it in their local area.

You can read the detail in National Standards, Local Action: Health and Social Care Standards and Planning Framework 2005/06-200708.

http://www.dh.gov.uk/assetRoot/04/08/60/58/04086058.pdf

This describes five key national targets for 2006-08 called Public Service Agreements (PSA’s). Although not specifying diabetes directly, diabetes services must meet all of them. This includes clear requirements for improved patient experience (which is also a key element in the Diabetes NSF), and an opportunity for diabetes services to contribute as much as 10% to targets to reduce emergency bed days. Since PCT’s will be closely monitored on these targets, local diabetes services can benefit by focussing on these areas. A fact sheet (Number 10) has been produced on how diabetes services can help reduce emergency bed days (http://www.diabetes.nhs.uk/downloads/Factsheet_length_of_stay.pdf).

National Standards, Local Action (http://www.dh.gov.uk/assetRoot/04/08/60/58/04086058.pdf) also makes clear that PCT’s will still be expected to achieve and maintain the targets outlined in the 2003-2006 Planning and Performance Framework (PPF). For diabetes, this means that PCT’s must achieve the two national targets on retinopathy screening and registers to underpin systematic patient care. All other standards in the NSF will need to be linked to local targets – all to be achieved by 2013.

The concept that local people know best has now been extended, with the realisation that it is grass roots clinicians who have the best knowledge of the needs of their communities and the best chance of involving them in decision making. Commissioning is therefore going to be practice based. Practices will be given indicative budgets, just as they have now for drugs, to decide what services they would like to buy for their patients. Experienced procurers will do the actual buying and negotiations to reduce the administrative burden on practices and get economies of scale. Practices may choose to group together to commission services.

For diabetes, it is important that local services are designed collaboratively so that practices are confident that the services they are recommending are of high quality and match communities’ needs. Specialists also need to be confident that wherever people with diabetes receive their care it really does meet the best standards of evidence-based practice.

Linking the different expertise of the generalists and the specialists with the expertise each person with diabetes brings to managing their condition can only do this. Diabetes networks are the ideal place for planning and service design across specialist, primary, community and social care. Diabetes professionals need to get involved now so services will not be developed with major gaps and inconsistencies.

Just as the needs of the population vary form place to place, so there are many different ideas about how to design and deliver services. Foundation Trusts were developed to give more flexibility to services to come with innovative ways of responding to what patients and commissioners want. The involvement of independent providers into the NHS delivery system also aims to introduce new ways of delivering services to suit people’s needs.

Previously independent providers have only been involved in patient, acute and diagnostic services. However, there will now be opportunities for them to be involved in providing primary care and community services. This was finally agreed as policy in the WP Our health, our care, our say. It is important that local diabetes networks have clear ideas about what they want for their patients so that Foundation Trusts and independent sector can respond to this. They may also come with their own exciting ideas. This is an opportunity for diabetes networks to be clear about what is needed for their patients in their patch. For too long diabetes service provision has been Hospital Specialist centric formulated with little or no primary care involvement.

If decisions are made locally and commissioners can buy services from whoever, provides the service that best fits the needs of their population, there has to be a national currency for everyone to use so that commissioners pay the same amount for the same services wherever it is in the country. The system that determines this currency is Payment by Results and the currency used is called the Tariff. This is a key issue for diabetes, and it will be crucial to ensure that people with diabetes and clinicians are involved in its development. A separate fact sheet (Number 11) is available to discuss Payment by Results in greater depth. (http://www.diabetes.nhs.uk/downloads/Factsheet_Payment_By_Results.pdf)

It is patients and clinicians who are usually best able to judge quality. However, a devolved system where the NHS has formal responsibility for quality of care requires not only a set of National Standards, but also an Inspectorate and Regulator.

The Standards, which apply equally to all providers of NHS services, are outlined in Standards for Betters Health.

The Healthcare Commission is the national inspectorate. The regulator for new foundation Trusts is called Monitor. Monitor’s job is to ensure that before and after they get approval or Foundation status, Trusts have the strong financial and governance structures making it safe for commissioners to do business with them.

The National Standards include ‘core’ standards, which outline a minimum level of quality and safety, which everyone receiving care anywhere should expect, and development standards to encourage improvement.

Aspects of the Diabetes NSF and the NICE appraisals related to diabetes are included in the ‘core’ standards. Delivery of all the NSF Standards is expected over a ten-year period, and implementing all NICE guidance will be developmental.

Fundamentally, the Healthcare Commission provides a way for the NHS to be called to account if it doesn’t achieve the Diabetes NSF Standards and NICE guidance. This provides a powerful lever for improvement, which clinicians can use locally to improve services and gain support from people with diabetes.

Clearly diabetes is only one of many services that the Healthcare Commission will be looking at. During the first year, the Healthcare Commission will be checking on delivery of the PSA and PPF targets (as outlined above) and specific NICE guidance. It has also commissioned a patient experience questionnaire for diabetes, which is likely to be used later this year. The links between diabetes and the Healthcare Commission will be described in a forthcoming NDST factsheet.

It is critical that diabetes healthcare professionals work in local networks. This provides opportunities to build and develop local plans enabling the PCT to meet these challenges.

Let there be no doubt, the DoH requires care of people with diabetes to improve and reach high quality, value for money standards as set out some years ago. A raft of policy documents and guidelines along with financial incentives and penalties (‘carrot and stick’) have been implemented to ensure that these changes take place.

Plymouth diabetes service must adapt and rise to the challenges presented within a modern NHS. Failure to do will place the service and its personnel at risk and potentially offer patients a disservice.

The current service model and care offered falls someway short of the standards outlined in this report.

Integrated care Pathway for Diabetes

Plymouth diabetes service is unique in the UK in setting up a fully