Diabetes care - progress against national priorities: commitments - 2021 to 2026

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

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

The Diabetes Improvement Plan 2014 highlighted the need for the diabetes community to work alongside public health colleagues to support prevention of type 2 diabetes and signpost people at risk of developing diabetes towards relevant information and services. Supporting people to understand the risks and learn what can be done to manage them can delay or prevent the onset of type 2 diabetes.

Type 1 diabetes presents more acutely, but early identification and urgent treatment can prevent the development of life threatening diabetic ketoacidosis (DKA). Understanding the signs and symptoms of type 1 diabetes is critical for early identification and treatment of type 1.

Approximately 80% of diabetes complications are preventable or can be significantly delayed through early detection, good care and access to appropriate self- management tools and support. People living with diabetes are encouraged to engage with health services regularly to enable early detection of complications and treatment to prevent or delay further deterioration.

Action 1.1 Enhance strategies to support people at risk of developing diabetes and early identification of those with diabetes

Prevention, Early Detection and Early Intervention of Type 2 diabetes

The Framework for the Prevention, Early Detection and Early Intervention of type 2 diabetes was launched in July 2018. To support the implementation of this framework the Scottish Government committed significant investment over 5 years. Three early adopter areas were identified (Tayside, East Region (Fife, Lothian and Borders) and Ayrshire and Arran) in September 2018 and all other Boards provided with the opportunity to apply for seed funding to scope how the framework could be implemented in their area. Since then, all 15 NHS Boards have come on stream and continue to receive funding annually to support implementation of their plans.

There are a number of specific work streams within this agenda. National milestones have been agreed with the T2D Framework oversight groups in each health board to ensure progress towards delivery is monitored, supported by the SG Diet and Healthy Weight team. These work streams are summarised below:

• Adoption of the Counterweight Plus Programme as the tool for Type 2 Diabetes remission. Counterweight Plus is a total diet replacement programme delivered in line with the DIRECT study evidence base. It involves a minimum of 1 year of intensive dietetic intervention and meal replacements, followed by a period of food reintroduction. Clinical measures are taken, monitored and analysed throughout.
• Promotion, implementation and delivery of structured patient education programmes for people diagnosed with pre-diabetes, or at high risk of developing Type 2 Diabetes, that are integrated with subsequent tier 2 and/or 3 weight management pathways if needed to provide a menu of options to suit the health needs of this population.
• Confirmed and operationalised pathways for gestational diabetes (GDM) education to ensure consistent, high quality education for women with GDM, with additional dietary and lifestyle support during pregnancy for those women who need it most. These pathways should extend to post-partum stage, improving follow up rates for all women with GDM, with timely access to Type 2 diabetes prevention education and appropriate weight management if sought and required by women.
• To support early identification of people with Type 2 diabetes another area of focus is around risk stratification, promotion of self-assessment tool to access risk and targeted screening for those identified as moderate to high risk.
• Operationalised pathways that ensure those newly diagnosed with Type 2 diabetes get access to accredited and validated diet and lifestyle type 2 Diabetes structured education with seamless links to tier 2 and 3 weight management programmes, remission programmes and bariatric surgery where appropriate.

Across all disease areas in response to COVID-19 virtual care models are becoming the norm. Digital solutions, such as Near Me, are now the cornerstone of clinical care. In addition, virtual and digital solution are being developed to replicate many of our face to face interactions. To support the roll out of the Framework, a virtual information sharing event took place in May 2020 to showcase the current solutions being utilised by some boards and discuss various options and levels of input across adult and child healthy weight, GDM, pre-diabetes and type 2 Diabetes. A market review has been undertaken for the Scottish Government's Diet and Health Weight Team by the Digital Health and Care Institute (DHI) improve access to digital programmes.

SIGN Update: Prevention of Type 2 diabetes

The Scottish Intercollegiate Guideline Network (SIGN) are developing an update to their existing guideline Management of Diabetes (SIGN 116) in relation to the Prevention of Type 2 diabetes.

Action 1.2 Earlier identification of the diagnosis of diabetes and its complications

Prevention of DKA at diagnosis of Type 1 diabetes

In Scotland, over 30% of people diagnosed with type 1 diabetes have the life threatening condition diabetic ketoacidosis (DKA) and this rises to nearly 40% in those under the age of 5. A national education campaign on the early detection and urgent referral for those with new onset type 1 diabetes was launched in 2015 to increase awareness of this condition and provide guidance to support generalist care. The campaign centred on Think, Test, Telephone (3Ts) and encouraged people to question if symptoms looked like diabetes. People were advised to test immediately using a finger prick blood glucose and if identified telephone the diabetes centre so they could be reviewed by diabetes specialists that day.

Revision of the diagnostic information pages on SCI-Diabetes now allows capture of detailed information at diagnosis of type 1 diabetes including DKA status and requirement for admission. This will help assess the impact of the Think, Test, Telephone campaign. Refinements of the diabetes dashboard recently developed within SCI-Diabetes will include a focus on these metrics to further drive improvements.

A recent publication reviewing deaths in Scotland for those with type 1 diabetes highlighted that although absolute mortality has fallen, the relative impact of type 1 diabetes on mortality below 50 years has not improved. Key areas to consider are premature circulatory diseases and excess deaths related to DKA. Given these findings the DKA prevention campaign will be extended to include those with existing type 1 diabetes as well as potential new presentations.

Nine Processes of Care

Screening for diabetes complications enables care to be optimised when complications are developing. For adults living with diabetes, there are nine processes of care that are currently checked on an annual basis and Managed Clinical Networks are required to report on performance and progress against this.

One of the challenges impacting on performance of screening uptake has been the loss of the Quality Outcome Framework in primary care which linked payment with screening uptake. It is noted however that while this may have contributed to a reduction in the number of people with type 2 diabetes getting all nine processes of care undertaken, there has also been a reduction in performance for people with type 1 diabetes who are primarily looked after within secondary care. The 2019 Scottish Diabetes Survey reports that the number of adults who have foot screening recorded is 57% and 65% for type 1 and type 2 diabetes respectively. It is noted that while individuals with type 1 diabetes are more likely to attend diabetes specialist clinics, they are less likely to get their feet examined despite being twice as likely to develop a foot ulcer compared to people with type 2 diabetes. We are mindful that the ending of the Quality Outcome Framework and new developments in primary care bring new challenges but also opportunities and we need to enhance the interface between generalist and specialist care to improve quality.

The e-learning resource, Foot Risk Awareness and Management Education (FRAME) was commissioned by the Scottish Government to upskill and help standardise diabetes foot screenings performed by health care professionals. Information leaflets for people living with diabetes tailored to the person's individualised foot risk are available for sharing following foot screening in a variety of languages.

In 2017 posters featuring a prominent Scottish comedian focusing on diabetes and the importance of the nine processes of care were issued to every community pharmacy across Scotland. As well as demonstrating the checks that people with diabetes should have to help detect and reduce their chances of complication this poster campaign also directed people to areas of further support eg My Diabetes, My Way, Diabetes Scotland and their local pharmacy.

One local example of good practice around this is demonstrated in NHS Fife where they have developed local posters for displaying in clinic areas their performance in the last month for each of the measures of care alongside promotion of why the checks are important. Other health boards share information of the essential health checks with patient appointments to encourage greater uptake of these.

Our response to the ongoing COVID-19 pandemic has required diabetes teams to consider revising care models to ensure they meet the challenges of healthcare delivery with the restrictions that are likely to be in place for some time. There are opportunities to further develop existing care models in line with the 'House of Care' philosophy and utilise community hubs to develop a robust approach to screening and the surveillance of diabetes, and other long term conditions, to address the decline in monitoring.

Being mindful of the principles of realistic medicine changes to the regularity of some of the processes of care for some people will take place in the near future with retinal screening and foot screening moving to two year intervals for individuals deemed at low risk. There is opportunity to review this further to ensure that where possible we are providing an evidence based personalised approach to care which supports shared decision making.

Alongside any changes that evolve there is a need to continue to promote the value of these processes of care being undertaken to health professionals and people living with diabetes is noted.

Reducing Microvascular Complications

In 2016, a national campaign to support the prevention of complications by improving glycaemic control 'Know Your Numbers' was launched and information resources were developed. These included posters, banner stands and leaflets to encourage people with type 1 diabetes to know what their blood glucose levels mean and what they should be aiming for. These were provided to all diabetes centres across Scotland and these continue to be a core component of person centred care and agenda setting. Separate materials were developed specific to adults and children with type 1 diabetes and more recently this format has been used to develop 'Know Your Numbers' materials to support people living with type 2 diabetes.

Heel Ulcer Prevention

The Check, Protect, Refer (CPR) for Feet initiative aims to ensure all individuals with diabetes who are admitted to hospital have their feet checked on admission, if they are at risk of developing a foot ulcer their feet are protected and if they have a current foot ulcer they are referred appropriately.

Developments to SCI-Diabetes has led to the development of the Ulcer Management System where clinicians are asked to record all foot ulcers. This has resulted in over 5,000 ulcers being recorded now with an overall prevalence of around 1.7%. There is however a wide range of results across health boards, ranging from 1.1 to 2.2% for type 2 prevalence and 1.6 to 3.9% for type 1 diabetes. Further promotion of this should see improvements in recording all new episodes of ulceration on SCI-Diabetes and the variation in prevalence decline.

Retinal Screening

In 2016, the National Screening Committee recommended that people with diabetes who have a low risk of sight loss, receive screening every two years instead of every year, as is the case currently. Those people at high risk of sight loss will continue to receive annual screening. It was also proposed that the Optical Coherence Tomography (OCT) Surveillance Cycle be managed and delivered from within the DRS Programme.

Out of Hours Care

To support improvements in care for people living with diabetes out of hours, some partnership working is underway with the Scottish Ambulance Service and NHS24.

The Scottish Ambulance Service and NHS Fife are working together to better manage hypoglycaemia in their patients with diabetes. NHS Fife have developed a triage process to follow-up and manage people with diabetes who have experienced a hypoglycaemic event which results in an ambulance call out. Clinical systems between the Scottish Ambulance Service and NHS Fife have been linked to allow for glucose results to be reported and therefore alert the diabetes team of the people that require follow up. This initiative has led to a significant reduction in the number of call outs due to a hypoglycaemic events and improvements in patient care. There is ongoing work to roll this programme out nationally.

NHS Greater Glasgow and Clyde, with the support of the Scottish Diabetes Group are reviewing the algorithms and triage tools used within NHS 24 to ensure people using this service are directed to the most appropriate service in a timely manner. Self-directed support is central to this and the Diabetes Education Action Group now has editorial control over the content of the NHS Inform Diabetes web pages with an update having taken place at the end of 2019. A self help guide for diabetes is being developed and will be hosted on NHS Inform similar to public support tools which exist for some other conditions.

SIGN Update: Pharmacological Management of Type 2 Diabetes

The Scottish Intercollegiate Guidelines Network (SIGN) supports improvements in the quality of health care for patients in Scotland by reducing variation in practice and outcome, through the development and dissemination of national clinical guidelines containing recommendations for effective practice based on current evidence.

In November 2017, SIGN published Guideline 154: Pharmacological management of glycaemic control in people with type 2 diabetes. This guideline provides guidance on optimal targets for glucose control for the prevention of microvascular and macrovascular complications, and outlines the risks and benefits of the principal therapeutic classes of glucose-lowering agents and insulins currently available.