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

Priority 3 - Person-Centred Care

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

The Diabetes Improvement Plan highlighted that person-centred care and well supported self-management were critical to ensuring good health outcomes and improved quality of life. Central to this was provision of quality and accessible patient education, supporting individualised care planning and recognising what is important to the person living with diabetes. A key area within this priority area was to improve outcomes for women with diabetes during pregnancy. There is a need to improve uptake of pre-pregnancy and pregnancy care for those with established diabetes and the screening for and management of those with gestational diabetes.

Action 3.1 Timely and appropriate access to high quality patient education and self-management support

Patient Education

For people living with diabetes, patient education can promote self-management, improves well-being and aid optimisation of glycaemic control. We need to reduce barriers to education and support by providing these opportunities at the right time, in the right place and with the most appropriate peer group or health care professional support.

To provide person centred care we continue to work across all aspects of the health and social care communities, including our partners in the third sector, to promote accessibility to educational and support opportunities. We continue to review how we open up education to everyone living with diabetes, their carers and families who may also need support.

We continue to develop and share resources across Scotland to optimise the educational message, information and support for all. The rate of change regarding new technologies to support team working during the COVID-19 pandemic could be used to evolve how patient group education is delivered. This removes previous barriers such as travel, numbers attending in a community setting and accessibility however we need to be mindful that new ways of delivering education does not exclude people from participating. It is noted that information governance issues within NHS Boards can limit progress with virtual patient education and so we strive to offer national resolution where possible.

STEP for people Newly Diagnosed with Type 1 Diabetes

As discussed under Action 2.2, STEP is a programme to support adults newly diagnosed with type 1 diabetes is in use or being rolled out across a number of health boards.

Development of National Education Pathway for Type 2 Diabetes

Work is underway to develop a national pathway for people newly diagnosed with type 2 diabetes to optimise their health and well-being. Uptake levels of type 2 diabetes education varies across Scotland and currently a range of packages/formats are offered depending on where the person with diabetes lives. In recognition of the importance of information on diagnosis a national stakeholder group is developing a toolkit of resources and options for learning (including online education) to ensure consistency of message which can be accessed in a format that is suitable to the person living with diabetes. Anything developed will include measurable outcomes to assess impact where possible while being mindful that requirements will vary based on an individual's needs. This work is being taken forward in collaboration with the DHI marketplace work with the SG Diet and Healthy Weight Team.

Action 3.2 Improvements in Care Planning

Care and Support Planning

There continues to be a move towards ensuring that people with diabetes are at the centre of the goal setting process and are able to develop mutually agreed care plans that meet the individuals care needs. The House of Care framework which has been implemented in many board areas across Scotland works to make Care and Support Planning conversations routine for people with long term conditions and supports self-management.

SCI-Diabetes has been progressively developed to ensure it has the functionality to generate person centred care planning booklets which include individualised goal setting. HCPs are encouraged to use these to inform consultations and actively promote self-management. The development of the diabetes dashboard shows the level of care planning that is taking place and we continue to strive to demonstrate improvements in this.

Action 3.3 Empowering and Engaging People living with Diabetes

Resources to support self-management

Websites, Social Media platforms and on-line learning (individual or group) have developed significantly in recent years but we need to ensure we are inclusive in promoting their use, ensure they support our person centred care models within communities while being mindful that digital solutions do not suit everyone. Education can open up opportunities to change behaviour and we need to be ambitious with our new developments and ideas to support self-management.

My Diabetes, My Way is an interactive diabetes website (and app) to help people who have diabetes through providing information on diabetes (leaflets, videos, educational tools and games) and giving access to diabetes clinic results to support them to manage their condition more effectively. Clinical teams have been proactively promoting this website and encouraging people to register to My Diabetes, My Way leading to an increase uptake in registrants and people actively using this website. By the end of 2019, the number of people living with diabetes who are registered to My Diabetes, My Way was 15.2% (47,343 people).

NHS Inform is Scotland's national health information service helping the people in Scotland to make informed decisions about their own health and the health of the people they care for. In addition to providing information on managing different types and complications of diabetes this website gives information on local services and healthy lifestyle advice. As noted earlier, the Scottish Diabetes Education Subgroup has recently taken over the editing rights on this website to ensure that the information and services are relevant to support people living with diabetes.

'What matters to you?' is a Scotland-wide campaign to encourage and support meaningful conversations between people who provide health and social care and the people, families and carers who receive such care. It is recognised that if personalised care that takes account of the things that matter most to people it will improves patients' outcomes and experiences.

Psychological Needs for People Living with Diabetes

The Psychology Provision to Support delivery of 'A Healthier Future: Type 2 Diabetes Prevention, Early Detection and Intervention Framework' was published in June 2020 to complement the Framework by outlining the need for and summarising the role of psychology in its delivery.

This document reports that psychological expertise can contribute to each of the four levels of the Framework and that best outcomes will be obtained by ensuring a suitable skill mix of staff providing psychological support. It highlights that provision of psychological support for those diagnosed with Type 2 diabetes is currently low throughout Scotland and that services for women with gestational diabetes (GDM) are variable. This document reports that early and appropriate support is crucial to improving service provision, physical health, mental health and well-being, and quality of life for people with a diagnosis of, or at risk of Type 2 diabetes. It also highlights how a psychologically informed and skilled healthcare team can support diabetes prevention.

In 2016, NHS Education for Scotland was asked by the Scottish Government to develop a set of resources to promote and implement trauma informed practice within Scotland. This was due to the growing recognition of the impact of traumatic experiences on people. These resources are being rolled out across the NHS workforce, including those who support people with diabetes to upskill and improve psychologically informed practice.

Action 3.4 Improve the outcomes in pregnancy

A pregnancy work stream was established to support NHS Boards to improve pregnancy related data collection and support improvements in care. This work is co-ordinated and driven by the Pregnancy Subgroup of SDG. There has been a particular focus on the identification and management of gestational diabetes, importance of pre-pregnancy guidance and assessment of the outcomes of diabetes related pregnancy.

Core data sets of information to collect in relation to diabetes related pregnancies have been developed but there have been barriers in terms of the various clinical systems linking with each other. There is the ongoing development of a link between SCI-Diabetes and the obstetric systems used in NHS Scotland. This will allow the introduction of pregnancy related measures within the diabetes dashboard.

Information relating to national trends in diabetes and pregnancy between 1998 and 2013 was published in 2018 and a further paper on factors associated with still birth in women with diabetes was published in 2019.

As noted earlier, people who develop gestational diabetes during pregnancy are at an increased risk of developing type 2 diabetes. This population is a key area of focus for the ongoing activity to support the Type 2 Diabetes Prevention, Early Detection and Intervention Framework and a core dataset for process and outcomes of gestational diabetes has also been developed.

SIGN Update: Diabetes in Pregnancy

The Scottish Intercollegiate Guidelines Network (SIGN) are producing a new guideline assessing Diabetes in relation to the management of diabetes in pregnancy including GDM.

SHTG Adaptation: CGM in Pregnancy and Type 1 Diabetes

In November 2020 the Scottish Health Technology Group (SHTG) recommended that CGM should be offered to all pregnant women with type 1 diabetes in Scotland from the first trimester. This advice reports that the use of CGM during pregnancy may improve maternal glycaemic control compared with self-monitoring of blood glucose (SMBG). It also reduces neonatal hypoglycaemia and the need for and duration of neonatal intensive care. Cost modelling estimates that the use of CGM in mothers with T1DM is cost saving compared with SMBG, with cost savings largely driven by a reduction in neonatal intensive care requirements.