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Publication - Strategy/plan

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

Published
25 February 2021
Directorate
Healthcare Quality and Improvement Directorate
Topic
Health and social care
ISBN
9781800046788

Our Diabetes improvement plan refresh reflects the current challenges facing people living with diabetes. It also strengthens the actions set in our original plan to improve the prevention, treatment and care for all people in Scotland affected by diabetes.

View supporting documents Supporting documents

Annex A: Summary of Commitments for 2021 - 2026

1. Prevention and Early Detection of Diabetes and its Complications
Commitment How will we monitor progress?
1.1 We will continue to support the implementation of the Framework for the Prevention, Early Detection and Early Intervention of Type 2 Diabetes. 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 but this is now in remission
1.2 We will work collaboratively with generalist care colleagues to raise further awareness of type 1 diabetes and relaunch a DKA prevention campaign. 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
1.3 We will ensure care pathways support individuals to have their processes of care completed whilst considering the principles of realistic medicine. We will review the:
  • % of people with diabetes who have all nine processed or care recorded diagnosis
  • % of people with diabetes who have had foot screening
  • % of people with diabetes who have had screening for microalbuminuria
2. Type 1 Diabetes
Commitment How will we monitor progress?
2.1 We will support early optimisation of glycaemic control in new onset type 1 diabetes. 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.
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. 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 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
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. We will work with paediatric teams to assess the use of this document and support any subsequent activity that may be required as a result.
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 the:
  • % of 18 - 25 with diabetes with optimal glycaemic control
  • % of 18 - 25 with diabetes who are engaged with diabetes services
2.5 We will continue to support improvements in care and outcomes for adults living with type 1 diabetes. We will review the:
  • % of people with type 1 diabetes who are recorded as having one on 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 HbA1c >75mmol/l and a systolic BP > over 130 mmHg
3. Person-Centred Care
Commitment How will we monitor progress?
3.1 We will ensure timely and appropriate access to structured education and support for people living with diabetes. 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 HbA1c >75mmol/l
3.2 We will work collaboratively with partner agencies to support improvements in out of hours care for people living with diabetes. We will work with the Scottish Ambulance Service and NHS24 to assess the patient flow out of hours and support any subsequent activity that may be required as a result.
3.3 We will work with NHS Boards, clinicians and third sector to promote good practice and reduce variation in the quality of mental health support access across the country so that everyone has the opportunity to live well with diabetes. We will work with Diabetes Scotland and 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 emotional health can be discussed and any improvements recorded. We will convene a Short Life Working Group to identify a Patient Reported Outcomes Measure (PROM) for anxiety and depression that can be incorporated into routine clinical care and to work with boards to ensure they have a robust pathway from screening to support for those who need it, dependent on local resources.
3.4 We will support ongoing work to improve outcomes in 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.
  • Ensuring 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)
3.5 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
  • improving timely input for patients with foot ulcers across all levels of social deprivation
  • improving healing rates with reduced rates of major amputations
4. Equity of Access
Commitment How will we monitor progress?
4.1 We will work collaboratively with NHS Boards/Heath 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 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 continue to engage with our communities and enhance our data capture to ensure people from more deprived areas, people from ethnic minority communities or people living with a disability are not disadvantaged from the services that are being delivered.
4.2 We will ensure that the outcomes for people living with diabetes are not disadvantaged as a result of digital exclusion. We will work key partners including Diabetes Scotland, My Diabetes, My Way andDigital Health and Care Institute to understand the scope of digital exclusion amongst people living with diabetes and the barriers to inclusion. We will consider age, deprivation status, ethnicity, and geographical location of people who are currently digitally include to help inform strategies to improve digital inclusion and mitigate against the risks of digital exclusion. An Equality Impact Assessment (EQIA) and Fairer Scotland Assessment will also be undertaken. We will consider the Rapid Response Evidence Review on Digital Exclusion/Digital Participation in Scotland published by Healthcare Improvement Scotland and will link with the 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.
5. Supporting and Developing Staff
Commitment How will we monitor progress?
5.1 We will up skill diabetes teams to support the mental health and wellbeing of individuals with diabetes, including the use of motivational interviewing and signposting to additional support where required. We will review the diabetes training opportunities available to health care professionals and uptake of these. We will undertake a further training needs analysis for our MDT Scotland-wide to gauge where improvement has taken place and where further support is required. We will encourage health care professionals to ensure that care and support planning considers the emotional wellbeing of the person living with diabetes and to capture person reported outcome measures around how supported that person feels.
5.2 We will support training and education on diabetes and ensure it is delivered/available to all healthcare professionals 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
6. Inpatient Diabetes
Commitment How will we monitor progress?
6.1 We will support boards to optimise diabetes inpatient care in hospitals across Scotland and reduce avoidable adverse events. 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
6.2 We will work with non-diabetes leads at health board level to optimise patient safety through the further roll out of Diabetes Think, Check, Act focusing on reducing insulin prescription errors and DKA. 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
6.3 We will work with non-diabetes leads at health board level to optimise in patient safety through the further roll out of CPR for Feet leading a reduction in iatrogenic foot harm. We will review the:
  • Uptake ofCPR for Feet modules
  • % of hospital acquired foot ulceration
7. Improving Information
Commitment How will we monitor progress?
7.1 We will ensure ongoing support and development of SCI-Diabetes to further enhance its capability to enhance clinical care and assist in driving improvement. We will ensure that the health care professionals, SCI-Diabetes and e-health teams work collaboratively to ensure that changes implement in SCI-Diabetes support clinical care and drive improvement in diabetes care.
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 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 dashboard.
8. Innovation
Commitment How will we monitor progress?
8.1 We will support the development and diffusion of innovative solutions to improve treatment, care and quality of life of people living with diabetes. We will continue to promote networking opportunities and mechanisms to support innovation which we hope will increase the pace of adoption of proven innovations.

Contact

Email: Clinical_Priorities@gov.scot

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