Diabetes Improvement Plan

1. Introduction

Context

1. One in 20 people in Scotland have diabetes. There were 268,154 people diagnosed with diabetes in Scotland recorded on local diabetes registers at the end of 2013^[1]. This represents 5% of the population. Crude prevalence of diabetes ranged from 4.34% to 5.8% across NHS Boards. The majority of people living with diabetes (88.2%) have type 2 diabetes and nearly 11% have type 1 diabetes. Annex A sets out these figures in more detail.

2. The Scottish Public Health Observatory (ScotPHO) has estimated that there are 49,000 people who have undiagnosed type 2 diabetes. In addition, Diabetes UK estimates previously suggested there are approximately 620,000 people in Scotland who are at high risk of developing type 2 diabetes. However they now consider this figure to be higher^[2].

3. The increasing prevalence of diabetes puts more and more pressure on diabetes services. For example, over the last decade the number of primary care contacts because of diabetes has risen by a quarter to an estimated 800,000 contacts per year^[3]. Diabetes services have worked extremely hard to absorb these pressures but new innovative approaches are required in order to continue to improve care into the future.

4. The rising numbers of people with diabetes comes at a heavy price both for individuals and their families, but also to the NHS and the economy. The York Health Economics Consortium recently calculated that diabetes currently accounts for approximately 10% of the total health resource expenditure in the UK and is projected to account for around 17% in 2035⁄36^[4]. They note that complications related to diabetes account for a substantial proportion of the direct health costs and that as prevalence increases, the cost of treating complications will grow if current care regimes are maintained.

5. Compared with the white population, type 2 diabetes is up to six times more common in people of South Asian descent and up to three times more common in those of African and African-Caribbean descent. The average age at diagnosis is younger and relative risk of death at any age between three and six times higher in minority ethnic groups.

Quality Strategy and the Route Map

6. The NHS Scotland Quality Strategy (2010) is the blueprint for improving the quality of care that patients and carers receive from the NHS across Scotland. It sets out ambitions which acknowledge:

• Putting people at the heart of everything the health service does;
• A focus on providing the best possible care; and
• Recognition that real improvement in quality of care involves all staff, both clinical and non-clinical, working at all levels in all roles.

7. The publication of the Quality Strategy, with its ambition for world class health care, encourages us all to aim for services that at least match the best that can be found elsewhere in the world. The Quality Strategy remains our vision and the anchor point which we should continually reference as we move forward.

8. Building on the Quality Strategy and emphasising the continued commitment to pursuing the three Quality Ambitions of Safe, Effective and Person-centred care, the Route Map to the 2020 Vision for Health and Social Care (2013) sets out a new and accelerated focus on 12 priority areas for action. The Route Map maintains the focus on improving quality at scale with regard to both health and social care. Working in partnership - across Scottish Government, with the wider public sector, the third sector, staff and with patients - has been crucial to our past successes and will remain so as we progress further in our ambition to deliver safe, effective and person-centred-care. Annex B maps the Diabetes Improvement Plan priorities against those of the Route Map.

Quality Improvement

9. Since 2013, the Scottish Government has been encouraging the use and implementation of the 3 step Improvement Framework for Scotland's Public Services. This has been supported further by the publication of the NHSScotland Quality Improvement Hub document on 'the spread and sustainability of quality improvement in healthcare' which identifies the factors vital to plan for at the onset of improvement work to optimise spread and sustainability. Further information on resources available is provided in Annex C.

10. This approach is not about developing something new but about unlocking and channelling the collective knowledge and energy of people towards a common goal of real and lasting improvement.

11. The methodology of the 3 Step Improvement Framework is designed to prompt self-assessment and debate. It is about getting started and 'doing': creating conditions for and implementing the improvements that will make a difference. It is easy to become distracted by a series of assumptions based on how things have always been rather than try something new. It is about encouraging people to work together locally to test and try new approaches and, where successful, work with our national advisory structures to ensure that there is spread and sustainability of these approaches.

12. In developing this Improvement Plan we have taken a partnership approach involving and engaging our national advisory group - the Scottish Diabetes Group - and its constituent parts. Successful implementation of this work will depend on continued collaboration between all those involved.

13. There are already a number of examples of a quality improvement (QI) approach being applied by the diabetes community, e.g. 'think, check, act', which is the new name for the Diabetes in Scottish Hospitals (DiSH) project. The challenge is to ensure that systematic quality improvement approaches are implemented more widely.

A Network Approach

14. Managed Clinical Networks (MCNs) have a crucial role in the continued development of structures and services to help support and influence the quality improvement of care and are the key vehicle for the delivery of our improvement aims. The functions and benefits of the MCN approach was most recently set out in July 2012^[5]. We encourage Boards to ensure that their MCNs are fit for purpose with a lead clinician working alongside a network manager to provide strong clinical leadership and working in collaboration with patients.

Person-centred Care

15. If care is to be truly person-centred then any improvement work must not just be about health issues but also about social care. Integration of health and social care is the Scottish Government's ambitious programme of reform to improve services, ensuring that health and social care provision across Scotland is joined-up and seamless. This Improvement Plan includes priorities relating to living with the condition.

16. The Scottish Government is taking forward a range of activity to further enhance person-centred care and ensure that the patient experience informs the development of health and social care. The House of Care is a framework which when implemented will help to achieve the delivery of coordinated person-centred care. The model is built on quality improvement methodology, supported by empowered patients and carers working in collaboration with healthcare practitioners to enable change at an organisational level. Central to its success is the interaction between patients and practitioners of care and support planning. Work in Scotland to adopt care and support planning supported by the House of Care framework is currently being aimed at general practitioners (GPs) but also has specialist involvement. This will build skills that support relational care responsive to the needs of people living with long term conditions through individualised care planning and goal setting. Specific activity is also in progress within the diabetes community in the three early adopter sites.

17. Listening and responding to the experiences of people using health and social care is an important part of informing the development of person-centred services. We need to build on the successes of existing initiatives which have been developed across a number of long term conditions including diabetes (such as Patient Voices) and for people to provide direct feedback at a local level regarding their experience of care (such as Patient Opinion). The Scottish Government is working with Healthcare Improvement Scotland and the Health and Social Care Alliance (the ALLIANCE) to develop a mechanism to ensure that the patient voice is heard at a national level.

18. As the integration agenda progresses we are committed to ensuring that we work with patients to ensure that any forthcoming priorities reflect their needs. Person-centred care will also mean recognising that many people live with more than one condition, that is have multi-morbidities, and as we take this work forward we must endeavour to ensure a holistic approach to their care.

Diabetes Care

19. The Diabetes Action Plan 2010: Quality Care for Diabetes in Scotland was centred around the principles of the Quality Strategy and was intended to drive up standards of care through genuine involvement of people with diabetes, sharing of outcome information and the promulgation of best practice. The new Diabetes Improvement Plan builds on progress to date, describes priority areas for improvement and outlines expectations in the context of new approaches to quality improvement (which are set out in more detail below).