Diabetes Improvement Plan

2. Diabetes in Scotland

Progress to Date

20. Considerable progress has been made since the Diabetes Action Plan was published in 2010. The annual Scottish Diabetes Survey describes the continued improvement in recording of key diabetes parameters despite the increasing number of people with diabetes in Scotland. This reflects the strength of the healthcare community supporting people with diabetes in Scotland, the active engagement with people living with diabetes and the support of the Scottish Government and the third sector. Some of the notable initiatives which the Scottish Diabetes Group has supported in recent years are highlighted below.

Diabetes in Childhood and Adolescence

21. The setting up of the Childhood and Adolescent sub group in 2011 has acted as a catalyst to push forward developments in paediatric and adolescent diabetes services. This multidisciplinary group has:

• Provided the support (e.g. tailored feedback) to enable all clinics to focus on improving the poor HbA1c levels in children and young people.
• Enhanced the paediatric pages in SCI-Diabetes so that it is now being used in all paediatric clinics.
• Produced "Supporting Children and Young People with type 1 Diabetes in Education" to help provide clarity and promote a team approach for young people with diabetes in schools.
• Under an umbrella project called "Making Connections" and working with the clinics, Diabetes Scotland and young people, the Group is developing and implementing a programme to improve adolescent transition. A unique feature of this initiative is the training of young people to work with local transition services to deliver workshops, support young people or facilitate the local use of social media. The aim is to help young people to develop the life skills and self-reliance during transition (16-25 yrs) that should encourage greater engagement with adult diabetes services in the future.

Insulin Pump Therapy

22. During the last three years there has been a significant increase in the number of people with type 1 diabetes using insulin pump therapy. As of September 2014 over 2,340 people in Scotland are using an insulin pump - over 5% of the total number of people over 18 with type 1, and more than 1 in 4 children and young people. This form of insulin delivery has made a big difference to those who have received it. Successful insulin pump therapy is only possible following intensive work by the patient in association with the local diabetes team. This achievement has required significant redesign of many diabetes teams and the support of Scottish Government and NHS Boards.

Psychology in Diabetes, Psychology and Diabetes (PiD-PaD)

23. Psychologists have a key role to play in education and training; service design; improving self-management, and person-centred care and helping staff support people with diabetes manage their condition as best they can. Sponsored by the Scottish Diabetes Group the PiD-PaD psychologists working across five health boards (2.0 wte) have trained over 500 primary and secondary care staff in how to understand and change health-related behaviours using evidence-based methods that ensured generalisation to everyday clinical practice. An important element of this training was the availability of psychologists in diabetes services to support staff in their efforts to use these new skills. Alongside other clinical and health psychologists from across Scotland the PiD-PaD team delivered the first national training conference in 2012 on understanding and changing health-related behaviours, an event which was both well attended and very positively evaluated.

Diabetes Clinical Management System and Audit

24. Delivery of diabetes care involves collection and analysis of core diabetes information which influences clinical decisions. Many different healthcare professionals are involved and it is therefore important that key information is available to all of those who need this, no matter where or when it is gathered. Within Scotland we have developed and use SCI-Diabetes to do this. This is recognised as a world leading system collecting core diabetes data from the whole population with diabetes in Scotland. During the last two years an update of SCI-Diabetes has been introduced to all diabetes centres in Scotland, replacing a previous clinical system.

25. Analysis of the data can be at many different levels - individual patient data changing over time, hospital clinic or GP surgery data used to compare and improve services, or at NHS Board or Scotland wide information for national or international comparison to stimulate discussion and improvement. Linking of the information with clinical management systems has also enabled the identification of inpatients with diabetes in hospitals to aid improvement in their management.

26. An international comparison of HbA1c values for our population with type 1 diabetes has stimulated a desire to improve this in Scotland. SCI-Diabetes data is now being used to support improvement in individual clinics through the use of run charts.

Scottish Diabetes Research Network

27. The Scottish Diabetes Research Network (SDRN) supports clinical and epidemiological research across Scotland. The network supports 6 research nurses and has made a positive contribution in increasing trial activity in Scotland. There were a total of 1202 patient trial visits in 2009 and 3667 last year. In the last year, the SDRN portfolio included 67 research projects. Individual trials include internationally funded trials in type 1 diabetes (Bioresource), a range of commercial trials of novel therapies for people with diabetes, a ground breaking multicentre trial of insulin pump therapy (REPOSE), and novel trials of pharmacogenomics (DIRECT).

28. Using information generated through SCI Diabetes, linked to other data within NHS Scotland, to examine many aspects of diabetes care and science, the network's epidemiology group has continued to improve our understanding of the impact of changing diabetes care on our population, the complications associated with diabetes and the development of new therapies.

29. Achievements include in depth examination of the diabetes retinal screening programme, of contemporary mortality in people with type 1 diabetes, rates of amputation in people with diabetes and examination of safety aspects of diabetes medication including insulin glargine and thiazolidinediones. Importantly SDRN epidemiology has also facilitated the use of routine datasets for longer term follow up of clinical trials (e.g. WOSCOPS) and specialised patient cohorts (e.g. the SCOTS study of patients undergoing obesity surgery) - making Scotland a more attractive site for a range of future research studies.

Education

30. The past three years have seen significant improvements in patient education throughout Scotland. This progress has been overseen by the Diabetes Education Advisory Group, and coordinated and supported by the national education lead and local MCN education leads. Through consultation documents, discussions and workshops, a consensus was reached on the essential criteria for what constitutes structured patient education. Criteria for ensuring a professional is a trained educator were developed and agreed. A process was developed to review and ensure that current patient education meets the recommended criteria and healthcare professionals, people with diabetes and carers from most of the Health Boards have now been trained as reviewers of patient education programmes.

31. It is important that patient education courses are tailored to suit local circumstances, but crucial that they are of an appropriate standard. The process developed can provide reassurance to people with diabetes and those delivering the courses that these meet our quality standards. The delivery of accredited structured education can now be recorded on SCI-Diabetes. With this in place, the delivery of structured education across Scotland can be measured to ensure that people with diabetes are able to access the education support they require.

Inpatient Diabetes

32. In 2012, in conjunction with the national NHSScotland Quality Improvement Hub, three Scottish Health Boards tested the NHS Diabetes Think Glucose approach to improving inpatient care, where diabetes is a secondary condition. Improvements were seen in hypoglycaemia management, insulin prescribing, early identification of patients with diabetes and rates of hypoglycaemia. The results and experience from the testing have led to NHSScotland Quality Improvement Hub developing a package of measures, interventions and education, using improvement methodology, for roll out across Scotland. The economic implications of improving diabetes care in hospital are being evaluated as part of the on-going work.

Foot care

33. Led and supported by the Scottish Diabetes Foot Action Group, a cohesive national Diabetic Foot network has been established dedicated to service improvement and better patient outcomes. This network has delivered a number of significant improvements including:

• National foot risk stratification. The number of patients with a foot risk stratification at any time has increased from 25% in 2007 to 91% in 2013; the variation between different parts of the country has greatly reduced; and traffic light risk stratification developed by the network (and highlighted in the 'Putting Feet First' campaign) is now being used UK wide and across many other countries.
• Nationally agreed patient information leaflets are now in use.
• Education programmes for staff have been implemented e.g. over 10,000 professionals have used the on line foot risk stratification module; and a podiatry competency framework for integrated diabetic foot care has been developed.
• A national inpatient foot care initiative ("CPR for diabetic feet") has been launched.