Diabetes Improvement Plan

4. Monitoring and Reporting

39. NHS boards have responsibility to deliver safe, effective and person-centred care to their local population and in most cases for diabetes, they look to their MCNs to support and monitor progress. This section of the Improvement Plan builds upon existing monitoring and reporting arrangements and sets out how we will monitor performance and progress in future.

40. The actions highlighted in this Plan will be kept under review by the Scottish Diabetes Group. Each of the groups and projects sponsored by the SDG will be expected to put in place proportionate and effective arrangements to measure and report their outcomes. In addition, MCNs will be expected to provide an annual report both to their own board and to the SDG setting out progress against the Improvement Plan priorities. Plans are being developed to increase the number of annual visits to MCNs by the SDG in order to provide focus, challenge and support for this reporting process.

41. The annual Scottish Diabetes Survey continues to provide a rich, comparative national overview of diabetes services which facilitates benchmarking between areas. However, there is a recognised need to provide - for diabetes services, NHS boards and the public - more robust and timely information about the quality of the care provided. This Plan outlines the first steps to put in place a new mechanism to generate this information.

42. SCI-Diabetes is currently developing a programme to enable MCNs to generate a quarterly report without additional administrative burden on local staff of a selection of key diabetes measures which, taken together and reported over time, will provide a "barometer of improvement". An initial set of 12 measures are described below.

Initial Measures

43. The limitations of existing outcome measures is acknowledged and therefore a key aim over the coming years will be to develop new and better measures of quality and outcome to support improvement. The first 12 measures will therefore be kept under review with a view to improving or extending these in the future.

Quarterly Diabetes Reporting - Initial measures
1. % people with diabetes who receive all 9 key indicator measurements for diabetes
2. % persons with an HbA1c <58mmol/mol at 1 year post diagnosis
3. % persons with an HbA1c <58 mmol/mol and >75 mmol/mol
4. % current smokers
5. % of people aged 50 to 80 with a total cholesterol <5mmol/l AND a systolic BP <140 mm Hg
6. % of new foot ulcers
7. % of people eligible for diabetic retinopathy screening actually screened within last 15 months
8. % of people with diabetes reaching end stage renal disease or requiring renal replacement therapy
9. % of people on CSII therapy
10. % of persons with a BMI ≥ 30 who have lost ≥ 5% body weight in the last year
11. % persons who have attended structured education
12. % disengaged from diabetes care i.e. no HbA1c and retinal screening in the preceding 15 months
In most cases, measures will be reported for T1DM <18yrs | T1DM >18 years | T2DM.

1. % people with diabetes who receive all 9 process of care measures for diabetes

Annual assessment of the following processes of care is important to ensure effective screening for microvascular complications and assessment of cardiovascular risk factors. These include; weight (and BMI measurement), blood pressure, smoking status, HbA1c, urinary albumin test, serum creatinine, cholesterol level, retinopathy screening and foot risk stratification.

2. % persons with an HbA1c <58mmol/mol at 1 year post diagnosis

Early intensification of glycaemic control plays an important role in determining metabolic memory and the future risk of complications. This is a marker of effective self-management and diabetes services.

3. % persons with an HbA1c <58 mmol/mol and >75 mmol/mol

Targeting a health improvement strategy aimed at improving overall glycaemic control is an assessment of effective self management and diabetes services.

4. % current smokers

One in four people with diabetes smoke - 23.5% (type 1) and 18.1% (type 2) - increasing the risk of micro and macrovascular complications. This measure is included in recognition of the importance of addressing this factor. A measure of referral of persons who smoke to cessation services would be helpful but is currently unavailable.

5. % of people aged 50 to 80 with a total cholesterol <5mmol/l AND a systolic blood pressure <140 mm Hg

Cardiovascular disease is the major cause of morbidity and mortality in people with diabetes. Cardiovascular disease increases with increasing age. It is important to manage cardiovascular risk factors in those at high risk who are likely to benefit most from the interventions offered. Two important modifiable risk factors are blood pressure and cholesterol. These are therefore useful markers of cardiovascular risk management.

6. % of new foot ulcers

Approximately 50% of non-traumatic lower limb amputations in Scotland are due to diabetes. People living with diabetes are at a 10 fold increased risk of amputation compared to those without diabetes Assessment of the new foot ulcers provides a useful marker of foot risk management.7. % of people eligible for diabetic retinopathy screening actually screened within last 15 months

Diabetes is the leading cause of blindness in persons of working age in Scotland. Assessment of visual loss is a measure of the effectiveness of screening and a way to maintain the focus on raising standards.

8. % of people with diabetes reaching end stage renal disease (ESRD) or requiring renal replacement therapy (RRT)

Diabetes is one of the leading causes of end stage renal disease in Scotland. Assessment of ESRD and RRT will be a measure of effective screening for microalbuminuria and management of progressive renal disease.

9. % of people on CSII therapy

The use of CSII therapy can improve glycaemic control and reduce the risk of severe hypoglycaemia. Assessment of the number of people on CSII therapy provides an indicator of use within geographical areas.

10. % of persons with a BMI ≥ 30 who have lost ≥ 5% body weight in the last year

Lifestyle interventions including effective weight loss programmes improve health related outcomes. Assessment of those individuals who are obese who achieve clinically meaningful weight loss is an indicator of self-management and effective weight management services.

11. % persons who have attended structured education

Structured education improves an individual's ability to self manage their diabetes and is associated with improved glycaemic control and quality of life. Assessment of uptake of structured education is an indicator of effective diabetes services in providing and promoting self management.

12. % disengaged from diabetes care i.e. no HbA1c and retinal screening in the preceding 15 months

Disengagement from diabetes services is associated with poorer health related outcomes. Assessment of disengagement provides an indicator of engagement with diabetes services.

Future measures

44. The proposed 12 measures represent a first step. We want and need to develop, report and act upon new and better measures of diabetes outcomes and care - measures which can provide meaningful data for people living with diabetes and for healthcare professionals to enable them to assess, understand, improve and reliably deliver high quality care. Crucially, these measures need to be collected and recorded in such a way that they do not create a data collection burden for staff. Such measures can be, and in some cases already are being developed and piloted on a small scale.

45. Some new measures might be suitable for routine on-going data capture, in which case the task is to refine and implement the measure at scale, most likely through SCI-Diabetes. Other measures might be useful as part of a targeted initiative. Some data might be most practically captured through a survey, by sampling, or by self-reporting by people living with diabetes.

46. There is also scope to consider what other existing data sources might help to illuminate service quality, safety and performance. For example, the rolling survey of the 15 Health Care Essentials undertaken across the UK by Diabetes UK (Scotland).

47. Areas where the diabetes community are exploring ways to reliably and efficiently measure care include:

• % of hypoglycaemia in hospital correctly treated / other measures of effective inpatient diabetes management.
• % of those with diabetic maculopathy, who meet eligibility criteria given anti VEGF therapy.
• Number of new foot ulcers developed while an inpatient.
• Self-reported satisfaction of diabetes control at discharge.
• % of cases in Diabetic Ketoacidosis (DKA) at diagnosis, of those under 18 years.
• % on CSII therapy within 6 months of fulfilling criteria.
• % people with type 2 undergoing structured education within 6 months of diagnosis.
• % increase in MyDiabetesMyWay sign up, including by subgroup e.g. deprivation, ethnicity.
• Measures in minimising risk for mothers with diabetes and their babies / maternal and foetal outcomes example.g. proportion of women with GDM who are identified at booking.

48. In addition, there are a number of areas where it would be useful to periodically collect information that would evidence progress against the actions identified in this plan. However, in some cases appropriate measures have not yet been defined and in some the mechanism to efficiently capture accurate and comprehensive information is not in place. The table below sets out some of the measures relevant to the actions in plan, the appropriate lead for collecting the information and the priority to which it relates.

Information/Lead	Priority
SDG/Scottish Diabetes Survey Group
Reduction in the number of people at high risk of developing diabetes	1
Increase in the number of diagnosed over expected annual increase	1
Diabetes Managed Clinical Networks
Evidence of patient feedback/experience informing the review, update and measurement of programmes	3
Number of opportunities available and taken up for patients to meet and learn from one another (e.g. peer learning opportunities)	3
Evidence of the use of agenda/goal setting approaches	3
Evidence of patient experience and patient reported outcomes	3
Number of staff who have taken part in development work on how to deliver positive care planning and evidence of implementation	3
Demographic information to ensure diversity of patient experience is captured	3
Evidence of patient involvement in the changes made to deliver improvement to local services	3
Number of people with diabetes involved in decision making and evidence of increase	3
Number of staff completing Health Literacy Training	4
Number of people completing consultation and patient engagement skills training	5
Increase in patient satisfaction	6
Reduction in bed days	6
Reduction in HbA1c at discharge	6
Scottish Diabetes Foot Action Group
Measure of the effectiveness of CPR for feet campaign and implementation	6
Increase in patients knowing their own foot risk score	1
Downloads and feedback statistics on Putting Feet First	1
Scottish Diabetes Group - Childhood and Adolescent Subgroup
% of completed care plans while in full time education	2
% utilising resources aimed at transitional care	2
% staff undergoing training in youth engagement	2
Assess glycaemic control in 'looked after' children	4
Diabetes Scotland
Increase in the number of people self reporting involvement in decision making process	3
Measure and quality assure implementation of sharps and blood glucose test strip guidance through patient feedback	3
Feedback from Careline	All