Scottish Diabetes Framework

Scottish Diabetes Framework

What is the purpose of the Scottish Diabetes Framework?

19. The consultation paper of July 2001 outlined six purposes of the Framework:

• To clarify the direction of travel and to give additional impetus to current positive developments in diabetes care.
• To set out short-term objectives, longer-term milestones and clinical standards in order to create a modern diabetes service.
• To highlight and encourage opportunities to improve services.
• To collate information on all Scottish initiatives relevant to diabetes and create a manageable and accessible resource.
• To highlight and disseminate throughout Scotland and internationally, examples of innovative and high quality services and projects.
• To help foster a climate of collaboration, co-operation and communication amongst the diabetes community in Scotland.

20. Some of these purposes have been achieved by the publication of this document. For some of the others, the Framework puts in place mechanisms for delivery in the longer term. This underlines the fact that the Scottish Diabetes Framework is at least as much about a process of collaboration and on-going service improvement, as it is about the production of a document. This was well recognised by the Working Group which acknowledged that diabetes care requires the co-ordination and co-operation of many people working across a wide range of professions and organisations, and that ensuring that high quality services are available to everyone with diabetes will require a sustained effort over many years. With this in mind, the Working Group set out with the hope of producing a pragmatic document which would:

• Act as a catalyst for change and an enabling document to help the NHS to accomplish more effectively what many people are already attempting to achieve.
• Promote equitable care and help to ensure that SIGN guidelines are put into practice by sharing best practice and addressing the current wide variations in standards.
• Include objectives which are specific, measurable, achievable, relevant, and time-related.
• Provide strategic leadership at locality and national level, without imposing rigid constraints on local implementation.
• Improve the co-ordination and integration of national initiatives on diabetes.
• Focus on implementation, setting clear milestones and putting in place a mechanism to follow-up and monitor progress.

21. Central to securing implementation and ensuring the drive and continuity necessary to achieve change over many years is the establishment of national leadership that will support local diabetes services. Discussions between the Scottish Executive and the Working Group about the shape of this leadership resulted in the decision to establish a Scottish Diabetes Group. This commitment was highlighted in the publication of the Framework milestones in November 2001. The Scottish Diabetes Group met for the first time in March 2002; its remit to support and monitor the implementation of the recommendations of the Framework.

'Give us the best care whoever we are and however severe our complications. Recognise that without our full co-operation you will be wasting your time. Do everything you can to ensure we stay motivated to look after ourselves, rescue us when we bugger it up, because as sure as hell we will. You can only do this through full integrated diabetes services of the highest quality, treating us as people and not as a medical condition.' (Person living with diabetes) Williams R, Airey M, Gilworth G. Integrating Diabetes Services - time to respond. Nuffield Institute for Health, University of Leeds, 2001.

What are the key features of a high quality diabetes service?

22. The Working Group sought to define what a high quality diabetes service should look like in order to guide their thinking about the steps necessary to make sustained improvements to the provision of care for people with diabetes. These features are set out in the table below along with examples of the ways in which these features can be demonstrated.

Table 7 Key features of a high quality diabetes service
Key features	Demonstrated by (for example)
Shared vision/ clear strategy	Existence of a district wide group of all the stakeholders in diabetes care. Published diabetes strategy (including explicit targets and milestones). Effective involvement of people with diabetes in developing the strategy. Explicit link to Local Health Plan and to the Community Plan.
Patient-focused care	All people with diabetes empowered to manage their own care. Culturally competent services (see Table 17). Patients treated as individuals - staff are caring and understanding, respectful and courteous. Responsive and flexible services. Easy access to services and information. Respect for patient confidentiality.
High quality care	Clinically effective care - use of evidence based clinical guidelines. Equitable and consistent delivery of services. Efficient and joined up services - patients seen promptly. Comprehensive range of services offered to all. Effective risk management. Services constantly developing and improving.
Integrated care	Multi-professional teamworking. Good communications with patients and between staff. Efficient services. Effective planning forum. Seamless care from the patient perspective. Managed Clinical Network.
Adequate resources	Appropriate staffing and facilities. Acceptable waiting times. Reliable and consistent service. Efficient and effective use of available resources.
Well-trained staff	Staff with appropriate qualifications and engaged in ongoing study.
Good clinical management systems and data	Clinical care supported by effective IT. Comprehensive information on all patients in area. Robust clinical audit. Results of care reported. Respect for confidentiality of patient information.

23. Having defined the scope and principles of a high quality service, the Working Group considered how this might be achieved in practice. The approach which was adopted (and which was later endorsed by the consultation process) was based on four simple ideas:

(a) To create a more manageable agenda for improving diabetes services by subdividing the complex whole of diabetes into logical component parts ('building blocks').

(b) To select a limited number of these topics for early action and not seeking to achieve everything at once.

(c) To concentrate initially on strengthening infrastructure and building capacity.

(d) To focus strongly on implementation. To ensure that words become deeds.

Building Blocks of Diabetes Care: An Overview

24. The model of diabetes care developed by the Working Group consists of 22 building blocks, divided amongst six broad headings. These are:

• Prevention and early detection
• Care, monitoring and treatment
• Specific groups
• Planning and managing services
• Implementation
• Community Issues.

25. This is a pragmatic model. It is acknowledged that there is some overlap between the 22 building blocks, and that subdividing the care and treatment of diabetes in this way brings with it the risk of losing the concept of holistic care. Nevertheless, the model is an attempt to make the complex and multi-professional nature of diabetes services more manageable. It is a planning tool, not a model for clinical management.

26. All of the 22 building blocks of diabetes are important. However, the Working Group concluded that significant progress towards securing real improvements in services for people with diabetes would only be achieved by focusing on a limited number of issues at a time, rather than by overloading the system with too many objectives. Seven issues for early action were identified by the Working Group and highlighted in the consultation paper. Each of the 22 building blocks is described overleaf.

Figure 2: Building Blocks of Diabetes Care

27. The response to the consultation paper strongly backed the need to limit the number of priorities. However, several written responses and comments at the open meetings proposed that the number of 'first stage priorities' should be extended. Of the topics suggested as additional early priorities, the issue of foot care was the one perhaps most frequently cited. Given the wide range of issues covered by the clinical standards, the commitment to review and revise the Framework within two years and the general level of support for the seven topics proposed during the consultation period, the Working Group concluded that the Framework priority list should not be extended.

The first stage priorities

28. The Working Group confirm the following seven topics as the Framework's 'first stage' priorities:

• Patient Information, Education and Empowerment
• Heart Disease
• Eye Care
• Strategy, Leadership and Teamworking
• Education and Training for Professionals
• IM&T and Diabetes Registers
• Implementation and Monitoring

This is not to ignore the other aspects of diabetes. These seven issues represent a starting point. Action is required across all of the building blocks. Furthermore, a commitment is made to periodically review the Framework in order to take account of progress and to ensure that all aspects of diabetes care are addressed.

MILESTONE

The Scottish Diabetes Group will review and revise the Scottish Diabetes Framework by Spring 2004.

29. Throughout the Framework a number of 'milestones' and 'actions points' have been included. A Milestone represents a significant stage on the way towards creating a high quality patient-centred diabetes service. It marks a point for reflection, assessment of progress and confirmation of direction. An Action Point is a specific piece of work that will be undertaken to support this process.

How it all fits together

30. The Scottish Diabetes Framework is a means to ensure that diabetes services serve the needs of people with diabetes and that the complex interactions of individuals and organisations which together provide and support these services are co-ordinated in the most productive way. This will be achieved by setting clear and realistic priorities and targets, by providing leadership and support and by promoting collaboration amongst all those with an interest in diabetes (most importantly, people with diabetes themselves). This demands relationships based on partnership, mutual respect and trust.

31. Figure 3 below outlines how the different parts of the system fit together. The Framework is the key driver to ensure that this process occurs in practice.

Figure 3: The Healthcare Cycle

Patients. People with diabetes are not only recipients of care, but also the most important determinants of the outcomes of care. They also have a great deal to contribute to research and the definition of standards, as well as to the planning and management of services. Patients have a right to information about the services they receive including about the outcomes of care.

Evidence Base. Services should be provided in line with the best available evidence. There are different sources of evidence, including formal research and development ( R&D) funded by the Government such as the work of the Chief Scientist Office (CSO), or by the pharmaceutical industry. In Scotland the evidence base of diabetes has been reviewed and synthesised by SIGN and published as a clinical guideline.

Standards. The delivery of services should be guided and evaluated against robust standards, derived from the evidence and based on an understanding of how this evidence can be applied in practice. The Clinical Standards Board is the organisation charged with setting standards for the NHS in Scotland. Standards for diabetes have now been published. These standards are currently being piloted and refined before national review begins.

Service Delivery. All public healthcare providers are subject to clinical governance requirements and have internal mechanisms to monitor their own performance. The service delivered to patients is modified by standards and by audit.

Outcomes. The outcomes of care provided by the NHS are reported in a variety of forms. This includes both general mechanisms such as the Performance Assessment Framework and the publications of the Information and Statistics Division (ISD) and mechanisms specific to diabetes, such as the annual Scottish Diabetes Survey. Reports published by the CSBS are another method of assessing the standard of diabetes care. This Framework also recommends (paragraph 99) that individual NHS boards should publish annual reports of diabetes care in their area as a means of informing local people of the care they can expect to receive. At an aggregate level, the results of care can frequently identify questions which cannot be answered without further research. For individuals, outcomes of care are primarily determined by their own actions.

Table 8 SIGN and Diabetes The Scottish Intercollegiate Guidelines Network (SIGN) was established in 1993 by the Academy of Royal Colleges and their Faculties in Scotland, to develop evidence-based clinical guidelines for the National Health Service (NHS) in Scotland. Clinical practice guidelines have been defined as 'systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances'. They are designed to help practitioners assimilate, evaluate and implement the ever-increasing amount of evidence and opinion on best current practice. Clinical guidelines are intended as neither cookbook nor textbook but, where there is evidence of variation in practice which affects patient outcomes and a strong research base providing evidence of effective practice, guidelines can assist doctors and other health care professionals in making decisions about appropriate and effective care for their patients. In 1996-97, SIGN published seven documents in the field of diabetes. Five clinical guidelines covered the prevention of visual impairment (SIGN 4), management of diabetes in pregnancy (SIGN 9), management of diabetic renal disease (SIGN 11), management of diabetic foot disease (SIGN 12) and management of diabetic cardiovascular disease (SIGN 19). In addition, reports were published on the good practice in care of children and young people with diabetes (SIGN 10) and a minimum dataset for collection in people with diabetes (SIGN 25). Late in 1999 work began on the review of these documents and involved the establishment of six new multidisciplinary review groups to consider each of the clinical areas covered by the original topics. A seventh topic, of lifestyle management, was added at this stage to take the number of healthcare professionals and patient representatives who were working on the review to around 100. In September 2000 the Working Group on IT to Support Shared Care in Diabetes which was set up by CRAG, published a document which laid out principles of support and promotion of integrated care for patients with diabetes and also discussed the data collection required in the clinical management of these patients. This group published an extended dataset, based on SIGN 25, which was felt to be more useful for recording information directly relevant to active clinical care than the SIGN document which was felt to be most useful for population-level registers. For this reason, SIGN 25 has not been reviewed at this time. The review guideline was published as a single volume in November 2001 (SIGN 55). The aim of the guideline has been to provide an updated evidence-based approach to influence current practice in order to reduce the burden of long-term complications, both microvascular and macrovascular, as well as improve pregnancy outcome for the mother with diabetes. The guideline also incorporates the new World Health Organization diagnostic criteria for diabetes mellitus which were implemented in the UK in June 2000.

Support.

Healthcare professionals and organisations can be expected to function at a higher level when they are able to access the appropriate support, such as education and training, information and communications technology, guidance on best practice, and opportunities to share innovative ideas. Such support can come from a variety of sources including professional organisations (such as the RCGP and their SPICE-PC programme), academic institutions, the pharmaceutical industry, other NHS bodies and the Scottish Executive. One of the goals of the Framework is to enhance the collaboration and communication between these 'support organisations' to ensure that those who actually deliver the care can obtain the support that they require.

Table 9 SPICE-PC The Scottish Programme for Improving Clinical Effectiveness in Primary Care (SPICE-PC) is an initiative funded by the Scottish Executive through the Clinical Resource and Audit Group (CRAG). The aim of the programme is to help primary care clinicians to manage common conditions by providing them with the answers to three vital questions: What should we be doing? What are we doing? How does our performance compare with our peers? The programme enables GP practices to record and review the relevant data. In addition, by means of an electronic analysis system, participating practices are able to receive feed back reports on the performance of their practice, along with comparative data from many other practices in Scotland. In Diabetes, the programme has produced a set of criteria tailored to primary care which informs clinical teams on the type of input required - for example that people with diabetes should have regular foot and eye checks, appropriate education, and monitoring of their diabetic status. These criteria have been defined to align with the standards set by the CSBS and the goals of the Scottish Diabetes Framework. Further details can be obtained from the Quality Department, Royal College of General Practitioners (See Annex D for contact details)