Managing diabetes Improving services for people with diabetes - Service review

 
Managing diabetes Improving services for people with diabetes - Service review
Inspecting Informing Improving

Managing diabetes
Improving services for people with diabetes

Service review
Managing diabetes Improving services for people with diabetes - Service review
First published in July 2007

© 2007 Commission for Healthcare Audit and Inspection

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ISBN 978-1-84562-154-4

The cover includes photographs from www.johnbirdsall.co.uk
Managing diabetes Improving services for people with diabetes - Service review
Contents

The Healthcare Commission                                                                          2

Executive summary                                                                                  3

Introduction                                                                                       8
   This report                                                                                     8
   Diabetes                                                                                        8
   Policy development                                                                             10
   The importance of ‘self care’                                                                  10

About the review                                                                                  14
  What is a service review?                                                                       14
  Why diabetes?                                                                                   14
  What did the review involve?                                                                    15

Key findings                                                                                      18
  Overall results                                                                                 18
  Conclusions                                                                                     20
  Patterns from our national survey                                                               21

Detailed findings                                                                                 23
  Adults with diabetes are looking after their condition                                          23
  Adults with diabetes feel supported to self care through care planning,
  information and education                                                                       32
  Adults with diabetes have key tests and measurements carried out                                40

Areas for improvement                                                                             47
  Recommendations                                                                                 50
  Further action by the Healthcare Commission                                                     51

References                                                                                        53

Appendix A:
  Data and information available to help those who commission and
  provide diabetes services                                                                       56

                            Healthcare Commission Managing diabetes: Improving services for people with diabetes   1
Managing diabetes Improving services for people with diabetes - Service review
The Healthcare Commission

The Healthcare Commission exists to promote                   The Healthcare Commission aims to:
improvements in the quality of healthcare and
public health in England and Wales.                           • safeguard patients and promote continuous
                                                                improvement in healthcare services for
In England, the Healthcare Commission is                        patients, carers and the public
responsible for assessing and reporting on the
performance of NHS and independent                            • promote the rights of everyone to have
healthcare organisations, to ensure that they                   access to healthcare services and the
are providing a high standard of care. The                      opportunity to improve their health
Healthcare Commission also encourages
providers to continually improve their services               • be independent, fair and open in our
and the way they work.                                          decision making, and consultative about our
                                                                processes
In Wales, the Healthcare Commission is more
limited and relates mainly to working on
national reviews that cover both England and
Wales, as well as our annual report on the
state of healthcare. In this role we work
closely with the Health Inspectorate Wales,
which is responsible for the NHS and
independent healthcare in Wales.

2    Healthcare Commission Managing diabetes: improving services for people with diabetes
Executive summary

Diabetes                                                 Diabetes does not affect everyone in the
                                                         population equally. People with Type 2
Diabetes is a life threatening, long term                diabetes tend to be overweight or obese, be
condition which affects more than 1.9 million            physically inactive, have a family history of
people in England. Whether Type 1 or Type 2              diabetes (including those women who have
(box 1), diabetes shortens people’s lives and            had diabetes while pregnant) or have South
affects their quality of life because of the long        Asian, African, African Caribbean or Middle
term complications.                                      Eastern descent. People from black and
                                                         minority ethnic (BME) populations are up to
 Box 1: Diabetes                                         six times more likely to develop diabetes.

 Type 1 diabetes develops most frequently in
 children, adolescents and younger adults.               Policy context
 Pancreatic cells that produce insulin have
 been destroyed by the body’s immune                     In 2001, the Government published the
 system resulting in a build-up of glucose in            diabetes national service framework (NSF).
 the blood. To control blood glucose levels,             This established 12 national standards, which
 insulin injections are required at least daily.         were aimed at raising quality and reducing
                                                         variation across diabetes services. A delivery
 Type 2 diabetes is more commonly                        strategy followed in 2003. Since then, the
 diagnosed in adults over 40 (although it is             Government has continued to emphasise that
 increasingly being diagnosed in children).              diabetes is a national priority by appointing a
 For most people, it is a preventable, lifestyle         National Clinical Director and forming a team
 disease caused by a combination of                      to support the NSF’s implementation.
 genetics, unhealthy diet and little physical
 activity. Either the pancreas is unable to              The NSF recognised that it is important to
 produce enough insulin to control glucose               support people to look after themselves.
 levels or the person has become insensitive             Caring for yourself, or ‘self care’, is
 to insulin. Diet and lifestyle need to be               fundamental to daily living. For people with
 adjusted and most people with Type 2                    diabetes, it is about dealing with the impact of
 diabetes will need to take tablets and/or               diabetes on their daily lives. A growing body of
 insulin to control their condition.                     evidence demonstrates that supporting people
                                                         with long term conditions to care for
                                                         themselves means that they do better, both in
Not only is there a human cost to the person             clinical terms and in their quality of life. It also
with diabetes, but the financial cost to the             can contain increases in healthcare costs.
NHS of caring for people with diabetes is
estimated to be around £9 billion every year.
With the number of people with diabetes                  Our review
predicted to rise as the population becomes
more obese and lives longer, NHS costs will              Our review looked at services commissioned
also rise.                                               by primary care trusts, focusing on how well
                                                         healthcare systems support adults (aged 17

                             Healthcare Commission Managing diabetes: Improving services for people with diabetes   3
and over) with diabetes to care for themselves.
                                                                Figure 1: Primary care trusts’ overall
We assessed primary care trusts with these
                                                                scores for the review (by percentage and
questions:
                                                                number)
1. Are adults with diabetes looking after their
   condition?                                                                          Excellent 5%
                                                                          Weak 12%          (7)
2. Do adults with diabetes feel supported to                                                      Good 11%
                                                                            (18)
   self care through care planning, information                                                     (16)
   and education?
3. Do adults with diabetes have key tests and
   measurements carried out?

We used data from three sources to assess
whether primary care trusts were meeting
these criteria: the Healthcare Commission’s
national patient survey of people with diabetes
and the Health and Social Care Information
Centre’s Quality and Outcomes Framework
and Hospital Episode Statistics. Each primary
care trust received a score in July 2007 on a                                         Fair 73%
four-point scale – “weak”, “fair”, “good” and                                           (111)
“excellent” – based on its performance
relative to all primary care trusts’
performances.                                                 Our review showed that the level of deprivation
                                                              of a primary care trust is not a factor in how
                                                              well it supports people with diabetes to look
Overall results                                               after themselves. We showed that there is a
                                                              similar spread of overall scores between all
Our review scored the performance of the                      trusts and the one-fifth of trusts that have the
majority (73%) of primary care trusts as “fair”               worst health and deprivation indicators.
in their work supporting adults with diabetes
to care for themselves (figure 1). We are
following up 12% of trusts because either we                  Findings
found that their services were “weak”, or we
could not make an assessment because we                       We found that most people with diabetes:
had too little information from them about the
views of the people with diabetes in their area.              • have regular checkups, at least one a year
                                                                with a healthcare professional, and most of
                                                                the key tests and measurements carried
                                                                out

4   Healthcare Commission Managing diabetes: Improving services for people with diabetes
• reported that they know enough about when
                                                          Figure 2: Percentages of people having
  to take their medication and how much
                                                          checkups and planning their care
  medication to take

• reported having the key tests carried out              100%
  that are easily recognisable, for example,              90%
  having their blood pressure taken or being              80%
  weighed                                                 70%
                                                          60%
• who smoke were offered advice about                     50%
  stopping smoking                                        40%
                                                          30%
While this performance is encouraging, we                 20%
also found that:
                                                          10%
• between 34% and 61% of people with                       0%
                                                                           Primary care trusts
  diabetes across all primary care trusts had
  agreed a plan to manage their condition                             The percentage of adults with
  (figure 2)                                                          diabetes diagnosed for more than
                                                                      a year, who report that they have
• between 1% and 53% of people with                                   had at least one diabetes
  diabetes across all primary care trusts                             checkup in the last 12 months
  reported attending an education course on
                                                                      The percentage of adults with
  how to manage their diabetes
                                                                      diabetes who have had a checkup
                                                                      who report that they ‘almost
• between 16% and 41% of people with
                                                                      always’...
  diabetes in primary care trusts would like
  to attend an education course on how to
                                                                           ... discuss ideas about the best
  manage their diabetes if they have not been
                                                                           way to manage their diabetes
  on one already
                                                                           at their checkup
• between 25% and 50% of people with                                       ... agree a plan to manage
  diabetes in primary care trusts felt that they                           their condition over the next
  were good at eating the right foods, knew                                12 months at their checkup
  enough about the food to eat and had                                     ... discuss their goals in caring
  ‘almost always’ received personal advice                                 for their diabetes at their
                                                                           checkup
• between 14% and 33% of people with
  diabetes in primary care trusts were good
  at being physically active, knew enough
  about physical activity and had ‘almost
  always’ received personal advice

                            Healthcare Commission Managing diabetes: Improving services for people with diabetes   5
Areas for improvement                                         knowledge of diabetes. Very few people with
                                                              diabetes report having all the key tests and
The review demonstrates that there are some                   measurements carried out because many did
aspects of care that are in great need of                     not know whether they had had a urine test for
improvement in many primary care trusts. To                   protein (a kidney function test). Also, most
increase the support offered to people with                   people did not know their HbA1c value (long
diabetes, there are five areas for improvement                term blood glucose level), particularly those
needed:                                                       people with Type 2 diabetes and people from
                                                              BME populations.
1. Better partnership between people with
   diabetes and their healthcare                              3. Working more closely with all
   professionals when planning and agreeing                      organisations providing and
   their care.                                                   commissioning diabetes services.

Annual checkups and most of the key tests and                 The results of our review demonstrate that in
measurements are being carried out. However,                  95% of primary care trusts there is scope to
many people with diabetes reported that                       reduce the number of admissions to hospital
aspects of care planning – discussing ideas and               for diabetic ketoacidosis (DKA) and
goals together and agreeing a joint plan to                   hypoglycaemic coma. There are two ways to do
manage their diabetes – were not happening.                   this. Firstly, there is a need to improve the way
Also, the personal advice that people with                    in which adults with diabetes prevent and,
diabetes need to help them adopt and                          when necessary, respond to diabetic
maintain a healthy lifestyle needs to be offered              emergencies – for example, by treating
to everyone routinely. Not one primary care                   themselves for hypoglycaemic episodes. This
trust had more than half of people with                       can be achieved through patient education.
diabetes reporting that they achieved their
lifestyle targets. People with Type 2 diabetes                Secondly, there is a need to look at the way
and those from BME populations were more                      primary care, secondary care and ambulance
likely to report that key aspects of their care               services work together within the community
were not being planned.                                       alongside non-healthcare organisations to
                                                              prevent cases of DKA through better
2. Increasing the number of people with                       management and early diagnosis and,
   diabetes attending education courses and                   including ambulance services, reduce the
   improving their knowledge of diabetes.                     number of hypoglycaemic episodes being
                                                              treated in hospital.
According to our results, some people with
diabetes want to go on education courses and                  4. Increasing the number of people with
have not been offered one, particularly people                   diabetes having long term blood glucose
from BME populations and those with Type 2                       levels (HbA1c) of 7.4 or a lower safe level.
diabetes.
                                                              One of the most important factors in reducing
However, our results also showed that some                    the long term effects of one’s diabetes is to
people with diabetes need to improve their                    have safe blood glucose levels. Our findings

6   Healthcare Commission Managing diabetes: Improving services for people with diabetes
showed that once the characteristics of the              Primary care trusts should implement the
primary care trust population were taken into            National Institute for Health and Clinical
account, on average across all trusts, 62% of            Effectiveness (NICE) health technology
people with diabetes met the long term blood             appraisal on structured education for patients,
glucose (HbA1c) target of 7.4. The better                which says that people with diabetes should
performing primary care trusts achieved 65%              be offered education courses, and trusts
and the poorer performers achieved 52%.                  should assess their current education
                                                         programmes against the guidelines. They also
5. Reducing variation in general practices’              need to improve the way they commission
   achievements.                                         diabetes services, by reviewing the data
                                                         submitted by their general practices and
In all but one of the clinical indicators we used        supporting the implementation of effective
in the review, we found that there was wide              processes for jointly planning care.
variation within primary care trusts of the
achievements of general practices. This was              Strategic health authorities should monitor
for both the outcome indicators, such as                 the implementation of all the
achieving long term blood glucose levels                 recommendations from this review and the
(HbA1c) of 7.4, where we found an elevenfold             improvement plans of primary care trusts
difference in the variation across trusts and            scoring “weak” in the overall assessment.
the process indicators, such as recording
HbA1c tests where we found a twelvefold
difference.                                              What is the Healthcare Commission
                                                         doing next?
Our main recommendations                                 We are:

We have summarised our main                              • working with the primary care trusts which
recommendations as follows.                                most need improvement either to produce
                                                           plans for how they will improve, or to check
Healthcare professionals, as part of the multi­            that people with diabetes in their area
disciplinary team caring for people with                   receive, at a minimum, a “fair” service
diabetes, should offer appropriate, individual
support to each person with diabetes to                  • monitoring the ongoing performance of all
encourage them to look after their diabetes.               primary care trusts, by following up some of
Good planning of care is where the patient’s               the indicators used in the review
experience is considered as important as the
healthcare professional’s view. The                      • examining further relationships between
professionals should listen to people with                 the national patient survey of people with
diabetes when coming to agreed, joint plans                diabetes and other data sources. We are
for their care, giving them the opportunity to             also developing methods for examining the
talk about what they think they can achieve.               quality of primary care services, including
                                                           diabetes care

                             Healthcare Commission Managing diabetes: Improving services for people with diabetes   7
Introduction

This report                                                   Diabetes

This report presents a national picture of how                What is diabetes?
well primary care trusts in England are                       Diabetes is a serious, long term, progressive
commissioning services to support adults                      condition. There are two major types:
(aged 17 and over) with diabetes to care for
themselves. It reports on the quality of                      • Type 1 diabetes develops most frequently in
support, encourages primary care trusts and                     children, adolescents and younger adults.
healthcare professionals to continue                            Pancreatic cells that produce insulin have
improving services, and highlights the                          been destroyed by the body’s immune
progress of primary care trusts in relation to                  system, resulting in a build-up of glucose in
some of the diabetes national service                           the blood. To control blood glucose levels,
framework standards.                                            insulin injections are required at least daily

It is written for a wide audience. This includes              • Type 2 diabetes is more commonly
people with diabetes and their carers, the                      diagnosed in adults over 40 (although it is
public, commissioners of diabetes services in                   increasingly being diagnosed in children).
primary care trusts, managers of diabetes                       For most people, it is a preventable, lifestyle
services, diabetes networks, and healthcare                     disease caused by a combination of
professionals involved in the care and                          genetics, unhealthy diet and little physical
treatment of people with diabetes.                              activity. Either the pancreas is unable to
                                                                produce enough insulin to control glucose
Individual results for all primary care trusts                  levels or the person has become insensitive
that participated in the review are on our                      to insulin. Diet and lifestyle need to be
website at www.healthcarecommission.org.uk.                     adjusted and most people with Type 2
People with diabetes, their carers and                          diabetes will need to take tablets and/or
members of the public can use this                              insulin to control their condition
information to check whether their primary
care trust is offering the support to enable                  Who is affected?
adults with diabetes to care for themselves.                  Diabetes affects an increasing number of
Anyone looking at the information can                         people. By 2006, nearly 1.9 million people in
compare primary care trusts against each                      England were diagnosed with diabetes and
other. Also on our website is a leaflet for                   identified on registers1, and a further half a
people with diabetes on key aspects of the                    million are estimated to have the condition2.
review outlining what they should expect, what                The total number of people with diabetes
we found and what they can do next.                           (those diagnosed and undiagnosed) is forecast
                                                              to rise by 15% between 2001 and 2010; 9% of
                                                              the rise is due to increasing numbers of obese
                                                              people and 6% to an ageing population2.

                                                              Diabetes is not equally distributed across the
                                                              country. The number of people diagnosed with
                                                              diabetes in some strategic health authority

8   Healthcare Commission Managing diabetes: Improving services for people with diabetes
areas is higher than in others, and in some
                                                              Box 2: The human costs of diabetes – long
areas statistical modelling shows that there
                                                              term complications
are many people yet to be diagnosed3.
                                                             • On average, life expectancy is reduced by
Although diabetes is becoming more common                      more than 15 years in those with Type 1
across all age groups and in all populations, it               diabetes, and between five and seven
does not affect everyone in the population                     years in those with Type 2 diabetes (at
equally. Its occurrence, particularly Type 2, is               age 55 years)2
highest among those who are overweight or
obese, physically inactive, those with a family              • The three most common complications
history of diabetes (including those women                     for people with diabetes are all related to
who have had diabetes while pregnant) and                      their hearts (angina, cardiac failure,
people of South Asian, African, African                        myocardial infarction)6
Caribbean and Middle Eastern descent4.
People from black and minority ethnic (BME)                  • Diabetes is a leading cause of end stage
populations are up to six times more likely to                 renal disease7 and blindness in people of
develop diabetes5.                                             working age8
Socio-economic deprivation also contributes                  • Diabetes is the most common cause of
to an increased risk of diabetes. The most                     non-traumatic lower limb amputation9
deprived people in the UK are two and a half
times more likely to develop the condition5.                 • The prevalence of depression is roughly
                                                               twice as high among people with diabetes
What are the effects?                                          as among the general population10
The impact of diabetes on people is
considerable. Not only is their life expectancy              • People with Type 2 diabetes are at almost
reduced by at least five years, but their quality              twice the risk of dying from any cause in
of life can be affected by the associated long                 a year than their peers without diabetes,
term complications (box 2). An individual with                 after adjusting for risk factors11
diabetes is more likely to have heart disease,
stroke, kidney failure, blindness, depression                • People with Type 1 diabetes are at over
and a lower limb amputated than a person                       three times the risk of dying from any
without diabetes.                                              cause in a year than their peers without
                                                               diabetes, after adjusting for risk factors12
“I felt really shattered, felt that my world has
ended, that there wasn’t anything for me. For
that one instant, I felt, that’s it I’m going to finish     Diabetes has a large and growing financial
in no time. How am I going to cope with it?”                impact on the NHS. In 2002, £1.3 billion,
(Person with diabetes)                                      nearly £4 million every day13 or around 5% of
                                                            total NHS expenditure14 was used to care for
                                                            people with diabetes. Estimates from 2006
                                                            suggest that total expenditure could be as
                                                            high as 10% of total NHS expenditure15, which
                                                            is planned to be around £92 billion in

                                Healthcare Commission Managing diabetes: Improving services for people with diabetes   9
2007/200816, and means that about £9 billion is               Since 2004, the National Clinical Director for
being spent on care for people with diabetes,                 Diabetes has published annual reports to the
which is over £25 million every day.                          Secretary of State on the progress made
                                                              towards the standards. The 2007 report noted
Caring for people with diabetes also has an                   that local services are now in a better position
impact on social services expenditure, as it is               to plan, commission and manage high-quality
four times more expensive to care for people                  care that centres around patients. This is
suffering from long term complications than                   because more detailed data and information
those without2.                                               on diabetes care is available, including
                                                              practical guidance documents and toolkits on
                                                              commissioning services and educating
Policy development                                            patients3, (see appendix A for a list of the
                                                              guidance).
The Government’s focus on diabetes has grown
considerably over the last five to six years. In              These initiatives have given healthcare
December 2001, the Government launched the                    professionals a framework when working with
diabetes national service framework (NSF) –                   people with diabetes to design care to meet
12 national standards aimed at raising quality                their individual needs, deliver that care largely
and reducing variation across diabetes                        in settings outside hospital, review care and
services4. The delivery strategy followed in                  treatment regularly and offer support and
January 200317. Together, the publications                    education to help them look after themselves.
describe the Government’s vision of what
services should look like in 2013.                            “It was a shock, certainly. On the other hand, it
                                                              was a relief to know that there was something
To achieve this vision, the Government                        that could be done about it.”
appointed a National Clinical Director for                    (Person with diabetes)
Diabetes in 2003 and created the National
Diabetes Support Team to work with frontline
healthcare professionals in 2004.                             The importance of ‘self care’

The National Institute for Health and Clinical                The importance for people with diabetes
Effectiveness (NICE) issued guidelines for the                For most of the time people with diabetes look
NHS on the management, care and education                     after themselves (box 3), spending only a few
of people with diabetes18, 19, 20. In addition, a new         hours a year with a healthcare professional17.
General Medical Services (GMS) contract with                  But with the number of people with diabetes in
GPs was introduced in 2004 on behalf of the                   England predicted to rise to 2.35 million by
Government, which contained the Quality and                   20102 as the population ages and obesity
Outcomes Framework (QOF)21. Within QOF                        levels climb, demand for services will grow
there are 18 indicators for financially                       and costs will increase. High-quality care that
rewarding primary care practitioners for                      enables people with diabetes to understand
identifying people with diabetes and reaching                 and manage their own condition is vital to both
thresholds for diabetes-related quality targets.              helping people live a life that is independent of
                                                              diabetes and reducing the human and
                                                              financial costs resulting from complications.

10   Healthcare Commission Managing diabetes: Improving services for people with diabetes
Research has shown that changing a person’s
Box 3: What is self care?                                lifestyle can significantly reduce the likelihood
                                                         of people at high risk (those with the diabetes
In general …                                             genes) developing Type 2 diabetes. It can also
“Self care is a part of daily living. It is the          slow down the progression in those already
care taken by individuals towards their own              diagnosed24. This is important given that when
health and wellbeing and includes the care               people with Type 2 diabetes are diagnosed,
extended to their children, family, friends              around half of them already have one or more
and others in neighbourhoods and local                   of the complications associated with diabetes2.
communities.
                                                         Also, there is evidence from controlled clinical
“Self care includes the actions individuals              trials suggesting that people with long term
take for themselves, their children and their            conditions have improved clinical outcomes
families to stay fit and maintain good                   when they take part in programmes teaching
physical and mental health; meet social and              skills in managing their conditions, and that
psychological needs; prevent illness or                  these programmes are more effective than
accidents; care for minor ailments and long              education which only provides information25. In
term conditions; and maintain health and                 other research, self-management
wellbeing after an acute illness or discharge            programmes for people with long term
from hospital.”22                                        conditions have improved their health in areas
                                                         such as depression, tiredness, pain and self-
For people with a long term condition like               efficacy (their beliefs about their own
diabetes, it is …                                        capabilities to produce effects). Another effect
“Self care by definition is led, owned and               of these programmes is to contain increases
done by the people themselves. It is the                 in health care costs for the individuals
activities that enable people to deal with the           concerned26.
impact of a long term condition on their
daily lives, dealing with the emotional                  Policy development
changes, adherence to treatment regimes,                 Making support available to people with long
and maintaining those things that are                    term conditions to care for themselves is
important to them – work, socialising,                   central to the Government’s policy, (box 4),
family.                                                  forming an integral part of the diabetes NSF
                                                         (box 4), the long term (neurological) conditions
“The NHS cannot do self care to people, but              NSF27 and the Department of Health’s generic
what it can do is create an environment                  model of care for people with a range of long
where people feel supported to self care.                term conditions28. This is further reinforced in
This can be done through developing                      the recent White Papers Choosing health29 and
organisational structures and networks,                  Our health, our care, our say30, which highlight
appropriate information, interventions and               the role of prevention in improving the nation’s
technology, to give people the opportunity to            health and the importance of people taking
improve their quality of life, and feel that             more responsibility for becoming and staying
they are still contributing in their                     healthy.
community.”23

                            Healthcare Commission Managing diabetes: Improving services for people with diabetes   11
Involvement in planning their own care,
 Box 4: Empowering people with long term
                                                              combined with education, can help people with
 conditions such as diabetes
                                                              diabetes decide how to manage their condition
 Diabetes NSF standard 3                                      day-to-day. Guidance on the care planning
 “All children, young people and adults with                  process has been developed by the joint
 diabetes will receive a service which                        Department of Health and Diabetes UK Care
 encourages partnership and decision                          Planning Working Group31. Educating patients
 making, supports them in managing their                      has been shown to be cost-effective (box 5),
 diabetes and helps them to adopt and                         and its importance emphasised by the
 maintain a healthy lifestyle.”                               reinstatement in 2006 of the NICE guidance on
                                                              the use of patient education models for
 Quality requirement 1 from the long term                     diabetes20. A self-assessment tool for primary
 (neurological) conditions NSF                                care trusts is available to assess the education
 “A person-centred service”                                   programmes they commission against the
 This is a main theme that runs throughout                    NICE guidelines32.
 the NSF. All people with long-term
 (neurological) conditions are offered a full                 “The nurses have been absolutely wonderful;
 assessment of their health and social care                   they never mind me ringing them up. They just
 needs. In addition, they are to be offered                   make you feel comfortable – I haven’t been a
 information and education about their                        very easy one – they’re always tolerant, always
 condition; the chance to make decisions                      caring, always understanding and helpful.”
 about their treatment; and to be involved in                 (Person with diabetes)
 writing a plan about how their needs will be
 met (a care plan).27                                         The development of policy continues, as the
                                                              evidence on what works is published. The
                                                              latest guidance was published in May 200733.
The Department of Health’s 2006 report                        The National Clinical Director for Diabetes,
Supporting people with long term conditions to                Dr Sue Roberts, set out her views on how
self care23 lists key actions for health and                  services need to change to meet the needs of
social care partners, including developing a                  people with diabetes. The message was clear:
strategy to support self care. It also                        organised, proactive services in partnership
emphasises the importance of skills, training                 with engaged, empowered patients equal
and information in supporting people with long                better outcomes.
term conditions to take more control.

“There’s a huge amount of self-learning.
You’re given targets right at day one, but it
takes a long time to understand the effects
of stress, exercise, all these other things
going on in your body that affect your blood
sugar level and obviously the dose of insulin
you’re going to take.”
(Person with diabetes)

12   Healthcare Commission Managing diabetes: Improving services for people with diabetes
Box 5: Educating patients

• The diabetes NSF proposes a “supported
  self care service model” for diabetes and
  recognises the importance of education in
  facilitating self management

• The NICE guidance recommends that
  structured patient education is made
  available to all people with diabetes at the
  time of initial diagnosis and then as
  required on an ongoing basis, based on a
  formal, regular assessment of need

• In addition to local education
  programmes, there are two national
  group education programmes for adults
  with diabetes that meet the key NICE
  criteria for structured education. They can
  be commissioned by trusts for use in their
  local area. They are:

  – DAFNE (Dose Adjustment for Normal
    Eating) for people with Type 1 diabetes,
    www.dafne.uk.com/

  – DESMOND (Diabetes Education and
    Self-Management for Ongoing and
    Newly Diagnosed) for people with
    Type 2 diabetes,
    www.desmond-project.org.uk/
• The cost of educating patients with
  diabetes depends on the type of
  programme. Costs for a patient attending
  a DESMOND course over one full or two
  half days in a primary care community
  setting are £66. Costs for DAFNE range
  from £250 to £290, and research has
  shown that this becomes cost effective
  after four years20

                          Healthcare Commission Managing diabetes: Improving services for people with diabetes   13
About the review

What is a service review?                                     Why diabetes?

The Healthcare Commission’s service reviews                   We identified diabetes as a priority for a
(previously called improvement reviews) look                  number of reasons, including the:
at how well healthcare organisations are
improving the care and treatment they provide                 • large numbers of adults with diabetes
to patients. We focus on aspects of health and
healthcare where there are substantial                        • increasing incidence of diabetes,
opportunities for improvement, helping                          particularly Type 2 diabetes, in all age
organisations to identify where and how they                    groups and populations
can better perform. We assess organisations
by measuring their performance on key                         • unequal way that diabetes affects the
questions that are important to patients and                    population
the public and those delivering services.
                                                              • reduced life expectancy experienced by
There are two parts to a service review: a                      adults with diabetes
comprehensive assessment of the
performance of each organisation taking part                  • high cost of treating diabetes
in the review, followed by work targeted
specifically at those organisations in greatest               • substantial evidence about what constitutes
need of improvement.                                            good care for adults with diabetes
                                                                documented in the diabetes national service
                                                                framework (NSF) and NICE guidelines

14   Healthcare Commission Managing diabetes: Improving services for people with diabetes
What did the review involve?                              Box 6: Who and how we consulted when
                                                          developing the review
We looked at services commissioned by
primary care trusts, focusing on how well                We asked people with diabetes and their
healthcare systems were supporting adults                carers, the public and healthcare
(aged 17 and over) with diabetes to care for             professionals which aspects of services for
themselves. We concentrated on self care                 people with diabetes should be included in
because of the following aspects:                        the review by:
• the evidence that helping people with                  • consulting national experts and those
  diabetes to care for themselves can delay                delivering diabetes services
  and prevent the onset of symptoms, reduce
  complications and therefore reduce the                 • visiting primary care trusts, general
  impact of the disease on those people with               practices and diabetes clinics
  diabetes and on health and social care
  services                                               • attending diabetes networks and
                                                           education sessions
• the focus placed on self care in the diabetes
  NSF, NICE guidelines, the Chronic Disease              • conducting 13 focus groups of people with
  Management model, recent White Papers,                   diabetes and their carers across England,
  the long term conditions NSF and                         including separate groups of people from
  Department of Health guidance                            black and minority ethnic groups (African
                                                           Caribbean, Somali, Bengali and other
• the lack of evidence available on how well               South Asians). The quotes of people with
  people with diabetes were being supported                diabetes in this report are from these
  to self care                                             focus groups
We then developed the content of the review              • releasing a draft framework on our
through consultation (box 6).                              website and receiving comments

                                                        We used the outcome and process criteria in
                                                        figure 3 to assess how well primary care
                                                        trusts were commissioning services to enable
                                                        people with diabetes to care for themselves.

                           Healthcare Commission Managing diabetes: Improving services for people with diabetes   15
Figure 3: The three criteria used to assess primary care trusts

                                                                      1
              Outcome
                                                          Adults with diabetes are
              criterion
                                                        looking after their condition

                                                     2                                      3
                                            Adults with diabetes                   Adults with diabetes
               Process
                                           feel supported to self                   have key tests and
               criteria
                                       care through care planning,                   measurements
                                        information and education                      carried out

To assess whether trusts were meeting these                   There is information about the content of this
criteria, we asked questions (table 1) against                review on our website. The framework of
each criterion and answered them using data                   assessment for the service review of diabetes36
from the following national sources:                          covers the background to the review, and
                                                              Service review of diabetes – Technical guidance
• national patient survey of people with                      on analysis and scoring37 shows how each of
  diabetes, Healthcare Commission34                           the indicators is calculated and how the
                                                              scores are derived.
• the Quality and Outcomes Framework
  (QOF), Health and Social Care Information                   We carried out a separate statistical analysis
  Centre1                                                     of the survey of people with diabetes at a
                                                              national level. We wanted to find out what the
• Hospital Episode Statistics (HES), Health                   national picture was like, for example, for
  and Social Care Information Centre35                        people with Type 1 and Type 2, and for people
                                                              from different ethnic backgrounds. We have
With the data collected about all of the 152                  reported the findings that are statistically
primary care trusts in England in existence on                significant, and have produced a separate
31 March 2007, we were able to assess                         document containing all the findings and more
whether they were meeting or progressing                      information about how we carried out the
towards both our review’s criteria and also                   analysis34. Further analysis of the whole of the
standards 3, 4, 7 and 10 from the diabetes                    survey is being carried out by the National
NSF. Each primary care trust received a score                 Centre for Social Research and is due to be
in July 2007 on a four-point scale – “weak”,                  published in summer 2007.
“fair”, “good” and “excellent” – based on its
performance relative to all primary care
trusts’ performances.

16   Healthcare Commission Managing diabetes: Improving services for people with diabetes
Table 1: The framework of assessment for the service review of diabetes

Criteria                Questions                                                      Source of data

1 Adults with diabetes 1.1 Are the key measurements for adults with                    QOF and HES
  are looking after        diabetes at recommended levels and are
  their condition          emergency admission rates low?

                        1.2 Do adults with diabetes feel that they are                 Survey of people
                            achieving their lifestyle targets?                         with diabetes

                        1.3 Do adults with diabetes feel knowledgeable                 Survey of people
                            about their diabetes?                                      with diabetes

2 Adults with diabetes 2.1 Do adults with diabetes report that they have               Survey of people
  feel supported to        regular checkups, feel involved and know                    with diabetes
  self care through        what to do next?
  care planning,
  information and      2.2 Do adults with diabetes report that they have               Survey of people
  education                received enough information, education and                  with diabetes
                           training to self care?                                      and QOF

3 Adults with diabetes 3.1 Do clinicians carry out key tests and                       QOF
  have key tests and       measurements?
  measurements
  carried out          3.2 Do adults with diabetes report that key tests               Survey of people
                           and measurements are carried out?                           with diabetes

                        3.3 Do adults with diabetes report that ALL key                Survey of people
                            tests and measurements are carried out?                    with diabetes

                         Healthcare Commission Managing diabetes: Improving services for people with diabetes   17
Key findings

Overall results                                                 Figure 4: Primary care trusts’ overall
                                                                scores for the review (by percentage and
Five per cent (seven) of primary care trusts                    number)
received an overall score of “excellent” (table 2)
and 11% (16) received a score of “good” (figure
4) in commissioning support to help people                                              Excellent 5%
with diabetes to care for themselves. However,                            Weak 12%           (7)
                                                                            (18)                   Good 11%
73% (111) of primary care trusts scored “fair”.
                                                                                                     (16)
Although these primary care trusts are meeting
minimum requirements and the reasonable
expectations of patients and the public,
improvements need to be made.

 Table 2: The primary care trusts scoring
 “excellent” for overall results
 Bath and North East Somerset PCT
 Bournemouth and Poole PCT
 Cumbria PCT
                                                                                      Fair 73%
 Dorset PCT                                                                             (111)
 Isle of Wight NHS PCT
 Redcar and Cleveland PCT
                                                              Four of the 10 strategic health authorities
 Western Cheshire PCT                                         (SHAs) are performing better than the others
                                                              overall (table 3), as these SHAs have the seven
The 12%, (18), of the primary care trusts which               primary care trusts scoring “excellent” within
scored “weak” fell into two groups. One group                 them. There are two SHAs that have no
(eight) is not commissioning services that                    primary care trusts scoring “weak”, South
offer enough support to people with diabetes                  West SHA and South East Coast SHA. South
to look after their condition. For the second                 West SHA is performing better than all SHAs
group (10), we were unable to assess their                    as it has a higher percentage of primary care
support to people with diabetes because there                 trusts scoring “excellent” and no primary care
was no data available for the national patient                trusts scoring “weak”.
survey of people with diabetes. The “weak”
primary care trusts are a particular area of
concern that the Healthcare Commission is
following up (see page 51, ‘Further action by
the Healthcare Commission’).

18   Healthcare Commission Managing diabetes: Improving services for people with diabetes
Table 3: Percentage of primary care trusts with overall scores of “excellent” and “weak”
 out of all primary care trusts in each strategic health authority (SHA)
 Percentage of primary care trusts                                                                  Percentage of primary care trusts
 scoring “excellent” in each SHA                               North
                                                                                                    scoring “weak” in each SHA
                                                               East

 South West SHA                21%                   North                                          South West SHA                 0%
                                                     West

 South Central SHA             11%                               Yorkshire and                      South East Coast SHA           0%
                                                                 The Humber

 North East SHA                 8%                                                                  North West SHA                 4%
 North West SHA                 8%                                     East
                                                                       Midlands
                                                                                                    West Midlands SHA              6%
                                                         West
 East Midlands SHA              0%                       Midlands                                   Yorkshire and Humber SHA       7%
                                                                                       East of
                                                                                       England
 East of England SHA            0%                                                                  North East SHA                 8%
                                                                       South
                                                                       Central    London
 London SHA                     0%                                                                  South Central SHA             11%
                                                                                   South East
                                                  South West                       Coast
 South East Coast SHA           0%                                                                  East Midlands SHA             11%
 West Midlands SHA              0%                                                                  London SHA                    26%
 Yorkshire and Humber SHA       0%                                                                  East of England SHA           29%

The distribution of overall scores for the
                                                                       Figure 5: Overall scores for primary care
Spearhead Group (figure 5)38 of primary care
                                                                       trusts in the Spearhead Group (by
trusts is similar to that for all. These primary
                                                                       percentage and number)
care trusts are in the bottom fifth of all trusts
with the worst health and deprivation
indicators. For example, the life expectancy in                                                        Excellent 3%
these areas, particularly for women, is                                                         Weak 13%    (2)
                                                                                                   (8)            Good 11%
increasing at a slower rate than in the areas                                                                        (7)
not in the Spearhead Group. The similar
spread of overall scores between the
Spearhead Group and all trusts shows that the
level of deprivation of an area is not a factor in
how well primary care trusts support people
with diabetes to look after themselves.

                                                                                                        Fair 73%
                                                                                                          (45)

                              Healthcare Commission Managing diabetes: Improving services for people with diabetes                      19
Conclusions                                                   • there is no primary care trust that has more
                                                                than half of people with diabetes achieving
Our review shows that the majority of people                    their lifestyle targets
with diabetes:
                                                              2. Increasing the number of people with
• have regular checkups, at least one a year                     diabetes attending education courses and
  with a healthcare professional, and most of                    improving their knowledge of diabetes,
  the key tests and measurements are                             because:
  carried out
                                                              • in 55% of primary care trusts, 10% of
• reported that they know enough about when                     people or fewer reported attending an
  to take their medication and how much                         education course on how to manage their
  medication to take                                            diabetes

• reported having the key tests carried out                   • between 16% and 41% of people with
  that are easily recognisable, for example,                    diabetes in primary care trusts would like
  being weighed or having their blood                           to attend an education course on how to
  pressure taken                                                manage their diabetes if they have not been
                                                                on one already
• who smoke are offered advice about
  stopping smoking                                            • those with Type 2 diabetes more than those
                                                                with Type 1, and those from black and
However, there are five areas that all                          minority populations more than white
commissioners and providers of diabetes                         people, report not attending an education
services need to focus on to improve the                        course but wanting to
support offered to people with diabetes.
                                                              • in three-quarters of primary care trusts,
1. Better partnership between people with                       half the people with diabetes, or less, knew
   diabetes and their healthcare professionals                  their long term blood glucose (HbA1c) value
   when planning and agreeing their care,
   because:                                                   • between 19% and 53% of people knew that
                                                                their urine was being tested for protein,
• between 34% to 61% of people with                             which is a kidney function test
  diabetes across all primary care trusts had
  agreed a plan to manage their condition                     3. Working more closely with all organisations
                                                                 providing and commissioning diabetes
• people with diabetes, particularly those with                  services, because:
  Type 2 diabetes and those people from black
  and minority ethnic populations, reported                   • in 95% of primary care trusts, there is
  that the key aspects of care planning were                    scope to reduce the number of emergency
  not happening. For example, between 23%                       admissions to hospital for diabetes-related
  and 58% of people with diabetes in trusts                     complications
  had discussed their goals in caring for their
  diabetes at their checkup

20   Healthcare Commission Managing diabetes: Improving services for people with diabetes
4. Increasing the number of people with                  the exception of those from the ‘Chinese/
   diabetes having long term blood glucose               other’ group) were less likely than white
   (HbA1c) levels of 7.4 or a lower, safe level,         people to know their HbA1c value, less likely
   because:                                              to know when to take their medication and
                                                         how much to take, and more likely to say they
• safe, long term blood glucose levels is one            had not attended an education course on
  of the most important factors in reducing              managing their diabetes but would like to
  the long term effects of diabetes                      attend one.

• in primary care trusts, the percentage of              Both Asian people and people from the
  people with diabetes achieving this level is           ‘Chinese/other’ groups were less likely than
  between 52% and 65% after taking account               white people to have discussed ways to
  of the characteristics of their populations            manage their diabetes and less likely to have
                                                         discussed their goals in caring for their
5. Reducing variation in general practices’              diabetes; they were also less likely to say they
   achievements, because:                                had received the right amount of verbal
                                                         information when first diagnosed or that they
• there is a wide variation between general              had had all the recommended tests in the last
  practices on some of the outcome                       12 months.
  indicators, such as achieving a long term
  blood glucose (HbA1c) level of 7.4, where              Both Asian and black people were more likely
  we found an elevenfold difference in the               than white people to say they had been given
  variation across primary care trusts and the           personal advice about the kinds of food to eat
  process indicators, such as recording a long           and their levels of physical activity.
  term blood glucose (HbA1c) test, where we
  found a twelvefold difference                          Differences by type of diabetes
                                                         Those with Type 2 diabetes were less likely
• some people with diabetes are receiving                than those with Type 1 to know their HbA1c
  better care than others. All practices                 value, less likely to know when to take their
  should work towards achieving the                      medication and how much to take, less likely
  performance of the better practices                    to say they received the right amount of verbal
                                                         information when first diagnosed and more
                                                         likely to say they had not attended an
Patterns from our national survey                        education course but would like to attend one.
                                                         On the other hand, they were more likely
We found the following patterns in our                   to have been given personal advice about
statistical analysis of the survey of people with        the kinds of food to eat and their levels of
diabetes34.                                              physical activity.

Differences by ethnicity                                 Differences by place of checkup
There were some consistent patterns across               Those having their usual checkups at hospital
people from black and minority ethnic (BME)              were less likely than those having them at
populations. People from all BME groups (with            their doctor’s surgery to know when to take

                            Healthcare Commission Managing diabetes: Improving services for people with diabetes   21
their medication and how much to take, and
less likely to have received personal advice on
levels of physical activity and the kinds of
foods to eat. On the other hand, they were
more likely to know their HbA1c value and
more likely to have participated in an
education course on managing their diabetes.

Differences by number of years since
diagnosis
The greater the number of years since
respondents’ diagnosis, the less likely they
were to have received personal advice on
levels of physical activity and the kinds of
foods to eat or have been offered or have
participated in an education course on
managing their diabetes. They were less likely
to have received the right amount of verbal
information when they were first diagnosed.
On the other hand the greater the number of
years since diagnosis the more likely they
were to say that they had had all the
recommended tests in the last 12 months.

Differences by long standing health problem
Those people with diabetes with an additional
long standing physical or mental health
problem were less likely than those without
one to have positive experiences for nearly all
the indicators examined. The main exceptions
were that they were no more or less likely to
have been offered an education course on
managing their diabetes and no more or less
likely to have attended one.

22   Healthcare Commission Managing diabetes: Improving services for people with diabetes
Detailed findings

This section of the report describes in turn the
detailed findings of each of the three criteria,
beginning with the outcome criterion (figure 6).

 Figure 6: Focus on criterion 1

                                                                1
            Outcome
                                                    Adults with diabetes are
            criterion
                                                  looking after their condition

                                              2                                       3
                                     Adults with diabetes                    Adults with diabetes
            Process
                                    feel supported to self                    have key tests and
            criteria
                                care through care planning,                    measurements
                                 information and education                       carried out

Adults with diabetes are looking after
their condition

Living with diabetes is challenging. Every day,         condition, in order to keep the risk factors of
people with diabetes are juggling decisions on          diabetes at or below recommended levels.
what and how much food to eat with the
amount of physical activity they have done, or          “The doctor goes through in his mind, asking the
are going to do. They are also taking their             questions and looking at the blood results and
medicine, monitoring their blood glucose                things – you can see him going through all of
levels and watching for signs of hypoglycaemia          this one step at a time. He’s systematic, no
and long term complications. Diabetes has a             question, I’m pleased with that.”
major physical and psychological impact on              (Person with diabetes)
those who develop it.
                                                        The diabetes NSF recognises the importance
People with diabetes need help from                     of controlling the factors that increase the risk
healthcare professionals to live with their             of acute and long term complications and of
diabetes and to manage their care on a day-             the part healthcare professionals play in
to-day basis. They can do this by supporting            minimising the risk of future recurrence of
people with diabetes to make lifestyle                  acute emergency complications. In particular,
changes, to take the right medication, to               there are two standards that are relevant.
monitor their blood glucose levels
appropriately, and to understand their

                           Healthcare Commission Managing diabetes: Improving services for people with diabetes   23
Table 4: The relevant diabetes NSF                             Figure 7: Primary care trusts’ scores for
 standards4                                                     criterion 1 (by percentage and number)

 Standard 4: Clinical care of adults with
 diabetes                                                                        Excellent 1%
 All adults with diabetes will receive high-                                          (2)
                                                                                          Good 8%
 quality care throughout their lifetime,                                  Weak 12%
                                                                                            (12)
 including support to optimise the control of                               (18)
 their blood glucose, blood pressure and
 other risk factors for developing the
 complications of diabetes.

 Standard 7: Management of diabetic
 emergencies
 The NHS will develop, implement and
 monitor agreed protocols for rapid and
 effective treatment of diabetic emergencies
 by appropriately trained healthcare
 professionals. Protocols will include the
 management of acute complications and
                                                                                      Fair 79%
 procedures to minimise the risk of                                                     (120)
 recurrence.

Our overall results for the criterion ‘Adults                 The distribution of criterion scores at
with diabetes are looking after their condition’              strategic health authority (SHA) level is shown
showed that of the 152 primary care trusts in                 in table 5. The two primary care trusts scoring
England, two scored “excellent”, Dorset PCT                   “excellent” are in different regions – one is in
and Cumbria PCT.                                              South West SHA and the other in North West
                                                              SHA. The remaining strategic health
                                                              authorities had none of the primary care
                                                              trusts in their area achieve “excellent” for this
                                                              criteria, while nine out of 10 of them had at
                                                              least one trust scoring “weak”.

24   Healthcare Commission Managing diabetes: Improving services for people with diabetes
Table 5: Percentage of primary care trusts scoring “excellent” and “weak” in each strategic
 health authority (SHA) for criterion 1
 Percentage of primary care trusts                                                                Percentage of primary care trusts
 scoring “excellent” in each SHA                               North
                                                                                                  scoring “weak” in each SHA
                                                               East

 South West SHA                 7%                   North                                        South East Coast SHA           0%
                                                     West

 North West SHA                 4%                               Yorkshire and                    North West SHA                 4%
                                                                 The Humber

 East Midlands SHA              0%                                                                Yorkshire and Humber SHA       7%
 East of England SHA            0%                                      East
                                                                        Midlands
                                                                                                  South West SHA                 7%
                                                         West
 London SHA                     0%                       Midlands                                 North East SHA                 8%
                                                                                        East of
                                                                                        England
 North East SHA                 0%                                                                South Central SHA             11%
                                                                        South
                                                                        Central    London
 South Central SHA              0%                                                                East Midlands SHA             11%
                                                                                    South East
                                                  South West                        Coast
 South East Coast SHA           0%                                                                East of England SHA           14%
 West Midlands SHA              0%                                                                West Midlands SHA             18%
 Yorkshire and Humber SHA       0%                                                                London SHA                    23%

To assess whether adults with diabetes are                             While emergency admission rates for diabetic
looking after their condition, we asked the                            ketoacidosis and hypoglycaemia indicate how
following questions:                                                   well people with diabetes are supported to
                                                                       cope with acute complications, and how well
1. Are the key measurements for adults with                            the healthcare system as a whole, including
   diabetes at recommended levels and are                              ambulance services, are working together to
   emergency admission rates low?                                      reduce emergency admissions.

2. Do adults with diabetes feel that they are                          Diabetes is a condition where glucose builds
   achieving their lifestyle targets?                                  up in the bloodstream rather than being
                                                                       moved to the body’s cells. Exposure to raised
3. Do adults with diabetes feel knowledgeable                          blood glucose levels can damage the small
   about their diabetes?                                               blood vessels in the body leading to micro
                                                                       vascular conditions such as visual impairment
                                                                       and blindness, kidney failure and nerve
Why did we look at key measurements and                                damage (which can lead to foot ulcers and
emergency admission rates?                                             lower limb amputation). There is also a
The measurements of blood glucose levels                               significantly increased risk of people with
(using glycated haemoglobin called HbA1c as                            diabetes, particularly those with Type 2
a marker), blood pressure and cholesterol                              diabetes, developing cardiovascular disease.
levels give an indication of how well an adult                         This results from damage to the walls of the
with diabetes is managing their condition.                             large blood vessels.

                              Healthcare Commission Managing diabetes: Improving services for people with diabetes                    25
Controlling the levels of glucose in the blood                hospital, the general practice and the
can prevent or delay the development of micro                 ambulance service which responds to the
vascular complications and may reduce the                     emergency. Looking at emergency admission
risk of people with diabetes developing                       rates gives us an indication of how well the
cardiovascular disease. The HbA1c test is                     health professionals work together as a multi­
used to measure the average blood glucose                     disciplinary team to support people with
level over the previous eight to 10 weeks.                    diabetes.
Therefore it shows how well people with
diabetes are controlling their diabetes over the              What did we find in the review?
longer term.                                                  For each primary care trust in England, we
                                                              used data from the Quality and Outcomes
Up to 70% of people with Type 2 diabetes have                 Framework (QOF)1 and standardised it to take
raised blood pressure4. The risk of                           account of the underlying social and
cardiovascular disease increases as blood                     demographic characteristics of the
pressure increases. Lowering blood pressure                   populations concerned, for example, the local
in people with diabetes reduces the risk of                   population’s age, gender and level of
cardiovascular disease and the micro vascular                 deprivation37. We then calculated the
complications associated with diabetes.                       percentage of people with diabetes, for a
                                                              primary care trust and the general practices
Raised cholesterol levels also increase the                   within it, whose:
risk of cardiovascular disease, so by reducing
these levels in people with diabetes who have                 • HbA1c level was 7.4 or less
raised cholesterol levels (over 70% of adults
with Type 2 diabetes)4, the risk of                           • last blood pressure reading was 145/85 or
cardiovascular disease may be reduced.                          less

There are two potentially fatal acute                         • cholesterol level was 5 or less
complications of diabetes: diabetic
ketoacidosis (DKA) and hypoglycaemia. DKA                     We found that, in all primary care trusts
may lead to drowsiness and hypoglycaemia                      (figure 8):
may lead to confusion and fits. Both can lead
to coma. People with diabetes can reduce the                  • between 52% and 65% of people had an
occurrences of DKA and hypoglycaemia by                         HbA1c value of 7.4 or less (with half of all
recognising the symptoms early and managing                     trusts reaching 62% or more)
to control their diabetes3. Most episodes of
hypoglycaemia can be managed outside of                       • between 69% and 80% of people had a
hospitals4.                                                     blood pressure reading of 145/85 or less
                                                                (with half of all trusts reaching 75% or
To reduce the number of these emergency                         more)
acute complications, it is important that
people with diabetes know what to do and can                  • between 74% and 82% of people had a
do it, and that healthcare professionals know                   cholesterol level below 5 (with half of all
how to support them. The healthcare                             trusts reaching 79% or more)
professionals involved are from the acute

26   Healthcare Commission Managing diabetes: Improving services for people with diabetes
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