Managing diabetes Improving services for people with diabetes - Service review
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Inspecting Informing Improving Managing diabetes Improving services for people with diabetes Service review
First published in July 2007 © 2007 Commission for Healthcare Audit and Inspection Items may be reproduced free of charge in any format or medium provided that they are not for commercial resale. This consent is subject to the material being reproduced accurately and provided that it is not used in a derogatory manner or misleading context. The material should be acknowledged as © 2007 Commission for Healthcare Audit and Inspection with the title of the document specified. Applications for reproduction should be made in writing to: Chief Executive, Commission for Healthcare Audit and Inspection, Finsbury Tower, 103-105 Bunhill Row, London, EC1Y 8TG. ISBN 978-1-84562-154-4 The cover includes photographs from www.johnbirdsall.co.uk
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
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 diabetesExecutive 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 3and 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 5Areas 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 diabetesshowed 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 7Introduction
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 diabetesareas 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 92007/200816, 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 diabetesResearch 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 11Involvement 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 diabetesBox 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 13About 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 diabetesWhat 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 15Figure 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 diabetesTable 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 17Key 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 diabetesTable 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 19Conclusions • 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 diabetes4. 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 21their 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 23Table 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 diabetesTable 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 25Controlling 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 diabetesYou can also read
