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Improving services for patient self-care in diabetes

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VOL: 103, ISSUE: 33, PAGE NO: 23

The Healthcare Commission has published a review of services that support adults with diabetes to care for themselv…


The Healthcare Commission has published a review of services that support adults with diabetes to care for themselves (NT News, 24 July, p5; Healthcare Commission, 2007). The National Service Framework for Diabetes (Department of Health, 2001) recognised the importance of supporting patients in self-care. The Healthcare Commission adds that a growing body of evidence shows that supporting people with long-term conditions to care for themselves leads to better outcomes, in both clinical terms and quality of life.



The review examined services commissioned by PCTs, focusing on how well healthcare systems support adults (aged 17 and over) with diabetes to care for themselves. Each PCT received a score in July 2007 on a four-point scale of ‘weak’, ‘fair’, ‘good’ and ‘excellent’, based on its performance relative to all trusts.



Overall Findings


The review scored the performance of the majority of PCTs (73%) as ‘fair’ in their work to support adults with diabetes in self-care. However, the commission is to follow up 12% of trusts because either it found their services were ‘weak’ or an assessment was not possible due to lack of information. Some 5% of trusts were rated as ‘excellent’ and 11% were rated as ‘good’.



Positive findings covered basic care. Most patients were having regular check-ups (at least one a year), with most of the key tests and measurements being carried out. Most people with diabetes who smoke received advice on quitting.



However, the Healthcare Commission identified five areas on which all commissioners and care providers need to focus (see Box, p24). These cover: care planning; patient education courses; improved joint working to cut hospital admissions; blood glucose control; and variations in GP practice achievement.



Key Results


The review found that only 34-61% of people with diabetes across all PCTs had agreed a management plan, and not one trust had more than half of people reporting achievement of lifestyle targets.



Across all PCTs, 1-53% of people with diabetes reported attending an education course on how to manage their condition, while in 55% of trusts 10% or fewer reported attending such a course. The review found 16-41% would like to attend one.



In the vast majority (95%) of PCTs, the review found scope to reduce the number of emergency hospital admissions for diabetes-related complications.



In the area of long-term blood glucose levels, 52-65% of people achieved the HbA1c target of 7.4%, after taking account of population characteristics.



In addition, there was wide variation of GP practices’ achievements in all but one of the Quality and Outcomes Framework (QOF) indicators. This was for both outcome indicators, such as achieving HbA1c levels of 7.4%, where an 11-fold difference in the variation was found, and process indicators, such as recording HbA1c tests, where a 12-fold difference was found.



Areas for Improvement


Planning and agreeing care: Many people with diabetes reported that aspects of care planning - discussing ideas and goals and agreeing a management plan - were not happening. People with Asian and Chinese/other origin and those with a long-standing health problem were more likely to report this than other groups.



The Healthcare Commission recommends that lifestyle advice should be offered to all patients with diabetes routinely. Analysis of the indicator on lifestyle targets revealed that the poor achievement was due to patients not being given advice about physical activity and diet.



Patient education courses: The review highlights that structured education is a key intervention recommended by the NSF for diabetes (DH, 2001) and NICE (2003). According to the review, very few people with diabetes reported having had all the key tests and measurements carried out, while healthcare professionals reported doing them. This may be because patients do not know what tests need to be carried out each year and do not know what is being done.



The review also reveals that patients with diabetes want to go on education courses, particularly people of BME origin, and have not been offered them.



Cutting hospital admissions through joint working: In the majority of trusts there is scope to reduce hospital admissions for diabetic ketoacidosis (DKA) and hypoglycaemic coma. The review identifies two ways to achieve this. The first is to help people with diabetes to both prevent and respond to diabetic emergencies through better patient education. The second is to improve joint working between primary and secondary care, ambulance services and non-healthcare organisations in order to prevent cases of DKA and reduce the number of hypoglycaemic episodes treated in hospital.



Improving blood glucose control: One of the most important factors in reducing the long-term effects of diabetes is the maintenance of safe blood glucose levels. The review shows that, after taking population characteristics into account, on average across all PCTs, 62% of people with diabetes met the HbA1c target of 7.4%. The better-performing trusts achieved 65% and the poorer performers achieved 52%.



Variation in GP practice achievements: The review states that some people with diabetes are receiving better care than others. It suggests that one of the reasons for the extent of this could be differences in exception reporting, a valid method to stop practices being penalised if, for example, a patient refuses an HbA1c test. Wide variations in levels of exception reporting were found in 2004-2005. The British Medical Association ( has published further guidance to ensure consistency and the Healthcare Commission is carrying out work on QOF achievement.





The Healthcare Commission recommends that healthcare professionals should:



- Offer appropriate, individual support to each patient with diabetes to encourage them to self-care;



- Listen to the patient to reach a joint agreement about priorities and the management plan, giving the patient the opportunity to talk about what they think they can achieve;



- Offer support to patients on how to manage DKA and hypoglycaemic attacks;



- Participate in the national clinical audit of people with diabetes and take appropriate action to improve clinical outcomes;



- Review the number of patients with diabetes excepted from the QOF and change how care is organised to include as many people as possible.



Nice Guidance


A NICE (2003) appraisal recommends that structured patient education is made available to all people with diabetes at the time of diagnosis then as required on an ongoing basis, based on a formal, regular assessment of need. This appraisal explains that there is insufficient evidence to recommend a type of education but it outlines some principles of good practice. The DH (2006) has also produced a toolkit to help assess education programmes.



The NICE (2004) clinical guideline on type 1 diabetes in adults highlights key messages including education, blood glucose control, arterial risk factor control and late complications. The NICE (2002) guidance on management of blood glucose in type 2 diabetes focuses on issues such as measurement, targets, self-monitoring, lifestyle interventions, patient education and drug therapy. NICE has also published guidelines on other aspects of management in type 2 diabetes (see



Five Key Areas for Improvement


- Better partnership between patients and healthcare professionals when planning and agreeing care.



- Increasing the number of patients attending courses and improving their knowledge of diabetes.



- Closer working with all organisations providing and commissioning diabetes services to reduce hospital admissions for diabetic emergencies.



- Increasing the number of patients with diabetes having HbA1c levels of 7.4% or a lower safe level.



- Reducing variation in GP practices’ achievements.



Source: Healthcare Commission (2007)

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