The Department of Health has outlined progress on the diabetes NSF but also points out where improvements are needed over the next five years. Nerys Hairon reports
Hairon, N. (2008) Report highlights areas for improvement in diabetes care. Nursing Times; 104: 35, 15–16.
Diabetes care is improving but much more needs to be done to ensure all patients are receiving the standards of care set out in the National Service Framework (NSF) for Diabetes, a progress report has found (Department of Health, 2008a; NT News, 26 August, p3). The report outlines performance against the standards in the NSF delivery strategy (DH, 2003). It also highlights key areas for improvement and further action during the second half of the timeframe set by the NSF, over the next five years.
Progress has been made in identifying people with diabetes earlier, increasing the numbers of people diagnosed, and providing more routine monitoring for complications. Key areas for further action include improving outcomes for children and young people with diabetes, and ensuring all patients with diabetes are offered retinopathy screening.
This follows a progress report in 2007 which analysed performance against 12 standards and highlighted areas for further work. This included finding more undiagnosed people and improving access to patient education, services for children, and screening for long-term complications (Roberts and the National Diabetes Support Team, 2007).
Prevention and diagnosis
Standard 1 in the NSF aims to prevent people from developing diabetes. While the ageing population is partly responsible for increasing numbers of people developing the condition, obesity is also predicted to play a major part. The DH therefore recommends that tackling obesity must be a top priority. The government’s obesity strategy (DH, 2008b) sets out population-wide plans to promote healthier food choices, make it easier to build physical activity into people’s lives and create incentives for better health.
The recently announced Vascular Screening Programme, involving health checks for everyone aged 40–74, is also expected to aid prevention and diagnosis. It is anticipated the programme will prevent around 4,000 cases of diabetes and identify around 25,000 people with diabetes or kidney disease every year.
The UK National Screening Committee and the University of Leicester recently published a resource for healthcare professionals undertaking vascular risk assessment, which is already being used by some PCTs with their own programmes (Davies et al, 2008). This provides examples of tools and resources for practitioners to use.
Standard 2 focuses on identifying people who are unaware they have diabetes. When the NSF standards were published in 2001, only around 1.3 million people were diagnosed with the condition. Now, as a result of the GP quality and outcomes framework (QOF), almost two million people over the age of 17 are recorded on practice registers with a diagnosis. This means that around 600,000 have been diagnosed in the last five years, equivalent to 2,000 a week.
However, the Yorkshire and Humber Public Health Observatory estimates there are around 2.44 million people with diabetes in England, which means there may still be over 400,000 with undiagnosed diabetes.
Standard 3 focuses on partnership in decision-making, helping patients to maintain a healthy lifestyle and agreeing a care plan. While the importance of care planning has been emphasised in some major policy documents, the DH (2008a) says standards are still variable across the country. The Healthcare Commission’s 2006 survey of people with diabetes found only 47% of respondents ‘almost always’ agreed a management plan, and just 48% reported they ‘almost always’ discussed their ideas about the best way to manage the condition.
The report highlights the Year of Care project as a means of improving care planning. It aims to transform the annual review process – which can sometimes be little more than a ‘tick box’ exercise – into a genuine discussion between patients and healthcare professionals. This approach uses care planning as a means of engaging and empowering patients with diabetes, by giving them more time to consider and discuss information important to them. The project is led by Diabetes UK and the National Diabetes Support Team, in partnership with the Health Foundation and the DH, and three local NHS teams have been recruited as pilot sites. For more information, see www.diabetes.org.uk.
The DH also stresses the importance of emotional and psychological support. However, a Diabetes UK survey of PCTs in 2007 found only 38% provided such support for adults, rising to 51% for children and young people. The DH argues this needs to change, and it has asked Diabetes UK to chair a group looking at how the NHS can improve this. For a good-practice example in this area, see box below.
Yoga for emotional well-being in diabetes
Source: DH (2008a)
Children and young people
Standards 5 and 6 focus on ensuring high-quality care for children and young people. The DH says although service provision for this group has improved significantly, current diabetes care can be variable and does not always meet their needs. Data from the National Diabetes Audit shows that, although children’s diabetes control is improving year on year, the percentage achieving good glycaemic control is still too low. The DH outlines a number of challenges that need to be tackled. These include: ensuring access to dedicated services with appropriate caseloads; providing good diabetes care when children are admitted to hospital for any reason; offering support during school time; and managing the transition from children’s to adult services.
Data from the Child Health Mapping exercise shows access to specialist care is improving but also that children with diabetes need better access to emotional and psychological support.
The DH says the RCN’s (2004) guidance on adolescent transition care aims to help practitioners provide a seamless transfer for young people from paediatric to adult care, and also contains an overview of the issues to consider while planning this.
In addition, the DH’s Children and Young People Implementation Support Group is taking forward a set of recommendations to tackle variations in diabetes care for this patient group. A subgroup is focusing on what is needed to promote better care for children with diabetes in school.
Standards 10, 11 and 12 focus on monitoring and treatment of long-term complications, and ensuring integrated health and social care. QOF data shows significant improvement in screening for diabetes complications. However, there is still a long way to go, as the National Diabetes Audit reports that not everyone receives every process of care. While the vast majority of patients receive regular check-ups, these do not always include proper dialogue between patients and healthcare professionals. The DH says local services need to adopt different strategies to ensure the annual check-ups reflect patients’ personal needs and circumstances.
The DH’s (2003) delivery strategy set a challenging target to tackle retinopathy – that by the end of 2007, 100% of people with diabetes would be offered screening to identify the condition. Data from April 2008 shows that 89.4% of people with diabetes were offered screening in the previous 12 months. The report points out the increasing numbers of diagnoses make the 100% target difficult to meet. However, it urges the NHS to continue to work towards it, as well as focusing on increasing the number of people who receive screening rather than simply being offered it.
For details on progress and further actions in clinical care of adults with diabetes, diabetic emergencies and inpatient care, pregnancy and practice examples, see www.dh.gov.uk
Davies, M. et al (2008) The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management. www.screening.nhs.uk
Department of Health (2008a) Five Years On: Delivering the Diabetes National Service Framework. www.dh.gov.uk
Department of Health (2008b) Healthy Weight, Healthy Lives. A Cross Government Strategy for England. www.dh.gov.uk
Department of Health (2003) National Service Framework for Diabetes: Delivery Strategy. www.dh.gov.uk
Roberts, S., National Diabetes Support Team (2007) Improving Diabetes Services: The NSF Four Years On. The Way Ahead: The Local Challenge. London: DH.
RCN (2004) Adolescent Transition Care: Guidance for Nursing Staff. www.rcn.org.uk