Standards to support patients with diabetes exist, but are they enhancing their care?
In this article…
- Details of the NICE Quality Standards Programme
- Findings of the National diabetes Audit
- Summary of diabetes standards and quality statements
Debbie Hicks is a nurse consultant in diabetes, Enfield Community Services.
Hicks D (2011) Setting standards for diabetes care. Nursing Times; 107, 32/33, early online publication.
This article explores the NICE Diabetes in Adults Quality Standard document published this year. The document outlines 13 areas of care that should be commissioned to ensure people with diabetes have access to services that provide quality care.
The article also looks at whether diabetes care delivery has met other diabetes standards.
Keywords: Diabetes, Quality standards, Long-term conditions, Audit
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article
5 key points
- The Quality Standards Programme provides markers of quality, cost-effective care for adults with diabetes
- People with diabetes should have tests carried out by their GP practice at an annual review of their diabetes management
- Many people with diabetes are missing out on care that could reduce the risk of long-term complications
- Living with diabetes brings with it restrictions concerning dietary intake, complex medication regimens and potential complications
- Health professionals need to hone their skills to encourage people with diabetes to self-manage their care
Diabetes a long-term condition that is essentially self-managed but requires regular monitoring by health professionals.
To reduce the risk of long-term complications, such as kidney disease, heart attacks and stroke, it is important to monitor patients’ blood–glucose levels, blood pressure and lipid levels, along with weight.
Patients with diabetes should expect at least an annual review of these parameters, along with a foot assessment and retinal screening. Often, screening is more frequent depending on individual needs (General Medical Services, 2004).
Healthcare providers are charged with ensuring services are of a high quality and produce good clinical outcomes in a cost-effective manner (National Institute for Health and Clinical Excellence, 2011).
In 2001 the Department of Health published the National Service Framework for Diabetes, which included 12 quality standards (DH, 2001); two years later, it published a delivery strategy for the framework (DH, 2003).
The main objective of the NSF was to ensure everyone with diabetes was on a register. This would ensure their care needs could be better planned – especially retinal screening, given that diabetes is still the main cause of blindness in the working population (DH, 2003).
Quality Standards Programme
The NICE Quality Standards Programme covers different disease areas and includes diabetes in adults (NICE, 2011).
The diabetes document has a set of standards within diabetes care that look remarkably like those from the NSF document launched 10 years ago (Box 1.)
Box 1. Quality statements
- People with diabetes and/or their carers receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education
- People with diabetes receive personalised advice on nutrition and physical activity from an appropriately trained health professional or as part of a structured educational programme
- People with diabetes participate in annual care planning, which leads to documented agreed goals and an action plan
- People with diabetes agree with their health professional a documented personalised HbA1c target, usually between 48mmol/mol and 58mmol/mol (6.5% and 7.5%), and receive an ongoing review of treatment to minimise hypoglycaemia
- People with diabetes agree with their health professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance
- l Trained health professionals initiate and manage therapy with insulin within a structured programme that includes dose titration by the person with diabetes
- Women of childbearing age with diabetes are regularly informed of the benefits of preconception glycaemic control and of any risks, including medication that may harm an unborn child
- Women with diabetes planning a pregnancy are offered preconception care and those not planning a pregnancy are offered advice on contraception
- People with diabetes receive an annual assessment for the risk and presence of the complications of diabetes, and these are managed appropriately
- People with diabetes are assessed for psychological problems, which are then managed appropriately
- People with diabetes with, or at risk of, foot ulceration receive regular review by a foot protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to and treated by a multidisciplinary foot care team within 24 hours
- People with diabetes admitted to hospital are cared for by appropriately trained staff, provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing their own insulin
- People admitted to hospital with diabetic ketoacidosis receive educational and psychological support before discharge and are followed up by a specialist diabetes team
- People with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist diabetes team
Source: NICE (2011)
It describes markers of high-quality, cost-effective care that, when delivered collectively, should improve the effectiveness, safety and experience of care for adults with diabetes by:
- Preventing people with diabetes from dying prematurely;
- Enhancing the quality of life of those with long-term conditions;
- Helping patients to recover from episodes of ill health or after injury;
- Ensuring people have a positive experience of care;
- Treating and caring for people in a safe environment and protecting them from avoidable harm (NICE, 2011).
Specifically, it is expected that achieving the quality of care set out in this standard will reduce the complications associated with diabetes.
Audit of care
All people with diabetes should receive nine crucial tests from their GP practice at an annual review of their diabetes management. These include measurements of weight, blood pressure, smoking status, HbA1c, urinary albumin, serum creatinine, cholesterol, retinopathy screening and foot screening. These tests are essential in order to ensure that diabetes is controlled to prevent long-term complications.
Unfortunately, the reality may not measure up to the expectations. The National Diabetes Audit outlined performance regarding diabetes care delivery throughout England and Wales during 2008-09. It found that, while more people with diabetes were receiving all nine of the key tests for diabetes care recommended by NICE, thousands were still missing out on the essential tests (National Diabetes Audit, 2010).
The audit, which looked at the records of over 1.7 million people with diabetes in England and Wales, found that just over half of those with type 2 diabetes and onethird of those with type 1 diabetes received all nine tests in 2008-09.
While this compares with only 10.6% and 11.9% respectively six years ago when the first national audit was conducted, this means a large number of people with diabetes are still missing out on care that could reduce their risk of long-term complications, which can be devastating to the individual and costly to the NHS.
The latest figures are also below the recommended target levels set by NICE. While care process completion continues to improve, treatment target achievement has stalled, especially in younger people.
This audit suggests increasing levels of obesity may be a barrier to improving glucose and blood pressure control in type 2 diabetes. The high rates of recorded blood pressure, weight and HbA1c measurement reveal that more than 90% of people with both type 1 and type 2 diabetes are in contact with their healthcare teams at least once a year, yet the audit shows these contacts are not being converted into effective care.
So, would it be better if financial incentives were attached to outcomes rather than the completion of tasks?
Guidelines, programmes and quality initiatives are all well and good, but people with long-term conditions need to be engaged in self-care behaviour.
Living with conditions like diabetes is not easy and there is no cure. Diabetes brings with it long-term restrictions concerning dietary intake, complex medication regimens and potential complications.
All health professionals need to acquire and hone the skills that are required to engage people with diabetes towards self-management of their condition and achieve the outcomes aspired to in recent healthcare publications.
Department of Health (2003) National Service Framework for Diabetes: Delivery Strategy. London: DH.
Department of Health (2001) National Service Framework for Diabetes: Standards.London: DH.
General Medical Services (2004)The National Health Service (General Medical Services Contracts) Regulations 2004.
National Diabetes Audit (2010) National Diabetes Audit (NDA) Executive Summary 2008-2009.
National Institute for Health and Clinical Excellence (2011) Diabetes in Adults Quality Standard. London: NICE.