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Progress on the diabetes NSF

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VOL: 103, ISSUE: 12, PAGE NO: 23

A Department of Health report published this month discusses the progress the NHS has made against the 12 standards in the Diabetes National Service Framework (Roberts and the National Diabetes Support Team, 2007).

A Department of Health report published this month discusses the progress the NHS has made against the 12 standards in the Diabetes National Service Framework (Roberts and the National Diabetes Support Team, 2007).

PREVENTION AND DIAGNOSIS
The first two NSF standards focus on preventing and identifying diabetes. The report, from the national clinical director for diabetes, Dr Sue Roberts, outlines a range of public service agreements in the overall field of prevention of morbidity and mortality, and suggests that these 'will have profound effects on the diabetes community'.

For the second standard, intended to identify people who do not know they have diabetes, the report indicates that significant progress has been made towards this. The GP quality and outcomes framework, part of the new GP contract, has seen over 100,000 more people diagnosed with diabetes in the past year, as well as improvement in all the other diabetes indicators.

The report speculates that the 'missing million' people with undiagnosed diabetes is now 'more likely to be a missing half-a-million'. The estimated diagnosis rate is now more than 80%. However, it points out that some strategic health authorities have much higher incidence of diabetes than others and more success in diagnosing cases, which demonstrates they all have work to do to find undiagnosed people. The report highlights some innovative services that aim to support those at risk of diabetes and identify those who already have it. The forecast increase in prevalence between 2001 and 2010 is 15% across England, but it is estimated that two-thirds of diabetes cases can be prevented.

EMPOWERING PATIENTS
Standard three is concerned with engaging people with diabetes in their own care to help them adopt and maintain a healthy lifestyle. The report notes the steady increase in the quantity and quality of patient education now being delivered. But it argues there is still 'substantial evidence' that not every person with diabetes is aware of the need for structured education and training or can access it. The Diabetes UK (2006) Diabetes: State of the Nations report found that in England just under half (49%) of adults were aware of education courses, and 36% of adults found the course offered was at an inconvenient time or place.

A case study on reaching diverse communities in Hackney is featured in the report as an example of good practice to foster patient empowerment. Practice nurses and GPs are encouraged to refer patients with diabetes whose first language is not English to bilingual education groups.

A new project in Bolton is also featured, which aims to help people with diabetes set the agenda in consultations with nurses and GPs. The project involves agenda cards, which cover six aspects of life with diabetes, including food and eating, and medication and treatment. In each category there are several cards with different statements on each, which patients can use to express feelings, concerns or priorities.

Another case study focuses on patient information for people with learning disabilities (see box, p24).

CLINICAL CARE
The fourth standard focuses on high-quality care, including support for optimal control of blood glucose, blood pressure and other risk factors for developing complications.

The report says the quality and outcomes framework has shown considerable improvement in diabetes care. However, it adds that there is still a lot to do and that within each StHA there are differences between the PCTs that need to be addressed. The focus now needs to be on the 20-40% of people who are not achieving good results and who could be at a higher risk of complications in future years.

A case study featuring a collaborative, practice-based diabetes clinic in Adur, Arun and Worthing PCT in West Sussex is summarised as an example of good practice. It involves a practice nurse and a diabetes specialist nurse, and patients with type 2 diabetes are seen by the nurses as part of a shared approach. Medication is reviewed and if necessary altered, and lifestyle counselling is also given.

CARE OF CHILDREN AND YOUNG PEOPLE
The fifth and sixth standards cover high-quality care for children and young people (including optimal blood glucose control) and a smooth transition of care from paediatric diabetes services to adult services. The report argues that despite some excellent examples of local progress, services for children with diabetes and their families are 'still well below standard in many areas'.

A case study of a paediatric diabetes clinic in Guildford, Surrey is highlighted as an example of good practice. Here, children are put in charge of their diabetes right from the start. The clinic is run by a consultant paediatrician and a paediatric diabetes specialist nurse, and at diagnosis each child is brought into hospital for a day and given choices about treatment.

DIABETIC EMERGENCIES
Two standards in the NSF focus on agreed protocols for rapid and effective treatment of diabetic emergencies and effective care of diabetes for hospitalised patients. The report argues that while many patients receive care from hospital and ambulance services that is 'second to none', this is not always the case. It says there is evidence of people who have successfully self-managed their condition for years having their medication taken away from them, who have not been allowed to eat when they wanted to avoid a hypoglycaemic event or who have been in hospital for one condition and their diabetes not recognised.

Improving hospital care by reducing admission and lengths of stay has the potential to enhance patients' lives and save resources, the report adds.

DIABETES AND PREGNANCY
The ninth standard focuses on supporting pregnant women with pre-existing diabetes and those who develop the condition during pregnancy. It notes that although the data is encouraging in some areas of care, there is room for improvement in others.

LONG-TERM COMPLICATIONS
The last three standards examined in the report are concerned with surveillance for complications, protocols for investigation and treatment, and integrated health and social care for patients who need multi-agency support.

The long-term complications of diabetes include increased risk of heart disease, stroke, kidney failure, blindness and amputation, but early diagnosis, monitoring and self-management can do much to delay or prevent many of these complications. The report states that the prevalence of different diabetes-related complications still varies significantly between StHAs, as shown by the National Diabetes Audit 2004-2005.

A case study on the development of a software project to highlight complications is featured as an example of good practice in the report. It explains that Dorset PCT is developing new software that links to the general practice computer system and flags up people with or at risk of cardiovascular disease and diabetes. The programme uses existing practice data to highlight people and stratifies them according to their cardiovascular risk. Those at high risk, including people with diabetes, can then be seen by a practice nurse for further assessment and proactive management.

Retinopathy is also a significant complication in diabetes. Within 20 years of diagnosis nearly all patients with type 1 and around 60% of those with type 2 diabetes have some degree of retinopathy. The report states that by April 2006, 78.4% of people with diabetes had been offered retinopathy eye screening, very nearly achieving the 80% goal set out in the diabetes NSF delivery strategy. But it points out that there is still a huge variation across the country in the delivery of retinopathy screening.

CONCLUSION
This report outlines major advances in the diagnosis and management of diabetes since the launch of the NSF delivery strategy in 2003, and highlights examples of good practice. However, it also sets out areas for improvement for nursing staff in clinical care, targeting hard-to-reach communities for support and education, and improving screening in order to prevent complications.

LEARNING DISABILITIES SUPPORT IN DIABETES
An information pack for people with learning disabilities who have diabetes has been developed by Derbyshire County PCT. A diabetes specialist nurse and a learning disabilities nurse created the pack, which contains a booklet entitled You Have Diabetes.

This booklet contains information on:

- What diabetes is;

- How it is treated;

- Healthy living;

- Going to the clinic;

- Other tests.

The booklet is written in simple, accessible language and contains lots of pictures. Readers are guided through it by a character called Sam. There is also a booklet for carers explaining the essentials of the condition.

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