commissioning for diabetes diagnosis and continuing care ... · 7 nhs diabetes diabetes care – c...
TRANSCRIPT
CommissioningDiabetes Diagnosis and
Continuing Care Services
Supporting, Improving, Caring
March 2010
NHS Diabetes Information Reader Box
Review Date 2012
3
This commissioning guide has been developed byNHS Diabetes with key stakeholders includingclinical and social services professionals and patientgroups represented by Diabetes UK.
It is not designed to replace the Standard NHSContracts as many of the legal and contractualrequirements have already been identified in thisset of documents. Rather, it is intended to form thebasis of a discussion or development of diabetesdiagnosis and continuing care services betweencommissioners and providers from which acontract for services can then be agreed.
This commissioning guide consists of:
• A description of the key features of high qualityservices that provide diabetes diagnosis andcontinuing care for adults with diabetes.
• A high level intervention map . This interventionmap describes the key high level actions orinterventions (both clinical and administrative)diabetes and continuing care services shouldundertake in order to provide the most efficientand effective care, from admission to discharge(or death) from the service.
It is not intended to be a care pathway or clinicalprotocol, rather it describes how a true ‘diabeteswithout walls’ service should operate goingacross the current sectors of health care.
The intervention map may describe currentservice models or it may describe what shouldideally be provided by diabetes and continuingcare services.
• A contracting framework for diabetes andcontinuing care services that brings together allthe key standards of quality and policy relatingto the diagnosis and management of diabetes
• A template service specification for diabetes andcontinuing care services that forms part ofschedule 2 of the Standard NHS Contractcovering the key headings required of aspecification. It is recommended that thecommissioner checks which mandatory headingsare required for each type of care as specified bythe Standard NHS Contracts.
Commissioners are referred to the commissioningguides for children and young people and for olderpeople for a description of diabetes diagnosis andcontinuing care for these care groups as well as tothe diabetes emergency and in patient carecommissioning guide for the management ofpeople who present with acute diabeticemergencies.
For further detail on how to approach thecommissioning of diabetes services please seehttp://www.diabetes.nhs.uk/commissioning_resource/
Commissioning Diabetes Diagnosisand Continuing Care Services
4
High quality diabetes diagnosis and continuingcare services should ensure:
• a proactive approach to identify people withdiabetes
• that the needs of patients immediately followingdiagnosis are met, including:
• assessment in the domains of:o clinical care (including assessment
of risk) and co- morbiditieso health beliefs and knowledgeo social issueso emotional state, including
depressiono behavioural issues (ease of
carrying out self managementtasks)
• triage of acute potentially life-threateningcomplications, e.g. ketoacidosis, infectedfoot
• medication/treatment and/or adviceabout healthy lifestyle
• initial assessment of type of diabetes• initial care planning / management
planning• introduction to what the patient should
expect for themselves and from theservice
• that people newly diagnosed with diabetesreceive advice and support to help them selfmanage. This should include:
• structured education designed for peoplenewly diagnosed with diabetes
• support to optimise blood glucose control• support to manage cardiovascular risk
factors• an initial care plan• support for emotional and social issues
• co-ordination of other issues or co-morbidities
• opportunity for support from otherpeople with diabetes, e.g. via DiabetesUK local voluntary support groups orother local patient groups
• that people with diabetes receive regularstructured care (annual, or more frequently asappropriate) based on a care planning approach.This should include the following elements:
• on-going advice and support fromclinicians and other people with diabetesto help them self manage
• prevention and surveillance for long-termcomplications
• access to appropriate equipment andresources, pharmacological therapy,including oral agents, subcutaneousinsulin and CSII (insulin pump therapy)
• on-going structured education• emotional support
In addition, the service should:
• be developed in a co-ordinated way, taking fullaccount of the responsibilities of other agenciesin providing comprehensive care (as set out inNational Standards, Local Actioni) and involvingusers
• be commissioned jointly by health and socialcare based on a joint health needs assessmentwhich meets the specific needs of the localpopulation, using a holistic approach asdescribed by the generic choice model for themanagement of long term conditionsii
• provide effective and safe care to people withdiabetes in a range of settings including thepatient’s home, according to recognisedstandards including the Diabetes NSFiii
Features of Diabetes Diagnosis andContinuing Care Services
i Available on the DH website at http://www.dh.gov.uk/assetRoot/04/08/60/58/04086058.pdf
ii Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081105
iii Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH4002951
5
• take into account the emotional, psychologicaland mental wellbeing of the patientiv
• take into account race and inequalities withrespect to access to care
• ensure that services are responsive andaccessible to people with Learning Disabilitiesv
• have effective clinical networks, with clear clinicalleadership, across the boundaries of care whichclearly identify the role and responsibilities ofeach member of the diabetes healthcare team
• ensure that there are a wide range of optionsavailable to people with diabetes to support selfmanagement and individual preferences
• take into account services provided by socialcare and the voluntary sector
• provide patient/carer/family education ondiabetes not only at diagnosis but also duringcontinuing management at every stage of care
• provide education on diabetes management toother staff and organisations that supportpeople with diabetes
• have a capable and effective workforce that hasappropriate training, updating, skills and
competencies in the management of peoplewith diabetes
• provide multidisciplinary care that manages thetransition between adult and older peoples’services
• have integrated information systems that recordindividual needs including emotional, social,educational, economic and biomedicalinformation which permit multidisciplinary careacross service boundaries and support careplanningvi
• produce information on the outcomes ofdiabetes care including contributing to nationaldata collections and audits
• have adequate governance arrangements, e.g.local mortality and morbidity meetings ondiabetes care to learn from errors and improvepatient safety
• take account of patient experience, includingPatient Reported Outcome Measures, in thedevelopment and monitoring of service delivery
• actively monitor the uptake of services,responding to non-attenders and monitoringcomplaints and untoward incidents
iv Emotional and Psychological Support and Care in Diabetes, Joint Diabetes UK and NHS Diabetes Emotional and Psychological SupportWorking Group, February 2010
v http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
vi See York and Humber integrated IT system at http://www.diabetes.nhs.uk/document.php?o=610
6
NH
S D
iab
etes
Dia
bet
es c
are
–d
iag
no
sis
and
init
ial m
anag
emen
t
Ref
erra
l fro
m
Dia
bet
esp
reve
nti
on
serv
ices
Self
ref
erra
l
Pati
ent
iden
tifi
ed
fro
m a
t ri
sk
reg
iste
rs
e.g.
CH
D, o
besi
ty,
seve
re m
enta
l ill
ness
etc
Ref
erra
l fro
m
oth
er s
ervi
ces
e.g.
-an
tena
tal,
men
tal
heal
th, h
ealth
ch
ecks
, acu
te
care
, Car
e H
omes
,op
tom
etris
t,
podi
atris
t e
tc
Ap
po
intm
ent
mad
e at
d
iab
etes
serv
ice
Dia
gn
osi
sd
iscu
ssed
wit
h
pat
ien
t
-ac
cess
to
advo
cacy
se
rvic
es, i
f re
quire
d
Info
rmat
ion
give
n on
-w
hat
trea
tmen
t to
ex
pect
-pa
tient
edu
catio
n, e
.g.
Des
mon
d, X
pert
etc
-ho
w b
est
to c
ontr
ol
diab
etes
-av
oidi
ng c
ompl
icat
ions
-be
gin
med
icat
ion
-na
med
Dia
bete
s U
K
info
rmat
ion
book
s-
care
co-
ordi
natio
n pr
oces
s id
entif
ied
Ref
erra
l –re
re
leva
nt
soci
al
fact
ors
e.g.
-su
ppor
t to
car
er-
empl
oym
ent/
finan
cial
advi
ce e
tc
Ref
erra
l/si
gn
po
stin
g
to o
ther
pre
ven
tio
n
serv
ices
-pa
tient
edu
catio
n-
exer
cise
pr
ogra
mm
es-
heal
thy
diet
reg
imes
- re
tinop
athy
scr
eeni
ng
Ref
erra
l fo
r o
ther
su
pp
ort
-24
/7 h
elpi
ne-
self
help
gro
ups,
e.g
. Dia
bete
s U
K lo
cal s
uppo
rt g
roup
Psyc
ho
log
ical
su
pp
ort
, if
nec
essa
ry
-re
ferr
al t
o ps
ycho
logi
cal
the
rapi
es, i
f ap
prop
riate
-re
ferr
al t
o vo
lunt
ary
sect
or, i
f ap
prop
riate
-re
ferr
al t
o m
enta
l hea
lth s
ervi
ces,
if a
ppro
pria
te –
see
men
tal h
ealth
and
dia
bete
s co
mm
issi
onin
g gu
ide
Car
e co
-ord
inat
or
resp
on
sib
iliti
es
iden
tifi
ed
Ap
po
intm
ent
for
con
tin
uin
g
man
agem
ent
-pu
t on
dia
bete
s re
gist
er
Go
to
Pa
ge
7
-as
sess
men
t, in
clud
ing
tria
ge o
f ac
ute
pote
ntia
lly
life-
thre
aten
ing
com
plic
atio
ns, a
ccor
ding
to
agr
eed
prot
ocol
s-
scre
en f
or a
nxie
ty
dem
entia
and
dep
ress
ion
Incl
udes
man
agem
ent
of:
-co
mpl
icat
ions
of
diab
etes
-fo
ot c
are
-in
patie
nt h
ospi
tal c
are
-pr
egna
ncy
and
diab
etes
(in
clud
ing
gest
atio
nal
diab
etes
)-
men
tal h
ealth
-le
arni
ng d
isab
ility
-en
d of
life
car
e
Car
e p
lan
nin
g
agre
ed a
nd
in
itia
ted
wit
h
pat
ien
tin
volv
emen
t
Ref
erra
l to
sp
ecia
list
care
, if
app
rop
riat
e
-e-
cons
ulta
tion
Car
er’s
nee
ds
asse
ssed
Phys
ical
h
ealt
h
asse
ssm
ent
and
men
tal
hea
lth
as
sess
men
t an
d in
itia
l in
vest
igat
ion
s
-ass
essm
ent
and
prov
isio
n of
re
sour
ces
acco
rdin
g to
ag
reed
pro
toco
ls
Hea
lth
N
eed
s A
sses
smen
t
Firs
t p
rese
nta
tio
n
of
dia
bet
ic
emer
gen
cy
See
emer
gen
cy
and
in p
atie
nt
com
mis
sio
nin
g
gu
ide
Diabetes Diagnosis and ContinuingCare Service Intervention Map
7
NH
S D
iab
etes
Dia
bet
es c
are
–C
on
tin
uin
g c
are
Fro
m
Pag
e 6
Reg
ula
r sc
reen
ing
Co
nti
nu
ing
ed
uca
tio
n
Hea
lth
pro
mo
tio
n
acti
viti
es
Ref
erra
l to
sp
ecia
list
dia
bet
es
care
, if
req
uir
ed
Incl
udes
man
agem
ent
of:
-co
mpl
icat
ions
of
diab
etes
-fo
ot c
are
-in
patie
nt h
ospi
tal c
are
-pr
egna
ncy
and
diab
etes
(inc
ludi
ng
gest
atio
nal d
iabe
tes)
-m
enta
l hea
lth-
lear
ning
dis
abili
ty-
end
of li
fe c
are
-as
sess
men
t an
d tr
eatm
ent,
incl
udin
g tr
iage
of
acut
e po
tent
ially
lif
e-th
reat
enin
g co
mpl
icat
ions
,acc
ordi
ng
to a
gree
d pr
otoc
ols
-ac
cess
to
advo
cacy
se
rvic
es, i
f re
quire
d
e.g.
ret
inal
-
card
iova
scul
ar
-re
nal
-fo
ot c
are
etc
Clo
se m
on
ito
rin
g
req
uir
ed?
Yes No
Ref
erra
l fo
r ap
pro
pri
ate
care
E.g.
-re
tinal
-fo
ot c
are
- re
nal e
tc
Dat
e o
f n
ext
care
pla
n
revi
ew a
gre
ed
-se
cond
ary
prev
entio
n
Car
e p
lan
nin
g r
evie
w
(ph
ysic
al, m
enta
l h
ealt
h, s
oci
al,
emo
tio
nal
)
Rev
iew
of
care
r’s
nee
ds
- as
sess
men
t an
d pr
ovis
ion
of r
esou
rces
ac
cord
ing
to a
gree
d pr
otoc
ols
Tele
ph
on
e co
nsu
ltat
ion
av
aila
ble
b
etw
een
car
e p
lan
nin
g
revi
ews
8
IntroductionThis contracting framework sets out what is requiredof clinically safe and effective services that areproviding diabetes diagnosis and continuing care. The framework is designed to be read in conjunctionwith the high level patient intervention map, whichdescribes the interventions and actions requiredalong the patient pathway as well as entry and exitpoints and the standard service specification templatefor diabetes diagnosis and continuing care services.
The framework brings together the key quality areasand standards that have been identified by NHSDiabetes, Diabetes UK, the Royal Colleges and otherrelated organisations.
The principles that establish a safepathway for patient care Establishing the principles that underpin the systemsand processes of pathways for patient care leads tomore efficient patient throughput and can reducerisk of fragmentation of care and serious untowardincidents. The principles operate at four layers withina patient pathway:
• Commissioning• Clinical Case Direction or the overall Care Plan (i.e.
the management of an individual patient)
• Provision of the clinical service or process• Organisational platform on which the clinical
service or process sits (the provider organisation)
A straightforward or simple pathway is one in whichthe overall management including both Clinical CaseDirection and the delivery of the clinical processesconventionally sits within one organisation. However,with a more complex pathway, there is a danger thatfracturing the overall management pathway intocomponents carried out by different clinical teamsand organisations will require duplication of effortleading to inefficiency and increased risk at handoverpoints.. This can be managed by establishing cleargovernance arrangements for all the layers in thepathway. For the individual with diabetes, a clearcare planning process together with a relationshipwith an identified care co-ordinator and supportedby integrated personal records can ensure continuityof care.
In addition, Commissioning Bodies must balance thebenefits of fracturing the pathway against increasedcomplexity and ensure that the increased risks aremitigated.
The governance arrangements required for all threelayers and the commissioner responsibilities areshown below:
Contracting Framework for DiabetesDiagnosis and Continuing Care Services
9
In essence, at each level, there are governancearrangements to ensure sound and safe systems ofdelivery of patient care with clear lines ofaccountability between each level.
The diabetes servicesThe key principles of good diabetes diagnosis andcontinuing care is to provide a high quality servicethat is reliable in terms of delivery and timelyaccess for patients requiring that care.
Diabetes care is provided by a number of differentteams in the primary, community and acutesetting. It is essential that there is co-ordination ofcare of the patients through the care planningprocess and a consultant diabetologist retains theclinical accountability and responsibility for theservice. Responsibility for overall patient care acrossthe whole pathway rests with the patient’s GP whoalso retains overall responsibility to ensure themanagement of side effects and complications.
The initial management and continuing care ofindividuals with diabetes should include anassessment of their emotional and psychologicalwell-being, together with timely access toappropriate psychological and biological/psychiatricinterventions. Mental health disorders can posesignificant barriers to diabetes care and thereforemental health stability is vital for good self care 1.
The services themselves will also have clinicaloversight and accountability for governancepurposes.
This contracting framework focuses on adults withdiabetes. Commissioners are referred to thediabetes commissioning guides for children andyoung people2 and older people 3 for further detailon these care groups. This contracting frameworkshould also be read in conjunction with thediabetes commissioning guides for prevention and
risk assessment4, foot care 5, emergency and inpatient care 6, mental health 7, pregnancy8, thecomplications of diabetes 9, End of Life Care 10
and follow the principles for the effectivecommissioning of services for people with LearningDisabilities 11.
Ensuring qualityCommissioning Bodies should ensure that thediabetes services commissioned are of the highestquality. There may, in addition, be someorganisations that wish to offer their services, butdo not have a history of providing such care.
i) For provider organisations already involved inthe delivery of diabetes services, there should beretrospective evidence of systems being in place,implemented and working.
ii) For organisations new to the arena thecommissioner should reassure itself that theprovider has the organisational attributes,governance arrangements, systems andprocesses set up to provide the platform forsafe and effective delivery of diabetes servicesto be provided.
This framework describes what theCommissioning Body needs to ensure ispresent or addressed in its discussions withthe provider organisation.
Under the ‘elements’ column there are crossreferences to the Standard NHS Contract forCommunity Services – bilateral (main clauses andschedules)12. (The cross references also apply to theclauses and schedules in the Standard NHS Contractfor Acute Services).This is to assist commissionersand providers in having an overview of how theelements link to the Standard NHS Contract. Someof the areas are open to interpretation andconsequently the references are not exhaustive.
10
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Gov
erna
nce
Lead
ersh
ip
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:11
,16,
19,3
3,48
,49,
51,5
3, 6
0
Sche
dule
s:10
Cla
rity
of t
he o
rgan
isat
ion’
spu
rpos
e w
ith e
xplic
itco
mm
itmen
t to
pro
vidi
ng h
igh
qual
ity s
ervi
ces
A c
ultu
re t
hat
dem
onst
rate
s an
open
lear
ning
eth
os
An
orga
nisa
tion
that
is le
gal a
ndet
hica
l in
all i
ts a
ctiv
ities
Prov
ider
mus
t hav
e or
gani
satio
nal s
truc
ture
that
pro
vide
s le
ader
ship
for a
ll pr
ofes
sions
and
disc
iplin
es
In p
artic
ular
, the
re m
ust b
e a
corp
orat
e cl
inic
aldi
rect
or w
ith th
e re
spon
sibili
ty a
ndac
coun
tabi
lity
for t
he c
linic
al s
ervi
ce
Ther
e m
ust b
e a
lear
ning
fram
ewor
k in
the
orga
nisa
tion
Ther
e sh
ould
be
a de
sign
ated
clin
ical
dire
ctor
with
resp
onsi
bilit
y an
d ac
coun
tabi
lity
for
the
diab
etes
dia
gnos
is a
ndco
ntin
uing
car
e se
rvic
es
Gov
erna
nce
Inte
grat
ed G
over
nanc
e
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:11
,19,
27,4
8,49
,51
,53,
54,5
6,60
Sche
dule
s:
10
An
orga
nisa
tion
that
is g
uide
d by
the
prin
cipl
es o
f goo
d go
vern
ance
:
- cla
rity
of p
urpo
se- p
artic
ipat
ion
and
enga
gem
ent
- rul
e of
law
- tra
nspa
renc
y- r
espo
nsiv
enes
s- e
quity
and
incl
usiv
enes
s- e
ffec
tiven
ess
and
effic
ienc
y- a
ccou
ntab
ility
An
orga
nisa
tion
that
acc
epts
resp
onsib
ility
and
acc
ount
abili
tyfo
r all
its a
ctio
ns
Cle
ar o
rgan
isatio
nal a
nd i
nteg
rate
dgo
vern
ance
sys
tem
s an
d st
ruct
ures
in p
lace
with
cle
ar li
nes
of a
ccou
ntab
ility
and
resp
onsib
ilitie
s fo
r all
func
tions
. Thi
s in
clud
esin
terf
aces
and
tran
sitio
ns b
etw
een
serv
ices
Gov
erna
nce
Clin
ical
Gov
erna
nce
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:4,
4A,6
,9,1
0,12
,14,
15,1
6,17
,19,
21,2
5,26
27,2
9,30
,32,
33,
48,4
9,51
,53,
54
Sche
dule
s:
3 (p
arts
3,4
A a
nd 4
B),
10,1
2,18
Expl
icit
com
mitm
ent t
o qu
ality
and
patie
nt s
afet
y
Patie
nt fo
cuse
d w
ith re
spec
t for
the
pers
onal
wish
es o
f pat
ient
s in
all a
spec
ts o
f the
ir ca
re
A c
omm
itmen
t to
inno
vatio
n an
dco
ntin
uous
impr
ovem
ent
Clin
ical
Gov
erna
nce
syst
ems
and
polic
ies
shou
ld b
e in
pla
ce a
nd in
tegr
ated
into
orga
nisa
tiona
l gov
erna
nce
with
cle
ar li
nes
ofac
coun
tabi
lity
and
resp
onsib
ility
for a
ll cl
inic
algo
vern
ance
func
tions
e.g.
•C
linic
al A
udit
•C
linic
al R
isk M
anag
emen
t•
Unt
owar
d In
cide
nt R
epor
ting
•In
fect
ion
Con
trol
•M
edic
ines
Man
agem
ent
•In
form
ed C
onse
nt•
Raisi
ng C
once
rns
•St
aff D
evel
opm
ent
All
sub-
cont
ract
ors
mus
t mee
t gov
erna
nce
and
lead
ersh
ipar
rang
emen
ts o
f the
mai
n pr
ovid
er o
rgan
isatio
n
Com
miss
ione
r, pr
ovid
er a
nd N
HS
Litig
atio
n A
utho
rity
mus
t rev
iew
the
Clin
ical
Neg
ligen
ce S
chem
e fo
r Tru
sts
arra
ngem
ents
/or o
ther
orga
nisa
tiona
l / p
rofe
ssio
nal i
ndem
nity
arr
ange
men
ts
The
serv
ice
shou
ld h
ave
in p
lace
writ
ten
prot
ocol
s an
d pr
oced
ures
defin
ing
clea
r lin
es o
f acc
ount
abili
ty a
nd re
spon
sibili
ty.
The
serv
ice
is re
quire
d to
com
ply
with
gui
delin
es p
rodu
ced
by th
eN
atio
nal I
nstit
ute
for H
ealth
and
Clin
ical
Exc
elle
nce
that
are
rele
vant
to th
e ca
re p
rovi
ded
by th
e se
rvic
e in
clud
ing:
•D
iagn
osis
and
man
agem
ent o
f Typ
e 1
diab
etes
in c
hild
ren,
youn
g pe
ople
and
adu
lts 13
•Ty
pe 2
dia
bete
s: th
e m
anag
emen
t of t
ype
2 di
abet
es (u
pdat
e)14
11
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Gov
erna
nce
Clin
ical
Gov
erna
nce
•C
ompl
aint
s M
anag
emen
t•
Patie
nt a
nd P
ublic
Invo
lvem
ent
•Pa
tient
dig
nity
and
resp
ect
•Eq
ualit
y an
d di
vers
ity•
Intr
oduc
ing
new
tech
nolo
gies
and
trea
tmen
ts•
An
exte
rnal
ly a
ccre
dite
d Q
ualit
yA
ssur
ance
sys
tem
and
inte
rnal
err
orre
port
ing
invo
lvin
g al
l sta
ff g
roup
s.
CG
sys
tem
s sh
ould
hav
e cl
ear a
ndde
mon
stra
ble
links
to o
ther
NH
S sy
stem
sw
ith c
olla
bora
tive
CG
act
iviti
es a
nd s
harin
gof
exp
erie
nce
and
lear
ning
Prov
ider
sho
uld
prod
uce
annu
al C
linic
alG
over
nanc
e re
port
s as
par
t of N
HS
CG
repo
rtin
g sy
stem
Prov
ider
s ar
e re
quire
d to
agr
eeC
omm
issio
ning
for Q
ualit
y an
d In
nova
tion
sche
mes
(CQ
UIN
) for
dia
bete
s ca
re, e
.g.
mod
el C
QU
IN s
chem
e pr
opos
ed b
y th
e N
HS
Inst
itute
for I
nnov
atio
n an
d Im
prov
emen
t 26
•M
anag
emen
t of T
ype
2 di
abet
es -
prev
entio
n an
d m
anag
emen
tof
foot
pro
blem
s 15
•Ty
pe 2
dia
bete
s: n
ewer
age
nts
for b
lood
glu
cose
con
trol
in ty
pe2
diab
etes
16
•A
lloge
neic
pan
crea
tic is
let c
ell t
rans
plan
tatio
n fo
r typ
e 1
diab
etes
mel
litus
17
•A
utol
ogou
s pa
ncre
atic
isle
t cel
l tra
nspl
anta
tion
for i
mpr
oved
glyc
aem
ic c
ontr
ol a
fter
pan
crea
tect
omy
18
•Pa
ncre
atic
isle
t cel
l tra
nspl
anta
tion
19
•Pr
imar
y pr
even
tion
of ty
pe 2
dia
bete
s m
ellit
us a
mon
g hi
gh ri
skbl
ack
and
min
ority
eth
nic
grou
ps 20
•Th
e cl
inic
al e
ffec
tiven
ess
and
cost
eff
ectiv
enes
s of
long
act
ing
insu
lin a
nalo
gues
for d
iabe
tes
21
•Th
e cl
inic
al e
ffec
tiven
ess
and
cost
eff
ectiv
enes
s of
pat
ient
educ
atio
n m
odel
s fo
r dia
bete
s 22
•C
ontin
uous
sub
cuta
neou
s in
sulin
infu
sion
for t
he tr
eatm
ent o
fdi
abet
es (r
evie
w)23
•D
epre
ssio
n w
ith a
chr
onic
phy
sical
hea
lth p
robl
em24
•M
edic
ines
adh
eren
ce: i
nvol
ving
pat
ient
s in
dec
ision
s ab
out
pres
crib
ed m
edic
ines
and
sup
port
ing
adhe
renc
e 25
In a
dditi
on, d
iabe
tes
mul
tidisc
iplin
ary
team
s sh
ould
27:
•be
ale
rt to
the
deve
lopm
ent o
r pre
senc
e of
clin
ical
or s
ub-
clin
ical
dep
ress
ion
and/
or a
nxie
ty, i
n pa
rtic
ular
whe
re s
omeo
nere
port
s or
app
ears
to b
e ha
ving
diff
icul
ties
with
sel
f-m
anag
emen
t.•
be a
ble
to d
etec
t and
bas
ical
ly m
anag
e n
on-s
ever
eps
ycho
logi
cal d
isord
ers
in p
eopl
e fr
om d
iffer
ent c
ultu
ral
back
grou
nds
•be
fam
iliar
with
cou
nsel
ling
tech
niqu
es a
nd d
rug
ther
apy,
whi
lear
rang
ing
prom
pt re
ferr
al to
men
tal h
ealth
spe
cial
ists
•no
t use
spe
cial
man
agem
ent t
echn
ique
s or
trea
tmen
t for
non
-se
vere
psy
chol
ogic
al il
lnes
s, e
xcep
t whe
re d
iabe
tes-
rela
ted
arte
rial c
ompl
icat
ions
giv
e ris
e to
spe
cial
pre
caut
ions
ove
r dru
gth
erap
y•
be a
lert
to b
ulim
ia n
ervo
sa a
nd a
nore
xia
nerv
osa
and
insu
lindo
se m
anip
ulat
ion
if th
ere
is ov
er c
once
rn w
ith b
ody
shap
e an
dw
eigh
t, lo
w B
MI o
r poo
r glu
cose
con
trol
•m
ake
early
(and
occ
asio
nally
urg
ent)
refe
rral
s to
loca
l eat
ing
diso
rder
ser
vice
s, a
s ap
prop
riate
12
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Gov
erna
nce
Clin
ical
Gov
erna
nce
•en
sure
that
all
adul
ts w
ith T
ype
I dia
bete
s ha
ve, a
t reg
ular
inte
rval
s, c
ouns
ellin
g ab
out l
ifest
yle
issue
s an
d nu
triti
onal
beha
viou
r
Clin
ical
qua
lity
Qua
lity
assu
ranc
e
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:4,
12,1
6,17
,18,
19,2
0,21
,30,
31,
32,3
3, 5
4
Sche
dule
s:
2,3
(par
t 4A
and
4B)
,10
,12,
18
Und
erst
andi
ng th
e co
ncep
t of
clin
ical
qua
lity
Has
con
cern
for q
ualit
y w
hile
wor
king
eff
icie
ntly
An
unde
rsta
ndin
g of
the
use
ofau
dit,
patie
nt a
nd s
taff
feed
back
to im
prov
e qu
ality
An
orga
nisa
tion
that
pro
vide
scl
arity
of o
bjec
tives
and
pro
mot
esre
flect
ive
prac
tice
to im
prov
equ
ality
of p
atie
nt c
are
Qua
lity
assu
ranc
e sy
stem
s m
ust
be in
pla
cean
d ap
prov
ed b
y co
mm
issi
onin
g bo
dy w
ithre
gula
r re
port
ing
of o
utco
mes
Prov
ider
s ar
e re
quire
d to
pub
lish
qual
ityac
coun
ts f
or t
he p
ublic
rep
ortin
g of
qua
lity
incl
udin
g sa
fety
, exp
erie
nce
and
outc
omes
Prov
ider
s sh
ould
par
ticip
ate
in n
atio
nal
audi
t pr
ogra
mm
es
Dia
bete
s se
rvic
es m
ust c
ompl
y w
ith th
e ac
cess
targ
ets
for p
rimar
yan
d se
cond
ary
care
, i.e
.:
•In
sert
wai
ting
times
for p
rimar
y ca
re 28
•In
sert
18
wee
k ta
rget
29
The
serv
ices
are
requ
ired
to p
artic
ipat
e in
the
follo
win
gac
tiviti
es/p
rogr
amm
es:
•N
atio
nal D
iabe
tes
Aud
it 30
•Pa
tient
Exp
erie
nce
Surv
eys
31
•D
iabe
tes
E 32
•Pa
tient
Rep
orte
d O
utco
me
Mea
sure
s
Clin
ical
qua
lity
Wor
kfor
ce/ s
taff
Clin
ical
sta
ff a
ttrib
utes
criti
cal t
o sa
fety
and
qual
ity o
f int
erve
ntio
ns
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:11
,16,
19,2
5,26
,33
,48,
56
The
prov
ider
org
anisa
tion
has
syst
ems
and
proc
edur
es in
pla
ce to
assu
re th
e co
mm
issio
ner t
hat t
heir
clin
ical
team
has
the
nece
ssar
yqu
alifi
catio
ns, s
kills
, kno
wle
dge
and
expe
rienc
e to
del
iver
the
serv
ice
Staf
f ar
e co
mpe
tent
and
fit
for
purp
ose
Prov
ider
to
satis
fy c
omm
issi
oner
tha
t al
lst
aff
have
cur
rent
app
rais
al, c
lear
ance
s an
dre
gist
ratio
n ch
ecks
and
hav
e de
mon
stra
ted
com
pete
nce
in a
ll pr
oced
ures
rel
evan
t to
path
way
.
Prov
ider
to s
atisf
y co
mm
issio
ner t
hat t
hey
can
recr
uit (
or p
rocu
re)
and
reta
in a
com
pete
nt c
linic
al te
am to
del
iver
the
serv
ice
Spec
ific
qual
ifica
tions
requ
ired
of h
ealth
pro
fess
iona
ls pr
ovid
ing
the
serv
ice
are:
•Fo
r med
ical
pra
ctiti
oner
s: re
gist
ratio
n w
ith th
e G
MC
and
evid
ence
of f
urth
er q
ualif
icat
ion
in d
iabe
tes
care
or e
xper
ienc
ew
ithin
dia
bete
s cl
inic
•N
urse
s: re
gist
ratio
n w
ith th
e N
MC
and
furt
her e
vide
nce
ofqu
alifi
catio
n in
dia
bete
s ca
re o
r exp
erie
nce
with
in d
iabe
tes
clin
ic 33
•D
ietit
ians
: reg
istra
tion
with
the
HPC
and
abl
e to
dem
onst
rate
com
pete
nce
in d
eliv
erin
g ed
ucat
iona
l sup
port
•
Prac
titio
ners
with
a s
peci
al in
tere
st in
dia
bete
s sh
ould
dem
onst
rate
the
rele
vant
com
pete
nces
34
Hea
lthca
re p
rofe
ssio
nals
invo
lved
in d
eliv
erin
g di
abet
es c
are
are
requ
ired
to h
ave
the
follo
win
g co
mpe
tenc
ies
rele
vant
to th
eir
area
of w
ork
35
•D
iab
ED03
– p
rovi
de tr
eatm
ent f
or e
rect
ile d
ysfu
nctio
n in
am
an w
ith d
iabe
tes
•D
iab
HA
13 –
pro
vide
info
rmat
ion
and
advi
ce to
ena
ble
anin
divi
dual
with
dia
bete
s m
inim
ise th
e ris
ks o
f hyp
o gl
ycae
mia
13
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Wor
kfor
ce/ s
taff
Clin
ical
sta
ff a
ttrib
utes
criti
cal t
o sa
fety
and
qual
ity o
f int
erve
ntio
ns
•D
iab
IPT0
1 - a
sses
s th
e su
itabi
lity
of in
sulin
pum
p th
erap
y fo
ran
indi
vidu
al w
ith T
ype
1 di
abet
es•
Dia
b IP
T02
– pr
ovid
e pr
elim
inar
y ed
ucat
ion
abou
t ins
ulin
pum
pth
erap
y fo
r an
indi
vidu
al w
ith T
ype
1 di
abet
es•
Dia
b D
A4
– as
sist i
ndiv
idua
ls w
ith d
iabe
tes
to s
uppo
rt e
ach
othe
r •
Dia
b IP
T03
– pr
ovid
e di
etar
y ed
ucat
ion
for a
n in
divi
dual
with
Type
1 d
iabe
tes
who
is c
onte
mpl
atin
g in
sulin
pum
p th
erap
y•
Dia
b IP
T04
– en
able
an
indi
vidu
al w
ith T
ype
1 di
abet
es to
adm
inist
er in
sulin
by
pum
p•
Dia
b G
A2
– as
sess
and
inve
stig
ate
indi
vidu
als
with
sus
pect
eddi
abet
es•
Dia
b IP
T05
– pr
ovid
e on
goin
g su
ppor
t to
an in
divi
dual
adm
inist
erin
g in
sulin
by
pum
p•
Dia
b G
A3
– de
velo
p a
diag
nosis
of d
iabe
tes
•D
iab
IPT0
6 –
prov
ide
ongo
ing
diet
ary
educ
atio
n fo
r an
indi
vidu
al w
ith T
ype
1 di
abet
es a
dmin
ister
ing
insu
lin b
y pu
mp
•D
iab
GA
4 –
info
rm in
divi
dual
s of
a d
iagn
osis
of T
ype
2 di
abet
esor
impa
ired
gluc
ose
tole
ranc
e•
Dia
b H
A1
– as
sess
the
heal
thca
re n
eeds
of i
ndiv
idua
ls w
ithdi
abet
es a
nd a
gree
car
e pl
ans
•D
iab
HA
10 –
hel
p in
divi
dual
s w
ith d
iabe
tes
redu
ceca
rdio
vasc
ular
risk
•D
iab
HA
11 –
ass
ess
the
need
for a
n in
divi
dual
to s
tart
insu
linth
erap
y•
Dia
b H
A12
– e
nabl
e an
indi
vidu
al w
ith T
ype
2 di
abet
es to
sta
rtin
sulin
ther
apy
•D
iab
HA
2- w
ork
in p
artn
ersh
ip w
ith in
divi
dual
s to
sus
tain
car
epl
ans
to m
anag
e th
eir d
iabe
tes
•D
iab
TT02
– a
sses
s in
divi
dual
s w
ith s
ympt
oms
of d
iabe
tes
and
mak
e a
diag
nosis
•D
iab
HA
3 –
exam
ine
the
feet
of a
n in
divi
dual
with
dia
bete
san
d ad
vise
on
care
•D
iab
TT03
– in
form
indi
vidu
als
of a
dia
gnos
is of
Typ
e 1
diab
etes
•D
iab
HA
4 –
asse
ss th
e fe
et o
f ind
ivid
uals
with
dia
bete
s an
dpr
ovid
e ad
vice
on
mai
ntai
ning
hea
lthy
feet
and
man
agin
g fo
otpr
oble
ms
•D
iab
TX01
– p
rovi
de th
erap
y to
mee
t the
imm
edia
te h
ealth
care
need
s of
indi
vidu
als
new
ly d
iagn
osed
with
Typ
e 1
diab
etes
14
ELEM
ENTS
CH
AR
AC
TER
ISTI
CS,
SK
ILLS
AN
D B
EHA
VIO
UR
SO
UTP
UTS
DIA
BET
ES S
ERV
ICES
SPE
CIF
IC O
UTP
UTS
/CO
MM
ENTS
Clin
ical
qua
lity
Wor
kfor
ce/ s
taff
Clin
ical
sta
ff a
ttrib
utes
criti
cal t
o sa
fety
and
qual
ity o
f int
erve
ntio
ns
•D
iab
HA
5 –
help
an
indi
vidu
al u
nder
stan
d th
e ef
fect
s of
food
,dr
ink
and
exer
cise
on
thei
r dia
bete
s•
Dia
b TX
02 –
sup
port
an
indi
vidu
al w
ith T
ype
1 di
abet
es in
the
early
sta
ges
afte
r dia
gnos
is•
Dia
b H
A6
– he
lp in
divi
dual
s w
ith d
iabe
tes
to c
hang
e th
eir
beha
viou
r to
redu
ce th
e ris
k of
com
plic
atio
ns a
nd im
prov
eth
eir q
ualit
y of
life
•D
iab
TX03
– h
elp
an i
ndiv
idua
l usin
g in
sulin
pum
p th
erap
y to
man
age
thei
r dia
bete
s un
ders
tand
the
effe
cts
of fo
od, d
rink,
phys
ical
act
ivity
and
med
icat
ion
on th
eir h
ealth
and
wel
l-bei
ng•
Dia
b H
A7
– de
velo
p, a
gree
and
revi
ew a
die
tary
pla
n fo
r an
indi
vidu
al w
ith d
iabe
tes
•D
iab
HA
8 –
enab
le in
divi
dual
s w
ith d
iabe
tes
to m
onito
r the
irbl
ood
gluc
ose
leve
ls•
Dia
be H
A9
– he
lp a
n in
divi
dual
with
dia
bete
s to
impr
ove
thei
rbl
ood
cont
rol
•D
iab
HD
2 –
assis
t an
indi
vidu
al to
sus
tain
ora
l med
icat
ion
toim
prov
e th
eir c
ondi
tion
•D
iab
HD
3 –
help
indi
vidu
als
with
Typ
e 2
diab
etes
con
tinue
insu
lin th
erap
y•
Dia
b H
D4
– id
entif
y hy
pogl
ycae
mic
em
erge
ncie
s an
d he
lpot
hers
man
age
them
•H
AS3
.1 –
exa
min
e th
e fe
et o
f an
indi
vidu
al w
ith d
iabe
tes
and
asse
ss ri
sk s
tatu
s•
HA
S3.2
– p
rovi
de a
dvic
e an
d re
ferr
al to
hel
p in
divi
dual
s w
ithdi
abet
es c
are
for t
heir
feet
•D
iab
ED02
– a
sses
s a
man
with
dia
bete
s fo
r ere
ctile
dysf
unct
ion
•D
iab
ED01
– p
rovi
de a
dvic
e an
d in
form
atio
n to
men
with
diab
etes
abo
ut e
rect
ile d
ysfu
nctio
n
TOPI
C
15
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Wor
kfor
ce/ s
taff
Clin
ical
sta
ffco
mpe
tenc
ies
in u
se o
feq
uipm
ent
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:11
, 16,
17,
19,
25,
26,
30, 3
3
The
prov
ider
org
anisa
tion
has
syst
ems
in p
lace
to a
ssur
e th
eco
mm
issio
ner t
hat t
heir
clin
ical
team
are
com
pete
nt to
use
all
equi
pmen
t nee
ded
to d
eliv
er th
ese
rvic
e
Prov
ider
to
satis
fy t
he c
omm
issi
oner
tha
t al
lst
aff
have
had
doc
umen
ted
com
pete
nce
asse
ssm
ent
rela
tive
to a
ll eq
uipm
ent
used
inco
ntra
ct.
All
heal
thca
re p
rofe
ssio
nals
invo
lved
in d
eliv
erin
g di
abet
es c
are
are
requ
ired
to h
ave
the
rele
vant
com
pete
ncie
s in
usin
gap
prop
riate
equ
ipm
ent e
.g. b
lood
glu
cose
and
ket
one
mon
itors
,in
sulin
del
iver
y de
vice
s in
clud
ing
insu
lin p
umps
Clin
ical
qua
lity
Wor
kfor
ce /
staf
f
Dev
elop
men
t
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:11
,16,
19,2
5,30
48
The
prov
ider
org
anisa
tion
has
syst
ems
in p
lace
to a
ssur
e th
eco
mm
issio
ner t
hat t
heir
clin
ical
team
is fo
rmal
ly in
duct
ed a
ndre
ceiv
es o
ngoi
ng a
ssist
ance
tode
velo
p th
eir s
kills
, kno
wle
dge
and
expe
rienc
e to
ens
ure
that
they
are
alw
ays
fully
upd
ated
Prov
ider
to
satis
fy c
omm
issi
oner
of
thei
rco
mm
itmen
t to
indu
ctio
n an
d C
PD r
elev
ant
to r
oles
Prov
ider
to
satis
fy t
he c
omm
issi
oner
of
thei
rco
mm
itmen
t to
tra
in s
taff
to
mee
t fu
ture
serv
ice
need
s
All
Hea
lth C
are
prof
essio
nals
shou
ld h
ave
suff
icie
nt s
tudy
leav
eal
loca
tion
(tim
e an
d fin
ance
) to
enab
le th
em to
dev
elop
ski
llsap
prop
riate
ly
Clin
ical
qua
lity
Regi
stra
tion
Org
anisa
tions
are
requ
ired
to m
eet t
he re
quire
men
tsfo
r reg
istra
tion
aspu
blish
ed b
y th
e C
are
Qua
lity
Com
miss
ion
and
Mon
itor (
as a
ppro
pria
te)
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
t for
Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:4,
4A,1
2,16
,19,
30,
32,3
3,48
, 54,
56
Sche
dule
: 17,
18
Com
preh
ensiv
e un
ders
tand
ing
and
com
mitm
ent t
o im
plem
entin
gna
tiona
l sta
ndar
ds
Com
plia
nce
with
Car
e Q
ualit
y C
omm
issi
onre
quire
men
ts f
or r
egis
trat
ion
for
prim
ary
and
seco
ndar
y ca
re
Com
plia
nce
with
the
follo
win
g N
atio
nal S
ervi
ce F
ram
ewor
ks,
whe
re a
pplic
able
:
•D
iabe
tes
NSF
36
•C
oron
ary
Hea
rt D
iseas
e N
SF 37
•N
ew H
oriz
ons
38
•Lo
ng T
erm
Con
ditio
ns N
SF 39
•Re
nal N
SF 40
Com
plia
nce
with
Car
e Q
ualit
y C
omm
issio
n Re
view
s
16
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Patie
nt p
athw
ay
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:4,
4A,9
,10,
12,1
3,14
,15,
16,1
7,18
,19,
20,2
1,25
,27,
29,3
0,32
,33,
34,3
5,36
, 54
Sche
dule
s:
3 (p
arts
1 a
nd 2
)
Resp
onsiv
enes
s an
d pa
rtic
ipat
ive
appr
oach
to in
clud
ing
patie
nts’
view
s ab
out t
heir
care
in th
ede
sign
of c
are
path
way
s
Col
labo
ratio
n w
ith o
ther
orga
nisa
tions
invo
lved
in th
epa
tient
pat
hway
to p
rovi
de a
seam
less
pat
hway
of c
are
All
poss
ible
ent
ry a
nd e
xit
poin
ts m
ust
bede
fined
with
com
preh
ensi
ve p
atie
ntpa
thw
ays
that
fac
ilita
te s
moo
th p
assa
gean
d ef
fect
ive,
eff
icie
nt c
are
for
patie
nts
All
inte
rfac
es in
the
pat
hway
mus
t be
defin
ed s
o th
at c
ontin
uity
of
clin
ical
car
e is
ensu
red
with
no
frac
turin
g of
the
pat
hway
Ther
e m
ust
be s
peci
ficat
ion
of c
lear
timel
ines
and
ale
rt m
echa
nism
s fo
rpo
tent
ial b
reac
hes
Ther
e sh
ould
be
audi
t of
pat
hway
to
ensu
reth
at s
tand
ards
are
met
Ther
e m
ust
be e
xplic
it sp
ecifi
catio
n of
prov
ider
and
com
mis
sion
er r
espo
nsib
ilitie
sfo
r th
e w
hole
pat
ient
epi
sode
fro
mre
gist
ratio
n to
fin
al d
isch
arge
Acc
ount
abili
ties
shou
ld b
e ag
reed
and
docu
men
ted
by a
ll st
akeh
olde
rs
Ther
e ar
e a
num
ber
of s
ervi
ces
supp
ortin
gpa
tient
s w
ith d
iabe
tes
and
ther
e m
ust
becl
ear
sub
cont
ract
s st
atin
g th
e re
ferr
alcr
iteria
and
acc
ess
to t
hese
sup
port
ing
serv
ices
.
At
entr
y to
pat
hway
:
The
Com
mis
sion
er s
houl
d as
sure
them
selv
es t
hat
the
prov
ider
has
sys
tem
san
d pr
oces
ses
in p
lace
to
i) re
gist
er p
atie
nts
ii) c
olle
ct r
elev
ant
clin
ical
and
adm
inis
trat
ive
data
iii) m
anag
e th
e ap
poin
tmen
t pr
oces
s,(r
eapp
oint
men
t an
d D
NA
pro
cess
, if
appr
opria
te)
iv) p
rovi
de in
form
atio
n to
pat
ient
sv)
und
erta
ke in
itial
ass
essm
ent
in t
heap
prop
riate
loca
tion
The
serv
ices
sho
uld
follo
w th
e pr
inci
ples
iden
tifie
d by
the
Gen
eric
Cho
ice
Mod
el fo
r Lon
g Te
rm C
ondi
tions
. The
se in
clud
e 41
:
•D
iagn
osis/
asse
ssm
ent
•Se
lf ca
re a
nd s
elf m
anag
emen
t•
Clin
ical
sup
port
•Su
ppor
ting
inde
pend
ence
•Ps
ycho
logi
cal s
uppo
rt•
Oth
er re
leva
nt s
ocia
l fac
tors
Dia
bete
s di
agno
sis a
nd c
ontin
uing
car
e se
rvic
es s
houl
d in
clud
e th
efo
llow
ing
key
inte
rven
tions
:
i. D
iagn
osis
ii. In
itial
man
agem
ent
iii. C
ontin
uing
man
agem
ent
iv. R
efer
ral f
or th
e m
anag
emen
t of c
ompl
icat
ions
of d
iabe
tes
Dia
gnos
is:
Act
iviti
es/in
terv
entio
ns s
houl
d in
clud
e:•
Aw
aren
ess
raisi
ng a
ctiv
ities
– s
ee d
iabe
tes
prev
entio
n an
d ris
kas
sess
men
t com
miss
ioni
ng g
uide
4
•A
met
hod
of d
iagn
osis
that
use
s W
HO
crit
eria
•Th
e id
entif
icat
ion
of m
onog
enic
form
s of
dia
bete
s•
App
ropr
iate
ski
lls fo
r com
mun
icat
ing
diag
nosis
•D
iagn
osis
and
ethn
icity
reco
rded
in a
sta
ndar
d w
ay (a
s ou
tline
dby
the
natio
nal D
iabe
tes
Con
tinui
ng C
are
Dat
aset
)29
•Lo
cal p
roto
cols
for i
dent
ifyin
g pe
ople
with
und
iagn
osed
diab
etes
and
repo
rtin
g th
is to
pra
ctic
e re
gist
ers
Initi
al m
anag
emen
t:
Act
iviti
es/in
terv
entio
ns s
houl
d in
clud
e:•
Ass
essm
ent a
nd c
are
plan
ning
for a
ll pa
tient
s w
ith d
iabe
tes
incl
udin
g:43
o C
linic
al c
are
(incl
udin
g as
sess
men
t of r
isk) a
nd c
o-m
orbi
ditie
so
Hea
lth b
elie
fs a
nd k
now
ledg
eo
Soci
al is
sues
o Em
otio
nal s
tate
, inc
ludi
ng d
epre
ssio
no
Beha
viou
ral i
ssue
s (e
ase
of c
arry
ing
out s
elf m
anag
emen
tta
sks)
o
Tria
ge o
f acu
te p
oten
tially
life
-thr
eate
ning
com
plic
atio
ns,
e.g.
ket
oaci
dosis
, inf
ecte
d fo
ot
17
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Patie
nt p
athw
ayA
t po
int
of in
terv
entio
n:
The
Com
mis
sion
er s
houl
d as
sure
them
selv
es t
hat
the
prov
ider
has
sys
tem
san
d pr
oces
ses
in p
lace
to
ensu
re t
hat:
i) th
e in
terv
entio
n is
con
duct
ed s
afel
yan
d in
acc
orda
nce
with
acc
epte
dqu
ality
sta
ndar
ds a
nd g
ood
clin
ical
prac
tice.
ii) t
he p
atie
nt r
ecei
ves
appr
opria
te c
are
durin
g th
e in
terv
entio
n(s)
, inc
ludi
ng o
ntr
eatm
ent
revi
ew a
nd s
uppo
rt, i
nac
cord
ance
with
bes
t cl
inic
al p
ract
ice
iii) w
here
clin
ical
em
erge
ncie
s or
com
plic
atio
ns d
o oc
cur
they
are
man
aged
in a
ccor
danc
e w
ith b
est
clin
ical
pra
ctic
eiv
) the
inte
rven
tion
is c
arrie
d ou
t in
afa
cilit
y w
hich
pro
vide
s a
safe
envi
ronm
ent
of c
are
and
min
imis
esris
k to
pat
ient
s, s
taff
and
vis
itors
v) t
he in
terv
entio
n is
und
erta
ken
by s
taff
with
the
nec
essa
ry q
ualif
icat
ions
, ski
lls,
expe
rienc
e an
d co
mpe
tenc
e vi
) the
re a
re a
rran
gem
ents
for
the
man
agem
ent
of o
ut o
f ho
urs
care
acco
rdin
g to
bes
t cl
inic
al p
ract
ice
At
exit
from
pat
hway
:
The
Com
mis
sion
er s
houl
d as
sure
them
selv
es t
hat
prov
ider
has
sys
tem
s an
dpr
oces
ses,
whi
ch a
re a
gree
d w
ith a
ll pa
rtie
san
d ne
twor
ks, i
n pl
ace
to:
i) un
dert
ake
tele
phon
e tr
iage
ii) m
ake
urge
nt o
nwar
d re
ferr
als
whe
relif
e-th
reat
enin
g co
nditi
ons
or s
erio
usun
expe
cted
pat
holo
gies
are
dis
cove
red
durin
g an
inte
rven
tion/
asse
ssm
ent
iii) e
nsur
e th
at p
atie
nts
rece
ive
disc
harg
ein
form
atio
n re
leva
nt t
o th
eir
inte
rven
tion
incl
udin
g ar
rang
emen
ts
o M
edic
atio
n/tr
eatm
ent a
nd/o
r adv
ice
abou
t hea
lthy
lifes
tyle
o In
itial
ass
essm
ent o
f typ
e of
dia
bete
so
Intr
oduc
tion
to w
hat t
he p
atie
nt s
houl
d ex
pect
for
them
selv
es a
nd fr
om th
e se
rvic
e•
Ther
e sh
ould
be
loca
lly a
gree
d as
sess
men
t pro
toco
ls th
atin
clud
e tr
iage
of a
cute
pot
entia
lly li
fe th
reat
enin
g co
nditi
ons,
e.g.
ket
oaci
dosis
, inf
ecte
d fo
ot e
tc•
The
educ
atio
n pr
ogra
mm
e sh
ould
mee
t the
qua
lity
crite
ria fo
rst
ruct
ured
edu
catio
n pr
ogra
mm
es•
The
serv
ice
shou
ld s
uppo
rt p
eopl
e ne
wly
dia
gnos
ed w
ithdi
abet
es b
y pr
ovid
ing
advi
ce a
nd h
elp
with
sel
f man
agem
ent.
This
shou
ld in
clud
e:o
Stru
ctur
ed e
duca
tion
desig
ned
for p
eopl
e ne
wly
diag
nose
d w
ith d
iabe
tes
o Su
ppor
t to
optim
ise b
lood
glu
cose
con
trol
o Su
ppor
t to
man
age
card
iova
scul
ar ri
sk fa
ctor
so
Initi
al c
are
plan
o Su
ppor
t for
em
otio
nal a
nd s
ocia
l iss
ues
o C
o-or
dina
tion
of o
ther
issu
es o
r co-
mor
bidi
ties
o O
ppor
tuni
ty fo
r sup
port
from
oth
er p
eopl
e w
ith d
iabe
tes,
e.g.
Dia
bete
s U
K lo
cal s
uppo
rt g
roup
•Th
e C
are
Plan
ning
pro
cess
sho
uld
adhe
re to
the
qual
ity c
riter
iafo
llow
ed b
y th
e Ye
ar o
f Car
e ap
proa
ch 44
Con
tinui
ng m
anag
emen
t:A
ctiv
ities
/inte
rven
tions
sho
uld
incl
ude:
•Re
gula
r str
uctu
red
care
(ann
ual,
or m
ore
freq
uent
ly a
sap
prop
riate
) bas
ed o
n a
care
pla
nnin
g ap
proa
ch a
nd in
clud
esth
e fo
llow
ing
elem
ents
:o
on-g
oing
adv
ice
and
supp
ort f
rom
clin
icia
ns a
nd o
ther
peop
le w
ith d
iabe
tes
to h
elp
them
sel
f man
age
o pr
even
tion
and
surv
eilla
nce
for l
ong-
term
com
plic
atio
nso
acce
ss to
app
ropr
iate
equ
ipm
ent a
nd re
sour
ces,
phar
mac
olog
ical
ther
apy,
incl
udin
g or
al a
gent
s,su
bcut
aneo
us in
sulin
and
CSI
I (in
sulin
pum
p th
erap
y)o
on-g
oing
str
uctu
red
educ
atio
no
cont
inue
d gl
ucos
e m
onito
ring,
whe
re a
ppro
pria
teo
emot
iona
l sup
port
•Th
e ed
ucat
ion
prog
ram
me
shou
ld m
eet t
he q
ualit
y cr
iteria
for
stru
ctur
ed e
duca
tion
prog
ram
mes
18
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Patie
nt p
athw
ayfo
r co
ntac
ting
the
prov
ider
and
fol
low
up if
req
uire
div
) pro
vide
tim
ely
feed
back
to
the
refe
rrer
re in
terv
entio
n, c
ompl
icat
ions
and
prop
osed
fol
low
up
v) e
nsur
e th
at t
he p
atie
nt r
ecei
ves
requ
ired
drug
s/dr
essi
ngs/
aids
vi) e
nsur
e th
at s
uppo
rt is
in p
lace
with
othe
r ca
re a
genc
ies
as a
ppro
pria
te
Refe
rral
s fo
r the
man
agem
ent o
f com
plic
atio
ns o
f dia
bete
s:
Act
iviti
es/in
terv
entio
ns s
houl
d in
clud
e:
•Th
ere
shou
ld b
e pr
otoc
ols
in p
lace
for t
he s
urve
illan
ce o
f foo
tan
d re
nal d
iseas
e ac
cord
ing
to N
ICE,
retin
opat
hy a
ccor
ding
toth
e N
atio
nal S
cree
ning
Com
mitt
ee a
nd m
anag
emen
t of
HbA
1c, b
lood
pre
ssur
e an
d lip
ids
acco
rdin
g to
NIC
E gu
idan
ce•
Ther
e sh
ould
be
prot
ocol
s in
pla
ce to
dea
l with
unp
lann
edpr
oble
ms,
and
arr
ange
men
ts fo
r sol
ving
spe
cific
pro
blem
s in
man
agem
ent r
equi
ring
mor
e in
tens
ive
inte
rven
tion
Patie
nts
may
nee
d to
be
refe
rred
to th
e fo
llow
ing
serv
ices
as
part
of th
eir d
iabe
tes
care
(see
rele
vant
inte
rven
tion
map
, con
trac
ting
fram
ewor
k an
d se
rvic
e sp
ecifi
catio
n):
•Em
erge
ncy
and
inpa
tient
car
e 6
•se
rvic
es fo
r com
plic
atio
ns –
foot
car
e, e
yes,
vas
cula
r, ki
dney
care
, etc
9
•pr
egna
ncy
and
diab
etes
(inc
ludi
ng g
esta
tiona
l dia
bete
s) 8
•m
enta
l hea
lth 7
•en
d of
life
car
e 10
Ther
e sh
ould
be
a se
amle
ss tr
ansf
er o
f car
e to
dia
bete
s se
rvic
esfo
r old
er p
eopl
e w
hen
appr
opria
te
Prov
ider
s ar
e re
quire
d to
take
not
e of
the
resu
lts o
f the
Nat
iona
lSu
rvey
of P
eopl
e w
ith D
iabe
tes
45
Clin
ical
qua
lity
Clin
ical
em
erge
ncy
situa
tions
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:6,
11,1
2,13
,14,
15,1
8,32
,33,
42,
54
Sche
dule
s:
2, 3
(par
t 1 a
nd 3
), 12
Abi
lity
to n
egot
iate
and
agr
eear
rang
emen
ts w
ith a
ppro
pria
tepe
rson
nel a
nd o
rgan
isatio
ns to
prov
ide
effe
ctiv
ely
for e
mer
genc
ysit
uatio
ns
The
Com
mis
sion
ers
shou
ld s
atis
fyth
emse
lves
tha
t pr
ovid
er h
as s
yste
ms,
proc
esse
s an
d co
mpe
tent
per
sonn
el a
re in
plac
e an
d im
plem
ente
d to
ens
ure
that
all
clin
ical
em
erge
ncie
s an
d co
mpl
icat
ions
are
hand
led
in a
ccor
danc
e w
ith b
est
prac
tice
Ther
e sh
ould
be
loca
lly a
gree
d as
sess
men
t pro
toco
ls th
at in
clud
etr
iage
of a
cute
pot
entia
lly li
fe th
reat
enin
g co
nditi
ons,
e.g
.ke
toac
idos
is, in
fect
ed fo
ot e
tc
19
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Esta
tes
and
equi
pmen
t
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:5,
29, 3
0, 3
3, 5
6
Sche
dule
s: 3
,10
Und
erst
andi
ng o
f bui
ldin
gre
gula
tions
Acc
ess
to a
dvic
e on
“fit
-for
-pu
rpos
e” e
quip
men
t and
faci
litie
s
Com
mis
sion
ers
mus
t as
sure
the
mse
lves
tha
tpa
tient
car
e is
del
iver
ed in
app
ropr
iate
lybu
ilt a
nd e
quip
ped
faci
litie
s w
hich
mee
tre
leva
nt H
TMs
and
Build
ing
Not
es, a
nd,
whe
re a
ppro
pria
te, a
re r
egis
tere
d an
d ar
esa
fe a
nd c
lean
.
Equi
pmen
t m
ust
be f
it fo
r pu
rpos
e
Com
mitm
ent
to e
ffic
ient
use
and
satis
fact
ory
mai
nten
ance
of
equi
pmen
t
Clin
ical
qua
lity
Kno
wle
dge
and
unde
rsta
ndin
g of
hea
lthan
d sa
fety
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:5,
11, 1
9, 5
4, 5
6, 6
0
Und
erst
andi
ng o
f clin
ical
acco
unta
bilit
ies
of h
ealth
and
safe
ty p
olic
ies
H&
S st
rate
gy a
nd p
olic
ies
in p
lace
and
impl
emen
ted
with
aw
aren
ess
thro
ugho
utth
e or
gani
satio
n
Acc
essi
bilit
y to
exe
cutiv
e re
spon
sibl
e fo
rH
&S
for
quic
ker,
first
con
tact
ser
vice
s
Hea
lth a
nd s
afet
y po
licie
s as
per
pro
vide
r agr
eem
ent w
ithco
mm
issio
ners
Dat
a an
din
form
atio
nm
anag
emen
t
Stra
tegy
and
pol
icie
s
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:8,
9,17
,19,
21,2
3,24
,27,
29,
30, 3
2, 3
3,54
Sche
dule
s: 5
,6,1
5,16
,18
Stra
tegy
and
pol
icy
deve
lopm
ent
skill
s
The
abili
ty to
ana
lyse
dat
a an
dha
ve a
cces
s to
info
rmat
ion
that
can
pred
ict t
rend
s an
d th
at c
ould
iden
tify
prob
lem
s
The
abili
ty to
cap
ture
evi
denc
eba
sed
prac
tice
from
R&
D N
atio
nal
Serv
ice
Fram
ewor
ks, N
ICE
guid
ance
The
abili
ty to
use
dat
a an
din
form
atio
n ap
prop
riate
ly to
impr
ove
patie
nt c
are
Tran
spar
ency
and
obj
ectiv
ity
The
Prov
ider
sho
uld
have
an
expl
icit
data
and
info
rmat
ion
stra
tegy
in p
lace
that
cov
ers
•Ty
pes
of d
ata
•Q
ualit
y of
dat
a•
Dat
a pr
otec
tion
and
conf
iden
tialit
y•
Acc
essi
bilit
y•
Tran
spar
ency
•A
naly
sis
of d
ata
and
info
rmat
ion
•U
se o
f da
ta a
nd in
form
atio
n•
Dis
sem
inat
ion
of d
ata
and
info
rmat
ion
•Ri
sks
•Sh
arin
g of
dat
a an
d co
mpa
tibili
ty o
f IT
acro
ss d
iffer
ent
prov
ider
s w
ith r
espe
ct t
oca
re o
f pa
tient
s ac
ross
a p
athw
ay
This
info
rmat
ion
shou
ld b
e in
clud
ed in
the
Dat
a Q
ualit
y Im
prov
emen
t Pl
an
Ther
e sh
ould
be
polic
ies
in p
lace
tha
tin
clud
e:
The
Prov
ider
is re
quire
d to
hav
e in
form
atio
n sy
stem
s th
at re
cord
indi
vidu
al n
eeds
incl
udin
g em
otio
nal,
soci
al, e
duca
tiona
l,ec
onom
ic a
nd b
iom
edic
al in
form
atio
n w
hich
per
mit
mul
tidisc
iplin
ary
care
acr
oss
serv
ice
boun
darie
s an
d su
ppor
t car
epl
anni
ng 46
The
Prov
ider
is re
quire
d to
hav
e sy
stem
s in
pla
ce to
sen
d cl
inic
alre
sults
to p
eopl
e w
ith d
iabe
tes.
The
Prov
ider
is re
quire
d to
use
the
follo
win
g fo
r the
col
lect
ion
and
prod
uctio
n of
dat
a, w
here
app
ropr
iate
:
•N
atio
nal D
iabe
tes
Info
rmat
ion
Serv
ice
47
•N
atio
nal D
iabe
tes
Aud
it 30
•D
iabe
tes
E 32
•Q
ualit
y an
d O
utco
mes
Fra
mew
ork48
•M
yoca
rdia
l Isc
haem
ia A
udit
Proj
ect49
•H
ospi
tal E
piso
de S
tatis
tics50
•Pa
tient
Exp
erie
nce
31,4
5
•Pa
tient
Sat
isfac
tion
45
20
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Dat
a an
din
form
atio
nm
anag
emen
t
Stra
tegy
and
pol
icie
s•
Con
fiden
tialit
y C
ode
of P
ract
ice
•D
ata
Prot
ectio
n•
Free
dom
of
Info
rmat
ion
•H
ealth
Rec
ords
•In
form
atio
n G
over
nanc
e M
anag
emen
t•
Info
rmat
ion
Qua
lity
Ass
uran
ce•
Info
rmat
ion
Secu
rity
Ther
e m
ust
be a
nam
ed in
divi
dual
who
isth
e C
aldi
cott
Gua
rdia
n
•Pa
tient
Rep
orte
d O
utco
mes
Mea
sure
s •
Nat
iona
l Dia
bete
s C
ontin
uing
Car
e D
atas
et 42
21
Source documentsCommissioners and providers should takeresponsibility for making references to the latestversion of the various documents and guidance.
1. Emotional and Psychological Support and Care inDiabetes, Joint Diabetes UK and NHS DiabetesEmotional and Psychological Support WorkingGroup, February 2010
2. NHS Diabetes, children and young people withdiabetes commissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
3. NHS Diabetes, older people with diabetescommissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
4. NHS Diabetes, diabetes prevention and riskassessment commissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
5. NHS Diabetes, diabetes foot care servicescommissioning guide, 2010 http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
6. NHS Diabetes, Diabetes emergency and inpatientcare commissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
7. NHS Diabetes, Mental health and diabetes servicescommissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
8. NHS Diabetes, pregnancy and diabetescommissioning guide, 2010 http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
9. NHS Diabetes, complications of diabetescommissioning guides, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
10. NHS Diabetes, diabetes and end of life carecommissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
11. NHS Diabetes, Features of a service that isresponsive to people with learning disabilities whohave diabetes, 2010, http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
12. Department of Health, Standard NHS Contract forCommunity Services, January 2010,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111203
13. NICE, Diagnosis and management of Type 1diabetes in children, young people and adults,www.nice.org.uk/Guidance/CG15, 2004
14. NICE, Type 2 diabetes: the management of type 2diabetes (update), www.nice.org.uk/Guidance/CG66, June 2008 (update)
15. NICE, Management of Type 2 diabetes - preventionand management of foot problems,www.nice.org.uk/Guidance/CG10, January 2004
16. NICE, Type 2 Diabetes - newer agents (partialupdate of CG66)http://guidance.nice.org.uk/CG87, May 2009
17. NICE, Allogeneic pancreatic islet celltransplantation for type 1 diabetes mellitus,www.nice.org.uk/Guidance/IPG257, April 2008
18. NICE, Autologous pancreatic islet celltransplantation for improved glycaemic controlafter pancreatectomy, www.nice.org.uk/Guidance/IPG274, September 2008
19. NICE, Pancreatic islet cell transplantation,www.nice.org.uk/Guidance/IPG013, October 2003
20. NICE, Primary prevention of type 2 diabetesmellitus among high risk black and minority ethnicgroups, www.nice.org.uk/Guidance/PHG/Wave19/6, in progress, expected June 2011
21. NICE, The clinical effectiveness and costeffectiveness of long acting insulin analogues fordiabetes, www.nice.org.uk/Guidance/TA53,December 2002
22. NICE, The clinical effectiveness and costeffectiveness of patient education models fordiabetes, www.nice.org.uk/Guidance/TA60, April2003
23. NICE, Continuous subcutaneous insulin infusionfor the treatment of diabetes (review),www.nice.org.uk/Guidance/TA151, July 2008
24. NICE, Depression with a chronic physical healthproblem, http://guidance.nice.org.uk/CG91, Oct2009
25. NICE, Medicines adherence: involving patients indecisions about prescribed medicines andsupporting adherence, Jan 2009,http://guidance.nice.org.uk/CG76
22
26. NHS Institute for Innovation and Improvement,model CQUIN scheme: inpatient care for peoplewith diabetes, 2009
27. Diabetes UK, Minding the gap. The provision ofpsychological support and care for people withdiabetes in the UK, A report for Diabetes UK, 2008
28. Department of Health, Primary care andcommunity services:improving GP access andresponsiveness, July 2009, http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_102122
29. 18 week targetwww.18weeks.nhs.uk/Content.aspx?path=/
30. National Diabetes Audit.www.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/diabetes
31. The King’s Fund, The point of care. Measures ofpatients’ experience in hospital: purpose, methodsand uses. July 2009
32. DiabetesE - https://www.diabetese.net/
33. Training, Research and Education for Nurses inDiabetes – UK, An Integrated Career &Competency Framework for Diabetes Nursing(Second Edition), 2010
34. Royal College of General Practitioners, RoyalPharmaceutical Society of Great Britain,Department of Health, Primary Care Contracting,Guidance and competences for the provision ofservices using practitioners with special interests(PwSIs), (Diabetes), 2009http://www.pcc.nhs.uk/pwsi
35. Skills for Health, Diabetes CompetencyFramework, https://tools.skillsforhealth.org.uk/suite/show/id/40
36. Department of Health, Diabetes NSF, December2001 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002951
37. Department of Health, National Service Frameworkfor Coronary Heart Disease – modern standardsand service models http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094275
38. Department of Health, New Horizons: A sharedvision for mental health December 2009http://newhorizons.dh.gov.uk/index.aspx
39. Department of Health, The National ServiceFramework for Long Term Conditions, March 2005http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4105361
40. Department of Health, The national ServiceFramework for Renal Services, January 2004http://www.dh.gov.uk/en/Healthcare/Renal/DH_4102636
41. Department of Health, Generic Choice Model forLong Term Conditions, December 2007,www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081105
42. National Diabetes Continuing Care Dataset,www.ic.nhs.uk/webfiles/Services/Datasets/Diabetes/dccrdataset.pdf
43. Care planning in diabetes, Report from the JointDepartment of Health and Diabetes UK CarePlanning Working Groupwww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_063081
44. NHS Diabetes, Year of Care,http://www.diabetes.nhs.uk/year_of_care/
45. Healthcare Commission, National Survey of Peoplewith Diabetes, 2006,www.cqc.org.uk/usingcareservices/healthcare/patientsurveys/servicesforpeoplewithdiabetes.cfm
46. York and Humber integrated IT systemhttp://www.diabetes.nhs.uk/document.php?o=610
47. National Diabetes Information Service, TheInformation Centre,http://ndis.ic.nhs.uk/pages/index.aspx
48. Quality and Outcomes Framework,www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/QOF/Pages/QualityOutcomesFramework.aspx
49. Myocardial Ischaemia Audit Project (MINAP)www.rcplondon.ac.uk/CLINICAL-STANDARDS/ORGANISATION/PARTNERSHIP/Pages/MINAP-.aspx
50. Hospital Episode Statistics,www.ic.nhs.uk/statistics-and-data-collections/hospital-care/hospital-activity-hospital-episode-statistics--hes
23
This specification forms Schedule 2, Part 1,‘The Services - Service Specifications’ of theStandard NHS Contractsa.
Service specifications are developed in partnershipbetween commissioners and provider agencies.They are based on the needs of the population ofpeople with diabetes using evidence-based care,treatment models and examples of best practiceoutlined in NICE, the NSF and other referencematerial. Specifications should be open to scrutinyand available to all service users/carers as astatement of standards that the user/carer canexpect to receive.
The following documentation, developed bythe Diabetes Commissioning Advisory Group,provides further detail/guidance to supportthe development of this specification:
• The diabetes diagnosis and continuing careintervention map
• The contracting framework for diabetesdiagnosis and continuing care services
This specification template assumes that theservices are compliant with the contractingframework for diabetes diagnosis and continuingcare services.
This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.
Description of diabetes diagnosis andcontinuing care services:Diabetes diagnosis and continuing care servicesencompass the care an individual, who isdiagnosed with diabetes, may receive ranging fromthe initial physical, psychological and social
assessment and continued management of theirdiabetes and complications through care planningand care co-ordination.
The final specification should take intoaccount:
• national, network and local guidance andstandards for diabetes services.
• local needs.
This specification is supported by other relatedwork in diabetes commissioning such as:
• the web-based Diabetes Community HealthProfiles (Yorkshire and Humber Public HealthObservatory)
• the web-based Health Needs Assessment Tool(National Diabetes Information Service).
These provide comprehensive information forneeds assessment, planning and monitoring ofdiabetes services.
Introduction• A general overview of the services identifying
why the services are needed, includingbackground to the services and why they arebeing developed or in place.
• A statement on how the services relate to eachother within the whole system should beincluded describing the keystakeholders/relationships which influence theservices, e.g. multi-disciplinary team etc
• Any relevant diabetes clinical networks andscreening programmes applicable to the services
• Details of all interdependencies or sub-contractors for any part of the service and anoutline of the purpose of the contract should bestated, including arrangements for clinicalaccountability and responsibility, as appropriate
Standard Service SpecificationTemplate for Diabetes Diagnosisand Continuing Care Services
a Standard NHS Contracts http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111203
24
Purpose, Role and Clientele1. A clear statement on the primary purpose of the
services and details of what will be provided andfor whom:
• Who the services are for (e.g. individuals whorequire diagnosis and continuing managementof their diabetes and complications)
• What the services aim to achieve
• The objectives of the services
• The desired outcomes and how these aremonitored and measured
Scope of the Services2. What do the services do? This section will focus
on the types of high level therapeuticinterventions that are required for the types ofneed the services will respond to.
• How the services responds to age, culture,disability, and gender sensitive issues
• Assessment – details of what it is and co-morbidity assessment and referrals to allrelevant services/care
• Service planning – High level view of what theservices are and how they are used; howpatients enter the pathway/journey; what arethe stages undertaken and follow up care. Theaims of service planning are to:
o Develop, manage and reviewinterventions along the patient journey
o Ensure access to other services/care, asappropriate
o Ensure that care planning is undertakenby the diabetes multi-disciplinary team(as defined locally) with a clear care co-ordination function
• Holistic review of individuals who havediabetes using the principles of an integratedcare model for people with long termconditions that is patient-centred, includingself care and self management, clinicaltreatment, facilitating independence,psychological support and other social careissues
• Risk assessment procedures
• Detail of evidence base of the services – i.e.the contracting framework for diabetesprevention and screening services, guidanceproduced by the Royal College of Physicians,Diabetes UK, etc
Service Delivery3. Patient Journey/intervention map
Flow diagram of the patient pathway showingaccess and exit/transfer points – see the diabetesdiagnosis and continuing care intervention mapas a starting point
4. Treatment protocols/interventionsInclude all individual treatment protocols inplace within the services or planned to be used
5. This will include a breakdown of how thepatient will receive the services and from whom.It should be a clear statement of staffqualifications/experience and/or training (ifappropriate) and clinical or managerialsupervision arrangements. It should specify, asappropriate:
• Geographical coverage/boundaries – i.e. theservices should be available for adults who livein the PCT area
• Hours of operation including, week-end, bankholiday and on-call arrangements
• Minimum level of experience andqualifications of staff (i.e. doctors –diabetologists and GPs, Nursing staff –diabetes nurse specialists, district, practicenurses etc, other allied health professionals,e.g. podiatrists, dietitians, optometrists,pharmacists etc and other support andadministrative staff)
• Confirmation of the arrangements to identifythe Care Co-ordinator for each patient withdiabetes (i.e. who holds the responsibility androle).
• Staff induction and developmental training
25
6. Equipment
• Upgrade and maintenance of relevantequipment and facilities
• Technical specifications, e.g. specification forinsulin pumps according to national criteria
Identification, Referral andAcceptance criteria7. This should make clear how patients will be
identified, assessed (if appropriate) andaccepted to the services. Acceptance should bebased on types of need and/or patient.
8. How should patients be referred?
• Who is acceptable for referral and from where
• Details of evaluation process - Are there clearexclusion criteria or set alternatives to theservice? How might a patient be transferred?
• Response time detail and how are patientsprioritised
Discharge/Service Complete/PatientTransfer/Transition criteria9. The intention of this section is to make clear
when a patient should be transferred from thediabetes diagnosis and continuing care servicesto another and when this point would bereached.
• How is the intervention pathway reviewed?
• How does the service decide that a patient isready for discharge/transfer to other services?
• How are goals and outcomes assessed andreviewed?
• What procedure is followed on discharge,including arrangements for follow-up?
Quality Standards10. Each service specification will include service
specific standards, which are over and abovethe nationally mandated quality standards, i.e.based on standards identified in thecontracting framework for diabetes diagnosisand continuing care services. The servicespecific standards should encompass the totalservice from acceptance to discharge or
transfer including nationally applicable qualitystandards. These will be individually tailored toeach service and will include details on access,equity, assessment (if appropriate), time-scalesof intervention, waiting times and what toexpect on service discharge. Explicit withineach service specification will be theexpectation that patient and carerinvolvement/empowerment is incorporatedwithin the service.
11. This must include performance indicators,thresholds, methods of measurement andconsequences of breach of contract. These willbe set and agreed prior to the signing of theoverall agreement.
12. As a minimum, the Provider is required toagree a local Commissioning for Quality andInnovation scheme for services for people with diabetes.(Insert details of the CQUIN Scheme agreed)
Activity and PerformanceManagement13. Key Performance Indicators – List the
criteria/outcomes by which the service is /couldbe measured. Specific KPIs for diabetesdiagnosis and continuing care services are indevelopment. Please see the NHS Diabeteswebsite for further details:http://www.diabetes.nhs.uk/commissioning_resource
14. Activity plans – Where appropriate, identify theanticipated level of activity the service maydeliver; provide details of any activity measuresand their description /method of collection,targets, thresholds and consequences ofvariances above or below target.
Continual Service Improvement15. As part of the monitoring and evaluation
procedures, the service will identify a methodof agreeing measurements for continuousimprovement of the service being offered andwork to ensure unmet need is both identifiedand brought to the attention of thecommissioner.
26
16. ReviewThis section should set out a review date and amechanism for review.
The review should include both thespecifications for continuing fitness forpurpose and the providers’ delivery against thespecification.
This should set out the process by which thisreview will be conducted.
This should also identify how complianceagainst the specification will be monitored inyear.
17. Agreed byThis should set out who agrees/accepts thespecification on behalf of all parties.
This should include the diabetes providers,commissioner and network
With thanks to Dr Thoreya Swage who wrote this publication.
Further copies of this publication can be ordered from Prontaprint, by emailing [email protected] or tel: 0116 275 3333, quoting DIABETES 136
www.diabetes.nhs.uk