CommissioningDiabetes Emergency

and Inpatient Care

Supporting, Improving, Caring

June 2011

NHS Diabetes Information Reader Box

Review Date 2013

Commissioning Diabetes Emergency and Inpatient Care

NHS Diabetes would like to thank the following for their advice and contribution to the development ofthis commissioning guide:

The members of the Joint British Diabetes Societies Inpatient Care Group and the Association of BritishClinical Diabetologists.

And to Thoreya Swage who wrote this publication

3

Page

Commissioning for Diabetes Emergency and Inpatient Care 5

Features of Diabetes Emergency and Inpatient Care 7

Diabetes Emergency and Inpatient Care Intervention Map 9

Contracting Framework for Diabetes Emergency and Inpatient Care 14

Standard Service Specification Template for Diabetes Emergency 27Inpatient Care events to be provided by Ambulance Services

Standard Service Specification Template for Diabetes Emergency and Inpatient Care 31

Contents

5

Commissioning Diabetes Emergencyand Inpatient Care The NHS Diabetes commissioning approach helps to deliver high quality integrated care through a three-stepprocess that ensures key elements needed to build an excellent diabetes service are in place. The approach issupported by a wide range of proven tools, resources and examples of shared learning.

Step 1 – involves understanding the local diabetespopulation health needs by developing a local HealthNeeds Assessment and setting up a steering groupwith key stakeholder involvement including a leadclinician, lead commissioner, lead diabetes nurse andlead service user

Step 2 – involves the development of a servicespecification to describe the model of care to becommissioned. This becomes the document onwhich tenders may be issued.

Step 3 – involves monitoring the delivery of theservice specification by the provider and evaluatingthe performance of the service. Input from thesteering group with service user representation willbe an important mechanism for monitoring theservice as well as patient surveys.

This commissioning guide has been developed byNHS Diabetes with key stakeholders including clinicaland social services professionals and patient groupsrepresented by Diabetes UK.

It is not designed to replace the Standard NHSContracts as many of the legal and contractualrequirements have already been identified in this setof documents. Rather, it is intended to form the basisof a discussion or development of emergency and inpatient diabetes services between commissioners andproviders from which a contract for services can thenbe agreed.

This commissioning care guide consists of:

• A description of the key features of high qualityemergency and inpatient services for people withdiabetes

• A high level intervention map. This interventionmap describes the key high level actions orinterventions (both clinical and administrative)diabetes emergency and inpatient services shouldundertake in order to provide the most efficientand effective care, from admission to discharge (ordeath) from the service. For continuity, theintervention map also shows action to be takenwith respect to emergency care for children andyoung people with diabetes in the communitysetting. Commissioners are referred to thecommissioning guide for children and youngpeople with diabetes for further details followingadmission to hospital for this care group.

The map is not intended to be a care pathway orclinical protocol, rather it describes how a true‘diabetes without walls’1 service should operategoing across the current sectors of health care.

The intervention map may describe current servicemodels or it may describe what should ideally beprovided by diabetes emergency and in patientservices.

• A contracting framework for diabetes emergencyand in patient services that brings together all thekey standards of quality and policy relating todiabetes emergency and inpatient care

• Template service specifications for

Step 2

Step 3

• Understanding your diabetes population health needs

• Implementing improved services and evaluation

• Understanding what you need to commission for an integrated service

Step 1

1 Commissioning Diabetes Without Walls , 2011, http://www.diabetes.nhs.uk/commissioning_resource/

6

o Emergency diabetes care to be providedby ambulance services

o Inpatient diabetes services

The templates form part of schedule 2 of theStandard NHS Contract covering the key headingsrequired of a specification. It is recommended thatthe commissioner checks which mandatory headingsare required for each type of care as specified by theStandard NHS Contracts.

For further detail on how to approach thecommissioning of diabetes services please seehttp://www.diabetes.nhs.uk/commissioning_resource

7

High quality diabetes emergency and inpatientservices should ensure that:

• there are systems to manage people of all ageswho experience diabetic emergencies in thecommunity

• there are systems to ensure follow up of patientswho have had diabetic emergencies in thecommunity through liaison with local diabeticteams

• people with diabetes in hospital to have accessto appropriate specialist expertise both foremergency and planned care including access tothe children and young people diabetesmultidisciplinary team

• there are mechanisms in place to identify peoplewho present with acute illness to screen forpossible diabetesi

• there is timely assessment and treatment ofpeople who present with diabetic emergencies,e.g. diabetic ketoacidosis, severe acutehypoglycaemia and diabetic foot ulceration

• all patients with diabetes who have emergencyand planned in patient care have admission anddischarge care plans

• there are monitored protocols in place to ensurethat patients can continue to manage theirdiabetes themselves while in hospital (food andmedication)

• there is zero tolerance of prescribing errors andon the use of abbreviations for UNIT

In addition the services should:

• be developed in a co-ordinated way, taking fullaccount of the responsibilities of other agenciesin providing comprehensive care and placingusers at the centre of decisions about their careand support - "no decision about me withoutme" (Equity and Excellence: Liberating theNHSii).

• 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 model for themanagement of long term conditionsiii

• provide effective and safe care to people withdiabetes in a range of settings including thepatient’s home, in accordance with the NICEQuality Standards for Diabetesiv

• deliver the outcomes for diabetes as determinedby the NHS Outcomes Frameworkv

• take into account the emotional, psychologicaland mental wellbeing of the patientvi

• take into account all diverse and personal needswith respect to access to care

• ensure that services are responsive andaccessible to people with Learning Disabilitiesvii

• ensure that the family/carers of people withdiabetes have access to psychological support

• take into account race and inequalities withrespect to access to care

Features of Diabetes Emergency andInpatient Services

i NHS Institution for Innovation and Improvement, ThinkGlucose Toolkit,http://www.institute.nhs.uk/quality_and_value/think_glucose/welcome_to_the_website_for_thinkglucose.html

ii Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353

iii Available on the DH website at http://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_120915

iv Quality Standards: Diabetes in adults, http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp

v Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944

vi Emotional and Psychological Support and Care in Diabetes, Joint Diabetes UK and NHS Diabetes Emotional and PsychologicalSupport Working Group, February 2010 http://www.diabetes.nhs.uk/our_work_areas/emotional_and_psychological/

vii http://www.diabetes.nhs.uk/commissioning_resource

8

viii http://www.diabetes.nhs.uk/year_of_care/it/

ix http://www.ic.nhs.uk/proms

• 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 hasthe appropriate training and updating andwhere the staff have the skills and competenciesin the management of people with diabetes

• provide multidisciplinary care that manages thetransition between children and adult servicesand 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 careplanningviii

• 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 deliveryix

• actively monitor the uptake of services,responding to non-attenders and monitoringcomplaints and untoward incidents

9

NH

S D

iab

etes

Emer

gen

cy a

nd

in p

atie

nt

care

fo

r p

eop

le w

ith

dia

bet

es

Dia

bet

es e

mer

gen

cy c

are

in t

he

com

mu

nit

y (A

du

lts

and

old

er p

eop

le)

Hea

lth

Nee

ds

Ass

essm

ent

Pati

ent

has

d

iab

etic

emer

gen

cyco

nd

itio

n

-e.

g. D

iabe

tic

keto

acid

osis

999

call

Cal

l tri

aged

at

amb

ula

nce

call

cen

tre

-tr

iage

ac

cord

ing

to

agre

ed

prot

ocol

s

Am

bu

lan

ce

crew

d

isp

atch

ed

Am

bu

lan

ce

crew

arr

ive

at

the

scen

e

-m

axim

um r

espo

nse

tim

es i

dent

ified

Ass

essm

ent

by

amb

ula

nce

st

aff

-cl

inic

al a

sses

smen

t ac

cord

ing

to a

gree

d pr

otoc

ols

e.g.

UK

A

mbu

lanc

e C

linic

al

Prac

tice

Gui

delin

es

Ass

essm

ent

ou

tco

me

No

t g

lyca

emic

em

erg

ency

bu

t o

ther

cl

inic

al e

mer

gen

cy

Ass

essm

ent

ou

tco

me

gly

caem

ic/d

iab

etic

em

erg

ency

Ass

essm

ent

ou

tco

me

No

t g

lyca

emic

em

erg

ency

or

oth

er

clin

ical

em

erg

ency

Tran

sfer

to

nea

rest

A

&E

acco

rdin

g t

o

agre

ed p

roto

cols

E.g.

-hy

pogl

ycae

mia

-hy

perg

lyca

emia

-D

iabe

tic k

etoa

cido

sis

Trea

t g

lyca

emic

/d

iab

etic

em

erg

ency

ac

cord

ing

to

ag

reed

p

roto

cols

Go

to

p

age

10

Pati

ent

rem

ain

s at

th

e sc

ene

Ref

erra

l to

ap

pro

pri

ate

agen

cies

acc

ord

ing

to

ag

reed

pro

toco

ls

Emergency and Inpatient DiabetesServices Intervention Map

10

NH

S D

iab

etes

Emer

gen

cy a

nd

in p

atie

nt

care

fo

r p

eop

le w

ith

dia

bet

es

Dia

bet

es e

mer

gen

cy c

are

in t

he

com

mu

nit

y (A

du

lts

and

old

er p

eop

le)

Yes

Fu

llre

cove

ry a

nd

re

spo

nsi

ble

ad

ult

ar

ou

nd

?

Yes

Co

nta

ct

amb

ula

nce

cal

l ce

ntr

e fo

r fo

llow

u

p c

all t

o p

atie

nt

Leav

e p

atie

nt

at

scen

e

-gi

ve e

mer

genc

y co

ntac

t de

tails

-ad

vice

on

furt

her

self

man

agem

ent

Co

nta

ct p

atie

nt’

s d

iab

etes

tea

m

-co

nsen

t fr

om p

atie

nt

No

Pre-

aler

t ca

ll to

d

iab

etes

/A&

E te

am a

t n

eare

st s

uit

able

h

osp

ital

Tran

sfer

to

nea

rest

su

itab

le h

osp

ital

ac

cord

ing

to

ag

reed

p

roto

cols

-co

ntin

ue p

atie

nt

man

agem

ent

en r

oute

Pho

ne

call

to

pat

ien

t fr

om

am

bu

lan

ce c

all

cen

tre

–2

ho

urs

la

ter

-ch

eck

patie

nt’s

con

ditio

n

-en

sure

dia

bete

s te

am

cont

acte

d as

req

uire

d

Pati

ent

able

to

sel

f m

anag

e?

No

Ad

vice

on

nex

t st

eps

-e.

g. C

onta

ct

diab

etes

tea

m

urge

ntly

-at

tend

GP/

A&

E et

c

Yes

Go

to

p

age

12

Fro

m

pag

e 9

Impr

ovem

ent

afte

r in

itia

l tre

atm

ent?

--ac

cord

ing

to

agre

ed p

roto

cols

e.

g. U

K

Am

bula

nce

Clin

ical

Pra

ctic

e G

uide

lines

Co

nd

itio

n r

equ

ires

fu

rth

er s

pec

ialis

t cl

inic

al

inte

rven

tio

n

-ac

cord

ing

to

agre

ed p

roto

cols

e.

g. U

K

Am

bula

nce

Clin

ical

Pra

ctic

e G

uide

lines

-ac

cord

ing

to

agre

ed p

roto

cols

e.

g. U

K

Am

bula

nce

Clin

ical

Pra

ctic

e G

uide

lines

11

NH

S D

iab

etes

Dia

bet

es e

mer

gen

cy c

are

in t

he

com

mu

nit

y (C

hild

ren

an

d y

ou

ng

peo

ple

)

Hea

lth

Nee

ds

Ass

essm

ent

Pati

ent

has

d

iab

etic

em

erg

ency

co

nd

itio

n

999

call

Cal

l tri

aged

at

amb

ula

nce

call

cen

tre

Am

bu

lan

cecr

ew

dis

pat

ched

Am

bu

lan

cecr

ew a

rriv

e at

th

e sc

ene

Ass

essm

ent

by

amb

ula

nce

st

aff

Ass

essm

ent

ou

tco

me

No

t g

lyca

emic

/d

iab

etic

emer

gen

cy

bu

t o

ther

cl

inic

al

emer

gen

cy

Ass

essm

ent

ou

tco

me

Gly

caem

ic/

dia

bet

icem

erg

ency

Ass

essm

ent

ou

tco

me

No

t g

lyca

emic

em

erg

ency

or

oth

er c

linic

al

emer

gen

cy

Trea

t g

lyca

emic

/d

iab

etic

emer

gen

cy

acco

rdin

g t

o

agre

ed

pro

toco

ls

Pre-

aler

t ca

ll to

C

YP

dia

bet

es/

A&

E te

am

at n

eare

st

suit

able

ho

spit

al

Tran

sfer

to

nea

rest

su

itab

leh

osp

ital

ac

cord

ing

to

ag

reed

p

roto

cols

Tran

sfer

to

n

eare

st A

&E

acco

rdin

g t

o

agre

ed

pro

toco

ls

Pati

ent

rem

ain

s at

th

e sc

ene

wit

h

resp

on

sib

le a

du

ltR

efer

ral t

o o

ther

ag

enci

esac

cord

ing

to

ag

reed

pro

toco

ls

-e.

g. D

iabe

tic

keto

acid

osis

-Tr

iage

ac

cord

ing

to

agre

ed

prot

ocol

s

Max

imum

resp

onse

times

iden

tifie

d

-C

linic

al

asse

ssm

ent

acco

rdin

g to

ag

reed

pr

otoc

ols,

e.g

. U

K A

mbu

lanc

e C

linic

al P

ract

ice

guid

elin

es

E.g.

-hy

pogl

ycae

mia

-hy

perg

lyca

emia

-D

iabe

tic

keto

acid

osis

-e.

g. U

K

Am

bula

nce

Clin

ical

Pr

actic

e gu

idel

ines

-C

ontin

ue

patie

nt

man

agem

ent

en r

oute

Go

to

p

age

12

12

NH

S D

iab

etes

Emer

gen

cy a

nd

in p

atie

nt

care

fo

r p

eop

le w

ith

dia

bet

es

Dia

bet

es e

mer

gen

cy c

are

in h

osp

ital

Fro

m

pag

e 10

Dia

bet

icem

erg

ency

via

am

bu

lan

ce

Ref

erra

l via

G

P o

r o

ther

h

ealt

hca

re

pro

fess

ion

al

Oth

er c

linic

al

emer

gen

cy

-e.

g. M

yoca

rdia

l in

farc

tion,

str

oke

etc

Ch

ild d

iab

etic

em

erg

ency

Go

to

ch

ildre

n a

nd

you

ng

peo

ple

com

mis

sio

nin

gg

uid

e

Tran

sfer

to

A

&E

team

Imm

edia

te c

linic

al

asse

ssm

ent

and

tr

eatm

ent

of

emer

gen

cy

con

dit

ion

-re

susc

itate

- st

abili

se

-in

itiat

e tr

eatm

ent

acco

rdin

g to

agr

eed

prot

ocol

s

-in

volv

e di

abet

es

team

Ad

mis

sio

n

-id

entif

y an

y ne

w

diab

etic

s ac

cord

ing

to

agre

ed p

roto

cols

-co

ntin

ue

man

agem

ent

of

diab

etes

(adm

issi

on

care

pla

n)

-co

ntin

ue

man

agem

ent

of o

ther

cl

inic

al e

mer

genc

ies,

as

app

ropr

iate

-in

vest

igat

e an

d tr

eat

any

ass

ocia

ted

com

plic

atio

ns o

f d

iabe

tes

– se

e r

elev

ant

com

mis

sion

ing

guid

es

New

ly

dia

gn

ose

dd

iab

etes

?

- in

volv

e di

abet

es

team

Yes

Dis

cuss

d

iag

no

sis

wit

h

pat

ien

t

-in

itiat

e di

scha

rge

plan

-pr

omot

e se

lf ca

re

of d

iabe

tes

No

Rev

iew

car

e p

lan

nin

g

incl

ud

ing

d

isch

arg

e p

lan

-lia

ise

with

car

e co

-ord

inat

or

-in

itiat

e di

scha

rge

plan

-nu

triti

onal

as

sess

men

t (f

or

olde

r pe

ople

)

-pr

omot

e se

lf ca

re

of d

iabe

tes

-if

recu

rren

t hy

pogl

ycae

mia

, di

scus

s re

: im

plic

atio

ns f

or

driv

ing

Pati

ent

stab

le

-go

od g

lyca

emic

co

ntro

l

-ot

her

cond

ition

s tr

eate

d, a

s re

quire

d

-an

y di

abet

ic

com

plic

atio

ns

trea

ted,

as

requ

ired

Dis

char

ge

care

pla

nD

isch

arg

e

-in

form

GP

-in

form

dia

bete

s te

am in

co

mm

unity

for

fo

llow

up

- se

e di

agno

sis

and

cont

inui

ng

care

com

mis

sion

ing

guid

e

-di

scha

rge

med

icat

ion

Acu

te f

oo

t p

rob

lem

Go

to

fo

ot

care

com

mis

sio

nin

gg

uid

e

Fro

m

pag

e 11

Init

iate

car

e p

lan

nin

g in

clu

din

g

iden

tifi

cati

on

of

care

co

-ord

inat

or

and

as

sess

car

er’s

n

eed

s

13

NH

S D

iab

etes

Emer

gen

cy a

nd

in p

atie

nt

care

fo

r p

eop

le w

ith

dia

bet

es

Plan

ned

in p

atie

nt

care

Hea

lth

nee

ds

asse

ssm

ent

Ass

essm

ent

by

dia

bet

esle

ad (

CY

P o

rad

ult

as

app

rop

riat

e)

-de

cisi

on t

o un

dert

ake

oper

atio

n/

proc

edur

e

-de

cisi

on t

o un

dert

ake

day

case

or

in p

atie

nt

adm

issi

on

-gi

ve p

re-o

pera

tive/

pr

oced

ure

inst

ruct

ions

-lia

ison

with

car

e co

-ord

inat

or

Plan

to

ac

hie

ve g

oo

d

gly

caem

icco

ntro

l

-di

abet

es t

eam

or

CY

P s

peci

alis

t t

eam

to

man

age

with

pat

ient

/ fam

ily

-

adm

issi

on

care

pla

n

Pre-

op

erat

ive/

p

roce

du

re

asse

ssm

ent

-cl

erki

ng a

nd

inve

stig

atio

ns

acco

rdin

g to

ag

reed

pr

otoc

ols

Go

od

gly

caem

icco

ntr

ol?

No

Ass

ess

risk

of

dela

y in

op

erat

ion

/ pr

oced

ure

vs p

oor

post

ope

rati

ve/

proc

edur

al d

iabe

tes

cont

rol

Go

ah

ead

wit

h

pro

ced

ure

/ o

per

atio

n?

No

Yes

Yes

Peri

-o

per

ativ

e/

pro

ced

ure

man

agem

ent

of

dia

bet

es

-ac

cord

ing

to

agre

ed

prot

ocol

s

Post

-o

per

ativ

e/

pro

ced

ure

man

agem

ent

of

dia

bet

es

-ai

m t

o ac

hiev

e go

od g

lyca

emic

co

ntro

l fro

m d

ay

one

post

-op

/pr

oced

ure

-ot

her

post

-op

erat

ive/

pr

oced

ure

care

as

req

uire

d

-pr

omot

e se

lf ca

re o

f di

abet

es

Pati

ent

read

y fo

r d

isch

arg

e

-go

od

glyc

aem

icco

ntro

l

-go

od p

ost

-op

erat

ive/

pr

oced

ure

reco

very

-lia

ison

with

ca

re c

o -

ordi

nato

r

Dis

char

ge

care

pla

nD

isch

arg

e

- in

form

GP

-in

form

dia

bete

s te

am

in c

omm

unity

for

fo

llow

up

- se

e di

agno

sis

and

cont

inui

ng c

are

com

mis

sion

ing

guid

e

-di

scha

rge

med

icat

ion

Post

o

per

ativ

e/

pro

ced

ure

fo

llow

up

ap

po

intm

ent

14

Contracting Framework for DiabetesEmergency and Inpatient Services

IntroductionThis contracting framework sets out what isrequired of clinically safe and effective services thatare providing emergency and inpatient care forpeople with diabetes. The framework is designedto be read in conjunction with the high levelpatient intervention map, which describes theinterventions and actions required along thepatient pathway as well as entry and exit pointsand the standard service specification templatesfor diabetes emergency and inpatient services.

The framework brings together the key qualityareas and standards that have been identified byNHS Diabetes, Diabetes UK, the Royal Colleges andother related organisations.

The principles that establish a safepathway for patient care Establishing the principles that underpin thesystems and processes of pathways for patient careleads to more efficient patient throughput and canreduce risk of fragmentation of care and seriousuntoward incidents. The principles operate at fourlayers within a 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 inwhich the overall management including bothClinical Case Direction and the delivery of theclinical processes conventionally sits within oneorganisation. However, with a more complexpathway, there is a danger that fracturing theoverall management pathway into componentscarried out by different clinical teams andorganisations will require duplication of effortleading to inefficiency and increased risk athandover points. This can be managed byestablishing clear governance arrangements for allthe layers in the pathway.

In addition, Commissioning Bodies must balancethe benefits of fracturing the pathway againstincreased complexity and ensure that the increasedrisks are mitigated.

The governance arrangements required for allthree layers and the commissioner responsibilitiesare shown below:

15

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.

Diabetes emergency and inpatientservicesThe key principle of good diabetes care is toprovide a high quality service that is reliable interms of delivery and timely access for patientsrequiring 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 thespecialist diabetes service. Responsibility for overallpatient care across the whole pathway rests withthe patient’s GP who also retains overallresponsibility to ensure the management of sideeffects 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 care1.

The services themselves will also have clinicaloversight and accountability for governancepurposes.

This contracting framework focuses on adults,including older people, with diabetes who requireemergency or unscheduled care as well as plannedinpatient care. In addition, emergency care in thecommunity setting for children and young peoplewith diabetes is also considered in this document.

This contracting framework should also be read inconjunction with the commissioning guides forolder people and for diabetes diagnosis andcontinuing care and for children and young peoplewith diabetes and follow the principles for the

effective commissioning of services for people withLearning Disabilities 2.

Specialist emergency and in patient care forchildren and young people is dealt with in thecommissioning guide for children and youngpeople with diabetes and acute foot problems aredealt with in the diabetes foot care commissioningguide2.

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 for AcuteServices– bilateral (main clauses and schedules)3.Thisis to assist commissioners and providers in having anoverview of how the elements link to the StandardNHS Contract. Some of the areas are open tointerpretation and consequently the references arenot exhaustive.

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

Gov

erna

nce

Lead

ersh

ip

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:11

,16,

19,3

3,48

,49,

51,5

3, 6

0

Sche

dule

s: 1

0

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 ha

ve o

rgan

isat

iona

l str

uctu

reth

at p

rovi

des

lead

ersh

ip f

or a

ll pr

ofes

sion

san

d di

scip

lines

In p

artic

ular

, the

re m

ust

be a

cor

pora

tecl

inic

al d

irect

or w

ith t

he r

espo

nsib

ility

and

acco

unta

bilit

y fo

r th

e cl

inic

al s

ervi

ce

Ther

e m

ust

be a

lear

ning

fra

mew

ork

in t

heor

gani

satio

n

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

serv

ice

prov

idin

gem

erge

ncy

and

inpa

tient

car

e fo

r pe

ople

with

dia

bete

s.

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 Acu

te S

ervi

ces

Mai

n cl

ause

s:11

,19,

27,4

8,49

,51,

53,5

4,56

, 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

isat

iona

l and

int

egra

ted

gove

rnan

ce s

yste

ms

and

stru

ctur

es in

pla

cew

ith c

lear

line

s of

acc

ount

abili

ty a

ndre

spon

sibi

litie

s fo

r al

l fun

ctio

ns. T

his

incl

udes

inte

rfac

es a

nd t

rans

ition

s be

twee

nse

rvic

es

Qua

lity

Gov

erna

nce

in t

he N

HS.

A g

uide

for

pro

vide

r bo

ards

4

Gov

erna

nce

Clin

ical

Gov

erna

nce

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:4,

4A,6

,9,1

0,12

,14,

15,1

6,17

,19,

21,

27,2

9,31

,32,

33,

48,4

9,51

,53,

54

Sche

dule

s:

3 (p

arts

1,2,

4,4A

,4B,

4C,5

,6),

7,10

,12,

18,2

0

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

tre

view

the

Clin

ical

Neg

ligen

ce S

chem

e fo

r Tru

sts

arra

ngem

ents

/or o

ther

org

anisa

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

dpr

oced

ures

def

inin

g cl

ear l

ines

of a

ccou

ntab

ility

and

resp

onsib

ility

.

The

serv

ice

is re

quire

d to

com

ply

with

gui

delin

es, p

ublic

hea

lthgu

idan

ce a

nd a

ppra

isals

publ

ished

by

the

Nat

iona

l Ins

titut

e fo

rH

ealth

and

Clin

ical

Exc

elle

nce

that

are

rele

vant

to th

e ca

repr

ovid

ed b

y th

e se

rvic

e 5 .

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

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

y A

ssur

ance

syst

em a

nd in

tern

al e

rror

repo

rtin

gin

volv

ing

all s

taff

gro

ups.

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

t12

In a

dditi

on, t

he s

ervi

ce is

requ

ired

to c

ompl

y w

ith th

e fo

llow

ing:

i.

Gui

danc

e pu

blish

ed b

y N

ICE

• D

epre

ssio

n w

ith a

chr

onic

phy

sical

hea

lth p

robl

em6

• 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 7

ii. C

linic

al g

uide

lines

for T

ype

2 D

iabe

tes

Mel

litus

pro

duce

d by

the

Euro

pean

Dia

bete

s W

orki

ng P

arty

for O

lder

Peo

ple

8

Serv

ices

may

also

find

the

follo

win

g gu

idan

ce p

ublis

hed

by N

HS

Dia

bete

s he

lpfu

l :

i. Th

e H

ospi

tal M

anag

emen

t of H

ypog

lyca

emia

in A

dults

with

Dia

bete

s M

ellit

us 9

ii. M

anag

emen

t of a

dults

with

dia

bete

s un

derg

oing

sur

gery

and

elec

tive

proc

edur

es: i

mpr

ovin

g st

anda

rds

10

iii. T

he M

anag

emen

t of D

iabe

tic K

etoa

cido

sis in

Adu

lts 11

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 Acu

te S

ervi

ces

Mai

n cl

ause

s:4,

4A,1

2,16

,17,

18,

19,2

0,21

, 31,

32,

33, 5

4

Sche

dule

s:

2,3

(par

ts 4

, 4A

,4B,

4C,5

,6)

7,10

,12,

18,

20

Und

erst

andi

ng t

he c

once

pt o

fcl

inic

al q

ualit

y

Has

con

cern

for

qua

lity

whi

lew

orki

ng e

ffic

ient

ly

An

unde

rsta

ndin

g of

the

use

of

audi

t, p

atie

nt a

nd s

taff

fee

dbac

kto

impr

ove

qual

ity

An

orga

nisa

tion

that

pro

vide

scl

arity

of

obje

ctiv

es a

nd p

rom

otes

refle

ctiv

e pr

actic

e to

impr

ove

qual

ity o

f pa

tient

car

e

Qua

lity

assu

ranc

e sy

stem

s m

ust b

e in

pla

cean

d ap

prov

ed b

y co

mm

issio

ning

bod

y w

ithre

gula

r rep

ortin

g of

out

com

es

Prov

ider

s ar

e re

quire

d to

pub

lish

qual

ityac

coun

ts fo

r the

pub

lic re

port

ing

of q

ualit

yin

clud

ing

safe

ty, e

xper

ienc

e an

d ou

tcom

es

Prov

ider

s sh

ould

par

ticip

ate

in n

atio

nal a

udit

prog

ram

mes

Dia

bete

s se

rvic

es m

ust c

ompl

y w

ith th

e pe

rfor

man

ce m

easu

res

requ

ired

of N

HS

serv

ices

, i.e

mee

ting:

13

• Re

ferr

al to

Tre

atm

ent w

aits

(95t

h pe

rcen

tile

mea

sure

s)

• A

&E

Qua

lity

Indi

cato

rs•

Am

bula

nce

resp

onse

tim

es

The

serv

ice

is re

quire

d to

par

ticip

ate

in th

e fo

llow

ing

activ

ities

/pro

gram

mes

:

• N

atio

nal D

iabe

tes

Aud

it 14

• N

atio

nal D

iabe

tes

Inpa

tient

Aud

it of

Acu

te T

rust

s 15

(NB

Prov

ider

s m

ay w

ish to

con

duct

add

ition

al a

udits

in th

e ar

eas

iden

tifie

d in

this

docu

men

t)•

Patie

nt E

xper

ienc

e Su

rvey

s 16

• D

iabe

tes

E 17

• Pa

tient

Rep

orte

d O

utco

mes

Mea

sure

s18

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

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 Acu

te S

ervi

ces

Mai

n cl

ause

s:11

,16,

26,3

3, 4

8 ,5

6

The

prov

ider

org

anis

atio

n ha

ssy

stem

s an

d pr

oced

ures

in p

lace

to a

ssur

e th

e co

mm

issi

oner

tha

tth

eir

clin

ical

tea

m h

as t

hene

cess

ary

qual

ifica

tions

, ski

lls,

know

ledg

e an

d ex

perie

nce

tode

liver

the

ser

vice

Staf

f are

com

pete

nt a

nd fi

t for

pur

pose

Prov

ider

to s

atisf

y co

mm

issio

ner t

hat a

ll st

aff

have

cur

rent

app

raisa

l, cl

eara

nces

and

regi

stra

tion

chec

ks a

nd h

ave

dem

onst

rate

dco

mpe

tenc

e in

all

proc

edur

es re

leva

nt 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:

o 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 19

o re

gist

ratio

n of

non

-med

ical

pre

scrib

ers

• D

ietit

ians

: reg

istra

tion

with

the

HPC

and

abl

e to

dem

onst

rate

com

pete

nce

in d

eliv

erin

g sp

ecia

list s

uppo

rt/a

dvic

e in

ent

eral

and

pare

nter

al fe

edin

g•

Podi

atris

ts: r

egist

ratio

n w

ith th

e H

PC a

nd a

ble

to d

emon

stra

teco

mpe

tenc

e in

del

iver

ing

spec

ialis

t sup

port

/adv

ice

in th

em

anag

emen

t of t

he d

iabe

tic fo

ot –

see

also

com

miss

ioni

nggu

ide

for d

iabe

tes

foot

car

e 2

• Ph

arm

acist

s: re

gist

ratio

n w

ith th

e G

ener

al P

harm

aceu

tical

Cou

ncil

and

be a

ble

to d

emon

stra

te c

ompe

tenc

y in

med

icin

esm

anag

emen

t for

pat

ient

s w

ith d

iabe

tes

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

rele

vant

com

pete

ncie

s (s

ee S

kills

for H

ealth

-D

iabe

tes

Com

pete

ncie

s fo

r dia

bete

s) 20

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 Acu

te S

ervi

ces

Mai

n cl

ause

s:11

, 16,

17,

21,

26,

33

The

prov

ider

org

anis

atio

n ha

ssy

stem

s in

pla

ce t

o as

sure

the

com

mis

sion

er t

hat

thei

r cl

inic

alte

am a

re c

ompe

tent

to

use

all

equi

pmen

t ne

eded

to

deliv

er t

hese

rvic

e

Prov

ider

to s

atisf

y th

e co

mm

issio

ner t

hat a

llst

aff h

ave

had

docu

men

ted

com

pete

nce

asse

ssm

ent r

elat

ive

to a

ll eq

uipm

ent u

sed

inco

ntra

ct.

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

rele

vant

com

pete

ncie

s in

usin

g ap

prop

riate

equi

pmen

t e.g

. blo

od g

luco

se a

nd k

eton

e m

onito

rs, i

nsul

inde

liver

y de

vice

s in

clud

ing

insu

lin p

umps

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

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 Acu

te S

ervi

ces

Mai

n cl

ause

s:11

,16,

19,3

048

The

prov

ider

org

anis

atio

n ha

ssy

stem

s in

pla

ce t

o as

sure

the

com

mis

sion

er t

hat

thei

r cl

inic

alte

am is

for

mal

ly in

duct

ed a

ndre

ceiv

es o

ngoi

ng a

ssis

tanc

e to

deve

lop

thei

r sk

ills,

kno

wle

dge

and

expe

rienc

e t

o en

sure

tha

tth

ey a

re a

lway

s fu

lly u

pdat

ed

Prov

ider

to s

atisf

y co

mm

issio

ner o

f the

irco

mm

itmen

t to

indu

ctio

n an

d C

PD re

leva

ntto

role

s

Prov

ider

to s

atisf

y th

e co

mm

issio

ner o

f the

irco

mm

itmen

t to

trai

n st

aff t

o m

eet f

utur

ese

rvic

e ne

eds

• A

ll H

ealth

Car

e st

aff w

ho a

re n

ot p

art o

f the

dia

bete

sm

ultid

iscip

linar

y te

am a

nd w

ho d

eal w

ith p

eopl

e w

ho h

ave

orw

ho h

ave

prev

ious

ly u

ndia

gnos

ed d

iabe

tes

shou

ld h

ave

spec

ific

basic

trai

ning

in th

e re

cogn

ition

and

man

agem

ent o

fdi

abet

es•

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

and

licen

sing

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:4,

4A,5

,9,1

0,11

,12,

14,1

5,16

17,1

8,19

,21,

26,

27,2

9,33

,34,

35,

3643

,48,

49,5

253

,54,

56,6

0

Sche

dule

s:

2,3,

4,5,

6,8,

10,

12,1

3,15

,17,

19

, 20

The

Prov

ider

is r

equi

red

to b

ere

gist

ered

with

the

Car

e Q

ualit

yC

omm

issi

on t

o de

mon

stra

te t

hat

is m

eets

the

ess

entia

l sta

ndar

dsof

qua

lity

and

safe

ty f

or t

here

gula

ted

activ

ities

del

iver

ed.

The

Prov

ider

is r

equi

red

to b

elic

ense

d w

ith t

he N

HS

Econ

omic

Regu

lato

r (M

onito

r) in

ord

er t

opr

ovid

e N

HS

care

.

Com

plia

nce

with

the

Car

e Q

ualit

yC

omm

issio

n an

d M

onito

r req

uire

men

tsC

ompl

ianc

e w

ith th

e fo

llow

ing

Nat

iona

l Ser

vice

Fra

mew

orks

,w

here

app

licab

le:

• O

lder

Peo

ple’

s N

SF 21

• C

oron

ary

Hea

rt D

iseas

e N

SF 22

• Th

e M

enta

l Hea

lth S

trat

egy23

• Lo

ng T

erm

Con

ditio

ns N

SF 24

Com

plia

nce

with

:•

End

of L

ife c

are

Stra

tegy

25

Com

plia

nce

with

Car

e Q

ualit

y C

omm

issio

n Re

view

s

Clin

ical

qua

lity

Out

com

es

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:4,

4A,1

0,14

,15,

16,2

1

Sche

dule

s:3

(par

t 5),

5 (p

arts

1,2

,3),

12

Com

preh

ensi

ve u

nder

stan

ding

and

com

mitm

ent

to d

eliv

erin

gan

d im

prov

ing

outc

omes

of

care

Com

plia

nce

with

the

NH

S O

utco

mes

Fram

ewor

k26C

ompl

ianc

e w

ith th

e Q

ualit

y St

anda

rds

for D

iabe

tes,

spe

cific

ally

: 27

Qua

lity

Stat

emen

t 11

Peop

le w

ith d

iabe

tes

adm

itted

to

hosp

ital a

re c

ared

for b

yap

prop

riate

ly tr

aine

d st

aff,

prov

ided

with

acc

ess

to a

spe

cial

istdi

abet

es te

am, a

nd g

iven

the

choi

ce o

f sel

f-m

onito

ring

and

man

agin

g th

eir o

wn

insu

lin

Qua

lity

Stat

emen

t 12

Peop

le a

dmitt

ed to

hos

pita

l with

dia

betic

ket

oaci

dosis

rece

ive

educ

atio

nal a

nd p

sych

olog

ical

sup

port

prio

r to

disc

harg

e an

d ar

efo

llow

ed u

p by

a s

peci

alist

dia

bete

s te

am

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

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 Acu

te S

ervi

ces

Mai

n cl

ause

s:4,

4A,9

,10,

12,

14,1

5,16

,17,

18,1

9,20

,21,

27,2

9,32

,33,

34,

35,3

6,54

Sche

dule

s:

3 (p

arts

1 a

nd 2

)

Resp

onsi

vene

ss a

nd p

artic

ipat

ive

appr

oach

to

incl

udin

g pa

tient

s’vi

ews

abou

t th

eir

care

in t

hede

sign

of

care

pat

hway

s

Col

labo

ratio

n w

ith o

ther

orga

nisa

tions

invo

lved

in t

hepa

tient

pat

hway

to

prov

ide

ase

amle

ss p

athw

ay o

f ca

re

All

poss

ible

ent

ry a

nd e

xit p

oint

s m

ust b

ede

fined

with

com

preh

ensiv

e pa

tient

path

way

s th

at fa

cilit

ate

smoo

th p

assa

ge a

ndef

fect

ive,

eff

icie

nt c

are

for p

atie

nts

All

inte

rfac

es in

the

path

way

mus

t be

defin

ed s

o th

at c

ontin

uity

of c

linic

al c

are

isen

sure

d w

ith n

o fr

actu

ring

of th

e pa

thw

ay

Ther

e m

ust b

e sp

ecifi

catio

n of

cle

ar ti

mel

ines

and

aler

t mec

hani

sms

for p

oten

tial b

reac

hes

Ther

e sh

ould

be

audi

t of p

athw

ay to

ens

ure

that

sta

ndar

ds a

re m

et

Ther

e m

ust b

e ex

plic

it sp

ecifi

catio

n of

prov

ider

and

com

miss

ione

r res

pons

ibili

ties

for t

he w

hole

pat

ient

epi

sode

from

regi

stra

tion

to fi

nal d

ischa

rge

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 o

f ser

vice

s su

ppor

ting

patie

nts

with

dia

bete

s an

d th

ere

mus

t be

clea

r sub

con

trac

ts s

tatin

g th

e re

ferr

al c

riter

iaan

d ac

cess

to th

ese

supp

ortin

g se

rvic

es.

If pa

rt o

r who

le o

f the

ser

vice

is to

be

tran

sfer

red

to o

ther

pro

vide

rs, t

here

mus

t be

clea

r and

agr

eed

sub

cont

ract

s on

refe

rral

crite

ria a

nd a

cces

s to

thes

e se

rvic

es.

At e

ntry

to p

athw

ay:

The

Com

miss

ione

r sho

uld

assu

re th

emse

lves

that

the

prov

ider

has

sys

tem

s an

d pr

oces

ses

in p

lace

to

i) re

gist

er p

atie

nts

The

path

way

sho

uld

follo

w th

e pr

inci

ples

set

out

by

the

Gen

eric

Long

Ter

m C

ondi

tions

mod

el 28

. Thi

s in

clud

es:

• St

ratif

ying

the

leve

ls of

nee

d an

d ris

k •

Cas

e m

anag

emen

t•

Pers

onal

ised

care

pla

nnin

g•

Supp

ortin

g pe

ople

to s

elf c

are

• A

ssist

ive

tech

nolo

gy

1. E

mer

genc

y ca

re in

the

com

mun

ity

Ther

e sh

ould

be

prot

ocol

s in

pla

ce to

man

age

peop

le o

f all

ages

who

exp

erie

nce

diab

etic

em

erge

ncie

s in

the

com

mun

ity, e

.g. U

KA

mbu

lanc

e Se

rvic

es C

linic

al P

ract

ice

Gui

delin

es 29

,30

Emer

genc

y se

rvic

es s

houl

d en

sure

follo

w u

p of

pat

ient

s w

hoha

ve h

ad d

iabe

tic e

mer

genc

ies

thro

ugh

liaiso

n w

ith lo

cal d

iabe

ticte

ams

31

2. E

mer

genc

y tr

eatm

ent i

n A

&E

Ther

e sh

ould

be

clea

r pro

toco

ls fo

r the

ass

essm

ent o

f peo

ple

( inc

ludi

ng o

lder

peo

ple)

who

are

adm

itted

to h

ospi

tal w

ith a

nac

ute

illne

ss, t

o sc

reen

for p

ossib

le d

iabe

tes

e.g.

Thin

kGlu

cose

Tool

kit 32

Ther

e sh

ould

be

clea

r pro

toco

ls fo

r the

tim

ely

asse

ssm

ent a

ndtr

eatm

ent o

f peo

ple

who

pre

sent

with

dia

betic

em

erge

ncie

s, e

.g.

diab

etic

ket

oaci

dosis

, sev

ere

acut

e hy

pogl

ycae

mia

and

dia

betic

foot

ulc

erat

ion

Expe

rt a

dvic

e an

d/or

car

e fr

om th

e m

ultid

iscip

linar

y di

abet

este

am o

r the

chi

ldre

n an

d yo

ung

peop

le s

peci

alist

dia

bete

s te

am(a

s ap

prop

riate

) mus

t be

avai

labl

e fo

r the

man

agem

ent o

f peo

ple

who

pre

sent

with

dia

betic

em

erge

ncie

s 24

hou

rs a

day

and

also

for i

npat

ient

s

3. In

patie

nt c

are

All

patie

nts

with

dia

bete

s w

ho h

ave

emer

genc

y an

d pl

anne

din

patie

nt c

are

shou

ld h

ave

adm

issio

n an

d di

scha

rge

care

pla

ns

Qua

lity

Stat

emen

t 13

Peop

le w

ith d

iabe

tes

who

hav

e ex

perie

nced

hyp

ogly

caem

iare

quiri

ng m

edic

al a

tten

tion

are

refe

rred

to a

spe

cial

ist d

iabe

tes

team

Clin

ical

qua

lity

Out

com

es

21

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

ayii)

col

lect

rele

vant

clin

ical

and

adm

inist

rativ

e da

taiii

) man

age

the

appo

intm

ent p

roce

ss,

(reap

poin

tmen

t and

DN

A p

roce

ss, i

fap

prop

riate

)iv

) pro

vide

info

rmat

ion

to p

atie

nts

v) u

nder

take

initi

al a

sses

smen

t in

the

appr

opria

te lo

catio

n

At p

oint

of i

nter

vent

ion:

The

Com

miss

ione

r sho

uld

assu

re th

emse

lves

that

the

prov

ider

has

sys

tem

s an

d pr

oces

ses

in p

lace

to e

nsur

e th

at:

i) th

e in

terv

entio

n is

cond

ucte

d sa

fely

and

in a

ccor

danc

e w

ith a

ccep

ted

qual

ityst

anda

rds

and

good

clin

ical

pra

ctic

e.ii)

the

patie

nt re

ceiv

es a

ppro

pria

te c

are

durin

g th

e in

terv

entio

n(s)

, inc

ludi

ng o

ntr

eatm

ent r

evie

w a

nd s

uppo

rt, i

nac

cord

ance

with

bes

t clin

ical

pra

ctic

e

iii) w

here

clin

ical

em

erge

ncie

s or

com

plic

atio

ns d

o oc

cur t

hey

are

man

aged

in a

ccor

danc

e w

ith b

est

clin

ical

pra

ctic

eiv

) the

inte

rven

tion

is ca

rrie

d ou

t in

afa

cilit

y w

hich

pro

vide

s a

safe

envi

ronm

ent o

f car

e an

d m

inim

ises

risk

to p

atie

nts,

sta

ff a

nd v

isito

rsv)

the

inte

rven

tion

is un

dert

aken

by

staf

fw

ith th

e ne

cess

ary

qual

ifica

tions

, ski

lls,

expe

rienc

e an

d co

mpe

tenc

e vi

) The

re a

re a

rran

gem

ents

for t

hem

anag

emen

t of o

ut o

f hou

rs c

are

acco

rdin

g to

bes

t clin

ical

pra

ctic

e

At e

xit f

rom

pat

hway

:

The

Com

miss

ione

r sho

uld

assu

re th

emse

lves

that

pro

vide

r has

sys

tem

s an

d pr

oces

ses,

whi

ch a

re a

gree

d w

ith a

ll pa

rtie

s an

d

toge

ther

with

clo

se li

aiso

n w

ith th

eir c

are

co-o

rdin

ator

31

The

adm

issio

n ca

re p

lan

shou

ld in

clud

e:

a. In

form

atio

n ex

chan

ge

• re

view

of t

he p

erso

n’s

ongo

ing

care

pla

n, a

nd d

iscus

sion

• of

thei

r pre

fere

nces

for s

elf c

are

of th

eir d

iabe

tes

whi

le in

hosp

ital

• ex

plan

atio

n of

the

reas

ons

for a

dmiss

ion,

and

wha

t to

expe

ctin

hos

pita

l

b. S

yste

mat

ic re

view

of k

ey a

reas

from

pat

ient

and

pro

fess

iona

lvi

ew p

oint

s

• le

vel o

f kno

wle

dge

abou

t dia

bete

s an

d ne

ed fo

r fur

ther

info

rmat

ion

– e

g. th

e im

plic

atio

ns fo

r driv

ing

if th

e pa

tient

has

recu

rren

t hyp

ogly

caem

ic e

piso

des

• as

sess

men

t of n

eed

for i

nput

from

dia

bete

s sp

ecia

list t

eam

• fo

od c

hoic

e, ti

min

gs a

nd a

cces

s to

food

/sna

cks

• nu

triti

onal

ass

essm

ent,

espe

cial

ly in

old

er p

eopl

e•

risk

stat

us o

f fee

t in

all p

eopl

e w

ith d

iabe

tes,

risk

str

atifi

catio

n,an

d m

anag

emen

t pla

n•

med

icin

es m

anag

emen

t and

con

trol

.Es

tabl

ish if

sel

f man

agem

ent i

s de

sired

/app

ropr

iate

. Ens

ure

that

self

man

agem

ent i

nclu

des

adm

inist

ratio

n of

med

icat

ion/

insu

linin

ject

ions

/insu

lin p

ump

and

acce

ss to

thei

r ow

n ca

pilla

ry b

lood

gluc

ose

mon

itorin

g an

d qu

ality

con

trol

equ

ipm

ent.

• ne

ed fo

r em

otio

nal a

nd p

sych

olog

ical

sup

port

(par

ticul

arly

olde

r peo

ple,

chi

ldre

n, a

nd th

ose

new

ly d

iagn

osed

).•

mob

ility

(par

ticul

arly

in o

lder

peo

ple

with

dia

bete

s).

• es

tabl

ish th

e cu

ltura

l and

relig

ious

nee

ds o

f the

indi

vidu

alin

clud

ing;

sub

sequ

ent d

ieta

ry, t

reat

men

t, an

d fa

cilit

ies

requ

irem

ents

and

mat

ters

sur

roun

ding

phy

sical

con

tact

• es

tabl

ish e

thni

c id

entit

y•

esta

blish

pre

ferr

ed n

ame

• ot

her p

atie

nt c

once

rns

c. D

evel

opin

g an

d re

cord

ing

a pl

an

• ke

y el

emen

ts o

f the

pla

n, a

nd w

ho is

resp

onsib

le fo

r eac

h of

thes

e, n

eed

to b

e re

cord

ed.

• a

nam

ed c

onta

ct a

nd o

ther

rele

vant

info

rmat

ion

shou

ld b

epr

ovid

ed to

eac

h in

divi

dual

in w

ritte

n or

oth

er a

ppro

pria

te

22

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

ayne

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

disc

over

eddu

ring

an in

terv

entio

n/as

sess

men

tiii

) ens

ure

that

pat

ient

s re

ceiv

e di

scha

rge

info

rmat

ion

rele

vant

to th

eir

inte

rven

tion

incl

udin

g ar

rang

emen

ts fo

rco

ntac

ting

the

prov

ider

and

follo

w u

p if

requ

ired

iv) p

rovi

de ti

mel

y fe

edba

ck to

the

refe

rrer

re in

terv

entio

n, c

ompl

icat

ions

and

prop

osed

follo

w u

pv)

ens

ure

that

the

patie

nt re

ceiv

es re

quire

ddr

ugs/

dres

sings

/aid

svi

) ens

ure

that

sup

port

is in

pla

ce w

ithot

her c

are

agen

cies

as

appr

opria

te

form

at. R

elev

ant i

nfor

mat

ion

shou

ld c

over

how

dia

bete

sre

late

d em

erge

ncie

s w

ill b

e m

anag

ed, h

ow in

divi

dual

s ca

nac

cess

hos

pita

l pro

toco

ls an

d po

licie

s fo

r the

man

agem

ent o

fdi

abet

es, a

nd h

ow to

acc

ess

the

spec

ialis

t tea

m if

nec

essa

ry.

The

disc

harg

e ca

re p

lan

shou

ld in

clud

e:

• re

view

of t

he a

dmiss

ion

and

patie

nt e

xper

ienc

es•

chec

k on

und

erst

andi

ng o

f new

or c

hang

ed d

iabe

tes

man

agem

ent,

incl

udin

g ho

w to

obt

ain

devi

ces

or n

eedl

es fo

rth

e ad

min

istra

tion

of in

sulin

• id

entif

icat

ion

of o

ngoi

ng n

eeds

• pa

tient

edu

catio

n on

the

impo

rtan

ce o

f brin

ging

thei

rm

edic

atio

n an

d de

vice

s w

hene

ver t

hey

are

adm

itted

to h

ospi

tal

• a

nam

ed c

onta

ct in

the

com

mun

ity•

writ

ten

disc

harg

e su

mm

ary

to G

P, d

iabe

tes

team

and

rele

vant

othe

rs e

.g. s

ocia

l car

e.•

info

rmat

ion

for t

he o

rgan

isatio

n on

:•

accu

rate

cod

ing

of a

ll di

agno

ses

incl

udin

g di

abet

es•

syst

emat

ic re

cord

ing

of p

atie

nt e

xper

ienc

e.

The

serv

ice

is re

quire

d to

ens

ure

that

a c

ompr

ehen

sive

asse

ssm

ent

of a

ll ol

der p

eopl

e w

ho a

re a

dmitt

ed to

hos

pita

l with

dia

bete

sta

kes

plac

e w

ithin

72

hour

s of

adm

issio

n

Ther

e sh

ould

be

prot

ocol

s in

pla

ce to

allo

w p

atie

nts,

who

are

abl

eto

do

so, t

o se

lf m

anag

e th

eir d

iabe

tes

med

icat

ion.

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

com

miss

ioni

ng g

uide

s)2 :

• di

agno

sis a

nd c

ontin

uing

car

e •

Preg

nanc

y an

d di

abet

es c

are

• se

rvic

es fo

r com

plic

atio

ns o

f dia

bete

s –

foot

car

e, e

yes,

vas

cula

ret

c •

men

tal h

ealth

•

lear

ning

disa

bilit

ies

• en

d of

life

car

e

Prov

ider

s sh

ould

ens

ure

acce

ss to

tran

spor

t fac

ilitie

s to

ena

ble

atte

ndan

ce fo

r spe

cial

ist tr

eatm

ent,

as re

quire

d

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

33

23

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 Acu

te S

ervi

ces

Mai

n cl

ause

s:5,

29, 3

3, 5

6

Sche

dule

s: 3

,10,

19

Und

erst

andi

ng o

f bu

ildin

gre

gula

tions

Acc

ess

to a

dvic

e on

“fit

-for

-pu

rpos

e” e

quip

men

t an

d fa

cilit

ies

Com

miss

ione

rs m

ust a

ssur

e th

emse

lves

that

patie

nt c

are

is de

liver

ed in

app

ropr

iate

ly b

uilt

and

equi

pped

faci

litie

s w

hich

mee

t rel

evan

tH

TMs

and

Build

ing

Not

es, a

nd, w

here

appr

opria

te, a

re re

gist

ered

and

are

saf

e an

dcl

ean.

Equi

pmen

t mus

t be

fit fo

r pur

pose

Com

mitm

ent t

o ef

ficie

nt u

se a

nd s

atisf

acto

rym

aint

enan

ce o

f equ

ipm

ent

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 Acu

te S

ervi

ces

Mai

n cl

ause

s:5,

11, 1

9, 5

4, 5

6, 6

0

Und

erst

andi

ng o

f cl

inic

alac

coun

tabi

litie

s of

hea

lth a

ndsa

fety

pol

icie

s

H&

S st

rate

gy a

nd p

olic

ies

in p

lace

and

impl

emen

ted

with

aw

aren

ess

thro

ugho

ut th

eor

gani

satio

n

Acc

essib

ility

to e

xecu

tive

resp

onsib

le fo

r H&

Sfo

r qui

cker

, firs

t 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

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 Acu

te S

ervi

ces

Mai

n cl

ause

s:6,

11,1

2,14

,15,

16,1

8,32

,33,

42, 5

4

Sche

dule

s:

2,12

,20

Abi

lity

to n

egot

iate

and

agr

eear

rang

emen

ts w

ith a

ppro

pria

tepe

rson

nel a

nd o

rgan

isat

ions

to

prov

ide

effe

ctiv

ely

for

emer

genc

ysi

tuat

ions

The

Com

miss

ione

rs s

houl

d sa

tisfy

them

selv

esth

at p

rovi

der h

as s

yste

ms,

pro

cess

es a

ndco

mpe

tent

per

sonn

el a

re in

pla

ce a

ndim

plem

ente

d to

ens

ure

that

all

clin

ical

emer

genc

ies

and

com

plic

atio

ns a

re h

andl

edin

acc

orda

nce

with

bes

t pra

ctic

e

Ther

e sh

ould

be

prot

ocol

s in

pla

ce to

ens

ure

the

avai

labi

lity

ofad

vice

and

/or s

uppo

rt o

f spe

cial

ist d

iabe

tes

clin

ical

sta

ff to

man

age

diab

etes

clin

ical

em

erge

ncy

situa

tions

, e.g

. dur

ing

asu

rgic

al p

roce

dure

24

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

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:8,

9,17

,19,

21,2

3,24

,27,

29,3

2,33

,54

Sche

dule

s: 5

,7,1

5,16

,18

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 o

f dat

a an

d in

form

atio

n•

Use

of d

ata

and

info

rmat

ion

• D

issem

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 p

rovi

ders

with

resp

ect t

oca

re o

f pat

ient

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 Pla

n

Ther

e sh

ould

be

polic

ies

in p

lace

that

incl

ude:

• C

onfid

entia

lity

Cod

e of

Pra

ctic

e•

Dat

a Pr

otec

tion

• Fr

eedo

m o

f Inf

orm

atio

n•

Hea

lth R

ecor

ds•

Info

rmat

ion

Gov

erna

nce

Man

agem

ent

• In

form

atio

n Q

ualit

y A

ssur

ance

• In

form

atio

n Se

curit

y

Ther

e m

ust b

e a

nam

ed in

divi

dual

who

is th

eC

aldi

cott

Gua

rdia

n

Stra

tegy

and

pol

icy

deve

lopm

ent

skill

s

The

abili

ty t

o an

alys

e da

ta a

ndha

ve a

cces

s to

info

rmat

ion

that

can

pred

ict

tren

ds a

nd t

hat

coul

did

entif

y pr

oble

ms

The

abili

ty t

o ca

ptur

e ev

iden

ceba

sed

prac

tice

from

R&

D N

atio

nal

Serv

ice

Fram

ewor

ks, N

ICE

guid

ance

The

abili

ty t

o us

e da

ta a

ndin

form

atio

n ap

prop

riate

ly t

oim

prov

e pa

tient

car

e

Tran

spar

ency

and

obj

ectiv

ity

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 34

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

HS

Out

com

es F

ram

ewor

k26

• N

atio

nal D

iabe

tes

Info

rmat

ion

Serv

ice

35

• N

atio

nal D

iabe

tes

Aud

it 14

• D

iabe

tes

E 17

• Q

ualit

y an

d O

utco

mes

Fra

mew

ork36

• M

yoca

rdia

l Isc

haem

ia A

udit

Proj

ect37

• H

ospi

tal E

piso

de S

tatis

tics38

• Pa

tient

Exp

erie

nce

16,3

3

• Pa

tient

Sat

isfac

tion

33

• Pa

tient

Rep

orte

d O

utco

mes

Mea

sure

s 18

• N

atio

nal D

iabe

tes

Con

tinui

ng C

are

Dat

aset

39

25

Source documentsCommissioners and providers should takeresponsibility for making references to thelatest version of the various documents andguidance.

1. NHS Diabetes and Diabetes UK, Emotional andPsychological Support and Care in Diabetes, JointDiabetes UK and NHS Diabetes Emotional andPsychological Support, 2010http://www.diabetes.nhs.uk

2. The NHS Diabetes Commissioning Guides areavailable on the NHS Diabetes website athttp://www.diabetes.nhs.uk/commissioning_resource/

3.Department of Health, Standard NHS Contractshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324

4. National Quality Board, Quality Governance in theNHS, 2011 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_125239.pdf

5. NICE Diabetes guidance,http://guidance.nice.org.uk/Topic/EndocrineNutritionalMetabolic/Diabetes

6. NICE, Depression in adults with a chronic physicalhealth problem, treatment and management,http://guidance.nice.org.uk/CG91 , October 2009

7. NICE, Medicines adherence: involving patients indecisions about prescribed medicines andsupporting adherence, Jan 2009,http://guidance.nice.org.uk/CG76

8. European Diabetes Working Party for OlderPeople. Clinical Guidelines for Type 2 DiabetesMellitus, www.instituteofdiabetes.org

9. The Hospital Management of Hypoglycaemia inAdults with Diabetes Mellitus, March 2010,http://www.diabetes.nhs.uk/

10. Management of adults with diabetes undergoingsurgery and elective procedures: improvingstandards, April 2011http://www.diabetes.nhs.uk/

11. The Management of Diabetic Ketoacidosis inAdults, Joint British Diabetes Societies InpatientCare Group, March 2010,http://www.diabetes.nhs.uk/

12. NHS Institute for Innovation and Improvement,model CQUIN scheme: inpatient care for peoplewith diabetes, 2009

13. Department of Health, The Operating Frameworkfor the NHS in England 2011/12, 2010,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122738

14. National Diabetes Audit.www.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/diabetes

15. National Diabetes Inpatient Audit,http://www.diabetes.nhs.uk/our_work_areas/inpatient_care/inpatient_audit_2010/

16. The King’s Fund, The point of care. Measures ofpatients’ experience in hospital: purpose,methods and uses. July 2009

17. DiabetesE - https://www.diabetese.net/

18. Patient Reported Outcomes Measures,http://www.ic.nhs.uk/proms

19. Training, Research and Education for Nurses inDiabetes – UK, An Integrated Career &Competency Framework for Diabetes Nursing(Second Edition), 2010

20. Skills for Health, Diabetes CompetencyFramework, https://tools.skillsforhealth.org.uk/

21. Department of Health, National ServiceFramework for Older People, May 2001,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066

22. Department of Health, National ServiceFramework for Coronary Heart Disease – modernstandards and service modelshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094275

23. Department of Health, No health without mentalhealth: a cross-government mental healthoutcomes strategy for people of all ages,February 2011,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766

26

24. Department of Health, The National ServiceFramework for Long Term Conditions, March2005http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4105361

25. Department of Health, End of Life Care Strategy– promoting high quality care for all adults at theend of life, July 2008,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086277

26. Department of Health, The NHS OutcomesFramework 2011/12, December 2010http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944

27. NICE, Quality Standards: Diabetes in adults,March 2011,http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp

28. Generic Long-term conditions modelhttp://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_120915

29. Joint Royal Colleges Ambulance LiaisonCommittee, UK Ambulance Service ClinicalPractice Guidelines 2006, Glycaemic emergenciesin adults,www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/glycaemic_emergencies_in_adults_2006.pdf

30. Joint Royal Colleges Ambulance LiaisonCommittee, UK Ambulance Service ClinicalPractice Guidelines 2006, Glycaemic emergenciesin children, http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/glycaemic_emergencies_in_children_2006.pdf

31. National Diabetes Support Team, Improvingemergency and inpatient care for people withdiabetes, the report of a working party ofrepresentatives of the inpatient and emergencycare community in partnership with the NationalInstitute for Innovation and Improvement, March2008

32. NHS Institution for Innovation and Improvement,ThinkGlucose Toolkit,http://www.institute.nhs.uk/quality_and_value/think_glucose/welcome_to_the_website_for_thinkglucose.html

33. Healthcare Commission, National Survey ofPeople with Diabetes, 2006,www.cqc.org.uk/usingcareservices/healthcare/patientsurveys/servicesforpeoplewithdiabetes.cfm

34. York and Humber integrated IT systemhttp://www.diabetes.nhs.uk/

35. National Diabetes Information Service,www.diabetes-ndis.org

36. Quality and Outcomes Framework,http://www.nice.org.uk/aboutnice/qof/qof.jsp

37. Myocardial Ischaemia Audit Project (MINAP)www.rcplondon.ac.uk/CLINICAL-STANDARDS/ORGANISATION/PARTNERSHIP/Pages/MINAP-.aspx

38. Hospital Episode Statistics,www.ic.nhs.uk/statistics-and-data-collections/hospital-care/hospital-activity-hospital-episode-statistics--hes

39. National Diabetes Continuing Care Dataset,www.ic.nhs.uk/webfiles/Services/Datasets/Diabetes/dccrdataset.pdf

27

This specification forms Schedule 2, Parts 1-4,‘The Services - Service Specifications’ of theStandard NHS Contract for AmbulanceServicesa.

Service specifications are developed in partnershipbetween commissioners and provider agenciesand are based on agreed evidence-based care andtreatment models. Specifications should be opento scrutiny and available to all service users/carersas a statement of standards that the user/carercan expect to receive.

The following documentation, developed bythe Diabetes Commissioning Advisory Groupprovides further detail/guidance to supportthe development of this specification:

• The diabetes emergency and inpatientintervention map

• The contracting framework for diabetesemergency and inpatient services

This specification template assumes that theservices are compliant with the contractingframework for diabetes emergency and inpatientservices.

This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.

Part 1:Section A: Base ServicesDescription of emergency diabetes care:

Emergency diabetes care includes the immediateassessment, stabilisation, initial treatment ofpeople of all ages who have diabetic emergencyconditions, e.g. diabetic ketoacidosis andhyperosmolar non-ketotic hyperglycaemic state(HONK) etc, in the community. The care may alsoinclude the requirement for transfer to emergencyhospital services for continued management ofchildren, young people, adults and older peoplewho have diabetic emergency conditions.

The final specification should take intoaccount:

• national, network and local guidance andstandards for emergency 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

Standard Service SpecificationTemplate for Emergency DiabetesCare to be provided by AmbulanceServices

a Standard NHS Contractshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324

28

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 diabetes team,CYP multi-disciplinary diabetes team etc

• Any relevant diabetes clinical networks andscreening programmes applicable to theservices

• Details of all interdependencies or sub-contractors for any part of the service and anoutline of the purpose of the contract shouldbe stated, including arrangements for clinicalaccountability and responsibility, as appropriate

Purpose, Role and Clientele1. A clear statement on the primary purpose of

the services and details of what will beprovided and for whom:

• Who the services are for (e.g. CYP, adultsand older people who have diabeticemergencies in the community)

• What the services aim to achieve within agiven timeframe

• The objectives of the services

• The desired outcomes and how these aremonitored and measured

Scope of the Services2. What does the service 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 specialties

• Service planning – High level view of whatthe services are and how they are used; howpatients enter the pathway/journey; what arethe stages undertaken, e.g. assessment,stabilisation, initial treatment and continuingmanagement. The aims of service planningare to:

o Develop, manage and reviewinterventions along the patient journey

o Ensure access to other specialities /care,as appropriate

o Ensure that the diabetes multi-disciplinary team (as defined locally) isinformed (with the patient’s or parent’sconsent) of the diabetic emergency andis involved in the subsequent care andfollow up

• Holistic review of patients in themanagement of their diabetes using theprinciples of an integrated care model forpeople with long term conditions that ispatient-centred, including self care and selfmanagement, clinical treatment, facilitatingindependence, psychological support andother social care issues

• Risk assessment procedures

• Detail of evidence base of the service – i.e.the contracting framework for diabetesemergency and inpatient services, guidanceproduced by the Royal College of Physicians,Royal College of Paediatrics and Child Health,Diabetes UK, etc

Service Delivery3. Patient Journey/intervention map

Flow diagram of the patient pathway showingaccess and exit/transfer points – see thediabetes emergency and inpatient patientintervention map as a starting point

29

b www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/glycaemic_emergencies_in_adults_2006.pdf

c http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/glycaemic_emergencies_in_children_2006.pdf

d http://www.nice.org.uk/media/FCF/87/DiabetesInAdultsQualityStandard.pdf

e http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944

4. Treatment protocols/interventionsInclude all individual treatment protocols inplace within the services or planned to beused, e.g. Joint Royal Colleges AmbulanceLiaison Committee, UK Ambulance ServiceClinical Practice Guidelines 2006, Glycaemicemergencies in adultsb, and Glycaemicemergencies in childrenc

5. This will include a breakdown of how thepatient will receive the services and fromwhom. 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 children,young people, adults and older people whoin the clinical commissioning group area

• Hours of operation

• Minimum level of experience andqualifications of staff (i.e. nursing staff, alliedhealth professionals and other support andadministrative staff)

• Staff induction and developmental training

6. Equipment – see Clause 5 of the Standard NHSContract for Ambulance Services – ‘Servicesenvironment, vehicles and equipment’.

Identification, Referral andAcceptance criteria7. This should make clear how patients will be

assessed and accepted to the services.Acceptance should be based on types of needand/or patient.

8. How are patients referred?

• Who is acceptable for referral and fromwhere

• Details of evaluation process - Are there clearexclusion criteria or set alternatives to theservice? How might a patient be transferred?(insert call centre and triage processes andprotocols)

• Response time detail and how are patientsprioritised (insert Ambulance response times)

Discharge/Service Complete/Patient Transfercriteria – see Part 2: Transfer of and Dischargefrom Care Protocol (below)

Quality Standards9. The service is required to deliver care according

to the standards for clinical practice set by theNational Institute for Health and ClinicalExcellenced

10. As a minimum, the Provider is required toagree a local Commissioning for Quality andInnovation scheme for services for peoplewith diabetes. (Insert details of the CQUINScheme agreed)

12. The service is required to deliver the outcomesfor diabetes as determined by the NHSOutcomes Frameworke

Activity and PerformanceManagement13. This must include performance indicators,

thresholds, methods of measurement andconsequences of breach of contract. Thesewill be set and agreed prior to the signing ofthe overall agreement.

14. Activity plans – Where appropriate, identifythe anticipated level of activity the servicemay deliver; provide details of any activitymeasures and their description /method ofcollection, targets, thresholds andconsequences of variances above or belowtarget.

30

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 offeredand work to ensure unmet need is bothidentified and brought to the attention of thecommissioner.

16. ReviewThis section should set out a review date anda mechanism for review.

The review should include both thespecifications for continuing fitness forpurpose and the providers’ delivery againstthe specification.

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 by

This should set out who agrees/accepts thespecification on behalf of all parties.

This should include the diabetes providers,commissioner and network

Section B: Additional ServicesComplete according to local needs

Part 2: Transfer of andDischarge from Care ProtocolInsert locally agreed Transfer of and Dischargefrom Care Protocol

The intention of this section is to make clearwhen a patient should be transferred from theambulance service to another service ordischarged and when this would be reached.

• How does the service decide that a patient isready for discharge?

• What procedure is followed on discharge,including arrangements for follow-up

• If the patient requires continued care, what isthe process for transferring to other care, e.g.hospital emergency services?

Part 3: Emergency PreparednessComplete as required in the guidance for theStandard NHS Contract for Ambulance Services

Part 4: Essential ServicesComplete according to local needs

31

Standard Service SpecificationTemplate for Emergency andInpatient Diabetes Services This specification forms Schedule 2, Part 1, orsection 1 (module B), ‘The Services - ServiceSpecifications’ of the Standard NHSContracts.a

Service specifications are developed in partnershipbetween commissioners and provider agenciesand are based on agreed evidence-based care andtreatment models. Specifications should be opento scrutiny and available to all service users/carersas a statement of standards that the user/carercan expect to receive.

The following documentation, developed bythe Diabetes Commissioning Advisory Groupprovides further detail/guidance to supportthe development of this specification:

• The diabetes emergency and inpatientintervention map

• The contracting framework for diabetesemergency and inpatient services

This specification template assumes that theservices are compliant with the contractingframework for emergency and in patient diabetesservices.

This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.

Description of diabetes emergencyand inpatient care:Diabetes emergency and inpatient care includesthe immediate assessment, stabilisation andtreatment of people who present to hospitalemergency services with diabetic emergencyconditions, e.g. hypoglycaemia, diabeticketoacidosis (DKA) and hyperosmolar non-ketotichyperglycaemic state (HONK) etc. The serviceshould, in addition, identify people with newlydiagnosed diabetes admitted for medical orsurgical reasons which may or may not be relatedto diabetes.

Inpatient care also involves the management ofpeople with diabetes who are admitted tohospital for routine procedures or operations.

Please note

• Diabetes emergency care for children andyoung people from presentation at A&Eservices plus admission is included in thecommissioning guide for children and youngpeople with diabetes.

• Management of the acute foot is included inthe diabetes foot care commissioning guide

• Emergency care for people of all age groupswho have diabetic emergency conditions in thecommunity is included in the template servicespecification for ambulance services

The final specification should take intoaccount:

• national, network and local guidance andstandards for emergency and inpatientdiabetes services.

• local needs.

a Standard NHS Contractshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324

32

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 theservices

• Details of all interdependencies or sub-contractors for any part of the service and anoutline of the purpose of the contract shouldbe stated, including arrangements for clinicalaccountability and responsibility, as appropriate

Purpose, Role and Clientele1. A clear statement on the primary purpose of

the services and details of what will beprovided and for whom:

• Who the services are for (e.g. adults and olderpeople who present to hospital with diabeticemergencies and those who require diabetescare during their elective admission tohospital)

• What the services aim to achieve within agiven timeframe

• The objectives of the services

• The desired outcomes and how these aremonitored and measured

Scope of the Services2. What does the service 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 specialties

• Service planning – High level view of what theservices are and how they are used; howpatients enter the pathway/journey; what arethe stages undertaken, e.g. diagnosis andcontinuing management. The aims of serviceplanning are to:

• Develop, manage and review interventionsalong the patient journey

o Ensure access to other specialities /care,as appropriate

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 patients in the managementof their diabetes using the principles of anintegrated care model for people with longterm conditions that is patient-centred,including self care and self management,clinical treatment, facilitating independence,psychological support and other social careissues

• Risk assessment procedures

• Detail of evidence base of the service – i.e.the contracting framework for diabetesemergency and inpatient services, guidanceproduced by the Royal College of Physicians,Diabetes UK, etc

33

Service Delivery3. Patient Journey/intervention map

Flow diagram of the patient pathway showingaccess and exit/transfer points – see thediabetes emergency and inpatient interventionmap as 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 fromwhom. 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 andolder people who live in the clinicalcommissioning group 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, acute care nursesetc, other allied health professionals, e.g.podiatrists, dietitians, etc, health carescientists, e.g. pharmacists and other supportand administrative 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

6. Equipment

• Upgrade and maintenance of relevantequipment and facilities

• Technical specifications (if any)

Identification, Referral andAcceptance criteria7. This should make clear how patients will be

identified (including newly diagnosed peoplewith diabetes), 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 criteria9. The intention of this section is to make clear

when a patient should be transferred from thepregnancy and diabetes service to another andwhen this point would be reached

• How is a treatment pathway reviewed?

• How does the service decide that a patient isready for discharge

• How are goals and outcomes assessed andreviewed?

• What procedure is followed on discharge,including arrangements for follow-up

34

Quality Standards10. The service is required to deliver care

according to the standards for clinical practiceset by the National Institute for Health andClinical Excellenceb

11. As a minimum, the Provider is required toagree a local Commissioning for Quality andInnovation scheme for services for peoplewith diabetes. (Insert details of the CQUINScheme agreed)

12. The service is required to deliver the outcomesfor diabetes as determined by the NHSOutcomes Frameworkc

Activity and PerformanceManagement13.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.

14. Activity plans – Where appropriate, identifythe anticipated level of activity the servicemay deliver; provide details of any activitymeasures and their description /method ofcollection, targets, thresholds andconsequences of variances above or belowtarget.

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 offeredand work to ensure unmet need is bothidentified and brought to the attention of thecommissioner.

16. ReviewThis section should set out a review date anda mechanism for review.

The review should include both thespecifications for continuing fitness forpurpose and the providers’ delivery againstthe specification.

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

b http://www.nice.org.uk/media/FCF/87/DiabetesInAdultsQualityStandard.pdf

c http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944

Further copies of this publication can be ordered from Prontaprint, by emailing diabetes@leicester.prontaprint.com or tel: 0116 275 3333, quoting DIABETES 114

www.diabetes.nhs.uk