NHS Grampian. Local Report ~ March Diabetes

Transcription

1 NHS Grampian Local Report ~ March 2004 Diabetes

2 NHSScotland Board Areas NHS Argyll & Clyde 2 NHS Ayrshire & Arran 3 NHS Borders NHS Dumfries & Galloway 5 NHS Fife 6 NHS Forth Valley 7 NHS Grampian NHS Greater Glasgow 9 NHS Highland 10 NHS Lanarkshire 11 NHS Lothian NHS Orkney 13 NHS Shetland 14 NHS Tayside 15 NHS Western Isles 4

3 Local Report ~ March 2004 Diabetes Diabetes is a common and chronic condition affecting at least 150,000 people in Scotland. The condition is self-managed by the patient and requires support from multidisciplinary teams in both general practice and acute hospital settings. Therefore providing good quality clinical care for people with diabetes requires the co-ordination and co-operation of people working across a range of professions and organisations. The Diabetes Standards Subgroup developed 10 standards, covering the provision of healthcare in both hospital and community settings. This report presents the findings from the peer review of performance against the standards.

4 NHS Quality Improvement Scotland 2004 ISBN First published March 2004 NHS Quality Improvement Scotland (NHS QIS) consents to the photocopying, electronic reproduction by uploading or downloading from the website, retransmission, or other copying of the findings contained in this report, for the purpose of implementation in NHSScotland and educational and not-for-profit purposes. No reproduction by or for commercial organisations is permitted without the express written permission of NHS QIS. Copies of this report, the Clinical Standards for Diabetes, and other documents produced by NHS QIS, are available in print format and on the website.

5 Contents Contents 1. Setting the Scene How the Standards were Developed How the Review Process Works Reports Summary of Findings Overview of Local Service Provision Summary of Findings Against the Standards Detailed Findings Against the Standards 17 Appendix 1 Glossary of Abbreviations 41 Appendix 2 Review Team Members 42 Appendix 3 Diabetes Standards Subgroup Members 43 Appendix 4 Timetable of Review Visits 45 Local Report (NHS Grampian) - March

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7 1 Setting the Scene 1. Setting the Scene NHS Quality Improvement Scotland (NHS QIS) was established as a Special Health Board on 1 January 2003, as a result of bringing together the Clinical Resource and Audit Group (CRAG), Clinical Standards Board for Scotland (CSBS), Health Technology Board for Scotland (HTBS), Nursing and Midwifery Practice Development Unit (NMPDU), and the Scottish Health Advisory Service (SHAS). The purpose of NHS QIS is to improve the quality of healthcare in Scotland by setting standards and monitoring performance, and by providing NHSScotland with advice, guidance and support on effective clinical practice and service improvements. About this Report The Clinical Standards for Diabetes (2 nd ed.) were published in October These standards are being used to assess the quality of services provided by NHSScotland nationwide on an NHS Board-wide 1 level, covering both community (including primary care) and hospital settings. This report presents the findings from the peer review of NHS Grampian. This review visit took place on 6 February 2003 and details of the visit, including membership of the review team, can be found in Appendix NHS Boards are responsible for strategic planning, performance management and governance of each of Scotland s 15 local health systems. Most NHS Board areas (excluding the three Island NHS Boards which have always had a combined strategic and operational role) contain one Acute and one Primary Care Trust, with operational and employment responsibilities, but since 2001 they have operated within a strategic framework drawn up by the NHS Board. By 2004 Trusts will have been abolished and replaced by operating divisions of the NHS Board. Both the NHS Board and its associated Trusts actively participated in the visit to their area. Peer review visits were conducted to all 15 NHS Board areas in Scotland, including the three Island NHS Boards. Local Report (NHS Grampian) - March

8 1. Setting the Scene 1.1 How the Standards were Developed In May 2001, a Diabetes Standards Subgroup was established under the chairmanship of Dr Malcolm Campbell, General Practitioner, Greater Glasgow, and Director of Quality Standards, Royal College of General Practitioners. This was a subgroup of the Scottish Diabetes Framework Working Group, which developed the Scottish Diabetes Framework published in April Membership of the Diabetes Standards Subgroup includes both healthcare professionals and members of the public (see Appendix 3). The Diabetes Standards Subgroup oversees the quality assurance process of: developing standards; reviewing performance against the standards throughout Scotland, using self-assessment and external peer review; and reporting the findings from the review. When developing the diabetes standards, a Scotland-wide consultation process was undertaken. The views of health service staff, patients, carers and the public were sought, and all the relevant evidence available at the time was taken into account. The first edition standards were piloted across three NHS Boards: Forth Valley, Lothian and Tayside. Following the pilots, the standards were revised and a second edition of the standards were published in October How the Review Process Works The review process has two key parts: local self-assessment followed by external peer review. The diabetes reviews are being conducted on an NHS Board-wide basis to encourage and facilitate an NHS Boardwide approach to the management of diabetes services. First, each NHS Board assesses its own performance against the standards. An external peer review team then further assesses performance, both by considering the self-assessment data and visiting the NHS Board to validate this information and discuss related issues. The review process is described in more detail below (see also the flow chart on page 9). 6 Local Report (NHS Grampian) - March 2004

9 Self-Assessment by the NHS Board On receiving the standards, each NHS Board assesses its own performance using a framework produced by NHS QIS. This framework includes guidance about the type of evidence (eg guidelines, audit reports) required to allow a proper assessment of performance against the standards to be made. The NHS Board submits the data it has collected for this selfassessment exercise to NHS QIS before the on-site visit, and it is this information that constitutes the main source of written evidence considered by the external peer review team. External Peer Review An external peer review team then visits the NHS Board and speaks with local stakeholders (eg Board and Trust staff, patients, carers) about the services provided. Review teams are multidisciplinary, and include both healthcare professionals and members of the public. All reviewers are trained. Each review team is led by an experienced reviewer, who is responsible for guiding the team in their work and ensuring that team members are in agreement about the assessment reached. The composition of each team varies, and members have no connection with the organisations they are reviewing. This promotes the sharing of good practice, and ensures that each review team assesses performance against the standards rather than makes comparisons between one NHS Board and another. At the start of the on-site visit, the review team meets key personnel responsible for the service under review. Reviewers then speak with local stakeholders about the services provided. After these meetings, the team assesses performance against the standards, based on the information gathered during both the self-assessment exercise and the on-site visit. The visit concludes with the team providing feedback on its findings to the NHS Board. This includes specific examples of local initiatives drawn to the attention of the review team (recognising that other such examples may exist), together with an indication of any particular challenges facing the NHS Board. Local Report (NHS Grampian) - March

10 1. Setting the Scene Assessment Categories Each review team assesses performance using the categories met, not met and not met (insufficient evidence), as detailed below: Met applies where the evidence demonstrates the standard and/or criterion is being attained. Not met applies where the evidence demonstrates the standard and/or criterion is not being attained. Not met (insufficient evidence) applies where no evidence is available for the review team, or where the evidence available is insufficient to allow an assessment to be made. A final category not applicable is used where a standard and/or criterion does not apply to the NHS Board under review. 8 Local Report (NHS Grampian) - March 2004

11 The process used for this review: After Visit During Visit Prior to Visit Standards published and issued î Self-assessment framework finalised and issued NHS Board undertakes self-assessment exercise and submits outcomes to NHS Quality Improvement Scotland ê NHS Quality Improvement Scotland sends information from self-assessment submission to peer review team ê Two-way presentations covering background on NHS Quality Improvement Scotland and local service provision Draft report produced and sent to review team for comment Draft report sent to NHS Board to check for factual accuracy Diabetes Standards Subgroup considers findings of local reviews and drafts national overview í Review team meets stakeholders to discuss local services Review team assesses performance in relation to the standards Review team feeds back findings to NHS Board ê ê ê ê NATIONAL OVERVIEW AND LOCAL REPORTS PUBLISHED Local Report (NHS Grampian) - March

12 1. Setting the Scene 1.3 Reports After each review visit, NHS QIS staff, with clinical input as appropriate, draft a local report detailing the findings of the review team. This draft report is sent to the review team for comment, and then to the NHS Board to check for factual accuracy. The local report is published only after all the visits for that topic have been undertaken nationwide. Once a national review cycle is completed, the relevant Project Group reconvenes to examine review findings and make recommendations. The Project Group then oversees the production of a national overview of service provision across Scotland in relation to the standards. This document includes both a summary of the findings (highlighting examples of local initiatives and challenges for the service) and recommendations for improvement. Part of the remit of NHS QIS is to report whether the services provided by NHSScotland, both nationally and locally, meet the agreed standards. This does not include reviewing the work of individual healthcare professionals. In achieving this aim, variations in practice (and potentially quality) within a service will be encountered. In such cases, variations are reported. Please note - all reports published are available in print format and on the NHS QIS website. 10 Local Report (NHS Grampian) - March 2004

13 2 Summary of Findings 2. Summary of Findings 2.1 Overview of Local Service Provision Grampian is situated in north-east Scotland and has a population of around 523,290. About 40% of the local population live in Aberdeen, which is the largest urban area in the region, although a significant proportion live in rural areas. The proportion of older people in the population is lower than the national average, as are levels of illness and deprivation. Local NHS System and Services Grampian NHS Board is responsible for improving the health of the local population and for the delivery of the healthcare required. It provides strategic leadership and has overall responsibility for the efficient, effective and accountable performance of the NHS in Grampian. At the time of the review visit, the Board area contained one Acute and one Primary Care Trust (Grampian University Hospitals NHS Trust and Grampian Primary Care NHS Trust), which together provided its clinical services. Both the NHS Board and the Trusts were accountable for the services provided, through the framework of clinical governance. Further information about the local NHS system can be accessed via the website of NHS Grampian: Service Organisation There are approximately 13,250 patients with a recorded diagnosis of diabetes in NHS Grampian in The Scottish Diabetes Survey 2002 indicated that 5,726 patients are registered on an integrated area diabetes register (information obtained from 38 GP practices). This figure can be broken down further to: 1,199 patients registered with Type 1 diabetes; 4,202 patients registered with Type 2 diabetes and 119 patients with other types of diabetes ( other includes gestational or maturity onset diabetes of youth [MODY]). There are 206 patients whose type of diabetes is not recorded or is not known. In Grampian, there are 85 GP practices and health clinics. Diabetes centres are located at Woolmanhill Hospital, Aberdeen and Dr Gray s Hospital, Elgin. In addition, in-patient care is provided at Aberdeen Royal Infirmary and Dr Gray s Hospital. Specialist clinics are located within Royal Aberdeen Children s Hospital and Aberdeen Maternity Hospital. Local Report (NHS Grampian) - March

14 2. Summary of Findings Diabetes-related patient support groups are represented through the Aberdeen & District Branch of Diabetes UK; Young Diabetes Association; Local Diabetes Service Advisory Group (LDSAG) and the Local Health Council. 2.2 Summary of Findings Against the Standards A summary of the findings from the review, including examples of local initiatives drawn to the attention of the review team, is presented in this section. A detailed description of performance against the standards/ criteria is included in Section 3. Organisation (Standards 1, 2) There is a highly motivated team working within, and across, NHS Grampian in relation to the provision, and management of, diabetes services. Strong evidence existed of comprehensive healthcare collaboration, and it was evident that much time had been invested in marketing the process for the integration of services to stakeholders. In addition, there is a good awareness of the challenges to be faced, with plans in place to move towards addressing them. There is no up-to-date population-based electronic clinical management system of people with a recorded diagnosis of diabetes in NHS Grampian. Rather, various systems are in place within the primary care setting, and a separate system which holds information for secondary care clinics. Work is in progress to develop a single entry central data repository, which will gather information from all diabetes systems used within Grampian. This system is to be piloted in April 2003, and all systems, laboratories and clinics should be able to link into, and populate, this central database. The Diabetes Integrated Care Project Team has been established to progress the redesign of diabetes services across Grampian, and is accountable to the Local Health Care Co-operatives (LHCCs). The Team has agreed a standard format of shared care which is gradually being implemented. In addition, the work of the Local Diabetes Service Advisory Group (LDSAG) is facilitated by this Team. Although there is no identified protocol for the collection and management of data, work is in progress to produce an audit tool which will address standardisation of data collection, quality and frequency of audit. It was reported that six out of the eight LHCCs are now using a standardised data set. 12 Local Report (NHS Grampian) - March 2004

15 Example of a local initiative The Grampian Guidelines for the Management of Diabetes Mellitus were produced to facilitate diabetes care and to establish and implement common standards of care. The guidelines cover diagnosis, screening for complications, treatment and care. These guidelines are known to be used by other NHS Board areas. The appointment of the vice-chair of Grampian NHS Board as chairman of the LDSAG was of particular note, demonstrating a commitment to local clinical leadership of the diabetes agenda, and proving useful in smoothing the implementation of improvements in local diabetes management. Patient Focus (Standard 3) Provision of education to people with diabetes, both newly diagnosed and existing patients, is comprehensive across primary and secondary care within NHS Grampian. This takes place within group settings, and on a one-to-one basis. The direction contained within the Grampian Guidelines is used as a baseline across the NHS Board area, with individual localities tailoring the information to suit their specific client base. Care programmes for the diverse client groups are in place, including arrangements for patients in residential or nursing homes. Diabetes UK provide Type 1 diabetes information packs to the nurse training school at The Robert Gordon University, Aberdeen, for use in its midwifery training programme. Patient involvement is evident in many areas. The Diabetes Integrated Care Project Team has two full-time patient representatives. There is also a Patient Consultation Group. Patient feedback is actively sought via questionnaires and surveys. Access to identified key health professionals is very good. Although there was no clinical psychology service at the time of the review, the care plan used within secondary care addresses many psychology issues. Training for staff members involved in patient education is also widely available. Local Report (NHS Grampian) - March

16 2. Summary of Findings Example of a local initiative The Diabetes Integrated Care Project Team is developing a regional educational strategy; part of this strategy will include scoping training provision and delivery throughout the region to minimise duplication of effort and improve quality and consistency of training. Clinical Review (Standard 4) The Grampian Guidelines contain protocols for the measurement and review of clinical and lifestyle factors. However, some tests are not routinely offered to all people with diabetes. Developments, ie guideline review, are under way to ensure that all patients will be routinely tested for all factors in the near future. As access to clinical psychology is limited, much of the psychological assessment of patients is carried out by GPs and nurses. An annual call-recall system is established in primary care for review of clinical and lifestyle factors. While secondary care has no formalised annual check, there is a rolling programme in place, and developments are in progress to ensure that all patients are screened annually. Blood results are normally available when a patient attends his/her clinic appointment. The systems in primary and secondary care for informing patients of test results do vary across the NHS Board area. Some practices are in the process of working on a standard policy for result handling. In all cases, however, the patient is given the opportunity to discuss the results, and any implications, with an appropriate healthcare professional. Clinical Management (Standards 5, 6, 7, 8, 9, 10) Eyes The Grampian diabetic retinopathy screening programme is highly regarded, not only within NHS Grampian, but also in other NHS Board areas. The programme is run in accordance with all current national guidelines. Example of a local initiative As part of the diabetic retinopathy screening programme, patients living outwith city boundaries are offered the screening service at their local GP practice; a screening nurse attends the practice with a mobile camera to take the retinal photograph. 14 Local Report (NHS Grampian) - March 2004

17 Cardiovascular Status There are protocols for the management of hypertension, and for the management of consistently high cholesterol, both of which are detailed in the Grampian Guidelines. However, there may be benefit in cross-referencing between, and management of, cardiology and diabetes protocols. It was reported that a proposal to develop a Managed Clinical Network (MCN) for cardiology in NHS Grampian is under way. Feet Podiatry staff have a good awareness of the issues surrounding their service. Although podiatry assessment guidelines for referrals are common across Grampian, there is no rapid referral service. In addition, foot care and screening are included within the Grampian Guidelines. However, there is no protocol for pressure relief treatment. Specialist diabetic podiatry services are available where patients are reviewed by specialists and their conditions are monitored. A digital camera is used to document foot ulcers at Woolmanhill Hospital s outpatients diabetes clinic. A diabetic foot triage has been developed, but is not yet fully adopted. There has been much multidisciplinary input, including podiatry, regarding education for practice nurses, who now carry out foot screening. However, management of the volume of referral numbers is required. It was reported that the orthotic service has been reduced in rural areas. Glycaemia Patients HbA1c is sequentially measured using a standardised Diabetes Control & Complications Trial (DCCT) compatible assay. The Grampian Guidelines contain a comprehensive general protocol for tailoring drug and insulin therapy for individuals. Although the guidelines do not currently contain specific guidance for children, this will be incorporated into the revised edition due to be published in The availability of, and communication between, specialist staff, in particular diabetes specialist nurses, was commended. It was recognised that the disparity between the various IT and paperbased systems used to store patient data constrains easy access by healthcare professionals across primary and secondary care, and steps are being taken to address this. Local Report (NHS Grampian) - March

18 2. Summary of Findings Renal The Grampian Guidelines state a threshold serum creatinine level of >300 micromols/l before patients are considered for referral to specialist renal services; these guidelines are currently being revised. Primary and secondary care protocols are in place to manage patients with impaired renal function. Provision of dietetic support and advice is good and a formal protocol for dietetic intervention was being written at the time of the review. Acute Management The Grampian Guidelines make reference to the management of diabetes emergencies in the community. In addition, all wards have protocols for the treatment of hypoglycaemia and the management of diabetic ketoacidosis. Every adult patient with diabetic ketoacidosis is seen by a hospital-based diabetes specialist nurse or a specialist registrar on-call. The lack of paediatric diabetes specialist nurses was noted. Example of a local initiative There is a separate adult in-patient diabetes specialist nurse who covers both the wards and the A&E department. This hospital-based diabetes specialist nurse covers all referrals from wards in Aberdeen Royal Infirmary, including the A&E department, Royal Cornhill Hospital, Aberdeen, and Woodend Hospital, Aberdeen. The diabetes specialist nurse works closely with the diabetes registrar in advising wards on diabetes management during surgery or acute illness, and sees patients in A&E with short admission for hypoglycaemia. Following recovery, patients are referred to a hospital-based diabetes specialist nurse or a diabetic specialist registrar for advice on clinical and lifestyle aspects of their care. Diabetic specialist registrars and/or diabetes specialist nurses are able to advise patients on psychological aspects of their care to some degree. Access to clinical psychologists for more complex problems is limited. 16 Local Report (NHS Grampian) - March 2004

19 3. Detailed Findings Against the Standards 3 Detailed Findings Against the Standards Standard 1: Organisation: IM&T, Clinical Management Systems, Audit and Monitoring Standard Statement All people with diabetes, with appropriate consent, are placed on a clinical management system which contains core information about their care and allows ongoing useful clinical information to be recorded for use in direct patient care and service audit. NHS Grampian Essential Criteria 1: There is an up-to-date population-based electronic clinical management system of all people with a recorded diagnosis of diabetes in the area which covers: initial diabetes diagnosis; development of significant diabetes micro- and macrovascular co-morbidities; year of onset of co-morbidities; measurement of ongoing modifiable risk factors; long-term medication for diabetes and other chronic conditions. STATUS: Not met There is no up-to-date population-based electronic clinical management system of people with a recorded diagnosis of diabetes. The most comprehensive register has been created by the Grampian Retinal Screening Programme, with approximately 13,250 patients registered. In addition, various systems are in place within the primary care setting (eg General Practice Administration System for Scotland (GPASS), EMISS, Vamp Vision, Torex and Meditel). PROTOS is the system which holds information for secondary care clinics. At the time of the visit, this system had 8,924 patients with diabetes recorded (from the age of 14 years). It was noted that the paediatric service use a separate system of data collection, but it was indicated that this system would shortly be linked to PROTOS. Grampian is collaborating with Scottish Care Information (SCI) to implement a clinical management system linking PROTOS and the GP systems. However, in the meantime, a central data repository is under development to gather information from all diabetes systems used within Grampian. PROTOS, GPs, laboratory results and clinics will be able to link into, and populate, the central database. It is proposed that this system will be piloted in April 2003, and will be replaced in due course by the Scottish Care Information - Diabetes Collaboration (SCI-DC) Network system. The current systems used in primary and secondary care record all information listed in the criterion. However, it was recognised that various systems are in place within primary care practices. It was reported that work is in progress towards standardising data sets. Six out of the eight Local Health Care Co-operatives (LHCCs) are now using a standardised data set. Local Report (NHS Grampian) - March

20 3. Detailed Findings Against the Standards The current primary care systems are updated by the primary care team at the time of the consultation. In addition, information from primary care is updated on PROTOS by administration staff. Following ward admission, or a visit to the secondary care clinic/gp/group session, PROTOS is updated. 2: Data interfaces are in place between primary and acute care such that a single data entry covers all recording needs. STATUS: Not met At the time of the review, there were no data interfaces in place such that one data entry populated the primary and secondary care information systems. However, work is in progress to develop a single entry central data repository which will gather information from all diabetes systems used within NHS Grampian. In addition, NHS Grampian is collaborating with SCI to implement a clinical management system linking PROTOS and the GP systems. 3: The Board participates in the Scottish Diabetes Survey. NHS Grampian participates in the Scottish Diabetes Survey. 4: Data are collected using the clinical management system on a continuous basis to facilitate regular audit and quality assurance. The quality of the data is also regularly audited. STATUS: Not met There is no identified protocol for the collection and management of data. However, work is in progress to produce an audit tool which will address standardisation of data collection, quality and frequency of audit. LHCCs are actively auditing, and within most GP practices there are LHCC-funded posts for identified audit quality controllers who assist practices with audits. Audits are then collated by each LHCC Clinical Governance Group. However, there is no co-ordination of audits undertaken across the LHCCs. 18 Local Report (NHS Grampian) - March 2004

21 Within secondary care, data is collected by clinical and reception staff and subsequently entered onto the PROTOS system by secretarial staff. However, issues were raised about the PROTOS system, namely incomplete data due to problems with the area network and size of the IT system. Efforts are under way to upgrade the local network system to enable direct entry of data by clinical staff. The PROTOS system has a comprehensive audit facility and is used regularly to produce clinical audit reports. Desirable Criteria 5: The computerised clinical management system is Board-wide and incorporates call and recall systems for screening/review of complications. STATUS: Not met There is no Board-wide clinical management system. However, a central data repository is currently under development, and collaboration with SCI is under way to implement a clinical management system linking PROTOS and the GP systems. Within primary care, the various systems used incorporate call and recall systems for screening/review of complications. However, each GP practice records varying amounts of information. The Patient Administration System (PAS) and PROTOS system used in secondary care incorporate similar functions, eg letters generated by PROTOS include the recall appointment date. Within the diabetic retinopathy screening system, patients are flagged up after the first defaulted appointment. Patients who have not consented to be placed on a clinical management system are still able to be identified for call and recall. Local Report (NHS Grampian) - March

22 3. Detailed Findings Against the Standards Standard 2: Organisation: Pathway of Care, Teamworking and Integration of Services Standard Statement There is an agreed area-wide structured programme of care which clearly defines: reporting arrangements and accountability; the care that people with diabetes should expect to receive; the processes of care that will be followed after diagnosis (including pre- and perioperative management); the protocols and guidelines that determine which clinician is responsible for the delivery of specific aspects of care; criteria for referral. NHS Grampian Essential Criteria 1: There is a local strategy and implementation plan for diabetes services that covers diagnosis, screening for complications, treatment and care. In 2000, a multidisciplinary team produced Grampian Guidelines for the Management of Diabetes Mellitus to facilitate diabetes care and to establish and implement common standards of care. These guidelines cover diagnosis, screening for complications, treatment and care. The guidelines were reported to be highly regarded and are known to be used by other NHS Board areas. 2: There is an effective, well-organised strategic planning group including stakeholders: a Local Diabetes Service Advisory Group (LDSAG), or equivalent, which is accountable to the NHS Board. There is a Local Diabetes Service Advisory Group (LDSAG), chaired by the vice-chair of Grampian NHS Board. The work of this Group is facilitated by the Diabetes Integrated Care Project Team. 3: There are agreed guidelines for shared care and referral and discharge between primary care teams and diabetes specialist care teams, which are regularly and jointly reviewed. These include protocols for the management of diabetes during other illnesses and procedures. STATUS: Not met The Grampian Guidelines are used in both primary and secondary care. These are reviewed every 2-3 years, and at the time of the visit, it was reported that the current review would be complete later in the year. 20 Local Report (NHS Grampian) - March 2004

23 The Diabetes Integrated Care Project Team has been established to progress the redesign of diabetes services across NHS Grampian, and is accountable to the LHCCs. The Team has agreed a standard format of shared care which is gradually being implemented. It was evident that much time had been invested in marketing the process for the integration of services to stakeholders. A protocol for variable intravenous insulin infusions is available. However, protocols for the management of diabetes during other illnesses and procedures require to be developed. It was noted that there is no allied health professional representation on the Diabetes Integrated Care Project Team. However, they are represented on several other diabetes fora, including the LDSAG and LHCC community forum. 4: All people with diabetes have an individualised plan of care including mutually agreed targets based on Clinical Standards and the Scottish Diabetes Framework. All patients have an individualised plan of care, generally recorded in secondary care diabetic casesheet notes (held separately from medical notes), which follow the patient s journey of care. This plan of care is communicated to the multidisciplinary team verbally, eg via team meetings, and after each clinic visit a letter is sent to the GP. Diabetes Z-cards were introduced in 2000 as a personally-held record to allow patients more involvement and participation in the management of their condition. These were completed by the patient and health advisers. However, the uptake of these cards was not good. The Diabetes Integrated Care Project Team is now assessing a patient record book, devised by Banff & Buchan LHCC. Part of the consideration includes implementation of the patient record book across NHS Grampian. The review team considered that patients do not have sufficient access to their individualised plan of care. Local Report (NHS Grampian) - March

24 3. Detailed Findings Against the Standards 5: There are identified lead clinicians for diabetes in acute and primary care. The head of diabetes services is the identified lead clinician for both primary and secondary care. In addition, there are identified lead consultants within the eight LHCCs. These consultants are linked to the lead diabetes teams for purposes of education and reorganisation of clinical services. 6: There are robust fail-safe arrangements for identifying and following up people with diabetes who default from clinics, which take into account patient choice and responsibility for their care. There is a protocol for the management of patients who default, which covers primary and secondary care. This takes into account identification of cancelled appointments in patient casenotes. 22 Local Report (NHS Grampian) - March 2004

25 Standard 3: Patient Focus Standard Statement All people with diabetes have equitable access to information and multidisciplinary programmes of education, which are tailored to individual needs and specific client groups. NHS Grampian Essential Criteria 1: All people newly diagnosed with diabetes are offered at least one appropriately tailored formal educational session about their condition and are provided with written material to reinforce that education. Provision of education to people newly diagnosed with diabetes within NHS Grampian is comprehensive. Formal group education sessions are held across primary and secondary care. A oneto-one advice service, either domicillary or clinic-based, is available from the diabetes centres. The checklist for the newly diagnosed patient, contained within the Grampian Guidelines, is used as a baseline across the NHS Board area. Information leaflets are produced locally, taking into account specific patient needs, and generic Diabetes UK information packs are also widely available. In addition, patients have access to the diabetes centre intranet. Feedback gathered from patients about the quality of information they are provided with has been very positive to date. In primary care, the GP and consultant for shared care are informed, in writing, after a patient has attended an education event, and this information is then used to update the patient s notes and casesheet. In the secondary care setting, the member of staff facilitating the education session keeps a hard copy record of attendee details. This is used to update PROTOS. Local Report (NHS Grampian) - March

26 3. Detailed Findings Against the Standards 2: Educational programmes continue after diagnosis and include diet, foot care and eye care, as well as day-to-day management of diabetes. Systems are in place to provide ongoing education for people with diabetes. General and specific information and advice is available to all patients via the multidisciplinary teams at the diabetes centres and in primary care. Specific educational programmes are arranged on an ad hoc basis, depending on the needs of the patient at the time. The NHS Board area is actively developing information packages for elderly and paediatric patients. Diabetes UK is keenly involved and runs monthly meetings and local public open sessions such as Living with Diabetes Day. 3: There are specific care programmes for different client groups in the population including children, adolescents, adults, elderly, preconceptional and pregnant women with diabetes, women with gestational diabetes, ethnic and vulnerable groups. The review team noted the specific care programmes for the different client groups in NHS Grampian. A diabetes specialist nurse regularly visits patients in nursing homes, and dietetic support and specialist advice is also offered. In addition, an on-call advice service is available over the telephone. A diabetic children s club is in operation, and an adolescent group is currently being set up. The majority of preconceptional and pregnant women with diabetes, as well as those with gestational diabetes, are managed in the first instance via the midwifery service. Diabetes UK provide Type 1 diabetes information packs to the nurse training school at The Robert Gordon University, Aberdeen, for use in its midwifery training programme. 4: People with diabetes are involved in consultation on service development. The review team commended the wide range of patient involvement evident in many areas. The Diabetes Integrated Care Project Team has two full-time patient representatives. An additional Patient Consultation Group allied to the Team provides a forum for wider discussion and input into the service development process. Diabetes UK has representation on local groups, and the individual LHCCs have appropriate mechanisms in place to involve patients. Patient feedback is actively sought via questionnaires and surveys. 24 Local Report (NHS Grampian) - March 2004

27 Desirable Criteria 5: People with diabetes have appropriate access to identified key health professionals including state registered podiatry and dietetic, nursing and psychology services. STATUS: Not met Access to podiatry services is very good. Patients are referred as per the Grampian Primary Care NHS Trust Podiatry Assessment Guidelines, and the podiatrists encourage telephone contact for advice on problem cases. In secondary care, newly diagnosed patients have appropriate access to a dietitian, and thereafter patients are flagged for follow up every 2 to 3 years. In primary care, all patients are seen in education groups, and from there, some will be seen on a one-to-one basis. The GP and practice nurses can refer to the dietitian according to agreed referral criteria. The diabetes specialist nurses affiliated to the individual LHCCs are based in the diabetes centres at Woolmanhill Hospital, Aberdeen, and Dr Gray s Hospital, Elgin. The Royal Aberdeen Children s Hospital and Dr Gray s Hospital have a dedicated paediatric diabetes specialist nurse service, and there is also diabetes specialist nurse input into the adolescent clinic at Aberdeen Royal Infirmary. Although at the time of the review, there were no specific clinical psychology sessions for people with diabetes, the care plan employed within secondary care contains an evaluation matrix which is used by the nursing staff to assess patients psychological care needs. 6: Members of the diabetes team who are involved in patient education, have access to a training programme. Training for staff involved in patient education is widely available. The Diabetes Integrated Care Project Team is currently developing a regional educational strategy; part of this strategy will include development and implementation of an education co-ordinator role. Included within the remit of this post will be the requirement to visit all sites in the NHS Board area with a diabetes service to scope training provision and delivery. Local Report (NHS Grampian) - March

28 3. Detailed Findings Against the Standards Standard 4: Clinical Review Standard Statement All people with diabetes are offered annual or more frequent examination, where clinically indicated, to monitor the management and progression of their condition. There is intervention as required, and support for the modification of lifestyle risk factors. NHS Grampian Essential Criteria 1: There is a protocol to ensure that all people with diabetes are offered review of the following indicators on an annual basis, or more frequently where clinically indicated, from diagnosis: Clinical Glycated haemoglobin (HbA1c); blood pressure; random total cholesterol; eye examination for diabetic retinopathy according to HTBS recommendations; urinalysis for microalbuminuria and proteinuria; serum creatinine; foot examination for ischaemia, neuropathy, and general foot care; review of medication. Lifestyle/Well-being Body Mass Index (BMI); dietary intake; physical activity; tobacco consumption (smoking habit); perception and understanding of condition; psychological well-being; sexual health. STATUS: Not met The Grampian Guidelines contain protocols for measurement of the clinical and lifestyle factors noted in the criterion. However, tests for random total cholesterol and urinalysis for microalbuminuria and proteinuria are not routinely carried out on patients who are over the age of 70. Developments are under way to ensure that all patients will be routinely tested for all factors in the near future. There are no specific questions within the guidelines about psychological well-being. However, many of these issues are already addressed within the education checklist for new patients contained within the guidelines. The majority of advice and counselling for psychological issues is provided by GPs and nurses. It is planned that the diabetes specialist nurses will undertake some specialised training in the future to facilitate this process. 26 Local Report (NHS Grampian) - March 2004

29 Primary care has an active annual call and recall system in place for review of clinical and lifestyle factors. The offer of, and/or outcomes of, the annual review are recorded in the Grampian diabetes recording sheets and, subsequently, on GP practice computer systems. Secondary care has no formalised annual check, but does run a rolling programme. The majority of patients involved in this are seen on a 12-month review cycle, and developments are under way to ensure that all patients are seen annually. The review is documented in patient casenotes and on the PROTOS system. Statistical information on numbers of patients tested or assessed for the various factors within primary and secondary care does exist, but reporting is constrained by the various disparate computer systems used to gather and store the data. Certain GP practices are trying to standardise their datasets using either the Scottish Diabetes Survey or the Scottish Programme for Improving Clinical Effectiveness (SPICE) as a benchmark. The review team noted two areas of exceptional practice in relation to the diabetic retinopathy screening programme and the provision of pre-pregnancy advice for women. 2: Patients are informed of their results and offered support to manage lifestyle risk factor changes. In primary care, patients are asked to attend to have blood taken approximately 1 week prior to their clinic date, with the results then available for discussion at the appointment. In cases where the patient is unable to attend in advance for bloods, the sample is taken at the appointment and the patient is asked to telephone the practice for his/her results. Near patient testing is also being carried out in some areas within NHS Grampian. In secondary care, most patients are given their blood results, and the opportunity to discuss them, on the day at the clinic, otherwise they are informed by letter. The letter format includes explanatory information and contact details if they wish to discuss the results further. Patients are informed of their diabetic retinopathy screening results by letter, and, similarly, a contact name for further explanation or discussion is provided. The systems in primary and secondary care for informing patients of their results do vary across the NHS Board area. Some practices are in the process of working on a standard policy for result handling. Local Report (NHS Grampian) - March

30 3. Detailed Findings Against the Standards Desirable Criteria 3: Referring practitioners (including optometrists, with patient consent) are given feedback regarding the outcome of their referrals. A concise letter of discussion, tailored for each individual patient, and a PROTOS summary sheet, are sent to the referring practitioner within the primary care team after each patient s visit to the diabetes centre. 28 Local Report (NHS Grampian) - March 2004

31 Standard 5: Clinical Management: Eyes Standard Statement All people with diabetes who have identified signs of developing diabetes-related, sight-threatening retinopathy, according to HTBS grading recommendations are referred to an ophthalmologist for assessment, and, if necessary, treatment. NHS Grampian Essential Criteria 1: There is a referral process to a consultant ophthalmologist-led service for people with diabetes with identified signs of developing diabetes-related, sight-threatening retinopathy according to HTBS grading recommendations. The review team commended the team involved in the diabetic retinopathy screening programme for their enthusiasm and commitment to provision of an excellent service. The screening programme is led by a consultant medical ophthalmologist. The service structure extends across NHS Grampian, with the main centres at Woolmanhill Hospital and Dr Gray s Hospital. Patients living outwith city boundaries are offered appointments at their local GP practice. As far as possible, appointments are arranged in accordance with the needs of the patient. The retinal screening co-ordinator is responsible for referring patients to the eye clinic and ensuring that they receive an appointment. The programme fully meets Health Technology Board for Scotland (HTBS) guidance in terms of camera specification, target population and image-grading guidelines. A clear budget has been identified to meet the ongoing costs of the programme. 2: All people whose eye examination has revealed retinopathy have their glycaemic control and blood pressure reviewed and treated as clinically indicated. The result letter sent to patients after their screening appointment includes advice on target levels for glycaemic control and blood pressure. A copy of this is sent to the patient s GP and to the hospital clinic. Patients are treated as per the protocol in the Grampian Guidelines and HTBS recommendations. Local Report (NHS Grampian) - March

32 3. Detailed Findings Against the Standards 3: All people with active proliferative diabetic retinopathy are offered laser treatment. All patients with active proliferative retinopathy are referred to the eye clinic, where they are reexamined, diagnosed and considered for laser treatment. For the small group of individuals for whom laser treatment is unsuitable, the medical and/or legal reasons for not treating are clearly documented in the patient casenotes. 30 Local Report (NHS Grampian) - March 2004

33 Standard 6: Clinical Management: Cardiovascular Status Standard Statement All people with diabetes who have identified associated cardiovascular problems are managed according to locally agreed protocols and are considered for referral and additional treatment as clinically indicated. NHS Grampian Essential Criteria 1: Where blood pressure is consistently greater than 140 systolic and/or 80 diastolic (140/80mmHg), attempts are made to lower the blood pressure according to locally agreed protocols. There is a protocol for the management of hypertension, detailed in the Grampian Guidelines. This states that treatment should be started on patients with sustained systolic or diastolic pressure >140/80mmHg, detailing the choice of antihypertensive agent to be used on Type 1 and Type 2 patients, and target blood pressure for patients below the age of 45 years. 2: There is a local protocol for the management of consistently high cholesterol (>5mmol/l). There is a protocol for the management of consistently high cholesterol, detailed in the Grampian Guidelines. This details that patients with total cholesterol >5mmol/l will require a statin. The cholesterol targets for hypolipidaemic agents state a 25% reduction, or <5mmol/l total cholesterol. 3: There is a local protocol for the management of angina. Although there is no specific protocol for the management of angina in patients with diabetes, evidence of protocols for post-myocardial infarction management of diabetes and hyperglycaemia, and an angina management pathway, was provided. Cross-referencing between, and management of, cardiology and diabetes-specific protocols may be considered beneficial. Local Report (NHS Grampian) - March