NHS Western Isles. Local Report ~ March Diabetes

Transcription

1 NHS Western Isles 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 16 Appendix 1 Glossary of Abbreviations 39 Appendix 2 Review Team Members 40 Appendix 3 Diabetes Standards Subgroup Members 41 Appendix 4 Timetable of Review Visits 43 Local Report (NHS Western Isles) - 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 Western Isles. This review visit took place on 3 July 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 Western Isles) - 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 Western Isles) - 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 Western Isles) - 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 Western Isles) - 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 Western Isles) - 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 Western Isles) - March 2004

13 2 Summary of Findings 2. Summary of Findings 2.1 Overview of Local Service Provision The Western Isles is a name covering the Outer Hebrides, an island group situated north-west of mainland Scotland. The population of around 26,200 live on 10 islands, the largest and most populous of which is the Isle of Lewis where the town of Stornoway is located. The proportion of older people in the population is above the national average, as are levels of illness and deprivation. Local NHS System and Services NHS Western Isles serves the combined functions of mainland NHS Boards and NHS Trusts. It is responsible for improving the health of the local population and for the delivery of the healthcare required. NHS Western Isles provides strategic leadership and has overall responsibility for the efficient, effective and accountable performance of the NHS in the Western Isles. It also provides the clinical services in the Western Isles and is accountable for these, through the framework of clinical governance. Further information about the local NHS system can be accessed via the website of NHS Western Isles: Service Organisation There are approximately 865 patients with a recorded diagnosis of diabetes in NHS Western Isles in The Scottish Diabetes Survey 2002 indicated that 833 patients are registered on an area diabetes register in NHS Western Isles. This figure can be broken down further to: 278 patients registered with Type 1 diabetes; 553 patients registered with Type 2 diabetes and 2 patients with other types of diabetes ( other includes gestational or maturity onset diabetes of youth [MODY]). In NHS Western Isles, there are 15 GP practices and health clinics. The diabetes centre is located at Western Isles Hospital, Stornoway. Diabetes-related patient support groups are represented through the local branch of Diabetes UK. Local Report (NHS Western Isles) - March

14 2. Summary of Findings 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 no up-to-date population-based electronic clinical management system of people with a recorded diagnosis of diabetes. NHS Western Isles uses the Lanarkshire Diabetes Care System in secondary care to record all people with diabetes. This register is updated manually after secondary care clinic visits, and from primary care data submitted to the diabetes secretary. The service is aware of the limitations of the present clinical management systems, and the challenges faced in terms of integrating the primary and secondary care systems. A diabetes co-ordinator has recently been appointed to take forward the development of a local strategy and implementation plan for diabetes services, as well as the development of a managed clinical network (MCN). Protocols have been developed for primary and secondary care for the management of patients with diabetes, however dissemination and implementation of the protocols remains a challenge for the service. The Local Diabetes Service Advisory Group (LDSAG) has no clearly identified function, and although accountable to the Board, there are no robust links between the LDSAG and the Board. The remit of the LDSAG is under review. Patient Focus (Standard 3) There is good access to the diabetes specialist nurse, who provides at least one appropriately tailored formal educational session with people newly diagnosed with diabetes about their condition. Other sessions are then provided as appropriate, thus staggering the information given to the patient into a more manageable fashion. There is good provision of diabetes education for healthcare professionals, with Board-wide study days held. A number of staff will start the University of Bradford diabetes course in November Local Report (NHS Western Isles) - March 2004

15 Although there is extensive Diabetes UK patient representation on the LDSAG, there are no other formal mechanisms to involve patients in consultation on service development. In addition, there is no formal training provided for lay representatives of the Group. Clinical Review (Standard 4) Many Type 2 patients routinely attend for an annual review in secondary care, contradicting the shared care guidance provided in the diabetes protocols. Example of a local initiative The diabetes protocols provide a checklist of key indicators and interventions applicable for initial appointments, 6-weekly check-ups, quarterly appointments, and for the 6-monthly or annual review. This checklist is used as a baseline across the NHS Board area. Although information on clinical and lifestyle/well-being factors is recorded on the diabetic assessment form, this information is not always complete. There are opportunities for patients to discuss issues on lifestyle and well-being through the drop-in diabetes centre, or through home visits undertaken by the diabetes specialist nurse or practice nurse. Duplication of patients seen in both primary and secondary care was identified as an issue. It was noted that the diabetes specialist nurse works across both primary and secondary care. Clinical Management (Standards 5, 6, 7, 8, 9, 10) Eyes The Tayside Mobile Screening Unit provides annual eye screening services to NHS Western Isles. This service is compliant with the Health Technology Board for Scotland (HTBS) grading system. Patients who require screening outwith the annual visit are offered an appointment at the hospital clinic and have access to a local qualified optician. Cardiovascular Status There are protocols for the management of associated cardiovascular problems for people with diabetes, including hypertension, consistently high cholesterol and angina. Local Report (NHS Western Isles) - March

16 2. Summary of Findings Feet The diabetic foot assessment documentation includes a referral process of low to high risk categories, and for those patients with active foot disease. In addition, a prioritised service for treatment in secondary care allows rapid referral for urgent conditions. The podiatry service provides an open referral system where patients, as well as healthcare professionals, can refer to the service. There is a Board-wide protocol with guidelines for the management of diabetic foot ulceration, including referral thresholds. Initial treatment of diabetic foot ulceration is undertaken by a range of healthcare professionals, including district nurses, practice nurses, community podiatrists and ward staff, with onward referral to the podiatry service for conditions not responding to treatment within 14 days. Patients with diabetic foot ulcers are therefore not always reviewed by a diabetes foot specialist. Access to the use of digital photography to document diabetic foot ulcers can occur when patients are referred to the podiatry service, with patients receiving a copy of the photograph. It was noted that this facility is available to podiatry staff across primary and secondary care, and in some parts of the district nursing service. The podiatry service provides a weekly clinic where these patients may then be seen quickly on referral. Glycaemia Patients are informed of their HbA1c measurement verbally at the diabetes clinic. Targets agreed at the secondary care clinic are documented in the patient casenotes and forwarded to the GP for information. Targets agreed in primary care are forwarded to the diabetes secretary for input onto the diabetes clinical management system. In addition, an information sheet recording the HbA1c measurement is available to all members of the multidisciplinary diabetes team. The development of a patient-held record is being planned, which will include HbA1c results and targets. Renal There is a local guideline which states that all patients with identified abnormal renal function should be considered for specialist referral when serum creatinine is >150 micromols/l. Although patients are considered for referral at this level, onward referral to the renal clinic at Raigmore Hospital, Inverness, usually occurs when serum creatinine is micromols/l. 14 Local Report (NHS Western Isles) - March 2004

17 It was reported that discussions are under way with NHS Highland in relation to the renal service provision in the Western Isles. Acute Management There are protocols in place for the treatment of hypoglycaemia and diabetic ketoacidosis. People with diabetes who are admitted to hospital with diabetic ketoacidosis are reviewed by the consultant physician or diabetes specialist nurse prior to discharge. Follow-up support and advice is available through the diabetes specialist nurse. In addition, patients recovering from hypoglycaemia are referred to the diabetes specialist nurse and consultant for advice, support and guidance on psychological, clinical and lifestyle aspects of their care. Local Report (NHS Western Isles) - March

18 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 Western Isles 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. NHS Western Isles currently uses the Lanarkshire Diabetes Care System in secondary care, and, at the time of the review, this system had 833 patients with a diagnosis of diabetes recorded. The service reported that all people with diabetes are recorded on this system. However, although this system records those with a diagnosis of diabetes, technical difficulties have resulted in the service not being able to provide other information accurately. NHS Western Isles is planning to implement Scottish Care Information - Diabetes Collaboration (SCI-DC) Clinical and SCI-DC Network by August This will allow many of the data problems reported to the review team to be rectified. General Practice Administration System for Scotland (GPASS) is used in the majority of GP practices. One GP practice uses EMIS, and one uses a paper-based system. 16 Local Report (NHS Western Isles) - March 2004

19 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 single data entry populated both the primary and secondary care information systems. It was reported that the Diabetes Care System is updated after each clinic visit with information taken from the casenotes. In primary care, data is sent to the diabetes secretary at Western Isles Hospital, Stornoway, who then manually enters the data onto the electronic clinical management system. 3: The Board participates in the Scottish Diabetes Survey. NHS Western Isles 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 a SIGN-based protocol for data set collection. Data collection relies on the manual entering of data onto the electronic clinical management system. There has been no auditing of the quality of data due to restraints within the present system, and, consequently, no validation of data by primary care is undertaken. There has been limited training for staff in the use of the clinical management system. It is anticipated that the implementation of the SCI-DC systems will resolve many of the issues identified. Local Report (NHS Western Isles) - March

20 3. Detailed Findings Against the Standards 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 call and recall systems for screening/ review of complications are initiated separately at practice level. NHS Western Isles has identified the issue of consent by patients to allow inclusion of information on the clinical management system. Data protection issues are being explored in respect of retaining data on people who have not consented to be placed on the system. 18 Local Report (NHS Western Isles) - March 2004

21 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 Western Isles Essential Criteria 1: There is a local strategy and implementation plan for diabetes services that covers diagnosis, screening for complications, treatment and care. STATUS: Not met There is no formal strategy and implementation plan for diabetes services in NHS Western Isles. However, at the time of the review, a diabetes co-ordinator had recently been appointed (on part-time secondment for 2 years) to take forward the development of a local strategy and implementation plan. In addition, the diabetes co-ordinator will have responsibility for the development of a managed clinical network (MCN). The review team noted the successful implementation of a business case, developed in 1997, for the redesign of diabetes services, providing a diabetic resource centre in Western Isles Hospital and a visiting service to the Isles of Uists and Barra. Local Report (NHS Western Isles) - March

22 3. Detailed Findings Against the Standards 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. STATUS: Not met There is a Local Diabetes Service Advisory Group (LDSAG), chaired by the director of public health. However, although the LDSAG is accountable to the Board, the review team did not consider the Group to have a clear function or robust links with the Board. It was noted that the remit of the LDSAG was under review at the time of the visit. The LDSAG has a broad membership, including three lay members, representing Type 1 and Type 2 patients, as well as a parent of a child with diabetes. However, due to travel implications, problems with attendance were reported. 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. The review team commended the primary and secondary care guidelines developed for the management of patients with diabetes in the Western Isles. All paediatric cases are referred to the paediatrician and diabetes specialist nurse. Patients with Type 1 diabetes are referred to secondary care under the consultant physician with a special interest in diabetes. Patients with a new diagnosis of Type 2 diabetes are managed in primary care, unless there are complications. However, during the visit, the review team was of the opinion that many Type 2 patients routinely attend for an annual review in secondary care. While this was reported to be for historical reasons, the agreed shared care in the guidelines contradicted what occurs in practice. 20 Local Report (NHS Western Isles) - March 2004

23 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 people with diabetes have an individualised plan of care, generally recorded in secondary care notes, with dietetic records kept separately. The plan of care with mutually agreed targets for HbA1c, weight, blood pressure etc is communicated directly to the patient. Following each clinic visit, a letter detailing these targets is sent to the GP. NHS Western Isles is planning to develop a patient-held credit card sized booklet for the recording of HbA1c. 5: There are identified lead clinicians for diabetes in acute and primary care. A consultant physician and a GP are the two identified lead clinicians for diabetes who have shared responsibility for the service. 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. Patients who default from clinics are identified by the diabetes secretary or practice staff. The diabetes specialist nurse, who works across primary and secondary care, telephones the patient in the first instance, then follows this up with a letter advising of the risks involved in non-attendance. The consultant and GP are notified, and the GP then writes an additional letter to the patient. Local Report (NHS Western Isles) - March

24 3. Detailed Findings Against the Standards 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 Western Isles 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. All people newly diagnosed with diabetes are offered at least one appropriately tailored formal educational session about their condition with the diabetes specialist nurse. Other sessions are then provided as appropriate, thus staggering the information given to the patient into a more manageable fashion. In addition, this education can be reinforced through leaflets which are widely available in both primary and secondary care. The protocols for the management of patients with diabetes provide an education checklist for staff with newly diagnosed patients, and this is used as a baseline across the NHS Board area. 2: Educational programmes continue after diagnosis and include diet, foot care and eye care, as well as day-to-day management of diabetes. The diabetes specialist nurse specifically tailors educational programmes depending on the needs of each individual patient. In addition, all members of the diabetes team reinforce education at every opportunity, and patients have access to information including diet, foot and eye care. Group patient education has been considered by the NHS Board, however patients have identified problems with this approach, specifically geographical. 22 Local Report (NHS Western Isles) - March 2004

25 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. There are specific care programmes in place for the different client groups in NHS Western Isles. Children are seen by the visiting paediatrician from Raigmore Hospital, Inverness, every 3 months. The diabetes specialist nurses are heavily involved in the support of paediatric patients with diabetes. The review team considered that the leaflets available for parents of children with diabetes would benefit from some revision. There are plans to develop a more responsive adolescent diabetes service, based on the results of a recent patient survey. Elderly patients are provided with generic adult information. Due to the small numbers involved, there are no specific formalised care programmes for ethnic groups or vulnerable groups of patients. Cases are dealt with on an individual basis, including those for Gaelic speaking patients. 4: People with diabetes are involved in consultation on service development. STATUS: Not met Although there is extensive Diabetes UK patient representation on the LDSAG, there are no other formal mechanisms to involve patients in consultation on service development. The review team noted the lack of formal training provided for lay representatives of the Group. Local Report (NHS Western Isles) - March

26 3. Detailed Findings Against the Standards 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 People with diabetes have access to state registered podiatry, dietetic and nursing services. The diabetes centre provides a drop-in facility where people can be seen on the same day. Newly diagnosed patients are seen on the same day in the hospital, or the diabetes specialist nurse will undertake a home visit. Needs assessments are undertaken to determine when patients will be seen, and by whom. In addition, there is an out-of-hours telephone service available. Patients have access to a podiatrist at the screening clinic, although there can be a delay for routine appointments. Patients can access dietetic staff at monthly out-patient clinics. For hospitalised patients, access is within 48 hours. Housebound patients are referred via the diabetes specialist nurse or GP. However, there is no psychology service provided locally. Patients, including paediatric patients, may be referred to NHS Highland for psychology input, although there was recognition that this service is not adequately addressed in the Western Isles. 6: Members of the diabetes team who are involved in patient education, have access to a training programme. Members of the diabetes team who are involved in patient education have access to a training programme. It is planned that a number of staff will undertake the University of Bradford diabetes course through distance learning in November A previous study day had approximately 80 attendees, and there are plans to hold a Board-wide similar event every 2 years. The review team was informed that there is provision of training for podiatrists including a diseasespecific induction programme and clinic rotation. 24 Local Report (NHS Western Isles) - March 2004

27 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 Western Isles 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 protocols in both primary and secondary care for the management of patients with diabetes provide a checklist of key indicators and interventions applicable for initial appointments, 6-weekly check-ups, quarterly appointments, and for the 6-monthly or annual review. This checklist is used as a baseline across the NHS Board area. It was noted that many Type 2 patients routinely attend for an annual review in secondary care. Information on clinical and lifestyle/well-being factors was reported to be recorded on the diabetic assessment form. However, the review team could not confirm that data are collected, and where data were available, it was not complete. There was reported to be many opportunities for patients to discuss issues on lifestyle/well-being, including the drop-in diabetes centre, and through home visits undertaken by the diabetes specialist nurse or practice nurse. Local Report (NHS Western Isles) - March

28 3. Detailed Findings Against the Standards Pre-pregnancy advice is provided by the diabetes specialist nurse, and patients are then referred to the consultant obstetrician. There are no sexual health clinics, but patient leaflets are available. Impotence is managed in primary care, with advice available from the visiting consultant urologist when required. 2: Patients are informed of their results and offered support to manage lifestyle risk factor changes. In primary care, blood samples are taken in advance of a clinic, with patients then verbally informed of normal and abnormal results. In secondary care, near patient testing is undertaken, allowing the opportunity for discussion with the patient at the clinic appointment. Results are communicated between colleagues in the primary and secondary care diabetes teams. In addition to verbally informing the patient, a follow-up letter may be written to them. The diabetes specialist nurse or practice nurse will undertake home visits for housebound patients following GP referral. Desirable Criteria 3: Referring practitioners (including optometrists, with patient consent) are given feedback regarding the outcome of their referrals. The review team was satisfied that referring practitioners are written to with feedback regarding the outcome of their referrals, through information compiled from the multidisciplinary team information sheet completed at each clinic. 26 Local Report (NHS Western Isles) - March 2004

29 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 Western Isles 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 Tayside Mobile Screening Unit undertakes annual eye screening visits in NHS Western Isles for all patients with diabetes over the age of 12 years. This service is compliant with the Health Technology Board for Scotland (HTBS) grading system. Patients who require screening outwith the annual visit are offered an appointment at the hospital clinic and have access to a local qualified optician. 2: All people whose eye examination has revealed retinopathy have their glycaemic control and blood pressure reviewed and treated as clinically indicated. All people whose eye examination has revealed retinopathy have more frequent review of glycaemic control and blood pressure undertaken. However, NHS Western Isles reported that they are developing a more robust system to ensure the regular review of patient blood pressure and glycaemic control. Local Report (NHS Western Isles) - March

30 3. Detailed Findings Against the Standards 3: All people with active proliferative diabetic retinopathy are offered laser treatment. All people with active proliferative diabetic retinopathy are offered laser treatment. Reasons for not offering laser treatment are communicated back to the referring GP or consultant physician, and recorded in patient casenotes. 28 Local Report (NHS Western Isles) - March 2004

31 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 Western Isles 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. Where blood pressure is consistently >140 systolic and/or 80 diastolic (140/80mmHg), attempts are made to lower the blood pressure according to primary care protocols for patients with diabetes. Patients are routinely recalled to the clinic/surgery 1 week later to monitor their blood pressure, and results are sent to the GP. 2: There is a local protocol for the management of consistently high cholesterol (>5mmol/l). There is a primary care protocol, which includes the management of consistently high cholesterol (>5mmol/l) through the use of statins. The service reported a high prescribing level of statins. 3: There is a local protocol for the management of angina. There is a primary care protocol for the management of angina, although it was reported that there is a significant waiting time following referral, notably for exercise tolerance testing. Angiograms and scans are undertaken on the mainland. There is a Personal Medical Services (PMS) pilot in development in primary care, which aims to examine a number of options for delivering primary care services. These services will focus on local needs and issues and bring about improvement in service delivery. Local Report (NHS Western Isles) - March

32 3. Detailed Findings Against the Standards 4: All people with diabetes who have been diagnosed with acute myocardial infarction are offered clinical care as detailed in the CSBS Clinical Standards for Secondary Prevention following Acute Myocardial Infarction. Key findings from Coronary Heart Disease (CHD) visit The Clinical Standards Board for Scotland (CSBS) conducted a review visit in August 2001 to Western Isles Hospital, assessing performance against the Clinical Standards for Secondary Prevention following Acute Myocardial Infarction. The local CHD report produced following the visit demonstrated that patients admitted to hospital with acute myocardial infarction are managed according to a local protocol, and are offered prophylactic medication. Local protocols were in place for the management of acute myocardial infarction patients identified as having diabetes. Progress since CHD visit An action plan has been developed following publication of the CSBS local report, identifying responsibility, actions required, timescales and evaluation of progress against the standards. 5: The Joint British Societies Coronary Risk Prediction Chart, or recognised equivalent, is used to assess coronary heart disease risk in primary care. The Joint British Societies Coronary Risk Prediction Chart is used to assess coronary heart disease risk in primary care. 30 Local Report (NHS Western Isles) - March 2004

33 Standard 7: Clinical Management: Feet Standard Statement All people with diabetes who have identified associated foot problems are referred for specialist assessment and, if necessary, treatment. NHS Western Isles Essential Criteria 1: There is a rapid referral process for people with diabetes with associated foot problems. The referral protocol states clearly whether referral is to primary or secondary care. In particular, conditions not responding to treatment provided by primary care are referred to secondary care. The diabetic foot assessment documentation includes a referral process of low to high risk categories, and for those patients with active foot disease. In addition, a prioritised service for treatment in secondary care allows rapid referral for urgent conditions such as ulceration and severe sepsis. 2: All people with diabetes have appropriate access to state registered podiatry services. The review team was satisfied that all people with diabetes in NHS Western Isles have appropriate access to state registered podiatry services. The podiatry service provides an open referral system where patients, as well as healthcare professionals, can access the service. Podiatry treatment programmes are standardised and tailored to particular groups, including people with diabetes. Podiatry treatment is provided in primary care and as part of the diabetes clinic held at Western Isles Hospital. Local Report (NHS Western Isles) - March

34 3. Detailed Findings Against the Standards 3: There is a local protocol for drug and pressure relief treatment of diabetic foot disease. STATUS: Not met NHS Western Isles have recently developed a protocol for antibiotic therapy for diabetic foot ulceration. The local protocol for pressure relief treatment for diabetic foot disease is under development. Desirable Criteria 4: All people with diabetic foot ulcers are reviewed by a diabetes foot specialist, using digital camera photographs for comparison. STATUS: Not met There is a Board-wide protocol with guidelines for the management of diabetic foot ulceration, including referral thresholds. Initial treatment of diabetic foot ulceration is undertaken by a range of healthcare professionals, including district nurses, practice nurses, community podiatrists and ward staff, with onward referral to the podiatry service for conditions not responding to treatment within 14 days. Patients with diabetic foot ulcers are therefore not always reviewed by a diabetes foot specialist. It was noted that patients have access to the consultant physician when required, although it was recognised by NHS Western Isles that more formal referral criteria are required. Access to the use of digital photography to document diabetic foot ulcers can occur when patients are referred to the podiatry service, with patients receiving a copy of the photograph. It was noted that this facility is available to podiatry staff across primary and secondary care, and in some parts of the district nursing service. The podiatry service provides a weekly clinic where these patients may then be seen quickly on referral. It was reported that the diabetic foot ulcer service is working well. 32 Local Report (NHS Western Isles) - March 2004

35 Standard 8: Clinical Management: Glycaemia Standard Statement All people with diabetes have HbA1c measured and recorded as clinically indicated. NHS Western Isles Essential Criteria 1: Drug and insulin therapy is tailored to achieve the best possible glycaemic control without frequent or severe hypo/hyperglycaemia, and there is specific guidance for children and pregnant women. Drug and insulin therapy is tailored to achieve the best possible glycaemic control. People with diabetes who commence insulin therapy in primary care are reviewed by the practice nurse, diabetes specialist nurse or GP, with subsequent review appointments tailored to the patient s needs. In secondary care, drug and insulin therapy is reviewed at the diabetes clinic every 3-6 months. In addition, a drop-in clinic is held at the diabetes centre twice a week, during which times patients have access to the diabetes specialist nurse. There is a pre-pregnancy review and counselling service in addition to specific guidance for pregnant women, with referral to the joint obstetrics/diabetes clinic on confirmation of pregnancy. A paediatric diabetes clinic is provided where a formal review of the patient s drug therapy is undertaken. 2: A DCCT compatible assay is used for the measurement of HbA1c. All HbA1c measurement is carried out using a standardised Diabetes Control and Complications Trial (DCCT) compatible assay. Local Report (NHS Western Isles) - March

36 3. Detailed Findings Against the Standards 3: Sequential HbA1c measurements are used to identify people with diabetes who have poor glycaemic control. Specific targets are agreed for each individual patient. Specific targets for HbA1c are jointly agreed with each individual patient. Details of HbA1c levels are outlined in the diabetes protocols, taking into account allowances for co-morbidities and age. Targets agreed at the diabetes clinic in secondary care are documented in patient casenotes and forwarded to the GP for information. Information on targets agreed in primary care are forwarded to the diabetes secretary for input onto the diabetes clinical management system. 4: The incidence of hypo/hyperglycaemia is monitored and the results are discussed with the patient. People with diabetes are requested to record any incidence of hypo/hyperglycaemia in their own patient diary. This information is reviewed at the diabetes clinic with results discussed with the patient, and specific targets agreed. In addition, the diabetes specialist nurse will record these episodes in the nursing notes and this information is transferred to the patient s hospital notes. Desirable Criteria 5: HbA1c measurements are made available to colleagues in the diabetes (primary and secondary care) team and sent to patients. Patients are informed of their HbA1c measurement verbally at the clinic by the consultant and the diabetes specialist nurse. The development of a patient-held record is being planned, which will include HbA1c results and targets. However, implementation has been delayed until SCI-DC is in operation. The results are also available to the GP prior to the diabetes clinic. In addition, an information sheet recording the HbA1c measurement is available to all members of the multidisciplinary diabetes team. At the time of the review, it was reported that SCI Store was shortly to be made available to primary and secondary care. 34 Local Report (NHS Western Isles) - March 2004

37 Standard 9: Clinical Management: Renal Standard Statement All people with diabetes and identified associated kidney problems are referred for specialist assessment and, if necessary, treatment. NHS Western Isles Essential Criteria 1: All people with identified abnormal renal function serum creatinine (greater than 150 micromols/l) are considered for referral to a renal clinic. There is a local guideline which states that all patients with identified abnormal renal function should be considered for specialist referral when serum creatinine is >150 micromols/l. Although patients are considered for referral at this level, onward referral to the renal clinic at Raigmore Hospital usually occurs when serum creatinine is micromols/l. It was reported that discussions are under way with NHS Highland with regards to the renal service provision in the Western Isles. 2: All people whose urinary albumin concentration is greater than 300mg/l (ie albuminuria which is thought to be due to diabetic nephropathy), have blood pressure, glycaemic control and serum cholesterol levels reviewed as clinically indicated. STATUS: Not met (insufficient evidence) The review team was informed that patients are reviewed more frequently for blood pressure, glycaemic control and serum cholesterol levels where urinary albumin concentration is greater than 300mg/l. However, there was no evidence to support this. Local Report (NHS Western Isles) - March