Dr Roger Gadsby highlights how the NICE quality standard for diabetes will help to improve care in a number of areas, such as provision of education and initiation of insulin therapy
The Department of Health asked NICE to develop evidence-based quality standards in an initial 150 areas of clinical care. Speaking at the launch of the quality standards, the Health Secretary Andrew Lansley said that: ‘Quality standards give an authoritative statement on what high quality NHS care should look like … (they) will support a service which is focused on outcomes and looks for the evidence on how to achieve continuously improving outcomes.’ The standards will:1
- form a consistent set of measures that will be the basis—rather than volume and price—of commissioning led by clinical commissioning groups
- be used as part of Care Quality Commission regulations
- be used in designing incentives.
Diabetes quality standard
The quality standard for diabetes was published in March 2011 (see Table 1, below) and was based on the evidence and recommendations from a number of NICE guidelines in this clinical area.2–5 Each quality statement within the standard is associated with a measure that is described as a high-level quality indicator. These measures include a numerator and a denominator, which define a proportion (e.g. for quality statement 2 [see Table 1, below] the denominator is the number of people with diabetes, the numerator is the number of those within the denominator who are receiving personalised advice on physical activity).
The standard includes a description of:
- what the quality statement means for each audience
- the source clinical guideline reference
- the data sources that will be used
- the definitions
- equality and diversity considerations.
We can conclude that diabetes care should improve because the quality statements can be measured and their achievement will be monitored as part of the contracting process. Additionally, the quality standard for diabetes will underpin the drawing up of commissioning contracts for delivery of diabetes services.
Improving diabetes care
The quality standard for diabetes states that it describes markers of high-quality, cost-effective care that, when delivered collectively, should improve the effectiveness, safety, and experience of care for adults by:6
- preventing people from dying prematurely
- enhancing quality of life for people with long-term conditions
- helping people to recover from episodes of ill health or following injury
- ensuring that people have a positive experience of care
- treating and caring for people in a safe environment and protecting them from avoidable harm.
Several of the quality statements for diabetes relate specifically to hospital care, (particularly 11 and 12) and also community care (in particular 10 and 13) (see Table 1, below). The remaining statements can be applied in primary care and this article examines how these will help to improve patient care.
|Table 1: NICE quality standard for diabetes6|
People with diabetes and/or their carers receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education.
People with diabetes receive personalised advice on nutrition and physical activity from an appropriately trained healthcare professional or as part of a structured educational programme.
People with diabetes participate in annual care planning that leads to documented agreed goals and an action plan.
People with diabetes agree with their healthcare professional a documented personalised HbA1c target, usually between 48 mmol/mol and 58 mmol/mol (6.5% and 7.5%), and receive an ongoing review of treatment to minimise hypoglycaemia.
People with diabetes agree with their healthcare professional to start, review, and stop medications to lower blood glucose, blood pressure, and blood lipids in accordance with NICE guidance.
Trained healthcare professionals initiate and manage therapy with insulin within a structured programme that includes dose titration by the person with diabetes.
Women of childbearing age with diabetes are regularly informed of the benefits of pre-conception glycaemic control and of any risks, including medication that may harm an unborn child. Women with diabetes planning a pregnancy are offered pre-conception care and those not planning a pregnancy are offered advice on contraception.
People with diabetes receive an annual assessment for the risk and presence of the complications of diabetes, and these are managed appropriately.
People with diabetes are assessed for psychological problems, which are then managed appropriately.
People with diabetes with or at risk of foot ulceration receive regular review by a foot-protection team in accordance with NICE guidance, and those with a foot problem requiring urgent medical attention are referred to, and treated by a multidisciplinary foot-care team within 24 hours.
People with diabetes admitted to hospital are cared for by appropriately trained staff, provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing their own insulin.
People admitted to hospital with diabetic ketoacidosis receive educational and psychological support prior to discharge and are followed up by a specialist diabetes team.
People with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist diabetes team.
Structured education programme—statement 1
This statement clearly recommends that everyone with newly diagnosed type 2 diabetes should be encouraged to receive a structured-education programme that fulfils nationally agreed criteria.6,7 Anecdotal evidence suggests that only a minority of eligible people attend such programmes probably because financial restrictions limit availability in many areas. Statement 1, which specifies that people should receive monitored and structured education of an approved level,6 should increase the provision of such programmes and subsequent patient attendance. The quality standard should encourage PCTs to prioritise spending on structured education and to make provisions for it as part of commissioning contracts for diabetes.
Advice on nutrition and physical activity—statement 2
Advice on nutrition and physical activity is often provided by a GP or practice diabetes nurse soon after a diagnosis of type 2 diabetes. The standard states that individuals giving this advice should be appropriately trained,6 thereby emphasising the importance of assessed and accredited diabetes education for all healthcare professionals looking after people with diabetes; a number of training courses are available (e.g. Warwick Medical School8). Moreover, attendance at structured diabetes education programmes would also enable patients to receive advice covering nutrition and physical activity.
Annual care planning, HbA1c goals, medications, and annual review for complications—statements 3, 4, 5, and 8
Currently, UK primary care practices perform annual reviews on people with diabetes to monitor for related complications and then manage these appropriately; the quality statements support high-quality GP practice in diabetes. This enables practices to aim for achievement of maximum points and financial reward from fulfilling the quality and outcomes framework (QOF) clinical indicators for diabetes.9 Achievement of the diabetes indicators for process and intermediate outcomes by primary care has improved since the introduction of the QOF in 2004.10 The quality standard encourages the continuation of high-quality proactive diabetes care in general practice, and emphasises that the patient is central to all consultations, particularly for agreement of treatment goals (e.g. glucose levels) and development of an action plan to achieve these objectives. The ‘year-of-care initiative’ was developed to ensure that people with chronic diseases, such as diabetes, are at the centre of care planning, and has been piloted in several areas.11 The partners-in-care guide11 applies the principles of a partnership approach to diabetes care. Emphasising the central role of the person with diabetes should promote best practice and improve diabetes care.
Insulin therapy—statement 6
This quality statement emphasises the importance of initiating and managing therapy with insulin within a structured programme that includes dose titration by the individual with diabetes. Initiation of insulin therapy used to require referral of the patient to secondary care, but in the last 10 years, training programmes have been developed to enable GPs and practice nurses to acquire these skills and gain experience so that they can start treatment in people with type 2 diabetes.12 These programmes include a structured education element and a dose-titration algorithm for initiation of insulin. This statement provides encouragement for GPs and practice nurses to become involved with starting injectable therapies for diabetes, therefore promoting best practice and improving diabetes care.
Pre-conception care—statement 7
Poor glycaemic control at conception and during the first trimester of pregnancy—when the major organ systems of the baby are developing—is associated with a risk of congenital malformation. Provision of information and support to achieve good glycaemic control in women at the time of conception and in early pregnancy has been linked with improvements in maternal and perinatal outcomes.13 Pre-conception care has in the past been provided largely in a hospital setting and required women with diabetes to indicate that they were planning to become pregnant, which in turn enabled them to be referred to a specialist pre-conception clinic; however uptake was poor.14
Statement 7 emphasises that all healthcare professionals should take every opportunity to communicate messages about the importance of good diabetes control before conception and into pregnancy with women of childbearing age who have diabetes. These educational messages should be given whenever practice nurses see such women. Pre-conception counselling services need to be commissioned and provided, and referral should be made to them where appropriate. If successfully implemented, this quality statement will increase the likelihood of improving outcomes in pregnant women with diabetes.
Assessment and management of psychological problems—statement 9
As part of the QOF, people with chronic diseases, such as diabetes, are asked two screening questions for depression annually. However, there is no QOF indicator for managing individuals who are positive for these screening questions. Moreover, there is no process for screening other psychological conditions, which may be associated with diabetes, such as eating disorders and anxiety. Surveys on the provision of diabetes services have indicated that the availability of staff who can support people with diabetes and psychological problems is low.15 The quality standard prioritises diagnosis and management of psychological problems by highlighting their importance. It may also help to encourage appropriately trained professionals who provide psychological support to become more involved in the care of people with diabetes.
Implementation of the standard
Implementation of the quality statements for diabetes will require action from healthcare professionals, commissioners, and people with diabetes. Some of these actions are listed below:
- Improved availability and uptake of structured diabetes education programmes requires:
- commissioners to appreciate their importance
- primary care staff to refer people with diabetes to them
- people with diabetes need to ensure that they attend structured education.
- People with diabetes need to be at the centre of goal setting and all aspects of their diabetes care. This requires a change of emphasis in diabetes care delivery with more time spent in discussion.
- Funding and support are needed to permit primary care staff to attend training programmes relating to initiation of insulin. Commissioners need to ensure that appropriate provision is made for education and training.
- All healthcare professionals delivering care to women of childbearing age with diabetes need to provide good pre-conception advice. Practice nurses are the ones who are in a position to action this, but they may require specific training.
- Psychological problems need to be identified and managed. More psychology services are needed, with clear timely access to appropriate local services.
The quality standard describes high-quality care for specific areas of diabetes. By providing an indicator for each statement, it will be possible to determine whether the standard is being achieved and if the quality of diabetes care is improving. The standard could form the basis of contracting and commissioning for diabetes care.
- The quality standard for diabetes is one out of 150 to be produced by NICE and will be represented in the NHS Outcomes Framework for commissioning
- In the future, this framework will form the basis for assessing clinical commissioning group performance and will direct payments for any quality premiums (subject to legislation)
- Many of the quality statements are specifically addressed through the QOF, which is an outcomes framework for provision of primary care
- However, GP commissioners should look to ensure that effective services which lie outside the QOF (particularly structured educational programmes for diabetes), are locally commissioned to NICE standards
- Commissioners should consider publishing a specific set of commissioning intentions for diabetes services at the start of the year, which covers all the interventions required to meet this framework and their costs
- As most of the quality statements relate to primary care, GP commissioners should liaise closely with PCT primary care contracting departments (and in the future, the NHS Commissioning Board) to set these contracts and avoid conflicts of interests.
- Cohen D. NICE issues the first of 150 quality standards for the NHS. BMJ 2010; 341: c3536.
- National Institute for Health and Care Excellence. Type 2 diabetes: prevention and management of foot problems. Clinical Guideline 10. London: NICE, 2004. Available at: www.nice.org.uk/cg10
- National Institute for Health and Care Excellence. Diagnosis and management of type 1 diabetes in children, young people and adults. Clinical Guideline 15. London: NICE, 2004. Available at: www.nice.org.uk/cg15
- National Institute for Health and Care Excellence. Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period. Clinical Guideline 63. London: NICE, 2008. Available at: www.nice.org.uk/cg63
- National Institute for Health and Care Excellence. Type 2 diabetes—newer agents (partial update of CG66). Clinical Guideline 87. London: NICE, 2009. Available at: www.nice.org.uk/cg87
- National Institute for Health and Care Excellence. Diabetes in adults quality standard. London: NICE, 2011. Available at: www.nice.org.uk/guidance/qualitystandards/diabetesinadults/diabetesinadultsqualitystandard.jsp
- Diabetes UK, Department of Health. Structured patient education in diabetes. London: DH, 2005. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4113195
- Warwick Medical School website. Diabetes. www2.warwick.ac.uk/fac/med/themes/diabetes (accessed 17 November 2011).
- British Medical Association. NHS Employers. Quality and outcomes framework guidance for GMS contract 2011/12. London: BMA, NHS Employers, 2011. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qofguidance2011.jsp
- Gadsby R. What has QoF ever done for diabetes? Practical Diabetes International 2009; 26 (8): 314–315.
- NHS Diabetes. Partners in care: a guide to implementing a care planning approach to diabetes care. NHS Diabetes, 2008. Available at: www.diabetes.nhs.uk/our_publications/reports_and_guidance/care_planning/
- Gadsby R. Insulin treatment in diabetes. InnovAIT 2009; 2 (12): 708–712.
- Kitzmiller J, Gavin L, Gin G et al. Preconception care of diabetes: glycemic control prevents congenital abnormalities. JAMA 1991; 265 (6): 731–736.
- Confidential Enquiry into Maternal and Child Health. Pregnancy in women with type 1 and type 2 diabetes in 2002–2003. England, Wales and Northern Ireland. Executive summary. London: CEMACH, 2005.
- Association of British Clinical Diabetologists, Diabetes UK. ABCD and Diabetes UK survey of diabetes specialist services. 2006. ABCD, Diabetes UK , 2008. Available at: www.diabetologists.org.uk/Shared_Documents/consultant_surveys/ABCD_DiabetesUK_Survey06.pdfG