Dr Roger Gadsby assesses the likely impact on primary care of the delivery strategy for the Diabetes NSF
The second part of the National Service Framework for Diabetes has finally been published. It lacks many of the detailed milestones and targets that other NSFs have contained but outlines a 10-year programme to build capacity and put in place basic building blocks so that diabetes care can be developed at PCT level.
The frameworkÍs first national priority is to focus on patients who are at greatest risk of developing diabetes complications, indicated by poor diabetes control, and those newly diagnosed with diabetes, where the opportunity to implement the NSF standards from day one is greatest.
A local approach, the document states, could initially offer:
- Information and psychological support and the opportunity to participate in structured education - usually in groups - for individuals diagnosed with diabetes after April 2003.
- An agreed care plan, a personal diabetes record and a named contact within the local service for all patients diagnosed with diabetes after April 2003 as well as those with poor blood glucose control (HbA1c >7.5%). In many clinics more than 50% of patients have an HbA1c greater than 7.5%.
The NSF establishes two critical diabetes-specific targets for eye screening and registers to be achieved by 2006. These are:
- 80% of individuals with diabetes will be offered retinal screening (and treatment if needed), rising to 100% coverage by the end of 2007.
- In primary care, practice registers should be updated so that patients with CHD and diabetes continue to receive treatment in line with NSF standards. By March 2006 practice based registers should also cover the majority of patients at high risk of CHD, particularly those with hypertension, diabetes and a BMI greater than 30.
The service structure to deliver the NSF, it states, should be at the population level served by a specialist service based within an NHS trust. It should be supported by a network manager, clinical and diabetes champions and information management.
The document acknowledges that the NSF will require additional resources and points to the extra funding for the NHS, with an average increase of 7.4% above inflation for 2003-4 to 2007-8, already announced. Revenue funds to deliver national targets will be included in general allocations to PCTs. Capital funds to support the development of diabetic retinal screening programmes will be available where they can generate a step change in services.
There is much less of a ïtop downÍ approach in this NSF than might have been expected and much more emphasis on local prioritisation and service development. There are few milestones and targets, apart from the ones for retinal screening and practice registers, with the emphasis on the newly diagnosed and poorly controlled.
As the money to deliver the NSF through local diabetes networks will have to come from general PCT allocations, a lot of intense effort will need to be put in at PCT level by clinical and diabetes champions to improve care. This will create considerable extra pressure for PCTs, which will have to decide on the priority they give to diabetes, and fund developments accordingly. There is a danger that the speed and extent of NSF implementation could vary across the country.
National Service Framework for Diabetes: Delivery strategy is available on the Department of Health website: http://www.doh.gov.uk/nsf/diabetes