Diabetes guide appendices - London Health Programmes

What is DAFNE?DAFNEDose Adjustment For Normal Eating

BackgroundSince the 1980’s, the diabetes team at the Diabetes Centre in Düsseldorf, led by the lateMichael Berger, has developed a five-day structured training programme in intensiveinsulin therapy and self-management. [1-3]The educational approach is based on the Assal model of “therapeutic education” [4] andpatients are taught to match their insulin dose to food intake on a meal-by-meal basis.The principle aim is that in the future, they maintain healthy glycaemic control without anincreased risk of severe hypoglycaemia with minimal support from healthcareprofessionals. It is noteworthy that the Düsseldorf course does not specifically addressemotional issues which concern living with diabetes but is purely skills based.The DAFNE ApproachThe DAFNE (Dose Adjustment For Normal Eating) project examined the feasibility ofdelivering a course based on the Düsseldorf model but with individuals attending thecourse on an outpatient basis. [5] A similar outpatient course has been run in Graz, Austria,under the supervision of Thomas Pieber, [6] and has produced equally successfuloutcomes to those demonstrated in Germany. This approach has been widely adaptedand developed elsewhere in Europe. [7]The CourseThe main principles of the DAFNE course are:• Skills based training to teach flexible insulin adjustment to match carbohydrate in a freediet on a meal-by-meal basis.• Emphasis on self-management and independence from the diabetes care team.• The use of adult education principles to facilitate new learning in a group setting.Participants attend the course for the full 5 consecutive days in groups of 6-8. In theory,those using twice daily insulin regimens might benefit, but in practice, participants inDAFNE switch to a multiple injection regime on the first day of the course to maximisethe opportunities for dose adjustment.Participants assemble at the course venue at around 9am on the Monday morning. Theyare greeted initially by the educators (dietitians and DSNs) and a medical member of thediabetes team.An example of a typical week’s timetable can be seen on page 5.The course consists of 3 main areas:• Nutrition topics.• Insulin dose adjustment at mealtimes and special circumstances (exercise, illness).• Other topics such as hypoglycaemia, complications, sick-day rules and pregnancy.There is also a course handbook for participants.4

DAFNE Draft TimetableMonday Tuesday Wednesday Thursday Friday9.15 - 9.30 9.15 - 9.30 9.15 - 10.30 9.15 - 10.30 9.15 - 10.30Introduction Discuss individual Discussion and Discussion and Discussion andblood glucose control Insulin Adaptation Insulin Adaptation Insulin Adaptation9.30 - 10.45What is Diabetes?10.45-11.00 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee 10.30-10.45 Coffee11.00 - 12.30 10.45 - 12.30 10.45 - 12.30 10.45 - 12.30 10.45 - 11.45Nutrition 1 Insulin injection Hypoglycaemia Nutrition 4 Sick Day RulestechniqueInsulin action 11.45 - 12.30Insulin strategies Social Aspects /Contraceptionand Pregnancy12.30-13.30 Lunch 12.30-13.30 Lunch 12.30-13.30 Lunch 12.30-13.30 Lunch 12.30-13.30 Lunch13.30 - 14.30 13.30 - 15.00 13.30 - 15.00 13.30 - 15.00 13.30 - 14.30Metabolic self monitoring Nutrition 2 Nutrition 3 Long term Quiz• Blood glucose complications• Ketones 14.30 - 15.30Evaluation15.00-15.15 Coffee 15.00-15.15 Coffee 15.00-15.15 Coffee 15.00.15.15 Coffee Close14.30 - 17.00 15.15 - 16.15 15.15 - 16.15 15.15 - 16.15Definition of individual Insulin Dose Exercise Discussion withtherapeutic goals / Adjustment physicianInsulin regime16.15 - 17.00 16.15 - 17.00 16.15 - 17.00Individual Dose Discussion and Discussion andAdaptation Insulin Adaptation Insulin Adaptation5

Nutrition TopicsThe emphasis on nutrition is to teach patients to count carbohydrates so that when theyhave decided what food they would like to eat, they can then choose an appropriateinsulin dose. The theme of the DAFNE course is “eat what you like, like what you eat”.This course does not teach healthy eating although there is an opportunity to mention itsbenefits as a minor part of one of the sessions on the final day of the course.The four nutrition sessions cover the following topics:Nutrition 1 Nutrition 2 Nutrition 3 Nutrition 4Previous advice; differences Estimating CPs Food labelling Eating outand similarities Practice exercises Recipes AlcoholIdentifying protein/fat/CHO Snacks Sweeteners Weight controlEstimating CHOHealthy eatingGlycaemic indexIntroduction to CP estimationCHO = CarbohydrateDefining CHO portions (CPs)CP = Carbohydrate PortionThe early nutrition topics are designed to show participants how to estimate thecarbohydrate content of meals and this is done using practical exercises withphotographs, food models and food packets. The remainder of the sessions focus on avariety of social situations that may require CHO estimations. One CP is roughlyequivalent to 10-12g CHO, ie approximately one “old fashioned” CHO exchange.However, this enables participants to estimate the CHO content of whatever they want toeat rather than to restrict them with a prescribed diet. Participants also receive a CHOportion booklet to take home.Insulin Dose AdjustmentThe insulin regime is based on a basal/bolus regimen with basal insulin supplied by 2injections of isophane insulin given at bedtime and before breakfast, with food covered bypre-meal soluble insulin. Those participants who are already taking a quick-acting insulinanalogue usually continue to do so and it may also be useful for those people who eatmeals containing large amounts of CHO (see page 7). Blood glucose monitoring isperformed before each main meal. This value, the results of previous blood glucosemeasurements and the quantity of the proposed intake of CHO are all taken into accountwhen calculating the dose of insulin, using standard algorithms as a starting point.The emphasis of the course is on active participation, using the meal-times of all theparticipants both at home and lunchtime, as exercises in which the whole groupcontributes to agreeing the correct dose of insulin. Insulin dose adjustment starts withlunch on the first day so that each participant has at least 12 opportunities to practice thisduring the week (and more if they eat snacks). The aim is that participants learn fromothers’ experience of dose adjustment throughout the week.6

Inevitably at the start of the week these choices are largely those suggested by thenurses and dietitian but by Wednesday or Thursday, patients are usually making theirown choices encouraged by other members of the group.Principles of insulin dose adjustmentAt the beginning of the week, basal insulin requirements are supplied by isophane insulindivided into 2 equal doses given at breakfast and before bed with a starting dose ofaround 1 unit/h, ie 12 units bd. The total split dose is usually adjusted during the weekand over subsequent months, with the evening dose determined by the fasting glucoselevel on the following morning. The morning NPH dose is adjusted according to bloodglucose measurements of the previous two days, particularly the pre-evening meal value,roughly aiming for a 50:50 basal/quick acting split.Glucose targets are:Fasting 5.5 - 7.7mmol/lPre-meal 4.5 - 7.7mmol/lBedtime 6.5 - 8.0mmol/lParticipants are advised to give a standard proportion of quick acting insulin percarbohydrate portion which varies at different times of the day: Ratios of quick-acting toCP usually vary between:Breakfast 2 - 3 units per CPLunch 1 - 2 units per CPEvening meal 1 - 2 units per CPPatients are free to miss meals if they choose, although a dose of quick-acting insulinmay be needed at breakfast even if no carbohydrate is eaten due to the slow onset ofbasal insulin and the effect of the “Dawn Phenomenon”. These suggested values are, ofcourse, only starting guidelines and individuals gradually work out what proportions ofinsulin to carbohydrate intake suit them. Carbohydrate content at any given meal is oftenhigher in the UK than Germany (more chips, pasta and bread!). If pre-meal solubleinsulin doses are regularly above 15 units these large doses can have an extendedduration of action. If this leads to problems with hypoglycaemia, we advise thesubstitution of quick-acting insulin analogues which have a shorter duration of action athigher doses.7

High and low results can be corrected by extra quick-acting insulin or carbohydrate andparticipants are encouraged to use these to keep blood glucose values within the targetrange.They begin by working on the principle that:• 1 unit of quick acting insulin lowers blood glucose by 2-3mmol/l.• 1-2 CPs raise blood glucose by 2-3mmol/l.HyposParticipants are encouraged to accept mild hypoglycaemia as an inevitable and normalconsequences of life with diabetes. Standard guidance is provided for treatinghypoglycaemic symptoms, (equivalent to 100-120ml Lucozade or 5 glucose tablets)followed by an additional 1-2 CPs of slower acting CHO depending upon when the nextmeal is due.Sick-day RulesThere is a clear set of instructions to deal with illness which include testing urine forketones and using quite large corrective doses of quick-acting insulin. If ketonuria ispresent and blood glucose above 13mmol/l, patients are taught to take 20% of theprevious day’s total daily insulin dose at each mealtime until their glucose falls to normal.Other sessions during the week are devoted to additional aspects of life with diabetesand are comparable to many other diabetes training programmes. They take up about aquarter of the course. These include sessions on the risk and consequence of diabeticcomplications, pregnancy and contraception and hypoglycaemia and gender make-up ofthe group and their own needs will dictate the exact content to some extent.The final day includes a group discussion with the educators, including a doctor. All theparticipants are encouraged to describe their experiences and explain how they mightuse these skills in the future.8

References1. Mühlhauser I, Jorgens V, Berger M, Graninger W, Gurtler W, Hornke L et al. Bicentricevaluation of a teaching and treatment programme for type 1 (insulin-dependent)diabetic patients: improvement of metabolic control and other measures of diabetescare for up to 22 months. Diabetologia 1983;25:476.2. Mühlhauser I, Bruckner I, Berger M, Cheta D, Jorgens V, Scholz V et al. Evaluation ofan intensified insulin treatment and teaching programme as routine management oftype 1 (insulin-dependent) diabetes. The Bucharest-Düsseldorf Study. Diabetologia1987;30:681-90.3. Bott, S., Bott U., Berger, M., and Mühlhauser, I. Intensified insulin therapy and the riskof severe hypoglycaemia. Diabetologia 40, 926-932. 974. Assal JP, Mühlhauser I, Pernet A, Gfeller R, Jorgens V, Berger M. Patient education asthe basis for diabetes care in clinical practice and research.Diabetologia 1985;28:602-135. The DAFNE Study Group. Training in flexible, intensive insulin management to enabledietary freedom in people with type 1 diabetes: the dose adjustment for normal eating(DAFNE) randomised controlled trial. BMJ 2002; 325: 746.6. Pieber TR, Brunner GA, Schnedl WJ, Schattenberg S, Kaufmann P, Krejs GJ.Evlauation of a structured outpatient group education program for intensive insulintherapy. Diabetes Care 1995;18:625-30.7. Howorka K. Functional insulin treatment. Berlin: Springer, 1996.9

Diabetes mellitus indicators2006/2007Sources:Retrieved from website: http://www.gpcontract.co.ukThe Quality and Outcomes Framework (QOF) 2006/2007. All rights reservedValidity indirectly confirmed: Outputs using the Database has been confirmed against other measures. The database has notbeen directly compared against QOF downloads. The data in this spreadsheet was retrieved from a 3rd party website. Thespreadsheet has not been directly checked against the direct DoH data.

About these charts• The middle of each circle indicates the average results of eachindividual practice within a PCT.• All charts, except for DM5, are based on whole practice registers.• Exception reporting (excluding individuals from returns) occurs for avariety of reasons. The scale of exception reporting variesenormously between practices and PCTs.• To fully assess the needs of people with diabetes, PCTs andpractices need to assess their performance based on all the patientswho are registered with diabetes in the PCT or practice.• To highlight the effect of exception reporting, the charts for DM5show both types of data.• In all cases, the results are significantly worse when all people withdiabetes are considered.• The ambition in London is to reduce exception reporting tothree per cent.

DM 2 - Percentage of patients with diabetes whosenotes record BMI in last 15 months100%DM 2 - % of diabetes with BMI in last 15 monthsReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.90%Individual GP surgery achievement (%)80%70%60%50%40%30%20%10%0%BEXLEY CARE TRUSTBARKING AND DAGENHAM PCTBARNET PCTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTGREENWICH TEACHING PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTLondon PCTPortion of Indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTSUTTON AND MERTON PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTTop 75% performing surgeries in PCT minimum scoreTOWER HAMLETS PCTWANDSWORTH PCTWALTHAM FOREST PCTWESTMINSTER PCT

DM 5: Percentage of patients with diabetes who havea record of HbA1c in past 15 months (whole register)DM 5 - % of diabetes and HbA1c checked in 15 monthsReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.100%90%Individual GP surgery achievement (%)80%70%60%50%40%30%20%10%0%BEXLEY CARE TRUSTBARKING AND DAGENHAMBARNETBRENT TEACHINGBROMLEYCAMDENCITY AND HACKNEY TEACHINGCROYDONEALINGENFIELDGREENWICH TEACHINGHAMMERSMITH AND FULHAMHARINGEYHARROWHAVERINGLondon PCTHILLINGDONHOUNSLOWISLINGTONKENSINGTON AND CHELSEAKINGSTONLAMBETHWESTMINSTERLEWISHAMNEWHAMREDBRIDGERICHMOND AND TWICKENHAMSOUTHWARKSUTTON AND MERTONTOWER HAMLETSWALTHAM FORESTWANDSWORTHPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreTop 75% performing surgeries in PCT minimum score

DM 5: Percentage of patients with diabetes who havea record of HbA1c in past 15 months (with exceptions)100%DM 5 - % of diabetes and HbA1c checked in 15 monthsNon-exception reported QOF indicator scores for GP surgeries by London PCT2006/2007 data. All exceptions included.90%Individual GP surgery achievement (%)80%70%60%50%40%30%20%10%0%BEXLEY CARE TRUSTBARKING AND DAGENHAM PCTBARNET PCTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTGREENWICH TEACHING PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTLondon PCTHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTTop 75% performing surgeries in PCT minimum scoreWESTMINSTER PCTSUTTON AND MERTON PCTTOWER HAMLETS PCTWALTHAM FOREST PCTWANDSWORTH PCT

DM 5 – continued100%DM 5 - % of diabetes and HbA1c checked in 15 monthsComparison of top 75% performing surgeries (with exceptions vs. whole registers)98%% of GP surgery achievement96%94%92%90%88%86%BEXLEY CARE TRUSTBARKING AND DAGENHAMBARNETBRENT TEACHINGBROMLEYCAMDENCITY AND HACKNEY TEACHINGCROYDONEALINGENFIELDLondon PCTGREENWICH TEACHINGHAMMERSMITH AND FULHAMHARINGEYHARROWHAVERINGHILLINGDONHOUNSLOWISLINGTONKENSINGTON AND CHELSEAKINGSTONLAMBETHLEWISHAMNEWHAMREDBRIDGESUTTON AND MERTONRICHMOND AND TWICKENHAMSOUTHWARKTOWER HAMLETSWANDSWORTHWALTHAM FORESTWESTMINSTERTop 75% performing surgeries in PCT min. score (with exceptions)Top 75% performing surgeries in PCT min. score (whole registers)Top 75% performing surgeries in London min. score (with exceptions)Top 75% performing surgeries in London min. score (whole registers)

DM 7: Percentage of patients with diabetes in whomHbA1c is 10 or less in past 15 months100%DM 7 - % of diabetes where HbA1c is 10 or lessReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.90%80%Individual GP surgery achievement (%)70%60%50%40%30%20%10%0%BARKING AND DAGENHAMBARNETBEXLEY CARE TRUSTBRENT TEACHINGBROMLEYCAMDENCITY AND HACKNEY TEACHINGCROYDONEALINGENFIELDGREENWICH TEACHINGHAMMERSMITH AND FULHAMHARINGEYHARROWHAVERINGHILLINGDONHOUNSLOWISLINGTONKENSINGTON AND CHELSEAKINGSTONLAMBETHLEWISHAMNEWHAMREDBRIDGERICHMOND AND TWICKENHAMSOUTHWARKSUTTON AND MERTONTOWER HAMLETSWALTHAM FORESTWANDSWORTHWESTMINSTERLondon PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreTop 75% performing surgeries in PCT minimum score

DM 9: Percentage of patients with diabetes with recordof peripheral pulses in past 15 months100%90%DM 9 - % of diabetes and pulses checked in 15 monthsReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.Individual GP surgery achievement (%)80%70%60%50%40%30%20%10%0%BARKING AND DAGENHAM PCTBARNET PCTBEXLEY CARE TRUSTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTGREENWICH TEACHING PCTHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTSUTTON AND MERTON PCTTOWER HAMLETS PCTWALTHAM FOREST PCTWANDSWORTH PCTWESTMINSTER PCTLondon PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreTop 75% performing surgeries in PCT minimum score

DM 10: Percentage of patients with diabetes with a recordof neuropathy testing in past 15 months100%DM 10 - % of diabetics receiving a neuropathy test in the last 15 monthsReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.90%80%Individual GP surgery achievement (%)70%60%50%40%30%20%10%0%BARKING AND DAGENHAM PCTBARNET PCTBEXLEY CARE TRUSTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTGREENWICH TEACHING PCTHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTLondon PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTSUTTON AND MERTON PCTTOWER HAMLETS PCTWALTHAM FOREST PCTWANDSWORTH PCTWESTMINSTER PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreTop 75% performing surgeries in PCT minimum score

DM 11: Percentage of patients with diabetes who have arecord of BP in past 15 months100%DM 11 - % of diabetics whose blood pressure has been check in 15 monthsReported QOF indicator scores for GP surgeries by London PCT2006/2007 Data. Exceptions excluded.90%Individual GP surgery achievement (%)80%70%60%50%40%30%20%10%0%BARKING AND DAGENHAM PCTBARNET PCTBEXLEY CARE TRUSTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTGREENWICH TEACHING PCTHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTSUTTON AND MERTON PCTTOWER HAMLETS PCTLondon PCTWALTHAM FOREST PCTWANDSWORTH PCTWESTMINSTER PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreTop 75% performing surgeries in PCT minimum score

DM 12: Percentage of patients with diabetes in whom lastBP was 145/85 or lessDM 12 - % of diabetes whose blood pressure is 145/85 or lessReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.100%90%80%Individual GP surgery achievement (%)70%60%50%40%30%20%10%0%BEXLEY CARE TRUSTBARKING AND DAGENHAM PCTBARNET PCTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTLondon PCTGREENWICH TEACHING PCTHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTSUTTON AND MERTON PCTTOWER HAMLETS PCTWALTHAM FOREST PCTWANDSWORTH PCTWESTMINSTER PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreTop 75% performing surgeries in PCT minimum score

DM13: Percentage of patients with diabetes who have arecord of micro-albuminuria testing in past 15 months100%DM 13 - % of diabetes and micro-albuminuria testing doneReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.90%80%Individual GP surgery achievement (%)70%60%50%40%30%20%10%0%London PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreBARKING AND DAGENHAM PCTBARNET PCTBEXLEY CARE TRUSTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTGREENWICH TEACHING PCTHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTSUTTON AND MERTON PCTTOWER HAMLETS PCTTop 75% performing surgeries in PCT minimum scoreWALTHAM FOREST PCTWANDSWORTH PCTWESTMINSTER PCT

DM 15: Percentage of patients with diabetes with proteinuria or microalbuminuriawho are treated with ACE inhibitors (or A2 antagonists)100%DM 15 - % of diabetes and proteinuria or micro-albuminuria on ACEReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.90%80%Individual GP surgery achievement (%)70%60%50%40%30%20%10%0%BARKING AND DAGENHAM PCTBARNET PCTBEXLEY CARE TRUSTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTGREENWICH TEACHING PCTHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTSUTTON AND MERTON PCTTOWER HAMLETS PCTLondon PCTWALTHAM FOREST PCTWANDSWORTH PCTWESTMINSTER PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreTop 75% performing surgeries in PCT minimum score

DM 16: Percentage of patients with diabetes who have arecord of total cholesterol in the past 15 months100%DM 16 - % of diabetics whose cholesterol has been checked in last 15 monthsReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.90%80%Individual GP surgery achievement (%)70%60%50%40%30%20%10%0%BARKING AND DAGENHAM PCTBARNET PCTBEXLEY CARE TRUSTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTGREENWICH TEACHING PCTHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTSUTTON AND MERTON PCTTOWER HAMLETS PCTLondon PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreTop 75% performing surgeries in PCT minimum scoreWALTHAM FOREST PCTWANDSWORTH PCTWESTMINSTER PCT

DM 20: Percentage of patients with diabetes in whom thelast HbA1c is 7.5 or less in past 15 months100%DM 20 - % of patients with diabetes in whom the last HbA1c or equivalent in the previous 15 monthsReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.90%Individual GP surgery achievement (%)80%70%60%50%40%30%20%10%0%London PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreBARKING AND DAGENHAM PCTBARNET PCTBEXLEY CARE TRUSTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTGREENWICH TEACHING PCTHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTSUTTON AND MERTON PCTTOWER HAMLETS PCTWALTHAM FOREST PCTWANDSWORTH PCTWESTMINSTER PCTTop 75% performing surgeries in PCT minimum score

DM 21: Percentage of patients with diabetes who have arecord of retinal screening in the past 15 months100%DM 21 - % of patients with diabetes who have a record of retinal screening in the previous 15 monthsReported QOF indicator scores for GP surgeries by London PCT2006/2007 data. Exceptions excluded.90%Individual GP surgery achievement (%)80%70%60%50%40%30%20%10%0%London PCTPortion of indicator achieved by individual surgery (centre of circle indicates score)Top 75% performing surgeries in London minimum scoreBARKING AND DAGENHAM PCTBARNET PCTBEXLEY CARE TRUSTBRENT TEACHING PCTBROMLEY PCTCAMDEN PCTCITY AND HACKNEY TEACHING PCTCROYDON PCTEALING PCTENFIELD PCTGREENWICH TEACHING PCTHAMMERSMITH AND FULHAM PCTHARINGEY TEACHING PCTHARROW PCTHAVERING PCTHILLINGDON PCTHOUNSLOW PCTISLINGTON PCTKENSINGTON AND CHELSEA PCTKINGSTON PCTLAMBETH PCTLEWISHAM PCTNEWHAM PCTREDBRIDGE PCTRICHMOND AND TWICKENHAM PCTSOUTHWARK PCTSUTTON AND MERTON PCTTOWER HAMLETS PCTWALTHAM FOREST PCTWANDSWORTH PCTWESTMINSTER PCTTop 75% performing surgeries in PCT minimum score

Healthcare for LondonDiabetes indicators for primary care trusts (PCTs) in LondonApril 2009

ContentsIntroduction …………….…………………………………………………………………..................................... 3PCT population ………………………………………………………………….................................................. 4Screening …………………………………………………………………........................................................... 6Healthcare Commission 2007 ………………………………………………………………............................... 9National Survey of People with Diabetes …………………………………………………………………............. 10Appendix A: Web references ………………………………………………………………….............................. 13Appendix B: Summary of diabetes measures for SHAs (comparison among SHAs) .................................. 14Appendix C: Summary of diabetes measures for SHAs (London SHA) ..….................................................... 15End notes ………………………………………………………………….............................................................. 172

IntroductionFollowing its establishment in 2006, NHS London commissioned Professor Lord Darzi to undertake a review of London’s health services. Theresulting report, Healthcare for London: A Framework for Action, was published on 11 July 2007 and subject to public consultation betweenNovember 2007 and March 2008. A Framework for Action proposes that London-wide best practice care pathways should be developed for longtermconditions (LTCs) resulting in a web of integrated care centred around the individual. With particular regard to diabetes care, this approachis compatible with national guidance published by the Department of Health in Working together for better diabetes care: Clinical case forchange i .The Healthcare for London Programme Board, which replaces the London Commissioning Group, has overall responsibility for the planning anddelivery of workstreams associated with A Framework for Action and one of these workstreams is diabetes. During 2008, a Healthcare forLondon diabetes (LTCs) project, involving a broad spectrum of London-based professionals and organisations, considered a standard model ofcare and associated care pathways for delivering diabetes services in the capital. PCTs are encouraged to commission locally adapted carepathways that reflect the overall model of care in future.The purpose of this report is to provide commissioners with an overview of the comparative performance of their local services by setting out theresults of key performance indicators around service provision for people with diabetes. The report uses data from a range of sources (includingthe Quality of Outcomes and the Healthcare Commission) and brings together the comparative data that is available to describe diabetes careprovided to the PCT’s population, largely for the periods 2006/2007 and 2007/2008. In order to keep the report to an accessible length only keyitems of data have been included. Extensive additional information is readily available via the web references at Appendix A.We know that London trails behind the rest of the country in terms of comparative performance on diabetes care and that some results for eachof the London PCTs demonstrate sub-optimal levels of monitored care; see tables at Appendix B (from the Yorkshire and Humber Public HealthObservatory). We acknowledge that there are characteristics of the London resident base that may contribute to this difference, such as ethnicmix and transient population. Nonetheless, we must find ways to optimise care despite this. The aim of the project is to improve care for allLondoners with diabetes and, as a consequence, improve clinical outcomes and quality of life.We are aware that some of the comparative information in this report may have been superseded by the recent figures. We hope that this briefoverview stimulates the desire to find out more within your organisation.3

London’s population (1)The age structure of London’s population is set out in the top right table. Thehorizontal bars show the male and female populations in London by agegroup. The table provides an outline of London’s age structure compared toEngland, mid 2007 ii .Projections of the estimated number of people with diabetes in London areshown in the bottom left table. The cost to the NHS of diabetes and relatedconditions such as foot ulceration, nephropathy, retinopathy and heartdisease is enormous and is only likely to grow in size. Patient numbers areforecast to increase two-thirds by 2025, meaning a large and potentiallyunsustainable drain on resources.The gap between the number of people on PCTs’ diabetes registers and theestimated actual prevalence at March 2007 is highlighted in the bottom righttable.Diabetes projections for LondonPrevalence of Diabetes: QOF 2007-08 vs estimated prevalence 2010600,0008%7%Number of people with diabetes500,000400,000300,000200,000100,00002005 2010 2015 2020 2025percentage of people with diabetes6%5%4%3%2%1%0%ENGLANDLONDONBARKING &BARNETBEXLEY CAREBRENT PCTBROMLEY PCTCAMDENCITY ANDCROYDONEALING PCTENFIELD PCTGREENWICHEstimated prevalenceHAMMERSMITHHARINGEY PCTHARROW PCTHAVERING PCTHILLINGDONHOUNSLOWISLINGTONKENSINGTONKINGSTONLAMBETH PCTLEWISHAM PCTNEWHAMREDBRIDGERICHMOND &SOUTHWARKQOF prevalenceSUTTON &TOWERWALTHAMWANDSWORTHWESTMINSTER4

London SHAENGLANDLondon SHAENGLANDLondon’s population (2)The directly age-standardised mortality rate (DSR) is thenumber of deaths that would occur in a standardpopulation (per 100,000) if that population had the agespecificrates of a given area. Direct standardisationinvolves calculating the mortality rates that would havebeen observed had the age profile of the population of thePCT been the same as that of a standard population (thatis, the European standard population). Although the DSRwill depend to some extent on the ages of the people inthat area, age standardisation facilitates comparisonsacross geographical areas by controlling for differences inthe age structure of local populations.The observed mortality rates from diabetes for thepopulation in London shows that, compared with theEngland average, London has a high rate of DSR for ‘allages’ and ‘under 75s’, for both sexes iii .20151050Directly age-standardised mortality rates (DSR) from Diabetes for all ages 2005-07 pooled5per 100.000Havering PCTKingston PCTBromley PCTGreenwich Teaching PCTBarnet PCTHillingdon PCTEnfield PCTBarking and Dagenham PCTCity and Hackney Teaching PCTTower Hamlets PCTNewham PCTHaringey Teaching PCTHammersmith and Fulham PCTEaling PCTHounslow PCTBrent Teaching PCTHarrow PCTCamden PCTIslington PCTCroydon PCTKensington and Chelsea PCTWestminster PCTLambeth PCTSouthwark PCTLewisham PCTWandsworth Teaching PCTRichmond and Twickenham PCTSutton and Merton PCTRedbridge PCTWaltham Forest PCTBexley Care TrustLondon SHAENGLANDHavering PCTKingston PCTBromley PCTGreenwich Teaching PCTBarnet PCTHillingdon PCTEnfield PCTBarking and Dagenham PCTCity and Hackney Teaching PCTTower Hamlets PCTNewham PCTHaringey Teaching PCTHammersmith and Fulham PCTEaling PCTHounslow PCTBrent Teaching PCTHarrow PCTCamden PCTIslington PCTCroydon PCTKensington and Chelsea PCTWestminster PCTLambeth PCTSouthwark PCTLewisham PCTWandsworth Teaching PCTRichmond and Twickenham PCTSutton and Merton PCTRedbridge PCTWaltham Forest PCTBexley Care TrustLondon SHA - DSR: all ages, under 75 2005/07 pooled10987654328.417.877.335.175.554.874.794.433.992.782.472.1610Males DSRall agesFemalesDSR all agesMales DSRunder 75FemalesDSR under75rate per 100.000DSR 95% Confidence Limits: Lower - Upper20151050Directly age-standardised mortality rates (DSR) from Diabetes for under 75s 2005-07 pooledper 100.000Havering PCTKingston PCTBromley PCTGreenwich Teaching PCTBarnet PCTHillingdon PCTEnfield PCTBarking and Dagenham PCTCity and Hackney Teaching PCTTower Hamlets PCTNewham PCTHaringey Teaching PCTHammersmith and Fulham PCTEaling PCTHounslow PCTBrent Teaching PCTHarrow PCTCamden PCTIslington PCTCroydon PCTKensington and Chelsea PCTWestminster PCTLambeth PCTSouthwark PCTLewisham PCTWandsworth Teaching PCTRichmond and Twickenham PCTSutton and Merton PCTRedbridge PCTWaltham Forest PCTBexley Care TrustLondon SHAENGLANDHavering PCTKingston PCTBromley PCTGreenwich Teaching PCTBarnet PCTHillingdon PCTEnfield PCTBarking and Dagenham PCTCity and Hackney Teaching PCTTower Hamlets PCTNewham PCTHaringey Teaching PCTHammersmith and Fulham PCTEaling PCTHounslow PCTBrent Teaching PCTHarrow PCTCamden PCTIslington PCTCroydon PCTKensington and Chelsea PCTWestminster PCTLambeth PCTSouthwark PCTLewisham PCTWandsworth Teaching PCTRichmond and Twickenham PCTSutton and Merton PCTRedbridge PCTWaltham Forest PCTBexley Care Trust

Screening (1)HbA1c or ‘average blood glucose level’ is a critical measure because it iscurrently one of the best ways to check if diabetes is under control iv .TheHbA1C test informs how high the blood glucose of a person has been onaverage over the previous 8-12 weeks. A normal non-diabetic HbA1C is 3.5-5.5%. In diabetes about 6.5% is considered to be good.London reports offering 95.7% HbA1C screening, with an exception rate of3.37% and 95.37% as the total achievement against the indicator (DM05,QOF 2007-08). Also, the percentage of patients in which diabetes andHbA1C is 10 or less is 93.17%, with an exception rate of 6.83% and 89.67%as the total achievement against the indicator (DM07, QOF 2007-08). It isrecommended as a quality clinical indicator ‘the number of people withdiabetes in primary care with HbA1c less than 7.5%’. Regarding DM20, thepercentage of patients with diabetes that are registered to have received thelast HbA1c in 2007-2008 is 87.85%, with a 12.15% exception rate and63.43% as the total achievement against indicator (QOF 2007-08). The mainaim of treating both types of diabetes is to achieve blood glucose, bloodpressure and cholesterol levels as near to normal as possible.1009080706050403020100DM05 Diabetes and HbA1c checked in 15 months, QOF April2007- March 2008percentage (%)London SHABarking and Dagenham PCTBarnet PCTBexley Care TrustBrent PCTBromley PCTCamden PCTCity and Hackney PCTCroydon PCTEaling PCTEnfield PCTGreenwich PCTHammersmith and Fulham PCTHaringey PCTHarrow PCTHavering PCTHillingdon PCTHounslow PCTIslington PCTKensington and Chelsea PCTKingston PCTLambeth PCTLewisham PCTNewham PCTRedbridge PCTRichmond and Twickenham PCTSouthwark PCTSutton and Merton PCTTower Hamlets PCTWaltham Forest PCTWandsworth PCTWestminster PCT100DM07 Diabetes and HbA1c is 10 or less, QOF April 2007-March 20089080706050403020100Total achievement against indicator Total in Diabetes Register Proportion of exceptionsLondon SHABarking and Dagenham PCTBarnet PCTBexley Care TrustBrent PCTBromley PCTCamden PCTCity and Hackney PCTCroydon PCTEaling PCTEnfield PCTGreenwich PCTHammersmith and Fulham PCTHaringey PCTHarrow PCTHavering PCTHillingdon PCTHounslow PCTIslington PCTKensington and Chelsea PCTKingston PCTLambeth PCTLewisham PCTNewham PCTRedbridge PCTRichmond and Twickenham PCTSouthwark PCTSutton and Merton PCTTower Hamlets PCTWaltham Forest PCTWandsworth PCTWestminster PCTpercentage (%)Total achievement against indicator Total in Diabetes Register Proportion of exceptions1009080706050403020100DM20 The percentage of patients with diabetes in whom the last HbA1c orequivalent in the previous 15 months, QOF April 2007-March 2008percentage (%)London SHABarking and Dagenham PCTBarnet PCTBexley Care TrustBrent PCTBromley PCTCamden PCTCity and Hackney PCTCroydon PCTEaling PCTEnfield PCTGreenwich PCTHammersmith and Fulham PCTHaringey PCTHarrow PCTHavering PCTHillingdon PCTHounslow PCTIslington PCTKensington and Chelsea PCTKingston PCTLambeth PCTLewisham PCTNewham PCTRedbridge PCTRichmond and Twickenham PCTSouthwark PCTSutton and Merton PCTTower Hamlets PCTWaltham Forest PCTWandsworth PCTWestminster PCTTotal achievement against indicator Total in Diabetes Register Proportion of exceptions6

Screening (2)Body mass index (BMI) gives a measure which can be used to determine if aperson is underweight, of normal weight, overweight or obese v . The risk of diabetesincreases with increasing BMI values in men and women vi . Without the interventionof a healthy diet and appropriate exercise, obesity may develop into type 2 diabetesover a relatively short period of time. London reports offering 96.77% screening ofdiabetes with BMI in the last 15 months, with an exception rate of 3.23% and94.70% as the total achievement against the indicator (DM02, QOF 2007-08).Regarding blood pressure (BP), two levels of BP are measured - the higher, orsystolic, pressure which occurs each time the heart pushes blood into the vessels,and the lower, or diastolic, pressure which occurs when the heart rests. A reading of120/80 is the normal range (where 120 is the systolic and 80 is the diastolicpressure). Blood pressure is one of the recommended clinical quality indicators(less than 145/85 mmHg in the top 25th centile of national performance on QOFscores). London reports offering 93.03% screening for diabetes and BP145/85 orless, with an exception rate of 6.97% and 79.44% as the total achievement againstthe indicator (DM 12, QOF 2007-08). Also, London reports offering 98.32% diabetesand BP check, with an exception rate of 1.68% and 98.17% as the totalachievement against the indicator (DM11, QOF 2007-08).1009080706050403020100DM02 Diabetes with BMI in last 15 months, QOF April 2007-March 2008percentage (%)London SHABarking and Dagenham PCTBarnet PCTBexley Care TrustBrent PCTBromley PCTCamden PCTCity and Hackney PCTCroydon PCTEaling PCTEnfield PCTGreenwich PCTHammersmith and Fulham PCTHaringey PCTHarrow PCTHavering PCTHillingdon PCTHounslow PCTIslington PCTKensington and Chelsea PCTKingston PCTLambeth PCTLewisham PCTNewham PCTRedbridge PCTRichmond and Twickenham PCTSouthwark PCTSutton and Merton PCTTower Hamlets PCTWaltham Forest PCTWandsworth PCTWestminster PCT1009080706050403020100DM11 Diabetes and BP check in 15 months, QOF April 2007-March 2008Total achievement against indicator Total in Diabetes Register Proportion of exceptionsLondon SHABarking and Dagenham PCTBarnet PCTBexley Care TrustBrent PCTBromley PCTCamden PCTCity and Hackney PCTCroydon PCTEaling PCTEnfield PCTGreenwich PCTHaringey PCTHarrow PCTHavering PCTHillingdon PCTHounslow PCTIslington PCTKensington and Chelsea PCTKingston PCTLambeth PCTLewisham PCTNewham PCTRedbridge PCTRichmond and Twickenham PCTSouthwark PCTSutton and Merton PCTTower Hamlets PCTWaltham Forest PCTWandsworth PCTWestminster PCTpercentage (%)Total achievement against indicator Total in Diabetes Register Proportion of exceptions1009080706050403020100DM12 Diabetes and BP 145/85 or less, QOF April 2007-March2008percentage (%)London SHABarking and Dagenham PCTBarnet PCTBexley Care TrustBrent PCTBromley PCTCamden PCTCity and Hackney PCTCroydon PCTEaling PCTEnfield PCTGreenwich PCTHammersmith and Fulham PCTHaringey PCTHarrow PCTHavering PCTHillingdon PCTHounslow PCTIslington PCTKensington and Chelsea PCTKingston PCTLambeth PCTLewisham PCTNewham PCTRedbridge PCTRichmond and Twickenham PCTSouthwark PCTSutton and Merton PCTTower Hamlets PCTWaltham Forest PCTWandsworth PCTWestminster PCTTotal achievement against indicator Total in Diabetes Register Proportion of exceptions7

Screening (3)Diabetic retinopathy is damage to the retina caused by complications ofdiabetes mellitus. As the most common cause of blindness in people of workingage in the UK, the lack of treatment will usually lead to a loss of sight within twoyears and, in some cases, within 12 months. Early detection and proper andvigilant treatment and monitoring of the eyes is said to halve the risk of sightloss vii . It affects up to 80% of all diabetics who have had diabetes for 10 yearsor more viii . London reports offering 92.51% retinal screening, with an exceptionrate of 7.49% and 86.51% of achievement against the indicator (DM21, QOF2007-08).In addition, high cholesterol levels are as serious as high blood pressure ix .Heart disease and stroke, both of which have been linked to high cholesterol inboth men and women, are two of the leading causes of death for diabetics. Thegeneral recommended level for the total cholesterol for people with type 2diabetes is 5 mmol/L or less. London reports offering 96.96% cholesterolscreening, with an exception rate of 3.04% and 95.01% of achievement againstthe indicator (DM16, QOF 2007-08). London reports offering 90.60% cholesterolscreening, with an exception rate of 9.40% and 80.57% of achievement againstthe indicator (DM17, QOF 2007-08).1009080706050403020100DM21 The percentage of patients with diabetes who have a record of retinal screeningin the previous 15 months, QOF April 2007- March 2008percentage (%)London SHABarking and Dagenham PCTBarnet PCTBexley Care TrustBrent PCTBromley PCTCamden PCTCity and Hackney PCTCroydon PCTEaling PCTEnfield PCTGreenwich PCTHammersmith and Fulham PCTHaringey PCTHarrow PCTHavering PCTHillingdon PCTHounslow PCTIslington PCTKensington and Chelsea PCTKingston PCTLambeth PCTLewisham PCTNewham PCTRedbridge PCTRichmond and Twickenham PCTSouthwark PCTSutton and Merton PCTTower Hamlets PCTWaltham Forest PCTWandsworth PCTWestminster PCTDM16 Diabetes and Cholesterol check in last 15 months, QOF April2007- March 20081009080706050403020100Total achievement against indicator Total in Diabetes Register Proportion of exceptionsLondon SHABarking and Dagenham PCTBarnet PCTBexley Care TrustBrent PCTBromley PCTCamden PCTCity and Hackney PCTCroydon PCTEaling PCTEnfield PCTGreenwich PCTHaringey PCTHarrow PCTHavering PCTHillingdon PCTHounslow PCTIslington PCTKensington and Chelsea PCTKingston PCTLambeth PCTLewisham PCTNewham PCTRedbridge PCTRichmond and Twickenham PCTSouthwark PCTSutton and Merton PCTTower Hamlets PCTWaltham Forest PCTWandsworth PCTWestminster PCTpercentage (%)Total achievement against indicator Total in Diabetes Register Proportion of exceptions1009080706050403020100DM17 Diabetes and Cholesterol 5.0 or less, QOF April 2007-March 2008percentage (%)London SHABarking and Dagenham PCTBarnet PCTBexley Care TrustBrent PCTBromley PCTCamden PCTCity and Hackney PCTCroydon PCTEaling PCTEnfield PCTGreenwich PCTHammersmith and Fulham PCTHaringey PCTHarrow PCTHavering PCTHillingdon PCTHounslow PCTIslington PCTKensington and Chelsea PCTKingston PCTLambeth PCTLewisham PCTNewham PCTRedbridge PCTRichmond and TwickenhamSouthwark PCTSutton and Merton PCTTower Hamlets PCTWaltham Forest PCTWandsworth PCTWestminster PCTTotal achievement against indicator Total in Diabetes Register Proportion of exceptions8

Healthcare Commission 2007, Managing diabetes: improving services forpeople with diabetesAlthough the overall performance in diabetes care at a pan-London level ‘meetsminimum requirements’ and ‘reasonable expectations of patients and the public’ x ,there are areas that still need improvement, notably the testing and measurements ofadult diabetics and greater training and support for patient self-management.Despite having received a score of two in this area, only 13.9% of respondents in thenational survey of people with diabetes had participated in an education and trainingcourse on how to help manage their diabetes (page 11, Q.42). Additionally, 32.3% ofrespondents said that in the previous 12 months, when receiving care for diabetes,they ‘rarely or not at all’ agreed to plan to manage their diabetes for the following 12months (page 11, Q.12g).The vast majority of London PCTs had an overall score oftwo. Compared with the England pattern of distribution, London PCTs do not achievethe same level of attainment at higher scores.Pan-LondonAverageOverallscoreAdultswithdiabetesarelookingaftertheirconditionAdults withdiabetes feelsupported toself carethrough careplanning,informationand educationAdults withdiabetes havekey tests andmeasurementscarried out2 2 2 2percentage (%)100%90%80%70%60%50%40%30%20%10%0%Healthcare Commission - Performance scores:London SHA, England25.0%71.9% 73.0%3.1%0.0%Q36 London SHA11.8%10.6%ENG England4.6%1 Performance that does notmeet minimum requirements orthe reasonable expectations ofpatients and the public2 Performance that meetsminimum requirements and thereasonable expectations ofpatients and the public3 Performance that goesbeyond minimum requirementsand the reasonableexpectations of patients and thepublic4 Performance that goes wellbeyond minimum requirementsand the reasonableexpectations of patients and thepublic. A leader in this aspect ofperformance43210Comparison of the Overall Performance Score to other London PCTsB arking & Dagenham P CTBarnet PCTBexley CTBromley PCTCam den P CTCity & Hackney TPCTCroydon P CTE aling P CTE nfield P CTG reenwich TP CTHam m ersm ith & Fulham P CTHaringey TP CTHarrow PCTHavering P CTHillingdon P CTHounslow P CTIslington P CTK ensington & Chelsea P CTK ingston P CTLam beth P CTLewisham P CTNewham P CTRedbridge P CTRichm ond & Twickenham P CTS outhwark P CTS utton & M erton P CTTower Ham lets PCTW altham Forest P CTW e s tm in s te r P C TSurrey PCTB rent TP CTW andsworth P CT9

National survey of people with diabetes 2006-2007 (1)In 2006, the Health Commission commissioned the National Centre forSocial Research to run a national survey of people with diabetes xi . Thesurvey assessed whether people with diabetes received the care, treatmentand information they needed to manage their diabetes well and reduce therisk of complications xii .The survey indicated that, on average, for services administered in Londonthe percentage of respondents who have type 2 diabetes is 70.4%,compared to a 68.8% England average. Plus, the percentage of those whohave type 1 diabetes is 63.5%; which is similar to the England average.However, the percentage of those unsure whether they had type 1 or 2diabetes is 24.3% compared to a 17.3% England average (Q.6).percentage (%)100908070605040302010Q6. Do you have Type 1 or Type 2 diabetes?68.817.314.0 12.163.524.3Regarding the places where respondents usually went for their diabetescheck up, the percentage of respondents in London who attended thehospital clinic was 27.9%, compared to an England average of 19%. Plus,the percentage of those who went to their doctor’s surgery was 68.9%, incontrast to a 78.3% England average (Q.7).0ENG ENGLANDQ36 London SHAType 1 Type 2 Don't knowQ7. Where do you go for your diabetes check-up,where your test results and treatment are reviewed?10090807078.368.9percentage (%)605040302019.027.9100ENG ENGLAND1.4 1.4 1.5 1.7Q36 London SHAMy doctor's surgery The hospital clinic Somewhere else It varies10

National survey of people with diabetes 2006-2007 (2)Approximately 74% percent of respondents in London had not been given thephone number of a doctor or nurse to contact after hours about their diabetes(Q.13).The relatively small proportion of respondents who had ever participated ineducation and training is a great concern, and echoes the Project UserGroup’s view that strengthened education for all is an essential component ofdiabetes care.HbA1 (Q.14), blood pressure (Q.21), cholesterol (Q.23), and bare feet (Q.26)examinations are critical regular monitoring mechanisms to assess theprogress of disease and efficacy of management to minimise complications.Results from the survey show that London was largely comparable to theEngland average, though the latter examination shows a gap of approximately6% between the England average and the London SHA average (p.12). Moreresults from the survey are outlined overleaf.percentage (%)1009080706050403020100Q12g) Thinking about the last 12 months, when youreceived care for your diabetes…did you agree a plan tomanage your diabetes over the next 12 months?30.422.7ENG ENGLAND46.932.324.9Q36 London SHARarely or not at all Some of the time Almost always42.7percentage (%)100908070605040302010Q13. Have you been given the phone number of a doctor ornurse who you can contact about your diabetes after hours(that is, on weekends and after 6pm on weeknights)?73.7 73.713.2 12.19.1 10.86.78.1percentage (%)100908070605040302010Q42. Have you ever participated in an education or trainingcourse on how to help you manage your diabetes?10.589.513.986.10ENG ENGLANDQ36 London SHA0ENG ENGLANDQ36 London SHAYes,evenings Yes, nights Yes, weekends NoYesNo11

National survey of people with diabetes 2006-2007 (3)10090Q14. In the last 12 months have you had a special blood testto look at your long-term or ‘average’ blood glucose level?90.686.810090Q21. In the last 12 months, has a doctor or nursetaken your blood pressure?98.1 97.48080percentage (%)706050403020100ENG England9.413.2Q36 London SHApercentage (%)706050403020100ENG England1.9 2.6Q36 London SHAYesNoYesNo1009080Q23. In the last 12 months has a doctor or nursecarried out a cholesterol test?88.885.91009080Q26. In the last 12 months have you had your barefeet examined?83.076.27070percentage (%)60504030201011.214.1percentage (%)60504030201017.023.80ENG EnglandQ36 London SHA0ENG EnglandQ36 London SHAYesNoYesNo12

Appendix AWeb referencesYorkshire & Humber Public Health Observatoryhttp://www.yhpho.org.uk/Department of Health: diabetes carehttp://www.dh.gov.uk/en/AdvanceSearchResult/index.htm?searchTerms=Diabetic%20careDepartment of Health: diabetes serviceshttp://www.dh.gov.uk/en/AdvanceSearchResult/index.htm?searchTerms=Diabetes%20servicesHealthcare Commission: national survey of people with diabeteshttp://www.healthcarecommission.org.uk/nationalfindings/surveys/healthcareprofessionals/surveysofnhspatients/longtermconditionsdiabetes.cfmHealthcare Commission: national survey of people with diabetes: questionnairehttp://www.healthcarecommission.org.uk/_db/_documents/Questionnaire_Diabetes_survey_2006_v10_200608042427.pdfHealthcare Commission: service review of diabeteshttp://www.healthcarecommission.org.uk/healthcareproviders/serviceproviderinformation/reviewsandstudies/servicereviews/improvementre/diabetes.cfmHospital episode statistics (HES) - HES Onlinehttp://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=537Picker Institutehttp://www.pickereurope.org/The National Centre for Social Research (NatCen): health and lifestyles publicationshttp://www.natcen.ac.uk/natcen/pages/op_healthandlifestyles.htmThe quality and outcomes framework (QOF)http://www.ic.nhs.uk/services/qofThe quality and outcomes framework (QOF): statistics and data collections: diabeteshttp://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/diabetesUK Statistics Authorityhttp://www.statistics.gov.uk/National Centre for Health Outcomes Development (NCHOD)http://www.nchod.nhs.uk/The Global Diabetes Communityhttp://www.diabetes.co.uk13

Appendix BSummary of diabetes measures data for Strategic Health Authorities (Comparison among SHAs). Last updated 5th January 2009.Sources: Compendium of Clinical and Health Indicators, Health and Social Care Information Centre, Health Surveys for England, The Information Centre for health and social care, Prescribing Support Unit, HealthcareCommission Survey of People with Diabetes 2006Syntheticestimates ofobesityHSE2003/05PreventionIdentification &DiagnosisBM 4.01 BM4.02 BM4.03QOF0708 %pateients withrecordof BodyMassIndexQOF0708PatientsofferedretinalscreeningInitial assessment& management% ofpatientsthatwere asinvolved astheywant tobe intheircareApproximationtoBM4.09% ofpatientswhohaveattended aneducation ortrainingprogramme 1QOF0708%patientswithrecordofmicroalbuminuriatestingServices for Complications Ongoing CareBM4.06 BM4.07 BM4.04 BM4.05QOF 0708% patientswithproteinuriaor microalbuminuria treatedwith ACEinhibitorsor A2antagonistsQOF0708%patientswithrecordofpresence/absence ofperipheralpulseQOF0708%patientswithrecordofneuropathytestingEngland 23.63% 94.93% 90.19% 81.71% 10.51% 86.53% 89.07% 91.07% 90.76% 97.09% 66.80% 92.32% 96.13% 83.20% 98.49% 79.35% 39.32% 3.81 £76.85QOF0708%patientswhohave arecordofHbA1cQOF0708%patients whohave aHbA1cof lessthan7.5QOF0708%patientswhohave aHbA1cof 10.0or lessQOF0708%patientswithrecordof totalcholesterolQOF0708%patientswhoselastmeasured totalcholesterol of5 orlessQOF0708%patientswithrecordofbloodpressureQOF0708%patientswithrecordofbloodpressure of145/85or lessApproximationtoBM4.12% ofpatientsthatalmostalwaysdiscussgoalsfor theirdiabetesmanagement 2Numberof itemsprescribed perregisteredpersonwithdiabetesPrescribingNetingredient costofdiabeticitemsperpersonwithdiabetesEastMidlandsEast ofEngland25.61% 94.75% 90.26% 83.33% 9.83% 87.56% 89.43% 91.22% 90.79% 97.68% 66.47% 92.81% 96.01% 83.73% 98.63% 80.10% 42.48% 3.86 £75.9724.83% 94.44% 91.94% 81.47% 9.07% 84.27% 86.75% 90.94% 90.64% 96.85% 64.73% 92.10% 95.60% 82.03% 98.34% 79.02% 38.09% 3.95 £79.47London 18.44% 94.55% 86.50% 76.31% 13.87% 84.93% 88.68% 90.81% 90.48% 95.37% 63.34% 89.67% 94.85% 80.43% 98.01% 79.44% 33.04% 3.57 £70.65North East 25.20% 95.72% 92.13% 84.08% 8.96% 89.96% 90.01% 91.34% 90.97% 98.18% 69.55% 93.82% 97.34% 84.68% 98.90% 79.67% 44.35% 3.80 £75.19North West 24.48% 95.01% 90.05% 82.85% 10.21% 87.38% 90.40% 89.85% 89.65% 97.28% 70.64% 93.13% 96.34% 84.70% 98.54% 80.65% 40.73% 3.97 £79.44South EastCoast21.79% 94.85% 92.70% 82.64% 11.19% 87.38% 89.09% 91.75% 91.48% 97.06% 68.97% 92.86% 96.11% 83.37% 98.45% 79.23% 39.75% 3.74 £83.16South Central 22.17% 95.48% 92.63% 83.82% 10.77% 86.84% 89.53% 91.82% 91.58% 97.22% 64.16% 92.17% 96.50% 83.10% 98.54% 79.35% 39.48% 3.67 £78.67South West 23.24% 95.21% 90.99% 84.51% 14.81% 87.70% 88.99% 92.00% 91.69% 98.07% 66.58% 93.45% 97.20% 84.28% 98.74% 78.69% 43.92% 3.70 £71.60WestMidlandsYorkshireand theHumber26.50% 94.93% 89.22% 80.01% 7.33% 86.76% 89.32% 91.55% 91.23% 97.05% 67.10% 92.14% 96.21% 83.95% 98.42% 77.78% 36.53% 3.88 £80.6224.08% 95.04% 89.77% 82.22% 7.28% 85.01% 89.42% 90.59% 90.22% 97.67% 67.48% 92.96% 96.39% 83.31% 98.77% 79.37% 39.90% 3.89 £76.17Significantly worse than England at 95% No significant differenceSignificantly better than England at 95%14

Appendix CSummary of diabetes measures data for Strategic Health Authorities (London SHA). Last updated 5th January 2009.PCTs A – HeSources: Compendium of Clinical and Health Indicators, Health and Social Care Information Centre, Health Surveys for England, The Information Centre for health and social care, Prescribing Support Unit, HealthcareCommission Survey of People with Diabetes 2006PreventionSyntheticestimates ofobesityHSE2003/05Identification&DiagnosisBM 4.01 BM4.02 BM4.03QOF0708 %pateients withrecordof BodyMassIndexQOF0708PatientsofferedretinalscreeningInitial assessment& management% ofpatientsthatwere asinvolved astheywant tobe intheircareApproximationtoBM4.09% ofpatientswhohaveattended aneducation ortrainingprogramme 1QOF0708%patientswithrecordofmicroalbuminuriatestingServices for Complications Ongoing careBM4.06 BM4.07 BM4.04 BM4.05QOF 0708% patientswithproteinuriaor microalbuminuria treatedwith ACEinhibitorsor A2antagonistsQOF0708%patientswithrecordofpresence/absence ofperipheralpulseQOF0708%patientswithrecordofneuropathytestingQOF0708%patientswhohave arecordofHbA1cQOF0708%patientswhohave aHbA1cof lessthan 7.5QOF0708%patientswhohave aHbA1cof 10.0or lessQOF0708%patientswithrecordof totalcholesterolQOF0708%patientswhoselastmeasured totalcholesterol of5 orlessQOF0708%patientswithrecordofbloodpressureQOF0708%patientswithrecordofbloodpressure of145/85or lessApproximationtoBM4.12PrescribingEngland 23.63% 94.93% 90.19% 81.71% 10.51% 86.53% 89.07% 91.07% 90.76% 97.09% 66.80% 92.32% 96.13% 83.20% 98.49% 79.35% 39.32% 3.81 £76.85London SHA 18.44% 94.55% 86.50% 76.31% 13.87% 84.93% 88.68% 90.81% 90.48% 95.37% 63.34% 89.67% 94.85% 80.43% 98.01% 79.44% 33.04% 3.57 £70.65B&D PCT 23.94% 96.00% 87.29% 70.57% 13.33% 82.84% 90.46% 93.45% 93.36% 95.69% 61.52% 88.65% 95.78% 81.30% 98.44% 80.70% 23.80% 4.01 £76.56Barnet PCT 16.83% 93.96% 89.93% 76.73% 6.07% 86.64% 88.06% 91.52% 91.04% 96.00% 67.07% 91.29% 95.57% 82.48% 97.95% 79.32% 37.03% 3.25 £70.48Bexley Care Trust 21.49% 95.61% 92.03% 80.24% 28.01% 86.70% 89.55% 91.21% 90.98% 95.69% 73.74% 92.56% 94.78% 79.30% 98.04% 79.98% 36.23% 3.22 £69.52Brent TPCT 21.59% 94.57% 86.93% - - 87.53% 90.97% 91.30% 90.96% 95.29% 62.80% 89.34% 95.01% 80.21% 97.70% 79.57% - 3.17 £62.36Bromley PCT 17.63% 94.65% 88.25% 83.10% 16.46% 87.37% 86.93% 91.48% 91.24% 96.42% 69.27% 93.02% 96.23% 81.84% 98.33% 77.49% 38.52% 2.98 £73.02Camden PCT 13.32% 94.85% 79.64% 73.16% 9.31% 84.99% 84.72% 89.55% 89.14% 95.51% 64.90% 89.95% 95.45% 82.46% 98.46% 79.09% 33.85% 3.03 £63.74C&H TPCT 18.41% 96.12% 87.71% 81.19% 20.73% 87.93% 89.51% 93.32% 93.16% 96.82% 58.35% 87.90% 96.56% 80.79% 98.86% 78.85% 33.96% 3.74 £74.11Croydon PCT 19.29% 94.77% 93.18% 77.36% 11.52% 96.68% 89.70% 91.32% 91.10% 95.97% 61.30% 89.53% 94.36% 79.42% 98.26% 78.65% 33.90% 3.42 £66.49Ealing PCT 20.00% 94.13% 90.06% 66.92% 6.93% 85.26% 86.30% 90.97% 90.84% 94.51% 59.76% 88.48% 94.20% 81.25% 97.87% 79.25% 23.03% 3.30 £64.58Enfield PCT 20.15% 92.13% 83.24% 74.67% 5.28% 83.79% 83.03% 86.80% 85.20% 94.09% 66.62% 88.67% 93.75% 79.18% 97.24% 76.30% 29.28% 3.59 £80.15Greenwich PCT 20.19% 94.57% 85.88% 76.83% 27.94% 78.84% 88.59% 87.44% 86.91% 94.14% 53.72% 85.72% 93.40% 76.74% 97.39% 76.95% 34.57% 4.10 £69.04H&f PCT 15.39% 93.39% 83.37% 75.90% 7.91% 85.68% 91.81% 90.07% 89.99% 95.23% 65.66% 89.73% 94.51% 78.85% 97.35% 78.07% 30.35% 3.68 £80.97Haringey TPCT 17.86% 95.38% 85.12% 70.89% 10.52% 81.57% 80.40% 89.56% 87.85% 94.45% 66.52% 88.48% 94.67% 79.80% 97.71% 77.39% 32.74% 3.66 £64.63Harrow PCT 19.13% 94.33% 91.17% 80.54% 13.94% 89.24% 92.21% 92.72% 92.47% 96.19% 63.25% 91.15% 95.74% 80.02% 97.88% 78.96% 37.21% 4.19 £61.08Havering PCT 22.05% 95.27% 86.51% 76.09% 7.39% 85.81% 91.15% 91.08% 91.05% 95.62% 65.21% 90.53% 95.23% 83.19% 97.91% 81.42% 27.23% 3.60 £71.73Numberof itemsprescribed perregisteredpersonwithdiabetesNetingredient costofdiabeticitemsperpersonwithdiabetesSignificantly worse than England at 95% No significant difference Significantly better than England at 95%15

PCTs Hi – ZSources: Compendium of Clinical and Health Indicators, Health and Social Care Information Centre, Health Surveys for England, The Information Centre for health and social care, Prescribing Support Unit, HealthcareCommission Survey of People with Diabetes 2006PreventionSyntheticestimates ofobesityHSE2003/05Identification&DiagnosisBM 4.01 BM4.02 BM4.03QOF0708 %pateients withrecordof BodyMassIndexQOF0708PatientsofferedretinalscreeningInitial assessment& management% ofpatientsthatwere asinvolved astheywant tobe intheircareApproximationtoBM4.09% ofpatientswhohaveattended aneducation ortrainingprogramme 1QOF0708%patientswithrecordofmicroalbuminuriatestingServices for Complications Ongoing careBM4.06 BM4.07 BM4.04 BM4.05QOF 0708% patientswithproteinuriaor microalbuminuria treatedwith ACEinhibitorsor A2antagonistsQOF0708%patientswithrecordofpresence/absence ofperipheralpulseQOF0708%patientswithrecordofneuropathytestingQOF0708%patientswhohave arecordofHbA1cQOF0708%patientswhohave aHbA1cof lessthan 7.5QOF0708%patientswhohave aHbA1cof 10.0or lessQOF0708%patientswithrecordof totalcholesterolQOF0708%patientswhoselastmeasured totalcholesterol of5 orlessQOF0708%patientswithrecordofbloodpressureQOF0708%patientswithrecordofbloodpressure of145/85or lessApproximationtoBM4.12PrescribingEngland 23.63% 94.93% 90.19% 81.71% 10.51% 86.53% 89.07% 91.07% 90.76% 97.09% 66.80% 92.32% 96.13% 83.20% 98.49% 79.35% 39.32% 3.81 £76.85London SHA 18.44% 94.55% 86.50% 76.31% 13.87% 84.93% 88.68% 90.81% 90.48% 95.37% 63.34% 89.67% 94.85% 80.43% 98.01% 79.44% 33.04% 3.57 £70.65Hillingdon PCT 20.92% 93.84% 91.87% 79.12% 2.85% 85.86% 90.68% 88.76% 88.54% 95.24% 60.52% 89.33% 94.38% 81.60% 97.73% 80.17% 29.91% 3.85 £73.00Hounslow PCT 21.46% 92.89% 87.27% 70.95% 13.43% 84.22% 91.69% 88.87% 88.85% 94.55% 61.37% 88.67% 94.07% 78.04% 97.67% 80.23% 25.67% 3.70 £75.01Islington PCT 15.96% 94.91% 84.36% 71.47% 15.72% 89.06% 90.90% 92.76% 92.56% 96.28% 67.91% 91.41% 95.73% 82.77% 98.60% 82.85% 31.45% 3.23 £71.36K&C PCT 13.09% 96.35% 89.21% 79.00% 8.80% 88.65% 78.73% 93.37% 93.32% 95.41% 64.25% 90.31% 94.76% 81.22% 98.03% 81.22% 36.08% 3.47 £75.75Kingston PCT 17.27% 95.45% 94.63% 77.71% 8.62% 94.70% 91.11% 93.23% 92.99% 97.20% 67.41% 93.70% 96.73% 82.01% 98.66% 80.72% 36.70% 3.21 £66.64Lambeth PCT 18.56% 94.11% 85.03% 85.34% 20.38% 86.05% 87.39% 90.49% 90.22% 95.52% 64.27% 89.51% 94.44% 80.33% 98.05% 78.76% 40.62% 3.91 £67.72Lewisham PCT 19.22% 91.61% 72.66% 79.86% 21.91% 82.72% 87.67% 87.06% 86.30% 94.09% 62.29% 87.64% 92.86% 75.66% 97.19% 74.75% 41.68% 3.76 £66.11Newham PCT 21.24% 96.70% 87.00% 77.79% 19.29% 85.94% 91.07% 93.85% 93.66% 94.94% 57.21% 87.33% 94.71% 80.78% 98.65% 83.50% 32.06% 4.09 £82.22Redbridge PCT 19.60% 94.56% 81.52% 75.88% 24.50% 80.87% 87.63% 88.33% 88.36% 93.96% 61.22% 88.64% 94.23% 79.19% 97.73% 81.10% 31.98% 3.33 £72.22R&T PCT 14.33% 95.64% 91.94% 79.88% 9.86% 90.51% 93.81% 93.97% 93.99% 97.94% 67.67% 94.03% 96.61% 81.52% 99.05% 77.83% 39.93% 3.59 £68.26Southwark PCT 19.73% 93.76% 86.73% 72.85% 11.74% 84.65% 87.89% 88.68% 88.56% 95.47% 63.24% 89.14% 94.40% 80.55% 97.82% 77.19% 35.56% 3.53 £66.21S&M PCT 18.26% 94.58% 88.26% 78.78% 23.95% 86.47% 92.60% 91.62% 91.42% 95.65% 63.43% 90.17% 95.18% 79.83% 98.13% 79.11% 40.71% 3.45 £71.37TH PCT 11.93% 95.37% 74.93% 78.44% 14.36% 61.22% 90.91% 91.65% 91.45% 96.09% 58.85% 89.98% 95.85% 85.74% 98.60% 82.13% 33.18% 4.05 £75.41Waltham Forest 20.22% 94.64% 84.74% 75.64% 5.89% 87.04% 92.87% 91.60% 91.63% 94.94% 70.18% 91.24% 94.73% 78.94% 97.78% 82.42% 31.80% 3.38 £78.84Wandsworth PCT 14.20% 94.56% 87.78% - - 85.01% 92.14% 91.05% 90.83% 95.79% 60.67% 90.09% 94.51% 79.51% 98.27% 78.74% - 3.70 £69.05Westminster PCT 14.72% 94.29% 86.43% 73.46% 16.73% 85.89% 86.25% 90.85% 89.67% 94.48% 62.74% 88.87% 94.64% 81.92% 97.83% 79.57% 27.85% 3.47 £71.77Numberof itemsprescribed perregisteredpersonwithdiabetesNetingredient costofdiabeticitemsperpersonwithdiabetesSignificantly worse than England at 95% No significant difference Significantly better than England at 95%16

Endnotesi Department of Health, May 2007ii Source: NCHOD: www.nchod.nhs.ukiii Data are based on the original underlying cause of death. Data are based on the latest revisions of ONS population estimates for the respectiveyears, current as at 29 September 2008. ONS data suggest that selective migration over time can contribute to a widening of health inequalities –such as in limiting long-term illness. This effect is, however, hard to capture in the tracking of trends against the life expectancy element of thehealth inequalities target. Measuring trends in health inequalities using area-based measures is complicated by the fact that the population ofareas changes over time.iv Glucose sticks to the haemoglobin to make a 'glycosylated haemoglobin' molecule, called haemoglobin A1C or HbA1C. The more glucose inthe blood, the more haemoglobin A1C or HbA1C will be present in the blood. Red cells live for 8 -12 weeks before they are replaced.v The body mass index (BMI), or Quetelet index, is a statistical measurement which compares a person's weight and height.vi NAASO – The Obesity Society: http://www.obesityonline.org/slides/slide01.cfm?q=abdominal+fat&dpg=3vii Dept of Health publications and statistics. Q3 2007/08 - Patients with diabetes offered screening for diabetic retinopathy.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083895viii PJ Kertes, TM Johnson Eds. Evidenced Based Eye Care (c) 2007ix It exits in tow forms: the ‘good’ High Density Lipoprotein (HDL) and, the ‘bad’ Low Density Lipoprotein (LDL).x This service review of diabetes was undertaken by the Health Commission. All 152 new PCTs participated in the review and received an overallscore, which was broken down into scores for the three criteria. The measures used in this review were derived from aspects of the DiabetesNational Service Framework, Department of Health Standards for Better Health, and relevant NICE guidelines, as well as key issues raised inconsultation with patients and health professionals. For more information on how this review was developed, what it assessed and how please goto:http://www.healthcarecommission.org.uk/guidanceforhealthcarestaff/nhsstaff/annualhealthcheck/reviewsandstudiesofservices/2006/07/diabetes.cfmxi For reasons of space, the questions presented have been reduced. The full version can be found at:http://www.healthcarecommission.org.uk/guidanceforhealthcarestaff/nhsstaff/nhsstaffandpatientsurveys/patientsurveys/servicesforpeoplewithdiabetes.cfmxii The results of the survey were used in the Healthcare Commission’s service review of diabetes (Healthcare Commission 2007: ManagingDiabetes, Improving Services for People with Diabetes).17

Healthcare for LondonDiabetes quality and outcomes framework targetsetting 2008/09: An example framework for PCTsAdapted from work by Sue Hogarth and Stephen DoreyJune 20081

1. IntroductionThis document provides an example to PCTs for measuring performance against the quality andoutcomes framework (QOF) and for setting targets to improve future performance. The datacontained in this document has been supplied by a PCT within London, referred to as ‘XX PCT’. Alldata has been anonymised.An analysis of 2006/07 and 2007/08 quality and outcomes framework (QOF) data suggests thatthere has been an overall improvement in diabetic care in XX PCT. This is shown in columns ‘XXPCT 06/07’, ‘XX PCT 07/08’ and ‘Change (%)’ in table 1 below. For a full explanation of this table,please see the methodology section on page 2.As table 1 shows, in 2006/07 four of the eight indicator achievements were still below that ofLondon and England (see column ‘Comment 06/07’). In order to build on the improvementsachieved since 2006/07 the PCT has developed targets for 2008/09 (see column ‘Target 08/09’) tosignificantly improve health outcomes for diabetic patients in the PCT.England London XX PCT06/07 1 06/07 2 06/07XX PCT07/08Change(%)Comment(06/07)Registersize1,961,976 300,567 9,827 10,474Target08/09HbA1c

2. MethodologyThis section details how the charts and targets in this document have been produced and gives anexplanation of the data that is included in them.Section three of this document features a number of charts based on the information provided inappendix A. The charts display disaggregated data – in part summarised in table 1 – to show howfar practices are from achieving the targets (including the number of patients required). The chartsare intended to be an easy illustration of how practices can achieve the targets for 2008/09.QOF achievement data for England and London comes from the NHS Information Centre 3 and forXX PCT it comes from the QMAS database 4 . To calculate all QOF achievements we have usedthe number of patients who have reached the QOF indicator requirement e.g. HbA1c

2.2 How to read the chartsThis section provides an example of how to interpret the charts provided on pages 5-12, andappendix A (page 13).If we assume for illustrative purposes that XX PCT was a practice, the following would be true: For HbA1c

3. Practice-level charts (see pages 3 and 4 for information about interpreting these charts)Figure 1: HbA1c

-9-4-5Practice 5Figure 2: HbA1c

-34-13-33-7Practice 35Practice 5Practice 8Figure 3: BP

-7-6-7-3Prac tic e 2 5Practice 5Figure 4: Chol

-20-19-18Practice 13Practice 35Figure 5: Record of neuropathy testing (DM10) percentage indicator achievement 07/08 against 08/09 target, indicating thenumber of patients needed to achieve target, by practice.942-59-3-2-3-4-9-6-6-3-11-9-9-30-81193138547291071727715172754430Practice 14Practice 30Practice 12Practice 7Practice 17Practice 21Practice 15Practice 31Practice 10Practice 18Practice 37Practice 1Practice 9Practice 26Tower HamletsPractice 11Practice 19Practice 29Practice 28Practice 8Practice 6Practice 23Practice 22Practice 3Practice 4Practice 33Practice 16Practice 36Practice 34Practice 25Practice 24Practice 5Practice 27Practice 2Practice 201009080706050403020100Practice07/08 % indicator achievement No.= pts required for target 08/09 target% Achievement

-18-13-10Practice 5Figure 6: Record of microalbuminuria testing (DM13) percentage indicator achievement 07/08 against 08/09 target,indicating the number of patients needed to achieve target, by practice.10405-10-16-15-11-12-2381131864323046221925186862223912363744513191391011-2-4-6-5Practice 31Practice 36Practice 37Practice 3Practice 20Practice 9Practice 21Practice 26Practice 14Practice 12Tower HamletsPractice 30Practice 18Practice 28Practice 19Practice 23Practice 11Practice 4Practice 6Practice 33Practice 8Practice 29Practice 153Practice 35Practice 24Practice 7Practice 34Practice 22Practice 13Practice 1Practice 10Practice 25Practice 2Practice 27Practice 16Practice 171009080706050403020100Practice07/08 % indicator achievement No.= pts required for target 08/09 target% Achievement

-6-25-11Practice 27Figure 7: Record of retinopathy testing (DM21) percentage indicator achievement 07/08 against 08/09target, indicating the number of patients needed to achieve target, by practice.111819237182154304945991103616817366264215572132583724514217281881121-1-6Practice 30Practice 5Practice 26Practice 17Practice 20Practice 22Practice 23Practice 18Practice 9Practice 31Practice 21Practice 19Practice 7Practice 15Practice 25Practice 35Tower HamletsPractice 34Practice 2Practice 24Practice 8Practice 1Practice 28Practice 3Practice 33Practice 11Practice 12Practice 10Practice 4Practice 6Practice 16Practice 36Practice 13Practice 29Practice 371009080706050403020100Practice07/08 % indicator achievement No.= pts required for target 08/09 targetPractice 14% Achievement

-10-19-26-8Practice 27Practice 25Figure 8: Flu immunisation (DM18) percentage indicator achievement 07/08 against 08/09 target,indicating the number of patients needed to achieve target, by practice.121134-1-3-8-5-5-23-15-10-11-13-14-18025375172576125519418323523Practice 7Practice 17Practice 21Practice 12Practice 19Practice 34Practice 6Practice 15Practice 10Practice 31Practice 30Practice 20Practice 37Practice 4Practice 36Practice 18Tower HamletsPractice 26Practice 28Practice 9Practice 29Practice 11Practice 23Practice 5Practice 24Practice 8Practice 22Practice 33Practice 35Practice 1Practice 13Practice 16Practice 2Practice 31009080706050403020100Practice07/08 % indicator achievement No.= pts required for target 08/09 targetPractice 14% Achievement

Appendix A – Data for the charts on pages 5-12PracticeRegistersize(07, 08)07,08 dataRecord ofRecord of microalbuminuriatesting retinopathy testingRecord ofHbA1c 10 BP

Consensus meeting on reporting glycated haemoglobin(HbA 1c ) and estimated average glucose (eAG) in the UKReport to the National Director for Diabetes, Department of HealthReported by Julian H Barth, Sally M Marshall, Ian D WatsonA consensus paper [1] on worldwide standardisation of measurement and reporting ofHbA 1c has been published recently by the American Diabetes Association (ADA),European Association for the Study of Diabetes (EASD), International Federation ofClinical Chemistry and Laboratory Medicine (IFCC) and the International DiabetesFederation (IDF). This proposal has accepted that the IFCC Reference Measurementprocedure [2] should be the international method for calibrating all assays used for themeasurement of glycated haemoglobin. The consensus proposed five points which arereproduced in table 1.A meeting convened at the request of Dr Sue Roberts, National Director for Diabetes, washeld in London on 23 rd January 2008. Representatives of 18 professional organisations andrepresentatives of the diagnostic industry involved in the management of people withdiabetes as well as patients with diabetes (see table 2) attended to discuss these proposalsand how they should be incorporated into clinical practice in the UK.1. HbA 1c test results should be standardized worldwide, including the referencesystem and results reporting.2. The new IFCC reference system is the only valid anchor to implementstandardization of the HbA 1c measurement.These two points were universally accepted and, indeed, they were first proposed at anearlier consensus held in London in 2000 [3].3. HbA 1c results are to be reported worldwide in IFCC units (mmol/mol) and derivedNGSP units (%), using the IFCC-NGSP master equation.There was agreement that it was necessary for glycated haemoglobin to be standardised tothe IFCC Reference Measurement procedure but there was concern regarding theintroduction of a dual reporting system including new units with which patients andclinicians were unfamiliar. It was felt that there was a real risk that patient control woulddeteriorate due to lack of understanding, particularly with an unheralded change to IFCCunits. It was agreed that dual reporting would be necessary for a considerable period untilboth unitary systems were understood. However, this should only occur after extensiveeducational programmes had been performed. Moreover, it must be ensured that theseprogrammes will reach all the appropriate health care professionals as well as patients.4. If the ongoing “average plasma glucose study” fulfils its a priori specified criteria,an HbA 1c -derived average glucose (ADAG) value calculated from the HbA 1c resultwill also be reported as an interpretation of the HbA 1c results.A report of the preliminary findings of the ADAG study was presented by one of the studyinvestigators [4]. Data was presented on approximately 2/3 of the subjects although it wasstated that it was anticipated at this stage that the final results would not be different. Thegroup attending uniformly felt there was insufficient information regarding entry criteria,study design and data analysis on which to accept any conclusions at this stage and that

further studies validating the findings from the ADAG study would be required beforeimplementation could be considered.The conceptual benefits of reporting glycated haemoglobin in terms that patientsunderstand was accepted for patients who measure their own blood glucose levels, despitethe fact that no patient survey had been performed to study this aspect. However, there wasconcern that it would not be beneficial for the vast majority of patients with diabetes whohave type 2 disease and who do not routinely measure capillary glucose.Moreover, there was concern that the formula for calculating estimated average glucose(eAG) would give a different value than the capillary (finger-prick) samples used for dailymonitoring. Overall, it was felt that due to issues raised about study design and clinicalapplicability of the eAG measurement in practice, it was not possible to considerimplementing this recommendation in the UK.5. Glycaemic goals appearing in clinical guidelines should be expressed as IFCCunits, derived NGSP units and as ADAG.There was general agreement that reporting a single measurement in three different formatswas considered to be unacceptably complicated.There was mention of the need for a consistent international measurement for themonitoring of diabetes in a world with huge population mobility to ensure that all patientswould have optimal care.It was felt that eAG was an interesting concept that had the potential to help patients withdiabetes improve their understanding of diabetes and therefore improve their health.Participants recommended that studies of eAG should be performed in the UK and thatthese studies should include patient populations who have been excluded from ADAG.These include children, pregnant women, the elderly and ethnic populations.Summary Recommendations for the UK• HbA1c test results should be standardized using the new IFCC ReferenceMeasurement procedure• An extensive education programme should be developed urgently for all healthcare professionals and people with diabetes to help the understanding andinterpretation of the new IFCC units. Provision of this programme will requireconsiderable resource.• HbA1c results should be reported in both IFCC units (mmol/mol) and derivedNGSP units (%) (synonymous with DCCT), using the IFCC-NGSP master equationfor the time being• There is currently insufficient experimental evidence to support the introduction ofeAG.• Further research into the individual utility of eAG and of its use in all groups ofindividuals with diabetes is required in order to determine what role reporting ofeAG has in clinical practice.

References1. Consensus statement on the worldwide standardisation of the HbA1c measurement.Diabetologia 2007;50:2042-3.2. Finke A, Kobold U, Hoelzel W, Weycamp C, Jeppsson JO, Miedema K. Preparation ofa candidate primary reference material for the international standardisation of HbA 1cdeterminations. Clin Chem Lab Med 1998;36:299-308.3. Marshall SM, Barth JH. Standardisation of HbA1c measurements – a consensusstatement. Ann Clin Biochem 2000;37:45-56 & Diabet Med 2000;17:5-64. http://www.easd-lectures.org/amsterdam/index.php?menu=view&id=201

Table 1: ADA, EASD, IFCC, IDF 2007 Consensus [1]1. HbA1c test results should be standardized worldwide, including the reference systemand results reporting.2. The new IFCC reference system is the only valid anchor to implement standardizationof the HbA1c measurement.3. HbA1c results are to be reported worldwide in IFCC units (mmol/mol) and derivedNGSP units (%), using the IFCC-NGSP master equation,.4. If the ongoing “average plasma glucose study” fulfils its a priori specified criteria, anHBA1c-derived average glucose (ADAG) value calculated from the HbA1c result willalso be reported as an interpretation of the HbA1c results.5. Glycaemic goals appearing in clinical guidelines should be expressed as IFCC units,derived NGSP units and as ADAG.Table 2: Professional organisations represented at the London meetingAssociation for Clinical BiochemistryAssociation of Clinical PathologistsAssociation of British Clinical DiabetologistsAustralian Association of Clinical BiochemistsBritish In-Vitro Diagnostics AssociationDepartment of Health of EnglandDiabetes UKEuropean Federation of Clinical ChemistryInternational Diabetes FoundationInternational Federation of Clinical Chemistry and Laboratory MedicinePrimary Care Diabetes SocietyRoyal College of General PractitionersRoyal College of NursingRoyal College of Obstetricians and GynaecologistsRoyal College of PathologistsRoyal College of PhysiciansUK National External Quality Assessment Scheme (UK NEQAS)Wales External Quality Assessment Scheme (WEQAS)

Healthcare for LondonEducation for primary care health professionals indiabetes careCharles Gostling, Deborah Colvin, Clare Davisonand Douglas RussellMarch 2009

SummaryEducation and training has been identified as an essential requirement if primary care is toeffectively manage a significant proportion of the diabetes workload. The service user group hasidentified this as a need to help overcome the disparity in the quality of service provision betweenpractices. Specialist teams would also welcome this development to ensure that when people withdiabetes are discharged from specialist services primary has the skills to maintain a high standardof care. Primary care trusts (PCTs) need to ensure sufficient capacity to manage diabetes in primarycare. The minimum requirement should be one trained GP, one trained nurse (band 7) andideally one trained health care assistant (HCA) per team. Where necessary, this can be ashared arrangement across a cluster of practices. GP and nursing staff are to be trained to Warwick Certificate in Diabetes Care standard orsimilar at each practice (or require evidence of competency to show that this is not required). Healthcare for London should ensure that accredited training for health professionals indiabetes care is appropriate to the needs of London’s population. Any HCA dealing with diabetes must be must be competent to undertake all data collection,take blood tests, urine tests, measure height and weight, measure waist circumference andperform a basic foot examination. More basic training should be available to primary care health professionals not directly relatedto the delivery of diabetes care. If a trained member of staff leaves a practice, succession planning must take into account thespecialist needs of the new post-holder. These needs should be made clear in the personspecification for the post. Diabetes-trained primary care staff should ensure that a minimum level of ongoing diabetestraining is incorporated into their continuing professional development. Such training should bedefined and quality assured according to the needs of individual PCTs. The intermediate care team (levels two and three) should have specific responsibility forensuring the quality of ongoing training for primary care staff in diabetes care. Primary care staff delivering diabetes care should ensure that their skills in performing specifictasks achieve the competency levels defined in the Skills for Health Frameworkhttps://tools.skillsforhealth.org.uk/2

Diabetes certificate / diploma level coursesappropriate to primary careEducation and training must be available to allow primary healthcare staff to deliver diabetes careat levels one and two. While it is recognised that expecting all such professionals to undertakeaccredited training in the short term is unrealistic, in the longer term this is a desirable goal. Shortunaccredited courses for diabetes care which encompass consultation skills and basic diabetescare should be provided in the interim to ensure safety and quality assurance.A variety of certificate / diploma level courses are available nationally. The content of courses mayvary, and not all are necessarily appropriate to London’s needs. A further workstream is necessaryto establish education and training to meet the core needs identified in appendix 1. The following isa brief resume of currently available courses.1. Warwick Certificate in Diabetes Care30 credits at level 5 (EWNI) – University of Warwick6 days work-based learning practical experience self-directed learningAreas covered: anatomy and physiology diagnosis and classification living with diabetes culture and ethnicity behaviour change nutrition lifestyle and physical activity oral therapies insulin therapy (including CSII) cardiovascular disease blood glucose monitoring acute complications chronic complications special situations (children, pregnancy).Assessment: anatomy and physiology pre-course work case study (peer reviewed) audit of care (peer reviewed) written project approx 3000 words.3

2. Diploma in Diabetes Management in Primary Care (Bradford Primary Care TrainingCentre)20 credits at level 5 (EWNI) – University of Huddersfield2 compulsory workshop days + 1 non-compulsory study day. + distance learning. Notional study200 hoursAreas covered: setting the scene healthy living treatment complications specialist section (GP / nurse, podiatrist, dietician, pharmacist).Assessment: unseen examination comprising true/ false statements and short answer questions 2000 word reflective case study.3. Diabetes in Primary Care Diploma, Kings College London30 credits level 6 (EWNI) – Kings College London5 days study + ½ day revision (optional)Areas covered: current trends in diabetes (normal metabolism, pathophysiology, diagnosis) diabetes care systems assessment and risk care and treatment.Assessment: multiple choice examination project - written assessment of candidate’s own practice Objective Structured Clinical Examination (OSCE).4. Diabetes as a cardiovascular disease diploma (Education for health), accredited byOpen University30 credits level 5 (EWNI) – Open UniversityAreas covered: epidemiology of diabetes and metabolic syndrome anatomy and physiology treatment and management: pharmacological and non-pharmacological risk factor assessment and lifestyle management national and local policy guidelines application of evidence based practice organisation of care targeting, prioritising and prevention strategies supported self care.4

Assessment: formative practical workshop one hour unseen written exam coursework 1 submitted 8 weeks into the module coursework 2 submitted 26 weeks into the module.5. Management of diabetes mellitus – stand alone module, University of York20 credits level 5 and level 6 (EWNI). “This module has been designed to provide an enhanced indepthunderstanding of diabetes suitable for the generalist healthcare practitioner.”The following courses may also be suitable but are more onerous.6. Postgraduate Certificate (Diabetes) Roehampton University – part of PostgraduateCertificate/ Postgraduate Diploma/ MSc programme60 credits level 7 (EWNI) at Roehampton University (in association with St. Bartholomew’s andRoyal London). Multi-professional. Intended for “those health professionals working in diabeteswho want to improve their knowledge and understanding of the disease in a multi-professionalcontext and hence to improve their practice.”Modules covered: Understanding diabetes: principles of care (15 credits) Understanding diabetes: exploring clinical cases (15 credits) Managing the complications associated with diabetes (15 credits) Managing clinical care (15 credits).Can lead on to Diploma or MSc.7. Postgraduate Certificate (Diabetes) University of Brighton – part of PostgraduateCertificate/ Postgraduate Diploma/ MSc programme60 credits level 7 (EWNI) at University of Brighton. Multi-professional. “The aim of the course is toenable practitioners in a range of professions and disciplines to explore critically the aetiology,epidemiology and management of diabetes, including its complications and the impact of thedisease on patients, carers and families.”Modules: Clinical management of diabetes (20 credits) Living with diabetes (20 credits) Complications of diabetes (20 credits).Can lead on to Diploma or MSc.5

8. Post Graduate Certificate/ Diploma, Diabetes for Practitioners with a Special Interest.University of Bradford60-120 credits level 7 (EWNI). Multi-professional. The programme is intended to: enable GPs and other practitioners to work confidently at a ‘special interest’ level in diabetes; contribute to the extension of the role of the PwSI in diabetes; provide a nationally-recognised standard in the training of PwSIs in diabetes; establish and/or extend professional collaboration within care of patients with diabetes, in orderto develop the most appropriate care pathways for the patient.The first two modules must be completed for certificate to be awarded. All four are required for adiploma: Applied methodologies (30 credits) Glycaemic control (30 credits) Microvascular management in diabetes (30 credits) Macrovascular management in diabetes (30 credits).9. Advanced Diploma in Management of Long Term Conditions, Middlesex University60 credits level 6 (EWNI). Multi-professional, but with nursing bias. “The diabetes care moduleaims to support health care staff in the provision of safe, effective diabetes care, which is deliveredin a manner, which is sensitive to the clients’ needs, is essential to the health of the individual andreflects the local and national initiatives aimed at reducing the personal and nationwide burden ofthe disease.”Two of the following three modules are to be completed: Managing long-term respiratory disease (30 credits) Managing long-term cardiovascular disease (30 credits) Diabetes care (30 credits).This course may be attractive for diabetes care if the latter two modules undertaken.6

Appendix 1The anticipated core components for an accredited course are outline below:Diabetes care systems registers, recall and review needs assessment matching/ commissioning servicesappropriate to local needs patient and public involvement auditWhat is diabetes? Physiology Pathophysiology Who is at risk DiagnosisHealth beliefs,Culture and ethnicityEmpowerment andself-management indiabetesNutrition,lifestyle and physicalactivityManagement of diabetes goal setting annual review glycaemic control, oraltherapies and insulin management of- hypertension- dyslipidaemia- cardiovascular riskScreening for andmanagement ofcomplications eyes renal cardiovascular feet neuropathy depressionBehaviour change people with diabetes health careprofessionals cognitivebehavioural therapy(CBT) motivationalinterviewingSpecial situations pregnancy and prepregnancy children mental healthEmergencies hypoglycaemia ketoacidosis HONKLiving with diabetes Person with diabetes Friends, family, workcolleagues7

Directly Age-Standardised MortalityRate (DSR) from Diabetes all ages2004-06 pooledThe London Health Observatory: monitoring health and health care inthe capital, supporting practitioners and informing decision-makers

Pan - LondonDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland2

Barking and Dagenham PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland3

Barnet PCTDirectly age-standardised mortality rates (DSR) from Diabetes for allages 2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland4

Bexley PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland5

Brent Teaching PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled2015rate per 100,0001050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland6

Bromley PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland7

Camden PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland8

City & Hackney PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland9

Croydon PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland10

Ealing PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland11

Enfield PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland12

Greenwich Teaching PCTDirectly age-standardised mortality rates (DSR) from Diabetes for allages 2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland13

Hammersmith & Fulham PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages 2004-6 pooled20Rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland14

Haringey Teaching PCTDirectly age-standardised mortality rates (DSR) from Diabetes for allages 2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland15

Harrow PCTDirectly age-standardised mortality rates (DSR) from Diabetes for allages 2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland16

Havering PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland17

Hillingdon PCTDirectly age-standardised mortality rates (DSR) from Diabetes for allages 2004-6 pooled20Rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland18

Hounslow PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland19

Islington PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20Rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland20

Kensington & Chelsea PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland21

Kingston PCTDirectly age-standardised mortality rates (DSR) from Diabetes for allages 2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland22

Lambeth PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20Rate per 100,00015105h0City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland23

Lewisham PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages 2004-6 pooled20Rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland24

Newham PCTDirectly age-standardised mortality rates (DSR) from Diabetes forall ages 2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland25

Redbridge PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney TeachingTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and TwickenhamSouthwark PCTHarrow PCTIslington PCTHammersmith and FulhamSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and ChelseaHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney TeachingWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and FulhamHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and TwickenhamHavering PCTWestminster PCTKensington and ChelseaSource: NCHODSource: NCHODLondonEngland26

Richmond & Twickenham PCTDirectly age-standardised mortality rates (DSR) from Diabetes forall ages 2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland27

Southwark PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland28

Sutton & Merton PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20Rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland29

Tower Hamlets PCTDirectly age-standardised mortality rates (DSR) from Diabetes for allages 2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland30

Waltham Forest PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20Rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland31

Wandsworth Teaching PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20rate per 100,000151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandNewham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTSource: NCHODSource: NCHODLondonEngland32

Westminster PCTDirectly age-standardised mortality rates (DSR) from Diabetes for all ages2004-6 pooled20151050City and Hackney Teaching PCTTower Hamlets PCTWaltham Forest PCTHounslow PCTHaringey Teaching PCTNewham PCTBrent Teaching PCTEnfield PCTLambeth PCTEaling PCTRedbridge PCTGreenwich Teaching PCTBarking and Dagenham PCTHillingdon PCTCroydon PCTLewisham PCTRichmond and Twickenham PCTSouthwark PCTHarrow PCTIslington PCTHammersmith and Fulham PCTSutton and Merton PCTBarnet PCTBromley PCTCamden PCTKingston PCTWandsworth Teaching PCTKensington and Chelsea PCTHavering PCTBexley Care TrustWestminster PCTLondonEnglandrate per 100,000Newham PCTHaringey Teaching PCTLambeth PCTIslington PCTCity and Hackney Teaching PCTWandsworth Teaching PCTHounslow PCTTower Hamlets PCTLewisham PCTEaling PCTHillingdon PCTGreenwich Teaching PCTWaltham Forest PCTBrent Teaching PCTBarnet PCTCroydon PCTBarking and Dagenham PCTKingston PCTSutton and Merton PCTSouthwark PCTHammersmith and Fulham PCTHarrow PCTCamden PCTBromley PCTRedbridge PCTBexley Care TrustEnfield PCTRichmond and Twickenham PCTHavering PCTWestminster PCTKensington and Chelsea PCTLondonEnglandSource: NCHOD33

Directly Age-Standardised MortalityRate (DSR) from Diabetes for under75s 2004-06 pooledThe London Health Observatory: monitoring health and health care inthe capital, supporting practitioners and informing decision-makers

Pan - LondonDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHOD

Barking and Dagenham PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHOD

Barnet PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Bexley PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Brent Teaching PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Bromley PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Camden PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

City & Hackney PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Croydon PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Ealing PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Enfield PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Greenwich Teaching PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Hammersmith & Fulham PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Haringey Teaching PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Harrow PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Havering PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Hillingdon PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Hounslow PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Islington PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Kensington & Chelsea20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHOD

Kingston PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHOD

Lambeth PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Lewisham PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Newham PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Redbridge PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Richmond & Twickenham20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Southwark PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Sutton & Merton PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Tower Hamlets PCTDirectly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled2015rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Waltham Forest PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Wandsworth Teaching PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Westminster PCT20Directly age-standardised mortality rates (DSR) from Diabetes forunder 75s 2004-6 pooled15rate per 100,0001050Tower Hamlets PCTWaltham Forest PCTCity and Hackney Teaching PCTHaringey Teaching PCTHounslow PCTGreenwich Teaching PCTBarking and Dagenham PCTNewham PCTIslington PCTLambeth PCTEaling PCTEnfield PCTCroydon PCTRedbridge PCTRichmond and Twickenham PCTBrent Teaching PCTBromley PCTSutton and Merton PCTHillingdon PCTBarnet PCTLewisham PCTHammersmith and Fulham PCTHarrow PCTKingston PCTKensington and Chelsea PCTBexley Care TrustSouthwark PCTHavering PCTCamden PCTWestminster PCTWandsworth Teaching PCTLONDONENGLANDHaringey Teaching PCTLambeth PCTNewham PCTIslington PCTTower Hamlets PCTSouthwark PCTEaling PCTWandsworth Teaching PCTGreenwich Teaching PCTCity and Hackney Teaching PCTSutton and Merton PCTHillingdon PCTHammersmith and Fulham PCTWaltham Forest PCTHarrow PCTHounslow PCTBarnet PCTCroydon PCTKingston PCTBarking and Dagenham PCTEnfield PCTRedbridge PCTKensington and Chelsea PCTBromley PCTWestminster PCTBrent Teaching PCTBexley Care TrustHavering PCTRichmond and Twickenham PCTCamden PCTLewisham PCTLONDONENGLANDSource: NCHODSource: NCHOD

Population Pyramids: AgeStructure of PCT Populations2007The London Health Observatory: monitoring health and health care inthe capital, supporting practitioners and informing decision-makers

Pan-LondonSource: Exeter (London), ONS 2006 mid-year estimates (England)

Barking & Dagenham PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Barnet PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Bexley Care TrustSource: Exeter (London), ONS 2006 mid-year estimates (England)

Brent Teaching PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Bromley PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Camden PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

City & Hackney Teaching PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Croydon PCT

Ealing PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Enfield PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Greenwich Teaching PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Hammersmith & Fulham PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Haringey Teaching PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Harrow PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Havering PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Hillingdon PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Hounslow PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Islington PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Kensington & Chelsea PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Kingston PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Lambeth PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Lewisham PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Newham PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Redbridge PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Richmond & Twickenham PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Southwark PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Sutton & Merton PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Tower Hamlets PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Waltham Forest PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Wandsworth Teaching PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Westminster PCTSource: Exeter (London), ONS 2006 mid-year estimates (England)

Prevalence of Diabetes:QOF vs estimated March 2007The London Health Observatory: monitoring health and health care inthe capital, supporting practitioners and informing decision-makers

Pan - LondonPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Barking and Dagenham PCT7Prevalence of Diabetes: QOF vs estimated March 2007percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Barnet PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Bexley PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Brent Teaching PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Bromley PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Camden PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

City & Hackney PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Croydon PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Ealing PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Enfield PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Greenwich Teaching PCT7Prevalence of Diabetes: QOF vs estimated March 2007percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Hammersmith & Fulham PCT7Prevalence of Diabetes: QOF vs estimated March 2007percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Haringey Teaching PCT7Prevalence of Diabetes: QOF vs estimated March 2007percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Harrow PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Havering PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Hillingdon PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Hounslow PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Islington PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Kensington & ChelseaPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Kingston PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Lambeth PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Lewisham PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Newham PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Redbridge PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Richmond & Twickenham7Prevalence of Diabetes: QOF vs estimated March 2007percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Southwark PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Sutton & Merton PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Tower Hamlets PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Waltham Forest PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Wandsworth Teaching PCT7Prevalence of Diabetes: QOF vs estimated March 2007percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Westminster PCTPrevalence of Diabetes: QOF vs estimated March 20077percentage of people with diabetes6543210NewhamBrentHarrowRedbridgeEalingWalthamTowerHounslowCroydonEnfieldLewishamBarking &BarnetHaringeyCity &SouthwarkGreenwichLambethHillingdonIslingtonHaveringBexleyBromleyKensington &WestminsterHammersmithCamdenSutton &KingstonWandsworthRichmond &Estimated prevalenceQOF prevalenceSource: IC (QOF), PBS2 (Estimated Prevalence)

Diabetes Projections 2005 -2025The London Health Observatory: monitoring health and health care inthe capital, supporting practitioners and informing decision-makers

Pan-LondonDiabetes projections for London600,000500,000Number of people with diabetes400,000300,000200,000100,00002005 2010 2015 2020 2025Source: PBS32

Barking & Dagenham PCT12,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS33

Barnet PCT30,00025,00020,00015,00010,0005,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS34

Bexley Care Trust16,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS35

Brent PCT30,00025,00020,00015,00010,0005,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS36

Bromley PCT25,00020,00015,00010,0005,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS37

Camden PCT18,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS38

City & Hackney PCT16,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS39

Croydon PCT30,00025,00020,00015,00010,0005,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS310

Ealing PCT25,00020,00015,00010,0005,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS311

Enfield PCT25,00020,00015,00010,0005,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS312

Greenwich PCT18,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS313

Hammersmith & Fulham PCT12,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS314

Haringey PCT16,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS315

Harrow PCT25,00020,00015,00010,0005,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS316

Havering PCT18,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS317

Hillingdon PCT20,00018,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS318

Hounslow PCT18,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS319

Islington PCT12,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS320

Kensington & Chelsea PCT16,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS321

Kingston PCT10,0009,0008,0007,0006,0005,0004,0003,0002,0001,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS322

Lewisham PCT20,00018,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS323

Lambeth PCT18,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS324

Newham PCT25,00020,00015,00010,0005,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS325

Redbridge PCT25,00020,00015,00010,0005,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS326

Richmond & Twickenham PCT12,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS327

Southwark PCT20,00018,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS328

Sutton & Merton PCT30,00025,00020,00015,00010,0005,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS329

Tower Hamlets PCT18,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS330

Waltham Forest PCT18,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS331

Wandsworth PCT16,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS332

Westminster PCT20,00018,00016,00014,00012,00010,0008,0006,0004,0002,00002005 Estimate 2010 forecast 2015 forecast 2020 forecast 2025 forecastSource: PBS333

Retinal screening: as proportionof total on diabetes registers2006-07The London Health Observatory: monitoring health and health care inthe capital, supporting practitioners and informing decision-makers

Pan - Londonpercentage offered retinal screening100%90%80%70%60%50%40%30%20%10%0%HillingdonKingstonProportion of people with diabetes on GP registers who wereoffered retinal screening in 2006-2007HarrowRichmond & TwickenhamHammersmith & FulhamBexleyBarnetSutton & MertonWandsworthCity & HackneyKensington & ChelseaExcluding exceptionsHaringeyEalingIslingtonBromleyLambethSouthwarkEnfieldHaveringWaltham ForestRedbridgeWestminsterCamdenLewishamBarking & DagenhamBrentCroydonGreenwichHounslowAs proportion of total on diabetes registerNewhamTower HamletsLondonSource: IC (QOF)

Barking and Dagenham PCTpercentage offered retinal screening100%90%80%70%60%50%40%30%20%10%0%HillingdonKingstonProportion of people with diabetes on GP registers who wereoffered retinal screening in 2006-2007HarrowRichmond & TwickenhamHammersmith & FulhamBexleyBarnetSutton & MertonWandsworthCity & HackneyKensington & ChelseaExcluding exceptionsHaringeyEalingIslingtonBromleyLambethSouthwarkEnfieldHaveringWaltham ForestRedbridgeWestminsterCamdenLewishamBarking & DagenhamBrentCroydonGreenwichHounslowAs proportion of total on diabetes registerNewhamTower HamletsLondonSource: IC (QOF)

Barnet PCTpercentage offered retinal screening100%90%80%70%60%50%40%30%20%10%0%HillingdonKingstonProportion of people with diabetes on GP registers who wereoffered retinal screening in 2006-2007HarrowRichmond & TwickenhamHammersmith & FulhamBexleyBarnetSutton & MertonWandsworthCity & HackneyKensington & ChelseaExcluding exceptionsHaringeyEalingIslingtonBromleyLambethSouthwarkEnfieldHaveringWaltham ForestRedbridgeWestminsterCamdenLewishamBarking & DagenhamBrentCroydonGreenwichHounslowAs proportion of total on diabetes registerNewhamTower HamletsLondonSource: IC (QOF)

Bexley PCTSource: IC (QOF)

Brent Teaching PCTSource: IC (QOF)

Bromley PCTSource: IC (QOF)

Camden PCTSource: IC (QOF)

City & Hackney PCTSource: IC (QOF)

Croydon PCTSource: IC (QOF)

Ealing PCTSource: IC (QOF)

Enfield PCTSource: IC (QOF)

Greenwich Teaching PCTSource: IC (QOF)

Hammersmith & Fulham PCTSource: IC (QOF)

Haringey Teaching PCTSource: IC (QOF)

Harrow PCTSource: IC (QOF)

Havering PCTSource: IC (QOF)

Hillingdon PCTSource: IC (QOF)

Hounslow PCTSource: IC (QOF)

Islington PCTSource: IC (QOF)

Kensington & ChelseaSource: IC (QOF)

Kingston PCTSource: IC (QOF)

Lambeth PCTSource: IC (QOF)

Lewisham PCTSource: IC (QOF)

Newham PCTSource: IC (QOF)

Redbridge PCTSource: IC (QOF)

Richmond & Twickenham PCTSource: IC (QOF)

Southwark PCTSource: IC (QOF)

Sutton & Merton PCTSource: IC (QOF)

Tower Hamlets PCTSource: IC (QOF)

Waltham Forest PCTSource: IC (QOF)

Wandsworth Teaching PCTSource: IC (QOF)

Westminster PCTSource: IC (QOF)

HbA1c measurements: asproportion of total on diabetesregisters 2006-07The London Health Observatory: monitoring health and health care inthe capital, supporting practitioners and informing decision-makers

Pan - Londonpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Barking and Dagenham PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Barnet PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Bexley PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Brent Teaching PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Bromley PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Camden PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

City & Hackney PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Croydon PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Ealing PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Enfield PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Greenwich Teaching PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Hammersmith & Fulham PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Haringey Teaching PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Harrow PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Havering PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Hillingdon PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Hounslow PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Islington PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Kensington & Chelseapercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Kingston PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Lambeth PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Lewisham PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Newham PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Redbridge PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Richmond & Twickenham PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Southwark PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Sutton & Merton PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Tower Hamlets PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Waltham Forest PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Wandsworth Teaching PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Westminster PCTpercentage (%)100%90%80%70%60%50%40%30%20%10%0%Hammersmith & FulhamHarrowRichmond & TwickenhamProportion of people with diabetes on GP registers that hadHBA1c measured in 2006-2007Kensington & ChelseaBarnetKingstonHillingdonWandsworthCroydonBromleyCamdenEnfieldEalingSutton & MertonNewhamHaveringBrentLewishamTower HamletsLambethSouthwarkCity & HackneyHaringeyBexleyHounslowRedbridgeIslingtonWaltham ForestWestminsterGreenwichBarking & DagenhamExcluding exceptionsAs proportion of total on diabetes registerLondonSource: IC (QOF)

Working in partnership withHealthcare for LondonDiabetes user groupPriorities for actionNovember 20081

Contents1. Research background and objectives....................................................................................................32. Induction .......................................................................................................................................................41.1. Question 1 - ‘What is the case for change?’ ...................................................................41.2. Question 2 - ‘What would the perfect care look like?’ .....................................................51.3. Question 3 - ‘What education do you want to receive about your condition and howwould you like it delivered?’........................................................................................................71.4. Question 4 - ‘‘What should we check to see if a diabetes service is a good service?’.....83. Group Work: 26 July 2008.......................................................................................................................103.1. Question 1: ‘What is the case for change?’...................................................................103.2. Question 2: ‘What would your personal care plan look like?’ ........................................113.3. Question 3: ‘What should we check to see if a diabetes service is a good service?’.....134. Group Work: 16 August 2008 .................................................................................................................144.1. Question 1: ‘Is the setting of care important to you?’ ....................................................144.2. Question 2: ‘How would effective education and training be formed?’ ..........................154.3. Question 3: ‘Emotional support, is it sufficient? ............................................................185. Email group contributions ......................................................................................................................215.1. Question 1: ‘Is the setting of care important to you?’ ....................................................215.2. Question 2: ‘How would effective education and training be formed?’ ..........................216. Group Work: 11 October 2008................................................................................................................236.1. Question 1: ‘What aspect of service delivery/performance would you like to havemeasured and reported on, on a regular basis?’ ......................................................................236.2. Discussion: ‘Project review’ ..........................................................................................242

1. Research background and objectivesAs part of the Healthcare for London long-term conditions project, Diabetes UK wascommissioned to set up and run a Service User Group of people living with diabetes.The group consisted of 22 people from across London living with diabetes. Members were agedbetween 25 and 75 years and came from a wide range of ethnic backgrounds. Some had beendiagnosed with diabetes in the preceding months, while others had many decades of experiencewith diabetes.The purpose of the Service User Group was to ensure the Healthcare for London diabetes projectwas appropriately informed and influenced by the needs and views of people with diabetes andthose who care for them. The project ran from June 2008 to October 2008.The role of the group was to:• respond to questions about diabetes services and raise issues to the diabetes projectteam and the project board based on their experiences of diabetes services;• be a critical friend to project team and board, offering an alternative perspective andchallenging beliefs if necessary;• identify representatives to sit on the project board and expert group;• seek the views of the wider community of people with diabetes to ensure broadrepresentation.Feedback from the Service User Group, as summarised in this document, has been used byHealthcare for London to inform development of the Diabetes guide for London; which looks totransform diabetes care services in London.3

Induction1.1. Question 1 - ‘What is the case for change?’‘If you could tell people who make decisions about your diabetes care about your personalexperiences, what two things would you tell them? What should have been done differently?’• Healthcare professionals should be aware of ethnic predispositions [and offer tests andinterventions as appropriate]• Awareness amongst healthcare professionals should be raised• Communication between healthcare professionals should be improved• There should be regular lifestyle reviews• A proactive approach to regular checkups is needed• Family and carers should be listened to• GPs should have specialist diabetes training• There should be better information and education to empower diabetics• Listen to the diabetic• Better information and education on diagnosis• Auditable competences are required for healthcare professionals• Clear pathways• Regular access is needed to specialist care• There is a lack of quality care, poor treatment• One person was happy with their diabetic care• Raise awareness of hypoglycaemia for parents, carers and the public• More peer and emotional support is needed• Raise awareness amongst the public• Be sensitive to people’s needs• As an isolated person, accessing services is difficult• More information is required on medicines and what they contain or side effects4

1.2. Question 2 - ‘What would the perfect care look like?’Group 1Target high riskgroups e.g. family withdiabetic history, ethnicgroups etcNon-emergencyaccess to 24/7diabetic services(GP, pharmacy)Interpreter alwaysavailableCarers of diabeticsshould get carersassessmentEducation should beput on the schoolcurriculumPerfect careTransfer from secondaryto primary care (auditingit and ensuring quality ofservice is monitored)Diabetes helplinewith specialistknowledgeContinuity andconsistency inpatient care by theCare TeamEducating the familyand creatingawarenessDiabetes care planningagreement betweenhealth care professionaland patientGroup 2PositiveattitudefrommedicsNHSPerfect careCommunicationPartnershipworking betweenspecialist anddiabeticMust feelconnectedwith experthelp for 24hoursEarly awarenessFrom schoolEasyaccess tomedicalresourcesEducation5

Group 3Diabetic support groups(patient/carers)EducationSpecialist heart/vascularSexual healthPublic educationPatientGP / Hospital careRoutine care (Nurse)Specialist care (chiropody,dietician)Referral processEducation (GPs, patient,carers etc)Specialist chiropodySpecialist dieticianPsychological careAccess to medicaltagsFree dental careSpecialist optical careGroup 4CurePartnership supportPartnership intreatmentQuality careConsistencyUpdated treatmentAccessPatientsCarersParentsEveryoneEyes, feet,diet, renalEmpathyCommunicationChoiceJoined uptreatmentPsychologicalsupportReassuranceEarly diagnosisEducation for all6

1.3. Question 3 - ‘What education do you want to receive about yourcondition and how would you like it delivered?’Group 1WhatInformation – when you want itTraining courses- General (Hamlet)- Specific (DAFNE)Courses or training to be ongoing as things changeHow1 day courses (face to face)Booklets at GPs and chemistsAnnual campsEmail or letter from surgeryAdvertise courses in papersNew medicationInformation to be available in librariesTargeted information- Children- Ethnic groupsCD, booklets, courses. Everyonelearns differentlyEducation at schoolsDownload video from internetGroup 2List of the types of education that would be beneficial:• Medical jargon demystified e.g. DESMOND, Hba1c• To the general public e.g. schools, employers etc• A national register of diabetics so that information on new products can easily besent through• Education on complications• How to access and get access to products e.g. the Talisman• Literature on specialist diabetic subjects and in ethnic languages• London wide support group to discuss all aspects of diabetes. The group suggestedthe name ‘Diabetics Non Anonymous’Group 3Main focus: how we would like the education delivered:• Education from the beginning, it would be good for this to be in the curriculum atschools• It should be delivered at a pace to suit the individual• Ongoing up to date information. This should be personalised to guide the individual• Basic minimum induction when diagnosed• Support groups – learning from your peers and other people with experience of livingwith Diabetes Literature should be in ‘plain English’• Imparting informed knowledge sensitively7

Group 4Main focus: how education should be delivered:• DAFNE / DESMOND• Support and interest groupso Comments made “Today I have learnt more than in three years”• Regular updates• Multi lingual / diversity• A diabetes ‘mentor’ i.e. Diabetes specialist nurse, practice nurse or user group• A detailed knowledge of our condition by means of:a. 1:1b. meetingsc. literatured. internete. emailf. ‘balance’g. CDsh. DVDs / videosi. Pictures / cartoonsList of everyday problems:• Travel information• Insurance• Research and development advances• Sick days• Interpreting monitoring charts• Exercise• Diet• Background – statistics and information• Associated problems i.e. Heart, feet, eyes, renal.1.4. Question 4 - ‘What should we check to see if a diabetes service is agood service?’Group 1The perspective of carers and type 2 diabetics:• Miscommunication, inconsistency and inaccurate advice• Treatment impractical e.g. exercise for people with arthritis to lose weight.• Fear of needles in relationship to taking insulin• No preparation prior to injection• Diabetics cannot see or feel condition and so are in a ‘self denial’ state. There are nosymptoms• Overlapping health conditions make it unclear to treat• Neglect from GP service, e.g. lack of medication review• Lack of support8

Group 2• Contradictory information e.g. told to eat more starch and to lose weight• Importance of self motivation• Advice given on blood sugars five times a day (painful)• The difficulty of managing at night• Different ways to exercise to make it more interesting• Support / guidance to get back to a healthy lifestyle• Making sure you have the resources to make the decisions• Lifestyle versus peer pressure• More exciting diets are neededGroup 3• Dieting and exercise is difficult to keep up especially because of our cultural food• It is hard to eat regular meals• There is an inconsistency of proper advice due to change of health carers i.e. doctors• Remembering to take medications at the proper times• More guidance and advice at times to manage with diet• Monitoring blood results• Cultural factors – problems with fasting and celebrations• Attending clinics• Attending the appointments with opticians and podiatristsGroup 4• One gets used to being tired, thirsty etc but not having any visible symptoms• Lack of motivation• Temptation• Lack of self discipline• Psychological side of it e.g. comfort eating• More regular checks are needed to keep on track with managing the diabetesGroup 5• Acceptance of condition• The difficulty in changing habits e.g. “I like to eat chocolate”• Know your patient, what do they need to be helped• The limitation of only 20 minutes for discussion• The pain every time a finger prick is needed• Target driven advice rather than a personal discussion• Education – repercussion of not doing what was advised• It was felt that there was no advice given9

2. Group Work: 26 July 20082.1. Question 1: ‘What is the case for change?’• Lack of consistency – post code lotteryWhat:o Not listened to – wrong insulin, medication (One member commented that ondiagnosis they were given 45 minutes of specialists time and found it beneficial)o No pumps, no sensors, multiple injections – work religiously to a model, you needto fight for things that should be providedo GPs knowledge• lottery if GP has any knowledge• receptionists don’t have any knowledge• didn’t get some medication• although moved not confident will receive some helpo GPs education• to carry SOS necklace etco GP Excellence• works in a polyclinic type environment (type 2)o Delay in treatment – was trying alternativeso Consultants don’t want to commit timeo Add on service also inconsistento Within hospital not all consultants are at the same standardo Alternative medication – complimentary therapyo People with enduring mental health issues are not properly catered forEffect:oooooooo25 hypos a monthPoor controlUndiagnosed for a period (because of young age)Remained unwellConcerned about moving to another GP‘Excellent care’ from GPWasting time. Can learn more from a bookConcern about taking tablets – not always the solution – personal mentalstate• Lack of empowerment, choice, informationo Empowerment: Everyone needs access to structured education to give them theability to make choices, this will then lead to self management and betteroutcomeso No information at diagnosiso No access to educationo No information for people with ethnic needs, learning disabilities and other specialneeds e.g. mental healtho Choice: Do we really have choice for diabetes care and services (Choose andbook?)o Consultants: Seen as ‘gods’ but they are only people. Patients need the right tobe heardo Human rights and rights of carers10

• Make diabetes more important – raise awareness (showing where diabetes has beenthe cause of death, monitoring services)o Include in standard blood testo Not enough resourceso Not enough advertising e.g. poster showing what parts of the body are affectedby diabeteso Tell people about their complications without frightening themo More public awareness in school curriculum, amongst families and workforceo Target families at risk and extended familyo Constant monitoring of public education in all relevant languages/and accessibleto all e.g. sensory impairmento To be included on death certificate, the cause of death can distort the trutho Raise awareness at local Diabetes Planning Groups and Support Groups• Poor services lead to harm and money being wasted – money should be ring fencedfor diabeteso Undiagnosed and poorly controlled diabetes leads to costly complications both forthe individual and the NHS e.g. blindness, amputations, strokeso Quicker availability of newer technology e.g. pumps save complications andhence money and sufferingo Lack of coordinated care leads to wasted time, increased stress and reducedquality of careo Poor services from not listening to patients results in hypo/hyper problems, wronginsulin and increased hospital admissionso A good point is that a pharmacist was proactive in offering a consultation leadingto the patient following up with the doctoro To include a test to determine what type of diabetes the patient has, if neededo Ongoing training for medical staffo Blindness at an early age – what is the long term cost?Other headlines raised but with no further discussion• Models of care not personal enough• More and better monitoring• Lack of education2.2. Question 2: ‘What would your personal care plan look like?’Group 1: How the care plan is put together• To have options available before to people with diabetes e.g. injections, pills, pumps• Expert input about diabetic complications• Paced information leading up to care plan date e.g. three lots of information over a threemonth period leading up to the date• Good information to enable patients to make good choices• Care plan on diagnosis for type 2 diabetes• People diagnosed with type 1 and children’s care plan should be given by expertsinitially. This can be developed personally at a later date• Care plan with consideration for ethnic needs and different languages and special needse.g. mental health• To be reviewed annually, monthly for people from ethnic backgrounds• Age should be taken in to consideration• To highlight SOS tags11

This group felt the need to highlight the difference of needs required by people with type 1and type 2 diabetes. It was felt that a very different approach was needed for both.Group 2: How the care plan is put together• A care plan when patients are first diagnosed• A named person responsible with you/carers for drawing up plan• Regular revision to see plan is carried out and services provided• In writing or other format e.g. tape, Braille, appropriate language• Sent round to everyone involved in care who should read/act on it• Plan reviewed six monthly or as necessary• Plan MUST include health/social care/mental health/learning difficulties• These must also be care plans to address carers/parents needs. Local authority duty toinform carers of their right to carers’ assessment• National standard/quality assurance for care plan• Regular audit/evaluation of care planning system involving service users and carersGroup 3: Information to include on care plan• One care plan to be looked at by anybody and everybody who needs to• All medication on the plan and updated• This means personalisation• Any complications updated• Times and dates of appointments updated• Key contacts with up to date details• More personal information e.g. do you live alone – background• Should think about the whole person e.g. social care• It has to be a partnership – all parties have to be involved• Emotional side needs to be considered• Not everyone is the same – plan has to take that into account• Space for partners comments about how session went and what needs to be changed• What to do in a crisis e.g. who to contact with a variety of optionsGroup 4: Information to include on care planFactsWhat type of diabetesHbalcCholesterol etc weight, BPMedicationLast checks e.g. eye, neuropathy etcIssues e.g. complications, allergies, side effects etcSocial care / health careTraining course 1:1Access to recordsRecording other health needsGoalsPatients goal (aspiration)Consultants goalActionsExerciseBlood checksReferrals to other specialists, care workers, schoolsWhoHospital, GP etcNurse, doctor, hospitalHospitalAgreement – going forwardAgreement – going forwardPatientPatientConsultant12

2.3. Question 3: ‘What should we check to see if a diabetes service is agood service?’• Access to a diabetic clinic where an integrated team is available• GPs, nurses, diabetic specialist up to date with new knowledge and equipment• Patient satisfaction survey with feedback acted on• Evidence of listening to patients and providing high quality, accessible information• Evidence of understanding cultural needs and other special needs e.g. learningdifficulties and mental health• Accessible and responsive diabetic team• A named health professional• National standards are being met and if not, a clear action plan should be in place andmechanisms to draw in other needs• Evidence that patient questions are answered and explained• Enough staff for population, including specialists• Out of hours advice and 24 hour support• Local enhanced services e.g. insulin training for GPs• Access to psychological support• Evidence of integrated care pathway• Access to medical records free of charge• Clear lines to leadership• Social care assessments• A named care coordinator• Evidence of written care plans• A diabetes mentor• Assessment of skills and competencies of GPs and all staff• Regular training programmes for patients, GPs and everyone involved• GPs able to refer to more competent GP• Capturing patient perspective at GP surgery and fed back• Evidence of effective relationships• No restrictions on patient referrals to specialist• Effective complaints system• Access to good podiatry services• Evidence of specialist expert care of children with diabetes, with 24 hour support, goodstructured education for parents of very young children and special structured educationprogramme for older children• Specialist expert care extended to cover hospital admissions and inpatient stays for anyreason• Good liaisons with schools13

3. Group Work: 16 August 20083.1. Question 1: ‘Is the setting of care important to you?’Group 1• We need quality and consistent care• With interpretation• Information – leaflets and advice• Catering for sensory impairments and special needs - mental health, learning difficulties• Appropriate transport services – more direct to facility• Welcoming, clear signs• Information on delays• Partnership in care programme• One-stop shop – everyone under one roof – would travel for thisGroup 2• Prefer to travel to receive treatment by a professional care team – full integrated service• Surroundings do count – high profile required, diabetes is serious• Flexibility for patients in denial, who may have difficulty accessing services (this includesteenagers and difficult to reach adults who cannot or do not find the time to attend clinicappointments) more flexibility in appointment time. I.e. being willing to see them if theyturn up late or on the wrong day etc. Take every opportunity to give them information andadvice when they need it. Maybe giving them appointments in the evening, after work orbefore work or school in the morning• Centres of Excellence for Care – would be willing to travel further for these• GPs and practice nurses delivering diabetes must have standardised competencieswhich must be audited• Improve communication between hospitals, GPs and other service providers• Nothing must be sacrificedGroup 3• Happy with skills of GP and hospital staff• But would move their settings if care was not up to standards – but why should we?• Care pathway should be the same throughout the GP and hospital setting• Appointments should include all aspects of care• Care should be tailored to individualsGroup 4• Local regular contact builds up trust• Do people (healthcare professionals) talk to each other if you see them in differentplaces?• Trust is also about having a choice for the care you want to receive• Admissions to hospital – inpatient stays – can the staff find out what your situation is?• We are prepared to travel for specialist care but not for procedures that can be doneelsewhere e.g. blood test• Needs consistency of information and joined up working – needs a central ‘pot’ ofinformation – accessible to everyone involved in your diabetic care and that could beadded/changed by them in ‘real time’. Would therefore allow a relationship of trust todevelop14

• However, although we would be prepare to travel if the consistency above existed, thereare issues of accessibility for all groups• Also a linked issue of education- local training for local people – shouldn’t have to travelfar – otherwise you may not go to essential training3.2. Question 2: ‘How would effective education and training be formed?’Group 1Education could be based on SMART objectives:S specific/structured: Personal Care Plan aimed at type 1 and type 2M measurable /meaningfulA achievable/accountableRTrealistic/reportabletimed/targeted: Milestones - diagnosis- changes in careSuggestions:What? When? Where? Who?Insulin initiation diagnosis clinical setting DSNOral medication diagnosis clinical setting DSN/GPBM testing diagnosis clinical setting PN/DSNDiet diagnosis/ongoing clinical setting DieticianLegal requirementsDiabetes UK /One Stop shopdiagnosisclinical settingDAFNEfrom 3 monthsanywhere(group or 1:1) PCTDESMOND from 3 monthsanywhere(group or 1:1) PCTanywhereComplicationsChange of medsAd hoc – insurance- travel- workNew meds/updatesdiagnosisas neededas neededAs needed(group or 1:1)anywhere(group or 1:1)anywhere(group or 1:1)anywhere(group or 1:1)PCTPCTAny – Diabetes UK, One StopShop, Support Groups,DSN/PN/GP, Internet, Media,Radio, TVClinical staff• Every PCT should have a ‘diabetes classroom’ where leaflets and information would beavailable and where courses could be run in groups or on a one to one basis.• Apart from the DAFNE and DESMOND courses, this education would apply to type 1,type 2, parents and carers.15

Group 2• Type 1 require information at diagnosis followed up by structured education e.g. DAFNEto be delivered by specialist or specialist team. e.g. one to one followed by DAFNE.• Type 2 require information at diagnosis (carer should be present if appropriate) includingleaflets to be referred to. To be delivered by specialist or specialist team. Reference tosupport group. Also mentor and group education and other local services.• Tailored to the needs of ethnic groups e.g. education and provision of interpreter andliterature in appropriate language. GPs should be made aware of availability ofinformation from Diabetes UK which can be accessed in most languages.• In London, for example where there are large numbers of people from ethnic groups, atrained member of a staff team could go into the community and deliver training in anappropriate language. This would lower costs of using interpreters.• Education to be ongoing yearly with access as and when. One to one and groupdelivered by specialist team via meetings. Leaflets in appropriate languages.• At changing condition personal visit at home specialist nurse with leaflets.• Working in partnership with Diabetes UK. My local PCT is using Diabetes UK‘s'Recommendations for the provision of services in primary care for people with diabetes'guidelines as a basis of the new local community diabetes service. It is such anexcellent, well thought out document which covers most of what we have been talkingabout.• IMPORTANT: Personal contact counts the most. Through one-to-one and groups andpeer support.Group 3• Education of GP / practice nurse – certificate on display to show this• Surveys on public knowledge of diabetes• Then provide letter/email/leaflet in surgery – for general information on updated thoughtsand changes• A list of education / training should be available (DAFNE/ DESMOND etc) and then theGP should discuss and match to personal requirements (including ethnic languages) andalso training available for parents, carers and family• Information should be available at libraries / retirement centre / specialised groups /community centres / pharmacies (free-of-charge) / post office / Diabetes UK• Would be good to have trained mentors• Local diabetic groups for discussion and support• Health workers in the local community should run regular education sessions – theyshould get people involved and the education should be interactive (like today’s session)and people should have the chance to break into small groups and work on a task• Local exercise session at recreation centre (which offers education and free exercisesessions)• Education through CDs / online courses / media• Curriculum in school health education should cover diabetes• Education should be available on linked health risks such as heart disease, stroke,kidney problems etcGroup 4• Newly diagnosed – to start, people should receive basic written information on diabetesas well as being given the option to go on further training• You should receive a letter saying what type of diabetes you have, why you have thattype and the opportunity to go on further training• Letter should be sent by the person who diagnosed the patient - letter on diagnosis mayactual make people take more notice of their diabetes16

• Hypo/ hyper training• Training on dental care• Medications and side-effects• As long as we get the training – whoever is trained to do so• Group sessions with people your age, to be delivered by the diabetic nurse dealing withstandard topics and topics decided by the group (this idea came from a person with type1 diabetes)• The setting has to be one in which you are comfortable with – one-to-one, group etc. thetrainer needs to be competent to deliver• Need to differentiate between newly diagnosed and those who have been diagnosed along-time ago• Need for regular booster training for carers• Not just group training but one-to-one, CDs, videos, tapes, internet and residentialcourses• Diabetes UK to try to have support groups in all areas• Regular information in appropriate media for those requesting it• Education for people with special needs as appropriate, e.g. learning difficulties, mentalhealth needs, sensory impairments• People who live alone should be able to nominate a carer or neighbour if they have nofamily to attend the necessary training with them or on their behalf.• What to do in an emergency? Need education on this• People should get a standard information pack on diagnosis and one-to-one tailoredinformation as well• Need to sell to patients that diabetes is a progressive condition and that by going ontablets or insulin you are not a failure / have not done something wrong – so that theyknow what to expect and can feel empowered• Religious beliefs –what the doctor says may conflict with people’s beliefs and so they willnot engage with their diabetes management• DAFNE training is required for health care professionals as sometimes the patient hashad DAFNE training and then they speak differently about their diabetes and the doctorsdo not understand what they are saying as they have not been on the DAFNE courses.Comments from a young person with type 1 diabetesNeed transition training – for young people moving to adult services• How to take injections• How often to use needles, how to dispose of them• Different types of insulin• How to know how much insulin you should take• Testing• Training on drink, drugs and sex• Training in a way to suit you e.g. location, suitable times• Diverse range of training opportunities not only ‘lecture type sessions’• Important to meet people their own age to ensure they don’t feel like the only ones theirage with diabetes17

3.3. Question 3: ‘Emotional support, is it sufficient?Times we have found that we needed or would have benefited from some emotionalsupport:• Upon diagnosis• At the time of complications• During hospital stays and for parents and carers• Work place• During emergencies and for parents and carers• When stress has been recognised• For parents / cares after training and education has been receivedAt time of complications and emergencies, the emotions felt include:• Worried• Shocked• Sad• Confused• Frightened• Angry• Powerless• Eye sight deteriorating – no support – just a letter and letter wasn’t on her file. Letter verydirect and as not on file, could not have a discussion• “Most of the time I am sad because I can not explain what I am feeling because oflanguage barriers”• Never asked if I had a carer and if they needed information• As a carer, I felt responsible, coping with the situation, plus coping with the person youcare for. I felt ignored, overlooked and not listened to• One group member spoke about her husband who was blind and had broken both legs.He was very depressed and at times suicidal. She had to self-refer on his behalf to theMental Health team as they had no psychological support for his depression and shewas no longer able to cope with his mental state. When he refused to go out of the houseto the appointment, she went along alone to explain the situation and was told that theydo not do domiciliary visits and that there was nothing they could do. She did in the firstinstance have someone come to assess him and they arranged the appointment,however failed to take into account how hard it was for him to leave the house (althoughthey were not told that the team do not make home visits at the assessment stage). Theyalso had to wait several months for the appointment• “I would like sympathetic and positive care and for healthcare professionals to be moreencouraging”• “I had an abscess on my foot and was told the foot would ‘have to come off’. I wouldhave liked someone to talk to me and understand and respect me.”For people with diabetes who are in denial, the emotions felt include:• Invincible• Frightened• ‘I’m different’• Stupid• Bullied• Stressed• Angry• Frustrated18

• As from a family of diabetics it was inevitable• Wanted to try alternative medicine• Wanted lots of reassurance• Psychological support can alleviate a life time of misery and misunderstanding• Second blood sugar test to confirm the diagnosis• Got counselling – but parent (myself) was not involved, so knew daughter wasn’t tellingtruth (about taking insulin, for example). Perhaps could have ‘parental counselling’separately so counsellor could bring out anything that was not true• Denied support for 21 years. Would have liked education, involvement and trust in me.Got emotional support from parents not health care professionals• I thought ‘I’ll be ok’, complications happen to other people• Because of psychological problems / stress I have bought this on myself• On diagnosis it would have been nice to be offered some counselling on an ongoingbasis• No attempt at helping address denial – was left for family / carer to work through alone.Upon diagnosis, emotions felt include:• Shocked• Left out• Sad• Helpless• Selfish• Blank• What will be, will be (denial?)• Fear of being a burden on my wife and kids• Is there a future?• The worst experience of my entire life due to the bad handling of my diagnosis. I knew Iwas a person with diabetes and at the time I went in to shock (depressed for 1 year). Ineeded some empathy, someone to be polite and a chance to sit down. Don’t treat melike I am no one or nothing• I was scared. I had no information• Very stressful. Fear of death• Bad news, but happy to know what was wrong with me• Wanted detailed explanation for this diagnosis• All control was taken away from me. I was never spoken to, just spoken at. Did not havean understanding of what was going on. Would have liked to be involved in all decisionmaking• All support went to my daughter and nothing for me (the parent). Would have welcomedinformation on support groups such as Carers UK and Diabetes UKDuring hospital stays (for both people with diabetes and parents, carers, families),emotions felt include:• Helpless• Worthless• Patronised• Angry• Invisible• Ignored• Fear• No voice, input or control, care out of my hands, clinical staff very direct, no time forinteraction19

• To be spoken to as an adult who knows about their diabetes• I felt isolated. I needed support form nursing staff at regular intervals• Interaction with the nursing staff is important (talking therapy). Especially if a patient is ontheir own• I felt disempowered regarding food. It was chosen for me for 3 days until I gave the nurse‘the eye’ and she gave me my own menu after that. Also before that there was no choicein the food offered. It was just placed in front of me and I kept asking if they had anythingelse• Worried about lack of knowledge about diabetes when on general ward and postoperation. There was also a general lack of knowledge on insulin pumps• Not listened to – having cared for someone for eight years then being told by staff whodid not know this person what was wrong and what he wanted/needed was verypatronising and often wrong• Ignored by A & E nurses and doctors, even though I knew my daughter better than them,they worked to their ‘book’ and no-one listened. My daughter was terrified and wantedme to stay with her in hospital but they wouldn’t let me – in the end I discharged her20

4. Email group contributions4.1. Question 1: ‘Is the setting of care important to you?’Participant A• The polyclinic has a clear role in diabetes care, although the GP surgery will be the initialport of call.• If intermediate diabetes care is available from the PCT in a polyclinic/polyclinics this willallow one stop shopping for:o retinopathy screeningo patient audit by a DSNo dieticiano podiatristo structured education as may be required as assessed by the DSN• Too often patients, particularly type 2s, do not get to see a DSN, dietician or podiatrist orget to receive any structured education.Participant B• Most people have confidence in their GP and diabetes nurse and this should be wherethe information is assessed.• The specialist is often viewed with trepidation and quite often the information givenverbally does not register at the time and is soon forgotten. A full report of such aninterview should be sent to the GP who can then see the patient and explain andinterpret any findings given.Participant C• At the time of diagnosis I think it’s important not to be bamboozled with too muchinformation, as due to shock I don’t think much actually sinks in. However, I think it isimportant that questions asked receive informed replies.• I have found my son’s care very informative but my own as an adult far less so.• Dietary requirements, treatment and recognising hypos, and day-to-day care need to beaddressed from the outset but many queries only arise as time goes on.• I think educating the general public would be useful as many people have little or nounderstanding of what having diabetes entails, and how to deal with a person who needsemergency assistance.4.2. Question 2: ‘How would effective education and training be formed?’Participant A• On diagnosis I would like to receive written general information that I can take away tostudy – something like the DUK pamphlet “Understanding Diabetes” and “What care toexpect”. This must include something about diet, the subject which most confusesdiabetics, particularly as dieticians would appear to be insufficiently available for 1 on 1discussion/briefing. A dietician should be available within 28 days of diagnosis and thesession should be a mandatory part of the care plan.• As I am a type 1 I would need showing immediately how to inject and how to test myblood sugars one-on-one, probably by the GP practice nurse or a hospital DSN. I wouldlikely to receive structured group education, preferably DAFNE for type 1s or Xpert fortype 2s, one month after diagnosis - by which time I would hopefully be stabilised. At thattime I would also like to receive contact details for my local DUK voluntary group.21

• One has an enormous number of questions during the initial months following diagnosis.I would like to see the practice nurse six months after diagnosis for a Q&A and care plansession.Participant B• Who – local GP and diabetes nurse• Where – should be available from GP or diabetes nurse• Where – on an A4 print out of the implications of diabetes, both for type 1 and type 2,including further details of what is available to offset these implications together with anunderstanding of the blood test and urine test figures and the optimal figures to aim for.• When – when first diagnosed and then every two years to include advances made intreatmentParticipant C• It would be useful not to have to travel too far. It is time consuming and tiresome to haveto do so.• Also, for my 13 year old son, having to regularly go to a hospital for check ups makeshim feel different from all his friends. As he says, I’m not ill or an invalid I just havediabetes.22

5. Group Work: 11 October 20085.1. Question 1: ‘What aspect of service delivery/performance would youlike to have measured and reported on, on a regular basis?’Group 1• The personal care plan - everyone has one• There is a named person co-ordinating and who is a contact for the patient• All diabetes (and other services which are necessary e.g. mental health) services areavailable and included in plan, with IT system and integrated team support• Patients needs are assessed; needs unable to be met locally are fed into planning forfuture services.• Personal care plan should be monitored regularly. If this is done well enough then it willcover everything important to the patientGroup 2• Access to an integrated team (including psychological support) available out of hours/24hour with enough staff for population. This team should have an accessible andresponsive diabetic team with clear lines to leadership. There should also be regulartraining for GPs, nurses and clinicians• Team/service to provide:o Services for cultural needso Up-to-date information on medication and their side effectso Named professional/mentoro Education and advice to family/carer/patient on prevention and everyday selfmanagement• Evaluation forms that can be acted on immediately if need beGroup 3The three main messages:• Competent clinical staff with up to date knowledge• Accessible treatment• Education for userso Measures, audits and reporting should be provided for all.o Implicit with this is that specialist integrated care and diversity is provided‘‘What should we check to see if a diabetes service is a good service?’• GPs, nurses, diabetic specialist up to date with new knowledge and equipment• A named health professional• Evidence of integrated care pathway• Regular training programmes for patients, GPs and everyone involvedGroup 4Group 4 felt that the care plan could be used to monitor some of the points• Check HBa1c and Urine (Albumin/creatinine) – 3 monthly• Blood pressure and Cholesterol/urea/electrolytes and weight – 6 monthly• Eyes – Annually or sooner if there’s an issue23

Other areas to monitor are:• Education: GPs, consultants, specialists (CPD) – annually• Patients (offering updated education) – annually• Response times from Diabetic nurse – within two hours (including out-of-hours)• Social Care Assessmentso are patients getting all the help they need?o social serviceso employer (adverse judgement)• Dietician, podiatry should be offered at annual review – automatically available. It shouldbe possible to co-ordinate appointments to save patients time and stress• National standards are being met – annually• Having co-ordinated appointments would reduce the stress of having to travel to hospitalor clinic5.2. Discussion: ‘Project review’Hopes:• That views of the group are taken on, acted upon and communicated throughout theproject [and after the project ends]• That this project will improve education levels for participants• That volunteers will receive clear information regarding Healthcare for London• That the outcome will influence Diabetes UK• That the project can be put in the wider contextFears:• That the points raised above will not happen – still a concern after the project ends• That the project fails – this is still a fear for most of the group• That on reaching the end of the project, the agenda will have moved on [and the workwill have been for nothing] – the group felt this was not the case• That the participants will not be kept informed after the six month – still a fear. The groupexpressed a wish to be kept up to date with developments and reportsThings we’d like to say to Healthcare for London:• Recognise that service users and carers can contribute to the changes proposed, “Thisis a good model”• Will the new model of care be rolled out uniformly throughout the SHA? ‘Minimumstandards’, we would like to see figures published by PCT• We really appreciate the opportunity for genuine dialogue with clinicians and theHealthcare for London team• The project should be ongoing• The communication continues with the Service User Group – this was noted on othertables• Healthcare for London reporting telephone line, a service to report problems withdiabetes care and services so they can act on problems• The Service User Groups should exchange contact details and keep in touch. Also thegroup should continue informally• We would have liked to see the Board’s minutes, agendas etc of the two groups forcomment if necessary• We feel that the user group has been listened to and we hope they will act upon theoutcomes• Being part of the user group we feel empowered to ask for what is needed. We didn’talways feel we knew what was available and how to get it24

• Generally at stakeholder events it was good to be treated as equals (not by everyone)• There are some good practices in some boroughs, so it proves it can be done. Let’shope they learn from each other• The stakeholder event didn’t seem to involve Social Services or council educationservices for children, which is important for adult and children• The emphasis seemed to be more on adults than children• Have more such projects• Knowledge gained should be shared with all concerned with diabetic care• Empowerment and an enthusiastic approach by participants• Use this framework to adapt to other long term illness• Consolidate knowledge and review the achievement• Ask us again (in a couple of years) to review progress• Diabetics are the experts on diabetics. So engage in dialogue for positive and negativefeedback• End the postcode lottery25

Diabetes care pathwayPrepared in collaboration with Bupa Commissioning

Map of pathways – click on any map to startPreconceptionGenericpathwayAdolescentcarepathwayMental healthand type 2diabetesPatients incare homesor houseboundInitiationInitiation &ongoing careInitiationInitiation (1)Ongoing careOngoing careInitiation (2) &annual check-upCommon testsfor all patientsBlood pressurecontrolCommon componentsMedications (1) Medications (2)Common testsfor adolescents

Preconception care for women with diabetesGeneral NotesNotesNotesNotes

Generic diabetes care pathway: Detection and initial treatment

Generic diabetes care pathway: Ongoing management

Adolescents: Diagnosis, initial treatment and managementGeneral NotesNotesNotesNotesNotesNotes

Mental health and type 2 diabetesNotesGeneral Notes

Mental health and type 2 diabetesNotes

Care homes / houseboundNotes

Care homes / houseboundNotes

Common set of tests for all patients over18 undergoing diabetes management

Common set of tests for adolescentsundergoing diabetes managementNotesNotesNotesNotesNotes

Generic diabetes care pathway: Blood pressure management

Generic diabetes care pathway: Medications (1)

Generic diabetes care pathway: Medications (2)

DIPP - SCCP40, Argyle Road, Ilford, IG1 3BG 0208 554 3377 dippsccp@yahoo.co.ukThe contact for DIPP, the Diabetes Intervention and Prevention Programme, is Miss Shushila Patel.The contact for SCCP, the Sikh Community Care Project, is Mrs Jasbir Sanger.What is DIPP?DIPP is a Diabetes Intervention Prevention Programme funded by the Department of Health.The programme is based with the Sikh Community Care Project (SCCP) to work with theAsian communities, GPs and pharmacists to raise their awareness and offer a preventativeprogramme around Diabetes and Obesity.DIPP - SCCP AimsThe DIPP will work in partnership with the local Asian Communities and others to publiciseand improve awareness of the causes, symptoms and prevention of Type 2 Diabetes. Workingin partnership with the local Primary Care Trust (PCT), the project will compliment thedelivery of the local Action Plan and National Service Framework on Diabetes.The DIPP - SCCP programme aims to:• Encourage and increase the number of early detections of Obesity and Diabetesthrough health checks and primary intervention in the community• Increase the awareness in individuals and their families about the causes, symptomsand prevention of Type 2 Diabetes through seminars and other education programmes• Encourage healthy eating and increase uptake of physical activity by delivering healthactivities in the community (see overleaf)• Encourage partnerships between the diverse Asian communities, GPs, pharmacists,retailers, the local PCT and local authority• Reduce avoidable hospital admissions, retinopathies, diabetes related neuropathiesand lower limb amputations, so that patient quality of life is improved.Why DIPP in Redbridge?Redbridge PCT’s Public Health Directorate has identified undetected Diabetes as one of themajor health concerns locally. Diabetes is on the increase and there is high prevalence ofType 2 Diabetes in the Asian community, which forms a large proportion of the localpopulation.If you are interested, please call DIPP on 0208 554 3377 or dippsccp@yahoo.co.uk

DIPP – SCCP40, Argyle Road, Ilford, IG1 3BG 0208 554 3377 dippsccp@yahoo.co.ukThe contact for DIPP, the Diabetes Intervention and Prevention Programme, is Miss Shushila Patel.The contact for SCCP, the Sikh Community Care Project, is Mrs Jasbir Sanger.Community based Health ActivityWeekday Time Health Activity Venue / postcodeMondayWednesdayThursdayFriday11am – 12 noon11am – 1pm11.30am – 12.30pm7pm – 8pm10am – 11am7pm – 8pm8pm – 9pm7pm – 8pm10am – 11am1pm – 3pm7pm – 8pmHealth-Walk inValentines ParkHealth Checks(alternate weeks)Gentle Exercisefor womenYoga and GentleExercisefor men/womenYoga for womenExercise(separate classes formen and women)Gentle Exercisefor women and teensYoga class for womenExercise for menYoga classMixedSaturday 10am – 11am Bhangra and Keep FitValentines Park, IG1 3BG40 Argyle Road, IG1 3BGSt Albans Church,99 Albert Road, IG1 1HSIlford Methodist Church,Ilford Lane, IG1 2JGIlford Methodist Church,Ilford Lane, IG1 2JGSt Georges ChurchWoodford Avenue, IG2 6XHIlford Methodist ChurchIlford Lane, IG1 2JGIlford Methodist ChurchIlford Lane, IG1 2JGThe Cardinal Heenan Centre,326 High Rd Ilford, IG1 1QPThe Drive Methodist Church,Eastern Avenue, IG1 3PPThe Vine United ChurchHolstock Rd, IG1 1HJProjectNameDIPPDIPP/SCCPDIPP/RAMDIPPSCCP£1.00DIPP/RBADIPPSCCP£1.00DIPP/SATKARSCCP£1.00DIPP/AWAAZAWAAZ - Redbridge Education & Social Welfare Support Group, Ms Bushra - 07748598663RAM - Redbridge Asian Mandal, Mr Odhavji - 07905528645RBA - Redbridge Bengali Association, Mrs Kamela Ishaque - 020 85500882SATKAR - Health and Social Club, Mr Gurparsad Singh Bains - 0774859663Do you want to Volunteer for, or take part in, DIPP activities ?Call Shushila Patel on 0208 554 3377 or send an e-mail dippsccp@yahoo.co.uk

Improving emergency and inpatientcare for people with diabetesMarch 2008‘On several occasions I found food delivered…to eat when…blood sugar was high and no insulin had been given and theinsulin dose was not given for up to another hour…had to let the food get cold and wait for the insulin…On other occasionsinsulin had been given when…blood sugar was at a moderate or low level and there was no food in sight…and I ended uptaking control of my injections as the nurses either did not seem to know what to do, or would arrive long after my meal hadbeen set down in front of me’. (Person with diabetes 1 )‘I had taken all my medications with me, insulin, blood pressure tablets, statins, aspirin, etc so they would know. These were alltaken off me on ward admission. I have some understanding of why they do that but of course you then start to feel that youare losing control. I was traumatised by the whole experience, the loss of my control, the feeling of not being listened to; youare so vulnerable. I know as I get older chances are I may need in patient care again and I am genuinely frightened by theprospect; no one knows you better than yourself’ (Person with diabetes)The Report of a Working Party of representatives of the inpatient and emergency carecommunity in partnership with the National Institute for Innovation and Improvement 1

ContentsPageForeword 3Top ten things to know about emergency and inpatientdiabetes care 5Chapter 1• Introduction and policy context 7• What this document intends to do 10Chapter 2: Preventing admissions due to diabetes 11emergencies• Preventing diabetes admissions through education 11• The Ambulance Service 13Chapter 3: People with diabetes in hospital 15• The inpatient experience 15• The impact of diabetes on bed occupancy 19• Acute foot problems in hospital 21• Approaches to improvement and clinical pathways 28Chapter 4: Next steps• Recommendations and commissioning opportunities 33• What else is missing? 36Annexes:1. Lay Glossary 372. Inpatient experience collated by Diabetes UK 393. Audit and quality assurance 404. Acknowledgements 42All the references in this document can be seen in the document Inpatient ReportReferences at www.diabetes.nhs.uk1

ForewordWith an estimated 2.35 million people with diabetes in England and, as the recent Quality andOutcomes (QOF) statistics indicate, the number diagnosed increasing by about 1,300 each week,it is clear that diabetes poses considerable challenges to the NHS. These challenges encompassall of the elements that constitute health care provision in England – from Public Health, throughprimary and specialist care, to ambulance services and those who commission such services. Todeliver safe, effective patient centred care that meets the Diabetes NSF standards requires asignificant degree of coordination between these elements. A key part of that effective care isfocused on emergency and inpatient services with an emphasis on reducing admissions, reducinglength of stay and improving patient experience.With about 10% of all hospital beds in England occupied by someone with diabetes, andmore than this in high risk groups such as older inpatients or those with an acute coronarysyndrome (ACS), strategies to reduce both admissions and length of stay would haveconsiderable benefits. Most people with diabetes in hospital have been admitted withdiabetes, rather than because of diabetes, and having it generally means a longer stay inhospital, whatever the reason for admission. Being in hospital has a significant impact onpeople with diabetes and evidence shows that they are often very unhappy about themanagement of their diabetes in hospital. It is not uncommon for them to lose control oftheir insulin treatment, the timing and quality of their meals, blood glucose monitoring, andoverall control of their condition. Many people with diabetes know more about managingtheir condition than the hospital staff looking after them. Hospital staff may have had littletraining or experience in diabetes, and it is usual for inpatients with diabetes not to have theopportunity to be seen by the hospital specialist diabetes team.Commissioners of diabetes services need to examine all of the support and care people withdiabetes in their locality need. However, the needs of people with diabetes in hospital andthose treated as emergencies must not be overlooked. As this report shows, there is strongevidence that care models for inpatients co-ordinated by specialist teams improve patientoutcomes, and provide good value for money.Improvements which may prevent attendance at or admission to hospital can also be made inthe care of people in emergencies. The role of the ambulance service in diabetes care issometimes overlooked but they are often the first port of call for people who experiencedifficulties managing their condition. There are an estimated 100,000 emergency 999 calls ayear for diabetes emergencies and of them 35% cent come from just 11% of addressesmeaning that there are many repeat callers. With the resulting knock-on effect of these callsoften leading to Accident and Emergency visits and emergency admissions, better care forthe person at home would have a significant impact on patient experience and reduceadmissions.Although not all diabetes emergencies can be prevented entirely it is obvious that any reportthat focuses on inpatient care and emergencies needs to mention the role of patienteducation in enabling people to manage their condition more effectively. The contribution ofbetter coordination between primary, specialist and ambulance services is also enormous.There is also a recognition that the skills of all hospital staff, not just diabetes specialists,need to be enhanced to deliver better care on the wards. However, these are enormoustopics in their own right and this report does not attempt to cover them comprehensively.What it does do is pull together many strands of work focusing on emergency and in3

hospital care for people with diabetes. We have focused on a few key areas, where theevidence base is strongest, and where we think improvements could be made quickly. Theseare:• Preventing diabetes emergencies out of hospital, and emergency admissions, with aemphasis on ambulance services• Improving quality and value for money for people in hospital with diabetes• Preventing and treating acute foot problems in hospital: strategies for improvementIt is heartening that, despite all the many challenges, local teams are designing and deliveringbetter ways to support people with diabetes in hospital and in emergencies. This reinforces theview that better care can often be delivered through better coordination of existing services andresources. We are sure that with the support of the diabetes community, the experiences ofpeople with diabetes in these key areas will improve.This document has been informed throughout by the inpatient experiences of people withdiabetes gathered by Diabetes UK, by information from UK professional groups, from a large‘Challenges and Solutions’ workshop of diabetes healthcare professionals and people withdiabetes, and by overlapping work undertaken by the National Institute of Innovation andImprovement. Our thanks go to them all and everyone who has contributed their time andknowledge to this report.This document is not intended to present clinical guidelines, but to inform discussionsbetween clinical teams, acute trusts and commissioners on these key aspects of inpatientdiabetes care.Mike Sampson,Chair of the Working PartySue Roberts,National Clinical Director for Diabetes4

Top 10 things to know aboutemergency and inpatient diabetes care.1. About 10% of all hospital beds in the UK are occupied by people with diabetes, andthis approaches 20 – 25% for high risk groups. People with diabetes are twice as likelyto be admitted to hospital, and 20% have experienced a hospital admission in theprevious year.2. Inpatients with diabetes stay in hospital longer, whatever the cause of admission, andthis excess length of stay can be substantial. This excess length of stay is most markedin younger inpatients; those less than 75 years old.3. Diabetes bed occupancy based on Health Resource Group (HRG) data suggests about165,000 diabetes discharges from English Hospitals per annum, with bed occupancy of1.34 million bed days. Few people with diabetes are reviewed by the specialist teamduring their stay. Unit cost per bed day estimates suggest a total unit cost for diabetesbed occupancy of about £465.25 million per annum.4. About 6,000 people are admitted each year to English hospitals with diabeticketoacidosis (DKA), the most dangerous metabolic complication of diabetes.5. About 100,000 people with diabetes make emergency ‘999’ calls to ambulanceservices each year, mostly due to extremely low blood glucose levels (‘hypoglycaemia’).Perhaps 40% of these are transferred to Accident and Emergency Departments, andabout 10% admitted overnight.6. Inpatients with diabetes are commonly unhappy about the standard of diabetes carethey receive in hospital, due to loss of control over their own self – management, andthe level of staff knowledge and competencies.7. Acute admissions for inpatient care with diabetic foot disease account for a significantamount of NHS spending. In the UK the estimate for foot complications includingamputations was £252 million per annum.8. There is now substantial evidence for proven care models that reduce the incidence of:hospital admission, excess length of inpatient stay, acute metabolic complications,diabetic foot disease and amputation.9. The application of these care models across the UK is variable with substantial gaps inservice. They are based on a specialist diabetes team commissioned to deliver anenhanced inpatient diabetes nurse, dietetic and foot care service for highest riskinpatients, educational programmes for all staff, and better care pathways between theambulance service and the specialist diabetes team.10. These care models are relatively low cost and good value for money. The models aredescribed in this report, and outlined in the recommendations section.5

Chapter 1Introduction and policy contextNational Diabetes FrameworkThe National Diabetes Framework (NSF)published by DH in January 2003, wasestablished to drive up service quality andtackle variations in care. It sets out twelvestandards to be achieved by 2013.The Diabetes NSF describes better liaisonbetween the specialist team and ward staff asa Key Intervention and notes the benefits ofemploying inpatient diabetes specialist nurses.While the number of these staff has doubledvariation still remains and service gaps exist inUK hospitals. Standards 7 and 8 of theDiabetes NSF highlight the importance ofcaring for people with diabetes when theyare ill or when their condition is unstable,either because of diabetes itself or for someother medical or surgical reason.Five years on from the publication of theDiabetes National Service Framework (NSF)Delivery Strategy, considerable progress hasbeen made in improving routine care forpeople with diabetes 2 . However, people withdiabetes, admitted to hospital for whateverreason, are often unhappy with the quality ofdiabetes care they receive as inpatients. Thishas been recognised as a leading concern ofpeople with diabetes and clinicians for manyyears. Hospital and emergency services stillface substantial challenges in ensuring thatpeople with diabetes experience a uniformlevel of care that meets NSF standards.Diabetes NSF standard 7 –Management of diabeticemergencies‘The NHS will develop, implement andmonitor agreed protocols for rapid andeffective treatment of diabeticemergencies by appropriately trainedhealth care professionals. Protocols willinclude the management of acutecomplications and procedures to minimisethe risk of recurrence’.Emergency admission to hospital and use ofemergency services by people with diabetescan be reduced and in many casesprevented. The provision of well-designedpatient education for everyone is key inhelping avoid diabetes emergencies, but stillonly a minority of people with diabetes arereceiving quality assured structurededucation. 3Good out-of-hours support services canreduce the need to call out ambulanceservices. Identifying those who are frequentusers, or who are at high risk ofemergencies, means that they can betargeted for preventative measures.Ambulance services themselves areincreasingly developing specific support forpeople with diabetes, to prevent and reduceadmission, and are auditing what they do.Local coordination between proactiveambulance services and well structured andresponsive local diabetes servicearrangements would mean that many morepeople could benefit from this. 4Diabetes NSF standard 8 - Care ofpeople with diabetes duringadmission to hospital‘All children, young people and adultswith diabetes admitted to hospital, forwhatever reason, will receive effectivecare of their diabetes. Wherever possible,they will continue to be involved indecisions concerning the management oftheir diabetes.’7

Most inpatients with diabetes report thathospital staff are aware they had diabetes,but a substantial minority are aware thatthe staff looking after them lack theappropriate knowledge and skills to delivergood diabetes care. 5 This may contributenot just to unnecessary problems withblood glucose control and prolongedinpatient length of stay, but anxiety anddistress for inpatients with diabetes. Mostpatients with diabetes receive no directinput from the specialist team.This document provides guidance forcommissioners, acute trusts and clinicalteams on quality measures, key outcomesand supporting examples of good practiceto improve diabetes inpatient andemergency care. There are various servicemodels that currently demonstrateimproved outcomes, and an objective of theproject has been to provide support to localservices to enable them to ‘map theirservice’ and develop new ways to supportinpatient diabetes care.Making Every Young Person withDiabetes MatterThis report (April 2007, DH), was aimed ateveryone involved in improving services forchildren and young people with diabetes.It provides guidance on the commissioning,organisation and provision of services andworkforce. In relation to young people withdiabetes in hospital, it states that whencommissioners and providers are assessingthe care need of young people, amongstother criteria, they should address the localhealth burden: hospitalisations, length ofstay, complication rates.CommissioningCommissioning a Patient-Led NHS (July2005, DH), stated that the NHS should bemoving from a provider driven service to acommissioning driven one. The documentset out the importance of expert andimaginative commissioning in order toachieve the aim of a patient-led NHS. 6Health Reform in England: update andcommissioning framework (July 2006, DH),provides a detailed framework forcommissioning. 7 The framework includespolicy and implementation guidance oncommissioning and practice basedcommissioning (PBC) and expectations ofhow PCTs, GPs and health and social carecommissioners will work together. 8The Diabetes Commissioning Toolkit(November 2006, DH) was based on theprinciples outlined in these nationaldocuments and provides detailed advice onhealth needs assessment, and the genericand specific elements that should be inevery good commissioning plan fordiabetes. There is a specific inpatient sectionin this toolkit. 9World Class Commissioning (December2007, DH) sets out a new approach tocommissioning for health and care services.The programme, based around 11 keycompetencies, sets out the knowledge, skillsand behaviours to bring about a stepchange in commissioning, ultimatelyimproving health and well-being outcomes.One of the 11 competencies requirescommissioners ‘to lead continuous andmeaningful engagement with clinicians toinform strategy, and drive quality, servicedesign and resource utilisation.’This document is a contribution to thatengagement.Payment by results (PbR)Health Reform in England: Update andCommissioning Framework, July 2006, DH,described the different reforms that arebeing made to the healthcare system andexplained how they are expected tointeract. 10 A key component is the Paymentby Results (PbR) funding system, includingthe use of a national tariff for certainprocedures and diagnoses. PbR aims to8

ensure that different providers receive thesame income for the same work and canthus compete on the basis of quality. Itsintroduction means that acute trusts arepaid on the basis of the work that they do.Understanding how diabetes is handled bythe PbR system can have importantimplications for both trusts and thespecialist services they employ. It provides afinancial incentive to reduce length of stay,can potentially incentivise the correctdischarge coding and diagnosis of peoplewith diabetes admitted to hospital, and canhelp diabetes teams demonstrate to theircolleagues within the acute hospitals thecritical role they play in providing support toother services and elective streams.Public Service Agreements TargetsThe Department of Health has a NationalPublic Service Agreement (PSA) targetspecifically on reducing emergency bed days. 11The 2008 target to reduce emergency beddays by 5% has been met. Howeveremergency bed days will continue to bemonitored as part of the 'vital signs' whichincludes a set of national priorities andpriorities for local determination, to be agreedin consultation with local partners as part ofthe LAA process. Emergency bed days willfall under priorities for local determination.Since 60% of inpatients with diabetes havebeen admitted as emergencies, and accountfor 10% of all occupied beds, reducing thenumber admitted, and also their length ofstay, would have a substantial impact inmeeting and maintaining this target.There is also a more generic PSA target toimprove patient experience:‘Secure sustained national improvementsin NHS patient experience by 2008,ensuring that individuals are fully involvedin decisions about their health care. Theexperiences of black and minority ethnicgroups will be specifically monitored aspart of these surveys’.The Healthcare Commission will monitorprogress against these PSA targets.Taking Healthcare to the Patient:Transforming NHS AmbulanceServicesThis key document, published July 2005 byDH, provided a new vision for the ambulanceservice as part of a ‘mobile health resource’,by providing an increasing range ofassessment, treatment and diagnosticservices, and thus plays an important role inproviding care closer to home. 12It saw developing effective and enhancedpartnerships and teamwork with other NHSorganisations, social care providers and theindependent sector as crucial to deliveringradical improvements for patients. They areexpected to work as part of the primary careteam to help provide services and supportpatients with long-term conditions.Interaction between Commissioningteams and clinical servicesImportant levers of service improvement arehigh-quality commissioning, clinical leadershipand responsive and innovative teams.Commissioners can use the general principlesassociated with World Class Commissioning,and the specific points raised in the diabetescommissioning toolkit to assess the needs oftheir local diabetes population, describe thecurrent service and identify gaps in serviceprovision. 13 Evidence of good practice, andhow this can improve quality and reducecost, is an important resource to helpcommissioners redesign and transformservices. Diabetes networks provide animportant forum where commissioners andclinicians can engage with people withdiabetes in supporting World ClassCommissioning. The National DiabetesSupport Team has produced the BeyondBoundaries series of publications tosupport the creation and development ofclinical networks. These are available atwww.diabetes.nhs.uk9

What this document intends to doThis report was written by a steering groupof people with diabetes and clinicians froma variety of professional backgrounds,working with the Department of HealthDiabetes Policy Team, Diabetes UK and theNational Diabetes Support Team. Thissteering group worked in partnership withthe NHS Institute of Innovation andImprovement. The work included anational ‘Challenges and SolutionsWorkshop’, which was attended by nearly100 people representing inpatient diabetesand emergency services and Diabetes UK,as well as people with diabetes. Theyexamined both the challenges and thepossible solutions of improving care andcontributed to the final recommendations,which were reviewed by professional groupsinvolved in diabetes care.This report is not intended as a guidelinesdocument, or as a clinical resource fordiabetes specialist teams, or as an exhaustivereview of inpatient diabetes services.This report is intended to provide qualityinformation and standards forcommissioners and providers, and to outlinetools for service improvement in inpatientdiabetes care. We hope to describe thescale of the problem, both clinically andfinancially, and identify models that lead toservice improvement and financial savings.We hope this will also provide a frameworkwithin which the diabetes community as awhole can discuss these problems.The working group decided to concentrateon three principal areas in whichimprovements are needed and whereprogress can be made relatively easily andmeasured:• Preventing diabetes emergencies out ofhospital, and emergency admissions, withan emphasis on ambulance services.• Improving quality and value for moneyfor people in hospital with diabetes.• Preventing and treating acute footproblems in hospital: strategies forimprovement10

Chapter 2Preventing diabetes emergency admissionsthrough education.The problemThe most common diabetes-specificmetabolic emergencies outside hospital aresevere acute hypoglycaemia and diabeticketoacidosis (DKA). These are both defined inthe glossary at the end of this report. The riskof these complications can be reduced byenhanced self management skills and byoptimising education, training and improvedservice delivery. This chapter focuses onpreventing hospital admissions via thesemechanisms. The other common and equallydangerous emergency admission – thediabetic foot – is dealt with in Chapter 3.An estimated 5,000-6,000 people withdiabetes are admitted to English acutetrusts each year with DKA, and theincidence of DKA may be increasing (Figure1). In addition, there is substantialvariability between PCTs in DKA admissionrates (Figure 2) The incidence of severeacute hypoglycaemia in a UK diabetespopulation11 was 11.5 (9.4 - 13.6) per 100patient years for Type 1 diabetes. 14Both of these conditions are more commonduring other illness, when there aredifficulties with individual treatmentregimens, a mismatch between food andphysical activity when treatment regimenschange, and at certain critical periods suchas adolescence and young adulthood.Figure 1. Patients withdiabetic ketoacidosis as aprimary diagnosis, age andsex standardised, acrossEnglish regions.Compendium of Clinical andHealth indicators, 2002(www.nchod.nhs.uk)11

Preventing emergency admissions– diabetes education and diabeteseducatorsMost diabetes emergencies can beprevented. This requires an integratedpackage of services commissioned across awhole community. The key components are• Basic structured education in ‘sick dayrules’ for everyone with diabetes• Proactive intervention in high risk groups• Access to emergency support forunexpected events• Prompt and appropriate intervention byemergency services• Close links to routine services to preventrecurrences.Diabetes education and diabeteseducatorsThe importance of patient education inreducing acute diabetes admissions hasbeen understood for the last 30 years.Since then the central role of selfmanagement and diabetes education hasbecomes clear, and diabetes specialistnurses, unknown before the 1980s, havebeen appointed nation-wide to supportthis. Testing Times reported this was thedevelopment most appreciated by peoplewith diabetes, although the recentHealthcare Commission survey reported thatonly 11% of respondents reported any formof educational course, quality assured ornot. The Patient Experience survey carriedout by the Healthcare Commission foundthat 39% of people said they would likemore information on managing diabeteswhen they were ill and 30% want moreinformation about what to do if their bloodglucose drops too low. 15There is now recent evidence that contactwith the specialist diabetes team, instructured educational approaches, reducesadmissions for DKA and metaboliccomplications, particular for younger peoplewith Type 1 diabetes. 16Personally relevant information, from timeof diagnosis, is needed for people tounderstand both how to avoidhypoglycaemia and “sick day rules”; that ishow to manage their condition when theyare unwell. Local guidelines and protocolsneed to ensure that people get the rightamount of information when diagnosedand are not overloaded with facts andfigures. Individuals’ educational needs willchange and need to be assessed regularly.We had a person on DAFNE (a qualityassured education programme for peoplewith Type 1 diabetes) who said he had tohave the paramedics out about 100 timesa year and he knew all the ambulancemen by name! His life was totallydisrupted and he felt very unsafe. Post-DAFNE he is nowhere near as familiarwith the paramedics’A DAFNE educatorProactive intervention for high-riskgroupsCertain groups of people with diabetes useemergency services more than others.Commissioners will want to ensure thatprocesses are in place to identify thesehigh-risk groups and engage them infurther education.Residents of care homes, for example, areparticularly vulnerable to admission due tometabolic decompensation. Mortality ishigh, probably due to multiple comorbiditiesand delays in admission. It isimportant that local guidelines includeroutine proactive monitoring andpreventative care.In younger people, recurrent hypo orhyperglycaemia with or without admissioncould indicate problems with managing aninsulin regimen in response to complex12

psychosocial and behavioural factors.This can be helped by individual casemanagement, provided by the diabetesteam and supported by experiencedpsychologists.Preventing emergency admissions -out of hours contactThe availability of out-of-hours services forpeople with diabetes varies across trusts.Estimates of the numbers of out-of-hourscalls made which are diabetes-related areunknown as this data is not collectedcentrally. Testing Times found that someservices provided people with diabetes withthe number of a mobile phone carried by amember of staff on a rota basis, while manyother centres have established a ‘duty’system whereby diabetes specialist nursesprovided cover for a dedicated telephoneline. The Healthcare Commission PatientSurvey recently found that 20% of peoplewith diabetes did not know who to contactoutside working hours and 78% of trustsvisited did not have formal arrangementsfor people with diabetes to contact staff atweekends. Good availability of out of hoursservices has been associated with a reducedadmission rate for DKA andhypoglycaemia. 17The Ambulance ServiceIt is now clear that ambulance trusts inEngland are a very major provider of acuteservices for people with diabetes,particularly hypoglycaemia, and that theyplay a central role in treating thesepatients and making decisions aboutwhether to transport people to Accidentand Emergency departments or the localacute trust.The UK ambulance services respond toapproximately 100,000 emergency ‘999’calls each year from people with diabetesexperiencing a diabetes emergency, most ofthese calls are to those experiencing severeacute hypoglycaemia.18Data from ambulance trusts confirms that asmall number of people with diabetesinitiate a much higher proportion of callsoverall, sometimes calling the 999ambulance services 6 – 10 times a year,indicating a group of very high intensityservice users where concentration ofsupport might improve quality and value.Ambulance trusts use the UK AmbulanceServices Clinical Practice Guidelines (JRCALC2006). Emergency Medical Technicians areable to give glucagon injection but are notpermitted to give any intravenous drugs. Aparamedic is able to administer intravenousglucose 10%. If treatment does not quicklyimprove the patient’s condition they arerapidly transported to Accident andEmergency. Patients who fully recover witha blood glucose measure of > 5.0 mmol/Lcan be left on scene with a responsibleadult and advice.In the East of England, 64% of peoplewith hypoglycaemia are treated at homebut there is wide variation across the restof England with the percentage taken toAccident and Emergency ranging from26% to 58%. 19 An indicator onhypoglycaemia has been included withinthe draft national ambulance servicesClinical Performance Indicator, and willhelp commissioners interpret localperformance against national comparators.13

Preventing diabetes admissions:Follow up and liaison with thediabetes specialist teamThe publication of Taking Healthcare to thepatient: Transforming NHS AmbulanceServices spelled out that ambulance serviceshave a duty to work in a more integratedway with partner organisations. Workingclosely with local diabetes specialist teamscan reduce some of the potential risk ofleaving people at home when they haverecovered and of preventing furtherepisodes. ‘Treat and release’ protocols forpeople with acute hypoglycaemia byambulance crew are now common. 20The East of England Ambulance ServiceNHS Trust has set up a new 24-hourPatient Call-Back System run by speciallytrained paramedics and nurses inresponse to a review of diabetes care inthe trust. In appropriate cases ambulancestaff will leave a person with diabeteswho has experienced a hypoglycaemicepisode after home treatment. A trainednurse or paramedic in Ambulance Controlwill telephone the patient two to fourhours after the ambulance crew leave thescene to check on the patient’s condition.The telephone contact gives staff extratime to speak with the patient where theycan offer advice and ensure that thepatient’s diabetes team is informed byeither the patient or the ambulanceservice with the patient’s permission. Thisis an important point as some patientschose not to have their GP informedbecause of the potential risk to theirdriving licence. This system, as well asassisting in risk management for the “leftat home” patient may also help preventrecurrence of acute emergencies byreinforcing or facilitating engagementwith routine diabetes care.In West Yorkshire a referral pathwaybetween the Ambulance Trust and thediabetes specialist nurse team led to 53%having their diabetes treatment adjusted,and 75% of people with diabetes inhospital feeling that this contact hadincreased their ability to managehypoglycaemia.Financial IssuesPeople with recurrent severe hypoglycaemia,making multiple 999 ambulance calls, areclearly at high risk and may benefit from extrasupport. There are models of care andpathways that can reduce the risk of severeacute hypoglycaemia, and the risk of beingtaken to hospital, and possibly admitted. 21These would improve quality of life for thesepeople, but may also have financialadvantages.For instance, there would be substantialsavings to be made by identifying theapproximately 10% of callers who make 33%of 999 calls. By helping them to improve theirself management it would reduce their use ofambulance services, Accident and Emergencyand hospital admission and could have asignificant cost benefit. With emergencyambulance attendance costing about £220,minor Accident and Emergency attendancetarrifed at £55 and significant additionaladmission costs there are obviously substantialincentives to improve.Many ambulance trusts operate a ‘see andtreat’ policy, but reducing the nationalvariability in the percentage of thesepatients carried on to Accident andEmergency, minimum 26%; mean inEngland: 43%, could also significantlyreduce Accident and Emergency andadmission costs.14

Chapter 3:People with diabetes in hospitalThere are three interrelated outcomes ofinpatient care where people with diabetesfare worse than comparable groups withoutdiabetes, and where new ways of workingand enhanced clinical leadership wouldimprove them all. These are:• Inpatient experience• Length of Stay• Health outcomesThe inpatient experienceThe Diabetes NSF recognises the issuesfaced by inpatients with diabetes, and theclinical staff that care for them. Standard 8of the NSF states:‘All children, young people and adultswith diabetes admitted to hospital, forwhatever reason, will receive effectivecare of their diabetes. Wherever possible,they will continue to be involved indecisions concerning the management oftheir diabetes.’Following hospital admission many peoplewith diabetes are not allowed to selfmanage, are left feeling disempowered,report poor experiences particularly inrelation to the inadequate knowledge ofhospital staff, myths surrounding food, thetiming of meals and medication, and reporta lack of information provided during the inpatient stay. These frustrations are sharedby many ward and specialist diabetes staff.The recent Healthcare Commission NationalSurvey of People with Diabetes obtainedthe views of almost 70,000 people withdiabetes in 2007, and included questions oninpatient experiences. Some of the keyfindings are set out below, and they showthere is still more to be done.Healthcare Commission, NationalSurvey of People with Diabetes:• 30% of people with diabetesreport staff are unaware of theircondition• 10% get no help with theirdiabetes in hospital• 11% do not receive the right food• 20% only sometimes or rarelycould take their medication as theywishedThe Steering Group asked Diabetes UK togather the inpatient experiences of peoplewith diabetes to identify the issues thatcurrently need to be addressed. Someresponses indicated that a hospitaladmission can be a positive experience andsupport recovery.‘After the operation, I was checkedhourly during the night, including myblood sugar levels, with the nursesadjusting the insulin drip accordingly.They seemed to know what they weredoing which gave me confidence not toworry and to leave things’Person with Diabetes.However, in general, people experiencepoor inpatient care caused by:• A lack of personalisation in the carereceived, leading to a perception by manypeople that they are not listened to.This can lead to stereotypes of diabetesbeing applied to everyone, regardless oftheir experience and individual need.• Insufficient knowledge or training ingeneral ward staff, leading to lack ofconfidence and sometimes inappropriatecare.15

The key themes and issues which emergedare set out below. Extracts from commentsthat were received can be found on theDiabetes UK website; www.diabetes.org.ukDisempowerment and ability toself-manageLoss of the ability to self manage while aninpatient is a common cause among manypeople with diabetes. Although selfmanagementis not appropriate for someinpatients (very ill, newly diagnosed etc) thisremains a principal cause of dissatisfaction.Most people with diabetes will be used tomaking their own decisions aboutmanaging their condition. A suddenexclusion from decisions is disempoweringand distressing. In the case of children withdiabetes, the parent or carer’s role in themanagement of their condition also needsto be considered.‘On being admitted for an operation …my insulins and syringes were removedand taken into the "care" of the Sister. Iwas informed that I was not permittedto administer any "medication" and thiswould be performed by a member ofStaff. No member of … staff had therequired certification to deliver this’.Person with diabetes‘Other diabetic patients on the ward hadtheir insulin taken away and refrigerated.It was returned near mealtimes but theywould not leave it with the patients whowere very compos mentis and able tocare for themselves, which after all is thewhole point of our regime’.Person with diabetesControl over food choices andtimingThe Diabetes Treatment SatisfactionQuestionnaire for Patients (DTSQ-IP) is thefirst psychometrically validated instrumentfor inpatients with diabetes and is related tothe original DTSQ. 22 In a pilot survey ofinpatients with insulin treated diabetes, asignificant minority said they would neverhave made similar meal choices at home.‘On several occasions I found fooddelivered…to eat when…blood sugarwas high and no insulin had been givenand the insulin dose was not given forup to another hour…had to let the foodget cold and wait for the insulin…Onother occasions insulin had been givenwhen…blood sugar was at a moderateor low level and there was no food insight…and I ended up taking control ofmy injections as the nurses either did notseem to know what to do, or wouldarrive long after my meal had been setdown in front of me’.Person with DiabetesResponsibility for the management ofdiabetes in hospital should be sharedbetween the person with diabetes and thehealthcare team. Wherever possible, peoplewith diabetes should be allowed to maketheir own food choices, though guidancemay be needed from the dietician to ensurethat all food choices are appropriate to thecircumstances of the illness.Many people with diabetes treated withinsulin, particularly those who haveaccessed structured education, will havegood self-management skills. They will beable to choose any item regardless of recipe16

content or size and judge the appropriatedose of insulin, provided this information isdisplayed on the menu. Others need thesecurity that items labelled as suitable havebeen appropriately modified and kitchenpractices may need to be supervised toensure this is the case. It is equallyimportant that appropriate food is availableto choose from, such as special menus forchildren. It is important that everyonelooking after people with diabetesunderstands specific cultural and religiousrequirements such as the type, content andpreparation of food, and etiquette aroundserving food. Labels designed to signpostthe patient to or away from certain foods,and involvement of the family are helpful.Frail older people may need enhancednutrition and supervision at mealtimes.Nutritional impairment leads to increasedmortality and greater lengths of stay. At thetime of admission, signs of malnutrition arepresent in as many as 25%of elderlypatients.. All older adults require anutritional assessment and suitableinstruments are available. 23Access to information and supportHaving accurate information about what toexpect, whether from ward staff or thespecialist diabetes team, is important topeople with diabetes when in hospital.Some will need extra emotional andpsychological support. This is particularlylikely in people newly diagnosed, in childrenand their families and in older people.‘… because I have type 2 diabetes, I wasinformed that I would need to beadmitted the night before so that mydiabetes could be monitored by specialiststaff. During my stay I saw no-one fromthe diabetes care team’.Person with diabetesStaff expertise and medicinesmanagementPeople with diabetes in hospital need theright expertise at the right time from atrained ward team supported by thediabetes specialist team itself. The mostcommon concern is lack of knowledgeamong ward staff about achieving steadyand safe blood glucose levels. Staff may beunfamiliar with how to deal quickly withhypoglycaemic events, the different effectsof different medication, or specific issuesaffecting children with diabetes.The specialist diabetes team can provideassistance to ward staff, and ensure thatprotocols are up to date and trainingavailable. However, only 24% of peoplewith diabetes report they had been visitedby the diabetes team during their stay. 24Blood glucose controlOne contributory factor to erratic bloodglucose control is staff mistiming of insulinin relation to meal times in those not selfmanagingtheir own insulin. 25Subcutaneous sliding scale insulin,associated with poorer blood glucosecontrol than other approaches, has beenheavily criticised, but is still used in abouthalf of UK hospitals. 26‘… my blood glucose was very high anderratic, so they insisted that I stayed ‘tilthey got it under control, whilst I wantedto get home to get it back under controlmyself…The DSN, who I knew verywell…arrived within 20 minutes and aftera few minutes conversation with me toldthe wards staff ‘He’s right … let him go.’Person17

‘I was put on ‘sliding scale’ and after theoperation, I asked to return to my usualregime. The request was refused … I wastold that as it is a bank holiday, if mylevels were still high on Tuesday theywould call somebody in. So, I made thedecision to discharge myself on theSaturday. Within 24 hours of being athome my levels were back to where theywere before the operation’Person with diabetes‘The next day I had a hypo, the nursewas called and did not know what to do…The charge nurse came and said [they]had nothing to give me, it was left foranother patient on my ward to give me asugary drink and biscuits, the nurses left,came back half an hour later, took myblood sugars, said the result was muchbetter and with that they went, no foodwas offered … except by the patients onthe ward.’PersonCommunicationCommunication is particularly important topeople with diabetes in hospital, whethercommunication between ward staff withthe specialist team, or with the patientthemselves. Staff will need the skillsnecessary to enable them to communicateeffectively with all people with diabetesincluding children and those whose firstlanguage is not English. Information shouldbe provided in an appropriate format andstaff should check that the information hasbeen understood. It is vital that all peoplewith diabetes are kept informed andincluded in decisions about their care.‘Everything that I read said that you didnot experience hypos with Metformin.The nurse then revealed that I had notbeen receiving Metformin but anotherdrug …This was the first time anybodyhad mentioned that my medication hadbeen changed. This was my firstexperience of a hypo and I was alreadyconcerned about my health, this causedme a bit of additional concern that wasunnecessary.’Person with diabetesChildren with diabetesRecently, the views of parents and carers ofchildren with diabetes who had been inhospital identified many of the same issuesreported by adults. Children and youngpeople with diabetes may also have specificneeds relating to their age and individualcircumstances.‘I still, however, had problems with theother hospital staff and ended uparguing with a registrar (who had notmet me or my son before) who wantedto give my son a sizeable insulin dosebefore breakfast time, even though atthat time my son had not eaten anyproper food since the operation’Person with diabetesNewly diagnosed diabetes in the young issomething that affects families and carersand it cannot be adequately supported onadult wards or where staff are notexperienced and understand theimplications for the young person, thefamily and their friends.The DIPEX project of interviews with youngpeople with type 1 diabetes consists of 18different videos and audios of young peopledescribing their experiences of hospitalinpatient stays for their diabetes.www.youthhealthtalk.org18

The impact of diabetes on bed occupancyWe know that about 10% of hospital bedsin England and Wales are occupied bypeople with diabetes, and this prevalence ishigher in people in hospital who are elderlyor have acute coronary syndromes (ACS). 27The activity associated with inpatients withdiabetes is increasing (see Figure 3).This is an underestimate of the trueinpatient activity, because diabetes as adischarge diagnosis is missed in as many as20 – 25% of inpatients with the condition,particularly those with non-insulin treateddiabetes. 28The coding of diabetes on which bedoccupancy is based is complex, and can bederived from Hospital Episode Statistics(HES) or Health Resource Groups (HRG).Using the International Classification ofDiseases (ICD-10) codes E10 (insulin treated)and E11 (non-insulin treated) there werenearly one million discharges in the mainmedical and surgical specialities between2000 -2004 in England. This accounted for6.5 million beds days or 8.1% of all hospitaldischarges. 29The largest single HRG diagnostic group ispeople with diabetes and coronary arterydisease, accounting for 700,000 bed days inone year, 17% of the total (Table1).Figure 3Count of finished consultant episodes (FCEs)with a primary or secondary diagnosis ofdiabetesEngland & Wales, 2001/02 - 2005/06FCEs1,000,000800,000600,000400,000200,00002001/02 2002/03 2003/04 2004/05 2005/06Admissions % emergency Bed days % emergencyPrimary cause 52,801 61% 373,105 84%CHD diagnosis codes 78, 563 67% 696,933 83%HRGs – lower limb 2,490 75% 45,211 78%HRGs – other diabetes 5,204 98% 35,721 95%HRGs – amputations/PVD 3,832 65% 103,974 71%Ophthalmology < 70ys 11,775 7% 7009 40%Nephrology 9,539 52% 86,677 75%Total 164,204 61% 1,348,630 82%Table 1 Data derived from HRG (2003/2004) for all diabetes related activity in key HRGshowing total admissions and bed occupancy, and percentage admitted as emergencies19

Excess bed occupancy due toprolonged length of inpatient stayin diabetes populationsInpatient populations with diabetes have anincreased length of stay compared to agematchedinpatients without diabetes. Thisobservation is consistent in all populationsstudied, and is apparent after age adjustment.Estimates of excess bed occupancy due toprolonged length of stay in diabetes inpatientsin England, with a main medical or surgicalspecialty discharge code, have been made atapproximately 80,000 bed days every yearand at 167.4 excess bed days per annum per1000 people with diabetes in a localpopulation. 30Around 60% of people with diabetes areadmitted as emergencies but these admissionsaccount for 82% of all diabetes related beddays. This is an important issue forcommissioners in contributing to theirongoing target to reduce emergency beddays.In England and Wales, this excess has beenestimated from a mean of 1.2 bed days foryounger surgical inpatients in England, to1.8 days per inpatient with diabetes lessthan 60 years old, up to 4,0 days in otherstudies. 31 Absolute bed occupancy isgreatest in the elderly, but excess bedoccupancy is more marked in younger agegroups indicating that this is where thegreatest improvement could be madewithin the hospital setting. 32 It is importantto age adjust or match length of stay databetween diabetes and control groups.Contributing issues to prolongedlength of stay in diabetesinpatientsThe reasons for prolonged length of stay ingeneral diabetes inpatient populations areunclear, and include higher rates of comorbiditiesin people with diabetes, but itmust also include variability in clinical care, asit can be reduced by clinical interventions.A recent audit by King’s College Londonfound that 10% of people in hospitalacross all conditions had diabetes, andaround 50% of these were on insulin(compared with 20% of the local diabetespopulation). Length of stay was increasedby 2.7 days.The direct contribution of hyperglycaemiato prolonged length of stay is unclear.Hyperglycaemia is associated with pooreroutcomes and prolonged length of stay inpeople with diabetes and many otherclinical conditions. The American DiabetesAssociation position statement makes a callto action to improve glycaemia in allinpatients with diabetes, on the premisethat this may translate into improvedoutcomes and reduced length of stay. 33There is little substantial evidence now tosuggest intensive efforts to improveglycaemic control will deliver this in generalinpatients with diabetes. 34The impact of diabetes on healthoutcomesPeople with diabetes in hospital may haveworse clinical outcomes than those withoutdiabetes.As many as 40% of patients in Coronary CareUnits (CCUs) have diabetes or impairedglucose tolerance. Failing to identify them andtreat them according to best practice can leadto poor short and long-term outcomes. TheMyocardial Infarction National Audit Project(MINAP) collects data from every hospital inEngland that treats people with acutecoronary syndrome. In a recent study, only athird of newly diagnosed people with diabetesreceived relevant diabetes treatment inhospital, and only two thirds of these had anongoing diabetes plan at discharge. Theroutine use of insulin in people with AcuteCoronary Syndromes (ACS) based on theDIGAMI study protocols may have declined inrecent years. 35 MINAP report that the deathrate was increased by 50% in those who didnot receive insulin for raised blood glucose.20

Acute foot problems in hospitalDiabetes is the commonest cause of nontraumaticlimb amputation, and foot problemsare amongst the most feared complications ofdiabetes. 36 They have a significant impact onpatients’ lives, including loss of occupationand status, disfigurement, reduced mobility,and depression. Furthermore, survival is bleak,with mortality rates after both amputationand foot ulceration of 50 per cent at twoyears and 75 per cent at six years. 37Foot complications have a significant financialimpact on the NHS through outpatient costsand increased bed occupancy and extendedlength of stay.It has been estimated that of the £3bn of NHSexpenditure on diabetes £600m could beattributed to diabetic foot complications. 38 Inthe UK in 2003 foot complications includingamputations cost £252 million. 39In 2003/4 in England there were around6,300 admissions associated with a diagnosisof diabetes combined with lower limb oramputation and peripheral vascular disease(Hospital Episodes Statistics, DH). 40 Theserecorded admission episodes equated toalmost 150,000 bed days and a cost, for beddays alone, of almost £30m. The total cost issignificantly greater when the cost ofamputation is also taken into account,furthermore the above bed days are based onhospital activity analysis which substantiallyunderestimates true activity.The National Institute of Health and ClinicalExcellence (NICE) has published guidelines onthe prevention and management of footproblems in people with Type 1 and Type 2diabetes. 41 This section will look at howinpatient care can be improved for thosepeople who are admitted to hospital with footcomplications, or at risk of foot complications,with considerable financial benefit.Preventing diabetes foot admissions– the evidence baseFoot complications of diabetes can beprevented. A substantial literature supportsthe roles of out-patient podiatry provision by amulti-disciplinary diabetic foot team andcommunity podiatry services as part of a footprotection programme. Multi-disciplinarydiabetic foot teams and foot protectionprogrammes have previously beenrecommended by NICE Guidance (NICE,2004).NICE also recommends that high-risk patientsshould be fast tracked to an expertmultidisciplinary foot care service, includingspecialist podiatry. This should enable accessto modern wound management,microbiological and revascularisationtechniques, pressure relief, and metaboliccontrol.Once ulceration, infection or critical ischaemiahave occurred the use of a comprehensiveprotocol for the evaluation of the foot, and acritical pathway for its treatment, togetherwith access to specialist expertise, increasesthe number of limbs saved and reduceswaiting times and length of stay. 42However only two thirds of hospitals inEngland have local guidelines for themanagement of the diabetic foot, and anumber of NHS trusts in England have neitherfoot care guidelines, nor referral pathways tothe diabetes specialist team. 43What has been shown to work?Successful inpatient foot care models all havethe same elements in common. These areroutine and systematic inpatient care, providedby specialist multidisciplinary teams of doctors,nurses and podiatrists. Structured approachesto defining the competencies needed withinthe team have been developed.There are several examples of good practice. 4521

At King’s College Hospital, Vascular and Diabetic Foot Teams introduced an integrated carepathway for the management of the inpatient with a critically ischaemic diabetic foot. Thispathway included the role of the Diabetic Foot Practitioner and the aim of closely supervisingdiabetic foot in-patients and co-ordinating all aspects of their foot care. This has resulted in alower amputation rate and a reduction in mean length of stay by two weeks per patient. 46Year 2001/02 2002/03 2005/06Neuroischaemic 89 62 59Admissions (number)Mean length of stay 51+46.7 31+27 28+25.8In Ipswich, a Specialist Diabetes Podiatrist and Diabetes Nurse Specialist (DNS) with an interestin foot care initiated twice-weekly ward visits to all wards to identify and co-ordinate themanagement of all inpatients with diabetes and foot problems and to educate medical andnursing staff. Major and total amputation rates fell consecutively for the next 5 years. Whenthe team was withdrawn in 2000, total amputation rates started to increase again. Using thedata they had collected the team was able to show that savings on bed days alone was 4-5times greater than staff costs. The DNS post was reinstated and amputation rates fell again.The Ipswich experience: Amputation rates (1995 – 2005) per 100,000 general population. 4722

When this specialist care in hospital is fullyintegrated with comprehensive outpatientservices, the benefits are even greater. InSouthampton a Diabetes Foot ProtectionTeam (DFPT) was developed which includedan advice line for staff and patients with adiabetic foot problem, a dedicated personproviding rapid access to inpatient podiatryfor all acute wards, as well as enhancedprimary care podiatry clinics and dischargesupport. This led to a fall in mean length ofstay for diabetic patients with complex footdisease from 50 days to 18.5 days. 48In Northamptonshire PCT andNorthampton General Hospital, integrateddiabetes foot services provide an activeFoot Protection programme and weeklyward round for diabetic foot inpatients by aConsultant and Podiatrist. Patientsundergoing forefoot amputations andknown to the Diabetic Foot Team prior totheir admission spent 50% less bed days inhospital than those patients admitted to theward with similar problems but who werenot under the care of the multi-disciplinaryfoot team prior to admission. 49 Allinpatients are followed up by the multidisciplinaryfoot team on discharge andwhen appropriate become long-term FootProtection Programme patients incommunity podiatry clinics.The next stepsThe evidence provided in this chapterhighlights the enormous improvementsthat could be made in managing diabetesinpatients with foot problems and thebenefits in terms of real patient outcomesas well as value for money via reducedlength of stay. The critical role of thespecialist foot team is increasinglyevidence based.Approaches to ImprovementImproving care for people with diabetes inhospital requires a coordinated approachright across the organisation. This sectionsets out some of the ways in which acutetrusts can approach this.Leadership and expertiseThe accumulating evidence is that it is thepresence and leadership of the specialistdiabetes team that is essential forimprovement and service development forinpatients with diabetes. The exactinterventions they bring, or whether one ofthe many care models being developed issuperior to another, is not yet clear.To address issues of variation in quality ofcare and to drive up standards it is usuallynecessary to look at the systemcharacteristics of the problem. For diabetescare, this is likely to require a combinationof linked interventions right across theorganisation, none of which by themselveswill necessarily result in improvement. It israre for specialist teams and managers towork together right across the organisationto plan care for people with diabetes -when this occurs, the outcomes can beimpressive.In Poole, the Consultant Diabetologistspends part of his time as an acutephysician, helping to run the EmergencyAdmissions Unit with colleagues fromother specialties. A local audit oflaboratory glucose measurement showedthat 22% of admissions had documenteddiabetes, newly diagnosed diabetes orimpaired glucose tolerance. The presenceof diabetes expertise from the moment ofadmission has helped to improve themanagement of people with diabetes inhospital, and direct involvement in policymaking has resulted in improved care forother patients throughout the hospital.23

Bringing these messages to the heart ofhospital clinical policy is important, and thespecialist team are well placed to do this.There are powerful financial and clinicalarguments to be made to commissioningteams and acute trusts on the benefits ofenhanced inpatient diabetes services, and awhole system approach to inpatientsdiabetes care.Protocols and guidelinesOne way to ensure a systematic andconsistent approach to care across anorganisation where patients and staff maymove from ward to ward is thedevelopment of guidelines and protocols. In2000, the Audit Commission found that thepresence of guidelines was variable. Arecent survey reported little change, andoverall only just over 20% of hospitals hadall 10 key inpatient diabetes managementguidelines although nearly 98% of UKhospitals have guidelines for DKA and themajority have for severe acutehypoglycaemia. 50Improvement through enhancedinpatient servicesObservational data from some large acutetrusts have shown that 41% of inpatientswith diabetes did not receive the care thatthe specialist team felt was required.The integration of diabetes expertise acrossthe whole organisation is important for theacute trust as a whole.‘A large 750 bed surgical hospital in theUSA (Greenville, North Carolina),developed a diabetes steering committeeto address diabetes care across the entirehospital. They appointed 5 nurse casemanagers (NCM) to make direct contactwith 85% of all inpatients with diabetes.They concentrated particularly on movingpatients from sliding scale insulinregimens to the use of basal insulin andNCM led dose adjustments. They foundthat the use of NCM led to a 0.26 daylength of stay reduction, about 1788 dayssaved per year, with an estimated $2.224million revenue through enhancedelective activity. This was more than 4times the original investment in thediabetes management programme.’ 51In the UK and elsewhere the employmentof a diabetes inpatient specialist nurse(DISN), diabetes nurse educator (DNE) ordiabetes specialist nurse (DSN) has resultedin impressive reductions in length of stay.Studies show a reduction in excess lengthof stay, of between 27– 47% with anabsolute reduction in mean or medianlength of stay of between 0.7 – 3.0 days,after the introduction of the service. 52This is equivalent to 1,330 bed days savedby one DSN in one year in a 1,000-bedtrust, or 1,788 bed days saved a year in a750 bed surgical hospital, using 5 nursecase managers. 53 These benefits are at leastpartly related to improved insulinmanagement and education. Involving thediabetes specialist team, rather than ageneral medical team), in DKAmanagement reduces length of stay.24

An audit in the South West compared themanagement of diabetic ketoacidosis byspecialist and non-specialist physicians.Those managed by non-specialists hadconsiderably longer lengths of stay inhospital due to unnecessarily extendedtime on intravenous insulin, inappropriateinsulin regimens and problems associatedwith converting back to subcutaneousinsulin. By contrast, the specialist teamwas able to discharge the averageuncomplicated patient within three days.Using the specialist team to deliver regulartraining and education to improve the skillsand confidence of all trust staff also seemsto reduce excess length of stay forinpatients with diabetes as primarydiagnosis. 54Expertise and workforceThe importance of the whole diabetesspecialist team in providing the expertise,leadership, clinical care and staff training ininpatient diabetes care should beemphasised, and is supported by all trialand observational data on bed occupancy.Skills for Health has produced a completeset of competencies for the care of peoplewith diabetes, including competencies inthe coordination of care. 55 These enable jobroles and job descriptions to be puttogether in ways that are most appropriateto each specialist team. These roles includemedical, speciality nursing, dietetic andpsychological elements.The central role of the DISN in improvingthe inpatient experience of people withdiabetes, reducing length of stay, reducingreadmission rates, and delivering financialsavings has been described. Only half of UKhospitals have a DISN service, although thisnumber has increased rapidly since thepublication of the Diabetes NSF. However,half of the 262 UK hospitals with a diabetesspecialist team still have no inpatientspecialist nurse input at all. 56Figure 4 . Numbers of diabetes inpatient specialist nurses (total 149) appointed eachyear in the UK in 123 Hospitals between1980 and 2005.25

Consultant Diabetologists in some centresare working to a new model of the‘Inpatient Diabetologist’ with a significantsessional commitment to inpatient diabetescare across an entire acute trust, incollaboration with a DISN. This model mayalso reinforce the value of specialist teamsto acute trusts by associating them withfinancial savings and reduced pressure onelective activity.The specialist dietitian is a key member ofthe inpatient team, with a lead educationaland coordinating role over all these aspects.The dietitian will also have a specialist rolein the supervision and monitoring of enteraland parenteral nutrition during times whenthe person with diabetes cannot take foodby mouth. However, only half of UKhospitals have access to a dietician forroutine inpatient diabetes care. 57There is a similar wide-ranging role,described previously, for the specialistpodiatrist and foot team. They have a leadrole not only in managing people in hospitalwith foot problems, but also in ensuringthat appropriate prevention strategies are inplace for all people with diabetes in hospitalat risk of developing foot problems.However, only half of UK hospitals haveaccess to a podiatrist for routine inpatientdiabetes care. 58Important financial issues for acutetrusts and commissionersIt is possible to make some estimates ofcosts associated with bed occupancy andexcess length of stay. It must be stressedthat these costs are estimates based onnational HES data, which mayunderestimate activity and that the data isderived for English trusts and for the mainmedical and surgical specialties alone. 59Without HRG reference cost information itis also not possible to apportion precisecosts to this data. Therefore, a unit cost of£286 per bed day was used from thePersonal Social Services Research Unit’s ‘UnitCost of Health and Social Care’. 60 Withthese limitations, it suggests a total unitcost of at least £450m a year of whichmore than £20m, recognised as anunderestimate, is due to excess length ofstay and could be reduced.ICD10 Diagnosis CodesE10 (insulin E11 (non insulin Combineddependent) dependent)Total bed days 1,422,728 5,085,940 6,508,668Total Cost £406,900,208 £1,454,578,840 £1,861,479,048Estimated Excess bed days 86,505 201,831 288,336Cost of Excess Bed days £24,740,430 £57,723,666 £82,464,096Estimates based on 4 years HES data for England in main medical and surgical specialties. 6126

Payment by resultsCurrently 20–25% of inpatients withdiabetes are not correctly coded as havingdiabetes. However, the way hospitals arepaid for diabetes should provide apowerful incentive to identify people withdiabetes in hospital and ensure they getthe best treatment.People in hospital for elective proceduresdiagnosed with a ‘co-morbidity orcomplication’, such as diabetes, mayattract a higher tariff with Payment byResults.The extra funding reflects the additionalresource and expertise often required totreat inpatients with diabetes or othersimilar complications. This extra amountvaries according to the primary HRG –many HRGs come in pairs, one where aprocedure or diagnosis is defined as withcomplications and co morbidities, and onewithout. The system is complex but will bedescribed in a technical fact sheet to bepublished shortly. The additional amountper case for an Acute Trust if diabetes is acomplicating factor of the treatment canbe as much as £1,894 for a hip or lowerlimb fracture.In Foundation Trusts where budgets areincreasingly apportioned to each clinicalservice the identification of diabetes as aco-morbidity will affect the proportion ofthe tariff that can be allotted to thediabetes specialist service. Accuraterecording of diabetes specialist teaminvolvement in care thus has an importantrole in raising the profile and theimportance of involving the specialistteam. Coding in diabetes is complicatedand there is evidence that Trusts andspecialist teams are losing out because thisis little understood. PbR as it applies todiabetes will shortly be described in thetechnical fact sheet mentioned above.There is a further incentive provided underPbR to encourage the reduction ofexcessive length of stay. The tariff is paidper HRG, regardless of length of stay. So ifyou can treat a patient in four days ratherthan five, you will save money.For unusually complex cases excess beddays are paid past a defined “trim point”(a length of stay which varies for eachHRG), but even here the level of the excessbed day payments is designed to ensurehospitals will not be making money fromkeeping patients in for longer. This shouldprovide a powerful incentive to usespecialist expertise to provide the bestpossible care to people with diabetes andreduce length of stay. It particularlyprovides an incentive to focus on foot carewhere the longest excess bed days occur.Reduction of length of stay allows thehospital to treat more patients and thusattract optimum payment for its services.27

Approaches to improvement and clinicalpathwaysWhilst there has been some improvement ininpatient care following the publication ofthe Diabetes NSF, this has not been as rapidas in other areas of care. The SteeringGroup therefore worked in partnership withthe NHS Institute of Innovation andImprovement to provide practical guidancebased on examples of good practice inEngland. Their key findings are producedhere so they can be incorporated in torecommendations for commissioners. Thedetails of their methodology and examplesof good practice are described in detail inDelivering Quality and Value: Focus on:Inpatient care for people with diabetes. Acollection of practical tools will be availablefor local teams to use early in the summer.Following a literature review and baselinedata collection, they selected a variety ofhospitals to visit during which they workedclosely with the local staff to tease out andunderstand the difficulties and examples ofgood practice. The Institute have developeda clinical pathway that is reproduced here,but more detail, recommendations and casestudies are available in the full document.This diagram shows a pathway used bysome hospitals visited by the NIII. Althoughthe pathway shows patients moving to award via an admissions unit, this should notbe common practice. Not only can patientsbe discharged from an admissions unit, theycan and should, be admitted directly to aninpatient ward directly from accident andemergency.The suggested pathways for people withdiabetes have a set of commoncomponents that are very similar whetherthe person is admitted in a planned orunplanned way. The important features are:• Identification of everyone with diabetesin hospital• Individual planning for care of diabetesduring admission and prior to discharge• Ensuring that everyone looking aftersomeone with diabetes is appropriatelyskilledThe multidisciplinary specialist diabetesteam working across the organisation tohelp plan pathways, write guidelines, trainand support staff and provide individuallytailored care is a key component.28

Delivering quality and valueInpatient care for people with diabetesNHSInstitute for Innovationand Improvement29

The admission and discharge planfor inpatients with diabetes.The admission and discharge plan.The Diabetes NSF describes routine careplanning as a process in which the personwith diabetes is actively involved indeciding, agreeing and owning how theirdiabetes is to be managed. It starts bysharing information with the professional,moves on to structured assessment ofrelevant issues, and ends with a jointlyagreed plan based on individual goals,needs and priorities. This approach shouldbe the foundation of the specific care planon admission and discharge.Everyone admitted to hospital should havean opportunity to be involved in such aprocess and have the details recorded.How and when this will be done willdepend on the person’s health, andwhether they are admitted in a planned orunplanned way. Each organisation will needto ensure these elements are effectivelyintegrated into organisation wide protocolsfor diabetes care.Planning on admission forinpatients with diabetes1. Information exchange• Review of the person’s ongoing careplan, and discussion• of their preferences for self care oftheir diabetes while in hospital• Explanation of the reasons foradmission, and what to expect inhospital2. Systematic review of key areas frompatient and professional view points• Level of knowledge about diabetesand need for further information• Assessment of need for input fromdiabetes specialist team• Food choice, timings and access tofood/snacks• Nutritional assessment, especially inolder people• Risk status of feet in all people withdiabetes, risk stratification, andmanagement plan• Medicines management and control.Establish if self management isdesired/appropriate. Ensure that selfmanagement includes administrationof medication/insulin injections/insulinpump and access to their owncapillary blood glucose monitoring andquality control equipment.• Need for emotional and psychologicalsupport (particularly older people,• children, and those newly diagnosed).• Mobility (particularly in older peoplewith diabetes).• Establish the cultural and religiousneeds of the individual including;subsequent dietary, treatment, andfacilities requirements and matterssurrounding physical contact• Establish ethnic identity• Establish preferred name• Other patient concerns3. Developing and recording a plan• Key elements of the plan, and who isresponsible for each of these, need tobe recorded.• A named contact and other relevantinformation should be provided toeach individual in written or otherappropriate format. Relevantinformation should cover howdiabetes related emergencies will bemanaged, how individuals can accesshospital protocols and policies for themanagement of diabetes, and how toaccess the specialist team if necessary.30

Planning on discharge for inpatients withdiabetes• Review of the admission and patientexperiences• Check on understanding of new orchanged diabetes management• Identification of ongoing needs• A named contact in the community• Written discharge summary to GP,diabetes team and relevant others e.g.social care.• Information for the organisation on:• Accurate coding of all diagnosesincluding diabetes• Systematic recording of patientexperience.31

Chapter 4 :RecommendationsPreventing diabetes admissions:Generally, commissioners may want toensure that that there are local communitywidemodels of care for preventing andmanaging diabetes emergencies. Theseshould be integrated into the routinemanagement of everyone with diabetes andinclude all the issues outlined below. A keycomponent is to ensure membership of thediabetes network, or close local links, withthe ambulance services and other membersof urgent care networks.Specifically, commissioners may also wantto:1. Ensure that all people with diabetesfrom diagnosis onwards, have accessto structured educationalprogrammes that meet nationalcriteria and include managingemergencies (sick day rules)Key outcomes: Falling DKA and severeacute hypoglycaemia admission rates,falling ambulance call out ratesEvidence for improvement:Improvement in access to quality assuredstructured educational programmesSuggested audit and quality assurancemeasures: Annex 3: D, G ; Better metrics14.09 (i, ii)Key outcomes: Reduction in number offrequent 999 callers and admissionsEvidence for improvement:Demonstrable engagement withambulance trust and new pathwaysSuggested audit and quality assurancemeasures: Annex 3:D, E; Better metrics14.113. Ensure that there is specific serviceprovision for groups at highest riskof a diabetes emergency – theseinclude adolescents transferring toadult clinics, individuals with eatingdisorders, people with substantialpsychosocial problems, residents innursing and care homes, andprisoners.Key outcomes: Reduction in number offrequent 999 callers and admission ratesEvidence for improvement:Demonstrable protocols, guidelines, andnew pathways; monitoring of individualcase management workloads in specialistdiabetes teamSuggested audit and quality assurancemeasures: Annex 3: C, D, E, F; Bettermetrics 4.112. Ensure that ambulance trusts arerepresented on local diabetesnetworks, or that close links existbetween ambulance services andspecialist services for people withdiabetes. This engagement shoulddevelop pathways between thespecialist team and ambulance Trustfor people with diabetes at highestrisk, particularly multiple callers, forfurther education and support.Improving quality and value forpeople with diabetes in hospital:general recommendations4. Commissioners may want to ensurethat acute trusts have explicitarrangements to take a strategicoverview and coordinate all aspectsof inpatient diabetes services acrossthe trust. This should be based onthe quality makers identified in thisdocument, led by a specialist33

multidisciplinary team, withmanagement representation,integrated into trust clinicalgovernance mechanisms.Key outcomes: Improved coordination ofinpatient services and recognisable wholesystem governanceEvidence for improvement: trust wideguidelines and protocols. Evidence of audit,and related measured service improvementSuggested audit and quality assurancemeasures: Annex 3:H, I, M ; Better metrics14.135. Commissioners may want to ensurethat acute trusts have educationalprogrammes for all staff who lookafter inpatients with diabetes, linkedto staff induction and mandatorytraining. These programmes shouldinclude training on medicinesmanagement, nutritional issues, andinsulin handling in acutely unwellpeople with diabetes.Key outcome: Falling incident reporting forprescribing errors; reduction in complaintsand improvement in patient experiencemeasuresEvidence for improvement: Percentageof relevant staff who have had competencybased training needs assessment andattended training annuallySuggested audit and quality assurancemeasures: Annex 3:A, B, K ; Better metrics14.10Improving quality and value forpeople with diabetes in hospital:Specific recommendationsCommissioners may also want to6. Ensure that all people with diabetesin hospital have comprehensive androutine admission and dischargediabetes care plans according to theprinciples and including thecomponents outlined in thisdocument.Key outcomes: Fall in complaints andincident reporting, improvement in patientexperience toolsEvidence for improvement: Writtenevidence of appropriate formal diabetescare planning by trained individualsSuggested audit and quality assurancemeasures: Annex 3: A, B, J7. Ensure that inpatients with diabetesare surveyed regularly using local orother validated inpatient satisfactionassessments to identify areas ofconcern and poor process.Key outcomes: Improvement in trustdiabetes satisfaction scoresEvidence for improvement:Quantification of inpatients viewsSuggested audit and quality assurancemeasures: Annex 3: B8. Ensure that all clinical areas haveaccess to the specialist medical,nursing, podiatric, dietetic andpsychological competencies requiredby people with diabetes in hospital.Key outcomes: Improved accessEvidence for improvement: WorkforceassessmentSuggested audit and quality assurancemeasures: Annex 3:M34

9. Review their portfolio of inpatientdiabetes-management guidelines, incollaboration with the diabetesspecialist team, to ensure asystematic approach to all aspects ofdiabetes care across a Hospital. Theseguidelines should indicate referral toand review by the specialist team ofall people with DKA, severe acutehypoglycaemia, or diabetic footulceration on the day of admissionKey outcomes: Increased guidelinesestablishmentEvidence for improvement: Availabilityoft trust-approved diabetes inpatientmanagement guidelinesSuggested audit and quality assurancemeasures: Annex 3: A, I, J,10. Ensure regular and recurring dataanalysis to estimate:• Admission rates with DKA and severeacute hypoglycaemia,• Minor and major amputation rates inthe diabetes population,• Age adjusted excess bed occupancydue to prolonged length of stay.11. Ensure effective service models forpeople with known diabetes, with‘new hyperglycaemia, or newlydiagnosed Type 2 diabetes,following an acute coronarysyndrome. The service model shouldinclude:• Glycaemic management while inhospital• Pathway towards confirmation ofdiagnosis post discharge• Follow up arrangements for possiblediabetes.This service model should be developedwith the diabetes specialist team.Key outcomes: Recognition and treatmentof hyperglycaemia /new T2DM on CCU’sEvidence for improvement: Guidelinesand protocols for managing glucose issuesin CCUSuggested audit and quality assurancemeasures: Annex 3: J, NKey outcomes: Falling admission rates;improved bed occupancy rateEvidence for improvement: Admissionrates and excess bed occupancySuggested audit and quality assurancemeasures: Annex 3:C, H, l35

What still needs to be doneIn the course of this work a number ofareas were identified where further work orthe development of consensus guidelineswould be helpful. Some of these areas werehighlighted in a large ‘Challenges andSolutions’ workshop in September 2007 forhealth care professionals and people withdiabetes, or were identified by otherprofessional groups. These areas include:GuidelinesThe need for consensus guidelines:• on the management of severe acutehypoglycaemia in the community or inacute hospitals.• The need for large scale research studiesusing a complex interventionmethodology, to examine the reasonswhy specialist diabetes services areeffective in reducing inpatient length ofstay.• The need to quantify the scale of underrecording of diabetes as a dischargediagnosis.• The need for detailed health economicanalysis of national diabetes bedoccupancy, excess diabetes bedoccupancy, and for modelling thepotential cost benefits of interventions toreduce diabetes bed occupancy.• on parenteral and enteral nutrition ininpatients with diabetes.• on the use, or misuse, of subcutaneoussliding scale insulin regimes in acutelyunwell medical and surgical inpatients.IndicatorsThe need for a robust indicator of thequality and outcome of inpatient diabetesservices to enable trusts to bench mark theirservices and commissioners to specify yearon year improvement. 62Research and Development• The need for a substantial UKrandomised controlled trial (RCT)examining evidence of benefit ofintensive glucose management of generalmedical and surgical inpatients withdiabetes, with length of stay and clinicaloutcomes as primary endpoints.• The need for research in the area ofinpatient diabetes care, particularly onthe feasibility and effectiveness ofdifferent service models.36

Annex 1:Lay Glossary of termsDiabetes - There are two ‘types’ ofdiabetes - In type 1 diabetes (T1DM) thecause is an immune reaction against theinsulin secreting pancreatic cells, usually inchildren and younger adults. Type 2diabetes (T2DM), is commoner, occurs inolder adults, and the cause is resistance tothe actions of insulin and falling insulinsecretion. People with Type 1 diabetesalways need insulin injections, as do manypeople with Type 2 diabetes within a fewyears of diagnosis.Diabetic Ketoacidosis (DKA) - A seriousclinical condition, usually occurring inpeople with Type 1 diabetes, characterisedby the appearance of ketones in the bloodand urine, usually associated with highblood glucose levels, which can lead tocoma and death. DKA requires a hospitaladmission.Diabetic Complications - Thecomplications which can arise fromdiabetes: these can be divided into acute(hypoglycaemia, dehydration andketoacidosis) and long-term tissuecomplications. The tissue complicationsinclude damage to the retina, damage tothe kidney, damage to the nerves, erectiledysfunction, circulatory, problems, andfoot ulcers.Diabetes Specialist Nurse (DSN) -Usually a senior specialist nurse, usuallyworking in an acute trust, who hasparticular training and expertise in diabeteseducation and diabetes management.Diabetes Inpatient specialist nurse(DISN) - Usually a senior specialist nurse,usually working in an acute trust, who hasparticular training and expertise in diabeteseducation and diabetes management, whois contracted to provide care for inpatientswith diabetes across an entire trust.Hyperglycaemia - Blood glucose level istoo high, often associated with symptomsHypoglycaemia - Blood glucose is toolow, often associated with symptoms ofhunger, sweating and irritability. It canprogress to confusion and loss ofconsciousness and require help fromsomeone else – a relative or health careprofessional.Insulin - The hormone which enables thebody cells to use glucose to generateenergy. All people with type 1 diabetes,and many with type 2 diabetes, needinsulin injectionsLength of stay and excess length ofstay - The duration (in days) of aninpatient stay. Excess length of stay is asubjective assessment describing aprolonged length of stay, beyond thatnormally expected.NDST - National Diabetes Support Team,set up to support the implementation ofthe National Service Framework forDiabetes.Neuropathy - Damage to the nerves,usually in the feet and lower limbs, whereit can lead to risk of ulceration andamputation. Risk of ulceration can bereduced by early identification andpreventative measuresNICE - National Institute for Health andClinical ExcellenceNSF - National Service Framework forDiabetes, the ten-year plan begun in 2003to improve the standards of care forpeople with diabetes37

Peripheral vascular disease - reducedcirculation in the feet, which increases therisk of ulceration and amputation. Risk ofulceration can be reduced by earlyidentification and preventative measuresPayment by results (PbR) - a financialmechanism whereby a standard payment(called the national tariff) applies for thesame inpatient (patients in the same HRG)and outpatient (patients of the samespeciality) treatment.Sick day rules - guidance for people withdiabetes, usually written by the specialisttem, on how to manage their bloodglucose and insulin treatment on dayswhen they are unwell.38

Annex 2:Inpatient experience collated byDiabetes UKDiabetes UK and members of the Working Party would like to thank the people who sharedtheir inpatient experiences. Approximately 50 experiences were collated and extracts of theseare available on the Diabetes UK website: www.diabetes.org.uk39

Annex 3:Audit and Quality Assurance for inpatientdiabetes careAcute and ambulance trusts may wish toaudit various aspects of their serviceconcentrating on areas of special interestand reporting through trust ClinicalGovernance structures.Some suggested audits and audit areas are:A: Review of the match between timing ofinsulin and food and number ofprescribing errors.B: Analysis of inpatient diabetes treatmentsatisfaction using local or availablevalidated instruments, linked to reviewof local processes and procedures.C: Benchmark incidence of DKA, severeacute hypoglycaemia, and diabetesadmission rates against equivalentnational and regional data foradmissions using widely available localand national datasets(www.nchod.nhs.uk)D: Analysis of local ambulance call-outrates for code 13 diabetes emergencies,transfer rates to Accident andEmergency, and admissions rates tohospital against national and regionaldata.E: Review of the use and outcomes oflocal protocols for severe acutehypoglycaemia, and the pathwaysbetween this service and the specialistteam.F: Review of the number of peopleadmitted to hospitals with emergenciesfrom care homes.G: Review local provision of NICErecommended and quality assurededucational programmes for peoplewith diabetes.H: Analysis of their serial data for diabetesbed occupancy, either from their ownTrust data source, related to age andspeciality matched groups withoutdiabetes, to allow estimated of totaland excess bed occupancy. This can bedone easily through returned HES datafor their trust from DH/ NorthgateInformation Solutions(contact@northgate-is.com).I: Availability of diabetes managementguidelines based on national examplesof good practice.J: Analysis of under recording of diabetesas a discharge diagnosis, and improvedperformance, through staff training inclinical coding and linkage with existingdiabetes databases (i.e. retinalscreening) to trigger diagnosis alert onadmission.K: Training needs assessment and reviewof training programmes provided by thespecialist team to all Health CareProfessionals involved in inpatientdiabetes care.L: Analysis of diabetes foot ulceration andamputation rates, and related bedoccupancy data, and benchmark thisand their model against availablenational data.M: Availability of hospital wide pathwaysagreed with diabetes speciality team andregular audit of key components.N: Analysis of MINAP data and trust datato examine clinical outcomes forinpatients with hyperglycaemia and /ordiabetes after an acute coronarysyndrome.40

Supporting tools:To support audit, service improvement andprovide key outcomes for commissioning anumber of validated tools or instrumentsare now available these includeBetter metrics‘Better metrics’ is a collection of testedindicators agreed by the diabetescommunity in England as suitable for theassessment across the range of diabetescare. Collected in a standard way by truststhey can be used for benchmarking. Wherean appropriate better metric exists it hasbeen linked with the appropriaterecommendation.For example, Metric 14.13 refers toinpatient careAge adjusted length of stay and length ofstay ratio in people in hospital with diabetesfor key indicator conditions compared topeople in hospital without diabetes.These metrics have been recommended forcommissioners in the DiabetesCommissioning Toolkit and are available forall PCTs in England where data is availableathttp://www.healthcarecommission.org.uk/_db/_documents/Better_Metrics_full_report.pdfDTSQ- IP. (copyright Professor ClareBradley, Royal Holloway University London)This 18 item questionnaire has been validated(2007)and provides a useful tool for theassessment of patient experience in hospital.The National Survey of Peoplewith Diabetes. (HealthcareCommission)Questions 52 – 61 refer to inpatient care.First used in a large national survey (70,000individuals) in December 2006 and resultsare available by PCT, it provides a usefulbaseline from which to judge improvement.A project to support assessment and analysisof these results on a routine basis is currentlyunderway in the Information Centre.http://www.healthcarecommission.org.uk/_db/_documents/Questionnaire_Diabetes_survey_2006_v10_200608042427.pdf(For the results of this survey, seehttp://www.healthcarecommission.org.uk/healthcareproviders/nationalfindings/surveys/healthcareproviders/surveysofpatients/longtermco/resultsofthe2006diabetessurvey.cfm)The views of hospital inpatients inEngland. (Healthcare Commission)This national questionnaire which is notspecific to people with diabetes was carriedout in 2006 and provides questions onambulance experience as well as all aspectsof admission, hospital stay and discharge.http://www.healthcarecommission.org.uk/_db/_documents/Inpatient_survey_briefing_note.pdfhttp://www.nhssurveys.org/Filestore/documents/Inpatient_2006_core_questionnaire_v1.pdfSpecific toolsMalnutrition Universal Screening Tool(MUST) MUST’ is a five-step screening toolto identify adults, who are malnourished, atrisk of malnutrition (undernutrition), orobese. It also includes managementguidelines that can be used to develop acare plan. It is for use in hospitals,community and other care settings and canbe used by all care workers. (recommendedby NICE and BAPEN)http://www.bapen.org.uk/pdfs/must/must_full.pdfThere are a variety of techniques to use toassess patient experience includingDiscovery Interviews.http://www.heart.nhs.uk/serviceimprovement/1338/4668/27794/Discovery%20Interviews%20final%20report%2025%20April.pdf41

Annex 4:AcknowledgementsWe would like to thank the following people for their membership on theemergency and in hospital care working group and for the contribution they havemade to this report:Mike Sampson (Chair)Caroline ButlerAlex FindlayJanet GrantMichelle GreenwoodDawn JonesKail GunaratnamJill MetcalfeSteve MortleyMaria MousleyBill O’LearyGerry RaymanSue RobertsBridget TurnerStella ValerkouMaureen WallymahmedConsultant Physician, Norfolk and Norwich UniversityHospital NHS TrustDiabetes UKNational Diabetes Support TeamDiabetes UK user representativeNational Diabetes Support TeamDiabetes Policy Team, Department of HealthDiabetes UK user representativeChief Diabetes Specialist Dietitian, Luton and DunstableHospital and British Dietetic Association// DiabetesManagement and Education Group RepresentativeClinical Specialist, East of England Ambulance ServiceNHS TrustConsultant Podiatrist, Northampton General HospitalNational Diabetes Support TeamConsultant Physician, Ipswich Hospital NHS TrustNational Clinical Director for Diabetes, Department of HealthDiabetes UKDiabetes UKNurse Consultant, University Hospital Aintree42

We would like to thank the following people for their contribution they have made to this report:Bev BooklessSandra CorryHannah DobrowolskaJames KennedyLaura LaddSuzanne PaylorAlan Sinclair,Jonathan ThowHelen WilkinsonDirector, National Diabetes Support TeamProject lead, NHS Institute for Innovation and Improvement(NHSI)Co – production manager NHSIGP ; clinical lead NHSIDiabetes Policy Team, Department of HealthDiabetes Policy Team, Department of HealthUniversity of Bedfordshire /Associate Dean Bedfordshire andHertfordshire Postgraduate Medical SchoolConsultant Diabetologist; clinical lead NHSINational Diabetes Support TeamWe would like to thank the following organisations for their contribution to this report:Diabetes UKAssociation of British Clinical Diabetologists (ABCD)UK Diabetes Inpatient Specialist Nurse (DISN) GroupPrimary Care Diabetes Society43

Further copies of this report can be ordered by emailing NDST@prolog.uk.comor tel: 08701 555455 quoting NDST064

Commissioning Toolkit for Diabetes"Where Are We Now?"A summary of diabetes measuresLast updated 5th January 2009A summary sheet for each of the SHAs is given here.To view PCT level data, simply click on the SHA required.Meta DataSummaryEast MidlandsEast of EnglandLondonNorth EastSources:Compendium of Clinical and Health Indicators / Clinical and Health Outcomes Knowledge Base (NCHOD)Health and Social Care Information Centre (HSCIC). © Crown Copyright. Health Surveys for England (HSE)National Centre for Social Research, (Extracts may only be reproduced by permission.)The Quality and Outcomes Framework (QOF) - QMAS database - 2007/08 data as at end of June 2008Copyright © 2006, The Information Centre for health and social care (IC), Prescribing Support Unit (PSU). All rightsreserved.North WestSouth East CoastSouth CentralSouth WestWest MidlandsYorkshire and the Humber

Healthcare for LondonIntegrated care pathways for diabetesTemplates for local adaptationPrepared in collaboration with Bupa Commissioning2008Note: The care pathways described in this document are generic. They are not intended to be adopted as theyare, but rather they form a template for local adaption and development by the diabetes network. Local userinvolvement will further inform the development of these pathways. Healthcare for London is working toimprove the format of information contained in this document and further updates will be provided on theHealthcare for London website as they become available.

Integratedcare tasksTask 1:DetectingdiabetesGeneric detection ofdiabetes pathwayStandard of care:Once, repeated every 3years or when indicated: People withsymptoms suggestiveof diabetes mellitus. Screen persons agedover 40 if:a. BMI>25 or waistmeasurement ofover: >94cm (>37inches) forwhite andblack men>80cm(>31.5inches) forwhite, blackand Asianwomen >90cm (>35inches) forAsian men.b. BP >130/80 orc. cardiovasculardisease presentd. first degreerelative with type2 diabetes.Women withpresumed PCOS.Care for the housebound/ those in care homesModified standard ofcare:At least once, onadmission into residentialor home-based care oronce every two years.People who arehousebound or in carehomes will usually beconsidered to be at highrisk of diabetes.An admission policy fornew residents whichhighlights those withknown diabetes andprovides a protocol toscreen for diabetes needsto be agreed betweencare home staff and thegeneral practitioner, butmay involve urinalysis forglycosuria and a fastingvenous plasma glucosemeasurement.For newly-admittedresidents of residentialhomes, screening fordiabetes may be bestundertaken prior toadmission.Pre-pregnancy for womenwith existing type 2diabetesModified standard ofcare:At every visit, considerthe possibility ofpregnancy annually in allpotentially fertile womenof child-bearing age withdiabetes mellitus, andprovide contraceptiveadvice when appropriate.Outcomes can beimproved if women withpre-existing diabetes aresupported to plan theirpregnancies and optimisetheir blood glucosecontrol before andthroughout theirpregnancies. They shouldreceive close monitoringand specialist carethroughout pregnancyand childbirth. (NationalService Framework forDiabetes)Research indicates thatwomen who feltdiscouraged frompregnancy by their doctorbecause of medicalAdolescence andtransitionModified standard ofcare:Consider screeningchildren over 10 yearsusing a fasting glucosetest for type 2 diabeteswhere: BMI >85th percentilefor age and sex; weight for height >85thpercentile, or weight>120% of ideal forheight; and either a strong familyhistory; or either from a higherriskethnic group orwith high bloodpressure/highcholesterolConsider a diagnosis oftype 1 diabetes inchildren with a severalweekhistory of polyuria,polydipsia, polyphagia,and weight loss.Screen with fastingglucose and repeat after1 day to confirm result(type 2).Type 2 with significantmental health issuesModified standard ofcare:People who have severemental health problemsshould be screened fordiabetes(Diabetes.co.uk).Individuals withschizophrenia and otherserious mental illnesseshave rates of type 2diabetes more than fourtimes higher than the ratein the general population.Mental health teamsshould take on someresponsibility formanaging general healthissues in their patients,e.g. providing educationabout healthy living,ensuring that screeningfor diabetes is done andthat other services areinvolved whennecessary iii .Screen all of the followingpeople: drug-naïve patients

Integratedcare tasksGeneric detection ofdiabetes pathwayWomen with a historyof gestationaldiabetes who havetested normalfollowing delivery(screen within sixweeks of delivery,then one year postpartumand thenthree-yearly).Aged over 55 years.Also note: People with impairedglucose tolerance(IGT) should betested every year. People with an initialplasma glucoseconsistent with adiagnosis of IGT/IFGwhich is notconfirmed onsubsequent testingshould be retestedafter one year.Screening protocol:EitherFasting plasma glucose>7mmol on two differentdaysOrRandom plasma glucose11.1mmol on two differentCare for the housebound/ those in care homesFor diabetes screening inthis population, it isrecommended that fastingglucose be augmented byPPG estimation,particularly in the leanerelderly population.Targeted screening ofelderly residents withdementia is also likely toidentify the highest ratesof undiagnosed diabetes i .Pre-pregnancy for womenwith existing type 2diabetesreasons were more likelyto have an unplannedpregnancy than womenwho had beenreassured ii .Also consider: Comprehensivediabetes review:Women with diabeteswho arecontemplatingpregnancy should beevaluated and, ifindicated treated fordiabetic retinopathy,nephropathy andcardiovasculardisease. Stop contraceptiononly when adequatecontrol is achieved. Optimal control of theHbA1c level (

Integratedcare tasksdays.Generic detection ofdiabetes pathwayLess than 5.5mmol/l isunlikely to be diabetes. Inthe absence of classicsymptoms confirmdiagnosis by 2 lab glucosemeasurements.Either2 fasting plasma glucose >7mmolOr2 random plasma glucose>11.1mmol or one of eachOr11.1mmol/1,2 hours post75g glucose (OGTT)Testing for type 2diabetes is recommendedfor the following high riskindividuals: people with impairedglucose tolerance orimpaired fastingglucose; people aged 40 andover who have eitheror both of the followingrisk factors - obesity(BMI 30 or greater),hypertension, allpeople with clinicalcardiovascularCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionthe possibility of diabetes:‐ vaginalcandidiasis,particularly in prepubertalgirls‐ vomiting‐ irritability anddecreasing schoolperformance‐ recurrent skininfectionsThe oral glucosetolerance test is rarelyused for making adiagnosis of type 1diabetes in children andadolescents.Glucose tolerance testingis rarely required, exceptin atypical cases or veryearly disease.If patient is acutely unwell- emergency referral viaA and E.Make same-day referralsto specialist services.Type 2 with significantmental health issuesdiabetic patientsestablished onantipsychoticmedication:- generalpractitioner (GP)or diabetesspecialist servicesto continue tomanage thediabetes;- mental healthteams to continueto manage themental illness;- patient to continuewith home bloodglucosemonitoring asusual;- communicate anyissues betweenservices.For patients whose testresults suggest impairedglucose tolerance ordiabetes: refer the patient toGP/diabetes specialistservices for properdiagnosis; if diagnosis is positive,GP/diabetes specialistservices to coordinate- 4 -

Integratedcare tasksdiseases (MI, angina,stroke), women withpolycystic ovariansyndrome who areobese; other high risk groupssuch as women withprevious gestationaldiabetes, people aged55 or over and peopleaged 45 or over whohave a first degreerelative with type 2diabetes.Consider a diagnosis ofdiabetes in patients withpolyuria, polydipsia,unexplained weight loss;obesity orcoronary/peripheralvascular disease.In presence of classicsymptoms confirmdiagnosis by single labglucose measurement.HbA1c between >6.5%may support thediagnosis but HbA1cshould not be used forthe diagnosis of diabetes.Diabetes UKrecommends that fastingCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionthe future managementof diabetes/impairedglucose tolerance andmake sure that thepatient is part of theirdiabetes follow-upservice, including theannual review process; a multidisciplinaryclinical decision maybe required regardingthe future use of anantipsychotic – achange in antipsychoticmedication will usuallybe unnecessary.Psychiatrists and primarycare practitioners whotreat patients withschizophrenia (or othermental health problems)should make an effort touncover medical illnessesby using a structuredinterview or routinephysical examinationwhenever a patient isseen for care.Higher rates of themetabolic syndrome(MetS) and diabetes isobserved for patients withschizophrenia, and- 5 -

Integratedcare tasksGeneric detection ofdiabetes pathwaycapillary or venous bloodglucose measurementshould be the preferredscreening method.Care for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesprevalence increases withage from 1.6% in the 15–25 age-band to 19.2% inthe 55–65 age-band iv .HbA1C testing has a 66%sensitivity and 98%specificity thereforebased on the assumptionof 6% prevalence 63% ofpatients with an A1C levelof more than 6.3% wouldhave diabetes.Measured capillaryplasma glucose >8.6mmol/l to have asensitivity of 90 per cent,specificity of 93 % andPV+ of 18%. A resultabove 11.1mmol/l isdiagnostic of diabetes.However, results between7.8 mmol/l and 11.1mmol/l would indicate theneed for further testing.Fasting venous bloodglucose measurementhas a higher sensitivityand specificity thancapillary testing butfasting capillary bloodtesting may be moreconvenient for GPs and- 6 -

Integratedcare tasksGeneric detection ofdiabetes pathwaypharmacists, althoughthis will miss 20-30% ofcases.Care for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesIn patients with symptomsand signs of diabetes(polyuria, polydipsia,polyphagia, weight loss,fatigue, blurred visionetc), the diagnosis ofdiabetes is made on thebasis of either a randomvenous plasma glucoseabove 11.1 mmol/L Theoral glucose tolerancetest (OGTT) isunnecessary if the patientmeets these criteria. Inpatients withoutsymptoms, biochemicalhyperglycaemia must beconfirmed by the 75 gr 2hour OGTT.Data on the performanceof screening tests islimited but it is clear thereis no single ideal test.- 7 -

Integratedcare tasksTask 2:DiagnosediabetesandclassifydiabetestypeGeneric detection ofdiabetes pathwayStandard of care:At every visit, considerand classify patients as: type 1 diabetes(results from β-celldestruction, usuallyleading to absoluteinsulin deficiency); or type 2 diabetes(results from aprogressive insulinsecretory defect onthe background ofinsulin resistance); or other specific types ofdiabetes due to othercauses, e.g. geneticdefects in β-cellfunction, geneticdefects in insulinaction, diseases of theexocrine pancreas(such as cysticfibrosis), and drug orchemical-induced(such as in thetreatment of AIDS orafter organtransplantation); or gestational diabetesmellitus (GDM).Care for the housebound/ those in care homesModified standard ofcare:NonePre-pregnancy for womenwith existing type 2diabetesModified standard ofcare:NoneAdolescence andtransitionModified standard ofcare:NoneType 2 with significantmental health issuesModified standard ofcare:If screening is positiverefer the patient toGP/diabetes specialistservices to coordinate thefuture management ofdiabetes/impairedglucose tolerance and tomake sure that thepatient is part of theirdiabetes follow-upservice, including theannual review process.- 8 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesBasic early investigationshelp with diagnosticdifferentiation and canprovide prognosticinformation. If age 40, likely type 2 If BMI 27, likely type 2 For Asian/PacificIslanders the BMIthreshold should be 23 If urinary ketonesmoderate to large,likely type 1 If urinary ketones lowto moderate,intermediate If urinary ketones noneto low, likely type 2- 9 -

Integratedcare tasksTask 3:ComprehensivebaselinediabetesreviewGeneric detection ofdiabetes pathwayStandard of care:At the time of diagnosisand repeated at least onan annual basis, performa comprehensivediabetes review.This should include atleast the following: Medical history;- eating patterns,nutritional status,and weight history;- history of diabetesrelatedcomplication:a. microvascularsuch asretinopathy,nephropathy,neuropathy(sensory,includinghistory of footlesions;autonomic,includingsexualdysfunctionandgastroparesis)b. MacrovascularCare for the housebound/ those in care homesModified standard of careNonePre-pregnancy for womenwith existing type 2diabetesModified standard ofcare:At the time of consideringa pregnancy, perform acomprehensive diabetesreview.There is good evidencethat a multidisciplinaryteam that includes aclinician with expertknowledge of diabetes,an obstetrician familiarwith the management ofhigh-risk pregnancies,diabetes educatorsincluding a nurse,dietician, and socialworker provide optimalpre-conception care forwomen with diabetes.The aim of the specialistservice should be that thewoman with diabetesmust become the mostactive member of theteam, working with theother members forspecific guidance andexpertise to help herachieve her goal of ahealthy pregnancy andAdolescence andtransitionModified standard ofcare:Refer to multidisciplinarypaediatric diabetesmanagement team forcomprehensive diabetesreview that should alsoinclude: screening for coeliacdisease: testing for tissuetransglutaminaseantibodies; test for endomysialantibodies; measure IgA levels; compare anddocument height andweight and BMI tostandard growthcharts.Intensify support forpatients withconcordance difficultieswith specific coping skillstraining and peer supportprogrammes.A sample of 104 familiesof adolescents withinadequate control of type1 diabetes wasType 2 with significantmental health issues- 10 -

Integratedcare tasksGeneric detection ofdiabetes pathwaysuch as CHD,cerebrovascular disease,PADc. otherpsychosocialproblems,dental diseased. mental healthassessmentincludingscreening fordepression. Physical examination- height, weight, BMI;- blood pressuredetermination,includingorthostaticmeasurementswhen indicated- fundoscopicexamination- skin examinationand insulin injectionsites- comprehensive footexaminationa. inspectionb. palpation ofdorsalis pedisand posteriortibial pulses- presence/absenceCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesnewborn.Also consider: If not scheduled, bringforward retinalexamination topreconception supportphase. Working with thepatient, set joint goalsto plan and optimisemanagement ofnephropathy andhypertension to avoidACE inhibitors. Offer a renalassessment, includinga measure of microalbuminuria,beforediscontinuingcontraception. If eGFRis less than 45ml/minute/1.73 m 2 ,referral to anephrologist should beconsidered beforediscontinuingcontraception. Discontinue statintreatment in fertilewomen withoutcontraception. Together with thepatient, set anappropriate scheduleAdolescence andtransitionrandomized to eitherremain in standard care(SC) or to augment thatregimen by 12 sessionsof either a multi-familyeducational support (ES)group or 12 sessions ofbehavioural familysystems therapy (BFST)over 6 months.BFST-D (targetingdiabetes-specificbehavioural problems,extension of treatmentfrom 3 to 6 months,training in behaviouralcontracting techniques forall families, a one weekparental simulation ofliving with type 1diabetes, and optionalextension of therapeuticactivities to other extrafamilialsocialenvironments affectingthe child’s diabetesmanagement) wassignificantly superior toboth SC and ES in effectson A1C.Peer support models area potentially low-cost,flexible means toType 2 with significantmental health issues- 11 -

Integratedcare taskshwayCare for the housebound/ those in care homesnAdolescence andtransitionType 2 with significantmental health issuesof reflexes- determination ofproprioception,vibration andmonofilamentsensation.2. Baseline laboratorytests: full blood count U+E TSH liver function tests S-lipids urinalysis (includingmicro-albumin testing) serum creatinine andeGFR3. Assess, identify andtreat cardiovascularrisk factors.4. Schedule one weekreview appointment.Review in one weekwhen tests back tomaintain patient’strust and compliance.for follow-up visits.The model of ‘Interactivepreconception diabetescare’ contains four mainelements. MDT membersshould agree how thefollowing areas of supportare allocated across theteam: patient education aboutthe interaction ofdiabetes, pregnancy,and family planning; education in diabetesself-management skills planned medical careand laboratory testing; counselling whenindicated to reducestress and improveadherence to thediabetes treatmentplan.All four elements areimportant for patients toachieve the level ofsustained glycaemiccontrol necessary toprevent excesscongenital malformationsand spontaneousabortions.supplement formal healthcare support. They alsopotentially benefit boththose receiving and thoseproviding support.Reciprocal models forboth receiving andproviding peer supportare being rigorouslyevaluated. The unifyingfeature of these programsis that they seek to buildon the strengths,knowledge andexperience that peers canoffer.Peer supportinterventions build on therecognition that peopleliving with chronicillnesses have a greatdeal to offer each other –they share knowledgeand experience thatothers, including manyhealth care professionals,cannot understand. Ifcarefully designed andimplemented, peersupport interventions canbe a powerful way to helppatients with chronicdiseases live moresuccessfully with their- 12 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionconditions.Type 2 with significantmental health issuesThere is still much tolearn about how best toorganise and delivereffective programs, whichtypes of programs arebest for different types ofpatients, and how best tointegrate peer supportinterventions into otherclinical and outreachservices. Many of themodels discussed in thisbrief overview have notyet been rigorouslyevaluated in randomised,controlled trials or haveonly been evaluated inone or two studies.There is much to be donein testing different peersupport models andbuilding knowledge toinform the developmentof improved models ofpeer support for diabetesself-management.- 13 -

Integratedcare tasksTask 4:SettreatmentgoalsGeneric detection ofdiabetes pathwayStandard of care:On initiation of therapyand reviewed andreinforced at every visit: achieve and maintainindividualised targetglycaemic levels asclose to the nondiabeticrange aspossible; cardiovascular riskfactor managementgoals; blood pressure goals; lowering A1C to anaverage of ~7% hasclearly been shown toreduce microvascularand neuropathiccomplications ofdiabetes and, possibly,macrovascular disease.Therefore, the A1C goalfor non-pregnant adultsin general is

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesabove 1-2%background rate ofnon-diabeticpregnancies at whichfirst trimester A1Cconcentrations are >1%above the normal rangefor a non-diabeticpregnant woman; work with patient tooptimise glycaemiccontrol and setpersonal goals; obtain and documentinformed consent onthe use of metformin inwomen with diabetesplanning a pregnancy; offer monthlymeasurement ofHbA1c; offer a meter to selfmonitorblood glucose; offer type 1 patientsketone testing strips totest for ketonuria orketonaemia if theybecomehyperglycaemic orunwell; work with patient tooptimise bloodpressure control andset personal goals.Adolescence andtransition for patients withdifficulties achievingtreatment goals or withrecurrent DKA, screenfor psychiatricdisorders includingeating disorders anddepression.Note that insulin omissioncan be viewed as aspecific type of eatingdisorder in order tocontrol weight.Transition to adult careproviders should beplanned and negotiatedamong the patient, thefamily, the paediatricdiabetes team, and theadult care providers.transportation, andunemployment.) posesignificant barriers todiabetes management.If such circumstancesare identified, involvingmental health, socialservices, and casemanagementprofessionals mayenhance patientcompliance withtreatment and followup.(VA) The determination ofstability is up to thejudgment of theprovider. (VA) Individual lifeexpectancy,barriers tocompliance and risk forhypoglycemia to setindividual and realisticglycaemic and othertreatment goals. Diabetes concordancesupport should formpart of the mentalhealth interaction. Mental health providersshould provide basiccare co-ordination andcounselling for peoplewith serious mentalillness and diabetes.- 15 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues Severe or frequenthypoglycemia is anindication for modifyingtreatment regimens,including setting higherglycaemic goals. In the VA, patients withdiabetes and seriousmental illness appearto receive diabetescare that is comparablewith the care that otherpatients with diabetesreceive, possiblybecause of increasedlevels of contact withthe health system andthe VA's integration ofmedical and mentalhealth services.Model of care: DiabetesTreatment Among VAPatients With Co-morbidSerious Mental Illness v .- 16 -

Integratedcare tasksTask 5:Initiateand titratetreatmentGeneric detection ofdiabetes pathwayStandard of care:At initiation and reviewedat every visit: lifestyle modification -advise on energyintake, diet physicalactivity and smokingcessation; agree an individualtreatment plan andtreatment goals; treatment concordanceand compliancebarriers; suitability/desirability forSMBG; consider and adjustmedicationmanagement:- metformin is first-linetherapy if BMI ≥25;- sulphonylurea may beused if BMI

Integratedcare tasksGeneric detection ofdiabetes pathwaynot tolerated orcontraindicated;- titrate dose untilmaximumrecommended ortolerated dose isreached – 'start low,go slow';- Combination oraltherapy:a. if already onmetformin, add asulphonylurea;b. if already on asulphonylurea, addmetformin;c. consider aglitazone* incombination witheither metformin ora sulphonylurea, ifeither is nottolerated orcontraindicated;d. for those onmaximum doses oforal therapy,consider insulintreatment.Care for the housebound/ those in care homesFor frail older adults,persons with lifeexpectancy of less than 5years and others in whomthe risks of intensiveglycaemia controlappears to outweigh thebenefits, a less stringenttarget such as 8% isappropriate.Adequate glycaemiccontrol to facilitatehealing and prevent: dehydration symptoms ofhyperglycaemia orhypoglycemia weight loss review all medications(including OTC) for those a thiazide orloop diuretic shouldhave electrolyteschecked within one totwo weeks of initiationtherapy or of anincrease in dosageand at least yearly.Pre-pregnancy for womenwith existing type 2diabetespersistent excess ofmalformations in infantsof diabetic mothers. Tominimise this, standardcare for all women withdiabetes who have childbearingpotential shouldinclude: education about therisk of malformationsassociated withunplanned pregnanciesand poor metaboliccontrol; use of effectivecontraception at alltimes, unless thepatient has goodmetabolic control and isactively trying toconceive.Work with the patient toprovide specific andculturally appropriatenutritional advice andsupplement folic acid.Adolescence andtransitionsupport andempowerment tomaintain familyinvolvement in diabetescare tasks andidentify/discuss ways toovercome barriers insuccessful diabetesmanagement.Early evaluation of familybarriers to concordanceis essential to avoid thesebehaviours to becomeentrenched.Indicators for barriers toconcordance includerepeated episodes ofDKA, other healthproblems (e.g. asthma,eating disorders), poorschool attendance,learning disabilities, andemotional andbehavioural disorders,(including risk-takingbehaviours resulting inchallenging behaviourand depression).Certain familycharacteristics have beenidentified as risk factorsfor poor diabetes control -Type 2 with significantmental health issuesidentification of a specificproblem or deteriorationin psychological status.Although the clinicianmay not feel qualified totreat psychologicalproblems, using thepatient-providerrelationship as afoundation for furthertreatment can increasethe likelihood the patientwill accept referral forother services. It isimportant to establish thatemotional well-being ispart of diabetesmanagement.Health and clinicalpsychologists withexpertise in diabetes cansupport themultidisciplinary team andimprove service.Model of care: Diabetes TreatmentAmong VA PatientsWith Co-morbidSerious Mental Illness vi A partnership betweenthe patient and theirclinical and support- 18 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionsingle-parent home,chronic physical ormental health problems ina parent or other closefamily member (includingsubstance abuse), arecent major life changefor the parent (e.g. loss ofa job or a death in thefamily), complex childcare arrangements, andhealth or cultural/religiousbeliefs making it difficultfor family to follow currentdiabetes treatment plans.Work with patient andfamily to develop aschool-day supportstrategy including aninformation sheet toshare with the school.Work with patient andfamily to develop anexercise plan and supportpackage includingstrategies to measureblood glucose levelsmanage hypoglycaemia,adjust carbohydrateintake and insulin doses.Offer an ongoingintegrated package ofType 2 with significantmental health issuesteam can improveoutcomes. Mental health, socialservices and casemanagementprofessionals mayenhance complianceand follow-up. Patients whosedifficulties in acceptingtheir diagnosiscompromise theirtreatment and maybenefit from cognitivebehavioural therapy. Psychological supportwill help people withdiabetes identifybarriers to managingtheir diabeteseffectively. Emotional andpsychological supportshould be an integralpart of the diabetescare packageModels of care: Overview of PeerSupport Models toImprove Diabetes Self-Management andClinical Outcomes vii . Psychological needsmust be properly- 19 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitioncare from amultidisciplinarypaediatric diabetes team.Home-based care withround the clock access toadvice from the localpaediatric diabetes teamis as effective and safeas initial inpatient care.Newly diagnosed childrenand young people mayexperience a partialremission phase where alow dose of insulin maybe sufficient (0.5units/kg/day) to maintaindesired HbA1c level of

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionbased care onconsideration of thefollowing:‐ clinical need‐ family wishes‐ familycircumstances‐ location of familyresidence inrelation to inpatientservices.Type 2 with significantmental health issuesNo local experience inthe outpatientmanagement of newlydiagnosed children withdiabetes inadequatestaffing to providecomprehensive outpatientcare patients withacidosis, patients whorequire intravenoushydration, distantreferrals patients orfamilies with significantpsychosocial challengesthat preclude outpatienteducation.Consider: Medical history. Symptoms and resultsof laboratory testsrelated to diagnosis. Recent or current- 21 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesinfections or illnesses. Previous growthrecords, includinggrowth chart, andpubertal development. Family history ofdiabetes, diabetescomplications, andother endocrinedisorders. Current or recent useof medications thatmay affect bloodglucose levels. History and treatmentof other conditions,including endocrineand eating disorders,and diseases known tocause secondarydiabetes (e.g. cysticfibrosis). Use of tobacco,alcohol, and/orrecreational drugs. Physical activity andexercise. Contraception andsexual activity (ifapplicable). Risk factors foratherosclerosis:smoking,hypertension, obesity,dyslipidemia, andType 2 with significantmental health issues- 22 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesfamily history. Prior A1C records* Previous treatmentprograms, includingnutrition and diabetesself-managementeducation, attitudes,and health beliefs. Results of past testsfor chronic diabetescomplications,includingophthalmologicexamination andmicro-albuminscreening. Frequency, severity,and cause of acutecomplications such asketoacidosis andhypoglycaemia. Current treatment ofdiabetes, includingmedications, mealplan, and results ofglucose monitoringand patients’ use ofdata. If signs and symptomsare suggestive of type2 diabetes:- evidence of isletautoimmunity (e.g.islet cell [ICA] 512or IA-2, GAD, andType 2 with significantmental health issues- 23 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesinsulin autoantibodies)- evidence of ß-cellsecretory capacity(e.g., C-peptidelevels) after 1 year,if diagnosis is indoubt. A1C. Lipid profile. Annual screening formicro-albuminuria. Thyroid-stimulatinghormone levels. Celiac antibodies atdiagnosis or initial visitif not done previously. Referrals andscreening. Yearly ophthalmologicevaluation. Medical nutritiontherapy (by aregistered dietician). As part of initial teameducation and onreferral, as needed;generally requires aseries of sessions overthe initial 3 monthsafter diagnosis, then atleast annually, withyoung childrenrequiring morefrequent re-Type 2 with significantmental health issues- 24 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionevaluations. Diabetes nurseeducator. Behavioural specialist Depression screeningannually for children≥10 years of age, withreferral as indicated Annual screening formicro-albuminuriashould be initiatedonce the child is 10years of age and hashad diabetes for 5years; more frequenttesting is indicated ifvalues are increasing Fasting lipid profileshould be performedat the time ofdiagnosis (afterglucose control hasbeen established). Ifvalues fall within theaccepted risk levels(measurement shouldbe repeated every 5years. The firstophthalmologicexamination should beobtained once thechild is ≥10 years ofage and has haddiabetes for 3–5 years.Type 2 with significantmental health issues- 25 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAfter the initialexamination, annualroutine follow-up isgenerallyrecommended.Type 2 with significantmental health issues- 26 -

Integratedcare tasksOptionaltask:specialistreferralGeneric detection ofdiabetes pathwayStandard of care:At initiation and reviewedat every visit, refer peoplewho present withcomplications (e.g.nephropathy or retinopathy): Consider patient’spotential to benefitfrom specialistdiabetes service.Alternatively, considerreferral to dietician,podiatrist, and retinalscreening service. People with urinaryalbumin:creatinineratios greater than orequal to 30mg/mmol(indicating overtdiabetic nephropathy)or proteinuria and/orwith serum creatininegreater than or equalto 0.15mmol/l or acalculated GFR of lessthan 60mo/min/1.73m 2should be consideredfor specialist referral. Refer for annualretinopathy screeningif aged 12 or over. Poor glycaemiccontrol.Care for the housebound/ those in care homesModified standard ofcare:Before referring tospecialist diabetesservice, assess thepatient’s functional statusto assess potential forimprovement, and aconcise review of thepresence of diabetesrelatedproblems.For older patients, acomprehensive geriatricassessment by amultidisciplinary teamand a consultantgeriatrician isrecommended. If there isevidence of cognitiveimpairment and deliriumhas been excluded as acause, an initialevaluation to identifyreversible conditions thatmay potentially cause orexacerbate cognitiveimpairment should beperformed promptly afterdiagnosis and with anysignificant change inclinical status.Pre-pregnancy for womenwith existing type 2diabetesStandard of care:Refer all pregnant womenwith diabetes, or thoseplanning a pregnancy, forspecialist diabetes care.Adolescence andtransitionStandard of care:All paediatric diabeticcare should becoordinated by aspecialist diabetesservice.Type 2 with significantmental health issuesModified standard ofcare:At every visit considerglycaemic and othertreatment goals in thecontext of patient barriersand mental health status.Consider the patient’spotential to benefit fromspecialist diabetesservice referral orwhether treatment goalscan more likely be met ina supported mentalhealth care-led setting.Refer selected patients tomental healthprofessionals beforesetting aggressiveglycaemic and othertreatment goals.- 27 -

Integratedcare tasksTask 6:RegularreviewandmonitoringGeneric detection ofdiabetes pathwayStandard of care:Annually, or whenindicated, conduct acomprehensive diabetesreview includingif not performed/availablewithin past year: fasting lipid profile liver function tests test for urine albuminexcretion with spoturine albumin-tocreatinineratio serum creatinine andeGFR thyroid-stimulatinghormone in type 1diabetes, dyslipidemiaor women over age 50Referrals: Annual dilated eyeexam Family planning forwomen of reproductiveage Registered dietician Diabetes selfmanagementeducation Dental examination Mental healthprofessional, ifdepression/anxiety orCare for the housebound/ those in care homesModified standards ofcare:Additional considerations: Older women withdiabetes are atincreased risk forurinary incontinence. Older people withdiabetes should bescreened for their fallrisk and foropportunities toprevent them falling. If an older adultpresents with evidenceof falls the clinicianshould document abasic falls evaluation,including anassessment of injuriesand examination ofpotentially reversiblecauses of the falls (e.g.medications,environmental factors). Older adults withdiabetes should bescreened for persistentpain using a targetedhistory and physicalexamination andevaluated further ifPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionModified standards ofcare:Schedule regular clinicappointments. Thechild/young personshould be reviewedregularly, three to fourtimes a year or more,with one major annualreview by themultidisciplinary team.Schedule a major annualreview, includingassessment of thefollowing: growth blood pressure pubertal status nutritionScreen for complications,including: retinopathy coeliac disease thyroid disease hypertension micro-albuminuria serumadrenocorticotrophichormone (ACTH)and/or morning serumcortisol level.Type 2 with significantmental health issuesModified suggestedstandard of care:Every two to threemonths conduct acombined GPwSI andmental health visit.A review of diabetesrelatedbarriers, goalsand behaviours shouldalso form part of everymental health review visit.Refer for acomprehensive diabetesclinical review once ayear. Thisrecommendation basedon Psychiatric Services57:1016-1021, July 2006.- 28 -

Integratedcare tasksGeneric detection ofdiabetes pathwayother mental healthissues identified Foot examinationEvery 2-6 months, or asindicated: HbA1C should bemonitored 3-6 monthly.The frequency dependson:‐ the acceptability ofHbA1C levels;‐ stability of selfmonitoredbloodglucose results;‐ changes in diabetestherapies. Measure HbA1c levelsat 2-6 month intervalsuntil blood glucose isstable on unchangedtherapy. Measure every6 months once stable.Care for the housebound/ those in care homesnecessary. The patientshould be monitored inline with local painguidelines. On presentation of anolder adult withdiabetes the clinicianshould assess thepatient for symptomsof depression using asingle screeningquestion orstandardisedscreening tool such asthe GeriatricDepression Scale,Beck DepressionInventory or Zung’sMood Scale. If an older adultpresents with newlyonset or recurrentdepression, evaluatemedications todetermine whether anyof them are associatedwith depression. Older adults withdiabetes have anincreased risk formajor depressionduring the initialevaluation period (firstthree months) and ifthere is anyPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionCarry out a review ofsystems, with particularattention to: gastrointestinalfunction (for symptomsof coeliac disease); symptoms of otherendocrine disorders,such ashypothyroidism; review results ofprevious testing forcomplications; measure height andweight in a privateroom and calculateBMI, plot againstgrowth charts; review HbA1c recordsand patient’s glucosemonitoring records; review past andcurrent treatmentprogramme; review frequency,severity, and cause ofacute complicationssuch as DKA, andhypoglycaemia; inspect injection sites.Consider the possibility ofrare complications: juvenile cataractsType 2 with significantmental health issues- 29 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesunexplained decline inclinical status. The older adult withdiabetes who presentswith newly-onset or arecurrence ofdepression should betreated or referredwithin two weeks ofpresentation, or soonerif the patient is indanger to them self,unless there isdocumentation that thepatient has improved. The older adult whohas received therapyfor depression shouldbe evaluated forimprovement in targetsymptoms within sixweeks of therapyinitiation. Depression in elderlydiabetics andsubsequent lack ofrecognition of thirstand dehydration areimportant factors to betaken into account inmanaging olderdiabetic patients.Skill, competency andteam requirements:Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransition necrobiosis lipoidica Addison’s disease,which should be ruledout in patients withrecurrent severehypoglycaemia.Monitor for signs ofdepression, eatingdisorders and riskybehaviours.Encourage regular clinicattendance as it is linkedto good glycaemiccontrol.Familiarisation withpracticalities of transitionto adult servicesimproves clinicattendance.Transition should becoordinated with other lifetransitions and occur in aperiod of relative stabilityin the person’s health.Paediatric and adultdiabetes care teamsshould jointly organiseage-banded clinics foryoung people and youngadults.Type 2 with significantmental health issues- 30 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homes For each care teamthat cares for diabeticsin the home orinstitutionalised caresetting agree,document and audit aseries of outcomedeterminants to assistin assessing thequality of diabetes caredelivered.Models of care: Document of care forolder people withdiabetes viii Development and auditof a home clinicservice ix Evercare evaluationinterim report:Implications forsupporting people withlong-term conditions –The nursing homemodel and vulnerableolder people x Transforming ChronicCare Programme xiPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionDuring this transition in16-18 year olds a visit tothe adult service orhaving an adult physicianattend the paediatricdiabetic clinic should beconsidered.Clear instructions mustbe provided during thetransition. An evaluationphase (18-19 years)needs to include followupto confirm successfultransition and clinicattendance.Type 2 with significantmental health issues Appoint a localdiabetes nursespecialist to liaise withand support the care- 31 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesteam. This can play avery important role inthe education of allrelevant partiesincluding the residentand care staff(including cateringstaff). Identify and liaise witha community dieticianto support the careteam especially withDiabetics on Insulintherapy. Educate, support andmonitor carer, cateringor kitchen staff toensure familiarity withthe key principles ofdietary planning forresidents with diabeteswho is able to providemeals in accordancewith these. Ensure access totransport facilities toenable access tospecialist treatment. For each patient,identify a designateddoctor (usually the GP)who will accept overallmedical responsibility. Ensure availability,maintenance andPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 32 -

Integratedcare tasksGeneric detection ofdiabetes pathwayknowledge of glucosemonitoring of capillarysamples fromresidents withdiabetes. An olderadult with diabeteswhose individualtargets are not beingmet should have his orher A1c levelsmeasured at leastevery six months andmore frequently, asneeded or indicated.For people with stableA1c over severalyears, measurementevery 12 months maybe appropriate Daily measures arerequired during periodsof acute illness butotherwise twice weeklyor weekly measuresare reasonable. Afasting venous plasmablood glucose everysix months and aglycosylatedhaemoglobin (HbA1c)taken at annual reviewby the care home GPare measures whichmay be of someclinical usefulness inPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 33 -

Integratedcare tasksGeneric detection ofdiabetes pathwaymonitoring themetabolic control ofmost residents. Clinicians shouldperform a carefulreview of eachmedication currentlybeing used by thepatient during the initialvisit at eachsubsequent visit anddocument whether thepatient is taking themedication properly. The management planfor the older adult withdiabetes who hassevere or frequenthypoglycaemia shouldbe evaluated. Thepatient should beoffered referral to adiabetes educator,endocrinologist ordiabetologist. Patientand caregiver shouldhave more frequentcontact with healthcareteam (e.g. physicians,pharmacists, nurses,case managers) whiletherapy is beingadjusted. Monitor liver andkidney function testsPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 34 -

Integratedcare tasksGeneric detection ofdiabetes pathwayperiodically eventhough diabetesmedications, alone orin combination, aresafe in older adultpatients when selectedcarefully.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 35 -

Integratedcare tasksTask 7:DiabetesselfmanagementskillsandeducationGeneric detection ofdiabetes pathwayStandard of care:Consider using selfmonitoringof bloodglucose. This should beavailable: to those on insulintreatment; to those on oralglucose loweringmedications to provideinformation onhypoglycaemia; to assess changes inglucose controlresulting frommedications andlifestyle changes; to monitor changesduring intercurrentillness; to ensure safetyduring activities,including driving.Assess at least annuallyand in a structured way: self-monitoring skills; the quality andappropriate frequencyof testing; the use made of theresults obtained; the impact on qualityCare for the housebound/ those in care homesModified standards ofcare:Special blood glucosemonitors are available forpatients with impaireddexterity, and there aretalking monitors andmonitors with largenumerical displays andbacklights available forpatients with impairedvision.The healthcare provideror educator needs toassess the patient'smonitoring technique atregular intervals, sincethe patient's mental andphysical status maychange over time.Emphasise theimportance of regularself-monitoring,especially before driving.Some older adults maynot be able to performself-monitoring due tophysical or cognitiveimpairment. In suchsituations, the glycaemicgoals may need to bePre-pregnancy for womenwith existing type 2diabetesModified standards ofcare:For most patients withtype 1 diabetes andpregnant women takinginsulin, self-monitoringblood glucose isrecommended three ormore times daily. For thispopulation, it is oftendifficult to reach A1Ctargets safely withouthypoglycaemia with theminimum of three dailytests.Educate all women withdiabetes about the needfor planning pregnancy toensure optimal outcomes.Educate women andpartners on importance oftight glycaemic and bloodpressure control foroptimal pregnancyoutcome.Adolescence andtransitionModified standards ofcare:There should be agradual transition towardsindependentmanagement through theages of 12 to 18, but it isimportant to maintainadult supervision in thisperiod.The ability to self-managewill vary with age, motordevelopment, emotionalmaturity and cognitiveability.Age 12-15 yearsPeople with diabetesaged 12-15 years (earlyadolescence) may copewith difficultiesassociated with puberty,such as: increased insulinrequirements; increasing difficulty ofglycaemic control; weight and bodyimage concerns.Negotiate new roles forthe parent andType 2 with significantmental health issuesModified standards ofcareIf self-monitoring isappropriate but bloodglucose monitoring isunacceptable to theindividual, discuss theuse of urine glucosemonitoring.- 36 -

Integratedcare tasksGeneric detection ofdiabetes pathwayof life; the continued benefit; the equipment used.If self-monitoring isappropriate but bloodglucose monitoring isunacceptable to theindividual, discuss theuse of urine glucosemonitoring.Self-monitoring bloodglucose should be carriedout three or more timesdaily for patients usingmultiple insulin injectionsor insulin pump therapy.For patients using lessfrequent insulininjections, non-insulintherapies, or medicalnutrition therapy (MNT)alone, SMBG may beuseful in achievingglycaemic goals.Assess annually selfmonitoringskills, thequality and frequency ofthe tests, the use of theresults obtained, theimpact of QOL, theequipment used and theCare for the housebound/ those in care homesadjusted to keep bloodglucose levels higher,and the regimen shouldbe simplified to avoidhypoglycaemia for thoseat risk. Referral foreducation andcounselling should beadvised if patient's abilityto drive is in question.Encourage caregivers toaccompany patients toeducation sessions andreceive appropriatetraining in glucosemonitoring and bloodglucose interpretation.For the older adult withdiabetes consider aschedule for selfmonitoringblood glucose,depending on theindividual’s functional andcognitive abilities. Theschedule should bebased on the goals ofcare, target A1c levels,the potential for modifyingtherapy and theindividual’s risk forhypoglycaemia.Provide individual ratherthan group education ifPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionadolescent in diabetesmanagement, with theadolescent taking onmore self-care, butmaintain some parentalguidance andsupervision.Teach coping skills tohelp with selfmanagement.Prevent orintervene in diabetesrelatedfamily conflict.Age 16-18 years (lateadolescence)This age group isbeginning a transition to anew diabetes team foryoung adults or adults.Provide support for thistransition.Make diabetesmanagement part of anew lifestyle. Teachcoping skills to help withself- management.Prevent or intervene indiabetes-related familyconflict.Although both NICE andType 2 with significantmental health issues- 37 -

Integratedcare tasksGeneric detection ofdiabetes pathwaycontinued benefitProvide structureeducation according tothe five standards areas:1. Any programmeshould have anunderpinningphilosophy, beevidence-based, andsuit the needs of theindividual. Theprogramme shouldhave specific aimsand learningobjectives, andsupport developmentof self-managementattitudes, beliefs,knowledge and skillsfor the learner, theirfamily and carers.2. The programmeshould have astructured curriculumwhich is theory-driven,evidence-based,resource-effective,have supportingmaterials, and bewritten down.3. It should be deliveredby trained educatorswho understand theCare for the housebound/ those in care homesthe patient has cognitiveor physical deficits.Use memory aids (e.g.personalised handouts)to reinforce points madeduring face-to-facesessions.Focus education onreinforcing medicationadherence using charts,pill boxes and otherreminders - since olderadults often take multiplemedications. Caregiversshould be instructed totrack amount ofmedication used.Educate the patient thatuncommon symptomssuch as confusion,dizziness and weaknesscan be manifestations ofhypoglycaemia.Provide very specificguidelines on whenpatient or caregivershould call the healthcareprovider.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionISPAD recommend anHbA1c target of 9.5%Inform of optimal targetblood glucose levels, 4-8mmol/l preprandially

Integratedcare taskseducational theoryappropriate to the ageand needs of theprogramme learners,and be trained andcompetent indelivering theprinciples and contentof the specificprogramme they areoffering.Model of care: California HealthcareFoundation Usingtelephone support tomanage chronicdisease xii NICE Patienteducation models xiii Transforming ChronicCare Programme xiv .4. The programmeshould be qualityassured, reviewed bytrained, competent,independentassessors, and beassessed against keycriteria to ensuresustained consistency.5. The outcomes fromthe programme shouldbe regularly audited.Care for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionhypoglycaemia andhyperglycaemia, or ifchild/ young person ispersistently unaware ofhypoglycaemia, offer acontinuous glucosemonitoring system.Encourage child/youngperson to keep a foodintake diary and alsorecord events such asillnesses.Test for ketones if bloodglucose is above15mmol/l and the child isunwell or adolescent.Test for ketones if thechild has the followingsymptoms, even if bloodglucose is less than15mmol/l: rapid breathing flushed cheeks high temperature abdominal pains vomiting diarrhoea inappropriatedrowsiness.Educational interventionsfor children andadolescents have aType 2 with significantmental health issues- 39 -

Integratedcare tasksGeneric detection ofdiabetes pathwayDSME is associated withimproved diabetesknowledge and improvedself-care behaviour,improved clinicaloutcomes such as lowerA1C lower self-reportedweight and improvedquality of life. Betteroutcomes were reportedfor DSME interventionsthat were longer andincluded follow-upsupport that were tailoredto individual needs andpreferences andaddressed psychosocialissues. Both individualand group approacheshave been foundeffective.Care for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionmodestly beneficial effecton glycaemic control, anda larger effect onpsychosocial outcomes.Patient and familyeducation plus intensivediabetes casemanagement and closetelephone contact withthe diabetes care teamreduce emergency roomvisits andhospitalisations.Ongoing, timelyopportunities for thechild/young person andtheir family to gaininformation about type 1diabetes should beprovided.Type 2 with significantmental health issuesThere is increasingevidence for the role of acommunity health workerin delivering diabeteseducation in addition tothe core team.Information should bereviewed regularly, andtailored to theindividual’s: age culture wishes existing familyknowledge any special needs,such as disabilities orlanguage barriers- 40 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransition local practice changes in diabetesmanagement andtechnology.Type 2 with significantmental health issuesProvide specificadditional education: using newertechnologies (e.g.DVDs, text messages,and computers) in aninteractive way toappeal to youngpeople. smoking, alcohol, andillicit drugs; school, highereducation,employment, anddriving; sexuality,contraception,pregnancy andchildbirth.Offer all patients and theirfamilies structured andpersonalised educationpaced to accommodateindividual needs andprovide casemanagementsupportand/ telephone access.Communicating basic- 41 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionspecialised diabeteseducation skills isrequired for adolescents.They requiremanagement skills withina context that addressesfamily dynamics andissues facing the wholefamily. It is essential thatsubstantial educationalmaterial (necessary forbasic management, oftenreferred to as "survivalskills") be conveyed to afamily of a child with type1 diabetes immediatelyafter the initial diagnosis.Type 2 with significantmental health issuesStudies suggest that tobe effective, educationalinterventions need to beongoing.Task 8:Lifestyleand dietStandard of care for allpatients:Refer to a registereddietician to providenutritional care advice.Modified standards ofcare:Every effort should bemade to minimise thecomplexity of mealplanning and to engageModified standards ofcare:All women with diabetesshould be prescribed prepregnancyfolatesupplementation (c.Frequent telephonecontact, and both inpersoncare andtelephone availabilityhave been demonstratedto improve A1C.Modified standards ofcare:Dietetic support shouldbe offered by a traineddietician, to help optimiseglycaemic control andModified standards ofcare:It is also recognisedthat all teammembers need to beknowledgeable- 42 -

Integratedcare tasksGeneric detection ofdiabetes pathwayProvide individualisedand ongoing nutritionaladvice from a healthcareprofessional with specificexpertise andcompetencies in nutrition.Provide dietary advice ina form sensitive to theindividual’s needs, cultureand beliefs - beingsensitive to theirwillingness to change,and the effects on theirquality of life.Emphasise advice onhealthy, balanced eatingthat is applicable to thegeneral population whenproviding advice topeople with type 2diabetes.Encourage high-fibre, lowglycaemic index sourcesof carbohydrate in thediet such as fruit,vegetables, wholegrainsand pulses; include lowfatdairy products and oilyfish, and control theintake of foods containingsaturated and trans fattyacids.Care for the housebound/ those in care homesthe spouse, or othersliving with the patient, increating a homeenvironment thatsupports positive lifestylechange.Weight loss diets,commonly recommendedto younger adults, shouldbe prescribed with greatcaution because undernutrition/malnutritionisoften more of a problemthan obesity in the olderadult. In chronic caresettings, there is no needfor a rigid and restrictivemeal plan. A regular dietwith consistent, moderatecarbohydrate intake maybe sufficient and helpavoid under-nutrition.The current trend is todistribute the patient'scarbohydrate intake asevenly as possiblethroughout the day.Education regarding theimportance ofconsistency incarbohydrate intake andthe timing of meals canhelp avoid largePre-pregnancy for womenwith existing type 2diabetes4mg), continuing up to 12weeks gestation.Adolescence andtransitionbody weight.There is little evidenceregarding which dietarystrategy, qualitative orquantitative, is the mosteffective.Children and youngpeople with diabeteshave the same basicnutritional requirementsas other people of thesame age.Food choices shouldprovide adequate energyand nutrients to optimisegrowth and developmentEncourage child oryoung person todevelop a goodunderstanding ofnutrition and itseffects on theirdiabetesA healthy diet,including fruit andvegetables, lowglycaemic indexfoods, andcontrolled levels andtypes of fats, isimportant forreducingabout nutritionaltherapy, and giveemphasis toconsistent dietaryand lifestyle advice.- 43 -

Integratedcare tasksGeneric detection ofdiabetes pathwayIntegrate dietary advicewith a personaliseddiabetes managementplan, including otheraspects of lifestylemodification, such asincreasing physicalactivity and losing weight.For people who areoverweight, target aninitial body weight loss of5–10%, whileremembering that lesserdegrees of weight lossmay still benefit and thatlarger degrees of weightloss in the longer termwill have advantageousmetabolic impact.Individualiserecommendations forcarbohydrate and alcoholintake, and mealpatterns.Reducing the risk ofhypoglycaemia should bea particular aim for aperson using insulin or aninsulin secretagogue.Advise individuals thatlimited substitution ofCare for the housebound/ those in care homesfluctuations in bloodglucose levels.Although diabetesnutritional guidelines forthe older adult are nodifferent than for youngeradults, unique challengesoften exist due to: poor motivation; altered tasteperception; weight loss andmalnutrition; co-existing illnesses; poor dentition; skipping meals due tocognitive dysfunctionor depression; altered gastrointestinalfunction; impaired foodshopping orpreparationcapabilities; Limited finances.Meals should provide avaried and nutritionallybalanced diet and ensurethat cultural and religiousthemes are maintainedas much as possible.Regular meals arePre-pregnancy for womenwith existing type 2diabetescardiovascular riskType 2 with significantmental health issues- 44 -

Integratedcare tasksGeneric detection ofdiabetes pathwaysucrose-containing foodsfor other carbohydrates inthe meal plan isallowable, but that careshould be taken to avoidexcess energy intake.Discourage the use offoods marketedspecifically for peoplewith diabetes.When patients areadmitted to hospital asinpatients or to any otherinstitutions, implement ameal planning systemthat provides consistencyin the carbohydratecontent of meals andsnacks.Care for the housebound/ those in care homesessential to preventhypoglycaemia and helpoptimise blood glucosecontrol. Snacks betweenmeals and at bedtimemay be required for thosetaking insulin orsulphonylureas.Weight-loss is desirablefor those who are obese.However, this may bedifficult to achieve withsome (e.g. those withmarked immobility) andmaintenance of weightmay be more realistic.Special 'diabetic' foodsshould be avoided asthey are usuallyunnecessary and willoffer no special benefitsin malnourishedresidents, wherenutritional supplementdrinks are needed orspecial diets are requiredFor example, in diabeticrenal disease, acommunity dietician ordoctor (generalpractitioner or hospitalspecialist) should beinvolved in providingPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 45 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesadvice to the care home.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesA specific dietary plan(including a weightassessment) for eachresident should bedesigned by a communitydietician with an interestin diabetes. This shouldfollow discussion andagreement with therelevant kitchen staffUse educational materialthat is easy to follow andexcludes extraneousinformation.- 46 -

Integratedcare tasksTask 9:Refer forpodiatricscreeningGeneric detection ofdiabetes pathwayStandard of care:All people with diabetesshould be screened forfoot disease by ahealthcare practitioner.Screening should occurfrom the time ofdiagnosis, and then atleast annually if there areno features indicating ahigh risk foot.Classify risk and referand review accordingly. Low risk – annualreview Medium risk – 3-6months High risk – 1-3 monthsMore frequentexamination (3-6 months)should occur if there arefeatures of a high riskfoot.People with type 2diabetes and peripheralneuropathy should beidentified as they have ahigh risk of foot ulcerationand amputation.Care for the housebound/ those in care homesAdditional considerations:Older adults may requireadditional education anddevices such as mirrorsto examine their feet dueto decreased mobility anddexterity.Older adults should beencouraged to see apodiatrist regularly (every9 weeks), along withspecial footwear forpatients with diabetesrelatedfoot problems.The older adult who hasdiabetes and anycaregiver should receiveeducation about riskfactors for foot ulcers andamputation. Physicalability to provide properfoot care should beevaluated withreassessment andreinforcement periodicallyas needed.Podiatry can be provideddirectly in the care homesor in day-care centres,health centres, outpatientPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionAdditional considerations:Provide education aboutthe importance of goodfootwear and foot care.Annual foot exams shouldbegin at pubertyType 2 with significantmental health issues- 47 -

Integratedcare tasksGeneric detection ofdiabetes pathwayPeople with diabetesshould be regularlyassessed for peripheralvascular disease.People with diabetes whohave had a previousamputation are at highrisk of ulceration andfurther amputation andtherefore require regularand frequent reviews.People with diabetesshould be assessedregularly for deformitiesincluding halluxdeformities, hammer orclaw toes, callus orCharcot’s foot.People with diabetes anda current foot ulcer are athigh risk from amputationand preventativeintervention to lower thatrisk should be institutedpromptly.People with diabetes anda history of a healedprevious foot ulcer shouldbe recognised as havinga life-long increased riskof recurrent ulcerationCare for the housebound/ those in care homesclinics or other clinicsettings. Referral may bemade by the generalpractitioner or by ahospital medical team.Assess pre-existing footpathologies includingphysical deformity, callusformation, infection,ulceration, vascularstatus, toe nailpathologies, andsuitability of currentfootwear. This involvesan initial inspectionfollowed by regularsurveillance. Active treatment ofdiabetic foot disease. Educate residents,carers and care staff inthe prevention ofdiabetic complicationsinvolving the feet,correct toe nail cutting,heel protection anduse of the mostappropriate footwear.This may also involvesupplying suitable insolesand orthoticswhere appropriate. Ensure that podiatryassessment forPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 48 -

Integratedcare tasksGeneric detection ofdiabetes pathwayand amputation.People with type 2diabetes should beassessed for peripheralvascular disease byenquiry about symptomsof intermittentclaudication or palpationof pedal pulses.Regular access toscreening, structured footcare, foot care educationand footwear advice.Consider TCAs/gabapentin in painfulneuropathy.Consider topicalcapsaicin for localisedneuropathic pain.Tissue replacementtherapy for refractoryulcers.Diagnose Charcot’s footby clinical exam andthermography. Treat bytotal contact casting andnon-weight bearing.Examine feet at diagnosisand review to include:diabetic foot diseaseoccurs as part of theannual review process. Regular identificationof ‘at risk’ feet by thepodiatrist andinstitution of anappropriate footwearprotocol. Routine threemonthly visits may bean appropriatemechanism ofmonitoring. Identify a ‘named’member of care stafffor each diabeticresident at each hometo liaise with podiatristto review footcareprotocol. Use a ‘fast-tracking’system which allowsrapid referrals ofresidents with earlyfoot ulceration tohospital diabetesdepartments forspecialist evaluation.However, it is recognisedthat some interventionssuch as photocoagulationfor diabetic retinopathy orangioplasty for peripheralvascular disease may bePre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 49 -

Integratedcare tasksGeneric detection ofdiabetes pathway test sensation using a10-g monofilament orvibration. palpation of footpulses. inspect for deformitiesand footwear.Care for the housebound/ those in care homesentirely inappropriate forsome residents, e.g.those with severephysical frailty, terminalillness (life expectancyless than six months), orprogressive dementia.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesRefer to foot care teamwithin 24 hours for newulceration, new swelling,discolouration infection,deep ulcer or Charcot’sfoot. If a 24 hour referralis not possible provideoral antibioticsFlucloxacillin 500mgsQDS x 7 days orErythromycin 500mgsQDS, swabs from base ofwound for C&S.Maintain good bloodglucose control, good BPcontrol and smokingcessation.However, even for olderresidents of nursinghomes, the averageduration of stay may beup to two years, which issufficient time for sightthreateningeye diseaseor gangrenous feet todevelop, both of whichhave devastating effectson the individual. Forthese, active therapeuticintervention may bewarranted.Consider low dose aspirinand statin.People with high risk footshould be referred to aspecialist diabetes footclinician or amultidisciplinary foot care- 50 -

Integratedcare tasksGeneric detection ofdiabetes pathwayteam. If this is notpossible, refer to apodiatrist.Care for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesFor mild neuropathic painparacetamol should beused as first line therapy.All people with diabeticfoot disease with tissueloss and arterial diseaseshould be referred forconsideration of arterialneurovascularisationprocedures.- 51 -

Integratedcare tasksTask 10:Refer forophthalmologyscreeningGeneric detection ofdiabetes pathwayStandard of care:For all patients, screenfor diabetic retinopathy atleast every two years witha shorter interval forthose with severity of riskfactors.Use tests achievingsensitivity of 80% orhigher; specificity of 95%or higher and technicalfailure rate of 5% orlower: retinal photography slit lamp indirectophthalmoscopy.Refer: all people with anydegree of diabeticretinopathy should beunder supervision of anophthalmologist.Refer for urgent review ifsudden loss of vision,rubeosis iridis, pre-retinalor vitreous haemorrhage,retinal detachment ornew vessel formation aredetected.Care for the housebound/ those in care homesAdditional considerations:The older adult who hasnewly-onset diabetesshould have an initialscreening dilated-eyeexamination performedby an eye-care specialistwith fundoscopy trainingAnnual screening shouldbe conducted for theolder adult who hasdiabetes and is at highrisk of eye disease(symptoms of eyedisease present;evidence of retinopathy,glaucoma or cataracts onan initial dilated-eyeexamination orsubsequent examinationsduring the prior 2yearsA1c ≥8.0% type 1diabetes or bloodpressure ≥140/80) on theprior examinationperformed by an eye-carespecialist withfundoscopy training atleast annually.It is recommended that,Pre-pregnancy for womenwith existing type 2diabetesModified standard ofcare:Women with pre-existingdiabetes who areplanning pregnancy orwho have becomepregnant should have acomprehensive eyeexamination and becounselled on the risk ofdevelopment and/orprogression of diabeticretinopathy.Eye examinations shouldoccur in the first trimesterwith close follow-upthroughout pregnancyand one year postpartum.Adolescence andtransitionModified standard ofcare:Screen for retinopathyannually from age 12.Screening should beperformed by anophthalmologist oroptometrist, and methodsmay include: 7-standard fieldstereoscopic-colourfundus photography,interpreted by atrained reader(suggested by CDA tobe the gold standard); direct ophthalmoscopyor indirect slit lampfundoscopy throughdilated pupil; digital fundusphotography.Type 2 with significantmental health issuesModified standard ofcare:- 52 -

Integratedcare tasksGeneric detection ofdiabetes pathwayRefer for review ifpreproliferativeretinopathy, significantmaculopathy, problematiccataracts or unexplainedchange in visual acuityare detected.Care for the housebound/ those in care homeswhenever possible,improvedaccommodation/ facilitiesat each care home toallow ‘on-site’ fulloptometric assessment tobe carried out.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesAddress risk factors –blood glucose, lipidlevels, and BP control.Cataract extractionsshould not be delayed inpeople with diabetes whohave co-existing diabeticretinopathy.An ophthalmologistshould assess peoplewith diabetes who havecataracts to determinethe optimum time forcataract removal.Educate care staff aboutthe importance ofmaintaining visual healthin residents withdiabetes. This mayrequire identifying amember of care staff whowould take someresponsibility fororganising visits byoptometrists and priorinstilling (whereappropriate) of eye dropsfor fundal dilatation toprevent unnecessarydelay in visualexamination.Visual acuitymeasurements (bynursing or other carestaff) and fundalexamination throughdilated pupils (by the GP)at each annual reviewwith a streamlinedreferral system to- 53 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesoptometrists wherenecessary.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesHowever, it is recognisedthat some interventions(such asphotocoagulation fordiabetic retinopathy orangioplasty for peripheralvascular disease) may beentirely inappropriate forsome residents, e.g.those with severephysical frailty, terminalillness (life expectancy

Integratedcare tasksTask 11:Initiateincreasein physicalactivityGeneric detection ofdiabetes pathwayStandard of careAll diabetics, at everyvisit: Advice about activityshould be individuallytailoredand diabetesspecific.It shouldinclude implications forglucose managementand provide ongoingsupport and tailoredadvice. Individual advice onavoiding hypoglycaemiawhen exercising shouldbe given to peopletaking insulin, includingadjustment ofcarbohydrate intake,reduction of insulindose and choice ofinjection site.Care for the housebound/ those in care homesConsiderations in thisgroup:Types of physicalactivities that may beappropriate for the someolder adults include: walking swimming or wateraerobics bicycle riding armchair exercises Tai Chi yoga gardening household chores chair exercises.The older adult withdiabetes often facesunique challenges tomaintaining a regularphysical activity program: fluctuations in health; co-morbidities, such ascardiovasculardisease, osteoarthritisand osteoporosis; risk and fear of falls; issues withtransportation; finding a safeenvironment forexercise.Pre-pregnancy for womenwith existing type 2diabetesConsiderations in thisgroup:There is insufficientevidence to recommendor advise against diabeticwomen enrolling in anexercise programme.Adolescence andtransitionConsiderations in thisgroup:Encourage regularexercise. Inform abouteffects of exercise onblood glucose, andstrategies to preventhypoglycaemia during orafter exercise.Specialist diabetes teamshould offercomprehensive advice ifchildren/young peoplewish to partake inrestricted sports such asscuba diving, which mayinclude advice aboutother potential sources ofinformation.Encourage the child tomonitor blood glucoselevels before and afterexercise and adjust foodor insulin intake ifneeded.Instruct child/youngperson and their familythat they need toconsume carbohydrates ifblood glucose levels areType 2 with significantmental health issues- 55 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homesIn addition, the risk ofhypoglycaemia isincreased among thosepeople who are takinginsulin and certaindiabetes medications.Extra precautions andfrequent self-monitoringmust occur to reduce thisrisk. A physical oroccupational therapist orexercise physiologist canprovide a supervisedenvironment to help apatient perform exercisessafely.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransition

Integratedcare tasksOptionalTask:SmokingcessationGeneric detection ofdiabetes pathwayStandard of care:Reinforce messagesannually in continuingsmokers and at everyclinical contact if stoppingis a possibilityOffer advice to never startsmoking.Smoking cessation anduse of services available.Use nicotine replacementtherapy as part ofcomprehensive diabetesmanagement.Care for the housebound/ those in care homesAdditional considerations:The older adult who hasdiabetes and smokesshould be assessed forwillingness to quit andshould be offeredcounselling andpharmacologicalinterventions to assistwith smoking cessation.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesAdditional considerations:Health professionals mayhave to learn to acceptthe patient’s choice toengage in potentiallyrisky behaviours, such assmoking.Use nicotine replacementtherapy cautiously (afterdiscussion with aspecialist) in theimmediate period post MI(4 weeks) and those withserious arrhythmias orsevere or worseningangina.- 57 -

Integratedcare tasksOptionalTask:MedicationoptionsGeneric detection ofdiabetes pathwayStandard of CareConcordance withtherapy should bediscussed with peoplewith diabetes andmonitored where the levelof glucose control isproblematic.Glucose loweringtherapies should beprescribed on a trial basisand patient’s responsemonitored using HbA 1cmeasurement (DCCTaligned). If glucosecontrol deteriorates tounsatisfactory levelsanother therapy shouldbe added rather thansubstituted.Consider statins in type 2diabetes if 10 year risk ofa major coronary event is≥30%.The target threshold forcholesterol should be toreduce TC to below5mmol/litre or by 20-25%,whichever is lower, OR toreduce LDL-C to belowCare for the housebound/ those in care homesConsiderations in thisgroupGeneral principles tokeep in mind whenprescribing diabetesmedications to an olderadult: ‘start low and go slow’with all medications; consider drug-druginteractions carefully,as most older adultpatients are onmultiple drugs as wellas supplements.When possible, simplifythe patient's careregimen, especially forpatients who havemultiple medicalproblems, cognitivedysfunction or functionaldisability (e.g. changinginsulin to two injections aday from four injections aday). Involve thecaregiver or arrange forvisiting nurse ifmedication adherence isan issue.Pre-pregnancy for womenwith existing type 2diabetesConsiderations in thisgroupMedications used bywomen should beevaluated beforeconception, sincedrugs commonly usedto treat diabetes andits complications maybe contraindicated ornot recommended inpregnancy includingstatins, ACEinhibitors, ARBs andmost non-insulintherapiesStop oralhypoglycaemicmedication and startinsulin if necessaryAdolescence andtransitionConsiderations in thisgroupThe mainstay oftreatment in childrenand young peoplewith type 1 diabetesis insulin;medications otherthan insulin currentlydo not have a role inpaediatric Type 1diabetesEach patient shouldbe prescribed anindividually tailoredinsulin regimen tosuit their needs andwishesSome guidelinessuggest consideringa child’s age whensetting treatmentgoalsTreatment targets:maintaining glycatedhaemoglobin(HbA1c)

Integratedcare tasksGeneric detection ofdiabetes pathway3.0mol/litre or by 30%,whichever is lower.Care for the housebound/ those in care homesThe older adult withdiabetes who isprescribed a newmedication and any caregiver should receiveeducation about thepurpose of the drug, howto take it, the commonside effects and importantadverse reactions withreassessment andreinforcement periodicallyas needed.Metformin: Use with caution in theolder adult withdiabetes because ofan increased risk oflactic acidosis inpatients with impairedrenal function. Measure creatinineclearance with a timedurine collection at leastannually and withincreases in dosage ofmetformin in frail olderadults, or those withdecreased musclemass. Avoid initiating inpatients >80 years ofage unless creatinineclearance is withinPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionassistance, whichcause ongoinganxiety aboutrecurrence, andsignificantlyadversely affectingquality of life)Assess body fat todetermineappropriate needlelength (longer forchildren/youngpeople with morebody fat, and shorterfor those with less)If a 2 or 3 injectionregimen fails tooptimise glycaemiccontrol, considerincreasing injectionfrequency, changinginsulin preparation,or changing regimenFor young people:offer MDI regimenas part of acomprehensivepackage of care,discuss withpatient/family thepotential for an initialincrease risk ofhypoglycaemia andweight gain in theshort-termwhich may cause thedevelopment ofdiabetesCognitive dysfunctionand depression caninfluence successfulmanagement –simplified medicationregimens canenhance theoutcomes- 59 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in carehomesnormal limits. Measure serumcreatinine and liverfunction testsperiodically in the olderindividual who receivesmetformin, and withany increase in dose. Older diabetic menwith a serum creatinineof 1.5mg/dL or greater,and older diabeticwomen with a serumcreatinine of 1.4mg/dLor greater, and olderdiabetic patients ofeither sex withcreatinine clearancethat indicates reducedrenal function shouldnot use metforminbecause of theincreased risk of lacticacidosis.Sulfonylureas: Use with caution inolder adult patientsbecause of the risk ofhypoglycaemia.Thiazolidinediones(TZDs):Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionThere is noevidence thatidentifies the mosteffective supportpackage, but thepackages usuallyinvolve increasedcontact betweenchild/young personand their familieswith themultidisciplinary careteam aimed atdelivering specifichealthcarestrategiesInitial regimensshould include atleast 2 dailyinjections of rapidand intermediateacting insulinAcarbose orsulphonylureas arenot used in childrenand young peopleas they may notimprove glycaemiccontrol, and mayincrease risk ofhypoglycaemiaThe effectiveness ofadding metformin toinsulin for improvingglycaemic control isType 2 with significantmental health issues- 60 -

Integratedcare tasksGeneric detection ofdiabetes pathwayCare for the housebound/ those in care homes TZDs are welltolerated by olderadults as they do notcause hypoglycaemia. Side effects of fluidretention and legoedema can be limitingfactors in using thisclass of medications inthe older adult. TZDs should beavoided in patientswith Class III andClass IV congestiveheart failure.Pre-pregnancy for womenwith existing type 2diabetesunknown, andshould thereforeonly be used in thecontext of a clinicaltrialType 2 with significantmental health issuesAlpha-GlucosidaseInhibitors: They are less effectivethan other agents andmay causegastrointestinal sideeffects.Dipeptidyl Peptidase-4(DPP-4) Inhibitors: Little is known aboutthe effects of this classof medications in olderadults at this time.Care should be takenin dose selection ifused. Considerassessing renalfunction prior to- 61 -

Integratedcare tasksGeneric detection ofdiabetes pathwayinitiating dosing andperiodically thereafter.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesInsulin: Older adult patientstaking insulin oftenface difficulties withself-administrationbecause of reduceddexterity, impairedvision and cognitivedeficits. In thesesituations, it isbeneficial to usesimpler insulinregimens with fewerdaily injections, suchas pre-mixed insulinpreparations, premeasureddoses, andeasier injectionsystems (e.g. insulinpens with easy to setdosages). A careful assessmentof the individual'sability to draw up andgive an injection needsto be made beforedevising the insulinand self-monitoringregimen. Other selfmanagementskills,such as treating- 62 -

Integratedcare tasksGeneric detection ofdiabetes pathwayhypoglycaemia andeating on a regularschedule, will need tobe assessed beforedetermining theperson's insulinregimen. In care homes, suchas nursing and dualregistered homes,qualified nursing staffwould be expected toadminister insulin. The most appropriateinsulin regimen willvary between residentsbut those who can selfinjectcan receiveinsulin in most carehome settings andshould be encouragedto use a pen deviceand any ancillarydevices where minordegrees of disabilityexist such as visualloss or reducedmanual dexterity. Inthese cases, a twicedailyregimen ofHuman Mixtard or aninsulin of the HumulinM 1-4 range is entirelyfeasible, althoughresidents in carePre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 63 -

Integratedcare tasksGeneric detection ofdiabetes pathwayhomes may be bettersuited for a twice dailyregimen of isophane(e.g. insulatard orHumulin 1) which inclinical practice has arelatively low risk ofhypoglycaemia. Where self-injection isnot possible, those inresidential homes (butusually not those innursing homes) willneed communitynursing support toadminister insulin. Inthese cases, a oncedaily regimen ofisophane insulin couldbe tried depending onwhat level of diabetescontrol is desired andwhether factors suchas terminal illness ordementia are involved. In some circumstancescombination therapy(insulin and oralagents) may beappropriate. Althoughthis may result in areduction in the dailyrequirement for insulinand possibly lessweight gain, often onlyPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 64 -

Integratedcare tasksGeneric detection ofdiabetes pathwaysmall improvements inmetabolic control areobserved in practice.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesExenatide andPramlintide: The same issuesrelating to insulinconcerning difficultieswith self-administrationapply to theseinjectable medications. Little is known aboutthe use of theseagents in the olderadult population. Side effects includenausea and increasedsatiety, which canaffect nutritional statusin the older adult.Other medications: Avoid agents likechlorpropamide andglyburide because oftheir prolonged lengthof action. Shorter acting agentslike glipizide, or thenon-sulfonylureainsulin secretagoguesrepaglinide andnateglinide, can beuseful to avoid- 65 -

Integratedcare tasksGeneric detection ofdiabetes pathwaynocturnalhypoglycaemia, or toavoid hypoglycaemiain patients with erraticoral intake. The older adult whohas diabetes and is noton other anticoagulanttherapy and does nothave anycontraindications toaspirin should beoffered daily aspirintherapy (81-325mg/d). If an older adult isprescribed an oralantidiabetic agentchlorpropamide shouldnot be used. Longer-actingsulphonylureas(chlorpropamide,glibenclamide) shouldbe strictly avoidedbecause ofunacceptablehypoglycaemia. Othersin this class, such asgliclazide and glipizide,should be prescribedwith caution especiallyin those aged 80 yearsand over who may bemore susceptible tohypoglycaemia. AgePre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 66 -

Integratedcare tasksGeneric detection ofdiabetes pathwayper se is not a barrierto using metformin, butas many as 50% ofresidents are likely tohave a contraindicationto its use.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 67 -

Integratedcare tasksGeneric detection ofdiabetes pathwayStandard of care:All patients, screenannually for urinarymicro-albuminuria.Measure serumcreatinine and eGFRannually foralbumin:creatinine ratioand refer if raised.Care for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesTask 12:Renalfunctionmonitoringand renoprotectionRepeat test if abnormalwithin three to fourmonths in those withoutproteinuria and/or UTI.Start ACE inhibitors andtitrate to full dose in allindividuals with confirmedraised albumin excretionrate (as above).Agree referral criteria forspecialist renal carebetween local diabetesspecialists andnephrologists.ACEIs should be includedin the regimen for allpatients with proteinuriaand diabetic patients withmicro-albuminuria.- 68 -

Integratedcare tasksGeneric detection ofdiabetes pathwayFor patients with diabeticmellitus and microalbuminuriaorproteinuria: continue efforts toachieve goodglycaemic control(HbA1c 6.5-7.5%); prescription of ACEI orARB (see notesabove) at least a yearlymeasurement of urinespot albumin:creatinine ratio, serumcreatinineconcentration andestimated GFR.Care for the housebound/ those in care homesPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 69 -

Integratedcare tasksOptionaltask:OptimalbloodpressurecontrolGeneric detection ofdiabetes pathwayStandard of Care:At every visit, or at leasttwice a year, measureblood pressure.Targets of

Integratedcare tasksGeneric detection ofdiabetes pathwayAustralian: Standing andsulphine blood pressuremeasurements arerecommended ifautonomic neuropathy issuspected.24 hour ambulatory bloodpressure should beconsidered in people withtype 2 diabetes andsuspected (white coat)hypertension or who areresistant to bloodpressure loweringtherapy.NICE: If on antihypertensivetherapy atdiagnosis of diabetes,review the control ofblood pressure andmedication use and makechanges only where thereis poor control or wherecurrent medications arenot appropriate becauseof microvascularcomplications or ametabolic problem.If the person is onmedication, monitor bloodpressure for one to twomonths until bloodCare for the housebound/ those in care homesshould have renalfunction and serumpotassium monitoredwithin 1 to 2 weeks ofinitiation of therapy, witheach medication doseincrease, and at leastyearly.For older adults takingthiazide diuretics or loopdiuretics, considermonitoring electrolyteswithin one to two weeksof initiation of therapy,with each medicationdose increase, and atleast yearly.There is some evidenceto suggest that treatmentwith calcium channelblockers, diuretics, andACE inhibitors is moreeffective than betablockers in thispopulation.Most patients requiremore than oneantihypertensivemedication to reach goal.The older adult who hasPre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 71 -

Integratedcare tasksGeneric detection ofdiabetes pathwaypressure is consistentlylower than 140/80mmHgor 130/80mmHg inkidney, eye andcerebrovascular damage.First line therapy is oncedaily generic angiotensinconverting enzymes(ACE inhibitor).Exceptions are people ofAfrican-Caribbeandecent, who should be onACE inhibitors plus eithera diuretic or a genericcalcium channel blocker.If the target isconsistently met checkblood pressure every fourto six months, checkingfor adverse effects.People presenting afteran acute myocardialinfarction should beconsidered for a betablocker and ACE inhibitorregardless of bloodpressure level,concurrently withintensive lifestyle advice.Care for the housebound/ those in care homesdiabetes andhypertension should beoffered pharmacologicaland behaviouralinterventions to lowerblood pressure withinthree months if systolicblood pressure in 140 to160mmHg or diastolicblood pressure is 90 to100mmHg, or within onemonth if blood pressure isgreater than160/100mmHg.Effective monitoring andcontrol of blood pressureis also an essentialaspect of medicalmanagement even withincare home settings and,in some situations, maybe more important overallthan blood glucosecontrol.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issues- 72 -

Integratedcare tasksOptionaltask:reducecardiovascularriskmanagementGeneric detection ofdiabetes pathwayStandard of care:For all patients, reviewcardiovascular risk statusannually and assesscardiovascular riskfactors. For a person 40years or over initiatetherapy with genericsimvastatin (to 40mg) ifcardiovascular riskexceeds 20% after 10yrs.Assess lipid profile one tothree months afterstarting treatment andannually thereafter.Increase the dose ofsimvastatin in anyone to80mg daily unless thetotal cholesterol level isbelow 4.0mmol/l or LDLis below 2.0mmol/l.People with type 2diabetes with triglycerides> 2.0mmol/l afterintervention to modifylifestyle and improveblood glucose controlshould be considered forfibrate therapy.Care for the housebound/ those in care homesAdditional considerations:Goals for therapy: Whenan individual does nothave evidence ofcardiovascular diseaseand has a life expectancythat is determined by theprovider to be three yearsor less, relaxation of thegoals of therapy may bemade.Monitoring after statins:Older adults withdiabetes who are newlyprescribed statins,fibrates or niacin shouldhave an alanineaminotransferase (ALT)measured within 6-12weeks of initiation of themedication or change indose, and with any signsor symptoms of liverdysfunction.A baseline creatinekinase (CK) should bechecked as well – thereis no need to recheck CKunless symptomswarrant.Pre-pregnancy for womenwith existing type 2diabetesAdditional considerations:If there is a possibility ofa women becomingpregnant do not use, ordiscontinue statins afterdiscussion with thepatient.Adolescence andtransitionAdditional considerations:Aspirin in notrecommended as anantiplatelet agent inpeople under 30 due tolack of evidence ofbenefit. It iscontraindicated inpatients under the age of21 because of theassociated risk of Reye’ssyndrome.Type 2 with significantmental health issuesPeople with type 2diabetes who do not haveOlder adults onmedications for- 73 -

Integratedcare tasksGeneric detection ofdiabetes pathwaycontraindications shouldbe considered forprophylactic aspirin (75-325mg/day) therapy.In people with venouscoronary artery bypassgrafting treatment shouldaim to lower the totalcholesterol to less than3.5 mmol/l and LDL-c toless than 2.0mmol/l.Care for the housebound/ those in care homeshyperlipidemia shouldhave periodic evaluationof liver enzymes. There isno specific evidencesupporting the intervals atwhich liver enzymescreening should occur.Pre-pregnancy for womenwith existing type 2diabetesAdolescence andtransitionType 2 with significantmental health issuesi Aspray, T. et al. (2006) ‘Diabetes in British Nursing and Residential Homes: A pragmatic screening study’ in Diabetes Care, Vol. 29. p. 707-708. http://care.diabetesjournals.org/cgi/content/full/29/3/707ii Hofmanova, I. (2006) ‘Pre-conception care and support for women with diabetes’ in Journal of Nursing, Vol. 15 Iss. 2, 26 Jan 2006, p. 90-94iii Royal College of Psychiatrists (2004), ‘Schizophrenia and Diabetes 2003 Expert Consensus Meeting, Dublin, 3–4 October 2003:consensus summary’ in The British Journal of Psychiatry, Vol. 184, p. s112-s114iv De Hert, M. et al. (2006) ‘Prevalence of diabetes, metabolic syndrome and metabolic abnormalities in schizophrenia over the course of theillness: a cross-sectional study’ in Clinical Practice and Epidemiology in Mental Health 2006, Vol. 2 Iss. 14v Krein, S. et al. (2006) ‘Diabetes Treatment Among VA Patients With Co-morbid Serious Mental Illness’ in Psychiatr Serv 2006, Vol. 57 p.1016-1021. http://psychservices.psychiatryonline.org/cgi/content/full/57/7/1016vi Ibid.vii Heisler, M. (2007) ‘Overview of Peer Support Models to Improve Diabetes Self-Management and Clinical Outcomes’ in Diabetes Spectr2007, Vol 20 p. 214-221. http://spectrum.diabetesjournals.org/cgi/content/full/20/4/214viii Sinclair A.J. et al. (1996) ‘Document of care for older people with diabetes - Clinical guidelines’ in Postgrad Med J 1996, Vol. 72 p.334-338ix Norman A. et al. (1998) ‘Development and audit of a home clinic service’ in J Diabetes Nurse 1998, Vol. 2 Iss. 22, p. 51-54x Boaden, R. et al. (2005) Evercare evaluation interim report: implications for supporting people with long-term conditions.http://www.erpho.org.uk/Download/Public/13212/1/evercarereport1_1.pdfxi University of Birmingham Transforming Chronic Care Programme. http://www.hsmc.bham.ac.uk/research/transforming_chronic_care.shtmlxii Piette, J. (2005) Using Telephone Support to Manage Chronic Disease. http://www.chcf.org/topics/chronicdisease/index.cfm?itemID=111784xiii National Institute for Health and Clinical Excellence, Patient education models. http://www.nice.org.uk/Guidance/TA60xiv University of Birmingham, op. cit.- 74 -

Healthcare for LondonLocalising care pathwaysEvidence-based diabetes pathwayVersion 1.84 December 2008Prepared in collaboration with Bupa Commissioning

Contents1. Introduction ................................................................................................................................32. Scope of this guide....................................................................................................................33. The toolkit process ....................................................................................................................43.1 How was the toolkit developed? .........................................................................................43.2 Who should use the toolkit?................................................................................................43.3 How should the toolkit be used?.........................................................................................44. The toolkit – key concepts ........................................................................................................54.1 Data, information, insight ....................................................................................................54.2 Data linkage........................................................................................................................54.3 The decision-making process .............................................................................................54.4 Information governance ......................................................................................................64.5 Skills and capabilities..........................................................................................................64.6 Prevalence, incidence and unmet need..............................................................................64.7 Integrating with Healthcare for London’s service commissioning model ............................85. The toolkit guide ........................................................................................................................95.1 Introduction .........................................................................................................................95.2 Where are we now?..........................................................................................................105.3 Where do we want to be? .................................................................................................225.4 How do we get there?.......................................................................................................325.5 How do we know when we are there? ..............................................................................366. What next?................................................................................................................................386.1 Next steps in the approach/project ...................................................................................386.2 Questions that are left unanswered by the toolkit.............................................................386.3 What more can be done? .................................................................................................39Appendix.......................................................................................................................................40Screening and unmet need.....................................................................................................402

1. IntroductionThis toolkit is a ‘how to’ commissioning guide for Primary Care Trust (PCT) staff to use toimplement local care pathways in their PCT. The guide sets out the tasks that need to beundertaken to localise the care pathways to PCT-specific populations and provider markets, andidentify the changes in services that need to be commissioned. The toolkit identifies appropriatestakeholders, inputs, influencing factors and suitable commissioning outputs.This toolkit was developed specifically to support implementation of the recommendations from theHealthcare for London diabetes project and should be used alongside the Healthcare for LondonDiabetes Model of Care issued in December 2008. The toolkit should also be used alongside theDiabetes Commissioning Toolkit, November 2006 (DCT 2006) as a technical resource to allcommissioners of diabetes care, with specific focus on translating generic ‘best practice’ pathwaysinto local commissioning actions.This toolkit provides a very practical guide to support commissioners in identifying, collecting andcollating the necessary data to support the informational requirements necessary to developcommissioning strategies and detailing key stakeholder engagements that should take placealongside the development of the analytic underpinnings.2. Scope of this guideThe activities involved incommissioning services (especiallynew or newly structured ones) mustbe placed in a broader context.Clinical pathway designThe task architecture diagramopposite attempts to do this. It locatesthe core activities defined by thisdocument and shows them circled bythe red dotted ellipse.CommissioningdesignData analysisModellingEngagementClinicalpathwaylocalisationScope ofthe guideChangemanagementThe discussions included here arespecific to understanding, making andcommissioning change in the healthservice using a new clinical pathwayas input. Very few (if any) guides existthat provide help in this process.‘Change management’ is excludedfrom the toolkit because, althoughvital, there are many guides availablethat already help describe theseissues. The ‘option appraisal’ processand ‘business case’ development arealso outside of scope because,although key to agreeing change, theytoo are already well understood andwell documented elsewhere.New approaches Problem solve WorkshopsOption appraisalAgreeing changeWriting and agreeing contractsPlan changeBusiness caseImplement changeMonitor and adaptIndividualTeamOrganisationLeadershipCultureRestructuringIT impactFigure 1. Task architecture – indicating the document’s scopeDesign phaseImplementphase3

3. The toolkit process3.1 How was the toolkit developed?This guide was developed by working with the Healthcare for London diabetes team and isinformed by the model arising from that project. It builds on the work undertaken by the NHS inproducing the Diabetes Commissioning Toolkit in November 2006. The guide is produced in a wayand format that is consistent with the competencies set out in World Class Commissioning.The guide and step by step framework set out below is based on practical experience of workingwith PCTs, SHAs and GPs in assisting service redesign.3.2 Who should use the toolkit?The toolkit is aimed predominately at NHS commissioners of diabetes care, at both PCT andpractice level. The toolkit supports commissioners in a number of ways. For example, it providesadvice on: which data to collect and how to collect it; how to translate this data into pathway and commissioning intelligence; who and how to engage with key stakeholders in diabetes services; how to create localised pathways of care based on generic best practice; how to translate these pathways into local commissioning strategies.3.3 How should the toolkit be used?The toolkit should be used as a ‘how to’ commissioning guide for PCT staff to use to implement thecare pathway in their PCT. The guide sets out the tasks that need to be undertaken to: localise the care pathways to PCT-specific populations and provider markets; identify the changes in services that need to be commissioned.4

4. The toolkit – key conceptsThe following points are essential grounding for commissioning and some of the conceptsexplained here underpin the tasks as set out in section five.4.1 Data, information, insightGood commissioning requires good information – and good information is only as reliable as thedata upon which it is built. Data can be pieced together in more flexible ways to provide informationto support strategic and commissioning decisions if it is collected at a very granular level.The health service is very data rich, but is often information poor. Information is often presented ina way which does not allow a full picture to be seen or allow the information to be manipulated insuch as way that is useful or fit for purpose.For data to be fully fit for commissioning purposes it is necessary to collect and maintain the dataat patient level. This allows the information to be examined and manipulated in a range of wayswhich allow commissioners to re-consider different service configurations and options.The basic process is to aggregate the data by various patient or conditions types (segmentations).The exact segmentation used locally will depend on a range of factors, geography, coding, diseasestage etc. The aim is to develop a local segmentation that allows you to explore the pathway in away that makes sense to you locally. Developing local segmentations is an iterative process. Thistoolkit outlines the key processes and concepts of patient level data collection to enablecommissioners to draw together key data.4.2 Data linkageData needs to be linked through unique patient identifiers (such as NHS number) to allow patientsto be followed through the healthcare system. Linked data allows commissioners to examine bothindividual and collective patient journeys through the system and consider whether there areblockages, how the system could be improved based on the information derived from linkeddatabases, and ultimately where and how investments or disinvestments should be made.Note - to create linkage (through encrypted NHS numbers) use the same encryption key on thedata whether it comes from secondary care or primary care.4.3 The decision-making processOnce the patient-level data has been created commissioners need to consider how to use theinformation this presents.It can be used to describe the current situation such as who, how and where services are actuallybeing used, but not to assess whether services are configured in the most efficient or equitableway, nor whether services are being accessed in the most appropriate way.5

The current situation can be benchmarked against neighbouring services or health economies;although this can present misleading pictures as different health economies face differentchallenges and constraints.The development of best practice clinical pathways allows commissioners to compare and contrastthe current situation with how it should look in an ideal configuration.Implementing best practice clinical pathways in a locality is not possible without tailoring them tolocal realities. These place constraints (budgetary, resource, targets, policy, etc) on implementingan ideal and trade-offs must be made between conflicting priorities and aims. Decisions also needto be based on a marginal analysis as well zero based budgeting.It is the comparison between the best practice clinical pathway and the current situation that twoallows these trade offs and marginal analyses to be undertaken.4.4 Information governanceThere is a range of information governance issues to be faced when drawing together patient leveldata with patient identifiable linkage, including confidentiality, Caldicott guidelines and datasecurity. Compliance with NHS best practice is essential. Comprehensive engagement with keystakeholders is key to overcoming some of these barriers and avoiding misunderstandings thatresult in unnecessary objections.4.5 Skills and capabilitiesThe ability and energy required to take a new best practice clinical pathway and introduce it into anexisting health system should not be underestimated. It requires tenacity, good people skills, goodanalytic skills, excellent communication and persuasive skills, learning new approaches, tools ortechniques, and huge resources of energy. It is unlikely that any one person will have all thesecapabilities, so building a good team is normally essential.4.6 Prevalence, incidence and unmet needCommissioning needs to be supported by an economic model that considers prevalence, incidenceand unmet need to ensure both robustness and completeness. Unmet need accounts for those who currently have the condition but are undiagnosed. It isnecessary to identify the size of unmet need to gain an understanding of what demand mightbe in the future, and also to ensure equity of access. The costs and benefits of identifying andtreating these people need to be considered. The appendix sets out some of the issuesinvolved in screening. Prevalence is the number of people who currently have the condition. Incidence is the numberof people who are diagnosed with the condition within a specific period of time. These twomeasures are different. A chronic disease like diabetes can have a low incidence but highprevalence. Prevalence is the sum of past years incidence.Implementing new pathways needs to take account of the impact of changes over time to unmetneed, prevalence and incidence on the resource needs across the pathway.For example, the following illustrates incidence and prevalence of type 1 diabetes.6

Gestational diabetes(Type 2 diabetesType 1 diabetesUnmetneedIncidentpopulationPrevalent populationFirst timeengagementOngoing engagementResource costResource costInitialactivityEarlyphaseMiddlephaseLatephaseFigure 2. Illustrative model demonstrating how incident andprevalence concepts impact commissioningPeople with newly diagnosed cases of diabetes (the incident population) are likely to havedifferent resource needs during their initial period of care than people with diabetes diagnosedsome time ago (the prevalent population).People with diabetes diagnosed some time ago who are in the later management stages of thedisease require different care from those more recently diagnosed. So a ‘time with disease’style model needs to be created, showing the number of patients at different stages of thedisease (as indicated by the histogram in the above illustration) each with significantly differentresource needs.Increased screening for unmet need will increase the number of people with newly diagnoseddiabetes and thus increase resource need. As this group moves from being newly diagnosed tobeing in a management stage it changes the resource profile of the prevalent population. Whena programme of screening is introduced it has a higher initial impact on resource usage asthere is a ‘catching up’ effect. Over time the number of newly diagnosed cases settles down toa new base level.Specific models need to be created for types of all diabetes (and sub-types) and aggregated to findthe total service requirements for the specific population with diabetes for whom services are beingcommissioned. To produce a local model requires a combination of analysis of historic data andclinical input. Together this will make it clear whether the model, or some variation, is useful or not.7

4.7 Integrating with Healthcare for London’s service commissioning modelHealthcare for London’s diabetes service commissioning model sets out that there will be fourfundamental levels of care, from basic care at level one to specialist care at level one.4HospitalSetting3CommunitySetting21GP SurgeryLevel of CareSettingFigure 3. Healthcare for London’s diabetes service commissioning modelPart of the work of localising the best practice clinical pathway (in particular section five, part two:‘Where do we want to be?’) entails thinking about how levels of care will best overlay on thepathway. Mapping levels of care needs to be driven by analysis and consultation. It is not a cut anddry process but is driven by considering a combination of: Local availability of the clinical skills necessary at each level. Expected levels of current and future activity locally. Local resource constraints.The output from this consideration will be a local best practice pathway overlaid with theHealthcare for London levels of care.8

5. The toolkit guideHow do we get from where we are to where we want to be?5.1 IntroductionThe structure of this toolkit outlines the process commissioners should follow when introducing anew clinical pathway. The process described below is not solely applicable to diabetes; much of itcan be applied to a range of long-term conditions.Many of the specific issues associated with pathway redesign will only arise once the pathway hasbeen specified and is ready for implementation. Where steps specific to the diabetes pathway canbe described the toolkit does so. Furthermore, where it is possible to anticipate potentialengagement or project pitfalls, approaches have been described to mitigate their effects.Commissioning a new pathway requires the dual approach of: generating supporting evidence for what the local service change should be through datadriven analytics; engaging with key local stakeholder to ensure they believe the evidence and that the solutionsmake sense locally.These two tasks of developing are very closely bound. They require that a relationship isdeveloped with key individuals over a period of time, and require a number of iterations arounddata, analysis and communication. It requires you to be both an analyst and a salesperson! Havingthe right answer and the right set of recommendations is not sufficient. You have to be credible, theevidence has to be believable, the solution needs to make sense locally, and the process has toensure widespread acceptance.Because this dual approach is the key, the guide is presented in this form − with data and analytics(shown in red) sitting alongside stakeholder engagement (shown in green).The detailed tasks described in the tables are a practical set of ‘how to’ notes. These have beenset out in a way which is useful to commissioners without becoming too embroiled in detail. Forclarity, they are broken down into four sequential steps, as illustrated in figure 4.Figure 4. The fundamental commissioning steps in the process of introducing a new clinical pathway.In practice these steps are often addressed in parallel, especially with respect to stakeholderengagement where past, present and future would normally be discussed in a single session.9

5.2 Where are we now?The first part of the journey is to obtain an accurate picture of current local diabetes services andpatient pathways. This requires a description of where current activity takes place in relation topatients with diabetes within the system as a whole, such that it represents the situation ‘as is’.This is a dual process of investigation and analysis using data combined with engagement(interviews and workshops) with key clinicians, management, commissioners and patients.The basic process has a number of key inputs and will produce a number of essential outputs. Thediagram below shows these basic components and the subsequent table then describes the tasksnecessary to create these outputs.I 2ComponentsserviceI 3CostsI 1Data( GP & HESetc.)I 4Key peopleAnalytics andmodellingEngagementand analysisUnderstanding the past / presentTrendsTasks, tools andapproachesExisting clinical pathways0701Pivot tables02ResourcedataExisting systems pictures06Issues/problems0304Cost05Figure 5. Fundamental inputs and outputs from the ‘Where are we now?’ step10

‘Where are we now?’ – inputsRef Analytic task description Ref Engagement task descriptionI2 Service componentsObtain a basic view of all resources /services in the locality (your PCT and thesurroundings) delivering diabetesservices.I4These may include:GPs, practice nurses, district nurses,secondary care hospitals, diagnosticservices, community hospitals, carehomes, out-of-hours organisations, walkincentres, NHS Direct, social care etc.Draw these services up on a map andcreate as comprehensive a list aspossible of general and dedicatedresources, such as buildings,organisations, people, and equipment.Wherever possible, get postcodeinformation as it is extremely useful increating geographical pictures withmapping software.Finding the key peopleThe view of service components can helpto ensure the appropriate stakeholdersare engaged with to obtain a roundedview of diabetes care. Experienced PCTpersonnel can help to identify key peoplein the locality; that is, opinion shapers andpeople with specific knowledge andinterest in diabetes. Diabetes networkswill be particularly useful here. Beprepared to adapt this list as time goes on– expanding and contracting it asnecessary.There is a number of resource linksavailable through the DH website -www.dh.gov.uk. Look under Healthcare >National Service Framework > Diabetes.Key people fall into four basic categories:clinicians (GPs and consultants), servicemanagement (primary and secondary),commissioners (your own staff who haveworked in these areas in previous years)and patients. Representation from allstakeholders is the key.Getting the dataThere are two primary data sourcesessential to good commissioning; that is,GP data kept by GP practices andsecondary care data available throughSUS. Both are needed in order to have acomplete picture. Additional data sourcessuch as out-of-hours GP services (OOH),ambulance services, NHS Direct andsocial care may also prove useful.I4Engaging with key peopleIt is important to engage with key peopleat the same time the data-gathering andanalysis is being undertaken in order toguide analytics and visa-versa. Theanalytics can also help to informengagement.With so many people involved inhealthcare delivery, the inevitablefragmentation of service provision andpotential animosity to yet another ‘changeinitiative’, good communication and arigorous methodology are essentialingredients for success. This guide aimsto give you a grounding in thatmethodology.I1GP dataGP data is accessible from the majority ofGP systems.There are 3 main GP systems (whichI4Primary care engagementIn any PCT there are typically between 40and 100 GP practices. Every GP practicehas a Caldicott Guardian and every GPpractice is rightfully very careful about11

Ref Analytic task description Ref Engagement task descriptionthemselves have various versions) beingused in the UK, which account for 90% ofthe market: EMIS – PCS, LV, GV (50%); INPRACTICE – VISION (20%); TOREX (20%); Others (10%).All these systems use a commonlanguage called MIQUEST which allowsyou to query the content of theirdatabases to extract the information.Note that implementing the MIQUESTquery in each instance is slightly different.Get a technical expert in MIQUEST tohelp you and you will save huge amountsof time. Ideally this whole area should bemanaged by dedicated personnel oroutsourced because of all the technicaldifficulties involved here. Use any one ofa number of new companies that are nowemerging and can carry out this role foryou.There are two fundamental types of dataavailable in GP systems and you shouldobtain both:Patient registration data.GP/patient activity data, codedusing read codes.How far back in time you should go withactivity data is often dictated by practicalconsiderations, such as when thepractice started coding their interactionswell and even how long the extract takes.Coding generally seemed to improve inGP practices around 2003 (when QOFtargets were introduced). This means that4/5 years of good data is now a practicalproposition. For trend analysis no lessthan 2 years should be considered. Thisis so that the effect of seasonality can beunderstood and any underlying trendobserved.Diabetes-specific analysis taskUsing the GP data you should create atable of patients diagnosed with diabetes,the type, when they where firstdiagnosed, their date of birth, sex,postcode and encrypted ID (seeparagraph 4.2 above on ensuringconsenting to allow access to its data;even to PCTs that commission their work.Ensure you have addressed encryptionand security issues prior toengaging/asking for data. Generate aletter written by the PCT’s CaldicottGuardian addressing all the GP’santicipated concerns.Communication with GPs should happenthrough their regular meetings; LocalMedical Committee, Practice-basedCommissioning groups and through theProfessional Executive Committee. Usethese forums to cut down the amount ofwork you need to do to communicate.Without buy-in of the key local GP foraand the purpose of the project beingexplained (including the potential benefitfor patients and GPs and how you haveaddressed their potential concerns) widespread acceptance or engagement willprove difficult.Identify 3 or 4 local GPs who can provideyou with ongoing input, help with analysis,advice and anecdote. Test any theoriesthey may have with hard data andevidence you can generate. Feed thisback to the GPs to confirm or refutebelief.Note, as we state above, the healthservice is full of myth and anecdote andshort on information and evidence. Beprepared to disagree based on analyticevidence. If still not believed, ask for apossible explanation and re-analyse tosupport or refute the extended argument.As well as GPs, engage with similarnumbers of practice nurses (3/4) andpractice managers (3/4). Views will oftenconflict, even within groups. Use yourdata and perform analysis to help teaseout underlying truth and test these withyour representatives. You will often needto see these people a number of timesbefore you begin to get some clarity.District nurses and community hospital12

Ref Analytic task description Ref Engagement task descriptionlinkage).This table (pulled together from all thepractices in your locality) will form the keyfor identifying and analysing the cohort ofpatients you are interested in finding inany of the other databases. As one of thespecial cases we are also considering isdiabetes patients with mental healthissues, a further indicator should beadded to this table noting ‘appropriate’mental health patients with a diagnosisdate.staff should also be consulted tounderstand how they currently work withdiabetic patients.NHS Direct and social services shouldalso be able to supply you with theirrelationship to patients with diabetes.I1Hospital episode statisticsHospital data obtained via SUS willcontain all the secondary care data: A&E; inpatient; outpatient; community hospital; mental health inpatient.The clinical coding on A&E and outpatientdata which is needed for more detailedanalysis of how clinical activity breaksdown is often poor. However for overallactivity, specialty groupings and in othermanagement coding areas the data issufficient and very useful forcommissioning purposes.Coding (human resource groups,diagnosis and procedure coding) withininpatient is far better for more detailedclinical segmentation. It is certainlysufficient for broad commissioninganalysis, such as that being carried outhere.How these data are organised (togetherwith the GP data) into a robust databasesystem or data warehouse with all data atthe patient level is essential for deliveringbusiness intelligence for commissioners.The topic of data maintenance, support,integrity checking, security and the like isnot discussed here except to highlightthat MS Access is insufficient and that amore enterprise-wide solution such asOracle or MS SQL is necessary.I4Secondary care engagementEngaging with hospital consultants andmanagement early in the process isessential to get buy in and engagement.Data are derived from various parts of theorganisations as well as potentially anynumber of individual trusts (hospitals,mental health hospitals and communityhospitals). The number of stakeholderscan become unmanageably large. Thelaw of diminishing returns should guideyou here; that is, when you find theadditional ‘useful’ information gained fromextra interviews starts to drop offsignificantly, stop interviewing.Talk to each hospital’s Director ofStrategy, Planning and Performance (or akey contact with a similar title) to identifykey management and clinical contacts.Engage with people who deal with thebulk of the activity. When people give youanecdotal information about problems,ask get them to quantify thosestatements.Often people concentrate on exceptionsthat have very low numbers. Rememberthat the average patient is not of interestto a clinical consultant from a clinicalinterest perspective, but of hugeimportance to a commissioner. Guidethem to the information you want and donot simply accept what they want to giveyou.13

Ref Analytic task description Ref Engagement task descriptionFront end data manipulation packagessuch as Business Objects, Tableaux oreven MS Excel mixed with SAP, SQL andCrystal Reports would typically providesufficient analytic and modellingcapability.As with the GPs you must be clear at theoutset on the aims and objectives of thework. You must also be ready to deal withand incorporate into the project some ofthe issues and concerns raised by thehospital staff.Ensure key personnel you engage withare aware they will be consultedthroughout the process and that they willbe shown analysis to back up or refutetheir analysis or the historic position. Takeinterview notes and consolidate themafterwards.I3Costs and pricesThe data obtained from SUS should alsohave associated price information for atleast the 80% of activity covered bynational tariffs. The remaining activity canbe priced according to locally-agreedtariffs.Publications such as Netton provide areference for costing other healthcarerelated areas you may be less familiarwith.I4Share with the providers the costingmethodology being used for the analysis.Wherever possible do this at thebeginning and not at the end of theprocess to ensure they in broadagreement with practitioners beforereaching any conclusions orrecommendations.Other data sourcesOften SUS or GP data will not provide thefine level data required to fullyunderstand what is happening at pathwaylevel. In these instances it can benecessary to identify representative datasets that are part of more detailedstudies, especially if the data has beencaptured in a methodical fashion(particularly if within Excel / Access or anequivalent). These can often then beused and applied to local data.I4Patient engagementCollate and obtain information from localand/or national diabetes studies (thatinclude data collection) or any otherdiabetes study. Local clinicians should bewell positioned to assist in this process.14

‘Where are we now?’ - outputsRef Analytic task description Ref Engagement task descriptionO1 Trends (business intelligence)All data, however segmented (see pivottable discussion below), should bepresented and mapped against time:hourly, daily, weekly, monthly or yearly.The type of time-related questions needinganswers are:Growth/decline questionsO1Can we see a trend (growth ordecline) in our activity acrossmultiple years?Can we attribute the growth ordecline to a specific segment orsegments?If we break the data down (usingvarious segmentations) can we findunexpected growth/decline that wasbeing masked; that is, one areawas growing while another wasdeclining?Is the growth in one area (say A&Eactivity) matched by a decline inanother area (GP or OOH)?Variation questions (plot using a range oftime bases) Does the service have to deal withseasonality (that is, activity risesand falls within a year) eitheroverall or in specific pathwaylocations? Are there strong weekly cycles toactivity either overall or in specificpathway locations? Is variability an issue for servicedelivery (daily, weekly, monthly,seasonally) either overall or inspecific pathway locations?Note: When considering inpatient activityon a daily basis you should not rely onadmissions alone as an indicator ofactivity. Admissions on a daily basis areonly half the picture as there is asimultaneous discharge of patients. Thebetter or complimentary view toadmissions is ‘bed use’.Almost all doctors, nurses or managersfeel that their activity is increasing. Insome cases this will be true and in othersit will not be. Some people are verysurprised when they see time-relateddata. This feeling of increasing pressurecan often be attributed to seasonality –and where the less active times arequickly forgotten about. The data shouldspeak for itself but be careful to break thedata down; it is easy for one area ofactivity to be masked by another.Show the plots that are generated to theclinicians and managers. Work togetherto find where any increase/decreasecomes from. If they strongly believe thenumbers are increasing for their area tryto find it in the data by segmenting it asthey direct.Put trend lines on your data. Be carefulabout end effects; data anomalies oftenexist at the beginning and end of timerelated data so consider removing the firstand last few data points.It is essential that you reach consensusabout trend related data. Forcommissioning purposes you will have totake this into account in futurecalculations. You may also need to makesome subjective assessment of it, whichshould be done with the managers andclinicians involved in delivery. Forexample you will need to take a view on: Is this trend something that willcontinue? Will it plateau at some point ordoes it have some other shape? Ifso, when/why? Which areas of the existing/newpathway does it or will itinfluence?All subjective assessments will need to besupported by a rational argument anddocumented.15

O2Business intelligence (pivot tables)The NHS Diabetic Commissioning Toolkitdocument provides a list of basic questionsto answer, such as:How many people need localdiabetes services? How common locally are Type 1,Type 2 and gestational diabetes?These are essential, but will not alwaysprovide the level of detail needed toanswer all of the questions posed as youconsider old and new pathways.The approach that should be adopted is totake all the patient level activity (primaryand secondary) and generate pivot tablesto enable the data to be cut in any waynecessary. This will give the flexibility toanswer most of the initial questions fromthe Diabetic Commissioning Toolkit as wellas the deeper ones required as the workprogresses.To get a clear view on the local cohort ofpatients with diabetes, the GP data withthe diagnosed key and diagnosed date canbe used. If you do not have GP data youwill need to use another key instead; forexample, a diabetes register if it uses NHSnumber or a proxy set of keys via thesecondary care data set.However, be aware that you do not alwayswant to see diabetes activity in isolation.Institutions, specialities and carers oftenhave to deal with diabetes sufferers at thesame time as they deal with otheractivities. Knowing the relative proportionsof non-diabetes activity in specific areas issometimes just as important, especiallywhen as commissioners you areconsidering shifting activity elsewhere. It isimportant to be able to separate out thetwo views so you can assess theconsequences.O2When starting your analysis you will notknow all the questions you need to ask ofyour data.An initial analysis will raise questions youmay not have anticipated. By feeding thisanalysis back to clinicians, nurses andmanagers you will be able to do furtheranalysis based on their comments thatwill ultimately lead to a thoroughunderstanding of the area.This process is also a key ingredient forinvolving those who deliver the service, inorder to: gain trust; demonstrate understanding; ensure solutions/changes arebased on sound evidence; involve participants in identifyingsolutions; adequately communicate and testthe benefit rational; overcome reticence for change.In addition to one-to-one interviews,workshops will be needed at some point.These provide fora to discuss and gainconsensus. They are also essential forbringing together the different parts of thecurrently fragmented delivery system sothat the service is viewed in a moreholistic way.Quite often clinicians will have differentviews, and it is often difficult for a nonclinicianto persuade or change aclinician’s mind. If this is the case use theworkshop as a mechanism for peer-topeerdebate. You will need to have someclinicians there who are alreadypersuaded to fight your cause. Identifyinglocal ‘champions’ in advance of thesemeetings can assist in this process.Identify those segments of the diabeticpopulation of specific interest to you ascommissioner. These could be16

adolescents, older people, pregnantwomen and people with mental healthissues. Create a definition for each ofthese in terms of the data. For example, awoman who is pregnant while receivingcare can be identified from a list createdfrom national statistics data or hospital orGP data with a birth date and a gestationperiod. An analyst can then create a key(an enumeration) on all activity data thatwill isolate each of these groups within themore generic pivot table.There are four outcomes from this work:. pictures that indicate historicactivity for basic segmentation,initial feedback and high levelcommissioning; the ability, through pivot tables,pivot charts and engagement-ledinvestigation, to dynamicallyquestion the data; with more sophisticated andinformed (pathway-dictated)segmentation deeper insights intothe historic workings and delivery ofdiabetes care can be gained. the ability to create ‘just the rightsize’ building blocks so that historicdata can be viewed andreconstituted along new pathways.O7Existing clinical pathwaysThe output should be a number of pathwaydrawings that detail the clinical activity,diagnostics, interventions, key decisionsand alternative paths.O7This is predominantly a one-on-oneexercise of creating the clinical logic usedlocally by GPs, nurses, and consultants inthe care of their diabetes patients. It’s adifficult exercise for a non-clinical personto perform. Get an experiencedGP/consultant or nurse to help you dothis.Use this diagram subsequently to helpsegment your hospital/GP dataappropriately so that you can estimateactivity down specific paths.The aim is to produce a map similar to the‘best practice pathway’ such that the twomaps can be compared and contrastedand it is possible to identify where theydiffer (or are similar) in order to help thechange process. Use the best practice pathways toguide you to a similar level ofdetail. Find the segmentation currently17

Check the answers you get with the peopledelivering the services to ensure theyaccurately reflect the situation.used to help simplify the drawings.Do not use the segmentation usedin the new pathways unless theyuse them locally in reality.Do not let your interviewees seethe new pathways first as it willinfluence their perception of thecurrent reality.Expect to find variation in howservices are being delivered.Capture the variation. This isalmost certainly one of the thingsyou are hoping to address. Identifythe number of patients going downeach of the variants.Once you have a set of pathwaysthat you think reflect the currentreality, share them more widely forcomments.If possible talk to patients andcarers about the pathway. Theirexperience of what actuallyhappens may be different fromwhat clinicians believe happens.Ideally, follow some patients tomap their experience.Have a workshop managed byclinicians to reach consensus. Usethis to test any differencesbetween what clinicians believehappens and what patientsdescribe as what actuallyhappens.O6Existing System PathwaysSystems maps are rich flow charts. Theyare extremely useful, but too many projectsget bogged down in producing flow chartsfor their own sake.O6This is another one-on-one interviewexercise to create a ‘systems’ map. Thismap covers the same ground as theclinical map, except the focus is onresource, geography, people,management systems and processingissues.Superficially it may look similar to thepathway map. However, we separate itfrom the clinical to avoid the picturebecoming too complicated and losingclarity.Flow charts miss a great deal, includingbehaviours, decisions, timing, delay,variation and even fragmentation. BeThe system maps should show: organisations; geography / fragmentation; higher level processing tasks; Information flows;18

aware of these shortcomings as these arethe system improvements that cantransform services. See reading material insuch areas as ‘theory of constraints’, ‘leanthinking’ and ‘systems thinking’.Flow charts are useful to: understand geography; quickly orient those less familiarwith the service; help enable discussion; help interpret data; help locate issues and systemicproblems, such as bottlenecks.Try to avoid the temptation to fill wall spacewith flow charts; these charts on their owndon’t necessarily give adequate return ontime invested.Other diagramming techniques that canadd greater insight include: decision diagrams; system dynamic plots.patient flows;time delays;responsibilities;clashes and Issues.O4ResourcesUsing the broad resource map identifiedfrom the activity and input data, it isnecessary to create a more detailedunderstanding of the relationship betweenactivity and resource.In order to do this the following questionsneed to be addressed: can we get a breakdown of staffingWTE for the diabetes service? can we further break this downaround the exiting pathways? are there any management (orprofessional body standard) staffmetrics for diabetes care? how do GP/nurse/consultantsessions break down in terms oftime for specific parts of thepathway in say in blocks of 15minutes? (i.e. 15, 30, 45, 60 and 90minutes) Can we position them onour existing pathway? what vital equipment sits on whichpathway?O4Getting the data as described opposite isextremely difficult. Unless staff arespecialists or all their time is spenttreating diabetes patients some estimatewill need to be made as to the proportionof their time related to diabetic patients.For management purposes a goodestimate is all that is required. You will notbe able to, nor should you feel the needto, identify this analysis to any decimalplaces. You may eventually getstatements like ”maybe a third of my timeis spent doing diabetes related activity”.Individual estimates aggregated togetherfor a locality will be sufficiently accurate.Add 10 to 15% safety margin to yourestimate to be conservative.19

O5CostsThere are a number of outputs that need tobe generated: calculate the overall costs;translating resource inputs intocosts; calculate the overall price usingPbR and fixed cost budgets; break these down into programmebudgets or current service pots; break these down into differentservice segments/paths; understand the difference betweenfixed, variable and marginal costs(to reflect the realities of attemptingto shift care and the costs/costsavings – e.g. it is not possible totake half a real person, or half ateam and place them somewhereelse on the pathway).O5CostsO3Issues & problemsUse data linkage and segmentation to tryto highlight problems and understand theunderlying causes.O3Issues & problemsDuring interviewing and workshops keepa log of issues and problems as theycome up.Putting in a new clinical pathway does notensure all issues are addressed and it isnot meant to. However it is an idealopportunity for the local health economyto potentially fix some of the keychallenges related to diabetes care. Seethe inequalities discussion below.Note that many issues will have a greaterscope than the diabetes service alone. Becareful how much you attempt to bite off.20

O2InequalitiesInequality is likely to be high on theagenda. To assess the extent ofinequalities it is necessary to performsome geographically based analysis usinga package such as MapInfo or MSMapPoint.O2Talk to the consultants and GPs about thebest way to remove factors that wouldlegitimately alter rates of access.The types of output you should be able togenerate will look something like this:It is important to obtain postcode data as itallows GP and secondary care data to bemapped by geographic area, enabling thefollowing (and more) to be considered: GP access rates; A&E access rates; consultant referral rates; inpatient LOS rates.Also, by using more sophisticatedsegmentation in the data it is possible tocut these data using any number of otherparameters to consider the interactionsbetween these services; e.g. access to GPand A&E services and whether patientsuse the services as substitutes.Note that you will need a way ofnormalising this data. In some areas youmight be looking for rates to be higher butreferrals; e.g. in more deprived areas withlower GP provision. To find these you willneed deprivation indices or othermechanisms, like risk scoring, to normaliseyour data.Mapping software can have some of thesebuilt in. Risk assessment is a new, moresophisticated capability increasingly usedto help health service delivery andanalysis..21

5.3 Where do we want to be?The next part of the journey requires the development of an accurate picture of where we want tobe. Once more, it’s a dual process of investigation and analysis using data and engagement, butincludes a vision for where we want to go. The principle objective is the local implementation of anew ‘best practice’ pathway. This is normally not the sole objective as there are often multiple aimsand objectives that must simultaneously be considered, such as equity of provision, shifting to amore preventative regime, or greater value for money. Implementing the new pathway must giveappropriate weight to each of the potentially conflicting objectives.As with the previous step the basic process has a number of key inputs and will produce a numberof essential outputs. The diagram below shows these basic components and the subsequent tablethen describes these and the tasks necessary to create them.New best practicepathway I 6I 7Policy, targets,objectives,benchmarksI 5Population,demographics,epidemiologyI 4Key peopleAnalytics andmodellingEngagementand analysisUnderstanding the possiblefuturesTrendsTasks, tools andapproaches I 5New system pictures01308Pivot tables09Issue/problemresolution010Resourcedata011Cost012Figure 6. Fundamental inputs and outputs in the ‘Where do we want to be?’ step22

‘Where do we want to be?’ – inputsRef Analytic task description Ref Engagement task descriptionI6 New best practice pathwayThis guide assumes we already have anew best practice clinical care pathway toimplement.That pathway should be in the form of alogic diagram and clinical notes that aresufficient for local clinicians to engage withand, if necessary, change their behaviour.This guide is for commissioners and notclinicians, and it is assumed that clinicianshave already understood and agreed thenew clinical pathways generated.I4Communicate best practice pathwayDiscuss the proposed best practicepathway with key clinicians. Ensure thatthe local clinicians are in broadagreement with the proposed changesbefore proceeding with thecommissioning exercise.Be careful with constraints and diligentlynote them. For example a GP’s feedbackof “we can’t work like that because wedon’t have sufficient nursing or GP cover”,is exactly the kind of comment you mightexpect when putting in a new pathway. Ofcourse it is being judged in light of currentprovision and not what you might wish tocommission in the future. This commentmay provide guidance when calculatingadditional service requirements.Note any other issues or problems and, ifthe new pathway is still (even afterremoving constraints) felt to be deficientin some respect for local consumption,revisit the ‘best practice’ clinical pathwayto ascertain if it needs any adaptation forlocal circumstances.I5Population, demographics andepidemiologyThe purpose of this step is to generate a‘what should be’ view or quantitativeanalysis of the new pathway. To do this it isnecessary to generate an activity mapbased on population data.UK Government national statistics willprovide local population data at localauthority level. It will also segment this byage, sex, ethnicity, weight etc.In addition it is necessary to obtainestimates (from research and publisheddata) of prevalence, incidence and unmetneed.I4Look at how the analysis of activity basedon population prevalence and incidencecompares to historic activity. Talk throughthe underlying assumptions you mayhave made to see if any differences canbe accounted for, or that the results aregenerally correct.Try running the data through the newpathway to look at overall change.Discuss how this new model was puttogether and whether it is a supportablemethodology. Adapt the approach ifnecessary.The effect of prevalence, incidence andunmet need on pathways andcommissioning analysis is discussed indetail above in section 4.6.23

Ref Analytic task description Ref Engagement task descriptionThese data can now be projected throughcurrent local pathways and the proposedfuture pathways to see how they compare.Annotated clinical and system path stylediagrams can be created that have yearlyactivity figures alongside as many of thepathways as possible. Activity will need tobe attributed proportionally on eachsegment and on paths within thosesegments according to epidemiologicalevidence and historic data.I7Policy / targets / objectivesCommissioning, like most managementtasks, requires multiple simultaneoustargets and objectives to be met. Putting ina new clinical pathway may address someobjectives but will not necessarily addressall.I4Take the local developed pathways fromthe previous stage and note where thetwo differ. Do this with the local cliniciansto confirm if the aims and objectives afterputting in the new pathway appearfeasible.List all the objectives you are tasked withaddressing. Analyse the changes you areimplementing to see which targets couldpotentially be impacted. If necessaryconsider how additional changes might beintroduced that could address unmet policy,targets or objectives.Share your analysis with the constituentsand find consensus around which targetsyou think you could impact.Agree the ones you are not attempting toinfluence.Benchmarking can be a useful exercise tosee how well you measure up to areas thatare similar to you. However, unless you aresignificantly (negatively) adrift of your peersavoid putting relying too heavily on thismethodology as it fails to allow for what arelikely to be important local factors.Consider the following: all areas should expect somenatural variation; natural demographic differencescreate additional variation; you are comparing yourself withothers, none of whom may beperforming as well as they could.This can give erroneousreassurance.24

‘Where do we want to be?’ – outputsRef Analytic task description Ref Engagement task descriptionO8 TrendsIn the previous step we looked at historictrends and here we are consideringanticipated trends. This is where aninflection point occurs in the future. Becareful here to avoid doubling growth ordecline by putting a future trend on anexisting trend that was already identifiedin the historic data.O8Some examples of a future trends yourhistoric data would not pick up include: changes in the impact ofimmigration because of futurepolicy changes or economic shifts; changes in the how the diseaseprogresses through patients due tothe introduction of a new class ofdrugs.Trends in obesityThe potential impact of obesity is also atopic that we should mention here. Theeffects of obesity are already being seenin growing diabetes activity and this wouldtherefore be covered under historic trend.However, growth in diabetes activity isalso due to other factors such as agrowing proportion of older people withinthe population and an increase in theconsumption of junk foods. Separatingtrends that may all have differing impactsis complex. However obesity is high onthe agenda and therefore two issuesremain for commissioners to consider. Do we currently see the rightshape for that growth? Is thegrowth rate something that isexpected to accelerate or plateauin the future? Is there something commissionerscan do to influence this, e.g.through social education orpromoting more active lifestyles?Consult with local authorities andgovernment bodies to capture any ofthese future policy related shifts.Engage with clinicians to discussanticipated future clinical advances andlikely consequences.Consider how diabetes is progressingnationally and internationally forcomparative purposes, including usingthe NSF framework. Look at anyresearch done at influencing obesityrates through social programmes.25

O9Business intelligenceFrom a commissioning perspective it isimportant to know the changes the newpathway will introduce to clinical practice,including: what they are; where they are; what they are intending to achieve.For commissioners the proposed changesin clinical practice need to be translated toa set of specific activity and resourcequestions:which patients will be affected?can these patients be segmentedin the historic data (the ‘what is’data)?can these segments be found inthe population data (the ‘shouldbe’ data)?will any change create a wholenew patient population and canthis be estimated?how will that impact different pathsnow and into the future?can the shifts in resources neededto service this change beestimated?O9Introducing a clinical pathway should, byits very nature, create a consistentclinical approach. It might shift theemphasis to prevention or change theapproach fundamentally for certainsegments of the population.Find this out by discussing the clinicalpathway with those that are proposing it,its aims and objectives – and where theythink it might be different from currentclinical provision. Mark this up on theclinical map and discuss this with localclinicians.Get the clinician to help define howactivity can be recognised in historic dataon specific new and old pathways.Answering these questions is an iterativeprocess that requires a combination of: historic data you can evidence/requery; epidemiological data you cansupport; pathways, both clinical andsystems; and stakeholder engagement toidentify what happened and islikely to happen.The result needs to be the old and newsegmented pathway maps with activity,both historic and ‘as it should be’, clearlyidentified.26

O10 Issues and problemsCarry out any further analysis to addressany of the stakeholder concerns. Go backto them with clarification or answers.O11 Resource dataThere are two key concepts that are interrelatedand essential to understand inrelation to this topic to ensure ‘technical’efficiency is considered in new pathwaydeployment. Both are related to matchingresource to catchment.Resource work in stepsThe first concept is that as activityincreases, resources to deal with themalso increase due to the nature of fixedcosts and overheads which are spreadacross the whole activity spectrum. Therewill always be a point where an additionalstaff member is needed or whereadditional office space or equipment isrequired – these cause the observed‘steps’ in the cost and resource maps asshown below.Furthermore, where teams are required todeliver a service and provide sufficientcover (which is very common in the healthservice) this step is further exaggeratedO10O11Interviews concerning future clinicalpathways need to gather from keystakeholders: issues with the proposedpathway; issues with how patients aremanaged (proposed systempathway); issues with the ‘what should be’activity analysis; issues with any assumptions.If you are not satisfied with the answersprovided, ensure that those issues arediscussed at subsequent workshops orat the Option Appraisal. This will ensurepeople know their concerns are not beingignored and all stakeholders can take aview as to whether these issuesseriously impact delivery.If necessary, and if the local analysissupports the issue, adapt yourimplementation.Find out from your key stakeholders howstaff currently work and how they willwork in future.Gain an understanding of how resourceswould need to be deployed throughoutthe delivery of service and, in particular,look at daily rates of activity andvariability.Find the underlying rules used to decidehow many staff are needed.Understand the proportion of time theymight spend on other non-diabeticservices.Communicate the rigour of your ‘demandto resource model’ to help drive change;demonstrating the efficiency savings andindicating where else that money mightbe deployed to improve health outcomes.27

and can have a significant effect onefficiency, especially where smallinefficiencies are multiplied many timesover.Resource Activity CapabilityActivityCatchment sizeThe diagram above illustrates this,showing how the linear increase in activitylooks versus a stepped resource function.Only where the two lines touch are wemaximising the use of our resource.Demand arrives in inconvenient surges-A similar and related issue is thevariability of demand. Some services incertain catchments have demand that isdominated by variability. Dealing withhighly variable demand means that therecan either be insufficient resources to dealwith peaks in demand (or that patientsface long waiting times) or that resourcesstand idle during troughs in demand. Onesolution to this can be to vary thecatchment size in order to balance waitingtimes with more efficient use of resources.Some matching of resources to demandlevels over time can obviously bearranged but this will only deal with theobvious. ‘Queuing theory’ is often requiredto provide a simple resolution to balancingcontract/SLA obligations and technicalefficiency.However, in reality the activity line is alsoa step function due to fragmentation ofservice. In order to manage size andcomplexity services have beensegmented into more manageable sizessuch as practices, local authorities, healthauthorities, PCTs and SHAs. The problemwith this is that these fragments can oftenproduce activity levels that do not fitefficiently with how resources arecurrently arranged.It is therefore essential that a PCT canmodel the relationship between catchmentsize, demand and service resources. This28

elationship sits at the heart of translatingneeds assessment into commissioningintelligence.It is possible, with the right skill sets (e.g.an operational researcher), to modelthese relationships from your base data.Your GP or secondary care historic datacan underpin this exercise. It will allowyou to consider putting practices togetherin different combinations to revealsegmented diabetes demand as aconsequence. You can then look at howthis demand would relate to resources (byhaving developed a set of rules forresources to activity on specific pathways)so that an optimum fit can be found either: practice wide; in clusters of practices; PCT wide; across multiple PCTs.For example, a children’s diabetestelephone support line may have highcomplexity for relatively low numbers –especially at PCT level. The questionmust be posed at what level ofaggregation of PCTs would such a servicebe both responsive and efficient. Thisrequires that commissioners address theconcepts discussed above. In realitycommissioners need to be asking thissame question for ALL services.O12 CostsAs with the historic picture, the newresource picture should be costed basedon the ‘what should be’ pathway. Withsecondary care you can now estimatenew activity and use PbR tariffs toestimate costs.Primary care is more difficult becausethere is no PbR. You will need to look at itfrom first principles (staff and equipmentcosts) in order to work out the costs. Inline with the previous discussion onresources, remember that how you breakthe work down will dictate how much youpay and what service your patientsreceive. In this respect you should notseparate purchasing and design ofservice.O12Communicate your costing methodology.In particular talk about assumed shifts tobe sure you get buy in. Where there isconcern try to find out what are thesensitivities – do they think it is plus orminus 5% out or more?Identify local constrains and adapt yourcosting methodology accordingly.29

Basic costing from anticipated resourcesis relatively straight forward since tariffsare nationally-published agreed rates and,where these don’t exist, there are oftenlocally agreed ones. However, these willonly give an average cost. Decisionsshould be made at the margin. That is,commissioners should be interested inhow much extra resource will be requiredto invest (or disinvest) based on localcircumstances. This ties in with the stepfunctions identified in the previous section– cost functions are not smooth in realityand average costs may misrepresent thesituation faced.Identifying marginal costs is morecomplex because it requires anassessment of how and where servicescurrently configured. For example, is thereany spare capacity within current serviceprovision? If so, the marginal costs ofproviding additional activity may be verylow. For example, if community nursesare in a position to fit an extra patient intheir rota then the extra, or marginal cost,of providing this service will simply be thecosts of dressings, drugs and travel, butwill not include any additional cost for thecommunity nurses time since s/he isalready employed and paid for.Another example might be a situationwhereby the new pathway might requireadditional laboratory tests to be carriedout – the average cost of which isrelatively low. However, if the local labsare under strain already then providingadditional tests might require additionalstaff to be taken on or, in the extremecase, a new lab being built. This impactsthe costs faced in reality and usingaverage costs or prices may lead to anunderestimation of the marginal costs.The practical constraints faced by theactual provision of new pathways will forman integral part of identifying the requiredresources and costs.30

Other questions that should beconsidered are: can we calculate an anticipatedshift of activity (say fromsecondary to primary)? can we calculate an anticipatedreduction in critically ill patients asa consequence of moreproactively managing patients? can we estimate the increase inthe managed care costs? can we estimate the impact thenew pathway’s preventativeapproach will have on thepharmaceutical expenditure?O13 New system pictureA new system or flow chart picture is onlynecessary if some of the systemicproblems in service delivery are beingaddressed. It is not necessary to do this ifthe complexity of the project is to be keptto a minimum or if, after the aims andobjectives of the project have beenidentified, they are sufficiently covered byintroducing the clinical pathway.The downside from not addressingsystemic problems is that this is wheresignificant improvements in efficiency ofdelivery can be achieved. Refer to thediscussion above on the relationshipbetween the catchment area, demand andresource utilisation.This is an area rich in theory and heavy intexts which cannot be adequately coveredin this toolkit. If these issues are ofimportance now is the time to do youranalysis and work with the stakeholders tosolve issues and to generate thealternative systems charts tocommunicate what you are prosing to dodifferently and why.31

5.4 How do we get there?In the third part of the journey we take the outputs from the two previous stages and analyse thedifferences. Again, it is a dual process of investigation and analysis using data and engagement.However, this time however we’re looking at some of the hard numbers from modelling of futuresand subjectively analysing the effects of shifting services and resources and balancing theseagainst cost and potential outcomes improvement.Figure 7. Fundamental inputs and outputs in the ‘How do we get there?’ step32

‘How do we get there?’ – outputsRef Analytic Task Description Ref Engagement Task DescriptionAnalyse differencesThis step fully brings our picturestogether to analyse:Workshops or option appraisal processDiscuss the difference funnels withclinicians and managers considering:what the differences are;how these differences are makingimprovement, and to whichissues;quantified and costed change.You should be able to present pictures,both conceptually and quantitatively, thatcontrast what has been happening withwhat you plan to happen. There may beseveral options available and there maybe a number of variables that could beadjusted to present various scenarioswithin those options.A key piece of analysis should contrasteach segment of the diabetes populationby level of interaction. The contrasts youshould consider are: old pathway using historic activityvs. ‘should be’ activity; new pathway using historicactivity vs. ‘should be’ activity.Overleaf is an example of how thesecontrasting pictures can be plotted, basedon previous work on an MSK pathway.They are called ‘funnel plots’ becausethey normally take up a funnel shape,with primary care activity at the top,outpatient activity lower down, diagnosticthen inpatient and surgery activity at thebottom, and possibly (if appropriate)rehabilitation below that.The historic case is on the left and the ‘asshould be’ activity is on the right. Theyare scaled (in the x axis) to contrastactivity. Waiting times are sometimesindicated on the y axis – otherwise the yaxis has no scale other than to indicate asequence of events downwards. Theplots can also have a costed counterpartthat can take up a quite different shapefrom a funnel.unmet need;services not currently provided;services no longer required (or to beadapted);service shifts between care levels(secondary to primary or visaversa).At this stage you should start considering anumber of workshops to focus on thedesired service or a formal option appraisalprocess.Option appraisal processes are useful ifthere is real reticence to change. This isbecause its formal structure ensures peoplefollow a logical decision making path anddocument it. If people aren’t particularlyhappy the ultimate outcome they can atleast see the clear process that took themthere.Discussion of an option appraisal process isoutside the scope of this document.33

Ref Analytic Task Description Ref Engagement Task DescriptionThere are no pre-set formulae with theseplots. They can be extremely helpful fordemonstrating and discussing differentprovision.Analyse services requiredThe counterpart analysis to looking athow clinical services differ is to work outthe optimum organisation of resources toachieve an efficient and timely service forthe anticipated new demand.Maybe there will be a time in the futurewhen this analysis is unnecessary; whencommissioners can see a plurality ofservices and pick from the ones thatprovide clinical rigour with a ‘customerfocused ethos’ and at a reasonable cost.Until that time (which may not arrive)commissioners will need to work withprivate and public providers to help definewhat it is they do want on behalf of thepublic and how they can obtain theservices at an affordable cost.As discussed in step 2 , the way to movefrom a clinical needs assessment tocommissioning needs assessment is bymodelling activity from catchment throughto resource. This will help to define thephysical arrangement of resources thatwill fit with the expected demand.The model created should be able to: permit adjustment for growth ordecline; allow catchment adjustment toexplore how demand changesthen influence resources, waitingtimes and costs; permit you to make some pathwayadaptation (e.g. adjustTrying to make decisions about how best tofit a new pathway into an existing service isa complex task; balancing clinical aspectswith considerations about how best todeploy resources.For the decision makers (ultimatelycommissioners) this involves having tobalance clinical demands with customerservice demands within a budget.Complicating the process is the need topersuade a range of stakeholders withdifferent perspectives, views, objectivesand prejudices that a solution has beenfound, that it is the right one, and that theyneed to work with it.Probably the most explosive issue is whenthe new pathway requires care to be shiftedfrom one location (physical or clinical) toanother. This can prompt defensivebehaviour from clinicians and otherprofessionals. If you are suggesting eitherof these you need to be clear what the shiftis and why it makes sense for the patientand the health economy as a whole.A strong analytic base and a rigorousmethodology are essential in this process.Communication is the key; pictures thatexplain the change and a model thattranslates this to a commissioning modelare absolute essentials in this process.34

Ref Analytic Task Description Ref Engagement Task Descriptionpreventative effects to modelchanges); allow you to explore sensitivity.are:You can create two types of model: a one off analysis that is done inthe background (a static analysis)– where you present the results –with the assumptions used; a dynamic tool – where you canexamine ‘what if’ scenarios whilstsitting with stakeholders so theycan alter the assumptions andplay with some of the variables.The impact of these two approaches isdiscussed in the engagement sectionopposite.The different plots and some modelling willdo this for you. However a dynamic modelhas a number of significant benefits. Thesegreater engagement through handsonuse of decision makers andclinicians;the ability to explore in more detailwhat an alternative future provisionmight look like;helps clinicians to appreciatemanagement issues;an appreciation of the rigor andscience behind the change;an ability to test sensitivity in themodel.Our experience has shown a dynamicmodelling approach will also: lower resistance to change; create enthusiasm; create active consideration ofalternative (better) options; provide ongoing modelling to adaptsolution.35

5.5 How do we know when we are there?In this forth part of the process we look at the metrics and monitoring issues. This needs to bedone as part of planning prior to implementation and agreed with service providers as part of theirSLA or contract.The DH Diabetes Commissioning Toolkit November 2006 defines suggested key outcomes whichcould form an initial set of high level KPIs that commissioners can use.Other metrics are suggested below that could be incorporated as part of the monitoring andgovernance process. Outputs from this phase should form part of the implementation plan.Figure 8. Fundamental outputs in the ‘How do we know when we are there’ step36

‘How do we know when we are there?’ – outputsRef Analytic task description Ref Engagement task descriptionBase line analysisAll the metrics used in the DHDiabetes Commissioning Toolkitshould be reviewed bycommissioners and stakeholderclinicians and adjusted if necessary inthe light of the new locally appliedpathway changes.Before any changes are made in thesystem a baseline assessment of allthe key outcomes should be madeusing these key metrics. This will formthe baseline from which all futureassessments are compared.The metrics are a combination ofclinical measures, process andoutcome metrics.Monitor pathway metrics - Doesthe pathway activity look like itshould?As part of the analysis in step two youplaced activity measures against all ofthe pathways (diagnosis, diagnostics,screening, treatment etc). This iswhat you will use duringimplementation to see if the newprocess is progressing as anticipated.In the first year, plan to carry out atleast quarterly reviews to checkstakeholders are finding, managingand referring patient numbers as youexpect.Agree with all key stakeholders groups(including patients) that these are a reasonableset of measures for the success of theimplementation.Against each of the aims and objectives of theproject place which measure you will use toindicate success or not. Ensure you havesufficient coverage. Create/measure thebaseline metrics and distribute to confirm withstakeholders that they are all in agreement withwhat has been recorded as the baseline.Stakeholder monitoring & governanceThe numbers of patients at key points withinthe new pathways are almost as important asthe higher level metrics, particularly in the firstyear. As part of a governance approach a localdiabetes governance board should beestablished, made up of a commissioningrepresentative and service representativesfrom primary and secondary care. In particularthere must be clinical representation, with a keysecondary care consultant positioned aschairman. The board should also have apatient representative on it. The board’smembership should, particularly early, be madeup from many of those who have been involvedin the work from an early stage.The board will need to convene frequentlyinitially to closely monitor the implementationand will have the ability to: see all flows and service shifts; get early site of high level metrics; ensure clinical peer review (not justmanagement review); request behaviour change fromconstituents; adapt the pathway; recommend incentive schemes.This last point can be a key to achieving thebehaviour change that may be necessary tomake the new pathways a success. Thegovernance board should think carefully abouthow incentives could be aligned to re-enforcegood practice and also to redistribute part ofany expected savings so that those involvedmay also invest the benefits where they wish.37

6. What next?6.1 Next steps in the approach/projectThis document is one of three principle inputs into the ‘doing it’ phase – or more specifically the‘design and implementation’ stages.The three inputs are: A best practice clinical pathway (a generic design for diabetes pathways); DH’s Diabetes Commissioning Toolkit November 2006 (a set of metrics and an initial diabetesspecificneeds assessment approach); This document, ‘Localising care pathways’ (a generic approach to localising a pathway).Best practice diabetes clinical pathwaysData analytics / clinical and systems analysisDH Diabetes Commissioning ToolkitNovember 2006EngagementHow to localize clinical pathwaysLeadership, people and cultureGENERIC DESIGN &METHODOLOGYLOCAL DESIGNFigure 9. Next stepsLOCALIMPLEMENTATIONArmed with these three things a PCT now has a launch pad for the next stage.What comes next is again best defined under three broad categories: data analytics and analysis,stakeholder engagement and a third area of leadership, people and culture. This third areanormally sits under the heading of ‘change management’.This document deals specifically with the first two, as there are no existing texts that we know ofthat detail these tasks. We recognise the importance of the third area but know that PCTs will beable to obtain plenty of standard texts to help with this. So getting help, or obtaining a good bookon change management would make a fourth, useful input into the next stage.6.2 Questions that are left unanswered by the toolkitThe difficulty with writing a document like this is that you want it to be as specific and practical aspossible, but of course you’re not always being asked to produce it at the perfect time or whenthere is sufficient time to create it. Consequently you have to make trade-offs between levels ofcomplexity, detail, applicability and how generic the tool is.38

To clarify this, consider the diagramopposite. It shows another way of seeingthe generic process for localising apathway, but still describes the processin this document.As you might expect it is an iterativeprocess, and once you have beenthrough it once, with real data to throwlight on a theoretical best practicepathway, it not only allows you to adaptand potentially improve the pathway butalso enables you to describe a morespecific localisation methodology forother pathway localisations in differentPCTs.From experience we know that without being able to make this journey round the loop at least once(using real historic data) you cannot know for sure what pictures work, how best to segment, whatis a clinical response, and what is a system response. As mentioned earlier in this document younormally have to go round this cycle at least once before you know what are the really importantquestions to ask stakeholders.6.3 What more can be done?For PCTs at the leading edge of specific pathway implementations, there is the pleasure of beingfirst, but also the pain of walking into the unknown. There is also a choice; you can do thelocalisation yourselves as one off exercises, or as you do the work you can create approaches andtools that others can use who follow you (saving them time and money – and, in all likelihood,producing better results).For example, two hugely useful outputs for those that follow behind would be: this guide, taken to the next level: a guide for localising diabetes pathways that includesspecific segmentations, how to find them in historic data, what to look for and how to resolvethe underlying problems that all diabetes services throw up. a generic diabetes (dynamic) modelling tool that will allow any PCT to model their new diabetesservice and adapt their local services to meet local conditions and constraints. Such a tool isdescribed in more detail within this guide.39

AppendixScreening and unmet needThe purpose of screening programmes in diabetes is to discover the condition at an early point intime on the assumption that either diabetes can be treated at lower social costs and/or there aregreater benefits associated with earlier treatment than would be the case if detected at later stagesof disease development. In general, three questions are at the forefront of screening programmes: Should screening be carried out at all (i.e. do the benefits outweigh the costs)?If so, what is the optimal target group to screen?Given budget constraints, how should resources be allocated and expended across differenttypes of screening programmes?To screen or not to screen?The high prevalence of undiagnosed diabetes and the proportion of cases with evidence ofcomplications at diagnosis undoubtedly create a strong imperative for screening. This is especiallybecause undiagnosed diabetes is common, is not generally characterised by recognisedsymptoms, and is as strongly associated with future health problems.At a simple level, if the benefits of screening early outweigh the costs of screening and treatmentthen screening should be undertaken.However, the detailed mathematics of the problem can be relatively complex for the followingreasons: expenditure today does not yield benefits for several years; forecasting benefits in the future is uncertain.In order to undertake an analysis of the costs and benefits of screening, the costs andeffectiveness of screening and treatment must be assessed, including; the costs of treatments such as control of hyperglycaemia, intensive reduction of bloodpressure, treatment with angiotensin converting enzyme inhibitors, and cholesterol loweringtreatment; the health benefit to people who have had the disease detected early by screening should alsobe assessed;. the costs of not screening. If an individual has the undiagnosed condition then they willinevitably, in the absence of a screening programme, access the healthcare system at a laterstage, which might well be more costly and the outcome poorer than if they were identified atan earlier stage in the condition. Up to 25% of people with diabetes have evidence ofmicrovascular complications at diagnosis and extrapolation of the association between theprevalence of retinopathy and the duration of disease suggests that the true onset of diabetesoccurs several years before it is recognised clinically.It is also important to consider the disadvantages of testing for diabetes and attributing thisdiagnostic label. Although the label might act as an incentive to behavioural change in somepeople, it could also increase their anxiety and reduce wellbeing. However, the diagnosis ofdiabetes may also have beneficial effects on the behaviour of health professionals. Once diabetesis diagnosed, patients can be included in programmes of recall, education and review which areassociated with improved recording of cardiovascular risk factors, more frequent lifestyle advice,and more aggressive risk reduction.40

The economic benefits of universal screening cannot simply be assumed. The costs and benefitsneed to be weighed up.Who should we screen?When screening, the target population to be screened is an important decision which impacts onthe cost-effectiveness of any programme. One of the main issues faced is how to identify theappropriate target population, or indeed whether a universal screening programme should beemployed. This depends on the sensitivity and specificity of the screening test and the positivepredictive value.Sensitivity - the ability of a test to correctly classify an individual as 'diseased’ - and specificity - theability of a test to correctly classify an individual as disease-free - are inversely proportional. Thismeans that as the sensitivity increases, the specificity decreases and vice versa.Positive predictive value (PPV) is the percentage of patients with a positive test who actually havethe disease. Positive predictive value is directly related to the prevalence of the disease in thepopulation. Assuming all other factors remain constant, the PPV will increase with increasingprevalence. Therefore the decision to screen must take into account the likely prevalence withinthe screened population. The more targeted the screening the higher PPV and the more costeffectivethe screening programme will become.If, for example, a population-based untargeted screening programme was implemented andproduced a low PPV there would, by definition, be a large proportion of the population that wouldbe referred to an endocrinologist for confirmation of the condition. This is an expensive andneedless referral.The effectiveness of screening for diabetes and treating the hyperglycaemia to reducecardiovascular disease depend on the prevalence of undiagnosed diabetes, the backgroundcardiovascular risk, and the reduction in the risk of cardiovascular events in those screened andthen treated. The small reduction in relative risk and the relatively low overall prevalence ofdiabetes and background cardiovascular risk mean that universal screening is unlikely to be costeffective. Screening may be more cost effective in subgroups of people with a high prevalence ofundiagnosed diabetes, which are also at high risk of cardiovascular complications.A full literature review to ascertain the current state of evidence is vital to be able to makejudgements regarding the implementation of screening programmes.Universal screening may be unmerited, but targeted screening in specificsubgroups may be justified.Effectiveness of diabetes screening in reducing cardiovascular diseasedepends on disease prevalence background cardiovascular risk and riskreduction in those screened and treated.41

Which types of screening should we employ?Many possible screening methods have been shown to be feasible, acceptable and accurate whencompared with these diagnostic criteria: glucose concentrations after fasting and two hours after glucose challenge and glycatedhaemoglobin values are equally good at predicting the future microvascular complications ofdiabetes and can be considered as diagnostic tests as well as screening tests; glycosuria detected by urine analysis has a high specificity but a low sensitivity; testing random blood glucose concentrations is more sensitive but a little less specific; risk factor questionnaires have reasonable predictive value, as do predictive models based onroutinely collected data on risk factors.Although many studies have compared and contrasted different screening tests, the major concernis not how to screen but who to invite and whether screening and subsequent treatment result inhealth gain.Evaluation of the performance of potential screening tests for diabetes is closely related to theissue of determining the diagnostic thresholds for the disease.42

Healthcare for LondonLocal enhanced service (LES) agreement exemplarLong-term conditions (diabetes) projectMarch 20091

Contents1. Note for PCT commissioners.........................................................................32. About the LES...................................................................................................32.1 Tiers of care ....................................................................................... 32.2 Screening ........................................................................................... 42.3 Targets ............................................................................................... 42.4 Remuneration ..................................................................................... 43. Tier one exemplar ............................................................................................3.1 Introduction......................................................................................3.2 Background .....................................................................................3.3 The aims of the scheme ..................................................................3.4 Service outline for tier one diabetes care ........................................3.5 Monitoring – basic principles ...........................................................3.6 Educational standards for practice staff...........................................3.7 Delivery and performance ...............................................................555566774. Tier two exemplar.............................................................................................4.1 Insulin initiation ................................................................................4.2 Education and training programmes for patients.............................8992

1. Note for PCT commissionersThis exemplar local enhanced service (LES) agreement has been drawn up to accompany theHealthcare for London Diabetes guide for London. The guide sets out the recommended model ofcare, along with the context for delivering diabetes care. It should be read before this exemplar isused for adaptation to local circumstances.The exemplar sets out key points only; it is not anticipated that it will be used without beingamended by PCTs for local agreement with primary care providers. PCTs should use this exemplaras a template to adapt to local circumstances.2. About the LES2.1 Tiers of careThe exemplar has two parts, one sets out the basic content of a LES for tier one care while theother is for tier two care in the recommended model of care for London.The tiers deliver enhanced services beyond the essential services covered by existing GMS/PMScontracts. Precise details of the services to be provided as essential or enhanced services are setout in the Diabetes guide for London and briefly described below. GMS/PMS - Services that are covered by GMS/PMS contracts and the quality and outcomesframework (QOF) mechanism are termed ‘essential’ services. For diabetes, this includesidentifying and diagnosing people with diabetes and meeting their day-to-day needs, keepingan up-to-date register of people with diabetes, and ensuring that those on the practice diabetesregister receive an annual review and are referred on to specialist services where required. Tier one - This is enhanced care carried out in the primary care practice by primary care staff,in line with minimum standards set out in this exemplar. The expectation is that practices willprovide care for a higher proportion of patients than is currently the case across London. Staffproviding this care will need to demonstrate that they have undertaken appropriate training andhave the necessary skills and competencies. The standards of care required are higher thanthose being delivered through the GMS/PMS contract, including QOF payment mechanism.PCTs are advised that the standards in the exemplar are those that they should be achieving. Tier two - This tier comprises delivery of tier one care to the same minimum standards, withthe addition of insulin initiation in people with type 2 diabetes (following accreditation of thepractice) and provision of structured patient education. Structured education may becommissioned separately from the intermediate diabetes team, e.g. to local PCT preference.It is expected that most primary care practices be able to deliver tier one care, with education,facilitation and support given by tier three providers as required. Tier two care is likely to beprovided by a smaller proportion of primary care practices, with the intermediate diabetes teamdelivering direct patient care at tier two for patients registered with practices that do not provide tiertwo care. PCTs will need to consider local capacity and circumstances and may choose tocommission part or all of tier two care from an alternative provider.LES agreements should not be used to fund primary care services where patient care is actuallyprovided by another service e.g. a community-based intermediate diabetes team.3

2.2 ScreeningThis exemplar does not address the identification of people at risk of diabetes or who havepreviously undiagnosed diabetes. From April 2009 PCTs will be expected to put in place vascularscreening programmes for people over 40 years of age. Precise details of what the screening willinclude are being worked through at present, with NHS taking the lead for London. It is anticipatedthat the screening programme will include screening for diabetes and PCTs will be expected toensure that this is implemented for their populations.2.3 TargetsThe targets set out in this exemplar reflect those set for PCTs as a whole and they are basedlargely on achieving the national upper 25 th centile of performance in 2006/7, using non-exceptionreported data.However, one target in the Diabetes guide for London − that is, for the gap between recordedprevalence and the estimated expected prevalence to be reduced by half within each PCT by 2012− has not been included in the exemplar. This is because PCTs will need to work out how toapproach reducing the proportion of people with undiagnosed diabetes (which this indicator relatesto) in a joint approach with vascular prevention screening once details are confirmed.PCTs may wish to apply different targets to different practices in order to reflect differentialbaseline performance, and they can adapt the exemplar to achieve this. However they should worktowards achieving the targets set out in the Diabetes guide for London (and included in thisexemplar) which PCTs will be expected to achieve as a whole.Note: new proposals from the Department of Health for the process of reviewing clinical indicatorswithin the QOF were subject to public consultation until 2 nd February 2009. The outcome ofconsultation may impact on indicators from April 2009. It is not possible to predict changes whichmay impact on the indicators at this stage. The key measures of clinical quality set out in thisexemplar will be reviewed once any changes to QOF indicator designation are known.2.4 RemunerationA standard remuneration for delivering the tiers has not been set. The Diabetes ProjectCommissioning Group recognised that individual PCTs have differing arrangements with theirprimary care providers on funding a range of enhanced services and, respecting the individuality ofPCT’s approaches, it has not attempted to establish a fixed remuneration for London in thisexemplar. However, where this model has already been adopted, current practice indicates thatremuneration is in the range of £20-£60 per patient per annum for tier one care and in the order of£200-£300 for tier two care.For tier one care, some PCTs apply a sliding scale that rewards practices more if they manage agreater proportion of patients within the practice. This reflects the fact that it becomes more difficultto increase the proportion as the mix of patients becomes more complex. For tier two care, PCTsmay adopt a staged approach to funding so that a sum, such as £50, is paid on patient entry to thescheme and the balance is paid upon exit, if insulin has been successfully initiated.4

3. Tier one exemplar3.1 IntroductionThis enhanced service specification outlines the more specialised services to be delivered topeople with diabetes and those suspected of having diabetes. This service is designed to cover adevelopmental and maintenance process to enhance clinical care to the patient − it is beyond therequirements of the quality and outcomes framework and the scope of essential services.3.2 BackgroundEvidence demonstrates the following: The prevalence of diabetes will rise across London consistently over the next few years due toa combination of an ageing population, rising rates of obesity and inactive lifestyles. The numbers of people with either type 1 or type 2 are predicted to rise. The ethnic mix in parts of London contributes to a greater incidence of type 2 diabetes, with itbeing much more common in people of Asian or African Caribbean origin. It is estimated that around 25% of people with diabetes in London are currently undiagnosed. The introduction of vascular screening for those over 40 years increases the detection rate ofthose currently undiagnosed. Effective management of the condition from diagnosis is essential to minimise the risk ofserious complications in the longer term such as stroke, blindness, cardiac and renal disease,and amputation. This management includes effective glycaemia and blood pressure control. A Healthcare Commission audit in 2006 found that only 13% of people with diabetes hadattended an education or training session. In 2008 a pan-London Diabetes Users Group putforward the lack of tailored education for users and carers as one of the most significantproblems they face. London’s PCTs perform less well than the national average on the diabetes proxy indicatorsembedded in the quality and outcomes framework.3.3 The aims of the schemeThe model of care aims to: deliver additional resources to primary care practices to provide systematic, high-qualitypatient-focussed care to those with diabetes and those not yet diagnosed; improve the quality of the annual review and to incorporate a systematic approach to careplanning, which is an essential foundation to the delivery of good diabetes care; complement a care planning approach by ensuring that patients are educated and empoweredto enable them to contribute a high level of self-care in managing their condition; improve measurable outcomes of diabetes care, as indicated by improvements in proxyindicators; increase the uptake of retinal screening (undertaken by the PCT’s contracted retinal screeningservice), in compliance with NSF targets; help primary care practitioners identify patients at risk of complications and refer them, asappropriate, to the intermediate diabetes team or the designated hospital-based service; ensure practice staff undergo professional development in diabetes care and update their skillson a regular basis; increase the proportion of people with diabetes who receive their ongoing care within generalpractice.5

3.4 Service outline for tier one diabetes careThe patient and, where appropriate, their carer should be at the centre of care and practice staffshould support them in self-management wherever possible. Specific responsibilities in deliveringthis service agreement include:1. maintaining a fully up-to-date (cleaned and validated) diabetes register with access to a fullytraineddisease register co-ordinator. This register may be shared with a cluster of otherpractices;2. agreeing an annual care plan between primary care professional and patient, as part of theannual review. A comprehensive print-out of the agreed care plan will be provided for thepatient to keep;3. organising and ensuring screening for complications, including retinal screening;4. reviewing medication to ensure cost-effective prescribing and to promote concordance, inliaison with the Community Pharmacy service where required;5. managing medication, with the support of specialist services as necessary;6. identifying women of child-bearing age and providing pre-conception / contraception advice;7. agreed referral and use of specialist services, according to the care pathways agreed by thePCT;8. practices working with the intermediate diabetes team, liaising on a regular basis and takingpart in joint meetings as required;9. maintaining the minimum staffing requirement in each practice of a team comprising onetrained GP and one trained nurse (absolute minimum Band 6, but preferably Band 7). It ispreferable that one trained Healthcare Assistant (HCA) be available as well. (Note: the trainedGP may not be required where the practice employs a nurse practitioner with clinicalassessment training who is an independent prescriber and has diabetes training.) Wherenecessary, shared arrangements can be put into place across a number of practices;10. ensuring that the competencies of GPs and other primary care healthcare workers dealing withdiabetes are certified at a minimum standard of competence and audited regularly. Refer tosection on educational standards for further information;11. all practices undertaking tier one diabetes care endeavouring to put in place appropriatesuccession planning so that turnover of staff does not destabilise care for those with diabetes.Where this is not practical, the intermediate diabetes team will need to provide the defaultservice for patients on an interim basis. Specifications for new members of staff shouldacknowledge the needs of the diabetes service and training should be provided as required.12. primary care professionals identifying, diagnosing and managing people at risk of diabetes as amatter of course.3.5 Monitoring – basic principlesThe PCT will be monitoring service delivery within the practice and will apply the followingprinciples: The PCT will monitor all QOF diabetes proxy indicators on a practice basis and will alsoshadow monitor the same indicators with no exceptions, as a comparator. Practices will be required to comply with any patient reported outcomes measures (PROMs)being introduced in their PCT. All practices are to complete the Department of Health Diabetes E self-assessment exercise toestablish a development plan for the practice annually. A patient’s annual review must be carried out by the practice and recorded as such, usingappropriate Read codes. Practices cannot count hospital-based reviews towards their total.See also section headed ‘Assessing effectiveness’ in the Diabetes guide for London.6

3.6 Educational standards for practice staffPCTs are advised that a workforce and education group, led by NHS London, will be consideringthe professional education and training needs of diabetes care providers during 2009/10. Theresult of this work will be an agreed set of competencies required, plus newly commissionededucation and training schemes.In the meantime, PCTs are advised to use existing mechanisms to meet primary care requirementsas listed below. GP and nursing staff are to be trained to Certificate in Diabetes Care standard or similar ateach practice (or provide evidence of competency to show that this is not required). Any HCA dealing with diabetes must be competent to undertake all data collection, take bloodtests, urine tests, measure height and weight, measure waist circumference and perform abasic foot examination. Diabetes-trained primary care staff should ensure that a minimum level of ongoing diabetestraining is incorporated into their continuing professional development. Practices providing tier two diabetes care must have a GP and nurse who have undertaken anapproved insulin initiation course. Basic training in the nature and management of diabetes should be available to all primary carehealth professionals in the practice, even though they may not be directly involved in deliveringdiabetes care. Primary care staff delivering diabetes care should ensure that their skills in performing specifictasks achieve the competency levels defined in the Skills for Health Frameworkhttps://tools.skillsforhealth.org.uk/ Practice staff delivering this agreement are expected to liaise with the intermediate diabetesteam as required. Where education and training issues are raised, the practice will work withthe intermediate diabetes team to address these. Staff will be expected to receive training in collaborative care planning. Basic training should be available for primary care professionals who are not directly involvedin delivering diabetes care.3.7 Delivery and performanceAchievement targets have been set against elements of the annual review. These are based on aminimum attainment of the national upper 25 th centile of PCT performance in 2006/7.Other standards to be achieved include: all people with diabetes of 17 years and over are to have a review of their condition carried outannually; at least 80% of all people with diabetes registered in a PCT should have their annual reviewcarried out in a primary care setting; the annual review should consist of all nine diabetes proxy outcome indicators in the QOF.These nine indicators are BP, BMI, HbA1c, proteinuria test, creatinine, eye examinationcompleted in line with QOF, smoking status, foot examination, cholesterol. (Read code forannual review is 66AS). In the annual review the following should be achieved:o a minimum of 80% for BP

Exception reporting based on the addition of the read codes "9H4, 9H41, 9H42" or "8BL0, 8BL1,8BL2" must be taken into account in achieving these aims. The local diabetes network shouldadvise on this. A maximum of three per cent exception reporting is consistent with the upper 25best performing PCTs in the UK. However, individual practices may require greater leeway onexception reporting, e.g. those who have catchment areas with higher than average numbers ofpeople where these targets are clinically inappropriate. It is also recognised that the denominatorpopulations include those patients who have been registered with diabetes at a practice for lessthan three months. The PCT and the local diabetes network should therefore assess whereexception reporting is above three per cent to determine appropriate practice-based levels. Thepractices that this applies to will be required to contribute to any PCT / network developments toreduce exception reporting rates, and an incremental improvement year-on-year may benegotiated; the annual review is to include care planning for the next year, whereby clinicians will fullyinvolve the user in negotiating and documenting their plans regarding ongoing care; the annual review must include a discussion of the ongoing education and training needs of theindividual, with facilitation into programmes as appropriate; all service users should be given a written care plan at the end of their annual review. If fullycomprehensive, this can act as a hand held record; 100% of patients on registers are to have their setting of care recorded electronically andupdated following annual review (Read codes: 66AU for hospital, 66AP for GP practice); each practice is to have outcomes against the nine individual outcome proxy measures in theQOF monitored against their own baseline each year to assess trends in delivery. A regressingtrend will be followed through by PCT; exception reporting must be taken into account in achieving these aims. A maximum of threeper cent exception reporting is consistent with the upper 25 best performing PCTs in the UK.Individual practices may require greater leeway on exception reporting, for example incatchment areas that have higher than average numbers of people where these targets areclinically inappropriate or currently unattainable. The network and the primary care lead will bein a position to advise on this. However, the practices that this applies to will be required tocontribute to any PCT / network developments to reduce exception reporting rates. Anincremental improvement year on year may be required; 90% of those eligible for retinopathy screening should attend screening; 100% newly diagnosed patients are to be offered structured education within three months ofbeing diagnosed and at least 50% are to attend; practices may offer a service to people with diabetes from another practice, if the latter hasfailed to deliver the key components in the service agreement and the former is achieving keycomponents. practices will offer telephone support − and email support where possible − to patients asrequired.4. Tier two exemplarThe exemplar for tier two includes all the requirements outlined in the tier one exemplar plus thefollowing extra services: insulin initiation in type 2 diabetes, following accredited training; provision of education and training programmes for users.8

4.1 Insulin initiationInitiation of insulin therapy is required for people with type 2 diabetes who are not achievingHbA1c targets with maximum tolerated oral combination therapy and who do not have otherreasons for requiring hospital assessment.The insulin initiation is to be delivered in the GP practice, by primary care professionals. Fortier 2 care the practice must have a trained nurse at minimum Band 7 providing care.Practices delivering this service would normally have an incidence over 2.5% within theirpractice population and be achieving a minimum of 70% of available QOF points for theirregistered patients.The service is to include provision of pre-insulin assessment, education and lifestyle advice.If it is not already successfully in place, blood glucose monitoring should be initiated.The practice is to maintain records in accordance with individual PCT templates, incorporatingall known information relating to any significant events (for example drug reactions, hospitaladmissions arising from the treatment), HbA1c levels, and outcome of initiation.Each practice is to ensure that all staff involved in providing any aspect of care for insulininitiation have the necessary training and skills. Any GP or practice nurse involved must havesuccessfully completed an accredited course for insulin initiation.4.2 Education and training programmes for patientsFor people undergoing insulin initiation practices will provide structured patient education thatis tailored to the specific needs of their local population (that is, which recognises specificcultural needs).Where necessary, shared access arrangements to structured education may be created for agroup of practices.Practices should record the attendance rate at structured education sessions for thoseundergoing insulin initiation.9