Summary of National Diabetes SCNs meeting held 19 May 2014
Professor Jonathan Valabhji, National Clinical Director for Diabetes and Obesity has attended a
number of network events across the county and noted CCGs were engaging with networks.
Partnership working was taking place between diabetes networks and other networks e.g. renal
and maternity networks. A number of networks reported they were carrying out work on
transition. Mental Health did not seem to be priority at CCG level but it was at national level.
Pre-diabetes event in Wessex SCN well attended by Diabetologists and East of England held
pre-conception care event.
Transition – noted concerns that if either the paediatric best practice tariff or children’s services
peer review were extended to 25 years of age, those young people that fail to attend or
disengage with secondary care services, the proportion of which is quite high, would not be
reached by such service improvements. An expert group being brought together to try to
define better care for those between 19-25 years of age and having defined what better care
would look like, the group will then decide which commissioning levers may be the most
appropriate to apply . It is believed evaluation of the best practice tariff will be linked with the
evaluation of peer review. The peer review programme is currently being re-evaluated by NHS
England.
Presentations by each Diabetes Clinical lead on good practice in their area and areas of
improvement were made.
Yorkshire & Humber – Chris Walton
Should there be more co-ordination between different types of networks to ensure the same
development work was not being repeated in different areas. It would be difficult to coordinate all the work taking place and the time and work involved would slow down
developments. It was noted that SCNs are looking at sub-regional issues across CCGs and that it
is difficult to get diabetes on the agenda because it is seen as a core business and doesn’t fit
into what CVD SCNs are doing.
South West – Dr Duncan Brown
This network has its own peer review group for foot services which uses NICE guidelines. The
group provides a supportive approach rather than just a punitive one. The group discussed the
importance of data collection. The pump audit is going to be linked up to the NDA. The
frequency of the audit may change from every year to every two years.
East of England – Dr Nick Morrish
No existing local or regional networks in the area and focus initially on making links locally.
Currently two areas have been prioritised. Foot care project to provide educational resources
for primary and secondary care and there has been a focus within this on the multi-disciplinary
foot team (MDFT). Network is trying to secure funding. Work is also taking place to raise
awareness and focus trusts and commissioners minds on MDFTs. Setting up three diabetes
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advisory groups based on a cardiac network style model and work is taking place to identify
local issues. Transition is included on the agenda of these groups. NDIS has shown a worrying
variation in performance and outcomes and based on initial analysis there isn’t a correlation
between the 9 care processes and outcomes in the area. It was important to look at outcomes
as well as processes. NDA and NDIS data is being reviewed so CCGs are able to benchmark
themselves. Small project taking place on people with diabetes on dialysis to ensure they
receive all aspects of diabetes care.
Thames Valley – Dr Richard Croft
Progress has been made over the last year in engaging CCGs. A supportive approach has been
taken and CCGs have been involved through a stakeholder group. The network is now looking
to engage CCGs at a senior level.
South East Coast – Dr David Lipscomb
Discussed around funding from pharmaceuticals and it was noted academic health science
network have been working with pharmaceuticals.
London – Dr Stephen Thomas
Presentation
Wessex – Dr Sarah Roberts
General CVD clinical network lead for the area. SR is the Diabetes Clinical Lead but there is no
funding for this work so it is mainly an influencing and liaison role. There is data available for
the area on outcomes performance which provides a good picture of the situation and overall
shows that performance is not great. The Wessex Maternity, Children and Young People SCN
are working on a project to improve outcomes for women of a child bearing age which will
involve scripted advice and information on what a pre-conception clinic looks like. Work on the
9 care processes has focused on work locally with a workshop taking place in Dorset looking at
the challenges to achieving the 9 care processes. A Wessex stakeholder’s event to look at
barriers to achieving the 9 care processes is planned. There is a HCP diabetes network in the
area which CCGs, AHSN and patients will be a part of. The SCN see this network as separate but
are working together with it and will see how the relationship evolves. The HCP network
doesn’t have any funding at present. Plans to pull together a directory of diabetes HCP
contacts in the area.
Northern – Alison Featherstone
House of care is likely to be a priority for the network. A Diabetes Clinical Lead is to be
confirmed this week and a stakeholder meeting is taking place next month. Despite early
reservations the network has been really pro-active. Collective work has taken place on
continuous glucose monitoring. Network has agreed to fund the insulin e-learning module and
are looking for future funding. The network has maintained its diabetes foot care network. They
are looking at a standardised regional model for MDFTs based on current guidelines. AHSN are
looking at tele-health and pregnancy which Rahul Nayar is leading on.
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The network is are looking at resources for a Diabetes Footcare Peer Review. The group
discussed whether it’s best for peer review to cover a whole speciality e.g. like endocrinology or
whether it should look at individual sub specialities e.g. feet, pumps, etc. Peer review for
pituitary tumours was done by sub speciality. Peer review takes time and there is a lot of other
work taking place as well. Noted there is a fair amount of crossover with Peer Review and CQC
visits. Peer review is different to inspections because it is not an exercise to find issues. Noted
that peer review has to achieve a high level of utility because it requires a lot of time and
resources and it was suggested it is best done at a local level as it will be difficult to achieve at a
national level. Peer review needs to be validated externally at a national level otherwise
people won’t listen to it. Suggested that a ‘data and shame’ approach works. Paediatric team
found peer review very helpful. The NDA foot module produces a lot of useful data. Different
organisations provide different elements of the pathway which means leverage is limited so it is
best to approach commissioners.
Cheshire and Mersey – Dr Aftab Ahmad
Presentation
Greater Manchester, Lancashire & South Cumbria – Dr Naresh Kanumilli
Network is in its infancy and it held its first meeting last week with good engagement from
different partners including representation from patients and optometry. Initial discussions
have focused on good practice for foot checks. Salford has a focus on children and transition.
Care planning has also been discussed. East Lancashire is focusing on feet and is providing drop
in reviews. Another area of work is access to health trainers and improving public health. Areas
for improvement identified 9 care processes, continuing to improve patient engagement, the
integration of pathways and improving psychological support. The network may link up with
David Savage on a generic model of integrated care. The network is also likely to use the
diabetes service specification currently being piloted in some CCGs by NHS England.
West Midlands – Rob Wilson
This is the third largest diabetes network with 22 CCGs which cover urban centres such as
Birmingham as well as rural areas towards Wales. Feet was identified as a priority and variation
was highlighted as an issue based on an analysis of the data. The network is trying to reestablish a west midlands foot network and a meeting was held in February. The network is
keen on a standardised process in order to reduce variation, which is supported by CCGs. CCGs
have been saying it’s difficult to commission diabetes and the 9 care processes. There is a new
operating structure within the West Midlands. The CVD network is covering work on pathways,
primary care, high impact changes and reconfiguration e.g. stroke pathways. The reorganisation is still taking place and there is the intention to have a Diabetes Clinical Lead.
Final comments
It was noted that the operational arm of NHS England has become more involved in the SCNs
this year with actions plans and overarching theme and group discussed whether this had had
an impact. It was noted there was additional work to produce one page plans but there has not
been a major impact yet and CCGs are still driving priorities. There has been a drive to focus on
making practical contributions.
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4. Cost of Diabetes Report
Robin Hewings, Diabetes UK Head of Policy, provided the group with a summary of Diabetes
UK’s Cost of Diabetes Report. This new report sets out a series of evidence-based ways to
improve care and save money. Examples include: specialist teams for inpatients and foot care,
structured education, care planning and intensive lifestyle behaviour change interventions. It
brings all these interventions together with the evidence behind them for the first time.
The document aims to help leaders in diabetes easily access the information they need to make
the case for better care for people with diabetes. It was a feature in the Health Service Journal
and the full report is available here.
5. National Priorities
5a. Kidney disease
Discussion about what can be done to intervene at an earlier stage as GP systems only flag up
issues when they deteriorate to a very low level and progressive deterioration is not picked up
until it reaches this stage. The system can be EMISS based or laboratory based and the IT
system is fairly straight forward. Could this be integrated into QOF and the points available for
high risk complex patients. It was noted that it couldn’t so there wasn’t a direct incentive for
GPs.
Noted whether results are acted upon depended on a responsive renal department. Agreed
that there is need for integration between different teams and noted kidney doctors are
normally keen to be involved because it saves money.
Is there any evidence that these interventions delay vascular problems. Reported that the
Heart of England Trusts doesn’t collect this data.
Noted the number of patients in an area affected by this are relatively small (in the 100’s) so it
is manageable for intermediary care. Noted the implications for this work included an increase
in appointments. It was asked where should patients who are progressively getting worse go. It
is up to the Diabetologist. 80% of interventions are dealt with by primary care or integrated
teams led by a Diabetologist with advice from a Kidney doctor.
Dialysis rates in parts of London have increased over the last few years but in other areas of the
UK they have flattened. Cost savings from the program go to specialist services and CCGs. There
is the potential for dialysis units to lose funding so outcome based commissioning is required. In
London the renal SCN is leading on this work. Noted the work in the West Midlands is peer
reviewed.
Emphasised the importance of collecting data and proving the clinical effectiveness of this
work. There is a need for a broader perspective on outcomes and to decide what outcomes
you are looking to prevent. Providing advice and feeding back to primary care was key. It was
important to get buy in from primary care and from commissioners.
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5b. 9 care processes
Discussion around documents circulated before the meeting on the 9 care processes.
Would a greater focus on care planning and outcomes based commissioning would bring better
outcomes as opposed to more focus on processes. Systematic education based care was the
best solution. Efforts should be focused on the hard to reach e.g. young people. Technology
should also be used to improve the use of resources too. A foundation is required where good
systems are in place initially and then built upon. Poorly performing organisations need to
improve fast and that a punitive approach is workable. There is a need to have a care planning
approach, structured education and HCP education.
Emphasised the need to consider the political aspects. NHS Diabetes was criticised in relation to
the 9 care processes and the NAO will look at the 9 care processes in future reviews.
The group discussed using data to compare practices and whether this data should be
anonymised or not. Noted NHS Choices provides practice level data via its accountability tool.
Suggestion it is possible for the sharing of all data to be a positive experience. The right culture
and leadership is needed. The group should share its different approaches.
5c. Foot disease
Presentation on foot disease to set up a diabetes foot service.It is useful to show the service is
serving to reduce emergency admission rates with foot disease. Currently there isn’t robust
data available on foot ulcer incidence, so that it is difficult to accurately project what
investment is needed to set up a diabetes foot service – NICE suggests that all those with foot
ulceration should be seen by the MDT within 24 hours. The diabetes service specification was
suggested as a good tool to use to campaign for a multi-disciplinary foot team.
6. HCP Education
The group discussed the findings of a CCG survey on HCP education. 43% of the 200 CCGs
contacted responded, and the finding were as follows:
 Two out of three CCGs do not have a formal (written) policy on diabetes education.
 Just over half the CCGs (56%) specifically funded time to participate in diabetes related
health professional educational events.
 CCGs were asked if they allocated specific funds to diabetes education for health
professionals – six out of ten CCGs do not fund such activity.
 CCGs were asked if they evaluated the effectiveness of their activities in diabetes education
for health professionals: approximately four out of ten CCGs carry out some form of
evaluation.
A number of members of the group stated there was concern over HCP Education. Highlighted
the vast majority of training isn’t mandatory. It was reported that 15% of diabetes inpatients
have been identified as having hypoglycemia.
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A Diabetes UK HCP education working group has produced a document setting out the
principles of a framework to assure the competencies of HCPs working in diabetes. The group is
currently trying to meet with HEE and the NMC to discuss this further.
The stroke association have a competency framework which may be worth looking at.
7. AOB
Pilot education course for deaf people with diabetes
The issue:
There are 101,107 Deaf adults in England (figures widely quoted by Deaf Organisations,
although the precise figure is disputed). Assuming diabetes prevalence of 6%, we expect
somewhere around 6,000 people have diabetes. In reality, we’d expect the prevalence to be
higher given that diabetes may predispose to a higher risk of developing deafness.
Our experience is that there is poor understanding of diabetes and the potential complications
among the deaf community. There is a lack of accessible information, knowledge about diet
and lifestyle and little or no access to structured education. BSL interpreters are expensive and
health services are often reluctant to pay for interpreting (of an appropriate level – ie
registered and qualified) for Deaf people to attend a course. Even if they do get access it can be
difficult for many to access the content without additional time.
The solution:
There is a need to increase awareness of the need for education and to pilot a course targeted
at the community with full communication support. The goal of the pilot will be to test whether
this form of training works for Deaf people and that there is demand from people in the deaf
community (we already have a list of willing potential participants in London).
Stephen Thomas has offered to run a course in London in November to try it out. Project
management, recruitment etc will be carried out by Catherine Forry of Deaf Diabetes UK.
Diabetes UK is supporting the activity. Video recording of the event may provide a valuable
resource so that it could be disseminated elsewhere on DVD.
If the pilot is successful we can consider how a model can be developed that can be funded
sustainably in future. Any contact about next steps can come to David.jones@diabetes.org.uk
or Catherine Forry at contactdeafdiabetesuk@gmail.com.