Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
Diabetes within Greater Manchester,
Lancashire and South Cumbria
(Version 1.0)
Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
NHS England
Greater Manchester, Lancashire, South
Cumbria Strategic Clinical Network &
Senate
First published: January 2015
Prepared by:
Gareth Lord - Quality Improvement Manager – SCN
(Gareth.lord@nhs.net)
Derived from:
The Greater Manchester, Lancashire and South Cumbria Strategic
Clinical Networks Diabetes Programme. This report is in relation to
NHS England’s ‘Action for Diabetes and reviews care against
recommendations across the conurbation. The data in this report has
been taken from several national audits that include: National
Diabetes Audit 2011-12 Report 1: Care Processes and Treatment
Targets, Report 2: Complications and Mortality, The National Diabetes
Inpatient Audit 2013, The National Diabetes Paediatric Audit 2012-13,
The National Pregnancy in Diabetes Audit 2013, The National
Cardiovascular Intelligence Network’s ‘Diabetes Outcomes Versus
Expenditure’ (DOVE) and National Clinical Commissioning Group
(CCG) profiles
Version:
Date:
Intended Audience:
Version 1.0
10th February 2015
GP’s, Community diabetes professionals, CCG Chairs, CCG CVD
Leads, Consultants involved in the care of diabetes, Specialist
Nurses, Service Managers and Other Interested Stakeholders
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
FORWARD
"Diabetes is inexorably on the rise. With increasing life expectancy and rising obesity rates,
the time to deal with the deluge has long gone. But this does not mean that we cannot start
to make a dent into the prevention of the onset, progression and complications of a condition
that has for far too long been ignored as an important determinant of morbidity and mortality
in the modern world.
Data is widely available that demonstrate the poor quality of car and increased variation in
provision of care across the country, but we should not forget that there are pockets of
excellent care.
The purpose of the network is to disseminate good practice, empower clinicians to strive to
achieve their best for the person with diabetes. It's purpose is also to ensure that the person
with diabetes is knowledgeable about their condition and that they are entitled to have the 8
care processes carried out on an annual basis.
We aim to promote a more collaborative and integrated approach to the management of
diabetes.
This document is meant to be a guide to the CCG's showcasing their best practice and also
areas for improvement in order to reduce variation. The network in its capacity as a clinical
organisation is able to provide support and offer advice and examples of best practice from
across the country which may help with improving areas of poor achievement and hence
reducing variation and improving the quality of care for the person with diabetes."
Dr. Naresh Kanumilli
Clinical Network Lead for Diabetes - Greater Manchester, Lancashire and S. Cumbria
Quality & Performance Lead - SMCCG Equality & Diversity Lead -SMCCG
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
CONTENTS
Diabetes within Greater Manchester, Lancashire and South Cumbria
Contents:
1.
2.
3.
4.
5.
6.
7.
8.
Introduction
Executive summary
Condition types
The impact on the population and economy
Prevalence
The guidance
Activity across the footprint
The care processes
Blood glucose level measurement
Blood pressure measurement
Cholesterol level measurement
Foot and leg check
Kidney function testing (urine)
Kidney function testing (blood)
Weight check
Smoking status check
9. The seven additional health care essentials
Care planning
Structured education
Paediatric care
Inpatient care
Pregnancy care
Specialist care
Emotional support
10. Integration
11. Conclusion
Appendix 1
Bibliography
5
6
8
8
9
12
13
15
16
19
20
22
24
25
25
26
27
27
28
31
33
41
44
44
45
48
49
50
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
1. INTRODUCTION
Diabetes is a life-long health condition where the amount of sugar in the blood becomes too
high because the body cannot use it properly. This is the result of either the pancreas not
producing any of the hormone insulin or producing insulin that does not work properly.
Insulin is needed to move sugar (glucose) out of the blood in to cells where it can be used as
energy or fuel. If this process cannot be done effectively it can produce symptoms that
include; feeling thirsty, tired, urinating more than usual particularly at night, weight loss,
blurred vision and wounds that heal slowly [1].
According to Diabetes UK there are 3.2 million people diagnosed with diabetes in the UK
and an estimated 630,000 people who have the condition, but don’t know it [2]. If left
untreated it will progressively get worse and it often can result in serious health
complications such as heart attack, stroke or amputation of limbs. Diabetes is also
associated with around 24,000 excess deaths each year [3].
In 2011, NHS spending on diabetes was almost £10 billion, or £1 million per hour [4] which
puts the total cost of diabetes at approximately £10bn for 2012/13. It is believed around 80
per cent of NHS spending on diabetes goes in to managing potentially preventable
complications. When all this is considered, it seems increasingly necessary that health
services help people to manage their condition more effectively. The results could not only
prevent progression and complications for people with diabetes but reduce unnecessary
demands on health services.
This report will review and compare diabetes and the care provided across the footprint of
Greater Manchester, Lancashire and South Cumbria. It is hoped clinicians and services
across the area can then use this report and work together to share good practice and
further improve care.
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
2. EXECUTIVE SUMMARY
Prevalence of diabetes is relatively high across the network areas with around 236,000
(6.4%) people compared with 6% nationally. The rate varies from a small geographical area
from Central Manchester and below having the lowest proportion (between 5.6 and 5.9%) to
7.5% in Bolton. Prescription costs are high with a collective cost of around £64 million a
year with the costs per person varying as much the relative blood glucose levels. Data
indicates the difference between the average highest and lowest spend per person is £89.38
and the difference between the average highest and lowest rate achieving HbA1c of
<64mmol/mol is 11.9%. This suggests if the rest of the whole footprint achieved the same
blood glucose and costs of the areas with the most effective results, there would be almost a
£9 million saving year on year.
In terms of delivery of care, there is huge variability. However, most areas have improved
when compared with audits undertaken 2 years prior. Comparison of the audits involving the
care processes reveal:
 The percentage of people who received all 8 processes (excluding retinal screening)
varies from as little as 47.3% to 72.0%. 7
 More than half of all areas are below the target rate of ensuring at least 65% of
people are offered all care processes.
 There is a challenge to offer care processes to people with type 1 diabetes.
Blood glucose - All areas are below the target rate of 75% of people having HbA1c
58mmol/mol (7.5%); type 1 having a worse rate than type 2.
Blood Pressure Management - The challenge is not offering blood pressure checks but
achieving optimum blood pressure levels (more so with type 2).
Cholesterol level measurement - The main challenges across the footprint is not just to
improve type 1 cholesterol levels but to offer tests at least annually.
Foot and leg checks - Needs to improve for type 1 patient’s with just 61.7% being offered in
some areas.
Kidney function tests (urine) - The percentage of people offered urine albumin tests at
least once a year varies greatly from 58.5% to 84.6%; type 1 being typically lower than type
2.
Kidney function testing (blood) - A large proportion of people are offered serum creatinine
tests at least once a year although more type 2 patients are offered than type 1.
Weight check - Monitoring at least once a year is generally high although variable for type 1
diabetes ranging from 70.4% to 91.0%. Type 2; weight monitoring is offered 85.1% and
93.4%.
Smoking status - Advice is offered more frequently in the northern part of the footprint
compared with the south with one area offering less than 68% suggesting large room for
improvement.
Aside from the care processes, there are an additional seven health care essentials that help
prevent diabetes from worsening.
One essential is ensuring people have a care plan to meet their individual needs. At present
it is not known how many people receive one, whether the plans meet the needs of the
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
patients or how consistent and informative they are. This is an area that needs to be
addressed by the Strategic Clinical Network, people with the condition and community
services.
Another area that requires attention is structured education. Guidance recommends offering
structured education to every person and/or their carer at and around the time of diagnosis,
with annual reinforcement and review. However, the numbers being offered are low are the
uptake is poor. Collectively only 14.6% were offered structured education and the uptake
was around 7.2% for both types. Some area’s offered no structured education especially for
type 1 patients with collectively just 3% were offered and not one patient recorded as having
attended. This may be due to the requirements of structured education for younger people
and the current services available. Further data on the services offered to younger people
does suggest a different standard of care is being provided. This is evidenced by data taken
from the National Paediatric Audit that shows across all local Paediatric Diabetes Units only
48 of the 476 patients registered (5.7%) were offered all care processes. Further analysis of
the services may provide an answer as to why this is but there are areas in the audit that
appear substantially more effective such as the Paediatric Diabetes Unit under the
management of the University Hospitals of Morcambe Bay. In this unit 52% of all care
processes are being offered to young people.
Other hospital units also appear effective when it comes to providing inpatient care and
access to a specialist diabetes team. Inpatients at Salford Royal were more than twice as
likely to be visited by a specialist diabetes team during their stay and over 6 times more
likely than inpatients in other units across the footprint. All patients received a foot risk
assessment during their stay and comparatively there were very few medication errors. It is
therefore little surprise the overall patient satisfaction (along with a handful of other units)
exceeded 90%. This suggests it may be beneficial for some units to understand a little more
about the services provided by Salford Royal.
Key findings from the national audit on pregnancy show women with diabetes in the North
West (inclusive of areas within Cheshire and Merseyside) are less prepared for pregnancy
than in many other parts of the country. This is due to less use of folic acid supplements and
less than ideal blood glucose levels. However, once pregnant women are seen earlier by a
specialist diabetes team than in other areas. For reasons not entirely clear, there are more
pre term deliveries either natural or through intervention in the North West; particularly in
women with type 1. This is one of the reasons why fewer babies receive normal neonatal
care and consequently spend more time in special or intensive care and less time with their
mothers.
All considered, the results support the need to review and share best practice across the
footprint; particularly when it comes to prevention. Improvement in the delivery of care
processes especially with young people can help manage the condition more effectively and
help prevent admissions through complications. After all, almost half of diabetic related
admissions are due to complications of diabetic foot and as diabetes UK reported, a large
percentage of unnecessary amputations can be avoided. Evidence suggests individualised
care plans and structured education can help and further exploration needs to be
undertaken as to how best to provide these locally. These could also benefit women with
diabetes hoping to conceive. A further phase of mapping out services across the
conurbation may help identify some of the barriers to equal service delivery and it is hoped
the next iteration of this report will feature this.
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
3. CONDITION TYPES
There are 2 main types of diabetes; type 1 diabetes and type 2 diabetes. There is also
gestational diabetes which occurs during pregnancy and disappears during birth.
Type 1 diabetes
Type 1 diabetes is where the body does not produce any insulin and accounts for around
10% of people with diabetes. Type 1 is an autoimmune condition where the body defence
system mistakes the cells produced by the pancreas as harmful and attacks them. It usually
presents in younger people; typically those under 40 and often teenage years. One in five
children who has Type 1 diabetes will be at increased risk of developing diabetic
ketoacidosis [5], a critical, life-threatening condition that requires immediate medical attention.
As with all diabetes, there is no cure and people with Type 1 require regular insulin injections
to keep the glucose levels normal. Lifestyle and diet also have to be closely monitored.
Type 2 diabetes
Type 2 diabetes is where the body doesn’t provide enough insulin (known as insulin
resistance). It accounts for 90% of people with diabetes. Type 2 is a progressive condition
and often associated with obesity, poor diet and lack of physical exercise. It is also
associated with genetics [6]. Unlike Type 1, Type 2 presents on older adults although the
incidence in increasing. Between 2006 and 2012 the number of people diagnosed with
diabetes in England increased from 1.9 million to 2.5 million [7]. By 2025 it is estimated that
five million people will have diabetes, most of which will be Type 2 diabetes. Treatments can
include dietary and lifestyle advice, medications and in later stages injected therapies such
as insulin.
Gestational diabetes
Gestational Diabetes occurs only during pregnancy (usually in the third trimester) and
disappears during birth. Controlled through diet and exercise and is usually treated with
medication to control blood glucose levels. According to NHS Choices between 2 to 5
women out of every 100 giving birth have diabetes. If left untreated it can lead to
complications at birth.
4. THE IMPACT ON THE POPULATION AND ECONOMY
According to Diabetes UK, diabetes is big, is growing out of control, and current spending
accounts for around 10 per cent of the National Health Service (NHS) budget. As it is a
progressive condition there is a high chance of it worsening with people developing
complications that result in poor outcomes such as disability or even death. The Health and
Social Care Information Centre stated in 2013 the risk of having a myocardial infarction is
55.1% higher in people with diabetes and the risks are significantly increased in having a
stroke (34.1%), Renal Replacement Therapy (164%), major amputation above the ankle
(221%) and minor amputation (337%) [8].
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
High death rates have typically been associated with heart attacks and strokes but recently
focus has been on major amputation in particular. A local study conducted by medical
students in Wythenshawe Hospital between March 2012 and April 2013 show that in that
period there were 69 major amputations or which 43 patients had Critical Limb Ischaemia.
Of this cohort, 52% had diabetes and 81% were male with an average age of 72 years. The
30 day mortality of these patients was 26% and the 12 month mortality 53% <REF>.
5. PREVALENCE LOCALLY
The impact of diabetes in the North West can be provided through the National Clinical
Commissioning Group (CCG) profiles. These reveal the prevalence of diabetes and the
prevalence of known risk factors such as deprivation, obesity and coming from an ethnic
background.
Graph 1:
% Diabetes: QOF prevalence >=17yrs (2012/13)
6.8
Wigan Borough
6.2
West Lancashire
Trafford
5.9
6.7
Tameside And Glossop
Stockport
5.7
South Manchester
5.6
Salford
5.9
6.7
Oldham
6.2
North Manchester
Lancashire North
5.8
6.9
Heywood, Middleton And Rochdale
Greater Preston
6.0
6.5
Fylde & Wyre
6.4
East Lancashire
6.3
Chorley And South Ribble
Central Manchester
Bury
5.6
6.1
7.5
Bolton
Blackpool
Blackburn With Darwen
6.9
7.1
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
Table 1:
% Diabetes and risk factors: QOF prevalence >=17yrs (2012/13)
%of people
from minority
ethnic groups
% of adults
classified as
overweight or
obese
% of adults
with low
levels of
physical
activity
52.4
30.8
67.9
36.9
6.9
48.1
3.3
72.1
34.9
Bolton CCG
7.5
41.4
18.1
60.1
30.8
Bury CCG
6.1
19.5
10.8
68.2
27.9
Central Manchester CCG
5.6
66.7
48.0
62.7
40.2
Chorley And South Ribble CCG
6.3
12.7
2.9
67.5
27.7
East Lancashire CCG
6.4
33.2
11.9
66.5
32.9
Fylde & Wyre CCG
6.5
9.8
2.1
70.0
33.2
Greater Preston CCG
6.0
29.2
14.7
61.1
30.6
Heywood, Middleton And Rochdale CCG
6.9
45.8
18.3
68.6
34.1
Lancashire North CCG
5.8
16.7
4.0
58.2
25.6
North Manchester CCG
6.2
75.2
30.8
62.7
40.2
Oldham CCG
6.7
44.2
22.5
69.6
36.3
Salford CCG
5.9
47.0
9.9
63.3
39.1
South Manchester CCG
5.6
51.9
19.6
62.7
40.2
Stockport CCG
5.7
12.8
7.9
65.9
25.9
Tameside And Glossop CCG
6.7
32.7
8.2
69.2
32.8
Trafford CCG
5.9
11.3
14.5
59.7
24.7
West Lancashire CCG
6.2
18.9
1.9
63.1
26.7
Wigan Borough CCG
6.8
30.3
2.7
65.3
33.2
%
Diabetes
prevalence
% of people
in the most
deprived
quintile
Blackburn With Darwen CCG
7.1
Blackpool CCG
The national average prevalence for England was recorded at 6% and the few CCG areas
with less diabetes than the national average tended to be Central Manchester and below
(geographically) but there is no obvious link from the risk factors above as to why this is.
As cited earlier, the cost of diabetes is high and appears to be increasing year on year which
may suggest diabetes prevalence is increasing faster than the rate the condition is being
controlled through effective management. In 2012/13 the collective cost across the area (not
including South Cumbria) on diabetic prescriptions was over £64 million with an average of
around £290 per person. The National Cardiovascular Intelligence Network’s ‘Diabetes
Outcomes Versus Expenditure’ (DOVE) Tool allows us to compare this spend by each CCG
alongside the relative outcome of achieving HbA1c <64mmol/mol. In the table below local
CCG’s are compared on annual spend on diabetic prescriptions and the percentage
achieving a blood glucose (HbA1c level) less than 64mmol/mol taken from the QOF register.
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Table 2:
Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
Prescription costs 2012/13 and relative outcome
Spend
Outcome
Prescription
cost per head
Total
Spend
% patients with HbA1c
<64mmol/mol
CCG Rank
(out of 211)
Blackburn with Darwen CCG
£284.51
£2,622,005
73.1%
162
Blackpool CCG
£267.69
£2,617,961
79.6%
15
Bolton CCG
£250.46
£4,398,793
78.6%
28
Bury CCG
£287.89
£2,591,598
76.6%
85
Central Manchester CCG
£330.87
£3,157,156
74.7%
135
Chorley and South Ribble CCG
£259.03
£2,299,913
76.6%
83
East Lancashire CCG
£302.43
£5,617,350
75.8%
109
Fylde & Wyre CCG
£274.77
£2,259,168
81.0%
8
Greater Preston CCG
£267.87
£2,696,118
73.8%
153
Heywood, Middleton and Rochdale CCG
£287.62
£3,419,534
69.2%
208
North Lancashire
£286.46
£2,185,110
73.8%
152
North Manchester CCG
£335.12
£3,038,158
69.4%
207
Oldham CCG
£324.47
£4,055,900
71.2%
194
Salford CCG
£251.85
£2,934,053
78.3%
35
South Manchester CCG
£339.84
£2,558,636
74.6%
136
Stockport CCG
£300.42
£4,135,939
78.2%
43
Tameside and Glossop CCG
£320.42
£4,161,337
76.2%
97
Trafford CCG
£312.79
£3,335,268
77.5%
61
West Lancashire CCG
£264.84
£1,491,643
79.9%
10
Wigan Borough CCG
£270.60
£4,727,738
81.1%
7
The last column ranks the countries 211 CCG’s in terms of highest percentage achieving HbA1c <64mmol/mol in order to make
the differences more distinguishable.
The comparison shows the variability on spend versus the achievement of the blood glucose
target across the footprint. This can be seen for example using Bolton, Salford and North
Manchester CCG’s. On average Bolton and Salford CCG’s spend less per person (around
£250) and have a relatively high percentage (close to 79%) achieving HbA1c below
64mmol/mol. However, other CCG’s such as North Manchester appear to spend much more
per person (£335) with a much lower percentage achieving HbA1c <64mmol/mol.
The difference between the average highest and lowest spend per person is £89.38 and the
difference between the average highest and lowest rate achieving HbA1c of <64mmol/mol is
11.9%. If the rest of the area achieved the blood glucose targets of Bolton and Salford
CCG’s with a similar cost per person of around £250, there would be almost a £9 million
saving year on year1. The 2012/13 rates in the aforementioned CCG’s prove that this is
possible but it should be noted target blood glucose is only one outcome and should be
provided as part of care that involves all recommended processes.
1
The number of prescriptions (221,625) multiplied by the lowest average cost per person (£250.36) =
£55,508,197 almost 9 million less than2012/13 £64 million.
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
6. CURRENT GUIDANCE
As early as 2004 the National Institute for Health and Care Excellence (NICE) released
guidance on Type 1 diabetes [9]. This was followed up with guidance for Type 2 diabetes [10]
in 2009 and later Diabetic foot problems: Inpatient management of diabetic foot problems [11].
Also in 2011, NICE built upon recommendations by the National Service Framework and
released their quality standard for diabetes in adults that featured 14 statements designed to
improve the management of people with the condition.
Out of the guidance came the 9 care processes it was felt that everyone with diabetes
should receive as part of their personalised care plans. The processes are:
1. Blood glucose level measurement
2. Blood pressure measurement
3. Cholesterol level measurement
4. Retinal screening
5. Foot and leg check
6. Kidney function testing (urine)
7. Kidney function testing (blood)
8. Weight check
9. Smoking status check
These important markers ensure diabetes is well controlled and are designed to prevent long
term complications [12]. If everyone received these processes it is more likely to achieve
better outcomes, leading to a better and healthier quality of life.
In recent years there have been a number of audits to ascertain what percentages of people
actually receive these 9 processes to improve the management of people with the condition.
This will be reviewed in the next sections of this report.
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
7. AUDITS
The following data has been collected and published by the Health and Social Care
Information Centre through a series of recent audits.
The National Diabetes Audit 2012-13 was published earlier this year and the information on
SCN footprint has been collated and separated to provide a local view of diabetes using
comparisons and performance.
Table 3 list the practice participation rates of the national audit for each CCG along with a
key (also provided in the audit) that helps easily identify high and low participation rates.
Table 3: National Audit Practice Inclusion Rates for 2012-13
CCG/LHB Name
NHS BLACKBURN WITH DARWEN CCG
NHS BLACKPOOL CCG
NHS BOLTON CCG
NHS BURY CCG
NHS CENTRAL MANCHESTER CCG
NHS CHORLEY AND SOUTH RIBBLE CCG
NHS CUMBRIA CCG
NHS EAST LANCASHIRE CCG
NHS FYLDE & WYRE CCG
NHS GREATER PRESTON CCG
NHS HEYWOOD, MIDDLETON AND ROCHDALE CCG
NHS NORTH MANCHESTER CCG
NHS OLDHAM CCG
NHS SALFORD CCG
NHS SOUTH MANCHESTER CCG
NHS STOCKPORT CCG
NHS TAMESIDE AND GLOSSOP CCG
NHS TRAFFORD CCG
NHS WEST LANCASHIRE CCG
NHS WIGAN BOROUGH CCG
England
Wales
Practice
Count
28
23
50
33
37
31
82
59
21
34
37
36
46
48
25
50
42
36
22
64
8003
473
Practices
Submitted
28
23
48
30
4
30
42
56
18
27
34
36
40
48
6
11
36
32
22
55
5666
314
2012-13
Participation
100.0%
100.0%
96.0%
90.9%
10.8%
96.8%
51.2%
94.9%
85.7%
79.4%
91.9%
100.0%
87.0%
100.0%
24.0%
22.0%
85.7%
88.9%
100.0%
85.9%
70.8%
66.4%
Status
r
Key
R
< 50% of practices submitted diabetes data
≥ 50% and < 90% of practices submitted diabetes data
≥ 90% of practices submitted diabetes data
It is not clear why relatively few practices from Central Manchester, South Manchester and
Stockport CCG’s submitted audit data but it is useful to bear in mind when reviewing some of
the audit data as it may not be a true reflection on the patch.
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
Table 4: Diabetes Registrations and Prevalence for 2012-13
Total number of registrations
All
diabetes
Type 1
NHS BLACKBURN WITH
DARWEN CCG
9070
NHS BLACKPOOL CCG
9,659
NHS BOLTON CCG
NHS BURY CCG
NHS CENTRAL MANCHESTER
CCG
NHS CHORLEY AND SOUTH
RIBBLE CCG
8,718
NHS CUMBRIA CCG
14,417
NHS EAST LANCASHIRE CCG
17,856
NHS FYLDE & WYRE CCG
7,016
NHS GREATER PRESTON CCG
NHS HEYWOOD, MIDDLETON
AND ROCHDALE CCG
NHS NORTH MANCHESTER CCG
% of the population
Approximate
registrations if all
practices
submitted*
Type 2
All
Diabetes
Type
1
Type 2
Type 1
Type 2
615
8400
5.41%
0.37%
5.01%
615
8400
687
8,809
5.60%
0.40%
5.11%
687
8809
16,279
924
15,194
5.66%
0.32%
5.28%
963
15827
8,758
674
7,935
4.74%
0.37%
4.29%
741
8729
971
57
900
4.26%
0.25%
3.94%
527
8325
748
7,888
5.03%
0.43%
4.55%
773
8151
1,362
12,934
5.03%
0.48%
4.52%
2659
25252
1,455
16,246
5.07%
0.42%
4.61%
1533
17116
506
6,452
5.39%
0.39%
4.95%
590
7527
8,114
675
7,344
4.94%
0.41%
4.47%
850
9248
9,881
735
9,055
5.22%
0.39%
4.78%
800
9854
8,918
726
8,002
4.70%
0.39%
4.21%
726
8002
NHS OLDHAM CCG
10,138
639
9,396
5.09%
0.33%
4.71%
735
10805
NHS SALFORD CCG
11,207
948
10,088
4.63%
0.40%
4.16%
948
10088
NHS SOUTH MANCHESTER CCG
1,831
167
1,630
4.49%
0.41%
3.99%
696
6792
NHS STOCKPORT CCG
NHS TAMESIDE AND GLOSSOP
CCG
3,343
291
3,025
4.99%
0.43%
4.52%
1323
13750
10,754
857
9,846
5.30%
0.42%
4.86%
1000
11487
NHS TRAFFORD CCG
9,702
839
8,713
4.62%
0.40%
4.15%
944
9802
NHS WEST LANCASHIRE CCG
5,539
473
4,999
4.98%
0.42%
4.49%
473
4999
NHS WIGAN BOROUGH CCG
14,110
1,137
12,404
5.44%
0.44%
4.73%
1323
14434
18,906
217,397
4.87%
0.40%
4.38%
Across SCN Footprint
186,281
14,515
169,260
England and Wales
2058321
177475
1835634
� Diabetes prevalence is calculated using patient registrations from primary care and patient registrations from secondary
care, where the patients GP practice participated in the audit.
� All diabetes includes maturity onset diabetes of the young (MODY), other specified diabetes and not specified diabetes
*Approximate registrations if all practices submitted was calculated by dividing the registrations by the number of practices
submitted and multiplied by the practice count.
The total number of registrations of both type 1 and type 2 diabetes equates to around
184,000 across the network area but it is estimated that if all practices submitted 100% of
data the figure is closer to being 236,000.
Generally the prevalence of diabetes (particularly type 2) is higher across the network area
than the national average. Blackburn with Darwin, Blackpool and Bolton CCG’s all have
high prevalence and considering these CCG’s had a high participation rate, this is likely to
be accurate.
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
8. THE CARE PROCESSES
All patients aged 12 years and over should receive all nine of the NICE recommended care
processes. According to HSCIC the number of people with diabetes recorded in electronic
patient records as having eye screening was not reported in 2012-13 due to variation in the
interpretation of Read Code terminology. The remainder can be compared using data from
the audits.
The tables in this section contain data taken directly from the national audit in
2012/13. As part of publicising this data, HSCIC applied a Red, Amber Green System
in order to make the results more distinguishable. The key below is applied to the
following table.
Key:
Red - <55%
Amber - 55% - 65%
Green - >65%
As the key has been applied nationally and individually to each CCG, the application
is used here to compare local provision in the hope it will prove useful for
benchmarking.
Table 5: Percentage of people receiving the recommended care processes (excluding eye
examinations)
Eight care
processes
2010/11
Blackburn with Darwen CCG
70.6%
56.6%
14.00%
Increased
Blackpool CCG
65.9%
62.3%
3.60%
Increased
Bolton CCG
62.5%
45.6%
16.90%
Increased
Bury CCG
49.9%
61.9%
-12.00%
Fallen
Central Manchester CCG
47.3%
53.9%
-6.60%
Fallen
Chorley and South Ribble CCG
66.0%
67.4%
-1.40%
Fallen
Oldham CCG
65.0%
58.2%
6.80%
Increased
East Lancashire CCG
66.7%
61.7%
5.00%
Increased
Heywood, Middleton and Rochdale
CCG
67.4%
62.4%
5.00%
Increased
Greater Preston CCG
62.6%
60.7%
1.90%
Increased
Salford CCG
63.6%
66.1%
-2.50%
Fallen
Cumbria CCG
70.1%
65.6%
4.50%
Increased
Lancashire North CCG
72.0%
71.0%
1.00%
Increased
North Manchester CCG
59.0%
59.1%
-0.10%
Fallen
South Manchester CCG
60.3%
56.4%
3.90%
Increased
Difference
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Strategic Clinical Network & Senate
Stockport CCG
65.6%
63.8%
1.80%
Increased
Tameside and Glossop CCG
63.5%
67.1%
-3.60%
Fallen
Trafford CCG
57.7%
59.7%
-2.00%
Fallen
West Lancashire CCG
63.9%
62.8%
1.10%
Increased
Wigan Borough CCG
68.4%
69.2%
-0.80%
Fallen
Fylde & Wyre CCG
71.5%
70.1%
1.40%
Increased
England and Wales
59.9%
From the above table it is clear that the percentage of people offered all 8 care processes
varies from as little as 47.3% to 72.0%. More than half of all areas are below the target rate
of 65% with 4 CCG’s being below national level. The last 3 columns have been taken from
older data to show how the proportion has changed compared to an earlier audit. They
show significant improvements for Blackburn and Darwin and Bolton CCG’s and quite a
large decrease in care processes received in Bury.
Blood glucose level measurement (Glycosylated haemoglobin)
Blood glucose levels or Glycosylated haemoglobin (HbA1c) should be measured at least
once a year and helps contribute to effective diabetes management only if it is part of a
comprehensive system of care where people receive all of the key care processes [7].
A blood test measures the average blood glucose levels over the previous three months.
Glucose attaches itself to red blood cells and as these cells live for approximately 120 days
the average glucose level during that time can be measured. HbA1c is expressed as a
percentage and indicates how well diabetes is controlled.
NICE guidance states blood glucose control should be optimised towards attaining Diabetes
Control and Complications Trial-harmonised HbA1c targets for prevention of microvascular
disease (less than 7.5%) and, in those at increased risk, arterial disease (less than or equal
to 6.5%) as appropriate, while taking into account:
 the experiences and preferences of the insulin user, in order to avoid hypoglycaemia
 the necessity to seek advice from professionals knowledgeable about the range of
available
 meal-time and basal insulins and about optimal combinations thereof, and their
optimal use [13]
The following table looks at the percentage of people with diabetes being offered this care
process and the effectiveness of the diabetic treatment via HbA1c levels in the 2012-13
period. The following key is applied to all care processes in this section.
Red - <70%
Amber - 70% - 75%
Green - >75%
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
Table 6: % all diabetics offered blood glucose monitoring 2012-13 and the % HbA1c level
HbA1c
HbA1c
<48mmol/mol (6.5%)
HbA1c
<58mmol/mol (7.5%)
HbA1c <86mmol/mol
(10.0%)
Blackburn with Darwen CCG
93.3%
19.2%
55.4%
89.0%
Blackpool CCG
90.2%
35.7%
66.5%
92.0%
Bolton CCG
93.8%
35.6%
68.6%
92.5%
Bury CCG
92.9%
19.4%
61.5%
91.4%
Central Manchester CCG
91.0%
30.4%
62.3%
91.1%
Chorley and South Ribble CCG
92.1%
25.8%
63.7%
92.3%
Oldham CCG
92.4%
16.7%
58.2%
89.5%
East Lancashire CCG
93.2%
19.0%
55.3%
89.6%
Heywood, Middleton and Rochdale CCG
93.4%
17.3%
56.9%
88.3%
Greater Preston CCG
92.2%
22.4%
60.3%
90.8%
Salford CCG
92.9%
32.7%
66.7%
92.1%
Cumbria CCG
95.5%
19.4%
59.8%
91.3%
Lancashire North CCG
91.0%
23.6%
63.5%
93.2%
North Manchester CCG
90.3%
20.0%
58.2%
87.8%
South Manchester CCG
91.5%
25.4%
58.3%
89.6%
Stockport CCG
94.0%
24.9%
62.7%
92.4%
Tameside and Glossop CCG
91.7%
26.6%
66.3%
91.6%
Trafford CCG
90.4%
33.0%
67.1%
93.7%
West Lancashire CCG
92.5%
38.6%
73.0%
95.4%
Wigan Borough CCG
90.6%
37.2%
72.1%
94.2%
Fylde & Wyre CCG
92.6%
35.5%
68.1%
93.3%
England and Wales
92.4%
25.1%
62.2%
92.4%
From the table it is clear that all areas are below the target rate of 75% for HbA1c
58mmol/mol (7.5%). Being below 7.5% is likely to minimise risk of developing diabetic eye,
kidney or nerve damage in the longer term.
This can be broken down further by reviewing type 1 and type 2 in order to identify the
challenging areas.
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Strategic Clinical Network & Senate
Table 7: % type 1 diabetics offered blood glucose monitoring 2012-13 and the % HbA1c
level
HbA1c
HbA1c <48mmol/mol
(6.5%)
HbA1c <58mmol/mol
(7.5%)
HbA1c <86mmol/mol
(10.0%)
Blackburn with Darwen CCG
83.7%
4.9%
18.3%
73.0%
Blackpool CCG
75.1%
8.4%
26.3%
81.1%
Bolton CCG
79.1%
6.9%
21.9%
78.7%
Bury CCG
77.7%
2.9%
21.3%
80.0%
Central Manchester CCG
66.7%
15.8%
28.9%
84.2%
Chorley and South Ribble CCG
74.1%
5.0%
21.8%
81.4%
Oldham CCG
80.8%
5.2%
19.1%
74.9%
East Lancashire CCG
81.9%
4.8%
21.1%
76.5%
Heywood, Middleton and Rochdale CCG
78.8%
5.1%
18.9%
73.2%
Greater Preston CCG
76.0%
4.8%
21.0%
78.8%
Salford CCG
81.3%
8.8%
30.2%
80.8%
Cumbria CCG
87.4%
3.9%
20.0%
77.3%
Lancashire North CCG
76.1%
3.4%
20.8%
79.2%
North Manchester CCG
78.4%
7.6%
22.5%
73.4%
South Manchester CCG
75.4%
5.6%
19.0%
75.4%
Stockport CCG
86.6%
6.3%
31.0%
83.7%
Tameside and Glossop CCG
73.7%
5.9%
23.0%
77.2%
Trafford CCG
75.7%
9.2%
31.8%
84.7%
West Lancashire CCG
82.0%
10.7%
35.3%
90.5%
Wigan Borough CCG
78.2%
9.0%
26.7%
82.3%
Fylde & Wyre CCG
81.8%
7.7%
24.6%
81.4%
England and Wales
80.5%
7.5%
27.3%
83.0%
Central Manchester, Chorley and South Ribble and Tameside and Glossop CCG’s appear
as the obvious CCG’s to have struggled to offer type 1 HbA1c testing in the period although
it should be reiterated Central Manchester provided a poor submission rate so it may not be
an accurate reflection. 13 out of 21 CCG’s (62%) across the footprint offered less than the
national average.
Achieving HbA1c <58mmol/mol (7.5%) nationally is a problem and although all areas are
rated red by HSCIC, area’s such as West Lancashire CCG are achieving almost twice as
much as other CCG’s in the patch.
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
Table 8: % type 2 diabetics offered blood glucose monitoring 2012-13 and the % HbA1c
level
HbA1c
HbA1c <48mmol/mol
(6.5%)
HbA1c <58mmol/mol
(7.5%)
HbA1c <86mmol/mol
(10.0%)
Blackburn with Darwen CCG
94.2%
20.1%
57.8%
90.1%
Blackpool CCG
91.7%
37.6%
69.3%
92.8%
Bolton CCG
94.9%
37.1%
70.8%
93.2%
Bury CCG
94.4%
20.5%
64.3%
92.1%
Central Manchester CCG
92.9%
30.9%
64.0%
91.5%
Chorley and South Ribble CCG
94.1%
27.4%
66.8%
93.1%
Oldham CCG
93.4%
17.3%
60.4%
90.3%
East Lancashire CCG
94.5%
20.0%
57.9%
90.6%
Heywood, Middleton and Rochdale CCG
94.8%
18.1%
59.6%
89.4%
Greater Preston CCG
94.0%
23.8%
63.2%
91.7%
Salford CCG
94.3%
34.5%
69.6%
93.1%
Cumbria CCG
96.5%
20.8%
63.5%
92.7%
Lancashire North CCG
93.0%
25.4%
67.4%
94.5%
North Manchester CCG
91.9%
21.1%
61.4%
89.1%
South Manchester CCG
93.4%
27.1%
61.8%
90.8%
Stockport CCG
94.8%
26.4%
65.5%
93.2%
Tameside and Glossop CCG
93.4%
28.0%
69.3%
92.6%
Trafford CCG
92.1%
34.9%
69.9%
94.4%
West Lancashire CCG
93.6%
41.0%
76.4%
95.8%
Wigan Borough CCG
93.3%
39.0%
75.4%
95.0%
Fylde & Wyre CCG
93.5%
37.3%
71.0%
94.1%
England and Wales
93.8%
26.4%
64.8%
93.1%
Blood glucose monitoring is much higher in type 2 patients as a whole with over 50% of
CCG’s faring better than the England and Wales average of achieving 7.5%. West
Lancashire and Wigan CCG’s are doing particularly well; however there is much room for
improvement as less than 10% of CCG’s are achieving the 7.5% target.
Blood pressure measurement
It is recommended people with diabetes have their blood pressure at least once a year.
Once diabetes has been confirmed, blood pressure should consistently be kept <140/80
mmHg: if the patient has kidney, eye or cerebrovascular damage, the target should be
<130/80 mmHg [12]. Poor blood pressure management can lead to significant
cardiovascular event such as heart attack or strokes so remains important to keep it under
control.
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
Table 9: Treatment target rates for blood pressure
All diabetes
Type 1
Type 2
Blood
pressure
BP
<=140/80
Blood
pressure
BP
<=140/80
Blood
pressure
BP
<=140/80
Blackburn with Darwen CCG
94.4%
72.1%
83.3%
81.0%
95.3%
71.6%
Blackpool CCG
93.2%
70.4%
84.3%
73.3%
93.9%
70.3%
Bolton CCG
95.2%
70.5%
86.5%
75.6%
95.9%
70.3%
Bury CCG
94.9%
72.3%
89.2%
74.3%
95.5%
72.3%
Central Manchester CCG
94.0%
63.8%
79.2%
85.4%
95.1%
62.8%
Chorley and South Ribble CCG
94.5%
73.2%
86.9%
71.3%
95.2%
73.4%
Oldham CCG
94.5%
67.3%
90.2%
75.3%
95.0%
66.8%
East Lancashire CCG
94.5%
70.9%
86.6%
72.9%
95.3%
70.9%
Heywood, Middleton and Rochdale CCG
94.4%
72.4%
87.3%
72.8%
95.1%
72.5%
Greater Preston CCG
95.1%
70.5%
87.6%
72.8%
95.8%
70.3%
Salford CCG
95.9%
71.3%
90.1%
73.3%
96.6%
71.3%
Cumbria CCG
97.5%
68.1%
93.3%
70.2%
98.0%
68.1%
Lancashire North CCG
95.8%
68.1%
86.9%
73.7%
96.9%
67.8%
North Manchester CCG
93.6%
67.1%
83.7%
73.6%
94.8%
66.8%
South Manchester CCG
93.6%
68.4%
84.6%
67.2%
94.8%
68.8%
Stockport CCG
95.0%
74.0%
84.7%
80.6%
95.9%
73.6%
Tameside and Glossop CCG
95.4%
69.3%
87.0%
74.7%
96.2%
68.8%
Trafford CCG
95.1%
67.7%
92.7%
67.3%
95.5%
67.9%
West Lancashire CCG
95.2%
74.2%
87.8%
81.3%
95.9%
73.8%
Wigan Borough CCG
94.8%
77.4%
84.7%
79.3%
95.9%
77.6%
Fylde & Wyre CCG
94.4%
69.7%
86.9%
75.1%
95.0%
69.5%
England and Wales
95.3%
69.0%
88.8%
73.4%
96.1%
68.7%
The percentage of people offered blood pressure checks nationally is high. It is the
challenge to control blood pressure levels that may need to be addressed. Type 2 more so
because of type is often attributed to lifestyle. Adults with diabetes should be offered
information on the potential for lifestyle changes to improve blood pressure control and
associated outcomes, and offered assistance in achieving their aims in this area.
Where intervention is required, the choice of intervention and level should be discussed with
the patient as well as the gains and potential negative effects of therapy.
Cholesterol level measurement
High cholesterol increases the risk of cardiovascular disease and subsequent cardiovascular
events. NICE recommend a full fasting lipid profile should be conducted and repeated
annually with an aim of total cholesterol below 4.0 mmol/L and low-density lipoproteins
below 2.0 mmol/L although it is accepted this is a huge undertaking.
Ideally personalised care planning should be in place, and support to self-manage should
include providing people with their HbA1c, blood pressure and cholesterol results prior to
their annual review.
20 | P a g e
Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
Table 10: Treatment target rates for Cholesterol
All Diabetes
Type 1
Type 2
Cholesterol
Cholesterol
<4mmol/L
Cholesterol
<5mmol/L
Cholesterol
Cholesterol
<4mmol/L
Cholesterol
<5mmol/L
Cholesterol
Cholesterol
<4mmol/L
Cholesterol
<5mmol/L
Blackburn with Darwen CCG
90.8%
38.3%
73.6%
77.1%
27.7%
66.5%
92.0%
38.9%
74.0%
Blackpool CCG
87.9%
40.3%
74.6%
66.6%
22.9%
63.0%
89.7%
41.6%
75.6%
Bolton CCG
92.6%
38.8%
75.1%
78.3%
24.9%
65.7%
93.6%
39.5%
75.6%
Bury CCG
92.3%
37.3%
75.3%
81.0%
25.9%
69.9%
93.4%
38.3%
75.9%
Central Manchester CCG
90.3%
44.0%
78.6%
77.4%
26.8%
63.4%
91.3%
45.1%
79.8%
Chorley and South Ribble CCG
89.4%
37.9%
74.7%
69.3%
27.0%
66.5%
91.5%
38.6%
75.4%
Oldham CCG
91.4%
45.3%
79.6%
79.9%
28.7%
69.4%
92.3%
46.3%
80.3%
East Lancashire CCG
91.3%
39.7%
74.9%
77.5%
30.8%
70.6%
92.6%
40.4%
75.2%
Heywood, Middleton and Rochdale CCG
93.2%
39.6%
76.7%
82.3%
29.6%
71.8%
94.2%
40.3%
77.0%
Greater Preston CCG
90.1%
38.7%
74.9%
71.2%
26.2%
69.0%
92.0%
39.7%
75.5%
Salford CCG
91.9%
41.4%
77.9%
81.7%
30.5%
72.5%
93.0%
42.5%
78.4%
Cumbria CCG
94.3%
35.5%
72.8%
86.6%
24.0%
66.5%
95.3%
36.7%
73.4%
Lancashire North CCG
91.4%
43.4%
78.3%
78.8%
24.8%
69.7%
93.0%
45.3%
79.2%
North Manchester CCG
89.9%
43.2%
78.6%
78.7%
30.6%
72.5%
91.4%
44.4%
79.3%
South Manchester CCG
89.6%
42.4%
78.4%
71.6%
29.3%
72.4%
91.7%
43.7%
79.2%
Stockport CCG
91.4%
50.6%
82.1%
80.1%
43.3%
75.0%
92.6%
51.3%
82.8%
Tameside and Glossop CCG
90.8%
47.7%
80.9%
75.8%
34.7%
72.8%
92.2%
48.7%
81.6%
Trafford CCG
88.5%
40.8%
77.0%
74.5%
31.2%
68.2%
90.0%
41.7%
77.9%
West Lancashire CCG
91.5%
38.5%
76.2%
78.6%
31.8%
74.9%
92.9%
39.2%
76.4%
Wigan Borough CCG
90.8%
41.5%
78.7%
72.2%
37.5%
76.5%
92.8%
41.7%
79.0%
Fylde & Wyre CCG
91.2%
38.3%
73.3%
74.9%
29.7%
69.0%
92.5%
38.8%
73.7%
England and Wales
91.1%
39.6%
76.2%
78.0%
28.7%
70.2%
92.5%
40.5%
76.8%
From the table it is evident the main task is not just improving type 1 cholesterol levels, but offering them cholesterol tests at least annually.
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Greater Manchester, Lancashire & South Cumbria
Strategic Clinical Network & Senate
Foot and leg checks
Complications of diabetes can result in foot problems that can have a severe impact on
mobility and quality of life. Common problems are infection, osteomyelitis, neuropathy,
peripheral arterial disease and Charcot arthropathy.
Diabetic foot requires urgent attention and failure to get the right care can lead to the
conditioning worsening to the point the person may require amputation or even die.
Amputations are associated with high death rates and according Diabetes UK 80% of these
is preventable if people receive the correct management [7].
Therefore, all people with diabetes should have annual foot checks, be told and understand
their risk score, know how to look after their own feet. People in all areas should have swift
access to Foot Protection or Multidisciplinary Foot Care Teams, which have been shown to
significantly reduce levels of risk. People with diabetes that go into hospital, for whatever
reason, should have their feet checked on admission and throughout their stay and
healthcare professionals need a greater understanding of the importance of diabetes foot
care.
Table 11 shows the foot surveillance offered to people with diabetes by CCG.
Table 11: % of people offered annual foot surveillance 2012-13
All
Type 1
Type 2
Blackburn with Darwen CCG
85.5%
64.3%
87.3%
Blackpool CCG
82.3%
63.4%
84.1%
Bolton CCG
80.1%
72.0%
80.8%
Bury CCG
85.1%
70.8%
86.8%
Central Manchester CCG
87.6%
73.6%
89.1%
Chorley and South Ribble CCG
82.5%
61.7%
84.8%
Oldham CCG
82.9%
64.8%
84.5%
East Lancashire CCG
82.9%
63.2%
84.9%
Heywood, Middleton and Rochdale CCG
88.1%
75.7%
89.4%
Greater Preston CCG
78.6%
64.7%
80.2%
Salford CCG
81.9%
75.2%
83.0%
Cumbria CCG
84.1%
72.9%
85.5%
Lancashire North CCG
85.9%
72.7%
87.7%
North Manchester CCG
80.5%
65.6%
82.7%
South Manchester CCG
82.7%
66.0%
85.0%
Stockport CCG
83.8%
69.0%
85.4%
Tameside and Glossop CCG
80.5%
66.1%
82.0%
Trafford CCG
84.2%
69.4%
86.1%
West Lancashire CCG
83.4%
67.3%
85.3%
Wigan Borough CCG
87.8%
76.2%
90.2%
Fylde & Wyre CCG
87.5%
76.0%
88.6%
England and Wales
85.1%
72.3%
86.7%
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Improving the foot surveillance offered to people with diabetes should be a priority across
the foot print; particularly those with type 1 diabetes.
Standards state there should be an assessment that looks at signs of neuropathy,
ischaemia, ulceration, inflammation and/or infection, deformity and Charcot arthropathy.
Any new or existing diabetic foot problems should be documented and urgent advice should
be sought from an appropriate specialist if fever or any other signs or symptoms of systemic
sepsis; clinical concern that there is a deep-seated infection (for example palpable gas) or
limb ischaemia is present.
Work has been undertaken across the SCN footprint in 2014 to improve pathways and
awareness of Critical Limb Ischaemia.
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Kidney function testing (urine)
Kidney disease is more common in people with diabetes and people with high blood
pressure. Renal failure in people with diabetes is up by almost a third since 2006-7. At
annual review checks should be carried out to look at how well the kidneys are working
[7].
This can be done in two ways. The first way is by asking the patient to bring in a first-pass
morning urine specimen once a year. This is a test for albumin: creatinine ratio which is
measured by pathologists. If there is an abnormal result the patient should have a
secondary test done within 3-4 months. If still abnormal (>=2.5 mg/mmol for men and >=3.5
mg/mmol for women) it could be a sign of renal disease. The test should be delayed if the
patient who is a woman who is menstruating or if the patient has a urinary infection.
Table 12: % people offered urine albumin tests at least once a year
All
Type 1
Type 2
Blackburn with Darwen CCG
77.8%
51.0%
79.9%
Blackpool CCG
79.5%
54.0%
81.7%
Bolton CCG
81.3%
59.6%
82.9%
Bury CCG
58.5%
46.5%
59.6%
Central Manchester CCG
73.2%
45.3%
75.2%
Chorley and South Ribble CCG
82.9%
58.6%
85.4%
Oldham CCG
83.2%
66.1%
84.6%
East Lancashire CCG
79.4%
54.6%
81.7%
Heywood, Middleton and Rochdale CCG
78.9%
63.4%
80.4%
Greater Preston CCG
81.1%
59.6%
83.3%
Salford CCG
81.7%
71.1%
83.0%
Cumbria CCG
84.6%
69.9%
86.3%
Lancashire North CCG
83.0%
63.8%
85.4%
North Manchester CCG
76.7%
59.2%
79.1%
South Manchester CCG
69.8%
45.1%
72.7%
Stockport CCG
83.6%
66.5%
85.3%
Tameside and Glossop CCG
81.8%
59.1%
84.0%
Trafford CCG
73.8%
51.5%
76.2%
West Lancashire CCG
82.7%
60.1%
85.3%
Wigan Borough CCG
83.5%
67.2%
86.5%
Fylde & Wyre CCG
83.4%
63.2%
85.0%
England and Wales
73.6%
57.1%
75.4%
Most areas are offering the required test for type 2 patients whilst type 1 continue to be less
than desired with a third of CCG’s below the national level in England and Wales.
In cases of raised ACR NICE guidance recommends:
 Start ACE inhibitor and titrate to full dose
 Advise women regarding pregnancy and ACE inhibitors
 If ACE inhibitors are not tolerated change to an angiotensin 2-receptor antagonist
 Maintain blood pressure <130/80 mmHg
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Kidney function testing (blood)
Serum creatinine is a blood test for kidney function that should be offered at the same
appointment as the urine sample. If serum creatinine levels are >130 micromol/L or the
estimated glomerular filtration rate is below 45 ml/min/1.73 m2 then the patient’s dose of
metformin should be reviewed if appropriate. Once the creatinine level reaches 150
micromol/L or the eGFR is <30 ml/min/1.73 m2 metformin should be stopped. A rising
serum creatinine and a decreasing eGFR are indicative of renal disease [12].
As table 11 shows, serum creatinine testing is currently offered to a high proportion of
people with diabetes at least once a year.
Table 13: % people offered serum creatinine tests at least once a year
All
Type 1
Type 2
Blackburn with Darwen CCG
93.4%
85.2%
94.1%
Blackpool CCG
91.2%
73.6%
92.7%
Bolton CCG
94.0%
81.2%
94.9%
Bury CCG
93.8%
83.9%
94.7%
Central Manchester CCG
91.8%
79.2%
92.9%
Chorley and South Ribble CCG
91.5%
70.0%
93.5%
Oldham CCG
93.0%
81.7%
93.9%
East Lancashire CCG
93.7%
83.5%
94.7%
Heywood, Middleton and Rochdale CCG
94.3%
84.3%
95.2%
Greater Preston CCG
91.9%
73.4%
93.7%
Salford CCG
93.6%
83.8%
94.8%
Cumbria CCG
96.3%
89.0%
97.1%
Lancashire North CCG
93.4%
78.8%
95.1%
North Manchester CCG
91.3%
79.8%
92.7%
South Manchester CCG
91.2%
75.9%
93.1%
Stockport CCG
93.3%
81.5%
94.4%
Tameside and Glossop CCG
92.6%
79.4%
93.9%
Trafford CCG
90.5%
77.6%
91.9%
West Lancashire CCG
92.7%
79.5%
94.0%
Wigan Borough CCG
91.9%
78.3%
94.4%
Fylde & Wyre CCG
93.3%
79.9%
94.4%
England and Wales
92.5%
81.0%
93.7%
Weight check
Weight management is important when managing people with diabetes.
Insulin resistance means that the body produces insulin but fails to recognise and use it. The
pancreas works harder to produce more insulin, but eventually fails. Over-production of
insulin stimulates the appetite, making people feel hungry and eat more; resulting in gradual
weight gain before and after diabetes is diagnosed. As a result, patients find it difficult to lose
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weight. Being either overweight or obese is a risk factor with type especially with type 2
diabetes and weight reduction is effective in improving glycaemic control and reducing
cardiovascular risk factors. Weight loss is also associated with a reduction in mortality of 25
per cent [14].
It is proposed that regular monitoring a patient’s weight should take place to help maintain a
healthy body weight. This includes taking a patients weight and determining their body mass
index.
Table 14: % people having their weight monitored at least once a year
All
Type 1
Type 2
England and Wales
90.7%
84.1%
91.5%
Blackburn with Darwen CCG
90.8%
74.4%
92.1%
Blackpool CCG
84.0%
70.4%
85.1%
Bolton CCG
90.7%
78.4%
91.6%
Bury CCG
90.5%
84.2%
91.3%
Central Manchester CCG
89.0%
84.9%
89.6%
Chorley and South Ribble CCG
90.8%
78.6%
92.1%
Oldham CCG
90.6%
84.6%
91.3%
East Lancashire CCG
90.0%
78.4%
91.1%
Heywood, Middleton and Rochdale CCG
92.0%
85.9%
92.7%
Greater Preston CCG
90.3%
83.1%
91.1%
Salford CCG
91.2%
84.8%
91.9%
Cumbria CCG
92.8%
87.7%
93.4%
Lancashire North CCG
90.9%
81.2%
92.3%
North Manchester CCG
88.8%
82.5%
89.9%
South Manchester CCG
88.6%
75.9%
90.4%
Stockport CCG
91.4%
81.5%
92.4%
Tameside and Glossop CCG
90.1%
81.6%
91.0%
Trafford CCG
90.2%
91.0%
90.3%
West Lancashire CCG
89.9%
81.5%
90.8%
Wigan Borough CCG
91.4%
78.5%
92.9%
Fylde & Wyre CCG
90.8%
81.7%
91.6%
Weight monitoring is high across the region. What is important is that advice is given to
patients to help a healthy balanced diet and prevent or recognise hypogryoaemia. A
structured education programme should be considered.
Smoking status check
On top other risk factors, smoking increases the risk of cardiovascular problems. Smoking
decreases the amount of available oxygen in the body and also has a significant effect on
lipid levels. By increasing low-density lipoproteins (LDL) and decreasing beneficial highdensity lipoproteins (HDL), atherosclerosis is speeded up and the likelihood of strokes, heart
attacks and peripheral vascular disease is increased [12].
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It is felt that continued advice and support should be offered to patients who smoke to help
them quit. NICE released some public health guidance in 2008 for smoking cessation
services in primary care, pharmacies, local authorities and workplaces, particularly for
manual working groups, pregnant women and hard to reach communities. Guidance offers
being referred to local stop smoking services, receiving behavioural support from the local
stop smoking service and the use nicotine replacement therapy (NRT)/varenicline or
bupropion if clinically indicated. The percentage offering smoking advice within the period is
seen below.
Table 15: % people being offered smoking advice at least once a year
All
Type 1
Type 2
England and Wales
86.1%
79.8%
86.8%
Blackburn with Darwen CCG
92.0%
85.7%
92.6%
Blackpool CCG
91.3%
81.2%
92.1%
Bolton CCG
88.6%
80.0%
89.2%
Bury CCG
87.5%
85.0%
87.8%
Central Manchester CCG
72.0%
67.9%
72.6%
Chorley and South Ribble CCG
86.8%
70.5%
88.3%
Oldham CCG
84.1%
81.7%
84.4%
East Lancashire CCG
87.9%
83.6%
88.3%
Heywood, Middleton and Rochdale CCG
88.4%
87.4%
88.6%
Greater Preston CCG
87.5%
79.2%
88.3%
Salford CCG
88.4%
79.4%
89.3%
Cumbria CCG
90.5%
84.5%
91.2%
Lancashire North CCG
91.1%
80.7%
92.3%
North Manchester CCG
81.5%
78.6%
81.9%
South Manchester CCG
86.5%
70.4%
88.4%
Stockport CCG
86.0%
80.4%
86.6%
Tameside and Glossop CCG
87.1%
77.0%
88.1%
Trafford CCG
82.1%
73.7%
83.0%
West Lancashire CCG
84.0%
76.0%
84.7%
Wigan Borough CCG
86.7%
80.1%
88.3%
Fylde & Wyre CCG
90.0%
80.7%
90.7%
9. SEVEN ADDITIONAL HEALTH CARE ESSENTIALS
As well as the care processes, additional healthcare essentials should be considered to
improve the care for people with diabetes. These have been highlighted by NICE and
Diabetes UK.
Care Planning
People should receive care planning to meet their individual needs and support their selfmanagement – they live with diabetes every day and should have a say in every aspect of
their care.
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A yearly care plan should be agreed as a result of a discussion between the person and their
diabetes healthcare team, where they discuss and agree individual needs and set targets.
Personalised care planning helps to achieve both processes and outcomes [7].
Structured Education
Guidance recommends offering structured education to every person and/or their carer at
and around the time of diagnosis, with annual reinforcement and review. It also
recommends informing people and their carers that structured education is an integral part of
diabetes care [10].
In 2011/12, the national diabetes audit reported that on average around 14% of people
diagnosed with diabetes within a year were referred to structured education [15]. In 2012/13,
audit data across the North West suggests that 14.6% of all newly diagnosed people were
offered structured education. Table 13 breaks this down.
Table 16:
Structured education for newly diagnosed people with diabetes, 2012-2013,
broken down by Clinical Commissioning Group (CCG)
Offered
or
Attended
in
Numbers
All newly
diagnosed
Offered
(%)
Offered
in
numbers
Attended
(%)
Attended
in
numbers
Offered
or
Attended
(%)
Blackburn with Darwen CCG
842
52%
438
1%
4
52%
442
Blackpool CCG
955
25%
237
6%
14
26%
251
Bolton CCG
1,675
2%
32
0%
0
2%
32
Bury CCG
1,059
2%
18
0%
0
2%
18
115
0%
0
0%
0
0%
0
CCG description
Central Manchester CCG
Chorley and South Ribble CCG
799
22%
175
6%
11
26%
186
Oldham CCG
1,161
4%
42
0%
0
4%
42
East Lancashire CCG
1,479
6%
91
1%
1
7%
92
Heywood, Middleton and Rochdale CCG
1,148
5%
63
1%
1
6%
64
695
8%
55
5%
3
12%
58
Salford CCG
1,101
8%
88
1%
1
9%
89
Cumbria CCG
2,009
57%
1145
14%
157
58%
1302
North Manchester CCG
1,050
3%
35
0%
0
4%
35
South Manchester CCG
189
5%
10
0%
0
5%
10
Stockport CCG
285
14%
39
2%
1
14%
40
Greater Preston CCG
Tameside and Glossop CCG
1,035
1%
13
0%
0
1%
13
Trafford CCG
732
9%
67
2%
1
11%
68
West Lancashire CCG
504
17%
88
3%
3
19%
91
Wigan Borough CCG
1,371
5%
64
0%
0
5%
64
630
8%
53
3%
1
9%
54
Fylde & Wyre CCG
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Collectively, the attendance rate of those offered structure education was around 7.2%.
Both the offered and attendance figures owe much to Blackburn and Darwen and Cumbria
CCG’s; the latter achieving a 14% attendance rate in the period.
Table 17:
Structured education for newly diagnosed people with Type 1 diabetes, 20122013
Attende
d (%)
0%
Attende
d
numbers
-
Offered
or
Attende
d (%)
36%
Offered
or
attended
numbers
9
3
0%
-
9%
3
-
0%
-
0%
-
3%
1
0%
-
3%
1
5
0%
-
0%
-
0%
-
23
0%
-
0%
-
0%
-
27
0%
-
0%
-
0%
-
East Lancashire CCG
64
0%
-
2%
-
2%
-
Heywood, Middleton and Rochdale CCG
40
5%
2
3%
0
8%
2
Greater Preston CCG
25
0%
-
0%
-
0%
-
Salford CCG
52
0%
-
0%
-
0%
-
Cumbria CCG
42
7%
3
0%
-
7%
3
North Manchester CCG
48
0%
-
0%
-
0%
-
South Manchester CCG
11
0%
-
0%
-
0%
-
Stockport CCG
15
0%
-
0%
-
0%
-
Tameside and Glossop CCG
47
0%
-
2%
-
2%
-
Trafford CCG
43
0%
-
0%
-
0%
-
West Lancashire CCG
21
5%
1
0%
-
5%
1
Wigan Borough CCG
54
0%
-
0%
-
0%
-
Fylde & Wyre CCG
19
0%
-
0%
-
0%
-
Type 1
newly
diagnosed
25
Offere
d (%)
36%
Offered
numbers
9
Blackpool CCG
32
9%
Bolton CCG
50
0%
Bury CCG
32
Central Manchester CCG
Chorley and South Ribble CCG
Oldham CCG
CCG description
Blackburn with Darwen CCG
Collectively only 19 people out of 675 people (3%) with newly diagnosed type 1 diabetes
were offered structured education in the period and not one patient attended.
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Table 18:
Structured education for newly diagnosed people with Type 2 diabetes, 20122013
Attende
d
numbers
Offered
or
Attende
dᵃ
Offered
or
attended
numbers
1%
4
53%
431
6%
14
26%
234
32
0%
-
2%
32
2%
16
0%
-
2%
16
0%
-
0%
-
0%
-
753
23%
172
7%
11
27%
183
Oldham CCG
1,110
4%
42
0%
0
4%
42
East Lancashire CCG
1,353
7%
91
1%
1
7%
92
Heywood, Middleton and Rochdale CCG
1,074
6%
61
1%
1
6%
62
Greater Preston CCG
628
8%
51
5%
3
13%
54
Salford CCG
984
9%
86
2%
1
10%
87
Cumbria CCG
1,901
59%
1,120
14%
158
60%
1,278
North Manchester CCG
926
3%
31
0%
0
4%
31
South Manchester CCG
166
5%
9
0%
-
5%
9
Stockport CCG
265
14%
38
2%
1
15%
39
Tameside and Glossop CCG
970
1%
12
0%
-
1%
12
Trafford CCG
645
10%
67
2%
2
12%
69
West Lancashire CCG
453
19%
86
4%
3
21%
89
Wigan Borough CCG
1,129
6%
63
0%
0
6%
63
601
9%
53
3%
1
9%
54
Type 2
newly
diagnosed
Offere
d (%)
Offered
numbers
Attende
d (%)
Blackburn with Darwen CCG
805
53%
427
Blackpool CCG
862
26%
220
1,557
2%
Bury CCG
949
Central Manchester CCG
104
Chorley and South Ribble CCG
CCG description
Bolton CCG
Fylde & Wyre CCG
15.5% of all people with newly diagnosed type 2 diabetes were offered structured education
with a 7.5% uptake. Again these higher percentages are due to the Blackburn and Darwen
and Cumbria CCG’s and the percentage offered is significantly greater than that offered type
1.
According to NICE:
 Any programme should be evidence-based and suit the needs of the individual. The
programme should have specific aims and learning objectives, and should support
development of self-management attitudes, beliefs, knowledge and skills for the
learner, their family and carers.

The programme should have a structured curriculum that is theory driven and
evidence-based, resource-effective, has supporting materials, and is written down.

The programme should be delivered by trained educators who have an
understanding of education theory appropriate to the age and needs of the
programme learners, and are trained and competent in delivery of the principles and
content of the programme they are offering.
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
The programme itself should be quality assured, and be reviewed by trained,
competent, independent assessors who assess it against key criteria to ensure
sustained consistency.

The outcomes from the programme should be regularly audited.

Ensure the patient-education programme provides the necessary resources to
support the educators, and that educators are properly trained and given time to
develop and maintain their skills.

Offer group education programmes as the preferred option. Provide an alternative of
equal standard for a person unable or unwilling to participate in group education.

Ensure the patient-education programmes available meet the cultural, linguistic
cognitive and literacy needs in the locality.

Ensure all members of the diabetes healthcare team are familiar with the
programmes of patient education available locally, that these programmes are
integrated with the rest of the care pathway, and that people with diabetes and their
carers have the opportunity to contribute to the design and provision of local
programmes.
Guidance since 2003 suggests structured education and self-management support helps
people manage their own diabetes. From the tables it is clear structured education is an
area that can be vastly improved in terms of a service available, offered and encouragement
of uptake.
Paediatric care
Children and young people with diabetes are entitled to high quality diabetes care however;
historically the services offered have been inconsistent putting them at risk of complications
later in life. According to the Hvidoere Study Group on Childhood Diabetes the UK was one
of the worst performing countries in Europe in terms of blood glucose levels for children with
diabetes [16].
Over the last 10 years, paediatric data such as incidence, registrations and provision of care
processes has been collected by the national paediatric diabetes audit. In 2012 – 13 the
audit collected data for over 25,000 children and young people under the age of 25 with a
diagnosis of diabetes and who were cared for in Paediatric Diabetes Units (PDU’s). The
following pie charts show the prevalence by age and ethnicity across the North West.
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Graphs 2 and 3:
Diabetes in the North West by age and ethnicity based on 2012-13
registrations
Diabetes by age
2012-13
Diabetes by Ethnicity
2012-13
White
1%
1%
28%
Asian
0 - 4yrs
7%
5 - 9yrs
20%
10 - 14yrs
15 - 19yrs
20 - 24yrs
Black
1%
23%
Mixed
1%
Other
1%
Not Stated
69%
4%
Unknown
44%
Steadily over recent years there has been an increase in the care processes recorded.
Graph 4: % of children and young people with diabetes aged 12 years and over having all
care processes recorded
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13
Although the percentage offered care processes nationally has increased, it is still below the
national average offered to adults with type 1 diabetes (42.4%). Table 16 shows the picture
locally.
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Table 19: % of care processes offered to young people with diabetes 2012 - 13
Registr
ation
>12 yrs
of age
HbA1c
BMI
Blood
Pressu
re
Albu
min
Choleste
rol
Creatini
ne
Eye
exam
Foot
exam
All care
process
es
Cumberland Infirmary
University Hospitals of
Morecambe Bay
59
95%
70%
19%
10%
15%
41%
0%
0%
0%
66
99%
100%
97%
77%
74%
96%
64%
83%
52%
Rochdale Infirmary
Royal Albert Edward
Infirmary
156
72%
78%
74%
16%
0%
67%
11%
20%
0%
52
56%
60%
52%
8%
39%
39%
0%
44%
0%
Royal Blackburn Hospital
115
1%
0%
0%
0%
0%
0%
0%
0%
0%
Royal Bolton Hospital
39
100%
97%
95%
97%
95%
100%
39%
0%
0%
Royal Preston Hospital
114
100%
0%
0%
0%
0%
0%
0%
0%
0%
Salford Hospital
33
100%
12%
36%
46%
46%
58%
9%
70%
0%
Stepping Hill Hospital
Trafford General
Hospital
Blackpool Victoria
Hospital
83
98%
96%
29%
7%
70%
70%
0%
0%
0%
26
100%
100%
65%
58%
81%
89%
85%
58%
27%
47
4%
0%
0%
11%
0%
2%
23%
30%
0%
Wythenshawe Hospital
55
33%
38%
58%
62%
67%
67%
75%
69%
13%
Paediatric Unit
Overall, across the local PDU’s only 48 of the 476 patients registered (5.7%) were offered all
care processes. Collectively, 68.2% were offered HbA1c; 50.8% offered BMI checks; 40.1%
blood pressure monitoring; 23.6% Albumin check; 29.1% cholesterol monitoring; 46.0%
Creatinine; 17.9% eye examinations and 23.6% foot examinations.
With regard to blood glucose levels, data for 2012-13 shows that locally the most areas
achieve 20% or less for the target range of less than 58 mmol/mol with the average being
between 70 and 80 mmol/mol (see appendix 1).
Inpatient care
People admitted to hospital either due to complications of diabetes or with other conditions
as well as having diabetes should expect a high standard of care from the staff with the right
expertise to aid their care. Once admitted they should have input from the specialist
diabetes team and should have the relevant support to be effectively managed whilst in
hospital.
Between 16th and 20th September 2013, 211 hospitals across England were audited as part
of the national inpatient audit. Albeit a snapshot, the results offer an interesting insight in to
diabetes care in hospitals. Table 17 looks at the prevalence and the percentage admitted
because of their diabetes
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Table 20: Inpatient prevalence of diabetes in September 2013
Hospital
Beds
Diabetic
Patients
Prevalence of
diabetes
% where diabetes was the cause
of the admission
Blackpool Victoria
702
108
15.40%
8.40%
Chorley
183
37
20.20%
10.80%
Cumberland Infirmary
343
30
8.70%
11.10%
Fairfield
211
27
12.80%
7.40%
Central Mcr
745
172
23.10%
6.10%
North Mcr
312
35
11.20%
0.00%
Blackburn
571
87
15.20%
8.20%
Bolton
445
80
18.00%
7.70%
Oldham
326
65
19.90%
9.40%
Preston
624
92
14.70%
2.20%
Salford
800
91
11.40%
4.40%
Stockport
589
91
15.40%
6.70%
Tameside
420
74
17.60%
6.90%
WWL
409
60
14.70%
6.90%
Wythenshawe
832
116
13.90%
8.10%
Across all hospitals 82.9% were an emergency admission and 93.2% were admitted for
medical or surgical reasons where diabetes was not the main cause of admission.
Graph 5:
% of diabetic inpatients by type in September 2013
% Diabetes Type Other
% Diabetes Type 2 - Diet only
% Diabetes Type 2 - Non insulin
% Diabetes Type 2 - Insulin
% Diabetes Type 1
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0%
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Table 21:
% of diabetic inpatients by type in September 2013
% Diabetes
Type 1
% Diabetes
Type 2 - Insulin
% Diabetes Type
2 - Non insulin
% Diabetes
Type 2 - Diet
only
% Diabetes
Type Other
Blackpool Victoria
12.3%
32.1%
38.7%
17.0%
0.0%
Chorley
10.8%
29.7%
37.8%
21.6%
0.0%
Cumberland Infirmary
11.1%
33.3%
40.7%
14.8%
0.0%
Fairfield
7.4%
29.6%
51.9%
11.1%
0.0%
Central Mcr
13.5%
40.6%
27.6%
14.7%
3.5%
North Mcr
5.7%
34.3%
48.6%
11.4%
0.0%
Blackburn
2.3%
27.9%
48.8%
18.6%
2.3%
Bolton
5.1%
55.1%
26.9%
12.8%
0.0%
Oldham
0.0%
38.1%
46.0%
14.3%
1.6%
Preston
5.4%
20.7%
47.8%
22.8%
3.3%
Salford
12.2%
30.0%
34.4%
21.1%
2.2%
Stockport
2.2%
25.6%
50.0%
21.1%
1.1%
Tameside
7.0%
28.2%
42.3%
22.5%
0.0%
WWL
12.1%
17.2%
43.1%
27.6%
0.0%
Wythenshawe
4.4%
39.5%
25.4%
18.4%
12.3%
7.7%
33.1%
38.4%
18.3%
2.5%
The North West figures are not dis-similar to the national figures with just marginally more
type 1 diabetes locally at the time of this snapshot. The male to female ratio was almost
even and the median length of stay was 8 nights for emergencies and 6 days for electives.
The average age for someone being admitted with diabetes at the time of the audit was 68
years. Nationally 68.6% of inpatients with Type 1 had been diagnosed for 15 years or longer
and 26.1% with diabetes type 2.
33% of people admitted with diabetes were visited by the specialist diabetes team although
the percentage varies from place to place as graph 5 shows.
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Graph 5:
% diabetes patients visited by specialist diabetes team
90%
80%
70%
60%
50%
40%
30%
20%
10%
Wythenshawe
WWL
Tameside
Stockport
Salford
Preston
Oldham
Bolton
Blackburn
North Mcr
Central Mcr
Fairfield
Cumberland Infirmary
Chorley
Blackpool Victoria
0%
National data indicates that the visits are much higher for type 1 diabetes and type 2 insulin
treated diabetes than visits to people with the other types. The data also suggests through a
patient questionnaire that was completed that fewer than half the patients were aware a
diabetes team was available to provide support and advice to ward staff.
NICE clinical guideline 119 states ‘each hospital should have a care pathway for patients
with diabetic foot problems who require inpatient care’ [11]. And that there should be a
multidisciplinary foot care team consisting of a number of specialists that include
diabetologist, a surgeon with the relevant expertise in managing diabetic foot problems, a
diabetes nurse specialist, a podiatrist and a tissue viability nurse (as well as access to
further specialists outlined in the guideline). Further to this, the multidisciplinary foot care
team should:







assess and treat the patient's diabetes, which should include interventions to
minimise the patient's risk of cardiovascular events, and any interventions for preexisting chronic kidney disease or anaemia and Anaemia management in people with
chronic kidney disease
assess, review and evaluate the patient's response to initial medical, surgical and
diabetes management
assess the foot, and determine the need for specialist wound care, debridement,
pressure off-loading and/or other surgical interventions
assess the patient's pain and determine the need for treatment and access to
specialist pain services
perform a vascular assessment to determine the need for further interventions
review the treatment of any infection
determine the need for interventions to prevent the deterioration and development of
Achilles tendon contractures and other foot deformities
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


perform an orthotic assessment and treat to prevent recurrent disease of the foot
have access to physiotherapy
arrange discharge planning, which should include making arrangements for the
patient to be assessed and their care managed in primary and/or community care,
and followed up by specialist teams.
For those people being admitted with diabetic foot problems, referral to the multidisciplinary
foot care team should take place within 24 hours of the initial examination of the patient's
feet. Table 19 shows the percentage of people admitted seen by the multidisciplinary foot
team, the rates of assessment and how quickly they were seen.
Table 22:
Diabetic inpatient foot care
Admitted
with foot
disease
Seen by the
MDT within
24 hours
Foot Risk
Assessment
completed <= 24
hours
Foot risk
assessment
after 24
hours only
Foot Risk
Assessment
completed during
the hospital stay
Blackpool Victoria
8.3%
77.8%
79.6%
5.6%
85.2%
Chorley
8.3%
33.3%
0.0%
2.8%
2.8%
Cumberland Infirmary
3.6%
100.0%
3.6%
0.0%
3.6%
Fairfield
7.4%
0.0%
48.1%
14.8%
63.0%
Central Mcr
8.2%
31.3%
39.5%
14.0%
53.5%
North Mcr
0.0%
N/A
88.2%
0.0%
88.2%
Blackburn
5.8%
80.0%
12.7%
1.8%
14.5%
Bolton
10.1%
75.0%
90.9%
3.9%
94.8%
Oldham
9.4%
66.7%
23.4%
6.3%
29.7%
Preston
3.3%
0.0%
2.3%
1.2%
3.5%
Salford
5.6%
85.7%
96.7%
3.3%
100.0%
Stockport
9.0%
63.6%
9.0%
7.9%
16.9%
Tameside
8.1%
0.0%
29.7%
9.5%
39.2%
WWL
10.2%
75.0%
11.9%
11.9%
23.7%
Wythenshawe
7.0%
50.0%
15.0%
5.6%
20.6%
It is interesting to note that there is room for improvement particularly in the current vascular
arterial centres across the area (Preston, Blackburn, Oldham, MRI and Wythenshawe).
When reviewing blood glucose control, the inpatient audit looked at the previous 7 days of
the hospital stay, excluding inpatients with diabetic ketoacidosis (DKA) or hyperglycaemic
hyperosmolar state (HHS) to look at the appropriateness of blood glucose testing. A ‘good
diabetes day’ was defined as a day on which the frequency of blood glucose testing was
appropriate (based on criteria of a patients status) and there was no more than one blood
glucose measurement greater than 11 mmol/L and no blood glucose measurements less
than 4 mmol/L. The percentage of ‘good diabetes’ days out of seven are shown in table 20.
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Table 23: % inpatient ‘Good diabetes days’
Appropriate Days
Good Diabetes Days
% Good Diabetes
Days
Blackpool Victoria
6.3
4.3
64%
Chorley
6.7
3.7
54%
Cumberland Infirmary
6.9
4.2
61%
Fairfield
5.9
5
74%
Central Mcr
6.4
3.3
49%
North Mcr
6.3
4.5
68%
Blackburn
6.1
5.1
77%
Bolton
6.6
4.6
69%
Oldham
5.8
3.7
55%
Preston
6.2
3.5
52%
Salford
6.2
4.3
65%
Stockport
6
4.4
66%
Tameside
5.8
4.3
64%
WWL
6.6
5.6
84%
Wythenshawe
6.5
5
75%
The percentage of medication errors for all inpatients within the snapshot locally was 35.3%
compared with the national figure of 37%. Medication errors, either prescription or
management are shown by PDU in graph 6 and table 21.
Graph 6:
Inpatient Medication errors
Medication errors
60%
50%
40%
30%
20%
10%
Wythenshawe
WWL
Tameside
Stockport
Salford
Preston
Oldham
Bolton
Blackburn
North Mcr
Central Mcr
Fairfield
Cumberland Infirmary
Chorley
Blackpool Victoria
0%
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Table 24:
Inpatient Medication errors
Prescription
errors
Management
errors
Insulin Errors
Blackpool Victoria
23.9%
17.0%
21.6%
Chorley
32.1%
25.0%
32.1%
Cumberland Infirmary
21.7%
30.4%
26.1%
Fairfield
10.5%
15.8%
10.5%
Central Mcr
20.3%
27.1%
27.1%
North Mcr
10.3%
20.7%
17.2%
Blackburn
24.0%
28.0%
28.0%
Bolton
11.5%
26.9%
15.4%
Oldham
14.0%
30.0%
24.0%
Preston
37.7%
30.4%
29.0%
Salford
9.9%
11.3%
12.7%
Stockport
25.7%
21.4%
17.1%
Tameside
9.1%
14.5%
14.5%
WWL
10.5%
13.2%
18.4%
Wythenshawe
12.5%
16.3%
20.0%
Medication errors were more frequent with type 1 diabetes and type insulin treated diabetes.
The most common insulin prescription error was where insulin was not signed as given, and
the most common oral hypoglycaemic agent (OHA) prescription error was where OHA was
given/prescribed at the wrong time. The most frequent insulin management error was failure
to increase insulin when the patient’s blood glucose was persistently greater than 11 mmol/L
and better blood glucose control would have been appropriate.
Only a small percentage of sites around the country had electronic prescribing but the
frequency of prescription errors was over 50% less.
Fundamental to assessment of care is patient experience. All patients in the audit were
handed a patient experience questionnaire of which the return rate across the South
Cumbria, Lancashire and Greater Manchester was 47%. Individually the returns rates
ranged from as high as 80% in Blackpool Victoria and as low as 12% in Salford. The overall
satisfaction and other interesting results are captured on the next page.
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Inpatient satisfaction
Graph 7 and Table 25:
Overall Satisfaction
100%
80%
60%
40%
20%
Wythenshawe
WWL
Tameside
Stockport
Salford
Preston
Oldham
Bolton
Blackburn
North Mcr
Central Mcr
Fairfield
Cumberland Infirmary
Chorley
Blackpool Victoria
0%
Meals
Timing
Meals
Choice
Staff Knowledge Answer to
Questions
Staff Knowledge
- Work together
All or most staff
know enough
about diabetes
Blackpool Victoria
86.6%
81.7%
80.8%
58.7%
79.7%
Chorley
64.7%
47.1%
48.8%
26.1%
65.0%
Cumberland Infirmary
54.0%
50.7%
83.3%
43.1%
51.1%
Fairfield
100.0%
72.3%
87.7%
66.7%
91.0%
Central Mcr
62.7%
53.6%
87.4%
40.3%
73.5%
North Mcr
45.4%
34.3%
72.1%
14.8%
29.1%
Blackburn
61.6%
65.2%
95.6%
62.5%
64.2%
Bolton
75.1%
83.3%
64.5%
56.2%
79.8%
Oldham
63.2%
57.1%
92.3%
41.6%
54.3%
Preston
56.9%
45.3%
83.6%
33.3%
36.7%
Salford
46.6%
60.7%
75.9%
51.0%
71.4%
Stockport
60.1%
51.7%
49.3%
36.3%
52.6%
Tameside
55.8%
64.3%
75.4%
39.1%
77.2%
WWL
92.2%
86.8%
87.9%
94.4%
100.0%
Wythenshawe
74.5%
54.0%
79.5%
48.8%
78.4%
The data suggests that PDU’s in Wigan achieve high patient satisfaction times and adequate
meal provision where as other area’s such as Chorley have large room for improvement.
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Strategic Clinical Network & Senate
Pregnancy Care
Women who have diabetes and are having a baby or planning to have a baby need to be
closely monitored and have access to specialist care to prevent harm to either the mother or
the child(ren). Recommendations over recent years can be categorised in to preconception,
ante-natal, neo natal and post natal care. To accompany those recommendations made by
NICE, a national audit was constructed for the first time to review the care given to all the
women who had diabetes during their pregnancy and gave birth in 2013.
The North West results were published last year and contain information from all the local
hospitals plus Aintree University Hospital NHS Foundation Trust, Isle of Man Secondary
Healthcare Directorate, Mid Cheshire Hospitals NHS Foundation Trust, North Cumbria
University Hospitals NHS Trust, St Helens and Knowsley Hospitals NHS Trust, Warrington
and Halton Hospitals NHS Foundation Trust and Wirral University Teaching Hospital NHS
Foundation Trust [17].
The numbers and characteristics of the pregnancies in the period are highlighted in tables 26
and 27 (both were taken directly from the audit).
Table 26:
Pregnancies included in the audit for 2013 in the North West region and in
England and Wales
All pregnancies
Pregnancies in
women with Type 1
diabetes
Pregnancies in
women with Type 2
diabetes
Pregnancies in other
women with diabetes
Number
Number
%
Number
%
Number
%
North West
338
161
47.6%
121
35.8%
56
16.6%
England and
Wales
1704
823
48.3%
680
39.9%
201
11.8%
*women recorded as having maturity onset diabetes of the young (MODY), ‘other’ diabetes types or
whose diabetes type was not recorded
Table 27:
Characteristics of pregnancies in the audit for 2013 in the North West region
and in England and Wales
All pregnancies
Pregnancies in
women with Type 1
diabetes
Pregnancies in
women with Type 2
diabetes
North
West
England
and
Wales
North
West
England
and
Wales
North
West
England
and
Wales
Average maternal age at completion of
pregnancy (years)
30.9
31.4
28.9
29.5
33.3
33.6
Average age at diagnosis of diabetes
(years)
21.2
21.6
15.3
15.5
28.7
29.1
Average duration of diabetes (years)
9.3
9.5
13.3
13.9
4.3
4.3
Average Body Mass Index (BMI),
kg/m2
29.8
29.9
26.9
26.9
33.2
33.1
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The figures from the table show that the North West is in line with the National average with
fractionally younger people presenting. However, the North West is not consistent with the
national average when it comes to several of the recommendations of care for example; the
use of folic acid as part of pre conception. Women with diabetes are at higher risk of being
affected with a neural tube defect and so it is recommended they should take at least 5
milligrams of folic acid while planning pregnancy and then up to 12 weeks gestation. The
next table (again taken directly from the audit) shows the use of folic acid in the North West
is below that of the national average.
Table 28:
Use of folic acid supplement prior to pregnancy in the audit for 2013 in the
North West region and in England and Wales
All pregnancies
Pregnancies in women
with Type 1 diabetes
Pregnancies in women
with Type 2 diabetes
North West
England
and Wales
North West
England
and Wales
North West
England
and Wales
Dose 400mcg
5.3%
7.1%
3.1%
4.6%
6.6%
9.7%
Dose 5mg
29.0%
33.0%
36.0%
42.6%
24.0%
24.7%
All doses
34.3%
40.1%
39.1%
47.3%
30.6%
34.4%
Not taken
54.1%
44.4%
49.1%
38.4%
58.7%
49.0%
Not Known
11.5%
15.6%
11.8%
14.3%
10.7%
16.6%
In addition, pre-conception recommendations include education on avoiding unplanned
pregnancies and trying to attain good glycaemic control to ensure women are adequately
prepared for pregnancy. Good glycaemic control before and throughout pregnancy reduces
the chances of congenital abnormalities, miscarriage, still birth and even neonatal death.
The NICE guideline recommends that if it is safely achievable, women with diabetes who are
planning to become pregnant should aim to maintain their HbA1c below 43 mmol/mol
(6.1%). It also states that women with diabetes whose HbA1c is above 86 mmol/mol (10.0%)
should be strongly advised to avoid pregnancy [17].
Table 29:
First trimester HbA1c measurement in the audit for 2013 in the North West
region and in England and Wales
All pregnancies
Pregnancies in
women with Type 1
diabetes
Pregnancies in
women with Type 2
diabetes
North
West
England
and
Wales
North
West
England
and
Wales
North
West
England
and
Wales
Result < 43 mmol/mol (6.1%)
8.1%
10.9%
2.9%
5.1%
13.6%
18.5%
Result <53 mmol/mol (7.0%)
27.3%
34.7%
17.4%
25.1%
37.5%
45.9%
Result >= 86 mmol/mol (10%)
10.8%
10.2%
13.0%
10.8%
8.0%
8.6%
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Figures from the North West clearly indicate recommended HbA1c levels are worse than the
England and Wales average and the audit concludes the overall percentage of women with
diabetes prepared for pregnancy is 15% compared with almost 21% nationally. Broken
down further type 1 preparedness in the North West is 10.5% compared with 18% nationally
and type 2 21.5% locally compared with 25.1% nationally.
In terms of care during pregnancy, it is recommended that as soon as a woman with
diabetes becomes pregnant there is contact with specialist antenatal diabetes team and this
should take place as early as possible. On average first contact with a specialist diabetes
team in the North West occurs earlier than the national average for women with type 1
diabetes. 64.8% of women had contact with the team within 7 weeks of their pregnancy
compared with 51.2% nationally. 88.7% had their first contact within 11 weeks and 2.5%
waited 16 weeks or more.
The picture for type 2 diabetes is a little different. 39.7% of type 2 women were seen within
7 weeks of pregnancy. This is less than type 1 but marginally better than the national
average of 36.6%. 75.2% had first contact with team by 11 weeks and around 10.7% waited
16 weeks or more; compared with 8.2% nationally.
Graph 8:
Preterm deliveries by diabetes type in 2013
Preterm deliveries
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
All pregnancies
Type 1
North West
Type 2
England and Wales
Graph 8 shows that slightly more births were delivered preterm either naturally or via
intervention. This is particularly so in Type 1 diabetes where the North West rate is more
than 10% higher. Using the GROW centile tool [18], it was calculated that approximately
45.5% of type 1 diabetes pregnancies and 28.6% of type 2 diabetes pregnancies were large
for gestational age. Macrosomia (a birth weight of >=4,000g) is recognised as a
complication for babies of women with diabetes.
The last part of the pregnancy audit looks at babies receiving normal neo natal care as it is
recommended that ‘babies of women with diabetes should be kept with their mother unless
there is clinical complication or there are abnormal clinical signs that warrant admission or
intensive or special care’ [19]. The results are taken directly from the audit show in the North
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West women spend less time with their babies following birth and suggest babies born
spend more time in special or intensive care than other parts of the country.
Table 30:
% Babies receiving normal neonatal care
All babies
Babies of mothers
with type 1 diabetes
Babies of mothers
with type 2 diabetes
North
West
England
and
Wales
North
West
England
and
Wales
North
West
England
and
Wales
Normal neonatal care delivered <
37 completed weeks
33.3%
40.2%
32.9%
36.0%
40.9%
50.4%
Normal neonatal care delivered
>=37 completed weeks
80.9%
82.5%
78.5%
77.8%
84.9%
87.1%
Specialist Care
All people with diabetes should have access to different specialist care to prevent
complications of the disease or when complications arise. Specialists may include
podiatrists, ophthalmologists and dieticians but access to these has been difficult due to
changes in the NHS or problems such as posts and services being cut [7].
North West figures show access to specialist teams in hospital were as low as 11.5% and
average at just one third (see inpatient section).
In 2012, Diabetes UK recommended the following work to be done:
 Specialist services should be commissioned and developed with specialist input and
ideally by specialist commissioning teams.
 Services specifically for people with diabetes such as pump management needs to
be adequately resourced and developed to be able to meet the local level of need,
and the ongoing management of people using pumps. All people with diabetes
meeting the NICE criteria for pumps should be able to have one
 Services must stop cutting specialist staff and roles. Diabetes UK has published core
staffing recommendations for the provision of specialist diabetes care.
Emotional Support
Being diagnosed with a long term condition such as diabetes can have a detrimental effect
on a person’s mental state and health. A decline in mental health can subsequently cause a
person to have additional problems that also reduce their quality of life. These include;
anxiety and depression, eating disorders, cognitive disorders and behavioural and social
problems. In 2008 it was reported that around 41% of people with diabetes suffer with poor
psychological well-being.
NICE recommend support is offered to children, young people and adults who are diagnosed
with diabetes by mental health professionals to help with emotional and behavioural
challenges. However, evidence suggests access to these services is limited. In 2008’s
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publication ‘Minding the gap’, Diabetes UK reported that 85% of people with diabetes in the
UK have either no defined access to psychological support and care, or at best only in the
form of generic services. Where services were available I was reported that only 2.6% of
services complied with all six psychologically relevant NSF standards/NICE guidance
recommendations and 25.8% do not comply with any of them. All of which suggest there is
plenty of work that needs to be done nationally to improve access and the services
themselves [20].
10. INTEGRATION
Traditional service models have been accused of being too rigid in how they distinguish
primary and secondary care and it has been suggested that service models should be
approach the system from the perspective of the patient [21]. Local services need to provide a
whole system approach from the diagnosis to the management of complications and all the
separate parts of the system should work together.
The Coalition for Collaborative Care recently outlined an approach referred to as the ‘house
of care framework’ (see below) that describes the key elements for delivering patient centred
care. Local models of integrated diabetes care should be commissioned to ensure delivery
of all components of the pathway [21].
Fig 1: The house of care framework
Within this is the integrated diabetes pathway that lists all the different components which
should be explained in local models of care (see fig 2).
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Fig 2. Diabetes integrated pathway
The integrated pathway is underpinned by multidisciplinary team working between
generalists and specialists (the latter not only providing care in hospitals). Clear channels of
communication between the two are fundamental and in several successful models across
the country specialists go out to the community and work alongside generalists offering
advice.
Diabetes UK suggested a number of key enablers to help these models. These include:
Integrated IT (all providers being able to access the same patients data). Systems used in
other integrated models include SystmOne, Graphnet’s Care Centric Portal and Diabeta3.
Collaborative care planning – where the patient is actively engaged and feels empowered
to agree goals with clinicians and support needs are identified for both patients and clinicians
Clinical engagement and leadership - where local champions lead and engage the full
range of local stakeholders such as managers, clinicians, commissioners and local service
providers to agree the necessary change(s).
Clinical Governance structures that outline ambitions and accountability.
Aligned finances and responsibility – being clear who does what such as more people
being given high quality care in the community whilst specialist s focus on the most complex
or unusual cases. Such responsibilities have been outlined in the non-mandatory diabetes
sample service specification produced last July (see fig 3) [22]
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Fig 3:
Example pathway as set out in draft service specification
Generalist Care
Specialist care
Community based multidisciplinary
team (MDT) may provide:
•
An individual’s practice MDT will
include their GP, practice nurse,
and in many cases a community
nurse and/or community
podiatrist. Some may also
include a sessional increasedaccess-to-psychologicaltherapies (IAPT) therapist
•
•
•
•
Patient education
programmes (QS1)
Pregnancy advice for
women of childbearing
age (QS7)
Foot protection team
(QS10)
Clinical psychology
support
Additional support for
those with Type 2
diabetes and poor
glycaemic control
Annual care planning cycle
(Quality Standard (QS) 3)
In some areas service provision
may be provided by a community
based multidisciplinary team
Community multidisciplinary team
(MDT) to include a Physician
(Consultant Diabetologist, but may
additionally include GPwSI),
Diabetes Specialist Nurse, Diabetes
Specialist care services will be
multidisciplinary, with membership of
the MDT varying according to the
specialty service. Specialist services
will include:
•
•
•
•
•
•
•
•
Transition service
Diabetic foot service
Diabetic antenatal service
T1DM service, including
insulin pump service
Diabetic inpatient service
Diabetic mental health service
Diabetic kidney disease
service
Diagnostic service where
there is doubt as to type of
diabetes
There should be clear referral
pathways for specialist care outside
istockphoto.com
The service specification also states:
‘The ideal service provision will therefore span primary, community, secondary, mental
health and social care. As such it will require the commissioners responsible for these
different sectors to collaborate (CCGs, Local Authorities and NHS England Area Teams). It
may also require different CCGs to work together across a broader geographical area to
commission diabetes services’.
With this mind, an appropriate next step is to review local services models of care to develop
a greater understanding of delivery of care across the conurbation. It would shed light on
how local models vary in terms of structure and resource, why some localities are successful
in the delivery of specific aspects of care, which good practice could be used elsewhere and
the weaknesses in some models.
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11. CONCLUSIONS
Comparing the care across the conurbation provides a clearer picture of the strengths and
weaknesses of each area. It is hoped this will enable local service providers to see which
other neighbouring areas have strengths where they are struggling to provide effective
results and potentially provides a mechanism in which good practice is shared. For diabetes
care to improve, it not only requires an integrated approach amongst local service providers
but needs to be open to effective models of care that are evidenced outside a providers own
locality.
At present, the delivery of care processes is inconsistent and largely below the current target
rate. The challenge appears to be offering more care processes to people with type 1
diabetes. In some areas significant progress has been made such as the improvement rate
for Bolton and Blackburn with Darwen CCG’s in offering all care processes. West
Lancashire CCG achieves some of the best rates for blood glucose and Wigan Borough
achieves the highest optimum rate for blood pressure and a review of services may help
understand how these areas if more effective practice are accomplished.
The introduction of standardised care plans that are adaptable for each person may help –
especially if they contain all useful information to ensure the patient understands their
responsibility and what they are entitled to from a service. A standardised structured
education programme may also help each locality and further work needs to be done to
understand how this can be achieved and what the barriers are to people being able to
attend. Such programmes and care plans may certainly help toward preparing women for
pregnancy (an area that needs addressing across the North West).
Additionally, much can also be learned for units that also appear to provide an effective
inpatient service. Inpatients at Salford Royal were more than twice as likely to be visited by
a specialist diabetes team during their stay and over 6 times more likely than inpatients in
other units across the footprint. All patients received a foot risk assessment during their
stay and comparatively there were very few medication errors. It is therefore little surprise
the overall patient satisfaction (along with a handful of other units) exceeded 90%.
Lastly further work can be done to entwine the provision of vascular services with diabetes
care to ensure diabetes is not handled as a service on it’s own but as part of a set of linked
services. Examples of this include how multidisciplinary foot clinics are recommended
locally as a necessity of vascular centres and how diabetes talks are included as part of
awareness workshops for conditions such as Critical Limb Ischaemia.
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Appendix one: HbA1c levels for children and young people with diabetes 2012-13
Total no. of
patient
submitted
to NPDA
Total no.
of
patients
eligible
for
HbA1c
analysis
Patients
used for
HbA1c
out-come
analysis
Patients
excluded
from
HbA1c
outcome
analysis
%
excluded
from
HbA1c
outcome
analysis
% with
HbA1c<58
mmol/mol
Mean HbA1c
(mmol/mol)
Median HbA1c
(mmol/mol)
% of
incomplete
records of
care
processes
except Hba1c
Cumberland Infirmary
104
104
91
13
12.5%
15.4%
74.6
73.8
61.1%
University Hospitals of Morecambe Bay NHS Foundation Trust
149
147
124
23
15.6%
5.7%
72.1
69.0
32.6%
Royal Albert Edward Infirmary
126
124
107
17
13.7%
17.8%
74.8
71.6
35.2%
Royal Blackburn Hospital
262
260
222
38
14.6%
15.8%
71.5
66.8
45.6%
Royal Preston Hospital
196
193
175
18
9.3%
13.1%
75.3
73.0
59.4%
Salford Hospital
140
140
126
14
10.0%
17.5%
71.5
67.5
23.3%
Stepping Hill Hospital
140
138
122
16
11.6%
20.5%
68.1
66.0
61.0%
Trafford General Hospital
69
69
64
5
7.2%
12.5%
76
72.0
23.8%
Blackpool Victoria Hospital
112
111
94
17
15.3%
17.0%
70.4
69.8
51.8%
Wythenshawe Hospital
90
89
55
34
38.2%
10.9%
70.7
67.2
52.0%
NOTE: Where the percentage of incomplete HbA1c data is high, or the number of patients submitted low, the validity of the percentage with an HbA1c <58
mmol/mol (7.5%), mean and median HbA1c for an individual Paediatric Diabetes Unit should be interpreted with caution, as it may not truly represent that
unit’s overall outcome. Incomplete data is defined as: no HbA1c submitted, invalid HbA1c result, no date attached to the result or date outside the Audit
period. HbA1c result less than 3 months from diagnosis are not included in the analysis.
*Eligible patients were those greater than 3 month post diagnosis.
**For HbA1c to be included in the analysis the patient needed a valid date of diagnosis, a valid submitted value and a date of submission which was within the Audit year.
Where more than one HbA1c was submitted for a patient the median value was used for the Audit year.
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