Action for Diabetes
Improving diabetes care across Calderdale and Greater Huddersfield
FIVE YEAR STRATEGY 2014/15 – 2018/19
(OCTOBER 2015 REFRESH)
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Calderdale & Greater Huddersfield Diabetes
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ACTION ON DIABETES IN CALDERDALE AND GREATER HUDDERSFIELD
STRATEGY REFRESH –OCTOBER 2015
It is now a year since we launched the Calderdale and Greater Huddersfield Diabetes
Strategy; a strategy with high aspirations to ensure we give our patients the best quality
care and support to manage their condition. Diabetes is one of the most difficult health
challenges of our times; the steep rise in diabetes cases in recent years has been
overwhelming for those charged with planning and providing healthcare services and
especially in primary care. In addition, there are a significant number of people whose
diabetes is undiagnosed and large numbers estimated to be pre-diabetic.
We know that diabetes is manageable, but that management is not always consistent
and every individual experiences it in different ways. Whilst there has been progress
major gaps still exist - in support for patients and clinicians. General Practice is now
carrying more responsibility for managing the condition than ever before; locally we are
looking to shift some planned care from hospital settings in line with our Care Closer to
Home models. In order to make this a reality, and to make the best use of unplanned
care, we need to ensure that EVERY patient and EVERY clinician they have contact
with, is well equipped and confident in managing the condition.
The Calderdale and Greater Huddersfield Diabetes Strategy has been updated to reflect
the following:
1) More recent data, where available (within the body of the strategy)
2) Recent best practice guidance and evidence (Appendix A)
3) Latest Operational Plan showing how we intend to deliver the strategy (Appendix B)
Dr Judith Parker
GP Governing Board member and
Clinical Lead for Diabetes
Greater Huddersfield CCG
Dr Steven Cleasby
GP Governing Body member and
Clinical Lead for Diabetes
Calderdale CCG
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1. FOREWORD1
Diabetes is one of the greatest threats of the 21st century. It is estimated that more than one in 16 people
in the UK has diabetes (diagnosed or undiagnosed). There are 3.9 million people living with diabetes in the
UK. The cost to the people affected (and their families) is considerable, with people with diabetes 34%
more likely to die earlier than their peers. Diabetes also significantly increases the risks of heart attacks,
stroke, blindness, kidney failure and amputation.
The statistics tell the story:

Every year more than 20,000 people with diabetes die before their time in England and Wales.

Diabetes doubles the risk of cardiovascular disease (heart attacks, heart failure, angina, stroke).

More than 135 amputations take place each week amongst people with diabetes, and in many
cases these are avoidable.

Diabetes accounts for around ten per cent of the NHS budget per year; that is around £10 billion. It
is estimated that 80% of these costs are incurred in treating potentially avoidable complications.

In addition, one in 20 people with diabetes incurs social services costs. More than three quarters
of these costs were associated with residential and nursing care.

In 2014/15, 47.2m items were prescribed to treat diabetes. £868 million was spent on drugs to
treat diabetes in primary care.

Many people with diabetes have other long term conditions as well, and there is predicted to be a
252% increase in the number of people with multiple long-term conditions by 2050.

Almost 1 in 5 people with diabetes have clinical depression and for those with anxiety and/or
depression health care costs increase by around 50%.
We want to commission for the people of Calderdale and Greater Huddersfield systematic, high quality,
personalised support to help people to avoid or reduce their risk of diabetes and to help those with
diabetes manage their condition in a way that reduces the risk of increasing ill health and the risk of
developing complications.
1
Data in this section are taken from Diabetes UK ‘Diabetes: Facts and Stats’ (May 2015)
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2. INTRODUCTION
Diabetes is a serious long-term condition in which the amount of glucose (sugar) in the blood is too high
because the body cannot use it properly. There are two main types of diabetes. Type 1 diabetes develops
if the body cannot produce any insulin, and is more prevalent in children and young adults. It is the least
common of the two main types; accounting for around 10 per cent of all people with diabetes. Type 2
diabetes is more commonly diagnosed in adults over 40, although it is increasingly being diagnosed in
children and young adults. It develops when the body cannot produce enough insulin, or when the insulin
that is produced does not work properly. In most cases this is linked with being overweight due to a
person’s diet and lifestyle.
Diabetes often leads to serious complications including heart disease, stroke, blindness, kidney disease
and amputations. It is the fifth most common cause of death in the world, and accounts for an estimated 15
per cent of deaths occurring in England, and is a major cause of premature mortality with over 20,000
additional deaths each year. It is estimated that the current annual cost of direct patient care is £1 billion
for people with Type 1 diabetes and £8.8 billion for those with Type 2 diabetes, and this is expected to rise
to £1.8 billion and £15.1 billion respectively by 2035. Good diabetes care reduces the major risk of people
dying prematurely from cardiovascular disease, as well as reducing the risk of developing serious
complications, which may begin years before an actual diagnosis has been made, and it is estimated that
80 per cent of these costs are incurred in treating potentially avoidable complications.
Preventing diabetes and improving diabetes care are priorities for both NHS Calderdale and NHS Greater
Huddersfield Clinical Commissioning Groups (CCGs) for the reasons set out in this strategy, and both
organisations are actively working together through the Calderdale and Greater Huddersfield Diabetes
Network (the Network) to ensure people with diabetes and those at risk of diabetes, receive the best care
and support available. Numerous health and social care services provide direct and indirect care and
support to those living with diabetes, and it is the role of the Network to make sure that these services are
meeting the needs of the local population in a way that improves health and social wellbeing in the most
cost efficient and effective manner.
3. NATIONAL DRIVERS
In 2001, a number of standards were developed through the publication of the National Service
Framework (NSF) for diabetes, covering various aspects of care and prevention. In addition a number of
guidelines and a set of quality standards have been produced by the National Institute for Health and Care
Excellence (NICE). The Government Mandate to NHS England and Clinical Commissioning Groups places
an emphasis on care and support for people with long-term conditions.
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The NHS Outcomes Framework 2013/14, developed by the Department of Health (DH), sets out the
accountability process for NHS England in relation to working with CCGs. It includes a number of
indicators targeted at improving diabetes care:
Domain 1: Preventing people from dying prematurely
•
Myocardial infarction, stroke and stage five chronic kidney disease in people with
diabetes.
Domain 2 Enhancing quality of life for people with long term conditions
•
People with diabetes who have received nine care processes
•
People with diabetes diagnosed less than a year who are referred to structured
education
•
People with diabetes who have an emergency admission for diabetic ketoacidosis
•
Complications associated with diabetes
•
Lower limb amputation in people with diabetes
In March 2015, NHS England, Diabetes UK and Public Health England launched the National Diabetes
Prevention Programme - a joint commitment to deliver at scale, an evidence based behavioural
programme to support people to reduce their risk of developing Type 2 diabetes.
LOCAL DRIVERS
There are an estimated 26,000 people diagnosed with diabetes in Calderdale and Greater Huddersfield,
and these numbers are set to increase due to rising obesity levels, an ageing population and a growing
population of south Asian origin. People from south Asian and black ethnic groups have a greater chance
of developing Type 2 diabetes than people from white ethnic groups.
The risk of diabetes also increases with age, and in 2010 the prevalence of all types of diabetes was 0.4%
for people aged 16 to 24 years, rising to 15.1% for people aged 70 to 84 years old. The individual
prevalence for Calderdale and Greater Huddersfield is shown in Table 1, which also includes information
on the increased risk of other diseases for people with diabetes.
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Table 1: Prevalence of diabetes in Calderdale and Greater Huddersfield and impact on other
conditions. 2012/13
Calderdale
Greater
Huddersfield
9,786
10,791
3,395
4,297
Myocardial infarction
83 %
76 % *
Stroke
19 %
25 % *
Prevalence:
People aged 17 and over diagnosed with diabetes2
Estimated further adults with
diabetes3
Additional risk of complication for those with
diabetes 4:
Hospital admission relating to heart failure
81 %
73 % *
*Kirklees PCT (which covered the population Greater Huddersfield and North Kirklees CCGs now cover)
Statistics published by Public Health England in August 2015 estimated that in Calderdale 19,584
people were pre-diabetic, as were 39,702 people in Kirklees.
Diabetes is the most common cause of lower limb amputation, with over 100 amputations carried out
each week. The Yorkshire and Humber Public Health Observatory produced Diabetic Footcare Activity
profiles for 2012/13 which show Greater Huddersfield and Calderdale as having higher annual rate of
amputation than the England average, as illustrated in Table 2.
Table 2: Rates per 1,000 population and number of lower limb amputations in people with
diabetes in Calderdale and Greater Huddersfield between 2011/12 and 2013/14 compared to
England average5
Major amputations
Minor amputations
Calderdale
Greater Huddersfield
England average
1.1
1.1
0.8
(31)
(36)
2.4
2.7
(69)
(88)
1.8
2
Source: Quality and Outcomes Framework 2012/13
Source: APHO Diabetes Prevalence Model
4
Source: National Diabetes Audit 2011/12
5
Hospital Episode Statistics and Quality and Outcomes Framework
3
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It is also worth noting the changes in the amputation rates from 2009/12 to 2011/14. For Calderdale: the
major rate has dropped by 0.1, and the minor rate has not changed. For Huddersfield: the major rate is
unchanged; the minor rate has increased by 0.7.
Diabetes is also the second most common cause of blindness in adults of working age, accounting for
14.4% of certifications of blindness between 1st April 2009 and 31st March 20106
Another major complication relates to kidney failure, which is one of the most severe and life threatening
complications of diabetes. It is more common in people who have high blood pressure and it is important
to undertake regular checks of kidney functions, while good weight management and other informed
lifestyle choices help to maintain good glucose levels. Additionally, gestational diabetes is a type of
diabetes that arises during pregnancy and women with diabetes are five times as likely to have a stillborn
baby and three times more likely to have a baby that dies prematurely.
Good diabetes care reduces the major risk of people dying prematurely from cardiovascular disease, as
well as reducing the risk of developing serious complications, which may begin years before an actual
diagnosis has been made. It is essential that people with diabetes are managed in a way that attempts to
reduce the above complications and mortality rates and a key area in achieving this is through good
management of the care processes delivered through primary care.
4. LOCAL SPEND AND ACTIVITY
Primary care
In Calderdale there are no specific services commissioned from primary care for Diabetes – GP practices
and pharmacies provide different levels of care according to their expertise/interest as part of their core
work. In Greater Huddersfield, thirteen practices provide a community service for diabetes injectable
therapies.
6
A comparison of the causes of blindness certifications in England and Wales in working age adults (16-64 years),
1999-2000 and 2009-10
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In terms of primary care data, the National Diabetes Audit focuses on the achievement of the following
eight care processes7:
•
Blood glucose (HbA1c)
•
Blood pressure
•
Cholesterol
•
Eye check (retinopathy screening)
•
Foot check
•
Kidney function (urinary albumin)
•
Kidney function testing (blood)
•
Weight check (BMI)
•
Smoking status check
The data from the 2012/13 Audit (latest available) demonstrates that there is a significant variation
between GP practices in the achievement of care processes. Several examples are show in the
table below.
Table 4. Percentage checked and within target 2012/13 by process8
Calderdale
Greater
Average for
(Individual practice
Huddersfield
similar CCGs
range)
(Individual practice
England average
range)
HbA1c
Cholesterol
Blood
pressure
65%
64%
(50% – 73%)
(44% - 77%)
76%
72%
(59% - 88%)
(55% - 86%)
68%
63%
(44% - 92%)
(31% - 83%)
61%
60%
73%
73%
68%
67%
Note. The HbA1c figures should be treated with caution as a national data quality issue has been
identified in relation to some submissions. This is in the process of being resolved.
77
These are eight of the nine processes recommended by NICE – the ninth, eye screening, is not currently included
in the National Diabetes Audit
8
National Diabetes Audit 2011/12
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More recent primary care diabetes data can be accessed through the Quality and Outcomes Framework
(QoF), which was introduced in 2003 as part of the contracting process with GP Practices. Data is
collected and published annually at practice level and Primary Care Trust (and now CCG) level. The latest
data are at the link below, and show a significant variation in performance between individual practices.
http://qof.hscic.gov.uk/
Prescribing
Spend on prescribing for diabetes items in 2012-13 was £2.9m for each CCG. The average spend per
adult with diabetes was slightly higher than the England average for Calderdale and slightly lower for
Greater Huddersfield.
Secondary care
Most hospital activity for people from Calderdale and Greater Huddersfield takes place with Calderdale &
Huddersfield NHS Foundation Trust. Table 3 sets out forecast expenditure and activity for 2013/14 for the
two CCGs relating to different types of hospital care.
Table 3: Forecast expenditure and activity 2013/14
Adults (over 18 years)
Calderdale
Greater
CCG
Huddersfield
CCG
Exp £000
£218
108
Inpatients
Spells
130
106
Exp £000
560
465
Outpatients
Spells
4,630
3,864
Exp £000
11
9
Accident & Emergency
Spells
91
77
Paediatrics (18 years and under)
Calderdale
Greater
CCG
Huddersfield
CCG
27
36
26
36
51
83
352
618
0.2
2
2
22
Data descriptions
Inpatients - Inpatient spells where spell primary diagnosis relates to diabetes
Outpatients - Mandatory Outpatient attendances - assigned to 300 - General Medicine which include Diabetes & Endocrine clinics
A & E Inpatient and Outpatient Spells – patients who have had an A & E attendance where primary
diagnosis is related to Diabetes
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5. ‘HOUSE OF CARE’ APPROACH
The CCGs support a ‘House of Care’, approach (described by the King’s Fund9) to ensuring quality of
life for people with long-term conditions, including diabetes. This approach, which is set out in Figure 1
was developed initially for patients with diabetes specifically, and centres around a care planning
process, where people with long-term conditions, their carers and health professionals work in
partnership to agree goals and outcomes, taking a whole life approach that goes beyond the symptoms
or a single condition. The Diabetes Network adopted this approach (Figure 2) to demonstrate the
dependencies within the programme and how these support the strategy.
Figure 1 – National ‘house of care’ model
The ‘House of Care’ has a solid foundation built on the commissioning cycle, pillars of patient
empowerment and clinical collaboration, and a roof composed of guidance, tools and resources. The
‘House’ falls down if all the constituent parts are not strong and working together; each part needs
equal and sustained focus.
9
King’s Fund Delivering better services for people with long-term conditions: building the house of care (2013)
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The Calderdale and Greater Huddersfield CCGs and the Diabetes Network have agreed to develop this
strategy and a more detailed operational plan to steer the development and improvement of local
diabetes care in the future. We have used the ‘House of care’ approach, localised to include the priority
areas, set out in Figure 2 below.
Figure 2: Local ‘house of care’ model
Specialist diabetes services
Foot Care
Education and training
Primary care
Supported self-care
Prevention
High quality care and
support
Excellent patient/carer
experience
Calderdale and Greater Huddersfield Diabetes Network
‘Action on Diabetes’ Strategy
Local prescribing strategies
Operational plans
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6. LOCAL MODEL OF CARE
The local model of care is shown below in Figure 3. This model supports the priority areas as described
above in the ‘House of Care’.
Hospital
Specialist
service
Foot care
Community
specialist service
Primary Care
Supported self-care
Education and Training
Figure 3. Local model of diabetes care in Calderdale and Huddersfield
Prevention
The levels can be described as follows:
Prevention: focuses on support to pursue healthy lifestyles as a means of preventing or reducing risk
of disease.
Supported self-care: focuses on self-care where the individual, as much as possible, manages his/her
health and wellbeing. This will mean that people are able to take more control of their lives, feeling
involved, supported, confident and resilient.
Primary care: focuses on primary and community health and social care services and general
management of conditions to maintain stability and reduce the risk of exacerbation.
Community specialist service: focuses on community based specialist services, which support and
maximise the capacity of multidisciplinary professionals to quickly manage early exacerbation that
cannot be managed in level 3, with the aim of moving care back down to level 3.
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Hospital specialist service: focuses on highly specialised hospital based clinical input which must be
delivered in a hospital environment for reasons of patient complexity, safety and/or economies of scale.
Services within this model will:

empower and support patients to control their own condition and self care

provide co-ordinated care with effective communication to provide smooth transitions between
sectors

deliver proactive care to reduce risks, complications and unnecessary hospital admissions/
attendances

be commissioned on use of competencies, not roles, to deliver care

involve multidisciplinary working

provide safe use of all diabetic medicines including insulin

provide early information and specialist support for pre-conception and pregnancy in women with
diabetes

ensure smooth transition into adult services for children and young people with diabetes

ensure dignity and respect
Every service commissioned by the CCGs will support/empower people to move to the lowest level
possible in the pyramid during every episode of care, giving them the highest level of appropriate
control of their care. This model of care will also support the wider work of the CCGs in developing their
Care Closer to Home models.
7.
PRIORITIES FOR SERVICE IMPROVEMENT
The Network held an event in January 2014 with over 60 people from key stakeholder groups to
identify the priorities for service improvement across the patch. The six priorities identified and these
are described below form the pillars of our local ’House of Care’ (see above), along with the vision
relating to each.
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Prevention
The best way to avoid Type 2 diabetes is to follow a healthy lifestyle. Two key factors that
impact on risk of conditions such as diabetes are being overweight or obese and being
physically inactive. The CCGs and Public Health will work in partnership to ensure services are
available to support people to lose and manage their weight better and to help people become
more physically active. Better local use will also be made of the NHS check to help identify
people at increased risk of cardiovascular diseases and diabetes and to use it as a lever to
promote local health improvement services and encourage patients to attend the services on
offer. For individuals not attending services, the CCGs and Public Health will work to make
sure that relevant and easy to understand information is available for individuals who may be
willing to make some small changes to their lifestyle in order to have a big impact on their
health.
Supported self-care/education
It is very important for patients to be aware of and involved in managing their own condition.
They will be encouraged and supported to take part in screening programmes such as diabetic
retinopathy10 and footcare screening. The CCGs will expect commissioned services to involve
patients/carers in care planning, focusing on what the patient is able to do for themselves, and
will provide and develop a variety of opportunities for education for patients/carers, using a
range of media. The CCGs want to see a personalised holistic care plan for each person with
diabetes developed and agreed in partnership with their clinical team through the careplanning process including action to be taken when problems arise. This care plan will be
shared with relevant people to ensure prompt, consistent action. The CCGs want to see all
those people with diabetes who use insulin as a treatment being supported to use it safely –
both in and out of hospital, including all pregnant women with diabetes being supported to
minimise risk to their babies.
10
The Diabetic Retinopathy Screening Programme is a nationally commissioned programme, and therefore does not
form part of this strategy
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Education/training
Health care professionals play a critical role in caring for and supporting people with diabetes.
To do this in the most effective way they need to receive accredited relevant training and
opportunities for development in relation to diabetes. The CCGs will ensure that systems are in
place to enable this, examples being taught courses, mentorship, etc.
Primary care
Most diabetes care can be delivered through primary care; however, at present there is
significant variation across practices. The vision of the Network is for all GP practices to be
upskilled to deliver a specific level of care, utilising the skills and experience of the workforce
within and outside each practice. The eight care processes set out in NICE guidance will be
undertaken with each patient with diabetes. Comprehensive annual health checks will be
undertaken, covering other co-morbidities where appropriate, and reviewing all medicines
being prescribed. GP practices will also be encouraged to identify their patient cohorts who are
most at risk of admission to hospital, using a multi-disciplinary approach to work with health
and social care professionals to deliver an enhanced care package for these patients.
Foot Care
It has been shown that regular foot checks can identify patients at risk of diabetic foot disease
and subsequent amputation. In future all patients with diabetes will receive an annual foot
check at which their risk status will be identified, and appropriate care/review provided. Health
and social care staff will be trained in awareness of foot disease and action to be taken, as will
patients/carers/families
Specialist diabetes services
Those with more complex needs requiring specialist care/support to help them manage their
condition will be cared for by specialist services delivered in the community where possible;
where this is not possible the diabetes patient will be cared for by a specialist hospital team.
Both these services will use the skills of the workforce in the most appropriate way.
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8.
MEASURING PROGRESS
National and local metrics for each priority area will be used or developed by the Network and progress
against them will be monitored regularly through the Network, with a highlight report being submitted to
each meeting.
Progress will also be reported back through the CCG governance and contract management structures.
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APPENDIX A
RECENT GUIDANCE AND BEST PRACTICE
The following guidance and best practice documents have been produced since the original publication of
the strategy.
Five Year Forward View
This document was published on 23 October 2014 and sets out a vision for the future of the NHS.
2015/16 NHS Outcomes Framework
The 2015/16 NHS Outcomes Framework, which sets out how NHS England will work with CCGs, includes
a number of outcomes relating to long term conditions including diabetes.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/385749/NHS_Outcomes_Fr
amework.pdf
Diabetes State of the Nation: Challenges for 2015 and beyond
In March 2015, Diabetes UK published ‘The State of the Nation: Challenges for 2015 and Beyond’,
which sets out fifteen healthcare essentials for people with diabetes, with actions to be taken by
organisations and individuals to put them in place. The healthcare essentials are set out at
Appendix C. The Network will use this report to guide its work.
https://www.diabetes.org.uk/Documents/About%20Us/What%20we%20say/State%20of%20the%20nation
%202014.pdf
NICE guidance

NICE guidance on the management of Type 2 diabetes (CG87) has been updated, and was reissued
in December 2014.
http://www.nice.org.uk/guidance/cg87/resources/guidance-type-2-diabetes-pdf

NICE guidance about gestational diabetes has also been updated and reissued
https://www.nice.org.uk/guidance/ng3

Type 1 diabetes in adults: diagnosis and management has been updated and reissued
https://www.nice.org.uk/guidance/ng17

Type 1 diabetes in children and young people: diagnosis and management has been updated and
reissued
https://www.nice.org.uk/guidance/ng18
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
Diabetic foot problems: prevention and management has been updated and reissued.
https://www.nice.org.uk/guidance/ng19

Diabetes in pregnancy: management of diabetes and its complications from preconception to the
postnatal period has been updated and reissued
https://www.nice.org.uk/guidance/ng3
NICE pathway for prevention of Type 2 diabetes
http://pathways.nice.org.uk/pathways/preventing-type-2-diabetes
What to expect at your annual foot check
This leaflet was produced by Diabetes UK in May 2015. It provides a checklist of the steps that a foot
check should include, a space to record the date of the check and the outcomes, as well as a useful list of
the signs to look out for that may indicate a foot problem.
https://www.diabetes.org.uk/Documents/What-to-expect-at-annual-foot-check.pdf
Quality and Outcomes Framework 2014-15
The Quality and Outcomes Framework (QOF) is the annual reward and incentive programme detailing GP practice
achievement results.
http://qof.hscic.gov.uk/
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APPENDIX B
CALDERDALE AND GREATER HUDDERSFIELD DIABETES STRATEGY REFRESH
OPERATIONAL PLAN 2015-2017
Where are now?
Where do we want to
be?
How we are going to get there?
Lead
Timescale
Make information on local services/support available
through various media
Communications
Team
November 2015
Identify action to be taken to address gaps/issues
Public Health/CCGs
December 2015
Identify areas to target for improving uptake of health
checks, using local data, and develop action plan
Public Health
To be confirmed
Develop local approach to motivation segmentation and
action plan
Public Health
To be confirmed
Prevention










Local public health
strategies
Food, Activity and
Weight Plan
Weight Management
Services
Better Living
Programme
(Calderdale)
Practice Activity and
Leisure Scheme
(Kirklees)
Huddersfield Giants
Exercise Programme
NHS Health Checks
for people aged 40 –
74
Food programmes
(Food for Life
partnership) –
community, schools,
hospitals
Active Travel
(Calderdale) e.g.
cycling, safer walking
Stop smoking services
Identify people most at risk
or with most causal factors
with aim of reducing
conversion to diabetes
Increase diagnosis rates to
reduce gap between
estimated prevalence and
number diagnosed
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Where are now?
Where do we want to
be?
Supported self-care – structured education
Co-production/
 DESMOND (Newly
empowerment of people
diagnosed and
Foundation in Greater with diabetes
Huddersfield, Newly
People with diabetes can
Diagnosed in
access a suite of supported
Calderdale)
self-management
education, linked to
 DAFNE
motivation segmentation
 X-Pert Programme in
Urdu and Punjabi
(Calderdale)
 Safer Ramadan
 Expert Patients
Programme (Kirklees)
How we are going to get there?
Lead
Timescale
Review capacity and content of programmes, identify
any gaps
CCGs/Education
providers
November 2015
Take action to address them
CCGs
December 2015
Review recommendations from All Party Parliamentary
Group on Diabetes report on Structured Education and
identify actions to be taken.
Network
January 2016
Map local and national supported self-care
services/support
CCGs/Public Health
November 2015
Communications
Team
December 2015
Identify action to be taken to address gaps/issues
CCG
December 2015
Evaluate services/support and use the outcomes to
inform commissioning
CCGs
Ongoing
Work with Practice Participation Groups to help inform
the diabetes agenda
Engagement and
Quality Teams
Ongoing
Develop community champions programmes
Calderdale CCG
Greater Huddersfield
CCG
January 2016
March 2016 (tbc)
Supported self-care – services and support
 Calderdale Diabetes
UK Support Group
 Honeyzz (Greater
Huddersfield)
 Self care handbook
(Kirklees)
 Improving Access to
Psychological Support
 Buddies (Greater
Huddersfield)
 Health Trainers
(Kirklees)
 Better Living
Programme
(Calderdale)
Co-production/
empowerment of people
with diabetes
Everyone with diabetes has
a co-created care plan
People with diabetes can
access a suite of supported
self-management
education, linked to
motivation segmentation
People with diabetes can
access peer support in the
community
Make information on supported self-care
services/support available through a variety of media
Page 20 of 25
Calderdale & Greater Huddersfield Diabetes
5 year strategy (refresh at October 2015)
Where are now?
Education and training
Free resources from
Diabetes UK to help with
skills, knowledge and
confidence
No specific programme of
education and training
around diabetes for staff.
No specific
education/training
standards for GPs and
primary care staff
Where do we want to
be?
Skilled, knowledgeable and
confident workforce, with
workforce development
programmes to continue
learning and development
planned and available to all
who need them.
A skilled, confident and
competent care home
workforce
Inconsistency around care
and treatment of
individuals with diabetes
living in care homes
How we are going to get there?
Lead
Timescale
Research models of psychological support and identify
transferable work and learning to inform future services
and commissioning
Network members and
others with interest in
diabetes
January 2016
Research models of support for people with severe
mental health/alcohol/drugs issues
Diabetes specialist
team/Network
January 2016
Research the use of technology for supported self-care.
Feed that information into the Network for further
dissemination
Network/specialist
staff/patients and
others with interest
January 2016
Explore possible funds for the provision of training e.g.
pharma
Greater Huddersfield
CCG
November 2015
Develop and agree education/ training standards for
GPs and primary care staff. Source and agree funding
routes
Greater Huddersfield
CCG
December 2015
and ongoing
Work with Huddersfield University on the development
of a rolling programme of education for all GP and
primary care clinicians
CCGs/providers/
Clinical Network
December 2015
Work with Continuing Care Teams and with Local
Authority contracting teams to support and encourage
training and education through, for example, the session
run in conjunction with the Diabetes Clinical Network
CCGs
Ongoing
Page 21 of 25
Calderdale & Greater Huddersfield Diabetes
5 year strategy (refresh at October 2015)
Where are now?
Where do we want to
be?
How we are going to get there?
Lead
Timescale
Develop improvement plans for the implementation of
the nine care processes
CCGs
December 2015
Implement the Level 3 diabetes service in Calderdale
with specialist training/mentoring/ support
Calderdale
CCG/CHFT
December 2015
Incorporate primary/community care functions including
collaborative care planning into care closer to home
models
CCGs/Locala/CHFT
December 2015
(Greater
Huddersfield)
June 2016
(Calderdale)
Research the use of technology to support clinicians
Network
January 2016
Feed in learning from Year of Care work
CCGs/providers
Ongoing
People with diabetes
receive information about
foot care and
prevention/identification of
foot problems
Development of business case to change the criteria for
access to podiatry so that ‘at Risk’/ high risk Diabetic
patients can be seen more rapidly.
Greater Huddersfield
CCG
To be confirmed
Review future capacity and demand in Calderdale
Calderdale CCG
November 2015
Fewer admissions to
hospital for a diabetic foot
problem
Development of foot protection assurance framework
Strategic Clinical
Network
December 2015
Primary/community care
Variation in level of care
received by people with
diabetes
Improved delivery of and
outcomes from care
processes
Levelling off of
achievement around QOF
diabetes targets
Increased skills,
knowledge and
confidence of workforce
Care Closer to Home
models being developed
Diabetes injectable
therapies community
service in 13 GP practices
in Greater Huddersfield
(ending Sept)
Keyworker function
(Diabetes Specialist Nurses
– formal, Practice Nurses –
informal)
Forthcoming changes in the
way of delivering social
care
Foot care
Provision of foot screening
for all patients with diabetes
in Calderdale by podiatry
service
Foot screening undertaken
in primary care in Greater
Huddersfield by nurses or
Health Care Assistants
Page 22 of 25
Calderdale & Greater Huddersfield Diabetes
5 year strategy (refresh at October 2015)
Where are now?
Foot care (continued)
Foot Protection Team
function provided by
podiatry in both areas
Where do we want
to be?
How we are going to get there?
Lead
Timescale
Fewer amputations
Evidenced learning from Root Cause Analysis of
samples of amputations
CHFT/Locala
To be confirmed
Develop a process and template for Root Cause
Analysis of samples of amputations
CHFT/Locala
To be confirmed
Develop community services as part of the care closer
to home model
Greater Huddersfield
CCG/Locala
December 2015
Develop community services as part of the care closer
to home model
Calderdale CCG/
CHFT
June 2016
Ensure that people with diabetes in hospital are
identified on admission so they can receive specialist
diabetes input and receive a foot check as part of their
overall care
CHFT
Ongoing
Introduce wi-fi system to enable review of HbA1c results
for self-testing by patients with diabetes in hospital (with
review of results by clinician)
CHFT
To be confirmed
Recruit additional hospital diabetes specialist nurse
CHFT
Multidisciplinary Foot Team
(consultant, podiatrist,
vascular, DSN) on each
site
Specialist services - community
Community Diabetes
More care taking place in
Specialist Nurses (Greater
the community (therefore
Huddersfield)
reduced outpatient
appointments)
No formal community
diabetes specialist services
in Calderdale
Specialist services - hospital
One hospital diabetes
specialist nurse covering
both sites
Patients encouraged and
supported to self-manage
while in hospital
CQUIN around supporting
people with diabetes in
hospital to manage their
own condition
To be confirmed
Page 23 of 25
Calderdale & Greater Huddersfield Diabetes
5 year strategy (refresh at October 2015)
Where are now?
Where do we want to
be?
How we are going to get there?
Lead
Timescale
Look into having a local ‘service champion’ from
Diabetes UK to link between the Network and the
community
Network
November 2015
Commissioners/
Engagement and
Comms Teams
Ongoing
Arrange a further stakeholder event and ensure strong
representation from people with diabetes and their
families/carers
Network
January 2016
Identify and facilitate opportunities for people with
diabetes and their families/carers to be involved in
specific service improvement projects
Network
Ongoing
Map health inequalities for Network to use to target
efforts
Public Health
To be confirmed
Look at ways to work with community pharmacies on
diabetes
Network
December 2016
Look into the application of near patient testing for
HbA1c
CCGs
January 2016
Patient/carer engagement and involvement
No formal arrangement
for patient/carer
engagement and
involvement
People with diabetes and
their families/ carers are
engaged in discussions
about local diabetes
services and support
No direct patient/carer
input into the Network
Develop an engagement and communication strategy,
including co-production
Reducing health inequalities
Lots of data relating to
health inequalities
Commissioners have a good
understanding of the needs of
their populations, and are able
to identify where efforts need to
be targeted, so that health
inequalities are reduced
Medicines Management
Community
Community pharmacies
pharmacies providing
supporting and signposting
varying degrees and
people with
types of support to
diabetes/families/carers
people with diabetes
and their
Technologies/ processes
families/carers
considered for implementation
where appropriate
Page 24 of 25
Calderdale & Greater Huddersfield Diabetes
5 year strategy (refresh at October 2015)
APPENDIX C
Diabetes UK – Healthcare essentials for everyone with diabetes
1. Get your blood glucose levels (HbA1C) measured at least once a year. This will
measure your overall blood pressure control and help you and your healthcare team
to set a target.
2. Have your blood pressure measured and recorded at least once a year, and set a
target that is right for you.
3. Have your blood fats, such as cholesterol, measured every year. You should
have a target that is realistic and achievable.
4. Have your eyes screened for signs of retinopathy every year.
5. Have your feet checked. The skin, circulation and nerve supply of your feet should
be checked annually. You should then be told if you have any risk of foot problems
and how serious they are.
6. Have your kidney function monitored annually. This should involve two tests: a
urine test for protein and a blood test to monitor kidney function.
7. Have your weight checked and your waist measured to see if you need to lose
weight.
8. Get support if you are a smoker, including advice and support on how to quit.
9. Engage in care planning discussions with your healthcare team to talk about your
individual needs and set targets.
10. Attend an education course in your local area to help you understand and manage
your diabetes.
11. Receive care from a specialist paediatric team if you are a child or young person.
12. Receive high quality care if admitted to hospital from specialist diabetes
healthcare professionals, regardless of whether or not you have been admitted
due to your diabetes.
13. Get information and specialist care if you are planning to have a baby as your
diabetes control has to be a lot tighter and managed very closely. You should expect
care and support from specialists at every stage, from preconception to postnatal
care.
14. See specialist diabetes healthcare professionals to help you manage your
diabetes, such as podiatrists, ophthalmologists and dietitians.
15. Get emotional and psychological support. Being diagnosed with diabetes and
living with a long-term condition can be difficult and you should be able to talk about
issues and concerns with specialist healthcare professionals.
Page 25 of 25
Calderdale & Greater Huddersfield Diabetes
5 year strategy (refresh at October 2015)