Dr Peter Winocour
Honorary Chairman of ABCD
Department of Diabetes & Endocrinology
QEII Hospital - Q114
Welwyn Garden City,
Hertfordshire
AL7 4HQ
peter.winocour@nhs.net
A response to Liberating the NHS from the Association of British Clinical
Diabetologists (ABCD) – Service Commissioning
Introduction
The Association of British Clinical Diabetologists (ABCD) represents specialist
trainees and consultants providing diabetes care in the United Kingdom, with
the majority of registered specialists current members.
ABCD support the aspirations of Liberating the NHS and strongly welcomes the
opportunity to comment on the opportunity this White Paper affords for high
quality patient focused care for the increasing number living with diabetes.
Current estimates suggest that over 1 in 15 adults have diabetes and this will
increase to 1 in 10 by 2030.
Diabetes as a multifactorial condition requiring multidisciplinary care
Diabetes mellitus is a UNIQUE complex multifactorial long term condition and
requires a separate strategy. Unlike other chronic diseases the effective
integration of care requires planning not only across primary and secondary
care, but between many specialist medical and nursing disciplines, with input
from podiatry, dietetics, psychologists and others.
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Seamless care
Individuals living with diabetes require services that operate seamlessly across
administrative and service boundaries which recognise the frequent need for
emergency access to specialist care. Failure to deliver this will lead to
fragmentation of care, cost inefficiencies and adverse outcomes Whole system
information programmes that communicate across these boundaries are vital to
minimise duplication and waste and ensure rapid transfer of key clinical data.
The commissioning of whole system diabetes care is best achieved with reference
to the NHS Diabetes Commissioning Toolkits. Whilst GPs as lead commissioners
have responsibility to ensure the vast majority of NHS care is provided ,
specialist diabetes services and integration of care will require close
collaboration with local specialist diabetes teams, and ideally through
engagement with effective local diabetes clinical networks or through diabetes
leads in local trusts. This engagement will also ensure avoidance of any conflict
of interests from commissioners with provider roles, and recognise the
importance of specialised aspects of diabetes care.
Diabetes networks work when there is full stakeholder engagement from
primary care teams and commissioners, specialists and those living with
diabetes, collaborating to deliver services.
The recognition that diabetes services have evolved locally is vital with the local
flavour enhancing the national guidelines and commissioning toolkits.
The role of specialist diabetologist care

Co-ordination of care for those with complications
The greatest danger for those living with diabetes in the potential fragmentation
of longer term diabetes care if many service providers are involved for bite size
chunks of diabetes care. The screening for care of, e.g. retinal disease, cannot
easily be separated from an individual’s frequent need for careful glycaemic, foot
or renal care.

Early intervention in those with complications to achieve optimal
outcomes
ABCD want to ensure that specialists involved in diabetes care are not simply
involved in the care of those most complex cases including those with
complication, but have earlier access to those with the first signs of
complications where the impact of intensive input is now beyond doubt.

New therapies including pumps
Specialist Diabetologists are best placed to lead on the introduction of new
therapies and the expansion of diabetes care in hospital in-patient settings , in
the provision of services for insulin pump-glucose sensing systems , and in joint
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specialist clinics supporting the care of those with complications. This approach
has been demonstrated clearly to improve both the quality of care and patient
outcomes.

Children, Young People and pregnancy
Models of optimal care emphasise the need for commissioned specialist
diabetologist services for women with pre-gestational or gestational diabetes
throughout pregnancy and in supporting the transitional care of adolescents
with diabetes

Patient education
Structured patient education is the key to effective self management and
specialist doctors’ input alongside other health professionals will ensure
programmes are up to date

Training of HCPs (specialist and generalist)
One major concern of ABCD is to ensure that the future training of specialist
doctors and other health care professionals (HCPs) is consolidated within future
service commissioning. At present deaneries and acute trusts provide a rigid
agreed training curriculum which is comprehensive. Future new diabetes service
models must recognise the crucial need for integrated services involving
specialists providing both service and training of patients and health care
professionals in the community. It is vital that commissioning recognises the
need to incorporate this aspect within any service level agreements.
 Research
The future health of those living with diabetes must recognise the ever expanding
research data base. This is making clear the need for much earlier proactive care
involving specialist input and new therapies earlier in the natural history of
diabetes.
Liberating the NHS- Maximising the potential for Diabetes
The need to ensure those living with diabetes see ‘the right person in the right
place at the right time’ requires services commissioned to facilitate early
specialist support rather than the current tariff based system which has operated
as a disincentive to secure such input for generalists.
The notion of integrated diabetes care was espoused in the Teams without Walls
principles that the Royal Colleges of Physicians , General Practitioners and
Child Health set out and which ABCD has fully engaged with, leading to the
publication of the NHS Diabetes document ‘Commissioning Diabetes Without
Walls’ in 2009.
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ABCD had previously collaborated with the NHS Alliance in our shared
document from 2008 –‘ Integrated Healthcare: From Aspiration to
Implementation’. This paper made clear the need for primary care
commissioners to ensure specialists were fully engaged to enable this vision to be
realised. This would need to cover the provision of diabetes care in both
community and hospital settings from childhood to old age.
The collaboration of primary care with specialist services and patient
representation in both planning and provision of care is vital to enable this to
take place.
Peter H Winocour
Consultant Diabetologist and Chairman of ABCD
October 2010
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