Section 1
Section B –Service Specification
Mandatory headings 1 – 3. Mandatory but detail for local determination and agreement.
Optional headings 4 – 6. Optional to use, detail for local determination and agreement.
All subheadings for local determination and agreement.
Service Specification No.
Service
Structured Education Programme Newly Diagnosed Type
2 Diabetes
Commissioner Lead
Karen Burton / Dr Mike Clark
Provider Lead
Period
12 month contract period
Date of Review
Within 12 months of the contract start date
B1_1.0
Population Needs
Diabetes is one of the most common chronic medical conditions in the UK, with an estimated
1.9 million adults diagnosed with the condition. Type 2 diabetes, accounts for around 90% of the
cases. Alongside this, estimates suggest that there are an additional 0.5 million people with
undiagnosed diabetes against a background of rising prevalence. The direct costs of type 2
diabetes are estimated to be around 7-12% of total NHS expenditure
Hypertension, depression and diabetes are the most common conditions, with the greatest
incidence being in GP practices in Knutsford, Handforth, Macclesfield, and Congleton which are
aligned to the areas of greatest deprivation – Data source ECCCG Risk Stratification data Oct
2014
People with diabetes in Central and Eastern Cheshire are 40.9% more likely to have a
myocardial infarction, 11.5% more likely to have a stroke, 77.1% more likely to have a
hospital admission related to heart failure and 43.7% more likely to have a lower life
expectancy.
Data source - Diabetes Community Health Profile NHS Eastern Cheshire CCG – updated 24th
June 2013
The prevalence of diagnosed diabetes among people aged 17 years and older in NHS
Eastern Cheshire CCG is 5.6% compared to 5.7% in similar CCGs;
In 2011/12 NHS Eastern Cheshire CCG 73.7% of adults with diabetes had a
HbA1c measurement of 59mmol/mol or less. This is higher than in other similar CCGs
and higher than England.
Spending on prescriptions for items to treat diabetes in 2011/12 cost £391.67 per adult
with diabetes in NHS Eastern Cheshire CCG compared to £415.89 across England.
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There are 8,094 patients aged 17+ on the Diabetes disease register in Eastern Cheshire
CCG (with an average prevalence rate of 4.7%)16 A breakdown by practice is available in the
table below. It is estimated that there are a further 2,583 adults with undiagnosed diabetes
Based on information gathered from the GP Practice registers for 2012/13 and 2013/14 it is
estimated that 660 individuals will be diagnosed with Type 2 Diabetes.
Diabetes is a chronic and progressive disorder that impacts upon almost every
aspect of life.
B1_2.0
Scope
B1_2.1
Aims and objectives of service
Provide diabetes education for groups of adults newly diagnosed with Type 2 diabetes within
the registered population of NHS Eastern Cheshire CCG.
Education that supports and enables individuals to have the knowledge, confidence and skills to
effectively self-manage their condition. The Education Programmes should be delivered by
appropriately trained educators, evidence-based and suit the needs of the individual. The
programmes should have specific aims and learning objectives to support the individual and his
or her family and carers in developing positive attitudes and beliefs to self-manage their
diabetes.
Evidence Base
The National Institute for Health and Care Excellence (NICE) Diabetes in adults quality standard 1
(2011) states: “People with diabetes and/or their carers should receive a structured educational
programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review
and access to ongoing education”. The National Service Framework
NICE Technology Appraisal Guidance 60 – Use of Education Models for Diabetes (2014) states that
the ultimate goal of education is improvement in the following areas:
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Control of vascular risk factors, including blood glucose, blood lipids and blood pressure
Management of diabetes- associated complications, if and when they develop
Quality
The National Service Framework for Diabetes proposes a supported self care service model for
diabetes and recognises the importance of education in facilitating self-management as a corner
stone of diabetes.
Active support for self-management for people with long term conditions is a key driver within
NHS Eastern Cheshire CCG’s Caring Together Programme to integrate care.
NICE Clinical Guidelines (CG66, CG87) endorse five standards for a structured education
programme.:
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1. Any programme should be evidence-based, and suit the needs of the individual. The
programme should have specific aims and learning objectives. It should support the
learner plus his or her family and carers in developing attitudes, beliefs, knowledge and
skills to self-manage diabetes.
2. The programme should have a structured curriculum that is theory-driven, evidencebased and resource-effective, has supporting materials, and is written down.
3. The programme should be delivered by trained educators who have an understanding of
educational theory appropriate to the age and needs of the learners, and who are trained
and competent to deliver the principles and content of the programme.
4. The programme should be quality assured, and be reviewed by trained, competent,
independent assessors who measure it against criteria that ensure consistency.
5. The outcomes from the programme should be regularly audited.
B1_2.2
General Overview
Structured education programme for newly diagnosed Type 2 diabetics – The majority of
individuals will be under the care of Primary Care. Table 1 details the average number of newly
diagnosed Type 2 by GP Practice per year.
GP Practice
Population
Estimated
newly
diagnosed
Type 2
Alderley Edge
7,740
11
Handforth
9,765
35
Chelford Surgery
Chelford
3,769
8
Kenmore Medical Centre
Wilmslow
12,377
29
Wilmslow Health Centre
Wilmslow
11,782
20
Lawton House Surgery
Congleton
10,171
34
Meadowside Medical Centre
Readesmoor Medical Group
Practice
Holmes Chapel Health Centre
Congleton
7,953
23
Congleton
13,155
42
Holmes Chapel
11,715
37
Annandale Medical Practice
Knutsford
5,717
22
Manchester Rd Medical Centre
Knutsford
7,189
24
Toft Road Surgery
Knutsford
9,753
52
Cumberland Hse
Macclesfield
15,121
80
High Street Surgery
Macclesfield
7,619
30
Park Green Surgery
Macclesfield
11,256
35
Park Lane Medical Centre
Macclesfield
9,171
30
South Park Surgery
Macclesfield
12,435
39
Broken Cross Surgery
Macclesfield
5,743
15
Poynton
6,409
28
GP Practice
Alderley Edge Medical Practice
Handforth Health Centre
McIIvride Medical Practice
Town Area
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Priorslegh Medical Centre
Poynton
11,364
38
Bollington Medical Centre
Bollington
10,909
28
The Schoolhouse Surgery
Disley
4,611
6
Total
205,724
Data Source: GP Practice register 2012/13 & 2013/14 averages
660
Providers wishing to provide a structured education programme will need to ensure they
comply with NICE guidelines and quality standards for Diabetes in adults.
Diabetic education programme will be offered to all newly diagnosed adults with Type 2
diabetes.
Provision of education to long standing diagnosed patients who may need a refresher or who
would benefit from participation in structured focused education.
Expected Outcomes
 improving knowledge, skills, health beliefs and lifestyle changes
 improving patient outcomes biomedical markers, for example body weight,
haemoglobin A1c, lipids and smoking; and psychosocial changes, for example quality of
life and levels of depression
 improving levels of physical activity
 Improving performance and patient-centred clinical care through implementing the
recommendations outlined in NICE clinical guideline CG87 Type 2 Diabetes - newer
agents (partial update of CG66);
 Reducing the need for, and potentially better targeting of, medication and other items, for
example blood testing strips;
 Reducing inequalities and improving access to educational support, especially among
black and minority populations, among those who report not attending an education
course but want to;
 Increasing patient choice and improving partnership working, patient experience and
engagement;
 Greater cost-effectiveness.
Help to increase individual’s self-efficacy, increase motivation and attitudes to self care, thereby
reducing complications and unplanned use of secondary care health services.
Individuals are able to set their own goals and develop their own personal action plan with
regard to their future diabetic management
Individuals have a greater understanding of the benefits to attending screening appointments
e.g. retinopathy and podiatry.
Referral Route
 the referrals will be direct from General Practitioners and Practice Nurses.
 Providers must provide literature for GPs and referrers to assist them in the decision
making processes associated with the most suitable group session for the individual.
The individual should be contacted within a maximum of [10] working days of
acceptance of the referral;
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 Individuals should be offered a choice of venue and time to attend a group session that
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is convenient to them
Sent a letter of confirmation within 5 working days of receipt of the booking
Contact either by telephone or text within 3 days prior to the course to remind the
individual of date, time and venue and request confirmation of attendance
Provider to detail how the referral process will operate and the mechanisms involved
which will need to be agreed with the Commissioner (NHS Eastern Cheshire CCG)
The Provider should ensure Patients have an adequate understanding of the purpose of
the education programme and what it involves before the group session by providing
written information/easy read in advance that explains the purpose of the ultrasound
scan, what it involves and when and how they can expect to receive the results. This
information should be reinforced on arrival at the session, consistent with the written
information already received;
The Provider shall not discriminate between or against Patients or Carers on the grounds
of gender, age, ethnicity, disability, religion, sexual orientation or any other non-medical
characteristics. The Provider shall provide appropriate assistance and make reasonable
adjustments for Patients and Carers who do not speak, read or write English or who
have communication difficulties
Providers will provide to Commissioners detailed referral statistical information on
referrers, referring organisation, service utilisation, referral rejection rate and clinical
outcome to allow refinement of the clinical pathway.
Service Delivery
Provide standardised high quality structured education for adults with Type 2 diabetes through
group sessions and individual face to face contacts where appropriate.
Empower adults with diabetes to manage their condition by enabling them to develop the
necessary knowledge and skills to manage their condition
Provide psychological support for adults diagnosed with diabetes aimed at improving mental
wellbeing by supporting the development of self-management / self-care skills. The emphasis
of the education programme is on self-management and action planning to enable individuals to
understand what their goals are and how they can achieve them. This information can then be
used as part of the care planning process at any subsequent meetings with health care
professionals.
Reduce the risk of people with diabetes from developing complications
The structured education programme offered must be consistent with the five standards detailed in
the NICE Clinical Guidelines (CG66, CG87) It is paramount that the provider supports these
standards and:
 Provides psychological support for adults diagnosed with type 2 diabetes aimed at improving
mental wellbeing by supporting the development of self-management / self-care skills
 Any advice relating to use of medicines, blood glucose meters and self-monitoring of blood
glucose levels must be consistent with national / local guidelines and the CCG’s Medicines
Management recommendations
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 The nature of any structured education to be offered, its aims, and outcomes will be
documented in the patient’s care plan.
 Participants must be able to define and agree personal healthcare targets and develop
strategies for meeting them
 The provider must ensure that programmes are integrated with the rest of the care pathway
and that all information provided during the programme is consistent with the care pathway
 The provider must ensure that patients with diabetes and their carers have the opportunity to
contribute to the design and provision of local programmes
 The provider will ensure that all education programmes are accessible to a broad range of
people taking into account their culture, ethnicity, any special needs (e.g. language, learning
disability) that they might have, and where they live.
 The provider must ensure that all members of the healthcare team are familiar with the
content of local education programmes, to ensure that consistent advice is given to all
individuals.
 The provider will ensure that the education programme will be delivered in accessible and
appropriate settings, with patients being offered a choice of dates and venue. The
programme will consist of a minimum of one 3 hour Group session for newly diagnosed Type
2 Diabetics and one 1 hour follow up session. The follow up session will be in 6 months of
the first group session.
 The provider will be responsible for following up anyone who does not attend a scheduled
education session to establish the reasons for this and to offer an appropriate alternative.
 The provider will ensure that the diabetes education needs of people caring for individuals
with diabetes are met. They will encourage carers to attend the education sessions either
independently or with the individual.
 The provider will establish links with a range of community groups and special interest
organisations, in order to ensure that educational needs are being met, awareness of
diabetes as a health issue remains high, and to support other health promotion work on risk
reduction in diabetes.
 The provider will provide details of staffing mix, staffing levels and with appropriate
qualifications which will be agreed with commissioners as minimum standards
 The provider must inform the individuals GP in writing of DNAs and the failure of any
individual to complete an education programme.
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B1_2.3
Population Covered
Individuals registered at the 23 GP practices within NHS Eastern Cheshire Clinical
Commissioning Group
B1_2.3.1
Acceptance Criteria
Referrals for inclusion:
Newly Diagnosed adults with Type 2 Diabetes
B1_2.3.2
Exclusion Criteria
Clinical exclusions
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Children and adolescents
Type 1 Diabetics
B1_2.4
Interdependencies with other services
The Provider needs to develop their relationships with other Providers to become an integral
member of the Health and Social Care Community. This includes third sector organisations
providing help and support for Patients. The development of local clinical networks will be
encouraged with the aim of providing parallel services which provide complementary services
allowing for further clinical services to be offered closer to home and within the community. The
role of service users as key stakeholders will be an important component of this development
and Providers should ensure effective mechanisms for their involvement.
The Provider may need to develop relationships within the Health Community to enable
fulfilment of the Quality Assurance requirements.
The Provider will be required to be involved in local care pathway work and discussions,
ensuring the best and most efficient means of caring for individuals are adopted, including the
movement of the relevant clinical information.
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B1_3.0
Quality and Performance Standards
B1_3.1.1
Quality Assurance
The Provider (GP Practice) must demonstrate robust quality assurance processes which ensure
their educators are fully competent
 Quality assurance processes must ensure high quality consistent delivery of the education
programmes
 Quality assurance process must include self-assessment, peer review and external review
 Provider should demonstrate user involvement and feedback in the delivery and review of the
service
 Any untoward incidents will be recorded on appropriate documentation with and details sent to
the commissioners as part of the contact reporting mechanisms. Providers must inform
commissioners immediately if the untoward incident will or has impacted on patient safety.
Audit
The service will be audited on an on-going basis which will include: quarterly reports, monthly
activity data and an annual service report
NICE guidelines state that structured education courses for patients must meet 5
guidelines.
1. Patient centred (not medically centred) (Equality etc.)
2. Structured written curriculum (consistency of delivery & supporting materials & audit)
3. Trained Educators (for effective delivery)
4. Quality assured (meets these 5 criteria- ideally independent or peer)
5. Audited (delivered as commissioned and achieves the outcomes)
Audit measures/ outcomes
These have been put together from a patient perspective with consideration given to the
CCG and GP following NHS England drivers and Diabetes UK (March 2014) and Diabetes
professional discussions on the World Wide Web.
The audit is based on an assessment of quality(Q), impact (I) and value (V) for money.
 Quality being the extent to which the education met its specific commissioned objectives.
 Impact being the effect on the patients’ health and well-being.
 Value for money investment in one model and the impact compared to alternatives.
Refer to B1-4.0 Key Service Outcomes
4 types of measures:
1. Clinical - reduce the risk of long term complications
2. Patient satisfaction - furthers understanding of need for treatment & Self-management.
3. Quality of life (psychosocial)
4. External statistical evidence & quality check (NICE point 4)
5. Caring together – joined up integration with aim of sustainable progress.
Suggested method: information collected by way of pre course questionnaire, start of course
medical data from last (annual) review, questionnaire at end of course and from course review
session 3-6 months after attending, data from course review and next annual review and
extracts from externally compiled statistics.
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Risk Management
The provider must assess the risks of the service they are providing and develop plans to
reduce and manage the risks. The provider shall ensure that appropriate contingency plans are
in place to minimise disruption to the delivery of services.
Information Governance
All confidential patient information will be stored and accessed according to NHS national
standards on confidentiality.
Freedom of Information
Each of the parties acknowledges the requirements of the Freedom of Information Act 2000 and
each of the parties shall assist and cooperate with the other party (at their own expense) to
enable the other party to comply with these information disclosure requests as appropriate.
B1_4.0
Key Service Outcomes
Table 1: Key service outcomes – Develop section from DJs information
Key Service Outcome
Method of Measurement
95% of individuals offered a
structured education programme
within 10 working days of referral to
start within 20 working days of
referral
.
Medical
Quality and Impact
HbA1C
Weight
Blood Pressure
Cholesterol
Eyes
Feet
Kidney Function
Annual Review
Quality
Individuals knowledge confidence and
skills to self manage
Patient Questionnaire
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Would you recommend course
Materials/preparation/location/duration/delivery
staff
Diabetes UK 15 essential checklist
Do you have a self-management action plan
Do you know who will carry out your annual
review
Do you feel able to live with your condition
Rate your feelings (of anxiety)
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Work
Driving
Holidays
Physical activity
Eating
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Key Service Outcome
Method of Measurement
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Impact
Physical Activity
Medication
Outlook for your health over the years
Friends & family relationships
Physical activity at the start of the course and at the
annual review
Individuals knowledge of wider team and Medical Team and Local support Groups
access to support
National and Local Information which may be used by the CCG to understand the Impact on the
local population (individuals accessing structured education) and Value for Money of the
commissioned service.
 National Diabetes Audit
 National Diabetes Inpatient Audit
 Patient Experience Measures
 Diabetes footcare Audit
 Quality Outcomes Framework
 Quality Improvement Schemes
Over the next 12 months 2015/16 (financial year) NHS Eastern Cheshire CCG will evaluate
the service to ensure that the structured education is embedded in an integrated
sustainable service as part of the Caring Together Programme of work.
SECTION B PART 2 - INDICATIVE ACTIVITY PLAN
B2_1.0
Indicative Activity Plan
Report
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The number of referrals for patient education - type 2
The number, and time of classes/ group sessions offered
The number of places available in each class
The number of patients attending in each class
The number of people declining to attend
Information on reason for why people decline to attend
The number of DNAs
The number of people completing the education programmes by type 2
The number of people who failed to complete their education programme
The above information also to be broken down by patients’ GP practices & sources of
referral
Breakdown of the above by ethnicity
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B2_2.0
Prices and Payment
Table 2: Prices and payment
HRG Code
Description
Price
N/A
Local Tariff
Cost per person attending group
session
£50
GP Practices providing this service will be paid via the NHS Eastern Cheshire
CCG’ multi claim form (quarterly).
The £50 cost per head is based on individuals newly diagnosed with Type 2
Diabetes attending one 3 hour group education session and one 1 hour follow up
session. The expectation is that the follow up session would be in 6 months of
the first group session.
Practices cannot claim for individuals diagnosed with Type 2 Diabetes prior to the
commencement of the contract.
Practices can invoice the CCG using the multi claim form following the first group
session but must evidence the follow up attendance otherwise a refund of £13 for
each follow up attendance not evidenced will be payable to the CCG.
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