Quality statement for diabetes

Diabetes has a significant impact on society because of the number of people affected, the personal impact of managing the condition, and the healthcare costs associated with treating the condition and its serious complications.

Type 2 diabetes makes up around 90% of cases, but there are also type 1 diabetes, gestational diabetes (during pregnancy) and some rarer forms of diabetes. More than 200,000 people in Wales, approximately 7% of the population, are known to have a form of diabetes (including around 16,000 cases of type 1 diabetes). It is estimated that a further 61,000 people are yet to be diagnosed with type 2 diabetes and 350,000 people are thought to be at high risk of developing type 2 diabetes. The prevalence of diabetes is also rising and is expected to reach 10% of the population by 2035. 

Managing diabetes has a significant impact on most people’s lives. People with type 2 diabetes will normally need to make significant and long-term changes to their lifestyle, some may require long-term medication to delay progression, and eventually some may need to inject insulin. People with type 1 disease will need to inject insulin for their entire lives and pay strict attention everyday to managing their blood glucose levels. Poorly managed diabetes can lead to serious short-term complications, such as diabetic emergencies, and long-term damage to the heart, kidneys, eyes and feet. Diabetes can have a significant impact on psychological wellbeing and a person’s ability to manage their diabetes. As well as these personal and societal impact, it also creates a very large healthcare burden for the NHS, estimated at around 10% of the cost of delivering NHS services.

Prevention in the wider sense, such as enablers of healthier lifestyle are not within the scope of this statement but are covered by other Welsh Government policy, such as the approach to tackling obesity in Healthy Weight, Healthy Wales. However, prevention in the specific sense is within the scope of this statement. Type 2 diabetes can be prevented, even among those at higher risk, and there is growing evidence that some people who have developed type 2 diabetes can be supported into remission. Even though type 1 diabetes cannot be prevented, the daily disruptions and impact, plus the serious complications that can result from poor management can be lessened. Therefore, good diabetes care is essential to delaying diabetes progression, preventing diabetic emergencies, and avoiding serious complications such as heart disease and stroke. 

Central to good disease management, throughout the life journey of people with diabetes, are improving knowledge of their condition and empowerment. This also applies to parents, families and carers. Support for self-management should be given equal weight in healthcare. Ultimately the aim is to support people living with diabetes to live healthy and happy lives. Much was achieved under the 2013 and 2016 Diabetes Delivery Plans and the next phase of service development will build on the expertise, engagement and tools that have been developed to empower people living with diabetes and support clinicians to deliver excellent diabetes care in the years ahead. Key areas of focus will be education and support programmes, evidence-based health and care pathways, and the use of data on variation in service provision and outcomes to guide service decisions.

The introduction of this quality statement forms part of the enhanced focus on quality in healthcare delivery and will be integral to the future planning and accountability arrangements for the NHS in Wales. The Quality Statement sets out key planning and accountability expectations for service planning, which will be enabled by national support and collaboration. This collaboration will continue at the national level through a successor to the new Diabetes Clinical Network as part of the NHS Executive. The new national leadership team for diabetes will support the NHS Executive to discharge its function by providing a quality assurance function.

The quality of diabetes care will be monitored through the NHS’s Value-Based Healthcare diabetes dashboard, Primary Care Information Portal, and the National Diabetes Audit and National Paediatric Diabetes Audit.

Equitable

1. The national leadership team will bring together health board lead clinicians from primary, community and secondary care, as well as service managers, third sector, and people with diabetes to develop national resources that support more consistent, and higher quality, delivery of diabetes care.
2. The national leadership team will use data driven insights from clinical audit, peer review and atlases of variation to demonstrate to local teams unwarranted variation and to encourage and support quality improvement activity.
3. The national leadership team will support equitable adoption of supportive technology (particularly pump technology); supported where appropriate by national procurement arrangements, training packages, and close working with national appraisal bodies.
4. Health board clinical teams pay particular attention to adapting service models and tailoring approaches to improve engagement with groups who may have challenges accessing traditional healthcare models and subsequently have lower rates of key care process completion and poorer treatment outcomes.

Safe

5. A system-wide focus on recovering and improving diabetes chronic condition management services to address any increased risk of harm resulting from disrupted access to healthcare during the pandemic.
6. Diabetic Eye Screening Wales provides accessible appointments at recommended intervals, results are available to relevant clinical teams to action, and uptake of screening is equitable.
7. Health boards provide appropriately resourced specialist teams and professionally competent generalist care to support people with diabetes to manage their condition in accordance with the nationally agreed pathways, locally adopted.
8. Health and social services that deliver domiciliary, residential or inpatient care for people with diabetes have appropriately trained staff and national tools to support the avoidance, identification, reporting and management of errors in diabetic care that have the potential to result in serious complications such as diabetic ketoacidosis and severe hypoglycaemia.
9. Children and young people with diabetes experience tailored support during transition to adult services in line with the transition standards and, where possible, avoid coming to harm as a result of continued engagement with their diabetes team.
10. Health boards provide effective preconception planning, early detection of diabetes in pregnancy, and appropriate support throughout pregnancy to achieve good glycaemic management and avoid the development of type 2 diabetes.

Effective

11. Health boards provide services that identify people at high risk of developing types 2 diabetes and refer people to the all-Wales Diabetes Prevention Programme to reduce their risk.
12. Health boards provide remission services to appropriate people living with type 2 diabetes to help reduce the prevalence of type 2 diabetes and the risk of developing serious complications.
13. Health boards apply the All-Wales Referral Pathway for new presentations of type 1 diabetes to prevent diabetic ketoacidosis and hospital admission.
14. Health boards offer people newly diagnosed with type 1 diabetes the opportunity to participate in research trials at diagnosis, supported by an up-to-date national register of open research programmes.
15. Health boards focus on delivering key care processes for people with diabetes and work towards achieving treatment targets at population level.

Efficient

16. Health boards plan diabetes services, across care settings, according to the nationally agreed clinical pathways that have been locally adapted to suit population need and workforce availability.
17. The all-Wales diabetes electronic patient record is adopted and enables greater integration of care across community, primary and specialist care.

Person centred

18. Health boards provide at regular intervals an accessible structured diabetes education programme to support people to better understand and manage their condition.
19. Health boards provide tools and appropriate support to people with diabetes to help address the emotional and psychological impact of living with diabetes.
20. Co-production of care ensures people living with diabetes achieve the outcomes that matter to them, including individualised timing and content of reviews, empowerment support, treatment targets and care planning.
21. Health boards will provide integrated community, primary and secondary care for people with diabetes according to the agreed management plan and a whole person approach to the management of co-morbidities.
22. Health boards and the third sector work together to provide peer support opportunities from others who live with diabetes.

Timely

23. Health boards ensure people newly diagnosed with diabetes receive comprehensive care, support, and education during their first year of diagnosis to develop effective self-management habits early in the life course of the disease.
24. Health boards use risk stratification tools to deliver prompt investigation of people with signs of diabetes, identifying early patients demonstrating poor disease management and referring them to the appropriate healthcare professional for support.

The following nationally agreed clinical pathways are available:

• Type 1 Diabetes
• Type 2 Diabetes
• Gestational Diabetes
• Psychological Care in Diabetes
• Transitional Care in Diabetes
• Foot Care in Diabetes
• Renal Care in Diabetes
• Prevention and Remission of Diabetes