Diabetes: Children and Young Adults

Leadership and Accountability Create a clear ICS-wide governance and accountability framework for the 0-25 diabetes pathway, with explicit clinical leadership at ICB level and across all commissioned services. This framework should set out unambiguous responsibility from ICB executives and clinical leads through to place-based leaders, provider collaboratives, trust boards, senior teams and frontline clinical staff. It should define how accountability operates across the whole system, with agreed escalation and review processes so that risk flows upwards and support flows downwards. Teams must be equipped to identify rising risk, act on data, escalate concerns confidently and receive timely organisational backing to deliver safe, high-quality care. All accountable partners should have access to the data required for effective oversight and assurance and decision-making.

Data, Intelligence and Insight Commission and govern a unified ICS-wide data and intelligence function for the 0-25 diabetes pathway, providing a single, shared and accessible version of the truth that generates actionable insight. All partners must work from complete, benchmarkable data rather than fragmented local datasets. Providers should be required to submit accurate, complete and timely information to national audits as a core contractual responsibility, supported by administrative and digital infrastructure. The system must maintain visibility of data missingness, missed care and rising risk, and use disaggregated clinical, psychosocial and vulnerability indicators to identify those at greatest need to support anticipatory prevention. Data should be available in real-time to provide immediate operational and clinical insight, with intentional visibility across transitions and other service boundaries so that care gaps, deterioration and inequity are exposed rather than obscured. Teams should be accountable for regular interrogation of service data to drive iterative PDSA cycles, testing changes, evaluating impact and embedding effective improvements into business-as-usual practice.

Standardisation of Care Define and implement nationally agreed, minimum standards of care for children and young adults with diabetes, grounded in evidence and clinical consensus. Standards should be specific, measurable and time-bound, delivered consistently across all neighbourhoods, and supported by the workforce capability and resources required to provide high-quality core care for all, with service resilience to intensify care proactively for those with greater need. Diabetes type, developmental maturity, and clearly defined clinical and psychosocial risk thresholds, not place of care, local service configuration or capacity, should determine the level and components of care. The same standard must apply for a given level of risk, whether care is delivered in specialist, community or neighbourhood settings, ensuring care is free from structural or cultural bias and that equitable outcomes are achieved for every child, young person and young adult. Standards should set out clear service specifications for each diabetes type, age and level of risk, including MDT provision with embedded psychological support, treatment-intensification thresholds, review frequency, equitable access to specialist therapies and technologies, prescribing and monitoring requirements, out-of-hours advice, peer support, mental health and wellbeing screening, structured education, delivery of all care processes, and standardised safety-netting and emergency pathways. Patient facing information should be a core component, aligned with NICE guidance, accessible across literacy levels and languages, and available through digital and handheld tools. This information should be co-produced with patients, families and charity partners.