Diabetes

All trusts providing type 1 diabetes care should have a dedicated transition service with a clear pathway between paediatric and 16-18 services, a named lead clinician for 16-18 patients, and a service for 19-25 year olds. These services should provide support for those on insulin pumps and new technologies, as well as ongoing psychological support.

Access to diabetes technology should be available to all people with type 1 diabetes who need it in their local area in line with the NHS Long Term Plan and NICE guidelines. Relevant staff should be trained to support patients using these technologies and given the time they need to complete this training, which should form part of their annual appraisal process.

All people with type 1 diabetes should be offered appropriate training to manage their condition through a QISMET-accredited, quality controlled structured education programme.

All trusts providing type 1 diabetes services should have a system, such as Diasend, to enable blood glucose data to be downloaded and presented in a meaningful way in all diabetes clinical areas – including paediatric, transitional, 16-18 and adult services as well as diabetes pregnancy services. Each department should have provision to offer virtual clinics to patients with type 1 diabetes. This should be supported by trust IT departments.

All trusts must have a dedicated multi-disciplinary team of specialist diabetes inpatient practitioners as indicated in the NHS Long Term Plan. Trusts should work towards providing base level specialist diabetes cover at weekends where this does not exist.

The MDiT should meet regularly to discuss day-to-day errors and safety issues, and report to a quarterly trust-level diabetes safety board which reviews the overall quality of the inpatient service, with support from IT, based on incident reporting, local and national audits of patient harms, diabetes medication errors, length of stay and readmissions.

All trusts should have a robust system to identify all people with diabetes on admission to hospital, including emergencies and elective and non-elective surgery, and a triage system to identify those at risk and rapidly refer them to the diabetes team. This should be an electronic system, integrated with web-linked blood glucose meters which provide an alert system for staff when any out-of-range reading is recorded.

Training should be provided for every healthcare professional who dispenses, prescribes and/or administers insulin, appropriate to their level of responsibility, including an assessment of competency.

All hospital trusts should have clear, audited perioperative pathways from pre-assessment through to discharge. These should be broadly in line with NCEPOD recommendations.

All trusts should have and promote a self-management policy, which supports patients who want to self-manage their diabetes to safely do so while in hospital, as clinically appropriate and in line with wider NHSE and NHSI policies on inpatient self-management.

All trusts should have a dedicated multi-disciplinary footcare service (MDFS) as stated in the NHS Long Term Plan and NICE NG19. The service should be well integrated with the community footcare protection service (FPS), and with hospital renal wards and dialysis units given the increased risk of amputation for diabetic patients in these areas. CCGs and STPs should ensure that community foot protection teams are trained to carry out foot screening and that the community service is structured to deliver the standards recommended in NG19.

Everyone with a diabetic footcare emergency requiring admission should be assessed the same day by the MDFS. If the MDFS identifies vascular impairment, they should have same day access to a vascular opinion, according to NICE NG19, whether the hospital is a vascular service hub or a spoke. If the MDFS is not present, the patient must still be assessed same day, which may require transfer to the vascular service.

Local commissioners should build in clear contractual requirements for trusts to collect and submit data to the National Diabetes Audit, including data on type 1 patients aged 19-25, the National Diabetes Inpatient Audit and the National Diabetes Footcare Audit. Trusts should work to improve the quality and consistency of clinical coding.

GIRFT and partner organisations should work together to assess the financial and clinical case for novel approaches to the procurement of insulin pumps, blood glucose testing strips, oral anti-diabetic agents and diabetes footwear, which may reduce costs and support increased uptake of continuous glucose monitoring and closed loop technology. This should be done in a way that maintains reasonable choice for people living with diabetes.

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