WORK PLAN - NHS Lanarkshire

MISSION STATEMENTOur aim is to motivate and encourage healthcare professionals, people with diabetes and their carers, voluntaryorganisations and partner agencies to work together across traditional boundaries in the planning, integration anddelivery of high quality, effective and innovative patient centred diabetes care in Lanarkshire.Diabetes MCN Steering Group

WORK PLAN 2009-2012WORK PLANArea Aim(s) Responsibilities1. Supporting improvement 1. Increase the MCN profileMCN Executive Group2. Encourage involvement in the MCNChair: Dr Susan Arnott, Diabetes3. Work with diabetes MCN Lead Clinicians and Managers throughout Scotland toprovide consistency of approach, identify areas of common interest and sharegood practiceMCN Lead Clinician4. Support and improve communication between Health Professionals involved indiabetes care (e.g. MCN newsletter and web page, telemedicine, internet,professional meetings, SCI DC)5. Advance the clinical governance and clinical effectiveness agenda, develop,implement, monitor and review clinical guidelines.6. Develop and produce a diabetes handbook for Lanarkshire7. Develop a risk management policy and a risk stratification tool2. Psychological support 1. Increase the recognition of the importance of psychological support in themanagement of this long-term condition2. Increase the provision of psychological care within the diabetes servicethrough training existing health care professionals to improve their skills inbehaviour change and psychological support3. Incorporate this skill into all aspects of diabetes careMCN Education SubgroupChair: June Currie, Diabetes MCNManagerDr Susan Arnott Page 2 of 12

WORK PLAN 2009-20123. Children and Youngpeople with Type 1Diabetes1. Provide a sensitive, responsive, needs based environment for the care and supportof children, young people and families affected by diabetes by developing amechanism for multidisciplinary, multiagency support and transitional careMCN Transitional CareSubgroupChair: Dr Helen AlexanderDiabetes MCN Manager4. Diabetes relatedemergencypresentations1. Assess the incidence of this presentation to A&E and SOS services2. Increase frontline staff awareness of the presentation of hyper- andhypoglycaemia3. Develop guidelines for the management of diabetes emergencies by firstresponders4. Improve identification of those who frequently access emergency services inrelation to poorly controlled diabetes and improve the mechanism of support tothem5. Improve multidisciplinary communication to provide consistent advice, educationand follow-up to patients following a diabetes related emergencyMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead Clinician5. In-patient Care 1. Assess the burden of diabetes on inpatient stay2. Improve staff awareness of the consideration and impact of diabetes on hospitalcare3. Standardise the prescription of insulin for inpatient treatment and provide trainingaround insulin administration in hospital4. Support the implementation and use of the national protocol for the managementof adolescents and adults with diabetes ketoacidosis (DKA)5. Investigate the potential benefits of early support of people recovering from adiabetes related admission to improve the awareness of the risk, recognition andprevention of such an event through patient empowerment and improved controlof the condition6. Improve multidisciplinary communication to provide consistent advice, educationand follow-up to patients following a diabetes related admissionMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead ClinicianDr Susan Arnott Page 3 of 12

WORK PLAN 2009-20126. Black and MinorityEthnic Communities1. Complete a needs assessment of the Lanarkshire population2. Improve recording of ethnicity in the diabetes population3. Improve access to culturally appropriate diabetes care, self management and carereducation for people with Type 1 and Type 2 diabetesMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead Clinician7. Diabetes Foot Care 1. Adopt and disseminate widely the nationally agreed patient education leaflets and thebooklet on foot care2. Record foot risk stratification to a minimum 75%3. Define the specialist multidisciplinary foot service in Lanarkshire and encourageconsistency of approach in all areas4. Identify key points for access for intervention regarding foot problems in Lanarkshire5. Inform out of hours services, A&E services, primary care and NHS 24 of arrangementfor ongoing care and assessment during office hours6. Develop pathways for accessing specialist foot services in Lanarkshire for themanagement of complications within 24 hours of presentation7. Develop guidelines for the management of diabetes foot emergencies8. Develop an efficient, easily accessible service for routine foot screening in people withdiabetes at low risk of foot complicationsMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead Clinician8. Retinopathy screening 1. Facilitate use of SCI-DC for recording screening information2. Facilitate the use of SCI-DC in the validation of DRS registers by Primary Care3. Strengthen the pathway between ophthalmology services and retinal screeningservices4. Improve access to screening throughout Lanarkshire including rural and vulnerablegroupsMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead ClinicianDr Susan Arnott Page 4 of 12

WORK PLAN 2009-20129. Structured patienteducation1. Deliver and monitor the X-PERT structured patient education programme forpeople with Type 2 Diabetes throughout Lanarkshire2. Train identified staff to enable implementation of the X-PERT programme acrossLanarkshire3. Increase capacity and monitor the delivery of DAFNE patient education to peoplewith Type 1 diabetes.4. Identify and train appropriate staff and time resource to deliver DAFNE patienteducation this consistently across Lanarkshire5. Explore an accredited structured patient education programme for children, youngpeople with Type 1 diabetes and their families6. Identify and train appropriate staff and time resource to deliver this consistentlyacross Lanarkshire.7. Contribute to the Scottish Diabetes Education Network in the development,organisation and delivery of a national education strategy for people with Type 1diabetesMCN Education SubgroupChair: June Currie, Diabetes MCNManager10. Professional education 1. Review and update the database of diabetes stakeholders, including identificationof those with a special interest in Primary Care, noting levels of achievement inpostgraduate experience or education within diabetes.2. Identifying a minimal level of competency to be achieved by health professionalsinvolved in the provision of care to people with diabetes3. Develop and implement an education strategy for all staff involved in the diabetescare across Lanarkshire4. Develop and disseminate a database of current, relevant educational courses andactivity in Scotland, focusing on Lanarkshire. Include information on the DiabetesMCN web page5. Develop a Lanarkshire ‘Diabetes Dilemmas’ forum offering responsive structuredprofessional multidisciplinary educational meetings on a regular basis, in varyingvenues throughout Lanarkshire. Co-ordinate the activity of this group andencourage attendance. Seek CPD accreditation for this activity for inclusion inpersonal development plansMCN Education SubgroupChair: June Currie, Diabetes MCNManager11. Research 1. Encourage involvement in high quality commercial and academic clinical trials indiabetes, in Scotland2. Increase awareness and opportunities for people with diabetes to be recruited toMCN Research andDevelopment SubgroupChair: Dr Helen Alexander,Dr Susan Arnott Page 5 of 12

WORK PLAN 2009-2012clinical trials3. Develop a strategy for high quality research in diabetes in Lanarkshire12. Out of Hours service 1. Improve access to out-of-hours diabetes advice for families with children withdiabetes. Increase awareness of the facilities available for this service.2. Explore the need and options for the adoption of a 24 hour helpline for diabetesadvice.3. Work with the out of hours service and A&E to develop pathways for the follow upand continued support of patients attending for advice out-with core practicehours4. Develop and disseminate robust guidelines on the identification and managementof common diabetes related problems5. Provide information and advice to people with diabetes on how to access servicesand identify those in the diabetes community with responsibility for providing thisservice. Include this information as part of structured patient education activityDiabetes MCN ManagerMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead Clinician13. Remote and ruralservices1. Consider the use of telehealth to improve access to diabetes specialist services andadvice to the rural communities in Lanarkshire2. Consider the ongoing development of local community services including drop infacilities or specialist clinics for people with diabetes to improve equity of access todiabetes services in the rural parts of LanarkshireMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead Clinician14. Pregnancy anddiabetes1. Provide a mechanism for the provision of high quality, consistent contraceptiveadvice and pre-pregnancy counselling.2. Develop links with the department of sexual and reproductive health to providetargeted information to people with diabetes.3. Evaluate the current approach to antenatal care from an experienced multiprofessionalteam led by a named obstetrician and diabetologist throughoutLanarkshireMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead ClinicianDr Susan Arnott Page 6 of 12

WORK PLAN 2009-201215. Insulin Pump Therapy 1. Review and update Lanarkshire’s insulin strategy2. Review and update the criteria for the provision of insulin pump therapy inLanarkshire to include the paediatric service3. Ensure permanent provision of the Lanarkshire diabetes insulin pump service4. Increase the pool of highly skilled staff able to support and manage a person withdiabetes on insulin pump therapy5. Train all diabetes specialist staff in the basic mechanism and management ofinsulin pump therapy6. Train acute adult and paediatric nursing staff on the management of a person withdiabetes, treated with an insulin pump, admitted for a diabetes related emergencyor concomitant condition7. Increase awareness and provide education on the principles of pump therapy tothe wider primary care community8. Maintain the structure for patient and carer education in intensive managementand insulin pump therapy9. Identify the need for training within Education and other partner agencies10. Assess the effectiveness of insulin pump therapy in Lanarkshire through a clearlydefined audit structureMCN Insulin Pump SubgroupChair: June Currie, DiabetesService Manager16. Care Homes 1. Review and ensure wide availability guidelines for the management of people withdiabetes in Care Homes, including storage and administration of insulin,management of diabetes during intercurrent illness and immediate intervention ina diabetes related emergency2. Continue to train staff in the implementation of these guidelines3. Increase access and availability to foot and retinal screening to people withdiabetes in Care HomesMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead ClinicianDr Susan Arnott Page 7 of 12

17. Diabetes and KidneyFailureWORK PLAN 2009-20121. Develop a strategy for the prevention, early detection and management ofdiabetes nephropathy, working with the renal specialists in LanarkshireMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead Clinician18. Patient Involvementand peer support1. Continue to survey people with diabetes to ascertain what kind of service theywould like, how they would like to access the service and where they would preferit to be delivered.2. Develop a patient involvement sub-group as part of the MCN in Lanarkshire3. Support patient and carer self management by working with partner agencies inthe provision of social and lifestyle support to encourage a healthier lifestyles4. Encourage the participation of patients and carers in the MCN steering group5. Host locality based open days for people with diabetes and their carers to provideinformation on local initiatives and services, providing a different way of accessingexpert advice and increase the profile of the diabetes community in Lanarkshire6. Support and encourage attendance of people with diabetes and their carers at theLanarkshire Diabetes Groups7. Seek patient representation at all MCN stakeholder events8. Support and facilitate the training of people with diabetes to contribute to theplanning of services in Lanarkshire9. Encourage use of the NHS Scotland interactive diabetes websitewww.mydiabetesmyway.scot.nhs.uk, by people who have diabetes, their families,friends and carersMCN Patient SubgroupChair: Dr Helen Alexander,Diabetes MCN ManagerDr Susan Arnott Page 8 of 12

19. Shifting the Balance ofCareWORK PLAN 2009-20121. Develop consistent patient pathways throughout Lanarkshire for the provision ofhigh quality, patient centred diabetes care2. Map the current pattern of service delivery and revise the clinical model fordiabetes to ensure implementation of local care pathways including a pathway forpeople with complex diabetes related issues to access diabetes specialist advice orservices consistently across Lanarkshire3. Identify a cohort of people with uncomplicated Type 2 diabetes who currentlyattend acute adult diabetes services for annual review, who could potentially bemonitored in primary care4. Support a change in the main locus of care for people with uncomplicated Type 2diabetes from the acute to primary care setting, working with NHS Lanarkshire,Acute Services Division, Primary Care Services and the LMC in the development ofa Primary Care Scottish Enhanced Service for Diabetes in Lanarkshire5. Develop and disseminate guidelines for the annual review of people with diabetes,management of Type 2 diabetes, management of diabetes during concurrentillness, management of diabetes emergencies and complications for Primary Care6. Support practices in the communication with patients about the change in practiceresponsibility and what care to expect.MCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead Clinician20. Access to diabetesservices1. Consider barriers to access and solutions to these to improve the attendance ratefor screening2. Monitor the prevalence of diabetes in Lanarkshire and identify gaps in serviceprovision3. Review appointment structures and processes in each of the acute services,identify mechanisms which may lead to inefficiencies or delays in the patientjourney an look at ways of communicating with the person with diabetes to reduceDNA rates and encourage involvement in their own care and surveillance4. Regularly monitor waiting times from referral to first out-patient appointment, andDNA rates.MCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead ClinicianDr Susan Arnott Page 9 of 12

WORK PLAN 2009-201221. Diabetes Prevention 1. Improve access to services to promote and support healthy lifestyle choicesthroughout Lanarkshire2. Identify the people in Lanarkshire at risk of developing Type 2 diabetes throughanalysis of QOF obesity recording and the encouragement of well person checksfor people over the age of 40, in line with the Scottish Government’s Better Health,Better Care programme.3. Consider the use of accredited online self assessment programmes complementedby telephone based assistance4. Encourage awareness of the significance of measuring waist circumference inaddition to BMI in the assessment of risk of developing diabetes5. Work with partner agencies to support people at increased risk of diabetes toimprove diet, increase physical activity and tackle obesity by making healthierlifestyle choicesMCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead Clinician22. Cardiovascular Risk 1. Develop and disseminate guidelines on how to identify and reduce the risk ofcardiovascular complications in people with diabetes2. Work with the smoking cessation services in Lanarkshire and communitypharmacies to improve access to smoking cessation advice and support3. Promote the use of the ASSIGN risk calculator to estimate the risk of developingCVD over ten years and target specific advice and intervention. This calculatorfactors in social deprivation and family history as well as sex, smoking history,cholesterol and Blood Pressure. It’s use is recommended by SIGN 97MCN Guidelines SubgroupChair: Dr Susan Arnott, DiabetesMCN Lead ClinicianDr Susan Arnott Page 10 of 12

WORK PLAN 2009-201223. IM&T 1. Ensure all people with diabetes and their type of diabetes consistently usingappropriate coding and promote the use of a single patient record of care2. Work with SCI-DC to improve communication and interface with Primary Care ITsystems.3. Improve access to SCI DC across all disciplines to facilitate the development of asingle patient record, improve the consistency and accuracy of informationrecording, thus improving the quality of data available for audit.4. Improve access to SCI-DC Clinical in the diabetes community to provide decisionmaking advice for all health professionals5. Facilitate training in SCI-DC to encourage familiarity in using the system tocomplement consultation with patients.6. Work with IT facilitators to develop IT support mechanisms for the Diabetes SESP(Scottish Enhanced Service Programme) and the provision of consistent patientinformation7. Use QOF data to assess any improvement in diabetes care in Lanarkshire and workwith clinical effectiveness to gain evidence of improvement in the provision of carein the acute sector in Lanarkshire8. Work with SCI Gateway to facilitate IT support for electronic referral pathwaysbetween primary, community and acute services9. Develop a risk register for recording significant events in relation to diabetes toprovide background information as a basis for the development of responsive,efficient, effective services to minimise risk to patients and health professionalsduring the care and management of people with diabetes10. Develop, update and regularly review the Diabetes MCN web page to ensureaccuracy and relevance of available information11. Develop a diabetes blog to create a forum for interaction and conversationbetween all disciplines involved in the care of people with diabetes, improvingaccessibility to peer support and opinion for issues in relation to diabetes serviceprovision, management and care of people with diabetes.12. Explore the use of twittering in providing real time information13. Explore the use of global text messaging to provide information14. Provide useful web addresses for the provision of information to patients, carersand health professionals involved in the management and care of people withdiabetes15. Develop a personal patient held record, available from diagnosis for people withType 1 and Type 2 diabetes, containing information about lifestyle, treatments,targets, educational needs and achievements, general advice and contact detailsof those relevant to their care, to improve communication across the diabetescommunity and facilitate effective education and patient empowermentMCN IM&T SubgroupChair: Dr Sandeep Thekkepat,Acute Lead Diabetes NHSLanarkshireDr Susan Arnott Page 11 of 12

WORK PLAN 2009-2012Bibliography (drivers of quality)Better Diabetes Care – A Consultation Document (The Scottish Government)Diabetes Action Plan 2010The Scottish Diabetes SurveyScottish Diabetes GroupNHS QIS (Quality Improvement Scotland) – Diabetes Clinical Standards review 2008The Quality and Outcomes Framework (QOF) for General Practice and the Scottish Enhanced Service Programme (SESP)SIGN (Scottish Intercollegiate Guideline Network) 55 – review due spring 2010SIGN (Scottish Intercollegiate Guideline Network) 116SCI-DC – diabetes information management and technology developmentThe short-life working group on Type 1 diabetes (draft - autumn 2009)Long Term Conditions Alliance ScotlandLiving Better – strategy to improve the mental health and wellbeing of people with diabetes abs coronary heart diseaseHEAT (Health Improvement, Efficiency, Access, Treatment) targetsFocus on diabetes – a guide to working with black and minority ethnic communities in Scotland living with long-term conditions (Diabetes UK and NRCEMH, 2007)Evaluation of diabetes services for Black and minority ethnic communities in Scotland – results of a survey of Diabetes Managed Clinical Networks (2006)Structured Diabetes Education Packs for South Asian and Chinese Communities (NHS Greater Glasgow and NRCEMH) – September 2009Scottish Diabetes Research NetworkBetter Together – The Patient Experience ProgrammeDiabetes UKThe International Diabetes Federation: a consensus on Type 2 diabetes preventionHealthy Eating, Active Living: an action planKeep WellEqually WellScotland’s future is smoke free, a smoking prevention action planDr Susan Arnott Page 12 of 12