Diabetes National Service Framework Summary

Standard 1
Prevention of Type 2 diabetes

• The NHS will develop, implement and monitor strategies to reduce the risk of developing Type 2 diabetes in the population as a whole and to reduce the inequalities in the risk of developing Type 2 diabetes

Standard 2
Identification of people with diabetes

• The NHS will develop, implement and monitor strategies to identify people who do not know they have diabetes

Standard 3
Empowering people with diabetes

• All children, young people and adults with diabetes will receive a service which encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle. This will be reflected in an agreed and shared care plan in an appropriate format and language. Where appropriate, parents and carers should be fully engaged in this process
  

Standard 4
Clinical care of adults with diabetes

Standards 5 & 6
Clinical care of children and young people with diabetes

• All children and young people with diabetes will receive consistently high-quality care and they, with their families and others involved in their day-to-day care, will be supported to optimise the control of their blood glucose and their physical, psychological, intellectual, educational and social development

• All young people with diabetes will experience a smooth transition of care from paediatric diabetes services to adult diabetes services, whether hospital or community-based, either directly or via a young people's clinic. The transition will be organised in partnership with each individual and at an age appropriate to and agreed with them

Standard 7
Management of diabetic emergencies

• The NHS will develop, implement and monitor agreed protocols for rapid and effective treatment of diabetic emergencies by appropriately trained health care professionals. Protocols will include the management of acute complications and procedures to minimise the risk of recurrence

Standard 8
Care of people with diabetes during admission to hospital

• All children, young people and adults with diabetes admitted to hospital, for whatever reason, will receive effective care of their diabetes. Wherever possible, they will continue to be involved in decisions concerning the management of their diabetes

Standards 10, 11 & 12
Detection and management of long-term complications

• All young people and adults with diabetes will receive regular surveillance for the long-term complications of diabetes

• The NHS will develop, implement and monitor agreed protocols and systems of care to ensure that all people who develop long-term complications of diabetes receive timely, appropriate and effective investigation and treatment to reduce their risk of disability and premature death

• All people with diabetes requiring multi-agency support will receive integrated health and social care

Key Interventions

• The overall prevalence of Type 2 diabetes in the population can be reduced by preventing and reducing the prevalence of overweight and obesity and the prevalence of central obesity in the general population, particularly in sub-groups of the population at increased risk of developing diabetes, such as people from minority ethnic communities, by promoting a balanced diet and physical activity (Level 4)*
• Individuals at increased risk of developing Type 2 diabetes can reduce their risk if they are supported to change their lifestyle by eating a balanced diet, losing weight and increasing their physical activity levels (Level 1)

• The NHS and partner organisations will need to review their local strategies for improving diet and nutrition, increasing physical activity, reducing overweight and obesity, and helping people to maintain weight loss, to ensure that they are targeting sub-groups of the population at increased risk of developing diabetes, particularly people from minority ethnic groups. Strategies will need to consider people of all ages, particularly children, and to link with existing work based in schools and the wider community
• The NHS will need to develop appropriate protocols and programmes to provide advice and support to people known to be at increased risk of developing Type 2 diabetes in order to help them reduce this risk. These protocols and programmes should be complementary to those for cardiovascular disease
• Health professionals, particularly those working in primary care, should receive continuing education about:
• the risk factors for diabetes
• the potential for preventing diabetes through the modification of these risk factors
• interventions that are effective in preventing, treating and managing overweight and obesity, and increasing physical activity

• Increased awareness of the symptoms and signs of diabetes among both health professionals and the general public can result in the earlier identification of people with diabetes (Level 3)
• Follow up and regular testing of individuals known to be at increased risk of developing diabetes (people who have previously been found to have impaired glucose regulation and women with a history of gestational diabetes) can lead to the earlier diagnosis of diabetes (Level 2)
• Opportunistic screening of people with multiple risk factors for diabetes can lead to the identification of some individuals with previously undiagnosed diabetes (Level 2)

• The NHS and partner agencies will need to develop local plans to ensure that health and other professionals most likely to come into contact with people with undiagnosed diabetes are aware of the symptoms and signs of diabetes. These include:
• primary care and community health care staff, particularly those working with older people or black and minority ethnic groups
• NHS Direct staff
• staff working in hospitals
• residential and nursing home staff
• staff working in specialist cardiology and renal teams
• pharmacists, optometrists, dentists and podiatrists
• The NHS will need to:
• be able to identify people who have previously been found to have impaired glucose regulation and women who have had a previous diagnosis of gestational diabetes, so that they can be followed up and offered regular testing
• use its information systems to benchmark the prevalence of diabetes in populations with similar socio-demographic characteristics so that any likely under-diagnosis can be identified

• Structured education can improve knowledge, blood glucose control, weight and dietary management, physical activity and psychological well-being, particularly when this is tailored to the needs of the individual and includes skills-based approaches to education (Level 1)
• Personal care plans can help empower people with diabetes (Level 4)
• Patient held/accessed records can facilitate self-care (Level 4)

• The NHS and partner agencies will need to develop, review and audit programmes for empowering people with diabetes, which include:
• behavioural change programmes
• structured education programmes
• the provision of information about diabetes and its management
• effective care plans
• patient-held accessible records
• the use of new technologies, including the Internet
• The NHS will need to ensure that service providers have the attitudes, skills and knowledge to provide person-centred care, including communication, counselling and behaviour change support skills. The Long Term Conditions Care Group Workforce Team, set up by the Department of Health, will review and make recommendations in this area

• Improving blood glucose control reduces the risk of developing the microvascular complications of diabetes in people with both Type 1 and Type 2 diabetes (Level 1)
• Improving blood glucose control may reduce the risk of people with diabetes developing cardiovascular disease (Level 1)
• Controlling raised blood pressure in people with diabetes who have co-existing hypertension reduces their risk of developing both microvascular complications and cardiovascular disease (Level 1)
• Reducing cholesterol levels in people with diabetes who have raised cholesterol levels may reduce their risk of cardiovascular disease (Level 2)
• Smoking cessation in people with diabetes who smoke reduces their risk of both cardiovascular disease and microvascular complications (Level 2)
• Regular recall and review of people with diabetes can improve the quality of diabetes care and subsequent outcomes for people with diabetes (Level 1)

• The NHS, with partner agencies, will need to review the local provision of diabetes services so that they can identify any deficiencies
• The NHS will need to agree, implement and audit protocols for:
• the initial assessment and care of people presenting with diabetes; these should be implemented in all health care settings where people with newly diagnosed diabetes may present (e.g. general practice, NHS Direct, accident and emergency departments, other hospital settings, community pharmacies)
• the continuing care of people with diabetes
• the identification and follow-up of non-attenders
• the provision of appropriate support for people who are housebound or who are living in residential or custodial settings, to ensure they are receiving structured diabetes care
• ensuring all laboratories undertaking HbA_1c estimations are participating in approved external quality assessment schemes and using analytical methods which meet the recommended minimum criteria for consistency and quality
• ensuring that analysers used for point-of-care testing of HbA_1c are included in approved external quality assessment schemes
• The NHS will need to ensure that all health professionals involved in the diagnosis and care of people with diabetes receive continuing training to ensure that they are appropriately skilled in the diagnosis and management of diabetes

• The provision of education for school staff and health professionals can lead to the earlier recognition of new-onset diabetes in children and young people before it progresses to diabetic ketoacidosis (Level 3)
• Small group interventions (either children with their parents, or young people without their parents) that address practical diabetes management issues and provide a forum for support and guidance can lead to improvements in knowledge of diabetes management, self-care and blood glucose control (Level 3)
• Good blood glucose control leads to optimal physical growth and development and reduces the risk of acute and long-term complications (Level 3)
• The planned transfer of the care of young people with diabetes from paediatric diabetes services to adult diabetes services promotes diabetes self-care and improves outcomes (Level 4)

• The NHS and partner organisations will need to agree, implement and audit protocols for:
• the initial assessment and care of children and young people presenting with diabetes; these should be implemented in all health care settings where people with newly diagnosed diabetes may present (e.g. general practice, NHS Direct, accident and emergency departments, other hospital settings, community pharmacies)
• the continuing care of children and young people with diabetes
• the transfer of young people from paediatric diabetes services to adult diabetes services
• the identification and follow-up of non-attenders
• the provision of appropriate support for children and young people living in residential settings, including boarding schools and care homes, and for looked after children

Key Interventions

• The risk and severity of diabetic ketoacidosis can be reduced by the provision of guidance and advice to people with diabetes on how to manage changes in blood glucose control that occur during other illnesses ('sick day' rules) (Level 4)
• Most episodes of hypoglycaemia can be managed in the community, either by the person with diabetes, a relative or carer, their GP or by ambulance personnel (Level 4)

• NHS, and partner agencies where appropriate, will need to agree, implement and audit protocols for the:
• provision of education for people with diabetes and their families and people who work with people at risk of the acute complications of diabetes, particularly those who work with children, about the signs and symptoms of diabetic emergencies, their avoidance and their management
• recognition and initial management of diabetic emergencies by frontline emergency staff (e.g. ambulance personnel, GPs, accident and emergency department staff) in all settings where people with acute complications of diabetes may present, including the home, general medical and dental practices and other primary care settings, accident and emergency departments and other hospital settings
• management of diabetic ketoacidosis and hyperosmolar non-ketotic syndrome in hospital
• Training will also need to be provided for local health and other relevant workers to ensure that they are aware of the local services available for the management of diabetic emergencies

• Outcomes for people with diabetes following admission to hospital can be improved by better liaison between the diabetes team and ward staff (Level 3)
• Perioperative outcomes for people with diabetes can be improved by the adherence to locally agreed evidence-based guidelines for the management of people with diabetes during surgical procedures (Level 3)

• The NHS will need to review the systems in place for ensuring that, when people with pre-existing diabetes are admitted to hospital, they continue to receive effective diabetes care and are enabled to continue to manage their own diabetes wherever possible
• Hospitals will be expected to have in place, and regularly to update and audit the implementation of, hospital-wide protocols for the management of people with diabetes in all clinical situations, including during investigative and operative procedures (including day surgery, booked and emergency surgery) and during admissions for other illnesses. These protocols will need to encompass:
• the involvement of people with diabetes in decisions concerning their diabetes care
• the provision of healthier food and snack choices
• the monitoring and maintenance of blood glucose control, including the provision of intravenous infusions of insulin and fluids
• diabetic wound management
• the appropriate timing of investigations or operative procedures
• the particular needs of people from different minority ethnic and religious groups, including access to appropriate food choices
• the provision of clear information to people with diabetes about the management of their diabetes during their hospital stay and after discharge
• liaison with and referral to the diabetes team

• Tight blood glucose control before and during pregnancy in women with pre-existing diabetes leads to a reduction in congenital malformation rates and perinatal mortality rates (Level 1)
• Tight blood glucose control during the third trimester can reduce the risk of fetal macrosomia and its associated consequences (Level 3)
• Tight blood glucose control during labour reduces the risk of neonatal hypoglycaemia (Level 3)

• The NHS will need to agree, implement and audit local protocols for the management of pregnant women with diabetes. These should cover:
• the provision of advice to all women of child-bearing age with diabetes about the importance of good blood glucose control before and during pregnancy
• the provision of pre-conception care
• the provision of antenatal care, including the detection and management of microvascular complications of diabetes and the detection and management of obstetric complications
• the provision of intrapartum and postpartum care
• the detection and management of neonatal hypoglycaemia and other neonatal complications in babies born to women with diabetes
• The NHS will also need to review local policies for the detection and management of gestational diabetes to ensure that they are in line with the latest guidance from the National Screening Committee

• Regular surveillance for diabetic retinopathy in adults with diabetes and early laser treatment of those identified as having sight-threatening retinopathy can reduce the incidence of new visual impairment and blindness in people with diabetes (Level 1)
• Treatment of people who have microalbuminuria with ACE inhibitors can reduce their rate of progression to diabetic nephropathy (Level 1)
• Tight blood pressure and blood glucose control in people with diabetic nephropathy can reduce the rate of deterioration in their renal function, as well as their risk of cardiovascular disease (Level 1)
• People with diabetes identified as being at increased risk of developing lower limb complications can reduce this risk by participating in a foot care programme that provides foot care education, podiatry and, where required, protective footwear (Level 1)
• In people with diabetes who develop foot ulceration, prompt intervention can minimise their risk of subsequent disability and amputation (Level 1)
• People with diabetes who have established cardiovascular disease can benefit from the secondary prevention measures already recommended for the general population in the National Service Framework for Coronary Heart Disease (Level 1)
• Administration of intensive insulin therapy to people with diabetes who sustain a heart attack can reduce their risk of death by 30% (Level 1)

• The NHS, with partner agencies, will need to:
• review the local provision of services for the detection and management of people with long-term complications of diabetes
• put systems in place for ensuring that all young people and adults with diabetes receive regular surveillance for the long-term complications of diabetes and for those conditions which occur more commonly in people with diabetes
• agree, implement and audit local guidelines for the management of people with long-term complications, which are consistent with national guidance