CommissioningDiabetes Emergency
and Inpatient Care
Supporting, Improving, Caring
June 2011
NHS Diabetes Information Reader Box
Review Date 2013
Commissioning Diabetes Emergency and Inpatient Care
NHS Diabetes would like to thank the following for their advice and contribution to the development ofthis commissioning guide:
The members of the Joint British Diabetes Societies Inpatient Care Group and the Association of BritishClinical Diabetologists.
And to Thoreya Swage who wrote this publication
3
Page
Commissioning for Diabetes Emergency and Inpatient Care 5
Features of Diabetes Emergency and Inpatient Care 7
Diabetes Emergency and Inpatient Care Intervention Map 9
Contracting Framework for Diabetes Emergency and Inpatient Care 14
Standard Service Specification Template for Diabetes Emergency 27Inpatient Care events to be provided by Ambulance Services
Standard Service Specification Template for Diabetes Emergency and Inpatient Care 31
Contents
5
Commissioning Diabetes Emergencyand Inpatient Care The NHS Diabetes commissioning approach helps to deliver high quality integrated care through a three-stepprocess that ensures key elements needed to build an excellent diabetes service are in place. The approach issupported by a wide range of proven tools, resources and examples of shared learning.
Step 1 – involves understanding the local diabetespopulation health needs by developing a local HealthNeeds Assessment and setting up a steering groupwith key stakeholder involvement including a leadclinician, lead commissioner, lead diabetes nurse andlead service user
Step 2 – involves the development of a servicespecification to describe the model of care to becommissioned. This becomes the document onwhich tenders may be issued.
Step 3 – involves monitoring the delivery of theservice specification by the provider and evaluatingthe performance of the service. Input from thesteering group with service user representation willbe an important mechanism for monitoring theservice as well as patient surveys.
This commissioning guide has been developed byNHS Diabetes with key stakeholders including clinicaland social services professionals and patient groupsrepresented by Diabetes UK.
It is not designed to replace the Standard NHSContracts as many of the legal and contractualrequirements have already been identified in this setof documents. Rather, it is intended to form the basisof a discussion or development of emergency and inpatient diabetes services between commissioners andproviders from which a contract for services can thenbe agreed.
This commissioning care guide consists of:
• A description of the key features of high qualityemergency and inpatient services for people withdiabetes
• A high level intervention map. This interventionmap describes the key high level actions orinterventions (both clinical and administrative)diabetes emergency and inpatient services shouldundertake in order to provide the most efficientand effective care, from admission to discharge (ordeath) from the service. For continuity, theintervention map also shows action to be takenwith respect to emergency care for children andyoung people with diabetes in the communitysetting. Commissioners are referred to thecommissioning guide for children and youngpeople with diabetes for further details followingadmission to hospital for this care group.
The map is not intended to be a care pathway orclinical protocol, rather it describes how a true‘diabetes without walls’1 service should operategoing across the current sectors of health care.
The intervention map may describe current servicemodels or it may describe what should ideally beprovided by diabetes emergency and in patientservices.
• A contracting framework for diabetes emergencyand in patient services that brings together all thekey standards of quality and policy relating todiabetes emergency and inpatient care
• Template service specifications for
Step 2
Step 3
• Understanding your diabetes population health needs
• Implementing improved services and evaluation
• Understanding what you need to commission for an integrated service
Step 1
1 Commissioning Diabetes Without Walls , 2011, http://www.diabetes.nhs.uk/commissioning_resource/
6
o Emergency diabetes care to be providedby ambulance services
o Inpatient diabetes services
The templates form part of schedule 2 of theStandard NHS Contract covering the key headingsrequired of a specification. It is recommended thatthe commissioner checks which mandatory headingsare required for each type of care as specified by theStandard NHS Contracts.
For further detail on how to approach thecommissioning of diabetes services please seehttp://www.diabetes.nhs.uk/commissioning_resource
7
High quality diabetes emergency and inpatientservices should ensure that:
• there are systems to manage people of all ageswho experience diabetic emergencies in thecommunity
• there are systems to ensure follow up of patientswho have had diabetic emergencies in thecommunity through liaison with local diabeticteams
• people with diabetes in hospital to have accessto appropriate specialist expertise both foremergency and planned care including access tothe children and young people diabetesmultidisciplinary team
• there are mechanisms in place to identify peoplewho present with acute illness to screen forpossible diabetesi
• there is timely assessment and treatment ofpeople who present with diabetic emergencies,e.g. diabetic ketoacidosis, severe acutehypoglycaemia and diabetic foot ulceration
• all patients with diabetes who have emergencyand planned in patient care have admission anddischarge care plans
• there are monitored protocols in place to ensurethat patients can continue to manage theirdiabetes themselves while in hospital (food andmedication)
• there is zero tolerance of prescribing errors andon the use of abbreviations for UNIT
In addition the services should:
• be developed in a co-ordinated way, taking fullaccount of the responsibilities of other agenciesin providing comprehensive care and placingusers at the centre of decisions about their careand support - "no decision about me withoutme" (Equity and Excellence: Liberating theNHSii).
• be commissioned jointly by health and socialcare based on a joint health needs assessmentwhich meets the specific needs of the localpopulation, using a holistic approach asdescribed by the generic model for themanagement of long term conditionsiii
• provide effective and safe care to people withdiabetes in a range of settings including thepatient’s home, in accordance with the NICEQuality Standards for Diabetesiv
• deliver the outcomes for diabetes as determinedby the NHS Outcomes Frameworkv
• take into account the emotional, psychologicaland mental wellbeing of the patientvi
• take into account all diverse and personal needswith respect to access to care
• ensure that services are responsive andaccessible to people with Learning Disabilitiesvii
• ensure that the family/carers of people withdiabetes have access to psychological support
• take into account race and inequalities withrespect to access to care
Features of Diabetes Emergency andInpatient Services
i NHS Institution for Innovation and Improvement, ThinkGlucose Toolkit,http://www.institute.nhs.uk/quality_and_value/think_glucose/welcome_to_the_website_for_thinkglucose.html
ii Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
iii Available on the DH website at http://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_120915
iv Quality Standards: Diabetes in adults, http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp
v Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
vi Emotional and Psychological Support and Care in Diabetes, Joint Diabetes UK and NHS Diabetes Emotional and PsychologicalSupport Working Group, February 2010 http://www.diabetes.nhs.uk/our_work_areas/emotional_and_psychological/
vii http://www.diabetes.nhs.uk/commissioning_resource
8
viii http://www.diabetes.nhs.uk/year_of_care/it/
ix http://www.ic.nhs.uk/proms
• have effective clinical networks with clear clinicalleadership across the boundaries of care whichclearly identify the role and responsibilities ofeach member of the diabetes healthcare team
• ensure that there are a wide range of optionsavailable to people with diabetes to support selfmanagement and individual preferences
• take into account services provided by socialcare and the voluntary sector
• provide patient/carer/family education ondiabetes not only at diagnosis but also duringcontinuing management at every stage of care
• provide education on diabetes management toother staff and organisations that supportpeople with diabetes
• have a capable and effective workforce that hasthe appropriate training and updating andwhere the staff have the skills and competenciesin the management of people with diabetes
• provide multidisciplinary care that manages thetransition between children and adult servicesand adult and older peoples’ services
• have integrated information systems that recordindividual needs including emotional, social,educational, economic and biomedicalinformation which permit multidisciplinary careacross service boundaries and support careplanningviii
• produce information on the outcomes ofdiabetes care including contributing to nationaldata collections and audits
• have adequate governance arrangements, e.g.local mortality and morbidity meetings ondiabetes care to learn from errors and improvepatient safety
• take account of patient experience, includingPatient Reported Outcome Measures, in thedevelopment and monitoring of service deliveryix
• actively monitor the uptake of services,responding to non-attenders and monitoringcomplaints and untoward incidents
9
NH
S D
iab
etes
Emer
gen
cy a
nd
in p
atie
nt
care
fo
r p
eop
le w
ith
dia
bet
es
Dia
bet
es e
mer
gen
cy c
are
in t
he
com
mu
nit
y (A
du
lts
and
old
er p
eop
le)
Hea
lth
Nee
ds
Ass
essm
ent
Pati
ent
has
d
iab
etic
emer
gen
cyco
nd
itio
n
-e.
g. D
iabe
tic
keto
acid
osis
999
call
Cal
l tri
aged
at
amb
ula
nce
call
cen
tre
-tr
iage
ac
cord
ing
to
agre
ed
prot
ocol
s
Am
bu
lan
ce
crew
d
isp
atch
ed
Am
bu
lan
ce
crew
arr
ive
at
the
scen
e
-m
axim
um r
espo
nse
tim
es i
dent
ified
Ass
essm
ent
by
amb
ula
nce
st
aff
-cl
inic
al a
sses
smen
t ac
cord
ing
to a
gree
d pr
otoc
ols
e.g.
UK
A
mbu
lanc
e C
linic
al
Prac
tice
Gui
delin
es
Ass
essm
ent
ou
tco
me
No
t g
lyca
emic
em
erg
ency
bu
t o
ther
cl
inic
al e
mer
gen
cy
Ass
essm
ent
ou
tco
me
gly
caem
ic/d
iab
etic
em
erg
ency
Ass
essm
ent
ou
tco
me
No
t g
lyca
emic
em
erg
ency
or
oth
er
clin
ical
em
erg
ency
Tran
sfer
to
nea
rest
A
&E
acco
rdin
g t
o
agre
ed p
roto
cols
E.g.
-hy
pogl
ycae
mia
-hy
perg
lyca
emia
-D
iabe
tic k
etoa
cido
sis
Trea
t g
lyca
emic
/d
iab
etic
em
erg
ency
ac
cord
ing
to
ag
reed
p
roto
cols
Go
to
p
age
10
Pati
ent
rem
ain
s at
th
e sc
ene
Ref
erra
l to
ap
pro
pri
ate
agen
cies
acc
ord
ing
to
ag
reed
pro
toco
ls
Emergency and Inpatient DiabetesServices Intervention Map
10
NH
S D
iab
etes
Emer
gen
cy a
nd
in p
atie
nt
care
fo
r p
eop
le w
ith
dia
bet
es
Dia
bet
es e
mer
gen
cy c
are
in t
he
com
mu
nit
y (A
du
lts
and
old
er p
eop
le)
Yes
Fu
llre
cove
ry a
nd
re
spo
nsi
ble
ad
ult
ar
ou
nd
?
Yes
Co
nta
ct
amb
ula
nce
cal
l ce
ntr
e fo
r fo
llow
u
p c
all t
o p
atie
nt
Leav
e p
atie
nt
at
scen
e
-gi
ve e
mer
genc
y co
ntac
t de
tails
-ad
vice
on
furt
her
self
man
agem
ent
Co
nta
ct p
atie
nt’
s d
iab
etes
tea
m
-co
nsen
t fr
om p
atie
nt
No
Pre-
aler
t ca
ll to
d
iab
etes
/A&
E te
am a
t n
eare
st s
uit
able
h
osp
ital
Tran
sfer
to
nea
rest
su
itab
le h
osp
ital
ac
cord
ing
to
ag
reed
p
roto
cols
-co
ntin
ue p
atie
nt
man
agem
ent
en r
oute
Pho
ne
call
to
pat
ien
t fr
om
am
bu
lan
ce c
all
cen
tre
–2
ho
urs
la
ter
-ch
eck
patie
nt’s
con
ditio
n
-en
sure
dia
bete
s te
am
cont
acte
d as
req
uire
d
Pati
ent
able
to
sel
f m
anag
e?
No
Ad
vice
on
nex
t st
eps
-e.
g. C
onta
ct
diab
etes
tea
m
urge
ntly
-at
tend
GP/
A&
E et
c
Yes
Go
to
p
age
12
Fro
m
pag
e 9
Impr
ovem
ent
afte
r in
itia
l tre
atm
ent?
--ac
cord
ing
to
agre
ed p
roto
cols
e.
g. U
K
Am
bula
nce
Clin
ical
Pra
ctic
e G
uide
lines
Co
nd
itio
n r
equ
ires
fu
rth
er s
pec
ialis
t cl
inic
al
inte
rven
tio
n
-ac
cord
ing
to
agre
ed p
roto
cols
e.
g. U
K
Am
bula
nce
Clin
ical
Pra
ctic
e G
uide
lines
-ac
cord
ing
to
agre
ed p
roto
cols
e.
g. U
K
Am
bula
nce
Clin
ical
Pra
ctic
e G
uide
lines
11
NH
S D
iab
etes
Dia
bet
es e
mer
gen
cy c
are
in t
he
com
mu
nit
y (C
hild
ren
an
d y
ou
ng
peo
ple
)
Hea
lth
Nee
ds
Ass
essm
ent
Pati
ent
has
d
iab
etic
em
erg
ency
co
nd
itio
n
999
call
Cal
l tri
aged
at
amb
ula
nce
call
cen
tre
Am
bu
lan
cecr
ew
dis
pat
ched
Am
bu
lan
cecr
ew a
rriv
e at
th
e sc
ene
Ass
essm
ent
by
amb
ula
nce
st
aff
Ass
essm
ent
ou
tco
me
No
t g
lyca
emic
/d
iab
etic
emer
gen
cy
bu
t o
ther
cl
inic
al
emer
gen
cy
Ass
essm
ent
ou
tco
me
Gly
caem
ic/
dia
bet
icem
erg
ency
Ass
essm
ent
ou
tco
me
No
t g
lyca
emic
em
erg
ency
or
oth
er c
linic
al
emer
gen
cy
Trea
t g
lyca
emic
/d
iab
etic
emer
gen
cy
acco
rdin
g t
o
agre
ed
pro
toco
ls
Pre-
aler
t ca
ll to
C
YP
dia
bet
es/
A&
E te
am
at n
eare
st
suit
able
ho
spit
al
Tran
sfer
to
nea
rest
su
itab
leh
osp
ital
ac
cord
ing
to
ag
reed
p
roto
cols
Tran
sfer
to
n
eare
st A
&E
acco
rdin
g t
o
agre
ed
pro
toco
ls
Pati
ent
rem
ain
s at
th
e sc
ene
wit
h
resp
on
sib
le a
du
ltR
efer
ral t
o o
ther
ag
enci
esac
cord
ing
to
ag
reed
pro
toco
ls
-e.
g. D
iabe
tic
keto
acid
osis
-Tr
iage
ac
cord
ing
to
agre
ed
prot
ocol
s
Max
imum
resp
onse
times
iden
tifie
d
-C
linic
al
asse
ssm
ent
acco
rdin
g to
ag
reed
pr
otoc
ols,
e.g
. U
K A
mbu
lanc
e C
linic
al P
ract
ice
guid
elin
es
E.g.
-hy
pogl
ycae
mia
-hy
perg
lyca
emia
-D
iabe
tic
keto
acid
osis
-e.
g. U
K
Am
bula
nce
Clin
ical
Pr
actic
e gu
idel
ines
-C
ontin
ue
patie
nt
man
agem
ent
en r
oute
Go
to
p
age
12
12
NH
S D
iab
etes
Emer
gen
cy a
nd
in p
atie
nt
care
fo
r p
eop
le w
ith
dia
bet
es
Dia
bet
es e
mer
gen
cy c
are
in h
osp
ital
Fro
m
pag
e 10
Dia
bet
icem
erg
ency
via
am
bu
lan
ce
Ref
erra
l via
G
P o
r o
ther
h
ealt
hca
re
pro
fess
ion
al
Oth
er c
linic
al
emer
gen
cy
-e.
g. M
yoca
rdia
l in
farc
tion,
str
oke
etc
Ch
ild d
iab
etic
em
erg
ency
Go
to
ch
ildre
n a
nd
you
ng
peo
ple
com
mis
sio
nin
gg
uid
e
Tran
sfer
to
A
&E
team
Imm
edia
te c
linic
al
asse
ssm
ent
and
tr
eatm
ent
of
emer
gen
cy
con
dit
ion
-re
susc
itate
- st
abili
se
-in
itiat
e tr
eatm
ent
acco
rdin
g to
agr
eed
prot
ocol
s
-in
volv
e di
abet
es
team
Ad
mis
sio
n
-id
entif
y an
y ne
w
diab
etic
s ac
cord
ing
to
agre
ed p
roto
cols
-co
ntin
ue
man
agem
ent
of
diab
etes
(adm
issi
on
care
pla
n)
-co
ntin
ue
man
agem
ent
of o
ther
cl
inic
al e
mer
genc
ies,
as
app
ropr
iate
-in
vest
igat
e an
d tr
eat
any
ass
ocia
ted
com
plic
atio
ns o
f d
iabe
tes
– se
e r
elev
ant
com
mis
sion
ing
guid
es
New
ly
dia
gn
ose
dd
iab
etes
?
- in
volv
e di
abet
es
team
Yes
Dis
cuss
d
iag
no
sis
wit
h
pat
ien
t
-in
itiat
e di
scha
rge
plan
-pr
omot
e se
lf ca
re
of d
iabe
tes
No
Rev
iew
car
e p
lan
nin
g
incl
ud
ing
d
isch
arg
e p
lan
-lia
ise
with
car
e co
-ord
inat
or
-in
itiat
e di
scha
rge
plan
-nu
triti
onal
as
sess
men
t (f
or
olde
r pe
ople
)
-pr
omot
e se
lf ca
re
of d
iabe
tes
-if
recu
rren
t hy
pogl
ycae
mia
, di
scus
s re
: im
plic
atio
ns f
or
driv
ing
Pati
ent
stab
le
-go
od g
lyca
emic
co
ntro
l
-ot
her
cond
ition
s tr
eate
d, a
s re
quire
d
-an
y di
abet
ic
com
plic
atio
ns
trea
ted,
as
requ
ired
Dis
char
ge
care
pla
nD
isch
arg
e
-in
form
GP
-in
form
dia
bete
s te
am in
co
mm
unity
for
fo
llow
up
- se
e di
agno
sis
and
cont
inui
ng
care
com
mis
sion
ing
guid
e
-di
scha
rge
med
icat
ion
Acu
te f
oo
t p
rob
lem
Go
to
fo
ot
care
com
mis
sio
nin
gg
uid
e
Fro
m
pag
e 11
Init
iate
car
e p
lan
nin
g in
clu
din
g
iden
tifi
cati
on
of
care
co
-ord
inat
or
and
as
sess
car
er’s
n
eed
s
13
NH
S D
iab
etes
Emer
gen
cy a
nd
in p
atie
nt
care
fo
r p
eop
le w
ith
dia
bet
es
Plan
ned
in p
atie
nt
care
Hea
lth
nee
ds
asse
ssm
ent
Ass
essm
ent
by
dia
bet
esle
ad (
CY
P o
rad
ult
as
app
rop
riat
e)
-de
cisi
on t
o un
dert
ake
oper
atio
n/
proc
edur
e
-de
cisi
on t
o un
dert
ake
day
case
or
in p
atie
nt
adm
issi
on
-gi
ve p
re-o
pera
tive/
pr
oced
ure
inst
ruct
ions
-lia
ison
with
car
e co
-ord
inat
or
Plan
to
ac
hie
ve g
oo
d
gly
caem
icco
ntro
l
-di
abet
es t
eam
or
CY
P s
peci
alis
t t
eam
to
man
age
with
pat
ient
/ fam
ily
-
adm
issi
on
care
pla
n
Pre-
op
erat
ive/
p
roce
du
re
asse
ssm
ent
-cl
erki
ng a
nd
inve
stig
atio
ns
acco
rdin
g to
ag
reed
pr
otoc
ols
Go
od
gly
caem
icco
ntr
ol?
No
Ass
ess
risk
of
dela
y in
op
erat
ion
/ pr
oced
ure
vs p
oor
post
ope
rati
ve/
proc
edur
al d
iabe
tes
cont
rol
Go
ah
ead
wit
h
pro
ced
ure
/ o
per
atio
n?
No
Yes
Yes
Peri
-o
per
ativ
e/
pro
ced
ure
man
agem
ent
of
dia
bet
es
-ac
cord
ing
to
agre
ed
prot
ocol
s
Post
-o
per
ativ
e/
pro
ced
ure
man
agem
ent
of
dia
bet
es
-ai
m t
o ac
hiev
e go
od g
lyca
emic
co
ntro
l fro
m d
ay
one
post
-op
/pr
oced
ure
-ot
her
post
-op
erat
ive/
pr
oced
ure
care
as
req
uire
d
-pr
omot
e se
lf ca
re o
f di
abet
es
Pati
ent
read
y fo
r d
isch
arg
e
-go
od
glyc
aem
icco
ntro
l
-go
od p
ost
-op
erat
ive/
pr
oced
ure
reco
very
-lia
ison
with
ca
re c
o -
ordi
nato
r
Dis
char
ge
care
pla
nD
isch
arg
e
- in
form
GP
-in
form
dia
bete
s te
am
in c
omm
unity
for
fo
llow
up
- se
e di
agno
sis
and
cont
inui
ng c
are
com
mis
sion
ing
guid
e
-di
scha
rge
med
icat
ion
Post
o
per
ativ
e/
pro
ced
ure
fo
llow
up
ap
po
intm
ent
14
Contracting Framework for DiabetesEmergency and Inpatient Services
IntroductionThis contracting framework sets out what isrequired of clinically safe and effective services thatare providing emergency and inpatient care forpeople with diabetes. The framework is designedto be read in conjunction with the high levelpatient intervention map, which describes theinterventions and actions required along thepatient pathway as well as entry and exit pointsand the standard service specification templatesfor diabetes emergency and inpatient services.
The framework brings together the key qualityareas and standards that have been identified byNHS Diabetes, Diabetes UK, the Royal Colleges andother related organisations.
The principles that establish a safepathway for patient care Establishing the principles that underpin thesystems and processes of pathways for patient careleads to more efficient patient throughput and canreduce risk of fragmentation of care and seriousuntoward incidents. The principles operate at fourlayers within a patient pathway:
• Commissioning• Clinical Case Direction or the overall Care Plan
(i.e. the management of an individual patient)
• Provision of the clinical service or process• Organisational platform on which the clinical
service or process sits (the provider organisation)
A straightforward or simple pathway is one inwhich the overall management including bothClinical Case Direction and the delivery of theclinical processes conventionally sits within oneorganisation. However, with a more complexpathway, there is a danger that fracturing theoverall management pathway into componentscarried out by different clinical teams andorganisations will require duplication of effortleading to inefficiency and increased risk athandover points. This can be managed byestablishing clear governance arrangements for allthe layers in the pathway.
In addition, Commissioning Bodies must balancethe benefits of fracturing the pathway againstincreased complexity and ensure that the increasedrisks are mitigated.
The governance arrangements required for allthree layers and the commissioner responsibilitiesare shown below:
15
In essence, at each level, there are governancearrangements to ensure sound and safe systems ofdelivery of patient care with clear lines ofaccountability between each level.
Diabetes emergency and inpatientservicesThe key principle of good diabetes care is toprovide a high quality service that is reliable interms of delivery and timely access for patientsrequiring that care.
Diabetes care is provided by a number of differentteams in the primary, community and acutesetting. It is essential that there is co-ordination ofcare of the patients through the care planningprocess and a consultant diabetologist retains theclinical accountability and responsibility for thespecialist diabetes service. Responsibility for overallpatient care across the whole pathway rests withthe patient’s GP who also retains overallresponsibility to ensure the management of sideeffects and complications.
The initial management and continuing care ofindividuals with diabetes should include anassessment of their emotional and psychologicalwell-being, together with timely access toappropriate psychological and biological/psychiatricinterventions. Mental health disorders can posesignificant barriers to diabetes care and thereforemental health stability is vital for good self care1.
The services themselves will also have clinicaloversight and accountability for governancepurposes.
This contracting framework focuses on adults,including older people, with diabetes who requireemergency or unscheduled care as well as plannedinpatient care. In addition, emergency care in thecommunity setting for children and young peoplewith diabetes is also considered in this document.
This contracting framework should also be read inconjunction with the commissioning guides forolder people and for diabetes diagnosis andcontinuing care and for children and young peoplewith diabetes and follow the principles for the
effective commissioning of services for people withLearning Disabilities 2.
Specialist emergency and in patient care forchildren and young people is dealt with in thecommissioning guide for children and youngpeople with diabetes and acute foot problems aredealt with in the diabetes foot care commissioningguide2.
Ensuring qualityCommissioning Bodies should ensure that thediabetes services commissioned are of the highestquality. There may, in addition, be someorganisations that wish to offer their services, butdo not have a history of providing such care.
i) For provider organisations already involved inthe delivery of diabetes services, there should beretrospective evidence of systems being in place,implemented and working.
ii) For organisations new to the arena thecommissioner should reassure itself that theprovider has the organisational attributes,governance arrangements, systems andprocesses set up to provide the platform forsafe and effective delivery of diabetes servicesto be provided.
This framework describes what theCommissioning Body needs to ensure ispresent or addressed in its discussions withthe provider organisation.
Under the ‘elements’ column there are crossreferences to the Standard NHS Contract for AcuteServices– bilateral (main clauses and schedules)3.Thisis to assist commissioners and providers in having anoverview of how the elements link to the StandardNHS Contract. Some of the areas are open tointerpretation and consequently the references arenot exhaustive.
16
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Gov
erna
nce
Lead
ersh
ip
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:11
,16,
19,3
3,48
,49,
51,5
3, 6
0
Sche
dule
s: 1
0
Cla
rity
of t
he o
rgan
isat
ion’
spu
rpos
e w
ith e
xplic
itco
mm
itmen
t to
pro
vidi
ng h
igh
qual
ity s
ervi
ces
A c
ultu
re t
hat
dem
onst
rate
s an
open
lear
ning
eth
os
An
orga
nisa
tion
that
is le
gal a
ndet
hica
l in
all i
ts a
ctiv
ities
Prov
ider
mus
t ha
ve o
rgan
isat
iona
l str
uctu
reth
at p
rovi
des
lead
ersh
ip f
or a
ll pr
ofes
sion
san
d di
scip
lines
In p
artic
ular
, the
re m
ust
be a
cor
pora
tecl
inic
al d
irect
or w
ith t
he r
espo
nsib
ility
and
acco
unta
bilit
y fo
r th
e cl
inic
al s
ervi
ce
Ther
e m
ust
be a
lear
ning
fra
mew
ork
in t
heor
gani
satio
n
Ther
e sh
ould
be
a de
sign
ated
clin
ical
dire
ctor
with
resp
onsi
bilit
y an
d ac
coun
tabi
lity
for
the
serv
ice
prov
idin
gem
erge
ncy
and
inpa
tient
car
e fo
r pe
ople
with
dia
bete
s.
Gov
erna
nce
Inte
grat
ed G
over
nanc
e
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:11
,19,
27,4
8,49
,51,
53,5
4,56
, 60
Sche
dule
s:
10
An
orga
nisa
tion
that
is g
uide
d by
the
prin
cipl
es o
f goo
d go
vern
ance
:
- cla
rity
of p
urpo
se- p
artic
ipat
ion
and
enga
gem
ent
- rul
e of
law
- tra
nspa
renc
y- r
espo
nsiv
enes
s- e
quity
and
incl
usiv
enes
s- e
ffec
tiven
ess
and
effic
ienc
y- a
ccou
ntab
ility
An
orga
nisa
tion
that
acc
epts
resp
onsib
ility
and
acc
ount
abili
tyfo
r all
its a
ctio
ns
Cle
ar o
rgan
isat
iona
l and
int
egra
ted
gove
rnan
ce s
yste
ms
and
stru
ctur
es in
pla
cew
ith c
lear
line
s of
acc
ount
abili
ty a
ndre
spon
sibi
litie
s fo
r al
l fun
ctio
ns. T
his
incl
udes
inte
rfac
es a
nd t
rans
ition
s be
twee
nse
rvic
es
Qua
lity
Gov
erna
nce
in t
he N
HS.
A g
uide
for
pro
vide
r bo
ards
4
Gov
erna
nce
Clin
ical
Gov
erna
nce
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:4,
4A,6
,9,1
0,12
,14,
15,1
6,17
,19,
21,
27,2
9,31
,32,
33,
48,4
9,51
,53,
54
Sche
dule
s:
3 (p
arts
1,2,
4,4A
,4B,
4C,5
,6),
7,10
,12,
18,2
0
Expl
icit
com
mitm
ent t
o qu
ality
and
patie
nt s
afet
y
Patie
nt fo
cuse
d w
ith re
spec
t for
the
pers
onal
wish
es o
f pat
ient
s in
all a
spec
ts o
f the
ir ca
re
A c
omm
itmen
t to
inno
vatio
n an
dco
ntin
uous
impr
ovem
ent
Clin
ical
Gov
erna
nce
syst
ems
and
polic
ies
shou
ld b
e in
pla
ce a
nd in
tegr
ated
into
orga
nisa
tiona
l gov
erna
nce
with
cle
ar li
nes
ofac
coun
tabi
lity
and
resp
onsib
ility
for a
ll cl
inic
algo
vern
ance
func
tions
e.g.
• C
linic
al A
udit
• C
linic
al R
isk M
anag
emen
t•
Unt
owar
d In
cide
nt R
epor
ting
• In
fect
ion
Con
trol
• M
edic
ines
Man
agem
ent
• In
form
ed C
onse
nt•
Raisi
ng C
once
rns
• St
aff D
evel
opm
ent
All
sub-
cont
ract
ors
mus
t mee
t gov
erna
nce
and
lead
ersh
ipar
rang
emen
ts o
f the
mai
n pr
ovid
er o
rgan
isatio
n
Com
miss
ione
r, pr
ovid
er a
nd N
HS
Litig
atio
n A
utho
rity
mus
tre
view
the
Clin
ical
Neg
ligen
ce S
chem
e fo
r Tru
sts
arra
ngem
ents
/or o
ther
org
anisa
tiona
l / p
rofe
ssio
nal i
ndem
nity
arr
ange
men
ts
The
serv
ice
shou
ld h
ave
in p
lace
writ
ten
prot
ocol
s an
dpr
oced
ures
def
inin
g cl
ear l
ines
of a
ccou
ntab
ility
and
resp
onsib
ility
.
The
serv
ice
is re
quire
d to
com
ply
with
gui
delin
es, p
ublic
hea
lthgu
idan
ce a
nd a
ppra
isals
publ
ished
by
the
Nat
iona
l Ins
titut
e fo
rH
ealth
and
Clin
ical
Exc
elle
nce
that
are
rele
vant
to th
e ca
repr
ovid
ed b
y th
e se
rvic
e 5 .
17
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Gov
erna
nce
Clin
ical
Gov
erna
nce
• C
ompl
aint
s M
anag
emen
t•
Patie
nt a
nd P
ublic
Invo
lvem
ent
• Pa
tient
dig
nity
and
resp
ect
• Eq
ualit
y an
d di
vers
ity•
Intr
oduc
ing
new
tech
nolo
gies
and
trea
tmen
ts•
An
exte
rnal
ly a
ccre
dite
d Q
ualit
y A
ssur
ance
syst
em a
nd in
tern
al e
rror
repo
rtin
gin
volv
ing
all s
taff
gro
ups.
CG
sys
tem
s sh
ould
hav
e cl
ear a
ndde
mon
stra
ble
links
to o
ther
NH
S sy
stem
sw
ith c
olla
bora
tive
CG
act
iviti
es a
nd s
harin
gof
exp
erie
nce
and
lear
ning
Prov
ider
sho
uld
prod
uce
annu
al C
linic
alG
over
nanc
e re
port
s as
par
t of N
HS
CG
repo
rtin
g sy
stem
Prov
ider
s ar
e re
quire
d to
agr
eeC
omm
issio
ning
for Q
ualit
y an
d In
nova
tion
sche
mes
(CQ
UIN
) for
dia
bete
s ca
re, e
.g.
mod
el C
QU
IN s
chem
e pr
opos
ed b
y th
e N
HS
Inst
itute
for I
nnov
atio
n an
d Im
prov
emen
t12
In a
dditi
on, t
he s
ervi
ce is
requ
ired
to c
ompl
y w
ith th
e fo
llow
ing:
i.
Gui
danc
e pu
blish
ed b
y N
ICE
• D
epre
ssio
n w
ith a
chr
onic
phy
sical
hea
lth p
robl
em6
• M
edic
ines
adh
eren
ce: i
nvol
ving
pat
ient
s in
dec
ision
s ab
out
pres
crib
ed m
edic
ines
and
sup
port
ing
adhe
renc
e 7
ii. C
linic
al g
uide
lines
for T
ype
2 D
iabe
tes
Mel
litus
pro
duce
d by
the
Euro
pean
Dia
bete
s W
orki
ng P
arty
for O
lder
Peo
ple
8
Serv
ices
may
also
find
the
follo
win
g gu
idan
ce p
ublis
hed
by N
HS
Dia
bete
s he
lpfu
l :
i. Th
e H
ospi
tal M
anag
emen
t of H
ypog
lyca
emia
in A
dults
with
Dia
bete
s M
ellit
us 9
ii. M
anag
emen
t of a
dults
with
dia
bete
s un
derg
oing
sur
gery
and
elec
tive
proc
edur
es: i
mpr
ovin
g st
anda
rds
10
iii. T
he M
anag
emen
t of D
iabe
tic K
etoa
cido
sis in
Adu
lts 11
Clin
ical
qua
lity
Qua
lity
assu
ranc
e
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:4,
4A,1
2,16
,17,
18,
19,2
0,21
, 31,
32,
33, 5
4
Sche
dule
s:
2,3
(par
ts 4
, 4A
,4B,
4C,5
,6)
7,10
,12,
18,
20
Und
erst
andi
ng t
he c
once
pt o
fcl
inic
al q
ualit
y
Has
con
cern
for
qua
lity
whi
lew
orki
ng e
ffic
ient
ly
An
unde
rsta
ndin
g of
the
use
of
audi
t, p
atie
nt a
nd s
taff
fee
dbac
kto
impr
ove
qual
ity
An
orga
nisa
tion
that
pro
vide
scl
arity
of
obje
ctiv
es a
nd p
rom
otes
refle
ctiv
e pr
actic
e to
impr
ove
qual
ity o
f pa
tient
car
e
Qua
lity
assu
ranc
e sy
stem
s m
ust b
e in
pla
cean
d ap
prov
ed b
y co
mm
issio
ning
bod
y w
ithre
gula
r rep
ortin
g of
out
com
es
Prov
ider
s ar
e re
quire
d to
pub
lish
qual
ityac
coun
ts fo
r the
pub
lic re
port
ing
of q
ualit
yin
clud
ing
safe
ty, e
xper
ienc
e an
d ou
tcom
es
Prov
ider
s sh
ould
par
ticip
ate
in n
atio
nal a
udit
prog
ram
mes
Dia
bete
s se
rvic
es m
ust c
ompl
y w
ith th
e pe
rfor
man
ce m
easu
res
requ
ired
of N
HS
serv
ices
, i.e
mee
ting:
13
• Re
ferr
al to
Tre
atm
ent w
aits
(95t
h pe
rcen
tile
mea
sure
s)
• A
&E
Qua
lity
Indi
cato
rs•
Am
bula
nce
resp
onse
tim
es
The
serv
ice
is re
quire
d to
par
ticip
ate
in th
e fo
llow
ing
activ
ities
/pro
gram
mes
:
• N
atio
nal D
iabe
tes
Aud
it 14
• N
atio
nal D
iabe
tes
Inpa
tient
Aud
it of
Acu
te T
rust
s 15
(NB
Prov
ider
s m
ay w
ish to
con
duct
add
ition
al a
udits
in th
e ar
eas
iden
tifie
d in
this
docu
men
t)•
Patie
nt E
xper
ienc
e Su
rvey
s 16
• D
iabe
tes
E 17
• Pa
tient
Rep
orte
d O
utco
mes
Mea
sure
s18
18
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Wor
kfor
ce/ s
taff
Clin
ical
sta
ff a
ttrib
utes
criti
cal t
o sa
fety
and
qual
ity o
f int
erve
ntio
ns
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:11
,16,
26,3
3, 4
8 ,5
6
The
prov
ider
org
anis
atio
n ha
ssy
stem
s an
d pr
oced
ures
in p
lace
to a
ssur
e th
e co
mm
issi
oner
tha
tth
eir
clin
ical
tea
m h
as t
hene
cess
ary
qual
ifica
tions
, ski
lls,
know
ledg
e an
d ex
perie
nce
tode
liver
the
ser
vice
Staf
f are
com
pete
nt a
nd fi
t for
pur
pose
Prov
ider
to s
atisf
y co
mm
issio
ner t
hat a
ll st
aff
have
cur
rent
app
raisa
l, cl
eara
nces
and
regi
stra
tion
chec
ks a
nd h
ave
dem
onst
rate
dco
mpe
tenc
e in
all
proc
edur
es re
leva
nt to
path
way
.
Prov
ider
to s
atisf
y co
mm
issio
ner t
hat t
hey
can
recr
uit (
or p
rocu
re)
and
reta
in a
com
pete
nt c
linic
al te
am to
del
iver
the
serv
ice
Spec
ific
qual
ifica
tions
requ
ired
of h
ealth
pro
fess
iona
ls pr
ovid
ing
the
serv
ice
are:
• Fo
r med
ical
pra
ctiti
oner
s: re
gist
ratio
n w
ith th
e G
MC
and
evid
ence
of f
urth
er q
ualif
icat
ion
in d
iabe
tes
care
or e
xper
ienc
ew
ithin
dia
bete
s cl
inic
• N
urse
s:
o re
gist
ratio
n w
ith th
e N
MC
and
furt
her e
vide
nce
ofqu
alifi
catio
n in
dia
bete
s ca
re o
r exp
erie
nce
with
in d
iabe
tes
clin
ic 19
o re
gist
ratio
n of
non
-med
ical
pre
scrib
ers
• D
ietit
ians
: reg
istra
tion
with
the
HPC
and
abl
e to
dem
onst
rate
com
pete
nce
in d
eliv
erin
g sp
ecia
list s
uppo
rt/a
dvic
e in
ent
eral
and
pare
nter
al fe
edin
g•
Podi
atris
ts: r
egist
ratio
n w
ith th
e H
PC a
nd a
ble
to d
emon
stra
teco
mpe
tenc
e in
del
iver
ing
spec
ialis
t sup
port
/adv
ice
in th
em
anag
emen
t of t
he d
iabe
tic fo
ot –
see
also
com
miss
ioni
nggu
ide
for d
iabe
tes
foot
car
e 2
• Ph
arm
acist
s: re
gist
ratio
n w
ith th
e G
ener
al P
harm
aceu
tical
Cou
ncil
and
be a
ble
to d
emon
stra
te c
ompe
tenc
y in
med
icin
esm
anag
emen
t for
pat
ient
s w
ith d
iabe
tes
Hea
lthca
re p
rofe
ssio
nals
invo
lved
in d
eliv
erin
g di
abet
es c
are
are
requ
ired
to h
ave
the
rele
vant
com
pete
ncie
s (s
ee S
kills
for H
ealth
-D
iabe
tes
Com
pete
ncie
s fo
r dia
bete
s) 20
Clin
ical
qua
lity
Wor
kfor
ce/ s
taff
Clin
ical
sta
ffco
mpe
tenc
ies
in u
se o
feq
uipm
ent
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:11
, 16,
17,
21,
26,
33
The
prov
ider
org
anis
atio
n ha
ssy
stem
s in
pla
ce t
o as
sure
the
com
mis
sion
er t
hat
thei
r cl
inic
alte
am a
re c
ompe
tent
to
use
all
equi
pmen
t ne
eded
to
deliv
er t
hese
rvic
e
Prov
ider
to s
atisf
y th
e co
mm
issio
ner t
hat a
llst
aff h
ave
had
docu
men
ted
com
pete
nce
asse
ssm
ent r
elat
ive
to a
ll eq
uipm
ent u
sed
inco
ntra
ct.
Hea
lthca
re p
rofe
ssio
nals
invo
lved
in d
eliv
erin
g di
abet
es c
are
are
requ
ired
to h
ave
the
rele
vant
com
pete
ncie
s in
usin
g ap
prop
riate
equi
pmen
t e.g
. blo
od g
luco
se a
nd k
eton
e m
onito
rs, i
nsul
inde
liver
y de
vice
s in
clud
ing
insu
lin p
umps
19
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Wor
kfor
ce /
staf
f
Dev
elop
men
t
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:11
,16,
19,3
048
The
prov
ider
org
anis
atio
n ha
ssy
stem
s in
pla
ce t
o as
sure
the
com
mis
sion
er t
hat
thei
r cl
inic
alte
am is
for
mal
ly in
duct
ed a
ndre
ceiv
es o
ngoi
ng a
ssis
tanc
e to
deve
lop
thei
r sk
ills,
kno
wle
dge
and
expe
rienc
e t
o en
sure
tha
tth
ey a
re a
lway
s fu
lly u
pdat
ed
Prov
ider
to s
atisf
y co
mm
issio
ner o
f the
irco
mm
itmen
t to
indu
ctio
n an
d C
PD re
leva
ntto
role
s
Prov
ider
to s
atisf
y th
e co
mm
issio
ner o
f the
irco
mm
itmen
t to
trai
n st
aff t
o m
eet f
utur
ese
rvic
e ne
eds
• A
ll H
ealth
Car
e st
aff w
ho a
re n
ot p
art o
f the
dia
bete
sm
ultid
iscip
linar
y te
am a
nd w
ho d
eal w
ith p
eopl
e w
ho h
ave
orw
ho h
ave
prev
ious
ly u
ndia
gnos
ed d
iabe
tes
shou
ld h
ave
spec
ific
basic
trai
ning
in th
e re
cogn
ition
and
man
agem
ent o
fdi
abet
es•
All
Hea
lth C
are
prof
essio
nals
shou
ld h
ave
suff
icie
nt s
tudy
leav
eal
loca
tion
(tim
e an
d fin
ance
) to
enab
le th
em to
dev
elop
ski
llsap
prop
riate
ly
Clin
ical
qua
lity
Regi
stra
tion
and
licen
sing
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:4,
4A,5
,9,1
0,11
,12,
14,1
5,16
17,1
8,19
,21,
26,
27,2
9,33
,34,
35,
3643
,48,
49,5
253
,54,
56,6
0
Sche
dule
s:
2,3,
4,5,
6,8,
10,
12,1
3,15
,17,
19
, 20
The
Prov
ider
is r
equi
red
to b
ere
gist
ered
with
the
Car
e Q
ualit
yC
omm
issi
on t
o de
mon
stra
te t
hat
is m
eets
the
ess
entia
l sta
ndar
dsof
qua
lity
and
safe
ty f
or t
here
gula
ted
activ
ities
del
iver
ed.
The
Prov
ider
is r
equi
red
to b
elic
ense
d w
ith t
he N
HS
Econ
omic
Regu
lato
r (M
onito
r) in
ord
er t
opr
ovid
e N
HS
care
.
Com
plia
nce
with
the
Car
e Q
ualit
yC
omm
issio
n an
d M
onito
r req
uire
men
tsC
ompl
ianc
e w
ith th
e fo
llow
ing
Nat
iona
l Ser
vice
Fra
mew
orks
,w
here
app
licab
le:
• O
lder
Peo
ple’
s N
SF 21
• C
oron
ary
Hea
rt D
iseas
e N
SF 22
• Th
e M
enta
l Hea
lth S
trat
egy23
• Lo
ng T
erm
Con
ditio
ns N
SF 24
Com
plia
nce
with
:•
End
of L
ife c
are
Stra
tegy
25
Com
plia
nce
with
Car
e Q
ualit
y C
omm
issio
n Re
view
s
Clin
ical
qua
lity
Out
com
es
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:4,
4A,1
0,14
,15,
16,2
1
Sche
dule
s:3
(par
t 5),
5 (p
arts
1,2
,3),
12
Com
preh
ensi
ve u
nder
stan
ding
and
com
mitm
ent
to d
eliv
erin
gan
d im
prov
ing
outc
omes
of
care
Com
plia
nce
with
the
NH
S O
utco
mes
Fram
ewor
k26C
ompl
ianc
e w
ith th
e Q
ualit
y St
anda
rds
for D
iabe
tes,
spe
cific
ally
: 27
Qua
lity
Stat
emen
t 11
Peop
le w
ith d
iabe
tes
adm
itted
to
hosp
ital a
re c
ared
for b
yap
prop
riate
ly tr
aine
d st
aff,
prov
ided
with
acc
ess
to a
spe
cial
istdi
abet
es te
am, a
nd g
iven
the
choi
ce o
f sel
f-m
onito
ring
and
man
agin
g th
eir o
wn
insu
lin
Qua
lity
Stat
emen
t 12
Peop
le a
dmitt
ed to
hos
pita
l with
dia
betic
ket
oaci
dosis
rece
ive
educ
atio
nal a
nd p
sych
olog
ical
sup
port
prio
r to
disc
harg
e an
d ar
efo
llow
ed u
p by
a s
peci
alist
dia
bete
s te
am
20
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Patie
nt p
athw
ay
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:4,
4A,9
,10,
12,
14,1
5,16
,17,
18,1
9,20
,21,
27,2
9,32
,33,
34,
35,3
6,54
Sche
dule
s:
3 (p
arts
1 a
nd 2
)
Resp
onsi
vene
ss a
nd p
artic
ipat
ive
appr
oach
to
incl
udin
g pa
tient
s’vi
ews
abou
t th
eir
care
in t
hede
sign
of
care
pat
hway
s
Col
labo
ratio
n w
ith o
ther
orga
nisa
tions
invo
lved
in t
hepa
tient
pat
hway
to
prov
ide
ase
amle
ss p
athw
ay o
f ca
re
All
poss
ible
ent
ry a
nd e
xit p
oint
s m
ust b
ede
fined
with
com
preh
ensiv
e pa
tient
path
way
s th
at fa
cilit
ate
smoo
th p
assa
ge a
ndef
fect
ive,
eff
icie
nt c
are
for p
atie
nts
All
inte
rfac
es in
the
path
way
mus
t be
defin
ed s
o th
at c
ontin
uity
of c
linic
al c
are
isen
sure
d w
ith n
o fr
actu
ring
of th
e pa
thw
ay
Ther
e m
ust b
e sp
ecifi
catio
n of
cle
ar ti
mel
ines
and
aler
t mec
hani
sms
for p
oten
tial b
reac
hes
Ther
e sh
ould
be
audi
t of p
athw
ay to
ens
ure
that
sta
ndar
ds a
re m
et
Ther
e m
ust b
e ex
plic
it sp
ecifi
catio
n of
prov
ider
and
com
miss
ione
r res
pons
ibili
ties
for t
he w
hole
pat
ient
epi
sode
from
regi
stra
tion
to fi
nal d
ischa
rge
Acc
ount
abili
ties
shou
ld b
e ag
reed
and
docu
men
ted
by a
ll st
akeh
olde
rs
Ther
e ar
e a
num
ber o
f ser
vice
s su
ppor
ting
patie
nts
with
dia
bete
s an
d th
ere
mus
t be
clea
r sub
con
trac
ts s
tatin
g th
e re
ferr
al c
riter
iaan
d ac
cess
to th
ese
supp
ortin
g se
rvic
es.
If pa
rt o
r who
le o
f the
ser
vice
is to
be
tran
sfer
red
to o
ther
pro
vide
rs, t
here
mus
t be
clea
r and
agr
eed
sub
cont
ract
s on
refe
rral
crite
ria a
nd a
cces
s to
thes
e se
rvic
es.
At e
ntry
to p
athw
ay:
The
Com
miss
ione
r sho
uld
assu
re th
emse
lves
that
the
prov
ider
has
sys
tem
s an
d pr
oces
ses
in p
lace
to
i) re
gist
er p
atie
nts
The
path
way
sho
uld
follo
w th
e pr
inci
ples
set
out
by
the
Gen
eric
Long
Ter
m C
ondi
tions
mod
el 28
. Thi
s in
clud
es:
• St
ratif
ying
the
leve
ls of
nee
d an
d ris
k •
Cas
e m
anag
emen
t•
Pers
onal
ised
care
pla
nnin
g•
Supp
ortin
g pe
ople
to s
elf c
are
• A
ssist
ive
tech
nolo
gy
1. E
mer
genc
y ca
re in
the
com
mun
ity
Ther
e sh
ould
be
prot
ocol
s in
pla
ce to
man
age
peop
le o
f all
ages
who
exp
erie
nce
diab
etic
em
erge
ncie
s in
the
com
mun
ity, e
.g. U
KA
mbu
lanc
e Se
rvic
es C
linic
al P
ract
ice
Gui
delin
es 29
,30
Emer
genc
y se
rvic
es s
houl
d en
sure
follo
w u
p of
pat
ient
s w
hoha
ve h
ad d
iabe
tic e
mer
genc
ies
thro
ugh
liaiso
n w
ith lo
cal d
iabe
ticte
ams
31
2. E
mer
genc
y tr
eatm
ent i
n A
&E
Ther
e sh
ould
be
clea
r pro
toco
ls fo
r the
ass
essm
ent o
f peo
ple
( inc
ludi
ng o
lder
peo
ple)
who
are
adm
itted
to h
ospi
tal w
ith a
nac
ute
illne
ss, t
o sc
reen
for p
ossib
le d
iabe
tes
e.g.
Thin
kGlu
cose
Tool
kit 32
Ther
e sh
ould
be
clea
r pro
toco
ls fo
r the
tim
ely
asse
ssm
ent a
ndtr
eatm
ent o
f peo
ple
who
pre
sent
with
dia
betic
em
erge
ncie
s, e
.g.
diab
etic
ket
oaci
dosis
, sev
ere
acut
e hy
pogl
ycae
mia
and
dia
betic
foot
ulc
erat
ion
Expe
rt a
dvic
e an
d/or
car
e fr
om th
e m
ultid
iscip
linar
y di
abet
este
am o
r the
chi
ldre
n an
d yo
ung
peop
le s
peci
alist
dia
bete
s te
am(a
s ap
prop
riate
) mus
t be
avai
labl
e fo
r the
man
agem
ent o
f peo
ple
who
pre
sent
with
dia
betic
em
erge
ncie
s 24
hou
rs a
day
and
also
for i
npat
ient
s
3. In
patie
nt c
are
All
patie
nts
with
dia
bete
s w
ho h
ave
emer
genc
y an
d pl
anne
din
patie
nt c
are
shou
ld h
ave
adm
issio
n an
d di
scha
rge
care
pla
ns
Qua
lity
Stat
emen
t 13
Peop
le w
ith d
iabe
tes
who
hav
e ex
perie
nced
hyp
ogly
caem
iare
quiri
ng m
edic
al a
tten
tion
are
refe
rred
to a
spe
cial
ist d
iabe
tes
team
Clin
ical
qua
lity
Out
com
es
21
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Patie
nt p
athw
ayii)
col
lect
rele
vant
clin
ical
and
adm
inist
rativ
e da
taiii
) man
age
the
appo
intm
ent p
roce
ss,
(reap
poin
tmen
t and
DN
A p
roce
ss, i
fap
prop
riate
)iv
) pro
vide
info
rmat
ion
to p
atie
nts
v) u
nder
take
initi
al a
sses
smen
t in
the
appr
opria
te lo
catio
n
At p
oint
of i
nter
vent
ion:
The
Com
miss
ione
r sho
uld
assu
re th
emse
lves
that
the
prov
ider
has
sys
tem
s an
d pr
oces
ses
in p
lace
to e
nsur
e th
at:
i) th
e in
terv
entio
n is
cond
ucte
d sa
fely
and
in a
ccor
danc
e w
ith a
ccep
ted
qual
ityst
anda
rds
and
good
clin
ical
pra
ctic
e.ii)
the
patie
nt re
ceiv
es a
ppro
pria
te c
are
durin
g th
e in
terv
entio
n(s)
, inc
ludi
ng o
ntr
eatm
ent r
evie
w a
nd s
uppo
rt, i
nac
cord
ance
with
bes
t clin
ical
pra
ctic
e
iii) w
here
clin
ical
em
erge
ncie
s or
com
plic
atio
ns d
o oc
cur t
hey
are
man
aged
in a
ccor
danc
e w
ith b
est
clin
ical
pra
ctic
eiv
) the
inte
rven
tion
is ca
rrie
d ou
t in
afa
cilit
y w
hich
pro
vide
s a
safe
envi
ronm
ent o
f car
e an
d m
inim
ises
risk
to p
atie
nts,
sta
ff a
nd v
isito
rsv)
the
inte
rven
tion
is un
dert
aken
by
staf
fw
ith th
e ne
cess
ary
qual
ifica
tions
, ski
lls,
expe
rienc
e an
d co
mpe
tenc
e vi
) The
re a
re a
rran
gem
ents
for t
hem
anag
emen
t of o
ut o
f hou
rs c
are
acco
rdin
g to
bes
t clin
ical
pra
ctic
e
At e
xit f
rom
pat
hway
:
The
Com
miss
ione
r sho
uld
assu
re th
emse
lves
that
pro
vide
r has
sys
tem
s an
d pr
oces
ses,
whi
ch a
re a
gree
d w
ith a
ll pa
rtie
s an
d
toge
ther
with
clo
se li
aiso
n w
ith th
eir c
are
co-o
rdin
ator
31
The
adm
issio
n ca
re p
lan
shou
ld in
clud
e:
a. In
form
atio
n ex
chan
ge
• re
view
of t
he p
erso
n’s
ongo
ing
care
pla
n, a
nd d
iscus
sion
• of
thei
r pre
fere
nces
for s
elf c
are
of th
eir d
iabe
tes
whi
le in
hosp
ital
• ex
plan
atio
n of
the
reas
ons
for a
dmiss
ion,
and
wha
t to
expe
ctin
hos
pita
l
b. S
yste
mat
ic re
view
of k
ey a
reas
from
pat
ient
and
pro
fess
iona
lvi
ew p
oint
s
• le
vel o
f kno
wle
dge
abou
t dia
bete
s an
d ne
ed fo
r fur
ther
info
rmat
ion
– e
g. th
e im
plic
atio
ns fo
r driv
ing
if th
e pa
tient
has
recu
rren
t hyp
ogly
caem
ic e
piso
des
• as
sess
men
t of n
eed
for i
nput
from
dia
bete
s sp
ecia
list t
eam
• fo
od c
hoic
e, ti
min
gs a
nd a
cces
s to
food
/sna
cks
• nu
triti
onal
ass
essm
ent,
espe
cial
ly in
old
er p
eopl
e•
risk
stat
us o
f fee
t in
all p
eopl
e w
ith d
iabe
tes,
risk
str
atifi
catio
n,an
d m
anag
emen
t pla
n•
med
icin
es m
anag
emen
t and
con
trol
.Es
tabl
ish if
sel
f man
agem
ent i
s de
sired
/app
ropr
iate
. Ens
ure
that
self
man
agem
ent i
nclu
des
adm
inist
ratio
n of
med
icat
ion/
insu
linin
ject
ions
/insu
lin p
ump
and
acce
ss to
thei
r ow
n ca
pilla
ry b
lood
gluc
ose
mon
itorin
g an
d qu
ality
con
trol
equ
ipm
ent.
• ne
ed fo
r em
otio
nal a
nd p
sych
olog
ical
sup
port
(par
ticul
arly
olde
r peo
ple,
chi
ldre
n, a
nd th
ose
new
ly d
iagn
osed
).•
mob
ility
(par
ticul
arly
in o
lder
peo
ple
with
dia
bete
s).
• es
tabl
ish th
e cu
ltura
l and
relig
ious
nee
ds o
f the
indi
vidu
alin
clud
ing;
sub
sequ
ent d
ieta
ry, t
reat
men
t, an
d fa
cilit
ies
requ
irem
ents
and
mat
ters
sur
roun
ding
phy
sical
con
tact
• es
tabl
ish e
thni
c id
entit
y•
esta
blish
pre
ferr
ed n
ame
• ot
her p
atie
nt c
once
rns
c. D
evel
opin
g an
d re
cord
ing
a pl
an
• ke
y el
emen
ts o
f the
pla
n, a
nd w
ho is
resp
onsib
le fo
r eac
h of
thes
e, n
eed
to b
e re
cord
ed.
• a
nam
ed c
onta
ct a
nd o
ther
rele
vant
info
rmat
ion
shou
ld b
epr
ovid
ed to
eac
h in
divi
dual
in w
ritte
n or
oth
er a
ppro
pria
te
22
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Patie
nt p
athw
ayne
twor
ks, i
n pl
ace
to:
i) un
dert
ake
tele
phon
e tr
iage
ii) m
ake
urge
nt o
nwar
d re
ferr
als
whe
relif
e-th
reat
enin
g co
nditi
ons
or s
erio
usun
expe
cted
pat
holo
gies
are
disc
over
eddu
ring
an in
terv
entio
n/as
sess
men
tiii
) ens
ure
that
pat
ient
s re
ceiv
e di
scha
rge
info
rmat
ion
rele
vant
to th
eir
inte
rven
tion
incl
udin
g ar
rang
emen
ts fo
rco
ntac
ting
the
prov
ider
and
follo
w u
p if
requ
ired
iv) p
rovi
de ti
mel
y fe
edba
ck to
the
refe
rrer
re in
terv
entio
n, c
ompl
icat
ions
and
prop
osed
follo
w u
pv)
ens
ure
that
the
patie
nt re
ceiv
es re
quire
ddr
ugs/
dres
sings
/aid
svi
) ens
ure
that
sup
port
is in
pla
ce w
ithot
her c
are
agen
cies
as
appr
opria
te
form
at. R
elev
ant i
nfor
mat
ion
shou
ld c
over
how
dia
bete
sre
late
d em
erge
ncie
s w
ill b
e m
anag
ed, h
ow in
divi
dual
s ca
nac
cess
hos
pita
l pro
toco
ls an
d po
licie
s fo
r the
man
agem
ent o
fdi
abet
es, a
nd h
ow to
acc
ess
the
spec
ialis
t tea
m if
nec
essa
ry.
The
disc
harg
e ca
re p
lan
shou
ld in
clud
e:
• re
view
of t
he a
dmiss
ion
and
patie
nt e
xper
ienc
es•
chec
k on
und
erst
andi
ng o
f new
or c
hang
ed d
iabe
tes
man
agem
ent,
incl
udin
g ho
w to
obt
ain
devi
ces
or n
eedl
es fo
rth
e ad
min
istra
tion
of in
sulin
• id
entif
icat
ion
of o
ngoi
ng n
eeds
• pa
tient
edu
catio
n on
the
impo
rtan
ce o
f brin
ging
thei
rm
edic
atio
n an
d de
vice
s w
hene
ver t
hey
are
adm
itted
to h
ospi
tal
• a
nam
ed c
onta
ct in
the
com
mun
ity•
writ
ten
disc
harg
e su
mm
ary
to G
P, d
iabe
tes
team
and
rele
vant
othe
rs e
.g. s
ocia
l car
e.•
info
rmat
ion
for t
he o
rgan
isatio
n on
:•
accu
rate
cod
ing
of a
ll di
agno
ses
incl
udin
g di
abet
es•
syst
emat
ic re
cord
ing
of p
atie
nt e
xper
ienc
e.
The
serv
ice
is re
quire
d to
ens
ure
that
a c
ompr
ehen
sive
asse
ssm
ent
of a
ll ol
der p
eopl
e w
ho a
re a
dmitt
ed to
hos
pita
l with
dia
bete
sta
kes
plac
e w
ithin
72
hour
s of
adm
issio
n
Ther
e sh
ould
be
prot
ocol
s in
pla
ce to
allo
w p
atie
nts,
who
are
abl
eto
do
so, t
o se
lf m
anag
e th
eir d
iabe
tes
med
icat
ion.
Patie
nts
may
nee
d to
be
refe
rred
to th
e fo
llow
ing
serv
ices
as
part
of th
eir d
iabe
tes
care
(see
rele
vant
com
miss
ioni
ng g
uide
s)2 :
• di
agno
sis a
nd c
ontin
uing
car
e •
Preg
nanc
y an
d di
abet
es c
are
• se
rvic
es fo
r com
plic
atio
ns o
f dia
bete
s –
foot
car
e, e
yes,
vas
cula
ret
c •
men
tal h
ealth
•
lear
ning
disa
bilit
ies
• en
d of
life
car
e
Prov
ider
s sh
ould
ens
ure
acce
ss to
tran
spor
t fac
ilitie
s to
ena
ble
atte
ndan
ce fo
r spe
cial
ist tr
eatm
ent,
as re
quire
d
Prov
ider
s ar
e re
quire
d to
take
not
e of
the
resu
lts o
f the
Nat
iona
lSu
rvey
of P
eopl
e w
ith D
iabe
tes
33
23
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Esta
tes
and
equi
pmen
t
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:5,
29, 3
3, 5
6
Sche
dule
s: 3
,10,
19
Und
erst
andi
ng o
f bu
ildin
gre
gula
tions
Acc
ess
to a
dvic
e on
“fit
-for
-pu
rpos
e” e
quip
men
t an
d fa
cilit
ies
Com
miss
ione
rs m
ust a
ssur
e th
emse
lves
that
patie
nt c
are
is de
liver
ed in
app
ropr
iate
ly b
uilt
and
equi
pped
faci
litie
s w
hich
mee
t rel
evan
tH
TMs
and
Build
ing
Not
es, a
nd, w
here
appr
opria
te, a
re re
gist
ered
and
are
saf
e an
dcl
ean.
Equi
pmen
t mus
t be
fit fo
r pur
pose
Com
mitm
ent t
o ef
ficie
nt u
se a
nd s
atisf
acto
rym
aint
enan
ce o
f equ
ipm
ent
Clin
ical
qua
lity
Kno
wle
dge
and
unde
rsta
ndin
g of
hea
lthan
d sa
fety
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:5,
11, 1
9, 5
4, 5
6, 6
0
Und
erst
andi
ng o
f cl
inic
alac
coun
tabi
litie
s of
hea
lth a
ndsa
fety
pol
icie
s
H&
S st
rate
gy a
nd p
olic
ies
in p
lace
and
impl
emen
ted
with
aw
aren
ess
thro
ugho
ut th
eor
gani
satio
n
Acc
essib
ility
to e
xecu
tive
resp
onsib
le fo
r H&
Sfo
r qui
cker
, firs
t con
tact
ser
vice
s
Hea
lth a
nd s
afet
y po
licie
s as
per
pro
vide
r agr
eem
ent w
ithco
mm
issio
ners
Clin
ical
qua
lity
Clin
ical
em
erge
ncy
situa
tions
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:6,
11,1
2,14
,15,
16,1
8,32
,33,
42, 5
4
Sche
dule
s:
2,12
,20
Abi
lity
to n
egot
iate
and
agr
eear
rang
emen
ts w
ith a
ppro
pria
tepe
rson
nel a
nd o
rgan
isat
ions
to
prov
ide
effe
ctiv
ely
for
emer
genc
ysi
tuat
ions
The
Com
miss
ione
rs s
houl
d sa
tisfy
them
selv
esth
at p
rovi
der h
as s
yste
ms,
pro
cess
es a
ndco
mpe
tent
per
sonn
el a
re in
pla
ce a
ndim
plem
ente
d to
ens
ure
that
all
clin
ical
emer
genc
ies
and
com
plic
atio
ns a
re h
andl
edin
acc
orda
nce
with
bes
t pra
ctic
e
Ther
e sh
ould
be
prot
ocol
s in
pla
ce to
ens
ure
the
avai
labi
lity
ofad
vice
and
/or s
uppo
rt o
f spe
cial
ist d
iabe
tes
clin
ical
sta
ff to
man
age
diab
etes
clin
ical
em
erge
ncy
situa
tions
, e.g
. dur
ing
asu
rgic
al p
roce
dure
24
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Dat
a an
din
form
atio
nm
anag
emen
t
Stra
tegy
and
pol
icie
s
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:8,
9,17
,19,
21,2
3,24
,27,
29,3
2,33
,54
Sche
dule
s: 5
,7,1
5,16
,18
The
Prov
ider
sho
uld
have
an
expl
icit
data
and
info
rmat
ion
stra
tegy
in p
lace
that
cov
ers
• Ty
pes
of d
ata
• Q
ualit
y of
dat
a•
Dat
a pr
otec
tion
and
conf
iden
tialit
y•
Acc
essi
bilit
y•
Tran
spar
ency
• A
naly
sis o
f dat
a an
d in
form
atio
n•
Use
of d
ata
and
info
rmat
ion
• D
issem
inat
ion
of d
ata
and
info
rmat
ion
• Ri
sks
• Sh
arin
g of
dat
a an
d co
mpa
tibili
ty o
f IT
acro
ss d
iffer
ent p
rovi
ders
with
resp
ect t
oca
re o
f pat
ient
s ac
ross
a p
athw
ay
This
info
rmat
ion
shou
ld b
e in
clud
ed in
the
Dat
a Q
ualit
y Im
prov
emen
t Pla
n
Ther
e sh
ould
be
polic
ies
in p
lace
that
incl
ude:
• C
onfid
entia
lity
Cod
e of
Pra
ctic
e•
Dat
a Pr
otec
tion
• Fr
eedo
m o
f Inf
orm
atio
n•
Hea
lth R
ecor
ds•
Info
rmat
ion
Gov
erna
nce
Man
agem
ent
• In
form
atio
n Q
ualit
y A
ssur
ance
• In
form
atio
n Se
curit
y
Ther
e m
ust b
e a
nam
ed in
divi
dual
who
is th
eC
aldi
cott
Gua
rdia
n
Stra
tegy
and
pol
icy
deve
lopm
ent
skill
s
The
abili
ty t
o an
alys
e da
ta a
ndha
ve a
cces
s to
info
rmat
ion
that
can
pred
ict
tren
ds a
nd t
hat
coul
did
entif
y pr
oble
ms
The
abili
ty t
o ca
ptur
e ev
iden
ceba
sed
prac
tice
from
R&
D N
atio
nal
Serv
ice
Fram
ewor
ks, N
ICE
guid
ance
The
abili
ty t
o us
e da
ta a
ndin
form
atio
n ap
prop
riate
ly t
oim
prov
e pa
tient
car
e
Tran
spar
ency
and
obj
ectiv
ity
The
Prov
ider
is re
quire
d to
hav
e in
form
atio
n sy
stem
s th
at re
cord
indi
vidu
al n
eeds
incl
udin
g em
otio
nal,
soci
al, e
duca
tiona
l,ec
onom
ic a
nd b
iom
edic
al in
form
atio
n w
hich
per
mit
mul
tidisc
iplin
ary
care
acr
oss
serv
ice
boun
darie
s an
d su
ppor
t car
epl
anni
ng 34
The
Prov
ider
is re
quire
d to
use
the
follo
win
g fo
r the
col
lect
ion
and
prod
uctio
n of
dat
a, w
here
app
ropr
iate
:
• N
HS
Out
com
es F
ram
ewor
k26
• N
atio
nal D
iabe
tes
Info
rmat
ion
Serv
ice
35
• N
atio
nal D
iabe
tes
Aud
it 14
• D
iabe
tes
E 17
• Q
ualit
y an
d O
utco
mes
Fra
mew
ork36
• M
yoca
rdia
l Isc
haem
ia A
udit
Proj
ect37
• H
ospi
tal E
piso
de S
tatis
tics38
• Pa
tient
Exp
erie
nce
16,3
3
• Pa
tient
Sat
isfac
tion
33
• Pa
tient
Rep
orte
d O
utco
mes
Mea
sure
s 18
• N
atio
nal D
iabe
tes
Con
tinui
ng C
are
Dat
aset
39
25
Source documentsCommissioners and providers should takeresponsibility for making references to thelatest version of the various documents andguidance.
1. NHS Diabetes and Diabetes UK, Emotional andPsychological Support and Care in Diabetes, JointDiabetes UK and NHS Diabetes Emotional andPsychological Support, 2010http://www.diabetes.nhs.uk
2. The NHS Diabetes Commissioning Guides areavailable on the NHS Diabetes website athttp://www.diabetes.nhs.uk/commissioning_resource/
3.Department of Health, Standard NHS Contractshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324
4. National Quality Board, Quality Governance in theNHS, 2011 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_125239.pdf
5. NICE Diabetes guidance,http://guidance.nice.org.uk/Topic/EndocrineNutritionalMetabolic/Diabetes
6. NICE, Depression in adults with a chronic physicalhealth problem, treatment and management,http://guidance.nice.org.uk/CG91 , October 2009
7. NICE, Medicines adherence: involving patients indecisions about prescribed medicines andsupporting adherence, Jan 2009,http://guidance.nice.org.uk/CG76
8. European Diabetes Working Party for OlderPeople. Clinical Guidelines for Type 2 DiabetesMellitus, www.instituteofdiabetes.org
9. The Hospital Management of Hypoglycaemia inAdults with Diabetes Mellitus, March 2010,http://www.diabetes.nhs.uk/
10. Management of adults with diabetes undergoingsurgery and elective procedures: improvingstandards, April 2011http://www.diabetes.nhs.uk/
11. The Management of Diabetic Ketoacidosis inAdults, Joint British Diabetes Societies InpatientCare Group, March 2010,http://www.diabetes.nhs.uk/
12. NHS Institute for Innovation and Improvement,model CQUIN scheme: inpatient care for peoplewith diabetes, 2009
13. Department of Health, The Operating Frameworkfor the NHS in England 2011/12, 2010,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122738
14. National Diabetes Audit.www.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/diabetes
15. National Diabetes Inpatient Audit,http://www.diabetes.nhs.uk/our_work_areas/inpatient_care/inpatient_audit_2010/
16. The King’s Fund, The point of care. Measures ofpatients’ experience in hospital: purpose,methods and uses. July 2009
17. DiabetesE - https://www.diabetese.net/
18. Patient Reported Outcomes Measures,http://www.ic.nhs.uk/proms
19. Training, Research and Education for Nurses inDiabetes – UK, An Integrated Career &Competency Framework for Diabetes Nursing(Second Edition), 2010
20. Skills for Health, Diabetes CompetencyFramework, https://tools.skillsforhealth.org.uk/
21. Department of Health, National ServiceFramework for Older People, May 2001,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066
22. Department of Health, National ServiceFramework for Coronary Heart Disease – modernstandards and service modelshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094275
23. Department of Health, No health without mentalhealth: a cross-government mental healthoutcomes strategy for people of all ages,February 2011,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766
26
24. Department of Health, The National ServiceFramework for Long Term Conditions, March2005http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4105361
25. Department of Health, End of Life Care Strategy– promoting high quality care for all adults at theend of life, July 2008,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086277
26. Department of Health, The NHS OutcomesFramework 2011/12, December 2010http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
27. NICE, Quality Standards: Diabetes in adults,March 2011,http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp
28. Generic Long-term conditions modelhttp://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_120915
29. Joint Royal Colleges Ambulance LiaisonCommittee, UK Ambulance Service ClinicalPractice Guidelines 2006, Glycaemic emergenciesin adults,www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/glycaemic_emergencies_in_adults_2006.pdf
30. Joint Royal Colleges Ambulance LiaisonCommittee, UK Ambulance Service ClinicalPractice Guidelines 2006, Glycaemic emergenciesin children, http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/glycaemic_emergencies_in_children_2006.pdf
31. National Diabetes Support Team, Improvingemergency and inpatient care for people withdiabetes, the report of a working party ofrepresentatives of the inpatient and emergencycare community in partnership with the NationalInstitute for Innovation and Improvement, March2008
32. NHS Institution for Innovation and Improvement,ThinkGlucose Toolkit,http://www.institute.nhs.uk/quality_and_value/think_glucose/welcome_to_the_website_for_thinkglucose.html
33. Healthcare Commission, National Survey ofPeople with Diabetes, 2006,www.cqc.org.uk/usingcareservices/healthcare/patientsurveys/servicesforpeoplewithdiabetes.cfm
34. York and Humber integrated IT systemhttp://www.diabetes.nhs.uk/
35. National Diabetes Information Service,www.diabetes-ndis.org
36. Quality and Outcomes Framework,http://www.nice.org.uk/aboutnice/qof/qof.jsp
37. Myocardial Ischaemia Audit Project (MINAP)www.rcplondon.ac.uk/CLINICAL-STANDARDS/ORGANISATION/PARTNERSHIP/Pages/MINAP-.aspx
38. Hospital Episode Statistics,www.ic.nhs.uk/statistics-and-data-collections/hospital-care/hospital-activity-hospital-episode-statistics--hes
39. National Diabetes Continuing Care Dataset,www.ic.nhs.uk/webfiles/Services/Datasets/Diabetes/dccrdataset.pdf
27
This specification forms Schedule 2, Parts 1-4,‘The Services - Service Specifications’ of theStandard NHS Contract for AmbulanceServicesa.
Service specifications are developed in partnershipbetween commissioners and provider agenciesand are based on agreed evidence-based care andtreatment models. Specifications should be opento scrutiny and available to all service users/carersas a statement of standards that the user/carercan expect to receive.
The following documentation, developed bythe Diabetes Commissioning Advisory Groupprovides further detail/guidance to supportthe development of this specification:
• The diabetes emergency and inpatientintervention map
• The contracting framework for diabetesemergency and inpatient services
This specification template assumes that theservices are compliant with the contractingframework for diabetes emergency and inpatientservices.
This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.
Part 1:Section A: Base ServicesDescription of emergency diabetes care:
Emergency diabetes care includes the immediateassessment, stabilisation, initial treatment ofpeople of all ages who have diabetic emergencyconditions, e.g. diabetic ketoacidosis andhyperosmolar non-ketotic hyperglycaemic state(HONK) etc, in the community. The care may alsoinclude the requirement for transfer to emergencyhospital services for continued management ofchildren, young people, adults and older peoplewho have diabetic emergency conditions.
The final specification should take intoaccount:
• national, network and local guidance andstandards for emergency diabetes services.
• local needs.
This specification is supported by other relatedwork in diabetes commissioning such as:
• the web-based Diabetes Community HealthProfiles (Yorkshire and Humber Public HealthObservatory)
• the web-based Health Needs Assessment Tool(National Diabetes Information Service).
These provide comprehensive information forneeds assessment, planning and monitoring ofdiabetes services
Standard Service SpecificationTemplate for Emergency DiabetesCare to be provided by AmbulanceServices
a Standard NHS Contractshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324
28
Introduction• A general overview of the services identifying
why the services are needed, includingbackground to the services and why they arebeing developed or in place.
• A statement on how the services relate to eachother within the whole system should beincluded describing the keystakeholders/relationships which influence theservices, e.g. multi-disciplinary diabetes team,CYP multi-disciplinary diabetes team etc
• Any relevant diabetes clinical networks andscreening programmes applicable to theservices
• Details of all interdependencies or sub-contractors for any part of the service and anoutline of the purpose of the contract shouldbe stated, including arrangements for clinicalaccountability and responsibility, as appropriate
Purpose, Role and Clientele1. A clear statement on the primary purpose of
the services and details of what will beprovided and for whom:
• Who the services are for (e.g. CYP, adultsand older people who have diabeticemergencies in the community)
• What the services aim to achieve within agiven timeframe
• The objectives of the services
• The desired outcomes and how these aremonitored and measured
Scope of the Services2. What does the service do? This section will
focus on the types of high level therapeuticinterventions that are required for the types ofneed the services will respond to.
• How the services responds to age, culture,disability, and gender sensitive issues
• Assessment – details of what it is and co-morbidity assessment and referrals to allrelevant specialties
• Service planning – High level view of whatthe services are and how they are used; howpatients enter the pathway/journey; what arethe stages undertaken, e.g. assessment,stabilisation, initial treatment and continuingmanagement. The aims of service planningare to:
o Develop, manage and reviewinterventions along the patient journey
o Ensure access to other specialities /care,as appropriate
o Ensure that the diabetes multi-disciplinary team (as defined locally) isinformed (with the patient’s or parent’sconsent) of the diabetic emergency andis involved in the subsequent care andfollow up
• Holistic review of patients in themanagement of their diabetes using theprinciples of an integrated care model forpeople with long term conditions that ispatient-centred, including self care and selfmanagement, clinical treatment, facilitatingindependence, psychological support andother social care issues
• Risk assessment procedures
• Detail of evidence base of the service – i.e.the contracting framework for diabetesemergency and inpatient services, guidanceproduced by the Royal College of Physicians,Royal College of Paediatrics and Child Health,Diabetes UK, etc
Service Delivery3. Patient Journey/intervention map
Flow diagram of the patient pathway showingaccess and exit/transfer points – see thediabetes emergency and inpatient patientintervention map as a starting point
29
b www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/glycaemic_emergencies_in_adults_2006.pdf
c http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/glycaemic_emergencies_in_children_2006.pdf
d http://www.nice.org.uk/media/FCF/87/DiabetesInAdultsQualityStandard.pdf
e http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
4. Treatment protocols/interventionsInclude all individual treatment protocols inplace within the services or planned to beused, e.g. Joint Royal Colleges AmbulanceLiaison Committee, UK Ambulance ServiceClinical Practice Guidelines 2006, Glycaemicemergencies in adultsb, and Glycaemicemergencies in childrenc
5. This will include a breakdown of how thepatient will receive the services and fromwhom. It should be a clear statement of staffqualifications/experience and/or training (ifappropriate) and clinical or managerialsupervision arrangements. It should specify, asappropriate:
• Geographical coverage/boundaries – i.e. theservices should be available for children,young people, adults and older people whoin the clinical commissioning group area
• Hours of operation
• Minimum level of experience andqualifications of staff (i.e. nursing staff, alliedhealth professionals and other support andadministrative staff)
• Staff induction and developmental training
6. Equipment – see Clause 5 of the Standard NHSContract for Ambulance Services – ‘Servicesenvironment, vehicles and equipment’.
Identification, Referral andAcceptance criteria7. This should make clear how patients will be
assessed and accepted to the services.Acceptance should be based on types of needand/or patient.
8. How are patients referred?
• Who is acceptable for referral and fromwhere
• Details of evaluation process - Are there clearexclusion criteria or set alternatives to theservice? How might a patient be transferred?(insert call centre and triage processes andprotocols)
• Response time detail and how are patientsprioritised (insert Ambulance response times)
Discharge/Service Complete/Patient Transfercriteria – see Part 2: Transfer of and Dischargefrom Care Protocol (below)
Quality Standards9. The service is required to deliver care according
to the standards for clinical practice set by theNational Institute for Health and ClinicalExcellenced
10. As a minimum, the Provider is required toagree a local Commissioning for Quality andInnovation scheme for services for peoplewith diabetes. (Insert details of the CQUINScheme agreed)
12. The service is required to deliver the outcomesfor diabetes as determined by the NHSOutcomes Frameworke
Activity and PerformanceManagement13. This must include performance indicators,
thresholds, methods of measurement andconsequences of breach of contract. Thesewill be set and agreed prior to the signing ofthe overall agreement.
14. Activity plans – Where appropriate, identifythe anticipated level of activity the servicemay deliver; provide details of any activitymeasures and their description /method ofcollection, targets, thresholds andconsequences of variances above or belowtarget.
30
Continual Service Improvement15. As part of the monitoring and evaluation
procedures, the service will identify a methodof agreeing measurements for continuousimprovement of the service being offeredand work to ensure unmet need is bothidentified and brought to the attention of thecommissioner.
16. ReviewThis section should set out a review date anda mechanism for review.
The review should include both thespecifications for continuing fitness forpurpose and the providers’ delivery againstthe specification.
This should set out the process by which thisreview will be conducted.
This should also identify how complianceagainst the specification will be monitored inyear.
17. Agreed by
This should set out who agrees/accepts thespecification on behalf of all parties.
This should include the diabetes providers,commissioner and network
Section B: Additional ServicesComplete according to local needs
Part 2: Transfer of andDischarge from Care ProtocolInsert locally agreed Transfer of and Dischargefrom Care Protocol
The intention of this section is to make clearwhen a patient should be transferred from theambulance service to another service ordischarged and when this would be reached.
• How does the service decide that a patient isready for discharge?
• What procedure is followed on discharge,including arrangements for follow-up
• If the patient requires continued care, what isthe process for transferring to other care, e.g.hospital emergency services?
Part 3: Emergency PreparednessComplete as required in the guidance for theStandard NHS Contract for Ambulance Services
Part 4: Essential ServicesComplete according to local needs
31
Standard Service SpecificationTemplate for Emergency andInpatient Diabetes Services This specification forms Schedule 2, Part 1, orsection 1 (module B), ‘The Services - ServiceSpecifications’ of the Standard NHSContracts.a
Service specifications are developed in partnershipbetween commissioners and provider agenciesand are based on agreed evidence-based care andtreatment models. Specifications should be opento scrutiny and available to all service users/carersas a statement of standards that the user/carercan expect to receive.
The following documentation, developed bythe Diabetes Commissioning Advisory Groupprovides further detail/guidance to supportthe development of this specification:
• The diabetes emergency and inpatientintervention map
• The contracting framework for diabetesemergency and inpatient services
This specification template assumes that theservices are compliant with the contractingframework for emergency and in patient diabetesservices.
This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.
Description of diabetes emergencyand inpatient care:Diabetes emergency and inpatient care includesthe immediate assessment, stabilisation andtreatment of people who present to hospitalemergency services with diabetic emergencyconditions, e.g. hypoglycaemia, diabeticketoacidosis (DKA) and hyperosmolar non-ketotichyperglycaemic state (HONK) etc. The serviceshould, in addition, identify people with newlydiagnosed diabetes admitted for medical orsurgical reasons which may or may not be relatedto diabetes.
Inpatient care also involves the management ofpeople with diabetes who are admitted tohospital for routine procedures or operations.
Please note
• Diabetes emergency care for children andyoung people from presentation at A&Eservices plus admission is included in thecommissioning guide for children and youngpeople with diabetes.
• Management of the acute foot is included inthe diabetes foot care commissioning guide
• Emergency care for people of all age groupswho have diabetic emergency conditions in thecommunity is included in the template servicespecification for ambulance services
The final specification should take intoaccount:
• national, network and local guidance andstandards for emergency and inpatientdiabetes services.
• local needs.
a Standard NHS Contractshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324
32
This specification is supported by other relatedwork in diabetes commissioning such as:
• the web-based Diabetes Community HealthProfiles (Yorkshire and Humber Public HealthObservatory)
• the web-based Health Needs Assessment Tool(National Diabetes Information Service).
These provide comprehensive information forneeds assessment, planning and monitoring ofdiabetes services
Introduction• A general overview of the services identifying
why the services are needed, includingbackground to the services and why they arebeing developed or in place.
• A statement on how the services relate to eachother within the whole system should beincluded describing the keystakeholders/relationships which influence theservices, e.g. multi-disciplinary team etc
• Any relevant diabetes clinical networks andscreening programmes applicable to theservices
• Details of all interdependencies or sub-contractors for any part of the service and anoutline of the purpose of the contract shouldbe stated, including arrangements for clinicalaccountability and responsibility, as appropriate
Purpose, Role and Clientele1. A clear statement on the primary purpose of
the services and details of what will beprovided and for whom:
• Who the services are for (e.g. adults and olderpeople who present to hospital with diabeticemergencies and those who require diabetescare during their elective admission tohospital)
• What the services aim to achieve within agiven timeframe
• The objectives of the services
• The desired outcomes and how these aremonitored and measured
Scope of the Services2. What does the service do? This section will
focus on the types of high level therapeuticinterventions that are required for the types ofneed the services will respond to.
• How the services responds to age, culture,disability, and gender sensitive issues
• Assessment – details of what it is and co-morbidity assessment and referrals to allrelevant specialties
• Service planning – High level view of what theservices are and how they are used; howpatients enter the pathway/journey; what arethe stages undertaken, e.g. diagnosis andcontinuing management. The aims of serviceplanning are to:
• Develop, manage and review interventionsalong the patient journey
o Ensure access to other specialities /care,as appropriate
o Ensure that care planning is undertakenby the diabetes multi-disciplinary team(as defined locally) with a clear care co-ordination function
• Holistic review of patients in the managementof their diabetes using the principles of anintegrated care model for people with longterm conditions that is patient-centred,including self care and self management,clinical treatment, facilitating independence,psychological support and other social careissues
• Risk assessment procedures
• Detail of evidence base of the service – i.e.the contracting framework for diabetesemergency and inpatient services, guidanceproduced by the Royal College of Physicians,Diabetes UK, etc
33
Service Delivery3. Patient Journey/intervention map
Flow diagram of the patient pathway showingaccess and exit/transfer points – see thediabetes emergency and inpatient interventionmap as a starting point
4. Treatment protocols/interventionsInclude all individual treatment protocols inplace within the services or planned to be used
5. This will include a breakdown of how thepatient will receive the services and fromwhom. It should be a clear statement of staffqualifications/experience and/or training (ifappropriate) and clinical or managerialsupervision arrangements. It should specify, asappropriate:
• Geographical coverage/boundaries – i.e. theservices should be available for adults andolder people who live in the clinicalcommissioning group area
• Hours of operation including, week-end, bankholiday and on-call arrangements
• Minimum level of experience andqualifications of staff (i.e. doctors –diabetologists and GPs, Nursing staff –diabetes nurse specialists, acute care nursesetc, other allied health professionals, e.g.podiatrists, dietitians, etc, health carescientists, e.g. pharmacists and other supportand administrative staff)
• Confirmation of the arrangements to identifythe Care Co-ordinator for each patient withdiabetes (i.e. who holds the responsibility androle).
• Staff induction and developmental training
6. Equipment
• Upgrade and maintenance of relevantequipment and facilities
• Technical specifications (if any)
Identification, Referral andAcceptance criteria7. This should make clear how patients will be
identified (including newly diagnosed peoplewith diabetes), assessed (if appropriate) andaccepted to the services. Acceptance should bebased on types of need and/or patient.
8. How should patients be referred?
• Who is acceptable for referral and from where
• Details of evaluation process - Are there clearexclusion criteria or set alternatives to theservice? How might a patient be transferred?
• Response time detail and how are patientsprioritised
Discharge/Service Complete/PatientTransfer criteria9. The intention of this section is to make clear
when a patient should be transferred from thepregnancy and diabetes service to another andwhen this point would be reached
• How is a treatment pathway reviewed?
• How does the service decide that a patient isready for discharge
• How are goals and outcomes assessed andreviewed?
• What procedure is followed on discharge,including arrangements for follow-up
34
Quality Standards10. The service is required to deliver care
according to the standards for clinical practiceset by the National Institute for Health andClinical Excellenceb
11. As a minimum, the Provider is required toagree a local Commissioning for Quality andInnovation scheme for services for peoplewith diabetes. (Insert details of the CQUINScheme agreed)
12. The service is required to deliver the outcomesfor diabetes as determined by the NHSOutcomes Frameworkc
Activity and PerformanceManagement13.This must include performance indicators,
thresholds, methods of measurement andconsequences of breach of contract. These willbe set and agreed prior to the signing of theoverall agreement.
14. Activity plans – Where appropriate, identifythe anticipated level of activity the servicemay deliver; provide details of any activitymeasures and their description /method ofcollection, targets, thresholds andconsequences of variances above or belowtarget.
Continual Service Improvement15. As part of the monitoring and evaluation
procedures, the service will identify a methodof agreeing measurements for continuousimprovement of the service being offeredand work to ensure unmet need is bothidentified and brought to the attention of thecommissioner.
16. ReviewThis section should set out a review date anda mechanism for review.
The review should include both thespecifications for continuing fitness forpurpose and the providers’ delivery againstthe specification.
This should set out the process by which thisreview will be conducted.
This should also identify how complianceagainst the specification will be monitored inyear.
17. Agreed byThis should set out who agrees/accepts thespecification on behalf of all parties.
This should include the diabetes providers,commissioner and network
b http://www.nice.org.uk/media/FCF/87/DiabetesInAdultsQualityStandard.pdf
c http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
Further copies of this publication can be ordered from Prontaprint, by emailing [email protected] or tel: 0116 275 3333, quoting DIABETES 114
www.diabetes.nhs.uk