NHS BORDERS DIABETES MCN REPORT

IMPACT OF DIABETES SERVICES REDESIGN IN NHS BORDERS

THE 5 YEAR PLAN 2007-12

Executive Summary

The prevalence of diabetes is increasing and is estimated to double by 2025.

NHS Borders has one of the highest prevalence of diabetes in Scotland with 1:20 living with diabetes.

Primary care

Community DSN clinics have improved glycaemic control in high risk patients by a significant 1%.

The improved glycaemic control has resulted in increase in QOF targets.

Community clinics have stabilised new patient referrals for 2012, with no increase in referral rates despite an increase in prevalence in people diagnosed with diabetes.

Feedback from our primary care colleagues has been positive with additional request for clinical and educational support for 2013.

Structures education for patients with type 2 diabetes has been well received and plans to expand to those already diagnosed are in place for 2013 in line with the Scottish Diabetes Action plan.

Out patient Activity

Reduction in capacity due to impact of unscheduled care and increased demand for review appointments has impacted negatively on out patient services. Our present capacity has a 15% shortfall based on current demand.

Reconfiguration of outpatient dept will have a detrimental effect on joint multidisciplinary working with dietetics, podiatry and specialist nurses. However, a dedicated diabetes centre incorporated into this development would improve team working.

In Patient Activity

The presence of an inpatient nurse has helped to improved bed occupancy and reduces length of stay by 1.1 days for all patients with diabetes regardless of primary reason for admission.

Furthermore there has been an increase of 4% in patients staying less then 7 days and a 1% reduction in those staying longer then 29 days.

Patient Safety

Improved management of patients with diabetes preoperatively with 80-100% patients achieving glycaemic targets pre and post-op (Scottish Patient Safety Standard).

The introduction of a specific treatment box for hypoglycaemia, improved education on treatment and a means of auditing effect.

Pump Therapy

Achieved the Scottish government pump target of 25% of children less than 18 years on pump therapy in advance of target deadline (April 2013).

Complications

Achieved the target of foot risk stratification and continue to maintain this throughout 2012.

Continue to National achieve targets in all areas of Scottish Diabetes Survey with the exception of Microalbuminuria screening in patients with type 2 diabetes.

Pregnancy

Following revised diagnostic criteria for gestational diabetes the team word load in this area has increased significantly.

Consistent input nationally to speciality developments.

NHS Borders Diabetes MCN

The Borders Diabetes MCN was established from the LDSAG (local diabetes service advisory group) in April 2004. The vision was; ‘bring together patients, carers and health professionals from all disciplines to identify local needs and drive forward local priorities, adopting a patient centred approach to service development’.

Over the last 8 years the diabetes MCN has been committed to delivering the Scottish Diabetes action plan to improve the quality of care for patient with diabetes in NHS Borders in line with the National Framework and simultaneously reviewed service needs and development in line with local requirements. The first progress report from the MCN was published in 2007 and this report contains the key projects driven by the MCN over the last five years.

Background

Diabetes is a common chronic condition associated with considerable morbidity and premature mortality. It is well recognised that Diabetes complications are preventable with appropriate care and treatment (UKPDS 35, DCCT).

The prevalence of diabetes in he Scottish Borders is higher then the National prevalence (4.9% vs 4.7%), approximately one in 20 of the population. (This difference could be explained by good ascertainment and/or the age structure within the Borders region. The prevalence continues to increase and is estimated to double by 2025. Since 2007 there has been a 10% increase in the prevalence of diabetes in NHS Borders. It is a growing economic burden on health services worldwide consuming over 5% of NHS Scotland budget and £300 million of this is spent on inpatient care alone. Therefore forward planning of diabetes services is essential and the diabetes MCN the means by which these changes are driven.

Shifting the Focus of Care

In 2007 a mapping exercise undertaken by the MCN found that service provision across primary care was inconsistent. In addition, some staff felt they did not have adequate training to provide care in the speciality. In 2008 an education programme was established targeting Practice nurses, predominantly who ran clinics in primary care. Funding was obtained to provide nurses with experience of specialist secondary cares services. The MCN set up a rolling education programme embedded in TiME for those providing diabetes services in primary care.

Community DSN Clinics

The next phase of the above project which was funded through Scottish Enhanced Services was to provide specialist diabetes nurse input directly to primary care to optimise diabetes control and reduce referrals to secondary care. This project was delayed until 2010 due to the vacancy factor process. Patients at high risk of complications (HbA1c> 8%) and likely to require secondary care input were targeted.

The figures represented in table 1 below are from 2011. From the initial review of evidence (SCI-DC Network data base) we anticipated an increase in referrals in the first year due to identification of patients who required additional therapies.

After 146 contacts, approximately (2 visits per practice) there was a significant reduction in reduction in HbA1C 1%). Table 1 Specialist Community Nurse Clinic Contacts Comments / Treatment changes Count Percentage Education 34 23.3% Medication Increased 64 43.8% Medication Reduced 7 4.8% Additional Medication Altered 8 6.4% Referred to Secondary Care 30 20.5% Not Recorded 2 1.2%

Total seen 145 Average HbA1C first visit 9.3 Average HbA1C second visit 8.3 Improvement in HbA1c 1.0%

Out patient activity

The aim of this change in practice was to enhance practical knowledge in the management of diabetes and increase awareness of current prescribing guidance and in doing so shift the focus of care, where possible to primary care. We anticipated that once the clinics were established in primary care and communication channels improved that this would have a positive impact on the number of referrals into secondary care.

Figure 1a demonstrates the number of referrals from primary care from September 2007 to September 2012. As discussed above, the number of patients with diabetes has increased over the last five years (≅ 600) and the expected knock on effect is an increase in the referrals to secondary care. The anomaly seen in the 2010 referral rate may reflect data recording rather then an actual reduction in number as a result of the change in the patient administration system from HOMER to TRAK.

At the beginning of this project we anticipated an increase in referrals as we were targeting the higher HbA1c as demonstrated in Table 1 and Figure 1 (2011). However, there has been a reduction, albeit small in the number of new patients seen in secondary care in 2012. As our community clinics are now established and communications improved we believe this reflects the beginning of change as a result of our service redesign and the shift of focus of care.

Figure 1a New Referrals to Outpatients 2007-2012

New Diabetic Outpatient Activity

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Demand vs Capacity

While the effect of the community clinics has been a positive one in terms of new patient referrals, unfortunately unscheduled care has had a negative impact on clinic capacity. As a consequence there has bee a reduction in consultant clinics (approximately 26 diabetes clinics per year), a change in the team on call day and cancellation of clinics post call day. Initially these clinics were picked up by the speciality doctors and laterally by the speciality registrars. However, due to financial constraints and reduced middle grade staff these solutions are no longer available.

Figure 1b illustrates the total number of clinic episodes/attendances each year (extracted from our diabetes data base SCI-DC Clinical) from 2007 to 2012. While the increase has plateau over the last year, patients are living longer with more complex morbidities and thus requiring more clinic time then allocated (currently 15 minutes for reviews). As a consequence clinics run late despite a 15% DNA rate. Analysis of our demand and capacity has identified a shortfall of 30 clinics per year (15%), (Appendix 1).

Figure 1b Clinic attendance from 2007-2012

Diabetic clinic attendances by year

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Primary Care Feedback

As the developments in primary care are in their third year we asked out primary care colleagues what they thought of the service developments. Almost 90% of practices participated in our survey (Figure 2).

We asked 5 simple questions: has the SES helped with education (Figure 3), has the SES improved communication with primary and secondary care (Figure 4), has the practice nurse found it helpful to have a named specialist nurse (Figure 5) and has the administration of the SES been labour intensive (Figure 6).

In addition we asked what further areas primary care would like to be addressing in future projects and the responses included use of hypoglycaemia agents, screening for diabetes, diabetes monitoring, polypharmacy, complications, the poorly controlled patient and insulin adjustment. Hopefully we can continue this initiative in 2013 and address some/all of these areas.

Figure 2.0 Practice Response

Figure 3.0 Impact of Diabetes Service in primary care

Figure 4.0 Improved communications

Figure 5 Key Specialist Nurse

In-Patient Diabetes Project

The cost of diabetes inpatient care is increasing and the needs of these patients in hospital are different to the community. There is evidence from the Think Glucose Project that a diabetes inpatient specialist nurse impacts positively on inpatient care and outcomes. In 2010 we seconded two nurses from primary and secondary care to train in diabetes inpatient specialist care. In 2011 this became one post funded from as backfill to support the community part of the SES project. In line with the Scottish Diabetes Action plan and local developments the following projects were initiated.

Length of Stay

Patient with diabetes on average have 1.5 more days in hospital then those with non-diabetes in any speciality. With the current patient administrative systems there is no way of identifying all patients with diabetes in the hospital at a given time. Working with our audit facilitator we devised a data base by cross referencing our SCI-DC Network database with the patient administrative system to identify these patients.

The diabetes inpatient nurse received a daily list of these patients , reviews them on the ward , and put a management plan in their notes (green SBAR form, devised by the nurse) to assist the ward staff. Feedback from staff has been very positive. Prior to the inpatient nurse these patients were referred on an ad hoc basis and often on day of discharge sometimes resulting in an extended stay depending on needs of patient and team availability to facilitate a safe discharge. Table 2 below demonstrated the reduction in occupied bed days over last 5 years for those who had diabetes coded at admission, based on T6 HEAT targets. Figure 5.0 demonstrated the change in length of stay for the same group of patients.

Table 3.0 illustrated the number of occupied bed days for all patients with diabetes regardless of the primary diagnosis. As expected this is significantly higher compared to that illustrated in table 2.0. Table 4.0 shows the length of stay for these patients.

There is a noticeable reduction in the length of stay occurring in the context of an increasing trend in all admissions which we believe reflects positively on the diabetes inpatient nurse. This is clearly illustrated in table 5. Patients staying less then 7 days are increasing while those with longer stays are decreasing.

Table 2.0: T6 Heat target - Occupied Bed Days Diabetes 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011 2011/2012 2012/201Diabetes Mellitus 822 955 1039 1643 784 545

Figure 5.0 Length of Stay Data split By Financial year and Month and LTC Grouping

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Table 3.0 Occupied bed days for all patients with diabetes regardless of primary presentation

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bed days Occupied Bed days - Dx Diabetes 11855 14002 12010 5608

Table 4 Length of stay for all patients with diabetes regardless of primary diagnosis precipitating admission

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All Admissions 8710 8716 9063 4623

Diabetics 1307 (15%) 1362 (15.6%) 1369 (15% 725 (15.7%)

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Table 5 Duration of Length of stay for all patients with diabetes regardless of diagnosis precipitating admission

Diabetes Audit

In November 2011 NHS Borders using the NHS England methodology National Diabetes Inpatient Audit protocol performed an audit of diabetic inpatient care on a single day. The data was presented at the National Diabetes Inpatients Conference (Appendix 2a, 2b). 91% of patients were admitted to hospital as an emergency (higher then the national figure of 85%), 67% of which were admitted for medical reasons and only 8% were admitted for diabetes related causes, which enforces the findings above. This audit looked at aspects of care including the management of hypoglycaemia. 27% of patients had a BM <4 but >3mmol while 10% had a BM <3mmol. Importantly more then 75% of these cases were not recorded and 50% were not treated in accordance with local guidance. This audit also demonstrated a 27% error rate in insulin prescribing.

Management of Hypoglycaemia

This inpatient audit highlighted the need for education and training in the management of hypoglycaemia. In 2011 hypoglycaemic boxes were introduced on all wards to provide a standard approach to the management of hypoglycaemia. Training was provided to nurses and doctors on their use in a simulated format. An audit of first year has enabled us to demonstrate the number of episodes of hypoglycaemia occurring in each ward (Figure 6.0) and the glucose result recorded post treatment (Figure 7.0). This is important and as you will see from the data the Hypoglycaemia has been treated effectively but not over treated which is often the case resulting in high blood glucose and potential impact on discharge. It is also important to note that 25% of all episodes of Hypoglycaemia were severe (BM ≤ 2.8mmol/l). Now that we have a means of identification of incidences of Hypoglycaemia and an education process in pace we hope that next year we will see a reduction in the number of episodes and in particular severe episodes of hypoglycaemia.

Length of stay group - Dx Diabetes

200910 (Percentage) 201011 (Percentage) 201112 (Percentage)

201213 (Apr-Sept) (Percentage)

7 days or less 66.7% 64.8% 67.3% 71.0% 8 to 14 days 16.1% 16.5% 16.0% 15.4% 15 to 21 days 7.3% 6.7% 7.2% 6.1% 22 to 28 days 3.3% 3.5% 3.1% 2.1% 29 days or over 6.7% 8.5% 6.3% 5.4% Range 1 - 207 Range 1 - 227 Range 1 - 170 Range 1 - 91

Ward Education

It is recognised that diabetes related problems (e.g. management of hypoglycaemia, hyperglycaemia, and use of insulin devices) are often poorly managed on wards by nursing and medical staff alike. Foundation doctors receive training on insulin therapy and day to day problems with patient with diabetes through the foundation teaching programme and in order to address the nursing staff needs the inpatient DSN set up a practical study day which was well attended and received very positive feedback. From this session link nurses have been identified in the wards and they are awaiting their first training day planned for November.

Figure 6.0 Figure 7.0

Hypoglycaemic episodes by ward Glucose Levels pre and post treatment

Hypoglycaemia Incidents by ward

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Additional In patient nurse services

Borders McMillan Centre: Throughout 2011 there were an increasing number of patients referred to the diabetes service from Mcmillian, often requiring urgent assessment. Some of these patients have pre existing diabetes and others were new diagnosis. In order to improve this referral pathway a referral form was devised to prompt staff to check if the patient had diabetes prior to commencing chemotherapy so that a diabetes treatment plan could be put in place. There are currently 9 patients attending McMillan Centre requiring regular input from the inpatient specialist nurse.

Dialysis unit: This is another specialist area where we now have regular input through the diabetes specialist nurse who visits the unit regularly.

National DKA protocol

In 2008 a National DKA protocol was devised and the Borders Diabetes MCN incorporated this into our protocols and made it available on line on our intranet site and subsequently our internet. An audit was undertaken following the first year of implementation and 90% adherence was demonstrated with an average length of stay of 3.5 days for those with DKA. Further audit has demonstrated continued adherence to protocol.

This audit also highlighted that a small group of individual patients are responsible fro the majority of admissions and readmissions. It is widely accepted that psychological input into this vulnerable group is essential to prevent readmission and this is currently a resource to which the team does not have access.

Pump Service

In 2006 the Borders diabetes MCN pump service was established for adults. Provision for pumps was based on NICE Guidance TA 57 which advised that 1% of patients with type 1 diabetes would be eligible for pump therapy . However in 2008 TA151 replaced the initial guidance and suggested that 10-14% of patients would be eligible for pump therapy. On the basis of the original guidance provision for 6 pumps per year was made but no allocation for staffing or replacement pumps was included in the original business plan.

In 2010 the business plan was reviewed and included paediatric pumps and replacement pumps with some provision for staffing and was strongly supported by patient and carer representatives on the MCN .

In October the cabinet secretary announced the decision to commit NHS Scotland to increase the provision of insulin pumps through out Scotland. As part of the work up a national audit was carried out and table 6 demonstrates that NHS Borders was one of only 4 heath boards throughout Scotland achieving the required target? To achieve the 25% of patients under 18 years (Appendix 3 ) receiving pump therapy NHS Borders only required 2 additional pumps through National procurement. The cabinet secretary commented on the high quality pump service provided by NHS Borders and others and suggested an opportunity to promote best practice.

To date there are 58 Patients on Insulin Pumps, One patient is due to start shortly and 13 patients being worked up for a pump. A total of 11 patients have started pumps since beginning of August 2012 and 1 Patient has stopped since beginning of August 2012 (Figure 8). Although there is a dip in 2010 this reflects pumps from that year that were commenced at the beginning of the financial year which have been counted in 2011 rather then 2010.

By the end of the financial 2013 we will have 22 under the age of 18 on pump therapy (29%). Currently children under the age of 16 fall under paediatric care while those above 16 becomes part of the adult service and attend the adolescent clinic. There are 7 children in transition from the paediatric to adult service for 2012 of which 3 are on pump therapy. The diabetes MCN has an integrated pump service for both paediatric and adults and this is the model aspired to by the National MCNs.

Within our service we have 2 days of nursing time allocated. However with increasing numbers of patients receiving pump therapy year on year (total number projected numbers on pump therapy by end of financial year 2013 is 67) in order to maintain the high quality of service we currently delivery further investment in staffing will be required.

Figure 8 Total number of patients on Pump therapy (Nov 2012)

Total number of patients on insulin pumps

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Table 6 Pump Provision in Scotland (2009 – 2010)

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2011 Ayrshire & Arran 2,238 18 0.80% 2,217 35 1.6%

Borders 601 29 4.80% 621 51 8.2% Dumfries & Galloway 888 20 2.30% 900 23 2.6%

Fife 1,911 113 5.90% 1,976 132 6.7% Forth Valley 1,568 40 2.60% 1,618 45 2.8% Grampian 3,045 63 2.10% 3,042 72 2.4% Greater Glasgow & Clyde

6,115 67 1.10% 6,195 95 1.5%

Highland 1,706 18 1.10% 1,773 29 1.6% Lanarkshire 3,480 45 1.30% 3,533 56 1.6% Lothian 4,109 173 4.20% 4,184 208 5.0% Orkney 116 3 2.60% 120 5 4.2% Shetland 119 2 1.70% 123 2 1.6% Tayside 1,837 104 5.70% 1,866 130 7.0% Western Isles 177 1 0.60% 178 1 0.6% Scotland 27,910 696 2.50% 28,346 884 3.1%

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Diabetes in Pregnancy Service

In March 2010 SIGN 116 (guidance on the management of diabetes and diabetes complications) was published. Incorporated in this guidance was the revised diagnostic criteria for Gestational Diabetes (Diabetes occurring in pregnancy, GDM). Concerns were raised at the workshops in relation to the revised guidance as the threshold for diagnosis was reducing and likely to increase the number of patients with GDM which would result in an increase on both Obstetric and Diabetes services.

The new guidance was adopted by NHS Borders in July 2010 and all relevant staff was educated on revised guidance and protocols designed. The threshold for diagnosis of GDM post 2010 was largely based on fasting glucose values (80%) and the numbers attending the joint obstetric/diabetic clinic almost trebled with implications for diabetes specialist nurse, dietetic and medical input as well as obstetric care. Figure 9 demonstrates the increase in percentage of patients diagnosed with GDM based on fasting glucose (Figure 9a) and 2 hour glucose (Figure9b). There is an increased incidence of obstetric complications as a result but this may be explained by the increased surveillance by the clinicians. An increase in larger babies were noted but interestingly interventional delivery rates have improved which could potentially be due to optimised management of these women (Figures 10a and 10b). (Appendix 4), Audit presented November 2012 Edinburgh Obstetrical Society)

The diabetes service has a team input to this clinic including a consultant, a specialist nurse also obstetrically trained and a specialist dietician. In 2012 we have had 2 successful pregnancy outcomes on pump therapy.

Figure 9

Percentage of those diagnosed with GDM based on fasting and 2 hour glucose (Oral Glucose Tolerance Test)

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Figure 10 Obstetric and Medical Complications

(a) Obstetric complications (b) medical complications

Surgical Services

It is well recognised that good glycaemia control prior to surgical intervention improves surgical outcomes and reduces length of stay in hospital. In order to improve the management of patients with diabetes going to surgery that have diabetes the diabetes team in conjunction with the anaesthetic service developed a pathway which outlines how to manage individuals with diabetes pre and post surgery (Surgical ICP, Appendix 5).

Initial analysis of the data from 2010-11 demonstrated that 65-95% of patients were achieving the target (Figure 11). Following the appointment of the full time inpatient specialist nurse in 2011, part of whose remit was to increase awareness of the pathway, analysis for this period (2012-12) shows more consistent results with 80-100% achieving the required target (Figure 12). The reduced numbers in January is related to a data collection problem and we are currently investigating this.

In August 2012 an awareness campaign was held by Dr Heather Matthews with the Diabetes inpatient specialist nurse to promote the use of the pathway with excellent attendance. In addition ward education and education of Foundation doctors was provided during this session which has resulted in an increase use of the pathway and currently being audited. This is of paramount to patient safety and is under the remit of our inpatient diabetes specialist nurse.

Pre-assessment clinic

In order to try and approve Glycaemic control in advance of elective surgical procedures the inpatient specialist nurse engaged with the pre-assessment clinic to refer patients directly to her who required improveme9874723205nt of control in advance of surgery. The inpatient DSN also devised a poster campaign to encourage patients waiting elective surgery to self refer to our service for assistance in improving control. Posters were placed in surgeries, in OPD and in pre-assessment.

Figure11 Percentage surgical diabetic patients achieving BM Target 2010-11

% of diabetic patients with BM < or = 11mmol/l in Recovery(March 2010 to October 2011)

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Figure 12 Percentage surgical diabetic patients achieving BM Target 2011-12

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Diabetes MCN WEB Page

In 2009 the MCN WEB page was launched on World Diabetes Day. The site contacts information relating to service provision and important information for patients and professional. It also has links to important WEB sites where further information can be obtained if required. While it has been used the site has not had as many hits as we would like so a further piece of work is required to make patients, patient carers and professionals more aware.

BM Strip Usage And Change Over

It is recognised nationally that BM strips prescribing is costly. For example the period April to Aug 2011 the cost of BM strips alone was £451,932. This has been addressed not only by rationalising current BM strip use by issuing guidance to practices but also in October 2011 the diabetes MCN met with National procurement to try and address this issue. A local tender process was set up under their guidance and a company chosen to provide meters and strips for a period of one year in the first instance to determine if savings could be made. The MCN in conjunction with the prescribing support team set up a project in the community to address the changeover. It was agreed that all patients with type 2 diabetes would be changed to the new meter and strips. Embedded in this project is section dealing with educating practice and patients on the appropriate use of strips based on NHS Borders BM policy. In addition we have also been collecting feedback from patients. This project is scheduled for completion in October 2012 and we hope to have further information available later in the year.

Figure 13: Glucose strip prescribing 2011-12

NHS BORDERS PRIMARY CARE PRESCRIBING OF BLOOD GLUCOSE STRIPS BY COST - TREND FROM Q1 AND Q2 2011-12 TO Q1 AND Q2 2012-13

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Podiatry

In 2009 the Scottish Diabetes Framework produced a nine point action plan of which achieving a foot risk stratification score for patients with diabetes was one of the action points. The difficulty within NHS Borders is that many patients were based in primary care and the foot risk screening tool was on SCI-DC Network which required the primary care staff to complete a double data entry system until the problem could be solved nationally. Therefore as par of our first SES in 2010 foot risk stratification was built into the requirements and together with our primary care team we have achieved the required target of 85% and above and continue to do so (figure 14).

In 2010 an audit was presented to the National Diabetes Conference (winner of best secondary care poster)which demonstrated a dramatic 75% reduction in the amputation rate between 2000 and 2009 falling from 4.1/1000 to 1.1/1000 in 2009 (Appendix 6). The developments within the service including a specialist podiatrist, independent prescribing and the use of Larvae therapy are positive changes within the service that reflect the improvement of care and outcomes. The continued improvement in amputation rates is seen in the recent survey as NHS Borders has one of the lowest amputation rates in type 1 and type 2 diabetes (Appendix 7).

The management of diabetic foot ulcers is an integral part of the diabetes service. Immobilisation of the affected limb has bee shown too beneficial in promoting healing. With increasing number of patients requiring immobilisation the pressure on the plastering service in A/E became apparent. In 2010 the diabetes specialist podiatrist obtained funding to attend a soft casting course so the service could provide our own plastering for immobilising. This has been very successful and we no longer require input from the A/E department. Further development of this service was supported by the successful grant application to SDG (Scottish Diabetes Group) in 2011-12 and 2012-13. This has funded the expansion of this service to the community and to care of the elderly to alleviate, prevent and treat pressure areas. This project is the first of its kind within Scotland and has now received National recognition and the hope is that other boards will adopt the process. The podiatrist has made a DVD to assist with this roll out.

Figure 14 Percentage of patients with foot risk stratification

Patients foot risk stratified by practice - snapshot 24/02/12

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Structured Education Programme in Primary Care

Obesity

It is widely accepted that the increase in type 2 diabetes is related to the rising levels of obesity. In the most recent Scottish Diabetes survey the percentage of patients with type 2 diabetes in the different categories of BMI reflect the national average (overweight 32%, obese 30%, severely obese 15% and morbidly obese 10%). However, NHS Borders has the highest percentage of patients (overweight 40%, obese 16.7%, severely obese 8.3% and morbidly obese 4.6%) with type 1 diabetes in the morbidly obese category compared to the Scottish average (4.6 vs. 2.6%).

The availability of the Weight Management Team to review, support and if necessary refer for bariatric surgery will be an essential to tackle this major problem. The only patient in 2001 to come off insulin treatment and achieve normoglycemia was due to surgical intervention.

In 2011 all health boards were required to identify an education coordinator in diabetes. A further requirement was the provision of structured education. We needed to set up Structured Education for Type 2 diabetes. One of our specialist dieticians was identified to take this forward. We have bought into a quality-assured package called ‘DESMOND’- which stands for ‘Diabetes Education and Self-Management for Ongoing and Newly-diagnosed Diabetes’. She identified staff to deliver this programme and arranged training- which has just been completed. We are now offering this programme to all those newly-diagnosed with Type 2 diabetes-with the aim of offering to those who have had diabetes longer-in the future.

As part of our SES GP practices were asked for permission to interrogate their lists to identify newly diagnosed patients with type 2 diabetes who require this education based on the current action plan criteria. The first cohort of patients for education was completed in October 2012 and verbal feedback was very positive. This initiative has the potential to reduce the work load of the community dietetic staff and ensure that all newly diagnosed patients are seen by the dietetic service. The aim is to empower patients to self manage (Appendix 8). Studies have shown that 1 DESMOND session (i.e. 6 hours) = 3 years of self-empowerment and is very cost-effective-as well as successful in reducing HbA1c, reducing weight and increasing physical activity, as well as increasing quality of life.

Community Projects

In conjunction with Scottish Borders council we are currently setting up a pilot exercise project for patient with type 2 diabetes. This will involve individual exercise programmes and cookery classes (appendix 9). If this project is successful we hope to expand it to the wider community.

Scottish Diabetes Survey

This year for the first time all health boards received an individual report of performance against other health boards (Appendix 7). The prevalence in NHS Borders is 4.9% and age adjusted is 4.2% which is higher then overall Scottish prevalence. The main issues were relating to:

Low recording of HbA1C

This was a data capture problem at the time of extraction. Previous HbA1C recording for NHS Borders has been in excess of 90%. A snapshot was undertaken on the 20/8/12 and the recoding of HbA1C for both type 1 and type 2 patients for the previous 15 months was in excess of 90%.

Non recording of Microalbuminuria in patients with type 2 diabetes

The low percentage of testing for Microalbuminuria in type 2 diabetics in 2011 and before has been because the local laboratory has not provided nor been funded to provide ACR testing. We were aware that this situation was not in line with SIGN guidelines 103 and 116 and therefore in 2011/12 there was a thorough review of the costs and benefits of ACR screening and treatment in type 2 diabetes, alongside PCR screening in those with chronic kidney disease (CKD).

Costs of testing and treatment were combined with estimated population benefits to derive cost effectiveness estimates. This clearly demonstrated that PCR screening and treatment of the CKD population was relatively cost effective and that ACR screening and treatment of Microalbuminuria in type 2 diabetics was far less cost effective.

PCR screening and treatment of patients with CKD, both diabetic and non-diabetic, BEGAN IN October 2012, but there are no plans to start routine ACR screening.

In the meanwhile we note the high levels of eGFR measurement in the type 2 diabetic population locally, over 94%, which will help to identify those with CKD who will then receive annual PCR screening and appropriate treatment to minimise disease progression.

Poor Glycaemic control in patients with type 1 diabetes

There are a number of projects pending for the next financial year to address this issue. Specifically we hope to look at methods of engaging vulnerable adults, addressing non attendees, considering the role of telemedicine and increasing number of patients on pump therapy in line with national targets.

Target BP

We suspect that we are achieving less then the national target for BP targets due to non recording of primary care readings, the use of home monitoring and 24 hour BP monitoring. SCI Diabetes will hopefully address this as there is a section to record this data and additional the back feed from SCIDC to EMISS will help. Furthermore we plan to target BP as part of our community project interventions in the next financial year.

Back population of GP systems to SCI-SD

In 2011-12 the GP in NHS Borders changed their database system to EMISS. This delayed the back population initially. In 2012 back population was commenced but subsequently halted as there were data extraction issues. These have now been resolved and the project is underway with all practices bar one signed up.

Diabetes Team National Involvement

• Dr Leslie was involved in the development of the SIGN 116 guidance on retinopathy and

is a member of the national Inpatient Diabetes subgroup.

• Dr Roddy Campbell was involved in the development of the Obstetric guidance for SIGN

116.

• Mrs Morag Low was appointed as the Scottish Government Action plan coordinator in

2011.

• Dr Olive Herlihy has been involved in the development of the National diabetes data

base SCI Diabetes and more recently in the National Diabetes prescribing strategy.

• The team has published on amputation rates, inpatient audit and a review of the

performance of Oral Glucose tolerance tests in primary care (Appendix 10).

• Amy Simmonds local DESMOND co-ordinator involved in National DESMOND

programmes.

• Pump Service recognised by Scottish Health Minister as an example of best practice in

CEL 2012 04 (Appendix 3).

• The paediatric specialist nurse Sandra Robertson was nominated for Nurse of the Year by

families of paediatric patients in the Borders.

• Mr Adam Smith has a publication pending in the Journal of wound care in January 2013

titled, ‘Economic Analysis of Soft Heel Casting for Diabetic Foot Ulcer: Prevention and

Treatment in NHS Borders (Appendix 11).

Future Service Developments

Continue development of specialist nurse in primary care.

• Structured Education programme Type 1 and Type 2.

• Role of non nursing staff in insulin administration.

• Injectable therapies

• Vulnerable adult groups.

• Foot Risk Screening.

• Study day GPs.

• TiME Teaching.

Pump service

• Pump Clinics.

• Transitional care clinics.

• Group starts.

Adolescent service

• Review nurse role, same nurse from paediatrics through transition.

• Hand over clinics.

In patient service

• Education in management of hypoglycaemia.

• Safer use of insulin.

• Pre assessment clinic.

• Education ward staff.

Outpatient services

• Dedicated multidisciplinary area

• Managing increasing obstetric work load

Unmet need

• Psychology services

• Weight management team specific to meet needs of patients with diabetes

Appendix

1. Demand Vs Capacity

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2a. Inpatient Audit

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2b. Inpatient Audit Poster

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3. Insulin Pump

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4. Gestational Diabetes Audit

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5. Integrated care pathway

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6. Amputation Poster

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7. Diabetes Survey

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8. Desmond Project

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9. Exercise Programme

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10. OGTT Paper (Practical Diabetes)

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11. Soft Cast Paper

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