Diabet. Med. 28, 1494–1500 (2011)
The increasing prevalence of diabetes, the drive to develop community services for diabetes and the Quality and Outcomes Framework for diabetes have led to improvements in the management of diabetes in primary care settings, with services traditionally provided only in specialist care now provided for many patients with diabetes by non-specialists. Consequently, there is a need to redefine roles, responsibilities and components of a specialist diabetes service to provide for the needs of patients in the National Health Service (NHS) today. The delivery of diabetes care is complex and touches on almost every aspect of the health service. It is the responsibility of those working within commissioning and specialist provider roles to work together with people with diabetes to develop, organize and deliver a full range of integrated diabetes care services. The local delivery model agreed within the local diabetes network, comprising specialist teams, primary care teams, commissioners and people with diabetes, should determine how the diabetes specialist services are organizsed. It should identify the roles and responsibilities of provider organizations to ensure that the right person provides the right care, at the right time, and in the right place. We summarize a report entitled ‘Commissioning Diabetes Specialist Services for Adults with Diabetes’, which has been produced, as a ‘Task and Finish’ group activity within Diabetes UK, to assist managers, commissioners and healthcare professionals to provide advice on the structure, roles and components of specialist diabetes services for adults.
Policy context and need for this document
The number of people with diabetes is increasing because of an ageing population and rising levels of obesity. It is anticipated that, by 2025, more than 4 million people in the UK will have diabetes . This epidemic has been accompanied by a shift in health policy to bring diabetes care ‘closer to home’, with emphasis on increasing prevention, improving self-care, promoting self-management and improving access to care. The various national plans/frameworks and Quality Standards for diabetes in England, Northern Ireland, Scotland and Wales and the National Institute for Health and Clinical Excellence and Scottish Intercollegiate Guidelines Network guidelines set out standards of care for people with diabetes and recognize the increasing role of primary care in the provision of appropriately structured routine care and the need for local diabetes care to be delivered in an integrated manner, ideally driven by local Diabetes Networks [2–8].
The Equity and Excellence: Liberating the NHS Health White Paper represents a major reorganization of the National Health Service (NHS) in England and will result in the abolition of Primary Care Trusts (PCTs) and will place most of the NHS budget in the hands of general practice consortia that will be responsible for commissioning health services for the local population . One of the major concerns expressed about these reforms is the potential lack of knowledge and expertise that commissioners may have about the role of specialist care. This article summarizes a report which was produced by a Diabetes UK ‘Task and Finish’ Group. Representatives from the Council of Health Professionals of Diabetes UK, the Association of British Clinical Diabetologists, the Primary Care Diabetes Society, Royal College of Nursing, the National Nurse Consultant Group, Training, Research and Education for Nurses in Diabetes (TREND UK) and the Diabetes Nurses Forum were all involved in the development of the document and the report has been endorsed by all these organizations . The aim of the document was to act as a commissioning guide and it was produced to assist managers, commissioners and healthcare professionals to provide advice on the structure of specialist diabetes services for adults and deliver the right care, in the right place, and at the right time as part of an integrated diabetes service.
Organization of core components of diabetes care within an agreed local model of diabetes care
The core components of diabetes care should include prevention of diabetes, early identification and diagnosis of diabetes, education and care planning for patients, continued care planning and medicines review, risk factor identification and management, surveillance for complications, treatment of complications (including inpatient care), and appropriate individualized management of special groups (such as including children and young people, pregnant women with diabetes, frail and elderly people).
Successful planning, delivery and monitoring of all these core components within a whole system of care requires effectively functioning local diabetes networks and advisory/implementation groups (e.g. Local Diabetes Service Advisory Groups) to be in place. These should comprise healthcare professionals working in primary care, specialist care, commissioners, managers and people with diabetes. The local network/group should be responsible for developing a defined local integrated model of diabetes care and local care pathways, with roles and responsibilities clearly identified. This local model of care should aim to support people with diabetes to manage their own diabetes, working together with their healthcare team through education and care planning. Healthcare professionals working in primary, community, specialist and social care services have a responsibility to provide high-quality diabetes care to support people with diabetes to self-manage, within this agreed system of care. The model must ensure delivery of quality care that meets national standards and ought to have a high level input from commissioning organizations, clinical leadership from specialist teams and dedicated management support. Information technology (IT) systems should be in place to facilitate implementation of the integrated model of care and support ongoing clinical audit and service improvement [2–5,11].
The role of specialist diabetes teams within a whole healthcare system
Specialist diabetes teams are best commissioned to provide services in a complementary fashion to other parts of the healthcare system as part of an agreed whole systems model of care. Specialist diabetes teams will be multidisciplinary, usually comprising physicians, nurses, podiatrists, dietitians, pharmacists and clinical psychologists, all of whom should have received extensive training accredited at a national level. The roles of specialist diabetes teams include direct delivery of clinical outpatient and inpatient care, leadership and coordination across whole system diabetes care, provision of education and training, and research and innovation.
The role of specialist diabetes teams in delivery of outpatient care
Specialist diabetes teams should provide direct care for people with diabetes who have complex needs, such as those whose needs cannot be met within the skills and competencies of the primary teams, and those whose care requires liaison between the diabetes team and another speciality, such as obstetric teams, vascular teams or nephrology teams. Examples include:
- • people newly diagnosed with Type 1 diabetes or suspected to have Type 1 diabetes;
- • people requiring specialist education (such as carbohydrate counting);
- • children and adolescents with diabetes;
- • pregnant women and those planning a pregnancy;
- • patients with significant and ongoing cardiovascular or peripheral vascular disease;
- • young patients with Type 2 diabetes, diabetes of an undefined nature or rare genetic forms of diabetes;
- • patients who develop diabetes after pancreatitis or pancreatic surgery;
- • patients with active foot ulcers or uncontrolled neuropathic pain;
- • patients with diabetes and renal disease or retinopathy requiring active management or complex monitoring;
- • people whose risk factors for complications have been unsuccessfully controlled in primary care;
- • patients with recurrent hypoglycaemia and hypoglycaemia unawareness;
- • patients with neuropathy, especially autonomic neuropathy;
- • patients requiring assessment for novel treatments and technology for people with diabetes; for example, continuous subcutaneous insulin infusion, new forms of continuous glucose monitoring, bariatric surgery, islet cell transplantation and new therapies;
- • people with diabetes requiring specialist inpatient care.
Specialist outpatient care remains a common way of organizing the care requirements specified above. This may often be provided jointly with other disciplines, such as joint transitional clinics with paediatricians, joint antenatal clinics with obstetricians, joint renal clinics with nephrologists and joint high-risk diabetic foot clinics with orthopaedic or vascular surgeons. The full ‘Commissioning Specialist Diabetes Services for Adults with Diabetes’ document defines components and service specifications for many of these services, including diabetes pregnancy, diabetes transitional care, diabetes foot, diabetes ophthalmology and diabetes renal services .
The role of specialist diabetes teams in delivery of inpatient care
Admission to hospital can be a vulnerable and disempowering time for people with diabetes, as those who usually self-manage their condition may often find control of their diabetes handed over to inexperienced members of clinical teams who may manage patients around hospital regimes rather than the therapeutic and dietary needs of the individual patient . Most patients with diabetes are admitted for reasons not directly related to diabetes itself, some may be admitted for other medical emergencies and some for pre-, peri- and post-operative care for elective procedures or dialysis. However, even this group of patients have a longer length of stay and greater mortality that those without diabetes .
There is evidence that the presence of a specialist inpatient diabetes team shortens the length of a hospital stay, within medical as well as non-medical wards, and improves clinical outcomes and the patient experience. Therefore, this is a core role for the specialist inpatient diabetes team, which will normally comprise of a consultant diabetologist with an interest in inpatient care (and with dedicated sessions to inpatient care recognized in job plan) and adequate provision of diabetes inpatient specialist nurse (DISN) time. Inpatient teams also require access to a diabetes specialist podiatrist and a diabetes specialist dietitian. Specific roles for an inpatient diabetes team also include the development of an inpatient footcare team, with a consequent need for specialist expertise in this field within the inpatient diabetes team.
People with diabetes who are admitted with a complication related to diabetes (such as diabetic ketoacidosis or infected foot ulcer) should normally be admitted under the care of a specialist consultant diabetologist. However, this does not invariably happen and, in the initial stages of a hospital admission, such patients may be cared for in an emergency department or an admissions unit by non-specialist teams. The inpatient diabetes specialist care team has a key role in delivery of care for these patients by provision of speciality inreach and then directly assuming responsibility for management of these patients.
The other roles of the inpatient specialist diabetes team are to provide adequate and relevant education and training for hospital staff in the management of diabetes, provide direct expert clinical advice and support to other teams, lead in the development of guidelines and protocols (such as pre- and post-surgery, management of diabetes in acute coronary syndrome and discharge planning), act as an expert point of contact for people with diabetes in hospital, facilitate a reduction in the expected length of hospital stays (ensuring safe discharge into the community and arrangement of appropriate follow-up), play a role in setting standards with regular audit of quality outcomes and patient experience, and work with other healthcare professionals to reduce insulin and management errors
Many acute trusts still report that they do not have a specialist diabetes inpatient service. Commissioning and funding of appropriate posts will have a profound effect on improving the quality of inpatient diabetes care.
The role of specialist diabetes teams in the leadership and coordination across the whole system of diabetes care
As the local experts, specialist teams are best placed to advise commissioners, provide leadership and coordinate care for diabetes services within a locality. Specialists have a responsibility to support primary care staff in providing high-quality diabetes care in general practice, intermediate tier settings, residential/nursing care settings and amongst hard-to-reach groups (such as homeless people).
In some cases, specialist teams may be required to deliver clinics in community settings (such as within a general practitioners’ practice or in an intermediate tier service), and specialist expertise ought to be easily accessible to primary care teams in order to provide advice on management of individual patients—including the provision of e-mail/telephone advice to general practitioners and/or practice and community nurses. Other key contributions by specialist staff include drafting of diabetes clinical pathways and protocols, definition of referral criteria for specialist care and provision of support for general practice in the introduction of new therapies and treatment regimens. Specialists will also often have a leadership, coordinating, facilitating and delivery role for some of the population-wide services, such as provision of structured education or surveillance for complications; for example, retinopathy screening programmes
The role of specialist diabetes teams in education and training
Specialist teams may be based in hospitals or community settings, but have a key role in provision of education in all locations. They have a responsibility to help develop and maintain the skills of other care teams, including delivering training, accreditation, ongoing supervision, appraisal, governance and evaluation of competencies of all healthcare professionals providing both inpatient and community diabetes care.
The role of specialist diabetes services to research, innovation and development
Research in diabetes should not be restricted to specialist teams, with increasing amounts of high-quality research conducted in primary care and community settings. Nevertheless, the majority of research will continue to be initiated and conducted by specialists, particularly those projects in novel therapies and recruitment of patients to large-scale multi-centre studies. Specialist teams also play a pivotal role in innovation, particularly in translating current research into evidence-based practice, and thereby also assisting in development of new forms/models of delivery of care.
Components of a specialist diabetes team
Models of diabetes care may vary between localities, depending on the needs of the local population. Therefore, individual components, staffing requirements, facilities and resources of the specialist diabetes team will also vary. However, there remain some common core components that will usually define the presence of a specialist team.
Consultant diabetologists have specialist training and accreditation in diabetes, together with experience of the full range of the medical and multi-organ aspects of diabetes mellitus. They will be on the General Medical Council specialist register and the vast majority will also have also progressed through a structured training programme obtaining a certificate of completion of (specialist) training (CCST/CCT) or equivalent.
Their main roles are to provide leadership to multidisciplinary diabetes specialist teams and to deliver care to people with diabetes. They also provide expertise and advice and are ultimately responsible for the performance of the specialist care teams they lead.
The majority of consultant physicians with a specialist interest in diabetes are based in acute hospitals and also deliver general medicine in hospitals, alongside their general management and research and training roles. Many consultant diabetologists consider themselves to be in a ‘community’ position, with considerable involvement in the delivery of care within a given geographical area. However, an increasing number of community diabetes consultants are employed to deliver and coordinate services in a community setting only.
Diabetes specialist nurses
Diabetes specialist nurses (DSNs) should be registered nurses and have practised for a minimum of 3 years and have proven interests in diabetes management and teaching and counselling. They work wholly in diabetes care and may be employed in primary or secondary care, or in both. Diabetes specialist nurses who are new to their post are required to have undertaken a diabetes diploma and/or be working towards or have a related degree, as identified in the Department of Heath Agenda for Change Job profiles. Senior diabetes specialist nurses should have worked for a minimum of 3 years as a diabetes specialist nurse and are expected to be working towards, or already have, a master’s degree. The title of diabetes specialist nurse should only be used if the practitioner has the qualifications, skills and competencies aligned to the Knowledge and Skills Framework and specific diabetes competencies in the Career and Competency Framework for Nurses in Diabetes, and is also assessed annually against these .
The function of the diabetes specialist nurse has evolved over the years and diabetes specialist nurses now cover multiple roles, including provision of support for general diabetes care, patient education and enabling self-management, cardiovascular risk management, independent prescribing and multidisciplinary working in clinics for patients with specific complications (such as renal disease). Although diabetes specialist nurses will also have their own caseload of patients, they are usually members of multidisciplinary teams. They should work with the clinical and governance support of a consultant diabetologist, as recommended in the Royal College of Nursing report defining such roles.
Diabetes specialist dietitians
Diabetes specialist dieticians (DSDs) work as members of multidisciplinary teams across a variety of healthcare settings, including primary and specialist care. There are a number of essential and desirable criteria in the job descriptions of diabetes specialist dieticians, which include a Bachelor of Science (BSc) in nutrition and dietetics (4-year degree or equivalent), experience of working in a number of clinical areas of dietetics (including diabetes) for a minimum of 3–5 years, postgraduate study and ongoing professional development in diabetes, such as a Master of Science (MSc) in diabetes care, training in counselling skills and experience of research and audit.
Diabetes specialist dieticians are uniquely skilled to perform various roles, including taking a lead role in the development and delivery of structured patient education programmes and weight management services. Within a specialist care setting, diabetes specialist dieticians can also provide education on carbohydrate counting and may support dose adjustment of insulin in patients with Type 1 diabetes, and support complex nutritional care as required by patients who are enterally fed or have pancreatitis
Diabetes specialist podiatrists
Diabetes specialist podiatrists are core members of specialist multidisciplinary diabetes foot teams and will be registered with the Health Professions Council (HPC) and have a Bachelor of Science from a school of podiatry at a university. They work across a variety of healthcare settings, including primary and specialist care, and have a key role in provision of foot care for people with diabetes, including education, prevention and management of foot ulceration, pressure off-loading, supervison of larval therapies and minor podiatric surgery.
Diabetes specialist pharmacist
Despite no formal definition of the role, there are a number of practising diabetes specialist pharmacists, the vast majority of them employed in secondary care. Diabetes specialist pharmacists should hold a bachelor’s or master’s degree in pharmacy (for those who trained from 2002 onwards, the course should have a master’s degree of at least 4 years’ duration), have undertaken a pre-registration training programme for 1 year (those who commenced their pre-registration training after 30 June 1992 should have successfully passed the pre-registration examination) and hold a clinical pharmacy Master of Science, diploma or equivalent postgraduate qualification. Some diabetes specialist pharmacists have attained the title of consultant pharmacist, as identified in A Vision for Pharmacy in the New NHS .
As well as the appropriate formal qualifications, diabetes specialist pharmacists should have expertise and experience to fulfil a wide range of roles, including research, teaching, evaluating ongoing clinical trials, evaluating drug expenditure within the speciality of diabetes, participation in the writing of local guidelines for patients with diabetes, advising on the safe use of diabetes medicines and performing root-cause analyses of adverse events with diabetes medicines to contribute to the patient/medicine safety agenda.
General practitioners with a special interest in diabetes
For many localities, the development of an enhanced community-based service provision for diabetes has often relied on the development and support of a general practitioner with a special interest in diabetes (GPwSI). A GPwSI may form one part of multidisciplinary care, working alongside consultant specialists, diabetes specialist nurses, dietitians, podiatrists and psychologists. It is a basic requirement that a GPwSI must have clinical and governance support from consultant specialist colleagues. The development of this role in England has standardized guidance that should be adhered to .
Components of a specialist diabetes service
The full Commissioning Specialist Diabetes Services for Adults with Diabete’ document comprehensively defines components and service specifications for many of the core specialist services . These are summarized below.
Specialist diabetic pregnancy service
National Institute of Health and Clinical Excellence (NICE) guidelines and Confidential Enquiry into Maternal and Child Health (CEMACH) reports both provide comprehensive guidance on the organizational and clinical issues in the management of diabetic pregnancy [17,18]. These define the various components needed for a multidisciplinary specialist diabetic pregnancy service. In particular, specialist pre-conception care should be accessible by all women with diabetes of childbearing age, and be provided in a variety of settings, and all pregnant women with diabetes must have access to a skilled team of specialist diabetes expertise and obstetric support. The role of the diabetes specialist pregnancy team should be to provide diabetes care in the pre-, peri- and post-natal stages, provide governance and service leadership, and lead development of diabetes pregnancy service.
Transitional/young person’s diabetes service
Transfer of care from paediatric to adult services is a sensitive time, and care should be individualized and planned around the personalized needs of each young person with diabetes and their family . Primary care teams generally do not deliver specialized diabetes care to children and young people, therefore transitional care will usually be organized and delivered by specialist teams. Local and regional components of a children and young people’s diabetes service should be commissioned, delivered and monitored to ensure delivery of a comprehensive service for young persons moving from paediatric to adult diabetes specialist services, as recommended in good practice guidance. Staff components in the delivery of transitional care should be in place to provide care and support to young people, link with partner services and put appropriate audit systems in place. Regional networks also need to be established to provide a route to support strategic development and service improvement of services for children and young people.
Diabetes renal service
Seamless integrated multi-specialty communication and management is an essential aspect of a diabetes renal service in order to implement practice advocated by clinical trials and guidance, provide early intervention to delay progression of renal disease to end-stage renal disease (ESRD) effectively, improve cardiovascular risk-factor profile and prepare patients for dialysis and support for those undergoing dialysis and education provision for staff on dialysis units.
Specialist assessment should be available to patients with, or at high risk of, renal disease, and a diabetes renal service should work closely with nephrology services to ensure effective communication and coordination of care. Diabetes nephrology services should have appropriately trained staff and systems in place to organize the service effectively and ensure rapid access for patients with deteriorating estimated glomerular filtration rate (eGFR) or worsening proteinuria.
Components of a specialist diabetic foot service
The National Minimum Skills Framework for Commissioning of Foot Care Services for People with Diabetes (2006) provides commissioning support for the development and audit of foot care services . Putting Feet First: Commissioning Specialist Services for the Management and Prevention of Diabetic Foot Disease in Hospitals, a Diabetes UK consensus document, defines standards and specifications for the management of active diabetic foot disease in both inpatient and outpatient specialist care . The components of a specialist diabetes foot service should include staff with a specialist interest in diabetes foot care, to appropriate facilities to deliver high-quality, effective and efficient care, and agreed protocols, rapid access and joint clinics and clear communications systems to support integration with the other elements of the diabetes care.
Intermediate diabetes service
In some localities, the drive to move the care of people with diabetes closer to home have resulted in the development of ‘intermediate diabetes care’ to provide elements of community-based specialist care. Staff may be employed by organizations delivering both community services and acute services. The intermediate diabetes service is best managed as one integrated service with unified clinical governance arrangements and with clinical leadership from a consultant diabetologist. Ideally, the same organization providing acute services should deliver and monitor the services provided by other parts of the local care model.
Specialist continuous subcutaneous insulin infusion service
National Institute of Health and Clinical Excellence guidance recommends that the use of continuous subcutaneous insulin infusion (CSII) should be recommended as an option for Type 1 diabetes for adults and children who are 12 years of age or older when either attempts to achieve target HbA1c levels with multiple daily insulin injections result in disabling hypoglycaemia or HbA1c levels have remained high on multiple daily injections (≥ 8.5%, DCCT-aligned or 69 mmol/mol, IFCC) despite a high level of care, including the use of long-acting insulin analogues, if appropriate . In children younger than 12 years old, it should be considered when multiple daily injections are considered to be impractical or inappropriate.
Numbers using this technology will increase in coming years, with the estimated uptake of insulin pumps for Type 1 diabetes being 10% in patients who are 12 years or older, and 25% in patients under 12 years old. Initiation and management of continuous subcutaneous insulin infusion should be considered an integral part of a Diabetes Specialist Service, and be delivered by a multidisciplinary specialist diabetes team trained in pump management. These teams should consist of staff with a special interest in insulin pump therapy with clinical, psychological and education expertise and other elements of care for people with diabetes.
Specialist diabetes psychological services
More than 40% of people with diabetes have elevated rates of depression and anxiety, and eating disorders. This has a negative impact on diabetes self-care and patients cite access to psychological and emotional support as the most commonly unmet need . Therefore, specialist diabetes psychological support is an essential part of integrated diabetes care. Professionals providing specialist psychological diabetes services may vary according to exact discipline (including counsellors, cognitive behavioural therapists, psychologists, liaison psychiatrists and psychotherapists). Although they may have no additional qualification, they should possess a range of skills to deliver psychological support to people with diabetes who have complex psychological needs associated with their diabetes. Key aspects of a psychological service include patient care, training and supervision of the wider diabetes team, research, audit and service development.
Specialist diabetes ophthalmology service
Retinal screening programmes in England, Scotland, Northern Ireland and Wales have been set up to identify sight-threatening diabetic retinopathy and reduce the risk of sight loss through early identification and effective treatment. Specialist eye services are necessary to treat and manage diagnosed sight-threatening retinopathy, with management of sight-threatening diabetic retinopathy accounting for a considerable workload in most ophthalmology departments. The Royal College of Ophthalmologists Delivery of Diabetic Eye Care Guidance (2009) recommends the service and organizational components of hospital eye services for management of sight-threatening diabetic retinopathy . These services require access to appropriate facilities and resources to deliver high-quality care, including leadership, trained staff, counselling and communication to integrate specialist eye services with retinal screening programmes. The organization of a specialist diabetes eye care service requires agreed guidelines, rapid access and access to treatment facilities.
Specialist diabetes services are a core part of integrated whole system diabetes care. Locally, the role of the specialist diabetes service should be defined and agreed within an approved model of care. World-class commissioning of diabetes services relies on commissioners having a knowledge and appreciation of the specialist care requirements of the local diabetes population and the aspects of specialist care that should be provided in order to deliver a complete diabetes service to this population. Providers should also be aware of the various components comprising diabetes specialist services to ensure that these standards are met in order to meet commissioning requirements and deliver high-quality diabetes care to patients.
Nothing to declare.
The document ‘Commissioning Specialist Services’ was developed by a ‘Task and Finish’ group of Diabetes UK, chaired by Professor J. Vora. Members of the group, other than the authors, who contributed to the preparation of the report included: John Dean, Felix Burden, Christopher Cheyette, June James, Margaret Guy, Martin Hadley-Brown, Patrick Sharp, Peter Winocour and Mike Sampson. The contributions of other colleagues who provided expertise in relation to specific services are also acknowleged.