Inquiry into National Service Framework for diabetes in Wales and its future direction – progress update from the Welsh Government (September 2014)

Following the publication of the Inquiry into National Service Framework for diabetes in Wales and its future direction (June 2013), I and my officials considered the report’s recommendations as part of the consultation on the development of the Welsh Government’s Diabetes Delivery Plan, which was launched in September 2013. A number of the recommendations from the report were included in the Diabetes Delivery Plan which is only in the first year of implementation; it will take time to deliver all of the actions set out in the plan. I have committed to provide annual reports on progress with the first report due by the end of the year. The Committee’s request for an update at this point in the implementation has meant that only some initial high level progress can be reported in some aspects of the Delivery Plan.

Diabetes Delivery Plan

The Diabetes Delivery Plan was launched in September 2013, and the majority of the recommendations from the Inquiry were included within the Plan. In October 2013, the NHS Wales Diabetes Implementation Group was established to give strategic leadership on the implementation of the Delivery Plan across Wales.

Following a stakeholder group exercise, the Implementation Group set its priorities for its first year. Their priorities are focussed on four specific areas: improving care for children with diabetes; preventing diabetes in our population; making our services as effective as possible; and helping people manage their care. Under these work streams, a number of specific areas of activity were identified that should be taken forward, either in the first year, or through the whole period of the Plan. Some of the specific areas include: the development of a paediatric diabetes network and implementation of paediatric diabetes unit peer assessment programme (both of which are under way); delivery of a diabetes patient management system; developing a whole patient pathway for foot care; and developing proposals for effective delivery of diabetes structured education. The Diabetes Implementation Group is also working with the Heart Disease Implementation Group on risk identification across both disease areas. The Implementation Groups priorities will be finalised at their meeting at the end of September 2014. In finalising their first year recommendations in September, it will allow health boards to give them due consideration as part of their annual planning cycle and enable them to include them in next year’s work programme.

All health boards have produced local diabetes delivery plans, which have taken into account the all Wales strategic priorities as set out by the Diabetes Implementation Group. They have also included the key outcomes from their local plans within their integrated three plans, to ensure that they are part of the overall strategic direction for their health board.

A generic monitoring process has now been established for all of the Welsh Government’s delivery plans. For diabetes, this requires health boards to submit data on progress against their plan by the end of October 2013. This data, alongside the other data sources such as the Diabetes National Clinical Audit, will form the basis of an annual report on progress against the Diabetes Delivery Plan, which will be published by the end of this year. In addition, health boards will publish their individual progress reports on their websites, and all Diabetes National Clinical Audit reports will publish data at local health board level. Through this process, the Welsh public will be able to assess the performance of diabetes services in Wales, both at a national and local level.

Welsh Government’s update against the recommendations set out in the HSC Committee’s report on their Inquiry into National Service Framework for diabetes in Wales and its future direction – September 2014

Report Recommendations	Welsh Government response – August 2013	Welsh Government update – September 2014
Recommendation 1 We recommend that the Welsh Government should ensure implementation of the National Service Framework through strengthened oversight and monitoring arrangements, as a priority in the forthcoming delivery plan. We believe this should include a national leadership post to coordinate health boards‘ progress in delivering the NSF, and to facilitate the sharing of experiences and good practice between health boards.	Response: Accept The Welsh Government remains committed to the implementation of the 12 standards set out in the National Service Framework for Diabetes in Wales (NSF) and the Diabetes Delivery Plan will include as a priority the development of effective oversight and monitoring arrangements. My officials will work with the Local Health Boards (LHBs), the Diabetes Delivery Plan Implementation Group and the Diabetes National Specialist Advisory Group (NSAG) to develop robust and effective monitoring arrangements both for the implementation of the plan the continued establishment of the NSF standards. A national diabetes clinical lead role will be developed to support both the delivery of the plan and to support Local Health Boards in the continued implementation of the NSF standards. The national lead will need to work closely with the Implementation Group to facilitate the sharing of experiences and best practice between LHBs.	A standardised monitoring arrangement has been developed by the Welsh Government for all the Delivery Plans, including the Diabetes Delivery Plan. Local health boards are required to provide an update on progress in delivering their local plans, and additional data from the various strands of the Diabetes National Clinical Audit data are utilised as part of the monitoring process. Audit data are now available across all audits at local health board level. Data collection for the first year monitoring of the Plan will be concluded by the end of October 2014, with an all Wales annual report being published by the end of the year. A national diabetes clinical lead role has been developed, and Dr Julia Platts has been appointed. Details of her appointment were sent to the Chair of the Health and Social Care Committee in July 2014.
Recommendation 2 We welcome the forthcoming delivery plan for diabetes, and recommend that the Welsh Government commits to taking appropriate action should health boards fail to deliver the services outlined in the plan.	Response: Accept The implementation of the Diabetes Delivery Plan falls to the NHS in Wales and at a local level to each individual LHB. In addition to monitoring progress, the Welsh Government and the Implementation Group will support LHBs through identifying opportunities for actions at an all Wales level and through facilitating the sharing of best practice through peer review. The Diabetes Delivery Plan will require each LHB to produce a local delivery plan to address progress against the plan, as well as continued implementation of the Diabetes NSF standards. LHBs will be held to account on their progress by the Welsh Government as well as by the local populations that they serve, and to facilitate this public accountability LHBs will be required to publish details of their progress on their websites. Appropriate action will be taken to challenge health boards which fail to deliver the services outlined in the Delivery Plan.	Following the launch of the Diabetes Delivery Plan in September 2013, all health boards produced their own local plans. These local delivery plans have taken into account the Diabetes Implementation Group’s priorities in their development, and outcomes have been included in all of the health boards’ three year integrated plans. The first monitoring cycle for local delivery plans is currently underway, with health boards required to submit data to the Welsh Government by the end of October 2014. Health boards will also publish their local data on their own web sites, and the Welsh Government will use the data to publish the first annual report on the Diabetes delivery Plan by the end of this year.
Recommendation 3 We recommend that the forthcoming delivery plan should include a requirement for all GP practices to participate in the National Diabetes Audit.	Response: Accept in principle Participation in the National Diabetes Audit (NDA) has been a crucial tool in developing improved diabetes services in Wales and continued, full participation will be a priority in the Diabetes Delivery Plan. Welsh GP participation in the Adult NDA has improved to over 80%, from about 50%, in the latest audit round, and the Diabetes Delivery Plan will instruct LHBs to continue to build on this improvement. It is the clear expectation of the Welsh Government that GP practices in Wales should participate fully in the National Diabetes Audit.	The Diabetes Delivery Plan did put a clear expectation on health boards to fully participate in all strands of the Diabetes National Clinical Audit programme. Data has now been collected for the core diabetes audit, which includes GP data. The first report from the core audit, Care Processes and Treatment Targets, is due to be published in October. Once published, the Welsh Government will assess the participation rate from GPs in Wales, and consider whether any action is required.
Recommendation 4 We recommend that the Welsh Government‘s delivery plan should require that all diabetes patients are offered all 9 key annual health checks, and that health boards‘ performance in meeting this requirement should be monitored through full participation in the National Diabetes Audit.	Response: Accept The Delivery Plan will have as a key priority that all patients are offered all 9 key annual health checks. These health checks are established indicators under the Quality and Outcomes Framework (QOF) as well as being monitored as part of the National Diabetes Audit (NDA). The NDA is currently working to ensure that the QOF and NDA measures are aligned, which would allow the monitoring of this to be conducted using either of these processes. As part of their work, the Implementation Group will consider the most appropriate way forward to ensuring compliance with the Delivery Plan, which will include the optimal approach towards monitoring progress. Full participation in the NDA will be a priority under the Diabetes Delivery Plan.	The Delivery Plan includes an action that all patients are offered all 9 key annual health checks. These checks should be part of routine care offered within primary care. Progress on the delivery of this action will be included in the annual report on the Diabetes Delivery Plan. The Diabetes National Clinical Audit also includes the uptake of this as part of their report on ‘Care Processes and Treatment Targets’, due to be published in October. Following discussions with the audit team, it was agreed that data from this audit report will also be published online at local health board level, so that local users are able to assess the performance of their health board.
Recommendation 5 We recommend that the forthcoming diabetes delivery plan should ensure that local Diabetes Planning and Delivery Groups‘ relationships with health boards are formalised. Health Boards should demonstrate how they take account of DPDG recommendations and fully engage with their work. Arrangements should be put in place to adopt a national approach for DPDGs, to include national terms of reference for their operation and a requirement to meet with each other to share best practice.	Response: Accept Each LHB has established a local DPDG as part of the implementation of the Diabetes NSF and these groups will be vital in assisting LHBs in the development of their updated local delivery plans; which need to take account of the needs of their local population. The Diabetes Delivery Plan will require LHBs to formalise their relationships with their DPDGs, and to include their DPDGs terms of reference (ToR) as part of their updated local plans. The Implementation Group will take forward a peer review approach to share best practice and DPDGs will be included in this process; including consideration of the development of a common set of ToR principles that all LHBs might adopt for their DPDGs.	All local health boards, with the exception of Powys tHB, have a DPDG that have been involved in the development of their local delivery plans. Powys tHB, as part of their consideration on how to support the delivery of all the Welsh Government Delivery Plans, have concluded that they will move to a locality based approach as the best method to deliver at a local level, linked to their three GP areas. The Chair of the Implementation Group, with the agreement of all health board Chief Executives, has made a commitment to visit each health board DPDG, accompanied by the local Chief Executive. These visits will link the work of the Implementation Group with the local delivery groups, and also assess whether there are any issues with the function of DPDGs. Although, with Powys now moving to a different delivery model, a single generic ToR for DPDG would not now be applicable, the feedback from these visits will be considered by the Implementation Group and, if appropriate, recommendations on future DPDG structures issued to local health boards.
Recommendation 6 We recommend that the introduction of an integrated diabetes patient management system should be a priority for the Welsh Government. We note the commitment already made to introduce such a system, and recommend that a clear timetable for its introduction is included in the forthcoming diabetes delivery plan.	Response: Accept The development of an integrated diabetes patient management system will be important for long term improvements in health care outcomes for people with diabetes in Wales. The Diabetes Delivery Plan will have the development of such a system as a key strategic priority for the NHS in Wales. The development of a patient management system will fall to the NHS Wales Informatics Service and my officials will work with this agency to finalise a timetable for its implementation.	Following discussions between the Welsh and Scottish Governments, it was agreed that Wales would be able to use the Scottish diabetes patient management system as a basis for developing our own version. The Scottish Government has allowed us to use their system for free. NHS Wales Informatics Service (NWIS) have worked with their Scottish counterparts, and diabetes clinicians in Wales, to scope the project and the requirements for a Welsh system. The requirements and indicative timescales for the project were developed this spring, and an Outline Business Case (OBC) is currently being developed to gain final approval for the project. Although, the system was gifted from the Scottish Government, there will be costs associated with its development, implementation and future running. These will be fully costed in the OBC so that the Welsh Government and health boards are able to effectively plan for its Implementation.
Recommendation 7 We recommend that future public health campaigns on diabetes should reflect the need to raise awareness of the risk factors associated with – and the early symptoms of - diabetes.	Response: Accept Prevention and early detection of diabetes are clear priorities for this Government and will be included in the Diabetes Delivery Plan. Any future public health campaigns will need to include raising awareness of the risk factors associated with diabetes, and early symptoms of the disease. Also, public health campaigns linked to lifestyle behaviours need to stress the risks associated with such behaviour, such as the links between obesity and diabetes.	To support the current public health messages, ‘Add to Your Life’ was launched in April 2014.  It is a confidential and easy to use self-assessment, which can be undertaken on-line or, with support, over the telephone by NHS Direct Wales.  It provides an opportunity for people who are 50 or over to get an overall picture of their health, and will support them to improve their health and well-being in small achievable steps, as well as improving access to the most effective prevention services. The system includes risk assessment for diabetes, and advice on prevention and the disease’s link with lifestyle behaviours.  We also have our Change Life Wales campaign, which promotes and encourages people to adopt healthier lifestyles including a balance diet and more physical activity.
Recommendation 8 We recommend that the Welsh Government and health boards work together to expand the role of pharmacies in conducting risk assessments, to help improve early identification of people with diabetes. Pharmacies should also play a direct role in future public health campaigns. We believe the Welsh Government should specifically consider the value of including the HbA1c test for existing patients as an enhanced service as part of the Community Pharmacy Contractual Framework.	Response: Accept The early detection of diabetes will be a key theme of the Diabetes Delivery Plan and risk assessments have an important role to play. The Welsh Government will introduce an over 50s health checks programme to provide an online resource for people to assess their health and wellbeing. It will help identify risks to their health and provide advice on actions to reduce those risks and improve their health. It will also sign-post people to the most appropriate local support for changing lifestyle behaviours, and where appropriate direct them to seek advice from their GP, or other health professional. In addition, with regards to diabetes specific risk assessment, the Implementation Group will be tasked to look at all Wales solutions to this issue. They will bring forward recommendations on the most appropriate and effective way to deliver diabetes risk assessment to the people who need it; where they need it. A key factor in any such solution will be community pharmacies. Due to their close community links, pharmacies need to be considered in the development of any new public health campaigns. The Welsh Government will also task the Implementation Group to specifically consider the value of including HbA1c testing in pharmacies as part of their work on developing all Wales solutions to diabetes specific risk assessments.	The early detection of diabetes is a key theme of the Diabetes Delivery Plan. Through the development of the Welsh Government ‘Add to Your Life’ service, confidential diabetes risk assessment  are now available on line, or through NHS Wales Direct, to the over 50s. It is designed to support them to improve their health and well-being in small achievable steps, as well as improving access to the most effective prevention services. The role out of the service includes targeted community support in partnership with the Communities First programme, so that its effectiveness will be maximised in those communities that need it the most. Since Add to Your Life was rolled out nationally in April 2014, there have been more than 5,000 visits to the site, with nearly 3,000 completed assessments undertaken. As part of the Implementation Group’s first year they set up a working group to look at risk assessment. This work will continue in the second year of the group with a focus on developing clear recommendations on the development of appropriate risk assessment interventions, which use innovative models to target hard to reach groups. This work is also considering the appropriateness, and viability, of developing HbA1c testing as part of a suite of risk assessment interventions. Regarding diabetes risk assessments the last formal work on this was undertaken in September 2012.   The national community pharmacy “1 in 10” public health campaign,which was facilitated by Public Health Wales and delivered in partnership with Diabetes UK and the Stroke Association, ran in all 713 pharmacies in Wales in September 2012. More than 14000 people completed the questionnaires and were provided with information and advice on diabetes and stroke risk factors. Analysis of completed questionnaires revealed that 14.5% were at high risk of developing diabetes i.e. a one in three risk of developing Type 2 diabetes in the next 10 years. The Diabetes Implementation Group is also working with the Heart Disease Implementation Group on risk assessment, as the risk factors for the two disease groups have much in common.
Recommendation 9 We recommend that the Welsh Government should urgently address the variances in the provision of structured education for people with diabetes. The forthcoming delivery plan should require all health boards to provide NICE-compliant structured education programmes and ensure equality of access to appropriate, timely education for all patients across Wales.	Response: Accept Patient empowerment is crucial to improving health care outcomes for people with diabetes and education is a vital part of developing patient empowerment. The provision of NICE compliant diabetes structured education programmes will be a priority under the Diabetes Delivery Plan. The Quality and Outcomes Framework for 2013/14 has established an indicator for referral to a structured education programme within 9 months of entry onto the diabetes register and LHBs will need to ensure that programmes are available for people who are referred to them. In addition to people with newly diagnosed diabetes having access to NICE-compliant structured education, the Implementation Group will consider other ways of delivering effective education to people with diabetes through the most appropriate and effective channels. Every opportunity needs to be taken to educate the person with diabetes if we are to improve health care outcomes for this sector of the population.	The provision of NICE compliant structured education is a key objective of the Diabetes Delivery Plan. The provision of improved access to diabetes structured education has been a key work stream for the Implementation Group in its first year. They have assessed current capacity and delivery in all health boards, and will issue costed recommendations to all health boards following their meeting at the end of September 2014. This will allow health boards to act on the recommendations of the group within their annual planning cycle, and make any changes from the beginning of the next financial year. In addition to the Implementation Group’s work on structured education, they are also considering other options to deliver diabetes education in situations where structured education is either not appropriate, or for groups that have been identified as resistant to this model of education.
Recommendation 10 We believe that insulin pump therapy and the necessary accompanying education should be available to all suitable candidates to improve their quality of life. We recommend that the Welsh Government‘s forthcoming delivery plan include a requirement to improve the availability of education and training on the use of insulin pumps.	Response: Accept The Diabetes Delivery Plan will set out to achieve significant progress in patient access to intensive insulin therapy as there is evidence that such treatment reduces microvascular complications in type 1 and type 2 diabetes. Any provision should be evidence based and take account of patient choice, but the plan will set as a priority the provision insulin pump service in line with NICE guidelines.	The Diabetes Delivery Plan set out the expectation that health boards need to deliver insulin pump services in line with NICE guidelines. Insulin pump therapy is an area of work that the Implementation Group is considering as a priority for its second year.
Recommendation 11 We recommend that the ThinkGlucose programme should be introduced in all health boards across Wales.	Response: Accept in principle ThinkGlucose is a commercial product and the 1000 Lives Plus programme is currently considering options for the introduction of a similar, non-commercial, pan Wales programme. It will be the remit of the Implementation Group to consider all Wales solutions for improvements in diabetes health care, and one of its first tasks will be to consider the most appropriate programme to implement; whether that be ThinkGlucose or a Welsh developed programme under the auspices of 1000 Lives Plus. The effectiveness of ThinkGlucose has highlighted the benefits of introducing such a programme across all LHBs in Wales. Therefore, an appropriate programme should be introduced at the earliest opportunity.	The Diabetes Delivery Plan put an expectation on health boards to establish and continue a rolling healthcare professional education programme, e.g. ThinkGlucose. ThinkGlucose has now been established in two health boards, Cwm Taf and Hywel Dda. Depending on the progress of the other health boards in implementing a healthcare professional education programme, which will be assessed following submission of monitoring data in October, the Implementation Group will consider whether it would be more appropriate to develop all Wales options as one of its priorities for its second year of operation.
Recommendation 12 We recommend that the Welsh Government undertake an audit of the number of diabetes specialist nurses in post across Wales, and the proportion of their time spent on general duties. The Welsh Government should consider the merits of issuing guidance to health boards on recommended numbers of diabetes nurses per head of population.	Response: Accept Diabetes Specialist Nurses have a crucial role to play in delivering improved care to people with diabetes, both in the community and hospital, and an important facilitation role in the delivery of structured education. The availability of this resource will need to adequately reflect local needs in the development of LHBs’ local diabetes delivery plans. The Welsh Government will conduct an audit of diabetes specialist nurses in line with the recommendation and work with the Diabetes NSAG to consider the merits of issuing guidance to health boards.	The Welsh Government requested data from all health boards for an audit of Diabetes Specialist Nurses (DSN). In addition to numbers of staff, the audit requested data on training and other support activity to fully reflect the role, and position, of the DSN within their local context. All health boards have submitted data, and a draft report is being prepared that will assess the responses and issue recommendations. It is expected that the report will be published autumn 2014.
Recommendation 13 We recommend that the Welsh Government monitors the capacity of the Diabetic Retinopathy Screening Service to provide annual checks for diabetic patients as the growing prevalence of diabetes increases demand for the service.	Response: Accept Since its introduction, the Diabetic Retinopathy Screening Service has provided all-Wales screening to detect sight-threatening diabetic retinopathy at an early stage before visual loss occurs. The continued effectiveness of this service is key to improving treatment and care for people with diabetes. The capacity of the Diabetic Retinopathy Screening Service to provide annual checks will be part of the monitoring of the implementation of the Diabetes Delivery Plan. The Implementation Group will also consider how this resource can optimally deliver screening in the future whilst utilising the service’s data to improve research; with a view to delivering additional health outcomes.	The Welsh Government has worked closely with the Diabetic Retinopathy Screening Service for Wales over the last year to ensure continued effectiveness and to consider how the delivery of the service may be optimised in the future. An annual report on the service’s activity in financial year 2013/14 has been published, so that there is full transparency on their current activity and effectiveness. Data from this report will be included in the annual progress report for the Diabetes Delivery Plan, which will be published before the end of the year.  On the 17^th of September, the Welsh Government announced funding worth £561,000 to replace 34 Digital Retinal Cameras (DRC). Investment in the latest high-tech cameras which will enable the Diabetic Retinopathy Screening Service Wales to continue to detect damage to the retina caused by diabetes.  This will allow all people over the age of 12 who have been diagnosed with diabetes and registered with a GP in Wales to be referred and screened every year.