commissioning guide diabetes prevention and risk ... · nhs diabetes information reader box review...
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CommissioningDiabetes Prevention andRisk Assessment Services
Supporting, Improving, Caring
July 2011
NHS Diabetes information Reader Box
Review Date 2013
Commissioning Diabetes Prevention and Risk Assessment Services
NHS Diabetes would like to thank Thoreya Swage who wrote this publication.
3
Page
Commissioning for Diabetes Prevention and Risk Assessment Services 5
Features of Diabetes Prevention and Risk Assessment Services 6
Diabetes Prevention and Risk Assessment Services Intervention Map 8
Contracting Framework for Diabetes Prevention and Risk Assessment Services 10
Standard Service Specification Template for Diabetes Prevention and Risk 22Assessment Services
Contents
5
Commissioning for Diabetes Preventionand Risk Assessment ServicesThe NHS Diabetes commissioning approach helps to deliver high quality integrated care through a three-stepprocess that ensures key elements needed to build an excellent diabetes service are in place. The approach issupported by a wide range of proven tools, resources and examples of shared learning.
Step 1 – involves understanding the local diabetespopulation health needs by developing a local HealthNeeds Assessment and setting up a steering groupwith key stakeholder involvement including a leadclinician, lead commissioner, lead diabetes nurse andlead service user
Step 2 – involves the development of a servicespecification to describe the model of care to becommissioned. This becomes the document on whichtenders may be issued.
Step 3 – involves monitoring the delivery of theservice specification by the provider and evaluatingthe performance of the service. Input from thesteering group with service user representation will bean important mechanism for monitoring the service aswell as patient surveys.
This commissioning guide has been developed byNHS Diabetes with key stakeholders including clinicaland social services professionals and patient groupsrepresented by Diabetes UK.
It is not designed to replace the Standard NHSContracts as many of the legal and contractualrequirements have already been identified in this setof documents. Rather, it is intended to form the basisof a discussion or development of diabetes preventionand risk assessment services between commissionersand providers from which a contract for services canthen be agreed.
This commissioning guide consists of:
• A description of the key features of goodprevention and risk assessment services
• A high level intervention map. This interventionmap describes the key high level actions orinterventions (both clinical and administrative)diabetes prevention and risk assessment servicesshould undertake in order to provide the mostefficient and effective care, from admission todischarge (or death) from the service.
It is not intended to be a care pathway or clinicalprotocol, rather it describes how a true ‘diabeteswithout walls’1 service should operate going acrossthe current sectors of health care.
The intervention map may describe current servicemodels or it may describe what should ideally beprovided by diabetes prevention and risk assessmentservices.
• A diabetes prevention and risk assessmentcontracting framework that brings together all thekey standards of quality and policy relating to thisaspect of care
• A template service specification for diabetesprevention and risk assessment services that formspart of schedule 2 part 1 / Module B, Section 1 ofthe Standard NHS Contract covering the keyheadings required of a specification. It isrecommended that the commissioner checks whichmandatory headings are required for each type ofcare as specified by the Standard NHS Contracts.
For further detail on how to approach thecommissioning of diabetes services please seehttp://www.diabetes.nhs.uk/commissioning_resource/
Step 2
Step 3
• Understanding your diabetes population health needs
• Implementing improved services and evaluation
• Understanding what you need to commission for an integrated service
Step 1
1 Commissioning Diabetes Without Walls , 2011, http://www.diabetes.nhs.uk/commissioning_resource/
6
High quality diabetes prevention and riskassessment services should:
• actively seek out those at risk of diabetes, e.g.through NHS Health Checks, assessingrecorded versus predicted prevalence ofdiabetes from primary care diabetes registers
• offer active intervention to people of all agesat risk of developing diabetes
• place emphasis on the prevention of type 2diabetes for all age groups through theprevention and reduction of the prevalence ofobesity in groups at increased risk ofdeveloping diabetes, e.g. minority ethniccommunities
• be developed in a co-ordinated way, taking fullaccount of the responsibilities of otheragencies in providing comprehensive careensuring people are at the centre of decisionsabout their care and support - ‘no decisionabout me without me’i.
• be commissioned jointly by health and socialcare based on a joint health needs assessmentwhich meets the specific needs of the localpopulation, using a holistic approach asdescribed by the generic model for themanagement of long term conditionsii
• be delivered in accordance with the standardsfor clinical practice for diabetes set by theNational Institute for Health and ClinicalExcellenceiii
• deliver the outcomes for diabetes asdetermined by the NHS Outcomes Frameworkiv
• take into account the emotional, psychologicaland mental wellbeing of the patientv
• take into account all diverse and personalneeds with respect to access to care
• ensure that services are responsive andaccessible to people with Learning Disabilitiesvi
• have effective clinical networks with clearclinical leadership across the boundaries ofcare which clearly identify the role andresponsibilities of each member of thediabetes healthcare team
• ensure that there are a wide range of optionsavailable to people at risk of developing tosupport self management and individualpreferences
• take into account services provided by socialcare and the voluntary sector
• provide patient/carer/family education ondiabetes and other lifestyle interventions
• provide education on diabetes prevention andrisk to other staff and organisations that maycome into contact with people at risk ofdeveloping diabetes
• have a capable and effective workforce thathas the appropriate training and updating andwhere the staff have the skills andcompetencies in the management of people atrisk of developing diabetes
• provide multidisciplinary care that managesthe transition between adult and olderpeoples’ services
Features of Diabetes Preventionand Risk Assessment Services
i Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
ii Available on the DH website at http://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_120915
iii http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp
iv Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
v Emotional and Psychological Support and Care in Diabetes, Joint Diabetes UK and NHS Diabetes Emotional and PsychologicalSupport Working Group, 2010, http://www.diabetes.nhs.uk/our_work_areas/emotional_and_psychological/http://www.diabetes.nhs.uk/ commissioning_resource/
vi http://www.diabetes.nhs.uk/ commissioning_resource/
7
vii http://www.diabetes.nhs.uk/year_of_care/it
viii http://www.ic.nhs.uk/proms
• have integrated information systems thatrecord individual needs including emotional,social, educational, economic and biomedicalinformation which permit multidisciplinary careacross service boundaries and support careplanningvii
• produce information on the outcomes ofdiabetes prevention and risk assessment careincluding contributing to national datacollections and audits
• have adequate governance arrangements, e.g.local mortality and morbidity meetings ondiabetes care to learn from errors and improvepatient safety
• take account of patient experience, includingPatient Reported Outcomes Measures, and theNHS Outcomes Framework, in thedevelopment and monitoring of servicedeliveryviii
• actively monitor the uptake of services,responding to non-attenders and monitoringcomplaints and untoward incidents
8
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Diabetes and Risk Prevention ServicesIntervention Map
9
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10
IntroductionThis contracting framework sets out what isrequired of clinically safe and effective services thatare providing diabetes prevention and riskassessment care. The framework is designed to beread in conjunction with the high level patientintervention map, which describes theinterventions and actions required along thepatient pathway as well as entry and exit pointsand the standard service specification template fordiabetes prevention and risk assessment services.
The framework brings together the key qualityareas and standards that have been identified byNHS Diabetes, Diabetes UK, the Royal Colleges andother related organisations.
The principles that establish a safepathway for patient care Establishing the principles that underpin thesystems and processes of pathways for patient careleads to more efficient patient throughput and canreduce risk of fragmentation of care and seriousuntoward incidents. The principles operate at fourlayers within a patient pathway:
• Commissioning
• Clinical Case Direction or the overall Care Plan(i.e. the management of an individual patient)
• Provision of the clinical service or process
• Organisational platform on which the clinicalservice or process sits (the provider organisation)
A straightforward or simple pathway is one inwhich the overall management including bothClinical Case Direction and the delivery of theclinical processes conventionally sits within oneorganisation. However, with a more complexpathway, there is a danger that fracturing theoverall management pathway into componentscarried out by different clinical teams andorganisations will require duplication of effortleading to inefficiency and increased risk athandover points.This can be managed byestablishing clear governance arrangements for allthe layers in the pathway.
In addition, Commissioning Bodies must balancethe benefits of fracturing the pathway againstincreased complexity and ensure that the increasedrisks are mitigated.
The governance arrangements required for allthree layers and the commissioner responsibilitiesare shown below:
Contracting Framework for DiabetesPrevention and Risk AssessmentServices
11
In essence, at each level, there are governancearrangements to ensure sound and safe systems ofdelivery of patient care with clear lines ofaccountability between each level.
The diabetes prevention and riskassessment serviceThe key principles of good diabetes prevention andrisk assessment service is to provide a high qualityservice that is reliable in terms of delivery and timelyaccess for patients requiring that care.
Diabetes prevention and risk assessment care isprovided by a number of different teams in theprimary, community and acute setting. It is essentialthat there is co-ordination of care of the patients andthat the General Practitioner retains responsibility foroverall patient care across the whole pathway andretains overall responsibility for the management ofany side effects and complications.
The initial advice and care of individuals at risk ofdeveloping diabetes should include an assessment oftheir emotional and psychological well-being,together with timely access to appropriatepsychological and biological/psychiatricinterventions. Mental health disorders can posesignificant barriers to subsequent diabetes care andtherefore mental health stability is vital for good selfcare and prevention1.
The services themselves will also have clinicaloversight and accountability for governancepurposes.
This contracting framework should also be read inconjunction with the diabetes commissioning guidesfor children and young people and older peopleand follow the principles for the effectivecommissioning of services for people with LearningDisabilities2.
Ensuring qualityCommissioning Bodies should ensure that thediabetes prevention and risk assessment servicescommissioned are of the highest quality. There may,in addition, be some organisations that wish to offertheir services, but do not have a history of providingsuch care. Commissioning Bodies should ensure:
i) for provider organisations already involved in thedelivery of diabetes prevention and riskassessment services, there should be retrospectiveevidence of systems being in place, implementedand working.
ii) for organisations new to the arena thecommissioner should reassure itself that theprovider has the organisational attributes,governance arrangements, systems and processesset up to provide the platform for safe andeffective delivery of diabetes prevention and riskassessment services to be provided.
This framework describes what theCommissioning Body needs to ensure is presentor addressed in its discussions with theprovider organisation.
Under the ‘elements’ column there are crossreferences to the Standard NHS Contract forCommunity Services – bilateral (main clauses andschedules)3. (The cross references also apply to theclauses and schedules in the Standard NHS Contractfor Acute Services).This is to assist commissionersand providers in having an overview of how theelements link to the Standard NHS Contract. Someof the areas are open to interpretation andconsequently the references are not exhaustive.
12
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13
ELEM
ENTS
CH
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SK
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AN
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acc
redi
ted
Qua
lity
Ass
uran
cesy
stem
and
inte
rnal
err
or re
port
ing
invo
lvin
gal
l sta
ff g
roup
s.
CG
sys
tem
s sh
ould
hav
e cl
ear a
ndde
mon
stra
ble
links
to o
ther
NH
S sy
stem
s w
ithco
llabo
rativ
e C
G a
ctiv
ities
and
sha
ring
ofex
perie
nce
and
lear
ning
Prov
ider
sho
uld
prod
uce
annu
al C
linic
alG
over
nanc
e re
port
s as
par
t of N
HS
CG
repo
rtin
g sy
stem
Prov
ider
s ar
e re
quire
d to
agr
ee C
omm
issio
ning
for Q
ualit
y an
d In
nova
tion
sche
mes
(CQ
UIN
)fo
r dia
bete
s ca
re, e
.g. m
odel
CQ
UIN
sch
eme
prop
osed
by
the
NH
S In
stitu
te fo
r Inn
ovat
ion
and
Impr
ovem
ent 9
In a
dditi
on, t
he s
ervi
ce is
req
uire
d to
com
ply
with
the
follo
win
g:
i. G
uida
nce
publ
ishe
d by
NIC
E
•Pr
even
ting
type
2 d
iabe
tes:
pop
ulat
ion
and
com
mun
ity-le
vel
inte
rven
tions
in h
igh-
risk
grou
ps a
nd t
he g
ener
al
popu
latio
n 6
•Ty
pe 2
dia
bete
s: p
reve
ntin
g th
e pr
ogre
ssio
n fr
om p
re-
diab
etes
to
type
2 d
iabe
tes
amon
g hi
gh r
isk
grou
ps (p
ublic
heal
th g
uida
nce)
exp
ecte
d pu
blic
atio
n M
ay 2
012
7
•M
edic
ines
adh
eren
ce: i
nvol
ving
pat
ient
s in
dec
isio
ns a
bout
pres
crib
ed m
edic
ines
and
sup
port
ing
adhe
renc
e 8
Clin
ical
qua
lity
Qua
lity
assu
ranc
e
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
C:
4,12
,16,
17,1
8,19
, 20,
21,3
1,32
,33,
54
Mod
ule
D:
Sche
dule
s:
2,3
,6,1
0,11
Mod
ule
E:
3,4
Und
erst
andi
ng th
e co
ncep
t of
clin
ical
qua
lity
Has
con
cern
for q
ualit
y w
hile
wor
king
eff
icie
ntly
An
unde
rsta
ndin
g of
the
use
ofau
dit,
patie
nt a
nd s
taff
feed
back
to im
prov
e qu
ality
An
orga
nisa
tion
that
pro
vide
scl
arity
of o
bjec
tives
and
pro
mot
esre
flect
ive
prac
tice
to im
prov
equ
ality
of p
atie
nt c
are
Qua
lity
assu
ranc
e sy
stem
s m
ust b
e in
pla
cean
d ap
prov
ed b
y co
mm
issio
ning
bod
y w
ithre
gula
r rep
ortin
g of
out
com
es
Prov
ider
s ar
e re
quire
d to
pub
lish
qual
ityac
coun
ts fo
r the
pub
lic re
port
ing
of q
ualit
yin
clud
ing
safe
ty, e
xper
ienc
e an
d ou
tcom
es
Prov
ider
s sh
ould
par
ticip
ate
in n
atio
nal a
udit
prog
ram
mes
Dia
bete
s pr
even
tion
and
risk
asse
ssm
ent s
ervi
ces
mus
t com
ply
with
the
follo
win
g ac
cess
targ
ets
10:
•In
divi
dual
s un
derg
oing
blo
od g
luco
se te
sts,
e.g
. as
part
of t
heN
HS
Hea
lth C
heck
s, w
ho a
re fo
und
to h
ave
resu
lts o
utsid
eno
rmal
par
amet
ers
shou
ld b
e re
ferr
ed to
and
see
n by
dia
bete
sdi
agno
sis a
nd c
ontin
uing
car
e se
rvic
es w
ithin
a w
eek
•Sy
mpt
omat
ic in
divi
dual
s un
derg
oing
blo
od g
luco
se te
sts
e.g.
as p
art o
f the
NH
S H
ealth
Che
cks,
who
are
foun
d to
hav
ere
sults
out
side
norm
al p
aram
eter
s sh
ould
be
refe
rred
and
see
nw
ithin
the
sam
e da
y•
Indi
vidu
als
who
are
vom
iting
sho
uld
be re
ferr
ed to
A&
Eim
med
iate
ly
The
serv
ice
is re
quire
d to
par
ticip
ate
in th
e fo
llow
ing
activ
ities
/pro
gram
mes
:
•Pa
tient
Exp
erie
nce
Surv
eys
11
•D
iabe
tes
E 12
TOPI
C
14
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Wor
kfor
ce/ s
taff
Clin
ical
sta
ff a
ttrib
utes
criti
cal t
o sa
fety
and
qual
ity o
f int
erve
ntio
ns
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
C:
11,1
6,19
,26,
33,4
8,56
Mod
ule
D:
Sche
dule
s:10
The
prov
ider
org
anisa
tion
has
syst
ems
and
proc
edur
es in
pla
ce to
assu
re th
e co
mm
issio
ner t
hat t
heir
clin
ical
team
has
the
nece
ssar
yqu
alifi
catio
ns, s
kills
, kno
wle
dge
and
expe
rienc
e to
del
iver
the
serv
ice
Staf
f ar
e co
mpe
tent
and
fit
for
purp
ose
Prov
ider
to
satis
fy c
omm
issi
oner
tha
t al
lst
aff
have
cur
rent
app
rais
al, c
lear
ance
s an
dre
gist
ratio
n ch
ecks
and
hav
e de
mon
stra
ted
com
pete
nce
in a
ll pr
oced
ures
rel
evan
t to
path
way
Prov
ider
to s
atisf
y co
mm
issio
ner t
hat t
hey
can
recr
uit (
or p
rocu
re)
and
reta
in a
com
pete
nt c
linic
al te
am to
del
iver
the
serv
ice
Spec
ific
qual
ifica
tions
requ
ired
of h
ealth
pro
fess
iona
ls pr
ovid
ing
the
serv
ice
are:
•Fo
r med
ical
pra
ctiti
oner
s: re
gist
ratio
n w
ith th
e G
MC
and
evid
ence
of f
urth
er q
ualif
icat
ion
in d
iabe
tes
care
or e
xper
ienc
ew
ithin
dia
bete
s cl
inic
13
•N
urse
s: re
gist
ratio
n w
ith th
e N
MC
and
furt
her e
vide
nce
ofqu
alifi
catio
n in
dia
bete
s ca
re o
r exp
erie
nce
with
in d
iabe
tes
clin
ic 14
•D
ietit
ians
: reg
istra
tion
with
the
HPC
and
abl
e to
dem
onst
rate
com
pete
nce
in d
eliv
erin
g ed
ucat
iona
l sup
port
All
heal
thca
re p
rofe
ssio
nals
invo
lved
in d
eliv
erin
g di
abet
espr
even
tion
and
risk
asse
ssm
ent c
are
are
requ
ired
to h
ave
the
follo
win
g re
leva
nt c
ompe
tenc
ies
(see
Ski
lls fo
r Hea
lth- D
iabe
tes
Com
pete
ncie
s fo
r dia
bete
s)15
Clin
ical
qua
lity
Wor
kfor
ce/ s
taff
Clin
ical
sta
ffco
mpe
tenc
ies
in u
se o
feq
uipm
ent
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mai
n cl
ause
s:11
, 16,
17,
19,
25,
26,
30, 3
3
The
prov
ider
org
anisa
tion
has
syst
ems
in p
lace
to a
ssur
e th
eco
mm
issio
ner t
hat t
heir
clin
ical
team
are
com
pete
nt to
use
all
equi
pmen
t nee
ded
to d
eliv
er th
ese
rvic
e
Prov
ider
to
satis
fy t
he c
omm
issi
oner
tha
t al
lst
aff
have
had
doc
umen
ted
com
pete
nce
asse
ssm
ent
rela
tive
to a
ll eq
uipm
ent
used
inco
ntra
ct
All
heal
thca
re p
rofe
ssio
nals
invo
lved
in d
eliv
erin
g di
abet
espr
even
tion
and
risk
asse
ssm
ent c
are
are
requ
ired
to h
ave
the
rele
vant
com
pete
ncie
s in
usin
g ap
prop
riate
equ
ipm
ent,
e.g.
blo
odgl
ucos
e an
d ke
tone
mon
itors
Clin
ical
qua
lity
Wor
kfor
ce /
staf
f
Dev
elop
men
t
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
t for
Com
mun
ity S
ervi
ces
Mod
ule
C:
11,1
6,19
,48
The
prov
ider
org
anisa
tion
has
syst
ems
in p
lace
to a
ssur
e th
eco
mm
issio
ner t
hat t
heir
clin
ical
team
is fo
rmal
ly in
duct
ed a
ndre
ceiv
es o
ngoi
ng a
ssis
tanc
e to
deve
lop
thei
r ski
lls, k
now
ledg
e an
dex
perie
nce
to e
nsur
e th
at th
ey a
real
way
s fu
lly u
pdat
ed
Prov
ider
to
satis
fy c
omm
issi
oner
of
thei
rco
mm
itmen
t to
indu
ctio
n an
d C
PD r
elev
ant
to r
oles
Prov
ider
to
satis
fy t
he c
omm
issi
oner
of
thei
rco
mm
itmen
t to
tra
in s
taff
to
mee
t fu
ture
serv
ice
need
s
15
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Regi
stra
tion
and
licen
sing
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
t for
Com
mun
ity S
ervi
ces
Mod
ule
B:
Sect
ions
:3,
5
Mod
ule
C:
4,4A
,5,9
,10,
11,1
2,14
,15,
1617
,18,
19,2
1,26
,27,
29,3
3,34
,35,
36,3
8, 4
0,43
,48,
49,5
2, 5
3,54
,56,
60
Mod
ule
D:
Sche
dule
s:
6,10
,11,
12,1
5
The
Prov
ider
is re
quire
d to
be
regi
ster
ed w
ith th
e C
are
Qua
lity
Com
miss
ion
to d
emon
stra
te th
atis
mee
ts th
e es
sent
ial s
tand
ards
of
qual
ity a
nd s
afet
y fo
r the
regu
late
dac
tiviti
es d
eliv
ered
.
The
Prov
ider
is re
quire
d to
be
licen
sed
with
the
NH
S Ec
onom
icRe
gula
tor (
Mon
itor)
in o
rder
topr
ovid
e N
HS
care
.
Com
plia
nce
with
the
Car
e Q
ualit
yC
omm
issi
on a
nd M
onito
r re
quire
men
tsC
ompl
ianc
e w
ith th
e fo
llow
ing
Nat
iona
l Ser
vice
Fra
mew
orks
,w
here
app
licab
le:
•C
oron
ary
Hea
rt D
iseas
e N
SF 16
•Th
e M
enta
l Hea
lth S
trat
egy17
Com
plia
nce
with
Car
e Q
ualit
y C
omm
issi
on R
evie
ws
Clin
ical
qua
lity
Out
com
es
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
t for
Com
mun
ity S
ervi
ces
Mod
ule
B:Se
ctio
n:1
(par
t 3),3
Mod
ule
C:
4A,1
4,
Mod
ule
D:
Sche
dule
11
Com
preh
ensiv
e un
ders
tand
ing
and
com
mitm
ent t
o de
liver
ing
and
impr
ovin
g ou
tcom
es o
f car
e
Com
plia
nce
with
the
NH
S O
utco
mes
Fram
ewor
k18
Clin
ical
qua
lity
Patie
nt p
athw
ay
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
t for
Com
mun
ity S
ervi
ces
Mod
ule
B:Se
ctio
ns:
1
Resp
onsi
vene
ss a
nd p
artic
ipat
ive
appr
oach
to in
clud
ing
patie
nts’
view
s ab
out t
heir
care
in th
ede
sign
of c
are
path
way
s
Col
labo
ratio
n w
ith o
ther
orga
nisa
tions
invo
lved
in th
epa
tient
pat
hway
to p
rovi
de a
seam
less
pat
hway
of c
are
All
poss
ible
ent
ry a
nd e
xit
poin
ts m
ust
bede
fined
with
com
preh
ensi
ve p
atie
ntpa
thw
ays
that
fac
ilita
te s
moo
th p
assa
gean
d ef
fect
ive,
eff
icie
nt c
are
for
patie
nts
All
inte
rfac
es in
the
pat
hway
mus
t be
defin
ed s
o th
at c
ontin
uity
of
care
is e
nsur
edw
ith n
o fr
actu
ring
of t
he p
athw
ay
The
path
way
of a
dia
bete
s an
d ris
k as
sess
men
t ser
vice
incl
udes
the
follo
win
g ac
tiviti
es:
i. Ra
isin
g aw
aren
ess
on h
ealth
y lif
esty
les
and
risk
fact
ors
for
diab
etes
ii. A
dvic
e on
hea
lthy
lifes
tyle
s an
d ris
k fa
ctor
s fo
r dia
bete
siii
. Ris
k as
sess
men
t/ s
cree
ning
for p
eopl
e at
hig
h ris
k of
dia
bete
s
iv. R
efer
ral t
o pr
even
tion
serv
ices
that
impr
ove
lifes
tyle
s/re
duce
risk
fact
ors
for d
iabe
tes
16
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Mod
ule
C:
4,4A
,9,1
0,12
,14,
15,1
6,17
,18,
19,2
0,21
,27,
29,
31, 3
3,34
,35,
36,3
8,40
,52
,54
Mod
ule
D:
Sche
dule
s:
2,3,
4, 9
,11,
17
Mod
ule
E:5
Ther
e m
ust
be s
peci
ficat
ion
of c
lear
timel
ines
and
ale
rt m
echa
nism
s fo
r po
tent
ial
brea
ches
Ther
e sh
ould
be
audi
t of
pat
hway
to
ensu
reth
at s
tand
ards
are
met
Ther
e m
ust
be e
xplic
it sp
ecifi
catio
n of
prov
ider
and
com
mis
sion
er r
espo
nsib
ilitie
sfo
r th
e w
hole
pat
ient
epi
sode
fro
m f
irst
cont
act
with
the
ser
vice
to
final
dis
char
ge
Acc
ount
abili
ties
shou
ld b
e ag
reed
and
docu
men
ted
by a
ll st
akeh
olde
rs
Ther
e ar
e a
num
ber o
f ser
vice
s su
ppor
ting
patie
nts
with
dia
bete
s an
d th
ere
mus
t be
clea
r sub
con
trac
ts s
tatin
g th
e re
ferr
al c
riter
iaan
d ac
cess
to th
ese
supp
ortin
g se
rvic
es.
At
entr
y to
pat
hway
:
The
Com
mis
sion
er s
houl
d as
sure
the
mse
lves
that
the
pro
vide
r ha
s sy
stem
s an
d pr
oces
ses
in p
lace
to
i) re
gist
er p
atie
nts
ii) c
olle
ct r
elev
ant
clin
ical
and
adm
inis
trat
ive
data
iii) m
anag
e th
e ap
poin
tmen
t pr
oces
s,(r
eapp
oint
men
t an
d D
NA
pro
cess
, if
appr
opria
te)
iv) p
rovi
de in
form
atio
n to
pat
ient
sv)
und
erta
ke in
itial
ass
essm
ent
in t
heap
prop
riate
loca
tion
At
poin
t of
inte
rven
tion:
The
Com
mis
sion
er s
houl
d as
sure
the
mse
lves
that
the
pro
vide
r ha
s sy
stem
s an
d pr
oces
ses
in p
lace
to
ensu
re t
hat:
i) th
e ad
vice
and
inte
rven
tion
is c
ondu
cted
safe
ly a
nd in
acc
orda
nce
with
acc
epte
dqu
ality
sta
ndar
ds a
nd g
ood
clin
ical
prac
tice.
v. R
efer
ral f
or in
vest
igat
ion
and
diag
nosis
of d
iabe
tes
Raisi
ng a
war
enes
s an
d ad
vice
: A
ctiv
ities
sho
uld
incl
ude:
•lo
cal c
ampa
igns
on
diab
etes
and
rela
ted
cond
ition
s, e
.g.
obes
ity 19
, CH
D e
tc•
supp
ort t
o na
tiona
l cam
paig
ns o
n di
abet
es a
nd re
late
dco
nditi
ons,
e.g
. cha
nge
for l
ife c
ampa
ign
20
•ta
rget
ing
spec
ific
popu
latio
ns, e
.g. A
sian,
obe
se, t
rave
llers
etc
•aw
aren
ess
rais
ing
in m
any
loca
tions
e.g
. sch
ools
, GP
prac
tices
,su
perm
arke
ts, s
port
s ce
ntre
s, p
harm
acie
s, L
TC c
entr
es,
pubs
/clu
bs, m
ater
nity
uni
ts, l
ocal
em
ploy
ers,
Car
e H
omes
,ce
ntre
s of
wor
ship
, for
peo
ple
with
lear
ning
dis
abili
ties
and
seve
re m
enta
l illn
ess,
pris
ons,
cha
ritie
s/ th
ird s
ecto
r pro
vide
rs
Risk
ass
essm
ent/
scr
eeni
ng:
•Th
ere
shou
ld b
e ag
reed
pro
toco
ls fo
r the
iden
tific
atio
nch
ildre
n, y
oung
peo
ple,
adu
lts a
nd o
lder
peo
ple
who
may
be
at ri
sk o
f dev
elop
ing
diab
etes
, e.g
. NH
S H
ealth
Che
cks
for 4
0 -
74 y
ear o
lds
10.
•Th
ere
shou
ld b
e ag
reed
pro
toco
ls fo
r the
scr
eeni
ng o
fpr
egna
nt w
omen
for g
esta
tiona
l dia
bete
s 2
•Th
ere
shou
ld b
e ag
reed
pro
toco
ls in
pla
ce to
scr
een
for
diab
etes
in N
ursin
g an
d C
are
Hom
es, i
nclu
ding
thos
e th
at c
are
for o
lder
peo
ple
with
men
tal h
ealth
con
ditio
ns, e
.g. d
emen
tia.2
•Th
ere
shou
ld b
e pr
otoc
ols
for t
he s
cree
ning
for d
iabe
tes
inol
der p
eopl
e th
at u
tilise
app
ropr
iate
met
hods
for t
his
popu
latio
n
Refe
rral
to p
reve
ntio
n se
rvic
es:
•Th
ere
shou
ld b
e pr
otoc
ols
to s
ignp
ost i
ndiv
idua
ls w
ho a
tten
ddi
abet
es p
reve
ntio
n an
d sc
reen
ing
serv
ices
for o
ther
hel
p an
dad
vice
, e.
g. h
ealth
y di
et re
gim
es, w
eigh
t man
agem
ent
prog
ram
mes
etc
•Pe
ople
at r
isk o
f dia
bete
s m
ay n
eed
to b
e re
ferr
ed to
the
follo
win
g pr
even
tion
serv
ices
to in
crea
se th
eir c
hanc
es o
fim
prov
ing
thei
r hea
lth:
•N
HS
Hea
lth C
heck
s 10
•W
eigh
t man
agem
ent p
rogr
amm
es•
Hea
lthy
diet
regi
mes
20
17
ELEM
ENTS
CH
AR
AC
TER
ISTI
CS,
SK
ILLS
AN
D B
EHA
VIO
UR
SO
UTP
UTS
DIA
BET
ES S
ERV
ICES
SPE
CIF
IC O
UTP
UTS
/CO
MM
ENTS
Clin
ical
qua
lity
Patie
nt p
athw
ayii)
the
pat
ient
rec
eive
s ap
prop
riate
car
edu
ring
the
inte
rven
tion(
s), i
nac
cord
ance
with
bes
t cl
inic
al p
ract
ice
iii) w
here
clin
ical
em
erge
ncie
s or
com
plic
atio
ns d
o oc
cur
they
are
man
aged
in a
ccor
danc
e w
ith b
est
clin
ical
pra
ctic
eiv
) the
inte
rven
tion
is c
arrie
d ou
t in
afa
cilit
y w
hich
pro
vide
s a
safe
envi
ronm
ent
of c
are
and
min
imis
esris
k to
pat
ient
s, s
taff
and
vis
itors
v) t
he in
terv
entio
n is
und
erta
ken
by s
taff
with
the
nec
essa
ry q
ualif
icat
ions
, ski
lls,
expe
rienc
e an
d co
mpe
tenc
e
At
exit
from
pat
hway
:
The
Com
mis
sion
er s
houl
d as
sure
them
selv
es t
hat
prov
ider
has
sys
tem
s an
dpr
oces
ses,
whi
ch a
re a
gree
d w
ith a
ll pa
rtie
san
d ne
twor
ks, i
n pl
ace
to:
i) m
ake
urge
nt o
nwar
d re
ferr
als
whe
relif
e-th
reat
enin
g co
nditi
ons
or s
erio
usun
expe
cted
pat
holo
gies
are
dis
cove
red
durin
g an
inte
rven
tion/
asse
ssm
ent
ii) e
nsur
e th
at p
atie
nts
rece
ive
disc
harg
ein
form
atio
n re
leva
nt t
o th
eir
inte
rven
tion
incl
udin
g ar
rang
emen
tsfo
r co
ntac
ting
the
prov
ider
and
fol
low
up, i
f re
quire
diii
) pro
vide
tim
ely
feed
back
to
the
refe
rrer
re in
terv
entio
n, c
ompl
icat
ions
and
prop
osed
fol
low
up,
if r
equi
red
iv) e
nsur
e th
at s
uppo
rt is
in p
lace
with
othe
r ca
re a
genc
ies
as a
ppro
pria
te
•Ex
erci
se fa
cilit
ies
20
•M
otiv
atio
nal w
orks
hops
•Sm
okin
g ce
ssat
ion
•Su
rger
y (e
.g. b
aria
tric
sur
gery
) or d
rugs
to re
duce
wei
ght
Refe
rral
to s
ervi
ces
that
will
inve
stig
ate
and
diag
nose
dia
bete
s:
•Pe
ople
at r
isk o
f dev
elop
ing
diab
etes
may
nee
d to
be
refe
rred
serv
ices
that
inve
stig
ate,
con
firm
and
man
age
diab
etes
as
part
of th
eir c
are
2
TOPI
C
18
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Esta
tes
and
equi
pmen
t
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
C:
5, 3
3,56
Mod
ule
D:
Sche
dule
s:2,
3,4
,6,1
1,17
Und
erst
andi
ng o
f bui
ldin
gre
gula
tions
Acc
ess
to a
dvic
e on
“fit
-for
-pu
rpos
e” e
quip
men
t and
faci
litie
s
Com
mis
sion
ers
mus
t as
sure
the
mse
lves
tha
tpa
tient
car
e is
del
iver
ed in
app
ropr
iate
lybu
ilt a
nd e
quip
ped
faci
litie
s w
hich
mee
tre
leva
nt H
TMs
and
Build
ing
Not
es, a
nd,
whe
re a
ppro
pria
te, a
re r
egis
tere
d an
d ar
esa
fe a
nd c
lean
Equi
pmen
t m
ust
be f
it fo
r pu
rpos
e
Com
mitm
ent
to e
ffic
ient
use
and
satis
fact
ory
mai
nten
ance
of
equi
pmen
t
Clin
ical
qua
lity
Kno
wle
dge
and
unde
rsta
ndin
g of
hea
lthan
d sa
fety
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
C:
4A,5
,11,
17,1
9, 5
4, 5
6,60
Und
erst
andi
ng o
f clin
ical
acco
unta
bilit
ies
of h
ealth
and
safe
ty p
olic
ies
H&
S st
rate
gy a
nd p
olic
ies
in p
lace
and
impl
emen
ted
with
aw
aren
ess
thro
ugho
ut th
eor
gani
satio
n
Acc
essib
ility
to e
xecu
tive
resp
onsib
le fo
r H&
Sfo
r qui
cker
, firs
t con
tact
ser
vice
s
Hea
lth a
nd s
afet
y po
licie
s as
per
pro
vide
r agr
eem
ent w
ithco
mm
issio
ners
Dat
a an
din
form
atio
nm
anag
emen
t
Stra
tegy
and
pol
icie
s
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
B:Se
ctio
ns:
5 Mod
ule
C:
9,17
,18,
19,
21,2
3,24
,27,
29, 3
2,33
,54,
56,
60
Stra
tegy
and
pol
icy
deve
lopm
ent
skill
s
The
abili
ty to
ana
lyse
dat
a an
dha
ve a
cces
s to
info
rmat
ion
that
can
pred
ict t
rend
s an
d th
at c
ould
iden
tify
prob
lem
s
The
abili
ty to
cap
ture
evi
denc
eba
sed
prac
tice
from
R&
D N
atio
nal
Serv
ice
Fram
ewor
ks, N
ICE
guid
ance
The
abili
ty to
use
dat
a an
din
form
atio
n ap
prop
riate
ly to
impr
ove
patie
nt c
are
Tran
spar
ency
and
obj
ectiv
ity
The
Prov
ider
sho
uld
have
an
expl
icit
data
and
info
rmat
ion
stra
tegy
in p
lace
that
cov
ers
•Ty
pes
of d
ata
•Q
ualit
y of
dat
a•
Dat
a pr
otec
tion
and
conf
iden
tialit
y•
Acc
essib
ility
•Tr
ansp
aren
cy•
Ana
lysis
of d
ata
and
info
rmat
ion
•U
se o
f dat
a an
d in
form
atio
n•
Diss
emin
atio
n of
dat
a an
d in
form
atio
n•
Risk
s•
Shar
ing
of d
ata
and
com
patib
ility
of I
T ac
ross
diff
eren
t pro
vide
rs w
ith re
spec
t to
care
of
patie
nts
acro
ss a
pat
hway
This
info
rmat
ion
shou
ld b
e in
clud
ed in
the
Dat
aQ
ualit
y Im
prov
emen
t Pla
n
Ther
e sh
ould
be
polic
ies
in p
lace
that
incl
ude:
The
Prov
ider
is re
quire
d to
hav
e in
form
atio
n sy
stem
s th
at re
cord
indi
vidu
al n
eeds
incl
udin
g em
otio
nal,
soci
al, e
duca
tiona
l,ec
onom
ic a
nd b
iom
edic
al in
form
atio
n w
hich
per
mit
mul
tidisc
iplin
ary
care
acr
oss
serv
ice
boun
darie
s an
d su
ppor
t car
epl
anni
ng 21
The
Prov
ider
is re
quire
d to
use
the
follo
win
g fo
r the
col
lect
ion
and
prod
uctio
n of
dat
a, w
here
app
ropr
iate
:
•N
HS
Out
com
es F
ram
ewor
k 18
•N
atio
nal D
iabe
tes
Info
rmat
ion
Serv
ice
22
•D
iabe
tes
E 12
•Q
ualit
y an
d O
utco
mes
Fra
mew
ork23
•N
HS
Hea
lth C
heck
s10
•Pa
tient
Exp
erie
nce
11
19
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Dat
a an
din
form
atio
nm
anag
emen
t
Stra
tegy
and
pol
icie
s•
Con
fiden
tialit
y C
ode
of P
ract
ice
•D
ata
Prot
ectio
n•
Free
dom
of I
nfor
mat
ion
•H
ealth
Rec
ords
•In
form
atio
n G
over
nanc
e M
anag
emen
t•
Info
rmat
ion
Qua
lity
Ass
uran
ce•
Info
rmat
ion
Secu
rity
Ther
e m
ust b
e a
nam
ed in
divi
dual
who
is th
eC
aldi
cott
Gua
rdia
n
20
Source documentsCommissioners and providers should takeresponsibility for making references to thelatest version of the various documents andguidance.
1.NHS Diabetes and Diabetes UK, Emotional andPsychological Support and Care in Diabetes,Joint Diabetes UK and NHS Diabetes Emotionaland Psychological Support, 2010http://www.diabetes.nhs.uk
2. The NHS Diabetes Commissioning Guides areavailable on the NHS Diabetes website athttp://www.diabetes.nhs.uk/commissioning_resource/
3. Standard NHS Contractshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324
4. National Quality Board, Quality Governance inthe NHS, 2011http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_125239.pdf
5. NICE Diabetes guidance,http://guidance.nice.org.uk/Topic/EndocrineNutritionalMetabolic/Diabetes
6. NICE Preventing type 2 diabetes: populationand community-level interventions in high-riskgroups and the general population (publichealth guidance), May 2011,http://guidance.nice.org.uk/PH35
7. NICE Preventing the progression from pre-diabetes to type 2 diabetes among high riskgroups (public health guidance) expectedpublication May 2012,http://guidance.nice.org.uk/PHG/Wave19/62
8. NICE, Medicines adherence: involving patientsin decisions about prescribed medicines andsupporting adherence, Jan 2009,http://guidance.nice.org.uk/CG76
9. NHS Institute for Innovation and Improvement,model CQUIN scheme: inpatient care forpeople with diabetes, 2009
10. Putting Prevention First, NHS Health Check,Vascular risk assessment and management ,Best practice guidance, 2009,www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_097489
11. The King’s Fund, The point of care. Measuresof patients’ experience in hospital: purpose,methods and uses. July 2009
12. DiabetesE - https://www.diabetese.net/
13. Department of Health, Royal College ofGeneral Practitioners, Royal PharmaceuticalSociety of Great Britain, NHS Primary CareContracting, Guidance and competences forthe provision of services using practitionerswith special interests (PwSIs) - Diabetes,http://www.rcgp.org.uk/pdf/CIRC_PwSI%20Diabetes.pdf
14. Training, Research and Education for Nursesin Diabetes – UK, An Integrated Career &Competency Framework for Diabetes Nursing(Second Edition), 2010
15. Skills for Health, Diabetes CompetencyFramework,https://tools.skillsforhealth.org.uk/
16. Department of Health, National ServiceFramework for Coronary Heart Disease –modern standards and service modelshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094275
17. Department of Health, No health withoutmental health: a cross-government mentalhealth outcomes strategy for people of allages, February 2011,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766
18. Department of Health, The NHS OutcomesFramework 2011/12, December 2010http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
21
19. NICE Obesity – working with localcommunities (public health guidance),expected November 2012,http://guidance.nice.org.uk/PHG/Wave20/53
20. Department of Health, Change4LifeCampaign, 2009http://www.dh.gov.uk/en/Publichealth/Change4Life/DH_119243
21 York and Humber integrated IT system,http://www.diabetes.nhs.uk
22. National Diabetes Information Service,www.diabetes-ndis.org
23. Quality and Outcomes Framework,http://www.nice.org.uk/aboutnice/qof/qof.jsp
22
This specification forms Schedule 2, Part 1 orsection 1 (module B), ‘The Services - ServiceSpecifications’ of the Standard NHS Contractsa.
Service specifications are developed in partnershipbetween commissioners and provider agencies andare based on agreed evidence-based care andtreatment models. Specifications should be open toscrutiny and available to all service users/carers as astatement of standards that the user/carer canexpect to receive.
The following documentation, developed bythe Diabetes Commissioning Advisory Group,provides further detail/guidance to support thedevelopment of this specification:
• The diabetes prevention and risk assessmentintervention map
• The contracting framework for diabetesprevention and risk assessment services
This specification template assumes that the servicesare compliant with the contracting framework fordiabetes prevention and risk assessment services.
This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.
Description of diabetes prevention andrisk assessment services:Diabetes prevention and risk assessment servicesencompass the care an individual who is at risk ofdeveloping diabetes may receive ranging fromraising awareness of the condition and other relatedlifestyle factors, to screening/risk assessment andencouragement of a healthy lifestyle for all agegroups.
The final specification should take into account:
• national, network and local guidance andstandards for diabetes services.
• local needs.
This specification is supported by other related workin diabetes commissioning such as:
• the web-based Diabetes Community HealthProfiles (Yorkshire and Humber Public HealthObservatory)
• the web-based Health Needs Assessment Tool(National Diabetes Information Service).
These provide comprehensive information for needsassessment, planning and monitoring of diabetesservices.
Introduction• A general overview of the services identifying why
the services are needed, including background tothe services and why they are being developed orin place.
• A statement on how the services relate to eachother within the whole system should be includeddescribing the key stakeholders/relationshipswhich influence the services, e.g. multi-disciplinaryteam etc
• Any relevant diabetes clinical networks andscreening programmes applicable to the services
• Details of all interdependencies or sub-contractorsfor any part of the service and an outline of thepurpose of the contract should be stated,including arrangements for clinical accountabilityand responsibility, as appropriate
Standard Service SpecificationTemplate for Diabetes Preventionand Risk Assessment Services
a Standard NHS Contracts http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324
23
Purpose, Role and Clientele1. A clear statement on the primary purpose of the
services and details of what will be provided andfor whom:
• Who the services are for (e.g. individuals of allages at risk of diabetes)
• What the services aim to achieve
• The objectives of the services
• The desired outcomes and how these aremonitored and measured
Scope of the Services2. What does the service do? This section will focus
on the types of high level therapeutic and lifestyleinterventions that are required for the types ofneed the services will respond to.
• How the service responds to age, culture,disability, and gender sensitive issues
• Assessment – details of what it is and referralsto all relevant services/care
• Service planning – High level view of what theservices are and how they are used; howpatients enter the pathway/journey; what arethe stages undertaken and follow up care. Theaims of service planning are to:
o Develop, manage and reviewinterventions along the patient journey
o Ensure access to other services/care, asappropriate
• Holistic review of individuals at risk ofdeveloping diabetes using the principles of anintegrated care model for people with long termconditions that is centred around the individual
• Risk assessment procedures, e.g. NHS HealthChecks
• Detail of evidence base of the service – i.e. thecontracting framework for diabetes preventionand risk assessment services, guidance producedby the Royal College of Physicians, Diabetes UK,etc
Service Delivery3. Individual Journey/pathway
Flow diagram of the patient pathway showingaccess and exit/transfer points – see the diabetes
prevention and risk assessment intervention mapas a starting point
4. Treatment protocols/interventionsInclude all individual treatment/interventionprotocols in place within the services or plannedto be used
5. This will include a breakdown of how the patientwill receive the services and from whom. It shouldbe a clear statement of staffqualifications/experience and/or training (ifappropriate) and clinical or managerial supervisionarrangements. It should specify, as appropriate:
• Geographic coverage/boundaries – i.e. theservices should be available for all individuals ofall ages groups who live in the clinicalcommissioning group area
• Hours of operation
• Minimum level of experience and qualificationsof staff (i.e. doctors – diabetologists and GPs,Nursing staff – diabetes nurse specialists, district,practice nurses etc, other allied healthprofessionals, e.g. podiatrists, dietitians,optometrists, pharmacists etc and other supportand administrative staff)
• Staff induction and developmental training
6. Equipment
• Upgrade and maintenance of relevantequipment and facilities
• Technical specifications (if any)
Identification, Signposting/ Referraland Acceptance criteria7. This should make clear how individuals will be
identified, assessed (if appropriate) and acceptedto the services. Acceptance should be based ontypes of need and/or individual.
8. How should individuals be referred or how arethey signposted?
• Who is acceptable for referral and from where
• Details of evaluation process - Are there clearexclusion criteria or set alternatives to theservice? How might an individual betransferred?
• Response time detail and how are individualsprioritised
24
Discharge/Service Complete/Transfer/Transition criteria9. The intention of this section is to make clear when
an individual should be transferred from thediabetes prevention and risk assessment service toanother and when this would be reached.
• How is the intervention pathway reviewed?
• How does the service decide that an individual isready for discharge/transfer to other services?
• How are goals and outcomes assessed andreviewed?
• What procedure is followed on discharge,including arrangements for follow-up?
Quality Standards10. The service is required to deliver care, where
appropriate, according to the standards forclinical practice set by the National Institute forHealth and Clinical Excellenceb
11. As a minimum, the Provider is required to agreea local Commissioning for Quality andInnovation scheme for services for people withdiabetes. (Insert details of the CQUIN Schemeagreed)
12. The service is required to deliver the outcomesfor diabetes as determined by the NHSOutcomes Frameworkc
Activity and Performance Management13. This must include performance indicators,
thresholds, methods of measurement andconsequences of breach of contract. These willbe set and agreed prior to the signing of theoverall agreement.
14. Activity plans – Where appropriate, identify theanticipated level of activity the service maydeliver; provide details of any activity measuresand their description /method of collection,targets, thresholds and consequences ofvariances above or below target.
Continual Service Improvement15. As part of the monitoring and evaluation
procedures, the service will identify a method ofagreeing measurements for continuousimprovement of the service being offered andwork to ensure unmet need is both identifiedand brought to the attention of thecommissioner.
16. ReviewThis section should set out a review date and amechanism for review.
The review should include both the specificationsfor continuing fitness for purpose and theproviders’ delivery against the specification.
This should set out the process by which thisreview will be conducted.
This should also identify how compliance againstthe specification will be monitored in year.
17. Agreed byThis should set out who agrees/accepts thespecification on behalf of all parties. This should include the diabetes providers,commissioner and network (if appropriate).
b http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp
c http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
Further copies of this publication can be ordered from Prontaprint, by [email protected] or tel: 0116 275 3333, quoting DIABETES 117
www.diabetes.nhs.uk