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CommissioningDiabetes Services for
Older People
Supporting, Improving, Caring
June 2011
NHS Diabetes information Reader Box
Review Date 2013
Commissioning Diabetes Services for Older People
NHS Diabetes would like to thank the following for their advice and contribution to the development ofthis commissioning guide:
Alan Sinclair Consultant in Diabetes (Older People), The Institute of Diabetes forOlder People (IDOP), University of Bedfordshire
Philip Ivory Service User/Diabetes UK
Elizabeth Fairclough Diabetes Nurse (Older People), Rotherham General Hospital
Sara Da Costa Senior Diabetes Nurse (Older People), Worthing and SouthlandsHospitals NHS Trust
Julian Backhouse Regional Programme Manager, NHS Diabetes
Margit Physant Health Policy Advisor, Age UK
And to Thoreya Swage who wrote this publication.
3
Page
Commissioning Diabetes Services for Older People 5
Features of Diabetes Services for Older People 6
Diabetes Services for Older People Intervention Map 8
Contracting Framework for Diabetes Services for Older People 11
Standard Service Specification Template for Diabetes 24Services for Older People
Contents
5
The NHS Diabetes commissioning approach helps to deliver high quality integrated care through a three-stepprocess that ensures key elements needed to build an excellent diabetes service are in place. The approach issupported by a wide range of proven tools, resources and examples of shared learning.
Step 1 – involves understanding the local diabetespopulation health needs by developing a local HealthNeeds Assessment and setting up a steering groupwith key stakeholder involvement including a leadclinician, lead commissioner, lead diabetes nurse andlead service user.
Step 2 – involves the development of a servicespecification to describe the model of care to becommissioned. This becomes the document onwhich tenders may be issued.
Step 3 – involves monitoring the delivery of theservice specification by the provider and evaluatingthe performance of the service. Input from thesteering group with service user representation willbe an important mechanism for monitoring theservice as well as patient surveys.
This commissioning guide has been developed byNHS Diabetes with key stakeholders including clinicaland social services professionals and patient groupsrepresented by Diabetes UK.
It is not designed to replace the Standard NHSContracts as many of the legal and contractualrequirements have already been identified in this setof documents. Rather, it is intended to form the basisof a discussion or development of diabetes servicesfor older people between commissioners andproviders from which a contract for services can thenbe agreed.
This commissioning guide consists of:
• A description of the key features of good diabetesservices for older people
• A high level intervention map. This interventionmap describes the key high level actions orinterventions (both clinical and administrative)diabetes services for older people shouldundertake in order to provide the most efficientand effective care, from admission to discharge (ordeath) 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 services for older people.
• A contracting framework for diabetes services forolder people that brings together all the keystandards of quality and policy relating to diabetesand older people
• A template service specification for diabetesservices for older people that forms part ofschedule 2, part 1 / Module B, Section 1, of theStandard NHS Contract covering the key headingsrequired of a specification.
For further detail on how to approach thecommissioning of diabetes services please seehttp://www.diabetes.nhs.uk/commissioning_resource/
Commissioning Diabetes Servicesfor Older People
1 Commissioning Diabetes Without Walls , 2011, http://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
6
High quality diabetes care for older people isprovided by services which actively identify andmanage those individuals with diabetes who havespecial needs as a result of extreme frailty,advanced age (>80y) or residency within a carehome. This should include:
• mechanisms for the appropriate screening anddetection of diabetes in older people
• an agreed care plan with clearly specifiedobjectives (in line with Single AssessmentProcess (SAP))
• appropriate support to optimise blood glucosecontrol
• co-ordination of specialist, community, andprimary care services including palliative care
• immediate access to appropriate specialistsupport, e.g. ophthalmology, cardiovascular andrenal services (including admission if necessary)
• supported discharge (including multi-disciplinaryneeds assessment)
• smooth transition to care home residency, whereappropriate
• support and guidance for family and carersincluding telephone ‘hot-line’ availability
• close healthcare professional liaison with CareHomes in the identification and care of olderpeople with diabetes
• provides a template for more detailedinformation gathering such as those of adiabetes minimum dataset for audit and /orresearch purposes
In addition, the services should:
• be developed in a co-ordinated way, taking fullaccount of the responsibilities of other agenciesin providing comprehensive care ensuring peopleare at the centre of decisions about their careand support - ‘no decision about me withoutme’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 long term conditionsmodelii
• provide effective and safe care to people withdiabetes in a range of settings including thepatient’s home, in accordance with the NICEQuality Standards for Diabetesiii
• take into account the emotional, psychologicaland mental wellbeing of the patientiv
• take into account all diverse and personal needswith respect to access to care
• ensure that services are responsive andaccessible to people with Learning Disabilitiesv
• ensure that the family/carers of older peoplewith diabetes have access to psychologicalsupport
• have effective clinical networks with clear clinicalleadership across the boundaries of care whichclearly identify the role and responsibilities ofeach member of the diabetes healthcare team
• ensure that there are a wide range of optionsavailable to people with diabetes to support selfmanagement and individual preferences
Features of Diabetes Services forOlder People
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 Quality Standards: Diabetes in adults, http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp
iv 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/
v http://www.diabetes.nhs.uk/commissioning_resource
7
vi See York and Humber integrated IT system at http://www.diabetes.nhs.uk/year_of_care/it/
vii European Diabetes Working Party for Older People. Clinical Guidelines for Type 2 Diabetes Mellitus. Available on:www.instituteofdiabetes.org
viii Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
• take into account services provided by social careand the voluntary sector
• provide patient/carer/family education ondiabetes not only at diagnosis but also duringcontinuing management at every stage of care
• provide education on diabetes management toother staff and organisations that supportpeople with diabetes
• have a capable and effective workforce that hasthe appropriate training and updating andwhere the staff have the skills and competenciesin the management of people with diabetes
• provide multidisciplinary care that manages thetransition between adult and older peoples’services
• have integrated information systems that recordindividual needs including emotional, social,educational, economic and biomedicalinformation which permit multidisciplinary careacross service boundaries and support careplanningvi
• produce information on the outcomes ofdiabetes care including contributing to nationaldata collections and auditsvii
• have adequate governance arrangements, e.g.local mortality and morbidity meetings ondiabetes care to learn from errors and improvepatient safety
• take account of patient experience, includingPatient Reported Outcome Measures and theNHS Outcomes Framework, in the developmentand monitoring of service deliveryviii
• actively monitor the uptake of services,responding to non-attenders and monitoringcomplaints and untoward incidents
NH
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Diabetes Services for Older PeopleIntervention Map
8
9
NH
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Dia
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ssm
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men
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for
old
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– C
on
tin
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are
Fro
m
Pag
e 9
Reg
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reen
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Co
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es
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erra
l to
sp
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list
dia
bet
es
care
, if
req
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ed
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udes
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agem
ent
of:
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mpl
icat
ions
of
diab
etes
, e.g
. ren
al,
card
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scul
ar e
tc
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ot c
are
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patie
nt h
ospi
tal c
are
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enta
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arni
ng d
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ility
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mpl
ex n
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der
peop
le w
ith m
ultip
le p
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d of
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car
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sess
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d t
reat
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t, in
clud
ing
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ge o
f ac
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pot
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feth
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Ref
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l fo
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pro
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lan
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)
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iew
of
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nee
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prov
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n of
res
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es
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rdin
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ypog
lyca
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isod
es
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vere
fun
ctio
nal d
eclin
e
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enta
l im
parim
ent
Tele
ph
on
e co
nsu
ltat
ion
avai
lab
le
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wee
n c
are
pla
nn
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rev
iew
s Sa
fety
Ala
rms
11
IntroductionThis contracting framework sets out what isrequired of clinically safe and effective services thatare providing care for older people with diabetes.The framework is designed to be read inconjunction with the high level intervention map,which describes the interventions and actionsrequired along the patient pathway as well as entryand exit points and the standard servicespecification template for diabetes services forolder people.
The framework brings together the key qualityareas and standards that have been identified byNHS Diabetes, Diabetes UK, the Royal Colleges andother related organisations.
The principles that establish a safepathway for patient care Establishing the principles that underpin thesystems and processes of pathways for patient careleads to more efficient patient throughput and canreduce risk of fragmentation of care and seriousuntoward incidents. The principles operate at fourlayers within a patient pathway:
• Commissioning• Clinical Case Direction or the overall Care Plan
(i.e. the management of an individual patient)
• Provision of the clinical service or process• Organisational platform on which the clinical
service or process sits (the provider organisation)
A straightforward or simple pathway is one inwhich the overall management including bothClinical Case Direction and the delivery of theclinical processes conventionally sits within oneorganisation. However, with a more complexpathway, there is a danger that fracturing theoverall management pathway into componentscarried out by different clinical teams andorganisations will require duplication of effortleading to inefficiency and increased risk athandover points.This can be managed byestablishing clear governance arrangements for allthe layers in the pathway.
In addition, Commissioning Bodies must balancethe benefits of fracturing the pathway againstincreased complexity and ensure that the increasedrisks are mitigated.
The governance arrangements required for allthree layers and the commissioner responsibilitiesare shown below:
Contracting Framework for DiabetesServices for Older People
12
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 serviceThe key principles of good diabetes service forolder people is to provide a high quality servicethat is reliable in terms of delivery and timelyaccess for patients requiring that care.
Diabetes care is provided by a number of differentteams in the primary, community and acutesetting. It is essential that there is co-ordination ofcare of the patients through the care planningprocess and a consultant diabetologist retains theclinical accountability and responsibility for theservice. Responsibility for overall patient careacross the whole pathway rests with the patient’sGP who also retains overall responsibility to ensurethe management of side effects and complications.
The initial management and continuing care ofindividuals with diabetes should include anassessment of their emotional and psychologicalwell-being, together with timely access toappropriate psychological and biological/psychiatricinterventions. Mental health disorders can posesignificant barriers to diabetes care and thereforemental health stability is vital for good self care1.
The services themselves will also have clinicaloversight and accountability for governancepurposes.
This contracting framework focuses on olderpeople with diabetes who are frail and havecomplex needs. This contracting framework shouldalso be read in conjunction with the diabetescommissioning guides for, prevention and riskassessment, foot care, emergency and in patientcare, mental health, the complications of diabetes(cardiovascular, renal, eyes and neuropathy), End
of Life Care and follow the principles for theeffective commissioning of services for people withLearning Disabilities2.
Ensuring qualityCommissioning Bodies should ensure that thediabetes services commissioned are of the highestquality. There may, in addition, be someorganisations that wish to offer their services, butdo not have a history of providing such care.
i) For provider organisations already involved inthe delivery of diabetes services, there should beretrospective evidence of systems being in place,implemented and working.
ii) ii) For organisations new to the arena thecommissioner should reassure itself that theprovider has the organisational attributes,governance arrangements, systems andprocesses set up to provide the platform forsafe and effective delivery of diabetes servicesto be provided.
This framework describes what theCommissioning Body needs to ensure ispresent or addressed in its discussions withthe provider organisation.
Under the ‘elements’ column there are crossreferences to the Standard NHS Contract forCommunity Services – bilateral (main clauses andschedules)3.This is to assist commissioners andproviders in having an overview of how the elementslink to the Standard NHS Contracts. Some of theareas are open to interpretation and consequentlythe references are not exhaustive.
13
TOPI
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prin
cipl
es o
f goo
d go
vern
ance
:
- cla
rity
of p
urpo
se- p
artic
ipat
ion
and
enga
gem
ent
- rul
e of
law
- tra
nspa
renc
y- r
espo
nsiv
enes
s- e
quity
and
incl
usiv
enes
s- e
ffec
tiven
ess
and
effic
ienc
y- a
ccou
ntab
ility
An
orga
nisa
tion
that
acc
epts
resp
onsib
ility
and
acc
ount
abili
tyfo
r all
its a
ctio
ns
Cle
ar o
rgan
isat
iona
l and
int
egra
ted
gove
rnan
ce s
yste
ms
and
stru
ctur
es in
pla
cew
ith c
lear
line
s of
acc
ount
abili
ty a
ndre
spon
sibi
litie
s fo
r al
l fun
ctio
ns
This
incl
udes
inte
rfac
es b
etw
een
serv
ices
Qua
lity
Gov
erna
nce
in t
he N
HS.
A g
uide
for
pro
vide
r bo
ards
4
Gov
erna
nce
Clin
ical
Gov
erna
nce
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
B:Se
ctio
ns:
1 (p
art 2
), 3,
4
Mod
ule
C:
4,4A
,6,9
,10,
12,1
4,15
,16,
17,1
9,21
,26
27,2
9,31
,32,
33,
48,4
9,51
,53,
54
Expl
icit
com
mitm
ent t
o qu
ality
and
patie
nt s
afet
y
Patie
nt fo
cuse
d w
ith re
spec
t for
the
pers
onal
wish
es o
f pat
ient
s in
all a
spec
ts o
f the
ir ca
re
A c
omm
itmen
t to
inno
vatio
n an
dco
ntin
uous
impr
ovem
ent
Clin
ical
Gov
erna
nce
syst
ems
and
polic
ies
shou
ld b
e in
pla
ce a
nd in
tegr
ated
into
orga
nisa
tiona
l gov
erna
nce
with
cle
ar li
nes
ofac
coun
tabi
lity
and
resp
onsib
ility
for a
ll cl
inic
algo
vern
ance
func
tions
e.g.
•
Clin
ical
Aud
it•
Clin
ical
Risk
Man
agem
ent
•U
ntow
ard
Inci
dent
Rep
ortin
g•
Infe
ctio
n C
ontr
ol•
Med
icin
es M
anag
emen
t•
Info
rmed
Con
sent
•Ra
ising
Con
cern
s•
Staf
f Dev
elop
men
t•
Com
plai
nts
Man
agem
ent
All
sub-
cont
ract
ors
mus
t mee
t gov
erna
nce
and
lead
ersh
ipar
rang
emen
ts o
f the
mai
n pr
ovid
er o
rgan
isatio
n
Com
miss
ione
r, pr
ovid
er a
nd N
HS
Litig
atio
n A
utho
rity
mus
t rev
iew
the
Clin
ical
Neg
ligen
ce S
chem
e fo
r Tru
sts
arra
ngem
ents
/or o
ther
orga
nisa
tiona
l / p
rofe
ssio
nal i
ndem
nity
arr
ange
men
ts
The
serv
ice
shou
ld h
ave
in p
lace
writ
ten
prot
ocol
s an
d pr
oced
ures
defin
ing
clea
r lin
es o
f acc
ount
abili
ty a
nd re
spon
sibili
ty.
The
serv
ice
is re
quire
d to
com
ply
with
gui
delin
es, p
ublic
hea
lthgu
idan
ce a
nd a
ppra
isals
publ
ished
by
the
Nat
iona
l Ins
titut
e fo
rH
ealth
and
Clin
ical
Exc
elle
nce
that
are
rele
vant
to th
e ca
repr
ovid
ed b
y th
e se
rvic
e 5
In a
dditi
on, t
he s
ervi
ce is
requ
ired
to c
ompl
y w
ith th
e fo
llow
ing:
i.
Gui
danc
e pu
blish
ed b
y N
ICE
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
Gov
erna
nce
Mod
ule
D:
Sche
dule
s:
3,6,
10,1
1,15
,17
•Pa
tient
and
Pub
lic In
volv
emen
t•
Patie
nt d
igni
ty a
nd re
spec
t •
Equa
lity
and
dive
rsity
•In
trod
ucin
g ne
w te
chno
logi
es a
ndtr
eatm
ents
•A
n ex
tern
ally
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 10
•D
epre
ssio
n w
ith a
chr
onic
phy
sical
hea
lth p
robl
em 6
•M
edic
ines
adh
eren
ce: i
nvol
ving
pat
ient
s in
dec
ision
s ab
out
pres
crib
ed m
edic
ines
and
sup
port
ing
adhe
renc
e 7
ii. C
linic
al g
uide
lines
for T
ype
2 D
iabe
tes
Mel
litus
pro
duce
d by
the
Euro
pean
Dia
bete
s W
orki
ng P
arty
for O
lder
Peo
ple
8
Old
er p
eopl
e di
abet
es m
ultid
iscip
linar
y te
ams
shou
ld 9
:
•be
ale
rt to
the
deve
lopm
ent o
r pre
senc
e of
clin
ical
or s
ub-
clin
ical
dep
ress
ion
and/
or a
nxie
ty, i
n pa
rtic
ular
whe
re s
omeo
nere
port
s or
app
ears
to b
e ha
ving
diff
icul
ties
with
sel
f-m
anag
emen
t.•
be a
ble
to d
etec
t and
bas
ical
ly m
anag
e n
on-s
ever
eps
ycho
logi
cal d
isord
ers
in p
eopl
e fr
om d
iffer
ent c
ultu
ral
back
grou
nds
•be
fam
iliar
with
cou
nsel
ling
tech
niqu
es a
nd d
rug
ther
apy,
whi
le a
rran
ging
pro
mpt
refe
rral
to m
enta
l hea
lth s
peci
alist
s•
not u
se s
peci
al m
anag
emen
t tec
hniq
ues
or tr
eatm
ent f
or n
on-
seve
re p
sych
olog
ical
illn
ess,
exc
ept w
here
dia
bete
s-re
late
dar
teria
l com
plic
atio
ns g
ive
rise
to s
peci
al p
reca
utio
ns o
ver d
rug
ther
apy
•be
ale
rt to
bul
imia
ner
vosa
and
ano
rexi
a ne
rvos
a an
d in
sulin
dose
man
ipul
atio
n if
ther
e is
over
con
cern
with
bod
y sh
ape
and
wei
ght,
low
BM
I or p
oor g
luco
se c
ontr
ol•
mak
e ea
rly (a
nd o
ccas
iona
lly u
rgen
t) re
ferr
als
to lo
cal e
atin
gdi
sord
er s
ervi
ces,
as
appr
opria
te•
ensu
re th
at a
ll ad
ults
with
Typ
e I d
iabe
tes
have
, at r
egul
arin
terv
als,
cou
nsel
ling
abou
t life
styl
e iss
ues
and
nutr
ition
albe
havi
our
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
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 t
he c
once
pt o
fcl
inic
al q
ualit
y
Has
con
cern
for
qua
lity
whi
lew
orki
ng e
ffic
ient
ly
An
unde
rsta
ndin
g of
the
use
of
audi
t, p
atie
nt a
nd s
taff
fee
dbac
kto
impr
ove
qual
ity
An
orga
nisa
tion
that
pro
vide
scl
arity
of
obje
ctiv
es a
nd p
rom
otes
refle
ctiv
e pr
actic
e to
impr
ove
qual
ity o
f pa
tient
car
e
Qua
lity
assu
ranc
e sy
stem
s m
ust b
e in
pla
cean
d ap
prov
ed b
y co
mm
issio
ning
bod
y w
ithre
gula
r rep
ortin
g of
out
com
es
Prov
ider
s ar
e re
quire
d to
pub
lish
qual
ityac
coun
ts fo
r the
pub
lic re
port
ing
of q
ualit
yin
clud
ing
safe
ty, e
xper
ienc
e an
d ou
tcom
es
Prov
ider
s sh
ould
par
ticip
ate
in n
atio
nal a
udit
prog
ram
mes
Dia
bete
s se
rvic
es m
ust c
ompl
y w
ith th
e pe
rfor
man
ce m
easu
res
requ
ired
of N
HS
serv
ices
, i.e
mee
ting:
11
•Re
ferr
al to
Tre
atm
ent w
aits
(95t
h pe
rcen
tile
mea
sure
s)
•A
&E
Qua
lity
Indi
cato
rs
The
serv
ices
are
requ
ired
to p
artic
ipat
e in
the
follo
win
gac
tiviti
es/p
rogr
amm
es:
•N
atio
nal D
iabe
tes
Aud
it12
•Pa
tient
Exp
erie
nce
Surv
eys
13
•D
iabe
tes
E 14
•Pa
tient
Rep
orte
d O
utco
me
Mea
sure
s 15
•D
iabe
tes
UK
Gui
danc
e an
d C
are
Hom
e A
udit
tool
kit 16
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
anis
atio
n ha
ssy
stem
s an
d pr
oced
ures
in p
lace
to a
ssur
e th
e co
mm
issi
oner
tha
tth
eir
clin
ical
tea
m h
as t
hene
cess
ary
qual
ifica
tions
, ski
lls,
know
ledg
e an
d ex
perie
nce
tode
liver
the
ser
vice
Staf
f are
com
pete
nt a
nd fi
t for
pur
pose
Prov
ider
to s
atisf
y co
mm
issio
ner t
hat a
ll st
aff
have
cur
rent
app
raisa
l, cl
eara
nces
and
regi
stra
tion
chec
ks a
nd h
ave
dem
onst
rate
dco
mpe
tenc
e in
all
proc
edur
es re
leva
nt to
path
way
.
Prov
ider
to s
atisf
y co
mm
issio
ner t
hat t
hey
can
recr
uit (
or p
rocu
re)
and
reta
in a
com
pete
nt c
linic
al te
am to
del
iver
the
serv
ice
Spec
ific
qual
ifica
tions
requ
ired
of h
ealth
pro
fess
iona
ls pr
ovid
ing
the
serv
ice
are:
•Fo
r med
ical
pra
ctiti
oner
s: re
gist
ratio
n w
ith th
e G
MC
and
evid
ence
of f
urth
er q
ualif
icat
ion
in d
iabe
tes
care
or e
xper
ienc
ew
ithin
dia
bete
s cl
inic
•N
urse
s: 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 17
•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
es c
are
are
requ
ired
to h
ave
the
rele
vant
com
pete
ncie
s (s
ee S
kills
for
Hea
lth- D
iabe
tes
Com
pete
ncie
s fo
r dia
bete
s an
d di
abet
icre
tinop
athy
) 18
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
Wor
kfor
ce/ s
taff
Clin
ical
sta
ff c
ompe
tenc
ies
in u
se o
f equ
ipm
ent
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, 1
1, 1
6, 1
7, 1
9, 2
6,33
,48
The
prov
ider
org
anis
atio
n ha
ssy
stem
s in
pla
ce t
o as
sure
the
com
mis
sion
er t
hat
thei
r cl
inic
alte
am a
re c
ompe
tent
to
use
all
equi
pmen
t ne
eded
to
deliv
er t
hese
rvic
e
Prov
ider
to
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
es c
are
are
requ
ired
to h
ave
the
rele
vant
com
pete
ncie
s in
usi
ngap
prop
riate
equ
ipm
ent
e.g.
blo
od g
luco
se a
nd k
eton
em
onito
rs, i
nsul
in d
eliv
ery
devi
ces
incl
udin
g in
sulin
pum
ps
Clin
ical
qua
lity
Wor
kfor
ce /
staf
f
Dev
elop
men
t
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
C:
11,1
6,19
,48
The
prov
ider
org
anis
atio
n ha
ssy
stem
s in
pla
ce t
o as
sure
the
com
mis
sion
er t
hat
thei
r cl
inic
alte
am is
for
mal
ly in
duct
ed a
ndre
ceiv
es o
ngoi
ng a
ssis
tanc
e to
deve
lop
thei
r sk
ills,
kno
wle
dge
and
expe
rienc
e t
o en
sure
tha
tth
ey a
re a
lway
s fu
lly u
pdat
ed
Prov
ider
to
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
All
Hea
lth C
are
prof
essi
onal
s sh
ould
hav
e su
ffic
ient
stu
dyle
ave
allo
catio
n (t
ime
and
finan
ce) t
o en
able
the
m t
o de
velo
psk
ills
appr
opria
tely
Clin
ical
qua
lity
Regi
stra
tion
and
licen
sing
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r 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
2,53
,54,
56,6
0
Mod
ule
D:
Sche
dule
s:
6,10
,11,
12,1
5
The
Prov
ider
is r
equi
red
to b
ere
gist
ered
with
the
Car
e Q
ualit
yC
omm
issi
on t
o de
mon
stra
te t
hat
is m
eets
the
ess
entia
l sta
ndar
dsof
qua
lity
and
safe
ty f
or t
here
gula
ted
activ
ities
del
iver
ed.
The
Prov
ider
is r
equi
red
to b
elic
ense
d w
ith t
he N
HS
Econ
omic
Regu
lato
r (M
onito
r) in
ord
er t
opr
ovid
e N
HS
care
.
Com
plia
nce
with
the
Car
e Q
ualit
yC
omm
issi
on a
nd M
onito
r re
quire
men
tsC
ompl
ianc
e w
ith t
he f
ollo
win
g N
atio
nal S
ervi
ce F
ram
ewor
ks,
whe
re a
pplic
able
:
•O
lder
Peo
ple’
s N
SF 19
•C
oron
ary
Hea
rt D
iseas
e N
SF 20
•Th
e M
enta
l Hea
lth S
trat
egy21
•Lo
ng T
erm
Con
ditio
ns N
SF 22
Com
plia
nce
with
:
•En
d of
Life
Car
e St
rate
gy 23
Com
plia
nce
with
Car
e Q
ualit
y C
omm
issi
on R
evie
ws
17
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Patie
nt p
athw
ay
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
B:Se
ctio
ns:
1 Mod
ule
C:
4,4A
,9,1
0,12
,14,
15,
16,1
7,18
,19,
20,2
1,27
,29,
31,
33,3
4,35
,36,
38,4
0,52
,54
Mod
ule
D:
Sche
dule
s:
2,3,
4, 9
,11,
17
Mod
ule
E:5
Resp
onsi
vene
ss a
nd p
artic
ipat
ive
appr
oach
to
incl
udin
g pa
tient
s’vi
ews
abou
t th
eir
care
in t
hede
sign
of
care
pat
hway
s
Col
labo
ratio
n w
ith o
ther
orga
nisa
tions
invo
lved
in t
hepa
tient
pat
hway
to
prov
ide
ase
amle
ss p
athw
ay o
f ca
re
All
poss
ible
ent
ry a
nd e
xit
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
clin
ical
car
e is
ensu
red
with
no
frac
turin
g of
the
pat
hway
Ther
e m
ust
be s
peci
ficat
ion
of c
lear
timel
ines
and
ale
rt m
echa
nism
s fo
rpo
tent
ial b
reac
hes
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
mre
gist
ratio
n to
fin
al d
isch
arge
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
of s
ervi
ces
supp
ortin
gpa
tient
s w
ith d
iabe
tes
and
ther
e m
ust
becl
ear
sub
cont
ract
s st
atin
g th
e re
ferr
alcr
iteria
and
acc
ess
to t
hese
sup
port
ing
serv
ices
.
The
path
way
sho
uld
follo
w t
he p
rinci
ples
set
out
by
the
Gen
eric
Lon
g Te
rm C
ondi
tions
mod
el 27
. Thi
s in
clud
es:
•St
ratif
ying
the
leve
ls o
f ne
ed a
nd r
isk
•C
ase
man
agem
ent
•Pe
rson
alis
ed c
are
plan
ning
•Su
ppor
ting
peop
le t
o se
lf ca
re•
Ass
istiv
e te
chno
logy
The
serv
ice
is r
equi
red
to u
se t
he c
omm
on f
ram
ewor
k fo
ras
sess
men
t an
d ca
re p
lann
ing
proc
ess
for
all p
atie
nts
with
diab
etes
28
Ther
e sh
ould
be
agre
ed p
roto
cols
for
the
iden
tific
atio
n of
olde
r pe
ople
who
may
dem
onst
rate
the
ris
k fa
ctor
s fo
rdi
abet
es, e
.g. f
alls
, car
diov
ascu
lar
dise
ase
etc
Ther
e sh
ould
be
agre
ed p
roto
cols
in p
lace
to
scre
en f
ordi
abet
es in
Nur
sing
and
Car
e H
omes
, inc
ludi
ng t
hose
tha
t ca
refo
r ol
der
peop
le w
ith m
enta
l hea
lth c
ondi
tions
, e.g
. dem
entia
.
Ther
e sh
ould
be
prot
ocol
s fo
r th
e sc
reen
ing
for
diab
etes
inol
der
peop
le t
hat
utili
se a
ppro
pria
te m
etho
ds f
or t
his
popu
latio
n
Ther
e sh
ould
be
clea
r pr
otoc
ols
for
the
asse
ssm
ent
of o
lder
peop
le w
ho a
re a
dmitt
ed t
o ho
spita
l with
an
acut
e ill
ness
, to
scre
en f
or p
ossi
ble
diab
etes
Clin
ical
qua
lity
Out
com
es
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
n:1
(par
t 3),3
Mod
ule
C:
4A,1
4,
Mod
ule
D:
Sche
dule
11
Com
preh
ensi
ve u
nder
stan
ding
and
com
mitm
ent
to d
eliv
erin
gan
d im
prov
ing
outc
omes
of
care
Com
plia
nce
with
the
NH
S O
utco
mes
Fram
ewor
k24C
ompl
ianc
e w
ith t
he Q
ualit
y St
anda
rds
for
Dia
bete
s 25
Com
plia
nce
with
the
Qua
lity
Stan
dard
s fo
r C
hron
ic K
idne
yD
isea
se 26
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
Patie
nt p
athw
ayA
t en
try
to p
athw
ay:
The
Com
mis
sion
er s
houl
d as
sure
them
selv
es t
hat
the
prov
ider
has
sys
tem
san
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
them
selv
es t
hat
the
prov
ider
has
sys
tem
san
d pr
oces
ses
in p
lace
to
ensu
re t
hat:
i) th
e in
terv
entio
n is
con
duct
ed s
afel
yan
d in
acc
orda
nce
with
acc
epte
dqu
ality
sta
ndar
ds a
nd g
ood
clin
ical
prac
tice.
ii) t
he p
atie
nt r
ecei
ves
appr
opria
te c
are
durin
g th
e in
terv
entio
n(s)
, inc
ludi
ng o
ntr
eatm
ent
revi
ew a
nd s
uppo
rt, 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 vi
) The
re a
re a
rran
gem
ents
for
the
man
agem
ent
of o
ut o
f ho
urs
care
acco
rdin
g to
bes
t cl
inic
al p
ract
ice
The
olde
r pe
ople
dia
bete
s m
ultid
isci
plin
ary
team
s sh
ould
ensu
re t
hat
ther
e is
clo
se li
aiso
n w
ith t
he o
lder
per
son’
s C
are
Hom
e te
am. T
his
is t
o en
sure
tha
t al
l par
ties
in t
he C
are
Hom
ear
e ed
ucat
ed in
clud
ing
staf
f (i
nclu
ding
cat
erin
g st
aff)
and
resi
dent
s
The
serv
ice
is r
equi
red
to p
rovi
de a
rap
id r
espo
nse
for
peop
lew
ith a
wid
e ra
nge
of f
unct
iona
l abi
lity
incl
udin
g th
eho
useb
ound
, fra
il, c
ogni
tivel
y im
paire
d, d
epre
ssed
and
tho
sein
car
e ho
mes
.
The
serv
ice
is r
equi
red
to e
nsur
e th
at a
com
preh
ensi
veas
sess
men
t of
all
olde
r pe
ople
who
are
adm
itted
to
hosp
ital
with
dia
bete
s ta
kes
plac
e w
ithin
72
hour
s of
adm
issi
on
Patie
nts
may
nee
d to
be
refe
rred
to
the
follo
win
g se
rvic
es a
spa
rt o
f th
eir
diab
etes
car
e (s
ee r
elev
ant
inte
rven
tion
map
,co
ntra
ctin
g fr
amew
ork
and
serv
ice
spec
ifica
tion)
2 :
•em
erge
ncy
and
inpa
tient
car
e •
serv
ices
for
com
plic
atio
ns –
foo
t ca
re, e
yes,
vas
cula
r et
c •
men
tal h
ealth
•
lear
ning
dis
abili
ties
•en
d of
life
car
e
Prov
ider
s sh
ould
ens
ure
acce
ss t
o tr
ansp
ort
faci
litie
s to
ena
ble
atte
ndan
ce f
or s
peci
alis
t tr
eatm
ent,
as
requ
ired
Prov
ider
s ar
e re
quire
d to
tak
e no
te o
f th
e re
sults
of
the
Nat
iona
l Sur
vey
of P
eopl
e w
ith D
iabe
tes
29
19
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
Patie
nt p
athw
ayA
t ex
it fr
om p
athw
ay:
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) un
dert
ake
tele
phon
e tr
iage
ii) m
ake
urge
nt o
nwar
d re
ferr
als
whe
relif
e-th
reat
enin
g co
nditi
ons
or s
erio
usun
expe
cted
pat
holo
gies
are
dis
cove
red
durin
g an
inte
rven
tion/
asse
ssm
ent
iii) 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 if
req
uire
div
) 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
v) e
nsur
e th
at t
he p
atie
nt r
ecei
ves
requ
ired
drug
s/dr
essi
ngs/
aids
vi) 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
Clin
ical
qua
lity
Clin
ical
em
erge
ncy
situa
tions
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
C:
6,11
,12,
14,1
5,18
,20
,32,
32,
42,
54
Mod
ule
D:
Sche
dule
s:
2, 3
, 4, 6
, 9,1
1
Abi
lity
to n
egot
iate
and
agr
eear
rang
emen
ts w
ith a
ppro
pria
tepe
rson
nel a
nd o
rgan
isat
ions
to
prov
ide
effe
ctiv
ely
for
emer
genc
ysi
tuat
ions
The
Com
mis
sion
ers
shou
ld s
atis
fyth
emse
lves
tha
t pr
ovid
er h
as s
yste
ms,
proc
esse
s an
d co
mpe
tent
per
sonn
el a
re in
plac
e an
d im
plem
ente
d to
ens
ure
that
all
clin
ical
em
erge
ncie
s an
d co
mpl
icat
ions
are
hand
led
in a
ccor
danc
e w
ith b
est
prac
tice
20
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Clin
ical
qua
lity
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 bu
ildin
gre
gula
tions
Acc
ess
to a
dvic
e on
“fit
-for
-pu
rpos
e” e
quip
men
t an
d fa
cilit
ies
Com
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
Dat
a an
din
form
atio
nm
anag
emen
t
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 cl
inic
alac
coun
tabi
litie
s of
hea
lth a
ndsa
fety
pol
icie
s
H&
S st
rate
gy a
nd p
olic
ies
in p
lace
and
impl
emen
ted
with
aw
aren
ess
thro
ugho
utth
e or
gani
satio
n
Acc
essi
bilit
y to
exe
cutiv
e re
spon
sibl
e fo
r H
&S
for
quic
ker,
first
con
tact
ser
vice
s
Hea
lth a
nd s
afet
y po
licie
s as
per
pro
vide
r ag
reem
ent
with
com
mis
sion
ers
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 t
o an
alys
e da
ta a
ndha
ve a
cces
s to
info
rmat
ion
that
can
pred
ict
tren
ds a
nd t
hat
coul
did
entif
y pr
oble
ms
The
abili
ty t
o ca
ptur
e ev
iden
ceba
sed
prac
tice
from
R&
D N
atio
nal
Serv
ice
Fram
ewor
ks, N
ICE
guid
ance
The
abili
ty t
o us
e da
ta a
ndin
form
atio
n ap
prop
riate
ly t
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tient
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Tran
spar
ency
and
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ectiv
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ider
sho
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icit
data
and
info
rmat
ion
stra
tegy
in p
lace
tha
t co
vers
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pes
of d
ata
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ualit
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dat
a•
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a pr
otec
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iden
tialit
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spar
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naly
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ata
and
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rmat
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se o
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ta a
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form
atio
n•
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sem
inat
ion
of d
ata
and
info
rmat
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sks
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arin
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dat
a an
d co
mpa
tibili
ty o
f IT
acro
ss d
iffer
ent
prov
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s w
ith r
espe
ct t
oca
re o
f pa
tient
s ac
ross
a p
athw
ay
This
info
rmat
ion
shou
ld b
e in
clud
ed in
the
Dat
a Q
ualit
y Im
prov
emen
t Pl
an
The
Prov
ider
is r
equi
red
to h
ave
info
rmat
ion
syst
ems
that
reco
rd in
divi
dual
nee
ds in
clud
ing
emot
iona
l, so
cial
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l, ec
onom
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nd b
iom
edic
al in
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atio
n w
hich
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ultid
isci
plin
ary
care
acr
oss
serv
ice
boun
darie
s an
dsu
ppor
t ca
re p
lann
ing
30
The
Prov
ider
is r
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red
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se t
he f
ollo
win
g fo
r th
e co
llect
ion
and
prod
uctio
n of
dat
a, w
here
app
ropr
iate
:
•N
HS
Out
com
es F
ram
ewor
k 24
•N
atio
nal D
iabe
tes
Info
rmat
ion
Serv
ice
31
•N
atio
nal D
iabe
tes
Aud
it 12
•D
iabe
tes
E 14
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ualit
y an
d O
utco
mes
Fra
mew
ork32
•M
yoca
rdia
l Isc
haem
ia A
udit
Proj
ect33
•N
HS
Hea
lth C
heck
s34
•H
ospi
tal E
piso
de S
tatis
tics35
21
TOPI
CEL
EMEN
TSC
HA
RA
CTE
RIS
TIC
S, S
KIL
LSA
ND
BEH
AV
IOU
RS
OU
TPU
TSD
IAB
ETES
SER
VIC
ES S
PEC
IFIC
OU
TPU
TS/C
OM
MEN
TS
Dat
a an
din
form
atio
nm
anag
emen
t
Stra
tegy
and
pol
icie
sTh
ere
shou
ld b
e po
licie
s in
pla
ce t
hat
incl
ude:
•C
onfid
entia
lity
Cod
e of
Pra
ctic
e•
Dat
a Pr
otec
tion
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eedo
m o
f In
form
atio
n•
Hea
lth R
ecor
ds•
Info
rmat
ion
Gov
erna
nce
Man
agem
ent
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form
atio
n Q
ualit
y A
ssur
ance
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form
atio
n Se
curit
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Ther
e m
ust
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nam
ed in
divi
dual
who
is t
heC
aldi
cott
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rdia
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tient
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nce
13,2
9
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tient
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isfa
ctio
n 29
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tient
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d O
utco
mes
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sure
s15
•N
atio
nal D
iabe
tes
Con
tinui
ng C
are
Dat
aset
36
22
Source documentsCommissioners and providers should takeresponsibility for making references to thelatest version of the various documents andguidance.
1. NHS Diabetes and Diabetes UK, Emotional andPsychological Support and Care in Diabetes, JointDiabetes UK and NHS Diabetes Emotional andPsychological Support, 2010http://www.diabetes.nhs.uk
2. The NHS Diabetes Commissioning Guides areavailable on the NHS Diabetes website athttp://www.diabetes.nhs.uk/commissioning_resource/
3. Standard NHS Contractshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324
4. National Quality Board, Quality Governance in theNHS, 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, Depression with a chronic physical healthproblem,http://guidance.nice.org.uk/CG91/Guidance/pdf/English, October 2009
7. NICE, Medicines adherence: involving patients indecisions about prescribed medicines andsupporting adherence, Jan 2009,http://guidance.nice.org.uk/CG76
8. European Diabetes Working Party for OlderPeople. Clinical Guidelines for Type 2 DiabetesMellitus, www.instituteofdiabetes.org
9. Diabetes UK, Minding the gap. The provision ofpsychological support and care for people withdiabetes in the UK, A report for Diabetes UK, 2008
10. NHS Institute for Innovation and Improvement,model CQUIN scheme: inpatient care for peoplewith diabetes, 2009
11. Department of Health, The Operating Frameworkfor the NHS in England 2011/12, 2010,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122738
12. National Diabetes Audit.www.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/diabetes
13. The King’s Fund, The point of care. Measures ofpatients’ experience in hospital: purpose,methods and uses. July 2009
14. DiabetesE - https://www.diabetese.net/
15. Patient Reported Outcomes Measures,http://www.ic.nhs.uk/proms
16. Diabetes UK, Good clinical practice guidelines forcare home residents with diabetes. A revisiondocument prepared by a Task and Finish Groupof Diabetes UK, 2010
17. Training, Research and Education for Nurses inDiabetes – UK, An Integrated Career &Competency Framework for Diabetes Nursing(Second Edition), 2010
18. Skills for Health, Diabetes CompetencyFramework, https://tools.skillsforhealth.org.uk/
19. Department of Health, National ServiceFramework for Older People, May 2001,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066
20. Department of Health, National ServiceFramework for Coronary Heart Disease – modernstandards and service modelshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094275
21. Department of Health, No health without mentalhealth: a cross-government mental healthoutcomes strategy for people of all ages,February 2011,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766
23
22. Department of Health, The National ServiceFramework for Long Term Conditions, March2005http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4105361
23. Department of Health, End of Life Care Strategy– promoting high quality care for all adults at theend of life, July 2008,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086277
24. Department of Health, The NHS OutcomesFramework 2011/12, December 2010http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
25. NICE, Quality Standards: Diabetes in adults,March 2011,http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp
26. NICE, Quality Standards: Chronic Kidney DiseaseQuality Standardhttp://www.nice.org.uk/guidance/qualitystandards/chronickidneydisease/ckdqualitystandard.jsp
27. Generic Long-term conditions modelhttp://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_120915
28. Department of Health, Care Planning in Diabetes:Report from the joint Department of Health andDiabetes UK Care Planning Working Group, 2006http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_063081
29. Healthcare Commission, National Survey ofPeople with Diabetes, 2006,www.cqc.org.uk/usingcareservices/healthcare/patientsurveys/servicesforpeoplewithdiabetes.cfm
30. York and Humber integrated IT systemhttp://www.diabetes.nhs.uk/
31. National Diabetes Information Service,www.diabetes-ndis.org
32. Quality and Outcomes Framework,http://www.nice.org.uk/aboutnice/qof/qof.jsp
33. Myocardial Ischaemia Audit Project (MINAP)www.rcplondon.ac.uk/CLINICAL-STANDARDS/ORGANISATION/PARTNERSHIP/Pages/MINAP-.aspx
34. Putting Prevention First, NHS Health Check,Vascular risk assessment and management , Bestpractice guidance, 2009,www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_097489
35. Hospital Episode Statistics,www.ic.nhs.uk/statistics-and-data-collections/hospital-care/hospital-activity-hospital-episode-statistics--hes
36. National Diabetes Continuing Care Dataset,www.ic.nhs.uk/webfiles/Services/Datasets/Diabetes/dccrdataset.pdf
24
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 can expectto receive.
The following documentation, developed bythe Older People with Diabetes Steering Group,provides further detail/guidance to support thedevelopment of this specification:
• The intervention map for diabetes services forolder people
• The contracting framework for diabetes servicesfor older people
This specification template assumes that the servicesare compliant with the contracting framework fordiabetes services for older people.
This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.
Description of diabetes care for olderpeople:Overall diabetes care encompasses the care an olderperson with diabetes may receive ranging frompreventative, diagnostic and continuingmanagement, including general principles for specificaspects of diabetic treatment such as for mentalhealth, foot care etc up to the end of life. For furtherdetails of the specific aspects of care, thecommissioner is referred to the relevant patient
journey, contracting framework and specificationtemplate for the care in question.
The final specification should take into account:
• national, network and local guidance andstandards for diabetes services for olderpeople.
• 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/relationships whichinfluence the services, e.g. multi-disciplinary teametc
• 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, includingarrangements for clinical accountability andresponsibility, as appropriate
Standard Service SpecificationTemplate for Diabetes Services forOlder People
a Standard NHS Contracts http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324
25
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. older people withdiabetes)
• What the services aim to achieve within a giventimeframe
• 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 interventionsthat are required for the types of need the serviceswill respond to.
• How the services responds to age, culture,disability, and gender sensitive issues
• Assessment – details of what it is and co-morbidity assessment and referrals to allrelevant specialties
• Service planning – High level view of what theservices are and how they are used; howpatients enter the pathway/journey; what arethe stages undertaken, e.g. diagnosis,continuing management up to end of life care.The aims of service planning are to:
o Develop, manage and review interventionsalong the patient journey
o Ensure access to other specialities /care, asappropriate
o Ensure that care planning is undertaken bythe diabetes multi-disciplinary team (asdefined locally) with a clear care co-ordination function
• Holistic review of patients in the managementof their diabetes using the principles of anintegrated care model for people with long termconditions that is patient-centred, including selfcare and self management, clinical treatment,facilitating independence, psychological supportand other social care issues
• Risk assessment procedures
• Detail of evidence base of the service – i.e. thecontracting framework for diabetes services forolder people, guidance produced by the RoyalCollege of Physicians, Diabetes UK, etc
Service Delivery3. Patient Journey/ intervention map
Flow diagram of the patient pathway showingaccess and exit/transfer points – see the diabetesservices for older people patient intervention mapas a starting point
4. Treatment protocols/interventionsInclude all individual treatment protocols in placewithin the services or planned to 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 older peoplewho live in the commissioning consortium area
• Hours of operation including, week-end, bankholiday and on-call arrangements
• 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)
• Confirmation of the arrangements to identifythe Care Co-ordinator for each patient withdiabetes (i.e. who holds the responsibility androle).
• Staff induction and developmental training
6. Equipment• Upgrade and maintenance of relevant
equipment and facilities
• Technical specifications (if any)
26
Identification, Referral and Acceptancecriteria7. This should make clear how patients will be
identified, assessed (if appropriate) and acceptedto the services. Acceptance should be based ontypes of need and/or patient.
8. How should patients be referred?
• Who is acceptable for referral and from where
• Details of evaluation process - Are there clearexclusion criteria or set alternatives to theservice? How might a patient be transferred?
• Response time detail and how are patientsprioritised
Discharge/Service Complete/PatientTransfer criteria9. The intention of this section is to make clear when
a patient should be transferred from one aspect ofthe diabetes service to another is and when thiswould be reached.
• How is a treatment pathway reviewed?
• How does the service decide that a patient isready for discharge
• How are goals and outcomes assessed andreviewed?
• What procedure is followed on discharge,including arrangements for follow-up
Quality Standards10. The service is required to deliver care according to
the standards for clinical practice set by theNational Institute for Health and ClinicalExcellenceb
11. As a minimum, the Provider is required to agree alocal Commissioning for Quality and Innovationscheme for services for people with diabetes.(Insert details of the CQUIN Scheme agreed)
12. The service is required to deliver the outcomes fordiabetes as determined by the NHS OutcomesFrameworkc
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 identified andbrought to the attention of the commissioner.
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
b http://www.nice.org.uk/media/FCF/87/DiabetesInAdultsQualityStandard.pdf
c http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
Further copies of this publication can be ordered from Prontaprint, by emailing [email protected] or tel: 0116 275 3333, quoting DIABETES 118
www.diabetes.nhs.uk