commissioning services for children and young people with ... · commissioning services for...
TRANSCRIPT
Commissioning Services for Children
and Young Peoplewith Diabetes
Supporting, Improving, Caring
February 2010
NHS Diabetes Information Reader Box
Review Date 2012
3
This commissioning guide has been developed byNHS Diabetes with key stakeholders includingclinical and social services professionals and patientgroups represented by Diabetes UK.
It is not designed to replace the Standard NHSContracts as many of the legal and contractualrequirements have already been identified in thisset of documents. Rather, it is intended to form thebasis of a discussion or development of diabetesservices for children and young people betweencommissioners and providers from which acontract for services can then be agreed.
This commissioning guide consists of:
• A description of the key features of high qualitydiabetes services for children and young peopleincluding the arrangements for transition toadult diabetes services
• A high level intervention map . This interventionmap describes the key high level actions orinterventions (both clinical and administrative)diabetes services for children and young peopleshould undertake in order to provide the mostefficient and effective care, from admission totransfer to adult diabetes services. For continuity,the intervention map also shows possible actionto be taken with respect to prevention and riskassessment services. Commissioners are referredto the diabetes prevention and risk assessmentcommissioning guide for further detailswww.nhs.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement
It is not intended to be a care pathway or clinicalprotocol, rather it describes how a true ‘diabeteswithout walls’ service should operate goingacross the current sectors of health care.
The intervention map may describe currentservice models or it may describe what shouldideally be provided by diabetes services forchildren and young people.
• A contracting framework for diabetes servicesfor children and young people that bringstogether all the key standards of quality andpolicy relating to diabetes and children andyoung people
• Template service specifications for
o diabetes services for children and youngpeople
o diabetes transition services for childrenand young people
The templates form part of schedule 2 of theStandard NHS Contract covering the key headingsrequired of a specification. It is recommended thatthe commissioner checks which mandatoryheadings are required for each type of care asspecified by the Standard NHS Contracts.
For further detail on how to approach thecommissioning of diabetes services please seehttp://www.diabetes.nhs.uk/commissioning_resource
Commissioning Diabetes Servicesfor Children and Young People
4
High quality diabetes services for children andyoung people should be:
• be developed in a co-ordinated way, taking fullaccount of the responsibilities of other agenciesin providing comprehensive care (as set out inNational Standards, Local Actioni)
• 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 choice model for themanagement of long term conditionsii
• provide effective and safe care to young peoplewith diabetes in a range of settings includingthe patient’s home, according to recognisedstandards including the Diabetes NSFiii
• take into account the emotional, psychologicaland mental wellbeing of the young personiv
• ensure that the family/carers of young peoplewith diabetes have access to psychologicalsupport
• take into account all diverse and personal needswith respect to access to care
• ensure that services are responsive andaccessible to young people with LearningDisabilitiesv
• take into account race and inequalities withrespect to access to care
• have effective clinical networks, with clearclinical leadership, across the boundaries of care
• ensure that there are a wide range of optionsavailable to young people with diabetes to
support self management and individualpreferences
• take into account services provided by socialcare and the voluntary sector
• provide patient/carer/family education ondiabetes not only at diagnosis but also duringcontinuing management at every level of care
• provide education on diabetes management toother staff and organisations that support youngpeople with diabetes
• deliver care in accordance with the Conventionon the Rights of the Childvi
• provide age and development appropriatestructured education of children and youngpeople and their family in the best managementof the diabetes with the aim of the child andfamily managing their own condition
• provide support in schools and othereducational settings and in the workplace toenable children and young people to achieve thebest control of their condition
• provide access to a Children and Young Peoples’Specialist Multidisciplinary Diabetes care team(CYPSD) with appropriate training andcompetencies
• ensure arrangements for the smooth transitionbetween children and adult services that takeinto account the developmental needs andpersonal choices of the individual
• have specific local agreements that enable 24hour access to emergency advice fromcompetent staff
Features of Diabetes Services forChildren and Young People
i Available on the DH website at http://www.dh.gov.uk/assetRoot/04/08/60/58/04086058.pdf
ii Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081105
iii Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4096591
iv Emotional and Psychological Support and Care in Diabetes, Joint Diabetes UK and NHS Diabetes Emotional and PsychologicalSupport Working Group, February 2010
v http://www.diabetes.nhs.uk/ commissioning_resource/step_3_service_improvement/
vi United Nations Convention on the Rights of the Child, November 1989
5
vi See York and Humber integrated IT system at http://www.diabetes.nhs.uk/document.php?o=610
• have provision outside of 9 to 5 , Monday toFriday, for care (not only emergency advice) toencourage full participation in school, and tosupport working parents
• have a capable and effective workforce with theappropriate training, skills and competencies inthe management of young people withdiabetes, and ensure these are continuouslyupdated
• 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 audits
• have adequate governance arrangements, e.g.local mortality and morbidity meetings ondiabetes care to learn from errors and improvepatient safety
• actively monitor the uptake of services,responding to non-attenders and monitoringcomplaints and untoward incidents
6
NH
S D
iab
etes
Ch
ildre
n a
nd
Yo
un
g P
eop
le w
ith
Dia
bet
es –
dia
gn
osi
s an
d in
itia
l man
agem
ent
Ref
erra
l fro
m
oth
er s
ervi
ces
-E.
g. A
nten
atal
, m
enta
l hea
lth,
prim
ary
care
,
etc
CY
Pd
iab
etic
em
erg
ency
in
th
e co
mm
un
ity
-se
e C
omm
issi
onin
ggu
ide
for
emer
genc
y an
d in
pat
ient
car
e
Ad
mis
sio
nfo
r fi
rst
dia
bet
ic
emer
gen
cy
epis
od
e in
a
pre
vio
usl
y u
nkn
ow
n
dia
bet
ic
Imm
edia
tecl
inic
al
asse
ssm
ent
and
trea
tmen
t
-re
susc
itate
-st
abili
se
-in
itiat
e in
sulin
th
erap
y ac
cord
ing
to
BSPE
D g
uide
lines
Urg
ent
refe
rral
to
C
YPS
Dte
am
CY
PSD
tea
m
Phys
ical
an
d
men
tal
asse
ssm
ent
and
init
ial
inve
stig
atio
ns
-as
sess
men
t
- he
ight
and
wei
ght
mea
sure
men
ts
Dia
gn
osi
sd
iscu
ssed
wit
h
pat
ien
t an
d
fam
ily, a
s ap
pro
pri
ate
Car
e p
lan
nin
g
agre
ed a
nd
in
itia
ted
wit
h
pat
ien
t an
d f
amily
in
volv
emen
t
-in
form
atio
n on
tr
eatm
ent
optio
ns
-co
ntin
ue t
reat
men
t as
agr
eed
-co
ntac
t de
tails
for
24
hr a
cces
s to
C
YPS
D t
eam
-ca
re c
oord
inat
ion
proc
ess
iden
tifie
d
Fam
ily /
care
r n
eed
s as
sess
ed
-ac
cess
to
advo
cacy
ser
vice
s, if
re
quire
d
-ad
vice
on
supp
ortin
g C
YP
with
di
abet
es
-av
oidi
ng c
ompl
icat
ions
of
diab
etes
-ad
dres
s sp
ecifi
c ne
eds
of
child
ren
in c
are
and
thei
r ca
rers
Car
e co
ord
inat
or
resp
on
sib
iliti
es
iden
tifi
ed
Ap
po
intm
ent
for
con
tin
uin
g
man
agem
ent
Put
on
d
iab
etes
reg
iste
r
Go
to
p
age
7
Liai
son
wit
h
sch
oo
l
-in
divi
dual
med
ical
man
agem
ent
plan
-tr
aini
ng f
or s
choo
l sta
ff-
polic
y fo
r m
anag
ing
med
icin
es in
sc
hool
s
Psyc
ho
log
ical
su
pp
ort
, if
nec
essa
ry
-sc
reen
for
anx
iety
/dep
ress
ion/
poss
ible
ea
ting
diso
rder
s et
c-r
efer
ral t
o ps
ycho
logi
cal t
hera
pies
, if
appr
opria
te-
links
with
CA
MH
S
Ref
erra
l re:
re
leva
nt
soci
al
fact
ors
E.g.
-su
ppor
t to
fam
ily-
empl
oym
ent/
finan
cial
adv
ice
-lo
cal p
aren
t/C
YP
supp
ort
grou
p-
refe
rral
to
Dia
bete
s U
K
Ref
erra
l to
oth
er
dia
bet
es s
pec
ialis
t ca
re
Ref
erra
l to
scr
een
ing
an
d
pre
ven
tio
n s
ervi
ces
E.g.
-ex
erci
se p
rogr
amm
es-
heal
thy
diet
reg
imes
-re
tinop
athy
scr
eeni
ng, p
odia
try
etc
Incl
udes
:-
inpa
tient
ca
re-
kidn
ey c
are
-pr
egna
ncy
and
diab
etes
ca
re-f
oot
care
-le
arni
ng
disa
bilit
y
Hea
lth
Nee
ds
Ass
essm
ent
Children and Young People withDiabetes Intervention Map
7
NH
S D
iab
etes
Ch
ildre
n a
nd
Yo
un
g P
eop
le w
ith
Dia
bet
es –
Co
nti
nu
ing
car
e
Fro
m
Pag
es 6
an
d 9
Reg
ula
r sc
reen
ing
(fro
m a
ge
12
on
war
ds)
Co
nti
nu
ing
ed
uca
tio
n
Hea
lth
pro
mo
tio
n
acti
viti
es
Ref
erra
l to
oth
er
dia
bet
es s
pec
ialis
t ca
re
Car
e co
-ord
inat
or t
o m
anag
e pr
oces
san
d en
sure
com
mun
icat
ion
Incl
udes
:-
in p
atie
nt h
ospi
tal c
are
-ki
dney
car
e-
preg
nanc
y an
d di
abet
es c
are
-fo
ot c
are
-C
AM
HS
-le
arni
ng d
isab
ility
Car
e p
lan
nin
g r
evie
w(p
hys
ical
/so
cial
/p
sych
olo
gic
al/
emo
tio
nal
)
-as
sess
men
t, in
clud
ing
glyc
aem
ic c
ontr
ol
acco
rdin
g to
agr
eed
prot
ocol
s
-as
sess
men
t of
life
styl
e ac
tiviti
es in
clud
ing
diet
, etc
-as
sess
men
t of
insu
lin
regi
men
s
-as
sess
men
t of
gro
wth
and
w
eigh
t
-ac
cess
to
advo
cacy
se
rvic
es, i
f re
quire
d
-fa
mily
and
car
er’s
nee
ds
e.g.
-re
tinal
-
rena
l etc
-
see
rele
vant
com
mis
sion
ing
guid
es
-ag
e an
d de
velo
pmen
t ap
prop
riate
str
uctu
red
educ
atio
n-
driv
ing
and
the
law
-lif
esty
le –
e.g.
smok
ing,
alc
ohol
, su
bsta
nce
mis
use,
se
xual
hea
lth e
tc
Inte
rven
tio
n
req
uir
ed?
Yes No
Ref
erra
l fo
r ap
pro
pri
ate
care
Is t
he p
atie
nt
read
y fo
r tr
ansi
tion
to
adu
lt s
ervi
ces?
-tr
ansi
tion
serv
ices
crit
eria
-di
scus
sion
with
pat
ient
and
fa
mily
/car
er
-ca
re c
o-or
dina
tor
to
man
age
proc
ess
and
ensu
re c
omm
unic
atio
n
No
Dat
e o
f n
ext
care
pla
n
agre
ed
Yes
-tr
ansi
tion
care
pl
an a
gree
d
-ca
re c
o-or
dina
tor
to m
anag
e pr
oces
s an
d en
sure
co
mm
unic
atio
n
-in
form
GP
Go
to
Pa
ge
8
See
rele
vant
co
mm
issi
onin
g gu
ides
-co
ntin
uing
ed
ucat
ion
Co
nti
nu
ing
su
pp
ort
-ac
cess
to
24hr
hel
plin
e-
tele
phon
e ac
cess
to
CY
PSD
tea
m
8
NH
S D
iab
etes
Ch
ildre
n a
nd
Yo
un
g P
eop
le w
ith
Dia
be
tes
–Tr
ansi
tio
n s
ervi
ces
Fro
m
Pag
e 7
Ref
erra
l fro
m
CY
PSD
tea
m
Ref
erra
l fro
m
oth
er
seco
nd
ary
care
ser
vice
s
Ref
erra
l fro
m
pri
mar
y ca
re
Ap
po
intm
ent
mad
e at
D
iab
etes
Tr
ansi
tio
n
Serv
ice
Ass
essm
ent
at
join
t d
iab
etes
p
aed
iatr
ic/
adu
lt c
linic
-ob
tain
cl
inic
al
reco
rds
Ref
erra
l to
sp
ecia
list
care
, if
app
rop
riat
e
Ag
ree
new
ca
re p
lan
-jo
int
paed
iatr
ic/
adul
t re
view
-ca
re c
o-or
dina
tor
to c
ontin
ue t
o m
anag
e tr
ansi
tion
Hea
lth
edu
cati
on
an
d
psy
cho
log
ical
su
pp
ort
-e.
g. d
iet
smok
ing,
alc
ohol
, su
bsta
nce
mis
use,
re
latio
nshi
ps, s
ex
and
preg
nanc
y
-lia
ison
with
sc
hool
soc
ial
serv
ices
etc
Incl
udes
:
-in
pat
ient
car
e-
kidn
ey c
are
-pr
egna
ncy
and
diab
etes
ca
re-
foot
car
e-
CA
MH
S-
lear
ning
dis
abili
ty
Reg
ula
r re
view
Dis
char
ge
fro
m t
ran
siti
on
se
rvic
es?
No
Yes
Ref
erra
l to
ad
ult
d
iab
etes
ser
vice
-di
scha
rge
info
rmat
ion
to
GP
-ha
nd o
ver
of
care
co-
ordi
natio
n to
ad
ult
serv
ices
Dis
char
ge
fro
m d
iab
etes
tr
ansi
tio
n
serv
ice
9
NH
S D
iab
etes
Ch
ildre
n a
nd
yo
un
g p
eop
le w
ith
dia
bet
es -
Plan
ned
in p
atie
nt
care
Ass
essm
ent
by
CY
P d
iab
etes
lead
-de
cisi
on t
o un
dert
ake
oper
atio
n/
proc
edur
e
-de
cisi
on t
o un
dert
ake
day
case
or
in p
atie
nt
adm
issi
on
-gi
ve p
re-o
pera
tive/
pr
oced
ure
inst
ruct
ions
-lia
ison
with
car
e co
-ord
inat
or
Plan
to
ac
hie
ve g
oo
d
gly
caem
ic
con
tro
l
-C
YP
diab
etes
tea
m
to m
anag
e w
ith p
atie
nt
-ad
mis
sion
ca
re p
lan
Pre-
op
erat
ive/
p
roce
du
re
asse
ssm
ent
-cl
erki
ng a
nd
inve
stig
atio
nsac
cord
ing
to
agre
ed
prot
ocol
s
Go
od
gly
caem
icco
ntr
ol?
No
Ass
ess
risk
of
dela
y in
op
erat
ion
/ pr
oced
ure
vs p
oor
post
op
erat
ive/
pro
cedu
ral
diab
etes
con
trol
Go
ah
ead
wit
h
pro
ced
ure
/ o
per
atio
n?
No
Yes
Yes
Peri
-o
per
ativ
e/
pro
ced
ure
man
agem
ent
of
dia
bet
es
-ac
cord
ing
to
agre
ed
prot
ocol
s
Post
-o
per
ativ
e/
pro
ced
ure
man
agem
ent
of
dia
bet
es
-ai
m t
o ac
hiev
e go
od g
lyca
emic
co
ntro
l fro
m d
ay
one
post
-op
/pr
oced
ure
-ot
her
post
-op
erat
ive/
pr
oced
ure
care
as
req
uire
d
-pr
omot
e se
lf ca
re o
f di
abet
es
Pati
ent
read
y fo
r d
isch
arg
e
-go
od
glyc
aem
ic
cont
rol
-go
od p
ost
-op
erat
ive/
pr
oced
ure
reco
very
-lia
ison
with
ca
re c
o -
ordi
nato
r
Dis
char
ge
Post
op
erat
ive/
p
roce
du
re
follo
w u
p
app
oin
tmen
t
-info
rm G
P
-di
scha
rge
med
icat
ion
-up
date
car
e pl
an
Go
to
p
age
7
Ref
erra
l fo
r in
p
atie
nt
pro
ced
ure
10
NH
S D
iab
etes
Ch
ildre
n a
nd
Yo
un
g P
eop
le w
ith
Dia
bet
es -
Prev
enti
on
of
Typ
e 2
dia
bet
es
-na
tiona
l and
loca
l ca
mpa
igns
on
diab
etes
an
d re
late
d co
nditi
ons,
e.
g. O
besi
ty, C
HD
etc
- ta
rget
ing
spec
ific
popu
latio
ns, e
.g. O
bese
, A
sian
etc
-aw
aren
ess
activ
ities
in:
-sc
hool
s-
GP
prac
tices
-su
perm
arke
ts-
spor
ts c
entr
es-
phar
mac
ies
-LT
C c
entr
es-
pubs
/clu
bs-
mat
erni
ty u
nits
-lo
cal e
mpl
oyer
s-
yout
h cl
ubs
e.g.
-G
P pr
actic
es
-ph
arm
acie
s
-ad
vice
on
self
man
agem
ent
- ad
vice
on
prev
entio
n of
ty
pe 2
dia
bete
s
-pa
edia
tric
ob
esity
/ov
erw
eigh
t cl
inic
e.g.
-W
eigh
t/BM
I
-U
rinar
y gl
ucos
e et
c, a
ccor
ding
to
agre
ed p
roto
cols
Hig
hR
isk?
Yes No
Ref
er f
or
dia
gn
osi
sG
o t
o
Pag
e 6
Dis
cuss
ion
and
ad
vice
-he
alth
y lif
esty
leR
efer
ral t
o o
ther
p
reve
nti
on
se
rvic
es
CY
P cl
inic
s fo
r:-
wei
ght
man
agem
ent
prog
ram
mes
-he
alth
y di
et r
egim
es
-ex
erci
se f
acili
ties
-m
otiv
atio
nal
wor
ksho
ps
-sm
okin
g ce
ssat
ion
Follo
w u
p, a
s re
qu
ired
Follo
w u
p,
asap
pro
pri
ate
Scre
enin
g o
f p
atie
nts
Dia
bet
es
pre
ven
tio
n
serv
ices
Ref
erra
l (se
lf
or
dir
ecte
d)
Rai
sin
g
awar
enes
sH
ealt
h N
eed
s A
sses
smen
t
CY
P w
ith
co
-m
orb
idit
ies,
e.g
. cy
stic
fib
rosi
s,
can
cer,
au
tist
ic
spec
tru
md
iso
rder
s et
c
11
IntroductionThis contracting framework sets out what is requiredof clinically safe and effective services that areproviding care for children and young people (CYP)with diabetes. The framework is designed to be readin conjunction with the children and young peoplewith diabetes intervention map, which describes theinterventions and actions required along the patientpathway as well as entry and exit points and thestandard service specification template for childrenand young people with diabetes services. Much ofthis document is based on Making Every YoungPerson with Diabetes Matter1.
The framework brings together the key qualityareas and standards that have been identified bythe National Paediatric Diabetes Network.
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 or Care Plan and thedelivery of the clinical processes conventionally sitswithin one organisation. However, with a morecomplex pathway, there is a danger that fracturingthe overall 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 Services forChildren and Young People with Diabetes
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.
Services for children and youngpeople with diabetes The key principles of good care for children andyoung people with diabetes is to provide a highquality service that is reliable in terms of delivery andtimely access for patients requiring that care.
Care for children and young people with diabetesmust be provided by a specialist CYP team. It isessential that there is co-ordination of care of thepatients through the care planning process and thatthe patient’s paediatric diabetologist retains theresponsibility for overall patient care across thewhole pathway and retains overall responsibility forthe management of side effects and complications.
The initial management and continuing care ofchildren and young people with diabetes shouldinclude an assessment of their emotional andpsychological well-being, together with timely accessto appropriate psychological andbiological/psychiatric interventions. Mental healthdisorders can pose significant barriers to diabetescare and therefore mental health stability is vital forgood self care2.
The CYP service itself will also have clinical oversightand accountability for governance purposes.
This contracting framework covers both paediatricdiabetes care and transition to adult services. Thiscontracting framework should also be read inconjunction with the diabetes commissioning guidesfor emergency and in patient care for people withdiabetes3 and diabetes prevention and risk
assessment services4 and follow the principles for theeffective commissioning of services for people withLearning Disabilities5.
Ensuring qualityCommissioning Bodies should ensure that the CYPdiabetes services commissioned are of the highestquality. There may, in addition, be someorganisations that wish to offer their services, but donot have a history of providing such care.
i) For provider organisations already involved inthe delivery of CYP diabetes services, thereshould be retrospective evidence of systemsbeing in place, implemented and working.
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 CYP diabetesservices 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 for AcuteServices – bilateral (main clauses and schedules)6.(The cross references also apply to the clauses andschedules in the Standard NHS Contract forCommunity 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.
13
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
Lead
ersh
ip
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:11
,16,
19,3
3,48
,49,
51,5
3, 6
0
Sche
dule
s: 1
0
Cla
rity
of t
he o
rgan
isat
ion’
spu
rpos
e w
ith e
xplic
itco
mm
itmen
t to
pro
vidi
ng h
igh
qual
ity s
ervi
ces
A c
ultu
re t
hat
dem
onst
rate
s an
open
lear
ning
eth
os
An
orga
nisa
tion
that
is le
gal a
ndet
hica
l in
all i
ts a
ctiv
ities
Prov
ider
mus
t ha
ve o
rgan
isat
iona
l str
uctu
reth
at p
rovi
des
lead
ersh
ip f
or a
ll pr
ofes
sion
san
d di
scip
lines
In p
artic
ular
, the
re m
ust
be a
cor
pora
tecl
inic
al d
irect
or w
ith t
he r
espo
nsib
ility
and
acco
unta
bilit
y fo
r th
e cl
inic
al s
ervi
ce
Ther
e m
ust
be a
lear
ning
fra
mew
ork
in t
heor
gani
satio
n
Ther
e sh
ould
be
a de
signa
ted
clin
ical
dire
ctor
with
resp
onsib
ility
and
acco
unta
bilit
y fo
r the
CY
P di
abet
es s
ervi
ce
Gov
erna
nce
Inte
grat
ed G
over
nanc
e
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:11
,19,
27,4
8,49
,51
,53,
54,5
6,60
Sche
dule
s:
10
An
orga
nisa
tion
that
is g
uide
d by
the
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 a
nd t
rans
ition
sbe
twee
n se
rvic
es
Gov
erna
nce
Clin
ical
Gov
erna
nce
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:4,
4A,6
,9,1
0,12
,14,
15,1
6,17
,19,
21,2
5,26
27,2
9,30
,32,
33,
48,4
9,51
,53,
54
Sche
dule
s:
3 (p
arts
3,4
A a
nd 4
B),
10,1
2,18
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
of a
ccou
ntab
ility
and
res
pons
ibili
ty f
or a
llcl
inic
al g
over
nanc
e fu
nctio
ns
e.g.
•
Clin
ical
Aud
it•
Clin
ical
Ris
k M
anag
emen
t•
Unt
owar
d In
cide
nt R
epor
ting
•In
fect
ion
Con
trol
•M
edic
ines
Man
agem
ent
•In
form
ed C
onse
nt•
Rais
ing
Con
cern
s•
Staf
f D
evel
opm
ent
•C
ompl
aint
s M
anag
emen
t
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
HSL
A m
ust r
evie
w C
NST
arra
ngem
ents
/or o
ther
org
anisa
tiona
l / p
rofe
ssio
nal i
ndem
nity
arra
ngem
ents
The
serv
ice
shou
ld h
ave
in p
lace
writ
ten
prot
ocol
s an
dpr
oced
ures
def
inin
g cl
ear l
ines
of a
ccou
ntab
ility
and
resp
onsib
ility
.
The
serv
ice
is re
quire
d to
com
ply
with
gui
delin
es p
rodu
ced
byth
e N
atio
nal I
nstit
ute
for H
ealth
and
Clin
ical
Exc
elle
nce
that
are
rele
vant
to th
e ca
re p
rovi
ded
by th
e se
rvic
e in
clud
ing:
•D
iagn
osis
and
man
agem
ent o
f Typ
e 1
diab
etes
in c
hild
ren,
youn
g pe
ople
and
adu
lts7
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
Clin
ical
Gov
erna
nce
•Pa
tient
and
Pub
lic In
volv
emen
t•
Patie
nt d
igni
ty a
nd r
espe
ct
•Eq
ualit
y an
d di
vers
ity•
Intr
oduc
ing
new
tec
hnol
ogie
s an
dtr
eatm
ents
•A
n ex
tern
ally
acc
redi
ted
Qua
lity
Ass
uran
cesy
stem
and
inte
rnal
err
or r
epor
ting
invo
lvin
g al
l sta
ff g
roup
s.
CG
sys
tem
s sh
ould
hav
e cl
ear
and
dem
onst
rabl
e lin
ks t
o ot
her
NH
S sy
stem
sw
ith c
olla
bora
tive
CG
act
iviti
es a
nd s
harin
gof
exp
erie
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
NH
S C
Gre
port
ing
syst
em
Prov
ider
s ar
e re
quire
d to
agr
eeC
omm
issi
onin
g fo
r Q
ualit
y an
d In
nova
tion
sche
mes
for
dia
bete
s ca
re f
or C
YP,
e.g
.m
odel
CQ
UIN
sch
eme
prop
osed
by
the
NH
SIn
stitu
te f
or In
nova
tion
and
Impr
ovem
ent
18
•Ty
pe 2
dia
bete
s: th
e m
anag
emen
t of t
ype
2 di
abet
es (u
pdat
e) 8
•M
anag
emen
t of T
ype
2 di
abet
es -
prev
entio
n an
dm
anag
emen
t of f
oot p
robl
ems
9
•D
iabe
tes
in p
regn
ancy
: m
anag
emen
t of d
iabe
tes
and
itsco
mpl
icat
ions
from
pre
-con
cept
ion
to th
e po
st n
atal
per
iod
10
•Ty
pe 2
dia
bete
s: n
ewer
age
nts
for b
lood
glu
cose
con
trol
inty
pe 2
dia
bete
s11
•Pr
imar
y pr
even
tion
of ty
pe 2
dia
bete
s m
ellit
us a
mon
g hi
gh ri
skbl
ack
and
min
ority
eth
nic
grou
ps 12
•Th
e cl
inic
al e
ffec
tiven
ess
and
cost
eff
ectiv
enes
s of
long
act
ing
insu
lin a
nalo
gues
for d
iabe
tes
13
•Th
e cl
inic
al e
ffec
tiven
ess
and
cost
eff
ectiv
enes
s of
pat
ient
educ
atio
n m
odel
s fo
r dia
bete
s 14
•C
ontin
uous
sub
cuta
neou
s in
sulin
infu
sion
for t
he tr
eatm
ent o
fdi
abet
es (r
evie
w)15
•D
epre
ssio
n w
ith a
chr
onic
phy
sical
hea
lth p
robl
em 16
•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 17
In a
dditi
on, C
YP
diab
etes
mul
tidisc
iplin
ary
team
s sh
ould
2 :•
be a
lert
to th
e de
velo
pmen
t or p
rese
nce
of c
linic
al o
r sub
-cl
inic
al d
epre
ssio
n an
d/or
anx
iety
, in
part
icul
ar w
here
som
eone
repo
rts
or a
ppea
rs to
be
havi
ng d
iffic
ultie
s w
ith s
elf-
man
agem
ent.
•be
abl
e to
det
ect a
nd b
asic
ally
man
age
non
-sev
ere
psyc
holo
gica
l diso
rder
s in
peo
ple
from
diff
eren
t cul
tura
lba
ckgr
ound
s•
be fa
mili
ar w
ith c
ouns
ellin
g te
chni
ques
and
dru
g th
erap
y,w
hile
arr
angi
ng p
rom
pt re
ferr
al to
men
tal h
ealth
spe
cial
ists
•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
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
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 Acu
te S
ervi
ces
Mai
n cl
ause
s:11
,16,
19,2
5,26
,33
,48,
56
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
•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 a
nd c
hild
rens
’ tra
ined
whe
re th
ey a
re lo
okin
g af
ter
child
ren
•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
and
chi
ldre
n’s
trai
ned
whe
re th
ey a
re lo
okin
g af
ter c
hild
ren
All
heal
thca
re p
rofe
ssio
nals
invo
lved
in d
eliv
erin
g C
YP
diab
etes
care
are
requ
ired
to h
ave
the
follo
win
g re
leva
nt c
ompe
tenc
ies22
:
•D
iab
CY
P01
– Id
entif
y sy
mpt
oms
of d
iabe
tes
in a
chi
ld o
ryo
ung
pers
on a
nd re
fer t
hem
for f
urth
er a
sses
smen
t•
Dia
b C
YP0
2 - A
sses
s a
child
/you
ng p
erso
n w
ith s
ympt
oms
ofdi
abet
es a
nd m
ake
a di
agno
sis•
Dia
b C
YP0
3 –
Info
rm a
chi
ld o
r you
ng p
erso
n an
d th
eir f
amily
of a
dia
gnos
is of
Typ
e 1
diab
etes
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 Acu
te S
ervi
ces
Mai
n cl
ause
s:4,
12,1
6,17
,18,
19,2
0,21
,30,
31,
32,3
3, 5
4
Sche
dule
s:
2,3
(par
t 4A
and
4B)
,10
,12,
18
Und
erst
andi
ng th
e co
ncep
t of
qual
ity
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
Acc
ess
targ
ets
for C
YP
diab
etes
ser
vice
s:
•A
ll C
YP
with
new
ly d
iagn
osed
dia
bete
s sh
ould
be
seen
by
the
CY
P sp
ecia
list d
iabe
tes
team
with
in 2
4 ho
urs
of re
ferr
al•
All
CY
P w
ith d
iabe
tes
to b
e se
en w
ithin
4 w
eeks
of r
efer
ral t
oot
her s
ervi
ces
e.g.
pod
iatr
y, p
sych
olog
y, o
ptom
etry
etc
•A
ll gi
rls w
ith d
iabe
tes
who
are
pre
gnan
t sho
uld
be re
ferr
ed to
join
t CY
P di
abet
es a
nd a
nten
atal
ser
vice
s w
ithin
thre
e da
ys.
The
serv
ice
is re
quire
d to
par
ticip
ate
in th
e fo
llow
ing
natio
nal
audi
t act
iviti
es/p
rogr
amm
e:
•N
atio
nal D
iabe
tes
Aud
its19
(CY
P au
dits
)•
Act
ive
mem
bers
hip
of R
egio
nal P
aedi
atric
Dia
bete
s N
etw
ork
•Pa
tient
Exp
erie
nce
Surv
eys
20
•D
iabe
tes
E 21
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 a
ttrib
utes
criti
cal t
o sa
fety
and
qual
ity o
f int
erve
ntio
ns
•D
iab
CY
P04
– in
form
a c
hild
/you
ng p
erso
n an
d th
eir f
amily
of
a di
agno
sis o
f Typ
e 2
diab
etes
or i
mpa
ired
gluc
ose
tole
ranc
e•
Dia
b C
YP0
5 –
prov
ide
ther
apy
to m
eet t
he im
med
iate
heal
thca
re n
eeds
of t
he c
hild
or y
oung
per
son
new
lydi
agno
sed
with
Typ
e 1
diab
etes
and
thei
r fam
ily•
Dia
b C
YP0
6 –
supp
ort a
chi
ld/y
oung
per
son
with
Typ
e 1
diab
etes
and
thei
r fam
ily in
the
early
sta
ges
afte
r dia
gnos
is•
Dia
b C
YP
07- p
rovi
de in
form
atio
n an
d su
ppor
t to
a ch
ild o
ryo
ung
pers
on re
cent
ly d
iagn
osed
with
Typ
e 1
diab
etes
and
thei
r fam
ily to
ena
ble
them
to e
stab
lish
safe
and
die
tary
aim
s•
Dia
b C
YP
08 -
sup
port
a c
hild
/you
ng p
erso
n w
ith T
ype
1di
abet
es a
nd th
eir f
amily
in th
e fir
st y
ear a
fter
dia
gnos
is•
Dia
b C
YP0
9 –
enab
le a
chi
ld o
r you
ng p
erso
n w
ith T
ype
1di
abet
es a
nd th
eir f
amily
dev
elop
thei
r kno
wle
dge
and
skill
sab
out d
iet a
nd d
iabe
tes
•D
iab
CY
P10
– ga
ther
and
eva
luat
e in
form
atio
n to
est
ablis
hth
e he
alth
care
nee
ds o
f chi
ldre
n an
d yo
ung
peop
le w
ithdi
abet
es•
Dia
b C
YP1
1 –
agre
e in
divi
dual
ised
care
pla
ns w
ith c
hild
ren
and
youn
g pe
ople
to m
anag
e di
abet
es•
Dia
b C
YP1
2 –
impl
emen
t and
mon
itor i
ndiv
idua
lised
car
epl
ans
to m
eet t
he n
eeds
of c
hild
ren
and
youn
g pe
ople
with
diab
etes
•D
iab
CY
P 13
– e
nsur
e th
e sa
fety
of a
chi
ld/y
oung
per
son
with
diab
etes
in s
choo
l•
Dia
b C
YP
14 –
sup
port
a c
hild
/you
ng p
erso
n an
d th
eir f
amily
usin
g in
sulin
ther
apy
to m
anag
e th
eir d
iabe
tes
•D
iab
CY
P15
– en
able
a c
hild
/you
ng p
erso
n w
ith d
iabe
tes
tobe
ing
to ta
ke o
ral m
edic
atio
n to
impr
ove
thei
r hea
lth•
Dia
b C
YP1
6 –
mon
itor a
nd s
uppo
rt a
chi
ld/y
oung
per
son
with
diab
etes
usin
g or
al m
edic
atio
n to
impr
ove
thei
r hea
lth•
Dia
b C
YP1
7- p
rovi
de c
are
and
supp
ort t
o m
eet t
he im
med
iate
need
s of
the
child
or y
oung
per
son
new
ly d
iagn
osed
with
Type
2 d
iabe
tes
and
thei
r fam
ily•
Dia
b IP
T01
– as
sess
the
suita
bilit
y of
insu
lin p
ump
ther
apy
for
an in
divi
dual
with
Typ
e 1d
iabe
tes
•D
iab
IPT0
2 –
prov
ide
prel
imin
ary
educ
atio
n ab
out i
nsul
inpu
mp
ther
apy
for a
n in
divi
dual
with
Typ
e 1
diab
etes
•D
iab
IPT0
3 –
prov
ide
diet
ary
educ
atio
n fo
r an
indi
vidu
al w
ithTy
pe 1
dia
bete
s w
ho is
con
tem
plat
ing
insu
lin p
ump
ther
apy
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
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
•D
iab
IPT0
4 –
enab
le a
n in
divi
dual
with
Typ
e 1
diab
etes
toad
min
ister
insu
lin b
y pu
mp
•D
iab
IPT0
5 –
prov
ide
ongo
ing
supp
ort t
o an
indi
vidu
alad
min
ister
ing
insu
lin b
y pu
mp
•D
iab
IPT0
6 –
prov
ide
ongo
ing
diet
ary
educ
atio
n fo
r an
indi
vidu
al w
ith T
ype
1 di
abet
es a
dmin
ister
ing
insu
lin b
y pu
mp
•D
iab
TPA
01 –
ena
ble
a yo
ung
pers
on w
ith d
iabe
tes
deve
lop
self
man
agem
ent s
kills
•D
iab
TPA
02 –
hel
p a
youn
g pe
rson
man
age
thei
r dia
bete
sdu
ring
adol
esce
nce
•D
iab
TPA
03 –
hel
p a
youn
g pe
rson
pre
pare
to m
anag
e th
etr
ansf
er fr
om c
hild
ren’
s to
adu
lts h
ealth
care
ser
vice
s•
Dia
b TP
A04
– h
elp
a yo
ung
pers
on a
dapt
to a
dults
’ hea
lthca
rese
rvic
es
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 Acu
te 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
es c
are
are
requ
ired
to h
ave
the
rele
vant
com
pete
ncie
s in
usin
gap
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 Acu
te S
ervi
ces
Mai
n cl
ause
s:11
,16,
19,2
5,30
,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
ssist
ance
tode
velo
p th
eir s
kills
, kno
wle
dge
and
expe
rienc
e to
ens
ure
that
they
are
alw
ays
fully
upd
ated
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
heal
th c
are
prof
essio
nals
shou
ld h
ave
suff
icie
nt s
tudy
leav
eal
loca
tion
(tim
e an
d fin
ance
) to
enab
le th
em to
dev
elop
ski
llsap
prop
riate
ly
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
Regi
stra
tion
Org
anisa
tions
are
requ
ired
to m
eet t
he re
quire
men
tsfo
r reg
istra
tion
aspu
blish
ed b
y th
e C
are
Qua
lity
Com
miss
ion
and
Mon
itor (
as a
ppro
pria
te)
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:4,
4A,1
2,16
,19,
30,
32,3
3,48
, 54,
56
Sche
dule
: 17,
18
Com
preh
ensiv
e un
ders
tand
ing
and
com
mitm
ent t
o im
plem
entin
gna
tiona
l sta
ndar
ds
Com
plia
nce
with
Car
e Q
ualit
y C
omm
issi
onre
quire
men
ts f
or r
egis
trat
ion
for
prim
ary
and
seco
ndar
y ca
re
Com
plia
nce
with
the
follo
win
g N
atio
nal S
ervi
ce F
ram
ewor
ks,
whe
re a
pplic
able
:
•D
iabe
tes
NSF
23
•N
SF fo
r Chi
ldre
n, Y
oung
Peo
ple
and
Mat
erni
ty S
ervi
ces24
Com
plia
nce
with
Car
e Q
ualit
y C
omm
issio
n Re
view
s
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 Acu
te S
ervi
ces
Mai
n cl
ause
s:4,
4A,9
,10,
12,1
3,14
,15,
16,1
7,18
,19,
20,2
1,25
,27,
29,3
0,32
,33,
34,3
5,36
, 54
Sche
dule
s:
3 (p
arts
1 a
nd 2
)
Resp
onsiv
enes
s an
d pa
rtic
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
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
All
child
ren
and
youn
g pe
ople
(CY
P) to
be
refe
rred
to s
peci
alist
CY
P di
abet
es s
ervi
ces
on th
e da
y of
dia
gnos
is
All
CY
P an
d fa
mili
es m
ust h
ave
nam
ed le
ad p
rofe
ssio
nal a
t eve
ryst
age
thro
ugho
ut a
ge –
ban
ded
clin
ics
All
CY
P w
ith d
iabe
tes
to h
ave
stru
ctur
ed e
duca
tion
and
revi
ewat
spe
cific
tim
es a
fter
dia
gnos
is an
d at
spe
cifie
d ag
es
All
child
ren
with
dia
bete
s (u
nder
age
17)
to b
e se
en a
t lea
st 4
mon
thly
in a
spe
cial
ised
child
ren’
s or
ado
lesc
ent d
iabe
tes
serv
ices
.
All
youn
g pe
ople
with
dia
bete
s (a
ge 1
7-25
) to
be s
een
at le
ast
ever
y 6
mon
ths,
pre
fera
bly
in a
spe
cial
ist s
ervi
ce
All
CY
P to
hav
e th
eir w
eigh
t and
hei
ght m
easu
red
and
plot
ted
at e
very
revi
ew
HbA
1C to
be
mea
sure
d an
d re
cord
ed a
t lea
st e
very
4 m
onth
s
All
CY
P ag
ed o
ver 1
2 ye
ars
to h
ave
an a
nnua
l rev
iew
eve
ry y
ear
at w
hich
the
follo
win
g w
ill b
e ca
rrie
d ou
t:
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
ccou
ntab
ilitie
s sh
ould
be
agre
ed a
nddo
cum
ente
d by
all
stak
ehol
ders
If pa
rt o
r w
hole
of
the
serv
ice
is t
o be
tran
sfer
red
to o
ther
pro
vide
rs, t
here
mus
tbe
cle
ar a
nd a
gree
d su
b co
ntra
cts
onre
ferr
al c
riter
ia a
nd a
cces
s to
the
se s
ervi
ces.
At
entr
y to
pat
hway
:Th
e C
omm
issi
oner
sho
uld
assu
reth
emse
lves
tha
t th
e pr
ovid
er h
as s
yste
ms
and
proc
esse
s in
pla
ce t
o
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
•Bl
ood
pres
sure
mea
sure
men
t•
Mic
roal
bum
in m
easu
rem
ent
•Re
tinal
pho
togr
aphy
for e
arly
iden
tific
atio
n of
retin
opat
hy•
Phys
ical
exa
min
atio
n in
clud
ing
exam
inat
ion
of th
e fe
et,
perip
hera
l ner
ve fu
nctio
n an
d ap
pear
ance
of i
njec
tion
sites
•M
easu
rem
ent o
f pla
sma
crea
tinin
e
•M
easu
rem
ent o
f lip
id p
rofil
e
All
child
ren
and
youn
g pe
ople
to u
nder
go a
nnua
l scr
eeni
ng fo
rco
elia
c an
d th
yroi
d di
seas
e at
leas
t eve
ry 3
yea
rs
Serv
ices
sho
uld
try
to m
aint
ain
cont
act w
ith n
on-a
tten
dees
CY
P re
quiri
ng a
dmiss
ion
to o
r inv
estig
atio
n in
hos
pita
l for
cond
ition
s ot
her t
han
thei
r dia
bete
s sh
ould
be
care
d fo
r by
com
pete
nt s
kille
d pe
rson
nel a
ccor
ding
to th
e st
anda
rds
of in
-pa
tient
car
e fo
r chi
ldre
n an
d yo
ung
peop
le w
ith d
iabe
tes
3,25
Chi
ldre
n an
d yo
ung
peop
le m
ay n
eed
to b
e re
ferr
ed to
the
follo
win
g se
rvic
es a
s pa
rt o
f the
ir di
abet
es c
are
(see
rele
vant
inte
rven
tion
map
, con
trac
ting
fram
ewor
k an
d se
rvic
esp
ecifi
catio
n) T
he re
ferr
als
shou
ld b
e ac
cord
ing
to th
e ag
reed
clin
ical
pro
toco
ls:
•em
erge
ncy
and
inpa
tient
car
e 3
•se
rvic
es fo
r com
plic
atio
ns 26
– e.
g. fo
ot c
are,
eye
s, v
ascu
lar e
tc
•pr
egna
ncy
and
diab
etes
27
•m
enta
l hea
lth 28
•le
arni
ng d
isabi
litie
s 5
Spec
ifica
lly th
ere
shou
ld b
e1 :
•sp
ecia
list d
iagn
ostic
ser
vice
s fo
r chi
ldre
n an
d yo
ung
peop
lew
ith m
atur
ity o
nset
dia
bete
s of
the
youn
g (M
OD
Y),
neon
atal
diab
etes
and
cys
tic fi
bros
is•
links
with
Chi
ld a
nd A
dole
scen
t Men
tal H
ealth
Ser
vice
s(C
AM
HS)
and
oth
er p
sych
olog
y se
rvic
es•
clos
e lia
ison
with
the
child
/you
ng p
erso
n’s
scho
ol o
r ear
ly y
ears
sett
ing
•jo
int p
rovi
sion
of s
exua
l hea
lth a
dvic
e or
join
t wor
k w
ithyo
ung
peop
les’
sex
ual h
ealth
ser
vice
s an
d/or
prim
ary
care
•pr
econ
cept
ion
and
safe
sex
cou
nsel
ling
serv
ices
•ac
cess
to d
enta
l hea
lth a
sses
smen
t•
acce
ss to
sm
okin
g, a
lcoh
ol a
nd d
rug
prev
entio
n se
rvic
es 4
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
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
At
exit
from
pat
hway
: Th
e C
omm
issi
oner
sho
uld
assu
reth
emse
lves
tha
t pr
ovid
er h
as s
yste
ms
and
proc
esse
s, w
hich
are
agr
eed
with
all
part
ies
and
netw
orks
, in
plac
e 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
ts
for
cont
actin
g th
e pr
ovid
eran
d fo
llow
up
if re
quire
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
Serv
ices
mus
t be
prov
ided
in a
chi
ld-a
ppro
pria
te e
nviro
nmen
tw
ith c
onsid
erat
ion
for c
hild
pro
tect
ion
issue
s.
Serv
ices
sho
uld
be p
rovi
ded
outs
ide
regu
lar w
ork/
scho
ol h
ours
CY
P se
rvic
es s
houl
d be
pro
vide
d ac
cord
ing
to th
e pr
inci
ples
of
the
‘You
're W
elco
me
qual
ity c
riter
ia’ 29
For C
YP
reac
hing
an
age
such
that
they
are
read
y to
mov
e to
adul
t ser
vice
s, th
ere
shou
ld b
e cl
ear p
roto
cols
for t
rans
fer t
otr
ansit
ion
serv
ices
incl
udin
g an
indi
vidu
al tr
ansit
ion
plan
. Prim
ary
care
team
s m
ust b
e ke
pt in
form
ed o
f tra
nsiti
on a
rran
gem
ents
.
Tran
sitio
n se
rvic
es fo
r you
ng p
eopl
e:
•sh
ould
be
run
by b
oth
adul
t and
pae
diat
ric c
onsu
ltant
diab
etol
ogist
sdi
abet
olog
ists
•Th
e ca
re p
lan
mus
t be
join
tly re
view
ed a
nd a
gree
d w
ith th
epa
tient
(and
car
er, i
f app
ropr
iate
)•
Ther
e sh
ould
be
age
appr
opria
te s
cree
ning
in a
ccor
danc
e w
ithN
ICE
and
Nat
iona
l Scr
eeni
ng c
omm
ittee
gui
danc
e
Prov
ider
s ar
e re
quire
d to
take
not
e of
the
resu
lts o
f Gro
win
g up
with
Dia
bete
s –
Nat
iona
l Sur
vey
of C
YP
with
dia
bete
s 30
Clin
ical
qua
lity
Patie
nt p
athw
ay
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
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 Acu
te S
ervi
ces
Mai
n cl
ause
s:6,
11,1
2,13
,14,
15,1
8,32
,33,
42,
54
Sche
dule
s:
2, 3
(par
t 1 a
nd 3
), 12
Abi
lity
to n
egot
iate
and
agr
eear
rang
emen
ts w
ith a
ppro
pria
tepe
rson
nel a
nd o
rgan
isatio
ns to
prov
ide
effe
ctiv
ely
for e
mer
genc
ysit
uatio
ns
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
•Se
rvic
es fo
r CY
P w
ith d
iabe
tes
shou
ld p
rovi
de 2
4 ho
ur a
cces
sto
spe
cial
ist s
uppo
rt in
clud
ing
a te
leph
one
help
line1
•A
ll C
YP
and
fam
ilies
to h
ave
acce
ss to
a s
peci
alist
dia
bete
snu
rse
and
diet
itian
at f
irst a
dmiss
ion
•C
YP
requ
iring
adm
issio
n fo
r dia
bete
s em
erge
ncie
s sh
ould
be
man
aged
by
com
pete
nt s
kille
d pe
rson
nel f
amili
ar w
ith th
eBS
PED
31gu
idel
ines
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 Acu
te S
ervi
ces
Mai
n cl
ause
s:5,
29, 3
0, 3
3, 5
6
Sche
dule
s: 3
,10
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
miss
ione
rs m
ust a
ssur
e th
emse
lves
that
patie
nt c
are
is de
liver
ed in
app
ropr
iate
ly b
uilt
and
equi
pped
faci
litie
s w
hich
mee
t rel
evan
tH
TMs
and
Build
ing
Not
es, a
nd, w
here
appr
opria
te, a
re re
gist
ered
and
are
saf
e an
dcl
ean.
Equi
pmen
t mus
t be
fit fo
r pur
pose
Com
mitm
ent t
o ef
ficie
nt u
se a
nd s
atisf
acto
rym
aint
enan
ce o
f equ
ipm
ent
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 Acu
te S
ervi
ces
Mai
n cl
ause
s:5,
11, 1
9, 5
4, 5
6, 6
0
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
utth
e or
gani
satio
n
Acc
essi
bilit
y to
exe
cutiv
e re
spon
sibl
e fo
rH
&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 agr
eem
ent w
ithco
mm
issio
ners
22
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
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Acu
te S
ervi
ces
Mai
n cl
ause
s:8,
9,17
,19,
21,2
3,24
,27,
29,
30, 3
2, 3
3,54
Sche
dule
s: 5
,6,1
5,16
,18
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
tha
tco
vers
•Ty
pes
of d
ata
•Q
ualit
y of
dat
a•
Dat
a pr
otec
tion
and
conf
iden
tialit
y•
Acc
essi
bilit
y•
Tran
spar
ency
•A
naly
sis
of d
ata
and
info
rmat
ion
•U
se o
f da
ta a
nd in
form
atio
n•
Dis
sem
inat
ion
of d
ata
and
info
rmat
ion
•Ri
sks
•Sh
arin
g of
dat
a an
d co
mpa
tibili
ty o
f IT
acro
ss d
iffer
ent p
rovi
ders
with
resp
ect t
oca
re o
f pat
ient
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
Ther
e sh
ould
be
polic
ies
in p
lace
tha
tin
clud
e:
•C
onfid
entia
lity
Cod
e of
Pra
ctic
e•
Dat
a Pr
otec
tion
•Fr
eedo
m o
f In
form
atio
n•
Hea
lth R
ecor
ds•
Info
rmat
ion
Gov
erna
nce
Man
agem
ent
•In
form
atio
n Q
ualit
y A
ssur
ance
•In
form
atio
n Se
curit
y
Ther
e m
ust
be a
nam
ed in
divi
dual
who
isth
e C
aldi
cott
Gua
rdia
n
The
Prov
ider
is re
quire
d to
ens
ure
that
the
follo
win
g is
in p
lace
1 :
•A
24
hour
s a
day,
7 d
ays
a w
eek
tele
phon
e he
lplin
e•
Enab
le u
sers
of t
he s
ervi
ce to
boo
k re
gula
r rev
iew
s on
-line
•C
linic
al s
taff
at d
iffer
ent s
ites
to h
ave
on-li
ne a
cces
s to
sha
red
prot
ocol
s, g
uide
lines
and
info
rmat
ion
rela
ting
to th
e C
YP
serv
ice
and
be a
ble
to a
dd e
ntrie
s to
the
elec
tron
ic h
ealth
reco
rd•
Dec
ision
sup
port
tree
s fo
r the
CY
P an
d th
eir f
amili
es to
use
for
sick
days
, hyp
ogly
caem
ia a
nd d
enta
l visi
ts a
nd fo
r hea
lthpr
ofes
siona
ls to
pro
vide
car
e du
ring
surg
ery
or in
dia
betic
keto
acid
osis
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 32
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
:
•H
ospi
tal E
piso
des
Stat
istic
s da
ta 33
•Pa
tient
Exp
erie
nce
20
•Pa
tient
Sat
isfac
tion
•N
atio
nal D
iabe
tes
Info
rmat
ion
Serv
ice
34
•N
atio
nal D
iabe
tes
Con
tinui
ng C
are
Dat
aset
35
23
Source documentsCommissioners and providers should takeresponsibility for making references to thelatest version of the various documents andguidance.
1. Department of Health, Making Every Young Personwith Diabetes Matter, Report of the Children andYoung People with Diabetes Working Group, April2007
2. NHS Diabetes, Emotional and PsychologicalSupport and Care in Diabetes, Joint Diabetes UKand NHS Diabetes Emotional and PsychologicalSupport Working Group, February 2010
3. NHS Diabetes, Diabetes emergency and inpatientcare commissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
4. NHS Diabetes, prevention and risk assessmentcommissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
5. NHS Diabetes, Features of a service that isresponsive to people with learning disabilities whohave diabetes, 2010,http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
6. Department of Health, Standard NHS Contract forAcute Services, January 2010,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111203
7. NICE, Diagnosis and management of Type 1diabetes in children, young people and adults,www.nice.org.uk/Guidance/CG15, 2004
8. NICE, Type 2 diabetes: the management of type 2diabetes (update),www.nice.org.uk/Guidance/CG66, June 2008(update)
9. NICE, Management of Type 2 diabetes - preventionand management of foot problems,www.nice.org.uk/Guidance/CG10, January 2004
10. NICE, Diabetes in pregnancy : management ofdiabetes and its complications from pre-conception to the post natal period,http://www.nice.org.uk/Guidance/CG63, March2008
11. NICE, Type 2 diabetes: newer agents for bloodglucose control in type 2 diabetes,http://guidance.nice.org.uk/CG66/, May 2009
12. NICE, Primary prevention of type 2 diabetesmellitus among high risk black and minorityethnic groups,www.nice.org.uk/Guidance/PHG/Wave19/6, inprogress, expected June 2011
13. NICE, The clinical effectiveness and costeffectiveness of long acting insulin analogues fordiabetes, www.nice.org.uk/Guidance/TA53 ,December 2002
14. NICE, The clinical effectiveness and costeffectiveness of patient education models fordiabetes, www.nice.org.uk/Guidance/TA60, April2003
15. NICE, Continuous subcutaneous insulin infusionfor the treatment of diabetes (review),www.nice.org.uk/Guidance/TA151, July 2008
16. NICE, Depression with a chronic physical healthproblem,http://guidance.nice.org.uk/CG91/Guidance/pdf/English, October 2009
17. NICE, Medicines adherence: involving patients indecisions about prescribed medicines andsupporting adherence, Jan 2009,http://guidance.nice.org.uk/CG76
18. NHS Institute for Innovation and Improvement,model CQUIN scheme: inpatient care for peoplewith diabetes, 2009
19. National Diabetes Audit.www.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/diabetes
20. The King’s Fund, The point of care. Measures ofpatients’ experience in hospital: purpose,methods and uses. July 2009
21. DiabetesE - https://www.diabetese.net/
22. Skills for Health, Diabetes CompetencyFramework, https://tools.skillsforhealth.org.uk/suite/show/id/40
23. Department of Health, National ServiceFramework for Diabetes: Standards, 2001,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4002951
24
24. National Service Framework for Children, YoungPeople and Maternity Services, 2004http://www.dh.gov.uk/en/Healthcare/Children/DH_4089111
25. Standards of in-patient care for children andyoung people with diabetes (in development)
26. NHS Diabetes, Commissioning guides for thecomplications of diabetes, 2010,http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement
27. NHS Diabetes, diabetes and pregnancycommissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
28. NHS Diabetes, mental health and diabetesservices commissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
29. Department of Health, You're Welcome qualitycriteria: Making health services young peoplefriendly, 2007,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073586
30. Royal College of Paediatrics and Child Health,Growing Up With Diabetes: Children and YoungPeople with Diabetes in England , March 2009,http://www.rcpch.ac.uk/Research/Research-Activity/Current-Projects/National-Diabetes-Survey
31. British Society for Paediatric Endocrinology andDiabetes (BSPED) guidelineshttps://www.bsped.org.uk/professional/guidelines/index.htm.
32. York and Humber integrated IT systemhttp://www.diabetes.nhs.uk/document.php?o=610
33. Hospital Episode Statistics,www.ic.nhs.uk/statistics-and-data-collections/hospital-care/hospital-activity-hospital-episode-statistics--hes
34. National Diabetes Information Service, TheInformation Centre,http://ndis.ic.nhs.uk/pages/index.aspx
35. National Diabetes Continuing Care Dataset,www.ic.nhs.uk/webfiles/Services/Datasets/Diabetes/dccrdataset.pdf
25
This specification forms Schedule 2, Part 1,‘The Services - Service Specifications’ of theStandard NHS Contractsa.
Service specifications are developed in partnershipbetween commissioners and provider agenciesand are based on agreed evidence-based care andtreatment models. Specifications should be opento scrutiny and available to all service users/carersas a statement of standards that the user/carercan expect to receive.
The following documentation, developed bythe National Paediatric Diabetes NetworksGroup, provides further detail/guidance tosupport the development of thisspecification:
• The intervention map for services for childrenand young people with diabetes
• The contracting framework for services forchildren and young people with diabetes
This specification template assumes that theservices are compliant with the contractingframework for services for children and youngpeople with diabetes.
This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.
Description of Services for Childrenand Young People with Diabetes:Services for children and young people withdiabetes provides the full range of care fromprevention, diagnosis, initial and continuingmanagement up to the age of 25, together with
the seamless transition to adult diabetes services.Commissioners should note that the care ofchildren and young people with diabetes must beundertaken by children and young peoplespecialist diabetes teams. The prevention and riskassessment of children and young people withrespect to diabetes can be delivered by generalistprimary care teams.
The commissioner is referred to thecommissioning guide for emergency and inpatient careb for management of acute diabeticemergencies in children and young people in thecommunity (i.e. ambulance care).
The final specification should takeinto account:• national, network and local guidance and
standards for diabetes services.
• local needs.
This specification is supported by other relatedwork in 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 forneeds assessment, planning and monitoring ofdiabetes services
Standard Service SpecificationTemplate for Services for Childrenand Young People with Diabetes
a Standard NHS Contracts http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111203
b NHS Diabetes, Diabetes emergency and inpatient care commissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
26
Introduction• A general overview of the services identifying
why the services are needed, includingbackground to the services and why they arebeing developed or in place
• A statement on how the services relate to eachother within the whole system should beincluded describing the keystakeholders/relationships which influence theservices, e.g. Children and Young Peoples’Specialist Multidisciplinary Diabetes care teametc
• Any relevant diabetes clinical networks andscreening programmes applicable to theservices
• Details of all interdependencies or sub-contractors for any part of the service and anoutline of the purpose of the contract shouldbe stated, including arrangements for clinicalaccountability and responsibility, as appropriate
Purpose, Role and Clientele1. A clear statement on the primary purpose of
the services and details of what will beprovided and for whom:
• Who the services are for (e.g. children andyoung people requiring diabetes care andprovision of support to families/carers)
• What the services aim to achieve
• The objectives of the services including fullaccess, timeliness and equity; wherepossible be close to home and based in thecommunity
• The range of options available to childrenand young people including supporting selfmanagement, informed choice andindividual preferences
• 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 therapeuticinterventions that are required for the types ofneed the services will respond to.
• How the services responds to age, culture,disability, and gender sensitive issuesincluding responding to children in care,children in the secure estate, refugees andasylum seekers
• Assessment – details of what it is and co-morbidity assessment and referrals to allrelevant specialties
• Service planning – High level view of whatthe services are and how they are used;how patients enter the pathway/journey;what are the stages undertaken andcontinuing management includingtransition to adults’ services. The aims ofservice planning are to:
o Develop, manage and reviewinterventions along the patient journey
o Ensure access to other specialities /care,as appropriate
o Ensure that care planning (includingplans to diabetes transition services) isundertaken by the diabetes multi-disciplinary team (as defined locally)with a clear care co-ordination function
o Ensure that all patients andfamily/carers receive appropriate timelystructured education
o Ensure that non-attendees are activelyfollowed up
o Ensure that transition from childrens’ toyoung peoples’ and adults’ services arenegotiated and explicitly plannedaround the assessed needs of eachindividual young person
• Holistic review of patients in themanagement of their diabetes using theprinciples of an integrated care model forpeople with long term conditions that ispatient-centred, including self care and selfmanagement, clinical treatment, facilitatingindependence, psychological support andother social care issues
• Risk assessment procedures
27
• Detail of evidence base of the service – i.e.the contracting framework for services forchildren and young people with diabetes,guidance produced by the Royal College ofPaediatrics and Child Health, Diabetes UK,etc
Service Delivery3. Patient Journey/intervention map
Flow diagram of the patient pathway showingaccess and exit/transfer points – see thediabetes CYP services intervention map as astarting point
4. Treatment protocols/interventionsInclude all individual treatment protocols inplace within the services or planned to beused
5. This will include a breakdown of how thepatient will receive the services and fromwhom. It should be a clear statement of staffqualifications/experience and/or training (ifappropriate) and clinical or managerialsupervision arrangements. It should specify, asappropriate:
• Geographical coverage/boundaries – i.e. theservices should be available for children andyoung people with diabetes who live in thePCT area, give an age range, etc
• Hours of operation including, provisionoutside 9 -5 to encourage full participationat school and to support working parentsand local agreements to enable 24-houraccess to emergency advice from competentstaff
• Minimum level of experience andqualifications of staff (i.e. doctors –diabetologists and GPs, Nursing staff –diabetes nurse specialists, district, practicenurses etc, other allied health professionals,e.g. podiatrists, dietitians, optometrists,pharmacists etc and other support andadministrative staff)
• Confirmation of the arrangements toidentify the Care Co-ordinator for eachpatient with diabetes (i.e. who holds theresponsibility and role)
• Staff induction and developmental training
6. Equipment• Upgrade and maintenance of relevant
equipment and facilities
• Technical specifications (if any)
Identification, Referral andAcceptance criteria7. This should make clear how patients will be
identified, assessed (if appropriate) andaccepted to the services. Acceptance shouldbe based on types of need and/or patient.
8. How should patients be referred?• Who is acceptable for referral and from
where
• Details of evaluation process - Are thereclear exclusion criteria or set alternatives tothe service? How might a patient betransferred?
• Response time detail and how are patientsprioritised
Discharge/Transition to Adults’Services criteria9. The intention of this section is to make clear
when a patient should be transferred fromone aspect of the diabetes service to anotherand when this point would be reached.
• How is a treatment pathway reviewed?
• How does the service decide that a patientis ready for discharge/transition to adults’services?
• How are goals and outcomes assessed andreviewed?
• What procedure is followed on discharge,including arrangements for follow-up orsmooth transition to adults’ services?
28
Quality Standards10. Each service specification will include service
specific standards, which are over and abovethe nationally mandated quality standards,i.e. based on standards identified in thecontracting framework for services forchildren and young people with diabetes. Theservice specific standards should encompassthe total service from acceptance to dischargeor transition to adults’ services includingnationally applicable quality standards. Thesewill be individually tailored to each serviceand will include details on access, equity,assessment (if appropriate), time-scales ofintervention, waiting times and what toexpect on service discharge. Explicit withineach service specification will be theexpectation that patient and carerinvolvement/empowerment is incorporatedwithin the service.
11. This must include performance indicators,thresholds, methods of measurement andconsequences of breach of contract. Thesewill be set and agreed prior to the signing ofthe overall agreement.
12. As a minimum, the Provider is required toagree a local Commissioning for Quality andInnovation scheme for services for peoplewith diabetes.(Insert details of the CQUIN Scheme agreed)
Activity and PerformanceManagement13. Key Performance Indicators – List the
criteria/outcomes by which the service is/could be measured. Specific KPIs for diabetesservices for CYP are in development. Pleasesee the NHS Diabetes website for furtherdetails:
http://www.diabetes.nhs.uk/commissioning_resource
14. Activity plans – Where appropriate, identifythe anticipated level of activity the servicemay deliver; provide details of any activitymeasures and their description /method ofcollection, targets, thresholds andconsequences of variances above or belowtarget.
Continual Service Improvement15. As part of the monitoring and evaluation
procedures, the service will identify a methodof agreeing measurements for continuousimprovement of the service being offeredand work to ensure unmet need is bothidentified and 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
29
This specification forms Schedule 2, Part 1,‘The Services - Service Specifications’ of theStandard NHS Contractsa.
Service specifications are developed in partnershipbetween commissioners and provider agenciesand are based on agreed evidence-based care andtreatment models. Specifications should be opento scrutiny and available to all service users/carersas a statement of standards that the user/carercan expect to receive.
The following documentation, developed bythe National Paediatric Diabetes NetworksGroup, provides further detail/guidance tosupport the development of thisspecification:
• The intervention map for services for childrenand young people with diabetes
• The contracting framework for services forchildren and young people with diabetes
This specification template assumes that theservices are compliant with the contractingframework for services for children and youngpeople with diabetes.
This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.
Description of Diabetes TransitionServices for Children and YoungPeople with Diabetes:The Diabetes Transition Service provides specialistoutpatient care for young people with diabetesbetween the ages of 16-25. To ensure a seamlesstransfer from paediatric to adult diabetes services,outpatient services should be led by bothpaediatric and adult consultant diabetologists.Services should be multidisciplinary includingdiabetes specialist nurses, specialist dietetics plusappropriate input from other disciplines such aspodiatry, psychology and ophthalmology. Thecommissioner is referred to the commissioningguide for emergency and in patient careb formanagement of acute diabetic emergencies inchildren and young people in the community (i.e.ambulance care).
The final specification should takeinto account:• national, network and local guidance and
standards for diabetes services.
• local needs.
This specification is supported by other relatedwork in 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 forneeds assessment, planning and monitoring ofdiabetes services
Standard Service SpecificationTemplate for Diabetes TransitionServices (CYP to adult)
a Standard NHS Contracts http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111203
b NHS Diabetes, Diabetes emergency and inpatient care commissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
30
Introduction• A general overview of the services identifying
why the services are needed, includingbackground to the services and why they arebeing developed or in place.
• A statement on how the services relate to eachother within the whole system should beincluded describing the keystakeholders/relationships which influence theservices, e.g. Children and Young Peoples’Specialist Multidisciplinary Diabetes care teamand the adult multidisciplinary diabetes team,liaison with education, social services and otheryouth organisations etc
• Any relevant diabetes clinical networks andscreening programmes applicable to theservices
• Details of all interdependencies or sub-contractors for any part of the service and anoutline of the purpose of the contract shouldbe stated, including arrangements for clinicalaccountability and responsibility, as appropriate
Purpose, Role and Clientele1. A clear statement on the primary purpose of
the services and details of what will beprovided and for whom:
• Who the services are for (e.g. children andyoung people between the ages of 16-25requiring diabetes care)
• What the services aim to achieve
• The objectives of the services including fullaccess, timeliness and equity; wherepossible be close to home and based in thecommunity
• The range of options available to childrenand young people including supporting selfmanagement, informed choice andindividual preferences
• 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 therapeuticinterventions that are required for the types ofneed the services will respond to.
• How the services responds to age, culture,disability, and gender sensitive issuesincluding responding to children in care,children in the secure estate, refugees andasylum seekers
• Assessment – details of what it is and co-morbidity assessment and referrals to allrelevant specialties
• Service planning – High level view of whatthe services are and how they are used;how patients enter the pathway/journey;what are the stages undertaken andcontinuing management includingtransition to adults’ services. The aims ofservice planning are to:
o Develop, manage and reviewinterventions along the patient journey
o Ensure access to other specialities /care,as appropriate
o Ensure that care planning (includingplans to transfer to adult diabetesservices) is undertaken by the diabetesmulti-disciplinary team (as definedlocally) with a clear care co-ordinationfunction
o Ensure that all patients andfamily/carers receive appropriate timelystructured education to improve self-management
o Ensure that non-attendees are activelyfollowed up
o Ensure that transition from childrens’ toyoung peoples’ and adults’ services arenegotiated and explicitly plannedaround the assessed needs of eachindividual young person
• Holistic review of patients in themanagement of their diabetes using theprinciples of an integrated care model forpeople with long term conditions that is
31
patient-centred and age appropriate,including self care and self management,clinical treatment, facilitating independence,psychological support and other social careissues
• Risk assessment procedures
• Detail of evidence base of the service – i.e.the contracting framework for services forchildren and young people with diabetes,guidance produced by the Royal College ofPaediatrics and Child Health, Diabetes UK,etc
Service Delivery3. Patient Journey/intervention map
Flow diagram of the patient pathway showingaccess and exit/transfer points – see the CYPdiabetes services intervention map as a startingpoint
4. Treatment protocols/interventionsInclude all individual treatment protocols inplace within the services or planned to beused. Specifically this would include:
• Structured education programmes suitablefor transition and in line with adulteducation programmes
• Provision of age appropriate information,e.g. diet, smoking, sexual health, alcohol,substance misuse, driving, contraceptionand pregnancy
• An acute in-reach service into local hospitalsto support newly diagnosed young peoplewith diabetes to provide information and tofacilitate referral to the outpatient transitionservices on discharge
• Preconception care and facilitation ofreferral to pregnancy servicesc
5. This will include a breakdown of how thepatient will receive the services and fromwhom. It should be a clear statement of staff
qualifications/experience and/or training (ifappropriate) and clinical or managerialsupervision arrangements. It should specify, asappropriate:
• Geographical coverage/boundaries – i.e. theservices should be available for children andyoung people with diabetes who live in thePCT area, give an age range, etc
• Hours of operation including, provisionoutside 9 -5 to encourage full participationat school and to support working parentsand local agreements to enable 24-houraccess to emergency advice from competentstaff
• Minimum level of experience andqualifications of staff (i.e. doctors –diabetologists and GPs, Nursing staff –diabetes nurse specialists, district, practicenurses etc, other allied health professionals,e.g. podiatrists, dietitians, optometrists,pharmacists etc and other support andadministrative staff)
• Confirmation of the arrangements toidentify the Care Co-ordinator for eachpatient with diabetes (i.e. who holds theresponsibility and role)
• Staff induction and developmental training
6. Equipment
• Upgrade and maintenance of relevantequipment and facilities
• Technical specifications (if any)
a see NHS Diabetes, diabetes and pregnancy commissioning guide, 2010http://www.diabetes.nhs.uk/commissioning_resource/step_3_service_improvement/
32
Identification, Referral andAcceptance criteria7. This should make clear how patients will be
identified, assessed (if appropriate) andaccepted to the services. Acceptance should bebased on types of need and/or patient.
8. How should patients be referred?
• Who is acceptable for referral and fromwhere
• Details of evaluation process - Are thereclear exclusion criteria or set alternatives tothe service? How might a patient betransferred?
• Response time detail and how are patientsprioritised
Discharge/Transition to Adults’Services criteria9. The intention of this section is to make clear
when a patient should be transferred from oneaspect of the diabetes service to another andwhen this point would be reached.
• How is a treatment pathway reviewed?
• How does the service decide that a patientis ready for discharge/transition to adults’services?
• How are goals and outcomes assessed andreviewed?
• What procedure is followed on discharge,including arrangements for follow-up orsmooth transition to adults’ services?
Quality Standards10. Each service specification will include service
specific standards, which are over and abovethe nationally mandated quality standards,i.e. based on standards identified in thecontracting framework for services forchildren and young people with diabetes. Theservice specific standards should encompassthe total service from acceptance to dischargeor transition to adults’ services includingnationally applicable quality standards. Thesewill be individually tailored to each service
and will include details on access, equity,assessment (if appropriate), time-scales ofintervention, waiting times and what toexpect on service discharge. Explicit withineach service specification will be theexpectation that patient and carerinvolvement/empowerment is incorporatedwithin the service.
11. This must include performance indicators,thresholds, methods of measurement andconsequences of breach of contract. Thesewill be set and agreed prior to the signing ofthe overall agreement.
12. As a minimum, the Provider is required toagree a local Commissioning for Quality andInnovation scheme for services for peoplewith diabetes.(Insert details of the CQUIN Scheme agreed)
Activity and PerformanceManagement13. Key Performance Indicators – List the
criteria/outcomes by which the service is/could be measured. Specific KPIs for diabetesservices for CYP are in development. Pleasesee the NHS Diabetes website for furtherdetails:http://www.diabetes.nhs.uk/commissioning_resource
14. Activity plans – Where appropriate, identifythe anticipated level of activity the servicemay deliver; provide details of any activitymeasures and their description /method ofcollection, targets, thresholds andconsequences of variances above or belowtarget.
Continual Service Improvement15. As part of the monitoring and evaluation
procedures, the service will identify a methodof agreeing measurements for continuousimprovement of the service being offeredand work to ensure unmet need is bothidentified and brought to the attention of thecommissioner.
16. ReviewThis section should set out a review date anda mechanism for review.
The review should include both thespecifications for continuing fitness forpurpose and the providers’ delivery againstthe specification.
This should set out the process by which thisreview will be conducted.
This should also identify how complianceagainst the specification will be monitored inyear.
17. Agreed byThis should set out who agrees/accepts thespecification on behalf of all parties.
This should include the diabetes providers,commissioner and network
With thanks to Dr Thoreya Swage who wrote this publication.
Further copies of this publication can be ordered from Prontaprint, by emailing [email protected] or tel: 0116 275 3333, quoting DIABETES 111
www.diabetes.nhs.uk