Download health overview and scrutiny committee scoping document

AGENDA ITEM ..................6...........................
HOSC/03/05
Committee Essex Health Overview and Scrutiny
Date
4 March 2005
Report by Josie Godfrey, Health Research Manager
_____________________________________________________________________
HEALTH OVERVIEW AND SCRUTINY COMMITTEE SCOPING DOCUMENT DIABETES
Implementing the Diabetes National Service Framework in Essex
Introduction
1. Essex, Southend and Thurrock have agreed to undertake a joint scrutiny study
of diabetes care across Essex. This note sets out:
 The background to the study;
 The scope and objectives; and
 The proposed scrutiny arrangements and timetable for the study.
Background
2. The reasons for selecting diabetes inlcude:
 Diabetes is a significant health problem for Essex residents, affecting about
3% of the population;
 Cost estimates vary but diabetes is likely to cost the Essex health economy
between 5-10% of NHS expenditure and at least 10% of NHS hospital
expenditure1;
 The National Service Framework (NSF) sets out clear standards and
recommendations for action which can be used as a framework for studying
diabetes services;
 The medical effects of the condition are multi-faceted and therefore involve
a number of clinical specialisms;
 The SHA has two diabetes related targets in its Local Delivery Plan (LDP)
and each Primary Care Trust (PCT) can be expected to have plans for
delivering the NSF; and
 Much of the initial data required for the study should be easily accessible
through existing Diabetes Networks and the regional representative of
Diabetes UK.
1
See for example www.diabetes.org.uk/infocentre/reports/in_the_UK_2004.doc.
1
3. Estimates of the prevalence of diabetes vary and figures from the Department
of Health, Diabetes UK and Essex SHA will be used here. About 3% of the
population, up to 45,000 people across Essex have diabetes2. This figure is
expected to grow. Diabetes is a condition that has far reaching implications for
people living with it (see appendix one). These range from the need to adopt a
suitable diet to possible long-term complications such as blindness or
amputation. Average life expectancy is reduced in people with Type 1 diabetes
by 20 years and by 10 years in those with Type 2 diabetes3. There is also an
inevitable impact on the families of people with diabetes.
4. In 2001 the Department of Health (DH) published the National Service
Framework (NSF) for Diabetes and in 2002 a delivery strategy. A number of
national standards for improving diabetes care were set out in these documents
(see appendix two). They also set out the rationale for these standards, key
interventions and implications for service planning. The NSF is a 10 year plan
but there are two early national performance targets:

By 2006, a minimum of 80 per cent of people with diabetes to be offered
screening for the early detection (and treatment if needed) of diabetic
retinopathy as part of a systematic programme that meets national
standards, rising to 100 per cent coverage of those at risk of retinopathy by
end 2007.

By March 2006, PCTs need to ensure that practice-based registers and
systematic treatment regimens cover the majority of patients at high risk of
coronary heart disease, particularly those with hypertension, diabetes and a
body mass index (BMI) greater than 304.
5. Essex, Southend and Thurrock Health Overview and Scrutiny Committees are
committed to considering the wider determinants of health and health
inequalities when selecting topics for scrutiny. The DH has published guidance
for Health OSCs that reflects this5. Several aspects of a diabetes study could
lend themselves to consideration of these issues, for example:



Any variations in services between the 5 Diabetes networks across the
Essex SHA area, particularly where these coincide with any variation in
need;
Older people are at greater risk of developing diabetes: one in twenty
people over 65 have diabetes rising to one in five people over 856;
People from the most deprived twenty percent of the population are oneand-a-half times more likely than average to have diabetes at any given
age7;
2
See Local Delivery Plan 2004/2005. Essex Strategic Health Authority at
www.essex.nhs.uk/documents/framework/localdeliveryplanjune04.pdf
3 See, Current and Future Research on Diabetes: A Review for the Department of Health and the Medical
Research Council, Department of Health at www.dh.gov.uk/assetRoot/04/09/14/75/04091475.pdf
4 See National Service Framework for Diabetes, Department of Health, at
www.dh.gov.uk/assetRoot/04/05/89/38/04058938.pdf.
5 See Overview and Scrutiny of Health - Guidance. Department of Health, at
www.dh.gov.uk/assetRoot/04/06/62/38/04066238.pdf.
6 See Department of Heatlh figures at http://www.dh.gov.uk/assetRoot/04/03/28/38/04032838.pdf.
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

People from disadvantaged groups are more likely to experience
difficulties in managing the disease and the consequent serious
complications8; and
The NSF highlights the needs of children and young people living with
diabetes, who whilst representing a small proportion of people with
diabetes, nonetheless have complex needs reaching beyond direct
health care provision. The number of children diagnosed with Type 2
diabetes is rising9.
6. Diabetes is thus an important area for health scrutiny. Other local authorities
have carried out studies into aspects of diabetes prevention, screening and
care and this study can build on this work. A list of the studies we are already
aware can be found at appendix three and steps will be taken to ascertain the
completeness of this data.
7. Essex, Southend and Thurrock are committed to considering the interests of
their residents and will be interested in aspects of diabetes of particular concern
to those living in Essex and the views of patients and members of the public
regarding diabetes services. Issues of particular interest may include:




The extent to which there are clear and seamless care pathways for
patients;
Services for children (including, prevention and diagnosis);
Services for older people; and
Any inequalities in service provision, particularly where these coincide with
greater health need and wider disadvantaged communities.
Project Scope and Objectives
8. This study will focus on the implementation of the NSF for diabetes across the
Essex SHA area and use the 12 NSF standards and the two national targets as
a framework for the investigation.
9. Key objectives are:

To investigate how the NSF for diabetes was introduced and is being
delivered across Essex.

To identify any differences in implementation of the NSF across Essex
and what actions are being taken to remedy any deficits in service
delivery by the relevant agencies (e.g. NHS organisations, local
authorities and voluntary groups).
7
As above.
For example, see Chaturvedi N, Jarrett J, Shipley MJ, and Fuller JH. Socioeconomic gradient in morbidity
and mortality in people with diabetes: cohort study findings from the Whitehall study. BMJ 1998; 318:100-6 at
http://bmj.bmjjournals.com/cgi/content/full/316/7125/100?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=
&author1=Chaturvedi&andorexactfulltext=and&searchid=1106915461856_5699&stored_search=&FIRSTINDE
X=0&sortspec=relevance&resourcetype=1.
9 See www.diabetes.org.uk/infocentre/reports/in_the_UK_2004.doc.
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
To make recommendations for improving delivery of the NSF.
10. The study will map existing services and the work undertaken in introducing
and implementing the Diabetes NSF across the Essex SHA area. It will also
involve discussions with patients groups and individual patients.
11. The study will then synchronise existing research and, where necessary,
undertake additional Essex based studies to measure local progress with the
successful delivery of national targets, in particular for:
 Children
 Older people
 Care pathways
 Health education
 Prevention and health promotion activity, including health education;
 Services for people newly diagnosed with diabetes, including the provision
of information; and
 Strategies for identifying people with undiagnosed diabetes.
Scrutiny arrangements
12. The proposed approach for the scrutiny study is to:
 Hold an initial Panel meeting as a training session which will could include
training on the following:
o Diabetes NSF
o Diabetes care in Essex
o Current work in Essex diabetes care
o Diabetes UK – regional representative
 Undertake an initial data collection exercise;
 If necessary, refine the focus of the study;
 Obtain the additional targeted Essex data and take evidence from expert
witnesses and other interested parties;
 Report on the Panel’s key findings and make any recommendations as to
service, policy and procedural improvements that could be put in place;
 Consult with the NHS on factual findings and then recommendations; and
 Confirm any monitoring arrangements to be put in place.
Panel
13. A panel of fifteen members (five from each of Essex, Southend and Thurrock)
will act as a steering group for the study and be chaired by Councillor Susan
Flack, member of the Essex Health Overview and Scrutiny Committee.
Members of the panel will meet to receive research results, hear evidence,
steer the drafting of reports and agree recommendations.
14. The three Overview and Scrutiny Committees will be asked to approve the final
report.
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Officer Project Team
15. An officer project team comprising officers from the Strategic Policy Unit and
the Law & Administration Group of Essex County Council will progress the
various aspects of the project. Officers at Southend and Thurrock will provide
some additional support.
Wider involvement
16. Other bodies may be asked to facilitate witnesses who will be able to provide
data, advise on professional issues and assist with forming useful contacts.
17. The Centre for Public Scrutiny (CfPS) is providing up to 5 ‘support days’ to
individual Health Overview and Scrutiny Committees and it has been agreed
that 10 days will be pooled from the 3 committees to enable support to be
provided for this project. The detail of what this support will entail has not yet
been agreed with the CfPS but it is hoped that it will be available throughout the
project from scoping to monitoring the implementation of any
recommendations.
18. Patients and the public will also be invited to contribute to the study. We will
contact voluntary patients organisation throughout the course of the study and
patients and members of the public wishing to comment on diabetes services
will have the opportunity to complete a questionnaire or send comments to
officers.
Timetable
19. The timetable is dependent on the availability of CfPS support and the
timetables for other scrutiny studies running is more clearly defined. However, a
proposed timetable is set out in appendix four.
____________________________________
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Appendix One: What is Diabetes?10
Diabetes mellitus is a condition in which the amount of glucose (sugar) in the blood
is too high because the body cannot use it properly. Glucose comes from the
digestion of starchy foods such as bread, rice, potatoes, chapatis, yams and
plantain, from sugar and other sweet foods, and from the liver, which makes
glucose.
In order to use glucose properly the body needs insulin. This is a hormone
produced by the pancreas that helps the glucose to enter the cells where it is used
as fuel by the body. The main symptoms of untreated diabetes are increased thirst,
going to the loo all the time – especially at night, extreme tiredness, weight loss,
genital itching or regular episodes of thrush, and blurred vision.
There are two main types of diabetes. These are:


Type 1 diabetes, also known as insulin dependent diabetes
Type 2 diabetes, also known as non insulin dependent diabetes
Type 1 diabetes develops if the body is unable to produce any insulin. This type of
diabetes usually appears before the age of 40. It is treated by insulin injections and
diet and regular exercise is recommended.
Type 2 diabetes develops when the body can still make some insulin, but not
enough, or when the insulin that is produced does not work properly (known as
insulin resistance). This type of diabetes usually appears in people over the age of
40, though in South Asian and African-Caribbean people often appears after the
age of 25. It is treated by diet and exercise alone or by diet, exercise and tablets or
by diet, exercise and insulin injections.
The main aim of treatment of both types of diabetes is to achieve blood glucose
and blood pressure levels as near to normal as possible. This, together with a
healthy lifestyle, will help to improve wellbeing and protect against long-term
damage to the eyes, kidneys, nerves, heart and major arteries.
10
The information in this appendix is adapted from the Diabetes UK website which can be found at
http://www.diabetes.org.uk/diabetes/index.html.
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Appendix Two: National Service Framework for Diabetes: Standards
The 2001 NSF for Diabetes set out twelve key standards for improving diabetes
prevention, screening and care. These standards are:
1. The NHS will develop, implement and monitor strategies to reduce the risk of
developing Type 2 diabetes in the population as a whole and reduce the
inequalities in the risk of developing Type 2 diabetes.
2. The NHS will develop, implement and monitor strategies to identify people who
do not know they have diabetes.
3. All children, young people and adults with diabetes will receive a service which
encourages partnership in decision-making, supports them in managing their
diabetes and helps them to adopt and maintain a healthy lifestyle. This will be
reflected in an agreed and shared care plan in an appropriate format and
language. Where appropriate, patients and carers should be fully engaged in
this process.
4. All adults with diabetes will receive high-quality care throughout their lifetime,
including support to optimise the control of their blood glucose, blood pressure
and other risk factors for developing the complications of diabetes.
5. All children and young people with diabetes will receive consistently highquality care and they, with their families and others involved in their day-to-day
care, will be supported to optimise the control of their blood glucose and their
physical, psychological, intellectual, educational and social development.
6. All young people with diabetes will experience a smooth transition of care from
paediatric diabetes services to adult diabetes services, whether hospital or
community-based, either directly or via a young people’s clinic. The transition
will be organised in partnership with each individual and at an age appropriate
to and agreed with them.
7. The NHS will develop, implement and monitor agreed protocols for rapid and
effective treatment of diabetic emergencies by appropriately trained health care
professionals. Protocols will include the management of acute complications
and procedures to minimise the risk of recurrence.
8. All children, young people and adults with diabetes admitted to hospital, for
whatever reason, will receive effective care of their diabetes, Wherever
possible, they will continue to be involved in decisions concerning the
management of their diabetes.
9. The NHS will develop, implement and monitor policies that seek to empower
and support women with pre-existing diabetes and those who develop diabetes
during pregnancy to optimise the outcomes of their pregnancy.
10. All young people and adults with diabetes will receive regular surveillance for
the long-term complications of diabetes.
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11. The NHS will develop, implement and monitor agreed protocols and systems of
care to ensure that all people who develop long-term complications of diabetes
receive timely, appropriate and effective investigation and treatment to reduce
their risk of disability and premature death.
12. All people with diabetes requiring multi-agency support will receive integrated
health and social care.
Each standard, or group of standards, is accompanied by detail of the rationale for
the standard, key interventions and implications for service planning.
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Appendix Three: Relevant Scrutiny Studies
The table below shows those scrutiny studies on diabetes that we are aware are
either underway or have been completed. Further information will be requested
where necessary:
HOS
Committee
Oxfordshire
Details
Warrington
Report on chiropody services
www.warrington.gov.uk/publications/scrutiny/FEET%20
FIRST%20Final%20Report.pdf
Hampshire
Review of access to foot care for people with diabetes.
It is not known if this review has been completed.
Wokingham
May be undertaking a review of diabetes services. The
scope and timetable for this work is not known.
Reference to undertaking this work can be found at
www2.oxfordshire.gov.uk/hlpdownloads/jh020904.htm).
Short report on podiatry services. Available at
www2.oxfordshire.gov.uk/hlpdownloads/JH04110407a-5-ii.htm.
Tower Hamlets Report on health promotion activity, with particular
consideration of high-risk groups. Available at;
www.cfps.org.uk/pdf/review/751.pdf
Cheshire
Report on diabetes services, with particular
consideration of NSF standards 1-3, focussing on
prevention and diagnosis and patient information. Draft
report available at:
www.cheshire.gov.uk/healthscrutiny/documents/Diabet
es_Report.doc
Cornwall
Detailed report on preventing diabetes through healthy
lifestyles. Available at
www.cornwall.gov.uk/Councils/scrutiny/hscosc/diabetes
.pdf
Southwark
Appears to be undertaking work on addressing type 2
diabetes through promoting healthy lifestyle choices.
Ealing
Is undertaking some work on diabetes and is holding
an event with Diabetes UK and Ealing PCT (see
www.ealing.gov.uk/diabetes.pdf).
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Appendix Four: Proposed Timetable
January
Initiation of review and constitution of Panel.
Partnership Forum to formally agree Terms of Reference
Draft scoping paper.
February - March
Refine scoping paper.
PF and local HOSCs to agree scoping paper.
Scoping paper sent to NHS for comments.
Initial literature review to pull out key messages from the
NSF.
Inaugural meeting of the Panel. A training session, hopefully
attended by appropriate NHS staff and a representative from
Diabetes UK who can present key issues in diabetes care.
April - September
Data requests and examination of witnesses.
Selection of areas for closer study.
Additional information requests and examination of
witnesses.
Review additional information and draft report
Development of any recommendations by Panel.
October November
Meeting of the Panel to agree the draft report.
Consideration of the report and any recommendations by
individual OSCs. The draft recommendations should be
confirmed by the OSCs prior to sending them to the NHS for
comment.
Meeting of Partnership Forum to agree to send report and
recommendations to the NHS for comment.
The NHS comments on factual report and any
recommendations (28 days must be allowed for this).
Presentation of health responses to individual OSCs.
Publication of the report.
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