2. National Service Framework Diabetes Action Plan Develop personal care plan and personal diabetes record people with diabetes through structured …
2 National Service Framework Diabetes Action Plan
A Tasks to meet the targets from the priorities and planning framework
2003-2006 and Standard 3 of the NSF from 2003 - 2006
|Area |Current |Outcomes Year 1- |Outcomes Year|Outcomes |Lead or Sub Group |
| |Provision/Progres|by March 2004 |2- by March |Year 3 and |see key at end |
| |s to March 2003 | |2005 |beyond | |
|Implement |Proposal written |Revise proposal |Start |Continue |Pan Avon Diabetic |
|retinopathy |and approved by |and update costs|implementatio|implementati|Retinopathy Group |
|screening programme|PCT Board |Develop plan for |n of plan if |on of plan | |
| | |phased |resources |if resources| |
| | |implementation |available |available | |
|Update practice |New information |Assess new |Implement |As per year |Clinical Info Group|
|registers so that |system being |information |revised data |2
| |
|people with CHD and|developed in |system to ensure |collection, | | |
|diabetes receive |primary care, |recording of care|carry out | | |
|appropriate care |builds on |is accurate |audit | | |
| |previous annual |Assess results of|Present | | |
| |reporting for |audit and make |results to | | |
| |Chronic Disease |improvements |Board | | |
| |Management |Identify leads at| | | |
| | |each practice | | | |
| | |Present results | | | |
| | |to Boards Update| | | |
| | |data collection | | | |
| |
|when new GP | | | |
| | |contract agreed | | | |
|Ensure registers |An Integrated |Assess audit |Review and |As per year |Clinical Info Group|
|systematic |Care Pathway with|results |take action |2 | |
|treatment cover |protocols has |Review ICP to | | | |
|people at high risk|been agreed and |assess links with|Update | |Education Group |
|of CHD and Diabetes|regular training |weight management|practice | | |
|raised BP, DM and |days |protocol and |information | |Children and |
|BMI 30 | |covers all |pack | |Adolescent Group |
| | |settings, | | | |
| | |customised for | | | |
| | |ambulance | |
| |
| | |personnel, dental| | | |
| | |practices etc | | | |
| | |Review management| | | |
| | |of Children | | | |
| | |Publicise and | | | |
| | |provide training | | | |
| | |to any | | | |
| | |revised/new ICP | | | |
| | | | | | |
| | |Begin producing | | | |
| | |information pack | | | |
| |
|for practices so | | | |
| | |all core | | | |
| | |information on | | | |
| | |protocols, | | | |
| | |prescribing etc | | | |
| | |is in one place; | | | |
| | |also all | | | |
| | |information to be| | | |
| | |on web | | | |
| |Funding allocated|Appoint | | |Chris Hine/Julia |
| |to 3 practices in|facilitator, | | |Fox |
| |Bristol South and|initiate project | |
| |
| |West and Bristol |in pilot | | | |
| |North to screen |practice | | | |
| |and treat people | | | | |
| |with diabetes | | | | |
|Develop personal |Some people will |Review the | | |Patient Info Group |
|care plan and |receive a |situation to | | | |
|personal diabetes |personal care |assess | | | |
|record |plan but may not |consistency and | | | |
| |be consistent |take action- | | | |
| | |waiting national | | | |
| | |guidance | | | |
|Provide a named
|Some people will |Review the |Ensure all |Ensure all |Patient Info Group |
|contact in the |receive a named |situation to |patients have|patients | |
|diabetes team for |contact but this |assess |named contact|have named | |
|each person with |may not be |consistency and | |contact | |
|diabetes |consistent |take action | | | |
|Advice |New information |Info pack |Review |As per year |Patient Info Group |
|information for |pack for people |disseminated and |website and |2 | |
|people with |newly diagnosed -|to be available |availability | | |
|diabetes through |being developed |in different |of | | |
|structured | |formats |information | | |
|education | |Information to be| | | |
| | |available on |
| | |
| | |website- links to| | | |
| | |national | | | |
| | |websites | | | |
| |Assessing |Gather | | |Education Group |
| |promoting role of|information and | | | |
| |staff eg |assess options to| | | |
| |pharmacists, |increase role | | | |
| |podiatrists | | | | |
| |Promoted the |Continue to | | |Patient Info Group |
| |Expert patient |recruit to the | | | |
| |programme |Expert patient | | | |
|
| |programme | | | |
| |Develop proposal |Costed proposal | | |Education group |
| |for a patient |and | | | |
| |education group |implementation | | |Children and |
| | |plan | | |Adolescent Group |
| | |Liaise with | | | |
| | |patient support | | | |
| | |group established| | | |
| | |by young people | | | |
| | |with diabetes in | | | |
| | |North Bristol | | | |
| | |Secure funding |
| | |
| | |for DAFNE Dose | | | |
| | |Adjustment for | | | |
| | |Normal Eating | | | |
| |Information on |Information to be| | |Patient Info Group |
| |what is available|available on | | | |
| |for diabetic |website | | | |
| |people to access | | | | |
| |eg local | | | | |
| |opportunities for| | | | |
| |physical | | | | |
| |activities and | | | | |
|
|healthy eating | | | | |
| |General |Review outcome of| | |Children and |
| |information/resea|study to | | |Adolescent Group |
| |rch being |determine | | | |
| |gathered |non-attendance at| | | |
| | |clinics for young| | | |
| | |people who have | | | |
| | |transferred to | | | |
| | |adult services | | | |
B Tasks to meet standards in the next ten years Key actions for next
three years NB Some areas need to be completed
|Area |Current |Outcomes Year 1-|Outcomes Year|Outcomes Year|Lead or Sub |
| |Provision/Progress
|by March 2004 |2- by March |3 and beyond |Group see key |
| |to March 2003 | |2005 | |at end |
|Std 1 Prevention|Local strategies for|Complete |Review and |Review and |Shireen |
|including |diet and nutrition |strategies and |implementatio|implementatio|Mathrani/ |
|tackling |and increasing |assess how they |n of |n of |Education Group|
|inequalities in |physical activity |target sub |strategy |strategy | |
|risk |are in progress |groups Ensure | | | |
| | |targeting of | | | |
| | |people at high | | | |
| | |risk ref PCT | | | |
| | |race equality | | | |
| | |plan | | | |
| |Weight management
|Training |Continue with|Continue with|Shireen |
| |protocol and |programmes to |training |training |Mathrani/ |
| |training |provide |programme |programme |Education Group|
| |disseminated to GP |information and | | | |
| |practices |skills about | | | |
| | |risk factors | | | |
| |Include physical | | | | |
| |activity component | | | | |
| |in structured | | | | |
| |education groups | | | | |
| |see above A43 | | | | |
|Std 2 |Annual feedback of |PCT to provide |Benchmark | |Clinical Info |
|Identification |data to
practices to|benchmarking |across wider | |Group |
|of people with |enable benchmarking |report to |range of PCTs| | |
|diabetes |of prevalence |practices |and from | | |
| | | |national | | |
| |Participation in | |data | | |
| |national pilot |Provide training| | | |
| |project for |programme so |Provide | | |
| |screening those at |staff can |training so | | |
| |high CHD stroke |diagnose people |staff can | | |
| |risk see above |with undiagnosed|identify | | |
| |will include |diabetes |people who | | |
| |screening for | |have | | |
|
|diabetes in those | |previously | | |
| |with multiple risk | |been found to| | |
| |factors | |have impaired| | |
| | | |glucose | | |
| | | |regulation | | |
| | | |and women who| | |
| | | |have had a | | |
| | | |previous | | |
| | | |diagnosis of | | |
| | | |gestational | | |
| | | |diabetes | | |
|Std 4 Clinical |Reviewed and agreed |Training | | |Education Group|
|care
of adults |funding priorities |programme | | | |
| |in Board |agreed- see C 4 | | | |
| |Network sub-group | | | | |
| |developing clinical | | | | |
| |audit plan | | | | |
|Std 5 Clinical |UBHT provides a |Secure adequate | | |Children and |
|care of children|specialist |psychology/diete| | |Adolescent |
|and young people|paediatric service |tic support at | | |Group |
|with diabetes |Audit data presented|diagnosis/period| | | |
| |on some aspects |s of poor | | | |
| |within past 2 years|control/transiti| | | |
| | |on to adult | | |
|
| | |care | | | |
| | | | | | |
| |Assessing care of |Improve links | | |Children and |
| |vulnerable groups of|with other | | |Adolescent |
| |children with |agencies eg | | |Group |
| |diabetes |residential | | | |
| | |care, | | | |
| | |co-ordinated | | | |
| | |approach to | | | |
| | |child protection| | | |
| | |issues | | | |
|Std 6 Transition|Links with |Protocols / | |
|Children and |
|from child to |childrens hospital |appropriate | | |Adolescent |
|adult service |/ potential for |arrangements for| | |Group |
| |joint clinics being |transition and | | | |
| |explored 2 monthly|management of | | | |
| |joint meetings to |adolescents | | | |
| |discuss cases in | | | | |
| |transition have been| | | | |
| |established and | | | | |
| |nurse-to-nurse | | | | |
| |handover protocol | | | | |
| |devised | | | | |
| |Assessing quality of|Reorganise | |
|Children and |
| |transfer from |service so young| | |Adolescent |
| |paediatric to adult |person | | |Group |
| |service |introduced to | | | |
| | |adult service in| | | |
| | |last year of | | | |
| | |attendance | | | |
| | |Develop handover| | | |
| | |protocol | | | |
| | |Initiate regular| | | |
| | |meetings between| | | |
| | |members of | | | |
| | |paediatric and |
| | |
| | |adult care | | | |
|Std 7 Management|Protocols in place |Continue | | |Colin Dayan and|
|of diabetic |for key conditions |training, ensure| | |Core Group |
|emergencies |eg ketoacidosis |protocols are | | | |
| |Widely available in |updated | | | |
| |AE and in ward |regularly, audit| | | |
| |resource files |and respond | | | |
| | |accordingly | | | |
| | |Improve usage of| | | |
| | |protocols Agree,| | | |
| | |implement and | | | |
| | |audit protocols |
| | |
| | |for diabetic | | | |
| | |emergencies | | | |
| | |Publicise to | | | |
| | |relevant | | | |
| | |staff/families/p| | | |
| | |atients | | | |
| | |Training | | | |
| | |programme to | | | |
| | |provide | | | |
| | |information and | | | |
| | |skills to mange | | | |
| | |diabetic
| | | |
| | |emergencies | | | |
|Std 8 Patient |Limited provision |Review the | | |Core Group |
|participation in| |situation and | | |liaise with |
|effective care | |identify action | | |UBHT |
|during hospital | |plan | | | |
|admission | | | | | |
|Std 9 Diabetes |Diabetes in |Establish audit |Agree, | |Core Group |
|pregnancy |pregnancy clinic |programme |implement and| |liaise with |
| |already in place | |audit local | |UBHT |
| |Dietitian 3 hours to| |protocols for| | |
| |be appointed | |management of| | |
| | |
|pregnant | | |
| | | |women with | | |
| | | |diabetes | | |
|Std 10 Regular |See retinopathy and |To be identified| | |Education group|
|surveillance for|register targets | | | | |
|long term |above | | | | |
|complications | | | | | |
|Std 11 Develop, |Integrated care |To be identified| | |Education group|
|implement and |pathway developed, | | | | |
|monitor |informs educational | | | | |
|protocols care |programmes fro | | | | |
|systems to |primary care | | | | |
|reduce |
| | | | |
|disability and |Clinical audit | | | | |
|premature death |planning as above | | | | |
|Std 12 People | |Review current | | |Children and |
|needing | |education | | |Adolescent |
|multi-agency | |programmes for | | |Group |
|support receive | |children and | | | |
|integrated | |young people | | | |
|health and | |Liaise with | | | |
|social care | |local support | | | |
| | |groups for | | | |
| | |children, | | | |
| |
|families and | | | |
| | |young adults to | | |Sue Field |
| | |gain views | | | |
| | |Review links | | | |
| | |with asylum | | | |
| | |seekers project | | | |
C Tasks to meet the Delivery Plan in the next ten years showing key
actions for next three years
|Area |Current |Outcomes Year 1-|Outcomes Year|Outcomes |Key Lead or Sub |
| |Provision/Progress |by March 2004 |2- by March |Year 3 and |Group see key |
| |to March 2003 | |2005 |beyond |at end |
|Diabetes Network|Network set up with |Diabetes network|Diabetes |As per Year|Core group |
|and |clinical champions |meets quarterly|network |2 | |
|accountability |Consultant
and Lead| |continues: | | |
| |GP, Lead Nurses, |Papers on |Review and | | |
| |Lead Managers and |progress, plans |adapt as | | |
| |lay people |and terms of |necessary | | |
| |Terms of reference |reference | | | |
| |written |approved by PCT | | | |
| | |and UBHT Board | | | |
| | |Recruit more | | | |
| | |service users | | | |
| | |onto the group | | | |
|Capacity to |This 1st draft plan |Plan finalised |Update plan |As per year|Core group |
|develop and |produced |and costed, |line with |2 | |
|implement plans |
|updated in line |national | | |
| | |with national |guidance and | | |
| | |guidance |resources | | |
|Workforce skills|Agreed key |Work with |Update plan |As per year|Core group |
|profile |priorities were to |Workforce |line with |2 | |
| |increase diabetes |Development |national | | |
| |nurse specialists, |Confederation to|guidance and | | |
| |dietetic support for|review staffing |resources | | |
| |pregnant women |needed | | | |
| |Other priorities | | | | |
| |include increasing | | | | |
| |the number of | | | | |
| |dieticians and
| | | | |
| |having a dedicated | | | | |
| |project work to | | | | |
| |support NSF | | | | |
| |implementation, more| | | | |
| |nurse time in GP | | | | |
| |practices | | | | |
|Training |187 clinicians were |Develop a |Review |As per year|Education Group |
|programme |trained so far on |systematic |training |2 | |
| |the ICP |training and |programme in | | |
| | |evaluation |view of | | |
| | |programme |evaluation | | |
| | |
|and resources| | |
Source:ocf.berkeley.edu
