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PCDS Newsletter: Year of care

Roger Gadsby, Gwen Hall

Year of care
The Year of Care project for diabetes is a partnership between Diabetes UK, the Department of Health and the NHS National Diabetes Support Team. As you would expect from such august bodies, the intention is to evaluate a model of care that is tailored to the individual and which gives the person with diabetes a greater role to play in self care while demonstrating improvements in health.

The deadline for applying to become one of three pilot sites for the Year of Care project passed on 6th July. Applications were invited from PCTs, diabetes networks or consortia of practice-based commissioners.

The ‘year of care’ concept was developed by Professor Pieter Degeling, Centre for Clinical Management Development, University of Durham. He described it as:

‘a way of drawing together clinical governance, standards of care, audit and effective commissioning through describing in a year the routine care a person with a long-term condition should expect to receive’
.

Those involved in commissioning services for people with diabetes within new organisations can assess their progress using The Diabetes Commissioning Toolkit (2006). One advantage of the Year of Care is that each stage can be allocated costs and essential resources can be identified.

Although the GMS contract has undoubtedly led to a greater emphasis on diabetes management, it can be seen as a ‘tick box’ system that is not flexible enough to meet individual need and target those most at risk. The Year of Care project describes all the planned care that a person with diabetes should expect over the course of a year. This concept follows on from the National Service Framework which advocated Personal Health Records for all comprising of individual care plans and results of investigations that are held by the patient. The best practices have written care plans and agreed goals and targets with people with diabetes, which gives meaning to self care. After all, how can an individual be expected to meet targets if they haven’t been involved in agreeing them and don’t know what they are? The Year of Care project takes it a step further by offering more time for education, more options for care and support and a greater involvement in informed choice. Of course, we in primary care will need to see if the resources are there to deliver it however it may look. 

Assessment of local need and an ability to commission appropriate services is key to the success of this project. It will consider NHS reform policy and how it could better support health professionals and patients alike. Northern Ireland, Scotland and Wales have different health services and are not involved in this commissioning process. They will develop their own systems and pathways.

The Year of Care project will be piloted in three local areas in England. These pilot sites will test the feasibility of using the Year of Care approach across a local population and explore how the Year of Care approach to designing, delivering and commissioning services can be developed. Watch this space.

Gwen Hall, Vice Chair, PCDS

Confidential Enquiry into Maternal and Child Health (CEMACH)
Diabetes in pregnancy: Are we providing the best care?
The Confidential Enquiry into Maternal and Child Health (CEMACH) diabetes programme is a unique study into diabetes and pregnancy. To date, there have been three reports. The first was a survey of diabetes maternity services, the second a descriptive study of 3808 pregnancies to women with type 1 and type 2 diabetes, and the third a review of the demographic, social and lifestyle factors, and clinical care in 442 pregnancies to women with type 1 and type 2 diabetes and their association with pregnancy outcomes. The third and final report was published in February, 2007.
Some of its key findings are as follows.

  • There is a 36% pre-term delivery rate and 67% caesarian-section rate for women with diabetes.
  • More than half of the singleton babies of women with diabetes have macrosomia (defined as a birth weight over the 90th centile).
  • Women with diabetes have an increased risk of stillbirth, perinatal mortality and foetal anomaly compared with the general maternity population.
  • Women with diabetes are poorly prepared for pregnancy with poor uptake of folic acid, poor provision of pre-pregnancy counseling and sub-optimal glycaemic control before and in the first trimester of pregnancy.
  • One third of term babies are admitted to a neonatal unit for special care and over half of these admissions are avoidable.
  • Women who have had a poor pregnancy outcome are more likely not to receive postnatal contraceptive advice and more likely to have suboptimal postnatal diabetes care.

In light of these findings, the report makes a series of recommendations. These cover social and lifestyle issues. In particular they emphasise that providers of diabetes care should develop educational strategies that will enable all women with diabetes of childbearing age to prepare adequately for pregnancy. They cover clinical issues in preconception where features of preconception services are described. Recommendations for clinical care in pregnancy include details of what a care plan should contain. Clinical governance issues include the need to commission a full multidisciplinary diabetes and pregnancy team. Recommendations for neonatal care of term babies include the promotion of breast feeding.
NICE is developing a clinical guideline for diabetes and pregnancy that is due for publication in March 2008. The NICE guideline recommendations will be informed by these CEMACH findings and the NICE recommendations are likely to build on many of the CEMACH recommendations.

Roger Gadsby, Treasurer, PCDS

Year of care
The Year of Care project for diabetes is a partnership between Diabetes UK, the Department of Health and the NHS National Diabetes Support Team. As you would expect from such august bodies, the intention is to evaluate a model of care that is tailored to the individual and which gives the person with diabetes a greater role to play in self care while demonstrating improvements in health.

The deadline for applying to become one of three pilot sites for the Year of Care project passed on 6th July. Applications were invited from PCTs, diabetes networks or consortia of practice-based commissioners.

The ‘year of care’ concept was developed by Professor Pieter Degeling, Centre for Clinical Management Development, University of Durham. He described it as:

‘a way of drawing together clinical governance, standards of care, audit and effective commissioning through describing in a year the routine care a person with a long-term condition should expect to receive’
.

Those involved in commissioning services for people with diabetes within new organisations can assess their progress using The Diabetes Commissioning Toolkit (2006). One advantage of the Year of Care is that each stage can be allocated costs and essential resources can be identified.

Although the GMS contract has undoubtedly led to a greater emphasis on diabetes management, it can be seen as a ‘tick box’ system that is not flexible enough to meet individual need and target those most at risk. The Year of Care project describes all the planned care that a person with diabetes should expect over the course of a year. This concept follows on from the National Service Framework which advocated Personal Health Records for all comprising of individual care plans and results of investigations that are held by the patient. The best practices have written care plans and agreed goals and targets with people with diabetes, which gives meaning to self care. After all, how can an individual be expected to meet targets if they haven’t been involved in agreeing them and don’t know what they are? The Year of Care project takes it a step further by offering more time for education, more options for care and support and a greater involvement in informed choice. Of course, we in primary care will need to see if the resources are there to deliver it however it may look. 

Assessment of local need and an ability to commission appropriate services is key to the success of this project. It will consider NHS reform policy and how it could better support health professionals and patients alike. Northern Ireland, Scotland and Wales have different health services and are not involved in this commissioning process. They will develop their own systems and pathways.

The Year of Care project will be piloted in three local areas in England. These pilot sites will test the feasibility of using the Year of Care approach across a local population and explore how the Year of Care approach to designing, delivering and commissioning services can be developed. Watch this space.

Gwen Hall, Vice Chair, PCDS

Confidential Enquiry into Maternal and Child Health (CEMACH)
Diabetes in pregnancy: Are we providing the best care?
The Confidential Enquiry into Maternal and Child Health (CEMACH) diabetes programme is a unique study into diabetes and pregnancy. To date, there have been three reports. The first was a survey of diabetes maternity services, the second a descriptive study of 3808 pregnancies to women with type 1 and type 2 diabetes, and the third a review of the demographic, social and lifestyle factors, and clinical care in 442 pregnancies to women with type 1 and type 2 diabetes and their association with pregnancy outcomes. The third and final report was published in February, 2007.
Some of its key findings are as follows.

  • There is a 36% pre-term delivery rate and 67% caesarian-section rate for women with diabetes.
  • More than half of the singleton babies of women with diabetes have macrosomia (defined as a birth weight over the 90th centile).
  • Women with diabetes have an increased risk of stillbirth, perinatal mortality and foetal anomaly compared with the general maternity population.
  • Women with diabetes are poorly prepared for pregnancy with poor uptake of folic acid, poor provision of pre-pregnancy counseling and sub-optimal glycaemic control before and in the first trimester of pregnancy.
  • One third of term babies are admitted to a neonatal unit for special care and over half of these admissions are avoidable.
  • Women who have had a poor pregnancy outcome are more likely not to receive postnatal contraceptive advice and more likely to have suboptimal postnatal diabetes care.

In light of these findings, the report makes a series of recommendations. These cover social and lifestyle issues. In particular they emphasise that providers of diabetes care should develop educational strategies that will enable all women with diabetes of childbearing age to prepare adequately for pregnancy. They cover clinical issues in preconception where features of preconception services are described. Recommendations for clinical care in pregnancy include details of what a care plan should contain. Clinical governance issues include the need to commission a full multidisciplinary diabetes and pregnancy team. Recommendations for neonatal care of term babies include the promotion of breast feeding.
NICE is developing a clinical guideline for diabetes and pregnancy that is due for publication in March 2008. The NICE guideline recommendations will be informed by these CEMACH findings and the NICE recommendations are likely to build on many of the CEMACH recommendations.

Roger Gadsby, Treasurer, PCDS

REFERENCES:

NHS (2006) The Diabetes Commissioning Toolkit. Diabetes UK, UKPDS, ABDC, NDST, YHPHO

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