It would not be inaccurate to say that devolution offered Scotland new opportunities for joined-up thinking in many areas of public life, including health.
Nine years on, the delivery of primary care services has taken two major forms, and local delivery across the nation is now facilitated by the advent of Community Health and Care Partnerships.
Since 2002, with the publication of the Scottish Diabetes Framework (Scottish Executive, 2002), there has been effective collaboration between clinicians, people with diabetes, managers and politicians. This has brought a highly structured approach to the care of the population with diabetes, which is now approaching some 200000 individuals. The framework sets out the various building blocks of diabetes care – from prevention through disease management to IT, research and service management. From a clinical perspective, the Framework aligns itself closely with the guidance set out in the Scottish Intercollegiate Guidelines Network guideline (2001) on management of diabetes – significant parts of which are currently being updated.
In 2006 the Framework review (Scottish Executive, 2006) highlighted nine aims across the diabetes care spectrum to be addressed by the end of 2009 (the so-called “9 by 9” strategy). Reducing inequalities in care, encouraging and enhancing self-management through structured educational approaches along with investment to promote positive lifestyle choices in the most deprived areas in Scotland (for example the “Keep Well” initiative) are given as much credence as the various clinical aims also set out in the Framework review (Scottish Executive, 2006).
The strengthening of Managed Clinical Networks – designed with some financial and managerial autonomy in order to take account of local vagaries of service – is central to the delivery of the aims of the Framework. These aims include improving 24-hour care, outcomes of diabetes emergencies, access for disadvantaged groups and the rolling out of the DAFNE and DESMOND programmes ([Dose Adjustment for Normal Eating] [Diabetes Education and Self-Management for Ongoing and Newly Diagnosed], respectively).
The Framework also recognises the importance of data management systems and accurate registers; and the associated e-health strategy has produced significant advances in the advent of real-time electronic patient records. Additionally, the SCI-DC (Scottish Care Information – Diabetes Collaboration) Clinical Management System and the Generic Clinical System also provide professional-decision support functionality, multi-location input and patient-accessible record summaries.
Noteworthy, (now that the infrastructure and technology are in place) is the increasing success of the National Retinopathy Screening Programme. From static cameras in city hospitals to the roving vans in the Highlands and Islands, this programme has won international admiration.
Through the Framework, the Scottish Diabetes Group has produced an extremely comprehensive, inclusive and ambitious programme for the management of people with diabetes. Rightly, a great deal of the emphasis lies with the empowerment and support of primary care services in the overall strategy. It is difficult to see any major omissions from the review and action plan, and with ongoing cross-party political support and adequate funding, the future of diabetes care in Scotland looks promising.
Nevertheless, Scotland has its continuing issues. An obesity incidence and prevalence second only to the US (Scottish Public Health Observatory, 2007), and an unenviable mortality rate from coronary heart disease (which sees 26 of our citizens drop dead each day from myocardial infarction [General Register Office for Scotland, 2007]) highlights the challenges ahead.
The danger is that the good ship “Scottish Diabetes Care” may be filling up as fast as we can bail her out.