The prevalence of diabetes continues to rise, with 4.3 million people in the UK now living with a confirmed diagnosis and a further 2.4 million at high risk of developing type 2 diabetes (Diabetes UK, 2023). As for the inpatient population, around 20% of all hospital beds are now occupied by a person living with diabetes, with the majority admitted for reasons unrelated to their diabetes and predicted to have poorer outcomes than those without a diabetes diagnosis (Rayman and Kar, 2020). Hospital admission can often affect usual diabetes management, from insulin therapy to changes in physical activity and nutritional intake.
As a result, over the last 20–25 years there has been a shift in the focus of diabetes teams to include the management of people with diabetes in hospital. Importantly, this shift has led to the creation and expansion of the role of the Diabetes Inpatient Specialist Nurse (DISN) and, more recently, the development of multidisciplinary inpatient diabetes teams. The Diabetes UK Making Hospitals Safe for People with Diabetes report (Diabetes UK, 2018) showed that inpatient diabetes care is not universally standardised and that currently there is no mechanism to provide assurance that services are delivered to a high standard for all people with diabetes in hospital. There is now a great deal of evidence suggesting that a DISN service leads to improved outcomes for people with diabetes. However, almost one fifth (18%) of hospital sites in the UK still had no dedicated DISN in 2019, according to the National Inpatient Diabetes Audit (NaDIA; NHS Digital, 2020).
In order to support the role of DISNs, services must be assisted to improve delivery and quality of care for people with diabetes. Diabetes UK has partnered with the Royal College of Physicians and stakeholders working in inpatient diabetes care to develop, pilot and launch the Diabetes Care Accreditation Programme (DCAP). DCAP, the first programme of its kind in diabetes, aims to improve inpatient care by setting quality standards and measuring how services perform against these.
DCAP will improve and standardise inpatient diabetes care across the UK by setting a framework of quality standards and measuring how services perform against them. The aims are to support teams to identify gaps in services within seven key domains and encourage continuous quality improvement. The domains cover all aspects of quality care, including leadership and operational delivery, clinical processes, clinical effectiveness, person centred care, safety and risk management, quality improvement and workforce.
The DCAP standards were developed by the Joint British Diabetes Societies for Inpatient Care (JBDS-IP), and supported by Diabetes UK, the Association of British Clinical Diabetologists, the Diabetes Inpatient Specialist Nurse UK Group and people living with diabetes, as part of a pilot programme. They combine recommendations from national guidance, including Making Hospitals Safe for People with Diabetes, NaDIA, Getting it Right First Time and JBDS-IP guidelines, to cover all aspects of high-quality diabetes inpatient care.
The DCAP team will support services through the process by facilitating online learning events to guide teams through the evidence upload and assessment process. The team will also host a resource library containing examples of best practice seen across the UK, for participating services to access. Each assessment will be completed by a multi-professional group of external peer assessors, consisting of nurses, consultants, pharmacists, podiatrists, dietitians and people living with diabetes. This will enable assessment of inpatient services from a holistic perspective, taking into consideration the views and needs of everyone.
The experiences from the pilot programme have demonstrated that accreditation is a collaborative process. During the pilot, nurses who volunteered as assessors recognised the value of partnership with external stakeholders and the wider diabetes inpatient team, as well as the importance of having an accreditation programme that will improve patient safety. They valued and benefited from peer support and peer learning, commenting that it helped to remove some of the barriers between the different inpatient healthcare professions. For the DCAP team, it would have not been possible to develop the standards and assess the sites without the support and contribution of DISNs, who often deliver the majority of the diabetes care on the wards.
Services will work towards achieving the standards by following a predesigned accreditation pathway. We recognise that with the current pressures on the NHS, workforce issues and post-pandemic backlog, services may be discouraged from joining DCAP. The pathway was, however, designed to allow for flexibility and to account for individual service circumstances and workforce pressures. This came from pilot feedback which highlighted that our approach to assessment may be too constraining for nurses to fully participate in while continuing to deliver care for people with diabetes on the wards. As such, services will have up to 18 months from registering with DCAP to request a Level 1 assessment.
Level 1 standards fall under the umbrella of “quality improvement”, and this is where services will work towards transforming and embedding quality improvement and system changes. Once the service is ready, an assessment will take place that will determine whether they can move to Level 2.
We know that DISNs play a pivotal role in improving inpatient care for people with diabetes, but they cannot possibly see all inpatients with diabetes who need some specialist input, nor can hospital-wide improvement be achieved by one group of staff alone. DCAP aims to ensure there is a full diabetes multidisciplinary team with an operational plan that is supported by hospital executive teams and IT infrastructure. Feedback from teams participating in the pilot has demonstrated that the structure of the programme allows for a full review and gap analysis of services, which teams have found invaluable.
Improvements in diabetes care achieved through accreditation can act as a form of assurance for people with diabetes, clinical staff, referrers and commissioners. DCAP will help standardise ways of working and reduce variation in clinical practice and services provided. Our 2022 pilot showed that joining DCAP increased staff satisfaction with working conditions, and improved efficiency and collaboration. The process was also a great way to highlight and share good practice, and to indicate where to focus improvement efforts.
The ambition is for DCAP to make a transformational impact on improving inpatient care and creating the change people living with diabetes need and deserve. Diabetes is a key feature of NHS England’s Long Term Plan, and it is known that improvements in care for inpatients can lead to a reduction in harm, reduced length of stay and an improved patient experience.
We encourage all DISNs to promote DCAP within their diabetes inpatient teams across the UK and to sign up to DCAP by visiting www.dcap.org.uk.