How commissioning could affect diabetes care for older people

Last autumn, I highlighted that pathways for the older person with diabetes were being developed by NHS Diabetes in the form of commissioning guides (Da Costa, 2009). These have now been published: Commissioning Diabetes Prevention and Risk Assessment Services (NHS Diabetes, 2010a) and Commissioning Diabetes Services for Older People (NHS Diabetes, 2010b). 

Development
Both guides were developed with key stakeholders, including clinical and social services professionals, and patient groups represented by Diabetes UK, Age Concern and others. The guides are not designed to replace standard NHS contracts, but rather to form the basis of discussion between commissioners and providers – in these specific examples regarding prevention, risk assessments and diabetes services.

Both documents describe key features of good services, high-level intervention maps (both clinical and administrative) or flowcharts; and, unlike care pathways or clinical protocols, they aim to describe how a true “diabetes without walls” service should operate across all healthcare sectors. All key standards of quality and policy relating to these aspects of care are thus brought together within a contracting framework. 

The guides
The focus of the prevention and risk assessment services tool (NHS Diabetes, 2010a; Box 1) is self-explanatory. Where it could impact on older people with diabetes is:

• Actively seeking out those at risk of diabetes.
• Offering active prevention to people of all ages.
• Reducing the prevalence of type 2 through prevention of obesity.
• Providing effective and safe care to those at risk of developing diabetes in a range of settings.
• Ensuring services are accessible and responsive to people with learning disorders.
• Supporting self-management.
• Providing people with diabetes and carer education, and other lifestyle interventions.
• Providing multidisciplinary care that manages the transition between adult and older people’s services.

Clearly, detecting more people with diabetes will increase the known population with the condition, and put further strain on already stretched services. There appears not to be the funding for more clinicians, which means we will need to approach this increased demand differently and more imaginatively, for example in different care settings and with non-professionals. It will require services to review and possibly prioritise their resources, which may enable integration of primary and secondary care as clarity of referral and access will be key.

The features of Commissioning Diabetes Services for Older People (NHS Diabetes, 2010b; Box 2) build on the prevention and risk assessment services tool, recognising that high-quality diabetes care is provided by services that actively identify and manage people with diabetes who have special needs as a result of extreme frailty, advanced age (>80 years) or residency within a care home. The intervention map encompasses raising awareness (nationally, locally and in targeted groups) and includes prevention, risk assessment and stages for high- or low-risk individuals. Referrals from care homes and other services are included, and the focus on care planning, which is agreed and initiated with user involvement, and includes education for the person with diabetes. It also includes referral to specialist care.

The contracting framework for both of these guides has governance at its heart. Elements such as leadership, characteristics, skills and behaviours, outputs generally and specifically are included. Finally, a standard service specification template for diabetes services for older people is included.

Conclusion
These guides, resourced from the Department of Health, informed by National Service Frameworks, NICE and other national initiatives, provide a framework we can assess our services against, change focus or resources, and hopefully improve care for what can often be a neglected group. Failing to meet a nationally agreed plan provides a more persuasive argument for resources, with certain caveats. Therefore, I would recommend to all readers that these guides are obtained, and their services reviewed against them.