Levels of care: Why planning is important

As time progresses and the magical 2013, when the National Service Framework (NSF) for diabetes has to be implemented in full, draws nearer more and more documents designed to help with the improvement of services for people with diabetes are published.

One of the latest is that dealing with service planning and design (National Diabetes Support Team [NDST], 2006). Although the context for this document relates to England, the principles contained within it could relate to the frameworks for other parts of the UK.

The document helps to clarify what is meant by terms, such as care pathways or models of care, used in the NHS today in relation to service improvement. An analogy (town planning) is used to help local diabetes networks understand the levels in practice.

Four levels of care are described. The first describes the overview of what should be available within every diabetes service in the country (analogous to a map of England). The NSF itself sets out what these generic components are.

The second level is also generated at a national level but explores in more detail each of the components outlined in the level 1 overview, giving information about what standards need to be achieved. National Institute for Health and Clinical Excellence guidance and other national work and directives, such as the diabetes competence frameworks from Skills for Health (Skills for Health, 2005), are level 2 components. The analogy here is planning a town and identifying what key features are necessary, such as sewage works and schools.

Level 3 is about the design of the local services – a local model of care – and it is this that will probably be most focused on by local diabetes teams over the next few months. The reorganisation of primary care trusts and health authorities and new commissioning arrangements are likely to necessitate some redesign of diabetes services, for instance. The analogy for level 3 is ensuring that all the aspects of town planning are organised and arranged in such a way as to fit the local geography. The specific needs of the local population and how to meet them are examined at this stage. The workforce needed, including new roles if necessary and the education required to enable it to deliver the care, is also explored.

If level 3 is about what needs to be done, level 4 is about specifically how it should be done. At this stage, analogous to the town’s operational plans, work developing local policies and protocols, perhaps called care pathways, occurs. The NDST (2006) suggest that this level is the area where most of us have the most expertise and are comfortable with. They also suggest that without the model of care having been developed in level 3, some elements of the national standards (level 2) may be missing and pathways of care may not be entirely effective.

Later in the year there will be a toolkit to help local diabetes networks further develop their ‘town plans’ (NDST, 2006). In the meantime the current NDST document can help us to clarify our thinking about what aspects of diabetes services need to be reviewed and, perhaps, redesigned. It may also help with the prioritisation of work. For instance, if teams of diabetes nurses in both primary care and the specialist team based in secondary care develop an insulin conversion pathway for people with type 2 diabetes and the model of care then changes to incorporate an intermediate primary care based specialist service as a result of service redesign, their work, although not wasted, would require adaptation. Investing time in contributing to service design at level 3 beforehand would prevent such problems.

So, from now on, whether we decide to wear our ‘hard hats’ or diabetes service design ones, we can, and should, get involved through our local diabetes networks in the planning of quality diabetes services, and have a common understanding of what all the terms mean.