New SIGN guidance on the management of diabetes

The Scottish Intercollegiate Guidelines Network (SIGN) published its first set of diabetes guidelines – covering each of the St Vincent Declaration clinical outcomes relating to visual impairment, pregnancy, renal disease, foot disease and cardiovascular disease – in 1996–1997, as well as a guideline on the management of children and young people and a recommended minimum dataset for collection in people with diabetes (SIGN, 2010a). The aim was to provide an evidence-based framework for the management of diabetes to reduce the burden of associated long-term complications. The guidelines were widely accepted by all healthcare professionals responsible for diabetes care in Scotland.

These guidelines were reviewed and updated, and in November 2001 were published as a single document, SIGN 55: Management of Diabetes: A National Clinical Guideline (SIGN, 2001), omitting the minimum dataset, which was published as a separate document.

SIGN 116
Since 2001, new evidence has been published in many of the areas covered by the SIGN 55 recommendations, resulting in the need for a selective update – SIGN 116: Management of Diabetes: A National Clinical Guideline (SIGN, 2010b). Where new evidence did not impact upon existing recommendations, the original recommendations were not changed. Where the evidence was thought likely to significantly change the content or grading in SIGN 55, it was identified and reviewed.

A number of new areas that were not considered in SIGN 55 have also been incorporated into the selective update, including new sections on blood glucose-lowering agents for people with type 2 diabetes, and on psychosocial factors. The updated guideline does not cover either the screening or prevention of diabetes or pre-diabetes, both of which will be addressed by the needs assessment on type 2 diabetes, commissioned from the Scottish Public Health Network by the Scottish Diabetes Group (SDG). 

SIGN 116 was launched at the Diabetes in Scotland Conference 2010 at the Edinburgh Conference Centre on 23 March. It provides recommendations based on current evidence for best practice and will be of interest to any healthcare professional delivering diabetes care, as well as to people with diabetes, their carers and members of the voluntary sector. 

A quick reference guide (SIGN, 2010c) and a booklet for people with diabetes and carers were published with it (SIGN, 2010d). The guideline, reference guide and patient booklet can be accessed at: www.sign.ac.uk/guidelines/fulltext/116/index.html. A cost and resource impact assessment report developed by SIGN is also to be made available as a companion document to the guideline.

Recommendations
The guideline provides recommendations on:

• Lifestyle management.
• Psychosocial factors.
• Management of type 1 diabetes.
• Pharmacological management of glycaemic control in people with type 2 diabetes.
• Management of diabetes in pregnancy.
• Management of diabetic cardiovascular disease.
• Management of kidney disease in diabetes.
• Prevention of visual impairment.
• Management of diabetic foot disease.

A number of key clinical recommendations from these areas has been highlighted by the SIGN 116 Guideline Development Group to be prioritised for implementation, which is the responsibility of each NHS Board in Scotland and is an essential part of clinical governance. Diabetes Managed Clinical Networks in each Board should lead the process, and a review of current practice and redesign of services will be necessary to incorporate some of the recommendations into existing practice.

Resources and implementation
As was inevitable, implementing the recommendations of SIGN 116 has significant resource implications, and in this era of cut-backs and little (if any) access to new resources, this will be a huge challenge to the NHS in Scotland. However, the revised Diabetes Action Plan is due for publication in April, and some of its actions have been based on recommendations from SIGN 116. NHS Boards are required to report progress against the Diabetes Action Plan twice a year to the SDG, and these reports will be published online (www.diabetesinscotland.org.uk/) and will therefore be available to all. 

Moreover, some of the actions are resourced by the SDG. These include the PIDPAD (Psychology in Diabetes, Psychology and Diabetes) project, which aims to fund five part-time psychology posts for 3 years to develop pathways of care and staff training initiatives and share learning between NHS Boards. The actions also include the proposed appointment of a national education coordinator, whose remit will include education both for healthcare professionals and people with diabetes. Both of these initiatives will help to support healthcare professionals, in particular nurses, in implementing some of the recommendations.

The Guideline Development Group included in SIGN 116 an audit tool to assist with implementation, and some of the results of this will be recorded in the electronic patient record – the Scottish Care Information Diabetes Collaboration (SCI-DC). These outcomes are then reported in the annual Scottish Diabetes Survey (SDS Monitoring Group, 2009), a copy of which is sent to the Chief Executive and Director of Public Health in each NHS Board. Any differences in care outcomes between Boards can then be assessed.

Conclusion
SIGN 116 is not meant to be seen as a standard of care. Rather, it aims to encourage the provision and development of high-quality care for all people with diabetes in Scotland.