Original recommendation

Original Response

2015 Update

Recommendation 1

We recommend that the Welsh Government should ensure implementation of the National Service Framework through strengthened oversight and monitoring arrangements, as a priority in the forthcoming delivery plan. We believe this should include a national leadership post to coordinate health boards’ progress in delivering the NSF, and to facilitate the sharing of experiences and good practice between health boards.

The Welsh Government remains committed to the implementation of the 12 standards set out in the National Service Framework for Diabetes in Wales (NSF) and the Diabetes Delivery Plan will include as a priority the development of effective oversight and monitoring arrangements. My officials will work with the Local Health Boards (LHBs), the Diabetes delivery Plan Implementation Group and the Diabetes National Specialist Advisory Group (NSAG) to develop robust and effective monitoring arrangements both for the implementation of the plan the continued establishment of the NSF standards. A national diabetes clinical lead role will be developed to support both the delivery of the plan and to support Local Health Boards in the continued implementation of the NSF standards. The national lead will need to work closely with the Implementation Group to facilitate the sharing of experiences and best practice between LHBs.

The Diabetes Delivery Plan included a series of actions to take forward areas of the NSF that had yet to be delivered. Following the launch of the delivery plan, an NHS-led Implementation Group was established and has been supporting health boards to deliver the actions in the national delivery plan. The National Clinical Lead for diabetes, Dr Julia Platts, has been appointed and is working across the health boards to drive consistency and quality in the diabetic patient pathways. Good progress has been made against some standards, for example paediatric diabetes departments have participated in a peer review process to ensure the best possible service provision. National audits in areas such as inpatient care and pregnancy in diabetes have provided information to shape service improvement on a national and local level. Implementation priorities for each year have been agreed with detailed recommendations for action by the health boards.

Recommendation 2

We welcome the forthcoming delivery plan for diabetes, and recommend that the Welsh Government commits to taking appropriate action should health boards fail to deliver the services outlined in the plan.

The implementation of the Diabetes Delivery Plan falls to the NHS in Wales and at a local level to each individual LHB. In addition to monitoring progress, the Welsh Government and the Implementation Group will support LHBs through identifying opportunities for actions at an all Wales level and through facilitating the sharing of best practice through peer review. The Diabetes Delivery Plan will require each LHB to produce a local delivery plan to address progress against the plan, as well as continued implementation of the Diabetes NSF standards. LHBs will be held to account on their progress by the Welsh Government as well as by the local populations that they serve, and to facilitate this public accountability LHBs will be required to publish details of their progress on their websites. Appropriate action will be taken to challenge health boards which fail to deliver the services outlined in the Delivery Plan.

All health boards produced delivery plans last year in line with the requirements of the Together for Health Delivery Plan; these were peer reviewed through the diabetes implementation group and feedback given to each health board. Health boards were expected to produce their diabetes annual report by September 2014; but a number of health boards did not provide them in time and the matter has been escalated.


Health boards are now in the process of updating their delivery plans and these are to be completed in March 2015. Each health board should also include diabetes as part of their Integrated Medium Term Plans, which are approved by Welsh Government. Welsh Government is also working with Diabetes UK to introduce a new performance management approach to diabetes; we expect this will be introduced later this year.

Recommendation 3

We recommend that the forthcoming delivery plan should include a requirement for all GP practices to participate in the National Diabetes Audit.

Participation in the National Diabetes Audit (NDA) has been a crucial tool in developing improved diabetes services in Wales and continued, full participation will be a priority in the Diabetes Delivery Plan. Welsh GP participation in the Adult NDA has improved to over 80%, from about 50%, in the latest audit round, and the Diabetes Delivery Plan will instruct LHBs to continue to build on this improvement. It is the clear expectation of the Welsh Government that GP practices in Wales should participate fully in the National Diabetes Audit.

The Delivery Plan includes the requirement for all health boards, which are integrated primary and secondary care organisations, to participate in all aspects of the National Diabetes Audit (NDA). All health boards have participated in the audit, which was last published on 29 January 2015. The NDA Report 1: Care Processes and Treatment Targets 2012-2013 published on 2 October showed around 70% of GP practises in Wales participated. More than 80% participated in the previous round, but one health board missed the cut-off for the submission of 2012-13 data and therefore numbers are lower this time. This problem will not occur in future rounds as the manually extracted data system used by the health board is currently being phased out.

Recommendation 4

We recommend that the Welsh Government‘s delivery plan should require that all diabetes patients are offered all 9 key annual health checks, and that health boards‘ performance in meeting this requirement should be monitored through full participation in the National Diabetes Audit.

The Delivery Plan will have as a key priority that all patients are offered all 9 key annual health checks. These health checks are established indicators under the Quality and Outcomes Framework (QOF) as well as being monitored as part of the National Diabetes Audit (NDA). The NDA is currently working to ensure that the QOF and NDA measures are aligned, which would allow the monitoring of this to be conducted using either of these processes. As part of their work, he Implementation Group will consider the most appropriate way forward to ensuring compliance with the Delivery Plan, which will include the optimal approach towards monitoring progress. Full participation in the NDA will be a priority under the Diabetes Delivery Plan.

The Annual Report reiterated every person with diabetes should receive a planned programme of nationally recommended checks each year. This is part of the personalised care planning that enables them and their healthcare professionals to jointly agree how they will manage their diabetes. There are nine key care processes that all adults with diabetes should receive annually; the NDA and the delivery plan annual report describe compliance against this standard. The 2015 report showed 40% of adults with type 1 diabetes and 67% of adults with type 2 diabetes are having all the annual tests and investigations associated with national standards (not including retinal screening). This testing bundle hides the high rates of provision of HbA1c testing for under 25s (98.9%), foot examination (91%) and retinal screening (93%). The Implementation Group, diabetes network and the NDA clinical leads will be looking at the reasons all care processes are not being undertaken more consistently and leading action to improve performance.

Recommendation 5

We recommend that the forthcoming diabetes delivery plan should ensure that local Diabetes Planning and Delivery Groups’ relationships with health boards are formalised. Health Boards should demonstrate how they take account of DPDG recommendations and fully engage with their work. Arrangements should be put in place to adopt a national approach for DPDGs, to include national terms of reference for their operation and a requirement to meet with each other to share best practice.

Each LHB has established a local DPDG as part of the implementation of the Diabetes NSF and these groups will be vital in assisting LHBs in the development of their updated local delivery plans; which need to take account of the needs of their local population. The Diabetes Delivery Plan will require LHBs to formalise their relationships with their DPDGs, and to include their DPDGs terms of reference (ToR) as part of their updated local plans. The Implementation Group will take forward a peer review approach to share best practice

and DPDGs will be included in this process; including consideration of the development of a common set of ToR principles that all LHBs might adopt for their DPDGs.

All health boards, including Powys, have diabetes delivery groups and patient reference groups in place. The implementation group has yet to peer review and standardise their working; this work is expected to commence later this year.

Recommendation 6

We recommend that the introduction of an integrated diabetes patient management system should be a priority for the Welsh Government. We note the commitment already made to introduce such a system, and recommend that a clear timetable for its introduction is included in the forthcoming diabetes delivery plan.

The development of an integrated diabetes patient management system will be important for long term improvements in health care outcomes for people with diabetes in Wales. The Diabetes Delivery Plan will have the development of such a system as a key strategic priority for the NHS in Wales. The development of a patient management system will fall to the NHS Wales Informatics Service and my officials will work with this agency to finalise a timetable for its implementation.

A patient engagement exercise has been undertaken to determine the delivery requirements of the system. An outline business case was taken to the National Informatics Management Board in September 2014 for discussion; the Board prioritises national investment in IT infrastructure. It agreed further clarification is required about whether or not existing systems are able to meet this need. The final business case is expected to go before the Board in March for authorisation and prioritisation.

Recommendation 7

We recommend that future public health campaigns on diabetes should reflect the need to raise awareness of the risk factors associated with – and the early symptoms of - diabetes.

Prevention and early detection of diabetes are clear priorities for this Government and will be included in the Diabetes Delivery Plan. Any future public health campaigns will need to include raising awareness of the risk factors associated with diabetes, and early symptoms of the disease. Also, public health campaigns linked to lifestyle behaviours need to stress the risks associated with such behaviour, such as the links between obesity and diabetes.

The delivery plan includes commitments to reduce the risk factors for diabetes. A number of all Wales programmes are being delivered outside the scope of the Implementation Group, such as the Obesity Pathway and Change4Life. However, the Implementation group has also agreed to prioritise prevention and is examining ‘information prescriptions’ for people at risk of developing diabetes, and to examine risk identification through community pharmacies.

Recommendation 8

We recommend that the Welsh Government and health boards work together to expand the role of pharmacies in conducting risk assessments, to help improve early identification of people with diabetes. Pharmacies should also play a direct role in future public health campaigns. We believe the Welsh Government should specifically consider the value of including the HbA1c test for existing patients as an enhanced service as part of the Community Pharmacy Contractual Framework.

The early detection of diabetes will be a key theme of the Diabetes Delivery Plan and risk assessments have an important role to play. The Welsh Government will introduce an over 50s health checks programme to provide an online resource for people to assess their health and wellbeing. It will help identify risks to their health and provide advice on actions to reduce those risks and improve their health. It will also sign-post people to the most appropriate local support for changing lifestyle behaviours, and where appropriate direct them to seek advice from their GP, or other health professional. In addition, with regards to diabetes specific risk assessment, the Implementation Group will be tasked to look at all Wales solutions to this issue. They will bring forward recommendations on the most appropriate and effective way to deliver diabetes risk assessment to the people who need it; where they need it. A key factor in any such solution will be community pharmacies. Due to their close community links, pharmacies need to be considered in the development of any new public health campaigns. The Welsh Government will also task the Implementation Group to specifically consider the value of including HbA1c testing in pharmacies as part of their work on developing all Wales solutions to diabetes specific risk assessments.

Over recent years community pharmacy has participated in two national public health campaigns involving diabetes and screening. There are three national public health campaigns a year that engage with community pharmacy and the topics for 2015/16 have already been agreed with Public Health Wales.


The annual report highlights the important work Diabetes UK and community pharmacy have been doing to risk assess people in the community. An estimated 30,000 assessments have been undertaken through the UK pilot and thousands of people have been referred to their GP or for further testing. The Implementation Group is establishing a small sub group to look at a pilot project in Wales, as part of work involved in its current priority area about preventing diabetes. However, the latest audit findings show 98.9% of under 25s received their annual HbA1c test. Therefore, testing should be extended to community pharmacies as part of an integrated treatment and management pathway agreed in collaboration with relevant cluster, according to local needs.

Recommendation 9

We recommend that the Welsh Government should urgently address the variances in the provision of structured education for people with diabetes. The forthcoming delivery plan should require all health boards to provide NICE-compliant structured education programmes and ensure equality of access to appropriate, timely education for all patients across Wales.

Patient empowerment is crucial to improving health care outcomes for people with diabetes and education is a vital part of developing patient empowerment. The provision of NICE compliant diabetes structured education programmes will be a priority under the Diabetes Delivery Plan. The Quality and Outcomes Framework for 2013/14 has established an indicator for referral to a structured education programme within 9 months of entry onto the diabetes register and LHBs will need to ensure that programmes are available for people who are referred to them. In addition to people with newly diagnosed diabetes having access to NICE-compliant

structured education, the Implementation Group will consider other ways of delivering effective education to people with diabetes through the most appropriate and effective channels. Every opportunity needs to be taken to educate the person with diabetes if we are to improve health care outcomes for this sector of the population.

SDE is crucial to the self management of diabetes and the avoidance of additional morbidity. A new diagnosis is a vital opportunity to influence lifestyle and educate people about their diabetes. The latest annual report showed 7.6% of newly diagnosed patients received structured education in 2012-13, although this has increased from 5.8% in 2011-12. The Implementation Group has made provision of SDE a priority area, has reviewed the available SDE resources and is considering all-Wales provision of an agreed package, which includes phased improvement of uptake.

Recommendation 10

We believe that insulin pump therapy and the necessary accompanying education should be available to all suitable candidates to improve their quality of life. We recommend that the Welsh Government‘s forthcoming delivery plan include a requirement to improve the availability of education and training on the use of insulin pumps.

The Diabetes Delivery Plan will set out to achieve significant progress in patient access to intensive insulin therapy as there is evidence that such treatment reduces microvascular complications in type 1 and type 2 diabetes. Any provision should be evidence based and take account of patient choice, but the plan will set as a priority the provision insulin pump service in line with NICE guidelines.

The annual report recognises that access to insulin pump treatment is much lower in Wales than countries such as Germany and Austria. It highlights the need to implement the NICE technology appraisal regarding pumps fully and equitably across all health boards in Wales. The Implementation Group will be taking this work forward in the coming year.

Recommendation 11

We recommend that the Think Glucose programme should be introduced in all health boards across Wales.

Think Glucose is a commercial product and the 1000 Lives Plus programme is currently considering options for the introduction of a similar, non-commercial, pan Wales programme. It will be the remit of the Implementation Group to consider all Wales solutions for improvements in diabetes health care, and one of its first tasks will be to consider the most appropriate programme to implement; whether that be Think Glucose or a Welsh developed programme under the auspices of 1000 Lives Plus. The effectiveness of Think Glucose has highlighted the benefits of introducing such a programme across all LHBs in Wales. Therefore, an appropriate programme should be introduced at the earliest opportunity.

Hywel Dda University Health Board has implemented the Think Glucose programme across all its main sites and one community hospital. This includes one referral form, hypoglycaemic guidelines, medication chart and self management plans. The Implementation Group has received costings to roll the programme out nationally and is considering how best to fund an all-Wales programme.

Recommendation 12

We recommend that the Welsh Government undertake an audit of the number of diabetes specialist nurses in post across Wales, and the proportion of their time spent on general duties. The Welsh Government should consider the merits of issuing guidance to health boards on recommended numbers of diabetes nurses per head of population.

Diabetes Specialist Nurses have a crucial role to play in delivering improved care to people with diabetes, both in the community and hospital, and an important facilitation role in the delivery of structured education. The availability of this resource will need to adequately reflect local needs in the development of LHBs’ local diabetes delivery plans. The Welsh Government will conduct an audit of diabetes specialist nurses in line with the recommendation and work with the Diabetes NSAG to consider the merits of issuing guidance to health boards.

Data collection has been undertaken and analysis of this information now needs to take place before a paper is taken to the implementation group.

Recommendation 13

We recommend that the Welsh Government monitors the capacity of the Diabetic Retinopathy Screening Service to provide annual checks for diabetic patients as the growing prevalence of diabetes increases demand for the service.

Since its introduction, the Diabetic Retinopathy Screening Service has provided all-Wales screening to detect sight-threatening diabetic retinopathy at an early stage before visual loss occurs. The continued effectiveness of this service is key to improving treatment and care for people with diabetes. The capacity of the Diabetic Retinopathy Screening Service to provide annual checks will be part of the monitoring of the implementation of the Diabetes Delivery Plan. The Implementation Group will also consider how this resource can optimally deliver screening in the future whilst utilising the service’s data to improve research; with a view to delivering additional health outcomes.

The Delivery Plan included a commitment to review and refresh the Diabetic Retinopathy Screening Service Wales (DRSSW) to ensure it achieves the best outcomes for all patients. The annual report showed 93% of diabetes patients in Wales have had a retinopathy examination in the past 15 months. An External Quality Assurance (EQA) review was also carried out in 2014. The EQA review recommendations are currently being implemented by the DRSSW. In addition, the screening interval times are under review by the National Screening Committee (NSC). The outcome of the NSC review will be ready in 2015. It is anticipated the screening interval times for some patients will move from 12 to 24 months, which will help to cope with increased demand.