Commissioning a patient education programme for people with type 2 diabetes
Type 2 diabetes is a progressive long-term medical condition that is predominantly managed by the person with diabetes and/or their carer as part of their daily life. Diabetes care is typically complex and time-consuming with correspondingly huge implications for the person with diabetes and/or their carers. The necessary lifestyle changes, the complexities of management and the side effects of therapy make education for people with diabetes a central part of diabetes management. Structured education and self-management programmes aim to improve outcomes by addressing the person's health beliefs, optimising their metabolic control, addressing their cardiovascular risk factors (helping to reduce the risk of complications), helping them to change their behaviour (such as increasing their physical activity), improving their quality of life and reducing any depression. These programmes are an investment for the future. The potential consequences of not investing in such programmes are increased complications, greater future healthcare costs, and an inability to meet future goals for individual, local and national improvement. Well-designed and well-implemented programmes are likely to be effective and cost-effective interventions for people with type 2 diabetes.
Diabetes is one of the most common chronic medical conditions in the UK, with an estimated 1.9 million adults diagnosed with the condition. Type 2 diabetes accounts for around 90% of these cases. Alongside this, some estimates suggest that there are an additional 0.5 million people with undiagnosed diabetes against a background of rising prevalence. The direct costs of type 2 diabetes are estimated to be around 7-12% of total NHS expenditure.
People with diabetes are more likely to have heart disease, stroke, kidney failure, blindness, depression and amputation of a lower limb than people without diabetes. Around half of the people with the condition already have complications present at the time they are diagnosed. Type 2 diabetes:
- can cause severe complications, affecting the eye, the nervous system and the kidney
- is a leading cause of end-stage renal disease and blindness in people of working age
- is the most common cause of non-traumatic lower limb amputation
- doubles the rate of depression compared with the general population
- doubles the overall risk of cardiovascular disease
- reduces life expectancy by an average of 7 years.
NICE clinical guideline CG66 on type 2 diabetes (update) recommends that structured education should be offered to every person and/or their carer at and around the time of diagnosis, with annual reinforcement and review. It also recommends that people with diabetes and their carers should be informed that it is an integral part of diabetes care.
The NICE quality standard for diabetes in adults includes a statement about structured education which reads:
‘People with diabetes and/or their carers receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education' (statement 1, NICE quality standard for diabetes in adults).
However, there is evidence that not all people with type 2 diabetes are able to access sufficient educational input and many are unaware of some of the most important information. The Healthcare Commission found that while every primary care trust (PCT) had some structures in place to offer an education or training course to people with diabetes, in two thirds of PCTs 20% of people or less had been offered courses. In approximately half of trusts (55%), 10% of people or less reported attending a course. Overall, between 1%and 53% of people with diabetes across all PCTs reported attending a course. Figure 1 illustrates the gap between people who have attended such a course and those who would like to.
Also, the length, content and style of educational options varies considerably between services. Some of these programmes are unstructured, very few have been formally evaluated and few people who deliver them have been formally trained for the purpose. If they are to be effective it is important that education programmes meet the criteria set out by NICE and the Department of Health and Diabetes UK Patient Education Working Group.
The potential benefits of robustly commissioning an effective patient education programme for people with type 2 diabetes include:
- improving knowledge, health beliefs, and lifestyle changes
- improving patient outcomes such as biomedical markers, for example body weight, haemoglobin A1c, lipids and smoking; and psychosocial changes, for example quality of life and levels of depression
- improving levels of physical activity
- improving performance and patient-centred clinical care through implementing the recommendations outlined in NICE clinical guideline CG66 on type 2 diabetes (update)
- reducing the need for, and potentially better targeting of, medication and other items, for example blood testing strips
- reducing inequalities and improving access to educational support, especially among black and minority populations, among those who report not attending an education course but want to, and those diagnosed some time ago
- increasing patient choice and improving partnership working, patient experience and engagement
- greater cost-effectiveness, which may help commissioners to manage their commissioning budgets more effectively.
Key issues in providing an effective patient education programme for people with type 2 diabetes are:
- ensuring suitably designed, structured programmes appropriate to local and individual patients' needs, delivered by trained and competent staff who are monitored, audited and quality assured
- ensuring the service is accessible for all people with type 2 diabetes, taking into account timing, venues and locations, and local cultural, linguistic, cognitive and literacy needs
- accurately identifying all people requiring or desiring education in diabetes
- ensuring that appropriate referral pathways are in place between the multiple services often involved in managing people with diabetes, for example, the primary care team, hospital teams, podiatry, dietetics, eye screening, and that the service is integrated with them to ensure continuity of care.
National priorities and initiatives relevant to commissioning a patient education programme for people with type 2 diabetes include:
- NHS Outcomes Framework 2012/13
- Public Health Outcomes Framework
- The NHS in England: The operating framework for 2012/13
- Liberating the NHS: legislative framework and next steps
- National service framework for diabetes and associated delivery strategy.
- Six years on: delivering the Diabetes National Service Framework
- Quality, innovation prevention and productivity (QIPP)
- Using the Commissioning for Quality and Innovation (CQUIN) payment framework - a summary guide
Implementation of NICE clinical and public health guidelines. These are core standards, and performance against these standards will be assessed by the Care Quality Commission in line with ‘Standards for better health'.
Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.
1. National Collaborating Centre for Chronic Conditions (2008) Type 2 diabetes: national clinical guideline for management in primary and secondary care (update). London: Royal College of Physicians
2. Healthcare Commission (2007) . Managing diabetes: improving services for people with diabetes.
3. National Institute for Clinical Excellence (2003) Guidance on the use of patient education models for diabetes. NICE technology appraisal 60. London: National Institute for Clinical Excellence.
This page was last updated: 03 April 2012
- Commissioning a patient education programme for people with type 2 diabetes
- Specifying a patient education programme for people with type 2 diabetes
- Determining local service levels for a patient education programme for people with type 2 diabetes
- Assumptions used in estimating a population benchmark
- The commissioning tool
- Ensuring corporate quality assurance