Shared learning database

Type and Title of Submission


The Alphabet Strategy for Diabetes Care: Delivering NICE Guidance and the POETIC Vision


There have been several NICE Clinical Guidelines in relation to managing the patients with diabetes mellitus. We have created a healthcare professional and patient strategy for diabetes care and education which delivers high standards of care with a focus on reducing complications of diabetes and prevention of diabetes in those at high risk. This is based around the mnemonic: Advice, Blood Pressure, Cholesterol, Diabetes Control, Eye-care, Foot-care and Guardian drugs.


Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG15 - Type 1 Diabetes

Category(s) that most closely reflects the nature of the submission:

Is the submission industry-sponsored in any way?

MSD have offered to provide 200 folders for education patient and healthcare professionals. This will contain Diabetes Care Plan, NICE Guideline summary, Patient Education Posters.

Description of submission


Our aim is to improve the care of the patient with diabetes and in doing so improve their lives. This is by improving the quality of the clinical and social aspects of care such that there is minimal interference with the daily life of the patients with diabetes, their family and carers. This would be facilitated by a reduction in diabetes complications such as blindness, renal disease, foot ulceration and amputation.

We also sought to:
- To deliver high quality patient centred, multi-professional, evidence-based diabetes care working across the PCT, Secondary Care and Community interfaces
- To provide high quality, effective Healthcare Professional and Patient Education
- To create a diabetes care programme that can lead to the prevention of diabetes.

The background guidance in relation to the above aims was taken from various sources including Diabetes UK, National DH Programme for Diabetes but mainly based on NICE Guidance. This was specifically; Type 2 Diabetes (CG 66, 87), Type 1 Diabetes (CG15), Diabetes in Pregnancy (CG 63). NICE Public Health Guidance, in relation to prevention of diabetes mellitus was also addressed.




There are at least 2.6 million people with diabetes in UK. DH estimate that around 10% of the total NHS budget which is at least 10 billion is spent on diabetes. A considerable proportion of this is due to the treatment of complications such as cardiovascular disease (especially stroke and heart disease), foot ulceration and amputation, renal replacement and visual loss and treatment. Yet there is now high quality evidence which shows that over a 12 year period, most of the complications of diabetes can be reduced by 50% in the high risk patient. This includes reduction in mortality by 46%, cardiovascular death by 57%, end-stage renal failure by 80%, laser treatment by 55%, amputation by 50%, bypass surgery by 50% (Steno-2 2008). Type 2 diabetes itself is caused by lifestyle factors in 90% of cases with evidence showing that intensive life-style support reduces new cases of diabetes by 58%. Empowering people with diabetes is one of the key standards of the Diabetes NICE Guidelines. Encouraging patients to self manage their diabetes care can help to improve glycaemic control, blood pressure and lipid profiles resulting in CVD risk reduction. The healthcare professional team needs to work seamlessly to facilitate this. The Alphabet Strategy provides a useful approach to Diabetes Care in this regard. Patient held booklets and passports have previously been introduced as an aid in the care of a range of specific conditions, including diabetes, cancer and coronary heart disease. Dijkstra et al (2005) carried out a controlled intervention involving the use of a diabetes passport and subsequently reported positive health changes in patients in the intervention group with a 0.5% decrease in HbA1c levels when compared to the control group. The idea of care planning has been promoted recently through the DH Year of Care programme. Our ideas are similar in concept but address all the main risk factors for future health in patients with diabetes.


Some of the Diabetes Care educational materials in relation to the Alphabet Strategy will be attached to this application. From the outset, the strategy, simple in its concept has been driven by Healthcare Professionals and Patients and adapted for the very many different care settings and circumstances. The strategy itself is a patient-centred, evidence-based diabetes care and education strategy based on the seven most important aspects of diabetes care: Advice, BP, Cholesterol, Diabetes Control, Eye care, Foot care, Guardian drugs. All the educational materials listed in the objectives section of this application have now been produced. To evaluate the strategy prospective clinical audits have been undertaken in 400 patients, patients have been assessed for their level of diabetes knowledge, healthcare professionals have been evaluated on their knowledge of management of diabetes patients and suitability for the strategy surveyed in 24 different countries (usually single centres only). The cost was minimal due to the basic nature of the products (PowerPoint slides, simple document files). The course at the university was delivered at a nominal cost of around 80 per delegate per day, to include all teaching materials. All the core output remains in the public domain and is freely available. Specific materials have been created for South Asian patients with diabetes and this include Ramadan advice care plans, culturally specific care plans and Healthcare Professional Talks. Diabetes UK has produced posters and slides sets on the strategy.

Results and evaluation

Our clinical management and education strategy has had several publications and presentations. A presentation was made to the Centre for Disease Control Conference in 2009. The strategy is best evaluated using Kirkpatrick's evaluation of teaching and learning. This can be summarised into 4 levels: Reaction, Learning, Behaviour change and Outcomes. Usually educational programmes only evaluate at the first level. In clinical practice it is outcomes are critical. Main Results. Level 1: Reaction. Education programme: Delivered on over 20 occasions, evaluations have been consistently positive. Some quotes are included below. GAIA (Global Alphabet Strategy Implementation Audit): Survey in 35 diabetes centres, 24 countries revealed that 57.5% of 146 healthcare professionals likely to adopt strategy. 84.5% felt it was evidence-based and 88.0% practical. Level 2: Knowledge Skills Attitudes acquired. Patient Education Programme: Knowledge of diabetes care was evaluated in 100 patients with improvement in scores from 61.5 % to 80.0% (p<0.01). i-DREAM Programme: In 100 multi-professional healthcare workers, improvement in clinical management scores: (69% before, 98% afterwards (p<0.001). Level 3: Changes in Professional Practice. ASIAD Study: Implementation in Indian setting. Main changes were: improvement in cholesterol (60% to 90%), statins (5% to 38%), aspirin (6% to 71%), and proteinuria (48% to 93%). Diabetes In-patient Care Evaluation (UK): Data collected on quality before and after implementing this strategy (100 patients). Improvement in 9 of 10 main parameters (p<0.05). Level 4: Patient Outcomes. Clinical Audit: Over 5 years BP, lipids, diabetes, eye and feet screening improved. CVD risk improved by 23.9% (p < 0.05). These outcomes are comparable to intensive cohorts of large trials. Patients' comments include: - It is very simple, very easy to understand and extremely informative. - JWF - This is a very good idea, can I take this? - JA

Key learning points

This free, public domain strategy has helped deliver high quality diabetes care, patient education and reduction in CVD risk. This has been achieved with a low level of human resources and other costs. We have published data showing that our results are similar to the intensively treated cohorts in well resourced randomised controlled trials. The programme has been presented with considerable success to local volunteer groups in various settings including Community Centres, Churches, Muslim Community Centres, Hindu Temples, a Sikh Temple and an Afro-Caribbean Centre. The concepts appear to translate well across to all local ethnic minority groups. Over 100 general practices now have the patient education posters. A recent questionnaire to GPs and Practice Nurses indicates overwhelming support for the strategy and especially its integration with the QoF financial and clinical audit template for Diabetes Care. The NHS West Midlands POETIC Vision provides algebra for effective delivery of services for all Long Term Conditions and Healthcare generally. This is based on: Patient-centeredness, Public Health need, and being Professionally inspired. This is well catered for in the Alphabet Strategy for Diabetes Care. The other components include being Outcome-focussed, Evidence-based, Integrated locally (primary care, secondary care, communities) and being Cost-effective but Clinically governed and safe are all addressed as well. The main learning remains that high quality evidence-based guidelines such the several published by NICE for diabetes care can be effectively delivered by the Alphabet Strategy. The major clinical outcomes are apparent and welcome. The very close working with patients and the whole multi-professional team in diabetes was unique in this venture and as such this project is suitable for shared learning.

This submission was shortlisted for the 2011 Shared Learning Award.

View the supporting material

Contact Details

Name:John Morrissey
Job Title:Associate Specialist in Diabetes Care
Organisation:Diabetes and Endocrinology Centre
Address:College Street
Postcode:CV13 0BU


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This page was last updated: 10 February 2011

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.