Introduction

This quality standard covers

  • preventing type 2 diabetes in adults (18 years and older)

  • structured education programmes for adults with diabetes

  • care and treatment for adults with diabetes

  • preventing and managing foot problems in adults with diabetes.

It does not cover diabetes in pregnancy or diabetes in children and young people (see related NICE quality standards).

For more information see the diabetes in adults topic overview.

This quality standard has been updated. It was identified for update after the annual review of quality standards in 2014. The review identified that there had been changes in the areas for improvement for diabetes in adults. For further information about the update, see update information. Statements from the 2011 quality standard that are no longer national priorities for improvement but are still underpinned by current accredited guidance are included after the updated statements in the list of quality statements.

Why this quality standard is needed

Diabetes is a condition resulting from loss of insulin-secreting cells (type 1 diabetes) or insulin resistance or insufficient pancreatic insulin production (type 2 diabetes). Diabetes is one of the most common chronic diseases in the UK and its prevalence is increasing. Around 3.5 million people in the UK have been diagnosed with diabetes, and an estimated 549,000 have diabetes but have not been diagnosed. It is estimated that 5 million people in the UK will have diabetes by 2025 (Diabetes: facts and stats Diabetes UK).

Many cases of type 2 diabetes are preventable through lifestyle changes. The NHS Diabetes Prevention Programme has been established to help people to reduce their risk of developing type 2 diabetes.

The life expectancy of people with diabetes is shortened by up to 15 years, and 75% die of macrovascular complications, such as heart attacks and strokes. Diabetes care is estimated to account for up to 10% of NHS expenditure[1]. Foot complications are common in people with diabetes. It is estimated that 10% of people with diabetes will have a diabetic foot ulcer at some point in their lives. The rate of amputations in England for people with diabetes was 26 per 10,000 people in 2011–2014, although there are wide variations across England (Putting feet first position statement Diabetes UK).

Multiple vascular risk factors and wide-ranging complications make care for people with diabetes complex and time-consuming, and many areas of healthcare services need to be involved for optimal management. Necessary lifestyle changes, the complexities of care and possible side effects of therapy mean that patient education and self-management are important aspects of diabetes care. The risk of complications is greatly reduced by treatment that keeps circulating glucose levels as near normal as possible, reducing tissue damage.

The quality standard is expected to contribute to improvements in the following outcomes:

  • incidence of type 2 diabetes

  • control of blood glucose levels

  • hypoglycaemia

  • cardiovascular risk

  • incidence of complications

  • rates of ulceration, infection, complications and amputation of feet and lower limbs

  • hospital admissions and readmissions

  • quality of life

  • life expectancy.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – safety, experience and effectiveness of care – for a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2016–17

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicators

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

i Adults

1b Life expectancy at 75

i Males ii Females

Improvement areas

Reducing premature mortality from the major causes of death

1.1 Under 75 mortality rate from cardiovascular disease*

2 Enhancing quality of life for people with long-term conditions

Overarching indicator

2 Health-related quality of life for people with long-term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Improving functional ability in people with long-term conditions

2.2 Employment of people with long-term conditions* **

Reducing time spent in hospital by people with long-term conditions

2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive conditions

ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

Enhancing quality of life for carers

2.4 Health-related quality of life for carers**

Improving quality of life for people with multiple long-term conditions

2.7 Health-related quality of life for people with three or more long-term conditions**

3 Helping people to recover from episodes of ill health or following injury

Overarching indicators

3a Emergency admissions for acute conditions that should not usually require hospital admission

3b Emergency readmissions within 30 days of discharge from hospital*

Improvement areas

Improving outcomes from planned treatments

3.1 Total health gain as assessed by patients for elective procedures

i Physical health-related procedures

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

i GP services

4b Patient experience of hospital care

4c Friends and family test

4d Patient experience characterised as poor or worse

i Primary care

ii Hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to inpatients' personal needs

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators

5a Deaths attributable to problems in healthcare

5b Severe harm attributable to problems in healthcare

Improvement areas

Improving the culture of safety reporting

5.6 Patient safety incidents reported

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Table 2 Public Health Outcomes Framework for England, 2016–19

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors that affect health and wellbeing and health inequalities

Indicators

1.08 Employment for those with long-term health conditions including adults with a learning disability or who are in contact with secondary mental health services* **

1.09 Sickness absence rate

1.16 Utilisation of outdoor space for exercise/health reasons

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

Indicators

2.11 Diet

2.12 Excess weight in adults

2.13 Proportion of physically active and inactive adults

2.17 Estimated diagnosis rate for people with diabetes mellitus

2.22 Take up of the NHS Health Check programme – by those eligible

2.23 Self-reported well-being

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities

Indicators

4.03 Mortality rate from causes considered preventable**

4.04 Under 75 mortality rate from all cardiovascular diseases (including heart disease and stroke)*

4.11 Emergency readmissions within 30 days of discharge from hospital*

4.12 Preventable sight loss

4.13 Health-related quality of life for older people

Alignment with Adult Social Care Outcomes Framework and/or NHS Outcomes Framework

* Indicator is shared

** Indicator is complementary

Table 3 The Adult Social Care Outcomes Framework 2015–16

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care-related quality of life**

Outcome measures

People manage their own support as much as they wish, so they are in control of what, how and when support is delivered to match their needs

1B Proportion of people who use services who have control over their daily life

Carers can balance their caring roles and maintain their desired quality of life

1D Carer-reported quality of life**

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation

1I Proportion of people who use services and their carers, who reported that they had as much social contact as they would like

2 Delaying and reducing the need for care and support

Overarching measure

2A Permanent admissions to residential and nursing care homes, per 100,000 population

Outcome measures

Everybody has the opportunity to have the best health and wellbeing throughout their life, and can access support and information to help them manage their care needs

Earlier diagnosis, intervention and reablement means that people and their carers are less dependent on intensive services

2B Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services*

2D The outcomes of short-term services: sequel to service

Placeholder 2E The effectiveness of reablement services

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care and their carers are satisfied with their experience of care and support services

3A Overall satisfaction of people who use services with their care and support

Outcome measures

Carers feel that they are respected as equal partners throughout the care process

3C The proportion of carers who report that they have been included or consulted in discussions about the person they care for

People know what choices are available to them locally, what they are entitled to, and who to contact when they need help

3D The proportion of people who use services and carers who find it easy to find information about support

People, including those involved in making decisions on social care, respect the dignity of the individual and ensure support is sensitive to the circumstances of each individual

This information can be taken from the Adult Social Care Survey and used for analysis at the local level.

4 Safeguarding adults whose circumstances make them vulnerable and protecting from avoidable harm

Overarching measure

4A The proportion of people who use services who feel safe**

Outcome measures

Everyone enjoys physical safety and feels secure

People are protected as far as possible from avoidable harm, disease and injuries

People are supported to plan ahead and have the freedom to manage risks the way that they wish

Alignment with NHS Outcomes Framework and/or Public Health Outcomes Framework

* Indicator is shared

** Indicator is complementary

Indicators in italics in development

Safety and people's experience of care

Ensuring that care is safe and that people have a positive experience of care is vital in a high-quality service. It is important to consider these factors when planning and delivering services relevant to diabetes.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to people using services. Quality statements on these aspects of patient experience are not usually included in topic-specific quality standards. However, recommendations in the development sources for quality standards that affect people's experience of using services and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for diabetes in adults specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole diabetes care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to adults with diabetes.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality diabetes service are listed in related NICE quality standards.

Resource impact considerations

NICE quality standards should be achievable by local services. The potential resource impact is considered by the quality standards advisory committee, drawing on resource impact work for the source guidance. Organisations are encouraged to use the resource impact products for the source guidance to help estimate local costs.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health, public health and social care practitioners involved in assessing, caring for and treating adults with diabetes should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with diabetes. If appropriate, health, public health and social care practitioners should ensure that family members and carers are involved in the decision-making process about investigations, treatment and care.



[1] Hex N, Bartlett C, Wright D et al. (2012) Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabetic Medicine 29: 855–62