Accreditation of NHS Inpatient Diabetes Care 'On Its Way'

Liam Davenport

October 31, 2019

LONDON — Inpatient diabetes care on the NHS in England is soon to be accredited, helping to even out variations in care and allowing services to be commissioned based on quality and value, experts have announced.

The idea was presented at Diabetes Professional Care 2019, as part of a day-long programme by the Association of British Clinical Diabetologists (ABCD).

Dr Daniel Flanagan, a consultant physician working at Derriford Hospital, Plymouth, told delegates that the system, which is currently in the planning phase, will be based on one developed by the Royal College of Physicians (RCP) for assessing endoscopy services.

Real World Example

To illustrate the need for accreditation, he gave the example of a 17-year-old male admitted to his hospital.

He had presented to the emergency department, dehydrated and vomiting, "having been unwell for 2 or 3 days".

He had a history of type 1 diabetes and had been on insulin for around 7 years, with which he had been struggling, due not least in part to a difficult home life.

In the 24 hours before he was seen by the diabetes team, he ended up being admitted to an adult acute medical unit but managed on a paediatric diabetic ketoacidosis pathway.

For Dr Flanagan, that underlines the need for quality standards, "as there were a number of things about that young man's admission that I wasn't very comfortable with".

He noted that the patient had a pH of 6.9, so "by most people's protocol should be managed on a high dependency or intensive care unit", and it was "perhaps a little unsafe" to use a paediatric protocol on an adult ward.

Wide Variations in Care

Prof Partha Kar, associate national clinical director for diabetes for NHS England, underlined Dr Flanagan's point when he told an earlier session at the meeting that there is wide variation in the delivery of inpatient diabetes care across the country.

One example is the identification of diabetes patients on admission.

"You'd have thought that when you came into hospital that most people know you've been admitted," Prof Kar said.

"Wrong. About 40% of trusts have no idea when you get admitted. How would they get to the diabetes team? By pure luck. That is not an acceptable place to be in."

He added that "you'd have thought that every hospital" would have transition services from paediatric to adult care. They "should have it," he said, but, "no, they don't".

"Some people after paediatrics just go into the ether. That can't be right."

'Jigsaw'

Dr Dinesh Nagi, elected honorary chairman of ABCD and a consultant at the Mid Yorkshire NHS Trust, Wakefield, chaired the accreditation session.

He told Medscape News UK that those kinds of issues are what it will aim to tackle.

"What [Prof Kar] was talking about was that the different pieces of the jigsaw in the delivery of inpatient diabetes care don't always fit in," Nagi said.

Referring to the example patient given by Dr Flanagan, he asked: "Do we have it set up where I, as a diabetologist, know within a few hours of this patient landing in hospital that here is a patient with a priority input from specialist services?

"Have we got that process right? Is that patient cared for at the right place, by the right people, using the right standards?"

Dr Nagi said that "we've got a lot more work to do but....we're under an enormous amount of pressure".

"Beds are being cut down, and we are really being pushed to deliver a very high-quality acute care [while] making sure that the patient gets the best possible treatment."

Dr Nagi said that developing accreditation would go a long way to delivering services to common standards, and that would be good for patients and clinicians.

Initiatives

Dr Flanagan began his presentation by asking whether it is even possible to perform accreditation of hospital diabetes services.

He said there have already been a number of national initiatives to improve diabetes care, including those by ABCD, the Care Quality Commission (CQC), the RCP, and the Joint British Diabetes Societies (JBDS).

In addition, the National Diabetes Audit has, since 2011, been measuring the effectiveness of diabetes healthcare in England and Wales against National Institute for Health and Care Excellence clinical guidelines and quality standards.

This includes an annual snapshot of diabetes inpatient care, looking at whether:

  • The risk of avoidable complications was minimised

  • Harm resulted from the stay

  • The patient experience was favourable; and

  • There have been any changes since previous audits

Since 2014, CQC has also been examining whether hospital experiences, including those relating to diabetes, are safe, effective, caring, responsive, and well-led, Flanagan noted.

Another initiative is Getting It Right First Time (GIRFT), an NHS improvement programme developed initially to rationalise orthopaedic surgery, with the aim of improving the quality of care by reducing unwarranted variations.

Dr Flanagan said that, in diabetes, GIRFT encompasses inpatient care, type 1 diabetes, and foot care, with two doctors, one of whom is Prof Kar, touring the country to individually assess every unit delivering diabetes care.

However, it is ABCD that has perhaps conducted the most detailed work in assessing the quality of inpatient diabetes care, with a number of ongoing national audits on the use of, for example, exenatide, liraglutide, and FreeStyle Libre .

Dr Flanagan believes there is nevertheless a need for the systematic accreditation of inpatient diabetes services.

He cited the example of endoscopy accreditation that is administered by the RCP and recognised by the CQC and health commissioners as a mark of quality. Achieving accreditation consequently attracts financial incentives, and thus is something hospitals are willing to pay for.

Proposed Accreditation

In diabetes, Dr Flanagan said that the purpose of accreditation would be to:

  • Ensure services are uniformly safe

  • Improve the quality of care in every hospital

  • Improve the patient and carer experience

  • Undertake independent, fair, service reviews

  • Provide development and learning; and

  • Spread good practice and ideas

Similar to the RCP model, he said that it will operate in 5-year cycles, with a site visit in year 1, data submission to maintain accreditation in years 2 to 4, and another site visit in year 5.

As they have so much experience in delivering accreditation, the RCP will administer the scheme, with oversight from the JBDS and an expert working group to update the assessment measures.

Inspections and administration will involve the close involvement of a team of diabetes experts, and the whole process would be paid for by the hospital being accredited.

Dr Flanagan emphasised that the accreditation will be in line with the recommendations of the Diabetes UK report Making hospitals safe for people with diabetes, which emphasises, among other things, multidisciplinary care and strong clinical leadership.

In addition, the accreditation will fit with current national policies and commissioning practices, allowing commissioning on the basis of quality and value, and will map to recognised standards, including the British Standards Institute (BIS) PAS 1616 Standards and the Diabetes UK quality domains.

He told the audience progress has already been made, including meetings with the CQC, the BIS, the RCP and the Diabetes UK working group.

However, there remain a number of open questions, including whether it's the right initiative for the right time, what is achievable in the pilot stage and who will fund it, how other audit data could be used, and how it will develop.

Primary Care

During the post-presentation discussion, Dr Flanagan was asked whether accreditation will also apply to primary care, where the majority of diabetes patients are treated.

He said that the issue is not so much about how accreditation is shared but how "ownership" is taken of care, as patients are “often somewhere between primary care and secondary care, and a number of other health providers".

Dr Nagi said the new standard would be "relevant" to primary care, and discussions are underway with the Primary Care Diabetes Society.

Dr Nagi then asked Dr Flanagan whether he thought GIRFT would take "a backseat" with the development of accreditation.

Dr Flanagan replied that there are differing opinions within the GIRFT team, but "I can't see that intensive visiting of every unit by one or two doctors is sustainable in the future".

He added that their experience of GIRFT was "very much somebody coming and telling us about a standard and how we compare rather than us developing our own care".

"And that's not really a model for significant improvement, it's simply being told this is where you are. It doesn't motivate people to go out and make things better," Dr Flanagan said.

No conflicts of interest or funding declared.

Diabetes Professional Care 2019: Quality standards in diabetes care. Presented 29 October.

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