Diabetes services in the UK: fourth national survey; are we meeting NSF standards and NICE guidelines?

Abstract

Background: Previous surveys of children's diabetes service provision in the UK have shown gradual improvements but continuing deficiencies. Aim: To determine whether further improvements in services have occurred. Methods: A questionnaire was mailed to all paediatricians in the UK identified as providing care for children and adolescents with diabetes. Responses were compared with results of three previous surveys, and with recommendations in the Diabetes NSF and the NICE type 1 diabetes guidelines. Results: Replies were received from 187 consultant paediatricians in 169 centres looking after children; 89% expressed a special interest in diabetes, 98% saw children in a designated diabetic clinic, and 95% clinics now have more than 40 patients. In 98% of the clinics there was a specialist nurse (82% now children's trained), but 61% clinics had a nurse:patient ratio ,1:100; 39% of clinics did not have a paediatric dietician and in 78% there was no access to psychology/psychiatry services in clinics. Glycated haemoglobin was measured routinely at clinics in 86%, annual screening for retinopathy performed in 80%, and microalbuminuria in 83%. All centres now have local protocols for ketoacidosis, but not for children undergoing surgery (90%) or severe hypoglycaemia (74%). Mean clinic HbA1c levels were significantly lower in the clinics run by specialists (8.9%) than generalists (9.4%). There have been incremental improvements over the last 14 years since the surveys began, but only two clinics met all the 10 previously published recommendations on standards of care. Conclusions: The survey shows continuing improvements in organisational structure of services for children with diabetes but serious deficiencies remain. Publication and dissemination of the results of the previous surveys may have been associated with these improvements and similar recurrent service review may be applicable to services for other chronic childhood conditions.

Current Issues in Measurement and Reporting of Urinary Albumin Excretion

“…A French study in 2003 of general practitioners caring for diabetic patients reported that only 36% of patients had a urine albumin test and that only a 24-h urine collection was considered adequate (53 ). A survey of British pediatric diabetes care practices reported in 2005 that ACR measurement in morning samples was the predominant test (81%), whereas timed overnight collections and 24-h collections were used by 14% and 5%, respectively (54 ).…”

Structured, intensive education maximising engagement, motivation and long-term change for children and young people with diabetes: a cluster randomised controlled trial with integral process and economic evaluation – the CASCADE study

“…It is essential that regulatory bodies emphasise the need for effective communication underlying high-quality clinical care for children with diabetes. 4,209 These skills need to be learned early on in professionals careers and/or as they enter the field of paediatric diabetes. Evidence for the effectiveness in changing difficult behaviour is provided in MI and SFBT research.…”

The best model of care for children and young people with diabetes

“…2,22,23,[27][28][29][30] From the guidelines and the available evidence it is difficult to define exactly how many patients an individual team should be responsible for, and how many professionals there should be in each team. There is evidence from the UK that children attending larger clinics with more specialised consultants receive better care, 31,32 although a comparison of 207 paediatric diabetes centres in Germany and Austria did not reveal an effect of centre size on HbA1c when comparing centres with less than 50 patients to those with more than 50 patients. 33 Within the UK, the Royal College of Nursing (RCN) recommends a ratio of diabetes specialist nurse to patient of one to no more than 70 children or young people based on their responsibilities and workload.…”

“…65 A recent survey of nursing practice in the UK found that UK ConsensUs ConferenCe on Diabetes S Williamson although numbers of specialist nurses had increased, the mean ratio of nurses to patients was 1:109, 66 well below the recommendation of 1:70, 34 and a survey of services in 2002 in the UK found that most clinics had very limited access to psychology services and inadequate dietetic resources. 32 These findings suggest that without strong incentives or increased financial resources, local health services will not automatically implement these standards in the UK.…”

“…Given the complexity of the advice required, specialist paediatric dieticians with experience in childhood diabetes should be part of each team and available at each clinic. 32,35 It is also recommended that advice from the team should be accessible 24 hours a day, by telephone. 2,22,30 The structure of care delivery should allow any child suspected of having diabetes to be referred without delay to the team.…”