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

Abstract

introDUCtionThe incidence of diabetes in childhood has been rising by 3.9% each year in Europe in recent years.1 This has been higher in the pre-school age group, where the incidence is predicted to double by 2020 from its 2005 figure.1 Young people (defined as individuals between the ages of 11 and 18 years 2 ) with diabetes struggle to attain the standards for glycaemic control set for them.3,4 They have a high mortality, 5 develop long-term complications at a relatively early age 6 and have high rates of mental health problems. 7 These factors challenge health services to find the best way of caring for increasing numbers of children and young people with diabetes, so the best model of care needs to be clearly defined. This paper summarises the available evidence and expert opinion on the factors that may contribute to the best model of care for children and young people with diabetes. What is a 'model of care'?A clear definition of 'model of care' is hard to find in the medical literature. Examples include: 'an overarching design for the provision of a particular type of health care service that is shaped by a theoretical basis, evidence based practice and defined standards' 8 and 'a multifaceted concept, which broadly defines the way health services are delivered'. 9 The main theme of these definitions is the provision, or delivery, of healthcare. Delivery of healthcare has three components: structure, process and outcome. 10 Structural data are characteristics of personnel and hospitals or clinics. With these a framework is created from which to deliver the process. Process data are the components of the encounter between a doctor or another healthcare professional and a patient (e.g. teaching carbohydrate counting or using a particular insulin regime). The process is intended to create a beneficial effect on outcomes. Outcome data refer to the patient's subsequent health status (e.g. glycosylated haemoglobin, HbA1c, or frequency of hypoglycaemia).A simple definition of the term 'model of care' would therefore be: 'The structures of healthcare and the processes they deliver.' What models of care are used for childhood diabetes?In the UK, children with diabetes in the most part have their care delivered by specific professionals based within secondary care.11 This has been directed by consensus agreements such as the St Vincent declaration and the recommendations of the British Paediatric Association in 1990, 12,13 but it relies on the structures underpinning the secondary healthcare services, which are not specifically designed for chronic care so may have a number of shortcomings. Models of care for childhood diabetes have evolved slowly from this by adopting novel 'processes' into slowly adapting structures (e.g. implementing intensive insulin therapy, then slowly increasing the numbers of nursing staff available to deliver it), rather than making radical changes to structures to enable the most efficient delivery of the process. We therefore do not find radically different models of care for childhood d...

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