Diabetes and Kidney Care

CommissioningDiabetes and

Kidney Care Services

June 2011

Supporting, Improving, Caring

NHS Diabetes information Reader Box

Review Date 2013

Commissioning Diabetes and Kidney Care

NHS Diabetes and NHS Kidney Care would like to thank the following for their advice and contribution tothe development of this commissioning guide:

Hugh Rayner Consultant in Renal Medicine, Heart of England NHS Trust

Charlie Tomson Consultant in Renal Medicine, North Bristol NHS Trust

Hugh Cairns Consultant in Renal Medicine, King’s College Hospital NHS Foundation Trust

Niru Goenka Consultant in Diabetes and Endocrinology, Countess of Chester NHS FoundationTrust

And to Thoreya Swage who wrote this publication.

3

Page

Commissioning for Diabetes and Kidney Care 5

Features of Diabetes and Kidney Care Services 6

Diabetes and Kidney Care Services Intervention Map 8

Contracting Framework for Diabetes and Kidney Care Services 11

Standard Service Specification Template for Diabetes and Kidney Care 25

Contents

5

Commissioning for Diabetes andKidney Care The NHS Diabetes commissioning approach helps to deliver high quality integrated care through a three-stepprocess that ensures key elements needed to build an excellent diabetes service are in place. The approach issupported by a wide range of proven tools, resources and examples of shared learning.

Step 1 – involves understanding the local diabetespopulation health needs by developing a local HealthNeeds Assessment and setting up a steering groupwith key stakeholder involvement including a leadclinician, lead commissioner, lead diabetes nurse andlead service user

Step 2 – involves the development of a servicespecification to describe the model of care to becommissioned. This becomes the document onwhich tenders may be issued.

Step 3 – involves monitoring the delivery of theservice specification by the provider and evaluatingthe performance of the service. Input from thesteering group with service user representation willbe an important mechanism for monitoring theservice as well as patient surveys.

This commissioning guide has been developed byNHS Diabetes and NHS Kidney Care with keystakeholders including clinical and social servicesprofessionals and patient groups represented byDiabetes UK.

It is not designed to replace the Standard NHSContracts as many of the legal and contractualrequirements have already been identified in this setof documents. Rather, it is intended to form the basisof a discussion or development of diabetes andkidney care services between commissioners andproviders from which a contract for services can thenbe agreed.

This commissioning guide consists of:

• A description of the key features of good diabetesand kidney care

• A high level intervention map. This interventionmap describes the key high level actions orinterventions (both clinical and administrative)diabetes and kidney care services shouldundertake in order to provide the most efficientand effective care, from admission to discharge (ordeath) from the service.

It is not intended to be a care pathway or clinicalprotocol, rather it describes how a true ‘diabeteswithout walls’1 service should operate going acrossthe current sectors of health care.

The intervention map may describe current servicemodels or it may describe what should ideally beprovided by diabetes and kidney care services.

• A diabetes and kidney care contracting frameworkthat brings together all the key standards of qualityand policy relating to diabetes and kidney care

• A template service specification for diabetes andkidney care services that forms part of schedule 2part 1 ,or section 1 (module B) of the StandardNHS Contract covering the key headings requiredof a specification. It is recommended that thecommissioner checks which mandatory headingsare required for each type of care as specified bythe Standard NHS Contracts.

For further detail on how to approach thecommissioning of diabetes services please seehttp://www.diabetes.nhs.uk/commissioning_resource

Step 2

Step 3

• Understanding your diabetes population health needs

• Implementing improved services and evaluation

• Understanding what you need to commission for an integrated service

Step 1

1 Commissioning Diabetes Without Walls , 2011, http://www.diabetes.nhs.uk/commissioning_resource/

6

High quality diabetes and kidney care servicesshould ensure:

• that people with diabetes have a regularassessment and review of renal function(including management of anaemia and boneconditions) as part of their diabetes assessmentand care planning process

• that patients with chronic kidney disease anddiabetes who require specialist care are seen injoint nephrology and diabetes services

• there is access to vascular services for vascularaccess for haemodialysis

• there is access to transplantation services whichprovide combined kidney and pancreatictransplantation as appropriate

• that there is regular training and development inbasic diabetes competences for hospital staffcaring for people who have renal conditions anddiabetes

• that there is regular training and developmentfor all health care professionals who providediabetes care on the management of kidneyconditions

• that there are monitored protocols for hospitalstaff on when to access diabetes specialistadvice and intervention for people with diabeteswho have renal conditions

• that there are monitored protocols in place toensure that patients can continue to managetheir diabetes themselves while in hospital (foodand medication)

• that data items included in the National RenalDataset are reported accurately and completelyon all patients on Renal Replacement Therapy

In addition, the service should:

• be developed in a co-ordinated way, taking fullaccount of the responsibilities of other agenciesin providing comprehensive care and placingusers at the centre of decisions about their careand support - "no decision about me withoutme" (Equity and Excellence: Liberating theNHSi).

• be commissioned jointly by health and socialcare based on a joint health needs assessmentwhich meets the specific needs of the localpopulation, using a holistic approach asdescribed by the generic model for themanagement of long term conditionsii

• provide effective and safe care to people withdiabetes in a range of settings including thepatient’s home, in accordance with the NICEQuality Standards for Diabetesiii

• deliver the outcomes for diabetes as determinedby the NHS Outcomes Frameworkiv

• take into account the emotional, psychologicaland mental wellbeing of the patientv

• take into account all diverse and personal needswith respect to access to care

• ensure that services are responsive andaccessible to people with Learning Disabilitiesvi

• ensure that the family/carers of people withdiabetes have access to psychological support

Features of Diabetes and KidneyCare Services

i Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353

ii Available on the DH website at http://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_120915

iii Quality Standards: Diabetes in adults, http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp

iv Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944

v Emotional and Psychological Support and Care in Diabetes, Joint Diabetes UK and NHS Diabetes Emotional and PsychologicalSupport Working Group, 2010 http://www.diabetes.nhs.uk/our_work_areas/emotional_and_psychological/

vi http://www.diabetes.nhs.uk/commissioning_resource

7

• have effective clinical networks with clear clinicalleadership across the boundaries of care whichclearly identify the role and responsibilities ofeach member of the diabetes healthcare team

• ensure that there are a wide range of optionsavailable to people with diabetes to support selfmanagement and individual preferences

• take into account services provided by socialcare and the voluntary sector

• provide patient/carer/family education ondiabetes not only at diagnosis but also duringcontinuing management at every stage of care

• provide education on diabetes management toother staff and organisations that supportpeople with diabetes

• have a capable and effective workforce that hasthe appropriate training and updating andwhere the staff have the skills and competenciesin the management of people with diabetes

• provide multidisciplinary care that manages thetransition between children and adult servicesand adult and older peoples’ services

• have integrated information systems that recordindividual needs including emotional, social,

educational, economic and biomedicalinformation which permit multidisciplinary careacross service boundaries and support careplanningvii

• produce information on the outcomes ofdiabetes care including contributing to nationaldata collections and audits

• have adequate governance arrangements, e.g.local mortality and morbidity meetings ondiabetes care to learn from errors and improvepatient safety

• take account of patient experience, includingPatient Reported Outcomes Measures, in thedevelopment and monitoring of servicedeliveryviii

• deliver the separate modules of care accordingto the best practice quality markers

• actively monitor the uptake of services,responding to non-attenders and monitoringcomplaints and untoward incidents

vii http://www.diabetes.nhs.uk/year_of_care/it/

viii http://www.ic.nhs.uk/proms

8

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Diabetes and Kidney Care ServicesIntervention Map

9

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11

IntroductionThis contracting framework sets what is requiredof clinically safe and effective services that areproviding care for people with diabetes who needkidney care. The framework is designed to be readin conjunction with the high level patientintervention map, which describes theinterventions and actions required along thepatient pathway as well as entry and exit points,and the standard service specification template forkidney care services for people with diabetes.

The framework brings together the key qualityareas and standards that have been identified byNHS Diabetes, NHS Kidney Care, Diabetes UK, theRoyal Colleges and other related organisations.

The principles that establish a safepathway for patient care Establishing the principles that underpin thesystems and processes of pathways for patient careleads to more efficient patient throughput and canreduce risk of fragmentation of care and seriousuntoward incidents. The principles operate at fourlayers within a patient pathway:

• Commissioning• Clinical Case Direction or the overall Care Plan

(i.e. the management of an individual patient)

• Provision of the clinical service or process• Organisational platform on which the clinical

service or process sits (the provider organisation)

A straightforward or simple pathway is one inwhich the overall management including bothClinical Case Direction and the delivery of theclinical processes conventionally sits within oneorganisation. However, with a more complexpathway, there is a danger that fracturing theoverall management pathway into componentscarried out by different clinical teams andorganisations will require duplication of effortleading to inefficiency and increased risk athandover points.This can be managed byestablishing clear governance arrangements for allthe layers in the pathway.

In addition, Commissioning Bodies must balancethe benefits of fracturing the pathway againstincreased complexity and ensure that the increasedrisks are mitigated.

The governance arrangements required for allthree layers and the commissioner responsibilitiesare shown below:

Contracting Framework forDiabetes and Kidney Care Services

12

In essence, at each level, there are governancearrangements to ensure sound and safe systems ofdelivery of patient care with clear lines ofaccountability between each level.

Diabetes and Kidney Care ServicesThe key principles of good diabetes and kidneycare services is to provide a high quality servicethat is reliable in terms of delivery and timelyaccess for patients requiring that care.

Care of people with diabetes who have renalcomplications is provided by a number of differentteams in the primary, community and acutesetting. It is essential that there is co-ordination ofcare of patients through the care planning processand that the nephrologist/diabetes physiciansretain joint responsibility for overall patient careacross the whole pathway and retain overallresponsibility for the management of side effectsand further complications.

The initial management and continuing care ofindividuals with diabetes should include anassessment of their emotional and psychologicalwell-being, together with timely access toappropriate psychological and biological/psychiatricinterventions. Mental health disorders can posesignificant barriers to diabetes care and thereforemental health stability is vital for good self care1.

The services themselves will also have clinicaloversight and accountability for governancepurposes.

This contracting framework focuses on peoplewith diabetes, including children and young peopleand older people, who require care for the renalcomplications of diabetes. This contractingframework should also be read in conjunction withthe diabetes commissioning guides for childrenand young people, prevention and risk assessment,

diagnosis and continuing care, older people, Endof Life Care and follow the principles for theeffective commissioning of services for people withLearning Disabilities2.

Ensuring qualityCommissioning Bodies should ensure that thediabetes and kidney care services commissionedare of the highest quality. There may, in addition,be some organisations that wish to offer theirservices, but do not have a history of providingsuch care.

i) For provider organisations already involved inthe delivery of diabetes and kidney careservices, there should be retrospective evidenceof systems being in place, implemented andworking.

ii) For organisations new to the arena, thecommissioner should reassure itself that theprovider has the organisational attributes,governance arrangements, systems andprocesses set up to provide the platform forsafe and effective delivery of diabetes andkidney care services to be provided.

This framework describes what theCommissioning Body needs to ensure ispresent or addressed in its discussions withthe provider organisation.

Under the ‘elements’ column there are crossreferences to the Standard NHS Contract for AcuteServices– bilateral (main clauses and schedules)3.(The cross references also apply to the clauses andschedules in the Standard NHS Contract forCommunity Services).This is to assist commissionersand providers in having an overview of how theelements link to the Standard NHS Contract. Someof the areas are open to interpretation andconsequently the references are not exhaustive.

13

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ce a

nd a

ppra

isals

publ

ished

by

the

Nat

iona

l Ins

titut

e fo

rH

ealth

and

Clin

ical

Exc

elle

nce

that

are

rele

vant

to th

e ca

repr

ovid

ed b

y th

e se

rvic

e 5

14

TOPI

CEL

EMEN

TSC

HA

RA

CTE

RIS

TIC

S, S

KIL

LSA

ND

BEH

AV

IOU

RS

OU

TPU

TSD

IAB

ETES

SER

VIC

ES S

PEC

IFIC

OU

TPU

TS/C

OM

MEN

TS

Gov

erna

nce

Clin

ical

Gov

erna

nce

•St

aff

Dev

elop

men

t•

Com

plai

nts

Man

agem

ent

•Pa

tient

and

Pub

lic In

volv

emen

t•

Patie

nt d

igni

ty a

nd r

espe

ct

•Eq

ualit

y an

d di

vers

ity•

Intr

oduc

ing

new

tec

hnol

ogie

s an

dtr

eatm

ents

•A

n ex

tern

ally

acc

redi

ted

Qua

lity

Ass

uran

ce s

yste

m a

nd in

tern

al e

rror

repo

rtin

g in

volv

ing

all s

taff

gro

ups.

CG

sys

tem

s sh

ould

hav

e cl

ear

and

dem

onst

rabl

e lin

ks t

o ot

her

NH

S sy

stem

sw

ith c

olla

bora

tive

CG

act

iviti

es a

nd s

harin

gof

exp

erie

nce

and

lear

ning

Prov

ider

sho

uld

prod

uce

annu

al C

linic

alG

over

nanc

e re

port

s as

par

t of

NH

S C

Gre

port

ing

syst

em

Prov

ider

s ar

e re

quire

d to

agr

eeC

omm

issi

onin

g fo

r Q

ualit

y an

d In

nova

tion

sche

mes

(CQ

UIN

) for

dia

bete

s ca

re, e

.g.

mod

el C

QU

IN s

chem

e pr

opos

ed b

y th

e N

HS

Inst

itute

for

Inno

vatio

n an

d Im

prov

emen

t 13

In a

dditi

on, t

he s

ervi

ce is

requ

ired

to c

ompl

y w

ith th

e fo

llow

ing:

i. G

uida

nce

publ

ishe

d by

NIC

E

•Ea

rly id

entif

icat

ion

and

man

agem

ent o

f chr

onic

kid

ney

dise

ase

in a

dults

in p

rimar

y an

d se

cond

ary

care

6

•A

naem

ia m

anag

emen

t in

peop

le w

ith c

hron

ic k

idne

y di

seas

e 7

•Th

e cl

inic

al e

ffec

tiven

ess

and

cost

eff

ectiv

enes

s of

pat

ient

educ

atio

n m

odel

s fo

r dia

bete

s 8

•M

edic

ines

adh

eren

ce: i

nvol

ving

pat

ient

s in

dec

ision

s ab

out

pres

crib

ed m

edic

ines

and

sup

port

ing

adhe

renc

e 9

The

serv

ice

is al

so re

quire

d to

com

ply

with

:

•cl

inic

al g

uide

lines

for T

ype

2 D

iabe

tes

Mel

litus

pro

duce

d by

the

Euro

pean

Dia

bete

s W

orki

ng P

arty

for O

lder

Peo

ple

10

•Re

nal S

peci

fic M

anag

emen

t of M

edic

ines

11

•G

uide

lines

for L

CP

Dru

g Pr

escr

ibin

g in

Adv

ance

d C

hron

icK

idne

y D

isea

se 12

Clin

ical

qua

lity

Qua

lity

assu

ranc

e

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:4,

4A,1

2,16

,17,

18,

19,2

0,21

, 31,

32,

33, 5

4

Sche

dule

s:

2,3

(par

ts 4

, 4A

,4B,

4C,5

,6)

7, 1

0,12

, 18,

20

Und

erst

andi

ng t

he c

once

pt o

fcl

inic

al q

ualit

y

Has

con

cern

for

qua

lity

whi

lew

orki

ng e

ffic

ient

ly

An

unde

rsta

ndin

g of

the

use

of

audi

t, p

atie

nt a

nd s

taff

fee

dbac

kto

impr

ove

qual

ity

An

orga

nisa

tion

that

pro

vide

scl

arity

of

obje

ctiv

es a

nd p

rom

otes

refle

ctiv

e pr

actic

e to

impr

ove

qual

ity o

f pa

tient

car

e

Qua

lity

assu

ranc

e sy

stem

s m

ust

be in

pla

cean

d ap

prov

ed b

y co

mm

issi

onin

g bo

dy w

ithre

gula

r re

port

ing

of o

utco

mes

Prov

ider

s ar

e re

quire

d to

pub

lish

qual

ityac

coun

ts f

or t

he p

ublic

rep

ortin

g of

qua

lity

incl

udin

g sa

fety

, exp

erie

nce

and

outc

omes

Prov

ider

s sh

ould

par

ticip

ate

in n

atio

nal

audi

t pr

ogra

mm

es

Dia

bete

s an

d K

idne

y C

are

serv

ices

mus

t com

ply

with

the

perf

orm

ance

mea

sure

s re

quire

d of

NH

S se

rvic

es, i

.e m

eetin

g: 14

•Re

ferr

al to

Tre

atm

ent w

aits

(95t

h pe

rcen

tile

mea

sure

s)

•A

&E

Qua

lity

Indi

cato

rs•

Am

bula

nce

resp

onse

tim

es

The

serv

ices

are

requ

ired

to p

artic

ipat

e in

the

follo

win

gac

tiviti

es/p

rogr

amm

es:

•N

atio

nal D

iabe

tes

Aud

it 15

•N

atio

nal D

iabe

tes

Inpa

tient

Aud

it of

Acu

te T

rust

s 16

(NB

Prov

ider

s m

ay w

ish to

con

duct

add

ition

al a

udits

in th

e ar

eas

iden

tifie

d in

this

docu

men

t)•

Nat

iona

l Kid

ney

Car

e A

udit

17

•Pa

tient

Exp

erie

nce

Surv

eys

18

•D

iabe

tes

E 19

•Pa

tient

Rep

orte

d O

utco

mes

Mea

sure

s 20

15

TOPI

CEL

EMEN

TSC

HA

RA

CTE

RIS

TIC

S, S

KIL

LSA

ND

BEH

AV

IOU

RS

OU

TPU

TSD

IAB

ETES

SER

VIC

ES S

PEC

IFIC

OU

TPU

TS/C

OM

MEN

TS

Clin

ical

qua

lity

Wor

kfor

ce/ s

taff

Clin

ical

sta

ff a

ttrib

utes

criti

cal t

o sa

fety

and

qual

ity o

f int

erve

ntio

ns

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:11

,16,

26,3

3, 4

8 ,5

6

The

prov

ider

org

anis

atio

n ha

ssy

stem

s an

d pr

oced

ures

in p

lace

to a

ssur

e th

e co

mm

issi

oner

tha

tth

eir

clin

ical

tea

m h

as t

hene

cess

ary

qual

ifica

tions

, ski

lls,

know

ledg

e an

d ex

perie

nce

tode

liver

the

ser

vice

Staf

f ar

e co

mpe

tent

and

fit

for

purp

ose

Prov

ider

to

satis

fy c

omm

issi

oner

tha

t al

lst

aff

have

cur

rent

app

rais

al, c

lear

ance

s an

dre

gist

ratio

n ch

ecks

and

hav

e de

mon

stra

ted

com

pete

nce

in a

ll pr

oced

ures

rel

evan

t to

path

way

.

Prov

ider

to s

atisf

y co

mm

issio

ner t

hat t

hey

can

recr

uit (

orpr

ocur

e) a

nd re

tain

a c

ompe

tent

clin

ical

team

to d

eliv

er th

ese

rvic

e

Spec

ific

qual

ifica

tions

requ

ired

of h

ealth

pro

fess

iona

ls pr

ovid

ing

the

serv

ice

are:

•Fo

r med

ical

pra

ctiti

oner

s:

o D

iabe

tes:

regi

stra

tion

with

the

GM

C a

nd e

vide

nce

offu

rthe

r qua

lific

atio

n in

dia

bete

s ca

re o

r exp

erie

nce

with

indi

abet

es c

linic

o N

ephr

olog

y: re

gist

ratio

n w

ith th

e G

MC

and

evi

denc

e of

furt

her q

ualif

icat

ion

in re

nal m

edic

ine

•N

urse

s:

o D

iabe

tes

: reg

istra

tion

with

the

NM

C, f

urth

er e

vide

nce

ofqu

alifi

catio

n in

dia

bete

s ca

re o

r exp

erie

nce

with

in d

iabe

tes

clin

ic a

nd a

n in

tere

st in

nep

hrop

athy

21

o N

ephr

olog

y: re

gist

ratio

n w

ith th

e N

MC

and

furt

her

evid

ence

of q

ualif

icat

ion

in re

nal m

edic

ine

or e

xper

ienc

ew

ithin

nep

hrol

ogy

clin

ic•

Die

titia

ns 21

:o

Dia

bete

s: re

gist

ratio

n w

ith th

e H

PC a

nd fu

rthe

r evi

denc

eof

qua

lific

atio

n in

dia

bete

s ca

re o

r exp

erie

nce

with

indi

abet

es c

linic

o N

ephr

olog

y: re

gist

ratio

n w

ith th

e H

PC a

nd fu

rthe

rev

iden

ce o

f qua

lific

atio

n in

die

tetic

s an

d re

nal m

edic

ine

orex

perie

nce

with

in n

ephr

olog

y cl

inic

•Po

diat

rists

:o

Dia

bete

s: re

gist

ratio

n w

ith th

e H

PC a

nd fu

rthe

r evi

denc

eof

qua

lific

atio

n in

dia

bete

s ca

re o

r exp

erie

nce

with

indi

abet

es c

linic

Hea

lthca

re p

rofe

ssio

nals

invo

lved

in d

eliv

erin

g ca

re fo

r peo

ple

with

dia

bete

s w

ho h

ave

rena

l com

plic

atio

ns a

re re

quire

d to

hav

eth

e re

leva

nt c

ompe

tenc

ies

in th

e m

anag

emen

t of22

:

•di

abet

es

•C

hron

ic K

idne

y D

isea

se

16

TOPI

CEL

EMEN

TSC

HA

RA

CTE

RIS

TIC

S, S

KIL

LSA

ND

BEH

AV

IOU

RS

OU

TPU

TSD

IAB

ETES

SER

VIC

ES S

PEC

IFIC

OU

TPU

TS/C

OM

MEN

TS

Clin

ical

qua

lity

Wor

kfor

ce/ s

taff

Clin

ical

sta

ffco

mpe

tenc

ies

in u

se o

feq

uipm

ent

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:11

, 16,

17,

21,

26,

33

The

prov

ider

org

anis

atio

n ha

ssy

stem

s in

pla

ce t

o as

sure

the

com

mis

sion

er t

hat

thei

r cl

inic

alte

am a

re c

ompe

tent

to

use

all

equi

pmen

t ne

eded

to

deliv

er t

hese

rvic

e

Prov

ider

to

satis

fy t

he c

omm

issi

oner

tha

t al

lst

aff

have

had

doc

umen

ted

com

pete

nce

asse

ssm

ent

rela

tive

to a

ll eq

uipm

ent

used

inco

ntra

ct.

All

heal

thca

re p

rofe

ssio

nals

invo

lved

in d

eliv

erin

g ca

re fo

r peo

ple

with

dia

bete

s w

ho h

ave

card

iova

scul

ar c

ompl

icat

ions

are

requ

ired

to h

ave

the

rele

vant

com

pete

ncie

s in

usin

g ap

prop

riate

equi

pmen

t e.g

. blo

od g

luco

se a

nd k

eton

e m

onito

rs, i

nsul

inde

liver

y de

vice

s in

clud

ing

insu

lin p

umps

etc

Clin

ical

qua

lity

Wor

kfor

ce /

staf

f

Dev

elop

men

t

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:11

,16,

19,3

0, 4

8

The

prov

ider

org

anis

atio

n ha

ssy

stem

s in

pla

ce t

o as

sure

the

com

mis

sion

er t

hat

thei

r cl

inic

alte

am is

for

mal

ly in

duct

ed a

ndre

ceiv

es o

ngoi

ng a

ssis

tanc

e to

deve

lop

thei

r sk

ills,

kno

wle

dge

and

expe

rienc

e t

o en

sure

tha

tth

ey a

re a

lway

s fu

lly u

pdat

ed

Prov

ider

to

satis

fy c

omm

issi

oner

of

thei

rco

mm

itmen

t to

indu

ctio

n an

d C

PD r

elev

ant

to r

oles

Prov

ider

to

satis

fy t

he c

omm

issi

oner

of

thei

rco

mm

itmen

t to

tra

in s

taff

to

mee

t fu

ture

serv

ice

need

s

All

Hea

lth C

are

prof

essi

onal

s sh

ould

hav

e su

ffic

ient

stu

dy le

ave

allo

catio

n (t

ime

and

finan

ce) t

o en

able

them

to d

evel

op s

kills

appr

opria

tely

Clin

ical

qua

lity

Regi

stra

tion

and

licen

sing

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:4,

4A,5

,9,1

0,11

,12,

14,1

5,16

17,1

8,19

,21,

26,

27,2

9,33

,34,

35,

3643

,48,

49,5

253

,54,

56,6

0

Sche

dule

: 2,

3,4,

5,6,

8,10

,12

,13,

15,1

7,

19, 2

0

The

Prov

ider

is r

equi

red

to b

ere

gist

ered

with

the

Car

e Q

ualit

yC

omm

issi

on t

o de

mon

stra

te t

hat

is m

eets

the

ess

entia

l sta

ndar

dsof

qua

lity

and

safe

ty f

or t

here

gula

ted

activ

ities

del

iver

ed.

The

Prov

ider

is r

equi

red

to b

elic

ense

d w

ith t

he N

HS

Econ

omic

Regu

lato

r (M

onito

r) in

ord

er t

opr

ovid

e N

HS

care

.

Com

plia

nce

with

the

Car

e Q

ualit

yC

omm

issi

on a

nd M

onito

r re

quire

men

tsC

ompl

ianc

e w

ith th

e fo

llow

ing

Nat

iona

l Ser

vice

Fra

mew

orks

,w

here

app

licab

le:

•Re

nal N

SF 23

•O

lder

Peo

ple’

s N

SF 24

•N

SF fo

r Chi

ldre

n, Y

oung

Peo

ple

and

Mat

erni

ty S

ervi

ces

25

•Th

e M

enta

l Hea

lth S

trat

egy26

•Lo

ng T

erm

Con

ditio

ns N

SF 27

Com

plia

nce

with

Car

e Q

ualit

y C

omm

issi

on R

evie

ws

17

TOPI

CEL

EMEN

TSC

HA

RA

CTE

RIS

TIC

S, S

KIL

LSA

ND

BEH

AV

IOU

RS

OU

TPU

TSD

IAB

ETES

SER

VIC

ES S

PEC

IFIC

OU

TPU

TS/C

OM

MEN

TS

Clin

ical

qua

lity

Patie

nt p

athw

ay

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:4,

4A,9

,10,

12,1

4,15

,16,

17,

18,

19,2

0,21

,27,

29,

32 ,3

3, 3

4,35

,36,

54

Sche

dule

s:

3 (p

arts

1 a

nd 2

)

Resp

onsi

vene

ss a

nd p

artic

ipat

ive

appr

oach

to

incl

udin

g pa

tient

s’vi

ews

abou

t th

eir

care

in t

hede

sign

of

care

pat

hway

s

Col

labo

ratio

n w

ith o

ther

orga

nisa

tions

invo

lved

in t

hepa

tient

pat

hway

to

prov

ide

ase

amle

ss p

athw

ay o

f ca

re

All

poss

ible

ent

ry a

nd e

xit

poin

ts m

ust

bede

fined

with

com

preh

ensi

ve p

atie

ntpa

thw

ays

that

fac

ilita

te s

moo

th p

assa

gean

d ef

fect

ive,

eff

icie

nt c

are

for

patie

nts

All

inte

rfac

es in

the

pat

hway

mus

t be

defin

ed s

o th

at c

ontin

uity

of

clin

ical

car

e is

ensu

red

with

no

frac

turin

g of

the

pat

hway

Ther

e m

ust

be s

peci

ficat

ion

of c

lear

timel

ines

and

ale

rt m

echa

nism

s fo

rpo

tent

ial b

reac

hes

Ther

e sh

ould

be

audi

t of

pat

hway

to

ensu

reth

at s

tand

ards

are

met

Ther

e m

ust

be e

xplic

it sp

ecifi

catio

n of

prov

ider

and

com

mis

sion

er r

espo

nsib

ilitie

sfo

r th

e w

hole

pat

ient

epi

sode

fro

mre

gist

ratio

n to

fin

al d

isch

arge

Acc

ount

abili

ties

shou

ld b

e ag

reed

and

docu

men

ted

by a

ll st

akeh

olde

rs

Ther

e ar

e a

num

ber

of s

ervi

ces

supp

ortin

gpa

tient

s w

ith d

iabe

tes

and

ther

e m

ust

becl

ear

sub

cont

ract

s st

atin

g th

e re

ferr

alcr

iteria

and

acc

ess

to t

hese

sup

port

ing

serv

ices

.

The

path

way

sho

uld

follo

w th

e pr

inci

ples

set

out

by

the

Gen

eric

Long

Ter

m C

ondi

tions

mod

el 30

. Thi

s in

clud

es:

•St

ratif

ying

the

leve

ls of

nee

d an

d ris

k •

Cas

e m

anag

emen

t•

Pers

onal

ised

car

e pl

anni

ng•

Supp

ortin

g pe

ople

to s

elf c

are

•A

ssis

tive

tech

nolo

gy

The

key

elem

ents

of d

iabe

tes

and

kidn

ey c

are

serv

ices

sho

uld

incl

ude

•C

hron

ic k

idne

y di

seas

e ris

k as

sess

men

t and

initi

al m

anag

emen

t •

The

early

iden

tific

atio

n an

d m

anag

emen

t of c

ardi

ovas

cula

rco

mpl

icat

ions

of d

iabe

tes

31

(see

als

o th

e C

omm

issi

onin

g G

uide

for c

ardi

ovas

cula

r ser

vice

s fo

rpe

ople

with

dia

bete

s) 2

•Sp

ecia

list k

idne

y ca

re

1. C

hron

ic k

idne

y di

seas

e ris

k as

sess

men

t and

initi

al m

anag

emen

t

•Th

ere

shou

ld b

e ag

reed

pro

toco

ls fo

r ass

essin

g th

e ris

k of

: o

diab

etes

o th

e ef

fect

s of

sm

okin

g o

chro

nic

kidn

ey d

isea

seo

hype

rten

sion

(e.g

. NH

S H

ealth

Che

cks

for 4

0 -7

4 ye

ar o

lds32

).•

Ther

e sh

ould

be

agre

ed p

roto

cols

for:

o th

e m

anag

emen

t of c

hron

ic k

idne

y di

seas

e o

man

agem

ent o

f ana

emia

o m

anag

emen

t of b

one

cond

ition

s

Clin

ical

qua

lity

Out

com

es

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:4,

4A,1

0,14

,15,

16,2

1

Sche

dule

:3

(par

t 5),

5 (p

arts

1,2

,3),

12

Com

preh

ensi

ve u

nder

stan

ding

and

com

mitm

ent

to d

eliv

erin

gan

d im

prov

ing

outc

omes

of

care

Com

plia

nce

with

the

NH

S O

utco

mes

Fram

ewor

k28C

ompl

ianc

e w

ith th

e Q

ualit

y St

anda

rds

for D

iabe

tes,

spe

cific

ally

29

18

TOPI

CEL

EMEN

TSC

HA

RA

CTE

RIS

TIC

S, S

KIL

LSA

ND

BEH

AV

IOU

RS

OU

TPU

TSD

IAB

ETES

SER

VIC

ES S

PEC

IFIC

OU

TPU

TS/C

OM

MEN

TS

Clin

ical

qua

lity

Patie

nt p

athw

ayA

t en

try

to p

athw

ay:

The

Com

mis

sion

er s

houl

d as

sure

them

selv

es t

hat

the

prov

ider

has

sys

tem

san

d pr

oces

ses

in p

lace

to

i) re

gist

er p

atie

nts

ii) c

olle

ct r

elev

ant

clin

ical

and

adm

inis

trat

ive

data

iii) m

anag

e th

e ap

poin

tmen

t pr

oces

s,(r

eapp

oint

men

t an

d D

NA

pro

cess

, if

appr

opria

te)

iv) p

rovi

de in

form

atio

n to

pat

ient

sv)

und

erta

ke in

itial

ass

essm

ent

in t

heap

prop

riate

loca

tion

At

poin

t of

inte

rven

tion:

The

Com

mis

sion

er s

houl

d as

sure

them

selv

es t

hat

the

prov

ider

has

sys

tem

san

d pr

oces

ses

in p

lace

to

ensu

re t

hat:

i) th

e in

terv

entio

n is

con

duct

ed s

afel

yan

d in

acc

orda

nce

with

acc

epte

dqu

ality

sta

ndar

ds a

nd g

ood

clin

ical

prac

tice.

ii) t

he p

atie

nt r

ecei

ves

appr

opria

te c

are

durin

g th

e in

terv

entio

n(s)

, inc

ludi

ng o

ntr

eatm

ent

revi

ew a

nd s

uppo

rt, i

nac

cord

ance

with

bes

t cl

inic

al p

ract

ice

iii) w

here

clin

ical

em

erge

ncie

s or

com

plic

atio

ns d

o oc

cur

they

are

man

aged

in a

ccor

danc

e w

ith b

est

clin

ical

pra

ctic

eiv

) the

inte

rven

tion

is c

arrie

d ou

t in

afa

cilit

y w

hich

pro

vide

s a

safe

envi

ronm

ent

of c

are

and

min

imis

esris

k to

pat

ient

s, s

taff

and

vis

itors

v) t

he in

terv

entio

n is

und

erta

ken

by s

taff

with

the

nec

essa

ry q

ualif

icat

ions

, ski

lls,

expe

rienc

e an

d co

mpe

tenc

e vi

) The

re a

re a

rran

gem

ents

for

the

man

agem

ent

of o

ut o

f ho

urs

care

acco

rdin

g to

bes

t cl

inic

al p

ract

ice

o m

anag

emen

t of h

yper

tens

ion

o w

hen

to re

fer f

or s

peci

alist

rena

l/dia

bete

s ca

re•

Ever

y pa

tient

with

chr

onic

kid

ney

dise

ase

shou

ld h

ave

aki

dney

car

e pl

an 33

2. T

he e

arly

iden

tific

atio

n an

d m

anag

emen

t of c

ardi

ovas

cula

rco

mpl

icat

ions

of d

iabe

tes

•th

ere

shou

ld b

e pr

otoc

ols

in p

lace

to id

entif

y an

d m

anag

e th

eca

rdio

vasc

ular

com

plic

atio

ns o

f dia

bete

s as

car

diac

co-

mor

bidi

ty h

as a

sig

nific

ant i

mpa

ct o

n re

nal c

ompl

icat

ions

31

3. S

peci

alis

t kid

ney

care

•pe

ople

with

dia

bete

s w

ho n

eed

spec

ialis

t kid

ney

care

sho

uld

be s

een

by jo

int n

ephr

olog

y an

d di

abet

es s

ervi

ces

•th

ere

shou

ld b

e pr

otoc

ols

in p

lace

to s

cree

n, p

reve

nt a

ndm

anag

e ot

her c

ompl

icat

ions

of d

iabe

tes,

e.g

. foo

t car

e,ca

rdio

vasc

ular

car

e an

d ey

es•

the

man

agem

ent o

f a

pers

on w

ith d

iabe

tes

who

is a

dmitt

edfo

r man

agem

ent o

f the

ir re

nal c

ondi

tion

shou

ld fo

llow

the

prin

cipl

es s

et o

ut in

the

emer

genc

y an

d in

patie

ntco

mm

issio

ning

gui

de, i

.e.2

o ha

ve a

cces

s to

the

mul

tidis

cipl

inar

y sp

ecia

list d

iabe

tes

team

o ha

ve a

dmis

sion

and

dis

char

ge c

are

plan

so

have

clo

se li

aiso

n w

ith th

eir c

are

co-o

rdin

ator

o th

ere

shou

ld b

e pr

otoc

ols

in p

lace

to a

llow

pat

ient

s, w

hoar

e ab

le to

do

so, t

o se

lf m

anag

e th

eir d

iabe

tes

med

icat

ion.

Patie

nts

may

nee

d to

be

refe

rred

to th

e fo

llow

ing

serv

ices

as

part

of t

heir

kidn

ey c

are:

•Va

scul

ar s

ervi

ces

(for

vas

cula

r acc

ess)

•D

ialy

sis

34,3

5

•Tr

ansp

lant

atio

n se

rvic

es –

incl

udin

g ac

cess

to c

ombi

ned

kidn

ey a

nd p

ancr

eatic

tran

spla

ntat

ion

serv

ices

, as

appr

opria

te•

Rena

l Wel

fare

Off

icer

36

•En

d of

Life

Car

e 37

( see

also

Com

miss

ioni

ng G

uide

for

Dia

bete

s an

d En

d of

Life

Car

e 2 )

19

TOPI

CEL

EMEN

TSC

HA

RA

CTE

RIS

TIC

S, S

KIL

LSA

ND

BEH

AV

IOU

RS

OU

TPU

TSD

IAB

ETES

SER

VIC

ES S

PEC

IFIC

OU

TPU

TS/C

OM

MEN

TS

Clin

ical

qua

lity

Patie

nt p

athw

ayA

t ex

it fr

om p

athw

ay:

The

Com

mis

sion

er s

houl

d as

sure

them

selv

es t

hat

prov

ider

has

sys

tem

s an

dpr

oces

ses,

whi

ch a

re a

gree

d w

ith a

ll pa

rtie

san

d ne

twor

ks, i

n pl

ace

to:

i) un

dert

ake

tele

phon

e tr

iage

ii) m

ake

urge

nt o

nwar

d re

ferr

als

whe

relif

e-th

reat

enin

g co

nditi

ons

or s

erio

usun

expe

cted

pat

holo

gies

are

dis

cove

red

durin

g an

inte

rven

tion/

asse

ssm

ent

iii) e

nsur

e th

at p

atie

nts

rece

ive

disc

harg

ein

form

atio

n re

leva

nt t

o th

eir

inte

rven

tion

incl

udin

g ar

rang

emen

tsfo

r co

ntac

ting

the

prov

ider

and

fol

low

up if

req

uire

div

) pro

vide

tim

ely

feed

back

to

the

refe

rrer

re in

terv

entio

n, c

ompl

icat

ions

and

prop

osed

fol

low

up

v) e

nsur

e th

at t

he p

atie

nt r

ecei

ves

requ

ired

drug

s/dr

essi

ngs/

aids

vi) e

nsur

e th

at s

uppo

rt is

in p

lace

with

othe

r ca

re a

genc

ies

as a

ppro

pria

te

Prov

ider

s sh

ould

ens

ure

acce

ss to

tran

spor

t fac

ilitie

s to

ena

ble

atte

ndan

ce fo

r spe

cial

ist tr

eatm

ent,

as re

quire

d

Prov

ider

s ar

e re

quire

d to

take

not

e of

the

resu

lts o

f the

Nat

iona

lSu

rvey

of P

eopl

e w

ith D

iabe

tes

38

Clin

ical

qua

lity

Clin

ical

em

erge

ncy

situa

tions

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:6,

11,1

2,13

,14,

15,1

8,32

,33,

42,

54

Sche

dule

s:

2, 3

(par

t 1 a

nd 3

), 12

Abi

lity

to n

egot

iate

and

agr

eear

rang

emen

ts w

ith a

ppro

pria

tepe

rson

nel a

nd o

rgan

isat

ions

to

prov

ide

effe

ctiv

ely

for

emer

genc

ysi

tuat

ions

The

Com

mis

sion

ers

shou

ld s

atis

fyth

emse

lves

tha

t pr

ovid

er h

as s

yste

ms,

proc

esse

s an

d co

mpe

tent

per

sonn

el a

re in

plac

e an

d im

plem

ente

d to

ens

ure

that

all

clin

ical

em

erge

ncie

s an

d co

mpl

icat

ions

are

hand

led

in a

ccor

danc

e w

ith b

est

prac

tice

Ther

e sh

ould

be

prot

ocol

s in

pla

ce to

ens

ure

the

avai

labi

lity

ofad

vice

and

/or s

uppo

rt o

f spe

cial

ist d

iabe

tes

clin

ical

sta

ff to

man

age

diab

etes

clin

ical

em

erge

ncy

situa

tions

, e.g

. dur

ing

asu

rgic

al p

roce

dure

or o

ther

clin

ical

inte

rven

tion

for t

hem

anag

emen

t of t

he re

nal c

ondi

tion

20

TOPI

CEL

EMEN

TSC

HA

RA

CTE

RIS

TIC

S, S

KIL

LSA

ND

BEH

AV

IOU

RS

OU

TPU

TSD

IAB

ETES

SER

VIC

ES S

PEC

IFIC

OU

TPU

TS/C

OM

MEN

TS

Clin

ical

qua

lity

Kno

wle

dge

and

unde

rsta

ndin

g of

hea

lthan

d sa

fety

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:5,

11, 1

9, 5

4, 5

6, 6

0

Und

erst

andi

ng o

f cl

inic

alac

coun

tabi

litie

s of

hea

lth a

ndsa

fety

pol

icie

s

H&

S st

rate

gy a

nd p

olic

ies

in p

lace

and

impl

emen

ted

with

aw

aren

ess

thro

ugho

utth

e or

gani

satio

n

Acc

essi

bilit

y to

exe

cutiv

e re

spon

sibl

e fo

rH

&S

for

quic

ker,

first

con

tact

ser

vice

s

Hea

lth a

nd s

afet

y po

licie

s as

per

pro

vide

r agr

eem

ent w

ithco

mm

issio

ners

Dat

a an

din

form

atio

nm

anag

emen

t

Stra

tegy

and

pol

icie

s

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:8,

9,17

,19,

21,2

3,24

,27,

29,3

2,33

,54

Sche

dule

s: 5

,7,1

5,16

,18

Stra

tegy

and

pol

icy

deve

lopm

ent

skill

s

The

abili

ty t

o an

alys

e da

ta a

ndha

ve a

cces

s to

info

rmat

ion

that

can

pred

ict

tren

ds a

nd t

hat

coul

did

entif

y pr

oble

ms

The

abili

ty t

o ca

ptur

e ev

iden

ceba

sed

prac

tice

from

R&

D N

atio

nal

Serv

ice

Fram

ewor

ks, N

ICE

guid

ance

The

abili

ty t

o us

e da

ta a

ndin

form

atio

n ap

prop

riate

ly t

oim

prov

e pa

tient

car

e

Tran

spar

ency

and

obj

ectiv

ity

The

Prov

ider

sho

uld

have

an

expl

icit

data

and

info

rmat

ion

stra

tegy

in p

lace

tha

t co

vers

•Ty

pes

of d

ata

•Q

ualit

y of

dat

a•

Dat

a pr

otec

tion

and

conf

iden

tialit

y•

Acc

essi

bilit

y•

Tran

spar

ency

•A

naly

sis

of d

ata

and

info

rmat

ion

•U

se o

f da

ta a

nd in

form

atio

n•

Dis

sem

inat

ion

of d

ata

and

info

rmat

ion

•Ri

sks

•Sh

arin

g of

dat

a an

d co

mpa

tibili

ty o

f IT

acro

ss d

iffer

ent

prov

ider

s w

ith r

espe

ct t

oca

re o

f pa

tient

s ac

ross

a p

athw

ay

This

info

rmat

ion

shou

ld b

e in

clud

ed in

the

Dat

a Q

ualit

y Im

prov

emen

t Pl

an

The

Prov

ider

is re

quire

d to

hav

e in

form

atio

n sy

stem

s th

at re

cord

indi

vidu

al n

eeds

incl

udin

g em

otio

nal,

soci

al, e

duca

tiona

l,ec

onom

ic a

nd b

iom

edic

al in

form

atio

n w

hich

per

mit

mul

tidisc

iplin

ary

care

acr

oss

serv

ice

boun

darie

s an

d su

ppor

t car

epl

anni

ng 39

The

Prov

ider

is re

quire

d to

use

the

follo

win

g fo

r the

col

lect

ion

and

prod

uctio

n of

dat

a, w

here

app

ropr

iate

:

•N

HS

Out

com

es F

ram

ewor

k28

•N

atio

nal D

iabe

tes

Info

rmat

ion

Serv

ice

40

•N

atio

nal D

iabe

tes

Aud

it 15

•N

atio

nal K

idne

y C

are

Aud

it 17

•Re

nal S

ervi

ces

Info

rmat

ion

Stra

tegy

: Sup

port

ing

part

one

of

the

Nat

iona

l Ser

vice

Fra

mew

ork

for R

enal

Ser

vice

s 41

•Re

nal s

ervi

ces

info

rmat

ion

stra

tegy

: Sup

port

ing

part

two

ofth

e N

atio

nal S

ervi

ce F

ram

ewor

k fo

r Ren

al S

ervi

ces42

•D

iabe

tes

E 19

Clin

ical

qua

lity

Esta

tes

and

equi

pmen

t

Cro

ss re

fere

nces

to th

eSt

anda

rd N

HS

Con

trac

tfo

r Acu

te S

ervi

ces

Mai

n cl

ause

s:5,

29, 3

3, 5

6

Sche

dule

s: 3

,10,

19

Und

erst

andi

ng o

f bu

ildin

gre

gula

tions

Acc

ess

to a

dvic

e on

“fit

-for

-pu

rpos

e” e

quip

men

t an

d fa

cilit

ies

Com

mis

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22

Source documentsCommissioners and providers should takeresponsibility for making references to thelatest version of the various documents andguidance.

1. Emotional and Psychological Support and Care inDiabetes, Joint Diabetes UK and NHS DiabetesEmotional and Psychological Support WorkingGroup, 2010 http://www.diabetes.nhs.uk/our_work_areas/emotional_and_psychological/

2. The NHS Diabetes Commissioning Guides areavailable on the NHS Diabetes website athttp://www.diabetes.nhs.uk/commissioning_resource/

3. Department of Health, Standard NHS Contractshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324

4. National Quality Board, Quality Governance in theNHS, 2011 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_125239.pdf

5. NICE Diabetes guidance,http://guidance.nice.org.uk/Topic/EndocrineNutritionalMetabolic/Diabetes

6. NICE, Early identification and management ofchronic kidney disease in adults in primary andsecondary care, 2008,http://guidance.nice.org.uk/CG73

7. NICE, Anaemia management in people withchronic kidney disease (CKD), 2011,http://guidance.nice.org.uk/CG114

8. NICE, The clinical effectiveness and costeffectiveness of patient education models fordiabetes, April 2003,www.nice.org.uk/Guidance/TA60

9. NICE, Medicines adherence: involving patients indecisions about prescribed medicines andsupporting adherence, Jan 2009,http://guidance.nice.org.uk/CG76

10. European Diabetes Working Party for OlderPeople. Clinical Guidelines for Type 2 DiabetesMellitus, www.instituteofdiabetes.org

11. Department of Health, Renal SpecificManagement of Medicines, 2004,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4082061

12. Department of Health and Marie Curie PalliativeCare Institute, Guidelines for LCP DrugPrescribing in Advanced Chronic Kidney Disease,2008, http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_085997.pdf

13. NHS Institute for Innovation and Improvement,model CQUIN scheme: inpatient care for peoplewith diabetes, 2009

14. Department of Health, The Operating Frameworkfor the NHS in England 2011/12, 2010,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122738

15. National Diabetes Audit.www.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/diabetes

16. National Diabetes Support Team, Improvingemergency and inpatient care for people withdiabetes, the report of a working party ofrepresentatives of the inpatient and emergencycare community in partnership with the NationalInstitute for Innovation and Improvement, March2008

17. The information centre , National Kidney CareAudit - http://www.knowledge.ic.nhs.uk/kidneycareaudit

18. The King’s Fund, The point of care. Measures ofpatients’ experience in hospital: purpose,methods and uses. July 2009

19. DiabetesE - https://www.diabetese.net/

20. Patient Reported Outcomes Measures,http://www.ic.nhs.uk/proms

21. Commissioning Specialist Diabetes Services forAdults with Diabetes - A Diabetes UK Task andFinish Group Report Oct 2010,http://www.diabetes.org.uk/Professionals/Publications-reports-and-resources/Reports-statistics-and-

23

case-studies/Reports/Commissioning-Specialist-Diabetes-Services-for-Adults-with-Diabetes---Defining-A-Specialist-Diabetes-UK-Task-and-Finish-Group-Report-October-2010/

22. Skills for Health, Diabetes CompetencyFramework and Renal Competences,https://tools.skillsforhealth.org.uk/

23. Department of Health, The National ServiceFramework for Renal Services, January 2004http://www.dh.gov.uk/en/Healthcare/Renal/DH_4102636

24. Department of Health, National ServiceFramework for Older People, May 2001,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066

25. National Service Framework for Children, YoungPeople and Maternity Services, 2004http://www.dh.gov.uk/en/Healthcare/Children/DH_4089111

26. Department of Health, No health without mentalhealth: a cross-government mental healthoutcomes strategy for people of all ages,February 2011,http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766

27. Department of Health, The National ServiceFramework for Long Term Conditions, March2005 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4105361

28. Department of Health, The NHS OutcomesFramework 2011/12, December 2010http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944

29. NICE, Quality Standards: Diabetes in adults,March 2011, http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp

30. Generic Long-term conditions modelhttp://www.dh.gov.uk/en/Healthcare/Longtermconditions/DH_120915

31. Renal Specialised Commissioners, The National

Service Framework for Renal Services Part OneDialysis and Transplantation ImplementationToolkit For Commissioners Based on Best Practice,2004 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4097253.pdf

32. Putting Prevention First, NHS Health Check,Vascular risk assessment and management , Bestpractice guidance, 2009,www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_097489

33. NHS Kidney Care, My Kidney Care Planhttp://www.kidneycare.nhs.uk/_Resourcestodownload-MyKidneyCarePlan.aspx

34. NHS Kidney Care, Specification for theCommissioning of Peritoneal Dialysis Pathway ,2009 http://www.kidneycare.nhs.uk/_Resourcestodownload-Specifications.aspx

35. NHS Kidney Care, Achieving Autonomy forKidney Services Seven Steps Toolkithttp://www.kidneycare.nhs.uk/Library/Achieving_Autonomy_for_Kidney_Services_FINAL.pdf

36. NHS Kidney Care, The Role of the Renal WelfareOfficer, Kidney Care Matters online, Case study,August 2009,http://www.kidneycare.nhs.uk/_Whatworks-Casestudies-Theroleoftherenalwelfareofficer.aspx

37. End of Life Care for Advanced Kidney Disease, Aframework for implementation, 2009,http://www.kidneycare.nhs.uk/Library/EndofLifeCareFINAL.pdf

38. Healthcare Commission, National Survey ofPeople with Diabetes, 2006,www.cqc.org.uk/usingcareservices/healthcare/patientsurveys/servicesforpeoplewithdiabetes.cfm

39. York and Humber integrated IT system,http://www.diabetes.nhs.uk/

40. National Diabetes Information Service,www.diabetes-ndis.org

41. Department of Health, Renal Services InformationStrategy, 2004,http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/

24

dh_4070588.pdf

42. Department of Health, Renal services informationstrategy: Supporting part two of the NationalService Framework for Renal Services, 2005http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4113496

43. Quality and Outcomes Framework,http://www.nice.org.uk/aboutnice/qof/qof.jsp

44. Hospital Episode Statistics,www.ic.nhs.uk/statistics-and-data-collections/hospital-care/hospital-activity-hospital-episode-statistics--hes

45. UK Renal Registry,http://www.renalreg.com/About-Us/about.html

46. National Diabetes Continuing Care Dataset,www.ic.nhs.uk/webfiles/Services/Datasets/Diabetes/dccrdataset.pdf

47. National Renal Dataset,http://www.ic.nhs.uk/services/datasets/document-

downloads/renal

25

This specification forms Schedule 2, Part 1 orsection 1 (module B), ‘The Services - ServiceSpecifications’ of the Standard NHSContractsa

Service specifications are developed in partnershipbetween commissioners and provider agenciesand are based on agreed evidence-based care andtreatment models. Diabetes and Renal Networkshave an important role to play in developing thespecifications. Specifications should be open toscrutiny and available to all service users/carers asa statement of standards that the user/carer canexpect to receive.

The following documentation, developed bythe Diabetes Commissioning Advisory Groupin conjunction with NHS Kidney Careprovides further detail/guidance to supportthe development of this specification:

• The intervention map for diabetes and kidneycare services

• The contracting framework for diabetes andkidney care services

This specification template assumes that theservices are compliant with the contractingframework for diabetes and kidney care services.

This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.

Description of diabetes and kidneycare services:Diabetes and kidney care services includes anassessment of risk of chronic kidney disease aspart of the initial and continuing management ofpeople with diabetes, management of renalfunction and associated conditions such ashypertension and metabolic bone disorders,management of all the stages of renal failure withspecialist input with access to transplantation anddialysis services.

The final specification should take into account:

• national, network and local guidance andstandards for diabetes and kidney careservices.

• local needs.

• cross references to the Specification for theCommissioning of Peritoneal DialysisPathwayb and the autonomous kidneyservices toolkitc

This specification is supported by other relatedwork in diabetes commissioning such as:

• the web-based Diabetes Community HealthProfiles (Yorkshire and Humber Public HealthObservatory)

• the web-based Health Needs Assessment Tool(National Diabetes Information Service).

These provide comprehensive information forneeds assessment, planning and monitoring ofdiabetes services

Standard Service SpecificationTemplate for Diabetes and Kidney Care

a Standard NHS Contracts http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324

b NHS Kidney Care, Specification for the Commissioning of Peritoneal Dialysis Pathway , 2009http://www.kidneycare.nhs.uk/i/assets/Commissioning_of_PD_Pathway_Nov09_FINAL.pdf

c NHS Kidney Care, Achieving Autonomy for Kidney Services Seven Steps Toolkithttp://www.kidneycare.nhs.uk/i/assets/Achieving_Autonomy_for_Kidney_Services_FINAL.pdf

26

Introduction• A general overview of the services identifying

why the services are needed, includingbackground to the services and why they arebeing developed or in place.

• A statement on how the services relate to eachother within the whole system should beincluded describing the keystakeholders/relationships which influence theservices, e.g. multi-disciplinary diabetes teamand renal team, etc

• Any relevant diabetes and renal clinicalnetworks and screening/risk assessmentprogrammes applicable to the services, e.g.NHS Health Check

• Details of all interdependencies or sub-contractors for any part of the service and anoutline of the purpose of the contract shouldbe stated, including arrangements for clinicalaccountability and responsibility, as appropriate

Purpose, Role and Clientele1. A clear statement on the primary purpose of

the services and details of what will beprovided and for whom:

• Who the services are for (e.g. children,young people, adults and older people withdiabetes who require kidney care for therenal complications of diabetes)

• What the services aim to achieve within agiven timeframe

• The objectives of the services

• The desired outcomes and how these aremonitored and measured

Scope of the Services2. What does the service do? This section will

focus on the types of high level therapeuticinterventions that are required for the types ofneed the services will respond to.

• How the services responds to age, culture,disability, and gender sensitive issues

• Assessment – details of what it is and co-morbidity assessment and referrals to allrelevant specialties

• Service planning – High level view of whatthe services are and how they are used;how patients enter the pathway/journey;what are the stages undertaken andcontinuing management up to end of lifecare. The aims of service planning are to:

o Develop, manage and reviewinterventions along the patient journey

o Ensure access to other specialities /care,as appropriate

o Ensure that care planning is undertakenby the diabetes multi-disciplinary team(as defined locally) with a clear care co-ordination function

o Ensure that transition from childrens’ toadults’ services or adults’ to olderpeoples’ services is negotiated andexplicitly planned around the assessedneeds of each individual person

• Holistic review of patients in themanagement of their diabetes using theprinciples of an integrated care model forpeople with long term conditions that ispatient-centred, including self care and selfmanagement, clinical treatment, facilitatingindependence, psychological support andother social care issues

• Risk assessment procedures

• Detail of evidence base of the service –i.e.the contracting framework for diabetesand kidney care, guidance produced byRoyal College of Physicians, Diabetes UK etc.

Service Delivery3. Patient Journey/intervention map

Flow diagram of the patient pathway showingaccess and exit/transfer points – see the patientintervention map for diabetes and kidney careservices as a starting point

4. Treatment protocols/interventionsInclude all individual treatment protocols inplace within the services or planned to be used

5. This will include a breakdown of how thepatient will receive the services and fromwhom. It should be a clear statement of staffqualifications/experience and/or training (if

27

appropriate) and clinical or managerialsupervision arrangements. It should specify, asappropriate:

• Geographical coverage/boundaries – i.e.the services should be available for childrenand young people, adult and older peoplewho live in the clinical commissioninggroup area

• Hours of operation including, week-end,bank holiday and on-call arrangements

• Minimum level of experience andqualifications of staff (i.e. doctors –diabetologists, nephrologists and GPs,Nursing staff – diabetes nurse specialists,renal care nurses etc, other allied healthprofessionals, e.g. dietitians, pharmacistsetc and other support and administrativestaff)

• Confirmation of the arrangements toidentify the Care Co-ordinator for eachpatient with diabetes (i.e. who holds theresponsibility and role).

• Staff induction and developmental training

6. Equipment• Upgrade and maintenance of relevant

equipment and facilities

• Technical specifications (if any)

Identification, Referral andAcceptance criteria7. This should make clear how patients will be

identified, assessed, and accepted to theservices. Acceptance should be based on typesof need and/or patient.

8. How should patients be referred?

• Who is acceptable for referral and fromwhere

• Details of evaluation process - Are thereclear exclusion criteria or set alternatives tothe service? How might a patient betransferred?

• Response time detail and how are patientsprioritised

Discharge/Service Complete/PatientTransfer/Transition criteria9. The intention of this section is to make clear

when a patient should be transferred from oneaspect of the diabetes service to another is andwhen this would be reached.

• How is a treatment pathway reviewed?

• How does the service decide that a patientis ready for discharge

• How are goals and outcomes assessed andreviewed?

• What procedure is followed on discharge,including arrangements for follow-up

Quality Standards10. The service is required to deliver care

according to the standards for clinical practiceset by the National Institute for Health andClinical Excellenced,e

11. As a minimum, the Provider is required toagree a local Commissioning for Quality andInnovation scheme for services for peoplewith diabetes. (Insert details of the CQUINScheme agreed)

12. The service is required to deliver the outcomesfor diabetes as determined by the NHSOutcomes Frameworkf

Activity and PerformanceManagement13. This must include performance indicators,

thresholds, methods of measurement andconsequences of breach of contract. Thesewill be set and agreed prior to the signing ofthe overall agreement.

14. Activity plans – Where appropriate, identifythe anticipated level of activity the servicemay deliver; provide details of any activitymeasures and their description /method ofcollection, targets, thresholds andconsequences of variances above or belowtarget.

d http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp

e http://www.nice.org.uk/guidance/qualitystandards/chronickidneydisease/ckdqualitystandard.jsp

f http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944

28

Continual Service Improvement15. As part of the monitoring and evaluation

procedures, the service will identify a methodof agreeing measurements for continuousimprovement of the service being offeredand work to ensure unmet need is bothidentified and brought to the attention of thecommissioner.

16. ReviewThis section should set out a review date anda mechanism for review.

The review should include both thespecifications for continuing fitness forpurpose and the providers’ delivery againstthe specification.

This should set out the process by which thisreview will be conducted.

This should also identify how complianceagainst the specification will be monitored inyear.

17. Agreed byThis should set out who agrees/accepts thespecification on behalf of all parties.

This should include the diabetes and kidneycare providers, commissioner and network.

Further copies of this publication can be ordered from Prontaprint, by emailing diabetes@leicester.prontaprint.com or tel: 0116 275 3333, quoting DIABETES 120

www.diabetes.nhs.uk