Recommendations

1.  The Lambeth and Southwark Diabetes Network should ensure that its initiatives to ‘listen’ to service users are fully implemented and that the results are considered in future planning of services. Current initiatives include:

• mapping existing service user groups and identifying named links from the Network to liaise with them
• mapping patients’ pathways through the services
• a recent MORI survey on hypertension and its relevance for diabetes patients
• an ‘appreciative enquiry’ with recently diagnosed diabetes patients
• the National Patient Survey in diabetes.

2.  Practices should ensure that patients know about the existence of user groups - especially those who are newly diagnosed.

3.  The L&S Diabetes Network should identify and disseminate information on opportunities for professional staff to be trained in patient self-care and consider implementing patient-held records.

4.  Practices with the largest shortfall in identified prevalence (eg through QOF) compared to estimated prevalence (extrapolated from the Health Survey for England) should be supported in developing their approach to diabetes care. Support might include:

• a simple tool to help practices identify priority at risk groups for diabetes screening
• guidelines for working with housebound patients
• cultural awareness training for diabetes staff.

5.  Practices should ensure that patients with diabetes are regularly screened for retinopathy in accordance with the NSF target and NICE guidance.

6.  As a matter of priority, practices should ensure that diabetes patients who smoke are strongly advised to give up smoking, preferably through the NHS cessation programme (Southwark Stop Smoking Service).

7.  Service planners and commissioners should fully deploy the triple-tier chronic disease service model for diabetes throughout Southwark as soon as possible. This should include establishing mainstreamed and well-resourced healthy lifestyle support services (eg. Stop Smoking, community dietetics and exercise referral service) and identified case-managers for the more complex cases.

8.  Commissioners should ensure that regular provision of hospital data on patient activity (eg. new to follow-up OPD ratio, emergency admissions, etc) is written into contracts and analysed to improve our understanding of each element of the clinical pathway.