CWS Locally Commissioned Service

Service Title Service Code

Diabetes 2020-21 CWS-LCS002

Introduction

Practices are contracted to provide essential and additional services for all registered patients including those with a diagnosis of diabetes, as well as, in partnership with specialist colleagues, more complex patients and those on insulin. Practices also provide diabetes services in line with the Quality and Outcomes Framework. No part of this specification by commission omission or implication defines or redefines essential or additional services.

This service must be provided in a way that ensures it is equitable in respect of race, creed culture, diversity, disability, and age.

This service specification is for 12 months from 1st February 2020 to 31st January 2021. The specification is unchanged from previous years other than practice groups have been replaced by Primary Care Networks (PCNs).

Background and Summary

One of the main challenges facing our current health service is the increasing prevalence of diabetes and the complications of diabetes. This service seeks to help practices deliver high quality evidence based care which is over and above GMS & QOF requirements.

It promotes best practice in the following key areas:1. Developing leadership through education2. Supporting high quality processes and demonstrating good performance3. Focusing on patient empowerment to self-manage4. Demonstrating achievement of the NICE Quality Standards for diabetes in adults5. Working towards an integrated diabetes service across the Community and Specialist interface6. Supporting patient intervention in ‘pre-diabetes’7. Encouragement for practices to work at scale and support each other

Comparative information will be gathered by the CCG so that best practice can be identified, shared and the whole pathway of care improved. To enable general practice to demonstrate achievement and value for money, payments for some elements of this service are target based, in a similar way to the current GP QOF.This scheme will run from 1.2.20 to 31.1.21 and practice performance will be measured on 31.1.21.

Practices are again asked to submit data after 6 months (on 31.7.20) for a ‘dummy run’, so that1. the CCG can ‘test’ the system in advance of year end2. the commissioners can estimate what payments will be due at year end3. the CCG can support practices regarding their claims and identify any data collection problems early

1

Aspiration payments will be made monthly, and achievement payments will be made after the end of the year once all the data has been submitted by all practices. It is therefore in all practices’ interests to submit year end data in a timely manner.

Other elements such as insulin initiation, care of insulin dependent patients and pre-operative reviews will be item of service payments which practices can claim monthly.

For the year 1.2.20 – 31.1.21, aspiration payments will be made as follows

1. February and March 2020: 80% of historical practice payments for 2018-192. April 2020 to January 2021: 80% of historical practice payments for 2019-20

Changes

The specification for 2020-21 remains unchanged from the 2019-20 version, other than practices groups are replaced by PCNs.

The main changes made to the specification the year 2019-20 are listed here for ease of reference. Please see the main specification for further details.

New requirements from 2019-20

All participating practices must submit their current diabetes QOF performance to the CCG quarterly

PCNso must provide insulin initiation for their registered population in the community where appropriate (if

necessary by interpractice referral rather than referral to secondary care)o must provide some diabetes review appointments outside of the hours 8.30am to 6pm weekdays

the number of appointments provided over the year 2020-21 should total at least 3% of the group diabetes population (measured at 31.1.20)

these should be face to face review appointments (not information gathering appointments)

Learning requiremento removal of case note review and reflective learning requirement and replacement with a new

requirement for a foot care / diabetic ulcer audit

PCN performance bonus

Where all practices in a PCN have achieved the following:a) at least 95% QOF andb) at least 70% in the care planning LCS indicatorc) the audit requirements in this LCSall practices in that group will receive a 2% bonus on the LCS indicator payments (those payments making up the 112 points available)

LCS Indicator changes

Retirement of the ‘9 care processes indicator’ and replacement with a practice audit based on the National Diabetes Audit (NDA)

2

o There has been poor correlation in previous years between the NDA data and this local indicator. This is because of factors such as different exception reporting rates between practices and sometimes difficulty with constructing the searches correctly.

o This year, those practices not achieving the England average in the NDA data, will be required to audit the reasons why and submit an action plan to improve NDA performance. NDA data is expected to be published in March 2020 and affected practices will be informed at that time.

A focus on referrals to the National Diabetes Prevention Programme (NDPP) for new patients with prediabetes, in that we will be asking practices to submit data on patients referred to this scheme

New indicator for (non care home) housebound patients annual care planning

Introduction of a new indicator of referrals to the Time to Talk chronic disease service

In line with proposed changes to QOF

o patients recorded as having moderate or severe frailty will be excluded from the care planning denominator. In view of this the payment threshold will slightly increase from 40-65% to 40-70%

o patients with mild moderate or severe frailty will be excluded from the prediabetes denominator

Reminder of changes from 2018-19

As a reminder, the following are changes introduced in 2018-19 will be retained in 2020-21

There is no longer any requirement for clinically stable people living with diabetes to have a face to face consultation as part of their Year of Care. Where deemed clinically appropriate the review can be delivered by telephone

Patients can be ‘exception reported’ from pre diabetes education where clinically appropriate, for example in patients with frailty where the ‘diagnosis’ of prediabetes may be of little significance.

There is a new payment for a pre-operative diabetes review for diabetic patients who are being referred for likely major elective surgery

Involvement in the retinal screening review and process is a requirement The provision of standardised information for women of child bearing age is encouraged.

Qualification for payment: Requirements

The following requirements are expected to be met in order for a practice to receive full payment. If practices do not meet these criteria then payment under this specification is not guaranteed.In the event that a practice does not, or cannot, meet these criteria, a supportive performance meeting may be held with the practice where practice performance and action plans will be discussed. A reasonable portion of the payment may be withheld and eligibility to continue to participate in this service may be considered.

1. Have a nominated GP lead and nominated lead Nurse

Practices must provide the name and contact details of the diabetes leads to the CCG at the commencement of this LCS and keep the CCG updated with any changes.

The Leads should have appropriate competencies in diabetes and practices must ensure that all health care professionals managing patients with diabetes should have appropriate competencies for the services that they

3

are providing.

The lead GP should demonstrate competence through the appraisal and revalidation system.

The lead Practice Nurse should be at Level 3, or working towards Level 3 as defined by Trend

www.trend-uk.org/documents/TREND_3rd.pdf at a minimum level 1 for dietetics as defined by DMEG www.dmeg.org.uk/Doccuments/Dietetic

%20Competency%20Framework%202011.pdfas well as maintaining Continued Professional Development in diabetes annually.

The lead GP or PN must keep themselves up to date with the latest information/training to help deliver excellent diabetic care.

Through IPC Ltd there will be a mix of diabetes updates, New to Diabetes with explantionof the 2 part process, motivational interviewing, gap analysis sessions utilising the TREND model. All those providing foot checks must have attended appropriate training OR be deemed as competent (training will be offered by IPC Ltd).

There will be a half day mandatory YOC update delivered by IPC Ltd.

The nominated lead nurse for diabetes (or deputy) must take part in local diabetes network meetings such as the quarterly practice nurse forum.

2. Provide a ‘two stage annual care planning’ process for diabetic patients based on the Year of Care methodology

Practices may be asked to provide evidence of their two stage planning process on request.

Practices should have at least one clinical member of staff who has attended approved Year of Care Training and may draw on the expertise of the local Year of Care Trainers at SCT and WSHFT to support implementationcwsccg.yearofcareteam@nhs.uk

3. Achievement of at least 95% of available QOF points for Diabetes for the year ending 31st March 2020 including quarterly reporting of QOF performance to the CCG

Practices not achieving this will be expected to submit practice audit, reflection and an action plan to improve QOF performance to the CCG by 1.7.20. Guidance on this audit and action plan will be provided to the practice if required.

All participating practices must submit their current diabetes QOF performance to the CCG quarterly or on request.

4. Work collaboratively with local specialist services

Diabetes Specialist Nurses (DSN), Diabetes Specialist Dieticians and Psychological Therapists are commissioned to take part in joint collaborative clinics with practice teams, with the aims of supporting the management of patients with diabetes and contributing to the continued professional development of those practice teams.

Joint DSN clinics should be held in the practice or at PCN level if appropriate on a monthly basis on average.

It is a requirement that practices facilitate these collaborative clinics. The practice will identify the patients for these joint clinics and invite them to attend.

4

5. Audit (2 audit requirements)

a. Foot care / care of diabetic ulcers

Infections ulceration and amputation cause significant harm. Local guidelines state that

Feet assessed as at risk should be referred to podiatry services Ulceration should be referred urgently to the diabetes foot clinic

Practices are required to focus on, and audit, this area of care again this year.

A standardised audit should be performed and submitted to the CCG by 30th September 2020. Practices should discuss their results at a PCN education session and plan for improvement where appropriate

Details can be found in Appendix G

b. Performance on the National Diabetes Audit - NDA

Practices are required to submit data for the National Diabetes Audit. The national results are published each year in March. Practice performance is reported separately for type 1 and type 2 diabetes.This year we would like practices to focus on achievement of the NDA ‘treatment targets’. This is one of the IAF (CCG) targets and Coastal’s performance is below CCG average.

Further information can be found herehttps://digital.nhs.uk/data-and-information/clinical-audits-and-registries/national-diabetes-auditandhttps://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-audit/report-1-care-processes-and-treatment-targets-2017-18-full-report

Please note that no account is taken of exception reporting in the NDA data.

The treatment targets are as follows and a patient ‘passes’ if they achieve all 3 targets.

1. HbA1c 58 or less2. Blood pressure 140/80 or less3. Cholesterol 5 or less

Overall, performance in Coastal West Sussex CCG has been improving gradually but there is wide variation in practice performance. Therefore those practices where performance falls short of the England average for type 2 diabetes are required to

Audit as to possible reasons why Discuss the results within their clinical teams and at a PCN education session Produce a plan within the practice to improve NDA performance

Practices will be provided with comparative data from the latest NDA for information to support this audit. Those practices, whose performance is below the England average, will be informed at that time that an audit is required and provided with audit guidance.

6. Working at scale

5

Practices / PCNsa. must provide insulin initiation for their registered population in the community where appropriate (if

necessary by interpractice referral rather than referral to secondary care)

b. must provide a number of face to face diabetes review appointments for their population that meet the following criteria

i. the number of appointments provided over the year 2020-21 should total at least 3% of the PCN’s diabetes population (measured at 31.1.20)

ii. the appointments should be outside the hours of 8.30am – 6pm weekdays

7. The practice must take part in the National Diabetes Audit (NDA) and strive to at least achieve the England average performance

Practices not achieving the England average in the NDA must submit an audit into the reasons why and produce an improvement plan. The results of these practice audits should be discussed at a PCN education session.

8. The practice must fully participate in the retinal screening service

9. Submission of LCS performance data to the CCG must be made in a timely manner twice a year

a. 31st July data (for monitoring) by 14th August of the same year.b. 31st January (for payment) by 14th February of the same year.

Service Outline

Practices must complete the following elements for payment according to the schedules below. Some elements attract a ‘QOF style’ payment, and others an ‘item of service’ payment as detailed in (Appendix A).

There are now 112 points available across all domains.

10. Pre – diabetes (22 points)

a. The Practice should maintain a register of patients with pre-diabetes (2 points).The diagnostic criteria should be in line with current NICE guidance (Appendix C)http://www.nice.org.uk/guidance/ph38/chapter/glossaryPractices should code patients appropriately to include patients with the following:

last recorded fasting plasma glucose of 5.5–6.9 mmol/l an HbA1c level of 42–47 mmol/mol or a history of gestational diabetes

b. The Practice is required to perform a Fasting Glucose Test or HbA1c on patients on the pre diabetes register in the preceding 15 months and action appropriately (10 points)

c. Where appropriate, the Practice should offer all newly diagnosed pre-diabetics education to reduce the risk of progression to diabetes (10 points)

Patients should be offered the following options

The National Diabetes Prevention Programme

6

https://preventing-diabetes.co.uk/https://www.england.nhs.uk/diabetes/diabetes-prevention/Code: Referral to NHS Diabetes Prevention Programme

Local Health and Wellbeing Hubshttps://www.westsussexwellbeing.org.uk/topics/pre-diabetes

In house prediabetes education

Recommended content for education appointments and related information is given in the Supporting Guidance at Appendix B. All patients should be provided with supporting written literature and advice covering the options above.

Patients recorded with mild moderate or severe frailty will be excluded from the denominator.

Where it is otherwise deemed clinically inappropriate to deliver pre-diabetes education ‘exception reporting’ will be allowed. In the absence of an appropriate code the following code is suggested to exception report for this indicator:

‘diabetes structured education programme declined’EMIS practices may wish to use the code:

‘pre-diabetes structured education programme declined’

The payment threshold remains 80% achievement generates 100% payment.

11. Care Planning (60 points)

Practices are asked to report on the percentage of patients on the diabetes register who have followed a Year of Care style two step care planning process

Patients with moderate or severe frailty will be excluded from the denominator and the payment threshold will be 40-70%

“Care Planning is a powerful way of creating an environment which helps clinicians to support self-management by patients of their own LTC. This means supporting people to understand and confidently manage the condition itself, plus also supporting them to manage the inevitable consequences of living with a long term condition - consequences for the way they live their lives and the way they think and feel about themselves and their relationships.” RCGP, 2011

The practice must ensure that people with Diabetes have an annual care planning consultation. The jointly agreed goals and jointly developed action plan should be documented in a care plan. As part of this there should be a documented personalised HbA1C target (usually between 48 and 58mmol/l) and patients should receive an ongoing review of their treatment to minimise risks of hypoglycaemia where appropriate.

It is recommended that a total of 30 minutes is allocated for the annual care planning consultation.

It is acceptable, where appropriate, for the care planning appointment to be a telephone consultation. Clinical judgement should be exercised when deciding if this is an appropriate method for the individual patient. In general terms, it should only apply when the results of the diabetes checks are all satisfactory.

12. Care planning in housebound patients (6 points)

7

Housebound patients generally require a home visit for their care planning appointment. To encourage practices to ensure this hard to reach population receives the same level of care as ambulant patients there is now a separate indicator for this population.

The denominator is diabetic patients who are housebound but not in a care home. The payment threshold is 40-70% as for the general population and patients with moderate or severe frailty will be excluded

13. Women of childbearing age: Pre conception counselling and contraceptive advice (10 points)

This indicator applies to women aged 15-54 inclusive with diabetes or pre-diabetes.

To qualify for payment practices are required:

1. To provide standardised information (Appendix E) regarding the benefits of preconception, glycaemic control and of any risks that may harm an unborn child to those women of childbearing age with diabetes or pre-diabetes

2. To offer women with diabetes or pre-diabetes, not planning a pregnancy, advice on contraception.3. To report the percentage of diabetic or pre-diabetic female patients aged 15-54 who have been

offered contraceptive advice and/or pre-conceptual counselling in the last 15 months

Practices should continue to refer complex patients with diabetes who are planning a pregnancy to a specialist.

When reporting achievement for this indicator, in order to take account of patients where such advice is inappropriate (for example hysterectomised patients), it is acceptable to code ‘contraceptive advice: text not appropriate + reason’. All patients with diabetes who are pregnant should be referred to the diabetes antenatal clinic.

14. Insulin therapy initiation (item of service payment)

A Practice can claim for each new insulin initiation provided by its clinical team or within the collaborative clinic on any patient registered with a practice in Coastal West Sussex CCG.

Practices must ensure that insulin initiation is provided in the community where clinically appropriate, rather than by referral to secondary care services. Practices should therefore work within their PCNs to ensure that practices not able to provide this service in-house are able to refer patients to other practices in the PCN for insulin initiation. Where this occurs the practice providing the service should make the claim for payment.

Staff must be appropriately trained (MERIT or equivalent) and, together with the Diabetes Specialist Nurse Team, may initiate and manage therapy with insulin, within a structured programme that includes dose titration by the person with diabetes. Therapy should be in line with NICE guidance and patients should be provided with clear access to ongoing support and follow up.

15. Insulin management (item of service payment)

The practice can claim for patients on insulin whose diabetes is not predominantly managed in secondary care.

Complex adjustment of insulin regimes for patients not under specialist (consultant) care is an optional element for practices.

8

In CWS CCG, Diabetes Specialist Nurses (DSN) are commissioned to take part in collaborative clinics in practices. One of their roles is to support practices in the management of insulin dependent patients.

Practices claiming for management of these patients are required to:• Monitor and manage complications appropriately, referring where appropriate to specialist services

according to agreed local guidance• Care for complicated patients, with high clinical need in conjunction with support services• Manage changes in insulin regimes for Type 1 and Type 2 patients• Follow NICE guidance regarding the use of human insulin for Type 2 Diabetic patients. It is expected

that new type 2 patients initiated onto insulin will be offered human insulin as first line• Offer the advice and guidance single number for specialist support as appropriate (when available)

A basic level of care is expected for all patients on insulin from all practices partaking in this LCS, including simple dose adjustment.

All patients on insulin should be provided with details of how to contact their team whether that is DSN, care coordinator, practice diabetes nurse or GP.

16. Preparing patients for planned procedures - pre op assessment (item of service payment)

Practices can claim for a ‘preoperative’ diabetes review for patients referred for major elective surgery (Appendix F)

Patients requiring a planned or elective procedure should be particularly closely monitored to achieve the optimum blood glucose and diabetes stability prior to the procedure. This will reduce the number of cancelled or delayed operations due to poor diabetes control prior to the procedure and improve postoperative outcomes. Therefore practices are asked, at the point of referring diabetic patients for elective surgical procedures, to

a. Offer a diabetes reviewb. Check FBC Elecs HbA1cc. Optimise blood pressure controld. Optimise HbA1c (preferably to below 8)e. Optimise medicationf. Provide clear advice and guidance regarding smoking, alcohol, weight loss and fitness prior to the

procedure

The code “Preoperative counselling” is suggested.

17. Provision of diabetes review appointments outside the hours 08.30 – 6pm weekdays (12 points)

It is recognised that there is an increasing population of people with diabetes who are in full time work and who therefore can sometimes find it more difficult to attend for chronic disease review appointments. In line with the move towards working at scale and improved access, we wish to make diabetes review appointments available to our population out of normal GMS hours. This can be done at practice level or PCN level – the important thing is that the service is available where appropriate to all patients in Coastal West Sussex.

The expectation is that over the course of the year 2020-21 a number of face to face diabetes appointments will be made available outside the hous 08.30 – 6pm weekdays, that is equal to or greater than 3% of the diabetes register (as measured on 31.1.21). The number of such appointments provided should be evidenced at the end of the year. Where practices choose to work together they can combine the end of year data submission as evidence – for example, if a PCN has 4000 diabetic patients and can evidence having provided 120 such

9

appointments, accessible to all patients in the PCN, then all practices in that PCN will have achieved this indicator.

For the purposes of this indicator an appointment will count if it is a face to face review appointment with the appointment time outside of the hours 08.30 – 18.00 Monday to Friday.

18. Referrals to IAPT service (Time to Talk Health) (2 points)

There is good evidence that access to psychological therapies is beneficial in diabetes and we wish to encourage practices to signpost patients to these services where appropriate.Further information on the service can be found at www.sussexcommunity.nhs.uk/services/servicedetails.htm?directoryID=22972

To achieve this indicator, each practice is expected to refer at minimum of 1% of their diabetes patients to this service during the year, or evidence why this has been inappropriate or they have been unable to do so

19. PCN Performance Bonus

To encourage practices to genuinely work at scale and to support each other to provide high standards of care, those PCNs, where all practices in the PCN achieve:

> 95% of available QOF points > 70% of two stage care planning indicator The audit requirements

will be paid a 2% PCN performance bonus. The 2% will be applied to those payments making up the 112 points available (and not to the item of service payments) in this service agreement.

Clinical Governance

For verification purposes, adequate records will need to be maintained at the practice to provide an audit trail for post payment verification purposes. The CCG may routinely check practice held information at any time, without warning, to satisfy the requirements of this service specification.

Accreditation and Qualifications

Each practice must ensure all staff involved in providing any aspect of care under this scheme have received the necessary training and professional development, and have the required competencies and skills to provide the primary care responsibilities.

Pricing

Appendix A sets out the payment schedule for this service

For each of the 12 month periods April 2019 to March 2020 and April 2020 to March 2021 there is a fixed total budget made available to practices within Coastal West Sussex to provide the above service to their patients. The advantage of designing the payment system this way is to reduce risk for the commissioners whilst allowing the full budget to be made available to practices.

The totality of the CCG budget is managed as follows:

10

From the total budget the following allocations are made in this order

1. A fixed fee per patient is available for practices for

a) initiating patients on insulin, andb) overseeing patients on insulin who are not receiving their ongoing care from a consultantc) pre-operative diabetes review

2. A small element of the budget is retained to fund the training sessions, and support staff in primary care who would like to become primary care facilitators or trained Year of Care Trainers. This payment will support practice back fill and payment for staff time to deliver support directly to Practice and/or collaboratively at Locality Network Level.

The remainder of the total budget will be apportioned to practices depending on their relative prevalences and points achieved on the indicators in this specification.

The enhanced service will run from 1.2.20 to 31.1.21. Practices will be asked to submit their achievement for 31.1.21 within 2 weeks of that date.

Throughout the year practices will be paid a monthly aspiration payment which, for the year 1.2.20 - 31.1.21 will be made as follows,

1. February and March 2020: 80% of historical practice payments for 2018-192. April 2019 to January 2020: 80% of historical practice payments for 2019-20

These 12 monthly instalments throughout the year should be viewed in a similar way to the aspiration payment made under QOF.

At the end of the year the practice will receive the balance of the payment depending on their achievement in each section on 31.1.21. This will be calculated on the basis of a points system, similar to QOF. To enable practices to calculate their potential income the approximate value of a point for a typical practice will be approximately £116 for 2020-21

Practices should submit their year-end data by 14.2.21. Please note that the final practice payments can only be accurately calculated when all practices have submitted data.

Please do not delay payment for your colleagues by submitting your data late.

Performance Monitoring and Key Performance Indicators (KPIs)

Practices are expected to meet all the qualifying criteria. If practices do not meet these criteria then payment under this specification is not guaranteed but will become discretionary.

In the event that a practice does not or cannot meet these criteria, a supportive performance meeting may be held with the practice where practice performance and action plans will be discussed. A reasonable portion of the payment may be withheld and eligibility to continue to participate in this service may be considered.

Coastal West Sussex CCG reserves the right to request supporting information as detailed within the specification on an ad-hoc basis.

As detailed in Appendix A it is expected that both the GP Lead and practice nurse will attend at least one training event.

11

The CCG reserves the right to withhold the achievement element of the payment if the training has not been attended.

Please note in particular that practices taking part in this LCS will be expected to have achieved at least 95% of available QOF points for the full year ending March 2020. Any practice that received fewer points will be asked to submit an action plan to improve QOF performance and may be invited to a supportive performance meeting where audit and action plans will be discussed. A reasonable portion of the payment may be withheld and eligibility to continue to participate in this LCS may be considered.

Breach and Termination

Disputes within the practice will be handled by the practice.

In the event of disagreement or dispute, the CCG and the practice will use best endeavours to resolve the dispute without recourse to formal arbitration. If unsuccessful, the matter will be determined in accordance with the normal contractual dispute resolution procedure as detailed in the General Conditions Section of the LCS contract.

Review

Date Review1st Review completed 8th August 2017 Dr Allan2nd review completed 31st October 2018 Dr Allan3rd Review completed 12th December 2019 Dr Allan4th Review completed

12

List of Appendices

A: Payment Schedule

B: Supporting guidance

C: World Health Organisation Diagnostic Criteria

D: Practice report, query sequence and codes

E: Preconception and contraceptive advice

F: Pre-operative ‘enhanced recovery’ guidance

G: Foot care audit guidance

H: Diabetes Complete

13

Appendix A: Payment Schedule Diabetes LCS

There is a total budget of approximately £1.5 million available to practices within Coastal West Sussex providing an enhanced service for diabetes to their patients for the 12 month period ending March 2020. Please note that the achievement element of this payment will rely on the practice having met the qualifying criteria as detailed in the service specification.

Indicator Payment Partial Achievement criteria Reporting methodology & notes (Appendix D)

Pre-DiabetesPoints available / Price

Target thresholds and payment

The number of patients on the Pre-diabetes register2 points

(Relative prevalence of pre-diabetes) * (points) Practice report 31.1.21

The percentage of those eligible patients on the Pre-diabetes registers who have been screened with glucose or HbA1c in the last 15 months.

Patients with frailty (any) will be excluded

10 points 50-80%(Relative prevalence of pre-diabetes) * (points)

Practice report 31.1.21

Percentage of those placed on a Pre-diabetes register between 15 and 3 months previously, who have been provided with appropriate education in the last 15 months

Patients with frailty (any) will be excluded

10 points 50-80%(Relative prevalence of pre-diabetes) * (points)

Practice report 31.1.21

Year of Care / Two stage care planning

The percentage of eligible patients on the diabetes register who have followed a Year of Care type two stage care planning process in the previous 15 monthsExcludes patients with QOF exception report or moderate/severe frailty

60 points

40-70%

(Relative prevalence of eligible diabetics) * (points)Patients excepted from the whole diabetes register will be excluded from the denominator

Practice report 31.1.21

Indicator Payment Partial achievement criteria Reporting methodology & notes

The percentage of eligible housebound (excluding patients living in registered care homes) patients on the diabetes register who have followed a Year of Care type two stage care planning process in the previous 15 monthsExcludes patients with QOF exception report or moderate/severe frailty

6 points 40-70%

(Relative prevalence of eligible and housebound diabetics) * (points)Patients excepted from the whole diabetes register will be excluded from the denominator

Practice report 31.1.21

Pre-conceptual and contraceptive advice

The percentage of diabetic and pre diabetic female patients aged 15-54 who have been offered contraceptive advice and/or pre-conceptual counselling in the last 15 months.

10 points 40-75%

(Relative prevalence of F15-54y diabetics) * (points)

Practice report 31.1.21

Provision of ‘out of hours’ diabetes review appointments

Provision of ‘out of hours’ appointments totalling at least 3% of the diabetes population

12 points Must be fully achieved for payment Practice report 31.1.21

Referrals to IAPT (Time to Talk Health) services

Referral of at least 1% of the practice diabetes population to Time to Talk Health

2 points Must be fully achieved for payment Practice report 31.1.21

15

Indicator Payment Partial achievement criteria Reporting methodology & notes

Insulin Initiation

Patients initiated on to insulin £134.60 per pt n/a Monthly Multi claim form

Insulin therapy management

Number of insulin dependent patients receiving care predominantly in primary care

£45.56 per pt n/aMonthly Multi claim formPatients eligible for payment should be calculated as the number on insulin not receiving regular on going hospital care

Pre-operative diabetes review

Number of diabetes patients receiving a pre-operative diabetes review at the point of referral for an elective procedure (GA)

£30.42 per review

n/a Monthly Multi claim form

Practice PCN Performance bonus

All practices in a PCN have achieved all of the following: QOF requirement 70% care planning The audit requirements

2% bonus on payments relating to the 112 points available

n/a Evidenced from audit submissions and from practice reports 31.1.21

16

Appendix B: Supporting Guidance

This LCS intends to build on the service previously provided by:

“Properly supporting and empowering people with diabetes so that they are truly confident about managing their own condition calling on healthcare professionals when they choose.”

Dr Sue RobertsNational Clinical Director for Diabetes

Pre diabetes

People with undetected diabetes and people at risk of developing diabetes should be identified and receive support to manage their condition within primary care. The following pathway is based on NICE PH38, July 2012.

1. Stage one - Risk assessment

It is recommended that patients in the following categories are risk assessed using NHS Health Check or Diabetes UK risk assessment or similar.

all eligible adults aged 40 and above, except pregnant women people aged 25–39 of South Asian, Chinese, African-Caribbean, black African and other high-

risk black and minority ethnic PCNs, except pregnant women adults with conditions that increase the risk of type 2 diabetes (particular conditions can

increase the risk of type 2 diabetes these include: cardiovascular disease, hypertension, obesity, stroke, polycystic ovary syndrome, a history of gestational diabetes and mental health problems)

2. Stage 2 – matching interventions to risk

Patients at low or intermediate risk should be offered brief advice on the risks of developing diabetes, the benefits of a healthy lifestyle and modifying risk factors. NICE recommend that these patients are risk assessed every five years.

Patients at high risk and patients aged 25 and over of south Asian or Chinese descent whose body mass index (BMI) is greater than 23kg/m2 should be offered a blood test either FPG or HbA1c.

a) Moderate riskFPG ˂ 5.5 mmol/l orHbA1c ˂ 42 mmol/mol (6.0%)Action: Offer brief intervention and screen every 3 years. Please note that this is not a requirement of this service specification but is a recommendation to practices in order to identify patients with pre-diabetes and diabetes.

b) High RiskFPG 5.5 – 6.9 mmol/l orHbA1c 42 - 47 mmol/mol (6.0-6.4%)Action: add to pre-diabetes register, provide education and screen annually

The initial education appointment should include: the need for ongoing screening lifestyle education explanation of the potential to avoid developing Diabetes consideration of onwards referral to services such as Health Trainers, Health Advisors,

Walk Away from Diabetes, Why Weight, Well-being Hubs an assessment of the individuals readiness to achieve lifestyle change assessment of vascular risk offering statin therapy and hypertension treatment

according to NICE guidance where appropriate

The Annual Review should include: A review of changes made, assessment of CVD risk, weight, BP, exercise, cholesterol,

smoking, kidney function. Referral to lifestyle change advice as appropriate.

c) Possible Type 2 diabetesFPG ≥ 7.0 mmol/l orHbA1c ≥ 48 mmol/mol (6.5%)Action: Confirm diagnosis and follow DM2 pathway or if negative diagnosis return to Pre-diabetes register

Maintaining a Pre-Diabetes Register

The ‘pre-diabetes’ register, for the purposes of this service, will include patients with the following:

FPG 5.5 – 6.9 mmol/l or HbA1c 42 - 47 mmol/mol (6.0-6.4%) or History of gestational diabetes

CWS will support practices by reporting practice prevalence (expected and actual).

18

Flowchart: identifying and managing risk of type 2 diabetes, NICE PH 38, July 2012

19

Early Diagnosis and Tight Control

The UKPDS follow up study 2008, found that early improvement in glycemic control in type 2 diabetes patients was associated with a continued reduction in micro- and macro-vascular events even after the early improvement in glycemic control was lost. It reported that it matters both how well a patient is treated now and how well the patient was treated in the past. The prolonged benefits of good glucose control are referred to as a legacy effect of therapy.

https://www.dtu.ox.ac.uk/generic/publications.php?Section=3&Year=2008 (accessed 16.07.14)

After event analysis

Practices should aim to learn and improve processes following feedback from emergency hospital admissions where diabetes was the primary cause of the admission.

Practices are encouraged to retrospectively analyse significant events or unexpected hospital admissions (where diabetes was a primary factor) to understand what actions/processes could have prevented the event.

Practices are invited to take part in the SECAMB hypo pathway to benefit from the feedback from SECAMB to practice on patients that were stabilised and not conveyed to hospital following a call out for suspected hypo. Practices can expect to be directly notified by SECAMB on patient specific cases, and be involved in the CCG and practice specific dashboard data. Read codes have been provided to practices for all clinical systems.

Blood Glucose Meters

The use of Blood Glucose meters should be as per local guidelines and as set out in the agreed formulary. BG meters should only be routinely offered for patients on agents causing hypoglycaemia e.g. insulin, sulphonylurea, repaglinide and nateglinide.

Patient education

Patients with Type 2 diabetes and/or their carers should be referred to receive structured education that meets nationally agreed criteria from the time of diagnosis e.g. Desmond. Practices should inform the education coordinator of the referral with contact details for the patient, and receive read code evidence from the education coordinator on completion of the structured education course to audit attendance and ensure patient concordance.

Patients with Type 1 diabetes should be offered an appointment at the collaborative clinic with the dietician and if suitable referred to education courses that meet nationally agreed criteria such as “Image“ and “Sailing”. Practices should inform the education coordinator of the referral with contact details for the patient.

20

Patients who have been initiated onto insulin will be referred via the referral management system into IMAGE, carb counting and other education sessions as appropriate.

Where individuals are unsuitable or/unwilling to undergo PCN education, or DESMOND is not available, practice based support should be given, providing the clinician is trained to give this training. Practices should collect data of numbers referred to, & uptake of courses.

Practices are encouraged to collaborate with Diabetes Nurse Specialists to deliver patient education that is appropriate to the patient through face to face, PCN sessions and virtually via a selection of sources.

Partnership working – Integrated Diabetes Service for Coastal West Sussex Patients

It is important for people with diabetes, who need specialist input, to receive timely advice to keep them well and to recognise triggers when patients become unwell. This includes how to make effective use of healthcare resources.

Practices will use the referral management system to improve placing appropriate complex patients in the right place at the right time to receive timely care and support. Both practice and patients will use the single advice and guidance number to receive specialist help.

In addition to the joint multi-disciplinary meetings with DSN and Dietitician, from 2017 Practices will also be able to invite Psychological Therapists directly through the DSN route into the joint meetings to support patients requiring the psychological pathway delivered by Time to Talk. For patients requiring the mental health pathway delivered by SPFT, this transfer will be made on behalf of the practice seamlessly by the Time to Talk psychological therapy team.

For patients requiring podiatry input for diabetic complications of the feet and legs, practice can directly access the podiatry pathway. This pathway will include expert triage by a podiatrist or DSN to ensure timely transfer of patient care from the practice to the appropriate specialist.

From 2018 as part of the new way of working through the Integrated Diabetes Service for Coastal patients, a Virtual Clinical Case Discussion (VCCD) forum will be available to practice. A consultant and other relevant specialist MDT members will be available at Network level to discuss the most complex practice patients requiring specialist input. The result of the VCCD will result in a range of options that will be discussed by the DSN as appropriate at the following Joint MDT patient clinic at practice.

Practices will be asked to share examples of how seeking advice, referring onwards, joint clinics and shared care protocols are working and/or making a difference to patients at future education events. This will contribute to discussions regarding pathways and inform future commissioning decisions.

21

Care planning and reviews

The NICE diabetes in adults Quality Standard QS6 Statement 3 states that people with diabetes participate in annual care planning which leads to agreed goals and an action plan. Care planning was also identified as one of the key interventions required to achieve standard 3 of the NSF: empowering people with diabetes.

Practices must ensure that people with diabetes are offered a two stage Year of Care style annual care planning consultation. First of all; a data collection consultation, followed by the delivery of their test results in a meaningful way to the patient. This has allowed time for the patient to reflect on their condition and to generate ideas about what would be important for them to cover in the second visit (goal setting and action planning).

The second visit then takes place a couple of weeks later and takes the form of a collaborative Care Planning’ consultation to support self-management as well as to screen for complications and initiate medical treatment. The personal goals and action plans agreed in the Care Planning consultation are then worked on until the next Care Planning visit.i

Care planning is a process which offers people active involvement in deciding, agreeing and owning how their diabetes will be managed. It aims to help people with diabetes achieve optimum health through partnership approaches with healthcare professionals in order to learn about the condition, manage it and related conditions better, and cope with it in their daily lives.

People with diabetes need to be enabled to take part in the care planning process. It is important that the process is flexible and adaptable to individual needs in order to meet the needs of the individual.

During a care planning consultation, the person with diabetes and the healthcare professional raise and discuss their respective concerns, priorities, explore options available and make mutually agreed informed decisions about on-going care. This approach recognises that people with diabetes may engage with the process in different ways and choose a different degree of control over their care from another individual.

For patients that have their diabetes condition stable and under control, the second part of the care planning consultation can take the form of telephone, or other appropriate consultation portal appropriate to both the patient and clinician.

Practices are encouraged to include multi-morbidity conditions of the patient as appropriate such as Heart Failure and COPD etc. into the care plan

The principles of the Care Planning process are set out below:

22

Source: Getting to Grips with the Year of Care: A Practical Guide, October 2008

The care planning consultation will be a joint decision making goal setting discussion which may include psychological and social concerns as well as the biomedical aspects of care.

Good glycaemic control is associated with lower complication rates in diabetes. Therefore it should be a focus for discussion in reviews. Personalised targets should be set alongside agreed specific goals designed to achieve the targets. See http://www.coastalwestsussexccg.nhs.uk/diabetes for the Glycaemic Control Guidelines. Care planning will occur at least annually, but the actions resulting from it may need to be reflected on and revised at shorter intervals. Patients will be actively involved in decisions about what health outcomes their care plan is designed to achieve.

An example is embedded below. Further details on Year of Care Partnership can be found at: http://www.yearofcare.co.uk/

23

Personalised advice on nutrition and physical activity

People with diabetes should receive personalised advice on nutrition and physical activity from an appropriately trained healthcare professional or as part of a structured education programme within the integrated diabetes service model.

Practices should ensure that people with diabetes are able to benefit from ongoing support as they come to terms with changing their lifestyle and as their needs continue to change over time.

Roles of other health services

It is acknowledged and understood that it may be clinically appropriate for patients usually managed under this LCS to be reviewed and care for in specialist care settings.

Community teams (e.g. Diabetes Specialist Nurses) and secondary care services within the integrated diabetes service pathway will be available for/to the following:

Patients under 18 going through transition Maternity patients Insulin pump therapy Ad hoc telephone advice DESMOND education PCN education sessions Support practices via joint clinics Complex foot care via podiatry service Complex dietary support via dietetics service

Bibliography

National Standards Framework for DiabetesNICE Clinical Guideline 87NICE Clinical Guideline 15DiabetesEQuality & Outcomes Framework 2011/12Year of Care www.yearofcare.co.ukNICE Quality Standards for Diabetes in Adults (March 2011)‘Impaired glucose tolerance: qualitative and quantitative study of general practitioners’ knowledge and perceptions’ Graeme Wylie, A Pali, S Hungin, Joanne Neely. BMJ 2022; 324: 1190 doi: 10.1136/bmj. 324.7347.1190 (Published 18 May 2002Care planning, Improving the Lives of People with Long Term Conditions, RCGP 2011UKPDS https://www.dtu.ox.ac.uk/generic/publications.php?Section=3&Year=2008 (accessed 16.07.14)

24

Appendix C: WHO Diagnostic Criteria

Use of haemoglobin (HbA1c) in the diagnosis of diabetes mellitus, WHO 2011

http://www.who.int/diabetes/publications/diagnosis_diabetes2011/en/index.html

Definition and diagnosis of diabetes mellitus and intermediate hyperglycaemia, WHO 2006

http://www.who.int/diabetes/publications/diagnosis_diabetes2006/en/

25

Appendix D: Practice report query sequence and codes

QUALIFICATION REQUIREMENTS – please complete details below

Practice:

Lead GP:

Lead Nurse:

QOF points achieved 2019

NDA audit and action plan required? YES / NO

Date NDA audit and action plan submitted

Date of submission of foot care audit

PRACTICE PERFORMANCE

Indicator 31.7.20 31.1.21

1 Practice list size

2 Number of patients on pre diabetes register

3 Number of patients on pre diabetes register excluding mild moderate or severe frailty

4Number of eligible patients on the pre-diabetes register who have been screened for diabetes with blood glucose or HbA1c in the last 15 months

5 Number of newly diagnosed patients with pre-diabetes diagnosed in the previous 3-15 months

6Number of newly diagnosed patients with pre-diabetes diagnosed in the previous 3-15 months excluding those with mild moderate or severe frailty or who have been declined from pre diabetes education

7Number of eligible newly diagnosed patients with pre-diabetes, diagnosed in the previous 3-15 months, who have been referred for or provided with pre-diabetes education

8Number of eligible newly diagnosed patients with pre-diabetes diagnosed in the previous 3-15 months who have been referred to the NDPP

9 Number of patients with diabetes

10 Number of patients with diabetes who have moderate or severe frailty

11Number of patients with diabetes, exclusing those with moderate or severe frailty, who have been exception reported in the last 15 month from the whole diabetes domain (9h… codes)

12

Number of patients on the diabetes QOF register (excluding those with moderate or severe frailty or exception reported from the whole disease area) who have had a ‘Year of Care / two stage planning process annual review’ in the last 15 months

13 Number of patients with diabetes who are recorded as housebound

14

Number of patients with diabetes who are housebound (excluding patients with moderate or severe frailty) who have been exception reported in the last 15 months from the whole diabetes domain (9h… codes)

15

Number of patients with diabetes who are housebound (excluding those patients with moderate or severe frailty and excluding those exception reported from the diabetes domain), who have had a ‘Year of Care / two stage planning process annual review’ in the last 15 months

16 Numbers of women on the diabetes and/or pre diabetes register who are between ages of 15 to 54 inclusive

17Numbers of women on diabetes and pre diabetes register who are between age 15 to 54 inclusive who have had (appropriate) contraceptive or preconception advice in the last 15 months

18

Number of ‘out of hours’ face to face diabetes review appointments provided over the last 12 months(if this service has been provided at PCN level, please provide PCN performance data a) diabetic population at 31.1.19 b) total appointments provided in the PCN)

19 Number of pre-operative diabetes review appointment provided in the last 12 months

20 Number of diabetic patients referred to IAPT (Time to Talk Health) services in the last 12 months

27

I certify that these figures are an accurate reflection of practice performance

Responsible Partner

Name:

Signature:

28

Diabetes searches 6 monthly query sequence

Search 1: Insert practice list size as at last month end

Search 2: Number of patients on pre diabetes registerStep 1: search for currently registered patients with

a. Impaired glucose toleranceb. Impaired fasting glycaemiac. Gestational diabetes mellitusd. Pre-diabetes

Step 2: exclude patients on your diabetes registerStep 3: report number

Search 3: Number of patients on pre diabetes register exclusing mild moderate and severe frailty

Step 1: use pre diabetes register as parent populationStep 2: exclude patients with mild moderate or severe frailtyStep 3: report total number

Search 4: Number of eligible patients on pre diabetes register screened in the last 15 months

Step 1: use search 3 as parent populationStep 2: search for any instance of the following occurring in the previous 15 months

a. Blood glucose level (any)b. HbA1c level (DCCT aligned)c. HbA1c level (IFCC standardised)

Step 4: report total number

Search 5: Number of newly diagnosed patients with pre diabetes diagnosed in the previous 3-15 months

Step 1: search for currently registered patients with a new diagnosis between 3 and 15 months ago of:

a. Impaired glucose toleranceb. Impaired fasting glycaemiac. Gestational diabetes mellitusd. Pre-diabetes

Step 2: exclude patients on your diabetes registerStep 3: exclude patients with a ‘prediabetes’ diagnosis more than 15 months agoStep 4: report number

Search 6: Number of newly diagnosed patients with pre diabetes diagnosed in the previous 15 months excluding those with mild moderate or severe frailty or those who have been declined from prediabetes education

29

Step 1: use result of search 5 as parent populationStep 2: exclude mild moderate or severe frailtyStep 3: exclude those with your chosen ‘declined’ code occurring in the last 15 monthsStep 4: report number

Search 7: Number of eligible newly diagnosed patients with pre diabetes diagnosed in the previous 15 months who have attended for a pre diabetes education appointment

Step 1: use result of search 6 as parent populationStep 2: search for “Review of impaired glucose tolerance” (or alternative codes used by the practice) occurring in the last 15 monthsStep 3: report number

Search 8: Number of eligible newly diagnosed patients with pre diabetes diagnosed in the previous 15 months who have been referred to the NDPP

Step 1: use result of search 6 as parent populationStep 2: search for “Referred to NHS Diabetes Prevention Programme” occurring in the last 15 monthsStep 3: report number

Search 9: Number of patients with diabetes

Step 1: search for diabetesStep 2: report number

Search 10: Number of patients with diabetes who have moderate or severe frailty

Step 1: result of 9Step 2: search for moderate or severe frailtyStep 3: report number

Search 11: Number of patients with diabetes, excluding those with moderate or severe frailty, who have been exception reported in the last 15 month from the whole diabetes domain

Step 1: Search for diabetesStep 2: Exclude moderate or severe frailtyStep 3: Search for ‘exception reported from diabetes’ codes (9h4..) in the last 15 monthsStep 4: report number

30

Search 12: Number of patients with diabetes excluding moderate /severe frailty and those exception reported in the last 15 months who have had a ‘Year of Care annual review’ in the last 15 months

Step 1: search for diabetesStep 2: exclude patients exception reported from diabetes domain in the last 15 monthsStep 3: exclude moderate and severe frailtyStep 4: search for ‘Diabetes Year of Care annual review’ in the last 15 monthsStep 5: report number

Search 13: Number of patients with diabetes who are housebound

Step 1: search for diabetesStep 2: search for ‘housebound’Step 3: report number

Search 14: Number of patients with diabetes who are housebound (excluding those patients with moderate or severe frailty) who have been exception reported in the last 15 month from the whole diabetes domain (9h… codes)

Step 1: use results of search 13 as parent populationStep 2: exclude moderate and severe frailtyStep 3: search for ‘exception reported from diabetes…’ (9h4..) in the last 15 monthsStep 4: report number

Search 15: Number of eligible patients with diabetes who are housebound (excluding moderate / severe frailty and excluding those exception reported from the diabetes domain), who have had a ‘Year of Care / two stage planning process annual review’ in the last 15 months

Step 1: use results from search 13 as parent populationStep 2: exclude moderate and severe frailty and ‘exception reported from diabetes…’ (9h4..) in the last 15 monthsStep 3: search for ‘Diabetes Year of Care annual review’ in the last 15 monthsStep 4: report number

Search 16: Number of eligible females on the diabetes and pre diabetes registers

Step 1: search for all patients with diabetes OR pre diabetes Step 2: include only females age 15-54 inclusiveStep 3: report number

31

Search 17: Numbers of eligible women on the diabetes and pre diabetes registers who have had contraceptive and/or pre- conceptual advice in the last 15 months

Step 1: use search 16 as parent population Step 2: search for any instance of contraceptive advice in the last 15 months or any instance of pre conceptual counselling in the last 15 monthsStep 3: report number

18 – reported separately (number of ‘out of hours’ appointments)

Search 19: Number of pre-operative diabetes review appointments in the last 12 months

Step 1: search for diabetesStep 2: search for preoperative counsellingStep 3: report number

Search 20: Number of diabetic patients referred to IAPT (Time to Talk Health) services in the last 12 months

Step 1: search for diabetesStep 2: search for ‘Referral to improving access to psychological therapies prog’ (8HkK)

32

Read code term Read code SystmOne Code

Impaired glucose tolerance C11y2 X40JhImpaired fasting glycaemia C11y3 XalRY[D] Impaired glucose tolerance test R102[D] Impaired fasting glycaemia R10D0 XalRK[D] Impaired glucose tolerance R10E XalnlGestational diabetes mellitus L1808 & L1809

Review of Impaired glucose tolerance 6ACImpaired fasting glycaemia annual review EMISNQIM4Impaired glucose tolerance annual review EMISNQIM3

Plasma fasting glucose 44g1Serum fasting glucose 44f1Plasma glucose 44g XMOiySerum glucose 44fBlood glucose level 44TJ X772zFasting blood glucose 44TK XE2mqPlasma glucose 44TA XMOIy120 minute serum glucose level 44f6 XaEOZ120 minute plasma glucose level 44g6 XaEOV2 hour post prandial blood glucose level 44U7HbA1c (DCCT aligned) 42W4 XaERpHbA1c (IFCC standardised) 42W5 XaWP9

Attended diabetes structured education programme 9OLB XaKHOAttended DESMOND structured programme 9OLEDESMOND diabetes structured education programme completed 9OLK XaN1zException reporting: Diabetes quality indicators 9h4.. XaJ4QDiabetes care plan agreed 8CS0 XaKSnDiabetes Year of Care annual review 66AS0General contraceptive advice 611Advice about long acting reversible contraception 8Caw XaPnnContraceptive counselling 6777Pre conception advice 67IJ XaIwmTarget cholesterol 662X XaIQbTarget weight 66CF Ua16mTarget HbA1c 66Ae0 XaJPTTarget physical activity

MinimalLight

Moderate Strenuous

13CI XaIUT13CQ XaJPL13CR XaJPO13CS XaJPP13CT XaJPN

Preoperative counselling 677VReferral to improving access to psychological therapies prog 8HkK

i

Appendix E: Preconception and contraceptive advice

Appendix F: Pre-operative ‘enhanced recovery’ guidance

As part of the enhanced recovery program, to ensure patients have the best chance of a good outcome and swift recovery from planned procedures, the surgery department has long asked that GPs consider the above factors.

In the case of uncontrolled hypertension and Diabetes, it is likely a patient wo has been referred will have their surgery cancelled or delayed unless steps have been taken to optimise the management of these conditions.

As part of the LCS for diabetes we are asking that GPs, when they are referring a patient with diabetes for an elective procedure, try to optimise their diabetic and blood pressure control. If HbA1c is above 8 and best care in practice has been unable to get the control better than this, early input from the DSN should be sought to reduce delays the patient may experience to their surgery.

Appendix G: Audit of foot care

Audit standards

1. Feet at high risk (‘severe’) should have been referred to podiatry services or have a recorded exceptionStandard 100%

2. Ulceration should have been referred urgently to the diabetic foot clinic or have a recorded exceptionStandard 100%

Practices should report using the following table. Results should be discussed in teams and together with other practices at a practice group education session

The data collection, evidence of discussions and any action plans should be submitted to the CCG by 30th September 2020

Audit of foot care

Practice

Diabetes Lead

Number of staff performing foot checks in the practice

Confirmation that all staff performing foot checks have up to date appropriate training

YES / NO

Number of SEA’s or incidents related to diabetes foot care reported in the practice n the last 12 monthsDate of data collection

Number of patients with diabetes

Number having had foot check in last 12 months

Assessed as low risk

Assessed as medium risk

Assessed as severe risk

Number at severe risk referred to podiatry or under care of podiatry in the last 12 months (or with recorded exception)Number with active ulceration

With ulceration referred to or under the care of the diabetes foot clinic

With ulceration referred to or under vascular / appropriate specialist clinic

With ulceration recorded as not appropriate for referral

With ulceration not referred nor recorded that referral inappropriate

Date of discussion in practice

Date of discussion at practice group

Action plan produced? (please append) Y / N

Name and signature of diabetes lead: Date