commissioning diabetes foot care services · 2017-09-18 · 5 commissioning for diabetes foot care...
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CommissioningDiabetes Foot Care
Services
Supporting, Improving, Caring
June 2011
NHS Diabetes information Reader Box
Review Date 2013
Commissioning Diabetes Foot Care Services
NHS Diabetes would like to thank the following for their advice and contribution to the development ofthis commissioning guide:
William Jeffcoate Consultant Diabetologist, Nottingham University Hospitals NHS Trust
Stella Vig Consultant Vascular Surgeon, Croydon Health Services NHS Trust
And to Thoreya Swage who wrote this publication.
3
Contents
Page
Commissioning for Diabetes Foot Care Services 5
Features of Diabetes Foot Care Services 6
Diabetes Foot Care Services Intervention Map 8
Contracting Framework for Diabetes Foot Care Services 10
Standard Service Specification Template for 21Diabetes Foot Care Services
5
Commissioning for Diabetes FootCare ServicesThe 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 localHealth Needs Assessment and setting up a steeringgroup with key stakeholder involvement includinga lead clinician, lead commissioner, lead diabetesnurse and lead 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 with key stakeholders includingclinical and social services professionals and patientgroups represented by Diabetes UK.
It is not designed to replace the Standard NHSContracts as many of the legal and contractualrequirements have already been identified in thisset of documents. Rather, it is intended to form thebasis of a discussion or development of diabetesfoot care services between commissioners andproviders from which a contract for services canthen be agreed.
This commissioning guide consists of:
• A description of the key features of gooddiabetes foot care
• A high level intervention map. This interventionmap describes the key high level actions orinterventions (both clinical and administrative)diabetes foot care services should undertake inorder to provide the most efficient and effectivecare, from admission to discharge (or death)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 foot care services.
• A diabetes foot care contracting framework thatbrings together all the key standards of qualityand policy relating to diabetes and foot care
• A template service specification for diabetes footcare services that forms part of schedule 2 of theStandard NHS Contract covering the keyheadings required of a specification. It isrecommended that the commissioner checkswhich mandatory headings are required for eachtype of care as specified by the Standard NHSContracts.
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
A high quality foot care service for people withdiabetes should:
• be designed to prevent or delay the footcomplications of diabetes, including peripheralneuropathy, peripheral arterial disease, gangrene,and limb loss from amputation
• provide opportunities for all healthcareprofessionals who are involved in the managementof diabetes to acquire the skills and knowledgenecessary to recognise and manage people atincreased risk of developing new foot disease
• provide facilities for the expert assessment andtreatment of any newly occurring, or deterioratingcase of foot disease within one working day
• be designed to reduce recurrence in those whohave had an episode of active foot disease
In addition, the service should:
• be developed in a co-ordinated way, taking fullaccount of the responsibilities of other agencies inproviding comprehensive care ensuring people areat the centre of decisions about their care andsupport - ‘no decision about me without me’i.
• be commissioned jointly by health and social carebased on a joint health needs assessment whichmeets the specific needs of the local population,using a holistic approach as described by thegeneric model for the management of long termconditionsii
• 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 determined bythe NHS Outcomes Frameworkiv
• take into account the emotional, psychological andmental wellbeing of the patient
• take into account all diverse and personal needswith respect to access to care
• ensure that the family/carers of people withdiabetes have access to psychological support
• ensure that services are responsive and accessibleto people with Learning Disabilitiesv
• have effective clinical networks with clear clinicalleadership across the boundaries of care
• ensure that when it is appropriate, differentoptions are available which accommodate theindividual preferences of people with diabetes
• take into account services provided by social careand the voluntary sector
• provide patient/carer/family education on diabetesand foot care not only at diagnosis but also duringcontinuing management at every stage of care
• have a workforce that has the mandatorycompetencies in the assessment and managementof the foot in diabetes
• produce information on the outcomes of diabetescare including contributing to national datacollections and audits
• have adequate governance arrangements, e.g.local mortality and morbidity meetings on diabetescare to learn from errors and improve patientsafety
Features of a Good Service for FootCare in Diabetes
i http://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 http://www.diabetes.nhs.uk/ commissioning_resource/
7
• take account of patient experience, includingPatient Reported Outcomes Measures in thedevelopment and monitoring of service deliveryvi
• actively monitor the uptake of services, respondingto non-attenders and monitoring complaints anduntoward incidents
• have integrated information systems that recordindividual needs including emotional, social,educational, economic and biomedical informationwhich permit multidisciplinary care across serviceboundaries and support care planningvii
vi http://www.ic.nhs.uk/proms
vii See York and Humber integrated IT system at http://www.diabetes.nhs.uk/year_of_care/it/
8
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Diabetes Foot Care ServicesIntervention Map
9
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8
10
IntroductionThis contracting framework sets out what isrequired of clinically safe and effective servicesproviding diabetes foot care services. The framework is designed to be read inconjunction with the foot care diabetes servicesintervention map which describes the interventionsand actions required along the patient pathway aswell as entry and exit points, and the standardservice specification template for foot carediabetes services.
The framework brings together the key qualityareas and standards that have been identified byNHS Diabetes, Diabetes UK, the Royal Colleges andother 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 or Care Plan and thedelivery of the clinical processes conventionally sitswithin one organisation. However with a morecomplex pathway there is a danger that care canbe fragmented when it is subdivided intocomponents which are carried out by differentclinical teams and organisations, and care isrequired to avoid duplication of effort and toensure efficient communication at handoverpoints. Clear lines of communication are requiredand defined criteria for referral between differentorganisations are essential, with robustarrangements for governance in place for eachbody.
Contracting Framework for Foot CareServices for People with Diabetes
11
Foot care services for people withdiabetesThe key principle of good foot care for people withdiabetes is to provide a high quality service whichencompasses both prevention and treatment, andwhich is both efficient and accessible.
Foot care services for people with diabetes shouldbe provided by healthcare professionals who havethe necessary knowledge and skills in theprevention and management of foot disease inpatients with diabetes, as well as the resources andclose contacts with other health care providerswhich may be necessary for optimal care. It isessential that there is risk assessment of all peoplewith diabetes in the community, as well as in thoseadmitted to hospital for whatever reason.Prevention schemes must be available for high riskpatients and fast tracking of patients with acutedisease to early expert assessment.
Foot care for people with diabetes should be inplace at two levels:
• (Diabetic Foot Protection Team (DfPT))– Thisinvolves the assessment and risk categorisationof the feet as part of the generalmultidisciplinary diabetes physical and mentalassessment. It also includes education of thepatient and carers on how to look after theirfeet and urgent referral for specialist assessment(Multidisciplinary foot care team) if active footdisease is found.
• (Multidisciplinary foot care team – MDfT(Specialist services) ) This involves themanagement and treatment of patients at highrisk or with active foot disease. This team shouldbased at secondary care level because of theneed for close liaison with other specialists andaccess to expert resources, but should work withprofessionals based in the community in order toserve the best interests of the patient.
The diabetes foot care services should identifydesignated clinical leads with responsibility andaccountability for the service with leadership andpartnership of the Diabetic Foot Protection Teamand the Multidisciplinary foot care team.
The initial management and continuing care ofindividuals with diabetes should include anassessment of their emotional and psychologicalwell-being, together with timely access to
appropriate psychological and biological/psychiatricinterventions. Mental health disorders can posesignificant barriers to diabetes care and thereforemental health stability is vital for good self care1.
This Contracting Framework should also be read inconjunction with the diabetes commissioningguides for children and young people, diagnosisand continuing care, older people, emergency andinpatient care, complications of diabetes especiallycardiovascular and kidney care and follow theprinciples for effective commissioning of servicesfor people with Learning Disabilities2.
Ensuring qualityCommissioning Bodies should ensure that the footcare services for people with diabetes aim for thehighest quality, and that there are systems ofgovernance in place to ensure achievement of setstandards. There may, in addition, be someorganisations that wish to offer their services, butdo not have a history of providing such care.
i) For provider organisations already involved inthe delivery of foot care services for people withdiabetes, there should be retrospective evidenceof the necessary systems being in place that areimplemented and working.
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 foot care servicesfor people with diabetes, and the cliniciansinvolved must have the necessary skills, contactsand resources.
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 forCommunity Services – bilateral (main clauses andschedules)3.This is to assist commissioners andproviders in having an overview of how the elementslink to the Standard NHS Contract. Some of theareas are open to interpretation and consequentlythe references are not exhaustive.
12
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
Lead
ersh
ip
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
C:
11,1
6,19
,33,
48,4
9,51
,53,
60
Mod
ule
D: S
ched
ules
:6
,15
Cla
rity
of t
he o
rgan
isat
ion’
spu
rpos
e w
ith e
xplic
itco
mm
itmen
t to
pro
vidi
ng h
igh
qual
ity s
ervi
ces
A c
ultu
re t
hat
dem
onst
rate
s an
open
lear
ning
eth
os
An
orga
nisa
tion
that
is le
gal a
ndet
hica
l in
all i
ts a
ctiv
ities
Prov
ider
mus
t ha
ve o
rgan
isat
iona
l str
uctu
reth
at p
rovi
des
lead
ersh
ip f
or a
ll pr
ofes
sion
san
d di
scip
lines
In p
artic
ular
, the
re m
ust
be a
cor
pora
tecl
inic
al d
irect
or/le
ad w
ith t
he r
espo
nsib
ility
and
acco
unta
bilit
y fo
r th
e cl
inic
al s
ervi
ce.
Ther
e m
ust
be a
lear
ning
fra
mew
ork
in t
heor
gani
satio
n
Ther
e sh
ould
be
a de
sign
ated
clin
ical
dire
ctor
with
resp
onsi
bilit
y an
d ac
coun
tabi
lity
for
the
foot
car
e se
rvic
e
Gov
erna
nce
Inte
grat
ed G
over
nanc
e
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
C:
11,1
9,27
,48,
49,
51,5
3,54
,56,
60
Mod
ule
D:
Sche
dule
s:
6,12
,15
An
orga
nisa
tion
that
is g
uide
d by
the
prin
cipl
es o
f goo
d go
vern
ance
:
- cla
rity
of p
urpo
se- p
artic
ipat
ion
and
enga
gem
ent
- rul
e of
law
- tra
nspa
renc
y- r
espo
nsiv
enes
s- e
quity
and
incl
usiv
enes
s- e
ffec
tiven
ess
and
effic
ienc
y- a
ccou
ntab
ility
An
orga
nisa
tion
that
acc
epts
resp
onsib
ility
and
acc
ount
abili
tyfo
r all
its a
ctio
ns
Cle
ar o
rgan
isat
iona
l and
int
egra
ted
gove
rnan
ce s
yste
ms
and
stru
ctur
es in
pla
cew
ith c
lear
line
s of
acc
ount
abili
ty a
ndre
spon
sibi
litie
s fo
r al
l fun
ctio
ns
This
incl
udes
inte
rfac
es b
etw
een
serv
ices
Qua
lity
Gov
erna
nce
in t
he N
HS.
A g
uide
for
pro
vide
r bo
ards
4
Gov
erna
nce
Clin
ical
Gov
erna
nce
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
B:Se
ctio
ns:
1 (p
art 2
), 3,
4
Mod
ule
C:
4,4A
,6,9
,10,
12,1
4,15
,16,
17,1
9,21
,26
27,2
9,31
,32,
33,
48,4
9,51
,53,
54
Expl
icit
com
mitm
ent t
o qu
ality
and
patie
nt s
afet
y
Patie
nt fo
cuse
d w
ith re
spec
t for
the
pers
onal
wish
es o
f pat
ient
s in
all a
spec
ts o
f the
ir ca
re
A c
omm
itmen
t to
inno
vatio
n an
dco
ntin
uous
impr
ovem
ent
Clin
ical
Gov
erna
nce
syst
ems
and
polic
ies
shou
ld b
e in
pla
ce a
nd in
tegr
ated
into
orga
nisa
tiona
l gov
erna
nce
with
cle
ar li
nes
ofac
coun
tabi
lity
and
resp
onsib
ility
for a
ll cl
inic
algo
vern
ance
func
tions
e.g.
•
Clin
ical
Aud
it•
Clin
ical
Risk
Man
agem
ent
•U
ntow
ard
Inci
dent
Rep
ortin
g•
Infe
ctio
n C
ontr
ol•
Med
icin
es M
anag
emen
t•
Info
rmed
Con
sent
•Ra
ising
Con
cern
s•
Staf
f Dev
elop
men
t•
Com
plai
nts
Man
agem
ent
All
sub-
cont
ract
ors
mus
t m
eet
gove
rnan
ce a
nd le
ader
ship
arra
ngem
ents
of
the
mai
n pr
ovid
er o
rgan
isat
ion
Com
mis
sion
er, p
rovi
der
and
NH
S Li
tigat
ion
Aut
horit
y m
ust
revi
ew t
he C
linic
al N
eglig
ence
Sch
eme
for
Trus
tsar
rang
emen
ts /o
r ot
her
orga
nisa
tiona
l / p
rofe
ssio
nal i
ndem
nity
arra
ngem
ents
The
serv
ice
shou
ld h
ave
in p
lace
writ
ten
prot
ocol
s an
dpr
oced
ures
def
inin
g cl
ear
lines
of
acco
unta
bilit
y an
dre
spon
sibi
lity.
The
serv
ice
is r
equi
red
to c
ompl
y w
ith g
uide
lines
pro
duce
d by
the
Nat
iona
l Ins
titut
e fo
r H
ealth
and
Clin
ical
Exc
elle
nce
that
are
rele
vant
to
the
care
pro
vide
d by
the
ser
vice
inc
ludi
ng 5 :
13
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
Mod
ule
D:
Sche
dule
s:
3,6,
10,1
1,15
,17
•Pa
tient
and
Pub
lic In
volv
emen
t•
Patie
nt d
igni
ty a
nd re
spec
t •
Equa
lity
and
dive
rsity
•In
trod
ucin
g ne
w te
chno
logi
es a
ndtr
eatm
ents
•an
ext
erna
lly a
ccre
dite
d Q
ualit
y A
ssur
ance
syst
em 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 a
ndde
mon
stra
ble
links
to o
ther
NH
S sy
stem
s w
ithco
llabo
rativ
e C
G a
ctiv
ities
and
sha
ring
ofex
perie
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 N
HS
CG
repo
rtin
g sy
stem
Prov
ider
s ar
e re
quire
d to
agr
ee C
omm
issio
ning
for Q
ualit
y an
d In
nova
tion
sche
mes
for f
oot
care
ser
vice
s fo
r peo
ple
with
dia
bete
s, e
.g.
mod
el C
QU
IN s
chem
e pr
opos
ed b
y th
e N
HS
Inst
itute
for I
nnov
atio
n an
d Im
prov
emen
t 7
•D
iagn
osis
and
man
agem
ent
of T
ype
1 di
abet
es in
chi
ldre
n,yo
ung
peop
le a
nd a
dults
•
Type
2 d
iabe
tes:
the
man
agem
ent
of t
ype
2 di
abet
es(u
pdat
e)
•M
anag
emen
t of
Typ
e 2
dia
bete
s –
prev
entio
n an
dm
anag
emen
t of
foo
t pr
oble
ms
•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 di
abet
es
•M
edic
ines
adh
eren
ce: i
nvol
ving
pat
ient
s in
dec
isio
ns a
bout
pres
crib
ed m
edic
ines
and
sup
port
ing
adhe
renc
e 6
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 Com
mun
ity S
ervi
ces
Mod
ule
C:
4,12
,16,
17,1
8,19
, 20,
21,3
1,32
,33,
54
Mod
ule
D:
Sche
dule
s:
2,3
,6,1
0,11
Mod
ule
E:
3,4
Und
erst
andi
ng th
e co
ncep
t of
qual
ity
Has
con
cern
for q
ualit
y w
hile
wor
king
eff
icie
ntly
An
unde
rsta
ndin
g of
the
use
ofau
dit,
patie
nt a
nd s
taff
feed
back
to im
prov
e qu
ality
An
orga
nisa
tion
that
pro
vide
scl
arity
of o
bjec
tives
and
pro
mot
esre
flect
ive
prac
tice
to im
prov
equ
ality
of p
atie
nt c
are
Qua
lity
assu
ranc
e sy
stem
s m
ust b
e in
pla
cean
d ap
prov
ed b
y co
mm
issio
ning
bod
y w
ithre
gula
r rep
ortin
g of
out
com
es
Prov
ider
s ar
e re
quire
d to
pub
lish
qual
ityac
coun
ts fo
r the
pub
lic re
port
ing
of q
ualit
yin
clud
ing
safe
ty, e
xper
ienc
e an
d ou
tcom
es
Prov
ider
s sh
ould
par
ticip
ate
in n
atio
nal a
udit
prog
ram
mes
Acc
ess
targ
ets:
On
conf
irmat
ion
of d
iagn
osis
of T
ype
1 or
Typ
e 2
diab
etes
pat
ient
ssh
ould
hav
e a
rout
ine
risk
asse
ssm
ent o
f the
feet
and
rece
ive
basic
foot
car
e ad
vice
as
soon
as
poss
ible
– w
ithin
one
mon
th8
Ther
eaft
er a
nnua
l foo
t car
e ad
vice
and
revi
ew s
houl
d be
car
ried
out.
Patie
nts
shou
ld b
e re
ferr
ed a
s so
on a
s po
ssib
le (w
ithin
one
wee
k)fo
r exp
ert a
sses
smen
t and
car
e of
the
foot
if th
ere
is in
crea
sed
risk
of d
iseas
e an
d in
clus
ion
in a
long
term
sur
veill
ance
pro
gram
8
Patie
nts
shou
ld b
e se
en w
ithin
one
wor
king
day
for e
xper
tas
sess
men
t and
trea
tmen
t if t
here
is a
ctiv
e fo
ot d
iseas
e, e
.g. f
oot
ulce
ratio
n or
acu
te C
harc
ot fo
ot8
The
serv
ice
is re
quire
d to
par
ticip
ate
in th
e fo
llow
ing
activ
ities
/pro
gram
mes
:
•N
atio
nal D
iabe
tes
Aud
it 9
•Pa
tient
Exp
erie
nce
Surv
eys
10
•D
iabe
tes
E 11
•Pa
tient
Rep
orte
d O
utco
mes
Mea
sure
s12
•A
udit
of fo
ot c
are
and
ampu
tatio
n ra
tes
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
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 Com
mun
ity S
ervi
ces
Mod
ule
C:
11,1
6,19
,26,
33,4
8,56
Mod
ule
D:
Sche
dule
s:10
The
prov
ider
org
anisa
tion
has
syst
ems
and
proc
edur
es in
pla
ce to
assu
re th
e co
mm
issio
ner t
hat t
heir
clin
ical
team
has
the
nece
ssar
yqu
alifi
catio
ns, s
kills
, kno
wle
dge
and
expe
rienc
e to
del
iver
the
serv
ice
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 (
or p
rocu
re)
and
reta
in a
com
pete
nt c
linic
al te
am to
del
iver
the
serv
ice
Spec
ific
qual
ifica
tions
requ
ired
of h
ealth
pro
fess
iona
ls pr
ovid
ing
the
serv
ice
are:
•Fo
r dia
bete
s ph
ysic
ians
: reg
istra
tion
with
the
GM
C a
ndev
iden
ce o
f fur
ther
qua
lific
atio
n in
dia
bete
s ca
re in
clud
ing
Cer
tific
ate
of th
e C
ompl
etio
n of
Tra
inin
g, a
nd to
hav
e th
ene
cess
ary
com
pete
ncie
s in
ass
essm
ent a
nd m
anag
emen
t of t
hefo
ot a
t risk
and
of f
oot d
iseas
e 13
•N
urse
s: re
gist
ratio
n w
ith th
e N
MC
and
furt
her e
vide
nce
ofqu
alifi
catio
n in
dia
bete
s ca
re w
ith a
spe
cial
inte
rest
and
trai
ning
in th
e as
sess
men
t and
man
agem
ent o
f the
foot
in d
iabe
tes
14
•Po
diat
rists
: reg
istra
tion
with
the
HPC
and
furt
her e
vide
nce
ofqu
alifi
catio
n in
dia
bete
s ca
re w
ith a
spe
cial
inte
rest
and
trai
ning
in th
e as
sess
men
t and
man
agem
ent o
f the
foot
in d
iabe
tes
•Va
scul
ar S
urge
ons:
regi
stra
tion
with
the
GM
C a
nd C
ertif
icat
eof
the
Com
plet
ion
of T
rain
ing
with
the
nece
ssar
y co
mpe
tenc
ies
in a
sses
smen
t of t
he fo
ot
The
mem
bers
of M
ulti
Disc
iplin
ary
foot
car
e Te
am (M
DfT
) inv
olve
din
del
iver
ing
foot
car
e to
peo
ple
with
dia
bete
s ar
e re
quire
d to
colle
ctiv
ely
have
the
nece
ssar
y sk
ills
and
com
pete
ncie
s (s
ee S
kills
for H
ealth
- Dia
bete
s C
ompe
tenc
ies)
15
In a
dditi
on, f
oot c
are
team
is re
quire
d to
hav
e th
e sk
ills
nece
ssar
yto
com
ply
with
The
Nat
iona
l Min
imum
Ski
lls F
ram
ewor
k fo
rC
omm
issio
ning
of F
oot C
are
Serv
ices
for P
eopl
e w
ith D
iabe
tes
8
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 Com
mun
ity S
ervi
ces
Mod
ule
C:
5, 1
1, 1
6, 1
7, 1
9, 2
6,33
,48
The
prov
ider
org
anisa
tion
has
syst
ems
in p
lace
to a
ssur
e th
eco
mm
issio
ner t
hat t
heir
clin
ical
team
are
com
pete
nt to
use
all
equi
pmen
t nee
ded
to d
eliv
er th
ese
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 di
abet
es c
are
are
requ
ired
to h
ave
the
rele
vant
com
pete
ncie
s in
usin
gap
prop
riate
equ
ipm
ent ,
e.g
. blo
od g
luco
se a
nd k
eton
em
onito
rs, i
nsul
in d
eliv
ery
devi
ces
incl
udin
g in
sulin
pum
ps
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 /
staf
f
Dev
elop
men
t
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
C:
11,1
6,19
,48
The
prov
ider
org
anisa
tion
has
syst
ems
in p
lace
to a
ssur
e th
eco
mm
issio
ner t
hat t
heir
clin
ical
team
is fo
rmal
ly in
duct
ed a
ndre
ceiv
es o
ngoi
ng a
ssist
ance
tode
velo
p th
eir s
kills
, kno
wle
dge
and
expe
rienc
e to
ens
ure
that
they
are
alw
ays
fully
upd
ated
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
essio
nals
shou
ld h
ave
suff
icie
nt s
tudy
leav
eal
loca
tion
(tim
e an
d fin
ance
) to
enab
le th
em to
dev
elop
ski
llsap
prop
riate
ly
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 Com
mun
ity S
ervi
ces
Mod
ule
B:
Sect
ions
:3,
5
Mod
ule
C:
4,4A
,5,9
,10,
11,1
2,14
,15,
1617
,18,
19,2
1,26
,27,
29,3
3,34
,35,
36,3
8, 4
0,43
,48,
49,5
2, 5
3,54
,56,
60
Mod
ule
D:
Sche
dule
s:
6,10
,11,
12,1
5
The
Prov
ider
is re
quire
d to
be
regi
ster
ed w
ith th
e C
are
Qua
lity
Com
miss
ion
to d
emon
stra
te th
atis
mee
ts th
e es
sent
ial s
tand
ards
of
qual
ity a
nd s
afet
y fo
r the
regu
late
dac
tiviti
es d
eliv
ered
.
The
Prov
ider
is re
quire
d to
be
licen
sed
with
the
NH
S Ec
onom
icRe
gula
tor (
Mon
itor)
in o
rder
topr
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 C
are
Qua
lity
Com
miss
ion
Revi
ews
Clin
ical
qua
lity
Out
com
es
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
B:Se
ctio
n:1
(par
t 3),3
Mod
ule
C:
4A,1
4,
Mod
ule
D:
Sche
dule
11
Com
preh
ensiv
e un
ders
tand
ing
and
com
mitm
ent t
o de
liver
ing
and
impr
ovin
g ou
tcom
es o
f car
e
Com
plia
nce
with
the
NH
S O
utco
mes
Fram
ewor
k16C
ompl
ianc
e w
ith th
e Q
ualit
y St
anda
rds
for D
iabe
tes,
spec
ifica
lly:17
Qua
lity
Stat
emen
t 10
Peop
le w
ith d
iabe
tes
with
or a
t risk
of f
oot u
lcer
atio
n re
ceiv
ere
gula
r rev
iew
by
a fo
ot p
rote
ctio
n te
am in
acc
orda
nce
with
NIC
E gu
idan
ce, a
nd th
ose
with
a fo
ot p
robl
em re
quiri
ng u
rgen
tm
edic
al a
tten
tion
are
refe
rred
to a
nd tr
eate
d by
am
ultid
iscip
linar
y fo
ot c
are
team
with
in 2
4 ho
urs
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
Patie
nt p
athw
ay
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
B:Se
ctio
ns:
1 Mod
ule
C:
4,4A
,9,1
0,12
,14,
15,
16,1
7,18
,19,
20,2
1,27
,29,
31,
33,3
4,35
,36,
38,4
0,52
,54
Mod
ule
D:
Sche
dule
s:
2,3,
4, 9
,11,
17
Mod
ule
E:5
Resp
onsiv
enes
s an
d pa
rtic
ipat
ive
appr
oach
to in
clud
ing
patie
nts’
view
s ab
out t
heir
care
in th
ede
sign
of c
are
path
way
s
Col
labo
ratio
n w
ith o
ther
orga
nisa
tions
invo
lved
in th
epa
tient
pat
hway
to p
rovi
de a
seam
less
pat
hway
of c
are
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
If pa
rt o
r w
hole
of
the
serv
ice
is t
o be
tran
sfer
red
to o
ther
pro
vide
rs, t
here
mus
tbe
cle
ar a
nd a
gree
d su
b co
ntra
cts
onre
ferr
al c
riter
ia a
nd a
cces
s to
the
se s
ervi
ces.
At
entr
y to
pat
hway
:
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) r
egis
ter
patie
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
The
key
prio
ritie
s fo
r go
od q
ualit
y di
abet
es f
oot
care
se
rvic
es a
re:
•Th
e ex
amin
atio
n an
d ris
k as
sess
men
t of
the
fee
t of
peo
ple
with
dia
bete
s •
To m
anag
e an
d re
fer
patie
nts
at r
isk
of d
evel
opin
g fo
otdi
seas
e fo
r ex
pert
ass
essm
ent,
edu
catio
n an
d pl
anni
ng f
orlo
ng t
erm
sur
veill
ance
•
To p
rovi
de s
peci
alis
t fo
ot t
reat
men
t fo
r a
patie
nt w
ithdi
abet
es w
ho h
as a
ctiv
e fo
ot d
isea
se, a
nd t
o en
sure
tha
tst
eps
are
take
n to
min
imis
e re
curr
ence
.
Peop
le w
ith d
iabe
tes
shou
ld h
ave
info
rmat
ion
on h
ow t
oac
cess
the
exp
ertis
e of
the
mul
tidis
cipl
inar
y fo
ot c
are
team
,e.
g. in
form
atio
n ca
rd f
rom
‘Put
ting
Feet
Firs
t’ 18
Prov
ider
s ar
e re
quire
d to
tak
e no
te o
f th
e re
sults
of
the
Nat
iona
l Sur
vey
of P
eopl
e w
ith D
iabe
tes
19
17
ELEM
ENTS
aCH
AR
AC
TER
ISTI
CS,
SK
ILLS
AN
D B
EHA
VIO
UR
SO
UTP
UTS
DIA
BET
ES S
ERV
ICES
SPE
CIF
IC O
UTP
UTS
/CO
MM
ENTS
Clin
ical
qua
lity
Patie
nt p
athw
ayA
t po
int
of in
terv
entio
n:Th
e C
omm
issi
oner
sho
uld
assu
reth
emse
lves
tha
t th
e pr
ovid
er h
as s
yste
ms
and
proc
esse
s in
pla
ce t
o en
sure
tha
t:
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
At
exit
from
pat
hway
: Th
e C
omm
issi
oner
sho
uld
assu
reth
emse
lves
tha
t pr
ovid
er h
as s
yste
ms
and
proc
esse
s, w
hich
are
agr
eed
with
all
part
ies
and
netw
orks
, in
plac
e 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
ts
TOPI
C
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
Clin
ical
em
erge
ncy
situa
tions
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
tfo
r Com
mun
ity S
ervi
ces
Mod
ule
C:
6,11
,12,
14,1
5,18
,20
,32,
32,
42,
54
Mod
ule
D:
Sche
dule
s:
2, 3
, 4, 6
, 9,1
1
Abi
lity
to n
egot
iate
and
agr
eear
rang
emen
ts w
ith a
ppro
pria
tepe
rson
nel a
nd o
rgan
isatio
ns to
prov
ide
effe
ctiv
ely
for e
mer
genc
ysit
uatio
ns
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
for
cont
actin
g th
e pr
ovid
eran
d fo
llow
up
if re
quire
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
Arr
ange
men
ts s
houl
d be
in p
lace
to
man
age
all a
cute
pres
enta
tions
of
the
diab
etic
foo
t
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 Com
mun
ity S
ervi
ces
Mod
ule
C:
5, 3
3,56
Mod
ule
D:
Sche
dule
s:2,
3,4
,6,1
1,17
Und
erst
andi
ng o
f bui
ldin
gre
gula
tions
Acc
ess
to a
dvic
e on
“fit
-for
-pu
rpos
e” e
quip
men
t and
faci
litie
s
Com
miss
ione
rs m
ust a
ssur
e th
emse
lves
that
patie
nt c
are
is de
liver
ed in
app
ropr
iate
ly b
uilt
and
equi
pped
faci
litie
s w
hich
mee
t rel
evan
tH
TMs
and
Build
ing
Not
es, a
nd, w
here
appr
opria
te, a
re re
gist
ered
and
are
saf
e an
dcl
ean.
Equi
pmen
t mus
t be
fit fo
r pur
pose
Com
mitm
ent t
o ef
ficie
nt u
se a
nd s
atisf
acto
rym
aint
enan
ce o
f equ
ipm
ent
Clin
ical
qua
lity
Patie
nt p
athw
ay
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
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 Com
mun
ity S
ervi
ces
Mod
ule
B:Se
ctio
ns:
5 Mod
ule
C:
9,17
,18,
19,
21,2
3,24
,27,
29, 3
2,33
,54,
56,
60
Stra
tegy
and
pol
icy
deve
lopm
ent
skill
s
The
abili
ty to
ana
lyse
dat
a an
dha
ve a
cces
s to
info
rmat
ion
that
can
pred
ict t
rend
s an
d th
at c
ould
iden
tify
prob
lem
s
The
abili
ty to
cap
ture
evi
denc
eba
sed
prac
tice
from
R&
D N
atio
nal
Serv
ice
Fram
ewor
ks, N
ICE
guid
ance
The
abili
ty to
use
dat
a an
din
form
atio
n ap
prop
riate
ly to
impr
ove
patie
nt c
are
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
tco
vers
• T
ypes
of
data
• Q
ualit
y of
dat
a•
Dat
a pr
otec
tion
and
conf
iden
tialit
y•
Acc
essi
bilit
y•
Tra
nspa
renc
y•
Ana
lysi
s of
dat
a an
d in
form
atio
n•
Use
of
data
and
info
rmat
ion
• D
isse
min
atio
n of
dat
a an
d in
form
atio
n•
Ris
ks•
Shar
ing
of d
ata
and
com
patib
ility
of
ITac
ross
diff
eren
t pr
ovid
ers
with
res
pect
to
care
of
patie
nts
acro
ss a
pat
hway
This
info
rmat
ion
shou
ld b
e in
clud
ed in
the
Dat
a Q
ualit
y Im
prov
emen
t Pl
an
Ther
e sh
ould
be
polic
ies
in p
lace
tha
tin
clud
e:
• C
onfid
entia
lity
Cod
e of
Pra
ctic
e•
Dat
a Pr
otec
tion
• F
reed
om o
f In
form
atio
n•
Hea
lth R
ecor
ds•
Info
rmat
ion
Gov
erna
nce
Man
agem
ent
• In
form
atio
n Q
ualit
y A
ssur
ance
•In
form
atio
n Se
curit
y
Ther
e m
ust
be a
nam
ed in
divi
dual
who
isth
e C
aldi
cott
Gua
rdia
n
The
Prov
ider
is r
equi
red
to h
ave
info
rmat
ion
syst
ems
that
reco
rd in
divi
dual
nee
ds in
clud
ing
emot
iona
l, so
cial
,ed
ucat
iona
l, ec
onom
ic a
nd b
iom
edic
al in
form
atio
n w
hich
perm
it m
ultid
isci
plin
ary
care
acr
oss
serv
ice
boun
darie
s an
dsu
ppor
t ca
re p
lann
ing
20
The
Prov
ider
is r
equi
red
to u
se t
he f
ollo
win
g fo
r th
e co
llect
ion
and
prod
uctio
n of
dat
a, w
here
app
ropr
iate
:
• N
HS
Out
com
es F
ram
ewor
k 16
• N
atio
nal D
iabe
tes
Info
rmat
ion
Serv
ice
21
• N
atio
nal D
iabe
tes
Aud
it 9
• Q
ualit
y an
d O
utco
mes
Fra
mew
ork22
• D
iabe
tes
E 11
• H
ospi
tal E
piso
de S
tatis
tics23
• P
atie
nt E
xper
ienc
e 10
,19
• P
atie
nt S
atis
fact
ion
10
• P
atie
nt R
epor
ted
Out
com
es M
easu
res
12
• N
atio
nal D
iabe
tes
Con
tinui
ng C
are
Dat
aset
24
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 Com
mun
ity S
ervi
ces
Mod
ule
C:
4A,5
,11,
17,1
9, 5
4, 5
6,60
Und
erst
andi
ng o
f clin
ical
acco
unta
bilit
ies
of h
ealth
and
safe
ty p
olic
ies
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
20
Source documentsCommissioners and providers should takeresponsibility for making references to the latestversion of the various documents and guidance.
1. Emotional and Psychological Support and Care inDiabetes, Joint Diabetes UK and NHS DiabetesEmotional and Psychological Support WorkingGroup, to be published early 2010
2. The NHS Diabetes Commissioning Guides areavailable on the NHS Diabetes website athttp://www.diabetes.nhs.uk/commissioning_resource/
3. Standard NHS Contractshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324
4. National Quality Board, Quality Governance in theNHS, 2011http://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, Medicines adherence: involving patients indecisions about prescribed medicines andsupporting adherence, Jan 2009,http://guidance.nice.org.uk/CG76
7. NHS Institute for Innovation and Improvement,model CQUIN scheme: inpatient care for peoplewith diabetes, 2009
8. Foot in Diabetes UK, Diabetes UK, The Associationof British Clinical Diabetologists, The Primary CareDiabetes Society and the Society of Chiropodistsand Podiatrists, The National Minimum SkillsFramework for Commissioning Foot Care Servicesfor People with Diabetes, November 2006 (to bereviewed in 2008)
9. National Diabetes Audit.www.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/diabetes
10. The King’s Fund, The point of care. Measures ofpatients’ experience in hospital: purpose, methodsand uses. July 2009
11. DiabetesE - https://www.diabetese.net/
12. Patient Reported Outcomes Measures,http://www.ic.nhs.uk/proms
13. Department of Health, Royal College of GeneralPractitioners, Royal Pharmaceutical Society ofGreat Britain, NHS Primary Care Contracting ,Guidance and competences for the provision ofservices using practitioners with special interests(PwSIs) - Diabetes, http://www.rcgp.org.uk/
14. Training, Research and Education for Nurses inDiabetes – UK, An Integrated Career &Competency Framework for Diabetes Nursing(Second Edition), 2010
15. Skills for Health, Diabetes CompetencyFramework, https://tools.skillsforhealth.org.uk/
16. Department of Health, The NHS OutcomesFramework 2011/12, December 2010http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
17. NICE, Quality Standards: Diabetes in adults, March2011, http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp
18. NHS Diabetes and Diabetes UK, Putting Feet First,Commissioning specialist services for themanagement and prevention of diabetic footdisease in hospitals, June 2009
19. Healthcare Commission, National Survey ofPeople with Diabetes, 2006,www.cqc.org.uk/usingcareservices/healthcare/patientsurveys/servicesforpeoplewithdiabetes.cfm
20. York and Humber integrated IT system,http://www.diabetes.nhs.uk/
21. National Diabetes Information Service,www.diabetes-ndis.org
22. Quality and Outcomes Frameworkhttp://www.nice.org.uk/aboutnice/qof/qof.jsp
23. Hospital Episode Statistics,www.ic.nhs.uk/statistics-and-data-collections/hospital-care/hospital-activity-hospital-episode-statistics--hes
24. National Diabetes Continuing Care Dataset,www.ic.nhs.uk/webfiles/Services/Datasets/Diabetes/dccrdataset.pdf
21
This specification forms Schedule 2, Part 1, orsection 1 (module B), ‘The Services - ServiceSpecifications’ of the Standard NHS Contractsa
Service specifications are developed in partnershipbetween commissioners and provider agencies andare based on agreed evidence-based care andtreatment models. Specifications should be open toscrutiny and available to all service users/carers as astatement of standards that the user/carer can expectto receive.
IntroductionThe following documents provide furtherdetail/guidance and can be used to support thedevelopment of this specification:
• The intervention map for diabetes foot careservices
• The contracting framework for diabetes foot care services
This specification template assumes that the servicesare compliant with the contracting framework fordiabetes foot care services.
This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.
Description of foot care services forpeople with diabetes:Foot care services for people with diabetes include
• routine assessment and care of the foot withoutany ulceration or lesion, in order to detect those atincreased risk
• action to minimise the onset of new foot disease inthose at increased risk
• prompt expert assessment and care of the foot atincreased risk with new foot disease
• development of a strategy to minimise the onset ofrecurrence in those who have had a new episodeof foot disease successfully treated.
The final specification should take into account
• national, network and local guidance andstandards for diabetes foot care services.
• Individual needs and priorities of the patient.
This specification is supported by other related workin 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 for needsassessment, planning and monitoring of diabetesservices
Purpose, Role and Clientele1. A clear statement on the primary purpose of the
aim of the specialist foot care services and forwhom they should be available:
• Who the services are for (e.g. people of all ageswith diabetes)
• What the services aim to achieve
• 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 organisation of care and theinterrelationships between different health careproviders who are involved. This will include basic
Standard Service SpecificationTemplate for Foot Care Services for People with Diabetes
a Standard NHS Contracts http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324
22
clinical procedures undertaken as part of routinescreening in primary care, as well as the integrationof specialist investigations and treatment inspecialist centres.
• How the services responds to age, culture,disability, and gender sensitive issues
• Assessment – details of the methods employed,and action taken as a result of the findings
• Service planning – Strategic view of the aim andscope of the services, including:
o Their deployment and implementationo Access of users to them (define, develop,
manage and review interventions alongthe patient journey)
o Their interrelationships with other healthcare professionals at all stages of thepatient pathway (ensure that foot care isincluded in care planning and undertakenby the diabetes multi-disciplinary team (asdefined locally) and the specialist foothealthcare professional)
• Holistic review of patients in the management oftheir diabetes, and other medical and socialproblems in a way that is patient-centred, andincluding self care and professionalmanagement, psychological support and othersocial care issues, with the aim of facilitatingoptimal recovery and retention of function andindependence.
• Development of patient-centred educationalprogramme for self care of foot disease risk
• Detail of evidence base of the service, andguidance outlined in The Contracting Frameworkfor Diabetes Foot Care Services, The NationalMinimum Skills Framework for CommissioningFoot Care Services for People with Diabetesb, andthe Putting Feet First report of Diabetes UK andNHS Diabetesc.
Service Delivery3. Patient Journey/intervention map
Flow diagram of the patient journey showingaccess and exit/transfer points – see the diabetes
foot care services patient intervention map as astarting point
4. Treatment protocols/interventionsInclude all individual treatment protocols in placewithin the services or planned to be used
5. This will include a breakdown of how the patientwill receive the services and from whom. It shouldbe a clear statement of the necessary skills of staffand the resources to which they have access, aswell as links with other relevant health careproviders, with appropriate arrangements forclinical or managerial supervision. It should specify,as appropriate:
• Geographical coverage/boundaries – i.e. the footcare services both for screening and prevention,and for treatment, that should be available forpeople with diabetes who live in the clinicalcommissioning group area
• Hours of operation including, week-end, bankholiday and on-call arrangements
• The skills and competencies required ofhealthcare professionals or teams involved in thedelivery of care at all stages, together withsupport and administrative staff
• Staff induction and developmental training
6. Equipment• Upgrade and maintenance of relevant
equipment and facilities
• Prompt access to imaging and biochemicalinvestigations
• Prompt access to microbiological services andadvice
• Prompt access to input from vascular,orthopaedic and plastic surgical advice
• Close liaison with facilities for casting and off-loading
• Close liaison with orthotic services for theprovision of both temporary off-loading devicesand fitted footwear
b Foot in Diabetes UK, Diabetes UK, The Association of British Clinical Diabetologists, The Primary Care Diabetes Society and the Societyof Chiropodists and Podiatrists, The National Minimum Skills Framework for Commissioning Foot Care Services for People withDiabetes, November 2006 (to be reviewed in 2008)
c NHS Diabetes and Diabetes UK, Putting Feet First, Commissioning specialist services for the management and prevention of diabeticfoot disease in hospitals, June 2009
23
Identification, Referral and Acceptancecriteria7. This should make clear how people with diabetes
who require foot care will be identified, assessed (ifappropriate) and accepted to the services.Acceptance should be based on types of needand/or patient.
• How should patients be referred?
• Who is acceptable for referral and from where
• Details of evaluation process - Are there clearexclusion criteria or set alternatives to theservice? How might a patient be transferred?
• Response time detail and how patients areprioritised
Discharge/Service Complete/PatientTransfer criteria8. The intention of this section is to make clear
when a patient should be transferred from thefoot care services for people with diabetes toanother and when this would be reached or,when appropriate, when the patient will continuein long-term shared care
• How is a treatment pathway reviewed?
• How does the service decide that a patient isready for discharge/transfer?
• How are goals and outcomes assessed andreviewed?
• What procedure is followed on discharge,including arrangements for follow-up?
Quality Standards9. The service is required to deliver care according to
the standards for clinical practice set by theNational Institute for Health and ClinicalExcellenced
10. As a minimum, the Provider is required to agree alocal Commissioning for Quality and Innovationscheme for services for people with diabetes.(Insert details of the CQUIN Scheme agreed)
11. The service is required to deliver the outcomes fordiabetes as determined by the NHS OutcomesFrameworke
Activity and Performance Management12. This must include performance indicators,
thresholds, methods of measurement andconsequences of breach of contract. These willbe set and agreed prior to the signing of theoverall agreement.
It should be accepted, however, that somemeasures (such as incidence of amputation) arenot governed entirely by specialist services which,by their nature, tend to be referred patients whoalready have established disease.
13. Specific KPIs for foot care services for people withdiabetes might include one or more of following,and selected according to national and localpriorities:
a. Incidence• Number of new episodes of foot disease
(expressed in terms of total population withdiabetes)
• Number of new cases of foot disease arising inin-patients with diabetes being cared for inhospitals, nursing and care homes
• Number of hospital admissions for diabetic footproblems
b. Outcome• Amputation (expressed in terms of total
population with diabetes)
• Incidence of ulcer healing by a fixed time, or timeto healing
• Survival
• Being ulcer (or lesion) free at 12 months withfeet intact
• Functional outcome
• Patient feedback on satisfaction, experience andhealth status
d http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp
e http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
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c. Process• Hospital length of stay for diabetic foot problems
• Use of antibiotics
• MRSA and multidrug resistant organisms(MDROs) prevalence at referral of new diseaseand during management
• Use of specialist investigations (such as imaging,revascularisation, orthopaedic surgery, orthotics
14. Activity plans – Where appropriate, identify theanticipated level of activity the service maydeliver; provide details of any activity measuresand their description /method of collection,targets, thresholds and consequences ofvariances above or below target.
Continual Service Improvement15. As part of the monitoring and evaluation
procedures, the service will identify a method ofagreeing measurements for continuousimprovement of the service being offered andwork to ensure unmet need is both identified andbrought to the attention of the commissioner.
16. ReviewThis section should set out a review date and amechanism for review.The review should include both the specificationsfor continuing fitness for purpose and theproviders’ delivery against the specification.This should set out the process by which thisreview will be conducted.This should also identify how compliance againstthe specification will be monitored in year.
Agreed by17. This should set out who agrees/accepts the
specification on behalf of all parties.This should include the diabetes foot careproviders and commissioner.
Further copies of this publication can be ordered from Prontaprint, by emailing [email protected] or tel: 0116 275 3333, quoting DIABETES 113
www.diabetes.nhs.uk