Quality Standards for Diabetes Care Toolkit

Implementation advice

‘People with diabetes are in charge of their own lives and self-management of their diabetes, and are the primary decision-makers about the actions they take in relation to their diabetes management’ (Diabetes UK et al 2008, p 39).
Care planning consultations should be available to all people with diabetes and reflect the information needed, as well as both technical and emotional support to enable the person with diabetes to make the best decisions about their care (Diabetes UK et al 2008; NICE 2011). The person with diabetes is more likely to undertake action if it is related to decisions they have made, rather than decisions made for them (Diabetes UK et al, 2008).
People with diabetes need to be orientated to the care planning approach and what to expect. Health professional should undertake further training in developing patient-centred interventions if required (Scottish Intercollegiate Guidelines Network 2010). If the patient agrees, families and carers should have the opportunity to be involved in decisions about treatment and care and given the information and support they need (NICE 2009).

At each care planning consultation, time should be allowed to share information about issues and concerns, share results of biomedical tests, discuss the experience of living with diabetes and address needs to manage obesity, food and physical activity. The person with diabetes should receive help to access support and services, and, agree to a plan for managing diabetes that addresses the individual priorities and goals. These should be jointly agreed, including jointly setting a goal for HbA1c. Specific actions are in response to identified priorities that include an agreed timescale (Diabetes UK et al 2008; Joint Department of Health and Diabetes UK Care Planning Working Group 2006; NICE 2011).

This care planning approach will incorporate:

nutritional advice

discussing psychological wellbeing (identify support groups)

managing obesity

structured education

screening for complications

smoking cessation advice

physical activity

self-management programme

agreeing goals for HbA1c

agreeing plans for managing diabetes

discussing goals

follow-up support by telephone.

(Joint Department of Health and Diabetes UK Care Planning Working Group 2006.)

The documented individual care plan should be reviewed at least annually and modified according to any changes in wishes, clinical circumstance and medical findings (NICE 2004). In addition, diabetes registers should be established to support annual recall systems for surveillance of complications, cardiovascular risk, and for quality management (NICE 2004).
The shared treatment decisions should consider the individual’s clinical state, age, comorbidities and frailty, personal preferences and available research evidence. The absolute benefits and harms of interventions must be considered, and it is acknowledged that people interpret these risks differently and will have their own inclinations and limits (Cardiovascular Disease Risk Assessment Steering Group 2013).
When setting a target HbA1c:

involve the person in decisions about their individual HbA1c target level

encourage the person to maintain their individual target, unless the resulting side-effects (including hypoglycaemia) or their efforts to achieve this impair their quality of life

offer therapy (lifestyle and medication) to help achieve and maintain the HbA1c target level

inform a person with a higher HbA1c that any reduction in HbA1c towards the agreed target is advantageous to future health

avoid pursuing highly intensive management (NICE 2009).

A guide to implementing care planning in diabetes is available from Diabetes UK – www.diabetes.org.uk/documents/reports/careplanningdec06.pdf (Joint Department of Health and Diabetes UK Care Planning Working Group 2006).