NHS Lothian Diabetes Managed Clinical Network (MCN)

Diabetes MCN Role and Remit

The Diabetes MCN supports co-ordination, planning and development of diabetes services across primary and secondary care in Lothian.

The aim of the Network is:

  • To maximise the quality of life for those with diabetes by detecting and treating the disease and its complications at an early stage.
  • To minimise complications and premature death in those with diabetes
  • To provide equal access to high quality diabetes care for all residents of Lothian. People with diabetes should be enabled and empowered to safely and effectively self-manage their condition by accessing consistent, high quality education and by creating mutually agreed individualised care plans.
  • To minimise the impact of deprivation, ethnicity and disadvantage on diabetes care and outcomes.
  • To ensure all people with diabetes are given the right treatment by the right person at the right time in the right place.
  • To ensure that appropriate and accurate information is available in a suitable format and is effectively and reliably used by all those involved in diabetes care
  • Create plans to support the implementation, monitoring and reporting against the National Diabetes priorities outlined in the National Diabetes Improvement Plan 2014[1]
  • .

In 2016, in the light of organisational change within the strategic planning department, secondary care services and the establishment of four Lothian health and social care partnerships, the diabetes MCN has undergone reviewand refreshment which has included a review of the MCN membership and sub groups as outlined in Appendix 1 and 2.

The diabetes MCN will be re-launched in November 2016 and will meet quarterly thereafter.

The diabetes MCN clinical leads will report bi-annually to the Nurse Director / Director of Strategic Planning and annually to NHS Lothian Healthcare Governance Committee.

MCN Sub Groups

The nominated Chairs of the MCN Sub Groups are required to:

  • Identify sub group membership
  • Meetquarterly and / or progress work virtually via e-mail
  • Chairs are expected to attend quarterly Diabetes MCN meetings to provide regular reportsof sub group activities or if unable to attend nominate a member of the sub group to attend
  • Support performance improvements associated with the national diabetes improvement plan for inclusion in quarterly reports
  • Key Performance with the Diabetes Improvement Plan
  • Sub Groups will be provided with administrative support from the MCN management team

Role and Remit of Diabetes MCN Sub Groups – sub groups are aligned to 8 priorities in the National Diabetes Improvement Plan. Person Centred Care, Equity of Access and Improving Information needs to be a common theme which runs through all MCN activities, in keeping with the MCN’s aims as listed above.

Public Health, Prevention, Primary Care and Prescribing Chair – Dr Sarah Wild

To establish and implement appropriate approaches to support the prevention and early detection of type 2 diabetes, the rapid diagnosis of type 1 diabetes and the implementation of measure to promptly detect and prevent the complications of diabetes.

Adopt House of Care methodologies to empower individuals to self- manage their diabetes and encourage the registration and activities utilising My Diabetes My Way to support self-management.

Key performance measures relate to the 9 key indicator measurements for diabetes relates to the percentage of people with diabetes who receive all 9 process of care measures for diabetes. This includes; HbA1c, weight (and BMI measurement), bloodpressure, smoking status, HbA1c, urinary albumin test, serum creatinine, cholesterollevel, retinopathy screening and foot risk stratification. The MCN aims for 60% of people to receive all 9 key indicators by the end of 2016 and to:

  • improve the documentation of smoking status and for those patients who do smoke to increase the number of referrals to the smoking cessation service
  • reduce proportion of people aged 50-70 with no recorded SBP and cholesterol to <10%
  • Increase percentage of people aged 50-80 with cholesterol and SBP within target to >55% by the end of 2016
  • % persons with an HbA1c <58mmol/mol at 1 year post diagnosis
  • % persons with an HbA1c <58 mmol/mol and >75 mmol/mol

Through a Short Life Working Group, develop an action plan to support implementation of the refreshed national diabetes prescribing strategy which is due for publication in 2017-18.

Type 1Chair - Dr Fraser Gibb

To improve the care and outcomes of all people living with type 1diabetes with a focus on:

  • Good glycaemic control
  • Timely access to structured education
  • Monthly monitoring of access to insulin pumps with the aim of delivering the Scottish Government target of 20% of the type 1 population provided with a pump
  • Support early identification and referral of children and young people with type 1 diabetes and their management of diabetes
  • Provision of transitional care and improvements in youth engagement

Key National Performance Indicators: % of people on CSII (insulin pump) therapy

% persons with an HbA1c <58mmol/mol at 1 year post diagnosis

% persons with an HbA1c <58 mmol/mol and >75 mmol/mol

The MCN aims to maintain performance above the national average for type 1 diabetes.

Reverse the trend in type 1 18+ age group so that the proportion with hbA1c <58mmol/mol 1 year after diagnosis increases and the % with HbA1c >75mmol/mol falls over the next year. Planned changes to structured education at diagnosis should help address this.

Innovation - Chair Dr Fraser Gibb

Review and enhance the clinical system holding clinical data to ensure that it meets the needs of frontline healthcare professionals and that: patient data isavailable and more accessible for use during each consultation; design of theinterface is driven by the service user; and enhancing mechanisms to prioritisesystem improvements.

Continue to encourage individuals with diabetes to register with My Diabetes My Way to support self-management (July 2016 10.5% Lothian diabetes population registered with 4.5% of accounts active).

Encourage health professionals to discuss My Diabetes My Way with patients.

Accelerate the development and diffusion of innovative solutions to improve treatment, care and quality of life of people living with diabetes.

Key National Performance Indicator: % of people on CSII (insulin pump) therapy

Other indicators: provision of continuous glucose monitoring systems, proposal to pilot Guidepost (1:1 coaching to support patient education)

Diabetes Foot Care - Chair Emma Brewin

Improve diabetes foot care to reduce the number of people developing avoidable ulcers. Improve adherence to and train healthcare professionals in the Check, Protect, Refer (CPR) initiative and improve recording of foot assessment on SCI-Diabetes in both primary and secondary care.

Key National Performance Indicator: % of New Foot Ulcers

The figures for new foot ulcers are very low, not just in Lothian but across Scotland. This almost certainly reflects under-reporting rather than very low ulcer numbers. Scottish Diabetes Survey 2015 data for Lothian suggests that 5.7% of people with diabetes were recorded as having a foot ulcer but the ulcer management screen data suggests that only 5 people( out of approximately 38,000 with diabetes) developed ulcers over the last 3 quarters.

Supporting and Developing Staff including Professional and Patient Education Chair – Jill Little

To ensure healthcare professionals caring for people living with diabetes have access to consistent, high quality diabetes education to equip them with theknowledge, skills and confidence to deliver safe and effective diabetes care.

Convene a Short Life Working Group to undertake a review of diabetes structured patient education to ensure people with diabetes are enabled and empowered to safely and effectively self-manage their condition by accessing consistent, high quality educationand by creating mutually agreed individualised care plans.

Key National Performance Indicator: % persons who have attended structured education

Establish systems for accurately recording how many people have been offered structured education, how many people have opted to attend structured education and identify any barriers to accurate recording for discussion with the Scottish Government.

Inpatient DiabetesChair – Dr Stuart Ritchie

Support the roll out of Think, Check, Act across all wards and hospital sites within Lothian to improve the management and glycaemic control of people with diabetes admitted to hospital.

Key National Performance Indicator: % persons with an HbA1c <58mmol/mol at 1 year post diagnosis

% persons with an HbA1c <58 mmol/mol and >75 mmol/mol

Lothian Diabetes Representative Group (LDRG)

The LDRG are invited to nominate two members to attend diabetes MCN group meetings representing the views of individuals with diabetes across Lothian.The LDRG will also be invited to nominate representatives to support the activities of the diabetes MCN sub groupsand any short life working groups established to take forward time limited pieces of work.

Diabetes MCN Membership Appendix 1
Member / Designation / email address
Karen Adamson / Consultant Physician /
Dawn Arundel / Clinical Nuse Manager, South East Locality Health Partnership /
Louise Bath / Consultant Paediatrician /
Dervilla Bray / Prescribing Advisor /
Carl Bickler / GP - Edinburgh IJB /
Emma Brewin / Podiatrist /
Alison Cockburn / Lead Pharmacist /
Alyson Cumming / Strategic Programme Manager /
David Jolliffe / Clinical Lead - Primary Care /
Adele Dawson / Advanced Nurse Practitioner /
Amanda Fox / Project Manager: Long Term Conditions /
Fraser Gibb / Consultant /
Sarah Gossner / Clinical Nurse Manager /
Smita Grant / Manager - Edinburgh IJB /
Belinda Hacking / Consultant Clinical Psychologist & Head of Service /
Fiona Huffer / Head of Dietetics /
Mairead Hughes / Chief Nurse West Lothian IJB /
Lorna Jarrett / Chief III Diabetes Specialist Podiatrist /
Isobel Miller / Lothian Diabetes Representative Group (LDRG) /
Lynn Keane / Community Diabetes ANP /
Linda McGlynn / Diabetes Scotland (Vol Org) /
Jill Little / Diabetes Specialist Nurse - Education /
Liz Mackay / Diabetes Specialist Nurse /
Marie McCallum / Diabetes MCN Co-ordinator /
Andrew McNutt / West Lothian IJB /
Paula Collings / Lothian Diabetes Representative Group (LDRG) /
Stuart Ritchie / Consultant /
Emma Shaw / Senior Dietitian /
Mairi Simpson / Pubic Health Practioner - Midlothian IJB /
Sarah Wild / Public Health Consultant /
Nicola Zammitt / Clinical Lead - Secondary Care /

Structure Diabetes Managed Clinical Network Appendix 2

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[1] National Diabetes Improvement Plan , November 2014, Scottish Government