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CommissioningDiabetes End of Life
Care Services
Supporting, Improving, Caring
June 2011
NHS Diabetes information Reader Box
Review Date 2013
Commissioning Diabetes and End of Life Care Services
NHS Diabetes would like to thank the following for their advice and contribution to the development ofthis commissioning guide:
Anita Hayes End of Life Care Team, Department of Health
Charles Daniels Consultant in Palliative Care, North West London Hospitals NHS Trust
And to Thoreya Swage who wrote this publication.
3
Page
Commissioning for Diabetes and End of Life Care Services 5
Features of Diabetes and End of Life Care Services 6
Diabetes and End of Life Care Services Intervention Map 8
Contracting Framework for Diabetes and End of Life Care Services 11
Standard Service Specification Template for Diabetes and End of Life Care Services 24
Contents
5
Commissioning for DiabetesEnd of Life Care services
1 Commissioning Diabetes Without Walls , 2011, http://www.diabetes.nhs.uk/commissioning_resource/
The 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 local HealthNeeds Assessment and setting up a steering groupwith key stakeholder involvement including a leadclinician, lead commissioner, lead diabetes nurse andlead 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 including clinicaland social services professionals and patient groupsrepresented by Diabetes UK.
It is not designed to replace the Standard NHSContracts as many of the legal and contractualrequirements have already been identified in this setof documents. Rather, it is intended to form the basisof a discussion or development of diabetes End ofLife Care services between commissioners andproviders from which a contract for services can thenbe agreed.
This commissioning guide consists of:
• A description of the key features of good diabetesEnd of Life Care
• A high level intervention map. This interventionmap describes the key high level actions orinterventions (both clinical and administrative)diabetes End of Life Care services shouldundertake in order to provide the most efficientand effective care, from admission to discharge (ordeath) 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 End of Life Care services.
• A diabetes End of Life Care contracting frameworkthat brings together all the key standards of qualityand policy relating to diabetes and End of Life Care
• A template service specification for diabetes End ofLife Care services that forms part of schedule 2part 1 / Module B, Section 1, of the Standard NHSContract covering the key headings required of aspecification. It is recommended that thecommissioner checks which mandatory headingsare required for each type of care as specified bythe Standard NHS Contracts.
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
6
A high quality diabetes End of Life Care (EoLC)service should:
• ensure that all individuals approaching the endof life and their carers should:
o have their physical, emotional, social andspiritual needs and preferences assessed byprofessionals who have appropriate expertise
o have a care plan for their diabetes and endof life care
o have their needs, preferences and care planreviewed as their condition changes
o carers have access to bereavement support
o know that there are systems in place toensure that information about their needsand preferences can be accessed by allrelevant health and social care staff 24 hours7 days per week
o maintain dignity and respect for theindividual
• ensure that there is optimal delivery of careacross all relevant services in all settings
• ensure that there is good quality care in the lastdays of life
• ensure there is effective and timely verificationand certification of death and care after death
• ensure that there are equalities in access to andprovision of end of life care services
• demonstrate a clear and effective pathway ofcare which ensures how diabetic, renal, cardiac,stroke or care of the elderly services will identifypatients approaching the end of their life and
utilise all relevant support and coordinate careprovided by generic and specialist staff to deliverhigh quality EOLC.
o Such best practice consists of
■ Anticipatory Care planning
■ Use of the GP supportive or palliativeCare Register
■ Use of tools for delivery of high classEOLC eg Liverpool care of the dyingpathway, Gold Standards Framework,preferred priorities of care tools
■ Effective Standards for Out of Hoursprimary care services (eg Harmonistandards)
In addition the service should:
• be developed in a co-ordinated way, taking fullaccount of the responsibilities of other agenciesin providing comprehensive care ensuring peopleare at the centre of decisions about their careand support - ‘no decision about me withoutme’i
• be commissioned jointly by health and socialcare based on a joint health needs assessmentwhich meets the specific needs of the localpopulation, using a holistic approach asdescribed by the generic long term conditionsmodelii
• 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
Features of high quality DiabetesEnd of Life Care Services
i Available on the DH website athttp://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
7
iv Available on the DH website athttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
v Emotional and Psychological Support and Care in Diabetes, Joint Diabetes UK and NHS Diabetes Emotional and PsychologicalSupport Working Group, 2010 http://www.diabetes.nhs.uk/our_work_areas/emotional_and_psychological/
vi http://www.diabetes.nhs.uk/commissioning_resource/
vii See York and Humber integrated IT system at http://www.diabetes.nhs.uk/ year_of_care/it/
viii European Diabetes Working Party for Older People. Clinical Guidelines for Type 2 Diabetes Mellitus. Available on:www.instituteofdiabetes.org
• deliver the outcomes for diabetes as determinedby the NHS Outcomes Frameworkiv
• assess and manage the emotional, psychologicaland mental wellbeing of the patientv
• take into account all diverse and personal needswith respect to access to care
• ensure that services are responsive andaccessible to people with Learning Disabilitiesvi
• ensure that the family/carers of people withdiabetes have access to psychological support
• have effective clinical networks with clear clinicalleadership across the boundaries of care whichclearly identify the role and responsibilities ofeach member of the diabetes healthcare team
• ensure that there are a wide range of optionsavailable to people with diabetes to support selfmanagement and individual preferences
• ensure coordination of services provided byhealth, social care and the voluntary sectors
• provide patient/carer/family education ondiabetes not only at diagnosis but also duringcontinuing management at every stage of care
• provide education on diabetes management toother staff and organisations that supportpeople with diabetes
• have a capable and effective workforce that hasthe appropriate training and updating and
where the staff have the skills and competenciesin the management of people with diabetes
• provide multidisciplinary care that manages thetransition between adult and older peoples’services
• have integrated information systems that recordindividual needs including emotional, social,educational, economic and biomedicalinformation which permit multidisciplinary careacross service boundaries and support careplanningvii
• produce information on the outcomes ofdiabetes care including contributing to nationaldata collections and auditsviii
• have adequate governance arrangements, e.g.local mortality and morbidity meetings ondiabetes care to learn from errors and improvepatient safety
• take account of patient experience, in thedevelopment and monitoring of service delivery
• actively monitor the uptake of services,responding to non-attenders and monitoringcomplaints and untoward incidents
NH
S D
iab
etes
Dia
bet
es E
nd
of
Life
Car
e
Hea
lth
Nee
ds
Ass
essm
ent
-te
rmin
al p
hase
of
com
plic
atio
ns o
f di
abet
es, e
.g. R
enal
fa
ilure
-in
divi
dual
with
di
abet
es w
ho h
as
adva
nced
incu
rabl
e ill
ness
, e.g
. can
cer
-re
cogn
ition
by
indi
vidu
al
with
adv
ance
d in
cura
ble
illne
ss
- re
cogn
ition
by
heal
th a
nd
soci
al c
are
team
look
ing
afte
r in
divi
dual
with
ad
vanc
ed in
cura
ble
illne
ss
-ch
ange
in s
ocia
l ci
rcum
stan
ces
Fast
Tra
ck f
or
con
tin
uin
gh
ealt
h c
are
nee
ded
?
Yes No
Ass
essm
ent
for
pre
ferr
ed
pla
ce o
f ca
re
Tran
sfer
to
p
refe
rred
p
lace
of
care
E.g.
-re
mai
n at
hom
e-
hosp
ice
etc
Co
nd
itio
nd
eter
iora
tin
gan
d p
oss
ibly
ente
rin
g d
yin
gp
has
e
Yes
Go
to
p
age
10
No
Go
to
Pag
e 9
‘Cau
se f
or
con
cern
’re
gis
ters
fo
r ad
van
ced
kid
ney
d
isea
se
Rec
og
nit
ion
of
trig
ger
s fo
r En
d o
f Li
fe C
are
dis
cuss
ion
(G
old
St
and
ard
s Pr
og
no
stic
In
dic
ato
r)
Diabetes End of Life Care Servicesintervention Map
8
9
NH
S D
iab
etes
Dia
bet
es E
nd
of
Life
Car
e
E.g.
-si
ngle
as
sess
men
t pr
oces
s
-co
mm
on
asse
ssm
ent
fram
ewor
k
-re
view
of
diab
etes
car
e pl
an
-ac
cord
ing
to
agre
ed p
roto
cols
Fro
m
pag
e 8
-ac
cord
ing
to a
gree
d pr
otoc
ols
-op
tion
of
adva
nce
care
pl
anni
ng, e
.g.
Pref
erre
d pr
iorit
ies
of c
are
-op
tion
of
appo
intin
g La
stin
g Po
wer
of
Att
orne
y
- cl
arity
on
resu
scita
tion
-sp
iritu
al c
are
-si
ngle
poi
nt o
f ac
cess
for
Eo
LC
-di
abet
es c
are
team
/ car
e co
-or
dina
tor
info
rmed
Co
nti
nu
ing
ca
re f
or
dia
bet
es/
com
plic
atio
ns
Co
-ord
inat
ion
o
f Eo
LC
serv
ices
Dat
e o
f ca
re
pla
n r
evie
w
agre
ed
info
rmat
ion
on
-24
hou
r te
leph
one
help
line
-ra
pid
resp
onse
co
mm
unity
nurs
ing
care
-sp
ecia
list
palli
ativ
e ca
re
Car
e p
lan
nin
g
revi
ew
-ac
cord
ing
to
agre
ed p
roto
cols
-co
mm
unic
atio
n w
ith d
iabe
tes
care
tea
m
Rev
iew
of
care
r’s
nee
ds
-ac
cord
ing
to
agre
ed p
roto
cols
-co
mm
unic
atio
n w
ith d
iabe
tes
care
te
am
Co
nd
itio
n
det
erio
rati
ng
an
d p
oss
ibly
en
teri
ng
dyi
ng
p
ase
YesNo
Go
to
p
age
10
Full
asse
ssm
ent
of
nee
ds
Ass
essm
ent
of
care
r’s
nee
ds
Op
en
dis
cuss
ion
w
ith
in
div
idu
alan
d c
arer
o
n t
he
app
roac
h
to E
nd
of
Life
Car
e p
lan
ag
reed
id
enti
fyin
g
pre
ferr
ed
pri
ori
ties
fo
r ca
re (
typ
e an
d lo
cati
on
o
f Eo
LC)
End
of
Life
C
are
co-
ord
inat
ion
p
roce
ss
iden
tifi
ed
-lin
k w
ith
diab
etes
ca
re p
lan
10
NH
S D
iab
etes
Dia
bet
es E
nd
of
Life
Car
eC
are
in t
he
last
day
s o
f lif
e
Fro
m
pag
es 8
an
d 9
Rev
iew
of
nee
ds
and
p
refe
ren
ces
for
pla
ce o
f d
eath
-re
cogn
ition
of
wis
hes
rega
rdin
g re
susc
itatio
n
-sp
iritu
al c
are
-in
form
atio
n on
ou
t of
hou
rs
palli
ativ
e ca
re
serv
ices
-in
form
atio
n to
di
abet
es c
are
team
Tran
sfer
to
p
refe
rred
p
lace
of
dea
th,
as a
gre
ed w
ith
in
div
idu
al/
care
r
Ap
pro
pri
ate
EoLC
as
per
in
div
idu
al’s
w
ish
es
-co
mfo
rt m
easu
res,
e.
g. P
allia
tive
dial
ysis
fo
r ad
vanc
ed k
idne
y di
seas
e
-an
ticip
ator
y pr
escr
ibin
g of
m
edic
ines
, for
sy
mpt
om c
ontr
ol
-di
scon
tinua
tion
of
inap
prop
riate
in
terv
entio
ns, e
.g.
DN
AR,
dia
bete
s m
edic
atio
n
-ps
ycho
logi
cal c
are
-sp
iritu
al c
are
-ca
re o
f th
e fa
mil y
Ind
ivid
ual
die
sTi
mel
y ve
rifi
cati
on
of
dea
th
-ac
cord
ing
to
agre
ed p
roto
cols
-in
form
atio
n to
ca
rer
-su
ppor
t to
car
er
-in
form
atio
n to
pr
imar
y ca
re t
eam
/di
abet
es t
eam
Cer
tifi
cati
on
o
f d
eath
-ac
cord
ing
to
agre
ed p
roto
cols
-in
form
atio
n to
ca
rer
-su
ppor
t to
car
er
-re
ferr
al t
o co
rone
r ac
cord
ing
to a
gree
d pr
otoc
ols,
if
requ
ired
Emo
tio
nal
an
d
pra
ctic
alb
erea
vem
ent
sup
po
rt t
o
care
r an
d
fam
ily
-ac
cord
ing
to
agre
ed
prot
ocol
s
Dis
char
ge
fro
m
the
serv
ice
11
IntroductionThis contracting framework sets out what is requiredof clinically safe and effective services that areproviding End of Life Care for people with diabetes.The framework is designed to be read in conjunctionwith the Diabetes End of Life Care servicesintervention map, which describes the interventionsand actions required along the patient pathway aswell as entry and exit points and the standard servicespecification template for Diabetes End of Life Careservices.
The framework brings together the key quality areasand standards that have been identified by NHSDiabetes, Diabetes UK, the Royal Colleges and otherrelated organisations. This framework supports theNational End of Life Care Strategy1 and Informationto commissioners2 on commissioning these services.
The principles that establish a safepathway for patient care Establishing the principles that underpin the systemsand processes of pathways for patient care leads tomore efficient patient throughput and can reducerisk of fragmentation of care and serious untowardincidents. The principles operate at four layers withina 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 in whichthe overall management including both Clinical CaseDirection and the delivery of the clinical processesconventionally sits within one organisation. However,with a more complex pathway, there is a danger thatfracturing the overall management pathway intocomponents carried out by different clinical teamsand organisations will require duplication of effortleading to inefficiency and increased risk at handoverpoints.This can be managed by establishing cleargovernance arrangements for all the layers in thepathway.
In addition, Commissioning Bodies must balance thebenefits of fracturing the pathway against increasedcomplexity and ensure that the increased risks aremitigated.
The governance arrangements required for all threelayers and the commissioner responsibilities areshown below:
Contracting Framework for DiabetesEnd of Life Care Services
12
In essence, at each level, there are governancearrangements to ensure sound and safe systems ofdelivery of patient care with clear lines ofaccountability between each level.
Diabetes end of life careThe key principles of good diabetes end of life careservices is to provide a high quality service that isreliable in terms of delivery and timely access forpatients requiring that care.
Diabetes end of life care services are provided by anumber of different teams in the primary,community and acute setting. It is essential thatthere is co-ordination of care of the patientsthrough the care planning process and that theindividual’s GP/consultant diabetologist andspecialist palliative care professionals retain jointclinical accountability and responsibility for overallpatient care and overall responsibility for themanagement of side effects. Each professional is,however, responsible for their own actions.
As with other diabetes services, the managementof individuals with diabetes who require end oflife care should include an assessment of theirphysical, emotional and psychological well-being,together with timely access to appropriatepsychological and biological/psychiatricinterventions3. In addition, support for carers andfamilies, the provision of timely information andaccess to spiritual care services are essentialcomponents of care for people nearing the end oflife1.
The services themselves will also have clinicaloversight and accountability for governancepurposes.
This contracting framework describes the care tobe provided for:
i) individuals with diabetes who have advanced,incurable illness,
ii) individuals who are in the terminal phases ofthe complications of diabetes, e.g. advancedrenal disease, heart failure or stroke
This Contracting Framework should also be read inconjunction with the diabetes commissioningguides for diagnosis and continuing care, olderpeople and the complications of diabetes (diabetesand kidney care, and cardiovascular complicationsof diabetes) follow the principles for the effectivecommissioning of services for people with LearningDisabilities4.
Ensuring qualityCommissioning Bodies should ensure that thediabetes and End of Life Care servicescommissioned are of the highest quality. There may, in addition, be some organisations thatwish to offer their services, but do not have ahistory of providing such care.
i) for provider organisations already involved in thedelivery of diabetes and End of Life Care services,there should be retrospective evidence of systemsbeing in place, implemented 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 for safeand effective delivery of diabetes and End of LifeCare services to be provided.
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)5. (The cross references also apply to theclauses and schedules in the Standard NHS Contractfor Acute Services).This is to assist commissionersand providers in having an overview of how theelements link to the Standard NHS Contract. Some of the areas are open to interpretation andconsequently the references are not exhaustive.
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
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 th
e or
gani
satio
n’s
purp
ose
with
exp
licit
com
mitm
ent
to p
rovi
ding
hig
h qu
ality
ser
vice
s
A c
ultu
re th
at d
emon
stra
tes
anop
en le
arni
ng e
thos
An
orga
nisa
tion
that
is le
gal a
ndet
hica
l in
all i
ts a
ctiv
ities
Prov
ider
mus
t hav
e or
gani
satio
nal s
truc
ture
that
pro
vide
s le
ader
ship
for a
ll pr
ofes
sions
and
disc
iplin
es
In p
artic
ular
, the
re m
ust b
e a
corp
orat
ecl
inic
al d
irect
or w
ith th
e re
spon
sibili
ty a
ndac
coun
tabi
lity
for t
he c
linic
al s
ervi
ce
Ther
e m
ust b
e a
lear
ning
fram
ewor
k in
the
orga
nisa
tion
Ther
e sh
ould
be
a de
signa
ted
clin
ical
dire
ctor
with
resp
onsib
ility
and
acco
unta
bilit
y fo
r the
dia
bete
s en
d of
life
car
e se
rvic
es
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
isatio
nal a
nd i
nteg
rate
dgo
vern
ance
sys
tem
s an
d st
ruct
ures
in p
lace
with
cle
ar li
nes
of a
ccou
ntab
ility
and
resp
onsi
bilit
ies
for a
ll fu
nctio
ns. T
his
incl
udes
inte
rfac
es a
nd tr
ansi
tions
bet
wee
n se
rvic
es
Qua
lity
Gov
erna
nce
in th
e N
HS.
A g
uide
for p
rovi
der b
oard
s6
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
onsi
bilit
y fo
r all
clin
ical
gove
rnan
ce fu
nctio
ns
e.g.
• C
linic
al A
udit
• C
linic
al R
isk
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
• R
aisin
g C
once
rns
All
sub-
cont
ract
ors
mus
t mee
t gov
erna
nce
and
lead
ersh
ipar
rang
emen
ts o
f the
mai
n pr
ovid
er o
rgan
isatio
n
Com
miss
ione
r, pr
ovid
er a
nd/o
r NH
S Li
tigat
ion
Aut
horit
y m
ust
revi
ew th
e C
linic
al N
eglig
ence
Sch
eme
for T
rust
s ar
rang
emen
ts /o
rot
her o
rgan
isatio
nal /
pro
fess
iona
l ind
emni
ty a
rran
gem
ents
The
serv
ice
shou
ld h
ave
in p
lace
writ
ten
prot
ocol
s an
d pr
oced
ures
defin
ing
clea
r lin
es o
f acc
ount
abili
ty a
nd re
spon
sibili
ty.
The
serv
ice
is re
quire
d to
com
ply
with
gui
delin
es, p
ublic
hea
lthgu
idan
ce a
nd a
ppra
isals
publ
ished
by
the
Nat
iona
l Ins
titut
e fo
rH
ealth
and
Clin
ical
Exc
elle
nce
that
are
rele
vant
to th
e ca
repr
ovid
ed b
y th
e se
rvic
e 7
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
Gov
erna
nce
Mod
ule
D:
Sche
dule
s:
3,6,
10,1
1,15
,17
• S
taff
Dev
elop
men
t•
Com
plai
nts
Man
agem
ent
• P
atie
nt a
nd P
ublic
Invo
lvem
ent
• P
atie
nt d
igni
ty a
nd re
spec
t •
Equ
ality
and
div
ersi
ty•
Intr
oduc
ing
new
tech
nolo
gies
and
trea
tmen
ts•
An
exte
rnal
ly a
ccre
dite
d Q
ualit
y A
ssur
ance
syst
em a
nd in
tern
al e
rror
repo
rtin
gin
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
sw
ith c
olla
bora
tive
CG
act
iviti
es a
nd s
harin
gof
exp
erie
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
eeC
omm
issio
ning
for Q
ualit
y an
d In
nova
tion
sche
mes
(CQ
UIN
) for
dia
bete
s ca
re, 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 11
In a
dditi
on, t
he s
ervi
ce is
requ
ired
to c
ompl
y w
ith th
e fo
llow
ing:
i.
Gui
danc
e pu
blish
ed b
y N
ICE
• Im
prov
ing
supp
ortiv
e an
d pa
lliat
ive
care
for a
dults
with
can
cer
8
• M
edic
ines
adh
eren
ce: i
nvol
ving
pat
ient
s in
dec
ision
s ab
out
pres
crib
ed m
edic
ines
and
sup
port
ing
adhe
renc
e 9
ii. G
uida
nce
publ
ished
by
the
Dep
artm
ent o
f Hea
lth a
nd M
arie
Cur
ie P
allia
tive
Car
e In
stitu
te
• G
uide
lines
for L
iver
pool
Car
e Pa
thw
ay D
rug
Pres
crib
ing
inA
dvan
ced
Chr
onic
Kid
ney
Dise
ase
10
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
clin
ical
qua
lity
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
Dia
bete
s se
rvic
es m
ust c
ompl
y w
ith th
e pe
rfor
man
ce m
easu
res
requ
ired
of N
HS
serv
ices
, i.e
mee
ting:
12
• R
efer
ral t
o Tr
eatm
ent w
aits
(95t
h pe
rcen
tile
mea
sure
s)
• A
&E
Qua
lity
Indi
cato
rs
The
Prov
ider
is re
quire
d to
mee
t the
qua
lity
mar
kers
and
mea
sure
s fo
r End
of L
ife C
are
13
The
Prov
ider
is re
quire
d to
par
ticip
ate
in a
gree
d au
dits
e.g
.:
• N
atio
nal C
are
of th
e D
ying
aud
it 14
• V
iew
s of
Info
rmal
Car
ers
– Ev
alua
tion
of S
ervi
ces
15
• D
iabe
tes
E 16
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/ 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 are
com
pete
nt a
nd fi
t for
pur
pose
Prov
ider
to s
atisf
y co
mm
issio
ner t
hat a
ll st
aff
have
cur
rent
app
raisa
l, cl
eara
nces
and
regi
stra
tion
chec
ks a
nd h
ave
dem
onst
rate
dco
mpe
tenc
e in
all
proc
edur
es re
leva
nt to
path
way
.
The
Pro
vide
r to
satis
fy c
omm
issio
ner t
hat t
hey
can
recr
uit (
orpr
ocur
e) a
nd re
tain
a c
ompe
tent
clin
ical
team
to d
eliv
er th
ese
rvic
e
The
staf
f pro
vidi
ng d
iabe
tes
end
of li
fe c
are
serv
ices
in a
llor
gani
satio
ns, e
.g. m
edic
al p
ract
ition
ers,
nur
ses,
alli
ed h
ealth
prof
essio
nals,
pha
rmac
ists,
soc
ial c
are
staf
f, ch
apla
ins,
mor
tuar
yan
d am
bula
nce
staf
f etc
mus
t hol
d th
e re
leva
nt re
gist
ratio
n w
ithth
eir p
rofe
ssio
nal b
odie
s, w
here
app
ropr
iate
. The
y m
ust a
lso h
ave
appr
opria
te le
vel o
f pos
tgra
duat
e tr
aini
ng
The
wor
kfor
ce g
roup
s ar
e 1 :
Gro
up A
– s
taff
wor
king
in s
peci
alist
pal
liativ
e ca
re w
ho s
pend
mos
t of t
heir
wor
king
live
s de
alin
g w
ith e
nd o
f life
car
e.
This
grou
p sh
ould
hav
e sp
ecia
list t
rain
ing
in e
nd o
f life
car
ein
clud
ing
com
mun
icat
ion
skill
s, a
sses
smen
t, ad
vanc
e ca
repl
anni
ng a
nd s
ympt
om m
anag
emen
t
Gro
up B
: e.g
. sta
ff w
orki
ng in
dia
bete
s ca
re w
ho fr
eque
ntly
dea
lw
ith e
nd o
f life
car
e as
par
t of t
heir
role
. Thi
s gr
oup
shou
ld h
ave
spec
ialis
t tra
inin
g in
end
of l
ife c
are
incl
udin
g co
mm
unic
atio
nsk
ills,
ass
essm
ent,
adva
nce
care
pla
nnin
g an
d sy
mpt
omm
anag
emen
t. Sp
ecifi
cally
this
grou
p sh
ould
hav
e th
e sk
ills
to d
eal
with
the
‘trig
ger’
disc
ussio
ns a
t the
sta
rt o
f the
pat
hway
and
cont
inui
ng c
are
Gro
up C
: e.g
. sta
ff w
orki
ng in
dia
bete
s ca
re w
ho d
eal
infr
eque
ntly
with
end
of l
ife c
are.
This
grou
p sh
ould
hav
e a
basic
gro
undi
ng in
the
prin
cipl
es a
ndpr
actic
e of
end
of l
ife c
are
and
know
whe
n to
refe
r or s
eek
expe
rtad
vice
All
heal
thca
re p
rofe
ssio
nals
invo
lved
in d
eliv
erin
g di
abet
es e
nd o
flif
e ca
re a
re re
quire
d to
hav
e th
e re
leva
nt c
ompe
tenc
ies
17
Ther
e sh
ould
be
trai
ning
on
deat
h ce
rtifi
catio
n fo
r jun
ior d
octo
rsin
trai
ning
1 .
All
heal
th a
nd s
ocia
l car
e pr
ofes
siona
ls sh
ould
hav
e co
reco
mpe
tenc
ies
in s
pirit
ual,
cultu
ral a
nd re
ligio
us c
are
1
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
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 s
atisf
y th
e co
mm
issio
ner t
hat a
llst
aff h
ave
had
docu
men
ted
com
pete
nce
asse
ssm
ent r
elat
ive
to a
ll eq
uipm
ent u
sed
inco
ntra
ct.
All
heal
thca
re p
rofe
ssio
nals
invo
lved
in d
eliv
erin
g di
abet
es a
nden
d of
life
car
e ar
e re
quire
d to
hav
e th
e re
leva
nt c
ompe
tenc
ies
inus
ing
appr
opria
te e
quip
men
t 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
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
ssis
tanc
e to
deve
lop
thei
r ski
lls, k
now
ledg
e an
dex
perie
nce
to e
nsur
e th
at th
ey a
real
way
s fu
lly u
pdat
ed
Prov
ider
to s
atis
fy c
omm
issi
oner
of t
heir
com
mitm
ent t
o in
duct
ion
and
CPD
rele
vant
to ro
les
Prov
ider
to s
atisf
y th
e co
mm
issio
ner o
f the
irco
mm
itmen
t to
trai
n st
aff t
o m
eet f
utur
ese
rvic
e ne
eds
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
Info
rmat
ion
to s
uppo
rt h
ealth
and
soc
ial c
are
prof
essio
nals
onen
d of
life
car
e ca
n be
foun
d at
ww
w.e
ndof
lifec
aref
orad
ults
.nhs
.uk
Clin
ical
qua
lity
Regi
stra
tion
and
licen
sing
Cro
ss re
fere
nces
to th
eSt
anda
rd N
HS
Con
trac
t for
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
Com
preh
ensiv
e un
ders
tand
ing
and
com
mitm
ent t
o im
plem
entin
gna
tiona
l sta
ndar
ds
Com
plia
nce
with
Car
e Q
ualit
y C
omm
issi
onre
quire
men
ts fo
r reg
istra
tion
for p
rimar
y an
dse
cond
ary
care
Com
plia
nce
with
the
follo
win
g N
atio
nal S
ervi
ce F
ram
ewor
ks a
ndSt
rate
gies
, whe
re a
pplic
able
:
• L
ong
Term
Con
ditio
ns N
SF 18
• R
enal
NSF
19
• N
atio
nal E
nd o
f Life
Car
e St
rate
gy 1
• E
nd o
f Life
Car
e in
Adv
ance
d K
idne
y D
iseas
e 20
Com
plia
nce
with
Car
e Q
ualit
y C
omm
issio
n Re
view
s
17
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
onsi
vene
ss a
nd p
artic
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 p
oint
s m
ust b
ede
fined
with
com
preh
ensiv
e pa
tient
path
way
s th
at fa
cilit
ate
smoo
th p
assa
ge a
ndef
fect
ive,
eff
icie
nt c
are
for p
atie
nts
All
inte
rfac
es in
the
path
way
mus
t be
defin
ed s
o th
at c
ontin
uity
of c
linic
al c
are
isen
sure
d w
ith n
o fr
actu
ring
of th
e pa
thw
ay
Ther
e m
ust b
e sp
ecifi
catio
n of
cle
ar ti
mel
ines
and
aler
t mec
hani
sms
for p
oten
tial b
reac
hes
Ther
e sh
ould
be
audi
t of p
athw
ay to
ens
ure
that
sta
ndar
ds a
re m
et
Ther
e m
ust b
e ex
plic
it sp
ecifi
catio
n of
prov
ider
and
com
miss
ione
r res
pons
ibili
ties
for t
he w
hole
pat
ient
epi
sode
from
regi
stra
tion
to c
are
afte
r dea
th
Acc
ount
abili
ties
shou
ld b
e ag
reed
and
docu
men
ted
by a
ll st
akeh
olde
rs
Ther
e ar
e a
num
ber o
f ser
vice
s su
ppor
ting
patie
nts
with
dia
bete
s w
ho re
quire
End
of
Life
car
e an
d th
ere
mus
t be
clea
r sub
cont
ract
s st
atin
g th
e re
ferr
al c
riter
ia a
ndac
cess
to th
ese
supp
ortin
g se
rvic
es.
The
path
way
sho
uld
follo
w th
e pr
inci
ples
iden
tifie
d by
the
Nat
iona
l End
of L
ife C
are
Stra
tegy
1
i. di
scus
sions
as
the
end
of li
fe a
ppro
ache
sii.
ass
essm
ent,
care
pla
nnin
g an
d re
view
iii. c
o-or
dina
tion
of in
divi
dual
pat
ient
car
eiv.
del
iver
y of
hig
h qu
ality
ser
vice
s in
diff
eren
t set
tings
v. c
are
in th
e la
st d
ays
of li
fevi
. car
e af
ter d
eath
End
of L
ife C
are
disc
ussio
ns:
This
incl
udes
:
• e
arly
iden
tific
atio
n of
a p
atie
nt w
ho m
ay b
e ap
proa
chin
g th
een
d of
life
• re
cogn
ition
of t
rigge
rs fo
r end
of l
ife c
are
disc
ussio
n (G
old
Stan
dard
s Pr
ogno
stic
Indi
cato
r)24
Ass
essm
ent,
care
pla
nnin
g an
d re
view
:Th
is in
clud
es:
• fa
st tr
ack
asse
ssm
ent f
or p
refe
rred
pla
ce o
f car
e if
the
patie
nt’s
cond
ition
is d
eter
iora
ting
rapi
dly
• F
ull a
sses
smen
t of n
eeds
of t
he p
atie
nt a
nd th
eir c
arer
, e.g
.sin
gle
asse
ssm
ent p
roce
ss o
r com
mon
ass
essm
ent f
ram
ewor
k•
Agr
eem
ent o
f a c
are
plan
that
iden
tifie
s th
e pr
efer
red
prio
ritie
sfo
r car
e (ty
pe a
nd lo
catio
n of
end
of l
ife c
are)
• C
o-or
dina
ting
the
End
of L
ife C
are
plan
to th
e di
abet
es c
are
plan
, as
appr
opria
te
• T
here
sho
uld
be ‘d
o no
t att
empt
resu
scita
tion’
pol
icie
s th
at a
re
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
k21C
ompl
ianc
e w
ith th
e Q
ualit
y St
anda
rds
for D
iabe
tes
22
Com
plia
nce
with
the
Qua
lity
Stan
dard
s fo
r End
of L
ife C
are
23
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
Patie
nt p
athw
ayA
t ent
ry to
pat
hway
:
The
Com
miss
ione
r sho
uld
assu
re th
emse
lves
that
the
prov
ider
has
sys
tem
s an
d pr
oces
ses
in p
lace
to
i) re
gist
er p
atie
nts
ii) c
olle
ct re
leva
nt c
linic
al a
ndad
min
istra
tive
data
iii) m
anag
e th
e ap
poin
tmen
t pro
cess
,(re
appo
intm
ent a
nd 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 i
n th
eap
prop
riate
loca
tion
At p
oint
of i
nter
vent
ion:
The
Com
miss
ione
r sho
uld
assu
re th
emse
lves
that
the
prov
ider
has
sys
tem
s an
d pr
oces
ses
in p
lace
to e
nsur
e th
at:
i) th
e in
terv
entio
n is
cond
ucte
d sa
fely
and
in a
ccor
danc
e w
ith a
ccep
ted
qual
ityst
anda
rds
and
good
clin
ical
pra
ctic
e.ii)
the
patie
nt re
ceiv
es a
ppro
pria
te c
are
durin
g th
e in
terv
entio
n(s)
, inc
ludi
ng o
ntr
eatm
ent r
evie
w a
nd s
uppo
rt, i
nac
cord
ance
with
bes
t clin
ical
pra
ctic
eiii
) whe
re c
linic
al e
mer
genc
ies
orco
mpl
icat
ions
do
occu
r the
y ar
em
anag
ed in
acc
orda
nce
with
bes
tcl
inic
al p
ract
ice
iv) t
he in
terv
entio
n is
carr
ied
out i
n a
faci
lity
whi
ch p
rovi
des
a sa
feen
viro
nmen
t of c
are
and
min
imis
es ri
skto
pat
ient
s, s
taff
and
visi
tors
v) th
e in
terv
entio
n is
unde
rtak
en b
y st
aff
with
the
nece
ssar
y qu
alifi
catio
ns, s
kills
,ex
perie
nce
and
com
pete
nce
vi) T
here
are
arr
ange
men
ts fo
r the
man
agem
ent o
f out
of h
ours
car
eac
cord
ing
to b
est c
linic
al p
ract
ice
cons
isten
t with
oth
er lo
cal p
rovi
ders
in th
e lo
calit
y
Co-
ordi
natio
n an
d de
liver
y of
pat
ient
car
e:Th
is in
clud
es:
• Id
entif
icat
ion
of a
co-
ordi
nato
r for
the
end
of li
fe c
are
• C
omm
unic
atio
n w
ith th
e di
abet
es c
are
team
• In
form
atio
n on
o 24
hou
r tel
epho
ne h
elpl
ines
o ra
pid
resp
onse
com
mun
ity n
ursin
g ca
reo
Spec
ialis
t pal
liativ
e ca
re•
Con
tinui
ng c
are
of th
e pa
tient
by
the
diab
etes
team
, as
appr
opria
te
Car
e in
the
last
day
s of
life
:Th
is in
clud
es:
• R
ecog
nitio
n th
at th
e pa
tient
’s c
ondi
tion
is de
terio
ratin
g•
The
re s
houl
d be
pro
toco
ls in
pla
ce to
reco
gnise
pat
ient
s w
hoar
e ap
proa
chin
g th
e en
d of
life
, or w
ho a
re a
t sub
stan
tial r
iskof
dyi
ng o
n ad
miss
ion
to h
ospi
tal
• R
evie
w o
f ne
eds
and
pref
eren
ces
for p
lace
of d
eath
• T
here
sho
uld
be h
ando
ver a
nd c
omm
unic
atio
n pr
otoc
ols
inpl
ace
to e
nsur
e th
at o
ut o
f hou
rs p
rovi
ders
who
rece
ive
calls
from
pat
ient
s ap
proa
chin
g th
e en
d of
life
imm
edia
tely
iden
tify
and
tran
sfer
thes
e ca
lls to
an
appr
opria
te c
linic
ian
who
is a
war
eof
the
back
grou
nd to
the
call,
the
patie
nt’s
wish
es a
nd if
poss
ible
Adv
ance
Car
e Pl
anni
ng. T
here
may
be
a de
dica
ted
tele
phon
e lin
e•
The
re s
houl
d al
so b
e tim
ely
acce
ss to
equ
ipm
ent,
e.g.
syr
inge
driv
er, m
edic
atio
n et
c du
ring
wor
king
and
out
of h
ours
• T
rans
fer t
o th
e pl
ace
of d
eath
, if r
equi
red,
as
agre
ed w
ith th
epa
tient
/car
er•
App
ropr
iate
end
of l
ife c
are
as p
er th
e pa
tient
’s w
ishes
Car
e af
ter d
eath
:Th
is in
clud
es:
• T
here
sho
uld
be p
olic
ies
in p
lace
to e
nsur
e th
e tim
ely
verif
icat
ion
of d
eath
. Thi
s m
ay in
clud
e ve
rific
atio
n by
nur
ses
• C
ertif
icat
ion
of d
eath
(ref
eren
ce s
houl
d be
mad
e to
dia
bete
s as
a ca
use
of d
eath
)•
Em
otio
nal a
nd p
ract
ical
ber
eave
men
t sup
port
to c
arer
and
fam
ily
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
Clin
ical
qua
lity
Patie
nt p
athw
ayA
t exi
t fro
m p
athw
ay:
The
Com
miss
ione
r sho
uld
assu
re th
emse
lves
that
pro
vide
r has
sys
tem
s an
d pr
oces
ses,
whi
ch a
re a
gree
d w
ith a
ll pa
rtie
s an
dne
twor
ks, i
n pl
ace
to:
i) pr
ovid
e tim
ely
feed
back
to th
e re
ferr
erre
: End
of L
ife c
are
and
care
aft
er d
eath
• T
here
sho
uld
be p
olic
ies
in p
lace
to e
nsur
e th
e se
nsiti
veha
ndlin
g of
the
dece
ased
and
rela
tives
acc
ordi
ng to
thei
rcu
ltura
l and
spi
ritua
l wish
es•
The
re s
houl
d be
pro
toco
ls in
pla
ce to
ens
ure
the
corr
ect
iden
tific
atio
n of
the
dece
ased
and
that
per
sona
l pos
sess
ions
are
hand
led
in a
saf
e an
d se
nsiti
ve w
ay
Patie
nts
and
thei
r fam
ilies
/car
ers
may
nee
d to
acc
ess
a co
mpl
exco
mbi
natio
n of
diff
eren
t ser
vice
s as
par
t of t
heir
palli
ativ
e ca
re a
sfo
llow
s 1 :
• P
rimar
y ca
re•
Dist
rict n
ursin
g ca
re•
Per
sona
l soc
ial c
are
• P
sych
olog
ical
sup
port
•
Acu
te m
edic
al c
are
• S
peci
alist
pal
liativ
e ca
re•
Out
of h
ours
car
e•
Am
bula
nce/
tran
spor
t•
Info
rmat
ion
serv
ices
• R
espi
te c
are
• S
peec
h an
d la
ngua
ge th
erap
y•
Equ
ipm
ent
• O
ccup
atio
nal t
hera
py•
Phy
sioth
erap
y•
Day
car
e•
Pha
rmac
y•
Fin
anci
al a
dvic
e•
Die
tetic
adv
ice
• C
arer
sup
port
• S
pirit
ual c
are
• C
omm
unity
and
vol
unta
ry s
ecto
r sup
port
• In
terp
rete
r ser
vice
s•
Wel
fare
sup
port
• E
mpl
oym
ent s
uppo
rt•
Ber
eave
men
t cou
nsel
ling
Patie
nts
and
thei
r fam
ilies
/car
ers
shou
ld h
ave
info
rmat
ion
on th
era
nge
of s
ervi
ces
avai
labl
e fo
r End
of L
ife c
are,
e.g
. a d
irect
ory
oflo
cal s
ervi
ces
Prov
ider
s ar
e re
quire
d to
take
not
e of
the
resu
lts o
f the
Nat
iona
lSu
rvey
of P
eopl
e w
ith D
iabe
tes
25
20
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
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
Any
bui
ldin
gs in
whi
ch c
are
is pr
ovid
ed a
nd m
ortu
ary
faci
litie
ssh
ould
be
of a
hig
h st
anda
rd a
nd s
houl
d m
eet t
he n
eeds
of
rela
tives
and
car
ers,
incl
udin
g th
ose
who
wish
to v
iew
the
body
afte
r dea
th 1
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
ut th
eor
gani
satio
n
Acc
essi
bilit
y to
exe
cutiv
e re
spon
sibl
e fo
r H&
Sfo
r qui
cker
, firs
t 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
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
fy th
emse
lves
that
pro
vide
r has
sys
tem
s, p
roce
sses
and
com
pete
nt p
erso
nnel
are
in p
lace
and
impl
emen
ted
to e
nsur
e th
at a
ll cl
inic
alem
erge
ncie
s an
d co
mpl
icat
ions
are
han
dled
in a
ccor
danc
e w
ith b
est p
ract
ice
Ther
e sh
ould
be
prot
ocol
s in
pla
ce to
reco
gnise
pat
ient
s w
ho a
reap
proa
chin
g th
e en
d of
life
, or w
ho a
re a
t sub
stan
tial r
isk o
fdy
ing
on a
dmiss
ion
to h
ospi
tal 1
Ther
e sh
ould
be
prot
ocol
s in
pla
ce to
ens
ure
that
out
of h
ours
prov
ider
s w
ho re
ceiv
e ca
lls fr
om p
atie
nts
appr
oach
ing
the
end
oflif
e tr
ansf
er im
med
iate
ly id
entif
y an
d tr
ansf
er th
ese
calls
to a
nap
prop
riate
clin
icia
n/or
ther
e m
ay b
e a
dedi
cate
d te
leph
one
line
(see
abo
ve) 1
21
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
that
cov
ers
• T
ypes
of d
ata
• 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
lysis
of d
ata
and
info
rmat
ion
• U
se o
f dat
a an
d in
form
atio
n•
Diss
emin
atio
n of
dat
a an
d in
form
atio
n•
Ris
ks•
Sha
ring
of d
ata
and
com
patib
ility
of I
Tac
ross
diff
eren
t pro
vide
rs w
ith re
spec
t to
care
of p
atie
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 Pla
n
Ther
e sh
ould
be
polic
ies
in p
lace
that
incl
ude:
• C
onfid
entia
lity
Cod
e of
Pra
ctic
e•
Dat
a Pr
otec
tion
• F
reed
om o
f Inf
orm
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 b
e a
nam
ed in
divi
dual
who
is th
eC
aldi
cott
Gua
rdia
n
The
Prov
ider
is re
quire
d to
hav
e in
form
atio
n sy
stem
s th
at re
cord
indi
vidu
al n
eeds
incl
udin
g em
otio
nal,
soci
al, e
duca
tiona
l,ec
onom
ic a
nd b
iom
edic
al in
form
atio
n w
hich
per
mit
mul
tidisc
iplin
ary
care
acr
oss
serv
ice
boun
darie
s an
d su
ppor
t car
epl
anni
ng fo
r bot
h di
abet
es a
nd E
nd o
f Life
car
e1, 2
6
The
prov
ider
mus
t ens
ure
that
robu
st s
yste
ms
are
in p
lace
for
chap
lain
s w
ho re
ques
t acc
ess
to p
atie
nt in
form
atio
n to
hav
eob
tain
ed p
rior p
atie
nt c
onse
nt1
The
Prov
ider
is re
quire
d to
con
trib
ute
to/s
uppo
rt lo
calit
y w
ide
regi
ster
s on
peo
ple
with
dia
bete
s w
ho a
re in
rece
ipt o
f End
of L
ifeca
re
The
Prov
ider
mus
t obt
ain
the
patie
nt’s
con
sent
prio
r to
plac
ing
anin
divi
dual
on
an E
nd o
f Life
Car
e re
gist
er
The
Prov
ider
is re
quire
d to
use
the
follo
win
g fo
r the
col
lect
ion
and
prod
uctio
n of
dat
a, w
here
app
ropr
iate
:
• N
HS
Out
com
es F
ram
ewor
k 21
• N
atio
nal D
iabe
tes
Info
rmat
ion
Serv
ice
27
• D
iabe
tes
E 16
• Q
ualit
y an
d O
utco
mes
Fra
mew
ork28
• M
yoca
rdia
l Isc
haem
ia A
udit
Proj
ect29
• H
ospi
tal E
piso
de S
tatis
tics30
• P
atie
nt E
xper
ienc
e 31
• P
atie
nt S
atisf
actio
n 24
22
Source documentsCommissioners and providers should takeresponsibility for making references to the latestversion of the various documents and guidance.
1. National End of Life Care Strategy - promoting
high quality care for all adults at the end of life,
July 2008, http://www.dh.gov.uk/en/Publications
andstatistics/Publications/PublicationsPolicyAndGui
dance/DH_086277
2. Information for commissioning end of life care,
National End of Life Care Programme, 2008,
http://www.endoflifecare.nhs.uk/eolc/files/NHS-
EoLC_Info_for_Commissioning_EoLC_Dec2008.pdf
3. Emotional and Psychological Support and Care in
Diabetes, Joint Diabetes UK and NHS Diabetes
Emotional and Psychological Support Working
Group, to be published early 2010
4. The NHS Diabetes Commissioning Guides are
available on the NHS Diabetes website at
http://www.diabetes.nhs.uk/commissioning_resource/
5. Standard NHS Contracts
http://www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_1
24324
6. National Quality Board, Quality Governance in the
NHS, 2011 http://www.dh.gov.uk/prod_consum_dh/
groups/dh_digitalassets/documents/digitalasset/dh_1
25239.pdf
7. NICE Diabetes guidance,
http://guidance.nice.org.uk/Topic/EndocrineNutritiona
lMetabolic/Diabetes
8. NICE, Improving supportive and palliative care for
adults with cancer,
http://guidance.nice.org.uk/CSGSP, 2004
9. NICE, Medicines adherence: involving patients in
decisions about prescribed medicines and supporting
adherence, Jan 2009,
http://guidance.nice.org.uk/CG76
10. Department of Health and Marie Curie Palliative
Care Institute, Guidelines for LCP Drug Prescribing
in Advanced Chronic Kidney Disease, 2008,
http://www.dh.gov.uk/prod_consum_dh/groups/dh_
digitalassets/documents/digitalasset/dh_085997.pdf
11. NHS Institute for Innovation and Improvement,
model CQUIN scheme: inpatient care for people
with diabetes, 2009
12. Department of Health, The Operating Framework
for the NHS in England 2011/12, 2010,
http://www.dh.gov.uk/en/Publicationsandstatistics/P
ublications/PublicationsPolicyAndGuidance/DH_122
738
13. End of Life Care Strategy, quality markers and
measures for end of life care, 2009,
http://www.dh.gov.uk/prod_consum_dh/groups/dh_
digitalassets/documents/digitalasset/dh_101684.pdf
14. The Marie Curie Palliative Care Institute Liverpool,
Royal College of Physicians and Clinical
Effectiveness and Evaluations Unit, National Care of
the Dying Audit, 2006/07,
http://www.rcplondon.ac.uk/clinical-
standards/ceeu/Documents/NCDAH-Generic-
Report.pdf
15. Views of Informal Carers – Evaluation of Services
(VOICES)
16. DiabetesE - https://www.diabetese.net/
17. National End of Life Care Programme, Skills for
Health, Skills for Care, Department of Health, Core
competences for end of life care. Training for health
and social care staff, 2009,
http://www.endoflifecare.nhs.uk/eolc/files/NHS-
EoLC_Core_competences-Guide-Jul2009.pdf
18. Department of Health, The National Service
Framework for Long Term Conditions, March 2005
http://www.dh.gov.uk/en/Publicationsandstatistics/P
ublications/PublicationsPolicyAndGuidance/DH_410
5361
19. Department of Health, The National Service
Framework for Renal Services, January 2004
http://www.dh.gov.uk/en/Healthcare/Renal/DH_410
2636
20. End of Life Care for Advanced Kidney Disease, A
framework for implementation, 2009,
http://www.endoflifecare.nhs.uk/eolc/files/NHS-
EoLC_Advanced_Kidney_Disease_Framework-
Jun2009.pdf
23
21. Department of Health, The NHS Outcomes
Framework 2011/12, December 2010
http://www.dh.gov.uk/en/Publicationsandstatistics
/Publications/PublicationsPolicyAndGuidance/DH_
122944
22. NICE, Quality Standards: Diabetes in adults, March
2011, http://www.nice.org.uk/guidance/
qualitystandards/qualitystandards.jsp
23. NICE, End of life care Quality Standard (in
development) due Nov 2011
http://www.nice.org.uk/guidance/qualitystandards/i
ndevelopment/endoflifecare.jsp
24. Gold Standards Framework,
http://www.goldstandardsframework.nhs.uk/
25. Healthcare Commission, National Survey of People
with Diabetes, 2006,
www.cqc.org.uk/usingcareservices/healthcare/patien
tsurveys/servicesforpeoplewithdiabetes.cfm
26. York and Humber integrated IT system
http://www.diabetes.nhs.uk/
27. National Diabetes Information Service,
www.diabetes-ndis.org
28. Quality and Outcomes Framework,
http://www.nice.org.uk/aboutnice/qof/qof.jsp
29. Myocardial Ischaemia Audit Project (MINAP)
www.rcplondon.ac.uk/CLINICAL-
STANDARDS/ORGANISATION/PARTNERSHIP/Pages/
MINAP-.aspx
30. Hospital Episode Statistics, www.ic.nhs.uk/statistics-
and-data-collections/hospital-care/hospital-activity-
hospital-episode-statistics--hes
31. The King’s Fund, The point of care. Measures of
patients’ experience in hospital: purpose, methods
and uses. July 2009
24
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 opento scrutiny and available to all service users/carersas a statement of standards that the user/carer canexpect to receive.
The following documentation, developed bythe Diabetes Commissioning Advisory Group,provides further detail/guidance to supportthe development of this specification:
• The diabetes End of Life Care intervention map
• The contracting framework for diabetes End ofLife Care services
This specification template assumes that theservices are compliant with the contractingframework for diabetes End of Life Care services.
This template also provides examples of whatcommissioners may wish to consider whendeveloping their own service specifications.
Description of diabetes End of LifeCare services: End of Life care is the support provided for anindividual when they have advanced, incurableillness, e.g. cancer, until they die. This care ismarked at the beginning of this phase in life by acomprehensive assessment of supportive andpalliative care needs of the individual concernedand their family. The support includes themanagement of pain and other symptoms,provision of psychological, social, spiritual andpractical help as well as support to the carersduring the illness and into their bereavement.
Individuals with diabetes may require end of lifecare for the complications of the condition, e.g.renal failure, heart disease, strokes etc.
The final specification should take intoaccount:
• national, network and local guidance andstandards for diabetes End of Life Careservices.
• local needs.
This specification is supported by other relatedwork in 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 forneeds assessment, planning and monitoring ofdiabetes services.
Introduction• A general overview of the services identifying
why the services are needed, includingbackground to the services and why they arebeing developed or in place.
• A statement on how the services relate to eachother within the whole system should beincluded describing the keystakeholders/relationships which influence theservices, e.g. multi-disciplinary team etc. This should describe the diabetic services and theirinteractions, as well as the specialist palliativecare services and then the relationship betweenthe services
• Any relevant diabetes and supportive andpalliative care clinical networks and screeningprogrammes applicable to the services
Standard Service SpecificationTemplate for Diabetes End of LifeCare Services
a Standard NHS Contracts http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124324
25
• Details of all interdependencies or sub-contractors for any part of the service and anoutline of the purpose of the contract should bestated, including arrangements for clinicalaccountability and responsibility, as appropriate
Purpose, Role and Clientele1. A clear statement on the primary purpose of the
services and details of what will be provided andfor whom:
• Who the services are for (e.g. individuals withdiabetes who require end of life care, i.e. arecognition by the patient and/or professionalteam that palliative care is required).
• 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 do the services do? This section will focus
on the types of high level therapeuticinterventions that are required for the types ofneed the services will respond to.
• How the services responds to age, culture,disability, and gender sensitive issues
• Assessment – details of what it is and co-morbidity assessment and referrals to allrelevant services/care
• Service planning – High level view of what theservices are and how they are used; howpatients enter the pathway/journey; what arethe stages undertaken and follow up care. Theaims of service planning are to:
o Develop, manage and reviewinterventions along the patient journey
o Ensure access to other services/care, asappropriate
o Ensure that care planning is undertakenby the diabetes multi-disciplinary team(as defined locally) with a clear care co-ordination function between hospitaland community diabetes, primary careand specialist palliative care services
• Holistic review of individuals who havediabetes using the principles of an integratedcare model for people with long term
conditions that is patient-centred, includingself care and self management, clinicaltreatment, facilitating independence,psychological support and other social careissues
• Risk assessment procedures
• Detail of evidence base of the services – i.e.the contracting framework for diabetes end oflife care, guidance produced by the RoyalCollege of Physicians, Diabetes UK, etc
• The scope of the services should reflect thekey actions and co-ordination of care mappedout on the intervention map
Service Delivery3. Patient Journey/pathway
Flow diagram of the patient pathway showingaccess and exit/transfer points – see the diabetesend of life care intervention map as a startingpoint
4. Treatment protocols/interventionsInclude all individual treatment protocols inplace within the services or planned to be used
5. This will include a breakdown of how thepatient will receive the services and from whom.It should be a clear statement of staffqualifications/experience and/or training (ifappropriate) and clinical or managerialsupervision arrangements. It should specify, asappropriate:
• Geographic coverage/boundaries – i.e. theservices should be available for all individualsof all ages groups who live in the clinicalcommissioning group area
• Hours of operation including, week-end, bankholiday and on-call arrangements
• Minimum level of experience andqualifications of staff (i.e. doctors –diabetologists and GPs, Nursing staff –diabetes nurse specialists, district, practicenurses etc, other allied health professionals,e.g. podiatrists, dietitians, optometrists,pharmacists etc and other support andadministrative staff). Each palliative careservice should comply with the Standardscontained in the NICE Guidance on SupportiveAnd Palliative Care (2004).
26
• Confirmation of the arrangements to identifythe Care Co-ordinator for each patient withdiabetes at the end of life (i.e. who holds theresponsibility and role). Alternatively, a keyworker should be identified in each team toensure close liaison and working relationshipsbetween them.
• Staff induction and developmental training.There should be a minimum level of trainingfor diabetic staff according to those specifiedcore competencies in the National End of LifeStrategy and agreed core competencies forthe Specialist Palliative Care Team in Diabetesmanagement
6. Equipment.
• Upgrade and maintenance of relevantequipment and facilities
• Technical specifications, e.g. specification forinsulin or subcutaneous end of life care pumpsaccording to agreed or national criteria
Identification, Referral andAcceptance criteria7. This should make clear how patients will be
identified, assessed (if appropriate) andaccepted to the services.
• Acceptance should be based on types of needand/or patient.
• This should include a fast tracking facility forpatients who require continuing healthcarewhose condition is deteriorating rapidly andwho may be entering a terminal phase.
8. 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 are patientsprioritised
Discharge/Service Complete9. The intention of this section is to make clear
when a patient and their carer/family no longerrequire the diabetes and end of life careservices.
• State how the service determines that apatient and their carer/family may improve soas to no longer require end of life care
• What procedures are followed up after thedeath of an individual who has used thediabetes and end of life service?
• State the services offered in bereavement care
Quality Standards10. The service is required to deliver care according
to the standards for clinical practice set by theNational Institute for Health and ClinicalExcellenceb
11. As a minimum, the Provider is required toagree a local Commissioning for Quality andInnovation scheme for services for people withdiabetes. (Insert details of the CQUIN Schemeagreed)
12. The service is required to deliver the outcomesfor diabetes as determined by the NHSOutcomes Frameworkc
Activity and PerformanceManagement13.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.
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.
b http://www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp
c http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
27
Continual Service Improvement15. As part of the monitoring and evaluation
procedures, the service will identify a methodof agreeing measurements for continuousimprovement of the service being offered andwork to ensure unmet need is both identifiedand brought to the attention of thecommissioner.
16. ReviewThis section should set out a review date and amechanism for review.
The review should include both thespecifications for continuing fitness forpurpose and the providers’ delivery against thespecification.
This should set out the process by which thisreview will be conducted.
This should also identify how complianceagainst the specification will be monitored inyear.
17. Agreed byThis should set out who agrees/accepts thespecification on behalf of all parties.
This should include the diabetes providers,commissioner and network
Further copies of this publication can be ordered from Prontaprint, by emailing [email protected] or tel: 0116 275 3333, quoting DIABETES 119
www.diabetes.nhs.uk
