What is the optimal way to deliver diabetes services? UK consultant paediatrician Dr Neil Hopper, in his presentation at a paediatric study day held by Diabetes Ireland, stressed that there was little difference in outcomes according to size of unit, but that proper service organisation and resourcing underscored by peer review were key, however the service was delivered.

Dr Hopper, who is consultant paediatrician at City Hospitals in Sunderland, England, outlined the importance of high-quality local diabetes care for families living with diabetes.

In this context he dealt with the issue of how best to deliver diabetes services; whether the best model is through a large number of local units, or to have a smaller number of larger units, or a ‘hub and spoke’ model, and which type of service organisation delivers the best outcomes.

He said there is a good deal of evidence to suggest that diabetes care can be successfully delivered in smaller units. England is currently divided into regional paediatric diabetes networks.

Dr Hopper dealt with the organisation of diabetes services in his local region in the north-east of England, Tyne and Wear and Teesside, which includes major urban diabetes units and smaller units treating between 55 and 280 patients each. The region includes large urban areas and extensive rural areas with a good deal of geographical isolation, and areas of considerable deprivation, which all add to the challenges of delivering diabetes care.

Dealing with a typical adolescent patient with diabetes and his needs, he said such a patient needs a motivated personal key worker who has a good relationship with the family. This worker needs to be part of a multidisciplinary team (MDT), which needs to have all the necessary skills and treatment options easily available, and that MDT needs to have good clinical governance and scrutiny of outcomes. The child accessing the service, Dr Hopper said, needs minimum disruption to his life and family finances and requires school and home visits from key workers.

He asked whether such a service is best delivered through larger or smaller local diabetes centres. Dr Hopper examined data relating to this across a number of studies. Some studies showed no significant difference in outcomes based on unit sizes.

Dr Hopper said national UK results from 2013 to 2014, while overall showing a trend towards lower HbA1c levels in the very big units, also showed that smaller units can achieve good HbA1c results too.

He felt that in terms of convenience for patients, optimal diabetes services can be best delivered through a local MDT.

Crucially, however, variation in practice needs to be eliminated, and to achieve this, services need to be organised properly. With this aim in mind, in England,  services had been grouped together into effective and robust clinical networks.

An important part of this process is a ‘best practice tariff’ – a payment made available to spend on additional staff and to improve services. In order to attract this payment, services need to achieve 13 specific care outcome measures. However, services that do not score highly enough will not receive the tariff.

Dr Hopper said this process forced every unit in the UK to start collecting robust outcomes data. Standardisation of care and peer review were key components of the service reorganisation. This reorganisation, coupled with the data collection and audit processes, helped improve care. He stressed that until you have robust data, there is no real evidence that the work you are doing is the best you can do. He said there was now evidence that outcomes are improving in England and Wales, associated with the best practice tariff. He said he firmly believed it was possible to deliver good quality care in smaller units.

Dr Hopper said an important part of ensuring the development of standardised high quality care in England has been the development of regional guidelines for diabetes care, peer review, the holding of quarterly business meetings, and six-monthly outcome discussion, where units show each other their data. This process can help units with poorer outcomes to improve their performance.

He said since the service reorganisation, the mean HbA1c level in his region has reduced.

In summary, Dr Hopper pointed out that recent years had seen major changes in UK paediatric diabetes services encompassing reorganisation, additional investment and audit and peer review of results. 

However, there was a variability in how diabetes care teams had benefited. In order to continue to improve outcomes, there was a need to use the available evidence base to disseminate best practice from teams who are achieving good results, and identifying, supporting and challenging teams who are not doing so well.