Health CommitteeWritten evidence from the national Dose Adjustment For Normal Eating programme (LTC 75)

This submission is made on behalf of the national DAFNE programme and as such relates to the provision of structured education for adults with Type 1 diabetes.

Dose Adjustment For Normal Eating (DAFNE) is a skills-based structured education programme in flexible intensive insulin therapy and self-management for adults with type 1 diabetes. On a DAFNE course adults (17+ years) with type 1 diabetes are provided with the knowledge and skills to match their insulin dose to their chosen food intake, enabling them to manage their food choices on a meal by meal basis and in a range of different situations. Specially trained diabetes nurses and dietitians deliver every DAFNE course, which provides 38 hours of structured education to groups of 8 on an outpatient basis over five consecutive days or one day per week for five weeks.

The DAFNE Collaborative comprises all healthcare professionals involved in DAFNE from all of the participating training centres, steered by an elected DAFNE Executive Board. This central DAFNE function provides strategic leadership and direction to DAFNE development, research and implementation. DAFNE is a not for profit hosted within the NHS. The current funding structure relies on financial contributions from all participating diabetes services to sustain the key contributions to quality assurance, peer review and audit.

Provision of the DAFNE programme as a component of diabetes services for people with type 1 diabetes will achieve improved patient outcomes in terms of reduced complications and extended life expectancy with associated cost savings, improved quality of life, and fulfilment of the five NICE standard criteria for structured education.

The DAFNE Collaborative comprises all healthcare professionals involved in DAFNE from all of the participating centres, steered by the elected DAFNE Executive Board. The DAFNE programme is currently funded by annual contributions from all participating diabetes services.

Summary

The delivery of DAFNE can lead to better integration of primary and secondary care teams.

There should be dedicated and specific commissioning for adult type1 diabetes that is separate from services for type 2 diabetes.

Practical assistance with regard to the commissioning of structured education is available for commissioners.

Skills based structured education in intensive insulin therapy with an evidence base should be an integral part of the care pathway for type 1 diabetes and not be seen as an optional extra

Structured education, such as DAFNE, leads to educated and empowered people with type 1 diabetes who are better able to manage their condition.

Evidence from the DAFNE programme reveals that this training:

improves biomedical and psychological outcomes;

pays for itself within four—five years due to reduced development of long-term complications;

could produce an additional five years life expectancy; and

is both cost saving and cost effective.

Provision of structured education for type 1 diabetes which meets the nationally agreed criteria should be centrally funded, mandated and audited.

1. The Scope of Current Mix of Service Responsibilities so that People are Treated Outside of Hospital.

1.1 Doctors, diabetes specialist nurses and diabetes dietitians can be trained to deliver DAFNE to people with type 1 diabetes in any location. Traditionally, most type 1 diabetes care is delivered in hospitals, but many DAFNE diabetes teams deliver courses in community and primary care settings, and utilise staff from primary care teams. As such, this bridges the gap between primary and secondary care, and increases knowledge of type1 diabetes and its management within the primary care setting.

2. The Readiness of Local NHS and Social Care Services to Treat Patients with Long-Term Conditions (Including Multiple Conditions) within the Community

2.1 Type 1 diabetes is characterised by insulin deficiency that can only be treated with insulin injections. The management issues of type 1 diabetes are very different from type 2 diabetes, and require the input from experienced specialist teams, for example:

serious and costly medical emergencies due to insulin excess (hypoglycaemia) or deficiency (Diabetic Ketoacidosis—DKA); and

early age of onset results in long-term disease exposure with resultant complications of eyes, feet and kidneys. Type 1 diabetes costs the NHS £1.9 billion per year, half of which is spent on the treatment of complications.1

2.2 Currently the massive demand for type 2 diabetes services overwhelms the need for specialist type 1 diabetes care and it is neglected. We propose specific and specialised type 1 diabetes care is of paramount importance. The DAFNE Collaborative fully supports the Association of British Clinical Diabetologists (ABCD) “Lost Tribe” campaign for dedicated and specific commissioning for adult type 1 diabetes services in England.2

3. The Practical Assistance Offered to Commissioners to Support the Design of Services which Promote Community-Based Care and Provide for the Integration of Health and Social Care in the Management of Long-Term Conditions

3.1 DAFNE have been actively engaged with NHS Diabetes to provide education and support for commissioning of type 1 diabetes services.3 The current payment mechanisms have thwarted primary and secondary care integration. New models of care could be developed, for example, after the provision of the structured education programme by the specialist team the patient can be discharged to primary care but with open access to the specialist team for insulin management support, structured education refreshers and follow-up as part of the care pathway.

3.2 Ultimately, appropriate structured education can result in adults with type 1 diabetes functioning independently in the community, with a reduced requirement for support from healthcare professionals for glycaemic control. This benefits the patient but also the health service by freeing up healthcare professional time to focus on more complex cases.

3.3 Type 1 diabetes is a different disease from type 2 diabetes, with different treatment needs and education requirements. This is not often understood by commissioners. We believe that it is counterproductive for commissioners to be required to “reinvent the wheel” when commissioning for type 1 diabetes services. National programmes which fully meet the required key criteria, such as DAFNE, are available off the peg fully evidence based and costed. We propose that structured education for type 1 diabetes should be commissioned centrally to facilitate commissioning high quality type 1 diabetes care and make it easy for commissioners to avoid the current post code lottery.

4. The Ability of NHS and Social Care Providers to Treat Multi Morbidities and the Patient as a Person

4.1 Structured education programmes, such as DAFNE, are designed to educate individuals, taking their own insulin requirement and lifestyle into consideration. Each patient will develop the skills to adjust their insulin dose on a meal by meal basis in a range of situations (eg physical activity and during illness). Goal setting and action planning are integral tools of the course and are reviewed at follow-up. Ultimately DAFNE training provides the individual with knowledge and skills empowering them to control their condition rather than have the condition control them.

5. Implications of an Ageing Population for the Prevalence and Type of Long Term Conditions, together with Evidence about the Extent to which Existing Services will have the Capacity to Meet Further Demand

5.1 People with better controlled type1 diabetes and an empowered understanding of their condition are less likely to access acute services for complications of their condition and its treatment. Healthy people with diabetes will be economically productive in the workforce, sustaining employment and not accessing income related support due to inability to work.

5.2 Type 1 diabetes costs the NHS £1.9 billion per year, half of which is spent on the treatment of complications. Maintaining good glycaemic control can help prevent or delay the onset of these complications.4 There is evidence5 that DAFNE training leads to clinically and statistically significant improved glycaemic control.

5.3 The economic impacts of DAFNE are significant. York Health Economics Consortium published an economic evaluation of DAFNE showing it:

would save the NHS an estimated £2,237 per patient over 10 years;

could produce an additional five years life expectancy;

pays for itself within five years due to reduced rate of development of diabetic complications; and

is both cost effective and cost saving.

5.4 DAFNE data were considered by NICE as part of the initial consultation for NICE Technology Appraisal60, in which DAFNE is the only programme named as an example of high quality structured education.

5.5 Review of national and local DAFNE service clinical audit data shows:

severe hypoglycaemia is reduced by 70% and DKA is reduced by more than 60% producing cost savings through reduced paramedic call outs, A&E attendances and hospital admissions.6

restoration of hypoglycaemia awareness in 43% of individuals reporting unawareness pre-DAFNE.478

reduced insulin prescribing costs from a 16% reduction in total insulin use after DAFNE, equating to a saving of £60–£70 per annum for a patient weighing70kg.7

5.6 The economic and audit data from DAFNE have been used to prepare a case study for the Quality, Innovation, Productivity and Prevention(QIPP) collection on the NHS Evidence database. The QIPP case studies are examples of initiatives improving quality and productivity across the NHS and social care. Case studies are evaluated based on quality improvements, savings, evidence and implementation and are peer reviewed. The DAFNE case study:

shows an estimated £98,133 of real cash savings per 100,000 population achieved through reduced expenditure and improved productivity in healthcare.

scores within the top 10% of all case studies published in the QIPP collection, and as such is tagged as a recommended publication

5.7 Hence the provision of DAFNE by specialist diabetes teams can lead to increased life expectancy, whilst reducing NHS costs by the reduction of hypos, DKA and the development of the costly long-term diabetic complications.

6. The Interaction Between Mental Health Conditions and Long-Term Physical Health Conditions

6.1 People with diabetes are more likely to have depression than those without diabetes. The stress of the diagnosis of a long-term condition, the possibility of developing or the development of long-term diabetic complications and not feeling in control can all lead to mental health issues.

6.2 Structured education leads to informed and empowered individuals who feel in control of their diabetes. In addition to the biomedical and economic evidence for DAFNE, there is also evidence of improved psychological outcomes following the completion of the DAFNE course in terms of improved quality of life and psychological wellbeing8 sustained for up to four years post course.9 There is evidence that anxiety and depression also reduce post DAFNE.10

7. The Extent to Which Patients are being Offered Personalised Services (Including Evidence of their Contributions to Better Outcomes)

7.1 High quality structured education to enable self-management is the corner stone, and a requirement11 ^, 12of diabetes care. NICE Technical Appraisal 60 recommends that “structured education is made available to all people with diabetes at the time of initial diagnosis and then as required on an on-going basis, based on formal, regular assessment of need”. DAFNE was uniquely mentioned in the NICE guidance as an example of high quality structured education.

7.2 The provision of structured education that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to on-going education, is the first of the 13 quality standards set out in the Diabetes in Adults Quality Standard13 issued in March 2011.

7.3 DAFNE is the only nationally delivered programme for adults with type 1 diabetes which meets the nationally agreed key criteria. It is delivered by 60 specialist diabetes teams (across 138 localities) in England and as of the 29 April 2013, 22,382 adults with type 1 diabetes had completed a DAFNE course.

7.4 Currently there is a huge variation in access to structured type I diabetes education across England. We estimate that DAFNE is available in approximately 50% of specialist diabetes services. There is no reliable information to verify what education people with type 1 diabetes are offered. There is a plethora of guidance about structured type 1 diabetes education but a postcode lottery of access to it.We believe that there should be a national mimimum standard for type 1 diabetes care that is mandated and audited to drive improvement for this costly and burdensome condition.

9 May 2013