Principles of care delivery

The overarching principles of care delivery and systems necessary to ensure delivery of effective diabetes care in any health community is described in Diabetes Without Walls (PDF 1.8MB)

• They are developed in a coordinated way, taking full account of the responsibilities of other agencies in  providing comprehensive care (as set out in National Standards, Local Action (DH))
  
• Are designed in response to the loca needs assessment, ensuring the service can meet the specific needs of the local population
• Have an inclusive design process that involved people with diabetes, service user representatives and champions, and all clinicians with both specialist and generalist expertise
  
• Take note of the principles of delivery for all long term conditions, embodied in the chronic care model (see the NHS and Social Care Long Term Conditions Model)
• Take into account the overarching principles of the Diabetes NSF, including the centrality of self management as the key to good outcomes and the need for a proactive organisation
  
• Ensure that there is a range of options available to people with diabetes to support self management and individual preferences
  
• Where possible and realistic services are close to the user’s home and based in the community
  
• Ensure and demonstrate that staff have the competencies needed to deliver the functions
• Are covered by written protocols and guidance that are adhered to and monitored
  
• Agree local plans to deliver key outcomes such as timeliness, continuity of care etc
  
• Contribute to national data collections or audits
  
• Provide the complete range of services to those people who are not able to access services in line with the locally agreed model of care, e.g. residential homes, prisons, travellers, housebound, those with long term complications and disabilities
  
• Have arrangements in place for local audit, benchmarking against national quality markers (including patient/people with diabetes experience of services and a process for addressing the outcomes of such audits)
  
• Actively monitoring take up of the service, responding to non-attenders, monitoring complaints and managing outcomes across the population of patients by seeking out areas and individuals where further input would create improvements.