The setting

Yorkshire and Humber Strategic Health Authority (SHA) served a population of over 900,000 children aged 0–14 years.(1) Within the area, 21 secondary care units provide care for children and young people with diabetes, including Bassetlaw Hospital, which is affiliated with Doncaster Hospital as part of the Doncaster and Bassetlaw Hospitals NHS Foundation Trust. The geographical coverage encompasses 14 PCTs. In 2009/10, the population of children and young people, aged 0–24 years, with diabetes who received care within the region was 2400; for those aged 0–15 years, the number was 1635.

The problem

Demographic and clinical data on children and young people with diabetes have been collected for the Yorkshire Register of Diabetes in Children and Young People (YRDCYP) since 1978, and the register contains records of over 7000 children, stretching back 33 years for some units.

Through analysis of this dataset, clinicians and public health specialists made four observations:

 › Yorkshire and Humber has a higher incidence of diabetes in children and young people than the national average;

› Incidence of diabetes in children and young people in the region has been rising steadily since 1978;

› There was wide variation in the rates of children and young people with diabetes being admitted to hospitals;

› There was wide variation in the proportion children with diabetes with very good and very poor control of their diabetes in the region (as measured by HbA1c values of <7.5% and >9.5%)

 What action was taken?

The 21 services in Yorkshire and Humber SHA agreed to collaborate on reducing variation and improving outcomes for children and young people with diabetes in the region.

The Children and Young People Diabetes Programme Board (CYPDPB) was set up in 2008 to coordinate the efforts of the newly created paediatric diabetes regional network. The CYPDPB has a multidisciplinary membership, including management, researchers, public health professionals and patient/family representatives.

Clinical leadership is embedded within the management structures, and there are strong, formal links to local commissioners of child health services.

The Board has coordinated a series of network-wide initiatives aimed at improving the care of children with diabetes in the region.

Data collection and submission

The collection and submission of data was improved across the region by formalising links among the units, and the creation of a network facilitator post. Since 2008, the region has achieved a 100% data submission rate to the Paediatric National Diabetes Audit (NDA).

Benchmarking and audit

The network produces reports of clinical practices and outcomes, highlighting variations in process, structure and outcomes for children with diabetes among providers. The first annual report was published in 2010 (2) in conjunction with a detailed clinical audit of practice and outcomes.(3) Even within this relatively short timeframe, the open sharing of information has resulted in improved clinical outcomes, such as an increase in the proportion of children meeting the best practice standard for HbA1c measurement of <7.5%. (2,3)

Shared learning and education

Regular meetings of the Board, with representation from all of the provider units, have facilitated the dissemination of local innovation and best practice. Pooling resources has meant that educational opportunities for staff in all units can be maximised. As of 2010, staff from units across the network have had the opportunity:

› To undertake accredited educational modules on diabetes care;

› To attend clinics on efficiency and technology use in diabetes care;

› To attend a network-wide study day centring on sharing good practice and learning from high performing international units.

 Economies of scale make these learning opportunities affordable and accessible to all within the network.

 Peer-review process

Based upon the approach of the National Cancer Peer Review, a peer-review process of diabetes services for children and young people has been piloted at three sites within the network. Eighteen multidisciplinary staff and parents from across the region were trained to review the care processes at individual units. Following the success of the pilot, the peer-review process is being rolled out to all 21 provider units in the network, all of which are expected to have completed this review by March 2012.

 Service specification for commissioning

To ensure minimum standards of care for children and young people with diabetes, the Board has developed a service specification to support the commissioning of a high-quality diabetes pathway at all units in the network.

Learning points

The experience of the Yorkshire and Humber Paediatric Diabetes Network exemplifies the power of clinical and patient group leadership and collaborative working. Creation of a network of providers across a large geographical area requires a shared vision and a considerable level of trust and engagement. This cannot be achieved without strong leadership from all of the clinicians involved.

The challenge of improving the processes and structures of diabetic care is the length of time it takes to translate action into improved outcomes for patients. Improvements in outcomes for diabetes care take time to achieve because of the complex nature of the disease, and the psychological, socio-economic and family factors which have such a strong infl uence on the level of diabetic control. Collaborative working across a network of providers enables processes and outcomes to be benchmarked and audited. As the Yorkshire and Humber network shows, reporting of variation in quality of care and outcomes has a powerful effect of driving improvements through local innovation and the sharing of best practice. Outcomes across the network have improved, and the model has been replicated in most of the other SHAs in England, which is testament to the success of this network.

 Resources required

No structural investment was required to undertake this work. With respect to resources, there were three main items:

 › A network facilitator post (0.4 WTE);

› Strong clinical leadership, which required both enthusiasm and time;

› Patient group involvement.

 With respect to data, although not all networks have the benefit of a regional dataset such as the YRDCYP, which is funded externally and hosted at a university academic centre, all units in England submit data to the Paediatric NDA and there is no reason why national audit data cannot be used for this purpose.

Acknowledgements

This case-study is based on work led by Fiona Campbell, Consultant Paediatrician at The Leeds Teaching Hospitals NHS Trust.

References

1. ONS, 2001.
2. Children and Young People with Diabetes Annual Report 2010-11. NHS Yorkshire and Humber. 2010.
3. Paediatric Epidemiology Group (2010) Clinical audit of children and young people with diabetes in the Yorkshire and Humber Strategic Health
Authority, January 2007 to March 2010. University of Leeds.