EXECUTIVE SUMMARY AND RECOMMENDATIONS

  The MODEL (Management of Diabetes for ExceLlence) Group is a group of health professionals with a wide range of knowledge and experience in the care of diabetes that advocates excellence as the only effective response to what is a chronic epidemic in diabetes, and brings a professional perspective on the current state of diabetes care and its future direction.[333] This submission focuses on health inequalities in diabetes.

  Diabetes is a complex, insidious, long-term condition, marked by serious health inequalities, that requires multiple interventions and care services. The number of people affected by diabetes is growing at such an alarming rate that it threatens to overwhelm the health service. Diabetes particularly affects deprived, aged, and black and minority ethnic (BME) populations. Children with diabetes need specialist care. Quality and access to diabetes care vary significantly.

  Excellent diabetes care will go a long way to addressing important health inequalities. The diabetes epidemic can be slowed down and health inequalities addressed if the balance of care shifts from treatment of expensive and avoidable complications to targeted prevention and intensive management of blood sugar, blood lipids and blood pressure. Multi-stakeholder approaches have been seen to work, involving the health service, industry, food producers/retailers, schools/universities, social services and architects/town planners. Special measures are required for deprived and difficult-to-reach populations. The current quality of care for children is grossly inadequate and DH/Diabetes UK recommendations for improvements should be fully implemented (and funded).

  Diabetes is well served to address these challenges, backed as it is by a National Service Framework, NICE guidance, QOF, robust epidemiological data, diabetes networks supported by the National Diabetes Support Team, validated and cost-effective structured education programmes, and a toolkit for commissioners. However, frequent organisational change, short-term budget pressures, unintended consequences of moving care closer to home, poor inter-agency communication, often exacerbated by competitive rather than collaborative behaviour, fragmentation of provider services, and deficiencies in commissioning knowledge and skills are preventing local agencies from bringing these together into a cohesive package.

  Strong commissioning and multi-agency working are critical. Diabetes Networks are best placed to ensure that local agencies work together and that resources are deployed effectively.

 RECOMMENDATIONS:

—  Diabetes Networks are given the authority and resources to bring NHS purchasers and providers, public health officials and community stakeholders together to develop joint needs assessments, plans and care pathways.

—  The recommendations of the report, "Making Every Young Person with Diabetes Matter", are implemented as a matter of urgency.

—  Diabetes is given priority in "testing" implementation of the new Commissioning Framework piecing together the jigsaw of major policies, national guidelines and support tools that already exist into a cohesive package to deliver high-quality and cost-effective care.

—  The potential of Practice Based Commissioning to improve the quality and consistency of diabetes care is fully realised.

1.  INTRODUCTION

  1.1  The MODEL Group was launched on 17th May 2007 and has made two important contributions to the debate on diabetes care:

—  The MODEL Report, which represents the views of the Group on diabetes care in England and Wales and provides a holistic assessment of the current and future state of diabetes care and a vision for the future. The report was compiled on the basis of desk research, a series of roundtable discussions between group members, and interviews with 26 expert witnesses.

—  A MODEL for Excellence: setting out the Group's vision for better diabetes care (Appendix 1).

  1.2  The MODEL Group welcomes this Inquiry into a highly important aspect of healthcare delivery in England, as diabetes is characterised by substantial health and social inequalities.

2.  DIABETES

  2.1  Diabetes is a chronic disease where blood glucose is too high, either because insulin is not produced or is insufficient. Type 1 diabetes occurs when the body is unable to produce any insulin and can happen at any age. In Type 2 diabetes, the islets of Langerhans in the pancreas do not make enough insulin and the insulin action is often reduced; it is more common in those over 40 and with a family history.

  2.2  The number of people affected by diabetes is growing at a rate that threatens to overwhelm the health service. One in 25 people in England and Wales has diabetes, the equivalent of at least one child in every school class developing the disease. Diabetes costs 10% of NHS spending. By 2010, the number of people with diabetes in England will reach 2.5 million and costs will rise by 25% by 2040. Perhaps up to one third of people with diabetes have not been diagnosed.

  2.3  The complications arising from diabetes can be devastating:

—  Diabetes increases the risk of major medical complications 11-fold

—  Diabetes increases the need for hospital admission 5-fold

—  Diabetes reduces average life expectancy: Type 1 by 15-20 years and Type 2 by at least five years

—  Half of those with diabetes die from a diabetes-related condition

Complication	Risk
Heart attack	3 times as likely
Heart disease	4 times as likely
Stroke	4 times as likely
Amputation	15% develop foot ulcers 15% of these need amputation
Total kidney failure	3 times as likely 30% Type II patients have renal disease
Blindness	Single largest cause of new cases of adult blindness
Depression	2 times as likely 1/3 has significant depressive symptoms

Deaths from diabetes and other chronic disease, 1980-96

  2.4  These complications are not only devastating for the patient, they are also very costly: more than 50% of expenditure on diabetes care arises from the management of complications, half of which can be avoided.

  2.5  A key characteristic of diabetes is its continually changing nature as the patient progresses through life and the disease. Whereas in some long-term conditions, eg hypertension, simple lifestyle and pharmacological intervention can sustain control in the long term, diabetes changes subtly and insidiously even in patients who are well managed. This means that the health system has to work continually with the patient to manage the disease according to his/her particular circumstances in order to prevent unnecessary and costly complications.

3.  HEALTH INEQUALITIES IN DIABETES

  3.1  Diabetes is marked by substantial and important inequalities.

  3.2  Deprivation: both the symptoms of diabetes and risk of death are increased in more deprived populations, including the unemployed and those with less education[334]. GP registration suggests that diabetes incidence in the most deprived areas is two-thirds higher than in the most affluent. While diabetes is increasing in all areas, the rate of increase is greatest in deprived areas.

  Source:   National Statistics: Health Inequalities decennial supplement 1997 (1-9).

  £  Standardised mortality ratios (SMRs) are used to compare death rates in different segments of the population, taking into account differences in their composition. The SMR for males aged 20-64 in England and Wales is 100. SMRs below 100 indicate lower mortality than expected. SMRs greater than 100 indicate higher than average mortality.

  3.3    Ageing:   diabetes prevalence increases dramatically with age, from 0.33% of the population under 30 to 13.8% of those over 60. The prevalence of diabetes in nursing homes is up to 25% compared to 3% in the general population[335].

  3.4  Ethnicity:   people from BME populations are particularly susceptible to Type 2 diabetes, especially those with an Asian or Afro-Caribbean background. Diabetes also develops some ten years earlier than in European populations.

Doctor-diagnosed diabetes by ethnic groups, aged 16 and over, 2004, percentage

  3.5  Children:   diabetes has a devastating effect on children who are the most under-served group. The incidence of Type 2 diabetes in children is increasing at an unprecedented rate and there are concerns that incidence will rise significantly in the next 10 years.

  3.6  Other disadvantaged groups:   people with severe mental illness, learning difficulties, the homeless, prisoners, travellers, refugees and asylum seekers are at higher risk of ill-health and may have poorer access to the health system.

  3.7  Obesity is the single most important predictor of diabetes, although lack of exercise, poor diet and smoking are all associated with increased risk. The risk of Type 2 diabetes is almost 13 times greater in obese women as in women of normal weight; or five times greater in men. In 2001, about half of Type 2 cases in England were estimated to be related to overweight.

  3.8  Deprivation is strongly associated with higher levels of obesity, physical inactivity, unhealthy diet, and smoking, with a 50% greater likelihood of smoking in lower socio-economic groups, and less likelihood of access to a healthy balanced diet and facilities for physical activity.

4.  WHAT CAN THE NHS AND OTHER AGENCIES DO?

  4.1  Excellent diabetes care would go a long way to addressing important health inequalities. Type 2 diabetes is preventable, as are many diabetes complications. The key to cost effective care is active investment in targeted prevention and intensive management of blood glucose, blood lipids and blood pressure, and supporting people with diabetes to fit diabetes to their lives not their lives to diabetes. Unfortunately, the NHS is focused on expensive treatment and management of avoidable complications.

  4.2  The complexity of diabetes and its multiple complications means that patients need multiple interventions—medical, psychological, behavioural, social, familial—delivered by a wide range of health professionals.

  4.3  The following are the key elements of care:

—  Early identification and diagnosis

—  Prevention strategies targeted at high-risk groups (see Appendix 2)

—  Multiple medical options aimed at retaining a normal life, including a balanced primary and specialist care provision

—  Actively engaged and informed patients able to manage their condition and to take their medication correctly

—  Structured educational support for people with diabetes and their families

—  Psychological support to help change lifestyle and behaviour and overcome the difficulties of stressful transition periods

—  Extra and separate specialist care for children and young people

—  Support in pregnancy

  4.4  The multi-faceted nature of the risks for developing diabetes requires concerted action not only by the health system. Political and communal will is required, involving industry, business, food producers and retailers, schools and universities, social services, architects and town planners. Experience in Finland shows that a multi-stakeholder approach can work (see Appendix 2).

  4.5  Once diabetes has developed, addressing inequalities also requires special targeted measures for particular, high-risk populations. People from deprived or ethnic communities are less likely to access appropriate care, have their body mass index or smoking status recorded or have records for blood glucose, retinal screening, and blood pressure. They may be difficult to reach via mainstream channels, face inequalities in accessing care, be constrained by language or literacy difficulties or by culture, religious beliefs, and lifestyle. Many good examples exist of such targeted measures (see Appendix 3).

  4.6  Previous work on diabetes services means that much is in place to address these challenges. There are evidence-based national standards in the form of the National Service Framework and 13 pieces of NICE guidance. Robust data are available on prevalence from the Public Health Observatory, Brent, ScHARR Model and on people registered with diabetes under the Quality and Outcomes Framework (QOF). Ninety-three of the 655 QOF points in the clinical domain relate to diabetes.

  4.7  Resource has been specifically allocated to help design and configure services according to local need through the formation of about 150 diabetes networks supported by the National Diabetes Support Team. Commissioners have been supported through the publication of a Diabetes Commissioning Toolkit, which describes how to carry out a diabetes health needs assessment, specifies diabetes care, and suggests key outcomes for services.

  4.8  In recognition of the need for structured education for people with diabetes, as advocated in NICE guidance, two national programmes have been developed: Dose Adjustment for Normal Eating (DAFNE) for Type 1, and Diabetes Education and Self-Management for Ongoing and Newly-Diagnosed (DESMOND) for Type 2. DAFNE has been shown to cover its own costs in about four years[336], and a randomised controlled trial will report on DESMOND in 2008. The "year of care" approach, enabling people with diabetes to exercise choice in the design of a package to meet their individual needs, is being piloted in diabetes.

  4.9  Commissioners and providers are therefore well supported by this "jigsaw" of initiatives and policies.

5.  INEQUALITIES IN NHS CARE

  5.1  Health inequalities in diabetes do not only arise from variable risk but from inequalities in care quality and delivery. The Healthcare Commission found that the QOF scores for practices in poorer areas tend to be lower than those for richer areas, especially in single-handed practices[337]. In Eastern Leicester, which is a poor area, where half the population is South Asian, and where there are a high number of single-handed practices, only 10% of practices offered any structured education, and 76% were unable to produce a practice protocol for diabetes. Inadequate training, access to nurse hours and dietitian support were also evident[338].

  5.2  Access to a dietitian varies considerably across the country. All diabetes patients should ideally have advice from a specialist dietitian within four weeks of diagnosis but some 70% do not, and less than half of the dietitians offer an annual review. Waiting times for direct access to hospital dietitians range from 5 weeks to 27 weeks. Also the quality of dietetic advice appears to vary significantly[339],[340]. Concern has been expressed about the training of other health professionals and peer educators to deliver consistently high quality dietary advice[341]. Access to personalised advice on exercise is even rarer than dietary advice.

  5.3  NICE guidance recommends that structured education be undertaken at the time of diagnosis and beyond, based upon formal assessment of need, but notes that the length, content and style of education varies considerably. Validated programmes such as DAFNE and DESMOND are not available in substantial areas of England for geographical or financial reasons despite their proven cost-effectiveness. The DH/DUK Patient Education Working Group identified a number of areas lacking adequate provision, including children/adolescents and BME groups.

  5.4  A diabetes diagnosis is often associated with depression. Families need help too. The NHS provides no psychological support to families, or information to employers and friends.

6.  CHILDREN

  6.1  Inequalities and deficiencies in care for children with diabetes are of such concern to the DH that it commissioned a Children and Young People's Diabetes Services working group which reported in 2007. Children need care from specialist units. They have particular needs for education and psychological support, and their families also need help. Yet care is grossly inadequate. According to the National Diabetes Audit 2006[342], the proportion of children and young people receiving all the care processes they should was only 2%, and only 54% of PCTs had guidelines for the management of children and young people. Psychological and psychiatric support is highly variable with waiting times as long as 18 months.

  6.2  "Making Every Young Person with Diabetes Matter" came up with a comprehensive list of recommendations to coordinate services via regional networks, appropriately managed and able to audit services and provide some regional support for pump therapy and complex cases. Although care would continue to be delivered as close as possible to the patient's home it would be coordinated and equitable across the region. Such regional solutions require several PCTs to come together, perhaps under the aegis of the SHA, and ultimately some degree of top slicing of PCT funds. It is vital that the report's recommendations are implemented.

  Source:   National Diabetes Audit (2006) (3-2).

7.  BARRIERS TO IMPROVING EQUALITY

  7.1  Achievement of excellent care in diabetes would play a significant part in reducing health inequalities, alongside special measures for deprived and hard-to-reach groups. However, there are a number of factors that the MODEL Group believes mitigate against the NHS's ability to deliver this care.

  7.2  Short Term Pressures: diabetes is a long-term condition, but short-term pressures, much of which are driven by attempts to "balance the books", are leading to a dismantling of high quality services that will be hard to replace and increase inequalities. For example:

—  Diabetes nurses are losing their jobs

—  Training budgets are being cut—both for professionals and patients

—  The priority given to public health and programmes to prevent disease and promote healthy lifestyles is being reduced

One of the threats of a growing epidemic is that funding streams may not increase in proportion to the size of the problem or funding is diverted to fulfil short term aims and financial balance.

  7.3  Moving Care Closer to Home: there is value in moving as much care as possible into primary care. However, in order to achieve this in a way that delivers safe and high-quality care, primary care professionals have to be adequately trained and resourced. We are concerned that the shift is taking place without ensuring that the necessary training and expertise are in place. The shift has resulted in some PCTs downsizing specialist diabetes units at a time when numbers of people with diabetes are growing at an alarming rate and the need for specialist expertise to manage complex cases is increasing.

  7.4  Fragmentation: whilst we recognise that capacity increases are necessary and that in some areas a plurality of providers may be a solution, the imposition of new providers, who can be in competition with one another, into local health economies is leading to fragmentation of services that does little to support "seamless care" or safety. Emphasis needs to be given to working with Practice Based Commissioning Groups to ensure that services commissioned address this issue. Diabetes network meetings are often managed by commissioners and may be convened only to dispense information rather than receive opinions. This could be improved by appointing local expert leads/chairs.

  7.5  Communication: without effective communication there is little hope for the delivery of equitable care. We do not believe that IT systems are fit for purpose or will be in the near future. Communication, in the absence of good IT systems, relies on active cooperation between organisations and departments, and in many areas, competition rather than collaborative behaviour is the norm—hospital against hospital and specialist against primary services—that is destructive. We advocate investment into local information exchange—a relatively cheap option where the benefits are immediately apparent and where the technology generally exists. Waiting for an all embracing solution is now inappropriate.

  7.6  QOF: the QOF has undoubtedly helped to ensure that people with diabetes are properly registered and checked by their local practice, but QOF only requires assurance that checks have been made, not that quality is assured or a holistic approach taken. It is known that some people with diabetes are being required to visit their practices more than 10 times a year in order to fulfil QOF checks—an unstructured approach to diabetes care that is contrary to that advocated by the Royal College of General Practitioners since 1994. QOF is also blazoned on its own website as a mechanism for adjusting GP income—a financial process rather than a care package.

  7.7  Skilled and Resourced Commissioners: commissioners are key to addressing health inequalities in diabetes but this requires that they have adequate knowledge, skills and resources. The commissioning function needs to be mature enough to consult and achieve the commitment of providers to design and implement structured care pathways. Gaining local consensus requires active facilitation and management. Practice based commissioning may have the effect of stimulating preventative care and developing better care for diabetes. Early evidence is promising.

January 2008

PROFESSIONAL EXCELLENCE

—  Healthcare professionals with competence and confidence in managing people with diabetes throughout the progress of their disease

—  GPs with time and expertise providing a large volume of care to large numbers of patients, based on a sound knowledge of local needs of the community and insight into personal needs

—  Specialist diabetologists in centres of excellence supported by specialist nurses and a multi-disciplinary team providing expert input to model care development, continuous support for patients in high clinical need or in periods of transition, and emergency support in complicated cases

—  Support by healthcare professionals for intermediate care if this is in line with local needs

COMMUNICATIONS EXCELLENCE

—  Active, informed patients participating as partners in managing care resources

—  A mechanism for all healthcare providers and users to communicate with each other, through existing IT with appropriate interconnectivity and local diabetes networks appropriately convened and managed.

  We believe the following measures need to be taken:

DIAGNOSIS AND MONITORING

—  Intensive management of blood glucose, blood lipids and blood pressure

—  Evidence-based treatment according to the needs and events in the life of the person with diabetes

—  Integrated and evidence-based multiple interventions: medical, psychological, behavioural, social, familial

—  Regular monitoring of clinical indicators, allocating enough time to discuss patients' concerns, plus surveillance for early signs of complications

SUPPORT FOR PEOPLE WITH DIABETES:

—  Provision of lifestyle advice, especially to those at high risk

—  Excellent information for people with diabetes, their families and carers, and provision of structured education

—  Psychosocial support when needed

A SEAMLESS SYSTEM:

—  Patients progressing seamlessly between primary and secondary diabetes care, and back to primary care if possible

—  Seamless referral to specialists in other disciplines, eg cardiovascular, renal

—  Seamless flow of patient information to all members of the multi-disciplinary team

  Key to the delivery of the MODEL for excellence is good collaborative working between all the agencies involved in diabetes care.

  The Finnish programme for the prevention of Type 2 diabetes is a great example of addressing multiple complications and is the first national level programme of its kind in the world. At least a third of Finns have a genetic predisposition to developing Type 2 diabetes, and 10-20% have impaired glucose tolerance. The programme is based on the experience gained in the Finnish Diabetes Prevention Study, which involved over 500 overweight, middle-aged men at high risk of diabetes. After four years, those given a better diet and increased physical activity showed more than a 50% reduction in diabetes incidence. The whole concept of health promotion was pioneered in Finland in the 1970s and is well established at the municipal level.

  The prevention programme, which builds on this initial experience, has three concurrent strands. The Population Strategy aims to promote the health of the whole population, by means of nutritional guidance and increased physical activity so that the risk factors for Type 2 diabetes, such as obesity and metabolic syndrome, are reduced in all age groups.

  This is coupled with the High-Risk Strategy which uses individually-designed measures to target people with a particularly high risk of developing Type 2 diabetes, including screening, education and monitoring.

  The third strand is the Strategy of Early Diagnosis and Management directed towards newly-diagnosed Type 2 patients and designed to bring them into systematic treatment to prevent the development of expensive diabetic complications. It includes practical instructions for intensive lifestyle management.

  Importantly, putting this multi-pronged programme into action involves improvement of the Finnish healthcare system and restructuring of health promotion activities, plus the services of non-governmental organisations involved in public health, nutrition and physical education. Cooperation under the Population Strategy encompasses the entire range of Finnish non-governmental organisations as well as participants from the business community and the education sectors. The feasibility and cost-effectiveness of the prevention programme is being assessed in four hospital districts between 2003-7. Training and materials related to the prevention programme have been made available throughout the country. The results available so far show an impressive confirmation of the feasibility of such a multi-stakeholder approach.

SLOUGH

  Diabetes specialist nurse Grace Vanterpool used Dr Foster software to gather information about the location of Asian businesses and homes in Slough. This enabled her Health Activist team to pinpoint the best locations to offer health information. They took a highly visible double-decker bus to key places frequented by the Pakistani people in Slough, including supermarkets, community centres, leisure centres, and mosques—and enlisted the support of lay community leaders. Key points about risk factors for diabetes could then be passed on to a large number of people through these well-known and trusted people. Visitors to the bus were given information, the chance to ask questions, and offered pinprick testing for blood glucose. As a result of the initiative the level of diagnosed diabetes in the Slough population doubled[343].

NORWICH

  An initiative in Norwich shows how preventive steps toward obese children and young people can become the focus of a multiple stakeholder initiative reaching beyond the healthcare system to enlist the support of other elements in the community. The Nutrifit Kidz Club in Norwich is a charitable programme run by North Earlham, Larkman and Marlpit Development Trust, the Norfolk Sports Alliance and the Football in the Community team at Carrow Park. Free of charge, it offers up to 80 young people the chance to exercise, and also build self esteem and a greater knowledge and appreciation of food and health. Young people with weight problems are referred to the club by dietitians, GPs and consultants at the Norfolk and Norwich Hospitals. One in four of Norfolk's population under 15 years (15,700) is overweight, and a third of these (5,700) are obese; giving rise to medical costs of up to £40m a year[344].

MEND (MIND, EXERCISE, NUTRITION—DO IT!)

  The MEND (Mind, Exercise, Nutrition—Do it!) programme is a countrywide initiative with local activities for families with overweight or obese children. Its mission is to educate, motivate and transform children and families to change their unhealthy habits to ones that support a healthier lifestyle, and to ensure sustained health for the whole family[345].

LEICESTER

  Leicester, with its high South Asian population, is a particular centre for diabetes research and related healthcare initiatives. Project Dil, for example, is a coordinated primary care and health promotion programme aimed at reducing the risk factors for coronary heart disease in the South Asian community. It has used a training and awareness programme for healthcare professionals, organisational changes to develop an effective secondary prevention programme in general practice, and a public awareness programme. Leicester University Hospitals NHS Trust is also one of the 21 universities, hospitals and medical centres participating in the Europe-wide project called Diabetes in Europe—Prevention using lifestyle, physical activity and nutritional intervention (DE-PLAN), which is funded by the EU under its public health programme. This initiative aims to build on the results of the Finnish diabetes prevention study by assessing the risk of Type 2 diabetes in European populations and to develop and evaluate a lifestyle intervention programme to prevent its incidence in high-risk individuals[346].

NEWHAM

  Newham in London has about 14,000 diagnosed diabetes patients but a suspected further 5,000 who are not even registered with GPs. A new public health initiative aims to identify as many people as possible who may be at risk of diabetes in the community, and encourage them to register, when they can begin proper assessment and treatment. Newham's Communities of Health initiative is building on the many natural social groups in Newham, eg Somali women's cultural groups or South Asian men's groups. The health messages can "piggyback" on the activities of these groups; and special events, on hypertension or diabetes for example, can be held to deliver specific information. Those identified as being at high risk can be given letters to GPs and follow-up can often be shared with the community group leaders. Newham is also encouraging the involvement of pharmacists, who are well placed to identify people at high risk of diabetes and are able to offer advice or even tests for blood glucose. Again, those identified can be referred to a GP. The two approaches also have a secondary impact in the awareness they create in the community[347].

HULL

  Hull has a population of predominantly white people with a high level of unemployment and, at 6-7%, a relatively high prevalence of diabetes. Its programme to improve the situation is well under way and includes both primary and secondary prevention measures. Raising awareness in the general public about diet, exercise and diabetes is being addressed by a variety of means including talks in schools, health promotion DVDs shown in pharmacies and public advertising screens, podcasts prepared by a dietitian and open days and other awareness events. For those who have had diabetes diagnosed, care is much more focused in GPs' surgeries than formerly and the improvement programme provides extra training for GPs and practice nurses, to expand their detailed knowledge of diabetes so they can encourage better self-management. Diabetes consultants are now regularly working alongside GPs in their clinics and also conducting case reviews to advise on patient care and develop the skills of the primary sector[348].

WALES

  In Wales the Inequalities in Health Fund was set up in 2001 to support local action to address differences in access to health services. It supports over 60 projects in disadvantaged communities through joint action by the NHS, local authorities and the voluntary sector. Some examples of projects relating to diabetes prevention are in Pembrokeshire, where screening, nutrition and lifestyle change advice had helped well over 6,000 people by the end of 2005, with clinics held in the evenings and at weekends to be more accessible to working people. In Merthyr Tydfil are the Diabetes Peer Support Programme and one on promoting health in small workplaces[349].

334   Yorkshire and Humber Public Health Observatory (2005): PBS Diabetes Population Prevalence Model Phase 2. www.yhpho.org.uk/viewResource.aspx?id=71 Back

335   Diabetes UK: Diabetes and the disadvantaged: reducing health inequalities in the UK. A report by the All Parliamentary Group for Diabetes and Diabetes UK. World Diabetes Day. 14 November 2006. Back

336   Loveman, E., C. Cave, C. Green, P. Royle, N. Dunn, N. Waugh (2003): The clinical and cost-effectiveness of patient education models for diabetes: a systematic review and economic evaluation. NHS R&D Health Technology Assessment Programme 7, No 22. Back

337   Healthcare Commission (2006): State of Healthcare 2006. Back

338   NHS National Diabetes Support Team (2006): Primary care commissioning factsheet. Back

339   Nelson, M, Lean, M. E. J., Connor, H., Thomas, B. J., Lord, K., Hartland, B., Waldron, S., McGough, N., Walker, L., Ryan, A. & Start, K. (2000): Survey of dietetic provision for patients with diabetes. Diabetic Medicine 17, 565. Back

340   Dyson, P. (2006): OCDEM: expert witness to MODEL Group. Back

341   Blackledge, H. and J. Belza (2003): Health Needs Assessment for People with Diabetes in Leicester, Leicestershire and Rutland. Back

342   National Diabetes Audit (2006): Key findings about the quality of care for children and young people with diabetes in England incorporating registrations from Wales. Report for the audit period 2004-05. Back

343   Vanterpool, G. (2006): MODEL Group evidence. Back

344   Thalange, N. (2006): expert witness to MODEL Group. Back

345   The MEND Programme (2006): http://www.mendprogramme.org/ Back

346   Davies, M. (2006): MODEL Group evidence. Back

347   Elkheir, R. (2006): expert witness to MODEL Group. Back

348   Bowker, P. (2007): expert witness to MODEL Group. Back

349   Welsh Assembly Government (2005): Inequalities in Health: The Welsh dimension 2002-2005. Back