Summary
The four paediatric diabetes units (PDUs) in Kent and Medway (Dartford, Medway, Maidstone & Tunbridge Wells, East Kent) piloted a regional peer review programme in 2021-22. All four units responded positively to the reviews. One unit was required by the children and young people (CYP) diabetes network to provide an urgent action plan. The review process delivered useful feedback within a reasonable resource commitment. The regional model simplified logistics of the review visits, promoted collaboration and allowed identification of regional themes. Oversight by the CYP diabetes network provided accountability for the PDUs following review. The review process will be refined and repeated in 2-3 years.
Innovation
It is essential to continually improve the care of CYP with diabetes to reduce the risk of future complications. Peer review is an essential driver, alongside national initiatives, such as national CYP networks and the best practice tariff (BPT). A national peer review programme brought positive changes for many PDUs, but funding was cut and a subsequent programme funded by participating units was too expensive. In February 2020 the four PDUs in Kent endorsed a pilot, Kent-wide peer review programme. A guidance group was formed, with representatives from all disciplines in the PDUs. It was supported by the South East Coast (SEC) and London CYP diabetes network manager and endorsed by the network and the Integrated Care Board (ICB) for Kent and Medway. Regional NHSE transformation managers helped design the programme. Support was provided by a Diabetes UK (DUK) staff member and the Paula Carr Diabetes Trust. The programme requirements were set out in a handbook. The process was piloted at one site, refined and rolled out to the remaining three sites. Four reference questions were used to define three points in four areas: good or outstanding practice; active improvement; requiring improvement, plus future development
Equality, Diversity and Variation
The value of peer review rests in the ability of true peers to make meaningful comparisons between the team under review and a standard position. Within the guidance group and each review team there was equal participation, with the key disciplines represented in all meetings. Parent representatives were actively involved and gave positive feedback. Equality and diversity were prioritised for reviewers; requirements were kept simple to ensure that any professional could consider taking part, but certification of up-todate equality and diversity training had to be provided. NHSE and DUK representatives brought valuable insights, and the ICB and CYP diabetes network chairs worked to ensure equitable delivery. The overall purpose of a peer review is to promote equity of care across diverse teams. The commissioning of continuous glucose monitoring (CGM) following the programme demonstrates its value in reducing inequality.
Results
This programme demonstrated the feasibility of conducting a regional peer review programme at a cost achievable within existing commissioning/funding pathways. All four units were reviewed as specified in the handbook. Each unit developed an action plan based on its report, integrated with existing work plans. Members reported that regional peer review allowed them to prioritise and escalate issues within their organisations and beyond. Examples of resulting improvements included: developing countermeasures when rising HbA1c was identified; an action plan enabling appointment of additional staff; sharing of good practice regionally; commissioning for CGM made consistent with NICE guidance. The resource burden for teams under review was reduced. Each team presentated its educational resources and attended the review day. Required documents were considered normal business. DUK and NHSE supported the pilot using existing resources. The handbook defined the peer review process, including the required documents, timetable and the model for the report. Review teams included a consultant, specialist nurse, dietitian and a parent representative. The same improving care manager from DUK attended the reviews, providing unbiased oversight. A representative from the regional NHSEI team reviewed all reports, observed two of the reviews and provided feedback. Review visits took 3.5 hours.
User Feedback
The senior leader of the trust was invited to the feedback discussion, to promote recommendations within its leadership structure. Learning discussion and feedback immediately following the review ensured the process was completed on time, that all stakeholders participated and good or improving practice could be shared. Feedback reports were copied to stakeholder organisations, including NHSE, DUK and commissioners. The final report was shared with the senior leadership team and individual unit action plans were created. Inadequate provision of CGM systems in Kent and Medway was identified on more than one PDU review. One PDU had rising median HbA1c, enabling corrective actions to be put in place. Concern from a parent representative about staff well-being added gravitas to feedback with internal managers. Escalation of serious concerns regarding staffing levels resulted in positive outcomes for two units.
Dissemination and Sustainability
The project was designed and delivered by the four Kent and Medway PDUs with regional support and endorsement from the ICBs, NHSE improvement team and DUK. The regional CYP diabetes network provided oversight, financing and administration. Regional priorities and local improvements were identified with individual teams working through their action plans. CGM is now commissioned. Rollout in accordance with NICE guidance will reduce inequality. Following escalation regarding staffing, two PDUs appointed additional whole-time dietetic staff. The structured education programme SEREN at diagnosis was working well in just two PDUs; the other two focused on this to ensure equity for families across the area. The process will be reviewed and repeated in 2-3 years. CYP will be involved, as well as parents, and a means of disseminating feedback to CYP/parent groups will be incorporated. Embedding administrative support within PDUs will decrease reliance on the network coordinator. The pilot project was disseminated through the regional CYP diabetes network and nationally (DUK Professional conference 2023). Local dissemination between units provided opportunity to share good practice. The aim was for replication and local collaboration, rather than expansion. The guidance group will consider the appropriate scaling model during review evaluation, eg effectiveness of regional expansion or series of regional reviews.
