Legacy or Let Down? A Decade of the Diabetes National Service Framework

With great promise and excitement, the ambitious 10 year delivery strategy of the diabetes national service framework (NSF) was launched in January 2003. For the first time, a government was taking a long view of long term conditions care with these 10 year programmes, enacted from ‘the NHS Plan’ of 1997. Diabetes was just the third NSF to be published, showing what we thought was a brilliant commitment to this important and growing condition

At the time, 10 years seemed an age away with plenty of time to do everything the standards demanded. Yet here we are in 2013 with a whole new health policy world and with the next huge NHS reform upon us. So did the NSF achieve anything and will its legacy live on in the current incarnation of diabetes care - or were we let down on its promises?

As is our wont here at SD Comments, we’ll start by looking at some of the success stories that seem to be here to stay and have undoubtedly changed the face of diabetes care:

LEGACY: Eye screening for retinopathy is universally available and pretty much everyone with diabetes is invited to have their eyes photographed annually. As a result, blindness rates due to diabetes in the working population are getting lower every year, thanks to the early intervention on problems detected through retinal photography

LEGACY: Local diabetes networks bringing together people working within hospital, community and general practice services for diabetes have grown and persisted. Communication between health professionals working together has improved and faster referrals and decisions about acute situations such as foot ulcers can be made as a result. The latest recommendations about communication between services have just been published by NHS Diabetes, quite rightly highlighting their continuing importance in the ‘new’ NHS

LEGACY: Specific mention of children and young people as well as adults with diabetes. The NSF was very clear about the needs of children and young people as a specialty, a distinction that hadn’t always been so clearly made. Every one of the 12 NSF standards mentioned each age group and today, the focus on children and young people with diabetes is intense, with Diabetes UK’s most recent awareness campaign highlighting the need for prompt and early recognition of symptoms of Type 1 diabetes in children

Unfortunately, there are also some let downs when looking back at the NSF and these have to be examined too – so these important aspects don’t continue to be forgotten

LET DOWN: Diabetes structured education. Despite the NSF heralding the importance of supported self management and the provision of high quality information and education, there is still a massive lack of access to structured education and enormous variation throughout the country. Even more worrying (as detailed in this blog before) is the very low invitation to and uptake of diabetes education courses. In addition, education courses are often the first to be cut when economies in services have to be made, as in recent years in the NHS. This leads to people being unable to manage their condition for lack of the ‘tools to do the job’.

LET DOWN: Personalised care planning and participation in decision making. Despite a whole standard to do with empowering people to manage their condition themselves and being helped to make decisions based on their own goals and aspirations, there is still very little results sharing prior to consultations and consultations still often follow the traditional medical model of ‘health professional knows best’, despite the day to day management of diabetes actually being in the hands of the person living with it.

Happily, the current health policy is still promoting a personalised approach with the ideal of ‘no decision about me, without me’ and there is a strong focus on this for people with long term conditions in the Government’s recent instructions to the NHS, so maybe there is a glimmer of hope that this let down will become a legacy in the end

LET DOWN: User involvement in how services are planned and delivered. This aspect of the NSF started with great promise, with a number of initiatives and organisations, guidelines and recommendations dedicated to developing this approach. However, enthusiasm for it seems to have waned over the years, even among campaigning organisations. Proper, proactive involvement of people who use services is now extremely patchy. Apparantly, the new NHS will have a much stronger ‘patient’ voice, but this may be more to do with complaints and accountability than involvement and consultation in how services are actually run

So that’s our take on what is and what might have been. Ever optimistic, however, we will continue to bang the drum for person centred approaches, access to diabetes education and user involvement, and do all we can to ensure that the ‘brave new NHS’ will take note of these let downs as well as the legacies


References

Department of Health (2003). Diabetes National Service Framework: delivery strategy http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003246

Department of Health (2012). The Mandate. A mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015
http://mandate.dh.gov.uk/

NHS Diabetes (2013). Implementing Local Diabetes Networks
http://www.diabetes.nhs.uk/our_publications/


Do you agree with what we’ve said? If so – and if not – your views and comments are welcome below!

Tops in 2012!

At the start of a new year, it’s traditional to look back on the highs and lows of the last one. In our case, we don’t really do ‘lows’ but prefer to concentrate on successes, as this has a much better track record when it comes to positive mental health. But enough of our philosophy, (which is covered in detail on our website if you’d like to know more) and here we go with some of the highlights from the last year, many of which we covered in this blog.

They get our votes because they really focussed on the people side of health and wellbeing and are consistent with all that we promote here at SD

So imagine a drum roll and let’s hear it for the following!

• The Health Foundation – released a series of practical reports and reviews in relation to making a reality of person centred consultations, helping people make decisions, collaborative healthcare and supporting self care. Absolutely vital stuff to help the new, personalised NHS achieve its objectives

• Diabetes UK – kept up a relentless focus on the basic checks people with diabetes need to have, from blood pressure to foot examinations – and reminded the world at every opportunity how these were not universally offered or taken up, despite them being ‘must do’s

• The Irish Health Service – made rolling out pump therapy for the under 5s a priority in its health budget for 2013

• The National Diabetes Audit for England and Wales for including statistics about the poor offering and uptake of diabetes structured education and giving campaigners the opportunity to wave these statistics and press for change

• Diabetes Australia – for publishing a wonderful document about awareness of language in relation to diabetes. Just creeping in from December 2011, but we’re guessing it was 2012 before anyone read it and it remains one of our favourites!

• Last but not least – anyone living or working with diabetes who has reflected on their approach, made changes or generally tried to make their diabetes or the environment in which they work a better experience during the year. As we never tire of quoting, from a dear friend with diabetes “diabetes is a marathon not a sprint; I need help to stay in the race”. Every bit of help along the way matters equally every year.

Hoping to see much more great work like this in 2013 and wishing all our readers a very happy and healthy – and Successful - new year!

Reference
www.successfuldiabetes.com

To eat or not to eat?…A question many with diabetes would love to ask

Will Self’s recent ‘point of view’ certainly gave me food for thought.

He argues that we have become obsessed with food, which dominates our high streets and our television programmes and we could do well to remember that eating is really a way of satisfying hunger rather than being a creative occupation. He also reminds us that there are plenty of people going hungry in our own localities, with food banks opening up with depressing frequency, even as we make the agonising choice of which ready meal to purchase from the heaving supermarket shelves. He suggests that we tend to take the easy option of an eating culture instead of attending to more challenging cultural developments in arts or science. He begs us to resolve to purge ourselves of our food obsession in 2013.

He has a point. There’s a lot to digest in his column (pun intended!), including the observation that when hungry, it doesn’t matter to our bodies whether the food we consume is cooked in a celebrity kitchen or a billy can over a single gas ring. This particular point made me reflect on how, actually, we know these days that food does matter to our bodies and that maybe all the attention on food in recent years has been a force for good - for example we know our bodies react differently to unsaturated and saturated fat, complex or simple carbohydrate, animal and vegetable protein and soluble and insoluble fibre. The outcomes of eating different proportions of these can literally be the difference between life and death, so for all of us these developments are in fact, vital.

That’s not to say there’s a direct relationship between ‘media cooking’ and health, quite the opposite sometimes, if recent reports on the unhealthiness of celebrity endorsed recipes, are to be believed, with many found to be way over the recommendations for fat, sugar and salt. However, another way of looking at this is that such research can actually serve to offer a new way of bringing healthy eating recommendations to the attention of the masses consuming food related news – perhaps another benefit of our food-orientated culture?

My main reflection generated by this column was the thought that for the couple of million people with diabetes in this country, eating or not eating is not a simple option, although many would dearly like it to be. I have heard many times from people with diabetes that just to choose to skip a meal would be a luxury and the liberation felt by those who have experienced this, perhaps through starting pump therapy, reversing the early signs of type 2 diabetes, or for the lucky few, an islet cell transplant, is immense.

For the rest, eating is often a daily grinding juggling act, a way of getting through the day without experiencing hypos or high blood glucose symptoms, catching a hypo in time to prevent embarrassment, and simply being able to fit food in with their social or work schedule. Many say that an obsession with food ‘comes with the diagnosis’ and that looking at food in an enjoyable way can become a rare thing. Someone with Type 1 diabetes I met recently explained it like this ‘you see a lovely roast dinner and prepare to enjoy it….I see a maths equation - ‘how many carbs + insulin will equal a normal blood glucose level?’. Such mathematical calculations are part and parcel of everyday life with diabetes.

We’ve written in this column before about our wish for more and better access to technologies such as insulin pumps, and more flexible medication regimens that do so much to expand the options around eating for people with diabetes. Whilst we do our bit to make eating and cooking calculations easier with diabetes, for example with our carb-counted recipe book, it's also our regular new year hope that even more people with diabetes will get the chance to ask the question ‘to eat or not to eat?’ and answer it in any way they like.


References
The Never-ending Culinary Merry Go-Round
http://www.bbc.co.uk/news/magazine-20836616


'Carb-Counted Recipes for Diabetes’
http://www.successfuldiabetes.com/component/content/article/220

Structured Education for People with Diabetes – A Box Waiting to be Ticked

There are many important statistics inside the latest report from the National Diabetes Audit (NDA), covering England and Wales, published earlier this week. Sadly, most of them lead to one main conclusion – that diabetes care is variable and because of the lack of receiving some well-known basics, people with diabetes run a 40% excess risk of death and also have a massively increased incidence of heart failure and many other complications. The NDA co-ordinators and diabetes organisations have called for the NHS to wake up and put nationally recommended care and treatment plans into practice. As ever, we support this call wholeheartedly.

To our mind, one eye-catching aspect to the report, which unfortunately didn’t make the headlines, was the finding that very few people with diabetes were either offered or attended a structured education programme when they were diagnosed. The figures covering 2009-2011, are not only low but stunningly low. In all, just under 8.5% of people were offered a structured education programme and just under 3.5% attended. Applied to Type 1 diabetes, the figures were 2.79% and 1.55% respectively and for Type 2, 8.72% and 3.57%.

If true, this is horrific – it means that most people being diagnosed with a lifelong condition that they themselves will need to manage day in, day out are not offered the opportunity to learn about how to do this. And even when they are offered it, it looks like only about half of them take up their place.

Another scary aspect of these figures is that although information about the offer and uptake of structured education has been gathered by the audit since 2005, this is the first time that there has been sufficient quality of data to publish. That means that in previous years, the figures were possibly even tinier than this year. The report’s conclusion, unsurprisingly, is that these figures are a great cause for concern. Again, we would definitely agree with this… but we’ve also been thinking ‘what on earth can be going on to create this situation?’ and so here’s our take on the issues and a suggestion for a way forward:

First and most obviously, are these figures accurate? The report itself says that under-recording is likely, and in our experience there are many, many services providing diabetes education, sometimes struggling to get takers because of low referrals. The referrals they do get are not always formal and documented and can even be through ‘word of mouth’. So it might well be that the people ‘ticking the boxes’ actually don’t know that education is taking place because it isn’t recorded. One possible way forward for this is that as well as a ‘yes/no’ answer box, there could be a ‘don’t know’ box, so that the audit can identify services where better information or communication of provision is needed.

Another key issue, and in our opinion, probably the most likely cause, is lack of provision of education programmes. Education in diabetes is still seen by many as an ‘added extra’ rather than the stuff of diabetes care itself. Because it isn’t seen as essential (and doesn't attract any money!), in pinched financial times such as the ones the NHS has experienced recently, it is one of the easiest parts of a service to cut and this has been the case in many places in recent years. But it’s also important to note that in many places structured education has never even got going, let alone been cut. This is not always through a lack of desire for it by diabetes services on the frontline, and they themselves will often cite lack of funds and educational expertise to get courses off the ground – another whole, vital issue that needs to be addressed.

When it comes to the diabetes audit then, if there is no provision, offering education is not going to make any difference – hence a ‘no’ in both boxes. The answer to this one is a radical rethink of the fundamental purpose of diabetes care services – of which more later.

On that note, the actual data recording in the audit might contribute to the results – for example, why record only whether people have been offered structured education and if they participated or not? Asking for the individuals’ reasons for not taking up the offer would be much more informative, because so much could depend on how education is offered. Given that for many, including health professionals, diabetes education is an ‘also ran’, it follows that this ambivalence might well be communicated to the person diagnosed, giving them the impression they can take it or leave it. Indeed, reasons we have heard from people with diabetes as to why they cannot be offered structured education range from ‘because we don’t have it in this area’ to ‘you probably don’t need it as you seem to be getting on ok’. Health professionals themselves often also say that they don’t believe that group education (which is recommended and has been shown to be effective), is right for everyone, so they end up not offering it to anyone. Given these examples and pre-judgements, it is not surprising that it is a bit hit and miss who gets offered an education programme.

Finally and amazingly, people still debate whether diabetes education ‘works’. It’s true that programmes studied often show little effect on diabetes control measures such as HbA1c. However, this is not always the case so this is not in itself a good reason to abandon it.

Here’s another way of looking at this argument: if you think that education is not designed to show medical outcomes, but is designed to show learning, and if the learning is done effectively, then it is a fantastic achievement. Imagine results in terms of many more people with diabetes keeping themselves out of hospital, fewer making costly phone calls to diabetes specialist nurses and practice nurses to ask about dose adjustment, and all able to confidently defend their decisions about what and when to eat. That’s what learning to live with diabetes effectively is all about and indeed, many educational programmes do show effects on these educational outcomes – increased confidence in day to day managing the condition, such as increased understanding of diabetes itself, increased self esteem and decreased anxiety and stress related to diabetes, to name but a few.

Here’s our suggested framework for success that might just tick the box for improved information AND improved education for people with diabetes and boost these audit figures no end

• Everyone diagnosed with diabetes follows a pathway straight to a group-based education programme within 3 months of their diagnosis – this is seen as the treatment for the first few months.

• There are few and specific reasons why someone should not undertake this pathway: for example, they are admitted to hospital or they are mentally or physically ill to the extent that they cannot manage their life alone, or they are in an institutional setting (although there’s no reason not to provide diabetes education in prisons or secure hospitals, is there?)

• The initial, group-based education programme is followed by update group education sessions every 6 months, which could be followed by one to one appointments if necessary

• Medical annual reviews for diabetes complications screening are scheduled at the appropriate time each year.

• Attendance and appointment logs for the education programmes are kept for each individual, which include invitation information and the person’s own reasons for not attending (if this is the case), and these are what is submitted to the national diabetes audit each year.

Not only would these data provide a much more accurate picture for the National Diabetes Audit, but this kind of pathway would encourage all diabetes services to be truly educationally focussed, staff to gain badly-needed skills and qualifications in education and learning and, most of all, people with diabetes to feel that they are getting what they need – information, answers to their questions and support from other people experiencing the condition, often one of the most overlooked and under utilised resources in the educational toolkit. Having all this would certainly be a welcome tick in the box!


References

National Diabetes Audit 2010-2011 Report 2: Structured Education http://www.ic.nhs.uk/diabetesaudits

(download from right hand panel)

Diabetes fuels heart failure risk
http://www.bbc.co.uk/news/health-20629398

Remember, Remember…

Even though it’s the right day, the title of this blog doesn't continue with 'the 5th November' (as you might have been starting to sing in your head). Instead, the next line is 'remember, remember... all the basics of living with diabetes'. We're referring to those small actions and timely interventions that can make the crucial difference between diabetes fitting neatly into your life and you constantly feeling you're backpedalling to keep up with it and pick up the pieces.

Take blood testing for example... yes, it is a pain, can be messy, inconvenient, embarrassing even, but without it, maybe you get an embarrassing hypo, an inconvenient thirst or the annoying call of the loo every 5 minutes. You get the idea?

To celebrate World Diabetes Day this month, we will be publishing a brand new book with reminders of all these essentials, revisiting the basics of diabetes and answering some of those often heard questions-to-self 'why am I doing this?' or, more often 'how did I end up in this situation?' If you've ever experienced this, we may be able to help you - just watch this space and our website for more info on when this useful addition to your diabetes bookshelf is available!

And importantly in this blog, we also want to ‘remember, remember’ something else: World Diabetes Day itself. It's a day supported by the International Diabetes Federation and celebrated around the world on 14 November, the birthday of Frederick Banting. Banting was a member of the Nobel prizewinning team who discovered insulin back in the 1920s. Blue is the colour of the WDD symbol, and many countries, towns and cities light up their most iconic buildings in blue to mark the occasion. It's a day to reflect on what's needed in diabetes care here and now.

With so many days and weeks set aside for different conditions these days, it's easy to think this is just another one, albeit with a good gimmick. Here's why we think it's important...

In the 1920s, the treatment for diabetes looked simple: insulin transformed people from emaciated remnants of humanity to vital beings, restored like the biblical Lazarus to their families and to life. Many of those who were first treated with insulin went on to have long and fulfilling, even pioneering lives, like Elizabeth Hughes Gossett, who died in her 80s after over decades on insulin, and Robin Lawrence, the famous doctor and founder of the British Diabetic Association, still thriving as Diabetes UK.

A few years down the line and for very many more people with diabetes, however, the picture was not so rosy. From the miracle of restoring life, the ravages of long-term high blood glucose levels became clear. Lost limbs, blindness, kidney failure and miscarriage and stillbirth rates spiralled upwards among those with long-term diabetes. It became clear that there was much more to diabetes than taking a daily injection of insulin and preventing hypos at all costs. Landmark research studies followed, showing that these catastrophic complications CAN be prevented and careful surveillance of their health both for and by people with diabetes must be taken, throughout their lives. In addition, it’s now known that Type 2 diabetes itself can be prevented through specific identification and intervention among those at risk.

It's great to say that modern day diabetes care can offer this care and prevention. Unfortunately, though, modern day diabetes care is not everywhere and not for everyone. Some governments still ignore the vast problem of diabetes among their people and some people still miss their care appointments. Focussing on education and campaigning, and highlighting the tragedies of missed diagnoses and lost working lives, are all important features of World Diabetes Day, as well as celebrating the successes and massive strides forward that are made by dedicated scientists, health professionals and people with diabetes themselves each year.

So don't forget to remember World Diabetes Day and maybe mark it with something special, however small, that signals your commitment to spreading the word. We've put together some ideas to start you off...

• Tell someone (anyone!), a single fact about diabetes, or your own diabetes, to raise awareness about it and its impact
• Dress in blue for the day - and tell people why
• Make a small donation to a local or national diabetes charity
• Make some blue-iced cupcakes and take them to work or school
• Visit the World Diabetes Day website to find out more about diabetes worldwide and spread this information on your social networking site
• Make a commitment to yourself if you have diabetes, to find out more about a particular aspect, or get help with something that is concerning you about it

Whatever you do, it will make a difference. Oh, and another thing to remember… put 14 November in next year’s diary to do it all again!

Websites

World Diabetes Day

Successful Diabetes

Insulin pumps: an experiment or a solution?

Insulin pumps are being used increasingly in diabetes, and a comment made by someone with diabetes before they started using one got us thinking. They said that they had undergone so many discussions to make sure that they were suitable for a pump, that they were scared of what might happen if it didn't work for them. They felt pressured to make it work, and also got the feeling that they had a one-off chance of trying a pump, so if using it didn't go well they would never get the chance again.

Hearing this reminded us that insulin pumps are still not seen, in most diabetes teams at least, as a standard choice for the treatment of Type 1 diabetes. Despite the clarity of NICE guidance (NICE, 2008), people still have to undergo relatively rigorous assessments from their diabetes health professionals, and also insulin pumps are used in many cases as a 'last resort' rather than just one of the potential insulin delivery methods to choose from.

Why is this? Well, insulin pumps are regarded by many diabetes teams as an expensive luxury that should be reserved for a select few people with diabetes. However, expensive relative to what? Many long-term conditions have far more expensive investigations and treatments, including sophisticated scans and surgical procedures, and by comparison the 'routine' treatment for diabetes to keep people healthy and prevent complications is relatively cheap even when insulin pumps are included. They also have the added advantage of taking away the sheer tedium and public nature of insulin injections, two aspects that have such an impact on how people cope with having type 1 diabetes. In these cash-strapped NHS times, there is a danger of diabetes health professionals succumbing to the pressure to use the cheapest treatments rather than those that people might prefer long term if given a real choice.

So come on, the world of diabetes in 2012. Let's start putting insulin pumps in their right place - as a real choice for the majority of people with Type 1 diabetes, in common use in every diabetes team, with all health professionals trained and competent to use them.

To pump or not to pump? Let us know your thoughts…..

Reference
NICE (2008) Diabetes - Insulin pump therapy (TA151)
http://www.nice.org.uk/nicemedia/live/12014/41300/41300.pdf

Consultations – A Meeting of Minds or an Appointment with Fear?

This week, the spotlight has well and truly shone on consultations, in the form of several reports released by the Health Foundation, including one entitled ‘When doctors and patients talk: Making sense of the consultation’ (Health Foundation, 2012).

This is welcome news to us, as consultations and how they are conducted, and helping health professionals develop more person centred skills, has long been a central theme of our work. This is because we know that people with diabetes have mixed and often unpredictable experiences with their health professionals, and frequently spend days and even weeks before their meetings feeling anxious and concerned about what might happen, particularly about whether they might hear bad news about their health. Not least of their worries is being judged for not achieving better control of their blood glucose, without the chance to explain the complexity of managing diabetes day by day in the face of other pressures and demands. As one person memorably put it ‘consultations for me are about attending to receive my ritual telling off’ (although in reality the words ‘telling off’ were said in rather more colourful language!). Another lady put it like this – with tears in her eyes -  ‘I feel like I’ve failed an exam every time I go to the clinic’. 

The Health Foundation review, which is based on extensive interviews and workshops with a range of doctors and patients, not only completely validates this aspect and discusses fear of patients as a key influencer of their participation in a consultation, but also suggests that the fear of doctors is a factor too. Their fear centres on making the wrong diagnosis or on potentially being regarded as less professional if they alter the way they work. With the power in healthcare still largely residing with the health professional, the consultation is often structured to allay the fears of the doctor rather than the patient, giving rise to the experience of many of being talked at rather than with and being unable to fully express their thoughts, feelings and wishes.

It’s not all bad news for consultations of course - many go very well, and the bond between health professionals and the people they see is often close and productive. Diabetes UK’s magazine ‘Balance’ runs a regular column ‘I couldn’t do without…’ in which people describe where their best support comes from. This very often features a nurse, doctor or other health worker. What we need is more of these obviously successful encounters and less of the ones that are, frankly, a waste of time and effort, not to mention money, for all concerned.

But the good news is, a knight in shining armour may be coming to the rescue. A new way of working is hovering on the edge of diabetes care, looking for ways into the mainstream. This is personalised care planning, which features shared decision making at its core and has been shown to be successful in transforming the routine, health professional-based consultation to one that is truly collaborative, to the satisfaction, and in many cases delight, of both health professionals and people with diabetes.

With personalised care planning, people with diabetes are able to have a much greater say, literally, in the consultation, and no longer have to wait in trepidation for their own test results (blood, eyes, feet and so on) to be given - or often partially supplied - to them by their health professional. Personalised care planning means they receive a comprehensive set of results and have time to reflect on them well before their consultation. They can then make decisions in the comfort of their own home before meeting up with the health professional to talk about what aspects of their diabetes, if anything, they wish to work on as a priority. Quite often, they attend having already made a decision about changing something, and have got started on it, so saving a lot of time which can then be used to discuss other aspects of their health or make for a shorter consultation.

Health professionals are naturally sceptical and need convincing about new practices, an aspect highlighted by another of the recent Health Foundation reviews on the evidence for shared decision making in consultations (de Silva, 2012). This review describes principles that are known to promote shared decision making, which happily including many that feature in personalised care planning, such as: goal setting and review; making care plans in partnership together; emphasising options; problem solving; and preparation for the consultation in advance. However, even though this evidence is available, health professionals are also as vulnerable to the difficulties of changing their practice and behaviour as anyone else, and for these reasons, personalised care planning has not yet been widely implemented. 

Fortunately, the body of evidence for personalised care planning is increasing all the time, and we are proud to be contributors to this in a number of ways:

·      Our website resources, including workshops (Successful Diabetes, 2012)

·      2 recently published papers (Walker et al, 2012; Walker and Rodgers, 2012)

·      Our book explaining the nuts and bolts of how to set up personalised care planning (Walker and Rodgers, 2011).

Now, with the Health Foundation’s timely reviews, we sincerely hope that services will be able to stop saying ‘why should we?’ and see that ‘how can we?' is the only question they need to ask!

Does anything in this blog ring true for you? Do you have experiences of consultations or personalised care planning... or the opposite? Post your thoughts and comments and share them with us here…

References

de Silva, D. (2012). Helping people share decision making: a review of the evidence considering whether shared decision making is worthwhile. Health Foundation. http://www.health.org.uk/publications/helping-people-share-decision-making/

Fischer, M., Ereaut, G. (2012). When doctors and patients talk: making sense of the consultation. Health Foundation. http://www.health.org.uk/publications/when-doctors-and-patients-talk-making-sense-of-the-consultation/

Successful Diabetes Workshops http://www.successfuldiabetes.com/workshops

Walker, R., Rodgers, J. (2011). Implementing Personalised Care Planning in Long Term Conditions. SD Publications. www.successfuldiabetes.com/books

Walker, R. et al (2012). Introducing personalised care planning to Newham: outcomes of a pilot project. Diabetic Medicine, 29, 8, 1074-1078. Abstract can be viewed at

http://onlinelibrary.wiley.com/doi/10.1111/j.1464-5491.2011.03523.x/abstract

Walker, R., Rodgers, J. (2012). Personalised care planning for long-term conditions. Diabetes and Primary Care, 14, 3, 177- 181. Online at

http://www.diabetesandprimarycare.co.uk/journal-content/view/personalised-care-planning-for-long-term-conditions