Diabetes services in the UK: fourth national survey; are we meeting NSF standards and NICE guidelines?

Background: Previous surveys of children's diabetes service provision in the UK have shown gradual improvements but continuing deficiencies. Aim: To determine whether further improvements in services have occurred. Methods: A questionnaire was mailed to all paediatricians in the UK identified as providing care for children and adolescents with diabetes. Responses were compared with results of three previous surveys, and with recommendations in the Diabetes NSF and the NICE type 1 diabetes guidelines. Results: Replies were received from 187 consultant paediatricians in 169 centres looking after children; 89% expressed a special interest in diabetes, 98% saw children in a designated diabetic clinic, and 95% clinics now have more than 40 patients. In 98% of the clinics there was a specialist nurse ( 82% now children's trained), but 61% clinics had a nurse: patient ratio,1: 100; 39% of clinics did not have a paediatric dietician and in 78% there was no access to psychology/psychiatry services in clinics. Glycated haemoglobin was measured routinely at clinics in 86%, annual screening for retinopathy performed in 80%, and microalbuminuria in 83%. All centres now have local protocols for ketoacidosis, but not for children undergoing surgery ( 90%) or severe hypoglycaemia ( 74%). Mean clinic HbA1c levels were significantly lower in the clinics run by specialists ( 8.9%) than generalists ( 9.4%). There have been incremental improvements over the last 14 years since the surveys began, but only two clinics met all the 10 previously published recommendations on standards of care. Conclusions: The survey shows continuing improvements in organisational structure of services for children with diabetes but serious deficiencies remain. Publication and dissemination of the results of the previous surveys may have been associated with these improvements and similar recurrent service review may be applicable to services for other chronic childhood conditions.