Tayside Diabetes MCN Handbook
Follow up of Patients with Established Diabetes

NHS Tayside Diabetes Integrated Care Pathway


An Integrated Care Pathway has been designed to facilitate effective care for all adult patients with diabetes across NHS Tayside (see below). The Pathway ensures that patients with diabetes will receive appropriate care of an assured standard at every stage in their ‘diabetes journey’and that they will move seamlessly between one part of the system and another as determined by their clinical needs.

In developing the pathway of care for patients with diabetes, four levels of care have been described, reflecting the changing and often progressively complex needs of patients.

  1. Initial Management –See Management of Newly Diagnosed Diabetes
  2. Community Diabetes Care
  3. Specialist Consultation Service
  4. Continuing Specialist Care Services

See diagram



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Community Diabetes Care - Clinical Control Targets and Minimum Recommended Review Intervals


This section, based on national and international evidence-based guidelines, provides general guidance to healthcare professionals involved in diabetes care in NHS Tayside in relation to minimum recommended review intervals relating to core aspects of care.

It is recognised that control targets and review intervals should be individualised, based on the patient’s overall health status.

As a general rule patients should be reviewed every 6 months if they are well controlled and more frequently (3-4 monthly) if control is sub-optimal.

ProcessTargetReview interval
HbA1c 53mmol/mol 3-4 monthly if not at target
6 monthly if at target
Estimated GFR Stable Individualised in line with Renal Association Guidance www.renal.org/eGFR/stage3.html
Blood Pressure 130/80 3-4 monthly if not at target
6 monthly if at target
BMI 20-25 3-4 monthly if not improving
6 monthly if improving
Urinary protein / microalbumin - ve Repeat x2 within a few weeks to confirm status if positive.
12 monthly if negative.
Refer in line with Tayside protocol
Smoking Status   6 monthly
Foot Risk Assessment   12 monthly
Retinal Photography   12 monthly
Screen for Erectile Dysfunction   12 monthly
Screen for Depression   12 monthly

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Consultation Service


Health care professionals providing Community Diabetes Care and ward-based staff should use this service for advice, or to refer patients for specialist assessment when:

  • difficulty is experienced in establishing / maintaining control of blood pressure, HbA1c, lipids or other metabolic indices, at levels appropriate to the patient
  • a patient is considered for insulin therapy
  • a patient is planning a future pregnancy
  • symptoms and signs develop that are thought to be related to diabetes (other than serious medical emergencies, which should be admitted through the acute medical admissions procedures).
  • patients are admitted to general hospital wards with conditions related to or affecting their diabetes.

Once the referring problem has been assessed and a management plan established, the patient will be:

  • discharged back to Community Diabetes Care if the patient is stable and the specialist team feel that their input has achieved all it is likely to
  • transferred to the Continuing Specialist Care Service for ongoing Specialist care if clinically appropriate

Continuing Specialist Care Service (CSCS)


Patients should be referred to this service in the following circumstances:

  • All patients with Type 1 diabetes at diagnosis or as migration from the Paediatric Diabetes Service
  • Patients with referable retinopathy (on Tayside Grading Scheme)
  • Presence of renal impairment above agreed levels
  • Presence of foot ulcer
  • Patients who are pregnant, including those with gestational diabetes
  • Patients with symptomatic neuropathy
  • Patients with severe or unstable cardiovascular disease

Such patients will usually be given long-term specialist follow-up and referred on to other specialists at appropriate times. Within this context, arrangements for GP involvement in ongoing monitoring may be agreed between GP and specialist team on a patient-by-patient basis, for:

  • well controlled Type 1 diabetes without complications or with stable complications
  • well controlled Type 2 diabetes and stable complications

The responsibility for follow-up of patients considered clinically appropriate for CSCS care, including those with Type 1 Diabetes, who are clinic defaulters or poor attendees for care will primarily be the responsibility of the Diabetes Specialist Nursing Service who will develop a structured and full-proof mechanism to ensure ongoing contact with this group of patients. This mechanism will include communication and collaboration with the patient’s GP. Within the Continuing Specialist Care Service there are specialist clinics, often operated in collaboration with specialists from other disciplines. e.g. foot, renal and antenatal clinics.

Type 1 Diabetes


Patients with Type 1 Diabetes will enter the System as young adults, either at diagnosis or following transfer from the Paediatric Diabetes Service.

Ongoing care, assessment and monitoring will routinely be offered within the Continuing Specialist Care Service.

Shared-care arrangements can be agreed between GP and specialist team on a patient-by-patient basis, for patients with well-controlled Type 1 diabetes without complications or with stable complications. Such patients should receive an assessment within the Specialist service at least annually.

Patients with Type 1 Diabetes who are clinic defaulters or poor attendees, will be followed up by the Diabetes Specialist Nurses in the first instance. Thereafter a letter will be sent to inform the relevant GP of those patients who chronically default for review by the specialist team. In such cases, no routine review appointments may be made but re-referral after discussion with the patient would be welcomed.

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