NaDIA 2018 - Full Report
Source: data.gov.uk (2020-10-16)

National Diabetes Inpatient Audit (NaDIA) - 2018. The information available from this webpage comes from the National Diabetes Inpatient Audit. The National Diabetes Inpatient Audit is a snapshot audit of diabetes inpatient care. 

During September and October 2018, hospitals across England and Wales collected data on the characteristics of the hospital, including participation, staffing levels and care improvement initiatives.

2018 was a designated NaDIA Quality Improvement Collaborative (QIC) year. To reduce the burden on QIC participants, the NaDIA 2018 collection undertook the Hospital Characteristics (HC) survey only.
# Making clinical audit data transparent
In his transparency and open data letter to Cabinet Ministers on 7 July 2011, the Prime Minister made a commitment to make clinical audit data available from the national audits within the National Clinical Audit and Patient Outcomes Programme.
# What information is being made available?
National Diabetes Inpatient Audit data for 2018 is available at hospital site level for:

* Audit participation
* Measures of staffing levels and care improvement initiatives.

These data do not list individual patient information nor do they contain any patient identifiable data.
# Using and interpreting the data
Data from the National Diabetes Inpatient Audit should not be looked at in isolation when assessing standards of care.
# Accessing the data
The data are being made available on the data.gov website. Each year a data file from the National Diabetes Inpatient Audit will be made available in CSV format. Hospitals are identified by name and their national code.
# What does the data cover?
The audit looks at the following areas:
* Participation in the audit
* Inpatient staffing levels
* Take-up of care improvement initiatives
# What period does the data cover?
This report covers hospital characteristics during September and October 2018. The audit report was published on 9 May 2019. Historic data is available for previous audit years (2010-2013, 2015-2017) where survey questions were comparable.

National Diabetes Inpatient Audit 
Hospital characteristics, 2018
England and Wales
9 May 2019
V1.0
Hospital characteristics report

The NaDIA team would like to thank all the people and teams who have 
worked hard to contribute to this unique and valuable insight into the 
inpatient care of people with diabetes.
Foreword
2
Bob Young, Clinical Lead, National Diabetes Audit
The NaDIA Hospital Characteristics report covers the structures of care that are 
fundamental to achieving the standards of safe effective inpatient diabetes care. 
Achievement of these standards is measured by the bedside NaDIA snapshot audit and 
the new NaDIA-Harms audit a continuous measurement that commenced in July 2018. 
The first NaDIA-Harms report will be published in May 20191.
The analysis, findings and recommendations in this report are reinforced by important 
recent publications by Diabetes UK2 and NHS England3, including the NHS Long Term 
Plan3 published in January 2019. It is good to see that issues identified by NaDIA –
including specialist inpatient staffing and appropriate use of health technology – are high 
on the national healthcare agenda.
2018 was a NaDIA Quality Improvement Collaborative (QIC) year and as a result only the 
Hospital Characteristics survey was undertaken. In 2019 there will be another Bedside 
Audit and Patient Experience survey alongside the Hospital Characteristics element.
Notes: 1. NHS Digital, http://digital.nhs.uk/pubs/nadia-harms2018, 2019
2. Diabetes UK, Making hospitals safe for people with diabetes, 2018 3. NHS England, NHS Long Term Plan, 2019.

Introduction: Overview
3
Prepared in collaboration with:
Supported by:
•
The National Diabetes Inpatient Audit (NaDIA) 
measures the quality of diabetes care provided 
to people with diabetes while they are admitted 
to hospital whatever the cause, and aims to 
support quality improvement.
•
Because 2018 was a NaDIA Quality 
Improvement Collaborative year, only the 
Hospital Characteristics survey was 
undertaken. In 2019 the Bedside Audit and 
Patient Experience surveys will resume.
•
The NaDIA audit is part of the National Diabetes 
Audit (NDA) portfolio within the National Clinical 
Audit and Patient Outcomes Programme 
(NCAPOP), commissioned by the Healthcare 
Quality Improvement Partnership (HQIP).

Introduction: Audit questions
4
2018 was a designated NaDIA Quality Improvement Collaborative (QIC) year. 
To reduce the burden on QIC participants, the NaDIA 2018 collection has 
focused on the Hospital Characteristics survey only. The Bedside Audit and 
Patient Experience surveys will be repeated for NaDIA 2019.
This report uses the Hospital Characteristics survey to answer the following 
questions:
•
Have staffing levels for inpatient diabetes teams increased since 2015?
•
Has take-up of care improvement initiatives and healthcare technologies for 
diabetes care increased since 2013?
•
What additional transformation funding has been provided for inpatient 
diabetes teams in 2018?
The report will be of interest to the public, especially to people with 
diabetes. Health planners and policy makers, as well as acute NHS 
Trusts, Clinical Commissioning Groups (CCGs), Local Health Boards 
(LHBs), Sustainability and Transformation Partnerships (STPs), 
Clinical Networks (CNs; formerly Strategic Clinical Networks or SCNs) 
and other providers and commissioners of specialist diabetes services 
will also make use of the information in this report.

Introduction: Why is this report important? (1)
5
In October 2018 Diabetes UK published a report into Making Hospitals Safe 
for People with Diabetes1. The recommendations in this report overlap with 
much of the analysis in NaDIA 2018, reaffirming the importance of the NaDIA 
Hospital Characteristics collection:
Notes: 1. Diabetes UK, Making hospitals safe for people with diabetes, 2018
Staffing levels:
All hospitals should have a 
fully staffed diabetes inpatient 
team, made up of the 
following:
•
Diabetes consultant.
•
Sufficient diabetes inpatient 
specialist nurses (DISNs) 
to run a daily and weekend 
service (7 day service).
•
Access to a diabetes 
specialist podiatrist, 
pharmacist and dietitian
and access to 
psychological support.
Care improvement initiatives:
•
Effective electronic prescribing (EP) system for detecting, 
recording, and avoiding insulin and oral hypoglycaemic agent 
(OHA) prescribing errors should be used across hospitals. 
•
Web-linked blood glucose and ketone meters should be actively 
used to alert the diabetes inpatient team to out of range glucose 
values and to monitor glucometrics across the trust and at ward 
level (remote blood glucose monitoring [BGM]).
•
All diabetes inpatient teams should host mortality and morbidity
meetings.
•
Basic training on the safe use of insulin and the main diabetes 
harms and how they can be prevented should be mandatory for 
all healthcare professionals caring for people with diabetes.
•
Training should be provided to all undergraduate doctors and 
nurse trainees in the important aspects of inpatient diabetes care.
Selected recommendations from Making Hospitals Safe for People with Diabetes1

Introduction: Why is this report important? (2)
6
In January 2019 NHS England published the NHS Long Term Plan1. The 
recommendations in this report overlap with much of the analysis in NaDIA 2018, 
reaffirming the importance of the NaDIA Hospital Characteristics collection:
Notes: 1. NHS England, NHS Long Term Plan, 2019
Staffing levels:
The Plan will ensure that 
“all hospitals in future 
provide access to Multi-
disciplinary Foot Care 
Team and diabetes 
inpatient specialist 
nursing teams to 
improve recovery and to 
reduce lengths of stay 
and future readmission 
rates”.
Care improvement initiatives:
“Over the next five years, all providers will be 
expected to implement electronic prescribing 
systems to reduce errors by up to 30%.”
The Plan will “accelerate the roll out of Electronic 
Patient Record systems and associated apps”.
Selected recommendations from the NHS Long Term Plan1
“The NHS cannot fully embrace the opportunity 
offered by new technologies if many hospitals 
and services remain largely paper-based.”
NHS Long Term Plan, 2019

Introduction: Contents and acronyms
Chapter
Slide
Key messages
8
1 Participation
13
2 Transformation funding
16
3 Staffing levels
20
4 Care improvement initiatives
27
Glossary
35
Additional information
42
7
Acronyms
The following acronyms and abbreviations are used throughout the report and are not 
always defined on the slide. Further acronyms are outlined in the Glossary (Slide 41):
DISN = Diabetes inpatient specialist nurse
DSN = Diabetes specialist nurse
EP = Electronic prescribing
EPR = Electronic Patient Record
M&M = Diabetes Morbidity and Mortality meeting,
including a regular M&M meeting where diabetes can be discussed.
MDFT = Multi-disciplinary Foot Care Team
Remote BGM = Remote Blood Glucose Monitoring

National Diabetes Inpatient Audit 2018
Key messages
8

Key messages: Summary 
9
•
All NaDIA sites should participate in the Hospital Characteristics 
survey, which continues to offer valuable insights into inpatient care 
even as a standalone collection. Over 20 NaDIA sites did not 
participate in NaDIA 2018.
•
More than 90 per cent of organisations that have received 
transformation funding have used (or plan to use) the funding to 
recruit new staff.
•
There have been substantial increases in inpatient staffing levels 
for almost all diabetes professionals since 2017. Diabetes inpatient 
specialist nurses (DISNs) hours have increased by 19 per cent per 
inpatient, diabetes consultants by 14 per cent, podiatrists by 47 per 
cent and specialist dietitians by 87 per cent. 
•
Nonetheless, it is concerning that one fifth (22 per cent) of NaDIA 
sites still have no DISNs. Access to diabetes specialist pharmacists
continues to be low, averaging 3 minutes of input per inpatient per 
week.
•
Although usage of electronic prescribing and Electronic Patient 
Records continues to increase, new take-up of health technologies 
is slow. For example, almost two-thirds (65 per cent) of NaDIA sites 
still do not fully-utilise electronic prescribing technology.

Key messages: Summary (Infographic 1)
10
All NaDIA sites should 
participate in the Hospital 
Characteristics survey, which 
continues to offer valuable 
insights into inpatient care 
even as a standalone 
collection.
The large majority (more 
than 90 per cent) of 
organisations that have 
received transformation 
funding have used (or 
plan to use) the funding to 
recruit new staff.
96 per cent1
have used or 
intend to use 
transformation 
funding to 
recruit more 
staff
21
21 NaDIA sites 
that submitted 
data in 2017 did 
not submit any 
data in 2018. 
96%
Notes: 1. Of organisations receiving transformation funding.

Key messages: Summary (Infographic 2)
11
There have been substantial increases in 
inpatient staffing levels for almost all 
diabetes professionals, including diabetes 
inpatient specialist nurses (DISNs), diabetes 
consultants, podiatrists and dietitians.
For DISNs, this equates to a rise from 2017 to 
2018 of:
hours per week per inpatient.
Nonetheless, it is concerning that one 
fifth of NaDIA sites still have no 
DISNs. Access to diabetes specialist 
pharmacists continues to be low, 
averaging 3 minutes of input per 
inpatient per week.
However, new take-up of 
electronic prescribing and the 
Electronic Patient Record is 
slow. For example, over half 
of NaDIA sites still do not use 
electronic prescribing 
technology.
0.61
0.73
2018
2017
The percentage of NaDIA 
sites using electronic 
prescribing (EP) rose from 
16.1 in 2013 to 34.6 in 2018
1
2018
2013
2015
2016
2017
0%
40%
Using EP?

Key messages: Recommendations
12
NaDIA supports Diabetes UK and NHS England’s recommendations on 
inpatient specialist staffing and care improvement initiatives, as outlined 
in Making Hospitals Safe for People with Diabetes1 (2018) and the NHS 
Long Term Plan2 (2019).
For commissioners
The top priority should be to achieve diabetes inpatient specialist nurse (DISN) 
and Multi-disciplinary Foot Care Team (MDFT) provision in every acute hospital.
For healthcare providers
•
It is vitally important that all NaDIA sites participate in the 
Hospital Characteristics survey, which continues to offer valuable 
insights into inpatient care even as a standalone collection.
•
Hospitals without Electronic Patient Records (EPR), electronic prescribing 
(EP), remote blood glucose monitoring (BGM) and junior doctor/nurse 
training programmes should plan to implement all of these initiatives as soon 
as possible.
•
Pharmacy teams should work with diabetes teams to support safe insulin use.
Notes: 1. Diabetes UK, Making hospitals safe for people with diabetes, 2018 2. NHS England, NHS Long Term Plan, 2019.

National Diabetes Inpatient Audit 2018
1. 
Participation
13

Participation: Overview
14
Audit question: 
How many hospital sites participated in the audit?
Why is this important?
Participation in NaDIA 2018 is essential to answer 
key audit questions around the funding, staffing 
levels and structures of care for inpatients with 
diabetes.
The results from the audit can be used to drive 
improvements in inpatient care, though the 
implementation of audit recommendations and 
local Quality Improvement initiatives. The end goal 
is to improve the inpatient experience, minimise 
harms and improve outcomes.
Key finding
21 hospital sites that took 
part in NaDIA 2017 did not 
participate in NaDIA 2018.
Recommendation
It is vitally important that all 
NaDIA sites participate in the 
Hospital Characteristics 
survey, which continues to 
offer valuable insights into 
inpatient care even as a 
standalone collection.
i
How is data collected?
Each participating hospital site completed a Hospital Characteristics
questionnaire providing information on additional funding, staffing levels and 
care initiatives for inpatient diabetes care.

Participation: Submissions
Notes: b = break in time series. 1. A NaDIA ‘site’ may represent a single hospital, multiple hospitals or an entire NHS Trust /Local Health 
Board. Because NaDIA site aggregations vary over time, year-on-year changes in number may not represent real changes in participation. 
2. In 2017, hospital sites that submitted Patient Experience or Bedside Audit forms could take part in NaDIA without submitting a Hospital 
Characteristics form.
15
Table 1.1: NaDIA organisational participation, England and Wales, 2011-18
Audit year
Number 
of sites1
NHS 
Trusts/
LHBs
2018 England
169
122
2018 Wales
16
6
2018 total
185
128
2017
208
2016
209
2015b
206
2013b
211
2011
206
i
Non-participants 
Are the 2018 non-participating sites different from consistent participants? This question 
has been addressed by comparing results between 2017 (all participants) and 2017 (with 
2018 non-participants removed). A substantial difference would suggest that there is a real 
difference between the groups. Results are discussed alongside the relevant outputs.
Findings
The audit is open to participation from acute hospitals in 
England and Wales that treat inpatients with diabetes. 
The inclusion criteria for patients is outlined in Slide 36.
•
185 hospital sites (representing 122 NHS Trusts in 
England and 6 Local Health Boards in Wales) took 
part in the 2018 audit. 
•
21 NaDIA sites that submitted a Hospital 
Characteristics form in 20172 did not participate in 
NaDIA 2018.
•
2 NaDIA sites participated in 2018 that did not take 
part in NaDIA 2017.

National Diabetes Inpatient Audit 2018
2. 
Transformation Funding
16

Audit questions: 
•
How many hospital sites received diabetes transformation 
funding to improve access to DISNs and MDT?
•
Has diabetes transformation funding been used to fund 
additional posts in diabetes care?
Why is this important? In 2016 NHS trusts and CCGs in 
England could apply for a share of £44 million of 
transformation funding to improve diabetes care. Funds were 
allocated by NHS England the following year, including for 
the following two interventions most relevant to NaDIA:
•
Improving access to diabetes inpatient specialist 
nursing teams: Whatever reason someone with diabetes 
is in hospital, these teams make sure people get the care 
they need and have a better and shorter stay in hospital1.
Transformation funding: Overview
17
Notes: 1 Diabetes UK: Campaign win: £40 million more for diabetes care in England. 2017
i
Key findings
•
Two fifths of NaDIA sites 
received transformation 
funding to improve access 
to an MDFT.
•
One quarter of NaDIA 
sites received 
transformation funding to 
improve access to DISNs.
•
The large majority (more 
than 90 per cent) of 
organisations that have 
received transformation 
funding have used (or plan 
to use) the funding to 
recruit new staff.
How is data collected? The NaDIA 2018 Hospital Characteristics form included two 
questions about transformation funding in relation to MDFT and DISN interventions.
•
Improving access to a foot care team for people with 
diabetic foot disease: Foot problems for people with 
diabetes can develop rapidly. Being able to see to foot care 
team quickly plays a vital part in preventing amputations1.

Yes, 
75.4%
No, 
24.6%
Transformation funding: Received
* There was no audit collection or report in 2014, so 2014 data is not available.
Table 2.1: Percentage of sites that received 
transformation funding, England, 2018
Percentage of sites with funding for:
2018
n
Per cent
•
Improving access to a Multi-
disciplinary Foot Care Team (MDFT)
61
40.1
•
Improving access to Diabetes 
Specialist Nurses (DISNs)
40
25.8
18
Findings
•
Two fifths of NaDIA sites 
received transformation funding 
to improve access to an MDFT.
•
One quarter of NaDIA sites 
received transformation funding 
to improve access to DISNs.
i
Yes, 
75.0%
No, 
25.0%
Did the sites receiving 
transformation funding 
already have a MDFT?
Did the sites receiving 
transformation funding 
already have DISNs?

Transformation funding: Usage
* There was no audit collection or report in 2014, so 2014 data is not available.
Notes: 1. ‘New posts’ includes sites without MDFT / DISN staffing in place that used transformation funding to employ their first posts in 
these areas and sites with MDFT / DISN staffing where the transformation funding was used to add posts to an existing service.
2.. DISN = Diabetes inpatient specialist nurse. MDFT = Multi-disciplinary Foot Care Team.
Finding
•
More than 90 per cent of organisations that have received 
transformation funding have used (or plan to use) the funding to 
recruit new staff.
19
Table 2.2: Percentage of sites that that used transformation funding 
for new1 posts, England, 2018
Funding used for new1 posts?
Sites receiving 
MDFT funding
Sites receiving 
DISN funding
n
Per cent
n
Per cent
•
Yes – some or all new staff in post
50
82.0
36
90.0
•
Yes – but staff not yet in post
2
3.3
4
10.0
•
No – but plan to 
3
4.9
0
0.0
•
No – and do not plan to
4
6.6
0
0.0
•
Don’t know / Not applicable
2
3.3
0
0.0
i

National Diabetes Inpatient Audit 2018
3. 
Staffing levels 
20

Key findings
•
Staffing levels for inpatient diabetes care have 
increased for all professions between 2017 and 
2018, apart from pharmacists.
•
Access to podiatry services has improved: the 
proportion of hospital sites with no podiatry services 
has halved since 2017, from 32 to 16 per cent.
•
There has been an increase in the proportion of 
sites with 7 day DISN provision since 2017 (from 9 
to 12 per cent), which tallies with the increase in 
DISN staffing levels found elsewhere.
•
Nonetheless, more than a fifth of hospital sites have 
no diabetes inpatient specialist nurses (22 per cent).
•
The proportion of sites with 7 day Diabetes 
Physician access has decreased by almost 4 
percentage points.
•
One sixth of hospital sites do not have a Multi-
disciplinary Foot Care Team, though this
proportion has halved since 2011.
Staffing levels: Overview
21
Why is this important? Caring for people 
with diabetes in hospital requires specialist 
knowledge about treatments and medication, 
and an understanding of how a patient’s care 
may be affected by their diabetes.
It is important that hospitals have enough 
specialist staff with this knowledge to help to 
look after patients with diabetes and to 
support other ward staff in delivering good 
diabetes care.
How is this measured? Hospitals were 
asked to estimate the amount of staffing time 
spent each week on inpatient diabetes care. 
Stated hours, derived from whole time 
equivalents, was compared to the numbers of 
admitted people with diabetes reported by 
each hospital last year.
The NaDIA team acknowledge the difficulty of 
estimating staff hours. Caution is therefore 
advised when interpreting staffing levels, 
particularly at site level.
Audit question: 
What specialist staff are available to look after people with diabetes when they are admitted to hospital?
i

Staffing levels: Results
Table 3.1: Average staffing for care of inpatients with diabetes1,
England and Wales, 2015-18
Profession
Hours per week of inpatient care per 
inpatient with diabetes
20152
20162
20173
20183,4
•
Diabetes inpatient 
specialist nurse (DISN)
0.50
0.49
0.61
0.73
•
Diabetes specialist nurse 
(DSN)
0.17
0.17
0.23
0.35
•
Any diabetes specialist 
nurse (DISN and DSN)
0.67
0.66
0.84
1.08
•
Diabetes consultant
0.19
0.19
0.29
0.34
•
Podiatrist
0.11
0.11
0.16
0.23
•
Specialist diabetes dietitian
0.03
0.03
0.04
0.08
•
Non-specialist dietitian
0.06
0.05
0.05
0.09
•
Any dietitian
0.09
0.08
0.09
0.16
•
Diabetes specialist 
pharmacist
0.03
0.04
0.07
0.05
22
Notes: 
1. The stated figures are derived from the total number of hours of inpatient care per week divided by 
the total number of Bedside Audit forms. The NaDIA team acknowledge the difficultly of estimating 
staff hours. Caution is therefore advised when interpreting staffing levels, particularly at site level. 
Please see the explanatory note (top right) about data collection changes in this year’s audit..
2. Staffing originally collected in hours. 
3. Staffing originally collected as whole time equivalents. 
4. Since no Bedside Audit was conducted in 2018, staff hours are divided by the number of Bedside 
Audit forms collected by each organisation in 2017.
Finding
•
At national level staffing 
levels for inpatient diabetes 
care have increased for all 
professions between 2017 and 
2018, apart from pharmacists.
Non-participants
Removing 2018 non-participants 
from the results has a negligible 
effect on overall 2017 staffing 
levels, differing by less than 0.02.
This suggests that year-on-year 
comparisons between 2017 and 
2018 are robust.
i

Staffing levels: Delivery of diabetes care
* There was no audit collection or report in 2014, so 2014 data is not available.
Table 3.2: Percentage of sites with staff deficiencies, 
England and Wales, 2011-18
Notes: 
b = break in time series. r = revised. 7A6AV erroneously excluded from 2017 analysis – now included.
1. DISN = Diabetes inpatient specialist nurse.
Findings
•
More than a fifth of hospital sites have no diabetes 
inpatient specialist nurses (22 per cent).
•
The proportion of hospital sites with no podiatry services 
has halved since 2017.
Percentage of sites 
with:
2011
2013b
2015b
2017
b, r
2018
•
no inpatient DISNs1
31.9
31.7
31.1
28.2
21.6
•
no specialist inpatient 
dietetic provision for 
people with diabetes
70.8
71.2
71.4
73.3
65.9
•
no inpatient podiatry 
service for people 
with diabetes
33.6
34.1
26.2
32.0
15.7
23
i
Non-participants
Removing 2018 non-
participants from the 2017 
results does have a small 
effect on the outputs, 
differing by a maximum of 
two percentage points, 
though the underlying 
downward trends do not 
change.
This suggests that year-
on-year trends between 
2017 and 2018 are 
robust, though the actual 
2018 percentages may be 
affected slightly by the 
non-participants.

Staffing levels: 7 day care provision
* There was no audit collection or report in 2014, so 2014 data is not available.
Table 3.3: Percentage of sites with 7 day DISN provision1, 
England and Wales, 2015-18
Notes: r = revised. 7A6AV erroneously excluded from 2017 analysis – now included.
1. DISN = Diabetes inpatient specialist nurse
Findings
•
There has been an increase in the proportion of sites 
with 7 day DISN provision since 2017 (from 9 to 12 per 
cent), which tallies with the increase in DISN staffing 
levels found elsewhere.
•
The proportion of sites with 7 day Diabetes Physician 
access has decreased by almost 4 percentage points 
since 2017.
Percentage of sites with:
2015
2016
2017r
2018
•
7 day DISN provision
6.4
7.7
8.7
12.4
24
Table 3.4: Percentage of sites with 7 day Diabetes Physician 
access, England and Wales, 2016-18
Percentage of sites with:
2016
2017
2018
•
7 day Diabetes Physician access
15.2
25.2
21.6
i
Non-participants
Removing 2018 non-
participants from the 
2017 results only has a 
small effect on the 
outputs, differing by a 
maximum of 0.2 
percentage points.
This suggests that year-
on-year comparisons 
between 2017 and 2018 
are robust.

Staffing levels: Multi-disciplinary Foot Care Team
Figure 3.1 Percentage of sites not having a Multi-disciplinary Foot Care Team, 
England and Wales, 2011-18
* There was no audit collection or report in 2014, so 2014 data is not available.
25
Notes: b = break in time series. r = revised. 7A6AV erroneously excluded from 2017 analysis – now included.
Findings
•
One sixth of hospital sites do 
not have a Multi-disciplinary 
Foot Care Team.
•
The proportion of hospital sites 
not having a Multi-disciplinary 
Foot Care Team has more than 
halved since 2011.
i
Non-participants
Removing 2018 non-participants from the 2017 results has a 
small effect on the outputs, increasing the proportion of sites 
not having an MDFT in 2017 by 0.7 percentage points.
This suggests that year-on-year trends between 2017 and 
2018 are robust (i.e. downwards), though the actual 2018 
percentage may be affected slightly by the non-participants.
 1. 
28.2
 1. 
20.4
1 . 
0
10
20
30
40
50
2011
 0 3 
 0   
 0    
2018
 ercentage o  
sites
Audit year
 

Staffing levels:
Clinical comment and recommendations
26
i
Recommendations
•
The top priority should be to achieve DISN 
and MDFT provision in every acute hospital.
•
Pharmacy teams should work with the 
diabetes teams to support safe insulin use.
NaDIA supports Diabetes UK’s 
recommendations1 that:
All hospitals should have a fully staffed diabetes 
inpatient team, made up of the following:
•
Diabetes consultant.
•
Sufficient DISNs to run a daily and weekend 
service (7 day service).
•
Access to a diabetes specialist podiatrist, 
pharmacist and dietitian and access to 
psychological support.
And NHS England’s policy aim2 that:
“All hospitals in future provide access to MDFT and 
DISN teams to improve recovery and to reduce 
lengths of stay and future readmission rates”.
Notes: 1. Diabetes UK, Making hospitals safe for people with diabetes, 2018 2. NHS England, NHS Long Term Plan, 2019.
The overall trends towards increased 
provision of basic inpatient diabetes 
care, especially by DISNs, is 
encouraging.
It is of concern, however, that 
although the proportions are lower 
each year, one in five hospitals still
do not have dedicated Diabetes 
Inpatient Specialist Nurse (DISN)1
provision and one in six still do not 
have a Multi-disciplinary Foot 
Care Team (MDFT).
Furthermore, there remains a very 
low and concerning lack of 
pharmacist time in inpatient diabetes 
care, given that 33% of the medical 
errors that caused death within 48 
hours of the error involved insulin 
therapy (Barker et al 2015).
NaDIA team

National Diabetes Inpatient Audit 2018
4. 
Care improvement 
initiatives 
27

Care improvement initiatives:
Overview
28
Key findings
•
An increasing proportion of hospital sites 
are now fully-utilising electronic prescribing 
(EP) and remote blood glucose monitoring 
(BGM). The proportion having regular ward 
staff training has also increased.
•
Nonetheless, take-up of these 
technologies is still slow. For example, 
only 4 in 10 sites fully-utilise an Electronic 
Patient Record (EPR), with one third fully-
utilising EP.
Why is this important?
The introduction of initiatives to improve 
the care received by inpatients with 
diabetes may help improve the overall 
patient experience and reduce the harms 
experienced during admission.
For example, NaDIA 2017 found that 
inpatients with diabetes were less likely to 
have prescription errors if an Electronic 
Patient Record was used (although 
causation cannot be confirmed). 
Audit question: Which initiatives have hospitals introduced in order to improve the 
care of people with diabetes?
How is this measured?
Hospital staff were asked to provide information on:
•
Their use of technologies such as Electronic Patient Record (EPR), electronic 
prescribing (EP) and remote blood glucose monitoring (BGM).
•
Whether regular ward nurse diabetes training was carried out.
•
Whether diabetes Mortality and Morbidity meetings are undertaken.
i

Care improvement initiatives: EPR
29
Figure 4.1: Percentage of sites using an Electronic Patient Record (EPR)1, 
England and Wales, 2013-18
Notes: 
b = break in time series. 
r = revised. 7A6AV erroneously excluded from 2017 analysis – now included. 1. Data for all comparable years is shown. 
i
Findings
•
The proportion of sites fully-utilising 
the Electronic Patient Record (EPR) 
in 2018 is similar to that in 2017.
•
Less than half of sites fully-utilise 
EPR, but the proportion of sites with 
no EPR use continues to decrease
(22 per cent in 2018). 
Non-participants
Removing 2018 non-participants from the 
2017 results has a small effect on the outputs, 
raising the proportion of sites using EPR in 
2017 by 0.7 percentage points.
Because the adjusted 2017 figure is very close 
to the 2018 figure (within 0.6 per cent), it can 
be inferred that the year-on-year trend 
between 2017 and 2018 is static.
  .1
  . 
  . 
  . 
  . 
  . 
  . 
 1. 
  . 
  . 
  . 
  . 
  . 
  . 
  . 
0
10
20
30
40
50
60
70
80
Yes
Partial
No
 ercentage
o  sites
Usage
2013
 0   
2016
 0  
2018
Audit year
 
 

Care improvement initiatives: EP
30
Figure 4.2: Percentage of sites using electronic prescribing (EP)1,
England and Wales, 2013-18
Notes: 
b = break in time series.
r = revised. 7A6AV erroneously excluded from 2017 analysis – now included. 1. Data for all comparable years is shown. 
i
Findings
•
The proportion of sites fully-
utilising electronic 
prescribing (EP) has 
increased since 2017.
•
Only one third of sites fully-
utilise EP.
Non-participants
Removing 2018 non-participants from the 2017 results has 
an effect on the outputs, raising the proportion of sites 
using EP in 2017 by 1.7 percentage points.
Because the adjusted 2017 figure is still substantially 
below the 2018 figure (3.8 per cent), it appears that year-
on-year trends between 2017 and 2018 are robust (i.e. 
upwards), though the actual 2018 percentages may be 
affected by the non-participants.
1 .1
1 . 
 1. 
  . 
1 . 
  . 
  . 
 . 
  . 
  .1
 . 
 1. 
  . 
11. 
  . 
0
10
20
30
40
50
60
70
80
Yes
Partial
No
 ercentage
o  sites
Usage
2013
 0   
2016
 0  
2018
Audit year
 
 

Care improvement initiatives: Remote BGM
31
Figure 4.3: Percentage of sites using remote blood glucose monitoring (BGM)1, 
England and Wales, 2013-18
Notes: 
b = break in time series. r = revised. 7A6AV erroneously excluded from 2017 analysis – now included.
1. Data for all comparable years is shown. 
i
Non-participants
Removing 2018 non-participants from the 2017 results has 
an effect on the outputs, raising the proportion of sites 
using remote BGM in 2017 by 1.4 percentage points.
Because the adjusted 2017 figure is still substantially 
below the 2018 figure (5.4 per cent), it appears that year-
on-year trends between 2017 and 2018 are robust (i.e. 
upwards), though the actual 2018 percentages may be 
affected by the non-participants.
  . 
1 . 
  . 
  . 
1 . 
  . 
  .1
1 . 
  . 
  . 
 . 
  . 
 1. 
1 .1
  . 
0
10
20
30
40
50
60
70
80
Yes
Partial
No
 ercentage
o  sites
Usage
2013
 0   
2016
 0  
2018
Audit year
 
 
Findings
•
The proportion of sites fully-
utilising remote blood glucose 
monitoring (BGM) has 
increased since 2017.
•
Less than two-thirds of sites 
fully-utilise remote BGM.

Care improvement initiatives: Training
32
Figure 4.4: Percentage of sites with regular ward nurse training carried out1, 
England and Wales, 2013-18
Notes: 
b = break in time series. 1. Data for all comparable years is shown. 2. The option ‘Locally adapted’ was only available for NaDIA 2015
 and
NaDIA 2016. Consequently results in 2015 and 2016 
6 are not directly comparable to other years, where the ‘Locally adapted' option was not available. 
i
Non-participants
Removing 2018 non-participants from the 2017 results has 
a negligible effect on the outputs, raising the proportion of 
sites having regular ward nurse training in 2017 by less 
than 0.1 percentage points.
This suggests that year-on-year comparisons between 
2017 and 2018 are robust.
  . 
  . 
 . 
  . 
1 . 
1 . 
1. 
  . 
1 . 
1 . 
 . 
  . 
1 .1
1. 
  . 
1 . 
 . 
0
20
40
60
80
100
Yes
Locally adapted²
No
Unsure
 ercentage
o  sites
Usage
 0 3 
 0   
2016
2017
2018
Audit year
Findings
•
The proportion of sites having 
regular ward nurse training 
has increased since 2017.
•
Almost 90 per cent of sites 
have regular ward nurse 
training.

Care improvement initiatives: M&M
33
Figure 4.5: Percentage of sites holding diabetes Mortality and Morbidity meetings1, 
England and Wales, 2017-18
i
Findings
•
The proportion of sites having 
diabetes M&M meetings in 
2018 is similar to that in 
2017.
•
Almost 90 per cent of sites 
have diabetes M&M 
meetings.
Non-participants
Removing 2018 non-
participants from the 2017 
results has a small effect 
on the outputs, raising the 
proportion of sites having 
diabetes Mortality and 
Morbidity meetings in 2017 
by just 0.1 percentage 
points.
This suggests that year-
on-year comparisons 
between 2017 and 2018 
are robust.
Initiative
2013 to 
2018
2017 to 
2018
• EPR
Up
Similar
• EP
Up
Up
• Remote BGM
Up
Up
• Ward nurse 
training
Up
Up
• M&M
–
Similar
Notes: r = revised. 7A6AV erroneously excluded from analysis in 2017 report – now included. 
1. Data for all comparable years is shown.

Care improvement initiatives:
Clinical comment and recommendations
34
The overall trend to improvements in the use of care improvement 
initiatives in hospital sites – Electronic Patient Records (EPR), 
electronic prescribing (EP), remote blood glucose monitoring (BGM) 
– is encouraging.
But the rate of improvement is slow and the take up of technologies 
is still uneven.
i
Recommendation
Hospitals without Electronic Patient Record (EPR) systems, electronic prescribing 
(EP), remote blood glucose monitoring (BGM) and junior doctor/nurse training 
programmes should plan to implement all of these initiatives as soon as possible.
NaDIA supports Diabetes UK’s recommendations1 on care improvement 
initiatives (see Slide 5 above).
And NHS England’s policy aims2 to:
•
Ensure providers implement electronic prescribing systems.
•
Accelerate the roll out of Electronic Patient Record systems and associated apps.
Notes: 1. Diabetes UK, Making hospitals safe for people with diabetes, 2018 2. NHS England, NHS Long Term Plan, 2019.

National Diabetes Inpatient Audit 2018
Glossary
35

Glossary: NaDIA data collection
Data collection 
Each participating hospital site completed a Hospital Characteristics (HC) questionnaire 
providing information on the hospital’s resources and staffing structure. In 201
9 there will 
be a Bedside Audit and Patient Experience survey alongside the Hospital 
Characteristics questionnaire, following a process similar to that undertaken in previous 
NaDIA years (2010, 2011, 2012, 2013, 2015, 2016, 2017).
Which patients are included in the audit?
A patient was included in the inpatient audit (NaDIA) if they had been admitted to a 
hospital bed for 24 hours or more. Patients on an Obstetric or Paediatric ward were 
excluded from this audit. Mental Health wards were also excluded due to the high 
prevalence of long stay patients. Other exclusions included:
36
•
Patients who were hyperglycaemic but not yet
formally diagnosed with diabetes
•
Accident and Emergency
•
Day case ward
•
Day surgery unit patients
•
Observation ward (if patients had been 
admitted for less than 24 hours)
•
Surgical short stay unit (if patients had been admitted for less than 24 hours)
•
Palliative care centres and community hospitals

Glossary: Healthcare providers
NaDIA data is collected and submitted by healthcare professionals that work on applicable hospital 
wards in England and Wales.
For NaDIA Hospital Level Analysis, data is aggregated by NaDIA site, which may be an NHS Trust, 
Welsh Local Health Board (LHB), an individual hospital or a grouping of hospitals that have chosen to 
have their results aggregated together.
Commissioners decide what health services are needed and ensure that they are provided. Clinical 
Commissioning Groups (CCGs) in England and LHBs in Wales are responsible for commissioning 
healthcare services.
The National Institute for Health and Care Excellence (NICE) produces guidelines for the treatment of 
diabetes. All diabetes inpatient services should follow these guidelines, so that people with diabetes 
receive the best possible healthcare.
37

Glossary: Healthcare professionals
38
A wide variety of healthcare professionals are involved in the care of inpatients with 
diabetes, including (but not restricted to) the following professions:
o
Diabetes consultants are senior hospital physicians who diagnose and treat 
patients with diabetes. Diabetes consultants are specialists in diabetology and 
endocrinology (the specialism concerning the glands and hormones).
o
Diabetes specialist nurses (DSN) work to meet the needs of people with diabetes 
and provide experience and expertise as part of dedicated diabetes teams. DSNs 
work wholly in diabetes care. A diabetes specialist inpatient nurse (DISN) 
provides hospital inpatient care1.
o
A dietitian is a healthcare professional with expertise in diet and nutrition. A 
specialist diabetes dietitian advises people with diabetes on the most suitable diet 
to control and manage their diabetes.
o
Podiatrists are healthcare professionals that specialise in conditions of the feet and 
lower limbs. This includes the prevention, management and treatment of foot 
complications commonly experienced by people with diabetes (e.g. diabetic foot 
disease).
o
Diabetes specialist pharmacists are healthcare professionals that specialise in the 
safe and effective management of medication for controlling and treating diabetes.
Notes: 1. Diabetes UK (2014) Position Statement: Diabetes Specialist Nurses: Improving Patient Outcomes and Reducing Costs

Glossary: Healthcare technologies
39
Hospitals may use some or all of the following healthcare technologies which 
support inpatient care:
o An Electronic Patient Record (EPR) is a computer system designed to 
collect and store patients' clinical and health information in one place, 
replacing paper-based health records and multi-platform data collection. 
Hospital staff involved in patient care can access and update the EPR 
system at different points in the patient's care. A variety of EPR systems are 
used. More than one third of hospitals use an EPR system.
o Hospital electronic prescribing (EP) is a computer system designed to 
allow prescriptions to be sent to pharmacies through IT systems, rather than 
through paper prescriptions. Almost one third of hospitals use EP.
o Remote blood glucose monitoring (BGM) tools allow remote access to 
the measurement of patient blood glucose (BG) levels. Results can be 
transmitted to patients and caregivers in real time, providing an early 
warning if BG levels are outside the expected levels. More than half of 
hospitals use remote BGM.

Glossary: Healthcare teams
40
“Specialists involved in the delivery of diabetes care must work in Multi-disciplinary Foot 
Care Teams for care to be truly effective. They should have received extensive training 
accredited at a national level.”
Diabetes UK1
Healthcare professionals form multi-disciplinary specialist teams in hospitals to co-
ordinate diabetes care, including (but not restricted to):
•
Inpatient specialist diabetes teams co-ordinate diabetes care in hospitals. diabetes teams 
usually consist of diabetes consultants, diabetes specialist (inpatient) nurses (DSN/DISN), 
podiatrists and dietitians, who will also work with other specialists who might also form part of 
the team (e.g. pharmacists and clinical psychologists).
•
Inpatient Multi-disciplinary Foot Care Teams (MDFT) co-ordinate diabetes foot care in 
hospitals. MDFTs meet weekly and consist of a diabetes consultant (diabetologist), a podiatrist 
with skills in managing the diabetic foot and a surgeon (general, orthopaedic or vascular 
surgeon). MDFTs will also work with other specialists who might be incorporated into the team 
(e.g. DSN/DISNs, podiatrists, interventional radiologists, microbiologists, tissue viability nurses). 
About three quarters of hospitals have MDFTs.
About half of hospitals host regular diabetes Mortality and Morbidity meetings (M&M) for 
healthcare professionals to discuss patient deaths and adverse incidents relating to diabetes, and 
another third of hospitals discuss diabetes cases at general M&M meetings. At M&M meetings staff 
can discuss incidents in detail, report problems and share lessons to prevent the recurrence of 
adverse incidents. 
Notes: 1. Diabetes UK (2010): Commissioning specialist diabetes service for adults with diabetes

Glossary: Acronyms
41
BA form = NaDIA Bedside Audit form
BG = Blood glucose
CCG = Clinical Commissioning Group
DISN = Diabetes inpatient specialist nurse
DKA = diabetic ketoacidosis
DSN = Diabetes specialist nurse
EP = Electronic prescribing
EPR = Electronic Patient Records
HC form = NaDIA Hospital Characteristics form
HHS = hyperosmolar hyperglycaemic state
HQIP = The Healthcare Quality Improvement
Partnership
LHB = Welsh Local Health Board
M&M meeting = Mortality and Morbidity meeting
MDFT = Multi-disciplinary Foot Care Team
NaDIA = National Diabetes Inpatient Audit
NCAPOP
=
National
Clinical
Audit
Patient
Outcomes Programme
NCVIN = National Cardiovascular Intelligence
Network
NDA = National Diabetes Audit
NICE = National Institute for Health and Care
Excellence
PE form = NaDIA Patient Experience form
QOF = Quality and Outcomes Framework
Remote
BGM
=
Remote
blood
glucose
monitoring
Data collection 
Each participating hospital site completed a Hospital Characteristics (HC) questionnaire 
providing information on the hospital’s resources and staffing structure. 
Glossary: NaDIA data collection

National Diabetes Inpatient Audit 2018
Additional information
42

Additional information: Summary
The following documents are available from 
http://content.digital.nhs.uk/pubs/nadia2018
• A one page executive summary of this report.
• A PowerPoint version of this report. 
• Hospital site level 2010-2018 data
• Supporting data in Excel format
• Data Quality Statement
• Methodology
43

Additional information: Future plans
Future plans:
•
A full NaDIA will be implemented in September 
2019 including the Hospital Characteristics, 
Bedside Audit and Patient Experience 
questionnaires.
44
• The audit team is working with Diabetes UK following publication of 
their report ‘Making hospitals safe for people with diabetes’ (201
8) to 
ensure the audit supports implementation of the recommendations.
• Working with the teams involved in the Quality Improvement 
Collaborative (QIC) to ensure that the audit supports measurement of 
actions implemented to improve patient care, for example, increased 
use of electronic prescribing (EP) and staff training.
•
A review of the NaDIA dataset is underway to 
ensure the questions are relevant and the burden on 
service providers is minimised.

Additional information: References
45
•
Barker et al (2015) Peri‐operative management of the surgical patient with diabetes 
2015: Association of Anaesthetists of Great Britain and Ireland. 2015 Dec; 70(12): 
1427–1440. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5054917/
•
Diabetes UK (2017) Campaign win: £40 million more for diabetes care in England: 
https://www.diabetes.org.uk/about_us/news/40-million-more-for-diabetes-care-in-
england1
•
Diabetes UK (2010): Commissioning specialist diabetes service for adults with diabetes 
https://www.diabetes.org.uk/resources-s3/2017-
09/defining%2520specialist%2520diabetes%2520service%2520for%2520adults%2520
with%2520diabetes.doc
•
Diabetes UK (2018) Making hospitals safe for people with diabetes: 
https://www.diabetes.org.uk/resources-s3/2018-
10/Making%20Hospitals%20safe%20for%20people%20with%20diabetes_FINAL.pdf
•
Diabetes UK (2014) Position statement: Diabetes specialist nurses: Improving patient 
outcomes and reducing costs: https://www.diabetes.org.uk/Professionals/Position-
statements-reports/Healthcare-professional-staffing-competency/Diabetes-Specialist-
Nurses-improving-patient-outcomes-and-reducing-costs/
•
NHS Digital: National Diabetes Inpatient Audit (NaDIA) 2017: 
http://digital.nhs.uk/pubs/nadia2017
•
NHS England: NHS Long Term Plan (2019): https:/www.longtermplan.nhs.uk/wp-
content/uploads/2019/01/nhs-long-term-plan.pdf

Additional information: Acknowledgements
The NaDIA team would like to thank all the people and teams who have worked hard 
to contribute to this unique and valuable insight into the inpatient care of people 
with diabetes.
Development and delivery of the NaDIA is guided by a multi-professional advisory group of clinicians and patient 
representatives, chaired by Gerry Rayman. The NaDIA Advisory Group members include: 
Gerry Rayman
Consultant Diabetologist and National Clinical Lead for Inpatient Diabetes 
Bob Young
NDA Specialist Clinical Lead
Belinda Allan
Consultant Diabetologist, Michael White Centre for Diabetes and Endocrinology (Hull)
Alex Berry
NDA Engagement Lead, Diabetes UK
Anne Claydon 
Nurse Consultant for Diabetes, Barts Health NHS Trust
Sophie Colling
NDA Project Support Officer, Diabetes UK 
Ketan Dhatariya
Consultant Diabetologist, Norfolk and Norwich University Hospitals NHS Foundation Trust
Karen Goodman-Jones
Patient Representative
Anne Kilvert
Consultant Diabetologist, Northampton General Hospital NHS Trust
Peter Knighton
Principal Information Analyst, NHS Digital
Alistair Lumb
Consultant in Diabetes and Acute General Medicine, Oxford University Hospitals NHS Foundation Trust
Claire Meace
Higher Information Analyst, NHS Digital
Maureen McGinn
Patient Representative
Julie Michalowski
Audit Manager, NHS Digital
Omar Mustafa
Consultant Diabetologist, Kings College Hospital
Rustam Rea 
Consultant in Diabetes and Acute General Medicine, Oxford University Hospitals NHS Foundation Trust
Aled Roberts
Consultant Physician, University Hospital of Wales
David Roberts
Patient Representative
Debbie Stanisstreet
Lead Nurse for Diabetes and Endocrinology (Lister Hospital) and Diabetes Inpatient Specialist
Nurse Network
Michael Sykes
Quality Improvement Lead, Diabetes UK
Garry Tan
Consultant Diabetologist, Oxford Centre for Diabetes, Endocrinology and Metabolism
Andrew Whitehead
Audit Coordinator, NHS Digital
Arthur Yelland
Senior Information Analyst, NHS Digital
46

The Healthcare Quality Improvement Partnership (HQIP). The National Diabetes 
Inpatient Audit (NaDIA) audit is part of the National Clinical Audit and Patient Outcomes 
Programme (NCAPOP) which is commissioned by the Healthcare Quality Improvement 
Partnership (HQIP) and funded by NHS England. HQIP is led by a consortium of the 
Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its 
aim is to promote quality improvement, and in particular to increase the impact that clinical 
audit has on healthcare quality in England and Wales. HQIP holds the contract to manage 
and develop the NCAPOP Programme, comprising more than 30 clinical audits that cover 
care provided to people with a wide range of medical, surgical and mental health 
conditions. The programme is funded by NHS England, the Welsh Government and, with 
some individual audits, also funded by the Health Department of the Scottish Government, 
DHSSPS Northern Ireland and the Channel Islands.
NHS Digital is the new name for the Health and Social Care Information Centre. NHS 
Digital managed the publication of the 2018 annual report.
Diabetes UK is the largest organisation in the UK working for people with diabetes, 
funding research, campaigning and helping people live with the condition.
The National Cardiovascular Intelligence Network (NCVIN) is a partnership of leading 
national cardiovascular organisations which analyses information and data and turns it 
into meaningful timely health intelligence for commissioners, policy makers, clinicians 
and health professionals to improve services and outcomes.
Supported by:
47
Prepared in collaboration with:

National Diabetes Inpatient Audit 2018
Published by NHS Digital
Part of the Government Statistical Service
Responsible Statistician
Peter Knighton, Principal Information Analyst
For further information
digital.nhs.uk
xx-xxxx-xxxx
xxx@xxx.xx
Copyright © 2019, the Healthcare Quality Improvement Partnership, National Diabetes Audit. All rights 
reserved.
This work remains the sole and exclusive property of the Healthcare Quality Improvement Partnership 
and may only be reproduced where there is explicit reference to the ownership of the Healthcare Quality 
Improvement Partnership.
This work may be re-used by NHS and government organisations without permission.
48