Step 2. Understand the current situation

Understand your system - the processes, people and how they interact with each other. This helps identify the changes required and the impact they might have elsewhere in the system.

Suggested actions - understanding systems

Health boards

• Is this a clinical priority for the health board? If not, why not?
• Does the board have an identified clinical lead for this?

Managed Clinical Network (MCN) and Respiratory Specialists in secondary care

• Is the MCN aware of the guidelines and ready to lead by example in implementing these?
• Does the MCN link with local groups of people and can these be developed locally?

Clusters and Cluster Quality Leads (CQLs)

• Have the CQLs and clusters reviewed the recently published cluster reports?
• Are the clusters willing to work together to share experience and learning and work together to focus implementation on this area?

GP Practices and Primary Care Team

• Is there a clinical lead within the practice for T2DM? Is this the sole practitioner managing these people? 
• How does the practice direct/support the prescribing of others in the practice for the benefit of those living with T2DM? How do patient groups link with this?

Engage with key stakeholders  

How will you engage with patient groups, wider MDT, community link workers/third sector groups to co-design your approach?

Understand your system - the processes, people and how they interact with each other. This helps identify the changes required and the impact they might have elsewhere in the system.

Suggested actions - understanding systems and available data

Dashboard - National therapeutic indicators data visualisation - Public Health Scotland

National therapeutic indicators available include

• Metformin - percentage of people with T2DM prescribed an anti-diabetic medicines (aim for high percentage)
• Polypharmacy - prescribed three or more categories of anti-diabetic medicines (aim for minimal medication to manage condition)
• Sulfonylureas in individuals aged over 75 years (aim for lower percentage to reduce risks)
• Individuals with diabetes and CVD treated with a SGLT-2 inhibitor and/or GLP-1RA (higher level of prescribing should reduce complications)
• Glucose self-monitoring products prescribed in individuals (ensure valid rationale for prescribing)

NTI are available at https://scotland.shinyapps.io/nhs-prescribing-nti/

• Scottish Therapeutic Utility (STU) in GP practices linking prescribing data with GP system read codes, values, etc.
• Information and download instructions for practices
• STU installation

• Process map – a QI tool to help you understand your system and key processes which may need to be improved.
• Pareto Chart - a tool to help you understand your system. 

IT systems

• GP systems – update drug dictionaries, highlight formulary choices, update prescribing synonyms, update ScriptSwitch messages for clinicians
• Hospital prescribing systems – highlight new formulary choices and update dispensary stock systems