The NHS spends at least £3.9 billion a year on diabetes services and around 80% of that goes on treating avoidable complications of the disease, a committee of MPs has reported.
24,000 people in England die prematurely every year because their diabetes has not been managed effectively, and many more develop avoidable complications such as blindness and kidney disease, says the House of Commons Committee of Public Accounts (CPA), in a new report.
In 2001, the Department of Health published the National Service Framework for Diabetes, which set out clear minimum standards for diabetes care, including nine basic checks for the early signs of avoidable diabetic complications. However, fewer than half of people with the condition are now receiving all of these tests, says the CPA.
Fewer than one in five have the recommended levels of blood glucose, blood pressure and cholesterol, “leaving an unacceptably high number at risk of developing complications, being admitted to hospital and costing the NHS more money,” said CPA chair Margaret Hodge MP.
“The Department gave local NHS organisations freedom to decide how to deliver diabetes services and did not introduce mandatory performance targets as it did for cancer, stroke and heart disease. There is no strong national leadership and no effective accountability arrangements for commissioners,” she said.
Moreover, variation in the level of progress across the NHS means there is an unacceptable “postcode lottery,” with the quality of diabetes care varying dramatically across the NHS, the report notes.
“We have seen no evidence that the Department of Health will ensure that these issues are addressed effectively in the new NHS structure. It must set out how improvements in diabetes care will be delivered under the new arrangements and what steps it will take, alongside Public Health England, to improve public awareness of the risk factors for diabetes such as obesity,” added Lady Hodge, the Labour MP for Barking.
Among the CPA report’s conclusions and recommendations, it finds that NHS accountability structures have failed to hold commissioners of diabetes services to account for poor performance; when NHS Diabetes offered assistance to the 20 worst-performing Primary Care Trusts (PCTs), only three took up the offer.
It also criticises the Department for failing to incentivise delivery of all aspects of its recommended standards of care through the payments system. Although the Quality and Outcomes Framework (QOF) for GPs initially improved diabetes outcomes in primary care, there has been little improvement lately and the current system is not driving the required outcomes. GPs are paid for each individual test they carry out rather than being rewarded for ensuring all nine tests are delivered, while the Payment by Results (PbR) tariff system for hospitals does not incentivise the multi-disciplinary care required to treat complex long-term condition such as diabetes.
“The Department needs to ensure its payment systems effectively incentivise good care and better outcomes for people with diabetes,” the MPs recommend.
They also note that while the Department has improved information on diabetes to support the commissioning, planning and monitoring of services, PCTs are making limited use of these data at local level to inform how services are delivered or to benchmark and improve services. In addition, the MPs point out that estimates of the cost of diabetes vary widely, from £1.3 billion to almost £10 billion a year.
“The Department should use its information to hold the NHS to account and should work with the NHS to ensure that the costs of diabetes are fully captured and understood to promote appropriate services and better outcomes for patients,” say the MPs.
The failure by primary care professionals to carry out regular checks and tests means that patients are developing diabetes-related complicates that could be avoided, often requiring hospital treatment, they go on.
“The NHS Commissioning Board should build into national contracts for primary and secondary care a requirement for people with diabetes to receive multi-disciplinary care from appropriately trained staff and structured regular education and support for help them manage their condition,” they advise, adding: “we received evidence about the impact of specialist diabetic nurses in improving patient outcomes and we conclude that this is a cost-effective way of improving outcomes for diabetic patients.”
Finally, they note that the number of people with diabetes in England is set to rise from 3.1 million currently to 3.8 million in 2020. Unless care improves significantly, the NHS will face ever-increasing costs, not least because of the high costs of treating related complications, they warn.
