For anyone involved in diabetes care, the last few years have been characterised by a tidal wave of new cases all of whom have required education, self management advice and screening for complications, not to mention the escalation of drug therapy. Much of this clinical input is guided by nine care processes initially described in the Diabetes NSF over 10 years ago – glycaemia, BP, cholesterol, weight, smoking, renal function & microalbuminuria as well as foot and retinal screening.
The implementation of these processes has recently been investigated by the National Audit Office, their May 2012 report being grim reading. It reports that the NHS is currently spending (£3.9bn – 4% NHS budget) on 3.1 million people with diabetes – due to rise to 3.8million by 2020. Given this epidemiology, even if the rate of complications has stabilised, the absolute numbers will increase. The NAO report also highlighted that the National Diabetes Audit found that the percentage of people with diabetes receiving all nine recommended care processes varied from 6% to 69% (mean 49%) between primary care trusts. There were also widespread variations between PCTS in patients reaching targets for HbA1c and those developing certain complications such as end stage renal failure. These Discrepancies were felt to be due to the organisation of care rather than finance. However an improvement from 2006/7 (where only 36% received all care processes.)The NAO also highlighted the potential to save money by reducing the impact on secondary care such as reducing diabetes related admissions would save £34m, as would reducing late referrals to foot care teams.
Comparing this performance against the expected levels of care, the low achievement of treatment standards and the high number of avoidable deaths, the NAO concluded that diabetes services in England are not delivering value for money.
Whereas over the last few years, the remedy has been to spend more money, the inequitable care and rising numbers of patients has to be addressed in the current economic climate of static NHS funding. It also has to be reviewed in context of the changes to the NHS outlined in the Health & Social Care bill where new commissioning groups will be responsible for diabetes care including specialist services. This will be a situation where the overseeing NHS commissioning board will be closely watched.
So what does this report mean to the practising clinician? Possibly increased awareness of the care processes (the incentivised nature of QoF was meant to address this) but if doctors are truly able to commission services that positively impact on their patients then diabetes is a good place to start.
Dr Mark Freeman