Memorandum submitted by Diabetes UK (PCT
24)
Diabetes UK is one of Europe's largest patient
organisations. Our mission is to improve the lives of people with
diabetes and to work towards a future without diabetes through
care, research and campaigning. With a membership of over 170,000,
including over 6,000 health care professionals, Diabetes UK is
an active and representative voice of people living with diabetes
in the UK.
INTRODUCTION
The Health Select Committee has decided to undertake
an inquiry into potential changes to primary care trusts' functions
and numbers arising from Commissioning a Patient Led NHS,
including:
— Rationale behind the changes.
— Likely impact on commissioning of
services.
— Likely impact on provision of local
services.
— Likely impact on other PCT functions,
including public health.
— Consultation about proposed changes.
— Likely costs and savings.
We welcome the opportunity to submit evidence
to this enquiry. We would like to use this submission to examine
and highlight our fears about these proposals for people with
long term conditions, especially people with diabetes. Diabetes
UK feels that some issues have not been fully addressed in the
development of these PCT changes and would like them to be examined
further and, where necessary, changed.
LIKELY IMPACT
ON COMMISSIONING
OF SERVICES
1. Monitoring quality and delivery
Diabetes UK would like to raise questions around
the ability of PCTs to effectively monitor and assess the quality
of services in their area under the new system. They will have
responsibility for monitoring services such as practice based
commissioning and the pharmacy contract in their areas but we
fear that they will not have enough capacity to do this effectively
for small clusters of practices. This monitoring and assessment
will be essential to ensure that the new systems and services
being provided are of high quality but there is no assurance that
this will occur.
2. Economies of scale
Diabetes UK has concerns that practices may
be too small to establish and deliver practice based commissioning
effectively. It doesn't seem to be realistic to expect all practices
to have the skills and capacity to be able to achieve all the
prioritising, budgeting, managing, contracting and monitoring
that the PCT previously did. There will be a need for some practices
to work together to achieve the right outcomes and this brings
its own problems with willingness to co-operate. There needs to
be further investigation into the cooperation required of practices
and adequate support to encourage this. Without joint working
the likely results will be that those patients registered with
proactive practices will benefit at the expense of those smaller
practices, thereby increasing inequalities in care and access.
LIKELY IMPACT
ON PROVISION
OF LOCAL
SERVICES
3. Service fragmentation
Diabetes UK has consulted with our UK Advisory
Council which consists of healthcare professionals and people
with diabetes. They have fed back to us that they are very concerned
that new systems introduced may lead to increased fragmentation
of services. The reconfiguration of local services that will occur
must ensure that people with diabetes are not disadvantaged by
unstructured re-organisation of service providers. People with
diabetes and existing and future care providers must be fully
involved in decisions made about changes to service providers.
These changes should be structured, agreed and take into account
individual needs and preferences.[16]
Contestability within the health service could lead to further
fragmentation of services because it could lead to a change of
providers and unclear pathways of care between routine, ongoing
and specialist care. It is likely that these changes of providers
will not be discussed with the patient and might in fact not be
what patients want.
The key to successful diabetes management and
service delivery is co-ordination across multiple care providers
and care settings. The nature of diabetes care means that each
person with diabetes will have different healthcare needs that
the healthcare system has to meet, according to NSF standards.
Individual needs will vary from person to person according to
the progression of the condition and individual management needs.
This relies on the individual being able to make informed choices
about their own, complex and changing care needs, with the support
of competent practitioners who are willing and able to work collaboratively.
Emphasis must be on enabling everyone to have access to the level
of care they individually need, as well as reducing health inequalities
for people with diabetes who are disadvantaged because of educational,
physical, emotional or demographic barriers.
Integrated diabetes care is very important to
the management of diabetes and it should aim to be organised and
individualised to the person with diabetes. The appropriate care
providers will change over time according to the wishes of the
person with diabetes, the progression of the condition and the
need for optimum management. Integrated care is about:
(a) Putting the patient first.
(b) Providing a high quality service matching
skills to the needs of the individual patient.
(c) Colleagues working together, learning
together eg multi-disciplinary training programmes, and reviewing
outcomes together; and
(d) Involving the patient/carer as a member
of the team.
4. Access to specialist care
The new system may put integrated care in jeopardy
further because of problems that may emerge for specialist care.
There needs to be a critical mass of funding in order to support
specialised services and the changes will make funding uncertain
and difficult to plan ahead of time. If specialist services only
serve a small number of people with unpredictable severity of
the condition, it may be difficult to keep to cost. If you look
at the US experience, the evidence shows that unless some services
are protected and mandated, you will see providers withdrawing
from those services for economic reasons, which would disadvantage
people with diabetes.
5. Payment by Results and the national tariff
Through Payment by Results there will be a fixed
tariff for each "episode" of care. Under Payment by
Results healthcare providers will be reimbursed on the basis of
a standard tariff for the activity they undertake. The national
tariff is set by the Department of Health, derived from average
costs in all NHS providers. It is hoped that the tariff system
will drive down costs for providers that currently have above
average costs, as well as reinforcing incentives to deliver services
efficiently in all providers. It is supposed to allow commissioners
to focus on quality. Providers are paid on a per case basis, with
funding being withdrawn if volume falls short. Diabetes UK has
serious concerns about the tariff level for diabetes because the
cost appears not to reflect the real cost and the differing complexity
of care between conditions. This could make it difficult for complex
diabetes cases to access appropriate care, especially where a
multi-disciplinary team is required. The tariff doesn't take into
account the extra cost for the more complex cases and this means
that providing these services will not be cost efficient. The
Government has stated that if providers fail to provide services
at or below the current tariff, funding will be withdrawn and
the service will close. Diabetes UK fears that if this happens
patients will not be able to access these necessary specialist
services. The closing down of specialist services goes against
the patient choice agenda. It will cut down on the choice for
patients of where they access their care because the number of
the specialist services will be reduced and may not now be provided
near to where they live. It will also mean that the services that
do manage to survive will have many patients to see and this may
hamper patients accessing the services.
6. Workforce
Altering the administration of the system will
not increase the availability of crucial services such as psychological
support, podiatry, dietetics, diabetes specialist practitioners
and structured education because there still are not enough staff
trained in diabetes care. There will need to be an increase in
the number of administrators to work the new commissioning system
but questions arise about the lack of investment to increase staff
levels for crucial services. People with diabetes need to build
relationships with their diabetes care team and prioritise continuity
of care. Feedback from people with diabetes has told us that people
feel it would be better to see someone who knows about diabetes
at a less convenient time or location rather than see someone
who knows less at a convenient time/location. They do not want
a "dumbing down" of diabetes services in the rush to
provide people with more points of access, contacts and advice.
Care delivered by a variety of providers does not, in itself,
constitute team care. A functional team is characterised by regular
communication among its members and by the pursuit of common and
agreed goals. The organisation of integrated care should be such
that no unnecessary barriers are created between sites of health
service delivery.
The pressure placed on PCTs to divest themselves
of their provider function is likely to lead to job insecurity
and a lack of continuity of services. Existing services are unlikely
to be further developed and initiatives within PCT provided services
stifled. PCT staff are unlikely to be in a position to exploit
the opportunities presented by Practice based Commissioning if
they are uncertain of their own futures.
LIKELY IMPACT
ON OTHER
PCT FUNCTIONS, INCLUDING
PUBLIC HEALTH
7. Retinal screening
Diabetes UK supports retinal screening programmes
remaining at PCT and managed diabetes network level. A bigger
area for retinal screening can bring advantages for the programmes
so PCT mergers could help retinal screening programmes become
more effective. The programme needs to meet a minimum required
size. It needs to be big enough to produce robust statistical
data so that trends within the programme can be identified, to
make sure that graders do not grade in isolation to avoid mistakes,
that graders grade sufficient images to remain competent and that
the system is assessed independently and externally to make sure
that standards are met and sustained. All programmes need to have
a centrally managed system, across a population, for call/recall
and service provision to ensure consistency and quality care.
However, it has recently come to the attention
of Diabetes UK that difficulties are being experienced in establishing
a centrally funded, managed and independent quality assurance
programme for retinal screening in England. Retinopathy is the
leading cause of blindness in the working population, and regular
systematic screening as part of a formal screening programme,
to prevent retinopathy was therefore prioritised within the national
diabetes framework. It is essential that the tried and tested
monitoring systems used within existing screening programmes,
such as cervical cancer, are in place for retinopathy screening.
If the Quality Assurance programme is paid for by those also paying
for and providing the services to be monitored, there is significant
danger that commissioning bodies will provide self-serving responses.
Furthermore, there will be limited incentive for poorly performing
services to pay for the assurance. On the other hand, those perceiving
that they are performing well will want to participate to prove
this will pay. It will also benefit people with diabetes by providing
an independent "watchdog" to ensure consistent quality
standards, prevent errors and improve service delivery and practice
across all local areas. High standards of quality assurance save
both sight and the financial burden on both the disadvantaged
patient and the taxpayer. Diabetes UK questions how such screening
programmes can be adequately monitored and assured if a proliferation
of providers are commissioned to deliver services across small
populations.
There could be problems with retinal screening
linked to the issues around contestability, mentioned previously.
If private companies are bought in to carry out retinal screening
the effectiveness of the programmes could be affected. Possible
problems could be encountered if the NHS is unable, and the person
with diabetes does not give consent for, passing on patient details
to private organisations so patients will not be able to be called
or recalled for services. These issues of patient confidentiality
need to be resolved if contestability is introduced.
8. Public Health
A benefit of the new system can be seen in the
recent move of the Department of Health to strengthen public health
roles within PCTs. The Department of Health has stated that SHAs
should not use posts working on Choosing Health as a way to make
savings and that public health should be exempt from cuts. Savings
can be achieved though cutting the number of director roles through
the merging of PCTs but front line staff and consultant and specialist
public health posts should be protected. This will be good for
public health programmes and the prevention of diabetes and we
hope that SHAs abide by this advice. However, we would like to
raise concerns about public health prevention and health promotion
programmes to be provided at practice level. Some GPs are enthusiastic
about providing public health prevention services but others are
not and do not always see it as their role. With GPs in the new
system having responsibility for commissioning some prevention
services, this might lead to problems. Patients won't demand services
from GPs that they don't know they need or that they don't want.
The GPs mentioned above that are less keen to provide prevention
services will not provide services that are not demanded. This
could affect prevention programmes such as weight management and
physical activity.
Diabetes UK
November 2005
16 Joint Diabetes UK and Association of British Clinical
Diabetologists (ABCD) Position Statement. Ensuring Access to high
quality care for people with diabetes. 2005. Back
| 
