Conclusions and recommendations
1. 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 only 3 trusts took up the offer. Most primary
care trusts delivered the nine care processes to more diabetic
patients between 2006-07 and 2009-10 but the extent of improvement
was highly variable and the performance in 11 primary care trusts
got worse. The Department should set out how the NHS will deliver
improvements specifically in diabetes care under the new accountability
arrangements, setting out under what circumstances and how the
NHS Commissioning Board will intervene.
2. Only half
of people with diabetes receive all the basic tests to monitor
their condition. There is
very broad consensus around the importance of the basic tests
in monitoring treatable risks for diabetic complications yet improvements
in the percentage of people with diabetes receiving the nine tests
have been lower than expected, increasing from 36% in 2006-07
to 49% in 2009-10. The Department should aim to achieve universal
coverage and urgently set out clear outcomes it would expect to
achieve by 2014/15 and beyond.
3. Fewer
than one in five people with diabetes have achieved the recommended
levels for blood glucose, blood pressure and cholesterol. Failure
to carry out these simple checks heightens the risk of diabetic
patients developing complications.
If people develop complications they are more likely to die early
and also cost the NHS more money. The Department should set out
when it expects to increase significantly the proportion of people
with diabetes achieving all three outcomes, and define what that
proportion should be.
4. The Department
is not effectively incentivising delivery of all aspects of its
recommended standards of care through the payments systems. Although
the Quality and Outcomes Framework for GPs initially improved
diabetes outcomes in primary care, there has been little improvement
lately and the current payment 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.
Similarly, the Payment by Results tariff system for hospitals
does not incentivize the multi-disciplinary care required to treat
a complex long-term condition such as diabetes. The Department
needs to ensure that its payment systems effectively incentivise
good care and better outcomes for people with diabetes.
5. The Department
has improved information on diabetes but this information is not
being used effectively by the NHS to assess quality and improve
care, and cost information needs to be improved.
The Department has improved data on diabetes to support those
commissioning, planning and monitoring services. However, primary
care trusts are making limited use of these data at a local level
to inform how services are delivered or to benchmark and improve
services. Estimates of the cost of diabetes also range 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..
6. Many people
with diabetes develop avoidable complications because they are
not effectively supported to manage their condition and do not
always receive care from appropriately trained professionals across
primary and secondary care.
Primary care professionals are not carrying out regular checks
and tests and diabetic patients are developing diabetes-related
complications that could be avoided, often requiring hospital
treatment, as a result of poorly managed blood glucose, blood
pressure and cholesterol. In hospital, some people with diabetes
experience poor care, with over a third having a medication error
whilst an inpatient. There are also high rates of readmission
to hospital for people with diabetes. 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 to help them manage their condition. 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"
7. The projected
increase in the diabetic population could have a significant impact
on NHS resources. The number
of people with diabetes is projected to increase from 3.1 million
to 3.8 million by 2020. This will put pressure on NHS resources
because of the high costs of treating related complications. The
Department and Public Health England should set out the steps
they will take to minimise the growth in numbers through well-resourced
public health campaigns and action on the risk factors for diabetes,
such as the link with obesity, and the complications they can
cause.
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