Department of Health: The management of adult diabetes services in the NHS - Public Accounts Committee Contents

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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© Parliamentary copyright 2012
Prepared 6 November 2012