Health CommitteeWritten evidence from Diabetes UK (LTC 67)

Key recommendations:

The five key elements for improving diabetes care are:

prevention;

risk assessment and early diagnosis;

implementation of NICE quality standards;

education for self management; and

individual care planning underpinned by access to well co-ordinated care based on multidisciplinary local networks;

People with diabetes need timely access to specialist services and interventions to help manage their condition;

Integrated pathways of care for diabetes must be commissioned across primary, intermediate and secondary care providers across the whole local system of care.

1. About Diabetes

1.1 Type 1 diabetes develops if the body cannot produce any insulin. About 10% of people with diabetes have Type 1. It cannot be prevented and is treated by daily insulin doses by injections or via an insulin pump.

1.2 Type 2 diabetes develops when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance). It usually appears in people over 40 and accounts for around 90% of people1 with diabetes. It is treated with a healthy diet and increased physical activity. Tablets and/or insulin can be required.

1.3 Diabetes is one of the biggest health challenges of our time:

3.9 million people live with diabetes in the UK.2

Numbers are rising rapidly with 140,000 new diagnoses each year.

It is estimated that over five million people in the UK will have diabetes by 2025.3

Seven million people in the UK are at high risk of diabetes, this number is rising every year.4 It is estimated 80%5 of these cases are preventable with good risk assessment and effective lifestyle interventions.

24,000 people with diabetes die early from diabetes in the UK every year.6

Diabetes is a progressive condition, affecting all parts of the body. It is now the major cause of lower limb amputation, blindness, kidney failure and stroke.7

41% of people with diabetes have depression and 30–50% of cases are undetected.8

Cost of diabetes:

The NHS spends £10 billion on diabetes every year.9

80% of NHS spending on diabetes is for managing avoidable complications.10

Societal costs associated with diabetes (from increased death and illness, work loss and the need for informal care) are estimated at £13.9 billion.11

This submission is divided into three priority sections for improving diabetes care and reducing costs: provision of care; integrated and personalised care and managing contributory factors.

2. Provision of Care

The scope for varying the current mix of service responsibilities so that more people are treated outside hospital and the consequences of such service redesign for costs and effectiveness and

The readiness of local NHS and social care services to treat patients with long term conditions (including multiple conditions) within the community

2.1 Integrated pathways of care must be commissioned across primary, intermediate and secondary care to ensure people with diabetes get the care and specialist treatment they need to manage their condition. Diabetes care cannot be provided solely in primary and community care. Access to specialist care when required is vital. In particular, Type 1 diabetes support should be co-ordinated primarily from secondary care.

Stronger community and primary care services with appropriate upskilling in diabetes expertise should ensure the focus of care is: coordination, prevention, structured chronic disease management, patient education and care planning to support greater self management. This will help cut wastage and inappropriate hospital admissions.12 Where hospital admissions are needed, ensuring patients have access to specialist inpatient treatment can reduce length of stay by three days and save £400 per admission.13

2.2 Good quality care provision in the areas outlined below would help to reduce the need for hospital inpatient care, by improving the management of diabetes within primary and community services.

Prevention and early diagnosis

2.3 Up to 850,000 people are unaware they have Type 2 diabetes.14 By diagnosis, half show signs of complications.15 Early diagnosis is therefore crucial to ensure good management of diabetes can start before expensive and life-threatening complications develop and also prevents existing complications getting worse. It is estimated that by 2025, five million people will have diabetes—most of which will be Type 2.16 Investment in effective public awareness campaigns (explaining the seriousness of Type 2 diabetes and its complications) and full implementation of the NHS Health Checks programme will help prevention and early diagnosis.

2.4 25% of children and young people are diagnosed with Type 1 due to being admitted to hospital with Diabetic Ketoacidosis (DKA).17 ^, 18 Increasing awareness of the signs and symptoms of Type 1 diabetes, through public health initiatives aimed at schools, the general public and general practice, can help earlier diagnosis of Type 1 and cut the number of people who suffer DKA.

Provision of appropriate care checks

2.5 Everyone with diabetes should get a planned programme of NICE recommended checks each year. They are designed to identify the early signs of avoidable diabetic complications. However, only a third of adults with Type 1 diabetes and half of people with Type 2 diabetes are getting all the recommended annual tests. This is compounded by a “postcode lottery” of care, which means the percentage of people receiving all checks ranges from 16–71% depending on their location.19

2.6 These nine checks must be made accessible to all people with diabetes through annual care planning reviews. The results of these checks must be used to ensure effective treatment and support for self-management and so cut complications. Where the checks are delivered within an integrated care pathway, they can make a significant difference in supporting effective self management and reducing complications.

Education for self management

2.7 It is estimated that around 95% of diabetes care is self management. NICE guidelines, backed by strong international evidence,20 recommend that structured education is made available to all people with diabetes to help them understand and manage their diabetes.

2.8 But too few people are offered it and not enough attend courses:

A 2012 Diabetes UK survey showed nearly a third (31%) had never been offered structured education, not even at initial diagnosis.

The National Diabetes Audit found that people with diabetes recorded as having attended structured education ranged from 0%–46.1% between PCTs.21

The interaction between mental health conditions and long-term physical health conditions

2.9 There is a greater prevalence of psychological conditions such as depression, anxiety and eating disorders among people with diabetes than the general population.22 Poor emotional wellbeing is associated with sub optimal blood glucose control, which in turn can lead to the development of complications. For example, depression is twice as common in people with diabetes and can have an affect on an individual’s ability to control their diet or manage their medication.23

2.10 Despite this, and the fact that treatment of psychological conditions has been shown to improve psychological wellbeing and other health related outcomes,24 85% of people with diabetes have no access to psychological care and support.25 Access to emotional and psychological care should become a routine part of diabetes management, reducing the “costs” of untreated psychological conditions.

3. Supporting the Implementation of Integrated and Personalised Care

The practical assistance offered to commissioners to support the design of services which promote community-based care and provide the integration of health and social care in the management of long-term conditions

3.1 To achieve maximum efficiency, effectiveness and to avoid duplication and gaps in service, evidence shows the need to commission fully integrated and well co-ordinated pathways of diabetes care across primary, secondary and community providers. This is key to providing positive health and management outcomes.

3.2 There is a wealth of information to support this:

Commissioning Diabetes Without Walls (2009) describes how to commission a whole system, integrated approach, covering the entire diabetes patient journey to ensure that opportunities for improving care and making most efficient use of resources is realised;

Best practice for commissioning diabetes services: an integrated care framework (2013), explains how CCGs should be commissioning services to achieve effective and fully integrated diabetes services.

The extent to which patients are being offered personalised care

3.3 People with diabetes can live for as little as a few years or as long as 80 years with their condition. Personalised care should be coordinated around the person with diabetes, who is enabled to take a proactive lifelong role in shaping their care.26

The advantages of better partnership working are shown in the 2011 Year of Care Programme. Care planning delivered personalised care in routine practice for people with long term conditions, using diabetes as an example.

It worked in disadvantaged communities: patient-reported involvement in care rose from 56% to 82% in the Tower Hamlets pilot site.27

Service redesign also encouraged a systematic approach to routine care. Tower Hamlets achieved the highest rate of people with Type 2 diabetes receiving all nine key care processes in England (72.4%) and individuals with good control of HbA1c, blood pressure and cholesterol increased from 24% to 35%.28

3.4 Despite this, only 50% of English patients29 reported that clinicians share decisions about treatment with them, and a Diabetes UK survey in 2012 found that only 36% had developed a care plan by discussing their individual needs to set targets with their healthcare professional.

Examples of effective integrated care

3.5 North West London Integrated Care Pilot: Introduced integrated care pathways for people with diabetes. The pilot standardised and improved co-ordination of existing good practice and held regular multi-disciplinary case conferences (involving specialist consultants). Over one year, the rate of hospital admissions for foot ulcerations fell from 84% to 47% and the median length of stay reduced from 16 to 11 days.30

3.6 Integrated Care for Patients with Diabetes, The Derby Model: Introduced a new organisation commissioned to provide the routine and specialist aspects of diabetes care. Between 2009 and 2011 significant improvements included:

51% increase in the percentage of patients achieving a cholesterol target of <5mmol/L.

Reduced admissions of patients with a primary diagnosis of diabetes.

3.7 Integrated foot care pathway. Where effective services are in place for people with diabetes who have foot problems they are at much lower risk of amputation.31 As part of the integrated footcare pathway, people with a foot problem should have speedy access to a multidisciplinary specialist foot team. This has been shown to significantly reduce the risk of amputation meeting national standards, saving costs, feet and lives.32

3.8 While these examples are encouraging, they are the exceptions and not nationally representative.

4. Managing contributory factors

Obesity as a contributory factor to Type 2 diabetes

4.1 Obesity accounts for 80–85% of the overall risk of developing Type 2 diabetes.33 As almost two in every three people in the UK are overweight or obese,34 the main strategy for reducing the rising prevalence of Type 2 diabetes should be to tackle the rise in obesity. Full implementation of the NHS Health Check programme would lead to better early diagnosis and prevention of diabetes. Other priorities are:

Incentivising GPs to know who is at risk of developing diabetes and helping those people cut their risk.

Marketing restrictions on unhealthy foods, and positive marketing of healthier food.

Schools should educate and normalise healthy eating.

The implications of an ageing population for the prevalence of diabetes, and the extent to which services have the capacity to meet future demands

4.2 Older people are more likely to have diabetes. In England the prevalence of diabetes across all ages is currently 5.5%. This increases with age to 14% prevalence in over 65s.35 It is likely therefore, that the ageing population will contribute significantly to the increasing prevalence of diabetes and co-morbidities.

4.3 Current services do not have the capacity to meet predicted future demand. This is largely because diabetes in older people requires careful management due to the complex interaction between the process of ageing, the increased prevalence of co-morbidities, widespread vascular disease and functional loss.

4.4 It is therefore essential that prevention, education, better care and the implementation of integrated pathways of care are prioritised to address this.

5. Conclusion

5.1 People with diabetes must have access to high quality services to enable them to effectively manage their condition. Commissioning and care delivery needs to focus on improving organisational processes, engaging people with long term conditions in their own care and changing healthcare professionals attitudes across each local care system. To achieve this, strong national leadership, collaboration between multiple commissioners and providers, effective systems of accountability and a joined up system of incentivisation are needed to ensure integrated, personalised care is the norm.

9 May 2013