1Progress in delivering diabetes care
1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department), NHS England and Public Health England on the management of adult diabetes services in the NHS.1
2.Diabetes is a chronic condition where the body does not produce enough insulin to regulate blood glucose levels. In 2013–14, there were an estimated 3.2 million people aged 16 years or older with diabetes in England, of whom 2.8 million were diagnosed and 400,000 were undiagnosed. The number of people aged 16 and older with diagnosed diabetes is, on average increasing by 4.8% a year. There are two main types of diabetes. Around 10% of people diagnosed with diabetes have type 1 diabetes, which occurs when the body produces no insulin. The remaining 90% have type 2 diabetes, which occurs when the body cannot produce enough insulin to function properly, or when the body’s cells do not react to insulin. Being overweight is the main modifiable risk factor for type 2 diabetes and 90% of adults with type 2 diabetes are overweight or obese.2
3.With education and appropriate support most people with diabetes can manage their condition themselves. They also need regular checks to monitor treatable risks for diabetic tissue damage and to detect the early damage itself, so that treatment can be given to prevent deterioration. The risk of developing diabetic complications can be minimised by early detection and management of high levels of blood glucose, blood pressure and cholesterol. The estimated cost of diabetes to the NHS in England was £5.6 billion in 2010–11. The cost of complications (such as amputation, blindness, kidney failure and stroke) accounts for 69% of these costs.3 The Committee of Public Accounts last took evidence on diabetes services in 2012. In its report, the Committee concluded that too many people with diabetes were developing complications because they were not receiving the care and support they needed.4
Care processes, treatment standards and outcomes for diabetes patients
4.Outcomes for diabetes patients are improving—there have been reductions in an individual diabetes patient’s risk of mortality and risk of complications, such as heart failure. NHS England told us that these improvements are the result of improvements in diabetes care in the previous decade. However, the absolute number of diabetes patients with complications continues to rise.5 A review of international data published in 2013, showed that the UK had the lowest rates of early death due to diabetes of the 19 countries covered. NHS England cited other international evidence that also showed the UK performing well compared to other countries, such as an OECD study published in June 2015 showing that the UK has one of the lowest hospital admission rates for diabetes.6
5.In response to recommendations in the previous Committee’s report on diabetes, the Department set targets that by 2018, 80% of patients should receive all nine recommended care processes and 40% should be achieving all three of NICE’s treatment standards for blood glucose, blood pressure and cholesterol levels. When pressed on progress against the 80% target, NHS England told us that it did not “believe” that it was working towards this target anymore, but seemed uncertain, and the Department was non-committal.7 NHS performance in delivering the nine care processes has not improved since we last reported on diabetes services, with about 60% of patients now receiving all the care processes, except eye screening which is now reported separately. The Department told us that although performance is plateauing, in 2012–13 about 230,000 more people were receiving these care processes compared to 2009–10. The percentage of patients achieving all three treatment standards has also stalled at about 36%.8
6.There are significant geographic variations across clinical commissioning groups. For example: the percentage of people with diabetes receiving all the recommended care process, apart from eye screening, ranged from 30% to 76%; the percentage of people achieving the three treatment standards for blood glucose, blood pressure and cholesterol levels ranged from 28% to 48% in 2012–13; and the additional risk of death among people with diabetes within a one-year follow-up period, ranged from 10% to 65%.9 There are also significant variations between different groups of diabetes patients. For example, younger people with type 1 and type 2 diabetes and people with type 1 diabetes of all ages receive fewer of the recommended care processes and are less likely to achieve the three treatment standards.10
7.NHS England told us that much of the variation is down to GP practice-level organisational factors rather than socioeconomic factors in that area. For example, it told us that some of the variations may be down to how GP practices use their IT systems, with some practices not using the full functionality of these systems to support the delivery of local diabetes care. GP practices can use one of four IT systems. NHS England was confident that the type of IT system being used had no impact on outcomes for diabetes patients.11
8.In terms of spreading best practice to tackle these variations, NHS England told us that if a local health economy requires help, it can call in the Right Care programme to benchmark where its current level of service provision is compared with the gold standard clinical pathway and look to reduce the difference. Best practice is also shared through attendance at conferences.12
9.NHS England is accountable for ensuring that clinical commissioning groups deliver their statutory functions and improve outcomes for their populations, and it does so through an assurance framework.13 NHS England told us that it is developing a new performance framework, or scorecard, that will provide an overall rating for each clinical commissioning group, using the same rating methodology that the Care Quality Commission uses for NHS trusts. The scorecard will have a specific ‘domain’ on diabetes, with performance independently assessed, and scores being publicly available. NHS England will consult on the metrics to be used to assess performance and plans to introduce the scorecard in April 2016. The scorecard will be used to trigger interventions by NHS England where performance is poor.14
Patient education
10.Education programmes help patients to manage their condition themselves by, for example, providing information on eating a healthy diet, monitoring their blood glucose levels and taking insulin or glucose-lowering medication as needed. Structured education has been shown to be effective in reducing the risk of people with diabetes developing complications. In 2012–13, 16.4% of newly diagnosed diabetes patients were recorded as being offered structured education and 3.6% were recorded as taking up the offer. NHS England told us that the current model for delivering structured patient diabetes education is clunky and antiquated and needs modernising. Currently, education is delivered over a number of days during the week, when most adults are either at work, in school or further education. NHS England told us that they are exploring a web-based platform for the delivery of structured education.15
11.There have been problems with poor recording of the take-up of education programmes by GP practices, and in April 2013, an incentive to record whether a patient has been offered education was introduced in the Quality and Outcomes Framework, a voluntary annual reward and incentives programme for all GP practices in England. The Department told us that data recently published for 2014–15 showed that between 72% and 95% of patients were being offered structured education. However, we note that these figures exclude exceptions, such as where the GP deems the intervention inappropriate or the patient refuses the intervention. Therefore the actual percentage of patients newly diagnosed with diabetes who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register varied from 25% to 90%. No data is available on whether these patients attended the education programmes.16
The National Diabetes Audit
12.The National Diabetes Audit collects data on care processes and outcomes from GP practices and secondary care. NHS England told us that it is one of its flagship international audits and is the largest of its kind in the world. The level of GP practice participation in this audit is falling. In 2012–13, 71% of GP practices in England participated compared to 88% in 2011–12. The Department told us that new National Diabetes Audit data for 2013–14 and 2014–15 will be available in January 2015.17
13.The Department and NHS England told us that the participation rate had fallen as an unintended consequence of changing participation from an opt-out exercise to an opt-in exercise. This action was taken by an independent advisory group that reports to the Department and seeks to protect the confidentiality of patient information. The Department and NHS recognised that this was a very unsatisfactory situation and that they need to revisit it. NHS England also told us that NHS reorganisation had disrupted participation, and that some clinical commissioning group areas have better participation than others, depending on how much resource has been invested in supporting the GP practices to upload the data.18
1 C&AG’s Report, The management of adult diabetes services in the NHS: progress review, Session 2015-16, HC 489, 21 October 2015
4 Committee of Public Accounts, The management of adult diabetes services in the NHS, 17th report of Session 2012-13, HC 289, 6 November 2012
7 Qq 83; C&AG’s report paras 2.14 and 2.20; Committee of Public Accounts, The management of adult diabetes services in the NHS, 17th report of Session 2012-13, HC 289, 6 November 2012
© Parliamentary copyright 2015
Prepared 19 January 2016