E-news: Feature: NHS diabetes services are failing patients, NAO report says

In 2009-10, there were an estimated 3.1 million people aged 16 years and older with diabetes in England, of which 2.34 million were diagnosed and 760,000 were undiagnosed. NHS spending on diabetes services in 2009-10 was at least £3.9 billion, or around 4% of the NHS budget.

With structured education and appropriate support most people with diabetes can manage their condition themselves by. However, 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.

In 2001, the Department of Health (the Department) published the National Service Framework for Diabetes. The Framework set out the key interventions necessary to raise the standard of care provided by NHS organisations and healthcare professionals involved in delivering diabetes services, including as a minimum nine basic checks, or care processes, to detect the early signs of complications.

The National Audit Office report, called The management of adult diabetes services in the NHS,examines whether the NHS in England is meeting the standards of care for diabetes set by the DoH in 2001, and how effectively the DoH and local commissioners of diabetes services have supported those responsible for delivering the expected improvements in diabetes care.

Key findings:

1. The total number of people with diabetes is expected to increase by around 700,000 from 3.1 million in 2010 to 3.8 million in 2020. An increase in the number of people with diabetes will have a major impact on NHS resources unless the efficiency and effectiveness of existing services is substantially improved.

2. In 2009-10, national clinical audit data found that only half of the increasing number of people with diabetes received all the recommended care processes that could reduce their risk of developing diabetes-related complications.

3. Less than one in five people with diabetes are achieving recommended treatment standards that reduce their risk of developing diabetes-related complications. The risk of developing complications can be minimised if people with diabetes achieve recommended treatment standards to control blood glucose, blood pressure, and cholesterol levels. Our analysis found that in 2009-10, only 16% of people with diabetes achieved all three treatment standards combined, while 15% were not tested at all.

4. There is significant variation in the quality of care received by people with diabetes across the NHS. In 2009-10, the National Diabetes Audit found that the percentage of people with diabetes receiving all nine recommended care processes varied from 6% to 69% between PCTs.

5. The DoH has not managed effectively the performance of PCTs in delivering diabetes services or held them to account for poor performance.

6. The DoH’s cost data do not capture the full costs of diabetes nationally. Spending on diabetes services has increased from £0.9 billion in 200607 to £1.3 billion in 2009-10. These figures are likely to be a substantial underestimate because of a lack of good-quality cost data for primary care and community services. The report estimates that the total cost of diabetes to the NHS in 2009-10 was at least £3.9 billion.

7. The NHS does not clearly understand the costs of diabetes at a local level, and so lacks clarity about the most effective ways to deliver diabetes services.

Savings

We estimate that through better understanding and management of people with diabetes, the NHS could save £170 million a year. Through earlier detection and management of diabetes-related complications in primary care, fewer people with diabetes would require more costly specialist treatment. The NHS needs to:

• reduce hospital admissions (excluding readmissions) for people with diabetes by 10%, it could save £34 million a year by avoiding excess hospital activity;

• reduce insulin errors in hospital by 50%, it could save at least £3.25 million a year by improving patient care;

• reduce late referrals to specialist foot teams by up to 50%, it could save at least £34 million a year by decreasing the number of major amputations among people with diabetes; and

• ensure safer discharge from hospital for people with diabetes, it could save £99 million a year through reducing emergency readmissions to the same rate as for people of the same age without the condition.

Recommendations

1. The number of people with diabetes in England is projected to increase to 3.8 million people by 2020. The DoH and Public Health England should consider what further steps they will take to change this projection. The NHS Commissioning Board should include appropriate indicators within the Commissioning Outcomes Framework to ensure a local focus on delivering all nine care processes.

2. Payment mechanisms currently available to GPs are failing to ensure sustained improvements in outcomes for people with diabetes. The current system of incentives needs to be reviewed. GPs should only be paid for diabetes care if they ensure all nine care processes are delivered to people with diabetes.

3. Many people with diabetes currently experience poor levels of care following admission to hospital and, in 2009-10, significant numbers of these people developed avoidable complications owing to medication and other errors. The Commissioning Outcomes Framework and the NHS Commissioning Board’s guidance should make it a requirement for CCG contracts with providers to specify that diabetes care should be delivered by appropriately trained professionals.

4. There is significant variation in the quality of care received by people with diabetes across the NHS. The NHS Commissioning Board should state what specific actions it will take to ensure that people with diabetes across England receive recommended standards of care.

5. With access to education and support, many people with diabetes can manage their condition effectively, yet few people with diabetes receive patient education. The NHS Commissioning Board should work with clinical commissioning groups and providers to ensure that people with diabetes are offered education and support in how best to manage their condition.

6. The DoH and the NHS lack clarity about how to ensure effectiveness in diabetes services and do not clearly understand the total costs of treating diabetes in the NHS. The NHS Commissioning Board should ensure that cost data are available to CCGs to support them in meeting the recommended standards of care for people with diabetes locally. The NHS Commissioning Board and Monitor should work to develop tariffs to incentivise providers appropriately to maximise achievement of improved outcomes.

Amyas Morse, head of the National Audit Office, said: "The Department of Health has failed to deliver diabetes care to the standard it set out as long ago as 2001. This has resulted in people with diabetes developing avoidable complications, in a high number of preventable deaths and in increased costs for the NHS.

"The expected 23% increase by 2020 in the number of people in England with diabetes will have a major impact on NHS resources unless the efficiency and effectiveness of existing services are substantially improved."

Read the full report.