NHS RightCare has published a clinically-led diabetes pathway in an attempt to deliver better value to the NHS in terms of outcomes and cost. The pathway defines the key elements of an optimal diabetes service and highlights opportunities to reduce variation and improve outcomes, as well as the evidence-based interventions that the health service should focus on to result in the greatest improvements.
Clinical commissioning groups are tasked with making this happen in collaboration with their providers. The NHS has provided extra funding through the STP (segmentation, targeting and positioning) process to facilitate this.
Figure 1. The NHS RightCare Pathway for diabetes
Before making any changes, we need to consider how closely our current services provide mimic this pathway. As you can see from Figure 1, the pathway covers:
- The underlying issues relating to diabetes care throughout the UK.
- The service components required to address these underlying issues.
- The interventions required for each service component.
- The targets providers need to meet to ensure a high quality service is delivered.
- The evidence to prove the service has met its targets and care has improved.
The pathway – which is linked to the NICE Quality Standards (NICE, 2016) – is very detailed, filling 21 pages. It reminds me of the two previous attempts to improve standards within diabetes care: the 1989 St Vincent Declaration on the treatment of diabetes and the 2001 National Service Framework. For example, in pregnancy, the St Vincent Declaration aimed to achieve approximately the same pregnancy outcome in women with diabetes as in non-diabetic women and the National Service Framework aimed to achieve a good outcome and experience of pregnancy and childbirth for women with pre-existing diabetes and for those who develop diabetes in pregnancy. It is clear from this example that the reason we have got this new pathway is that the previous attempts have failed miserably to achieve what they set out to do.
Let us consider the reasons that this might be the case:
- The increasing prevalence of diabetes year on year.
- A lack of basic clinical staff to deliver care.
- A lack of specialist clinical staff to deliver complex care when problems arise.
- A lack of skills and knowledge at each level due to difficulty attending good quality education.
I do not believe that throwing extra money at the NHS will necessarily improve care, as there is a lot of duplication and many people choose not to access care for their diabetes. Our biggest untapped resource is people with diabetes themselves. It is well researched that people who are knowledgeable and self-managing will access healthcare far less than those who are not (Diabetes UK, 2009; The King’s Fund, 2013; Panagioti et al, 2014). The biggest challenge I face on a daily basis is how to motivate someone who has little interest in his or her own diabetes to become self-managing.
In addition to this, some people do not take up diabetes education, whatever programme is offered, even when readily available. Due to the increasing numbers of people with diabetes and the lack of investment in human resources with diabetes care, we have to give the management of diabetes back to the person with the diagnosis but be there to support and educate him or her at the appropriate time.
Diabetes UK (2009) Improving supported self-management for people with diabetes. Available at: https://www.diabetes.org.uk/supported-self-management (accessed 26.07.17)
