You would have been hard pressed to miss the conclusions of the Public Accounts Committee report, published in October last year (UK Parliament, 2012), with headlines like “Diabetes care depressingly poor, say MPs” (BBC, 2012). This report is on the back of both the National Audit Office (NAO) report “The management of adult diabetes services in the NHS” (NAO, 2012) and Diabetes UK report “Diabetes in the UK 2012” (Diabetes UK, 2012), which heavily criticise the performance of the NHS as a whole in managing the costs, both human and economic, of an epidemic of type 2 diabetes, which has been predicted longer than global warming.
The report focuses on information from the English National Diabetes Audit (www.hqip.co.uk), which shows not only that just half of people with diabetes are getting all nine basic processes of care such as blood pressure (BP) checks and retinal screening, but between primary care trusts (PCTs), there is a 10-fold variation, with some PCTs recording as few as 6% getting these tests done. They noted with dismay that fewer than one in five people with diabetes had reached recommended levels of blood glucose, BP and cholesterol.
The committee make a direct link between poor processes of care, 10 years after the diabetes National Service Framework, and high rates of complications from diabetes including an estimated 24 000 excess deaths per year and a six-fold variation in amputation rates across PCTs. The Public Accounts Committee looks essentially at value for money, and could see little evidence of the huge investment being related to improved outcomes or even better care.
Although the committee didn’t mince their words in criticising the Department of Health for not effectively managing the performance of PCTs in delivering the recommended standards of diabetes care across the NHS, as well as lacking a clear vision on the best way to deliver diabetes services, the impact of this and the other reports mentioned will undoubtedly be felt by frontline healthcare practitioners.
Diabetes is a chronic progressive condition that needs an array of supportive interventions over time, but crucially needs the involvement of the person with diabetes. PCTs have not effectively provided education and have not promoted supported self-management backed up by an integrated care system that works for people with diabetes and their carers, over their lifetime.
Given the current upheaval in care systems (in England at least) and the increasing appreciation of the costs and implications of suboptimal diabetes care, things are going to have to change. There was lots of talk in the committee about sanctions and “must dos” and it seems certain that there will be a much greater degree of performance management, based on outcomes both clinical and patient reported, than ever before.
The big question is: will this be done by facilitating better support for locality diabetes teams or by a system of financial incentives and penalties. The omens are not good and NHS Diabetes, which has done so much to provide information and support for care providers, is likely to be swallowed up in a new Improvement Body, under a vascular diseases banner, from April 2013. The intention is to focus on long-term conditions, and although some of the prevention strategies are in common, the needs of 3 million people with diabetes requires a separate commissioning and support organisation. Without this, the postcode lottery of diabetes care will get worse and any hope of containing the costs of diabetes will be lost for years.
The Public Accounts Committee will revisit diabetes care again in 2 years, by which time the politicians and NHS commissioning board mandarins will have moved on but the nurses, doctors and people with diabetes will still be there. Let’s hope for their sake this report gets heeded.