On 1 April this year, clinical commissioning groups (CCGs) and NHS England took on the responsibility for the effective spend of around £95 billion of public money through commissioning of healthcare in England. The changes involve the creation of NHS England as an arms-length body from the Department of Health, through which the Government sets its ambitions for health outcomes via a Mandate.
Focusing on outcomes, not process targets
Consistent with the current Mandate, the NHS Outcomes Framework introduces a new language and structure based on achieving improvements in health outcomes, through which NHS performance can be judged, commissioners of healthcare in England can be held to account, and quality improvement throughout the NHS can be driven. The NHS Outcomes Framework describes five domains (see box).
Commissioners – both NHS England in its direct commissioning role and CCGs as commissioners of secondary and community care – are mandated by the Government to make improvements against the indicators in all five of the domains.
Shift in emphasis from disease specificity
Approximately 70% of all health and social care spend is now directed to the 15–20% of the population who have three or more long-term conditions (http://bit.ly/11QUYFB [accessed 13.11.13]). This has informed a more generic approach that is reflected in the NHS Outcomes Framework and has contributed to decisions for disease-specific improvement bodies, such as NHS Diabetes, to be replaced by a single improvement body for England. NHS Improving Quality is more closely aligned with the new commissioning system, and, as the single improvement body, has a more generic approach to health improvement.
Where does diabetes sit?
Within the new framework, diabetes is seen as one of a family of cardiovascular diseases, reflected in its positioning in the Cardiovascular Disease Outcomes Strategy and within the Cardiovascular Strategic Clinical Networks.
However, the greater emphasis on multi-morbidity in old age and on cardiovascular disease, while important, must not detract from the importance of providing high-quality diabetes care and empowering individuals to self-manage their diabetes effectively at all stages of life. While high consumers of health and social care resource may often have three or more long-term conditions, diabetes is often the common antecedent. We must not allow the focus on cardiovascular disease to detract from the importance of the microvasculature in diabetes, and of course many aspects of diabetes care, such as preconception care and care during pregnancy, are not usefully seen through a cardiovascular lens at all.
Diabetes is a significant contributor to premature mortality, with around 6 years of life lost for those with type 2 diabetes (Emerging Risk Factors Collaboration, 2011). Years of life lost due to type 1 diabetes, a single long-term condition prior to the onset of complications, can be as high as 20. The apparent low rates of delivery of basic care processes and low rates of attainment of all three treatment goals for HbA1c, blood pressure and cholesterol described in the National Diabetes Audit were criticised by the National Audit Office report last year. Although it was thought to relate to a diabetes-related excess of 24 000 deaths annually, we did not know how our performance compared with other countries. Murray et al (2013) have suggested that premature mortality due to diabetes is lower in the UK than in the other 18 wealthy countries in their analysis. It may be, therefore, that our diabetes care delivery systems within the primary-care setting are already contributing positively to the longer-term clinical outcomes that really matter.