Primary care, diabetes and the changing NHS

Diabetes is a serious, chronic and progressive group of disorders associated with significant morbidity and mortality. As life-long conditions, type 1 diabetes and type 2 diabetes affect almost every aspect of life. The conditions themselves, their consequences and their treatments have a profound impact on the physical, psychological, and material wellbeing of individuals, their families and our society.

There is evidence to show that good care now, can make a difference to long-term outcomes for people with type 1 (DCCT) or type 2 diabetes (UKPDS (Diabetes Control and Complications Trial Research Group, 1993; UK Prospective Diabetes Study Group, 1998a, 1988b, 1988c, 1988d, 2000a, 2000b). A large proportion of health and social care resources are currently utilised in caring for people with diabetes. However, despite this investment significant health gaps still exist, with too many people:

• remaining at increased risk of developing diabetes;
• with diabetes being exposed to unnecessary cardiometabolic risk;
• suffering the often devastating consequences of diabetes related complications.

Patterns of care are variable both within individual localities and across the country, meaning that not all patients have the opportunity to benefit from best practice (Audit Commisison, 2000). The increasing prevalence of diabetes, new technology and cost of providing services mean that existing diabetes services need to change. If localities simply do more of what is already being done we are likely to see more people with diabetes, more people developing complications and more people dying.

People with diabetes need better care. The Government is pushing forward with its NHS Plan. Can Practice-Based Commissioning hold out any hope to those of us who want to get involved in providing services that are sensitive to the needs of our patients and local population? The government is ramping up the pressure on the NHS to commission and provide better and more appropriate care focusing on access, patient choice, improvement in outcomes and value for money. The recent revisions to the ever evolving practice-based contracts have brought this into sharp focus. Practice owners and their primary care team members now face the challenge of having to extend their ‘hours of availability’, improve the ‘quality of services’ they provide and ‘balance the books’ despite significant decreases in practice revenue through their current ‘GMS/PMS’ contract.

Indeed, the perception of these major changes could be that we have ‘no choice’. Not true. In fact, it is time for us to make a very real choice. Many practices will find themselves asking some difficult questions:

• Do we resist the government pressure for change and continue to struggle on as we are?
• Do we embrace the change, diversify and redesign our services in line with the Practice-Based Commissioning agenda?

Of course, neither option is easy. The commissioning frameworks are evolving and will probably always continue to evolve. The question is when will your practice get involved? In fact, can you afford not to?

These are choices that businesses have to make all the time in the ‘real world’. Over the last 10 years, the Government’s process of investment and reform in the NHS has created a foundation from which they can push much harder and drive through their health and social care agenda. Those practices that resist, may not survive in the brave new world of healthcare.

With these challenges in mind, Azhar Farooqi takes a look at the bigger picture of commissioning and explores the potential opportunities that exist to help those practices that are interested step up to the mark and make a difference for people with diabetes.