As in the rest of the UK, the Quality and Outcomes Framework has contributed to a significant improvement in diabetes care in England. Sadly, NHS reform in England can tend to drive a wedge between primary and secondary care; with Diabetes UK and others concerned about a lack of integration that is detrimental to patient care (Diabetes UK et al, 2007a). In England, diabetes services are commissioned. Commissioning is a way of moving funds around the health service to meet demand, and comes in several guises.
- Practice-based commissioning: practices take on delegated indicative budgets to become more involved in commissioning decisions.
- Payment-by-results: tariffs are set, enabling accurate movement of funding.
- Prinary care trust (PCT) commissioning: PCTs commission services on behalf of their local population.
- Joint commissioning: PCTs and local authorities commission services together.
Practice-based commissioning is intended to engage local GP teams in diabetes management, promote better care and encourage individual’s self-management through multidisciplinary support. To do this, GPs and PCTs should perform an assessment of local need, design a plan to meet that need, procure services to deliver the plan and monitor the results. A toolkit has been published to assist with this process (Department of Health [DH], 2006a). Take-up has been slow, but clusters of practices working together are taking up this challenge.
Under payment-by-results, there is a specific tariff for episodes of care such as outpatient appointments and inpatient stays. This is intended to clarify costs and assist movement of care from secondary to primary care. Savings made, it is suggested, can be transferred to primary or intermediate specialist care services. A negative result is that payment-by-results has encouraged competition between primary and secondary care – with hospital specialist teams feeling especially threatened. The White Paper Our health, our care, our say: a new direction for community services recognises that more work is needed to support people with long-term conditions (DH, 2006b).
Good commissioning arrangements are in place in many areas, but the Healthcare Commission review (2007) rated 73% of PCTs as “fair”, 11% as “good” and 5% as “excellent” for their diabetes services. Eighty-five per cent of PCTs did not have arrangements for diabetes education programmes in place (despite it being a recommendation of NICE way back in 2003), people with long-term conditions did not have the access they deserved to healthcare and, worryingly, many PCTs were found not to fully understand the healthcare needs of the population they served.
Where services have been planned and adequately funded, most people with diabetes will continue receiving high-quality care from their practice teams. The concern is for those who deserve specialist care and are finding it difficult to access. They may also be in the invidious position of requiring a referral to specialist services, therefore incurring a charge, in order to be prescribed therapies that their PCT has blocked for prescription in primary care.
Year of Care
The Year of Care is a pilot project across three sites in England, and describes all the planned care a person with diabetes should receive over a year (Diabetes UK et al, 2007b). The plan is to adopt a care-planning approach involving agreed self-management strategies with individuals. Achieving this through commissioning of appropriate services, and with limited resources, will be a challenge.
Diabetes care in England needs to be shared – not between primary and secondary care but between a variety of services and the person with diabetes themselves.