Testing times in diabetes care

A major Audit Commission report Testing Times: A Review of Diabetes Services in England and Wales, was published in April this year, and the findings were highlighted at the Commission’s conference held in London on 25 May. The report was the culmination of more than a year’s work, looking at the provision of diabetes services across acute and community NHS trusts and within primary care. Not only did they gather information from health professionals and Health Authorities, but they also consulted widely with people with diabetes to ascertain the constituents of a ‘good’ diabetes service and where problems arise.

Why diabetes?
Why did the Audit Commission select diabetes? The answers are obvious when we look at what is already known: at least 2% of the population are diagnosed as having diabetes; there are large numbers of people whose diabetes is currently undiagnosed; the numbers diagnosed are predicted to increase dramatically over the next ten to fifteen years; and people with diabetes develop major complications if the condition is poorly managed. As Lord Hunt, Parliamentary Under Secretary of State, indicated during the Audit Commission conference, treatment of diabetes and its complications accounts for at least 9% of healthcare costs, yet this is often not recognised in health services and diabetes care is not seen as a priority area. It therefore makes sense to look at how diabetes impacts on the NHS and the way we use our resources.

Shortcomings exposed
The report highlighted many gaps in service provision; for example, half of the Health Authorities surveyed lacked district-wide retinal screening services; there was wide variation in the range of professional expertise available within different general practices; two thirds of hospitals could not produce basic data on process and outcomes for their diabetes clinic population; and over one sixth of hospitals had no kind of diabetes registers.

The views of people with diabetes illustrated some serious shortcomings: two thirds reported no education or support in the previous twelve months; many were unaware of what to do in the event of hypoglycaemia, or who to contact out of hours. The lack of adequate services for those from ethnic minorities was highlighted. Clinic non-attendance rates were linked to people being unhappy with the way they were treated at previous appointments.

Primary care
Primary care came in for its own share of criticism: two fifths of practices had no guidelines for diabetes referrals; one in five GP referral letters was vague and lacked clarity as to why the patient was being referred, making it difficult for specialist services to prioritise effectively; and, at one hospital, half the patients referred to the foot clinic had serious problems that should have been referred much earlier. There was variation in the number of patients attending hospital clinics for their annual review – greater numbers were identified in areas where primary care was less well developed.

Good practice recognised
The news was not all bad; examples of good practice were also found, and these were highlighted in the report and at the conference. One example was the systematic annual review programme at Leicester General Hospital, which incorporated detailed care planning and good communication between the hospital, general practice and the patients attending the service. Other examples included the investment in practice nurse education by DSNs in the Bath area; development of a comprehensive service within a single general practice in Exeter; the setting up of PCG-wide diabetes strategies in Birmingham; fostering of a specific service for ethnic minorities in Derby; and the achievements of a committed and co-ordinated secondary care team in Hillingdon. These shining examples provided many different models of diabetes care, but all had common themes: the enthusiasm of the people involved, the reluctance to accept that systems couldn’t be changed, and the team spirit that had been generated locally.

The overwhelming message from Testing Times was that unacceptable variation exists in the provision of diabetes care across England and Wales and, although the report did not specifically study Scotland and Northern Ireland, similar variation may well exist across the UK.

Achieving quality care for all
One of the recommendations of the report was that specialist diabetes teams can play a huge part in supporting and developing primary care services in their locality, thereby encouraging more routine care to be undertaken away from the hospital environment. The report also criticised the current chronic disease management blanket payment system, and recommended real incentive payments for the provision of high quality diabetes care, and this message has been acknowledged by the Department of Health.

With the National Service Framework for Diabetes due to be published in Spring 2001, the report has provided timely information to support those areas where care needs to be improved. It was acknowledged during the conference that there is a vast amount of knowledge about what we need to do to provide good diabetes services. Despite this, there are numerous reasons why some services are not high quality: lack of awareness by some; lack of recognition of the problems that diabetes poses; and the difficulties of reallocating resources.

Partnership is the key
All of us, regardless of specific role, have a duty to ensure that we are playing our part in providing an adequate service for people with diabetes under our care. This not only means providing screening services, but also prescribing effective medication, referring patients to more expert services when we are not making progress, and sharing information with our patients every step of the way.

It is not likely that people with diabetes will self-manage their diabetes adequately if they have insufficient information or receive inadequate support from within the health service. They also need to be aware of what targets are being aimed for or, indeed, why there are targets. True partnership with patients may be the single most effective way of reducing future complications of diabetes.