National Audit report: We should be doing better

The recently published results of the National Diabetes Audit for 2009–2010 (NHS Information Centre, 2011) made headline news, yet again, stating that people with diabetes are still not receiving the necessary basic checks that could enable intervention and prevention of expensive complications, not only for the individual but for society as a whole. Dr Rosemary Leonard, BBC Breakfast’s resident GP, endeavoured to explain on breakfast television that it is the younger age group that are less likely to attend these basic check-up visits despite GPs offering them. But maybe we, as a healthcare system and as a society, need to address the barriers to attendance and take a good look at the systems and processes that are currently in place.

Basic checks are not being carried out enough in individuals of working age (16–55 years) (NHS Information Centre, 2011). Last month, Diabetes UK started Diabetes Week by releasing the results of a survey it carried out that found 1 million people could be risking their health by keeping their diabetes a secret (Diabetes UK, 2011). Of these people, a quarter had done so out of fear of discrimination or bullying. People with diabetes need to be made more aware that they have disability legislative rights and employers need to enable them to meet their healthcare needs. In an age when our place of work is not near our home address, for which GPs are allocated, and the clinic is not within easy commuting distance, people need better access to diabetes care near their workplace.

The Paediatric National Diabetes Audit still has to fully report its findings, but according to the NHS Information Centre (2011) only 4.1% of children and young people aged >12 years had all of the NICE key process of care recorded. The audit collects data on measurements of weight (BMI), blood pressure (BP), HbA1c, urine albumin–creatinine ratio, serum creatinine and serum cholesterol, and on assessment of eyes and feet and smoking status.

I would argue that very few centres will record all of these variables as not all are stated in the NICE (2004) recommendations for children and young people with type 1 diabetes. For example, it is not recommended that children and young people have regular checks of their blood lipid levels until they are transferred to an adult clinic, and there is no mention of measuring serum creatinine levels. Paediatric screening processes are different to that for adults, with some processes such as retinopathy screening, microalbuminuria screening and BP monitoring not being started until children are aged 12 years.

As children grow, the data collection of one BMI measurement in the audit year does not satisfy our guidance (NICE, 2004) of measuring height and weight and calculating BMI to check for normal growth and/or significant changes in weight, which may reflect glycaemic control. We are required to check for coeliac disease and thyroid disease on diagnosis of type 1 diabetes and to continue to screen for thyroid disease annually until transfer to adult care. However, we are not asked to record these data or to record check injection-site checks. A minimum of four HbA1c level measurements are required per year, but only one is submitted to the Audit. Therefore, I would recommend that the National Paediatric Diabetes Audit needs to be modified to collect relevant data before telling us we are not doing what is required.

What continues to be of concern is that, according to the National Diabetes Audit (NHS Information Centre, 2011), 85.5% of children and young people with a recorded HbA1c measurement have a level above the national target of 7.5% (58 mmol/mol) (NICE, 2004). It is these individuals who are at risk of future complications, especially in view of the Audit findings of them not attending check-ups. Next year will see the introduction of a compulsory Payment by Results tariff for paediatric diabetes (Department of Health, 2011). One component of this is a requirement for submission to the National Diabetes Audit. Let us work together to ensure the data collected are meaningful and relevant to enable improvement in the care processes for all people with diabetes.