How to stop diabetes engulfing the NHS

Diabetes is an important, and growing, issue for the NHS. There are 3.7 million people with diabetes in the UK and a further 7 million people are at high risk of developing it. It is estimated that more than 5 million people will have the condition by the next decade.

Record rates of devastating diabetes complications such as kidney failure and stroke mean not only heartache and dramatically shorter life expectancy for many people with the condition but also enormous financial pressures on the NHS.

To put it bluntly, unless the prevention and care of diabetes is greatly improved, the condition threatens to engulf our health service.

Despite the seriousness of the condition and the alarming rate at which it is growing, all too often the NHS is failing people when it comes to diabetes care. As the National Audit Office report published in May recognised, standards of care and the health outcomes for people with diabetes are in overall terms unacceptably poor and wildly variable across the country.

‘Improving diabetes care does not mean spending lots of extra money; a lack of money is not the problem’

For example, barely half of people with diabetes are getting all the checks recommended by the National Institute for Health and Clinical Excellence to manage their condition and as a result of this poor performance many people with the condition have, for example, high cholesterol, high blood glucose and high blood pressure, the three killer signals of poor outcomes.

If left unchecked, these can lead to devastating complications such as blindness, amputations and kidney failure.

The cost of complications

Improving diabetes care does not mean spending lots of extra money; a lack of money is not the problem. The NHS spends over £10bn a year – almost 10 per cent of its annual budget – on diabetes. A staggering 80 per cent of NHS diabetes spending goes on managing complications, which are often preventable with early diagnosis and the right care.

While we are spending heavily on treating devastating complications such as blindness, amputations and kidney failure, not enough is being done to prevent these complications developing in the first place.

This is why the NHS needs to place far greater focus on prevention, early diagnosis and effective screening through the NHS Vascular Health Check. This would help to reach the 850,000 people with Type 2 diabetes who don’t know they have it (about half these people already have signs of complications by the time they are diagnosed).  

The Health Check would also help find the 7 million people at high risk of Type 2 so that they can get the lifestyle support and care that they need to prevent progression to diabetes. This would not only greatly help to reduce costs to the NHS but would also ensure that those with the condition do better and live longer.

The NHS Health Check programme has the potential to play a crucial role in ensuring that this happens but so far this programme has been poorly implemented, risk assessing less than half the people who should have been according to DH targets.

Missing indicators

The priority must now be to ensure the reformed NHS can deliver the type of good care that is widely recognised as being desperately needed. We have been encouraged by how health leaders have recently acknowledged the poor state of diabetes healthcare but we now need them and all the emerging bodies under the new NHS to match these words with strong action.

This means, among other measures, the NHS Commissioning Board giving clear priority to improving the standard of diabetes care in its Commissioning Outcomes Framework and Commissioning Guidance to Clinical Commissioning Groups.

The release of the National Institute for Health and Clinical Excellence Commissioning Outcomes Framework (COF) Advisory Committee recommended national indicators for 2013-2014 showed a commitment to improve health outcomes for people with diabetes by recommending six diabetes indicators. We are particularly pleased that there are indicators for the rates of complications, rates of lower limb amputations, basic care checks and readmission rates for ketoacidosis.

All these indicators are important in terms of what CCGs can influence and how they can impact on outcomes for people with diabetes and the NHS Commissioning Board must take them up in the final COF indicators, which will be released later this autumn.

But we are concerned that indicators to measure the whole integrated pathway of diabetes care are not included. We are also missing indicators on important areas such as improving outcomes for diabetes foot problems. There are 100 diabetes-related amputations a week of which 80 are preventable. 

Of course in new NHS land, the primary responsibility falls to local commissioners as they write their commissioning plans and health and wellbeing strategies to ensure that all of the necessary components are in place to deal with diabetes. So the key question is how will the NHS Commissioning Board deal with CCGs who fail to deliver effective standards of diabetes care that meets the needs of people in their areas?

Radical shake-up

The previous system suffered from the postcode lottery. How, in a much more devolved system, can this be improved and what real levers will the commissioning board have if improvement doesn’t happen?

As the NHS goes through one of the most radical shake-ups in its history it is essential that when the new NHS bodies finally emerge they are fully equipped to meet the challenge of diabetes.  Diabetes UK is working with the emerging bodies and systems to make sure there is a sporting chance of that happening. 

However, that old, wise man of the NHS, David Florey, once told me that for things to happen in the old NHS, three things had to be in place: a compelling case, a minister who took an interest and a crisis. 

We have the compelling case for stopping the rise of diabetes and its complications, the inexorable growth of cases and costs is a crisis in the making, and even in the new NHS we still need ministerial and government leadership.  This epidemic of diabetes is too big to be left wholly to a myriad of local decisions alone.

Barbara Young is chief executive of Diabetes UK