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Shortcomings in diabetes services

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Diabetes services perform poorly against expected levels of care and achieve low treatment standards, according to a damning report by the National Audit Office.

Published last month, The management of adult diabetes services in the NHS is based on analysis of national data sets and visits to ten NHS diabetes services in England in 2009. It warns that services fail to deliver value for money and cause high numbers of avoidable deaths, also concluding that the cost of diabetes to the NHS has been vastly underestimated.

While describing the audit as 'a snapshot of what diabetes care looked like in 2009', care services minister Paul Burstow acknowledged the government's recent Atlas of Variation also revealed 'unjustifiable variation in the quality of diabetes care' and pledged to 'drive up standards for everyone'.

Regional inequalities

According to the NAO, regional inequalities have been caused by the range of different approaches taken to the provision of diabetes care. 'Some were led by GP practices, some by hospital and specialist services, and some by intermediate community services,' the report states.

It suggests that, rather than being tailored to the local needs, services were established in an arbitrary manner and 'it was not always clear what had led to the current design of the service'.

Chief executive of diabetes UK, Barbara Young, says the audit represents 'a damning indictment' of existing approaches to diabetes care.

'Action is needed now and escalating diabetes costs threaten to wreck the NHS budget so this is an issue that affects all of us, not just people with diabetes,' she says.

Clinical commissioning groups (CCGs), which take over commissioning responsibility from PCTs from April 2013, must capitalise on this change to boost standards of diabetes care, country-wide, the NAO recommends. The NHS Commissioning Board, which oversees CCGs, should require contracts with providers to 'specify that diabetes care should be delivered by appropriately trained professionals'.

But RCN long-term conditions adviser Amanda Cheesley warns the upheaval caused by the NHS restructure could hinder improvements.

'With any change, and this is a significant one, there is a risk that things won't get monitored properly,' she says. Commissioners need to understand what they are commissioning, and we are concerned about whether that is true across the board.'

In 2001, the DH set standards requiring all diabetes patients to receive nine care processes, including blood pressure and cholesterol monitoring, foot examinations, and creatine tests. In England, only half of patients are receiving all nine checks, the audit says, and there is huge regional variation: in the best-performing PCTs, 69 per cent of diabetes patients receive all nine checks; in the worst, the figure is 6 per cent.

In addition to the nine processes, NICE has set three treatment standards that, if achieved by a patient, will minimise their risk of developing complications. These relate to controlling blood pressure, blood glucose and cholesterol levels. According to the report, only 16 per cent of people with diabetes achieved all three standards, with 84 per cent falling short.

To boost performance, QOF payments to general practice should be tied more closely to delivery of the nine diabetes checks, the NAO says. While not all checks are carried out in general practice, GPs 'should only be paid for diabetes care if they ensure all nine care processes are delivered to people with diabetes'.

Commissioners should invest in expertise. The report raises concerns that some trusts are reducing costs by cutting training in diabetes care for NHS staff, including nurses; this runs counter to 'a body of evidence' accumulating 'that supports investing in training for NHS staff and people with diabetes.

'However, results from our visits to ten PCTs and wider departmental workforce surveys suggest these activities are among those currently being cut,' it says.

It claims some trusts are not replacing diabetes specialist nurses who leave their posts, ignoring 'long-term cost implications of removing such specialist skills from local health economies.'

Ms Cheesley says specialist nurses are viewed as 'an expensive luxury'.

'If you have a Masters degree and additional clinical skills and expertise, you might expect to be paid at AfC band 7 or even band 8a level,' she says. 'That is not being adhered to in many areas. But it isn't just about training specialist nurses.

'We need to ensure all primary care and community nurses have basic awareness of things like correct blood sugar levels and know about the nine recommendations.'

Cost of diabetes underestimated

The report concludes the DH has 'substantially underestimated' the cost of diabetes to the NHS, due to a 'lack of good quality cost data for primary care and community services and the way hospital costs are allocated'. Ministers put costs at £1.3 billion for 2009/10, while the audit shows it was 'at least £3.9 billion'.

It sets out four management processes that could save the NHS £170 million a year, and prevent around 240,000 avoidable deaths. For example, it estimates that reducing hospital admissions by 10 per cent could reap savings of £34 million.

However, this relies on the NHS taking a longer-term view of diabetes care and investing in effective strategies and specialist nurses rather than making short-term 'efficiency savings' which undermine services further down the line.

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