The management of adult diabetes services in the NHS

• Report: Department of Health: The management of adult diabetes services in the NHS
• Public Accounts Committee

The Rt Hon Margaret Hodge MP, Chair of the Committee of Public Accounts, today said:

"24,000 people die prematurely every year because their diabetes has not been managed effectively, and many more develop avoidable complications such as blindness and kidney disease.

The NHS spends at least £3.9 billion a year on diabetes services and around 80% of that goes on treating avoidable complications. The number of people with diabetes is set to rise from 3.1 million to 3.8 million between now and 2020 and unless care improves significantly the NHS will face ever-increasing costs.

More than 10 years ago, the Department set out clear minimum standards for diabetes care, including nine basic checks for the early signs of avoidable diabetic complications. Yet fewer than half of people with diabetes are receiving all nine of these tests.

Fewer than one in five people with diabetes have the recommended levels of blood glucose, blood pressure and cholesterol, leaving an unacceptably high number at risk of developing complications, being admitted to hospital and costing the NHS more money.

The Department gave local NHS organisations freedom to decide how to deliver diabetes services and did not introduce mandatory performance targets as it did for cancer, stroke and heart disease. There is no strong national leadership and no effective accountability arrangements for commissioners.

Variation in the level of progress across the NHS also means that there is an unacceptable “postcode lottery” of care, whereby the quality of diabetes care varies dramatically across the NHS.

We have seen no evidence that the Department of Health will ensure that these issues are addressed effectively in the new NHS structure. It must set out how improvements in diabetes care will be delivered under the new arrangements and what steps it will take, alongside Public Health England, to improve public awareness of the risk factors for diabetes such as obesity."

Margaret Hodge was speaking as the Committee published its 17th Report of this Session which, on the basis of evidence from expert witnesses and the Department of Health (the Department), examined the management of adult diabetes services in the NHS.

In 2009-10, there were 2.3 million adults diagnosed with diabetes in England and a further 800,000 people suffering from diabetes who remained undiagnosed. The percentage of the population diagnosed with diabetes doubled between 1994 and 2009 and is continuing to increase. The Department projects that the number of people with diabetes (diagnosed and undiagnosed) will rise from 3.1 million to 3.8 million by 2020. The NAO estimates that, in 2009-10, NHS spending on diabetes services in England was at least £3.9 billion, although this figure is likely to be an underestimate. The projected increase in the diabetic population could have a significant impact on NHS resources.

Too many people with diabetes are developing complications because they are not receiving the straightforward care and support they need, either through access to high quality care from appropriately trained NHS professionals or through effective training and support for patients so that they manage their condition. Most alarmingly, the Department estimates that 24,000 people with diabetes die prematurely each year because their diabetes has not been managed effectively. An estimated 80% of the costs of diabetes in the NHS are attributable to the treatment and management of serious, yet avoidable, diabetic complications. Unless diabetes care improves significantly the NHS will continue to incur ever-increasing costs as the number of people with the disease rises and individuals will continue to die prematurely. 

In 2001, the Department published the National Service Framework for Diabetes (the Framework). The Framework set out clear minimum standards for what constitutes good diabetes care, including nine basic care processes which check for the early signs of avoidable diabetic complications, such as blindness and kidney disease. The Department also set treatment targets for the management of blood glucose, blood pressure and cholesterol to minimise the risk of diabetic complications developing. Local NHS organisations determine locally how best to deliver diabetes services. The expected levels of care outlined in the national Framework were reinforced in 2011 by a National Institute for Health and Clinical Excellence (NICE) ‘Quality Standard’ for diabetes in adults.

Although there is consensus about what needs to be done for people with diabetes, progress in delivering the recommended standards of care and in achieving treatment targets has been depressingly poor. There is no strong national leadership, no effective accountability arrangements for commissioners, and no appropriate performance incentives for providers. We have seen no evidence that the Department will ensure that these issues are addressed effectively in the new NHS structure. Failure by it to do so will lead to higher costs to the NHS as well as less than adequate support for people with diabetes.

The improvements in diabetes services since the publication of the Framework have not been as great as we would have expected given that the Department set clear and clinically agreed standards 11 years ago and has had information showing that the NHS has not been delivering the expected standards of care for a number of years. Variation in the level of progress across the NHS also means that there is an unacceptable “postcode lottery” of care, whereby the quality of diabetes care varies dramatically across the NHS.