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The management of adult diabetes services in the NHS

The National Audit Office has today issued a report examining whether the NHS in England is providing recommended standards of care to people with diabetes. The report finds that, despite some improvements since 2006-07, there is poor performance against expected levels of care, low achievement of treatment standards and high numbers of avoidable deaths, and concludes that diabetes services in England are not delivering value for money.

In 2009-10, there were an estimated 3.1 million adults with diabetes in England. The number of people with the condition is expected to increase by 23 per cent to 3.8 million by 2020. The Department does not fully understand the cost of diabetes to the taxpayer, but it estimates that it has increased its spending on diabetes services from £0.9 billion in 2006 – 2007 to £1.3 billion in 2009-10. The NAO considers these figures to be a substantial underestimate, based on incomplete data, and estimates that NHS spending on diabetes services in 2009-10 was at least £3.9 billion, or around four per cent of the NHS budget.

According to today’s report, the Department’s data show that only half of people with diabetes received the recommended standards of care in 2009-10, even though the proportion has increased from 36 per cent in 2006-07. The standards, which the Department originally set in 2001, state that people with diabetes should receive nine basic care processes each year. These care processes can reduce their risk of diabetes-related complications such as blindness, amputation and kidney disease. As well as diminishing quality of life, diabetic complications place a significant burden on the NHS.

The risk of developing diabetic complications can also be reduced if people with diabetes achieve recommended treatment standards to control blood glucose, blood pressure and cholesterol levels. However, fewer than one in five people with diabetes are achieving recommended standards for controlling all three of these levels. The Department also estimates that up to 24,000 people die each year from avoidable causes related to their diabetes.

There is significant variation in the quality of care received by people with diabetes. This variation cannot be explained by need or spending alone and is likely to be influenced by the local organisation and management of health services. The Department’s data shows that no primary care trust achieved the aim of delivering all nine basic care processes to all people, with the highest trust scoring 69 per cent and the lowest just 6 per cent.

The Department has not managed effectively the performance of primary care trusts in delivering the recommended standards of diabetes care across the NHS. The NHS also lacks clarity about the most effective ways to deliver diabetes services and does not clearly understand the costs of treating diabetes in the NHS. Through better management of people with diabetes, the NHS could save £170 million a year.

"The Department of Health has failed to deliver diabetes care to the standard it set out as long ago as 2001. This has resulted in people with diabetes developing avoidable complications, in a high number of preventable deaths and in increased costs for the NHS. "The expected 23 per cent increase by 2020 in the number of people in England with diabetes will have a major impact on NHS resources unless the efficiency and effectiveness of existing services are substantially improved."

Amyas Morse, head of the National Audit Office

Notes for Editors

  • The nine basic care processes to be delivered annually are set out in the table below.
    Care process Purpose
    Micro-albuminuria A urine test is undertaken to check for protein, a sign of possible kidney problems.
    Blood pressure High blood pressure can indicate blockages or obstructions in the arteries, which can cause a variety of complications.
    Body mass index Approximate measure of obesity using height and weight. Obesity is a risk factor in developing complications due to diabetes.
    Cholesterol A blood test is undertaken to measure levels of fat in the blood. High levels increase the risk of complications developing.
    Creatinine A blood test is undertaken to check for possible kidney disease.
    Eye screening Using a specialised digital camera, a photograph of each eye is taken to look for any changes to the retina which may require treatment.
    Foot examination The skin, circulation and nerve supply of the feet are examined to check for numbness, sensation, reflexes and pulses.

    HbA1c level

    (a marker for blood glucose)

    High blood glucose levels can cause damage to blood vessels and increase the risk of diabetes complications developing.
    Smoking advice Having diabetes puts people at increased risk of heart disease and stroke. Smoking further increases this risk.
  • Press notices and reports are available from the date of publication on the NAO website, which is at www.nao.org.uk. Hard copies can be obtained from The Stationery Office on 0845 702 3474.
  • The National Audit Office scrutinizes public spending for Parliament and is independent of government. The Comptroller and Auditor General (C&AG), Amyas Morse, is an Officer of the House of Commons and leads the NAO, which employs some 860 staff. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether departments and the bodies they fund have used their resources efficiently, effectively, and with economy.

PN: 29/12