The management of adult diabetes services in the NHS: progress review
Progress has been made in reducing the additional risk of death for people with diabetes and the additional risk of diabetes-related complications has been stable or has reduced for most complications, according to today’s report from the National Audit Office. However, there are still 22,000 people estimated to be dying each year from diabetes-related causes that could potentially be avoided.
In 2013-14, an estimated 3.2 million people aged 16 or over in England had diabetes, and each year another 200,000 people are newly diagnosed. The estimated cost of diabetes to the NHS in England in 2010-11 was £5.6 billion, 69% of which was the cost of complications, such as amputation, blindness, kidney failure and stroke.
Today’s report on the Department of Health, its arm’s-length bodies and the NHS, finds that performance in delivering key care processes and achieving treatment standards, which help to minimise the risk of diabetes patients developing complications in the future, is no longer improving. In 2012-13, 60% of patients received all the care processes except eye screening, and 36% achieved all 3 treatment standards to control blood glucose, blood pressure and cholesterol levels. Very few newly diagnosed diabetes patients are recorded as attending structured education that could help them to manage their condition and reduce the risk of developing complications.
In 2013, people with diabetes in England were 34% more likely to die that year than the general population, an improvement since 2011 when they were 44% more likely to die. Since the NAO last reported on diabetes services, the relative risk for people with diabetes developing complications has not changed or has reduced for most complications. However, the increase in the number of people with diabetes means that the absolute number of diabetes patients with complications is rising.
There are significant variations across England in delivering key care processes, achieving treatment standards and improving outcomes for diabetes patients. For example, across clinical commissioning groups: the percentage of people with diabetes receiving all the recommended care processes, apart from eye screening, ranged from 30% to 76% in 2012-13; and the additional risk of death among people with diabetes within a one-year follow-up period, ranged from 10% to 65%.
In addition, some groups of diabetes patients receive worse routine care and treatment and have poorer outcomes. Younger people with type 1 and type 2 diabetes and all people with type 1 diabetes receive fewer of the recommended care processes and are less likely to achieve all 3 treatment standards. This can lead to poorer outcomes. For example, the relative risk of premature death for young women (aged 15 to 34) with type 1 diabetes is particularly high.
The NAO finds that although the percentage of beds in acute hospitals in England occupied by people with diabetes increased from 14.8% in 2010 to 15.7% in 2013, diabetes specialist staffing levels have not changed since it last reported on diabetes services.
Amongst the NAO’s recommendations is that NHS England should set out how it intends to hold clinical commissioning groups to account for poor performance in delivering key care processes, the 3 treatment standards and longer-term outcomes.
“Our previous report on diabetes services showed that there was an improvement in delivering the 9 key care processes that the NHS has identified as essential for diabetes patients. Data available since then shows that these improvements have been reflected in an uplift in long-term outcomes for these patients. However the improvements in delivery of these key care processes have stalled, as today’s report shows, and this is likely to be reflected in a halt to outcomes improvement for diabetes patients.”
Amyas Morse, head of the National Audit Office
Notes for Editors
Estimated cost to the NHS of diabetes in England, in 2010-11
People in England were estimated to have diabetes in 2013-14, with 2.8 million diagnosed
People in England estimated to be dying each year from diabetes-related causes that could potentially be avoided
Of registered diabetes patients received all eight key care processes, monitored through the National Diabetes Audit, in 2012-13
Of registered diabetes patients were achieving all three diabetes-related treatment standards for blood glucose, blood pressure and cholesterol levels, in 2012-13
Fewer than 4%
Of newly diagnosed diabetes patients were recorded as having taken up a structured education programme, in 2012-13
10% to 65%
Variation in the additional risk of death among people with diabetes, within a one-year follow-up period, compared with the general population
Of patients reported that they were able to take control of their own diabetes care while in hospital to the extent they would have liked, in 2012-13
1. Diabetes is a chronic condition where the body does not produce enough insulin to regulate blood glucose levels. The percentage of the adult population in England with diabetes has more than doubled between 1996-97 and 2013-14. There are two types of diabetes, type 1 diabetes, which occurs when the body produces no insulin, and type 2 diabetes, which occurs when the body cannot produce enough insulin to function properly, or when the body’s cells do not react to insulin.
2. The nine care processes are blood pressure, body mass index, cholesterol, creatinine, eye screening, foot examination HbA1c (a measure of blood glucose levels), micro-albuminuria
and smoking advice.
3. The NAO published a report on adult diabetes service in 2012, The management of adult
diabetes services in the NHS: https://www.nao.org.uk/report/the-management-of-adultdiabetes-services-in-the-nhs/
4. Press notices and reports are available from the date of publication on the NAO website. Hard copies can be obtained by using the relevant links on our website.
5. The National Audit Office scrutinises public spending for Parliament and is independent of government. The Comptroller and Auditor General (C&AG), Sir Amyas Morse KCB, is an Officer of the House of Commons and leads the NAO, which employs some 810 people. 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. Our studies evaluate the value for money of public spending, nationally and locally. Our recommendations and reports on good practice help government improve public services, and our work led to audited savings of £1.15 billion in 2014.