NHS: Diabetic Services

Lord Kakkar Excerpts

Thursday 29th November 2012 Lords Chamber

[Lord Kakkar]

My Lords, I join others in congratulating the noble Lord, Lord Harrison, on having secured this important debate and declare my own interest as professor of surgery and consultant surgeon at University College London Hospitals NHS Foundation Trust. We have heard during this debate about the profound burden of diabetes in our country. Some 24,000 excess deaths are reported in those with diabetes annually, some 13,000 strokes, 11,000 heart attacks and more than 4,000 minor and major amputations, in addition to the complications seen in the eye, the kidney and the nervous system. All have a profound impact on the individuals who suffer from this potentially devastating disease. As a result, and quite rightly, diabetes has received an awful lot of attention, not only in clinical practice and research but in government during the past 10 to 12 years, with the growing recognition that the burden of this chronic disease on society and the National Health Service will be profound.

The recent inquiry by the Public Accounts Committee in the other place failed to reach a consensus position with Her Majesty’s Government on the cost to the National Health Service of diabetes, but the figures range between some £4.6 billion and £10 billion, looking at the broad impact of the disease on NHS services. This is quite striking at a time when the service needs to spend its resources more efficiently and effectively. Among the issues raised in that report are: how diabetic services should be commissioned, why commissioning to date through primary care trusts appears to have failed patients and how looking at the new arrangements for the delivery and commissioning of NHS services as a result of the Health and Social Care Act 2012 might be used to improve outcomes for diabetic patients.

What we know in terms of reports and strategies such as the national service framework in 2001 and the production of NICE clinical standards in 2011 is that simple interventions provided annually for patients with diabetes can have a profound impact on improving their clinical outcomes. These include, for instance, annual examination of the eyes to determine whether patients are developing retinopathy; annual, or more frequent if necessary, examination of the feet to guard against diabetic foot complications; regular measurement of the blood sugar, particularly glycosylated haemoglobin, to determine whether the longer-term management of sugar is appropriate; the evaluation of blood lipids and blood pressure, because cardiovascular complications in diabetics can be more devastating and occur with greater frequency; and, of course, testing the urine for protein and testing the blood for creatinine to determine whether the kidney is being affected by diabetes and whether more careful clinical attention needs to be paid to protecting that important organ. In addition, it is well recognised that education of diabetics is vital. Of course, the preparation of women with diabetes for pregnancy is vital, too, to ensure that we do not see the devastating potential complications of diabetes during pregnancy.

These complications and the measures are well understood. What is often forgotten is the fact that diabetics entering hospital for management of other conditions will often have complications at a much higher rate and frequency as a result of having diabetes. One of the most important is, of course, the development of infection in hospital, which is seen more frequently in patients in whom diabetes is not appropriately controlled. It is quite right to say that multidisciplinary care is vital.

To return to the NICE care standards and processes described—simple, authoritative measures—if we ask how frequently and successfully those are being applied to patients with diabetes in communities around the country, the data are quite startling. For interventions that could prevent a heart attack, stroke, amputation or early death, we find that only 50% of diabetics have all nine simple care measures applied on an annual basis. In two PCTs, less than 10% of patients have those nine standards assessed on an annual basis, and in the best PCT only 69% have those measures conducted on a regular basis. The reality of the situation is that the Department of Health, giving evidence to the Public Accounts Committee in the other place, stated that 100% achievement of these nine care processes was unrealistic and a more realistic target was only 75%. That seems rather disappointing, bearing in mind the burden not only for the individual patient but for society more generally and the NHS in terms of its resources attending complications of diabetes.

It is clear that the current arrangements for holding commissioners to account have failed. Of course, we will see the disappearance of those arrangements—and of primary care trusts—on 31 March next year. The provision of these appropriate care measures to much larger numbers of diabetic patients would be a first, early and important test of the new commissioning arrangements through the NHS Commissioning Board and the clinical commissioning groups.

With that in mind, is the Minister able to say what progress has been made with regard to putting at the centre of diabetic care the provision of integrated care pathways? It is quite right for a chronic condition that the majority of care should be provided in the community setting but it is also very clear for diabetics that provision of or access to ancillary services is vital. We have heard about feet and eye services, but there is also access to specialists in hospital because diabetes is much more than a disease of blood sugar. It is a complex metabolic condition with profound cardiovascular, neurological and peripheral vascular implications. It is very important that any commissioning arrangements incentivise excellent care in the community but also make it mandatory for early referral to more specialist centres for early intervention on developing complications.

In this regard, will the quality outcomes framework in primary care be modified to incentivise integrated care? Will payment by results for secondary and tertiary care providers ensure that integrated care across multiple providers in the community and in hospital becomes the norm rather than the exception for the provision of the management of diabetes? In addition, if more care is to be given at the primary care level, it is vital that general practitioners are properly trained and continue to receive ongoing training and professional development to ensure that appropriate care is given to diabetic patients, and that we have an emphasis on ongoing research in both the primary and secondary environments if more patients are to be managed out of hospital.

Finally, the question of the role of Public Health England has been raised. This is a major societal problem with major public health implications. It is critical that Public Health England takes as one of its early priorities the question of screening for diabetes in high-risk populations—for instance, in certain ethnic minority communities, as we heard about from the noble Lord, Lord Harrison—and sees that every opportunity is used to ensure that patients who develop diabetes can be identified early rather than later and that intervention can be provided to avoid potentially devastating complications.