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At £10bn, the annual cost to the NHS in England of treating the 3m people diagnosed with diabetes is already huge – about 10 per cent of the budget as a whole.
If the 11m people estimated to be at high risk of developing the disease over the next decade do go on to acquire it, the burden could spell catastrophe for the already cash-strapped system.
No wonder diabetes – particularly type 2 – was highlighted in October’s five year strategy published by the NHS England chief executive Simon Stevens, who warned that without radical reductions in the demand for hospital-based health services, the NHS will face a multibillion pound funding deficit by the end of the decade.
“We are spending more on bariatric surgery [such as gastric banding] than we are on ways to help people stay healthy”, Mr Stevens said.
But bariatric surgery is just the tip of the iceberg of escalating costs and serious health complications stemming from poorly managed diabetes. Between 2006 and 2011, the number of diabetics in England experiencing cardiac failure more than doubled. The numbers suffering a stroke or kidney failure increased by 87 and 77 per cent respectively, while those developing blindness increased by almost two-thirds.
This rapid rise in the number of diabetes sufferers being hospitalised through medical emergencies means that of the £10bn spent a year on patients with diabetes, only £2bn is spent directly treating their diabetes – the rest is swallowed up by the costs of treating the life threatening complications that are the consequence of a failure to keep a patient’s diabetes under control.
There is little disagreement across the NHS that what is needed is a radical shift of focus and resources from hospital-based care to prevention. This means both preventing type 2 diabetes itself – by detecting those most at risk of developing the condition and persuading them to take up healthier lifestyles – and preventing those already with the condition going on to develop more serious and expensive complications.
There is agreement too about what interventions work: opportunities for individuals to introduce gentle exercise into their lifestyle gradually; education sessions for newly diagnosed patients to learn how to self-manage their blood sugar levels through diet; prescribed medicines and self-monitoring; and a series of regular tests and checks by a patient’s general practitioner.
However, these services are far from being universally available throughout England. Indeed, according to a national audit published in October, between 2011 and 2013, the percentage of diabetics receiving eight crucial recommended care processes from their GP – including blood sugar and pressure tests – actually fell to 62 per cent.
The statistics betray a lack of understanding among primary care practitioners of the urgency of dealing with the disease.
One patient, June Williams, says she felt her efforts to manage her condition herself – by monitoring her blood sugar at home and taking the recommended regular blood tests at her doctor’s surgery – were in effect “sabotaged” by her GP practice, which systematically refused to give her a home testing kit or any detailed breakdown of her in-surgery test results.
Part of the problem says Barbara Young, chief executive of the campaigning charity Diabetes UK, is that diabetes has lacked the political and media attention of other diseases to turn it into a national priority.
“There are 3.3m people with diabetes but less than 1m with dementia and yet the prime minister has hung his hat on dementia,” she says. “I asked the PM’s office why. They said ‘who looks after people with dementia?’ It’s women between the age of 55 to 65, and that’s a key part of the swing vote.”
That may now be changing, with Mr Stevens’ recent highlighting of the huge cost to the tax-funded system. But Ms Young worries that 18 months after a wide-ranging restructuring of the service, the NHS finds itself “uniquely ill-equipped” to see the universal introduction of best practice.
Gone is the centralised, top-down structure viewed by some as “Stalinist” and in its place some 200-plus separate commissioning organisations run by family doctors, free to design their own interventions and independent of parliamentary control.
“When I talk to my American mates, they think we are bonkers,” says Ms Young. “They would give their eye teeth to have the data, the single payer, to get to grips with the model that works”. Instead, she argues, the NHS is “reinventing the wheel” more than 200 times and slowly.
The reform also moved responsibility for public health interventions to local authorities, leaving, Ms Young claims, confusion over who should foot the bill for exercise and healthy eating programmes which could be seen as both prevention and treatment.
Professor Jonathan Valabhji, who is consultant diabetologist at Imperial College Healthcare NHS Trust and NHS England’s national clinical director for obesity and diabetes, acknowledges that the reforms have created potential problems, but says they have also opened up opportunities.
He cites the example of local plans to block new fast food outlets close to school gates as one of many lifestyle issues that are “more than about health”, and where local authorities, rather than the NHS, have the power to affect change.
While he admits there is now no mechanism whereby he, as a national director, can force a local NHS organisation to take up a specific intervention, Prof Valabhji says decentralisation can be a benefit rather than a hindrance to improvement.
For example, in some inner city areas, mosques and other local religious institutions have been recruited to help tackle the particularly high rate of type 2 diabetes found within south Asian communities, a tactic that would be of limited impact if centrally dictated as a blanket national measure.
But Prof Valabhji insists that a driving force behind local initiatives is the NHS’s unique central data set, which tracks each hospital visit and test result of almost every diabetic in the country – enabling family doctors to identify which patients are deteriorating on the basis of their hospital visits and allowing commissioners, in turn, to spot which doctors are failing to manage the conditions of their patients adequately.
“If you want a high quality service, you need the data, and we have those,” Prof Valabhji says. “We are now trying to achieve service quality on the back of that.”
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