Sort out diabetes and save the NHS

Diabetes is common and often undiagnosed. 2.3 million people in the UK know they’ve got it, another million don’t know they’ve got it and the incidence rises every year as we become older and fatter. Treatment can be complicated, and requires a lot of support, education and training, and close monitoring in times of illness.

It’s the commonest cause of blindness in the working population and can also lead to foot ulcers, nerve damage, infections, amputations, heart attacks, strokes, kidney failure, depression, serious pregnancy complications, erectile dysfunction and premature death. Poorly controlled diabetes knocks 10-20 years off your life and it costs the NHS over £1 million an hour to treat. So it’s vital, for both patients and NHS survival, that we treat it well.

The latest National Diabetes Inpatient Audit* is not encouraging. It looked at diabetic care in 93% of acute hospitals in England on a single November weekday in 2010, and found that people with diabetes had an average age of 75 and occupied 15% of beds. Their median length of stay was 8 days but only 9% had been admitted specifically for diabetes management. The majority (86.7%) had an emergency admission and 40% of inpatients were insulin treated. And now the bad news.

37.1% of inpatients with diabetes experienced at least one medication error. 26.0% of charts had prescription errors and 20.0% had one or more medication management errors. Insulin errors were particularly common. There was marked variation in prescription errors across hospitals from none to 54.3%. 44 developed ketoacidosis (severe uncontrolled diabetes) and 266 severe hypoglycaemia (too low blood sugar due to over-treatment) during their admission. Only 27.5% of patients had their feet examined at any time during admission, 2.2% developed a new foot complication during their hospital stay but 49.6% of these had no input from the foot specialist team.

So despite record funding for the NHS, there is still huge variation, substantial error and sub-standard care in the in-patient management of patients with the most common, expensive chronic disease. The audit found, rather alarmingly, that 31.0% of hospitals had no inpatient diabetes specialist nurses, 29.8% had no inpatient dietician for people with diabetes and 26.8% had no inpatient diabetic foot service. Few were under a diabetes consultant (9.0%) or on a diabetes ward (4.6%) and 69.4% of in-patients with diabetes had not been seen by a member of the diabetes team, including 46% with a diabetes management problem.

These alarming gaps in care are for the mother of all chronic diseases, so I’d what to think what level of expertise awaits patients with rarer diseases. Insulin requirements in sick people vary day by day, sometimes hour by hour, and they need expertise beyond the generalist nurse or the inexperienced junior doctor passing through on a shift. So while the tedious, point-scoring NHS reform debate plays out in Westminster, the premature death and disease of patients with chronic diseases continues on a massive scale.
The NHS now faces the toughest financial restrictions in its history. If specialist diabetic nurses are either not provided or made redundant, and diabetic consultants are not appointed, it’s hard to see how the care of this pivotal disease will improve. Patients often know how to manage their diabetes best and yet the audit found only 12.9% had a say in their treatment plan and less than a quarter were allowed to monitor their own sugar levels. In America, it’s been estimated that a small improvement in the management of diabetes could fund universal healthcare. If you can sort out diabetes, you can sort out the NHS. Time to stop the point-scoring and get on with it.

http://www.yhpho.org.uk/Diabetes_inpatient_audit

The Health Bill Balls

Should you feel sorry for Andrew Lansley? The Health Secretary has been polishing ideas for his Health and Social Care Bill for seven years and has spent nine months travelling around England explaining the changes to NHS staff, patients and MPs. But in the last few weeks the BMA has voted for the Bill to be withdrawn and reconsidered, the Lib Dems have voted overwhelmingly in favour of amendments, a study by the Nuffield Trust has found that only 23 per cent of GPs believe the reforms will improve the level of care already provided to patients, and 220,000 people have signed an on-line petition opposing it.

The headline concepts of the Health Bill are hard to argue against – get staff involved in designing and commissioning services, give power to patients and focus on better clinical outcomes. Lord Darzi, the Labour health minister, proposed just that and by the time Labour left office clinical outcomes were improving and patient satisfaction was at an all time high.

Labour’s good fortune was to invest heavily in the NHS without having to pick up the tab for the debt. Despite improvements in services, overall productivity hardly budged and Lansley is right to focus on this. But instead of laying waste to two tiers of NHS management in one sentence, he could have kept the best of the Primary Care Trusts, ditched or merged the bad ones and put more clinical staff and patients on the boards.

Lansley’s biggest error has been to downplay what effect the debt-reduction program will have on the NHS. The Tories made a big song and dance of securing a tiny increase in funding, year on year, but high inflation may wipe that out. The NHS has always swallowed up money at a rate far above inflation, so even if Lansley kept Labour’s NHS structure, the service would still be facing massive problems in the next few years. But because the focus of the debate is so heavily on his reforms, he’s likely to be blamed rather than the recession.
Lansley is desperate for clinical staff to take more responsibility for determining how limited resources are spent, and many would be happy to be involved in redesigning services if they weren’t already working eighty hours a week. Most major reforms need pump priming money to get them started, to pay for training and locum cover, but there’s little of that about. And although GPs are very adept at running small cottage industry practices, it’s a big step up for them to work together in commissioning groups and make the kind of instant productivity improvements that the NHS needs to stay afloat.

But it’s the labyrinthine complexity of the Health Bill that may sink it. The Outcomes Framework starts very well. There are only five of them 1. Preventing People from Dying Prematurely 2. Enhancing quality of life for people with Long Term Conditions 3. Helping people recover from episodes of ill-health or following injury. 4. Ensuring people have a positive experience of care 5. Treating and caring for people in a safe environment and protecting them from avoidable harm.

If the reforms focussed on those five outcomes, everyone would understand them. But they’re being translated into 150 quality standards and then they’ll be ‘fed into’ the Commissioning Outcomes Framework, the Commissioning Guidance and the Provider Payment Mechanisms of tariff, standard contract, CQUIN and QOF. Finally, the division of commissioning labour is split between the NHS Commissioning Board and GP Consortia, and the 60% of management costs that Lansley was so keen to save have been neatly reinvented.