National Diabetes Audit 2017
Date sent: Saturday 18 February 2017
Email sent to all GPs and Practice Managers in Wessex
The 2017 National Diabetes Audit published 31st Jan 2017
The data for this important audit comes from various sources but probably the most important is general practice. The submission of practice data has been voluntary.
In 2014 about 60% of practices submitted data, this year the numbers increased to a 82% (higher % achieved in Wessex closer to 90%) of practices submit data.
Submission of data for the annual national diabetes audit will become a contractual requirement form April 2017.
The Core National Diabetes Audit (NDA) answers four key questions:
1. Is everyone with diabetes diagnosed and recorded on a practice diabetes register?
2. What percentage of people registered with diabetes received the nine NICE key processes of diabetes care?
3. What percentage of people registered with diabetes achieved NICE defined treatment targets for glucose control, blood pressure and blood cholesterol?
4. For people with registered diabetes what are the rates of acute and long term complications (disease outcomes)?
QoF has proved to be a useful tool to help practices compare their practice with others in terms of care processes provided to their registered patients looking at a small number of well defined long term conditions. Most would agree that the benefits of QoF have been achieved and it has now become a bit of an annual tick box exercise and needs to be revised (or abolished with funding being moved into the global sum).
Practices might want to look at a more focused group of indicators for patients with diabetes.
It is recommended that all people with diabetes aged 12 years and over should receive all of the nine NICE recommended care processes that are:
1. HbA1c (blood test for glucose control)
2. Blood Pressure (measurement for cardiovascular risk)
3. Serum Cholesterol (blood test for cardiovascular risk)
4. Serum Creatinine (blood test for kidney function)
5. Urine Albumin/Creatinine Ratio (urine test for kidney function)
6. Foot Risk Surveillance (foot examination for foot ulcer risk)
7. Body Mass Index (measurement for cardiovascular risk)
8. Smoking History (question for cardiovascular risk)
9. Digital Retinal Screening (photographic eye test for eye risk)
Key Findings in the 2015/6 data reported 31.1.17
1. There has been a reduction in the number of patients with a recorded BMI from data published in 2013/4.
2. There has been a drop in the recorded number of patients who have has a Urine Albumin to Creatinine Ratio (UACR) measurement (the check for early kidney disease)
3. Structured Education - The percentage of people diagnosed with diabetes that have been offered structured education within one year of diagnosis has increased markedly, from 10 per cent in 2009 to 82 per cent in 2014 for those with Type 2 diabetes (this has increased from 5 per cent to 39 per cent for those with Type 1 diabetes).
Despite this the attendance rates ate less than 10%.
4. Treatment Targets (HbA1c, BP, Cholesterol) - comparing practices and CCG there is significant variation that cannot be explained by different populations.
5. The percentage of patients with Type 1 diabetes achieving NICE-recommended treatment targets for glucose control, blood pressure and cholesterol varied from 11 per cent to 34 per cent.
6. In general, more patients with Type 2 diabetes achieve treatment targets, but there is a sixteen percentage point variation, from 33 to 49 per cent, across localities.
7. The last six years have seen improvements nationally in achievement of all three treatment targets, in both Type 1 (1.6 percentage points) and Type 2 (5.1 percentage points) diabetes.
8. Gaining tight control of BP, Cholesterol and HBA1c will achieve a greater reduction in complications and improve life expectance and this will have the greatest impact in patients aged 65 and less, yet those aged under 65 do worst in terms of achieving the targets. This is true for both Type 1 and Type 2.
9. Older people are more likely than younger ones to achieve all three treatment targets; the difference for those with Type 2 diabetes is greater (46% of people aged 65 to 79 achieved all three treatment targets compared with 27% of people aged under 40) than for those with Type 1 diabetes (24% of people aged 65 to 79 and 18% for those aged under 40)
10. People with Type 2 diabetes are more likely to achieve all three treatment targets - 40% of people with Type 2 diabetes achieved all three treatment targets compared to only 18% of people with Type 1 diabetes
11. The percentage of people with Type 1 diabetes in England and Wales receiving all eight NICE-recommended care processes has fallen eight percentage points - from 45 per cent in 2013-14 to 37 per cent in 2015-16.
12. For people with Type 2 diabetes, the decline is greater - from 68 per cent in 2013-14 to 54 per cent in 2015-16. These declines are almost entirely due to reductions in delivery of the urine albumin care process (the check for early kidney disease).
I am sure we all want to improve the quality of care provided to our patients . The report allows you to look at your CCG data and compare this to your practice and with other local practices.
A Quality Improvement Toolkit has been developed in collaboration with the RCGP - click here for the toolkit.
• All services seek new approaches to diabetes service delivery for those aged under 65 to narrow the gap between them and older people.
• People with diabetes to review the results for their practice or specialist service and support any improvement initiatives.
The three NICE-recommended treatment targets for all patients with diabetes aged 12 years and over are:
1. HbA1c (blood test for glucose control) - HbA1c less than or equal to 58mmol/mol (7.5% in old units).
2. Blood pressure (measurement for cardiovascular risk) - blood pressure less than or equal to 140/80.
3. Serum cholesterol (blood test for cardiovascular risk) - cholesterol less than 5mmol/L.
A personal view
The number of patients with diabetes has increase significantly over the last few years and there are now more than 4 million people with diabetes in the UK. In my practice we had 200 diabetes patients in 1987 and now we have 670. The workload associated with the growing number of patients has been a significant contributor to the pressures that are faced by general practice.
There are more younger patients presenting with Type 2 diabetes and as life expectancy increases and we have an aging population that are more people aged 75+ and particularly 85+ who are diabetic.
The model that was in place when I trained being hospital based care for all has changed and rightly so, with more Type 2 patients being cared for in general practice and most Type 1 patients being cared for in a traditional hospital based clinic. It is estimated that the NHS spends over £10bn or 10% of the total budget on diabetes. Much of this is spent on managing complications including retinopathy, renal imparement and vascular complications. When my practice set up a practice based diabetic clinic in 1988 the management of Type 2 diabetes was quite simple - diet first, then add in metformin and/or a sulphunylurea. We now have a plethora of newer drugs for example:
- SGLT2 inhibitors
- DPP-4 Inhibitors (Gliptins)
- GLP-1 analogues
Evidence from places like Tower Hamlets have demonstrated that greater investment in primary care with a targeted approach to managing the 3 key measurement being BP, cholesterol and HBA1C reduced complications especially the cardiovascular complications such as Strokes and Myocardial Infarctions.
What does all this means?
1. The number of patients with diabetes is growing at an alarming rate and the resources available to manage these patients is not meeting the demand.
2. Although prevention is important, there needs to be a radical look at how to provide the most cost effective care to this large population.
3. Over the last 20-30 years the model of diabetic care has been over medicalised and patients need to take more responsibility for their long term conditions (LTC) both in terms of monitoring and management.
4. There should be greater use of technology to allow patients to be be better able to understand and manage their LTC, this could include the us of Apps, online access to clinical records and care plans or initiatives such as web access to their results and linked to help and advice.
5. QoF has served its day and should be replaced with the 3 key measurements being BP, cholesterol and HBa1c, each patient should have individual targets which create a care plan that is appropriate to their condition taking into account their general health and age.
6. There should be a greater focus on the 8 processes delivered at practice level (retinal screening is delivered by Commissioners).
7. A significant amount of diabetes care in the community is being delivered by practice nurses with GPs becoming de-skilled. At the same time as the management with medication becomes increasingly complex. I believe an new approach is needed as currently care is fragmented between the patient, GP, practice specialist nurse, diabetic specialist nurses and hospital based diabetic clinics with some areas also having a community specialist service. See below.
A new approach to diabetic care - Type 2
Although there needs to be a person centered approach to ensure the care and treatment is tailored to the individual, there needs to be a move to a population based approach to care rather than arranging care based on an organisation.
The gap between practice based care and the specialist hospital clinic approach has become too large. Because practices are funded on a capitation basis and hospitals are funded on an activity model it is not surprising that we are struggling to provide appropriate care delivered in the right place, particularly for he Type 2 diabetic population.
A different approach that some are developing is to target care at the most appropriate patients. For example a 90 yr old who has multiple medical conditions does not need the same level of monitoring and management as the 40 year old with uncontrolled blood glucose, raised blood pressure and a cholesterol of 7 mmol/l.
You could risk stratify patients (sorry I know many GPs don't like the term) into three groups:
1. Green - all key targets met or because of other circumstances need little in the way of intervention. (eg the 90 yr old above)
2. Amber - general ok but BP or cholesterol not to target or blood glucose control poor
3. Red - poor control at high risk of complications if situation not addressed.
My view is that with the increased prevalence and the greater complexity of management of Type 2 diabetes this is no longer a problem for general practice to solve alone and I would argue we no longer have the skills to do this.
Many see that diabetes is not a solely hospital based specialty but if we are going to move to a more population based approach there needs to be community based solution. The following would make a significant difference:
- Create a shared record between general practice, specialist services and patients - this can be achieved now with all GP clinical systems.
- The production of a patient owned care plan with clear targets that is shred between all providers.
- End fragmentation of care by creating a locality based specialist team (population based approach looking at natural communities of care 30 - 50,000)
- Locality based team could include specialist consultant, specialist GP (see capacity below), specialist nurse, practice nurse and other allied health professionals.
- The specialist consultant would work across more than one locality and focus on complex patients but also support the rest of the team with transfer of knowledge and wisdom!
- The specialist nurses and practice nurses would over time merge into one.
- The specialist GP would be a new post who would not only add capacity but provide an opportunity for GPs to diversify and help with recruitment and retention. In addition the service would provide an excellent training environment for both GPs and diabetic specialists who would not only gain knowledge and experience but also add capacity to the service.
- If patients are unwilling to attend face to face training we should promote online training delivered in bite size chunks.
- Current CCG commissioning plans for diabetes seem to focus on hospital based care and managing end stage complications, there needs to be a radically different approach with commissioners working with the developing community based providers - Vanguards, New Models of Care, MCPs, Federation etc.
I know the debate is already underway in parts of Wessex and nationally but I thought I would widen it to all practices in Wessex.
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)