Written evidence submitted by Diabetes UK
1.1. Diabetes UK is the leading charity for people living with diabetes in the UK and our vision is a world where diabetes can do no harm. We are the leading funder of medical research for diabetes, and conduct policy and campaigns work to improve the lives and health outcomes for people living with or at risk of the condition.
1.2. Diabetes is one of the fastest growing and potentially most devastating health crises of our time. Over 4.9 million people are currently living with diabetes in the UK and the number of people diagnosed has doubled in the last 15 years. That means 1 in 14 people in the UK have diabetes.
1.3. Diabetes is a serious condition and can lead to complications such as heart attack, stroke and amputation. Too often, these are avoidable through better care and prevention. Findings show that before the pandemic, diabetes accounted for 10 per cent of NHS spending, the majority of which was spent on treating complications which are largely avoidable, demonstrating the importance of preventing diabetes and improving care to ease the strain on the NHS and build resilience.
1.4. Diabetes UK is extremely concerned about the backlog of routine diabetes appointments that has built up during coronavirus as services have been disrupted. It is essential that people have access to the care and support they need to prevent serious complications. Measures to relieve pressure on GPs, such as suspending the Quality and Outcomes Framework (QOF), risk pushing people with diabetes to the back of the queue, so guidance must make clear that diabetes appointments should not be put on hold.
2.1. Type 2 diabetes is often picked up through NHS Health Checks, or at a visit to the GP for another reason. Early diagnosis is essential so that people can receive the support and advice they need to manage their condition and prevent devastating complications.
2.2. Concerningly, evidence shows that between March and September 2020, 2.5 million diagnostic diabetes blood tests were missed in the UK. This includes 213,000 missed pre-diabetes and 68,500 missed diabetes diagnoses, which in turn delays the advice and treatment that can prevent people from developing the condition or support them to live well[i].
2.3. Routine GP appointments and NHS health checks have continued to be disrupted throughout 2021, so we are concerned that the number of people living with undiagnosed type 2 diabetes is continuing to rise.
3.1. The funding announced in the Government’s plan for health and social care is targeted at elective care recovery. This has resulted in insufficient political priority and focus being given to the urgent need to tackle the backlog in routine care, especially for those living with or at risk of long-term conditions.
3.2. Further, the recent decision to suspend the Quality and Outcome Framework (QOF) for general practice and the Investment and Impact Fund (IIF) for Primary Care Networks for the remainder of 2021/2022 is of great concern. Diabetes UK is concerned that removing these incentivisation schemes which support delivery of quality routine care for people living with long term conditions, such as diabetes, risks leaving people with diabetes without access to the necessary care and support to stay well.
3.3. Diabetes UK understands the importance of the Covid-19 vaccination programme and applauds the NHS for its successful rollout. However, we are disappointed that there has been not been sufficient political focus and capacity planning to ensure that rollout of the booster programme takes place alongside recovery of routine care.
3.4. We call on the Government and local health system leaders to urgently set out how routine care for people living with or at risk of long-term care will be prioritised following the rollout of the booster vaccination programme. In the meantime, it is paramount that local health leaders ensure those most in need are able to access care, now and in the future.
3.5. People who are living with diabetes need regular checks to monitor their condition and to enable their healthcare teams to optimise their support and treatments. These checks are also essential to make sure that any complications are detected at the earliest stage, often before they are visible. There are eight care processes that NICE recommends everyone with diabetes receives regularly, most of these are annual.
3.6. Worryingly, last year, 2.26 million people with type 2 diabetes and more than 200,000 with type 1 did not have their usual consultations. 1.4 million monitoring blood tests in people with diabetes were also missed nationally, including over 500,000 in people with high blood glucose levels[ii].
3.7. Data from the National Diabetes Audit shows that across England there was a significant reduction in people with type 1 diabetes (-37.5%) and type 2 diabetes (-40.8%) who received all eight care processes during January to December 2020 compared to the same period in the previous year.
3.8. However, the size of the backlog in care processes varies significantly across the UK. There was significant regional variation for type 1, ranging from a decrease of 29.0% in London to a decrease of 46.7% in the North West. There was also significant regional variation for type 2 diabetes, ranging from a decrease of 32.7% in London to a decrease of 49.5% in the North West. In addition, there was significant CCG level variation in the percentage change[iii].
3.9. The backlog in diabetes care also risks further entrenching health inequalities, as those from disadvantaged backgrounds are less likely to have received sufficient care throughout the pandemic. There was a stark difference in the proportion of people who received the eight care processes according to deprivation: for the most deprived quintile (IMD1) compared to the least deprived quintile (IMD5) there was a difference of 8.8%. Efforts to manage the backlog must take into account and address these inequalities.
3.10. NHS England should support and direct Integrated Care Systems (ICS) to use available data and tools to prioritise delivery of routine diabetes care services and catch up on the backlog of appointments caused by coronavirus to avoid the potential serious consequences of missed appointments, checks and treatment and missed diagnoses of type 2 diabetes. ICS leaders should ensure support is targeted to those in greatest need and should be required to report on progress by the end of 2022.
4.1. The Government has pledged to open 40 new community diagnostic centres in England, with the aim of giving more patients access to earlier diagnostic tests[iv]. Clarity is now needed about what tests will be available through the centres and the role they will play in diagnosing type 2 diabetes or those at high risk of the condition.
4.2. Integrated Care Systems (ICS) should explore how diagnostic hubs can be used to support catching up on appointments for diabetes reviews by conducting blood tests and other checks.
5.1. The NHS workforce has endured incredible challenges over the last 21 months, working tirelessly to deliver care in unprecedented circumstances. Supporting, retaining and developing the diabetes workforce is essential to overcoming the backlog and transforming care for the future. Investment is needed into the workforce across primary care, specialist and inpatient diabetes services, and mental health care. In order to meet rising demand, the workforce across all of these areas requires development and expansion to improve outcomes for people with diabetes, and in turn reduce the impact that dealing with devastating and costly complications has on the NHS.
5.2. The NHS Staff Survey 2020 painted a picture of burnt out, stressed staff, with nearly half (44%) of staff reporting feeling unwell as a result of work-related stress in the past 12 months and almost one in five (18%) saying that they are considering leaving the health service[v]. A report on NHS and social care workforce published in June 2021 highlighted though that while coronavirus had a huge impact on workforce pressures, staff shortages were an issue before the pandemic[vi]. Investment in staff wellbeing must therefore be a priority within the plans to address the backlog.
5.3. Alongside other health organisations, Diabetes UK supports an amendment to the Health and Care Bill, to require the Government to publish independently verified assessments every two years of current and future workforce numbers required to deliver care to the population in England. Long-term workforce planning is essential in building a system that works for people with diabetes, transforming the healthcare landscape and ultimately reducing the strain on the NHS and its staff.
6.1. Diabetes technology
6.1.1. As health system leaders look to innovate and transform services to tackle the backlog, technology must be seen as a key part of this. We saw the use of Covid Oximetry @home in response to Covid-19 which improved care for patients and was welcomed by healthcare professionals, and we must work to identify other healthcare technologies that can build on this innovation and help tackle the backlog.
6.1.2. Financial investment is needed to make diabetes technology available to everyone who could benefit from it. Diabetes technology makes the day-to-day management of diabetes easier for many and enables healthcare professionals to deliver more high-quality care, including for remote consultations. Although face-to-face appointments will always be needed for some, diabetes technology-enabled remote consultations could help support local systems as they tackle the backlog, without having to compromise on quality of care.
6.1.3. Throughout the pandemic, people’s access to care and support from their diabetes healthcare teams has been understandably limited, meaning their ability to effectively self-manage their condition has been more important than ever. Use of diabetes technology has proved invaluable for people with diabetes who have access to it and local health care teams during the pandemic, with 84% of people who use technology agreeing that it helped self-management of their condition during the pandemic. Three quarters (76%) also agreed technology improved their wellbeing and 56% agreed technology made remote consultations easier.
6.1.4. Healthcare professionals working in type 1 diabetes care where people with diabetes have been using technologies like Flash and CGM, have been able to deliver a higher quality of remote care by monitoring issues such as HbA1c and time in range. This in turn allows them to provide more tailored support to people with diabetes. Data from these devices, which can be accessed remotely, has also allowed diabetes teams to effectively risk-stratify their patients, meaning those most in need of appointments are identified and offered the support they need.
6.1.5. Additional funding for diabetes technology would enable more people to benefit from greater control and reduce the burden on NHS services as they work to clear the backlog. The Government should provide ring-fenced budgets to local health commissioners, to continue to improve the uptake of existing technologies and enable access to new diabetes technologies for all children, young people and adults with diabetes to help management of blood glucose.
6.1.6. NICE recently published draft guidance that recommends that all people living with type 1 and some people with type 2 diabetes could have access to Flash and CGM[vii]. We welcome this as a huge step forward in utilising the technology available to transform lives, but now the Government should support local health systems to adopt these NICE recommendations by providing ring-fenced funding.
6.2. NHS Diabetes Prevention Programme
6.2.1. Amongst people who are at high risk of developing type 2 diabetes, around half could have the onset of the condition delayed or prevented with the right kind of support. Investment in the NHS Diabetes Prevention Programme (NHS DPP) in recent years has supported thousands of people to take action to reduce their risk. We must continue to build on the successes of the programme and not lose momentum, with a focus on increasing access to communities not being reached currently.
6.2.2. While face-to-face services and access to GPs for blood tests were disrupted during the pandemic, the NHS DPP adapted its referral pathway, improving access through online, remote and digital routes, by enabling people to self-refer onto the programme. Barriers to accessing GP services persist, so these routes, which remove the need for a GP referral are an important tool to expediate access to the programme and save GP’s time. Investment in the NHS DPP should support innovation to enable the programme to reach more people, particularly those who are currently least likely to access the service.
7.1. The backlog in diabetes care risks storing up significant problems for the future if people are left without the support and vital checks that they need to manage their condition. Preventing complications from diabetes and supporting people to maintain good mental health is essential not just for people living with the condition, but also to relieve the burden and cost on the NHS.
[i] D. Holland et al., Assessment of the effect of the COVID-19 pandemic on HbA1c testing: implications for diabetes management and diagnosis, EASD abstract 30, accessed here.
[ii] D. Holland et al., Assessment of the effect of the COVID-19 pandemic on HbA1c testing: implications for diabetes management and diagnosis, EASD abstract 30, accessed here.
[iii] NHS Digital (2021), National Diabetes Audit – Care Processes and Treatment Targets 3rd Quarter January–December 2020.
[iv] 40 community diagnostic centres launching across England - GOV.UK (www.gov.uk)
[v] NHS England (2021), NHS Staff Survey 2020.
[vi] Health and Social Care Select Committee (2021), Workforce burnout and resilience in the NHS and social care.
[vii] Consultation | Type 1 diabetes in adults: diagnosis and management – glucose monitoring and diagnosis | Guidance | NICE