FUTURE REQUIREMENTS FOR DIABETES SERVICES IN HIGHLAND AS A MODEL OF A LONG TERM CONDITION

Report by Dr Roderick Harvey and Dr Gerry Baptist, Lead Clinicians for the NHS Highland Diabetes MCN

The Board is asked to:
·  Note the predicted significant increase in the numbers of people with diabetes in Highland over the next ten years
·  Recognise the cost and service implications of the growth in the diabetic population, and the potential for future savings by appropriate investment now.
·  Understand the model for effective delivery of diabetes care in line with Delivering for Health which is aimed at maintaining health and preventing complications.
·  Appreciate that this model of care can be applied to the management of other long term conditions.

1 Background and Summary

Diabetes mellitus is a long term condition characterised by elevated blood glucose levels as a result of the deficiency of insulin or resistance to its action, and is associated with increased risks of coronary heart disease, stroke and peripheral arterial disease as well as specific complications affecting the eyes, kidneys and nervous system that can lead to blindness, kidney failure, and lower limb amputation.

Diabetes is a major and increasing health problem in all age groups in Scotland. Type 2 diabetes, in particular, is a growing problem with a rapidly increasing prevalence due to the ageing population and the increasing prevalence of obesity.

Diabetes is still the commonest cause of blindness in the working population. Twenty to twenty five percent of patients entering end-stage renal failure replacement programmes have diabetes. Foot problems are the commonest cause of admission to hospital in patients with diabetes who have a 15-20 fold increased risk of amputation. The life expectancy of a patient with type 2 diabetes is reduced by 8-10 years, and atherosclerotic vascular disease, especially coronary artery disease and stroke, is the principal cause of death in about 70% of these patients.

As with the management of most long term conditions, the majority of care for people with diabetes could be provided locally within primary care provided that adequate resources in terms of personnel and support services were available. Under this arrangement people with more complex needs would access specialist services on a needs basis in line with the principles of Delivering for Health. The aim of modern diabetes management is to target multiple risk factors prospectively with the aim of preventing the long term morbid (and costly) complications of diabetes, a policy for which there is now a robust evidence base.

In NHS Highland 34 people per thousand currently have diabetes with the population distribution skewed markedly to the elderly age group. Based on predicted changes in the population over the next decade the total number of people with diabetes is expected to increase by 17%, a figure that is certain to be an underestimate as it takes no account of the increasing trend in obesity.

The identifiable annual cost of the provision of care to people with diabetes in Highland directly attributable to the diagnosis is £18.4 million, although the true cost is believed to be higher. Of this sum £8.5 million is spent on the treatment of the potentially avoidable long term complications of diabetes. The cost of care for diabetes, excluding inflation, is predicted to rise by at least 19% over the next decade.

2 Growth prediction in diabetic population

The diabetic population in NHS Highland is now well documented through the SCI-DC register which is continuously updated through automatic extraction from primary care records and a link to the community health index. Detailed and accurate information from SCI-DC on the age, sex and locality prevalence of diabetes is available for all CHP areas other than Argyll and Bute. Estimates for Argyll and Bute have been made on the basis of known population demographics and the actual ascertained age and sex specific prevalence rates for the remainder of the NHS Highland Board region.

The total number of people with diabetes in Highland at the end of March 2007 was 11,111, giving an overall prevalence of diabetes of 3.4% but as can be seen from Figure 1 the distribution is skewed markedly to the middle aged and elderly age groups with prevalence rates as high as 12% in people in their eighth decade.

Figure 1 Total numbers of people with diabetes and prevalence in Highland by age band

There are two major drivers to an inevitable increase in the diabetic population over the next decade; demographic changes with an ageing population and the expected increase in obesity that is closely linked to the risk of developing Type 2 diabetes (47% of people with diabetes in Highland are obese – body mass index ≥ 30)

Using the current age sex prevalence of diabetes in Highland and population projections based on the GROS 2004, predictions for numbers of people with diabetes by locality can be made, though these are almost certainly an underestimate as no account is taken of increasing trends in obesity.

Figure 2 shows the predicted percentage increase in the diabetic population between 2007 and 2017 by local health partnership excluding any effect of obesity. There is a significant variation in the predicted growth rates across the localities, with those areas with the lowest current prevalence showing the highest growth, but the overall increase is 17%.

Figure 2

3  Financial burden of diabetes and implications of predicted growth

People with diabetes use a disproportionate amount of resource. Diabetes patients have increased rates of admission, an increased inpatient average length of stay and an increased rate of outpatient attendances for all causes. In Highland, 9% of hospital admissions, 12% of bed days and 10% of outpatient attendances are by people with diabetes.

Admissions and outpatient attendances for people with diabetes cost £26.9m; about 53% of this (£14.2m) is greater than would be expected if the patients did not have diabetes - this is termed excess cost – see Figure 3 below.

Figure 3

Sixty percent of the excess cost of acute care (£8.5 million) is attributable to the management of the complications of diabetes such as coronary heart disease and stroke, renal failure, ketoacidosis, lower limb amputations and retinopathy.

The attributable cost of providing diabetes care and surveillance in the community is £4.2 million. This is known to be an underestimate as it has not been possible to identify costs for drugs and other aspects of care not exclusively provided for diabetes.

The current total cost therefore directly attributable to diabetes in Highland is £18.4 million. This cost is projected to increase by at least 19% (£3.6 million) over the next ten years due to demographic changes alone (excluding effects of obesity trends) as shown in Figure 4 below.

Figure 4

Prediction for the growth of diabetes prevalence elsewhere in the UK indicates likely prevalence rates of 5% by 2010 taking into account expected trends in obesity. It is certain therefore that the above growth figures for cost increases in Highland represent a significant underestimate and a more likely figure would be an increase in cost of £6m.

4  Model for delivery of effective diabetes care

In common with other long term conditions effective diabetes care requires education to empower self care and regular prospective dedicated clinical review. In the case of diabetes the purpose of the clinical review is to monitor and optimise the control of blood glucose, blood pressure, cholesterol and kidney function, review lifestyle factors including smoking, diet and exercise, and provide systematic screening for the long term complications of the disease.

For the majority of patients it is possible to provide this intrinsically “low tech” care for both newly diagnosed and established patients in a local primary care setting provided that appropriately trained health professionals are resourced with adequate time and access to support services such as dietetics, podiatry and specialist nursing.

This is the strategy that the Diabetes Managed Clinical Network (MCN) has hitherto been endeavouring to follow in the three CHP areas other than Argyll and Bute[1] through the following

·  Guideline development

·  Education and Training

·  The development of a Locally Enhanced Service under the GMS contract

·  The provision of an area wide quality assured diabetic retinopathy screening service.

The role of specialist hospital based diabetes services will increasingly become divided between direct patient care for people with complex needs and the provision of education and remote support for front line practitioners within the community. Some patients with more complex needs as a result of either their type of diabetes, circumstances or the development of longer term complications will still undoubtedly need access to hospital based diabetes services. Effective and efficient care will allow patients to access these specialist services on a seamless needs basis, whilst retaining the management of the majority of patients within primary care.

This overall strategy is in line with the principles of Delivering for Health, provides a model for the management of other long term conditions and is compatible with the requirements of the long term conditions toolkit.

There is extensive evidence that scrupulous attention to metabolic and blood pressure control through lifestyle and drug interventions can reduce the risk of the development of both the macrovascular (stroke, CHD and peripheral arterial disease) and diabetes specific (retinopathy, neuropathy and kidney disease) complications of diabetes by between 30% and 50% (SIGN 55). As discussed above, the management of these complications account for more than half of the total current attributable cost of the care of people with diabetes in Highland.

Proper resourcing of an effective quality assured and organised preventative care programme for people with diabetes would therefore provide not only improved health and outcomes for patients, but also the potential for substantial downstream savings on the costs of more intensive treatment and the management of the morbid complications of diabetes that would otherwise inevitably be incurred.

Contribution to Board Objectives

Health Improvement / By emphasising the need to prevent complications of diabetes through the application of current knowledge, and the promotion of healthy lifestyle, the life expectancy and quality of health for this group of people will be increased.
Efficiency / By using a range of appropriately trained health professionals to deliver diabetes care this model can make best use of available resources. By aiming to reduce the incidence of costly long term complications of diabetes this model is both effective in terms of health gain and efficient in use of financial resource.
Access to services / This model promotes delivery of care close to home for as long as possible whilst avoiding compromise on the quality of care
Treatment / Improved standards of care, tailored to individual needs can be assured through the requirements of the Locally Enhanced Service for Diabetes, the on line availability of guidelines, staff training and access to specialist support services including retinopathy screening.

5  Governance Implications

In terms of staff governance, effective delivery of the service will reduce sickness absence due to complications of diabetes in an increasingly older workforce.

Patient and public involvement continues through charities such as the local groups of Diabetes UK.

The model of service described is best practice within the frame work of Delivering for Health, via a managed clinical network spanning the whole spectrum of care with an emphasis on preventative intervention and will provide improved health and outcomes for patients.

The financial impact is twofold. The development of this model of service delivery needs to properly resourced, but it has the potential for substantial downstream savings on the costs of more intensive treatment for the management of the morbid complications of diabetes that would otherwise inevitably be incurred.

6  Impact Assessment

Although an in-depth equality and diversity impact assessment has not been done, this model of service delivery should improve access and quality of care for people with complex needs due to diabetes. Monitoring of the service will include the development of patient and public involvement.

Dr Roderick Harvey and Dr Gerry Baptist

Lead Clinicians, NHS Highland Diabetes MCN

25 May 2007

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[1] Services for Argyll and Bute are currently organised separately, with MCN services, retinopathy screening and secondary care hospital diabetes services being provided through an SLA with NHS Greater Glasgow and Clyde, and there being no Locally Enhanced Service in that CHP area.