INTRODUCTION

  1.  Diabetes UK welcomes the Health Select Committee's inquiry into the contribution of the NHS to reducing health inequalities and the opportunity to have some input.

  2.  Our submission focuses on Diabetes UK knowledge and experience in four areas:

—  The extent to which the NHS can contribute to reducing health inequalities,

—  The quality of GP services and how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality of GP services to reduce health inequalities.

—  Effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity.

—  The effectiveness of the Department of Health in co-coordinating policy with other government departments, in order to meet its Public Service Agreement targets for reducing inequalities; and whether the Government is likely to meet its Public Service Agreement targets in respect of health inequalities.

ABOUT DIABETES UK

  3.  Diabetes UK is one of Europe's largest patient organizations. We are a major funder of research in both Type 1 and Type 2 diabetes with plans to spend £7.38 million in 2008. Our mission is to improve the lives of people with diabetes and to work towards a future without diabetes through, care, research and campaigning. With a membership of over 175,000 and over 6000 health care professionals, Diabetes UK is an active and representative voice of people living with diabetes in the UK.

THE EXTENT TO WHICH THE NHS CAN CONTRIBUTE TO REDUCING HEALTH INEQUALITIES

  4.  While poverty, unemployment and bad housing etc. are a major cause of the differences in health status and life expectancy, lack of access to good quality care is a critical factor in the persistence of health inequality. It is still the case that those in the greatest need for healthcare are still least likely to get it, as responses to this challenge remain consistently piece-meal and short sighted.

  5.  The most striking inequality is the almost universal tendency for people in lower socioeconomic groups to die younger and to suffer more illness during their lifetime compared to those in higher socioeconomic groups. These socioeconomic disparities cannot readily be dismissed as biological facts or historical inevitabilities, which mean most health inequalities point to a failure of national and local policy, planning and delivery of services including health.

  6.  Diabetes is a long term condition which is particularly illustrative of failures in provision which could help prevent Type 2 diabetes as well prevent, delay or reduce the seriousness of complications of Type 1 and Type 2 diabetes. The numbers diagnosed with diabetes are expected to reach over 3 million by 2010; around half of these will be people from disadvantaged communities. In fact the most deprived in the UK are 2.5 times more likely to have diabetes (in the North East of England the prevalence of diabetes is 45% higher in women and 28% higher in men than the national average). Also alarming is that complications of diabetes such as heart disease, stroke and kidney damage are three and a half times higher among lower socio economic groups. And those who are least well educated are more likely to have retinopathy, (diabetes is the leading cause of blindness in the working age population), heart disease and poor diabetes control.[300]

  7.  Alongside this evidence, many studies of specific NHS services, yield strong evidence that lower socio-economic groups access health services less in relation to need than higher ones.[301] Research shows that there are two distinct disadvantages that lower socio-economic groups experience: problems with making initial contact with the health service, and problems once contact has been established. Compared to higher socioeconomic groups, when ill, those in lower groups either tend to not go to the doctor at all, or present at a later stage with their condition, they often go to accident and emergency departments instead of GP surgeries; and when well, they tend not to access prevention services. When they do establish contact with services, lower socioeconomic groups have lower rates of referral to secondary and tertiary care, lower rates of intervention relative to need, and lower and irregular attendance at chronic disease management clinics, this includes diabetic clinics and diabetes reviews.[302]

  8.  Tackling this unfairness means changing the attitudes of commissioners, providers and health professionals to be more locally engaged and creative in the design and delivery of services. It also means building the capacity of local people to access and use health services, and their own ability to manage their health and well-being. Given the evidence that people in deprived areas are often reluctant to visit their GPs, it is incumbent on PCTs to identify these groups understand why they do not access traditional care and tailor services accordingly. This could mean using community nurses and pharmacists, offering services over the phone or in shopping centres and working with voluntary organisations as well as those in social care.

  9.  However findings from the Healthcare Commission published in Dec 2007 reveal that many PCTs do not fully understand the health needs of their local people, making it difficult for them to commission responsive services.[303] This means important provisions for diabetes prevention and management of the condition are not being made. Eighty five per cent of PCTs did not have arrangements for providing education programmes for patients with diabetes in their area, and 2,000 GP practices did not fulfill their PCT's plans to establish registers for people at risk of coronary heart disease (a complication of diabetes as well as a risk factor). In addition, 2.3 million people did not have their BMI index recorded as planned, with GPs not recording the data, which provides vital statistics on levels of obesity, another risk factor for diabetes.[304]

  10.  Diabetes education programmes are vital because 95 per cent of diabetes care is via self management, yet previous work by the Healthcare Commission shows that only 11 per cent of patients have received an education programme. In addition, four out of five people with Type 2 diabetes are overweight, so it's critical that BMI measurements are recorded. It is unacceptable that around a quarter of GP practices are failing to establish registers for those at risk of coronary heart disease which affects 80 per cent of people with diabetes.

  11.  These problems are magnified in socially deprived areas where there is a higher incidence rate of diabetes, and the most vulnerable are even less likely to get the diabetes support they need- with 18 per cent fewer GPs than in the least deprived areas.

  12.  In view of this, Diabetes UK greatly welcomes the Prime Minister's announcement that there will be monitoring/screening for heart disease, strokes, diabetes and kidney disease—conditions which affect the lives of 6.2 million people, cause 200,000 deaths each year and account for a fifth of all hospital admissions and also stronger sanctions against poor performance.

  13.  Diabetes UK has been calling for many years for programmes for the early identification of people with Type 2 diabetes early. People can remain undiagnosed with the condition for up to 12 years, so screening is vital to ensure appropriate diabetes care and treatment. There are upto 750,000 people in the UK who have Type 2 diabetes but are unaware.. Targeted screening programmes will go a long way towards reducing the devastating and costly diabetes-related complications of coronary heart disease, kidney disease, blindness, stroke and amputations."

  14.  Diabetes UK is aware of some pockets of good practice around the country. Slough PCT identified a growing diabetes problem in the community and developed the "Action Diabetes" project. The project identified a significant number of people with undiagnosed diabetes, raised the profile of the condition and strengthened links with Asian communities. Since the project launch in Oct. 2004, diabetes referrals have increased by 164%.

THE QUALITY OF GP SERVICES AND HOW THE QUALITY AND OUTCOMES FRAMEWORK AND PRACTICE-BASED COMMISSIONING MIGHT BE USED TO IMPROVE THE QUALITY OF GP SERVICES TO REDUCE HEALTH INEQUALITIES.

  15.  Implementation of the Quality and Outcomes Framework (QOF) has resulted in a very welcome increase in the monitoring of patients, especially those with Type 2 diabetes. At the same time though introduction of the QOF has managed to undermine real quality patient-centred care, and done little if anything to address inequalities.

  16.  The Quality and Outcomes Framework (QOF) is essentially a payment mechanism for clinical activities and processes. Thus it concentrates on tasks that are easily measurable giving the QOF a narrow remit, largely ignoring outcomes and patient focused elements of quality care such as information, education and empowerment which are deemed important by patients and the National Service Frameworks. The QOF is fundamentally a medical model of service delivery which is not built to deliver individual and holistic care. Clearly then there is a need for balance between a medical model and a patient-centred model which encourages patient engagement and self-care, and ultimately better health outcomes for the patient.

  17.  QOF points allocated to indicators should prioritise outcome measures, rather than process measures. The number of points awarded for "process targets" should be reduced and the number of points awarded for outcome targets should increase proportionally. Since nearly all GPs are reporting over 75% achievement of process measures, the points should be reallocated to outcome measures that are more challenging to achieve. For instance a higher proportion of people with diabetes should be achieving tighter management targets for HbA1c, blood pressure and cholesterol. Furthermore, thresholds for all diabetes indicators should be reviewed and increased to encourage those practices achieving the lower range of the threshold to focus on delivering better services to people with diabetes.

  18.  The submission of evidence within the QOF review process is very clinically focused with a bias towards Randomised Controlled Trials. While the results of such trials are of significant value, the process does not allow for qualitative evidence to feed into the process. Patient feedback and qualitative evidence have a role to play in influencing the development and quality of indicators that are evidence based and patient centred.

  19.  Diabetes UK has also received concerns from people with diabetes and professionals working within diabetes care about exception coding. We are concerned about the delivery of care for people with diabetes who are exception coded. Mechanisms need to be in place to ensure that that those who are excluded, for instance those within residential homes, have access to the care they need.

  20.  Presently the QOF does not encourage practices to support vulnerable patients, eg housebound patients, or those in residential care. Analysis shows that some practitioners are using exclusions to ensure that targets are achieved. Although exception reporting is not extensive, it has been identified is a strong predictor of achievement—with 1 per cent of practices excluding more than 15 per cent of patients. Further analysis of the impact of exception reporting on health outcomes and inequalities is required. The level, range and reasons why people are exception reported needs to be examined to identify the impact on patient outcomes. Diabetes UK is currently examining the varying levels of exception coding.

  21.  The QOF also does not encourage the proactive driving of health improvements. In the case of diabetes there is no incentive for a practice to develop register of those patients at risk of diabetes. An "at risk register" would target early on those people at risk of diabetes, thereby reducing their risk of further serious complications.

  22.  Another concern we currently have is the commissioning and co-ordination of diabetes care. Overtime most diabetes patients move between primary and secondary care according to their needs and the nature of their complications. Presently though "downsizing" of some specialist units by local primary care trusts, in line with the government's desire to transfer most, if not all of chronic disease management from secondary to primary care has begun to see a decline in recruitment into the specialty and many unfilled consultant posts. If as a result specialist services are lost or increasingly fragmented then it will be difficult to recreate them. Without competent professionals general practitioners and primary care will be left unsupported and access to specialists for patients with complicated diabetes related problems will be reduced, undoubtedly hitting the most disadvantaged groups the hardest. In theory, practice based commissioning could help to structure and coordinate services to deliver responsive patient-centred care, ensuring that only services that can be safely transferred to primary care do so, and the competence of staff providing these services is assured. However we presently have no evidence to support this theory, and we do have concerns about the capability of GP practices to undertake complex commissioning, as we do of current PCT commissioning.

  23.  Finally then mechanisms such as QOF, Practice Based Commissioning and Payment by Results need to work together, to produce an integrated system for monitoring and rewarding quality across the entire network of care provision. This is essential for a creating a system of care that is coordinated and designed around the needs of patients.

EFFECTIVENESS OF PUBLIC HEALTH SERVICES AT REDUCING INEQUALITIES BY TARGETING KEY CAUSES SUCH AS SMOKING AND OBESITY.

  24.  People in lower socio economic groups are 50% more likely to smoke than those on

 the higher socio-economic groups. Obesity is nearly 50% higher amongst women in lower socio economic groups. Deprivation is strongly associated with higher levels of obesity, physical inactivity and unhealthy diet, smoking and poor blood pressure control. All these factors put people at high risk of diabetes as well as serious risk of crippling complications amongst those already diagnosed with diabetes.[305] Therefore targeting key causes of ill-health such as smoking and obesity is a long overdue and a very much welcome move.

  25.  It is estimated that diabetes represents 9% of hospital costs. Diabetes increases by five the chance of a person needing hospital admission. Drugs used in diabetes are the second biggest cost on the national drugs bill, between 2004 and 2005 costs of drugs used in diabetes grew by 11% and items prescribed by 10%. Diabetes deaths already number over 30,000 in the UK and this figure is set to increase by 25 per cent by 2015. We know that adopting a healthy diet and increasing physical activity could prevent 80 per cent of Type 2 diabetes.

  26.  Furthermore work by the Strategy Unit reveals that in 2002 the cost of people being obese and overweight in England was estimated at nearly £7 billion including direct treatment costs, state benefits and loss of earnings. Obesity rates have trebled in the past 20 years and it is expected that 60 per cent of Britons will be obese by 2050. The Strategy Unit report says boosting fruit and vegetable consumption to the recommended five pieces per day could cut 42,000 premature deaths each year.[306]

  27.  The health and well-being of the next generation is a concern for all of society. Evidence of increase in childhood obesity and early onset of Type 2 diabetes demands tighter controls on the marketing of unhealthy foods to children, alongside building the capacity of children to understand food and health. Therefore Diabetes UK wants to see:

—  The introduction of a 9pm watershed for junk food television adverts

—  The introduction of statutory controls to reduce children's exposure to other junk food marketing, particularly online and via mobile phones

—  Making food skills, including cookery a compulsory part of the national curriculum, so that every child leaves school knowing how to make nutritious meals

—  Support the Food Standards Agency's traffic light labelling model by accelerating the process of making it a legal requirement (which means working with other EU countries)

  28.  With regard to smoking Diabetes UK welocmes the introduction of the new law on 1st July 2007 making virtually all enclosed public places and workplaces in England smokefree. A smokefree England ensures a healthier environment, so everyone can socialise, relax, travel, shop and work free from secondhand smoke.

  29.  Effective tobacco control measures are required to reduce the damage caused to people who smoke, but also children who are exposed to second hand smoke. The impact of smoking on the development and progression of micro vascular complications of diabetes is profound. In men who smoke the risk of developing diabetes alone is doubled. In women who smoke 25 cigarettes or more a day the risk of developing diabetes is increased by 40 per cent.[307]

  30.  Smokers with diabetes are at greater risk of developing the devastating complications of diabetes They are more likely to die of cardiovascular disease than their non-smoking counterparts. In combination with diabetes smoking greatly enhances the likelihood of premature mortality.

THE EFFECTIVENESS OF THE DEPARTMENT OF HEALTH IN CO-COORDINATING POLICY WITH OTHER GOVERNMENT DEPARTMENTS, IN ORDER TO MEET ITS PUBLIC SERVICE AGREEMENT TARGETS FOR REDUCING INEQUALITIES; AND WHETHER THE GOVERNMENT IS LIKELY TO MEET ITS PUBLIC SERVICE AGREEMENT TARGETS IN RESPECT OF HEALTH INEQUALITIES.

  31.  The Department of Health has made great strides in seeking to co-ordinate policy with many other government departments in relation to health and health inequalities. It is also encouraging to see explicit focus on health inequalities—tackling smoking prevalence, supporting early identification of disease etc. However it is debatable whether Government will meet all of its targets in relation to health inequalities. In view of the scale of the challenge of deep rooted inequalities it is perhaps more important that the government identifies and seeks to apply the appropriate solutions rather than chase artificial targets. Taking the example of childhood obesity, it is refreshing to see that the Government is developing a comprehensive cross-departmental strategy on obesity, building on the evidence in the Foresight report.

  32.  Regard to the PSA target on childhood obesity we have noted that the original target has been altered. The target set in 2004 sought to halt the year-on-year rise in obesity among children under the age of 11 by 2010. In the 2007 Comprehensive Spending Review the target seeks to reduce the rate of increase in obesity among children under 11 as a first step towards a long-term national ambition by 2020 to reduce the proportion of overweight and obese children to 2000 levels in the context of tackling obesity across the population. It could be argued that moving the target to 2020 is an admission of defeat; on the other hand it could also be interpreted as a more realistic timeframe for meeting the challenge. As such while we cannot be 100 per cent confident that current or future Government will meet the target, we are confident that the current Government is committed to trying to do so. The evidence for this so far is:

—  the commitment to spend £225 million over the next three years to:

—  offer every local authority capital funding that would allow up to 3,500 playgrounds nationally to be rebuilt or renewed and made accessible to children with disabilities;

—  create 30 new adventure playgrounds for 8- to 13-year-olds in disadvantaged areas, supervised by trained staff;

—  To improve children's health the Government will:

—  publish a Child Health Strategy in spring 2008, produced jointly between the Department for Children, Schools and Families and the Department of Health; and publish a play strategy by summer 2008

—  The focus on obesity will be enhanced by the creation of a cross-Governmental Ministerial Group. A new joint Obesity Unit, supported by the Department for Children, Schools and Families and the Department of Health, is being established to tackle obesity.

January 2008

301   Dixon A, Le Grand J,Henderson J, Murray Richard, Poteliakhoff E, (2003) Is the NHS equitable? LSE Health and Social Care Discussion Paper 11. Back

302   Ibid. Back

303   Healthcare Commission (2007), State of Healthcare report. Back

304   Ibid. Back

305   All Parliamentary Group for Diabetes (2006), Diabetes and the disadvantaged: reducing health inequalities in the UK. Back

306   The Strategy Unit (2008) Food: an analysis of the issues, Cabinet Office. Back

307   International Diabetes Federation Bulletin, vol 43, No. 4/98. Back