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Huge variation in quality of diabetes care, audit finds

Huge variation in the standard of diabetes care has been revealed by the latest National Diabetes Audit (NDA), showing as few as one in five patients with diabetes are getting all of their NICE-recommended checks in some areas.

The data show 60% of UK patients with diabetes received all the NICE recommended care processes overall, but there was wide variation in the proportion receiving all the checks between CCGs, ranging from less than 20% of patients at the very bottom end of the scale to nearly 80% at the top.

The figures suggest the Government will struggle to achieve its goal of ensuring 80% of all diabetes patients receive all the annual checks by 2018.

The report, produced by the Health and Social Care Information Centre (HSCIC), called for poorer performing commissioners and providers to look at how top performers achieve their results and consider adopting new approaches to delivering care.

The latest NDA results include eight NICE recommended annual care processes instead of nine in previous years, as retinopathy screening has been excluded in this year’s analysis.

Over a third of patients with type 2 diabetes did not receive all the checks. The report also highlighted poor control of risk factors according to NICE targets, with 62% of patients with type 2 diabetes failing to achieve the NICE-recommended goal blood pressure level of 140/80 mmHg, or 130/80 mmHg in those with complications.

Over a third of type 2 patients did not achieve the NICE goal for glucose control of HbA1c levels of 58 mmol/mol or lower and nearly 60% did not achieve the cholesterol target of less than 4 mmol/L.

The data are at odds with the latest QOF performance data for diabetes, which showed practices achieved 96% of available points in the diabetes clinical area, although these include less stringent targets for risk factor control.

As in previous years, patients with type 1 diabetes generally received less good care than type 2 patients according to the audit measures, with only 43% having all their annual checks, three-quarters not achieving the NICE target for glucose control and four out of five patients not reaching the cholesterol target.

The HSCIC concluded there was ‘considerable scope’ for risk factor management and that better access to structured education should be a priority to help people with diabetes understand their condition better – only 12% of patients newly diagnosed with type 2 diabetes and 2% of those newly diagnosed with type 1 were offered some form of structured education.

The report stated: ‘Effective risk factor management is dependent on people with diabetes understanding what the risk factors are, what they can do to minimise their risks and what support they receive.

‘Therefore, the presently limited amount of structured education for people with recently diagnosed diabetes would seem to be a major missed opportunity.’

Professor Roger Gadsby, associate clinical professor at Warwick University and GP lead on the NDA, told Pulse: ‘This NDA report highlights the fact that there is marked geographical variation in the achievement of care processes across England.

‘The achievement is particularly lower in people with type 1 diabetes. We do need to commission more specific services for people with type 1 diabetes with easy and rapid access to integrated specialist care. This is an important message for CCG’s.”

He added: ‘Some QOF diabetes targets have historically been slightly above NICE guideline targets. As QOF targets move to NICE guideline targets any discrepancies between performance on the two measures should become closer and just reflect the differences in the populations being reported on.

‘NDA reports on everyone with diabetes and QOF reports on those 17 and over who are not excluded by the practice.’

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Dr Andrew Green, chair of the GPC’s prescribing subcommittee and GP in Hedon, East Yorkshire, said the audit illustrated how ‘challenging modern strict targets for blood pressure and blood sugars are’.

He said: ‘Along with the general population, the diabetic population are increasing in number, aging, often have multiple problems, and are all individuals with their own priorities, and this can make the meeting of all targets difficult

Dr Green said the regional variations were ‘unsurprising’ and a reflection of how ‘personal income, education and lifestyles varying greatly across the country’.

He said: ‘The most important immediate challenge is to bring the most disadvantaged areas up to the standard of the best, but this will require changes within society as a whole as well as the best efforts of GPs.

‘Above all, GPs need adequate time to manage diabetic care to a high standard, but recent years have seen general practice being required to take on more and more activities with little or no patient benefits, and with a steady reduction in the proportion of total NHS funding it receives.’

GP leaders previously questioned the validity of the NDA records, saying they underestimate performance which shows over 90% achievement of individual care process targets, after a row over poor results led the government to propose bundling QOF depression indicators to drive improved outcomes.

A Department of Health review concluded differences in read codes for key process indicators accounted for much of the disparity between QOF and NDA figures.

Health and Social Care Information Centre - National Diabetes Audit


Readers' comments (4)

  • The NDA is farcical! To achieve all 9 (or 8) processes people who have never smoked and are rightly regarded as recorded non smokers by QoF need to be recorded again every 12 months. QoF may be too lax but manipulating data like this for the NDA is a total waste of clinical time and has a large opportunity cost. People in this group are also more likely to achieve the other indicators than those whose continue to smoke. Down go the outcome figures!

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  • The trouble with QOF practice achievment % data is that some fools use it as public health data when all it really reflects is what GPs get paid. What I object to is that QOF practice payments data is freely available on the internet and is misinterpreted by other fools as representing "quality" when its nothing to do with quality its all about payments and rations.

    What is even sadder is the Council's Public Health folk who should no better are the master minds behind this daft internet setup with their "practice profiles"

    Sooner there is harder data like the National Diabetes Audit HbA1c data - rather than QOF acheivement % data affected by exception reporting the sooner we can demonstrate real changes - or otherwise to patient outcomes. QOF is the engine to drive the change - not the measure

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  • Nigel - If QoF is a measurement of what a GP is paid, it surely reflects the checks carried out by that GP/practice. Therefore, is it not reasonable to assume that those GPs not being paid for cetrain checks are the same GPs not carrying out those checks (because who would carry out a payable service and not claim for it?) and so there would appear to be a direct correlation between the Quality Outcomes Framework and level of care provided. Do you define "care" as "Please tell us when your foot drops off then we will look after you" - or have you not heard of preventative medicine?

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  • Forgive me if I'm stupid or just naive but surely there's little or no correlation between practices QOF scores and quality of care they are delivering?

    QOF is fine as regards paying GPs to look after their patients - my point is the data it produces is about paying GPs - its daft to pretend its anything else.

    With QOF its possible to score 100% of the points for practice diabetic patients HbA1c levels as being within target (when across the country and virtually ever practice they are not) by exeception reporting all those who's HbA1C's aren't in the range because they don't takes their tablets or attend your clinic so long as you've sent them 3 letters or whatever the game is - how's that = "preventive medicine"

    Its anything but "preventive"

    But its missing my point practice QOF data is about GPs pay - not statisical evidence of delivery of quality care/prevention.

    Until we start looking at the actual laboratory data or hard data measurements - cleaned of the exeception reporting pay and rations stuff - we are never going to be taken seriously by non GPs - other than our chums in Public Health who seem not to mind using QOF data

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