GPs must be incentivised through the QOF if they are to slow a diabetes epidemic
Dr Alan Begg, a GP and co-editor of Practical Diabetes, warns that waves of new diagnoses will overwhelm the NHS unless general practitioners are appropriately funded through the QOF.
The prevention of diabetes must be included as a priority in the QOF to prevent a possible epidemic of type 2 diabetes in the UK. In 2011, there were estimated to be 366 million people with diabetes worldwide, and this is projected to rise to 552 million in 2030. In recent years, the number of patients with diabetes in the UK has risen from 1.4 million in 1996 to a current level of 2.9 million. A recent estimate has put the number in England alone at 3.1 million, but with as many as a quarter undiagnosed.
There is a variation in prevalence across the devolved nations, from 3.8% in Northern Ireland to 5.5% in England. The Scottish QOF prevalence rate is given as 4.3%, which although also increasing rapidly is lower than expected given the characteristics of the population – but this may be due to incomplete data collection.
The age-standardised prevalence is also higher in males and in more deprived communities, with the risk of developing type 2 diabetes in Scotland being 77% higher in deprived communities compared with the more affluent areas. Those with diabetes have an unacceptably higher level of morbidity and mortality, which includes a significant increase in the risk of a cardiovascular event. Any approach to preventing the onset of diabetes needs to be welcomed.
A recent report from the Primary Care Diabetes Society (PCDS) has proposed incentivising GPs through the QOF to keep a register of those with pre-diabetes – defined as those with impaired fasting glycaemia or impaired glucose tolerance – and providing those patients at high risk with the necessary plans to prevent or delay the onset of diabetes.
The recently published NICE guideline on preventing type 2 diabetes proposed GPs should use a validated, computer-based risk assessment tool to identify patients at high risk of diabetes, take a blood sample in those likely to be at high risk and, once identified, ensure an intensive lifestyle-change programme with annual review. However, this guideline is – like many others – probably going to gather dust unless an imaginative approach is taken with proper funding, which the QOF can offer and GPs can deliver.
The NICE guideline group sees its proposals for GP action as part of a multifaceted approach involving other professionals, and complimenting the work of the NHS Health Check in England. Any action to address diabetes risk needs to be seen in the context of addressing cardiovascular risk, and at present there is provision scattered across a variety of categories in the QOF. Using a targeted approach to high-priority groups rather than introducing a nationwide population-based screening, the approach is fragmented and the new NICE guidance will add to this fragmentation.
It is accepted that, as a nation, we are becoming more obese – yet the total energy from fat and sugar has reduced in the UK since 1975, with increased consumption of fresh fruit despite the reduction in fresh vegetables. The percentage of children meeting the recommended physical activity levels has changed little between 2002 and 2007, and the gradient for all factors between those in different socioeconomic groups favours the better off.
We know that a range of lifestyle interventions can produce improvement, but as we have seen from a recent evaluation of a diabetes education programme any benefit is short lived unless there is long-term reinforcement. These days, we also have commercial pressures to contend with – for example, consider the main sponsors of the 2012 Olympic Games.
In fairness, the NICE development group has highlighted the difficulties associated with implementation of their recommendations and the relatively low level of evidence for their approach. For instance, it mentioned the confusion on whether to measure blood glucose levels or HbA1c to signify impaired glucose regulation and increased risk.
Those at higher risk in deprived communities are often difficult to reach and engage with, so why not give the resources to primary care to see if it can do better?
The annual drug cost of treating diabetes is currently over £700m and rising fast. More controversially, NICE recommends the use of unlicensed metformin – as well as orlistat – for certain categories that appear to be progressing towards becoming diabetic despite intensive lifestyle change.
GPs may be reluctant to use this therapeutic approach, which is no surprise considering there will be additional work involved in monitoring and managing any side-effects. The regulatory authorities need to encourage public funding for a licensing trial of metformin. Type 2 diabetes currently costs the NHS £8.8bn a year, so if it helps prevent diabetes and its effects perhaps we need to consider prescribing it for this purpose.
Commissioners working in the current financial climate may not yet see prevention as a top priority, but considering the eventual cost to the nation can we afford not to make every effort to prevent diabetes and cardiovascular disease?
Giving adequate resources to primary care would be the most cost-effective approach to preventing diabetes and reducing the cost of the disease to society.
Dr Alan Begg is a GP in Montrose, Scotland, and co-editor of Practical Diabetes