Diabetes is a problem – and emblematic of the challenges in health and care

Clear opportunities to improve local diabetes care have been missed - on a continuous basis – for the past 15 years, according to a Northern Ireland Audit Office (NIAO) report released this week.

In March 2003 a major review into tackling Type 2 diabetes identified a range of key areas which required improvement. Blueprint for Diabetes Care in Northern Ireland in the 21st Century was subsequently never implemented.

Selected aspects of that paper’s recommendations did inform what the Audit Office describes as the “certain degree of strategic priority” afforded to diabetes care since then. A full strategic framework was eventually published by the Department of Health, but not until 2016. Even taking that into account, the 2003 report itself could still, despite being a decade and a half old, be a “roadmap to provide the basis for a way forward for service development”, according to the NIAO.

Type 2 diabetes has since suffered an explosion in Northern Ireland:

• Since 2003 the number of people diagnosed with diabetes has increased by 70% (largely down to a surge in Type 2), to more than one in twenty of the population - with the total expected to reach 100,000 by 2020.
• Treating diabetes is estimated to cost Health and Social Care (HSC) £400m per year, which is about 10% of the overall budget.

The NIAO’s assessment is critical - but its recommendations are just as relevant as its observations of mistakes.

The difficulty and the necessity of reforming diabetes provision is a good example of the need for massive structural change in HSC, an indicator of some of the barriers to reform, and a case study in how the passage of time only makes matters more acute.

This, however, makes everything seem simple: reform is obviously needed, the evidence is clear, so just get on with it. In reality, it is far from straightforward.

NIAO conclusions

Kieran Donnelly, the Comptroller and Auditor General, said: “Type 2 diabetes is a matter of concern, both in terms of its impact on human life and its cost to the public purse. Already it is estimated that treating diabetes costs Northern Ireland £400 million annually. This is 10 per cent of the local healthcare budget and forecasts indicate this may rise to 17 per cent of Health spending by 2035. The projected growth of Type 2 diabetes creates a real risk that the current model of care provision will become unsustainable.

“A review of diabetes care in 2003 pointed the way towards adopting many areas of best practice. Whilst a number of initiatives aimed at enhancing diabetes care were subsequently introduced, I was disappointed to note that there was limited implementation of the 2003 review and that the Department did not introduce a comprehensive strategy until late 2016. This was clearly a missed opportunity to slow the growing prevalence of the disease, and to reduce the numbers of serious complications which can arise, including blindness and lower limb amputations.

“The current strategy offers potential to secure real improvements. However, for too long, the prevalence of the condition, the serious healthcare outcomes for people living with it, and the costs associated with treating it have been increasing unchecked.

“I can only conclude that to date value for money has not been achieved in delivering Type 2 diabetes services.”

Reading his comments is like playing bingo with the main themes of wider Transforming Your Care (TYC)/Donaldson/Bengoa-inspired health reform. Going through the NIAO report and associated commentary only makes these comparisons stronger.

Transforming Your Care

The Audit Office says prevention and early intervention should be central to any future diabetes provision – two things which are key pillars of wider health reform, along with having a system that operates as far as possible in the community and in the home. And, while diabetes is a condition which relies on self-care from individuals on a day-to-day basis, the Audit Office also said that “a significant number and proportion of people with Type 2 diabetes have not yet been offered access to patient self-management education”.

So, the strategic changes needed in diabetes care mirror what is required in HSC generally. The reasons behind this are similar too – rising demand, growing far faster than the current system can cope with, ultimately leading to unsustainability.

Poor workforce planning has also affected diabetes services.

Workforce planning, however, is difficult when a complete structural overhaul is on the cards (albeit, in the case of diabetes, this is not an excuse for the whole picture). Rather than simply maintaining existing staffing, with one eye on changes in demand, it needs to anticipate what a future system will look like.

This is only one difficulty for diabetes care, and for overhaul of HSC. There are others.

What to do

Mr Donnelly, the Comptroller and Auditor General, gets to the heart of the matter when he says that, “value for money has not been achieved.” Reconfiguration is about just that – addressing structural inefficiencies and building a better, and sustainable, service without a huge change in resources.

Calls for getting value for money from the public purse are normally well received. Not so much with healthcare, an understandably emotive area, where it can be heard as penny pinching over matters of life and death. The public prefers to hear about more investment.

This is one reason why the TYC/Donaldson/Bengoa reforms have stalled. Another is the opacity of such a massive reconfiguration.

Restructuring is about give and take but it is much simpler for people to imagine the impact of losing the specific, extant services they currently rely on, rather than the possible benefits of a theoretical future replacement.

Reform is a hard sell. This has made it difficult for politicians to drive it forward; it would be one thing if, with a click of fingers, HSC could be transformed to our best-planned future service.

Instead, what is required is total reshaping of a gargantuan organisation with an unimaginable number of interconnected parts. Realistically, this will be a hard road and there will be mistakes – and those mistakes would occur at a time when services are already under huge pressure, with ballooning waiting lists and growing public dissatisfaction.

The crushing central dilemma of the transformation agenda is how it is possible to keep treating people and prevent waiting lists from spiralling further out of control (even reduce them, if possible) while, at the same time, pushing on with massive changes that will cost money, use the precious time of an already-stretched workforce, and (with the best will in the world) not go smoothly. As time passes, this problem only becomes tougher.

Getting support ahead of time will be critical – from clinicians, health organisations, campaigners, and the public at large. This will take a concerted effort.

Diabetes services are just one area of many that need to be fixed. They also illustrate how and why change is necessary.