COMMENTARY

The Big Cost to the NHS of Unmanaged Diabetes

Dr Adrian Heald

Disclosures

September 19, 2019

The European Association for the Study of Diabetes (EASD) Annual Meeting in Barcelona, Spain has heard how poor diabetes control was responsible for £3 billion in potentially avoidable hospital treatment in England in 2017–2018. One of the authors, Dr Adrian Heald, spoke to Medscape UK.

This transcript has been edited for clarity.

My name is Adrian Heald. I'm a consultant in diabetes and endocrinology based in Salford in Manchester. I also have a post at Manchester University in a research position as well.

What costs of unmanaged diabetes in England did your research presented at EASD uncover?

Well, our research looks at a variety of measures in health outcomes. Today I've been talking about how we can understand better the health economics of hospital admissions for people with diabetes, but also all hospital contact for people with diabetes. And what I've described is the fact that for type 1 diabetes, the excess cost of having type 1 diabetes in terms of hospital contact of all forms, just from outpatients through to complex admissions, is more than £2500 a year compared with the background population not having diabetes. And for type 2 diabetes the excess cost is around £1000 a year over and above people who don't have type 2 diabetes, even when you adjust for age effects.

What can the NHS do with these numbers?

First of all, I think these numbers are quite helpful to health planners at both a local and a national level just in terms of getting a handle on how much diabetes is costing in 2018-2019 in relation to hospital.

However, the question is, what do we do with that data? We know that there is also an impact of suboptimal glycaemia, so blood glucose levels that are above target on outcomes for people in terms of complications, whether it's heart, or kidneys, eyes, feet. And, therefore all of those things do have a cost attached to them.

Anything we can do now to improve people's control, through largely their contact with their family doctor in the GP practices, is going to impact on their longer-term outcomes. And what we've shown in other work is that there is quite a lot of variance between GP practices in terms of their performance, in terms of how many people on their type 2 and type 1 diabetes register they're getting to target. And what we'd like to do is to work with commissioners, work with Clinical Commissioning Groups, work with NHS England to see how we can get some of the less well performing practices doing as well as the best performing practices.

Now some of the factors that determine that are out of the GP and the practice nurse’s control because they relate to the underlying demography of the area. But many factors such as prescribing balance between different agents, such as the way that the practice is organising regular checks, the way that people are being brought to target in terms of their cholesterol and their blood pressure, as well as their glycaemia, and also the way that the patients are given access to expert patient programmes, can have a significant impact on the proportion of patients of a GP practice that we're getting to target whether it's with type 2, or with type 1 diabetes.

You said the NHS never actually saves money overall, so the £3 billion headline figure would go a long way in primary care?

Absolutely, and shall we say it's kind of invest to save in the future, which is always a difficult one to justify to health commissioners and to the people who ultimately have to apportion the budget for health in our publicly funded healthcare system.

My view would be that actually, it will help the GP practices because we know that practices that do very well with their diabetes management in terms of getting people to not just to glycaemia targets, but blood pressure targets as well, getting the people up regularly for their checks, actually, are slightly less busy in the longer-term in terms of dealing with complications. Of course, they're busy with everything else but they are actually less busy in terms of picking up the pieces with these people 5 or 10 years down the road.

Now, that's data that we can't put on any health economics around, it's just about numbers of people presenting with their, with their health issues. But you know, it comes back to that argument that actually, we do have to probably spend a little bit more but a lot of it is around helping practices to organise themselves in a way that's going to deliver the best outcomes for them as well as for the patient's attending. And that will then have the consequence of, shall we say, better control in the present and less complications, and therefore less hospital costs, in the future.

What else has your analysis shown?

What we've shown, again in this modelling is that around 1 million people, around a third of the people with diabetes, more with type 1 than type 2, because type 1's more difficult to manage, but obviously, the numbers are less for type 1, but overall, around a third of the people with diabetes are above target with their HbA1c.

And as I said, the glycaemia, the blood glucose is one of a number of factors that determines outcome. It's a very important factor. And what we have proposed is that around £3000 pounds excess cost just in terms of hospital activity, on average, goes with the people who've got suboptimal control.

Now, of course, that suboptimal control is in the past, and this is the current figures in terms of their cost to the NHS. But clearly, if we can get more people to target and bear in mind, in any year around 30% of those people who are off target in the year will still be off target a year later.

So it's, you know, it's a matter not just of the present, but also the fact that people tend in some cases to stay off target because actually they've got difficult to treat diabetes.

We're not saying this is easy. We're not saying that all of those million people can be got to target. But we know that some practices do better than others. And therefore, if we can help the less well performing practices to do better, to get them up to the level of the best performing practices, then actually we will get more people to target, and potentially in the future, the hospital consequences, in terms of hospital contact, and hospital costs of diabetes per person may be less.

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