Patients with type 1 diabetes are blocked from specialist services by NHS commissioning policies

BMJ 2012; 345 doi: (Published 08 November 2012) Cite this as: BMJ 2012;345:e7515
  1. Ingrid Torjesen
  1. 1London

NHS commissioning frameworks and policies are preventing patients in England with type 1 diabetes from getting the care that they need from specialist services, the Association of British Clinical Diabetologists has warned.

As a result, many patients with type 1 diabetes are being treated in hospital for hypoglycaemic incidents, diabetic ketoacidosis, and ultimately complications such as diabetic retinopathy and diabetic foot, which could have been avoided if they had received specialist support early on to help them manage their insulin concentrations better.

The national diabetes audit, published in June, showed that while just over half of patients with diabetes received all nine recommended annual checks annually (54.3%),1 the proportion of patients with type 1 diabetes receiving them was far lower (38.5%) than for type 2 diabetes (56.4%).2 Furthermore, episodes of diabetic ketoacidosis among patients with type 1 diabetes are rising.

Three issues currently affect the referral of patients with type 1 diabetes in primary care to specialist services: the NHS’s Payment by Results system, which attaches a cost to each referral to specialist services; the need for the NHS to make £20bn (€25bn; $32bn) in efficiency savings; and the Quality and Outcomes Framework, which encourages GPs to review the care of their diabetic patients.3

Although patients with the more prevalent type 2 diabetes can be managed in primary care, the Association of British Clinical Diabetologists, which represents consultant physicians who specialise in diabetes mellitus, has said that patients with type 1 were a distinct and different group of patients who needed care delivered through a collaborative pathway involving primary care and specialist teams.

Chris Walton, chairman of the association and a consultant physician at Hull and East Yorkshire NHS Hospitals Trust, said, “We would like specialist care to have more of a leadership role and to be more accountable; and if there are ways of finding incentives for those who employ specialists (the trusts) to do that then that would be something that could be discussed.

“It is not for [the association] to say exactly how that commissioning might occur, but there are alternative ways of commissioning which should enable a more inclusive collaborative arrangement between specialists and generalists.

“I would like to see specialists incentivised to deliver good care across the whole community of people with type 1 diabetes within a given area.”

He said that smarter commissioning would ensure that patients with type 1 diabetes had access through specialist services to fully accredited structured education programmes, such as DAPHNE, which was developed in Germany and ensured that there was adequate access to insulin pump provision.

Walton said that all areas should also have hypoglycaemia pathways, in which ambulance staff, for example, notify the specialist team when someone is brought to hospital with hypoglycaemia, so that the team can intervene promptly, and that specialist teams should also be targeting patients admitted with diabetic ketoacidosis.

Changes to driving regulations in recent years meant that the Driver and Vehicle Licensing Agency would suspend the driving licences of people with type 1 diabetes if they have two severe hypoglycaemic attacks, defined as those needing assistance from a third party. Walton said that if this happened patients could lose their jobs. “If specialist teams get in early they can make a real difference,” he said.


Cite this as: BMJ 2012;345:e7515


  • News: Only half of people with diabetes receive all the tests they need, report says (BMJ 2012;345:e7513, doi:10.1136/bmj.e7513)