Oral evidence: The management of adult diabetes services in the NHS: progress review, HC 563

Oral evidence, 16 November 2015.

Witnesses

Dame Una O'Brien, Permanent Secretary, Department of Health, Simon Stevens, Chief Executive, NHS England, Professor Jonathan Valabhji, National Clinical Director for Obesity and Diabetes, and Jonathan Marron, Director of Strategy, Public Health England, gave evidence.

Chair

Good afternoon, everyone, and welcome to the Public Accounts Committee on Monday 16 November 2015. Today we are looking at diabetes care, following on from a Report that the National Audit Office did three years ago, which the Committee looked at. We are now looking at an update from the NAO on whether there has been progress since then. Our witnesses, from my left to right, are, first, Jonathan Marron, director of strategy at Public Health England. Welcome, Jonathan. I think this is the first time you have appeared before this Committee.

Jonathan Marron

It is. Thank you. Good afternoon.

Chair

You may be a repeat visitor; we’ll see how you do today! Dame Una O’Brien is the permanent secretary at the Department of Health and one of our most frequent visitors—we are going to give you frequent flyer points at this rate, Dame Una. Simon Stevens is the chief executive of NHS England and also one of our regular customers. Welcome, Simon. Then we have Professor Jonathan Valabhji, who is the national clinical director for obesity and diabetes at NHS England. Welcome to all of you. To give a bit of context, especially for those who are watching but have not read the full Report, by 2030 nearly 9%—8.8%, I think—of the population will have diabetes, and the Report shows very clearly that the treatment pathway is what one might politely call patchy. However, all the evidence, including NICE guidelines, shows what works. In other words, it’s not rocket science to tackle diabetes. You, and in particular Professor Valabhji, know what needs to be done, but it is not happening universally on the ground. The variation is immense across the nation. As I said, we looked at this three years ago, and it’s a bit disappointing that progress has been so slow. The NAO talks about it stalling. That may be a polite way of putting it. We are here today to find out why it has gone so slowly and what can be done next. First, I want to touch on the variation, because that seems to me to be one of the biggest issues coming out of the Report, and to ask you how you are planning to tackle that. CCGs have their own freedoms locally, but they are clearly taking different approaches. I suppose I should start with Dame Una and Simon Stevens. What do you think the centre should be doing to make sure that whoever has diabetes is getting the right treatment wherever they live?

Dame Una O’Brien

Thank you very much for the opportunity to come back and discuss this. I think I’m the only one of the witnesses here today who was here in 2012. This was at the time and remains now a huge passion of mine, and it is a very, very important priority of the Department of Health and the health and care system. You have asked specifically about variation, and I think the Report and the maps in the Report demonstrate the degree of variation not only geographically, but in care for people with type 1 and type 2 diabetes and also with regard to age and, in some cases, gender and ethnic origin. These are all matters of deep concern to us. We have been working on them and will continue to work on them. We have some important new developments that were signified in the NAO Report. Others will talk about them in more detail than me, but from the Department’s perspective, in terms of greater transparency on the quality of and the outcomes from diabetes care in individual CCG areas, the CCG performance framework that we are working on currently will have a significant benefit in enabling direct area-to-area comparison.

Chair

Can we just be clear on when that will kick in? When will we be able to see the evidence from that?

Dame Una O’Brien

The work is already in train, and various elements of it get implemented progressively from the next financial year. Simon can talk in much more detail about how that will work. The efforts to tackle variation are very serious and very thorough. I want to touch on one point, though, about the need for a completely rounded picture in understanding where we are. In January, we will have two years of data published from the national clinical audit for diabetes, which will cover 2013-14 and 2014-15. I notice that the NAO Report, understandably, was only able to go up to 2012-13, so in effect you have only really got the national diabetes audit data for a few months after the last hearing; we have not got the full amount of data available to us yet on the intervening period.

Chair

But didn’t the number of GPs participating in that go down dramatically between those two periods?

Dame Una O'Brien

There are some issues with participation. I do not know if I would term it as going down dramatically, but—

Chair

From memory, wasn’t participation down from 88% to 72%? That is quite dramatic.

Dame Una O'Brien

There has been an issue about participation and we will absolutely be focusing on that when we get the full outcome from the report in January. But, if I may, the final point I wanted to make before I shut up and let others come in is that, in the period between 2009 and 2012, while, as the Report says, we are seeing the percentages for the care processes for people with diabetes plateauing, we have to factor in that nearly a quarter of a million more people received that care in 2012 than in 2009. So the percentages mask very significant increases in the quantum of people receiving care. I want to put that on the table right at the beginning so that, when we are looking at percentages, we also recognise that the system is coping with a significant increase in numbers of people.

Chair

Dame Una, you must have had a glass to the wall, because we were discussing that and we will come on to that in our questioning later. Simon Stevens, do you have anything to add, in particular about the participation rates of GPs in the survey?

Simon Stevens

I agree with Una’s overall description of the situation—

Chair

For the audience, can we refer to people not by first name, but by title or full name? That is helpful for people watching.

Simon Stevens

I completely agree with Dame Una’s remarks. On the audit, as I understand it, the issue here is that something called the confidentiality advisory group changed its mind on the question of whether opt-in or opt-out was required and, rather than there being an opt-out provision for GP practices, instead it is required that they now have to opt in. That may be understandable, but it is regrettable inasmuch as it appears to have had a dent in the participation rates and, given that this is one of our flagship international audits, I think that is something that we need to look at again.

Chair

Can you do something about that, Simon Stevens?

Simon Stevens

Well, as I understand it, it was this confidentiality advisory group that withdrew the previous section 251 provision—

Chair

Can you just be clear—this is the confidentiality advisory group to whom?

Simon Stevens

To the Department of Health.

Mr Bacon

Who do they report to?

Simon Stevens

To the Department of Health.

Mr Bacon

And who is the boss at the Department of Health?

Simon Stevens

The Secretary of State.

Mr Bacon

Right. Who are the two principal advisers of the Department of Health for the NHS?

Simon Stevens

This, having come to my attention, is something that we clearly do want to take up, because I think it is a very unsatisfactory situation.

Mr Bacon

So, just for the avoidance of doubt, the answer to my question is “us”.

Chair

You two.

Dame Una O'Brien

Yes.

Simon Stevens

Yes, absolutely.

Mr Bacon

It is just that, when you mentioned this group, you made it sound like some sort of extraterrestrial movement of the planets over which you had no control.

Simon Stevens

Since they are independent, we have no control, but obviously this is something that, with the Department, we now need to take a tight look at.

Chair

I hope that you can, because I think you have picked up that we are anxious about this.

Mr Jackson

Did they not do an impact assessment that planned ahead as to the likely ramifications of changing the regime from opting out to opting in? It does seem to be a cock-eyed way to run a system. You have got a flagship health programme that seeks to be as good as any international comparators and some faceless bureaucrat who in theory is answerable to Dame Una comes along and says, “We won’t worry about the impact this’ll have on data collection”—incidentally, that is referenced on page 23 as being one of the issues by the all-party parliamentary group on diabetes. And they say, “We’ll change the rules to completely”—forgive my French; this is unparliamentary—“bugger up the whole data collection.” Didn’t anyone think this through? Didn’t you think this through, Dame Una?

Dame Una O'Brien

There is an unintended consequence from their decision. Participation has always been voluntary, let us just be clear about that. I think it is an unacceptable consequence, and it is not one that I am happy about and we will certainly be acting to raise the participation rate in this audit.

Mr Jackson

Because you are the accounting officer, you get the flak. So, however much you try to do best, which I am sure you do, you say it is voluntary, but effectively it is outside your control, which is an issue of fairness. The responsibility comes back to you. People like me are concerned about this issue, yet you are saying there is really nothing you can do about it, because it is voluntary.

Dame Una O'Brien

The participation in this audit has always been voluntary. I am not happy that the participation rate has fallen off, as an unintended consequence of the confidentiality advisory group seeking to do the best it can to protect the confidentiality of patient information. Clearly, we will now need to look at that in light of the fall-off rate. And we will take action, have further discussions and reconsider the issues, so that we can up the participation rate in the audit in future, because, as you have quite rightly said, it is a flagship audit, and known around the world for the sheer numbers of people involved. And the other thing that is really fantastic about it is that it considers the care progress across boundaries—

Chair

It is fantastic only if people participate.

Dame Una O'Brien

Absolutely. We are in agreement on that.

Mr Jackson

So you are saying, effectively, that it is not the CCGs and the GPs that are at fault; it is this group of people who have unilaterally decided to change the regime. That is not good for the GPs, not good for the patients, and not good for you as the accounting officer. If I may, I will suggest that, instead of having another meeting and another review, you bring forward new guidelines, or even regulations, to effect a change back to the original situation. And let us just see if it scrubs its face.

Chair

I do not want to go down this path for too long, because I think that people are gathering that we may want to make a recommendation on this; I say that without revealing our report, but I think you are seeing where we are going. You have an independent committee, but we have all worked with such committees in Government. Surely you have some direction over them? What would be the procedure that would mean that we could quickly resolve this matter? Simon Stevens certainly nodded in agreement when Mr Jackson used the phrase, “cock-up”; he is nodding again. What would be required to make this happen better next time around?

Dame Una O'Brien

First, we have to understand why so many GPs, given the way that the decision architecture was reconstructed, pulled out of it, because there may be other reasons at play here. Then, I think that we want to refer that back to the confidentiality advisory group, in the knowledge of the consequences of that decision, and ask for it to be reconsidered.

Chair

How quickly could it be done if they changed—?

Dame Una O'Brien

I can’t answer that right now—

Chair

If you could drop us a note, that would be very helpful. Aside from the point that Mr Jackson has rightly pursued, GPs have had a varying degree of participation. Do you think GPs have taken their eye off the ball in tackling this issue? Perhaps I can ask Professor Valabhji.

Professor Valabhji

No. I think there is a number of reasons why participation has fallen off. The other thing to disentangle is that the PCTs invested quite a bit of manpower resource in supporting GP practices to upload the data. While that support has not all disappeared, the institutional memory was lost, to some extent, when the PCTs were broken up. So we saw some fall-off in participation that was attributable to the fact that PCTs are no longer in existence, and we have new organisations to take their place. Then, superimposed on that, we now have this second factor, if you like. It is very geographically determined. We can see from the data at the moment that, of the CCGs that have invested quite a lot of time, money and personnel in supporting GPs to upload the data, some are achieving 100% participation; others, who have not invested that resource, are way down the table. If we look at a map of England, it is coincident with the geographical boundaries of CCGs.

Chair

That brings me on, probably to Simon Stevens, but tell me, Simon Stevens, if it should be someone else. Is NHS England sighted on the issue? Are you content? And what would trigger your intervention if you think that a CCG is not performing well enough, both on the audit and the participation? It is a bit of a proxy—not entirely—for treatment and how seriously they take the issue.

Simon Stevens

For 2016-17—in other words, next year—we have said, as Dame Una identified a moment ago, that a new CCG scorecard will include, among other things, a specific domain on diabetes. As part of that, the score that the CCG attracts in terms of its performance on diabetes will feed into its overall rating. We will be using the same rating methodology for CCGs that is currently used for provider trusts by the CQC. How they are doing on the diabetes rankings will be independently assessed, in the same way that they will be independently assessed by outside patient groups on cancer, mental health, dementia, learning disabilities or maternity care. That will be the mechanism that triggers intervention where needed. Overall, my assessment is that NHS performance has improved dramatically on diabetes care over the course of a decade or more. As Dame Una said, the proportion of people with diabetes has doubled over 15 years. More patients are getting high-quality care, as—

Mr Bacon

Could you stop for a second? You are about to go off on a wonderful paean about how marvellous things are, although the Report in front of us says that things are getting worse.

Simon Stevens

Does it? Where does it say they are getting worse?

Mr Bacon

Well, I think it says that the number of people with diabetes is going up, but let us stick with the point that you made about the scorecard. You said that is the mechanism that will trigger intervention. When will the scorecard trigger intervention?

Simon Stevens

The scorecard goes live on 1 April.

Mr Bacon

Once the scorecard has gone live, when will the score be sufficiently poor to trigger the intervention?

Simon Stevens

Next year, beginning in April, is when the quarterly oversight of CCG performance against that scorecard will occur. Then we are required under the Health and Social Care Act 2012 to produce an annual assessment of how each CCG is doing against those criteria.

Mr Bacon

You still haven’t answered my question. What I am trying to find out is what will trigger it. Obviously, the scorecard is the metric that you hold and look at. When you have a bunch of scorecards in front of you for different CCGs, what is the score on them that will cause you to say, “We’ll intervene in that one and that one, but not in that one.”

Simon Stevens

We will be consulting on the criteria—

Mr Bacon

Is it numbers?

Simon Stevens

Yes.

Mr Bacon

So you haven’t got the criteria yet.

Simon Stevens

The Secretary of State announced this approach to CCG scorecards within the last several weeks. We will be consulting before the start of the new financial year on the metrics to be applied in each of the six care domains. We will then use that to mark the CCGs before—

Mr Bacon

You will be consulting, in other words, before 31 March next year?

Simon Stevens

Exactly.

Mr Bacon

When will it be announced what the metrics are?

Simon Stevens

By 1 April, obviously, because we will need CCGs to apply them then.

Mr Bacon

So there will be a number in there, and if a CCG falls below it, then you will intervene?

Simon Stevens

Yes. We have to apply human judgment to these matters, in just the same way that the CQC does in respect of provider trusts, but as the report rightly says, there is a trailing edge of performance in some CCGs. It also points out that the bottom 10% of areas have improved the fastest—by 22 percentage points—so there are signs of progress, but we need to accelerate that.

John Pugh

What will the intervention consist of?

Simon Stevens

As in the current CCG oversight regime, we have a range of measures at our disposal that are calibrated to the nature of the issue that needs to be sorted out.

John Pugh

What would be the appropriate one here?

Simon Stevens

In the first instance, it will be support and ensuring that a CCG has appropriate action linked to its particular gaps.

John Pugh

A word in their ear.

Simon Stevens

Well, no. Certainly marking their card, but the whole point of having a prospective quantified framework that people can—

John Pugh

But no financial penalty or anything?

Simon Stevens

Not so much a financial penalty. Ultimately, we are able to intervene, issue legally binding directions to CCGs that are not delivering and change the management where required, and we have done so in a number of cases.

Chair

How quickly would that trigger? In the first quarter or the second quarter, or does it have to be at the end of the first year?

Simon Stevens

As Dame Una said, the data are now 2.5 years old, but assume that when we get the more up-to-date information in January, we will still see a spread of performance; of course we will. I think it would be unreasonable to say, “Within 13 weeks, sort out what has been a decade’s worth of a problem, and if you don’t we’ll send in the equivalent of the 101st Airborne.” Of course not. It clearly illustrates the size of the improvement that individual CCGs will need to make with their GPs. Ultimately, a lot of the measures tracked here are about the quality of primary care performance, and we know that primary care is under stress. You cannot have an argument about secondary prevention of diabetes-related conditions without having a conversation about the overall functioning of the primary care system in that geography, too.

Mr Bacon

Will the scores be publicly available?

Simon Stevens

Yes.

Chair

Professor Valabhji, you are the clinical lead for this. We have a report on what targets have been set and on the care pathways. What would you see as the role of the centre in making sure that GPs who are not doing this start doing it? Why do you think some GPs are embracing it more than others? There are clearly financial incentives for them to do this. Are those incentives no longer as useful as they were?

Professor Valabhji

The incentives, via QOF, have done a huge amount both for the care processes and for the treatment targets. If you look at the plots right from the inception of QOF, 6.5% of people with diabetes had all the care processes and now we are at around 60%, which is a huge achievement. We plateaued, and I suspect that QOF, as a lever, has done what it can. We need an additional lever if we are to move beyond 60%. Personally, I think the logical way to go—Simon Stevens has been alluding to this—is to look at the distribution and tackle the variation. That is an important way to do it. The QOF incentives can shift the entire distribution, let’s say, of people with diabetes in terms of, for instance, their sugar control, and we have to be quite careful there because, if we reduce the sugar of everyone with diabetes, we could do significant harm. There is harm at the lower end of the spectrum. If I, in my clinic, increased someone’s insulin dose too much, they develop hypoglycaemia, which can be associated with harm and even death, so we have to be careful in how we tackle it. The right way to do it is to look at those lower than the median. You would then be bringing the high values of sugar towards the median without endangering those who already have fairly low sugars by taking them into the danger range. QOF has probably done a great job, and what you see is what you get now—that is the effect of QOF.

Chair

I certainly hear that that is what is happening locally.

Professor Valabhji

The next step is to tackle the variation, more importantly, at the worst end of the distribution, rather than shifting the entire distribution.

Chair

As you have all highlighted, the variation is very wide. How is best practice shared through the system? Why is it that some GPs and CCGs are seemingly content to oversee a very poor level of hitting the nine care pathways and the three test targets? What can you do, and what can you ask the Department and NHS England to do, to make sure that the worst are coming up to the standards of the best?

Professor Valabhji

We have gold-standard clinical pathways, and I should point out that the pathways do not just involve primary care. You need the whole spectrum of primary, community and secondary care, and we tend to get better outcomes across the piece, including on foot amputations and things like that, where that interface works particularly well, We now have a system, the Right Care programme, that defines the gold-standard clinical pathway. If a local health economy requires help, it can call in the Right Care programme to benchmark where its current service provision is compared with the gold standard and look to reduce the difference, so driving better outcomes. We have some mechanisms in place. There is also professional responsibility and knowledge. We all go to conferences x times a year—GPs and specialists both do—and a huge amount of sharing good practice goes on as a result of that.

Chair

That is what puzzles me because you talk about people wanting to do well professionally, but the variation is immense. It wasn’t looking good three years ago, so I don’t understand why the worst aren’t trying to do better to get to the level of the best. What levers are there in the centre? Basically, with whom does the buck stop when it comes to making sure that, wherever you live in the UK, this national crisis of 200,000 extra diagnoses a year is being tackled? Who does the buck stop with, and why aren’t the worst doing better?

Professor Valabhji

I think you are mixing up two things. As a professional in diabetes for more than two decades, I have seen two major differences that disentangle the two things to which you are alluding. First, I have seen massive improvements in the standards of care over two decades. In the data that we have from the national diabetes audit to date—the last three years alluded to in the Report—we are seeing significant reductions in the risk of complications per individual with diabetes. So we know that the risk of mortality is falling and that any individual with type 2 diabetes is less likely to die. That has been a big change since you sat three years ago, when—having read the transcripts over the weekend—that was a big focus for the Committee. We have done a lot to reduce the excess mortality. So the outcome per individual is much, much better, the clinical endpoints that matter to people: heart failure is reduced; major amputation is going down; and kidney failure and going on to dialysis is going down. That is the first observation I would make as a professional in the field. That has to some extent been swamped by my second major observation, which is the explosion in prevalence: more and more people are developing diabetes. On that score, in the last 12 months we have been making strides to tackle it through a national programme for type 2 diabetes prevention. So looking at the evidence base internationally, there is strong evidence that if you give those identified as high risk, but who as yet do not have diabetes, a prescriptive intervention—which we are developing as a national offer—you can reduce the risk of progression to diabetes by up to 60% over three years. In terms of my two observations, therefore, the outlook per individual is much better. The volume of complications that we as an NHS are dealing with is greater, but only because the number of people who have diabetes has gone up. We are now particularly strong on that, because we will probably be the first country in the world to scale up at national level a type 2 diabetes prevention programme.

Chair

You talked about this gold standard, and that is great. From a clinician’s point of view, I can understand why you are aiming for that, but it is not supposed to be a theoretical standard; it is actually supposed to be something that is implemented. So notwithstanding what you said about the progress, the number of people getting diabetes is a pathway that has been, and is, predictable. What will happen to make this gold standard not theoretical, but practically delivered? As I asked earlier, where does the buck stop? Where do you think that there needs to be more intervention—NHS England, the Department of Health or perhaps Public Health England—in terms of prevention?

Professor Valabhji

Two fundamental mechanisms will tackle the rising prevalence—the year-on-year increase—in the number of people with diabetes. First, the NHS health checks, which are a cardiovascular assessment for all members of the population between the ages of 40 and 74. Importantly, part of that assessment is a diabetes filter, which identifies through two stages those at high risk of developing type 2 diabetes. To date, we have lacked the appropriate offer for those individuals. While we have been identifying them through the health checks over the past few years, we have not necessarily across the country been empowering them to do something about that when they receive the information. The NHS type 2 diabetes prevention programme will do exactly that. So the first stage of national roll-out is scheduled for 1 April 2016.

Mr Jackson

May I clarify something? Unless I misheard you, Professor Valabhji, you said that heart failure had gone down, but figure 14 on page 33 shows that angina, heart failure, stroke, heart attack, end-stage kidney disease and both types of amputations have all gone up—in fact, heart failure has gone up by 25% in the two financial years up to 2011-12. Are you saying that it has plateaued and gone the other way since?

Professor Valabhji

This is a table showing the glass half empty, which is the total number of cases that we as the NHS have to deal with. What I am talking about and what is more important to individuals with diabetes is, “What is my risk as a person with diabetes of developing heart failure?” and that risk has clearly gone down for people both with type 1 diabetes and with type 2 diabetes.

Mr Jackson

But you said specifically that complications with respect to heart failure have gone down, but the figures do not show that.

Simon Stevens

Your chances as a patient of having heart failure and, indeed, your chances overall of dying early from diabetes have gone down from 44% to 34%, such that we are now the lowest in the industrialised world, but there are just more people with diabetes, so the absolute numbers have gone up.

Sir Amyas Morse

So your chances of getting diabetes have gone up, but your chances of what your outcomes might be once you have got it have gone down.

Simon Stevens

That’s right.

Sir Amyas Morse

Very comforting.

Chair

This Report would be a good exercise in statistics for an A-level student.

Simon Stevens

Rates versus volumes.

Mr Jackson

Madam Chair, the Report does say: “The estimated number of diabetes-related complications continues to rise.” Heart failure is up 25%. Sorry if I am being obtuse, but—

Professor Valabhji

This is the difference between the total number of cases that the NHS has to deal with and the risk of any individual developing that complication. As a professional, I sit and have a one-to-one relationship with my patients every day of the week. I can honestly tell the person in front of me that their risk of developing heart failure is a lot lower now than it was x years ago, which is significant.

Simon Stevens

But you have more people in your clinic.

Professor Valabhji

True.

Mr Jackson

It would be uncharitable not to concede that you are dealing with a massively increased cohort. In fairness, these figures are more mixed than they look because you are dealing with much bigger numbers.

Professor Valabhji

Sure, but as I said, we have jumped into the space of doing something about the rising numbers.

Dame Una O'Brien

It might help to look at figure 13, which illustrates the point you are making, if I have understood it correctly, Professor Valabhji.

Professor Valabhji

If you look at heart failure, the orange bar, which is for 2009-10, is the biggest. The yellow is intermittent, for 2010-11, and the latest data, which is for 2011-12, is the smallest. This is the absolute risk of—well, actually, it is a bit more complicated than that, statistically. If you look at the whole population, with or without diabetes, all of us, fortunately, are less likely to have heart failure, a heart attack or a stroke, but what this says is that the relative gain for an individual with diabetes is even greater than for the background population.

Mr Jackson

I am asking you to comment on a Report you did not write, which is slightly unfair. May I ask the NAO to clarify this for those of us who do not have degrees in statistics?

Robert White

I think what has been said is correct. In figure 14, the right side shows there are more people with complications because there are more people with diabetes. The left shows that your chance of developing some of those complications has gone down, but let’s be clear: it has gone down in all areas—some of them are slightly down and some more so. We have seen an increase in minor amputations; I will probably ask the clinician to clarify whether that is a good or a bad thing, given that major amputations have fallen, but with some of the other ones, like renal replacement therapy—kidney failure—there was nearly a 293% chance of developing a complication. That has fallen to 274%. That puts it in perspective; it is moving in the right direction.

Karin Smyth

I want to return to the incentives discussion. I accept that the numbers are going up and that clinical standards have certainly improved, but we should look at how the system can make a difference and improve in this area. You talked, Professor Valabhji, about QOF having been a successful lever but really having done what it could. I accept, with the cohort of patients who came through at that time, that that is possibly true, but what is not now left in primary care is an incentive similar to QOF to drive that behaviour in primary care, given that most of the savings in terms of amputations and so on are further upstream in secondary care. Given the turnover in GPs in primary care, the destabilisation we have seen in primary care and the increasing numbers of different patients coming through primary care, what is the driver for primary care to deliver this part of the programme now?

Professor Valabhji

In a health economy, we all feel a shared responsibility for the outcome of our people with, let’s say, diabetes—that is the theme of the day. I think GPs are very concerned about the risk of one of their patients losing a leg, so I do not think there is a lack of incentive from a clinical perspective. The cost savings are actually shared across the health economy. If you look at the cost savings to be had through avoidance of a major amputation, they are huge. The exact number is somewhere between £15,000 and £30,000 per major amputation saved, but that is felt right across the health economy and also across the whole economy. Often, with type 1 diabetes, you see people of working age succumbing to one of these awful complications. They can no longer work if they are not walking, so there are all sorts of consequences. The financial gains, which I think is what you are alluding to, are shared right across the health economy.

Karin Smyth

Okay, but they are not really shared—they are not being put back into primary care or held at the CCG or in the trust. Perhaps we can come back to Mr Stevens. If we look at an entire health economy, where you perhaps could save £3 billion of spend in one area, those savings are divided between different parts of the health economy. In a fractured and financially focused health economy, where are those savings really realised, and how will you ensure that all parts of the system are driven on the same goal?

Simon Stevens

That will be done by implementing the NHS five-year forward view, which is essentially a solution to the precise issue that you raised, which is that we have fragmented funding streams. We have disconnects between primary and specialist services, between physical and mental health services and between health and social care. Those parts of the country that have got going on the redesign of services are, under the so-called vanguard programme, joining up those services and, as a result, joining up the funding flows. They do not have the issue that you described. In fairness, we should acknowledge that there are a number of parts of the country that have found workarounds to the current regime and done well on the back of it. Northumberland for a long time has had a good integrated specialist and primary care diabetics service. In Portsmouth, South Eastern Hampshire CCG and its consultant diabetologists and GPs have, for their type 1 diabetes service, found a way of producing integration and sharing the savings across the care boundaries. In a sense, what you are describing is a specific instance of a broader problem that the NHS five-year forward view will tackle.

Karin Smyth

But most of the country is not under the vanguard programme, is it?

Simon Stevens

There are 50 vanguards, and we obviously want to be able to roll out more.

Karin Smyth

For those parts of the country that are not in the programme, and will not be in the next couple of years, how would you show the improvement, if you came back to the Committee in two years’ time?

Simon Stevens

The cost of a diabetic-related amputation is a cost to the CCG, and investment in avoiding that by the CCG will therefore produce downstream savings for the CCG. The incentives are aligned in that respect. One piece we have not paid sufficient attention to so far is what is happening in primary care and the pressures on GPs. The reality is that, over the last several years, diabetes cases have increased by 4.8% a year, but the number of GPs has been increasing by 1.8% a year. Part of what we have got to do is change the relative investment in GP services and primary care and look at new ways of providing primary care, such as with multidisciplinary teams. That is a big part of what the health service has got to get right over the next three years.

Chair

Sorry, you just very neatly skipped over an important point on new ways of doing things in primary care, such as, I suppose, workforce planning. Could you give us a bit more detail on what is being planned and how quickly—

Simon Stevens

Yes. It is workforce planning, but also GPs are coming together in a number of places in federations or super partnerships or other ways of moving beyond the individual two, three or four-person practice. As a result, they are able to bring in a wider array of primary care professions, including clinical pharmacists, more nurses and others. That, with the ability then to provide a wider range of primary care services, will be part of how we will tackle the gaps in care that we still see on some of these eight care measures. It is not just about the financial engineering; it is also about the investment in and resilience of general practice in this country. If we do not get that right, we are on a hiding to nothing when it comes to dealing with the vast increase that we are continuing to see and are bound to see in the number of people with type 2 diabetes. It also emphasises that the NHS is on this treadmill. We are running to stand still by virtue of the huge obesity problem in this country, and that is why we have to tackle that at source, not only through such things as the diabetes prevention programme that Professor Valabhji talked about, but through broader action to tackle obesity. We cannot, as a country or as the NHS, afford to deal with the downstream consequences that show up with such things as type 2 diabetes and cardiovascular disease.

Chair

We are going to come on to that downstream in our hearing with Mr Marron from Public Health England.

John Pugh

There are two areas of concern. One is on prevalence, and the other is responsibility. One accepted fact in the background to the whole Report is that the percentage of the adult population with diabetes has doubled over the past two decades. Has the number of people with diabetes doubled, or is that due in part to the better diagnosis of diabetes? Can you just clarify to what extent this is a genuine doubling or perhaps a better identification of those people who have diabetes?

Professor Valabhji

It is a very real phenomenon in terms of the rising prevalence. There are more people with glucose within the diabetes range. I think you do bring up an important point. When I started in the field, we would talk about a decade’s lag time to diagnosis of diabetes. When I saw people for the first time with a new diagnosis of diabetes they often had some of the complications present and that does not really happen any more. So we can model how many we think are out there with diabetes who do not yet have a diagnosis. You model it by working out the age of your population, the ethnicity and their body mass index—how much they weigh. Whereas the mismatch was 750,000 when I started in post two and a half years ago, the Report now talks about a 400,000 gap. So we have got much better at earlier diagnosis of type 2 diabetes. Sooner or later they will all feed into the—

John Pugh

Could, say, a third of that increase just be down to better diagnosis rather than higher incidence?

Professor Valabhji

Not a third.

John Pugh

Less than that.

Professor Valabhji

Less than that—well less than that. But it is a significant contributor.

Simon Stevens

And there are perhaps 5 million people on the cusp of having type 2 diabetes—the total pre-diabetic population—on top of the 3.2 million who Professor Valabhji was talking about.

John Pugh

Okay. I look at the other stat I am provided with, and it says that by 2030 the percentage of the adult population with diabetes is expected to rise to 8.8%. That is up from 7.4%. So you have what looks like quite a meagre increase projected for the next 20 years, as opposed to the increase you have seen in the past 20 years. What do you think is going to happen to slow the rate down?

Professor Valabhji

Our intervention, which I have mentioned—our diabetes prevention programme.

John Pugh

Right. The public health programme.

Professor Valabhji

Yes. So at the moment we are looking at a 4.8% increase per annum in the number of people with diabetes. I am not aware of any modelling that suggests that that will plateau, which I think is what you are suggesting with those figures.

John Pugh

Well, it seems to indicate a plateau.

Professor Valabhji

The thing to bear in mind is that when you try to project into the future the number who will have diabetes in 2030, 2050 or 2080, the margins of error get wider and wider for every year ahead you go. At the moment, for the past three years we have seen a fairly consistent 4.8% per annum increase.

John Pugh

So what you are saying, as the clinical director here, is that the figure of 8.8% could be a very conservative estimate unless something works effectively.

Professor Valabhji

It could be, yes.

John Pugh

Okay. Looking at diabetes as a whole, apparently it consumes 11% of NHS expenditure. One in seven hospital beds are diabetes-related—[Interruption.] One in six, with £5.6 billion of costs. If all the CCGs, or whoever we regard as responsible in this case, performed at optimum level, or as well as the best performers, what sort of savings—I am asking this question to Mr Stevens—would that engineer for the NHS? You are sweating over the NHS budget at the moment—you are warning us about it. Around the table, different constituencies have figures on the incidence and the variety is quite shocking, but if everyone got it all right, or got it as near right as they possibly could, and you could eliminate that variety and get performance up near the better performance, what would the NHS save?

Simon Stevens

If you take the £5.6 billion figure that you mentioned, which I think related to 2010-11, I believe the estimate was that 69% of that related to the complications of diabetes, which was £3.9 billion.

John Pugh

Some of which would occur anyway.

Simon Stevens

Thinking of it from first principles, the answer is some share of £3.9 billion multiplied by the increasing prevalence that may or may not occur to 2030. It is certainly going to be a seven-figure number, and it may well be an eight-figure number.

John Pugh

It is a highly laudable objective. Would early diagnosis help us get to that objective?

Professor Valabhji

Yes, we know that if you get in quick with a diagnosis—

John Pugh

It can be done well, and we know the sort of things that will make it go well, therefore it is a desirable objective. Who is accountable for achieving that objective at the end of the day? Is it NHS England? Is it you, Mr Stevens? Is it the Secretary of State? Who is really accountable? It is obviously an achievable goal. We all want it. The community wants it; society wants it; patients want it. Who ultimately has to see it delivered?

Simon Stevens

The three treatment goals that have been adduced around HbA1c’s—blood glucose, blood pressure and serum cholesterol—are the three that it is thought should be the principal focus. Obviously, we do not have compulsory medication or treatment in this country, so at the end of the day some of this will depend on the response of individual patients and what GPs do to them. I do not think we can pretend that we will have—

John Pugh

The GPs we can put pressure on to get rid of the unacceptable variety and also to get everybody up to the performance of the better, if not the best. Is that your responsibility?

Simon Stevens

Yes.

Chair

Wonderful. Two yeses.

Simon Stevens

Well, it is a shared responsibility.

Chair

We should get Mr Marron to explain how, in terms of meeting the target, a lot falls on Public Health England. Jonathan Marron, but perhaps Professor Valabhji and Dame Una might want to comment, you are the obesity and diabetes clinical lead, although type 1 is not down to obesity. Is there any issue there? You might want to pick up on that. Do you want to explain what you are doing?

Jonathan Marron

Certainly. The focus of Public Health England is on prevention. There are three major things. First, along with NHS England, we are running the diabetes prevention programme, which will be the first time anyone has introduced a national behaviour modification programme for people at higher risk of diabetes. It should make a significant contribution to slowing down the growth in the number of diabetics. That is the first part. Secondly, we have a real responsibility as the nation’s expert public health body to bring forward the evidence on the things that we know would work to help tackle the growing obesity crisis. Indeed, our recent report on sugar and the evidence-based interventions for how we might cut sugar in our diet are leading to a reduction in obesity. It sets forward a very clear menu. Taking that forward, we are working closely with the Secretary of State for Health on developing the Government’s obesity strategy, which we expect to see early in the new year, and we are hoping for significant progress on action in tackling obesity. Finally, we have a set of responsibilities to the public. We work closely with social marketing campaigns to try to influence behaviour. We also have regular debates in public health about how effective that is versus reducing sugar in food reformulation. We have a duty to help people understand what is in their diet—what they eat—and we have had some success. The sugar swaps campaign that you might have seen is largely aimed at mums. It has been very successful in getting people to think about changing diet.

Chair

When you say successful, how do you measure that?

Jonathan Marron

When it was first introduced in the summer of 2014, we used the Kantar Worldpanel data. It collects data on what people actually buy. We used that to look at people who had signed up for Change4Life versus those who had not, and we saw a 6% reduction in the amount of sugar eaten over the period of the study.

Mr Bacon

This is in people who have signed up for Change4Life.

Jonathan Marron

Change4Life is the broad campaign.

Mr Bacon

Can I sign up to change my life?

Jonathan Marron

You can sign up on our website.

Mr Bacon

I’d be delighted.

Chair

Richard and I are offering ourselves as guinea pigs.

Jonathan Marron

This particular campaign was about sugar swaps. We encouraged people to swap high sugar food for something healthier: if you drink sugar-sweetened beverages, swap to water or milk. Really simple, practical things.

Mr Bacon

What about Diet Coke?

Jonathan Marron

That’s fine as well. You have certainly taken calories out of your diet.

Simon Stevens

That is not a product endorsement.

Jonathan Marron

We have done really good work with families. The Change4Life campaign is family-orientated. From next year we have got a new campaign to launch—we are calling it One You—trying to get at adult health, aiming at people around 40 and a little over. Are we thinking properly about our health and how we get people to start thinking about their habits?

Mr Bacon

How much money are you spending on this campaigning?

Jonathan Marron

The total spend for Public Health England on social marketing is around £50 million.

Mr Bacon

So less than £1 per head of population.

Jonathan Marron

Yes. It has significantly reduced over the last four or five years.

John Pugh

Going back, I was quite impressed by Mr Stevens accepting responsibility for being £5.6 billion down, but he does not have sole responsibility; Professor Valabhji helped him. Something you said quite distressed me earlier. You said, “Patients I see every day of the week in my practice”. Is your job a part-time job?

Professor Valabhji

Yes. Well, I work full time. I am seconded for five sessions to my NHS England role, and in the rest of my time I do clinical work.

John Pugh

So you are the man delegated by Mr Stevens to get a £5.6 billion budget under control and you do five sessions. How many people are in your department with you?

Professor Valabhji

Which department? The NHS England end?

John Pugh

Well, presumably you have a department, a desk and staff—people who are working with you on the strategy.

Professor Valabhji

We have a whole team dedicated to—

John Pugh

How many?

Simon Stevens

The team of the medical directorate and Bruce Keogh’s medical directorate are—

John Pugh

No, I mean the team specifically devoted to dealing with obesity and diabetes in NHS England.

Simon Stevens

May I just interpose to suggest something? If you want a conversation about how an individual CCG is doing, we have a geographically-based team that is in charge of having that discussion with the CCG. Jonathan does not have 209 people scattered, each one talking about the CCG. He makes use of the full structure of NHS England.

John Pugh

No, but it is a very important, significant objective for the health service. I would like to believe that when you went in for these five session a week, you had a team of people who briefed you immediately and made up for what you can obviously not do yourself if you are involved in a serious clinical practice for the rest of the week. I ask you again: how many people do you work with on a day-to-day basis?

Professor Valabhji

I can’t give you that answer because it depends which bit of diabetes work I am working on that day or that hour. Take the diabetes prevention programme as an example. A good 20 of us are working on that.

John Pugh

Twenty people report to you.

Professor Valabhji

Well, there is a partnership between NHS England, Public Health England and Diabetes UK. The core management team is a sizeable team from the different organisations. If you ask me who I have to help with some other aspects of the treatment and care of diabetes, the answer would be different because it depends which part of the organisation—

John Pugh

No, I am not asking you that. I am asking who you have helping you to drive this strategy.

Simon Stevens

The whole organisation.

John Pugh

But specifically?

Mr Bacon

You said a sizeable team. How many?

Professor Valabhji

For which bit—prevention?

Mr Bacon

Well, the bit that you described as a sizeable team—the partnership of Diabetes UK, Public Health England and you. How many are in that sizeable team that you referred to?

Professor Valabhji

I said about 20.

David Mowat

To finish Mr Pugh’s line of questioning—this £3.9 billion times a factor would give you a saving if every GP practice was as good as the best. I suppose what I am interested in is that if the GP practices that were failing or were not so good were here now, what would they say? Would they say, “The data is not reliable and therefore the conclusions are not good” or would they say, “We’ve got other priorities”?

Simon Stevens

I think they would say that they are working under tremendous pressure because the rate of increase in funding for general practice relative to other parts of the health service has been far lower. The consultation rate is higher. They would say, in contrast to the suggestion that somehow they are not able to provide good quality care overall, more patients are getting high-quality care than was the case five years ago. Some 230,000 more people are getting the NICE eight care processes, and 180,000 more are getting—

David Mowat

I understand all that.

Simon Stevens

They would say, “My surgery is really busy. We are doing a good job. Give us extra resources. Get more GPs in and we will be able to do better.”

David Mowat

But your job then is to say to them, “Is your surgery differentially busier than another GP surgery that, for some reason, has good statistics?” Is there an issue with the coherence and validity of the statistics?

Simon Stevens

I think in the early days, there probably was.

David Mowat

The professor is shaking his head—so you think they are solid.

Chair

Speak, professor.

Professor Valabhji

I think the data are valid. If you look at the determinants of poorer performance, they are not what you might predict. They are not driven by socio-economic factors.

David Mowat

So, on the face of it, it is possible to have conversations with these GP practices at the moment, saying, “Based on this metric and only this metric, you are letting your patients down.”

Professor Valabhji

When you try to disentangle the determinants of the variation, much of it is down to practice-level organisation factors, even down to the make of IT system used in the practice.

David Mowat

Yes, but my question was about the validity and coherence of the data. When you say that it might be because the IT systems are different—I can understand that that may well be the case—that implies to me that the data might not be—

Professor Valabhji

Sorry, I have misled you. I did not mean to say that the collection of data on the IT system was unreliable. There are essentially four different packages that GPs can use for their IT system—

Mr Bacon

And the GP extraction service can’t use any of them.

Professor Valabhji

For example, in the most commonly used package there is a module, which you can choose to turn on or off, that will create a register of people at high risk of developing diabetes. Some practices have turned that on, and others have not. Some have done so because they see it as a priority; others haven’t simply because they are inundated with other things. My point is that the data are robust, but the determinants of the variation are things related to practice organisational factors, rather than the socioeconomic factors that drive the demographics in that area.

David Mowat

Okay, so you have just said to me that it is not about a clinical difference in performance but because of whether they have flags switched on in the various computer systems that might collect the data.

Professor Valabhji

There will not be a single cause, and there are clinical factors that come into play.

David Mowat

What I was getting at was that Mr Pugh’s analysis struck me as being right. If you could free up this amount of money by increasing the performance to the best, it matters quite a lot that the data on which we judge them all are accurate. I was just trying to get a feel for that.

Professor Valabhji

I think the answer is yes. I think the data are accurate.

David Mowat

I am not sure that your answer before that was quite the same.

Chair

I will bring in the Comptroller and Auditor General on this point.

Sir Amyas Morse

I too was fortunate to be present at the previous hearing, Dame Una, and I recollect that one reason given was that some local care pathways were very inconveniently and badly organised. Given the fact that the growth in patients has been going on for years—it is hardly a novelty—when will you achieve 80% coverage? Is that still your target, or have you gone away from it?

Simon Stevens

No, I don’t believe it is, but do you want to talk to that, Una?

Sir Amyas Morse

When will things start to improve materially over what they are now? I am interested in how that will happen. When should we expect it to happen?

Dame Una O'Brien

I think a number of different factors will come together to drive the improvement. The first thing to say is about the greater focus on these three particular treatment areas. The thing that has really struck me about that—I want to emphasise it for everyone’s recollection—is that it is about the individual person setting the targets on glucose, blood pressure and cholesterol for the individual person. We are now gearing up to really focusing on the thing that will make the greatest difference, and doing that systematically with, as Simon Stevens said earlier, a combination of the right care programme where there is actual capacity for NHS England to go into individual CCGs and—these things have to come together—much clearer data about performance. What is care like for people with diabetes in a particular locality? We have to make that visible and evident.

Sir Amyas Morse

Just to stick to the point, when you made these plans and decided that you were going to analyse how people were doing in different areas and put considerable investment into that, don’t tell me that you did not have a plan for how effectively or how soon it would have an effect. I just cannot believe that.

Simon Stevens

What are you talking about?

Sir Amyas Morse

When you made the plans to evaluate how effective the different commissioning groups were being, starting in April, you must have evaluated what impact you thought that would have—for example, what were your goals for that programme in terms of driving up better performance?

Simon Stevens

Yes, exactly.

Sir Amyas Morse

So you do know that. Presumably you can share it with us.

Simon Stevens

As I think I mentioned earlier to Mr Bacon, we’re going to consult publicly on that, so we will certainly be sharing it. Our point of view is that when we see the results of the 2013-14 and 2014-15 audit, we need to use the up-to-date information on where each CCG is, set improvement goals based on where they have got to and, frankly, decompose the challenge a little more forensically, given that a lot of variation is masked by the national average figure. To be specific about it, if you look at your excellent Report, you will obviously see that the clinical goals are much worse for people with type 1 diabetes, for younger people and for people of black or south Asian heritage. If we are going to be serious about inequalities, the lifetime exposure to uncontrolled diabetes and the particular challenges associated with type 1, we actually have to do something other than just set some aggregate national glob of a goal.

Sir Amyas Morse

I suspect that if you knew informally that things were getting considerably better, you would have found a way to convey it to us today—

Simon Stevens

I didn’t think that we were allowed to.

Sir Amyas Morse

Do you actually think as a clinician that things are being pursued with the level of urgency that they ought to be?

Professor Valabhji

Yes, I do. It’s overly simplistic just to look at the nine care processes and the three treatment targets. We have covered that in some of the other bits, but to take a brief example, we mentioned foot care earlier. One of the nine care processes is having a foot check. I think that that is very important, but am I confident that if we can get that up to 100%, we will have done the job for amputations? Absolutely not. It is one piece in a very large jigsaw. We have invested something like £94 million per annum on financial incentives for GPs to deliver on the care processes, so there isn’t an insignificant amount of investment in this. If you asked me whether I would invest more in that pot to drive more foot checks, I think I would prefer to have a multidisciplinary foot protection team to cover every part of the country to ensure that, once a check has happened, the clinician is actually doing something about an abnormal result. The care processes are important. I would love to see 100% acquisition of them all, but I don’t think we will. I also don’t think that if we did achieve 100%, we would have solved the problem. We have to be mindful of the need for the whole pathway. The other thing that we alluded to and that Dame Una has brought up are the treatment targets themselves. Going forward, I would prefer us to focus on those three targets, rather than the nine care processes. I would like to focus on both, but if we have to choose and to weigh investment relatively, I would go for the three treatment targets because they are nearer to the end points that count. Achieving sugar, blood pressure and cholesterol targets is closer to preventing your index heart failure case or heart attack or amputation than just checking the blood test or the feet. The other thing to say is that everyone is very different. What NICE has come out with in this latest tranche of guidelines around diabetes—three or four updates were published in August—really stressed the need to individualise the targets. That was predominantly borne out of data that came out in about 2008 or 2009. We all assumed that, to protect our people from complications, the lower the sugar, the better. We then found in a proper and well-conducted trial that the ones with really tight control were dying more often due to hypoglycaemia, so you have to individualise care. At the beginning it was said that we know what works, so why aren’t we doing it? I don’t know that I would wholly agree with that. The pathways are very clear to optimise outcomes, but you cannot achieve perfect outcomes. For example, we have the same treatment goal for the sugar level for type 1 and type 2 diabetes. It is infinitely more difficult to achieve a target for people with type 1 than for type 2. You could say the same for type 2, because the determinant of sugar control in type 2 diabetes is duration of diabetes. I can achieve a target very easily for someone who was diagnosed five years ago, but with much greater difficulty for someone diagnosed 30 years ago.

Chair

Those were some very good points and we will be coming back to type 1 diabetes.

David Mowat

I want to finish on what we were talking about and then perhaps talk briefly about international comparisons. As for the data and the differences that we are seeing between commissioning groups and the GPs within them, you mentioned that there were four computer systems that were pulling this data up. Just to put my mind at rest, would there be any correlation between which system was pulling the data up and which GPs were good, bad and indifferent, or is it entirely random? Have you looked at that?

Professor Valabhji

I am not wholly familiar with the dataset, but I know that one or two of those four are much easier—within the new opt-in system, it is a much easier task for practices using one or two of those four compared with the others, so there are differences.

David Mowat

So if I was a practice using one of those systems, I would be getting better numbers, which are being reported up to Mr Stevens to make the decisions that he has to make? If that is true, it undermines the whole basis of what we are talking about.

Professor Valabhji

It is not just the make. It is using the facilities and being IT-savvy as a practice.

David Mowat

No, exactly. There are the business processes around it as well, but if it is true that it depends on which of the four applications are being used and that will determine which GPs have good outcomes, versus bad outcomes, versus mediocre outcomes—i.e. that is a correlated factor—it undermines all the data that we are looking at and that the NAO has done a report on.

Simon Stevens

That is obviously a critical question. I am pretty confident the answer is that that is not what is going on, but let Professor Valabhji have a look at that subsequent to this hearing and write to you very shortly if it is.

David Mowat

You understand the point that I am making.

Simon Stevens

Indeed.

David Mowat

Because if that was the case, it means that the data integrity of the whole thing is weak.

Simon Stevens

Yes, but given—

David Mowat

And that is why I asked you at the start why some GPs—

Chair

If you can’t answer it now, will you write to us?

Simon Stevens

I think our answer is that we do not think that is going on, because the national diabetes audit has standardised for all those kinds of variables, but if it turns out on further inspection that there is a question there, we will write to you straight away.

David Mowat

That would be great. Finally, Mr Stevens, in one of your earlier answers, you mentioned international benchmarking. There was the Murray report, I think in 2013, talking about 2010, which you came out quite well in.

Simon Stevens

Indeed.

David Mowat

Have you got a feel for how it has moved since then?

Simon Stevens

As you say, that showed that we have the best performance relative to early deaths for diabetes-related causes of 19 countries. There have been other international studies since then. The OECD published a study in June on diabetes and cardiovascular disease showing that we had one of the lowest hospital admission rates for diabetes. It showed that our prescribing by GPs to manage high cholesterol was 40% higher than the OECD average, that prescribing medicines for diabetic-related conditions was 20% higher than OECD overage, and when you look at the amputation rate caused by diabetes, we were one of the best in the industrialised world, and certainly better than France, Germany or America. By international standards, we have an awful lot to be proud of, notwithstanding our ambition to do better across England.

David Mowat

So your view is that the Murray report and its conclusions—which said that you were the best, actually—are still the case.

Simon Stevens

Yes, there is no basis for thinking that that is not the case.

Professor Valabhji

The data collection for that went up to 2010 and the three data points on mortality that we have in the National Audit Office Report show that we have continued to make good headway on that, with statistical significant reductions in mortality beyond 2010.

David Mowat

Let me ask the question another way then. What are we doing right that other countries are not doing to be so much worse than us?

Simon Stevens

I think there are several things. There is the fact that we have had a focus on this in the national health service at least since 2001, when the first national service framework for diabetes was produced. We then had a strong set of incentives for primary care through the quality and outcomes framework, which on average, is putting about £12,000 extra into practices to help them with the costs of meeting those QOF targets for diabetic care, and we have continued since 2009-10, on the back of the NICE-based focus, to track improvement transparently. That combination—good primary care with strong incentives and clear clinical evidence fed back to people on how they are doing—is a winning formula.

Professor Valabhji

In terms of that international benchmarking, one thing that we have not mentioned is the lag time between good care today and better outcomes tomorrow. That is around a minimum of a decade, so I think it is highly likely that the positives that we dwelled on, in terms of the statistical issues earlier in the hearing, are very real returns. Better outcomes per individual almost certainly relate to the inroads that we made through QOF and through the national diabetes audit, which actually, is the biggest audit of its kind in the world, dating back to 2003, so I think we are reaping the benefits now of the investments that we put in back then. There are no international benchmarking systems that I am aware of. We cannot compare how we are doing with nine care processes with any other country, because no other country really collates data in that way, so we are very advanced in that respect. It is the same for the three treatment targets. I can give you a little more comparative data on sugar control, but not on the combination of sugar, blood pressure and cholesterol. Our data are fantastic, really, comparatively speaking. What we are seeing in terms of the better hard clinical outcomes that matter to people, including mortality, relates to all that we have put in place, going back 12 years or more.

Chair

Okay. We could go into a lot more detail, but I will hand over to Stewart Jackson.

Mr Jackson

Mr Marron, may I ask you a brief, straightforward question about the debate on the sugar tax? In terms of the Department and your organisation, where are we on that debate at the moment, formally?

Jonathan Marron

We are very clear on our position. We have published our review of the evidence. We found that there is evidence to support the idea that a sugar tax of 10% to 20% would reduce sugar consumption. That is our contribution to the debate, if you like. It is one of a range of measures. We also looked at reformulation, restricting advertising and restricting promotions, and the things we could do to help people make better choices. The Secretary of State for Health is considering the obesity strategy in his responses. My understanding is that to date the Government have ruled out a sugar tax—Una might say more on that —but we continue to work with them on an obesity strategy that we hope will see a broad range of measures to help tackle what is a very urgent problem. Another thing worth saying is that there is no silver bullet on this, and a sugar tax on its own is unlikely to have a significant impact on tackling obesity. We need a whole range of measures that help us change the environment that we live in, reduce the unhealthy choices that are available to us, help us understand the harm that we are doing by consuming so much sugar and having high-fat diets, and so help us change. We will need a broad range of actions.

Mr Jackson

May I also ask you and Professor Valabhji about the implied criticism in the Report that the conflation of obesity and diabetes has not been good for retaining the profile of the latter as possibly the major healthcare demographic issue in the next 20 years—do you have a specific response to that?

Jonathan Marron

We have two challenges, which are linked. The first is the broad population challenge: we are just getting more and more overweight. Long term, if we want a sustainable health service, we need to do something about that. The most effective way of reducing the long-term cost of diabetes will be to not have the number of obese and overweight people that we see today. That is definitely part of the solution, but is obviously quite a long-term task. In the short term, we have focused on the other things that we can do. With the new process of the national diabetes prevention programme, can we identify those people most at risk of developing diabetes, intervene early and prevent them from moving along the disease pathway and becoming diabetic? That is well worth doing: not only will it be beneficial to the patients themselves, but over the long term it should save costs to the NHS. Finally, we have had a long discussion today about the things we can do to make sure that we get high quality care for diabetes. I do not think that it is a choice between those areas; we need to make progress in all of them.

Chair

Professor Valabhji is the clinical lead for both obesity and diabetes—the connection is to type 2 diabetes. Perhaps you could answer Mr Jackson’s question, Professor.

Professor Valabhji

Whenever I am speaking I am very clear that I see myself as having three hats: national clinical director for type 1 diabetes, for type 2 diabetes and for obesity. That is important, because people take great offence if there is any implied association between obesity and type 1 diabetes, as there is no association. The association is with type 2. Has it been useful, having the obesity part of my portfolio married up with the type 2 part of it? I would say yes, actually. I mentioned the two major changes in my career, in terms of the two changes in clinical observations, namely better outcomes, but higher numbers; 80% of the variation causing those higher numbers is down to lifestyle. It is due to exercising less and eating more, and higher rates of obesity—62% of the adult population are overweight or obese now. It is difficult to disentangle the two. When you are practising in a clinical scenario, focusing on weight as well as on sugar control is very important, and your choice of medication for the individual in front of you will be based on their weight as well as their average sugar level. For type 2 diabetes and obesity, the two are intrinsically related. Personally, it has been very helpful to have both in the portfolio, but I can see why a proportion of the stakeholders were upset about obesity being in the title at all. There is an implied association—which isn’t there—with type 1 diabetes.

Chair

Can we keep it quick-fire, because of the time?

Mr Jackson

I am mindful of the time. Mr Stevens, can I briefly ask you two operational questions? One is about the criticism in the Report that staffing levels of diabetes specialist nurses have not changed in the past two years, and that a third of hospitals in England taking part in the audit have no specialist in-patient nurses. How are you going to tackle that issue? It seems to me that with massive increases in the cohort you are going to have to deal with it.

Simon Stevens

The care that hospital in-patients with diabetes get has nevertheless improved, as shown in the Report, on a whole range of measures, including access to foot services in the hospital. A lot of the pressure that is showing up will obviously force different approaches to staffing. Diabetes specialist nurses have a very important role to play, but there is no magic wand. There are obviously huge pressures across the health service, and we cannot conjure extra nurses out of thin air; that is not going to be on offer in the next 12 or 24 months, given everything else that hospitals are confronting in relation to their nurse staffing.

Mr Jackson

Finally, I am obviously very disappointed to see that my own CCG is bottom for care processes, the three bespoke treatments, treatment standards, complications and mortality. Apart from that, it’s doing great.

Chair

Just to be clear, is it bottom of the Committee members’ constituencies?

Mr Jackson

It is flagged red.

Chair

Not necessarily nationally.

Mr Jackson

Yes. That begs the question—I do not want to steal the Chair’s thunder, because I know that she wants to touch on this issue—how are you going to get rid of the huge variations between different parts of the country, which Mr Pugh mentioned earlier? One of the illustrations shows that if you draw a line from the Bristol Channel to the Wash, the performance is pretty poor—apart from inner London—particularly in the south-west. I think it is the one on—

Chair

There are two maps.

Mr Jackson

Yes, there are two or three of them. It seems that the north-west and inner London are doing quite well.

Chair

Do you mean figure 3 on page 14?

Mr Jackson

Yes, and figure 10. You talk about the new framework, but how are you going to close that gap in a timely way, bearing in mind that, as I mentioned earlier, the all-party group was critical of the culture? It said that “many healthcare professionals do not value, or are unaware of, the benefits of education programmes, leading to a lack of referrals and where referrals are made they are poorly explained, meaning that the patient is less likely to attend”. That is a culture question.

Simon Stevens

You are talking specifically about the structure of patient self-education.

Mr Jackson

Well, that and how you get the best CCGs’ practices to everyone. That seems to be how to deal with regional differences.

Simon Stevens

We have got a huge task in front of us across the national health service over the next four and a half years, in terms of the extra headroom we need to create over and above whatever resource the Government are able to make available through the spending review. As part of that, and as well as driving efficiencies in the individual hospitals, provider organisations and so on, we have got to get industrial in our approach to taking out clinical practice pattern variation. That is no longer just nice to have for the health service. We have run out of road on much of the other salami-slicing. Right Care has been mentioned a couple of times; it is the name of the process we are using in each CCG to say, “Here’s what our best practice would look like for your people and your area. Here’s how you’re doing. This is the gap, and this is therefore”—this relates to Mr Mowat’s question—“what that is worth in pound notes and lives saved for the people of Peterborough.” That is our task through CCGs for the next four and a half years.

Mr Jackson

Finally, is someone in NHS England or the Departments modelling the opportunity cost of different disciplines? You cannot stop people getting old and falling over and breaking their hip—it is always going to happen—but you can stop people getting more ill than they already are. Are you looking at that? Are you planning ahead as part of that plan? It seems to me that the cumulative savings for clinicians and the NHS as a whole are enormous if we get this right.

Simon Stevens

Precisely; and that is one of the reasons why we have to have a particular focus on type 1 diabetes, as well as type 2, given that the standards that are being achieved are often worse, and given that the age at which people get a type 1 diagnosis means that they can be living with it for decades. To go back to the conversation with Sir Amyas a little earlier, that is why a type 1 focus on the three treatment goals and the disparities that exist has got to be one of the central things that we do in this next phase of our action, alongside the work on diabetes prevention, and the other programme that we have launched with Diabetes UK.

Mr Jackson

With young people? Because that came up—young people and type 1.

Simon Stevens

Precisely. That has got to be a specific focus of what the Right Care programme will bring about.

Mr Jackson

And that will be in the methodology that you would develop, or that you are going to consult on next year?

Chair

We are approaching 5.30, so we are getting to our quick-fire round. I say this to the witnesses as well as the Committee—the Committee knows this, but the witnesses may want to bear it in mind. We have had quite a lot of background already, so we can take it, and what is in the Report, as read.

Karin Smyth

I think, Dame Una, you said that NHS England had the capacity to support this programme going forward. I am interested to know if, Mr Stevens, you think that NHS England on the ground in regional areas has the capacity to refocus now on driving this agenda forward.

Simon Stevens

Well, when everything is a priority, nothing is a priority, so that is why we have said that for the CCG scorecard we will be putting particular focus on six clinical areas for 2016-17 and beyond, and one of those is diabetes. So yes, we are going to marshal our forces to have an impact in that area and the others that we have identified, against the backdrop of a 50% reduction in the administrative costs of running the commissioning system over the last five years. So there are fewer people now than there were five years ago, but we are going to focus our efforts and get it right.

Karin Smyth

Can I put one question to Jonathan Marron: you talked about the social marketing work that your Department is involved in. Is that social marketing work with patients aligned to the marketing work and public health work that people are doing across the local authorities in this country?

Jonathan Marron

Yes, we put on national programmes and normally make available materials for local authorities to run—

Karin Smyth

I understand that. My concern is for patients in my constituency to get one message.

Jonathan Marron

Yes, so let’s think about the campaigns we have run—from Change4Life, which was very much family lifestyles, and so not really about patients, to the Act FAST on Stroke campaign. I hope that we managed to get those perfectly aligned with the NHS messages in similar areas.

Kevin Foster

In 2012 when we did the review, it noted that payment systems for hospitals did not encourage multidisciplinary care. Given that if someone is obese they are likely to have other health issues, and noting that the current funding models still do not support the delivery of integrated diabetes services, how do you see that being changed?

Chair

Professor Valabhji looks keen to intervene.

Professor Valabhji

I think the vanguard sites are our route into proper integrated care. The financial disincentives to be all pulling in the same direction across primary, community and secondary care are quite real, when you have a funding scenario that is based on payment by results. So the concept that I and my GP colleagues will all be employed by the same organisation pulling in the same direction is the major route forward to address that.

Kevin Foster

Let us say that in three years’ time we are looking at this again; what specific difference might we see?

Simon Stevens

Can I just add one other thing since the Committee last met, which I think is an important example of the kind of payment innovation that has responded to the Committee’s findings previously; and that is the introduction of a best practice tariff for hospital admissions. For emergency admissions of patients with ketoacidosis or hypoglycaemia, the hospital gets an extra payment on top of the index payment if that patient is seen by a diabetic specialist team at the point of admission, has an education review, sees a diabetic specialist nurse or a diabetologist, gets a written care plan and receives structured education on discharge, and so on. That is an example of putting an extra payment on top of the tariff to bring about precisely the kind of difference that you are describing.

Kevin Foster

That has been done, or is being done?

Simon Stevens

That has been done from 2013.

Kevin Foster

Okay. I see in the conclusions “do not support”, so what is the next thing that you have done?

Simon Stevens

Sorry?

Kevin Foster

I see in paragraph 14 in the findings on page 9 that funding models do not support it. That has been done so far, in 2013, and was presumably taken into account in this Report. What is going to be done to address that remark specifically?

Simon Stevens

It does come down to implementing the five-year forward view, in that we are saying to those parts of the country that have combined primary and community services that we will delegate to them the full population budget for their people. We will say in places such as Yeovil or Harrogate where the hospital and the CCG are coming together that they will get the full budget, crossing all the boundaries, so that they can make those kinds of trade-offs or reinvestments. But some parts of the health service will still be buying care per item, as it were, probably for some hip replacements, cataract extractions and so on. So it is going to be horses for courses in terms of the blended payment model, but that is what NHS England and NHS Improvement will be embarking on, beginning in April.

Professor Valabhji

You also mentioned the multidisciplinary team working, and the cardinal example would be the multidisciplinary foot services that we know reduce amputation rates by about 50%, which is really significant. In 2011 when we audited, I think about 60% of hospitals had such a service. In 2013, it was 72%. We just collected data in September this year, and I do not have the results yet. It is on the up.

Chair

Do you know when you will get the results?

Professor Valabhji

That is the in-patient part of the audit, so I think it will probably be around April.

Chair

Oh, so not in time for our Report.

Mr Bacon

Professor Valabhji, you said that some people felt offended when obesity was linked with type 1 diabetes; fair enough. On the other hand, it is true that that is only 10% of the total cohort of people with diabetes, isn’t it?

Professor Valabhji

Type 1 diabetes is, yes.

Mr Bacon

So type 2 is 90%. When you used the phrase “prescriptive interventions”, did you mean the issuing of a prescription, at which point a patient has to go and get something, or did you mean the issuing of a prescription to eat more cauliflower and carrots, and fewer Mars bars?

Professor Valabhji

The latter. I made that comment in the context of the diabetes prevention programme; we have done a very detailed literature review for the international evidence of what works to prevent diabetes. Where we can be prescriptive around an intervention, we are being. The three dimensions are weight loss, more physical activity and better quality of nutrition, so we are being as prescriptive as possible about what the interventions should look like.

Mr Bacon

Can you say those three again? Weight loss—

Professor Valabhji

Weight loss, more physical activity and better nutritional content of the food that is being consumed.

Mr Bacon

In other words, the same message that everyone has been getting already for quite a long time without its necessarily having the right effect. It is all good stuff, but it is not novel, is it?

Professor Valabhji

It is not novel, but if you deliver it as part of a behavioural change programme, we have got good evidence, as I mentioned earlier.