3.2 Ofwat already makes use of comparisons with other sectors in driving efficiencies by benchmarking financial performance and the cost of capital. In addition to incentivising financial efficiency, Ofwat encourages competition in the provision of a range of services and activities, so that customers benefit from market forces and the expertise and efficiency of a full range of suppliers. Where there are remaining areas of monopoly, Ofwat will set targets for efficient costs. Companies are required to demonstrate that they have undertaken proper options appraisals and that their cost estimates are efficient, including providing evidence of robust review and challenge by international suppliers. Ofwat is further strengthening how competition and efficiency are encouraged and incentivised. This will form part of the 2019 price review methodology.
5: Committee of Public Accounts conclusion:
Customers in areas of water scarcity are paying to develop expensive new capacity when water trading with other companies might be a more cost-effective option.
Recommendation 5a:
Ofwat should set out what it intends to do to promote more water trading between companies and greater transparency of costs, to encourage new more cost-effective suppliers to enter the market.
5.1 The Government accepts the Committee’s recommendation.
Target implementation date: December 2017.
5.2 Ofwat has set out options for a market design for water resources in its December 2015 consultation on its proposals for the 2019 price review. Ofwat’s preferred option is to set a binding price control for water resources to help better facilitate an effective market by revealing improved information that will help us set more targeted incentives. Similarly, Ofwat are proposing an information database and a framework that would allow for the ‘bidding in’ of resource options by third parties on an ongoing and fair basis that provides a level playing field between participants. As part of its consultation, Ofwat also updated its assessment of the benefits of water trading in the sector which suggested that the unrealised benefits of increased water trading are around £1 billion. The final proposals in relation to water trading will be included in the methodology statement in December 2017.
Introduction from the Committee
Since the previous Committee of Public Accounts reported in 2012, the Department of Health and NHS England have made progress in improving outcomes for diabetes patients. International evidence now available also suggests that the UK performs well compared to other countries in terms of outcomes for diabetes patients. However, there are significant variations in the routine care and support that diabetes patients receive, and in outcomes for diabetes patients.
The Committee is concerned that the witnesses from the Department and NHS England painted an unduly healthy picture of the state of diabetes services in England. Although an individual diabetes patient’s prospects are getting better, the number of people with diabetes is rising by 4.8% a year, and performance in delivering the nine care processes and achieving the three treatment standards, which help to minimise the risk of diabetes patients developing complications in the future, has stalled. In addition, very few new diabetes patients are taking up education that could help them manage their condition, and the number of diabetes patients experiencing complications (which account for over two-thirds of the cost of diabetes to the NHS) continues to rise.
This all means that the costs of diabetes to the NHS will continue to rise. In order to control these costs, the Department and NHS must take significant action to improve prevention and treatment for diabetes patients in the next couple of years.
Background resources
• NAO Report: The management of adult diabetes services in the NHS: progress review Session 2015-16 (HC 489)
• PAC Report: Management of adult diabetes services in the NHS: progress review Session 2015-16 (HC 563)
• Treasury Minutes: March 2016 (Cm 9237) Updated Government response to the Committee
There were 6 recommendations in this report. As of the last Treasury Minute (Cm 9237), the Department disagreed with 2 recommendations. 4 recommendations remained work in progress, all of which have now been implemented, as set out below.
1: Committee of Public Accounts conclusion:
There are unacceptable variations in the take up of education programmes, delivery of recommended care processes, achievement of treatment standards and in outcomes for diabetes patients.
Recommendation:
• The Department and NHS England should by April 2016, use the new diabetes data available in January to identify those clinical commissioning groups that are performing poorly in comparison to the national average and establish interventions to help them improve their performance.
• The Department and NHS England should by July 2016, set out a timetable to reduce geographical variations and variations between different patient groups.
• The Department and NHS England should clarify which diabetes targets remain in place.
• The Department and NHS England should develop a strategy for sharing best practice, including on using GP IT systems effectively to support the delivery of diabetes care, and report back to us within six months.
1.1 The Government agreed with the Committee’s recommendation.
Recommendation implemented.
Seventeenth Report of Session 2015-16 Department of Health
Management of adult diabetes services in the NHS: progress review
1.2 The Clinical Commissioning Group Improvement and Assessment Framework (CCGIAF), for which the first set of data were published in 2016, includes indicators in relation to two key diabetes measures; diabetes patients that have achieved all the NICE-recommended treatment targets: three (HbA1c, cholesterol and blood pressure) for adults and one (HbA1c) for children; and, people with diabetes diagnosed less than a year who attend a structured education course. For each of these measures, Clinical Commissioning Groups (CCGs) were assessed in relation to the national average position.
1.3 In December 2016, NHS England issued a Call to Bid to CCGs and providers, inviting them to submit proposals for transformation funding to support them to make improvements against four evidence-based interventions for diabetes. Two of these were in relation to the treatment targets and structured education as above. The other two were in relation to expanding the availability of multidisciplinary foot care teams and diabetes inpatient specialist nurses. 166 CCGs have successfully secured funding to support improvements.
1.4 In addition, NHS England has funded specific diabetes posts in regional teams and clinical networks in order to further support local improvements. The criteria for the transformation fund included CCGs and partners identifying whether there were specific patients groups who were under-represented in relation to any of the four interventions and to demonstrate that their proposals were targeted towards these groups. In addition, the scoring methodology for bids included a weighting towards bids from localities that has the poorest CCGIAF diabetes outcomes. Successful bids are based on planned improvement in outcomes during the period 2017-18 to 2018-19.
1.5 Clinical networks have worked with NHS Digital to advise CCGs and GPs on effective use of GP information systems to support National Diabetes Audit (NDA) participation and the appropriate coding of structured education. 82% of GP practices submitted data to the recently published 2015-16 NDA, a significant increase from the 57% participation in the 2014-15 NDA.
1.6 This response meets the requirement to report back to the Committee.
3: Committee of Public Accounts conclusion:
The Committee welcome the introduction of the new NHS Diabetes Prevention Programme but, by itself, this will not be enough to stem the rising number of people with diabetes.
Recommendation:
NHS England and Public Health England should, by April 2016, set out a timetable to ramp up participation in the national diabetes prevention programme to 100,000 people a year, set out what it will cost, and how the programme will target those areas with the highest prevalence of diabetes. Public Health England should also set out how its other public health activities, such as marketing campaigns, will contribute to preventing diabetes.
3.1 The Government agreed with the Committee’s recommendation.
Recommendation implemented.
3.2 In 2016, roll out of the NHS Diabetes Prevention Programme (DPP) commenced across approximately 50% of England (by CCGs), made up of 27 contract areas. All areas were actively generating referrals into the programme and running services for at risk patients by autumn 2016. To the end of March 2017 this had resulted in 42,068 at risk individuals referred to the service and 14,599 people commencing programmes.
3.3 In April 2017 roll out commenced in a further 25% of England, taking national coverage to 75%
and we anticipate generating up to 130,000 referrals into the service in 2017-18. NHS England will roll out to the remaining 25% of England in 2018-19, achieving nationwide coverage.
3.4 The estimated gross cost of NHS DPP interventions (excluding implementation and support costs) is £87 million. This is based on a three year roll-out of the programme to 100,000 people per year by 2020 and totalling 390,000 over five years of the programme running.
4: Committee of Public Accounts conclusion:
Current payment mechanisms do not incentivise secondary and primary care clinicians to work together to deliver integrated diabetes care.
Recommendation:
Whilst vanguard sites are testing new models of delivery, NHS England and Monitor should examine whether the current tariff arrangements support secondary and primary care clinicians to deliver integrated diabetes care. If they are a barrier to integrated care, NHS England and Monitor should develop a proposal in the next 12 months on how to resolve this.
4.1 The Government agreed with the Committee’s recommendation.
Recommendation implemented.
4.2 There are a number of initiatives taking place both within vanguard sites and in other localities to deliver a more integrated experience of care for adults with diabetes. These initiatives are at different stages and take different approaches with regards to payment, so it is too early to evaluate them at this time. National tariff rules should not be a barrier to delivering diabetes care in the most effective way.
Tariff can be varied locally to take into account local circumstances and these local variations can be agreed by providers and commissioners. This mechanism permits a move away from national tariffs where this will provide care that is in the best interest of patients.
4.3 A review of incentives and funding models for diabetes has been undertaken by NHS England in partnership with Diabetes UK and Public Health England.
5: Committee of Public Accounts conclusion:
Few newly diagnosed diabetes patients are taking up education programmes that can help them manage their condition effectively and reduce their risk of developing complications.
Recommendation:
NHS England needs to develop a better and more flexible range of education support for diabetes patients and set out by when this support will be available. To support the development of education services, NHS England also needs to improve the quality of data on take up of education programmes.
5.1 The Government agreed with the Committee’s recommendation.
Recommendation implemented.
5.2 An indicator on structured education was confirmed in the published CCGIAF in July 2016. This indicator is focussed on attendance at structured education. Combined with the Quality and Outcomes Framework measure incentivising GPs to refer newly diagnosed diabetes patients into structured education, this will enable CCGs to identify where action is needed to help ensure that referral of people with diabetes translates into actual attendance at structured education.
5.3 Work has also been undertaken by NHS England’s clinical networks and NHS Digital to improve the accuracy of recording the number of structured education attendances. In December 2016, NHS England invited CCGs, working with providers and other partners, to bid for diabetes transformation funding. One of the four priorities for the use of the funding was to improve uptake of structured education by both the newly diagnosed and prevalent diabetes populations, both by expanding the number of places available and by ensuring that these are well targeted at specific groups within local populations where take-up of structured education is low. NHS England plans to invest £11.1 million in 130 CCGs in 2017-18 to expand the number and range of structured education places available.
5.4 NHS England has allocated funds to support implementation of flexible learning options for people living with both Type 1 and Type 2 diabetes. This funding will be used in 2017-18 to support a number of demonstrator sites across England to test delivery of new and innovative ways of providing self-care support in practice, and to develop an evidence base and to further our understanding of the implementation issues. NHS England is also working with NHS Digital to improve digital support for people living with Type 1 diabetes and ensure it is informed by user need. In addition, the national programme is currently running a procurement exercise to implement and evaluate digital behaviour change interventions for individuals at risk of Type 2 diabetes in seven local health economies. These services will be implemented in 2017.
1.2 The Clinical Commissioning Group Improvement and Assessment Framework (CCGIAF), for which the first set of data were published in 2016, includes indicators in relation to two key diabetes measures; diabetes patients that have achieved all the NICE-recommended treatment targets: three (HbA1c, cholesterol and blood pressure) for adults and one (HbA1c) for children; and, people with diabetes diagnosed less than a year who attend a structured education course. For each of these measures, Clinical Commissioning Groups (CCGs) were assessed in relation to the national average position.
1.3 In December 2016, NHS England issued a Call to Bid to CCGs and providers, inviting them to submit proposals for transformation funding to support them to make improvements against four evidence-based interventions for diabetes. Two of these were in relation to the treatment targets and structured education as above. The other two were in relation to expanding the availability of multidisciplinary foot care teams and diabetes inpatient specialist nurses. 166 CCGs have successfully secured funding to support improvements.
1.4 In addition, NHS England has funded specific diabetes posts in regional teams and clinical networks in order to further support local improvements. The criteria for the transformation fund included CCGs and partners identifying whether there were specific patients groups who were under-represented in relation to any of the four interventions and to demonstrate that their proposals were targeted towards these groups. In addition, the scoring methodology for bids included a weighting towards bids from localities that has the poorest CCGIAF diabetes outcomes. Successful bids are based on planned improvement in outcomes during the period 2017-18 to 2018-19.
1.5 Clinical networks have worked with NHS Digital to advise CCGs and GPs on effective use of GP information systems to support National Diabetes Audit (NDA) participation and the appropriate coding of structured education. 82% of GP practices submitted data to the recently published 2015-16 NDA, a significant increase from the 57% participation in the 2014-15 NDA.
1.6 This response meets the requirement to report back to the Committee.
3: Committee of Public Accounts conclusion:
The Committee welcome the introduction of the new NHS Diabetes Prevention Programme but, by itself, this will not be enough to stem the rising number of people with diabetes.
Recommendation:
NHS England and Public Health England should, by April 2016, set out a timetable to ramp up participation in the national diabetes prevention programme to 100,000 people a year, set out what it will cost, and how the programme will target those areas with the highest prevalence of diabetes. Public Health England should also set out how its other public health activities, such as marketing campaigns, will contribute to preventing diabetes.
3.1 The Government agreed with the Committee’s recommendation.
Recommendation implemented.
3.2 In 2016, roll out of the NHS Diabetes Prevention Programme (DPP) commenced across approximately 50% of England (by CCGs), made up of 27 contract areas. All areas were actively generating referrals into the programme and running services for at risk patients by autumn 2016. To the end of March 2017 this had resulted in 42,068 at risk individuals referred to the service and 14,599 people commencing programmes.
3.3 In April 2017 roll out commenced in a further 25% of England, taking national coverage to 75%
and we anticipate generating up to 130,000 referrals into the service in 2017-18. NHS England will roll out to the remaining 25% of England in 2018-19, achieving nationwide coverage.
3.4 The estimated gross cost of NHS DPP interventions (excluding implementation and support costs) is £87 million. This is based on a three year roll-out of the programme to 100,000 people per year by 2020 and totalling 390,000 over five years of the programme running.
4: Committee of Public Accounts conclusion:
Current payment mechanisms do not incentivise secondary and primary care clinicians to work together to deliver integrated diabetes care.
Recommendation:
Whilst vanguard sites are testing new models of delivery, NHS England and Monitor should examine whether the current tariff arrangements support secondary and primary care clinicians to deliver integrated diabetes care. If they are a barrier to integrated care, NHS England and Monitor should develop a proposal in the next 12 months on how to resolve this.
4.1 The Government agreed with the Committee’s recommendation.
Recommendation implemented.
4.2 There are a number of initiatives taking place both within vanguard sites and in other localities to deliver a more integrated experience of care for adults with diabetes. These initiatives are at different stages and take different approaches with regards to payment, so it is too early to evaluate them at this time. National tariff rules should not be a barrier to delivering diabetes care in the most effective way.
Tariff can be varied locally to take into account local circumstances and these local variations can be agreed by providers and commissioners. This mechanism permits a move away from national tariffs where this will provide care that is in the best interest of patients.
4.3 A review of incentives and funding models for diabetes has been undertaken by NHS England in partnership with Diabetes UK and Public Health England.
5: Committee of Public Accounts conclusion:
Few newly diagnosed diabetes patients are taking up education programmes that can help them manage their condition effectively and reduce their risk of developing complications.
Recommendation:
NHS England needs to develop a better and more flexible range of education support for diabetes patients and set out by when this support will be available. To support the development of education services, NHS England also needs to improve the quality of data on take up of education programmes.
5.1 The Government agreed with the Committee’s recommendation.
Recommendation implemented.
5.2 An indicator on structured education was confirmed in the published CCGIAF in July 2016. This indicator is focussed on attendance at structured education. Combined with the Quality and Outcomes Framework measure incentivising GPs to refer newly diagnosed diabetes patients into structured education, this will enable CCGs to identify where action is needed to help ensure that referral of people with diabetes translates into actual attendance at structured education.
5.3 Work has also been undertaken by NHS England’s clinical networks and NHS Digital to improve the accuracy of recording the number of structured education attendances. In December 2016, NHS England invited CCGs, working with providers and other partners, to bid for diabetes transformation funding. One of the four priorities for the use of the funding was to improve uptake of structured education by both the newly diagnosed and prevalent diabetes populations, both by expanding the number of places available and by ensuring that these are well targeted at specific groups within local populations where take-up of structured education is low. NHS England plans to invest £11.1 million in 130 CCGs in 2017-18 to expand the number and range of structured education places available.
5.4 NHS England has allocated funds to support implementation of flexible learning options for people living with both Type 1 and Type 2 diabetes. This funding will be used in 2017-18 to support a number of demonstrator sites across England to test delivery of new and innovative ways of providing
5.4 NHS England has allocated funds to support implementation of flexible learning options for people living with both Type 1 and Type 2 diabetes. This funding will be used in 2017-18 to support a number of demonstrator sites across England to test delivery of new and innovative ways of providing