General practitioners in the United Kingdom are to be offered final incentives to refer individuals with nondiabetic hyperglycemia to a diabetes prevention program, the national health watchdog has announced, despite the fact it seems to be patients failing to take up the referral that is holding back participation rather than doctor referral.
The National Institute for Health and Care Excellence (NICE) published online August 1 some draft performance indicators for general practitioners working in the National Health Service (NHS) in England that include one that measures the proportion of “at-risk patients” that clinicians refer to the Healthier You: NHS Diabetes Prevention Program.
As reported by Medscape Medical News, Healthier You is a collaboration between NHS England, Public Health England, and the charity Diabetes UK, with the aim of reducing the risk of patients developing type 2 diabetes to both improve health and reduce health costs.
The program began with an initial rollout in 2016, covering 27 areas and 27 million people, offering up to 20,000 places on the scheme for patients with nondiabetic hyperglycemia (or prediabetes). It is intended that the whole of England will be covered by 2020, with 100,000 referrals per year.
However, an article published earlier this year in Pulse, a UK magazine for GPs, revealed that, although clinicians had referred 25,687 at-risk patients to the program, compared with a target of 24,605 individuals, patient participation was extremely low, with only 7232 of 20,000 places taken up.
There are therefore questions about whether this proposed financial incentive for GPs targets the wrong side of the equation when it comes to attendance at the program.
One GP who specializes in the treatment of diabetes, Naresh Kanumilli, MD, MRCGP, from the Northenden Group Practice, Manchester, United Kingdom, wonders whether the whole notion of incentivizing clinicians “is something of a false economy.”
Speaking to Medscape Medical News, he said: “How are you going to incentivize the person to attend the sessions to lose weight, to engage in healthy eating and exercise programs?”
There is a parallel, Dr Kanumilli noted, with the indicator that is already in place to refer diabetes patients to structured education.
Most general practitioners would likely reach referrals rates for 90% or 95% for structured education, he said, asking: “But how many people attend such an education? If you look at the national figures, it’s very low.”
Even Where DPP Programs Are Available, Waiting Lists Can Be Long
NICE highlights that, while individuals with an increased HbA1c levels of 42 to 47 mmol/mol (6%–6.4%) are at increased risk of developing type 2 diabetes, progression can be prevented or delayed via lifestyle changes such as diet and exercise.
The draft performance indicator proposes that clinicians will be incentivized based on the “percentage of patients newly diagnosed with nondiabetic hyperglycemia in the preceding 12 months who have been referred to a Healthier You: NHS Diabetes Prevention Programme for intensive lifestyle advice.” It is currently out for consultation.
NICE also recognizes that referral is only possible in areas where the program has already been implemented but notes that “it should be available throughout England by 2020.”
Dr Kanamilli stressed that access to the program is also currently a key issue. Even in areas where Healthier You is available, there are few places, and the waiting lists can be long, he said.
Moreover, a number of general practices are already referring patients to other healthy-living programs.
“If you take our practice, we have about 300 persons with nondiabetic hyperglycemia,” Dr Kanumilli said, “and we do a lot of work with them already, but that’s taking away time from the other things that a nurse or a doctor could be doing.
“Do the practices want to spend money on employing people to provide these public-health messages and advice, or is it something that the local council should be doing [instead]…to try to engage with the people with nondiabetic hyperglycemia?”
Dr Kanumilli has reported that he has served as a director, officer, partner, employee, advisor, consultant, or trustee for Primary Care Diabetes Society and Heart Networks and received income in an amount equal to or greater than $250 from Sanofi; Janssen Pharmaceuticals, Merck Sharp & Dohme, Takeda Pharmaceuticals, Boehringer Ingelheim/Lilly, and Abbot.
National Institute for Health and Care Excellence. Proposed standards and indicators. August 1, 2017. Available here.
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