Feature / The sharp end

Former national clinical director Rowan Hillson examines the economic cost of diabetes


Diabetes is common, chronic, complicated and costly. Costly to the person who has it in terms of distress, disability and premature death. Costly financially to everyone.

More than three million people in the UK know that they have diabetes and another 800,000 have it without realising. Seven million are at risk of diabetes and by 2030 9.5% of the adult population will have the disease.

The total cost of diabetes care is difficult to estimate because diabetes can cause problems in every part of the body and is found in patients throughout the healthcare service, and in every specialty. Yet often it is not coded, even though the patient’s main problem is a diabetic complication. This applies to death certificates too.

Diabetes currently accounts for about 10% of the total health resource expenditure in the UK. This expenditure is projected to increase to about 17% in 2035/ 2036.

Facts and figures

York Health Economics Consortium estimated that the cost of diabetes in the UK in 2010/11 was £23.7bn (£9.8bn in direct and £13.9bn in indirect costs), rising to £39.8bn (£16.9bn direct costs, and £22.9bn indirect costs) by 2035 / 2036.

Direct costs are those for diagnosis, treatment and monitoring, and for complications such as heart or kidney disease, while indirect costs include mortality, absenteeism and informal care.

The English National Diabetes Inpatient Audit (NaDIA) seeks out people with diabetes in hospitals. They occupy 15% of beds (range just over 5% to 31%). NaDIA publishes detailed analyses by named hospitals, including preventable errors such as new diabetic foot ulcers (half the patients with bedsores have diabetes). In 2011/12, 39% of inpatients had at least one glucose-lowering medication error (44% in 2009/10), which is both dangerous and can delay discharge. Patient experience is also analysed.

In 2011, the total cost of people with diabetes in hospital was estimated as being between £2.3bn and £2.5bn annually – 11% of NHS inpatient spend.

The estimated additional cost attributable to diabetes – expenditure over and above the sum spent on a population of the same age and gender without the condition – was £573m to £686m. This was made up of excess admissions (£434m, including excess emergency readmissions within 28 days costing £99m); lower day-case rate (£9m); and excess costs during admission (£129m to £243m).

In 2011, 5.5% of the population had diabetes and 9.7% of hospital admissions were coded as having diabetes. The 5,912,836 bed days in admissions of inpatients with recorded diabetes represented 19.8% of all bed days. Their mean length of stay was 7.8 days, compared with 4.8 days for patients without a record of diabetes.

Individual hospital trusts can see their own figures in summary, and broken down by HRG by using the variation in inpatient activity tool on the National Diabetes Information Service (NDIS) website www.diabetes-ndis.org.

One in three people with diabetes in hospital are not recorded as such, so the trust may not receive the full tariff for a costly admission. One 12-month study found the estimated average cost of inpatient care for people with diabetes exceeded the tariff paid by up to 8.5% – that amounts to a loss of about £240m a year for providers.

The increased length of stay for diabetic inpatients is particularly obvious in surgical specialties. Day-case surgery is less common among people with diabetes. Studies have shown that an inpatient specialist diabetes team, including consultant diabetologist and diabetes inpatient specialist nurse, can reduce admissions, incidents, length of stay and costs, as well as improving patient experience and increasing day surgery.

At New Cross Hospital in Wolverhampton, a diabetes outreach team reduced the number of diabetic inpatients by 35% and reduced delayed discharges of people with diabetes from 17% to 2%.

Infections and amputations

Diabetes causes numb feet, and circulatory damage, which may cause gangrene. Infections may be severe and hard to cure. There are more than 100 amputations a week among people with diabetes in the UK. The risk of leg amputation is more than 20 times that of a non-diabetic and the rate varies over 10 times around the UK. And 50% of those with leg amputations die within two years.

In 2010/11, the NHS in England spent an estimated £639m to £662m (0.6%-0.7% of its budget) on diabetic foot ulceration and amputation. Primary, community and outpatient care accounted for between £306m and £323m.

It is estimated that 80% of amputations among people with diabetes could have been avoided if those with healthy feet had been taught to care for their feet, or protective expert care had been administered to those whose feet were at risk – for example, those with numb or poor circulation. Prompt specialist care of those with problems – within 24 hours – also helps avoid amputation. 

Clinical and economic evidence suggests that multidisciplinary diabetic foot care teams (MDTs) with strong links to community podiatry services can improve patient outcomes and generate savings for the NHS that substantially exceed the cost of the team.

For example, lower-extremity amputation rates (major and minor combined) at James Cook University Hospital, Middlesbrough, fell by two-thirds after the introduction of an MDT. The annual cost of the team is estimated, in 2010/11 prices, at £33,000. The annual saving to the NHS from averted amputations is estimated to be £249,000.

Drugs and equipment

Glucose lowering and monitoring drugs for diabetes are the biggest item on the NHS primary care prescribing budget, with a net ingredient cost (NIC) of £760m in 2011/12, accounting for 8.9% of the total cost. More than 40 million items were prescribed for diabetes. This does not include other drugs used in people with diabetes.

In 2011/12 the 6.1 million insulin items represented 14.9% of all items prescribed for diabetes – an NIC of £314.7m.

Human analogue insulins were the most commonly prescribed form of insulin – and the most expensive per dose. Useful in patients with type 1 diabetes, they can be substituted in many type 2 patients by older human insulins.

Glucose monitoring cost £158.4m. These finger-prick blood tests are essential in type 1 diabetes to allow insulin dose adjustment and safety (for example, they are required by the DVLA to avoid car accidents). Glucose monitoring is helpful for people with type 2 diabetes in some situations.

The tests and the targets set by NICE for diabetes care are evidence based. Everyone with diabetes should be offered an annual check in primary care for risk factors for diabetes complications, and early signs of the complications themselves, to allow preventive care to be given.

However, in 2010/11, only 54% of patients received all nine of these care processes. Not only are complications preventable, but such care is highly cost-effective.

There are compelling reasons for GPs, clinical commissioning groups, hospital trusts and the NHS to ensure that every person with diabetes is offered comprehensive basic diabetes care, with prompt referral for specialist diabetes care when required. This will be better for patients and better for the nation’s pocket.

Rowan Hillson was national clinical director for diabetes between 2008 and 2013