Summary

Diabetes is a major health issue for New Zealand. Reducing the incidence and effect of diabetes is one of the Government’s population health priorities. Diabetes is also one of eight priority areas for improving Māori health.

The “Get Checked” programme (the programme) was set up in June 2000 by the Health Funding Authority to help people who have been diagnosed with diabetes better manage their condition and lower the risks of complications. DHBs are responsible for the programme and ensuring that it is delivered in their districts.

The programme entitles people who have been diagnosed with type 1 or type 2 diabetes to have a free annual health check from their general practitioner (GP) or appropriately trained registered primary healthcare nurse (diabetes nurse), who are usually members of primary health organisations (PHOs). The purpose of the check is to ensure that key tests (which assist in identifying diabetes complications early) have been completed for the year and to allow people to plan treatment for the year ahead.

The programme is part of the strategic direction for diabetes care set by the Ministry of Health (the Ministry) in 1997.

The programme’s objectives are to:

• systematically screen for the risk factors and complications of diabetes to promote early detection and intervention;
• agree on an updated treatment plan for each person with diabetes;
• prescribe treatment and refer people for specialist or other care if appropriate;
• update the information in the diabetes register, which is used as a basis of clinical audit and for planning diabetes services in the area;
• improve the planning and co-ordination of services delivered by all healthcare providers; and
• decrease the barriers to accessing high quality care for Māori and Pacific Island peoples.

We carried out a performance audit to assess the effectiveness of the programme. We assessed the extent to which the programme’s objectives were being met in a sample of six district health boards (DHBs) – Auckland, Counties Manukau, Tairawhiti, Hawke’s Bay, Capital & Coast Health, and Otago – and a selection of PHOs within these DHBs.

The DHBs had funding arrangements with various organisations to administer the programme (referred to as programme administrators in this report). The majority of programme administrators in our sample were PHOs, but they also included a community organisation, an independent practitioners association, and a DHB.

Programme administrators collect data from GPs, enter it in a database (the diabetes register), analyse the data, and report the results to GPs. They also arrange for DHBs to pay GPs, provide GPs with resources for carrying out the annual check, and provide a summary of the data to local diabetes teams (LDTs) and the Ministry of Health.

Five of the DHBs that we visited had an LDT that provided advice to the DHB on the effectiveness of healthcare services for people with diabetes within the district. The LDTs require data from the diabetes register to fulfil their function of reporting on the programme to the DHB and the Ministry of Health.

The programme operates alongside other national initiatives that contribute to caring for people with diabetes. For example, funding is available to PHOs and community groups to improve access to health services for people with high health needs by using innovative approaches to reach these people. Also, a national programme, Care Plus, was set up in July 2004 to provide co-ordination of care for people with chronic conditions and more complex needs.

Overall findings

Overall, we found that the programme has improved certain aspects of diabetes management. However, there are some issues that need to be addressed for the programme to operate more effectively.

Improvements made in diabetes management in primary care include:

• the numbers of people participating in the programme have increased;
• awareness of diabetes has heightened and monitoring of patients has improved;
• guidance provided to GPs on diabetes treatment and referrals to specialist diabetes services has improved; and
• innovative programmes to remove barriers for people accessing diabetes care, particularly Māori and Pacific Island peoples, are being used in some areas.

Issues that need to be addressed include:

• DHBs need to identify the population eligible to participate in the programme (that is, those people diagnosed with diabetes) so that the programme’s coverage can be accurately assessed and progress towards targets can be measured with certainty.
• Two of the six DHBs that we visited need to resolve information technology (IT) system problems that affect the integrity of the data in their diabetes registers.
• DHBs need to carry out audits to ensure that general practices are preparing good quality treatment plans, in line with the relevant guidelines, and are giving the necessary support to patients so they can implement the plans.
• DHBs need to work with LDTs to collect data on specialist diabetes services and carry out supply and demand analysis to assess the adequacy of the services.
• DHBs need to carry out more cohort studies, using repeated measurement of people who have participated in the programme over several years, to identify how effective the programme is and how best to improve diabetes management.

The following section discusses our findings in more detail against the programme objectives.

Screening and coverage

Few of the PHOs and none of the DHBs in our sample knew the number of people diagnosed with diabetes in their district. This means that it was not possible to accurately assess the coverage of the programme, and also that PHOs and general practices could not be sure that all patients entitled to join the programme had been invited to do so.

In place of actual figures, the Ministry has developed a model to estimate the number of new cases of diabetes diagnosed each year and the total number of people diagnosed with diabetes by ethnicity. The DHBs, PHOs, and programme administrators that we interviewed had little confidence in the accuracy of these estimates. While they thought the estimates may have some validity at a national level, they felt that the model became increasingly inaccurate as populations became smaller – that is, at the district and general practice level.

Programme coverage (the percentage of the estimated number of people diagnosed with diabetes who are participating in the programme) had increased in the six DHBs that we visited, with large increases in some districts – two DHBs (Counties Manukau and Otago) were achieving more than 80% coverage by 31 December 2006. However, two other DHBs in our sample (Tairawhiti and Hawke’s Bay) were achieving programme coverage of less than 60%, and we expected these results would have been higher six and a half years into the programme.

Treatment plans

We were told that treatment plans were being prepared. However, we could not review the quality of those plans because of patient privacy issues.

We note the importance of annual treatment plans in assisting and motivating people with diabetes to change their lifestyles. We are concerned that, apart from work carried out as part of the Diabetes Care Support Audit in the Counties Manukau DHB area, there was inadequate monitoring and audit to ensure the quality and consistency of these plans in the DHBs that we visited. Data collected as part of the programme indicates that people are generally not making lifestyle changes or may not be being given the appropriate support or treatment. Better monitoring and audit of the quality of treatment plans and the support provided to patients to implement the plans would help ensure that the plans fulfil their key role.

Treatment and referral to specialist diabetes services

We found that evidence-based best practice guidelines and national referral guidelines were available to assist GPs with diabetes treatment. The clinical staff in specialist diabetes services that we spoke to considered that GPs were not referring patients on all occasions recommended by the guidelines. However, they considered patients were being referred to them in an appropriate and timely manner, and strict adherence to the guidelines would result in a number of unnecessary referrals. This suggests that the guidelines need to be reviewed to ensure that they still reflect good practice.

We found that specialist diabetes services in the DHBs that we visited were finding it hard to cope with the demand for their services with the resources that they had available. However, the information that the specialist diabetes services were able to give us was not enough to accurately gauge the extent of any shortfall in resources. More detailed information needs to be kept to enable an analysis of supply and demand. This is especially important given the concerns of the specialist diabetes services that improved coverage of the programme and the diagnosis of more people with diabetes will increase the demand for their services.

Updating information in the diabetes register

We have concerns about the accuracy of the data in most of the diabetes registers that were included in our audit. IT system problems affected the reliability and accuracy of the data in most districts, especially in the Auckland area.

In the DHB districts that we visited, the information in some diabetes registers was being used to monitor results and report them to PHOs and GPs. The extent of this feedback and the timing varied significantly. In some cases, the feedback was provided quarterly or six-monthly, while for others it was done annually.

Improving planning and co-ordination of services

We found that only one of the DHBs that we visited (Capital & Coast Health) was using the information in the diabetes register to plan diabetes services in its district.

DHBs had set up LDTs, as recommended by the Health Funding Authority in Diabetes 2000, to identify the health needs of people with diabetes, their family/ whānau, and their communities; to monitor the use of resources related to diabetes; and to recommend any improvements deemed necessary.

The LDT representatives that we spoke to were dedicated in their commitment to improving diabetes services. However, the LDTs varied in how effectively they were able to provide advice on the effectiveness of healthcare services for people with diabetes. The LDTs told us they were constrained by not having enough resources, information, and influence. Although all analysed the information available from the programme, only two looked at information on wider services and none analysed specialist diabetes care data.

The LDTs were receiving information recorded in the diabetes registers and reporting it to DHBs and the Ministry of Health. However, this was only part of the information they needed to evaluate and plan diabetes services in their districts. None of the LDTs that we spoke to were receiving information from specialist diabetes services. They were therefore not able to do a comprehensive analysis of the supply and demand for each diabetes service in their districts.

We found that the relationship between the LDTs and their respective DHBs varied significantly between the districts that we visited. Only three DHBs (Counties Manukau, Capital & Coast Health, and Hawke’s Bay) had a constructive ongoing relationship with its LDT.

Decreasing the barriers for Māori and Pacific Island peoples

We found that some PHOs in our sample had identified barriers to Māori and Pacific Island peoples accessing the programme and put initiatives in place to remove these barriers.

The reported results from our sample showed that, while these initiatives were successful in increasing Pacific Island peoples’ participation in the programme, the numbers of Māori participating in the programme still fell short of the target rates.

Is the programme improving how diabetes is managed?

We do not consider that the measures currently being reported by DHBs to the Ministry are enough to establish whether diabetes management is improving, or identify the reasons for improvements. We consider that DHBs need to carry out robust analysis of the data collected through the programme to enable continuing improvements to diabetes management.

The cohort analysis that has been performed over the data collected shows that drug-prescribing practices by GPs have improved, although this may not be directly attributable to the programme. However, better drug prescribing is only one aspect of improving the management of diabetes. The programme on its own cannot effectively improve the management of diabetes unless it is accompanied by support for patients to self-manage their condition by implementing lifestyle changes.

The poor glycated haemoglobin (HbA1c) management that continues to be reported from the programme needs further analysis to understand what is driving current performance (that is, whether it is drug-prescribing practices or patient self-management) and where incentives need to be directed to improve results. This analysis will require further qualitative information on factors such as the quality of treatment plans and ongoing support for patients. This information can be obtained only through clinical audit.

Our recommendations

In making our recommendations we recognise that the arrangements for the administration of the programme differ among the DHBs that we audited. In implementing our recommendations, DHBs will need to work with the relevant organisations to resolve the issues that we have identified. The DHBs and the Ministry of Health will also need to ensure that a suitable mechanism is put in place to monitor that our recommendations are acted on.

To improve the quality of the programme data, we recommend that:

• district health boards work with programme administrators to identify those patients in patient management systems who have been diagnosed with diabetes (Recommendation 1, page 35);
• district health boards work with programme administrators to identify those people in the population diagnosed with diabetes who are not participating in the programme, ensure that they have been invited to join the “Get Checked” programme, and (if possible) note and address their reasons for declining (Recommendation 2, page 35);
• district health board specialist diabetes services maintain enough data on the numbers of patients attending their clinics, the complexity of patients’ conditions, and waiting times to enable the district health board to identify and plan for the funding and resources needed to provide adequate diabetes services at this level (Recommendation 5, page 42);
• district health boards ensure that the information in their diabetes registers is accurate and updated, and work with programme administrators to identify, clarify, and resolve current problems affecting data quality (Recommendation 7, page 47); and
• district health boards ensure that enough audit processes are in place to verify that payments are being made for genuine annual checks, and that they work with their programme administrators to achieve this (Recommendation 8, page 47).

To improve the effectiveness of the programme, we recommend that:

• district health boards work with primary health organisations to monitor the preparation and audit the quality of treatment plans, and establish the effectiveness of these plans over time (Recommendation 3, page 39);
• the Ministry of Health review and, if necessary, update the national referral guidelines (Recommendation 4, page 42);
• those district health boards where there are shortfalls in specialist diabetes services investigate the shortfalls and provide additional services as considered necessary (Recommendation 6, page 42);
• district health boards work with programme administrators to ensure that the data from the “Get Checked” programme is thoroughly analysed and the results regularly reported back to general practices to improve diabetes care (Recommendation 9, page 50);
• district health boards work with primary health organisations and programme administrators to ensure that adequate clinical audit is carried out to provide assurance that general practices are providing diabetes care in line with the evidence-based best practice guidelines and national referral guidelines (Recommendation 10, page 50);
• district health boards work with local diabetes teams to carry out a more robust analysis of supply and demand for diabetes services at both the primary and secondary care levels, so that any shortages in services provided at both the primary and secondary care levels can be identified (Recommendation 11, page 55);
• the Ministry of Health and district health boards review the role of the local diabetes teams to establish how these teams are best able to adequately fulfil the role of providing advice on the effectiveness of healthcare services for people with diabetes (Recommendation 12, page 55);
• the Ministry of Health and district health boards consider how to improve the adoption of the local diabetes teams’ recommendations (Recommendation 13, page 56);
• district health boards work with primary health organisations to continue to focus on removing the barriers to Māori and Pacific Island peoples accessing the “Get Checked” programme (Recommendation 14, page 63);
• the Ministry of Health and district health boards work with primary health organisations to evaluate existing initiatives for removing barriers to accessing diabetes care, and ensure that there is a mechanism in place to disseminate successful initiatives throughout district health boards and primary health organisations (Recommendation 15, page 63);
• district health boards consider whether initiatives need to be put in place for populations within their districts other than Māori and Pacific Island peoples who also experience barriers to accessing diabetes care (Recommendation 16, page 63);
• district health boards and the Ministry of Health carry out further analysis (for example, cohort analysis) of the effect that the “Get Checked” programme has had on diabetes care and management, to better understand how the programme and other factors contributing to diabetes care are linked and to identify what further improvements can be made in diabetes care and management (Recommendation 17 page 68); and
• district health boards work with local diabetes teams and programme administrators to make more use of the data available from the ”Get Checked” programme to plan their diabetes services (Recommendation 18, page 68).