EXECUTIVE SUMMARY
The CCA recommends that the Government and the NHS :
- Commission a national diabetes screening service from community pharmacies.
- Support the development of seamless IT referral pathways.
- Develop patient pathways allowing Independent Prescribing pharmacists to initiate treatment where needed.
Currently diabetes is a significant and growing problem for the NHS:
- Diabetes accounts for 10% of its total budget, an estimated £15bn.
- This is expected to grow to 17% by 2035/36.
- Nearly a month’s worth of GP appointments is dedicated to managing Type 2 Diabetes every year.
- Early diagnosis could dramatically reduce the cost and health impact of diabetes, with early intervention preventing cases of Type 2 Diabetes all together.
- National screening could identify over 45,000 undiagnosed diabetics and 180,000 people with pre-diabetes every year.
- Proactively treating these people could prevent nearly 7,000 heart attacks or strokes every year.
THE GROWING BURDEN OF DIABETES
Diabetes is the most common chronic disease in the UK, and its prevalence is increasing. [1] The cost of this disease, for patients, the NHS and wider society is significant. Concerningly, 80% of this spend is on complications from poorly managed diabetes, rather than direct costs of diabetes management. [7]
In addition to lifelong disease, diabetes impacts an individual’s whole health leading to stress, anxiety, and depression. Around 30% of people with Type 2 Diabetes (T2D) have CVD [8], increasing their risk of suffering heart attacks and strokes, whilst 1 in 3 adults with diabetes will suffer with kidney disease.
People with diabetes are 25 times more likely than the general population to become blind. In England and Wales, diabetic eye disease is the leading cause of blindness in adults under 65 years. [9]
Diabetes is the most common cause of non-traumatic amputations in the UK, accounting for over 180 amputations a week. Diabetes is therefore strongly linked to lower life expectancy. [10]
THE IMPACT ON THE NHS
An estimated 50% of people with diabetes are undiagnosed. Between 20% and 30% of these people already have serious complications when they are eventually diagnosed.
[11] Screening would allow for early diagnosis and treatment.
Each T2D patient costs the NHS an estimated £3,000 per year, through direct costs alone. [12] Avoidable complications cost the NHS over £6.2bn a year – which could be saved with better treatment and prevention. [13]
Diabetes has a huge impact on NHS capacity, alongside the significant financial cost. As many as 25 million GP appointments every year are estimated to be dedicated to the management of T2D. [14] This is nearly an entire month’s worth of GP appointments dedicated to T2D management. [15]
Since the pandemic, primary care, particularly general practice, has faced increased patient demand.
One in five people reported not being able to contact their GP practice, according to the recent NHS Primary Care Recovery Plan. [16] As the disease burden grows, so too will the demand on GP care.
One in five people reported not being able to contact their GP practice, according to the recent NHS Primary Care Recovery Plan. [16] As the disease burden grows, so too will the demand on GP care.
This impact is not restricted to primary care. Between 1999 and 2020 the rate of hospitalisations for T2D increased by 75%. [17] Concerningly, a quarter of these admissions were for peripheral circulatory complications including strokes, non- healing ulcers, and amputation. [17]
THE ROLE OF SCREENING WITHIN THE NHS
NHS England has committed to increasing the availability of Point-of-Care Testing (PoCT). This is an important part of a move to greater preventative health. Identifying people with disease early, allows earlier intervention and better outcomes. The 2019 Community Pharmacy Contractual Framework outlines an ambition to use community pharmacy to drive this. [18]
The Covid-19 pandemic demonstrated a public acceptance of PoCT, with Lateral Flow Tests (LFT) becoming commonplace and the public increasingly comfortable with self-testing. Pharmacies were a key provider of tests, with over 90% of community pharmacies providing LFT collection services amounting to over twelve million tests a week. [19]
Unfortunately, the impetus to move testing closer to home has not progressed. Following the pandemic, commissioners have not explored the benefits of PoCT services further. Whilst there are developments in the private healthcare market, mass uptake and changing patient expectations will require national, publicly funded, commissioning.
Screening for diabetes has been proven to be cost effective.
Screening and subsequent treatment has a positive impact on health and outcomes. [20] NICE have determined that diabetes screening services fall well under recommended cost thresholds.
“…identifying the nearly 850,000 undiagnosed diabetics could prevent nearly 7,000 cardiac events each year.”
Delays in diagnosis directly contribute to increased risk of cardiovascular disease. Modelling has shown the impact early diagnosis has on reducing mortality. [21]
Screening (and subsequent action) saves lives. Modelling shows that identifying the 850,000 undiagnosed diabetics could prevent nearly 7,000 cardiac events (such as heart attacks and strokes) each year.
ACCESSING SCREENING
Unfortunately, there are well reported, and significant access issues associated with both hospitals and general practice.
This is creating a growing unmet need.
Patients must travel long distances or spend an extended period waiting for an appointment, creating barriers to access. In turn, people are not receiving appropriate and timely treatment.
Limited access also has a disproportionate impact on deprived communities. The cost of travel creates an additional burden for those with limited financial security, who often rely on public transport. Reduced flexibility through working commitments often compounds this.
Community pharmacies, who are renowned for their accessibility, combined with the ease of use of PoCT services, offer a new way to tackle an ever-growing health challenge.
PoCT can play a critical role in identifying those with diabetes or crucially those in a ‘pre-diabetic state’. With early intervention and support, people can make lifestyle changes that can help them to avoid diabetes and stay healthy and productive.
Early diagnosis dramatically improves the life chances of diabetes sufferers. [21] Preventing diabetes altogether could have a transformative impact on the health of a large, and growing part of the population. Furthermore, it could significantly reduce costs to the NHS and help boost UK economic growth and productivity.
THE ADVANTAGES OF COMMUNNITY PHARMACY
Unfortunately, it is known that healthcare is often least accessible to patients who reside in communities who need care the most. This is known as the “Inverse Care Law”. [22] However, community pharmacy bucks this model of care. There are actually more community pharmacies in deprived areas in the UK (the “Positive Pharmacy Care Law”). [23]
There are over 10,500 community pharmacies across England. Existing national services such as vaccination, screening, and urgent care services (Pharmacy First), show that pharmacies regularly undertake proportionately more consultations in the most deprived communities. [24, 25, 26]
Diabetes is closely linked to both obesity and deprivation. [27] Prevalence of T2D is 40% higher is the most deprived communities than the least deprived. [28]
The recently commissioned Pharmacy First service provides urgent care for seven common conditions. There were two and a half times more consultations in areas of highest deprivation, in the first month. [29] Similarly, over a third of COVID vaccines provided by community pharmacies were in the most deprived communities. [25] National commissioning of care through community pharmacy, naturally provides greater access and activity in deprived areas.
Commissioning through pharmacies directly targets care to those who need it most.
Pharmacy has a reach to the general population that is essential for a national screening service. It is estimated around 1.6 million people visit a community pharmacy in England, every day. [30]
Many of those who visit a pharmacy do so for other reasons, such as to purchase over the counter medicines or even to purchase non-healthcare related products.
People who think that they are well visit their pharmacy regularly, whereas they would not think to book an appointment to see their GP for a screening test.
“… pharmacies are located near where people work and live.”
THERE ARE CURRENT EXAMPLES OF SUCCESS
Early diagnosis and action are key to tackling diabetes. Research has shown that point of care testing and the information this offers, helps people understand how lifestyle factors affect their health. [31] Indeed, the convenience of a “single appointment with point-of-care testing is a major advantage”.
Being able to link behaviour change to a changing test result dramatically improves the likelihood lifestyle changes are maintained. [32] Diabetic health, and potential remission, is closely linked to weight loss, reduction in waist circumference, and reductions in HbA1c. [32] HbA1c is a blood test used to monitor blood glucose control, a key marker of potential diabetes and disease control.
One example of a point-of-care testing device is the A1CNow+ device.
Pharmacies have been using this device for over a year. They are supporting patients with T2D or identifying those at risk through their family history and associated risk factors.
Pharmacy teams can provide patients with a clear picture of their health. They can do this by combining standard physical measurements (weight, waist etc.), with HbA1c measurements through the A1CNow+ point-of-care testing device.
Identifying pre-diabetic patients offers an opportunity to intervene early. Once pharmacies identify at-risk patients, they can offer targeted support. This includes goal setting, behavioural support, and information and advice.
A service led by BHR BIOSYNEX used a behavioural support process called MoREM®. This approach combines the power of taking a test (HbA1c) with the necessary support to make changes. The behavioural changes are essential to create the different outcomes in health.
MoREM® combines lifestyle coaching with goal setting and ongoing support from trained pharmacy teams to create change.
Results collected from initial small-scale trials, using MoREM® and glucose testing, are extremely promising. All patients showed a reduction in their Hb1Ac readings, with an average reduction of 12% (6mmol/mol) over 3 months. Similarly, 96% of patients recorded a reduction in their waist measurements, with an average of a 5cm reduction over 3 months.
People at risk of diabetes are identified through the current private service, providing an opportunity to intervene when people have pre-diabetes. It also provides support for current type 2 diabetics.
By returning blood sugar levels to non-diabetes levels long term, remission can be achieved. The combination of MoREM®-led behavioural change and glucose testing allowed 87.5% of type 2 diabetics in trial to achieve remission. This was following 3- months of pharmacy led support.
Patients are benefitting from this service across the UK. However, it is currently only available privately.
“All Patients showed a reduction in their Hb1Ac readings.”
The cost of accessing screening creates a barrier to access. Those without resources are unable to pay for screening. Worryingly, deprivation is known to correlate to disease prevalence. People in more deprived areas are more likely to be diabetic or pre-diabetic. [33] This means many of the people who would benefit from this care, are unable to due to the barrier of cost. A publicly funded solution is urgently needed.
“The service is a gamechanger, it’s a fantastic tool for prediabetic and diabetic patients. The ease of using the point of care A1CNow+ device was amazing. Results were obtained in less than 5 minutes.”
– Faiza Rafique, Pharmacist and Clinical Director
IDENTIFYING OVER 45,000 PEOPLE WITH UNDIAGNOSED DIABETES EVERY YEAR
Screening for another long-term condition (hypertension) is already commissioned from community pharmacies across England. In 2023, over 8,000 community pharmacies screened 1.6m people. [34] This identified nearly 100,000 people with hypertension who received advice or referral for treatment from their GP. [34]
Community pharmacies could screen 1.5 million adults every year for diabetes, a comparable number to the hypertension service. This would likely identify over 45,000 people with undiagnosed T2D and 180,000 people with pre-diabetes. [35, 36]
Concerningly, if they are not identified nearly a quarter of these people with pre- diabetes (45,000) would subsequently develop diabetes. [37]
The NHS Diabetes Prevention Programme reduces the incidence of people developing diabetes by 37%. With the same success rate, a national community pharmacy service could reduce the number of people who develop T2D by 18,000 people every year. This would save the NHS almost £50m every year for each cohort screened. This also increases life expectancy by almost 100,000 years for each cohort. [38]
It is difficult to estimate and quantify the impact of late diagnosis. Many would go on to develop problems such as:
- Heart disease or stroke
- Kidney disease
- Nerve damage
- Eye problems
- Sexual dysfunction
Of the 45,000 diabetics identified by a community pharmacy screening programme, we would expect around 14,500 to develop diabetic retinopathy over the course of their lifetime. [39] Early diagnosis and intervention could prevent up to 98% of severe sight loss. [9] As such, a screening programme supported by healthcare interventions could prevent up to 14,230 people from developing severe sight loss.
In addition, 41.7% of people with undiagnosed diabetes, and 17.7% of people with pre- diabetes have chronic kidney disease (CKD). [40] This would account for over 50,000 people per year of the screening programme. 55% (27,500) of those will likely have CKD in stages 1-2. [41] If you can prevent 90% of these patients progressing to the later stages of CKD, it would save the NHS £12.5m per year, per cohort. [41] This excludes the cost of dialysis and transplantation.
A nationally commissioned service could screen 1.5m people each year. Identifying and preventing people from developing diabetes will not only have immediate cost savings for the NHS, but for each year they do not need care and treatment. Each year that the service is operational, the NHS would benefit from £50m in recurring savings. This means that in the fifth year of the service, the NHS would save £250m or £750m since the start of the service.
Despite being difficult to quantify, there are models predicting the cardiovascular impact. Modelling was undertaken on the ADDITION-Europe survey data. [21] This showed that diabetes screening, followed by appropriate treatment, led to a reduced risk of cardiovascular disease or death within a 5-year follow-up period when compared to patients having no screening.
Modelling predicts that a 3-year delay in diabetes diagnosis and treatment, means 22.4% of those 45,000 people with undiagnosed diabetes would suffer cardiovascular disease – for example a stroke or heart attack. [21]
Screening could identify people with diabetes and allow treatments to be initiated immediately. Every year, this could help prevent 3,591 incidences of cardiovascular disease amongst those with undiagnosed diabetes. Based on the number of people with pre-diabetes likely to be identified, a further 3,375 incidences of cardiovascular disease could be prevented every year.
EVERY YEAR A NATIONALLY COMMISSIONED SERVICE COULD:
THE PATIENT JOURNEY
Community pharmacies excel at reaching large portions of the population, often those with limited interaction with other parts of the NHS. The positive pharmacy care law means many of these people are in the most deprived communities of the country. [23]
The basic pathway of a diabetes screening service would likely replicate that of the Hypertension Case Finding service, available nationally in England since 2021. [24] This would mean that the service would be familiar to patients and pharmacy teams and therefore quickly scalable.
People would be identified in pharmacies and offered testing. Following consent, simple body measurements and HbA1c PoCT would be completed.
Depending on the results, patients would be offered:
Simple healthy living advice to support continued good health [No concern] Support with lifestyle change underpinned by continued PoCT [Pre- diabetic]
Referral for treatment initiation from their GP. In time, this could be to a prescribing community pharmacist. [Un-diagnosed diabetic]
Importantly, following the ‘Delivery Plan for Recovering Access to Primary Care’ pharmacy teams are now able to update GP records. [16] A new system, called GP Connect, allows automatic writing to GP records following a community pharmacy service. Once updated for this new service, patient records can be updated with the outcomes of any screen completed.
Changes to the initial education and training of pharmacists means that from 2026, all new pharmacists will be qualified to prescribe. This means they will be able to write prescriptions for new medication, if commissioned to do so. Once pharmacists are routinely prescribing, they could initiate any treatment needed for undiagnosed diabetes. This will further reduce the time General Practices dedicate to patients with diabetes. The access to patient records through GP Connect will enable this.
MAPPING THE PATIENT JOURNEY
COMMISSIONING ACROSS AN INTEGRATED CARE SYSTEM – EXAMPLE:
GREATER MANCHESTER INTEGRATED CARE PARTNERSHIP
The Greater Manchester Integrated Care Partnership has identified diabetes as one of their key priorities, as have many ICSs. They have set out their diabetes strategy “Tackling Diabetes Together”. [42] In this, it is estimated 850,000 (30%) people living in Greater Manchester will develop diabetes in their lifetime. With a current prevalence of 7.4%, this is higher than the national average.
The 639 community pharmacies could provide a screening service to support this local strategy. If all pharmacies were commissioned it is calculated that:
- Almost 2,000 people with undiagnosed diabetes would be identified each year.
- 10,800 people with pre-diabetes would be identified
- 2,700 of whom would statistically develop diabetes in the following 5 years.
By identifying these people and providing targeted support, 536 people could be prevented from having a cardiac event every year.
Furthermore, screening and intervention would prevent 1,000 people from developing diabetes every year – saving the NHS in Greater Manchester £3m every year.
GREATER MANCHESTER INTEGRATED CARE PARTNERSHIP
639 COMMUNITY PHARMACIES
2,000 UNDIAGNOSED DIABETICS
10,800 PRE-DIABETICS
£3M IN RECURRING SAVINGS FOR EVERY YEAR OF THE SERVICE
NEXT STEPS
The reach and location of community pharmacy makes it a prime location for any national screening service.
The long-standing relationships that pharmacy teams hold with their local communities make them well placed to support patients with behavioural and lifestyle changes. Indeed, previous evidence, both with the A1CNow+ device and the national Hypertension Case-Finding service, has demonstrated the impact community pharmacies can have. Cost remains a significant barrier to maximising the benefits of this service and public funding is essential, both to increase uptake and tackle health inequalities.
We recommend the government and the NHS:
1
Commission community pharmacies to screen patients across England to identify and then support people with type 2 diabetes and pre-diabetes.
2
Support the development of IT connectivity, allowing results to be seamlessly added to patient records.
3
Develop patient pathways to allow newly diagnosed patients to receive treatment initiation from Pharmacist Independent Prescribers in community pharmacy.
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WHO WE ARE
COMPANY CHEMISTS’ ASSOCIATION
Established in 1898, the CCA is the trade association for large pharmacy operators in
England, Scotland and Wales. The CCA membership includes ASDA, Boots, Morrisons,
Pharmacy2U, Rowlands Pharmacy, Superdrug, Tesco, and Well, who between them own
and operate around 5,500 pharmacies, which represents nearly half the market. CCA
members deliver a broad range of healthcare and wellbeing services, from a variety of
locations and settings, as well as dispensing 500 million NHS prescription items every
year. The CCA represents the interests of its members and brings together their unique
skills, knowledge, and scale for the benefit of community pharmacy, the NHS, patients
and the public.
BHR BIOSYNEX UK – Read More on POCT Innovators
Established in 1990 as BHR Pharmaceuticals Ltd, and specialising in point-of-care
diagnostics since 1994, BHR BIOSYNEX is a market leader in the provision of POCT
solutions. We specialise in sourcing innovative and progressive technology from around
the world and delivering these innovative products to our customers in the UK.
Providing Point-of-care Solutions that meet the needs of a changing NHS Founded in 1990 as BHR Pharmaceuticals Ltd, BHR BIOSYNEX is a market leader in the provision of point-of-care diagnostics solutions. We specialise in sourcing advanced and progressive technology from around the world and deliver these innovative products to our customers in the UK &…