NHS hospitals are losing specialist diabetes consultants and nurses, with negative results for patient care, experts writing in the BMJ have said.

The editorial argues that poor management of diabetes by the NHS is due not only to patient lifestyles but also to financial pressure on hospitals.

It points to a major increase in the death rate of young women with type 1 diabetes as evidence that specialist NHS treatment capacity is declining.

Reports on the crisis of NHS diabetes care tend to focus on the increasing prevalence of type 2 diabetes, most cases of which are related to obesity.

However, according to the National Diabetes Audit, the death rate among women aged 15–34 with type 1 diabetes increased ninefold from 2007 to 2011. Obesity is rarely a factor in such cases.

The authors note that financial pressures on PCTs has led to a growing pattern of diabetes specialist teams being reduced or dropped altogether.

Hospital teams of diabetes specialist nurses are tending to be replaced by practice nurses who have less expertise in this complex treatment area.

Specialist diabetes consultants are being replaced by acute physicians. A recent survey showed that 30% of diabetes specialist registrars were unable to find a consultant position within a year of qualifying.

The authors argue that the payment by results tariff is “a barrier to integration” that “deprives patients of access to a specialist team”.

Some areas have “informally” bypassed PbR to make more integrated care of diabetes affordable, they note – and this approach “needs to be introduced nationally” to facilitate patient movement between primary, community and secondary care.

Financial performance related schemes do not motivate GPs and result in a drop in standards of primary care, researchers claim.

Professor Steffie Wollhandler from the New York School of Public Health warns that financially related systems are based on “flawed assumptions” about medicine, measurement and motivation.

She added that providing financial rewards for hitting set targets “changes the mindset needed for good doctoring”.

The DH’s Quality Outcomes Framework currently rewards doctors who hit set targets. But Professor Wollhandler said that while more “straightforward manual tasks” are completed, complex cognitive tasks are overlooked.

“A growing body of evidence from behavioural economics and social psychology indicates that rewards can undermine motivation and worsen performance on complex cognitive tasks, especially when motivation is high to begin with,” said Professor Wollhandler in an editorial with the BMJ.

“Highly detailed prescriptive contracts may be perceived as controlling and may undermine the intrinsic motivation crucial to maintaining quality when nobody is looking.

“Offering financial incentives to doctors, rather than enhancing their intrinsic motivation, may reduce their desire to perform an activity for its inherent rewards (such as pride in excellent work, empathy with patients).”

The new DH draft requirements for commissioners make the maintenance of a ‘level playing field’ for competing providers from all sectors mandatory.

Published for consultation, Securing best value for NHS patients proposes legal requirements that CCGs must observe “choice and competition” and must make their tendering processes and decisions transparent.

Commissioners would be banned from “preventing, restricting or distorting competition” unless it was “indispensable” to achieving patient benefit.

The document states that the reason for making this competitive framework statutory is that CCG autonomy will preclude its enforcement within the NHS: only making it a legal requirement will ensure compliance.

The DH says the “most important task” of CCGs is to “secure best value from limited resources”. It wants commissioners to “have flexibility”, but needs to ensure that they “carry out an objective assessment of different options”.

The draft requirements describe Monitor’s new role as the enforcer of these regulations. The watchdog will not be involved in every tender process, but rather “investigate possible breaches of the regulations”.

The DH intends to prohibit commissioners from treating independent or voluntary sector providers “less favourably” than public sector providers.

To ensure transparency, commissioners must “maintain appropriate records” showing how they have reached their decisions.

Protection of patient choice (as defined by the NHS Constitution) is also proposed as a mandatory principle for CCGs.

Finally, the document states that where a conflict of interests arises, it must be managed “effectively and transparently” by the commissioner.

The consultation will end on 26 October 2012.

The NHS Commissioning Board Authority (NHSCBA) has appointed its 15th Commissioning Support Unit (CSU) managing director.

Tim Andrews has been appointed to lead the Cheshire, Warrington and Wirral CSU after serving as its interim MD. He also previously led the Commissioning Lab.

His appointment follows five other MDs being selected by the NHSCBA in the second round of recruitment. The Authority initially planned to appoint 14 MDs during the second phase of recruitment but failed to fill its target of 14 positions.

The Commissioning Board has been criticised by certain CCGs for the amount of time it has taken to fill all 23 MD positions for CSUs. Dr Joe McGilligan, Chair of ESyDoc CCG, claimed the delay in appointing a MD for his regional CSU was slowing down the group’s authorisation process.

The Board recently renamed commissioning support organisations as CSUs in an attempt to differentiate those which are to be hosted until 2016 and suppliers from the private sector.