Why has diabetes increased? The answer may be economics rather than lifestyle

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Over the last couple of days we've seen reports that the numbers of diagnoses for diabetes in the UK has risen by 60% over the last decade.

The number of people living with diabetes has soared by nearly 60% in the past decade, Diabetes UK warns.

The charity said more than 3.3 million people have some form of the condition, up from 2.1 million in 2005.

There's no disputing the accuracy of these figures or indeed the impact of the increase on the NHS (although claims it will 'bankrupt' the service are stretching the point a little). And we obviously need to know what it is that's causing the increase so as to try and prevent or mitigate those causes.

The most common 'cause' fingered in the reports is "lifestyle":

Martin McShane, national medical director for long term conditions at NHS England, said: “These figures are a stark warning and reveal the increasing cost of diabetes to the NHS. Evidence is piling up that added sugar and excess calories are causing avoidable increases in obesity and diabetes.

“We’ve said it before and we’ll say it again, it’s time to get serious about lifestyle change. Prevention is better than treatment for individual health as well as the health of the NHS.”

And let's be clear here about lifestyle. There's a well established link between morbid obesity and type-2 diabetes (which makes up 90% of the increase):

The relationship between obesity and diabetes is of such interdependence that the term 'diabesity' has been coined. The passage from obesity to diabetes is made by a progressive defect in insulin secretion coupled with a progressive rise in insulin resistance. Both insulin resistance and defective insulin secretion appear very prematurely in obese patients, and both worsen similarly towards diabetes.

So if there has been a significant increase in obesity, we would expect a comparable increase in type-2 diabetes. The problem is that this dramatic increase in diabetes has come during a period when the UK's rates of obesity were pretty stable (perhaps rising slightly):

If obesity is the main cause of new diabetes cases, this graph suggests that the increase should have been significantly less than 60%. So we have to look for another cause - perhaps it's something specific in the diet - sugar is the usual culprit here (mostly because diabetes is all about blood sugars and stuff like that so it stands to reason, doesn't it). Listening to a radio report on the story, I heard the interviewer ask something like "but it's not every kind of sugar is it, there are good sugars like the ones in fruit" - receiving a response all about 'five-a-day' rather than an accurate answer explaining how there's a link between fructose and type-2 diabetes (fructose being the dominant sugar in fruit).

It's worth therefore looking at whether sugar makes up more or less of our calories than it did a decade age - if there has been a substantial increase in sugar as an element in our diet and especially fructose then we might be able to point at that as a reason for the huge increase:

So here are some facts about the consumption of "non-milk extrinsic sugars" (this is all the added sugar as well as honey) in the UK. The figures come from the National Nutrition and Diet Survey (NNDS) conducted by the Government to provide a nationally representative snapshot of the nutritional intake and status of the UK population.

In 2000/01 NMES consumption in daily grammes was:

Male: 79
Female: 51

In 2008-20011 the average is:

Male: 70
Female: 50.1

So our sugar consumption has fallen. And this includes ALL forms of added sugar - the scary hidden stuff in processed food and the spoonful of lovely honey you stir into your hot toddy. Other than for women over 65 every category of consumption has fallen - with the biggest fall being among children.

We still eat a lot of sugar but there's no indication that it can be blamed directly for the increase in diabetes and especially type-2 diabetes. Despite all the shouting about diet and obesity, all the damnation of 'lifestyle', we're not really any closer to understanding why the last decade has seen such a big increase in diabetes. There is, however, one other thing that changed in 2004:

The new GP contract has been quoted as the most radical change to health care since the advent of the NHS in 1948. A major component of the contract is the Quality and Outcomes Framework (QOF). This offers a scoring system for achievement of health-care targets which is linked to financial rewards.

Put more simply - from 2004 family doctors were given a direct financial incentive to diagnose conditions that were within health-care targets and this included diabetes. Prior to 2004 few GPs ran routine diabetes tests - afterwards, with a direct financial incentive, loads more cases were identified. Don't get me wrong here, I'm not suggesting the incentive was a bad thing (it did mean lots more people got their diabetes treated who didn't before) but that it was perhaps the main reason why we saw a steady increase in diagnoses for diabetes.

Finally there's the matter of demographics - or to put it another way, how we're living longer:

You can see (perhaps) the impact of the rapid increase in obesity during the 1990s but look at the prevelance in the over-65s. Combine an incentive for GPs with an ageing population more likely to be visiting those GPs and we can see the source of our 60% rise. And this means that, rather than shouting about lifestyle, we should be celebrating just how well we've done in identifying diabetics - the task is to get that diabetes managed so as to avoid the expensive clinical interventions that are the big drivers of cost.

But then shouting about fat people and blaming sugar is much easier isn't it!

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A good example of 'nudge'. It's also a cracking idea.

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Most of the left-wing world (and plenty of the Tory world too) thinks that 'nudge' is about pricing, taxing and regulating the hell out of things so as to make people change their behaviour. As the creators of the concept were clear this isn't so.

This is nudge:

A speedometer that indicates your speed and additionally gives you a money counter. What’s the deal? Each car that passes and stays below the speed limit of 30 kilometers per hour raises €0,03 for the neighborhood.

The money is paid out by the city of Amsterdam and is meant to be used in local community projects. The city’s slogan: “Max 30 — Save for the Neighborhood”. An interesting take on conditioning local residents to bring forth good citizenship instead of punishing car drivers for breaking minor traffic laws when being slightly over the speed limit.

Rather than the sign leading - as speed cameras do - to a fine and to punishment, we have a little gentle incentive. Slow down and the community gets some cash.

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Covering up failure - a lesson from the USA

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The lengths to which people will go to cover up institutional failure are frightening - especially in the public sector. Here Atlanta Public Schools (APS) provide a master class:

Teachers and principals erased and corrected mistakes on students’ answer sheets.


Area superintendents silenced whistle-blowers and rewarded subordinates who met academic goals by any means possible.

Superintendent Beverly Hall and her top aides ignored, buried, destroyed or altered complaints about misconduct, claimed ignorance of wrongdoing and accused naysayers of failing to believe in poor children’s ability to learn.

For years — as long as a decade — this was how the Atlanta school district produced gains on state curriculum tests. The scores soared so dramatically they brought national acclaim to Hall and the district, according to an investigative report released Tuesday by Gov. Nathan Deal.

Self-interest will always trump "ethos" and where the wrong incentives are in place we get this sort of result. Don't think a similar situation couldn't take place in England. It is for this reason that we need more choice - not just an "expression of a preference" - in Education.

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Freeport Bradford

I've been thinking about the idea of 'freeports' for some while - asking myself how, within the context of England's governance, we might use such an approach to stimulate a renewal of Bradford's fortunes. This is done against a background of regeneration programmes, schemes and plans that have largely failed at the macro level - even while delivering tangible benefits at the level of the communities in receipt of cash.

At its heart a free port is a place where customs duties are reduced significantly - most especially entrepot goods. The object is to use the low or no tariff regime - protected from the surrounding economy - as a way of attracting export-led businesses. Some of the success of Hong Kong and Singapore lies in their being free ports - places where transshipment and trading was very low tax.

The suggestion - being explored by ministers - of bringing back the idea of Enterprise Zones, provides a further push to allowing local authorities the scope to create lower tax, lower cost environments for businesses to develop:

Enterprise zones were pioneered in the 1980s and although they were criticised for the amount they cost and the number of the jobs they created, there were some success stories. The Docklands area of East London, for instance, was once mainly derelict buildings but since a zone was established it has become an international financial powerhouse.

The tax and regulatory tools now available to local authorities include:


Business Rates - at present these are set centrally with the local authority merely the collection agent. Council's have some emergency powers to waive or reduce rates but these are very tightly defined. There is a lobby to return to the pre-1992 situation where business rates were set and wholly retained locally. One aspect of these developments relates to 'tax increment financing' (TIF) where authorities borrow aganst anticipated future tax revenues from new development

Council Tax - the localism bill looks likely to give some scope for local councils to flex rates and, through ideas such as the 'New Homes Bonus', capture some of the forward value from development. It would be interesting to explore whether a TIF-type model could be developed using this bonus plus the extra council tax revenue.

Planning relaxation - under the new Local Development Framework (LDF) approach local authorities can consider granting de facto permitted development rights at specific locations and on identified sites. In effect, this removes planning costs from the system - both the costs associated with the process itself and also the wider costs connected to the delay. Although this acts primarily as an incentive to business investors, it might also provide a further financial opportunity through instruments underwritten by the implied savings.

Using these methods - plus a generally light-touch approach to regulation - would create an environment conducive to business development. However, the real benefits would arise if government looked at other taxes and duties - corporation tax, VAT and specific duties on particular goods and services. Allowing local authorities to reduce these imposts for exporting businesses would allow a further concentration of private industry.

Any programme of lower taxes would have to be semi-permanent - at least 20 years - to begin to have the desired effects. It would not work if firms were attracted by short-term incentives only to trip off somewhere else when those incentives were ended. In an ideal model, the low business tax, low tariff environment would be complemented by lower rates of personal tax - allowing authorities to drop income tax or NI. Such an approach would support enterprise and would provide an incentive for international capital to lodge in the 'freeport'.

In making these suggestions I am clear that past approaches to regeneration have largely failed to "close the gap" between successful and unsuccessful places. Broadly speaking the poorest places in the country back in 1968 are still the poorest places in 2011. There are some small beacons in this litany of underachievement - enterprise zones were one, the Enterprise Initiative another. However, the most effective (and the best thing Gordon Brown did by far) was Neighbourhood Renewal Fund - what the 'freeport' idea does is take this authority-wide approach and link it to new funding models and tax incentives.

It's either that or UDI for Bradford - creating a kind of Hong Kong of the South Pennines!

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Benefit fraud: In defence of the bounty hunter!

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Fraud, error and administrative cock up are a real problem for our benefits system. Despite this we sink to the level of ‘debate by headline’ where the prejudices and preferences of different sides to the argument are paraded like a political version of a 1960s Brighton Bank Holiday.

What follows is an attempt to put a little perspective into the argument – to escape from silly ad hominem and straw man arguments and actually talk about the issue – fraud, error and administrative cock up in our benefit system. And let’s be clear this stuff is there – benefit fraud isn’t the invention of frothing right-wing pundits writing in the Daily Mail. Every Government in my memory has, at some point, announced a ‘crack down’ on benefit fraud (albeit mostly to get a headline or two).

So what’s the deal? How big an issue is fraud and what should we do about it? Well much has been said about it – anecdotally and statistically and the new Government is no exception:

“We are looking urgently at different options for reform. Tougher penalties for
fraud, more prosecutions, encouraging those who know fraud is taking place to come forward, and making greater efforts to reclaim money that's wrongly paid," the prime minister wrote. "We will look at all these things and more. Including, for example, using more information from third parties such as credit referencing agencies to identify circumstances which are incompatible with the benefit claim. I have asked Iain Duncan Smith [the work and pensions secretary] to draw up an uncompromising strategy for tackling fraud and error which we will publish in the autumn."

Cue frothing media debate and a stream of absolute nonsense from pundits and politicians on all sides – from scaremongering about the use of credit referencing data to hyperbole about ‘bounty hunters’. Plus, of course, the compulsory “it doesn’t really matter, it’s just a drop in the ocean of Government spending” and “why are we worrying about benefit fraud, what about tax dodging?”

So, from me, an attempt at a more balanced analysis!

Firstly, benefit fraud is a problem – somewhere between £1.1bn and £5.5bn worth of problem. And it is compounded by the additional problems of overpayment, underpayment and ‘claims in error’. Once we shake all this stuff down there’s something around £10bn of spending involved – which is a lot of people’s taxes however you want to slice them (I would net this off against under-claiming of benefits except the Government already does that in its projections on public spending so to do so would be double counting – just as is the case with estimates of tax revenue).

The problem is that ‘clamping down on fraud’ costs money – you need to employ armies of fraud investigators and I’m sure they don’t come cheap. So there must come a point where further clamping down on fraud – however morally justified – actually costs the taxpayer more money than allowing the fraud to continue. Unless, of course, you can find another way to ‘fight fraud’.

Well there are two important considerations here – what negative incentives can we build in to prevent fraud? The obvious one is to catch more fraudsters (this influences both the fraudster caught and the whole market since the more caught the less incentive to cheat). Except that we’ve already spotted how this doesn’t make fiscal sense. Unless we shift the Government’s risk (in employing fifty grand’s worth of investigator) into the private sector. This is called by some ‘bounty hunting’ but it might be more sensibly named speculative private investigation – you bring evidence that leads to a successful prosecution for benefits fraud we pay you an agreed amount. This amount would represent the median cost of a benefit fraudster to the public purse – the only risk the government faces is that the investigator behaves badly. And, as far as I know, we have other laws to deal with that!

The other approach is to make is less profitable for the fraudster to take the risk – either because of the increased chance of being caught or else because the balance of risk and reward isn’t good enough. In a less complex system based on less information, fraud would be less profitable (and error less likely – addressing a related problem). At present we have a complex system that is relatively easy to game which results in a great deal of abuse – some of which is openly fraudulent while the rest is what might be called ‘pushing the envelope’.

As it stands – and given the number of claimants and the amounts of money involved – there is no chance of any Government making much of an impact on fraud. And with what we might call “fiscal ullage” running at a maximum of 2% and probably less, it makes little sense (beyond headline moralising) to run such programmes and campaigns. Unless of course you take my advice and shift collection risk into the private sector – which means fraudsters will either get caught or else the problem will disperse because the risks are too high. Simple really!

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Why should teachers care whether some of their colleagues can't teach?

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In an otherwise pretty moaning and self-justifying article in the Sunday Telegraph, former school governor, Joanna Leapman raises the question as to why (almost uniquely) teachers appear to deny the existence of any bad teachers.

Teachers take criticism less well than any other professional body I can think of. The teaching unions line up regularly to wheel out quotes attacking their portrayal in television dramas in a way no others do. I can’t recall ever seeing quotes from pub landlords or shopkeepers saying that they are unhappy with their latest characterisation on screen.

Sadly Joanna Leapman goes onto a whole array of unconnected attacks on the profession – there aren’t enough “top graduates” in teaching (I really fail to see how being a top graduate will assist in teaching 6 years olds to read and write or 11 year olds to string a coherent sentence or two together) and teachers can’t spell – this latter accusation arrived at through quoting anonymous posts on a teachers on-line forum, most of which seem to have had liquid assistance in their creation.

Mrs. Leapman misses the point. It isn’t that teachers are in denial about poor teachers but that this really doesn’t matter to them. If you work in a private business incompetence matters – it might cost you your job. In a state controlled and directed industry like education the presence of incompetence is irrelevant if annoying – there is absolutely no need and certainly no incentive to complain about another teacher. And despite the best intentions of Government and of organisations like Ofsted, these are not a substitute for raw self-interest.

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