The diagnosis rates of coeliac disease differ substantially between countries. Intriguingly, there has been recent evidence from Olmstead County, USA and Finland that in the last 5-10 years incidence has plateaued or even declined. In most populations the prevalence also varies widely, serological prevalence from 0% to 1.87% and clinical prevalence from 0.9 to 12.9 per 100000. Understanding of why this variation exists is minimal, yet one of the key aspects governing incidence rates of any disease are “health system drivers”, such as the availability and use of diagnostic tests. We previously reported rising incidence rates of coeliac disease from 1990 to 2011with inequality by deprivation in the UK. Although national guidance on recognition and diagnosis of coeliac disease published in 2009 suggested widening the patient groups that should be tested for coeliac disease, NHS financial constraints could have hindered implementation of these guidelines. Indeed in the USA it has been observed that over the period
2000-2010 there was a marked decrease in treated prevalence of many diseases alongside a sustained period of reduced spending on health care.