Diabetes ― Why I’m sold to the cause ― Dr Charles Gostling

By Dr Charles Gostling, joint clinical director (diabetes theme) of the Health Innovation Network, the Academic Health Science Network for south London and south London GP.

“We are two and half years in to the Health Innovation Network’s diabetes work stream. I have been lucky enough to be involved from the start and, whilst pleased with progress, have found the real world to be quite challenging in viewing diabetes to be an issue. I am sold to the cause, and rightly so with 2.7 million people currently estimated to have diabetes and likely to rise to 4 million by 2015.

Diabetes consumes 10 per cent of the health budget and over 20 per cent of people in hospital have diabetes. If this is not a growing public health disaster in waiting, I don’t know what is.

Diabetes seems to have been replaced by so many other issues as cause for concern. Mental health, dementia, child health ― all really important and resource hungry. All very different but sharing so much in the need to be able to deliver best practice with innovation at scale. We have to figure out ways of achieving best practice and doing more with the same (or maybe less). Value based medicine is the mantra.

Diabetes is not only costly but also delivers ill health and hardship in bucket loads. The Health Innovation Network’s mantra is: ‘Help me to minimise the effect of diabetes on my life’. Two major areas for the Health Innovation Network have been better self-management and improved use of technology.

Abject failure

One of the cornerstones of care for people with type 1 and type 2 diabetes is the ability to effectively self-manage the condition, to be able to make decisions away from a health care professional. A number of Structured Education Programmes have been developed to help empower people with diabetes to take greater control of their condition.

As of 2013 only 1.1 per cent of people with type 1 diabetes and 1.6 per cent of people with type 2 diabetes had attended such a course. The reasons for this abject failure are multiple, but include courses not being suitable or accessible to their communities, poor understanding of the benefits of patient education by health care professionals and people with diabetes, as well as poor referral processes and lack of effective measurement of achievement.

The Health Innovation Network has developed a toolkit charting best practice for allowing access to education programmes. This starts with health care professionals understanding and valuing self-management. Education needs to a population must be considered along with preferred means of delivery ― some cultures may prefer women only groups, some busy people may prefer digital platforms to allow them to access education at a time and place that suits them ― we are all different.

Let people self-refer and access education when most meaningful to them. Most of all, commissioners should ensure that the education they are commissioning is being delivered. Set robust service specifications, measure key performance indicators, expect providers to deliver. Our toolkit has been well received to date and has attracted interest from as far away as Northern Ireland. The measure of success will be improved uptake of education in south London with consequent improvement in people’s lives.

The use of insulin pump therapy presents the opportunity to transform the quality of life for many people with type 1 diabetes, as well as to improve blood glucose control and minimise the risk of hypos (low blood glucose levels). It is likely that approximately 15 per cent of people with type 1 diabetes might benefit from this treatment.

In the UK levels of uptake have languished at 6 to 7 per cent, compared to levels exceeding 15 per cent in the rest of Europe. Why is this, and what are the barriers to accessing best care? We have worked with people with type 1 diabetes, providers of type 1 diabetes services, commissioners and industry to attempt to address these conundrums. It soon became apparent that this was not just about pump therapy but about how to achieve an optimal type 1 diabetes service.

Although insulin pump technology has been endorsed by a NICE Technology Appraisal (2008) there is a wide variation in access to this technology for people with type 1 diabetes. Across south London our own audit revealed huge variation in the delivery of type 1 diabetes services and the uptake of insulin pump therapy (between 3 to 15 per cent, depending on borough). This is despite the evidence showing that having an insulin pump can reduce the risk of complications such as amputation and blindness, significantly improve quality of life and play a pivotal role in helping people to manage their own condition.

In order to address this issue we united and engaged 10 acute diabetes teams from across London in an improvement collaborative, to enable them to begin forging relationships within their teams and to provide the teams with service improvement tools and techniques. Since the project started in June 2014 we have seen an increase in the uptake of pump therapy by over 21 per cent. In real terms this means over 260 additional people with type 1 diabetes are now receiving pump therapy.

So the Health Innovation Network has been working with both people and technologies to try to improve diabetes care. One cannot exist without the other in our frenetic lives, but together they can ‘help me to minimise the effect of diabetes on my life’.”