Diabetes - From the front line of health challenges 2

Diabetes - credit Jill Brown

Much progress has been made in tackling Scotland’s biggest killers: heart and lung disease and cancer. Meanwhile, other leading causes of mortality have been more stubborn to shift. 

Holyrood approached leading clinicians from the front line to examine why, and what policy makers could do to help.

The second of our Q&A with clinicians facing Scotland's persistent health challenges is with Dr Nicola Zammitt and Dr David Jolliffe, the two clinical leads of the NHS Lothians Managed Clinical Network for diabetes.

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Is there a typical patient you see, and if so, what are they like?

The simple answer is no. That is what makes diabetes so interesting! 

One never knows what questions a patient will ask or what they are wanting from a consultation. Even if you could find two people with identical medical circumstances, the chances are that they would have completely different social circumstances, priorities, motivation to change and competing pressures on their time (such as work, children or elderly relatives). 

Consequently, the consultations with those two patients would be completely different. Because diabetes involves patients making lifestyle choices, the management of this condition is about so much more than blood tests, blood pressure measurement and medication. 

How do we encourage and empower change? We believe giving the patient as much information as possible is a key factor. Diabetes can affect anyone, regardless of age, gender or ethnicity so it is very important to tailor our care and objectives to each person. This is in part what makes caring for people with diabetes so rewarding.

Despite some high-profile advances in tackling Scotland’s biggest killers, the prevalence of diabetes has risen. Why does it remain a persistent problem?

There are a number of reasons why there are more patients with diabetes. Several years ago we recognised that type 2 diabetes was not “mild diabetes”. Patients were dying prematurely. 

Improved control of blood pressure, cholesterol and blood sugar has resulted in improved survival. Data from the 2015 Scottish Diabetes Survey shows that the prevalence of type 2 diabetes (number of people with this condition at any one time) has increased while the incidence (number of new cases per year) has not increased. This might indicate that the rate at which new people are developing diabetes is levelling off rather than continuing to rise. 

As life expectancy increases, there will be more cases of diabetes because people with the condition are living longer. Type 2 diabetes is also more common in older people so as the number of older people increases, so will the number of cases of type 2 diabetes. Type 2 diabetes is influenced by lifestyle, lack of exercise and obesity. 

There is no doubt the increasing prevalence of obesity is a major contributor. It is imperative that action is taken to tackle lifestyle risk factors which are directly linked to the risk of developing type 2 diabetes. There has also been a steady increase in the incidence of type 1 diabetes over the last 40 years, the reasons for which are unclear. However, the rise in type 1 diabetes is much less than the increase in type 2 diabetes. Unlike type 2 diabetes, type 1 diabetes is not directly linked to lifestyle and weight. 

Of the work you and your colleagues have done to tackle the problem, what are you most proud of?

Scotland has much to be proud of with regard to the care of patients with diabetes. SCI Diabetes is a software program for collection of patient data. It has enabled clinicians to monitor progress on screening of risk factors (such as diabetic retinopathy) and outcomes such as blood glucose levels, blood pressure and cholesterol. 

SCI Diabetes provides the data that populates the annual Scottish Diabetes Survey, which enables the Scottish Diabetes Group to monitor overall improvement across Scotland and to target specific problems in different areas of Scotland. Thanks to the survey, we have accurate figures on incidence and prevalence of different types of diabetes across Scotland.

Recently, health boards have been considering moving to a cheaper national IT system for diabetes but the diabetes community has clearly communicated to all health boards that it is vital that SCI Diabetes is maintained. 

This state-of-the-art system is so effective that some other countries are considering introducing SCI Diabetes. 

At a local level, we can be proud of improvements within primary care. With the ending of QOF (Quality and Outcomes Framework) in 2016, we need to ensure that these are maintained and that the Diabetes Improvement Plan (another significant achievement) is fully implemented. 

To ensure close links between primary and secondary care, the Lothian Diabetes Managed Clinical Network has recently shared its lead clinician role between a GP and a hospital consultant, that’s us. 

How could people be supported better to live healthier and take more preventative measures?

Diabetes is not just an issue for the health professions. Healthier lifestyles must be everyone’s responsibility. Tackling the issue involves education from school age upwards, public health measures, social care, personal responsibility and political influence! 

There are a number of initiatives to try and identify those individuals at most risk of developing diabetes and to prevent this happening. For example, the Lothian Weight Management Service and the Community Health Inequalities Team (CHIT) have been collaborating on a pathway to identify and target ‘at risk’ individuals so that they can be offered a range of interventions, including a six-week education and lifestyle programme. We also know that women who develop temporary diabetes during pregnancy (gestational diabetes) are at increased risk of developing type 2 diabetes later in life so the CHIT team are currently modifying the pre-diabetes education programme for this particular group. 

What could policymakers do to better support your work?

How do we encourage healthy lifestyles, more exercise, better diets and smoking cessation? 

The improvement in care of patients with diabetes started before the introduction of QOF but has continued in the last few years. The number of consultations for diabetes in primary care has significantly increased. With the ending of QOF we need to ensure that delivery of care in general practice continues to improve. 

Policymakers can help by ensuring adequate resources are made available to support work in primary care, particularly as an expanded role for general practice is central to NHS Scotland’s 2020 Vision for safe, effective and person-centred care as close to home as possible. These aims are also aligned with the National Diabetes Improvement Plan (2014), which include equality of access and patient-centred care as two of its eight priorities. Policymakers also need to recognise the importance of prevention so that resources are made available to reduce the number of people with pre-diabetes progressing to overt diabetes.

IT software has already been mentioned, and it is vital that support for SCI Diabetes is maintained, as Scotland is highly fortunate to have a truly national diabetes IT system which supports clinical care, audit and research. 

Insulin pumps are transforming the lives of patients with type 1 diabetes by delivering improvements in blood glucose control and quality of life. There is a variable level of funding for insulin pumps across Scotland, but most diabetes teams still have to justify their requests for insulin pumps to their health boards annually, with few […] having recurrent funding set aside. There are also many different continuous glucose monitors (CGM) available which can be life-transforming for people who have lost their warnings of hypoglycaemia (low blood glucose levels). 

No health board in Scotland has an identified funding stream for CGM, despite the fact that the 2015 NICE guidelines for type 1 diabetes provide clear clinical criteria for the provision of CGM. NHS Scotland will need to embrace the challenge of funding these expensive technologies which can help prevent the complications that can be costly for both the person with diabetes and the NHS.

What is the landscape likely to look like in 10 or 20 years’ time?

In the next 10 years the number of people with diabetes will increase. A ‘cure’ is unlikely. Islet cell transplants can help eliminate life-threatening low blood glucose levels but they are not a long-term guarantee of independence from insulin. 

A cure for type 2 diabetes would require a major reduction in the prevalence of obesity. More people with type 1 diabetes will have pumps and new CGM devices to monitor their blood glucose levels. Research is progressing on the ‘artificial pancreas’, which uses CGM technology linked to an insulin pump to adjust the rate of insulin delivery and maintain stable blood glucose levels. This technology will be expensive but has the potential to be a real game-changer by automating the process of insulin delivery and achieving reliable blood glucose control. 

This should lead to a reduction in the complications of diabetes over a number of years. 

Notwithstanding any advances in technology, the cornerstone of good care will remain the consultation, either in primary or secondary care, be it with a nurse or a doctor. Individual ‘care plans’ reviewed on a regular basis will be the norm. Patients will be empowered to jointly manage their diabetes with their healthcare professional.