Sort out diabetes and save the NHS

Diabetes is common and often undiagnosed. 2.3 million people in the UK know they’ve got it, another million don’t know they’ve got it and the incidence rises every year as we become older and fatter. Treatment can be complicated, and requires a lot of support, education and training, and close monitoring in times of illness.

It’s the commonest cause of blindness in the working population and can also lead to foot ulcers, nerve damage, infections, amputations, heart attacks, strokes, kidney failure, depression, serious pregnancy complications, erectile dysfunction and premature death. Poorly controlled diabetes knocks 10-20 years off your life and it costs the NHS over £1 million an hour to treat. So it’s vital, for both patients and NHS survival, that we treat it well.

The latest National Diabetes Inpatient Audit* is not encouraging. It looked at diabetic care in 93% of acute hospitals in England on a single November weekday in 2010, and found that people with diabetes had an average age of 75 and occupied 15% of beds. Their median length of stay was 8 days but only 9% had been admitted specifically for diabetes management. The majority (86.7%) had an emergency admission and 40% of inpatients were insulin treated. And now the bad news.

37.1% of inpatients with diabetes experienced at least one medication error. 26.0% of charts had prescription errors and 20.0% had one or more medication management errors. Insulin errors were particularly common. There was marked variation in prescription errors across hospitals from none to 54.3%. 44 developed ketoacidosis (severe uncontrolled diabetes) and 266 severe hypoglycaemia (too low blood sugar due to over-treatment) during their admission. Only 27.5% of patients had their feet examined at any time during admission, 2.2% developed a new foot complication during their hospital stay but 49.6% of these had no input from the foot specialist team.

So despite record funding for the NHS, there is still huge variation, substantial error and sub-standard care in the in-patient management of patients with the most common, expensive chronic disease. The audit found, rather alarmingly, that 31.0% of hospitals had no inpatient diabetes specialist nurses, 29.8% had no inpatient dietician for people with diabetes and 26.8% had no inpatient diabetic foot service. Few were under a diabetes consultant (9.0%) or on a diabetes ward (4.6%) and 69.4% of in-patients with diabetes had not been seen by a member of the diabetes team, including 46% with a diabetes management problem.

These alarming gaps in care are for the mother of all chronic diseases, so I’d what to think what level of expertise awaits patients with rarer diseases. Insulin requirements in sick people vary day by day, sometimes hour by hour, and they need expertise beyond the generalist nurse or the inexperienced junior doctor passing through on a shift. So while the tedious, point-scoring NHS reform debate plays out in Westminster, the premature death and disease of patients with chronic diseases continues on a massive scale.
The NHS now faces the toughest financial restrictions in its history. If specialist diabetic nurses are either not provided or made redundant, and diabetic consultants are not appointed, it’s hard to see how the care of this pivotal disease will improve. Patients often know how to manage their diabetes best and yet the audit found only 12.9% had a say in their treatment plan and less than a quarter were allowed to monitor their own sugar levels. In America, it’s been estimated that a small improvement in the management of diabetes could fund universal healthcare. If you can sort out diabetes, you can sort out the NHS. Time to stop the point-scoring and get on with it.

http://www.yhpho.org.uk/Diabetes_inpatient_audit