Public Health Issue: Diabetes Mellitus

This assignment will address the public health issue of the increasing prevalence of diabetes mellitus (diabetes) and explore links with health inequalities both nationally and locally. It will discuss the frameworks available which give guidance for standards of care for diabetes patients and their influence on diabetes care. It will then critically discuss the issue of diabetes management in relation to patient education and the ability of patients to self-manage their chronic long-term condition, evaluating both the role of both healthcare professionals and individuals in achieving the best possible healthy outcomes. It will then discuss whether all people get the same level of diabetes care, in particular focusing on people who are not able to attend GP surgeries.

Public health is defined as “The science and art of promoting and protecting health and wellbeing, preventing ill health and prolonging life through the organised efforts of society” (Faculty of Public Health 2008). Health equality is a key element of social justice and as such justifies the government and other health agencies to work in collaboration to develop health policies which improve the public’s health regardless of social class, income, gender or ethnicity through promoting healthier lifestyles and protecting them from infectious diseases and environmental hazards (Griffiths & Hunter 2007). Yet many health inequalities still exist in the UK, some of which will be discussed in this paper.

There are predominantly two types of diabetes mellitus (diabetes); type 1 diabetes occurs when the body does not produce any insulin and type 2 diabetes occurs when the body does not produce enough insulin to function properly or when the body cells do not react to insulin. Type 2 diabetes is the most common and accounts for around ninety five per cent of people with diabetes. If left untreated both types of diabetes can lead to further complications which include heart disease, stroke, blindness, and kidney failure (Who 2011). Life expectancy is reduced by up to 10 years in those with this type of disease (Whittaker, 2004). In the majority of cases, type 2 diabetes is treated with lifestyle changes such as eating healthier, weight loss, and increasing physical exercise (Diabetes UK, 2007b).

There are currently 2.6 million people in the UK with diabetes, and it is thought up to a further 1.1 million are undiagnosed. (Diabetes UK, 2010). Other evidence suggests that approx 50% of people are not aware they have the condition, living a normal life with only mild symptoms (reference). Men are twice more likely to have undiagnosed diabetes, than women, possible because on average they tend to visit their GP less (Nursingtimes.net 2009). Diabetes is one of the most widespread chronic diseases, which is potentially life threatening. It is currently thought to be the leading 4th disease causing death in most developed countries worldwide with estimated prevalence of 285 million people.

Most experts agree that more than 4 million people in the UK will have Type 2 diabetes by 2025 with potentially 5.5 million living with this chronic condition by 2030 (Diabetes UK 2010, and International Diabetes Federation (IDF)2010). These statistics are startling; type 2 diabetes is one of the biggest challenges facing the UK today with people often treated entirely by the National Health Service (NHS) who provide care for all levels of diabetes. Diabetes control is considered poor in Europe with the UK being identified as having the worst control. The reasons for this are not clearly identified. However what is clear is the potential impact on people in terms of complications and shorter lives (Liebl et al 2002). People with diabetes who have complications cost the NHS 3.5 times more than people who have no evidence of complications (IDF 2006).

The NHS currently spends about 10% of its total resources on diabetes, which equates to £286 per second. This places a significant drain on resources which will potentially rise in line with the growing prevalence of diabetes and associated complications unless alternative ways to reduce the burden of the disease can be found Diabetes.co.uk).

There are many reasons for the growing prevalence of type 2 diabetes in the UK, two of the main ones being the modernisation of industrialisation and urbanisation, which has changed people’s lifestyles and eating habits and caused and escalation in obesity (Helms et al 2003). Diabetes and obesity are closely linked; eighty percent of patients diagnosed with diabetes are obese at the time of diagnosis (Diabetes UK, 2006). Kazmi and Taylor (2009) agree and say type 2 diabetes can be linked to genetics, although increased levels are more likely to be attributable to obesity resulting from a decrease in physical exercise and westernised diets. A 2008 survey highlighted the UK as having the highest obesity levels in Europe, currently 24% of adults are considered obese which tends to increase with age. (Organisation for Economic Co-operation and Development 2010). However this figure should be treated with caution as England is one of the few countries who uses actual measurements of weight and height, other countries preferring to use self reported measures. The UK has an increasing elderly population which combined with rising levels of obesity is likely to further increase type 2 diabetes prevalence(DH2010).

The links between socioeconomic deprivation and ill health are well established (Yamey 1999, Acheson 1998, Chaturvedi 2004). This can be observed within the UK, as type 2 diabetes does not affect all social groups equally, it is more prevalent in people over 40, minority ethnic groups, and poor people (The National Service Framework (NSF) for Diabetes). Several studies have established people with type 2 diabetes living in deprive areas suffer higher morbidity and mortality rates than those in more affluent areas. (Roper et al 2001, Wilde et al 2008, Bachhmann 2003).

However globally the links between deprivation and type 2 diabetes are less clear as there is less information available on diabetes and deprivation related outcomes. In conflict with the UK, studies in Finland, Italy and Ireland found no significant variations in different socioeconomic groups (Gnavi et al 2004, O’Conner 2006). Reasons which may have negated the impact on socioeconomic deprivation may have been due to differences such in the population studied, health care delivery or available treatments.

Links between deprivation and type 2 diabetes appear evident in the locality of Derbyshire. All but three local areas in Derbyshire have a diabetes and obesity levels which are significantly worse than the England average (Derbyshire County Primary Care Trust (PCT) 2008). In Derbyshire there are clear significant variations in levels of deprivation, High Peak has very little deprivation, and yet Bolsover is in the 20 per cent most deprived areas in England, with thirty two per cent of people living in poverty and mortality and morbidity levels significantly worse than the England average (Bolsover District Financial Inclusion Strategy 2009). These worrying levels have triggered the Department of Health to declare Bolsover a Spearhead area for improvement (DH 2009, Derbyshire PCT 2008). Some steps have been taken in Bolsover to reduce morbidity and mortality rates by introducing healthy initiatives aimed at improving people’s life styles (Bolsover 2010). However, although morbidity and mortality rates have reduced over the last ten years they remain significantly higher than the England average (Bolsover District Financial Inclusion Strategy 2009). Derbyshire has a growing elderly population (Derbyshire PCT 2008). This together with proven links of levels of obesity rising with age would suggest a future increase in levels of diabetes.

Diabetes is a national priority and Derbyshire has a higher than England average prevalence, but the local NHS strategy (2008) does not specify diabetes as a key priority. This may be a factor why Derbyshire is failing to meet its targets to reducing morbidity and mortality by ten per cent by 2010 in the poorest areas of Derbyshire (DH 2009).

Frameworks and policies exist to give guidance on standards of care, improve the quality of life and life expectancy of people with diabetes and lessen the financial burden on health services. (Reference x2). In response to European influence the NHS plan (2000) set out guidance for modernising services, raising standards and moving towards patient centred care. Subsequently the NSF for Diabetes (2001) was published which outlines twelve standards of care aimed at delivering improved services and reducing inequalities over a ten year period with the ultimate vision of people suffering with diabetes receiving a world class service in the UK by 2013. This framework was followed by the NSF for Diabetes: Delivery Strategy (2003) which gives guidance on how the NSF for diabetes could be achieved.

Frameworks are a useful outline for action and set out clear goals and targets, but do not address the social, economical and environmental causes of ill health or take account of available financial and staffing resources (Reference from book). The NSF for Diabetes (2001) appears to support this statement; other than retinal screening, no funding was initially made available to implement the twelve standards (Cavan 2005). The availability of this funding will have been significant in the achievement of one hundred per cent of people with diabetes now being offered this service (English National Screening Programme for Diabetic Retinopathy, 2009). It wasn’t until 2004 the Quality Outcome Framework offered financial rewards to meet other targets within the NSF, for instance maintaining practiced based registers of people with diabetes, to enable primary care providers to provide proactive care (NHS 2004).

Ten years on this framework is still credible and sets the ‘gold standard’ of care for patients with diabetes in the UK (NICE 2000) which would seem to be an outstanding achievement. There have been significant improvements in caring for people with diabetes since it was published. However, it could be criticised that some standards are not enforceable until 2013 (NSF 2001).

Numerous publications have followed the NSF for Diabetes (2001) in an attempt to give guidance for health professionals to follow (NICE 2004, NICE 2008, NICE 2009, RCN, NMC). These frameworks are not intended to work in isolation but collaborate with each other at different levels, whilst attempting to produce a quality health service (Reference). .

The main reasons for the onset of diabetes and risk of further complications is due to suboptimal health relative behaviours which include little physical activity, high calorie intake and inadequacy to maintain good glucose control and it is said individuals with diabetes play a central role in determining their own health status (Clarke 2008 Reference 1). Whittaker (2004) concurs and says that much of the burden relating to care lies with individuals themselves. Patient education is seen as fundamental in the treatment of diabetes to ensure the best possible healthy outcomes for individuals (Alexander et al, 2006, Brooker & Nicol 2003, Walsh, 2002). Standard 3 of the NSF for Diabetes (2001) clearly demonstrates a move away from medical care to encourage individuals to take responsibility for their own health but also places the onus on health care professionals to educate, support and empower people to enable them to effectively care for themselves. The recent Public Health Whitepaper (2010) endorses future healthcare services should focus on wellness rather than treating disease and supports empowering people to put some effort into staying well. It acknowledges healthcare services only contribute to one third of improvement made to life expectancy stating that a change in lifestyle and removing health inequalities contribute to the remaining two thirds. Giving people the skills, knowledge and tools to take control of their own health logical as people with diabetes spend an average of 3 hours per year with their healthcare professional and around 8700 hours managing themselves (Ref N3. For example there is much evidence concluding that maintaining blood glucose levels as close to normal as possible slows down the progression of long term complications and if patients can be empowered to take control of their diabetes, not only will it increase the individuals quality of life but also reduce the financial burden on the NHS. (Whittaker, 2004). (Ref: 4.1, 4.2).

The Diabetes Year of Care programme (2008) has been developed to help healthcare professionals move away from a paternal approach to care planning to a more personalised approach for people with chronic long term conditions. This approach involves both healthcare professionals and patients working together to prioritise individual needs. Helmore (2009) agrees that a personalised approach to care planning which should be holistic and include the person’s social circumstances, will empower patients to take a central role in their own healthcare and suggests that nurses and patients should work together to set goals the patient can work towards which would include self care and the services they will use. For example a depressed patient will not want to venture outside to exercise and comfort eating may cause them to gain weight. The priority in this case would be to deal with the patient’s depression. The nurse could then liaise with other community services and social care to resolve non medical issues which would enable the patient to manage their weight and increase activities (Helmore 2009). Rollings (2010) believes nurses should take a lead role on behalf of the GP consortia as they are the ones best placed to identify the care requirements of patients with diabetes, they have experience in patient pathways and are able to co-ordinate local and professional services.

The Department of Health (2010) has highlighted care planning as an area for improvement to ensure one hundred per cent of diabetic patients have individual care plans (DH 2010). Currently it is thought only sixty per of people with long-term conditions in England have an individual care plan (www.gp-patient.co.uk).

Diabetes self-management education programmes (DSME) have been developed to educate and empower patients to take control of their own conditions by improving their knowledge and skills to enable them to make informed choices, self-manage and reduce any risk of complications. DSME also aims to help people to cope with physical and mental of living with diabetes (Ref 21 p 114. These programmes which should be age appropriate can be delivered to individuals or groups. (6 and 40 p 119 and 120). . (reference 7 p119). Programmes available include the Expert Patent Programme (EPP), its derivative X-PERT and Diabetes Education and Self-Management for ongoing and newly diagnosed (DESMOND) which are available in all PCT’s in the country. These programmes offer the necessary information and skills to people to enable them to manage their own diabetes care and they offer the opportunity for people with diabetes to share problems and solutions on concerns they may have with on everyday living (N9). They encourage people to find their own solutions to issues such as diet, weight management and blood glucose control, enlisting the help of diabetes professionals if needed (N9). The literature suggests this will result in well educated, motivated and empowered patients and consistently supports patient education as crucial to effective diabetes care (use many refs).

Much research has taken place on the effectiveness of DSME. Some of which suggests that patients who have not participated in DSME are four times more likely to encounter major diabetes complications compared to patients who have been involved in DSME (Reference).Other evidence suggests that it is not possible to establish whether patient education is effective at promoting self-management in the long term to reduce the effects of diabetes or the onset of complications and improve the patient’s quality of life (reference). From studies that have taken place, it is evident that although knowledge and skills are necessary they are not sufficient on their own to ensure good diabetes control. People require ongoing support to sustain the enable them to sustain self-management and therefore the longer period of time the course run the more likelihood people will remain empowered (Ref)

The majority of people in the UK are offered some form diabetes education, the bulk of which is offered at the time of diagnosis. Also the style, length, content and structure of DSME vary. Very few education programmes have been evaluated; therefore it is not conclusive which intervention strategy is the most effective for improving the control of diabetes. The America Diabetes Association suggest that as people are individuals and different methods of education suit different people, there is no one best programme, but generally programmes which incorporate both psychosocial and behaviour strategies appear to have the best outcomes.

However the Healthcare commission (2006) found people in England are not being offered adequate information about their condition to facilitate effective self-management. They reported just eleven per cent of respondents had attended an educational course on how to live with diabetes and disturbingly seventeen per cent of respondents did not even know whether they had type 1 or type 2 diabetes (Reference 2 p 119).

The success of DSME is dependent many variants which include the patient’s individual characteristics, the context of their social environment, the extent of the disease, and the patient’s interface with the care and education provided.

Overall there is a great deal of evidence to suggest DSME is the ‘cornerstone’ in effective diabetes care (NSF 2001). It is recommended that DSME is delivered by a multi-disciplinary team together with a comprehensive care plan (reference 1). Experts agree that effective management of diabetes mellitus increases life expectancy and reduces the risk of complications (NICE Guidenance for the use of patient education models of diabetes Referece 1 p 119

Changing the health related behaviours of people with diabetes has been proved to be successful in reducing or even eradicating the risk of complications (reference). Many different health promotion models of exist which can help a patient to digest health promotion advise and want to change their health related behaviours (Kawachi 2002). Health promotion models are useful tools to assist with this process. The Stages of Change health promotion is a frequently used model for weight management as it identifies 6 stages of readiness to change which helps health professionals identify the intervention actions to recommend and support.

Standard 3 has also ensured people with diabetes receive regular care (Hicks 2010), although Hillson (2009) would argue the quality of which is still open to debate. Every person with diabetes should receive the highest standards of individualised care, no matter who delivers it or where or when it is delivered. Access to specialist services should be available when required (Hillson 2009).

Diabetes patients receive different standards of care depending on whether or not they can attend their doctor’s surgery (Knights and Platt 2005). Diabetes patients who are unable to attend the surgery are being overlooked and missed out on screening and reviews of their diabetes, consequently receiving a lower standard of care despite the NSF for Diabetes stating inequalities in provision of services should be addressed to ensure a high standard of care which meets individual patient needs.(Gadsky 1994 ,Hall 2005, Harris 2005,).

Until recently the district nursing team were some of the few professionals who provided care in the home for diabetes patients and only usually had input with diabetes patients when treatment was required for a complication (Wrobel 2001). District nurses have historically been seen as generalists and able to provide care and treatment for patients with a wide range of conditions and therefore do not necessarily have specialist disease knowledge (Hale 2004). Sargant (2002) agree with this and suggests the quality and advise district nurses give to diabetic patients is questionable as they don’t have the in-depth level of knowledge in relation to diabetes. In recognition of the inconsistency of care being provided to patients with chronic illnesses in their own homes, the role of Community Matron was introduced in 2004 to ensure patients with diabetes receive the first class service advocated by the Department of Health (1999) and the NHS PLAN (2000) by managing their all encompassing care requirements and help patients effectively manage their long term conditions which in theory should result in reduce hospital admissions. (NHS Improvement Plan 2004). However a study conducted by Gravelle et al (2006) would suggest the Community Matron role has not been effective in reducing hospital admissions. Forbes et al (2004) concurs that district nurses, given the time and with the right training could extend their roles and satisfactory undertake appropriate care for housebound people with diabetes. However Brookes (2002) suggests training and resources are big issues and Harris (2005) says that district nurses may not be fulfilling their Professional Code of Conduct by failing to care sufficiently for this group of patients (Nursing and Midwifery Council 2008).

The growing prevalence of diabetes and the drain on NHS resources continues to be a concern for the UK, in terms of life quality and life expectancy of patients. Many health inequalities exist for people with diabetes; there are proven links with obesity and deprivation; and diabetes care provided is not equal for all patients. Patients who are able to attend their GP surgery receive better care than those who are housebound, although this inequality is being addressed and care is improving. The NSF for Diabetes is a useful framework for healthcare professionals to follow when providing care for people with diabetes. The quality of diabetes care has improved since this framework has been introduced. However, the implementation of some recommendations has been slow and will not be complete until 2013. Patient education is paramount to successful diabetes control and there appears no doubt that the key to successfully slowing the onset of diabetes and the recognised associated complications is to engage patients in DSME.