Posted 31 December 2020 - 01:00
Posted 31 December 2020 - 01:00
Analysis
Diabetes care catch-up: which services and patients should take priority as COVID-19 continues?
Many patients have missed out on care – now inpatient, outpatient and community services are under pressure
Despite rapid adaptations to services, many patients have missed out on care during the pandemic – now inpatient, outpatient and community services are under pressure
- Diabetes services have been dramatically disrupted by the pandemic and vital appointments and reviews put on hold for many people
- The pressure on services was complicated by the interplay between COVID-19 and diabetes and the resulting increase in caseloads
- The innovations to emerge from the pandemic that nurses in the specialty say should be retained in the long term
For diabetes services, as for so many NHS services throughout the COVID-19 pandemic, this year has been filled with uncertainty.
Caring for people affected by diabetes is a huge part of the overall NHS workload, with one in 15 people in the UK believed to have the condition.
Huge demand for diabetes services for treatment and prevention of further complications
Four million people in the UK have a diagnosis of diabetes, about 90% of whom have type 2, while an estimated 1 million people are thought to have the condition but are undiagnosed, according to Diabetes UK.
The nature of the condition means that constant self-management and vigilance, along with support from healthcare professionals, is required to maintain optimal blood glucose levels.
This helps prevent some of the serious conditions associated with the disease, which can affect the eyes, heart, kidneys and nervous system.
The shutdown of diabetes services
For nurses working in inpatient, outpatient and community specialist diabetes services, maintaining the usual level of services during the pandemic has generally not been possible.
Diabetes consultant nurse Lesley Mills, who works in inpatient and outpatient services at Warrington and Halton Teaching Hospitals NHS Foundation Trust in Cheshire, says the COVID-19 experience has been ‘horrific’ for nurses in diabetes care.
She led a group that recently put together a report for Trend Diabetes, Diabetes UK and the Association of British Clinical Diabetologists (ABCD) on how diabetes services have coped.
In the initial, intense phase of the lockdown that began in March, most NHS services were halted, including the majority of diabetes services, Ms Mills says.
NHS England instructed diabetes services to prioritise care for pregnant women and patients with foot and renal problems.
Playing catch-up with the diabetes care
There then followed a summer of trying to deliver services in all settings in different ways, mainly through online consultations, and trying to catch up with the backlog built up by the interruption.
This was then complicated when the NHS started to feel the strain of the second wave of the pandemic in autumn.
A survey of patients by Diabetes UK in September found that many had been unable to access the care they need.
Almost half (48%) of the 3,000 people with diabetes in England who responded said they had had appointments cancelled. Half said they had had no input from their diabetes team at all since the pandemic started; of these, 37% had experienced difficulties managing their condition. Most of the respondents put this down to not being able to access their healthcare team.
Waiting lists grew as demand for diabetes services rose
Nurses working in the community and the acute sector reported growing demand for services, and the need to use risk stratification to prioritise who is seen.
Ms Mills says the diabetes workload has gone up significantly in the acute sector.
‘We have a bigger waiting list now than before the pandemic,’ she says. ‘People we would normally see every four months are being seen every 12 months. We also have a whole new cohort of people with COVID-19 to care for.’
COVID-19 seems to have a complex relationship with diabetes. Patients with diabetes are at higher risk of becoming seriously unwell if they contract COVID-19, so there is a higher chance that they will need hospital care.
Meanwhile, people treated with steroids, now recognised as the standard treatment for patients seriously unwell with COVID-19, can start to experience hyperglycaemia.
There are also a growing number of reports that suggest that the virus itself may cause people to develop diabetes, and an international database has been set up to monitor these COVID-19-related cases.
‘Patients with steroid-induced hyperglycaemia need treating in the same way as someone with diabetes while they are in hospital and need to be followed up by outpatient or community diabetes services when they are discharged,’ Ms Mills says. ‘This is a massive additional workload.’
Normally about 18% of the beds at Ms Mills’ trust are occupied by patients with diabetes. In mid-November, as the COVID-19 second wave grew, 40% of the beds were filled with people in need of diabetes care.
COVID-19: a testing ground for innovative services
Diabetes services have had to adapt rapidly to provide remote consultations, and this element is likely to remain even after the pandemic.
The report from Trend Diabetes, Diabetes UK and the Association of British Clinical Diabetologists agreed that many elements that started out of necessity during COVID-19 should be maintained, adding it was unlikely most teams or patients would want to revert back wholly to the ‘traditional ways of service delivery’.
Training and technology and online consultations
A Diabetes UK review into diabetes inpatient care published in August also said that some of the opportunities for new ways of working should be kept. While the pandemic disrupted inpatient diabetes services, many clinicians considered this disruption to have had a positive impact in how agile the new environment was, it found.
Community diabetes specialist nurse Nicola Milne has seen that the shift to remote consultations has brought positive change for some groups, while leaving others behind.
Research from Manchester has shown that for adults with type 1 diabetes using sensors, regardless of their level of deprivation, having remote access consultations can have a significant improvement on glycaemic control.
‘These are people with busy lives, they may have children and they are generally working, and for them not having to take time off or travel to access their healthcare is a real positive and seems to work well,’ Ms Milne says.
But there are concerns that moving care to remote consultations is not equitable for everyone with type 2 diabetes, particularly when it comes to access in more deprived areas.
Consideration of health inequalities
A piece of research Ms Milne has been involved with has looked at GP records over the past decade. The study, which is not yet published, suggests there have been fewer remote reviews carried out for older males with type 2 diabetes who are socioeconomically deprived during the pandemic.
‘In Manchester we work with a lot of people from deprived areas and their health literacy can be very low,’ she says. ‘The average reading age is low, there are a lot of patients with English as a second language and many people with social and emotional worries. We are concerned about potential health inequalities.’
This suggests that by listening to the data provided by the extreme circumstances of COVID-19, a better service can be developed in the future. ‘We will need a mix, we know who the remote consultations can be targeted towards and we have a better idea of who will benefit from face-to-face appointments,’ Ms Milne says.
Community services were also disrupted by redeployment
In the community, there has also been major change and disruption to services. Nicola Milne, a Queen’s Nurse and community diabetes specialist nurse in Manchester, has seen primary care and community staff pull together to try to continue to provide diabetes services.
When the first lockdown began, Ms Milne’s diabetes specialist nurse colleague was called to a front-line acute post, but the need for specialist diabetes care in the community was escalating rapidly.
Many people with diabetes couldn’t access their usual secondary care services, as staff had been redeployed and their annual reviews, which would often be carried out in primary care, were halted.
Patients were being discharged from hospital more quickly, including those newly diagnosed with diabetes.
Staffing capacity in primary and community care was reduced by many nurses having to self-isolate or shield, further reducing opportunities for diabetes reviews.
Diabetes and COVID risks
In May came two worrying NHS England reports that highlighted that a third of people who died with COVID-19 in hospital had diabetes.
‘People were being discharged very quickly, including those with new diagnoses. There wasn’t the time to do as much patient education in hospital, as they had to clear beds’
Nicola Milne, Queen’s Nurse and community diabetes specialist nurse
There was also a lot of interest from healthcare professionals who wanted training in sick day rules (steps patients should follow temporarily during illness that can result in dehydration, such as vomiting, diarrhoea and fever) to help them advise people on managing their condition when unwell.
‘We quickly realised that in order to protect the front line you needed a strong back line to prevent hospital admissions,’ Ms Milne says.
‘People were being discharged very quickly, including those with new diagnoses of diabetes. There wasn’t the time to do as much patient education in hospital, as they had to clear beds.
‘We worked closely with district nurses, Macmillan teams, nursing homes and crisis teams on diabetes care, as keeping people with diabetes out of hospital had become more important than ever. It was a real team effort.’
A triage system is ensuring those most in need are seen by clinicians
Between the two waves of COVID-19 cases there was a major combined effort to ensure that reviews and appointments were carried out for people who needed it most.
Secondary and some community and primary care services used a risk stratification tool set out by ABCD, which helps clinicians triage patients.
Those involved in services, including Trend Diabetes and Diabetes UK, agree it is essential that more services stay running during the second wave of COVID-19.
Diabetes UK senior clinical adviser Karen Davies says there has been a decline in people at risk of type 2 diabetes being diagnosed this year, and reduced access to education programmes is likely to affect individuals’ ability to self-manage their condition.
‘We need people living with diabetes to know that the NHS is open if they have a problem or they need advice and care. Healthcare professionals can also signpost patients to online support and education such as the Diabetes UK Know Your Risk tool and learning zone,’ she says.
Winter will be challenging – and many nurses are exhausted
While diabetes services are better prepared for the second wave and are more used to the technology involved in running reviews remotely, there is a growing weariness among diabetes nurses and patients. This will make for a challenging winter, nurses suggest.
‘The difficulty is that nurses are tired,’ says Ms Milne. ‘During the first wave it was like the Blitz spirit in the face of crisis that got us through, but now people are tired. We have worked long hours. And I hear it with patients too. A lot of people are getting frustrated that they can’t get the care they want, and there are a lot of emotional and mental well-being needs.’
The patient’s experience: ‘It saved time for us and the NHS’
Linda Fox, whose seven-year-old son Freddie has type 1 diabetes, was feeling anxious about the prospect of going to his diabetes clinic during lockdown.
But the diabetes team at Warrington Hospital in Cheshire adapted to the crisis and moved his regular appointments online.
‘Our usual appointment takes around one and a half hours, but that doesn’t include travel to and from hospital nor does it factor in time off work and school,’ she says.
Faster, easier and still maintaining human contact
‘It entails seeing several clinicians round-robin style, discussing the same things with each one with a nerve-racking wait in between to find out his HbA1C result. ‘The online appointment took half an hour, the whole team were in the room together and you could have an open collaborative discussion. It saved time for us and the NHS, reduced stress and anxiety and meant no time off school for Freddie.
‘It was lovely to see the team all together, maintaining that human contact.’
Find out more
- Diabetes UK: Us, diabetes and a lot of stats and facts
- Association of British Clinical Diabetologists: Guidance to risk stratification and recovery of diabetes services in the post–COVID-19 era
- The New England Journal of Medicine: New-onset diabetes in COVID-19
- Trend Diabetes, Diabetes UK and ABCD: A collaborative overview and insight into diabetes services before and after the COVID-19 pandemic