Editor-in-chief’s viewpoint: The future of in-hospital diabetes care?

“Failure is simply a few errors in judgement, repeated every day.” – Jim Rohn

Everyone agrees that the NHS is feeling the strain. In diabetes care, the most recent national inpatient audit apparently highlights “shocking failings in hospital care” according to a post on the Diabetes UK website (Diabetes UK, 2013). The question is, how do we take things forward to improve care for people with diabetes admitted to hospital? 

Recently, the Keogh report into the quality of care provided by 14 NHS hospitals published eight “ambitions” (Keogh, 2013). They include recognition, (a) of the importance of accurate, insightful and easy to use data about quality at service-line level, (b) of the need to harness the leadership potential of patients and members of the public, (c) that best treatment is delivered by clinicians who are engaged in research and innovation, (d) that nursing staffing levels and skill mix should appropriately reflect the caseload and severity of the illness of the patients, and (e) that junior doctors in specialist training should not just be seen as the clinical leaders of tomorrow, but as the clinical leaders of today.

Problems with the care of people admitted to hospital with diabetes are not unique to the UK. Colleagues from the US have published a “call to action” to improve the evidence-base for this area of diabetes care (Draznin et al, 2013). They have emphasised the need for more research in eight specific areas, four classified as system-based issues such as standardising the metrics to assess performance and four as “patient-based” – an example being randomised controlled trials comparing different approaches to managing glucose control in people being treated with steroids. These are likely to require significant financial investment and quite a lot of time, but are necessary.

The bottom line is that it should be possible to agree metrics around inpatient diabetes care that matter to people with diabetes, which will guide and inform on an institution’s performance. Active participation in innovation and research should be seen as a marker of good care, as should the number and make-up of the in-hospital diabetes team. The metrics of performance need to be debated but should be ones that matter to the users – unexpected deaths, severe hypoglycaemia or ketoacidosis and length of stay as well as surrogate measures around achieved glucose levels and perhaps glucose variability.

Beyond this we need to foster innovation. With this in mind, at Diabetes Digest we are keen to investigate the feasibility of creating an online resource dedicated to this area, including a digest of relevant research, the development of a network of research-friendly hospitals, and also a focal point for junior doctors, nurses and others to bring their ideas for improving the in-hospital experience forward for the “diabetes crowd” to hear about, discuss and “vote” upon. This is crowd-sourcing and could provide a fertile ground for exploring alternatives to the status quo of often mediocre and sometimes appalling care in our hospitals today.