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As the vaccination programme gathers steam, what’s next for diabetes services?

Su Down highlights three recent publications that will prove valuable for diabetes services emerging from lockdown.
Welcome to the first editorial of 2021! As we start to emerge from what has felt like a very long winter, the COVID-19 vaccination programme has exceeded expectations. With over 15 million people receiving their first dose of vaccine, covering a huge percentage of the over-75s, the frail and the clinically extremely vulnerable groups, it has now been speculated that all adults in the UK may be fully vaccinated by the late summer. I have myself been part of the army of volunteer vaccinators and I can honestly say it has been a privilege to be a part of this historic undertaking.

 

Important new publications

COVID-19 and diabetes


As services across the country begin to focus on returning care delivery to pre-COVID status, we are all only too aware of the enormous task that lies before us. A recent joint statement from the Primary Care Diabetes Society, Association of British Clinical Diabetologists and Diabetes UK has highlighted the devasting consequences of COVID-19 on our population with diabetes. The statement outlines the immediate issues to consider in those with diabetes as well as linking to all the latest recommendations and resources. I strongly feel this is an important document to be aware of, not only for those working directly in primary care but also to highlight the challenges that all of us delivering diabetes services, across all sectors, will face over the next year at least.
 

Delegation of insulin administration


One of the challenges that has faced us over recent years is the increasing number of people requiring insulin administration. This task has often fallen to our district nursing teams. I have previously reported on projects to try and improve this service delivery (Down, 2018; 2019), but I have also commented that district nursing services across the country have often been at crisis point when trying to manage this growing need. The pandemic not only increased this challenge of service delivery but it also led to many care homes needing to manage reducing footfall into their facilities. It is timely, therefore, that NHS England has published resources for the delegation of insulin administration. TREND Diabetes was commissioned to develop the necessary competences, resources, documentation and an e-learning module. The project intended to extend the capacity of insulin administration to health and social care workers within a voluntary framework. This completed piece of work is to be applauded and I’m sure it will prove an invaluable resource to services across England.
 

Pregnancy outcomes


In the final publication I wish to highlight, Helen Murphy and colleagues have reported on the pregnancy outcomes of people with pre-existing diabetes, both type 1 and type 2 (Murphy et al, 2021). The National Pregnancy in Diabetes Audit has been gathering data for many years, and this latest report has analysed outcomes from the last 5-year period. What is striking is the increase in numbers of women with pre-existing diabetes over the years, with 4400 pregnancies in 2018 compared with 2290 in 2014. This may in part be due to increased participation in the audit but, from personal experience of running an antenatal clinic, it reflects what I have seen in practice. Sadly, this report again highlights the challenges of managing diabetes in pregnancy, with a resulting increase in rates of pre-term delivery, congenital abnormality and neonatal death. The risk factors for neonatal death were third-trimester HbA1c, socioeconomic deprivation and type 2 diabetes.

This timely report highlights the challenges at a time when, more positively, the use of technology in pregnancy has received national support and funding. Across England, the use of real-time continuous glucose monitoring (rt-CGM) is to be made available to all women with type 1 diabetes during pregnancy from April 2021. The decision to utilise and fund this technology followed the results of the CONCEPTT trial, which conclusively demonstrated that rt-CGM users saw an improvement not only in glycaemia but also in maternal and fetal outcomes (Feig et al, 2017). When modelling the costs of complications and hospital stay, it was also cost-saving despite the increased direct expense of using the technology (Murphy et al, 2019). I sincerely hope that the uptake of rt-CGM will start at last to show improvements in outcomes by the next audit review.

I hope this has provided you with some useful reading material!

Down S (2018) Challenge is the catalyst for innovation and evolvement: Let’s embrace it! Journal of Diabetes Nursing 22: JDN001

Down S (2019) Service update: The success of district nursing virtual clinics in Somerset. Journal of Diabetes Nursing 23: JDN066

Feig DS, Donovan LE, Corcoy R et al; CONCEPTT Collaborative Group (2017) Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial. Lancet 390: 2347–59

Murphy HR, Feig D, Patel N (2019) Continuous glucose monitoring in pregnant women with type 1 diabetes: cost-effectiveness analyses of the CONCEPTT randomized controlled trial. 79th Annual Scientific Sessions of the American Diabetes Association, San Francisco, CA, USA: Abstract 351-OR. Available at: https://bit.ly/2ZxbFeN (accessed 19.02.21)

Murphy HR, Howgate C, O’Keefe J et al; National Pregnancy in Diabetes (NPID) advisory group (2021) Characteristics and outcomes of pregnant women with type 1 or type 2 diabetes: a 5-year national population-based cohort study. Lancet Diabetes Endocrinol 28 Jan [Epub ahead of print]. https://doi.org/10.1016/S2213-8587(20)30406-X

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