Diabetes care: Do the basics well

Mo is 35 years of age. He is a businessman living in a village with his wife and children and commutes into London to work. He developed type 2 diabetes 10 years ago and takes metformin and simvastatin – when he remembers. He last attended an annual diabetes review 3 years ago. He keeps getting letters from the practice but puts the appointment off – the surgery is in the village but he is never at home during routine surgery hours. The last retinal screening appointment clashed with an important meeting. He gets tired and thirsty. He is overweight.

We meet Mo again 15 years later on the day of his daughter’s wedding. He is heartbroken that he cannot be there – but he is in hospital having a kidney transplant.

Jade is 22 years of age. She has had type 1 diabetes for 20 years. She hates it. Her mother used to bring her to the children’s diabetes clinic but at the age of 18 she was transferred to the adult clinic. She went once. It was big and scary. The waiting room was full of old people. And the doctor told her off because her blood glucose level was high and she hated him, too. So she did not go again. She cannot get a job and just hangs out with her friends. She takes some insulin but never checks her blood glucose. She was admitted to hospital twice with diabetic ketoacidosis (DKA). She gets letters from her GP and from the hospital but throws them away.

In 15 years time, Jade is now unable to work because she lost her vision due to proliferative diabetic retinopathy.

As healthcare professionals, we may assume that younger people are capable of managing their own health and understand the consequences of not doing so. But how many of us, working in busy jobs and focused on putting patients first, look after our own health as we should? How many of us find attending medical appointments easy or practical? And we were all teenagers once! 

Unfortunately, Mo and Jade are not unusual. The National Diabetes Audit (NDA; NHS Information Centre, 2011) shows that people with diabetes aged 16–55 years are less likely than older people to receive all nine basic checks required by NICE (2009; Box 1). Some 444 000 people of this age range have blood glucose levels that put them at risk of diabetes complications such as blindness or kidney failure.

The NDA results continue to show gradual improvements in care. Sadly, still only half of the people with type 2 diabetes, and under a third with type 1 diabetes had all nine of the basic care processes. About 95% of people with type 2 diabetes and 86% with type 1 diabetes saw their care provider at least once in the year because their blood pressure was recorded. So why are all the basic checks not being done? And why, when problems are found, are we not doing better at improving them?

Failure to support and educate people to control blood glucose safely in type 1 diabetes increases the risk of DKA. Over one in ten people with diabetes have had DKA in the past 5 years. Some die. In many cases this could have been prevented.

Diabetes care is a partnership between people with diabetes and healthcare professionals. We must ensure that people with diabetes know what to do to look after themselves to stay well, and that they are assertive in ensuring that they have all the checks and treatment they need. Healthcare managers and clinical staff must work together to provide accessible care (both geographically and at appropriate times), tailored to patients needs, and be rigorous about ensuring that every individual has every check and receives appropriate treatment tailored to his or her needs and wishes.

Do you look after people aged 16–55 years with diabetes? If so, have they had all nine basic processes of diabetes care in the past year? Please retrieve those who have not and check them – and, of course, act on the results. Do not forget your older patients too. Do the basics well. 

Mo and Jade are imaginary patients.