Diabetes care in Wales: Change is afoot

There is an increasing prevalence of diabetes within the population of Wales; in some areas it is higher than the rest of the UK, ranging from 4.5% to 6.3% (Diabetes UK, 2010). The Welsh population suffers from significant comorbidities, including high levels of cardiovascular disease and obesity. 

The Welsh Assembly Government (WAG)  has placed diabetes and its associated conditions on its current agenda. Both the former and the new health ministers have said that they wish to prioritise diabetes care within the Principality. There are several aims:

• To reduce hospital bed occupancy and improve discharge of patients (45% increased bed occupancy compared with the rest of the UK).
• To transfer certain aspects of hospital-based care into the setting of community-based or primary care.
• To consider redeployment of expert services by consideration of specialist-led community clinics or virtual clinics.
• To encourage and offer population screening to prevent late and expensive presentation.

Screening
Retinal eye screening
We have a world-class retinal screening service that has been developed and been in operation since it was commissioned in 2002. Despite planning, the demand has outstripped initial estimates and the service is continuing to evolve to accommodate the increasing numbers of referrals.

Vascular screening
Both England and Scotland have invested resources in a vascular screening programme (Department of Health, 2008). It has been placed on the current agenda by WAG. The debate arises as to how to go forward. The Scottish model involves online and telephone questionnaires at the age of 40 years with tailored advice being offered. The English model requires a more structured consultation by a health worker to assess and offer investigations as needed. The uptake of both these models has not been as good as predicted. WAG is currently looking at cost-effective mechanisms for the screening of people over the age of 50.

Cost efficiency
Wales, as with all areas of the UK, has not escaped the need for reducing medical expenditure. Prescribing costs use up to 80% of the NHS budget (Audit Commission, 2011). This is particularly evident in diabetes. Areas that are extensively being reviewed are the cost-effectiveness and sometimes rationing of newer therapies, as well as restriction in self-monitoring of blood glucose (SMBG). With the new Driver and Vehicle Licensing Agency (2011) regulations that have come into place, the use of SMBG will have to be reviewed in both people treated with insulin and those on insulin secretagogues.

There has been a great deal of debate regarding the excessive use of insulin analogues. Despite the NICE (2009) guidance of using neutral protamine Hagedorn (NPH) insulin first line, 96% of insulin prescribing within Wales is for basal insulin analogues. If NPH insulin was used as an alternative, a saving of £625 million would have been made over the past 10 years (Holden et al, 2011). The All Wales Prescribing Advisory Group has suggested a reduction in analogue use to reduce this excess. This has been translated by several areas around Wales into the idea of doing “switch clinics”, changing people from analogue insulin to NPH. (Of note, one of the analogues in question actually comes off patent next year). Both Diabetes UK (2012) and the PCDS recommend that any changes be made on an individualised and clinical basis rather than as a cost-saving exercise. 

Obesity management
Estimates suggest that 60% of the Welsh population are overweight or obese (Welsh Government, 2010).

The reporting of Welsh healthcare initiatives has been prioritised and Trusts are expected to report to WAG regarding their current strategies and planned actions regarding obesity management in their localities.

Increased funding for bariatric surgery in Wales has now become available within the past 12 months. However, this still only equates to 100 cases per year. The estimated need is at least double this. To curtail demand on bariatric services, the criteria remain strict – much stricter than in other parts of the UK. For example, criteria include a BMI of >40 kg/m² (previously >50 kg/m²) with at least two other comorbidities.

Issues that remain and need to be addressed
Structured education for people with diabetes
Throughout the Principality, there is a huge variation in structured education on offer and available to people with diabetes. As structured education is needed for fulfilment of both NSF and NICE criteria this must be taken seriously and requires investment on a national basis.

Diabetes specialist nurses 
The incidence of diabetes is increasing and management is becoming more complicated. The diabetes specialist nurse (DSN) offers an efficient service that helps to facilitate the passage of individuals through the course of their diabetes. It is of concern that DSN numbers are not being increased despite the apparent need.

IT services
To assess the needs of a population and the effectiveness of current care, accurate data are needed and new means of collecting these data are being reviewed. This should allow transparency of the care offered by both primary and secondary care services. The SCI-DC (Scottish Care Information – Diabetes Collaboration) IT service has been put forward as a possible assessment tool.

Conclusion
Changes are afoot, but how these will affect our individualised care remains to be seen. With the increasing prevalence of diabetes, obesity and cardiovascular disease, together with screening and the move of services into primary care, our workload is going to increase. The big question that we will all ask is what help is going to go along with these changes, including clinical support, time and financial help.