No one argues, do they, that outcomes in the people we see with diabetes are great. Progress is painfully slow, risking the adoption of a kind of therapeutic nihilism at the sharp end of patient care. Insufficient appointment time, poor patient engagement and complexity of management confront us on a daily basis. Furthermore, we can throw a mental switch and ponder that one in 20 people in the UK have a diagnosis of diabetes, that around 650 000 additional people are undiagnosed, and that the prevalence will hit 5 million by 2025 (Diabetes UK, 2014).
In an era of sophisticated data collection, management and targets, we are regularly confronted by our professional impotence. Who among us has not experienced the highs of a complex case, managed well, to be immediately faced with our next patient, both poorly controlled and poorly engaged? If we do not turn our efforts to this conundrum, we are destined to continue to fail. Our data already tell us this.
The challenge before us remains colossal. In Scotland, as elsewhere, the clinical epidemic is a population-level event, rooted in social inequalities, societal pressures and strained health resources. No surprise then that the Scottish Diabetes Improvement Plan (Scottish Government, 2014) is an astonishing read. The busy primary care health professional is unlikely to be familiar with Quality Improvement Hub, Digital Health Institute or the Innovation Partnership Board. Yet the enormous effort in data crunching and strategic planning, hidden behind the clinical front line, is the only real path to directing research, marshalling resources and, most importantly, engaging with people with diabetes.
Even a comprehensive document such as this acknowledges, by prioritising its aims, that the “holy grail” target of excellent care for all, is, in many senses, a moving one. Eight priorities, then, are offered, with the three most relevant to primary care colleagues discussed below.
Prevention and early detection of diabetes and its complications
Eighty per cent of diabetes complications either are preventable or have the potential to be ameliorated. That 19% of people with type 2 diabetes in Scotland have retinopathy within a year of diagnosis is one measure of how we have already “missed the boat”. The recording, follow-up and targeting of people with acute-illness hyperglycaemia, gestational diabetes, and impaired glucose tolerance or impaired fasting glucose provides us with an opportunity to care for patients when it matters most. Also planned is the roll-out of educational packages – for example, on the early detection and management of diabetic ketoacidosis – aimed at those individuals already diagnosed.
The Scottish Diabetes Group (SDG; a national advisory body) and managed clinical networks (run at the health board level) are tasked with, and in many circumstances are already successful in, achieving meaningful patient representation. Efforts and resources will be redoubled to encourage patients to engage with the award-winning My Diabetes My Way initiative, which gives people with diabetes access to their own data in real time. The SDG will also be ensuring that learnings and outcomes from strategic initiatives (e.g. the House of Care framework) are disseminated throughout the Scottish diabetes community.
Equality of access
Grasping the most difficult nettle of all, the SDG is tasked with setting up a Health Inequalities workstream, whose purpose is the identification of what works and what doesn’t in the hard-to-reach groups of deprived communities and rural and remote populations, and the application of culturally sensitive care for minority ethnic communities.
So that was a whistle-stop tour. Thanks are due to our colleagues in public health, epidemiology, government and healthcare management for their pivotal role in the care of people with diabetes. New pills and new jags are great, but in the end will not help if the mouths are missing and the abdomens absent.