Does the NHS White Paper signal a raw deal for older people?

While we wait for the detail of the recent White Paper (Department of Health, 2010) reforms to assess their impact on care and services, themes such as individual care planning and doing more with the same resources remain. What concerns me is that when resources become squeezed by having to reduce or restrict choice and care, it is often the already disadvantaged that feel the squeeze the most. That is why I am concerned at the potential impact on care for the older person with diabetes, for the following reasons.

We know that diabetes is the “the commonest metabolic long-term condition in older people and is characterised by a high rate of vascular complications and subsequent disability, frequent hospital admissions, and increased institutionalisation” (British Geriatrics Society, 2009). We also know that the diagnosis is often missed, with symptoms being attributed instead to old age, and that once diagnosed, diabetes doubles admission rates to residential care, hospitals, and length of stay. We know that 10% of those over 75 years of age have diabetes, as do 14% of those over 85 (Croxson, 2010), and also that most of these people will have comorbidities, many of which will complicate and compromise their diabetes management. 

We know a great deal about the scale of the problem, then, but do we incorporate this knowledge in our service planning? It is clear that we should, because in addition to the problems identified above, this group can be excluded from regular general practice care, particularly if housebound or in residential settings, so do not receive the minimum surveillance recommended. This happens despite the fact that many over-65s could live well, if we provided appropriate and timely care, for another 20 years or so. 

NHS Diabetes (2010) has identified the key features of services for older people, recommending screening, integrated information systems and clinical networks, coordination of services (specialist, community, primary care etc.) and support to optimise glycaemic control. We all agree that these recommendations would enhance care and safety, and quality of life (QoL), but they will depend on the priority commissioners place on achieving these goals.

Other influencing factors on QoL and outcomes include polypharmacy and residential care. Liver and renal impairment increases the risk of adverse drug reactions, and most drug trials exclude frail older people. Treatment for comorbidities can destabilise blood glucose levels, e.g. steroids for chronic respiratory diseases. Often treatments increase the risk of hypoglycaemia, which, if not monitored and appropriately treated, can seriously impact on patient safety, leading in some cases to coma and death. If staff are not aware of this risk, and have poor diabetes knowledge and access to hypoglycaemia treatment, then disaster is all the more likely.

One senses that issues such as this were the prompt behind Fiona Kirkland and her team’s investigation into the extent of hypoglycaemia in care homes in South Staffordshire, and the effect of introducing “hypoboxes” (page 311). In their study, the authors found evidence of comorbidities with diabetes that impacted on care, lack of knowledge by people regarding hypoglycaemia (such as side-effects of sulphonylureas), and lack of diabetes knowledge by carers.

The potential causes of hypoglycaemia were investigated, and educational gaps and access to specialist care, among other factors, were discovered. Strategies to resolve these problems are suggested and the audit process and solutions could certainly be applied in other areas. There is recognition within the audit that there are cost implications in improving care, which may need to be taken from other healthcare budgets. Given what we all know, isn’t it time to be proactive and present such solutions to improving access and quality of care, and start influencing our commissioners on our patients’ behalf?