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We need to improve quality and quantity of services for hard-to-reach populations

Lyndi Wiltshire

The importance of improving services for people with diabetes in prison and those who are homeless.

Diabetes affects many people in a number of environments and, sadly, it doesn’t exclude the most vulnerable people or the most hard-to-reach populations. Time and time again, it is the most vulnerable populations that find it the most difficult to engage with our diabetes services and, as a result, they are more likely than the general population to experience complications, which, while causing the individual distress, also mean costs for NHS. 

Despite cost-saving measures in the NHS, we need to recognise that the harder-to-reach populations have many more significant public health issues to deal with. Understanding this should encourage us to call for an improvement in financial and resource backing, which in the long term could lead to considerable financial benefits.

This section will review two sections of the population that are known to have a greater need: those in prison and those who are homeless. Multifactorial problems can affect these populations and this can lead to poor quality and quantity of services.

Prison is an environment that is known to lead to poorer physical, mental and social health than the general population. In general, the prison population comes from sections of society with high levels of poor health and social exclusion (Mills, 2014). Prisoners tend to have a lifestyle that puts them at risk of ill health (Hayton et al, 2010).

Recent reports highlighted we have over 85000 people in the prison population in the UK (Ministry of Justice, 2014), which, even with conservative estimates of 5% of the population with diabetes, suggests that there are likely to be over 4250 people with diabetes in prison at any one time.

We now have excellent studies illustrating the impact of good practice and also highlighting the importance of a good health promotion framework in prisons and this means there is the now the opportunity to develop understanding, improve knowledge and develop self-management skills. This work needs to be structured, systematic and robust to ensure the skilled diabetes staff are available to support the prison staff within the prison system to provide a united message to the offender. Our article by Lesley Mills provides excellent information of how this system can be successful and truly help to redesign services to reduce inequalities and benefit both the offender and the healthcare professional. 

Homeless people are among the most vulnerable and excluded in society. A report by Mental Health Today (2014) highlighted worrying evidence that homelessness services are still very much “Cinderella services”, as it reviewed a report by homeless charities reviewing audits of 50 Health and Wellbeing Boards. The audit found that 64% of Joint Strategic Needs Assessments (where local authorities outline their health priority) made no mention of single homeless people and another 14% made no mention of homeless people at all.

In all too many cases, homeless people are being let down by health services and not being considered in the planning of future provision. Diabetes care, as with care for other physical health conditions, needs to adapt the care for the homeless person. As diabetes practitioners, we need to provide a more flexible approach to care, especially for people with chaotic lifestyles, which is often the case in homelessness (Elder and Tubb, 2014). It is known that the homeless person still has to deal with discrimination and difficulties when dealing with some services.

Unfortunately, diabetes is a condition that creates many health challenges within our society. We need to understand the impact on services and wellbeing when dealing with someone from a vulnerable group.


Elder N, Tubb MR (2014) Diabetes in homeless persons: Barriers and enablers to health as perceived by patients, medical, and social service providers. Soc Work Public Health 29: 220–31
Hayton P, van den Bergh B, Moller L (2010) Health protection and prisons. The Madrid recommendations. Public Health 124: 635–6
Mental Health Today (2014) Homeless people with mental ill health overlooked by health services report. Available at: (accessed 23.10.14)
Mills L (2014) A prison based nurse-led specialist diabetes service for detained individuals. European Diabetes Nursing 11: 53–7
Ministry of Justice (2014) Prison population figures: 2014. Available at: (accessed 23.10.14)

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