Diabetes needs innovation on all fronts - patients, drugs, clinicians and technology, says Varya Shaw
Upskilling nurses enables patients to be seen in primary care, freeing up hospital consultants’ time
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Diabetes puts the NHS in a similar position to a diabetic patient: the problem is well understood and there is time to do something about it - but if nothing is done, the outcome will be devastating.
‘We are in the 21st century, we speak through virtual means, but somehow in the NHS we don’t do that’
In the case of the individual these consequences include blindness, stroke, amputation and death.
For the NHS, it means an intolerable financial strain and system collapse.
“We can’t go on as we are,” says Robin Hewings, head of policy at Diabetes UK.
Innovation runs on a spectrum, from incremental progress to radical new approaches that break with what went before. An example of the latter is the Super Six model pioneered by Partha Kar, a consultant endocrinologist at Portsmouth Hospitals Trust. This model takes the insight that hospital treatment for all is unsustainable to its logical conclusion.
It moves care of type 2 diabetes out of hospitals entirely by upskilling GPs and practice nurses - 90 per cent of patients are seen in primary care - while specialists reserve their attention for type 1 and for six clearly defined areas of care.
A 2013 evaluation showed the model saved £90,000 a year. Patients also felt more in control of their condition and 89 per cent said the model was “strongly beneficial”. There were 16 per cent fewer hypoglycaemic admissions and 18 per cent fewer cases of diabetic ketoacidosis.
‘Many service redesign ideas come from people with diabetes who know what works for them’
Another example is the multidisciplinary teams set up in 2010 at Imperial College Healthcare Trust to treat foot ulcers. These bring together diabetes specialist consultants, podiatrists, vascular surgeons, orthopaedic foot surgeons, footwear specialists and nerve specialists to stop foot ulcers leading to amputations.
The Imperial initiative has resulted in some of the lowest amputation results ever reported internationally.
Patients are an important starting place for innovation. Many service redesign ideas come from “people with diabetes who know what works for them and what doesn’t”, says Jonathan Valabhji, national director of diabetes and obesity at NHS England and consultant diabetologist at Imperial College Healthcare Trust.
Technology is another cradle of innovation. It can be medical - for example, the artificial pancreas being prototyped by the University of Cambridge that gives type 1 diabetics a “holiday” from the relentless monitoring of their blood glucose levels. This would be a game changer but is not going to be widely available for some time.
But technological innovation can also be digital. Monster Manor is a free app that aims to help children with type 1 diabetes to manage their condition. It encourages users to test and record their blood glucose levels more regularly. Incorporating a game, Monster Manor provides a fun experience for children struggling with this responsibility.
Overcoming the obstacles to innovation
“People think of innovation as something fantastically wonderful or Star Trek like, but it’s very simple - it’s about identifying the barriers people put up and removing them. People often don’t want to change, and they believe sticking with what they know will save them from change. On the other hand, constant change is also a problem. But many places have innovated in spite of this. Whenever people throw up multiple reasons why innovation can’t happen, I say: ‘Well it is happening in some places. You have to find out how they did it.’”
Partha Kar, consultant endocrinologist at Portsmouth Hospitals Trust
“Innovation means doing things differently to how they are done now, so it’s very broad. It has fallen into difficulties because of financial flows and complicated commissioning. But the overall message is that we are not lacking innovation.
“There are huge opportunities, and this is an exciting time with the NHS Five Year Forward View, which states very clearly we don’t need more top down reorganisation. What we do need are ways to promote innovation more directly.”
Jonathan Valabhji, national director of diabetes and obesity at NHS England and consultant diabetologist at Imperial College Healthcare Trust
“The biggest thing you are trying to achieve is getting people to look after their own diabetes. The second thing is to make sure their care is planned collaboratively, usually with their GP, so that people have a proper plan, which they feel a strong sense of ownership of. It’s a really big task… to make that the norm… When it comes to their health, people, very reasonably, are fairly conservative and it’s a complex system.
“If you want to get past this, you need organisational stability, good relationships, and a really good diabetes network. You need clinical governance of the whole diabetes system - this enables you to plan how you want your diabetes care… to move forwards.”
Robin Hewings, head of policy, Diabetes UK
In the field of diabetes there is no shortage of research, ideas and discoveries. As in other areas of healthcare, the problem is dissemination.
Mr Hewings says: “We do have some things which are relatively new and there’s good evidence that they work. They are not hot off the press but they’ve not been around for donkey’s years either. The priority is to make them happen at scale.
“An example is giving people the knowledge and motivation to be able to look after their own diabetes. Looking after it day in day out is hard and exhausting.
‘The way we run our young persons clinic, a lot of patients have direct access to me via phone and email’
“Really good patient education helps that happen and a few areas have been able to provide this at scale, but in most places patient education happens at a really marginal level.”
Another example is modern communication techniques. Portsmouth’s model takes full advantage of these.
“We are in the 21st century,” says Dr Kar. “We speak to everyone through virtual means. The world is smaller. But somehow in the NHS we don’t do that.
“The way we run our young persons clinic, a lot of patients have direct access to me via phone and email. It has reduced hospital admissions and patients are happier. You just communicate directly with the doctor and get an answer.”
So what is stopping new - and not so new - ideas from spreading? Why cannot every trust emulate the Super Six project at Portsmouth or the multidisciplinary teams at Imperial? Why cannot every area educate patients to manage their own condition, and harness their expertise to design care?
Mr Hewings says the ideal conditions for innovation are stability, trusting relationships and a dynamic group of individuals who look outwards beyond their organisations to the needs of patients and the health economy as a whole. Not every local health system meets this ideal, however.
‘The time it takes scientific innovation to become clinical innovation is something in the region of 17 years’
The complexity of the system is also a barrier. Dr Valabhji says: “We’ve got very complicated commissioning. Social care is commissioned by the local authority, primary care by NHS England and secondary care by clinical commissioning groups.”
Progress on this front may be in sight: the NHS Five Year Forward View recommended that provider models be simplified by limiting them to just a handful.
Medical technology is also notoriously slow to roll out in the UK. Dr Valabhji says: “The time it takes scientific innovation to become clinical innovation is something in the region of 17 years.”
Academic health science networks were set up to tie together the different organisations involved in innovation, from universities to the public sector to the NHS. It is hoped they promote rapid evaluation and early adoption to mitigate this lag.
The ultimate innovation would be an affordable cure for diabetes. There is promising progress at Harvard University on growing sugar sensing, insulin producing beta cells in the lab, but there have been many false dawns in the search for a cure and this is unlikely to be available or affordable any time soon.
In the absence of a cure, all facets of innovation - clinical, system, patient led, preventative, drug and technology - are vital.
As Dr Valabhji puts it: “There is not going to be one single magic bullet - everything is important.” But above all, innovation needs to spread faster if it is going to have a real impact on diabetes.
Barbara Young: Time to get a lot smarter
There are now 3.8 million people living with diabetes and growing numbers are experiencing devastating complications such as blindness, amputation and stroke.
Treating these complications takes up 80 per cent of the £10bn annual spend on diabetes.
But it doesn’t have to be this way. By thinking innovatively and investing funds differently - in diabetes care as a whole - care can be improved and complications and costs per patient reduced.
People with diabetes face daily challenges in managing their condition. They need support that meets their individual needs and swift access to a range of professionals in all parts of the NHS. Traditional divisions between primary, community and specialist care make this hard.
Diabetes UK’s report, Improving the delivery of adult diabetes care through integration, looked at five locations, including Derby, that have focused on redesigning processes to make the system work for people with diabetes while using limited resources more effectively.
In Derby, unacceptable variations in the quality of care and delayed access to specialist care for people with complex needs prompted providers and commissioners to look at the delivery of the whole pathway. They set up a new NHS organisation to pool budgets and align finances and incentives across the system.
Ripping up payment by results meant specialists helped improve skills in primary care, so more people were looked after closer to home. A shared IT system allowed rapid communication and referral between teams.
A year after the redesign, 63 per cent of patients rated the service as “excellent” and 22 per cent as “very good”. The model has saved £800,000 a year through increased efficiency, fewer admissions and improved outcomes.
Just one in 10 people newly diagnosed are offered structured education and only a quarter accept it.
To improve uptake, providers should innovate in how structured education courses are delivered - for example, by offering them in an accessible way. Tower Hamlets Clinical Commissioning Group runs courses in the evenings and allows patients to bring family.
Commissioners and providers must get smarter at learning from others, rather than constantly reinventing the wheel.
Barbara Young is chief executive of Diabetes UK