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Caring for patients with diabetes in the community

Ireland has a substantial shortage of diabetes clinicians across all parts of the health service and needs to do more to improve diabetes care, delegates at the 11th Diabetes in Primary Care Conference heard recently.

More than 200 healthcare professionals working in diabetes were in attendance, including GPs, practice nurses, podiatrists, dieticians and clinical nurse specialists in diabetes, among others.

The 11th conference is the product of collaboration between University College Cork (UCC), the HSE, the Irish Practice Nurses Association and the Diabetes in General Practice Group at UCC.

In his address, Prof Sean Dineen, HSE National Clinical Lead for Diabetes, said lack of knowledge around who has diabetes in Ireland was a major issue but could be addressed through the development of a national diabetes registry.

Fragmented care

It is believed around 200,000-to-250,000 people in Ireland have either type 1 or type 2 diabetes. While improvements have been made in recent years through the introduction of the Diabetes Cycle of Care in general practice, for example, care is still very fragmented. 

This fact is borne-out in research and reports on diabetes care across European countries.

The Euro Diabetes Index 2014 from the Health Consumer Powerhouse shows that across a number of categories, including prevention, outcomes, treatment, case finding, services and procedures, Ireland is ranked 20th out of 30 countries.

Commenting on the data, Prof Dineen remarked: “I think that’s a shame because we have very good GPs, nurses, dieticians, podiatrists. Our system, though, is not very well joined-up.”

Another paper published in the European Journal of Public Health looked at the Euro Diabetes Index 2014 ranking and the association between diabetes and depression in those countries.

The paper found Ireland is in the lowest quartile of diabetes care quality, along with the Czech Republic, Poland and Lithuania.

The paper reports the association between diabetes and depressive symptoms appears stronger in European countries with lower-quality diabetes care.

“I think this is sobering and important to reflect on,” Prof Dineen remarked.

He pointed out that five of the top 10 countries ranked in the paper have a diabetes register, emphasising that Irish diabetes care could improve through the introduction of a diabetes registry.

“I feel we’re letting people down in Ireland and I think we can improve with a little thought and reorganisation of our diabetic services,” he told delegates.

Spiralling costs

GP Dr Diarmuid Quinlan, ICGP and HSE Integrated Care Lead for Diabetes, outlined new, unpublished data by researchers at UCC on the costs associated with diabetes care in Ireland. Diabetes consumes about 10 per cent of our health budget and about €900 million is spent managing diabetes complications, such as foot amputations and blindness, Dr Quinlan said.

“But we spend less than 1 per cent of the diabetes budget on prevention, so there’s a huge mismatch in what we could be spending and what we could be achieving,” he said. 

“Even though we’re spending a lot of money on diabetes care in Ireland, our return in comparison to our European counterparts shows we are in the bottom third of the outcomes for diabetes.”

According to the data, people with diabetes make 1.5 extra GP visits per year, he stated.

Considering that 200,000 in Ireland have diabetes, this equates to an extra 300,000 visits annually.

People with diabetes make 87 per cent more outpatient department visits, increase hospital admissions by 52 per cent and make 33 per cent more emergency department visits annually.

“The additional cost of all this, in addition to the costs of diabetes care, is about €89 million a year,” he said.

Around 31 per cent of all Irish diabetes patients are private patients and are not entitled to free GP care.

He said this means “these patients have an incentive to keep attending the hospital, where they get free diabetes care”.

“The cost of doing nothing is enormous and the affect of diabetes is felt throughout the health service and beyond, because it consumes a vast amount of our healthcare budget,” Dr Quinlan added.

He called for all patients with diabetes to receive free care in the community.

Registry

Speaking to the Medical Independent (MI) after his address, Prof Dineen said plans are underway to introduce a national diabetes registry in Ireland. 

The plan was included in a proposal as part of the 2019 estimates, seeking resources to put together a team to write a business case, he said.

“Rather than putting in the ‘national diabetes register’, what we’re saying is we will appoint people with a public health background, a health informatics background. We will get a team together to look at the Retina Screening Programme, to look at the PCRS [Primary Care Reimbursement Service], to look at existing sources of information and data and try to bottom-out what needs to be done to develop and maintain a registry,” he explained.

“The big challenge here is, this isn’t a once-off thing. It’s about developing and maintaining a registry. A register is the spreadsheet, if you will, while a registry involves appointments of people to maintain it.”

If funding is made available for the team in the short-term, Prof Dineen hopes work on building a registry could commence in 2020. 

“Optimistically, it will be two-to-three years,” he said.

“I think it would be a game-changer for Ireland to have a handle on this population and to be able to track them.”

Integrated care

Dr Quinlan welcomed the development of the HSE Model of Integrated Care for Patients with Type 2 Diabetes.

The recommendations contained within the model have yet to be implemented, such as the rise from two-to-three visits annually for diabetes patients, but will help to improve care when introduced, the Cork GP said.

The Model of Care is “still awaiting final sign-off from the HSE senior management team,” Prof Dineen said, but he does not envisage any issues or changes to the model of care before final sign-off.

“The big issue is tying it into the GP contract,” he said.

Prof Dineen added that in the event a new contract, which is expected to include chronic disease care, is agreed, GPs would also be asked to screen for type 2 diabetes in primary care.

“A big part of our work in the next 12 months will be developing an approach for diabetes prevention; the prevention of type 2 diabetes,” he said.

“The scenario we’re anticipating is that if a new contract is delivered for GPs, then they would very likely be asked to screen for type 2 diabetes. If they screen for type 2, they’ll either find it, in which case you get a type 2 care pathway; if you screen negative, you come back again in a few years for screening; or you’ll have this group in the middle, who are pre-diabetes, we need to come up with some offering for that group and that’s what we’re working on.”

The “offering” would most likely be centred on behaviour change in the form of a lifestyle self-management education programme.

The national diabetes clinical programme is looking at community dieticians who are already appointed, 18 across the country, and perhaps piloting a prevention programme in the next 12 months, Prof Dineen revealed.

Diabetic foot care

The HSE Model of Care for the Diabetic Foot has just been updated and includes the formation of foot protection teams at Model 2 and Model 3 hospitals and multidisciplinary foot teams in Model 4 hospitals.

“Importantly, screening in the community and general practice is the model we’re recommending,” Prof Dineen said, regarding the new model.

There are around 400-to-500 lower-extremity amputations in Ireland annually and Prof Dineen admitted that there are not enough podiatrists in Ireland.

“Screening and organisation of care at hospital level could reduce amputations,” he said. 

Dr Quinlan argued there is a huge shortage of diabetes nurse specialists in Ireland. In particular, three in Cork and one in Kerry, is “nowhere near enough”, according to the Cork GP.

“In podiatry, there is a huge deficit. Podiatry is a really expensive complication of diabetes and podiatry in Cork does not have enough dietetic resources to see enough people with moderate-risk diabetic foot disease.

“There are large areas of Cork and Kerry with no dietetics. Youghal, a lot of East Cork, parts of Bishopstown, Ballincollig and Blarney have little or no access to dietetics.”

Type 1 diabetes

In June, a new guideline was launched to improve the quality and safety of treating type 1 diabetes in Ireland.

The national clinical guideline is applicable to all healthcare professionals working in healthcare settings and delivering care to adults living with type 1 diabetes.

Among the key priorities for implementation contained in the guideline are the provision of access to a high-quality, structured patient education programme for patients six-to-12 months after diagnosis.

HbA1c levels should be measured in individuals every three-to-six months and at least two consultations with a diabetes healthcare provider should occur annually.

Prof Dineen said the national diabetes clinical programme is trying to help Hospital Groups deliver on the guidelines.

In this way, across each Group, the programme is recommending the appointment of a nurse, dietician and administrator to deliver a self-management education programme to people with type 1 diabetes, he said.

The programme is also working on the development of a diabetes in pregnancy model of care. The HSE National Women and Infants Health Programme “will hopefully endorse it and we may get posts through that,” Prof Dineen said. 

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