Today, there are an estimated 5.6 million people with diabetes of which 1.2 million may be undiagnosed. 90% are living with type 2 diabetes. The cost to the health system? 10% of the entire NHS budget. Just last year alone, 66 million items were prescribed related to diabetes.
For GP practices, there are a myriad of objectives which broadly fall into three categories: (1) maintaining up an up-to-date register of individuals with diagnosed diabetes; (2) ensuring optimal ongoing management and treatment; and (3) case-finding undiagnosed individuals to facilitate earlier intervention and prevention.
However, as with any chronic condition, this is far from simple. Indeed, increasing complexity of the patient population has made this more difficult than before for primary care. NHS England’s 24/25 QOF Guidance notes:
“A greater understanding and knowledge of the complexities of diabetes has led to increasing difficulty in accurately diagnosing or classifying the type of diabetes.”
Furthermore, due to diabetes’ multifactorial nature, optimal solutions must embrace a population health approach to tackle an array of determinants spanning lifestyle, genetic and socio-economic factors.
In this article, we break down some ways primary care services can optimise approaches to diabetes.
We know individuals who are obese may be at risk of developing type 2 diabetes. And evidence shows that weight reduction not only supports blood sugar control and prevention of diabetes, but also remission in some cases.
An individual’s annual diabetes review should measure weight and height alongside blood pressure and foot checks. Additionally, providing education and facilitating discussion about weight loss can give individuals the support they need to make a change and support ongoing self-management.
“Treating obesity is the cornerstone in the prevention and management of type 2 diabetes”
For example, a clinical pharmacist can help patients pinpoint sources of sugar in their diet, and also provide tips and advice on lifestyles and eating. If further support is required, the individual can then be referred to a structured educational programme in accordance with NICE guidance.
In regards to the latter, findings from the DiRECT study show that 13% of people who received a weight management programme were in remission of type 2 diabetes at five years. While another study of a 16 week lifestyle programme reported that individuals who successfully completed it did not increase their oral diabetes medicine and were only half as likely to progress to insulin as those who did not complete the programme and those who did not lose weight.
Suvera delivered a 6.5% reduction in average weight loss for Acton PCN through a virtual group diabetes clinic (based on the average weight of 27 patients who submitted a recent weight for two or more sessions)
Living with diabetes not only impacts an individual’s physical health but also mental wellbeing. Diabetes distress has been defined as an emotional response to the condition, the burden of daily self-management and fear of complications.
Emotional responses associated with diabetes distress may include worrying about a possible attack, dietary intake or the potential guilt from veering off course with one’s daily diabetes routine. Diabetes management is a ‘round the clock’ concern which may also result in ‘diabetes burnout’ and disengagement when individuals experience continued poor control despite their best efforts.
One in five people with insulin-treated type 2 diabetes are said to experience severe diabetes distress. High levels of distress may result in higher HbA1c, sub-optimal self-management and impact quality of life.
Thus, adopting a holistic approach to diabetes management is essential. A seven step model has been developed to help healthcare providers identify and support individuals with diabetes distress. During a patient’s diabetes review, individuals may not expect a discussion around their mental health, but giving the patient a forum to talk openly can help identify if further support is required.
Our diabetes clinics delivered a 7.4 reduction in average diabetes distress score (DDS) (based on the average DDS of 41 patients who submitted a score for two or more sessions)
Optimally utilising data to also support diabetic case finding is also vital. You may have undiagnosed patients currently missing from your disease register and the faster these patients are identified and treated the better the potential outcomes. Coding errors or omissions are also consistent reasons practices can miss out on potential funding.
Proper register maintenance can ensure patients are called for review and support QOF achievement.
Here at Suvera, our data analytics team support our practice partners with searches, segmenting patient registers by risk, birth month and overlapping comorbidities to drive improvement and minimise duplication in CDM processes. We can also identify missed codes and optimise call and recall of patients.
For South One Newham PCN, part of North East London ICB, Suvera added an additional 223 patients with hypertension to the register, an increase of around 8% of patients who are now receiving appropriate treatment.
With the number of diagnosed diabetic cases doubling over the last 15 years at a time when the GP workforce has conversely continued to shrink, utilising a multidisciplinary team to support diabetic management has become crucial for demand management.
Furthermore, as prevalence of associated risk factors like frailty, hypertension and other co-morbidities have risen, specialist expertise in multiple chronic conditions can also have clinical benefit.
For example, experienced clinical pharmacists have become a foundational element of high-performing teams in practices. In practices where previously patients were invited to diabetes clinics regardless of need, cases have emerged where pharmacists have led a step-change in approach, leading patient analyses programmes to risk stratify and identify those in the greatest need based on HbA1c, blood pressure and lipid levels. Similar examples have also been shared by NICE.
At the same time, pharmacists can support medicines optimisation, de-prescribing and titration. For example, an analysis of 35 studies found pharmacist interventions in type 2 diabetic patients significantly reduced HbA1c, and improved control of blood pressure, LDL-C, BMI as well as medication adherence.
Thus, building out specialist expertise in diabetes and its risk factors can have many benefits. Upskilling and training your team in latest NICE guidelines and comorbidities such as lipid management and hypertension can be a solid foundation for a high-performing diabetes clinic.
With many practices facing a struggle to recruit specialist clinical resource, virtual models offer a solution that both improves outcomes and is cost-effective.
Suvera provides a number of services to support practices and PCNs with diabetes management. From comprehensive patient reviews and data coding through to our virtual group consultation service.
Our innovative virtual group clinic delivers diabetes education at scale.
For example, for Acton PCN, individuals were invited to discuss goals and develop plans in 90-minute sessions. Group clinics also included review of a diabetes results board for recent blood tests, blood pressure, weight/BMI and medication.
In addition to reductions in weight and diabetes distress scores shared above, we obtained a 90% patient satisfaction rate. And due to the success of our partnership, Suvera has been invited to cover non-diabetic hyperglycaemia and Level 1 Diabetes Enhanced Services.
“The team at Suvera have been a pleasure to work alongside. In addition to exceeding expectations, they genuinely care about the patient journey, building relationships and improving patient care.”
Suvera is proven to reduce both practice and patient burden of diabetic management.
If you would like to discuss your needs, contact partnerships@suvera.co.uk
