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  • A recent study suggests that a drug combined with dietary and lifestyle changes can prevent those with pre-diabetes from progressing to full blown type-2 diabetes (T2DM)
  • T2DM kills millions and cost billions
  • 35% of adults in the UK, and 50% in the US now have prediabetes
  • The UK has launched the world’s first nationwide diabetes prevention program called Healthier You based on personal education and training
  • Prevalence rates of T2DM are still rising 
  • Research on the gut-brain axis suggests that drugs have a role to play in preventing T2DM
  • An optimum strategy might consist of appropriate drug therapy combined with appropriate education, which leverages ubiquitous 21st century communications infrastructures
  
A new therapeutic approach to pre-diabetes
 
Findings of an international clinical study published in The Lancet in 2017 suggest that 3.0mg of the drug liraglutide, may reduce diabetes risk by 80% in individuals with pre-diabetes and obesity, and thereby significantly contribute to the prevention of type-2 diabetes (T2DM). The study investigated whether 3.0mg of liraglutide would delay the onset of T2DM safely in people with pre-diabetes.
 
Liraglutide is the active solution in a drug marketed as Victoza, which obtained FDA approval in 2010.  Victoza is available in 6 mg/ml pre‑filled pens, and is used as an adjunct to diet and exercise to improve glycaemic control in adults with T2DM. Victoza is used also as an add-on to other diabetes medicines, when these, together with exercise and diet, are not providing adequate control of blood glucose.
  

Pre-diabetes

Pre-diabetes is a condition that develops when your blood sugar levels are at the very high end of the normal range, but not quite high enough for a diagnosis of T2DM.  Risk factors include age, weight and ethnicity. People of South Asian origin are up to six times more likely to develop pre-diabetes as a genetic susceptibility means they start to develop insulin resistance at a much lower Body Mass Index (BMI). With pre-diabetes your body begins to have trouble using the hormone insulin, which is necessary to transport glucose, which your body uses for energy, into your cells via the bloodstream. Pre-diabetes means that your body either does not make enough insulin or it does not use it well (insulin resistance). If you do not have enough insulin or if you are insulin resistant, you can build up too much glucose in your blood, leading to higher-than-normal blood glucose level and perhaps pre-diabetes. Blood glucose is measured using a test called HbA1c, which provides a picture of your blood sugar levels over the past two to three months. It counts the number of glucose molecules stuck to the red blood cells, which reveals how much sugar you have carried in your blood over the two to three month lifespan of the red blood cell. If your blood sugar is between 5.7 to 6.4%, this is called pre-diabetes (6.5 is officially diabetes). Dr Roni Sharvanu Saha, a consultant in acute medicine, diabetes and endocrinology at St George's Hospital, London describes pre-diabetes:
 


Prevalence and cost 
 
It is estimated that 35% of adults in the UK, and 50% in the US now have pre-diabetes. Around 5-10% of these will progress to "full-blown" T2DM in any given year. Because there are no obvious symptoms for pre-diabetes the overwhelming majority of people with the condition do not know they have it, and are not aware of the long-term risks to their health, which include T2DM and its complications: heart attack, stroke, kidney failure, blindness and lower limb amputation. Over the past decade, the prevalence of T2DM has increased by almost two-thirds, and is now one of the world’s most common long-term health conditions.
 
An estimated £14bn is spent each year on treating diabetes and its complications in the UK. Treating obesity-linked illnesses costs £10bn a year. The annual medical cost of treating diabetes in the US is about US$176bn, and the cost of diabetes in reduced productivity is some US$69bn each year.
 
The gut-brain axis

The study published in The Lancet was led by John Wilding, Professor of Medicine, University of Liverpool, and is a continuation of work he started in 1996 when part of a team at Hammersmith Hospital in London, which first showed that the hormone GLP-1, on which liraglutide is based, was involved in the control of food intake.
 
Over the past two decades scientists have increased their understanding of the two-way communications between the gut and the brain, not only through nerve connections between the organs, but also through biochemical signals, such as hormones that circulate in the body. Dr Sufyan Hussain, Specialist Registrar and Honorary Clinical Lecturer in Diabetes, Endocrinology and Metabolism at Imperial College London, describes the gut-brain axis.
 
 
Targeting gut-brain pathways

An increasing number of different gut microbial species are now postulated to regulate brain function in health and disease. The westernized diet, which is high in saturated fats, red meats, and carbohydrates, and low in fresh fruits and vegetables, whole grains, seafood, and poultry, is hypothesized to be the cause of high obesity levels in many countries. For example, 63% and 69% of adults in the UK and US respectively are either overweight or obese, and therefore at risk of T2DM. Experimental and epidemiological evidence suggest that the gut microbiota is responsible for significant immunologic, neuronal, and endocrine changes that lead to obesity. The gut–brain axis influences obesity, and researchers such as Wilding have targeted communication pathways between the nervous system and the digestive system in an attempt to treat metabolic disorders. 
 
Bariatric surgery and diabetes

A previous HealthPad Commentary describes how bariatric surgery is associated with gut-brain signals, which promote the remission of diabetes in patients. Many of the mechanisms that underlie how bariatric surgery produces metabolic benefits remain unclear, but researchers do know that such surgical procedures elevate levels of the hormones peptide YY (PYY), and glucagon-like peptide-1 (GLP-1) that help to reduce appetite and have effects on the central nervous system.
 
Liraglutide

Liraglutide is a GLP-1 receptor agonist, which interacts with the part of the brain that controls appetite and energy intake. The drug slows food leaving the stomach, helps prevent your liver from making too much sugar, and helps the pancreas to produce more insulin when your blood sugar levels are high. The most common side effects with liraglutide are nausea and diarrhoea.
 
The clinical study

The three-year study followed 2,254 adults with pre-diabetes at 191 research sites in 27 countries worldwide. Participants were randomly allocated to either liraglutide or a placebo delivered by injection under the skin once daily for 160 weeks. Participants in the study were also placed on a reduced calorie diet and advised to increase their physical activity. The study showed that three years of continuous treatment with once-daily 3.0mg of liraglutide, in combination with diet and increased physical activity, reduces the risk of developing T2DM by 80% and results in greater sustained weight loss compared to the placebo.

"On the basis of our findings, liraglutide 3.0mg can provide us with a new therapeutic approach for patients with obesity and pre-diabetes to substantially reduce their risk of developing type 2 diabetes and its related complications . . . . It is very exciting to see a laboratory observation translated into a medicine that has the potential to help so many people, even though it has taken over 20 years,” says Wilding.
 
World’s first nationwide diabetes prevention program

NHS England, Public Health England and Diabetes UK launched the world’s first nationwide diabetes prevention strategy, Healthier You, in 2016. It provides personal coaches to educate people at risk of T2DM in healthy eating and lifestyle, and personal trainers to provide bespoke physical exercise programs that are expected to help people lose weight. By 2020 Healthier You expects to be rolled out to the whole country with 100,000 referrals available each year after that.
 
Extrapolating from previous studies

International clinical studies have shown evidence that lifestyle interventions such as those used in Healthier You can prevent or delay the onset of T2DM. However, the validity of generalizing the results of previous prevention studies is uncertain. Interventions that work in some societies may not work in others, because social, economic, and cultural forces influence diet and exercise. The UK’s Public Accounts Committee has expressed doubts about the way Healthier You is setting about its task, and has warned that, "By itself, it will not be enough to stem the rising number of people with diabetes".
 
Failure of the diabetes establishment and the Public Accounts Committee

Healthier You is a slow, labor-intensive and expensive program, which is unlikely to have more than a relatively small impact.Let us explain. Assume that after 2020 Healthier You obtains its projected annual 100,000 referrals, and that they all successfully reduce their blood glucose levels with diet and exercise. Also assume that the prevalence of pre-diabetes in the UK does not increase, (which is not the case) then Healthier You will take more than 110 years to counsel the estimated 11.5m people in the UK with pre-diabetes: which is long after most people with pre-diabetes would have died from natural causes.
 
21st century communications

Successfully changing the diets and lifestyles of the 11.5m people in the UK believed to have pre-diabetes, and slowing their progression to T2DM will require 21st century technologies. Inexpensive and ubiquitous healthcare technologies used to educate and support diets and lifestyles abound. Increasingly people are demanding devices that track weight, blood pressure, daily exercise and diet. From apps to wearable’s, healthcare technology lets people feel in control of their health, while also providing health professionals with more patient data than ever before. With more than 100,000 healthcare apps, rapid growth in wearables, and 75% of the UK population now owning a smartphone, digital technology is well positioned to significantly improve healthcare education and management.
 
Takeaways

Has Healthier You missed the elephant in the room? Wilding’s study suggests that an exercise and diet program needs to be complemented with a sustained program of appropriate drugs if we are to reduce those with pre-diabetes from progressing to full blown T2DM. Further, simple arithmetic suggests that the education element of such a strategy about diet and lifestyle should leverage ubiquitous 21st century communications infrastructures if they are to be efficacious.
 
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  • Diabetes UK’s (DUK) 2016 State of the Nation Report calls for diabetes education to be improved
  • Effective education can reduce the vast and escalating burden of diabetes and is significantly cheaper than treatment
  • Traditional diabetes education is failing miserably
  • DUK’s education only reaches a small percentage of people with diabetes
  • Self-management is the only realistic way forward to better diabetes management, but will require a transformation of the current patient-educator relationship
  • Could DUK play a leading role in this transformation?
 
Improving diabetes education to enhance patient outcomes
 
For the past decade at least, the charity Diabetes UK (DUK) has been “calling for governments to do more” to improve diabetes care in order to stem the vast and escalating burden of the condition. Currently, 4m people or 6% of the population are living with diabetes in the UK, and this is projected to rise to 5m by 2025. It is estimated that around 10% of the NHS yearly budget is contributed to the treatment of diabetes; which equates to £10.3bn a year.

The prevalence of type-2 diabetes (T2DM) in particular has been increasing rapidly, and is now one of the world’s most common long-term health conditions. Life expectancy on average is reduced by up to 10 years for people with T2DM. Experts say effective education can prevent the onset of T2DM, help with its management once diagnosed, and slow the onset of complications, such as heart failure, blindness, kidney disease and lower limp amputations. The 2016 DUK State of the Nation report called for diabetes education to be improved.

 
Traditional diabetes education is failing

In the video below Richard Lane, Ambassador and Immediate Past President of DUK, describes the significant improvements in diabetes education since he was first diagnosed in the 1970s, and briefly describes DAFNE (Dose Adjustment For Normal Eating), one of the official UK adult courses for managing type-1 diabetes. Also, a patient with type-1 describes how helpful she found some voluntary diabetes educational courses.
 
 

Notwithstanding individual successes, traditional diabetes education programs are failing to reach a sufficient number of people to be effective in reducing the overall burden of the condition. Only 2% of people diagnosed with type-1 diabetes and 6% with T2DM attend official diabetes educational courses. Each year there are 24,000 early deaths from diabetes-related complications, and also 7,000 avoidable amputations. DUK wants 50% of people living with diabetes to receive education over the next five years.
 
DUK's education and support

DUK spends about 50% of the money it raises annually on diabetes education. Of the £37m it raised in 2015 it spent £8.0m on its “Better Care Everywhere” program that works with healthcare institutions, “to make sure people had access to the 15 healthcare essentials”; £7.0m on its “Not Alone with Diabetes” program, which is its helpline; £1.5m “Reducing the Risk of Diabetes”, which is DUK’s participation in the National Diabetes Prevention Program; and £8.2m, “Growing the Impact of DUK’s Work”, which develops “networks of healthcare professionals,” to “work with local community groups and volunteers all over the country”: a total of £24.7m. 

Here we describe these expenditures as education and support services. 
Despite over £20m worth of diabetes educational and support services delivered by DUK each year, and the £10.3bn spent by the NHS on diabetes care and education, diabetes in the UK remains the largest and fastest growing health challenge of our time. “Diabetes is a very serious and complex health condition that requires constant self-management,” says Chris Askew, DUK’s CEO. 
 
A fundamental transformation is required

Increasing self-management is relevant, especially as resources for diabetes are shrinking as the prevalence of the condition is rapidly increasing, particularly among children. However, achieving effective self-management requires a fundamental transformation of the way diabetes education is delivered. 

It is projected that 66% of people in the UK will have smartphones by 2017. It seems reasonable to assume therefore that the majority of people  living with diabetes will have smartphones by 2017. People regularly use their smartphones for 24-hour banking, education, entertainment, shopping, and dating. Diabetes education has failed to effectively leverage this vast and rapidly growing free infrastructure and peoples’ changed lifestyles to introduce effective educational support systems to enhance the quality of diabetes care, increase efficiency, and improve patient outcomes. Today, mobile technology is part of everyday life and people expect to be connected with their relevant service providers 24-7, 365 days of the year from anywhere. 

Here is just one example of a simple evidence-based  dashboard designed to help re-engineer primary care management of diabetes by (i) increasing the connectivity between health professionals and patients, (ii) enhancing patient knowledge of diabetes, (iii) encouraging people to self-manage their condition, (iv) increasing the efficiency of GP clinics, and in the medium to longer term, (I) keep people out of A&E, and (ii) slow the onset of complications. 
 


Click on the image to see a demonstration of the dashboard
 

At very little cost, such a system could be rolled-out nationally through Clinical Commissioning Groups (CCG), integrated into GP clinics, and provide the basis of a national platform for diabetes education. Once patients and health professionals become engaged and familiar with the initial service offering, CCGs can bolt on additional services to further help people ward-off or manage their diabetes. This follows the model of digital champions, which succeed by using a core service to engage, and build a user base, and then add more services, so continuously increasing their users’ familiarity with their services. Engaging patients and health professionals any other way tends to fail.

The  diabetes education dashboard ensures that people either at risk of diabetes or living with diabetes will always be part of an educator-patient network, which should increase the variety; velocity, volume and value of educational healthcare information patients receive.

 
The escalating incidence of diabetes is not new

Data reported by DUK in 2015 revealed that over the past decade the number of people living with diabetes increased by 60%, and the charity’s leaders claimed that the public health situation in the UK with regard to diabetes is being allowed “to spiral out of control”. “Diabetes already costs the NHS nearly £10bn a year, and 80% of this is spent on managing avoidable complications,” said Barbara Young, then the CEO of DUK. Such findings, while shocking, are not new. 
 

The vast and escalating burden of diabetes

Tackling diabetes is important for the future of the NHS as there are over 4m people living with diabetes in the UK at present. This represents 6% of the UK population, or 1 in every 16 people. About 90% of the cases have T2DM. 90% of people with T2DM are overweight. Lifestyle changes and weight loss can help to prevent T2DM from ever occurring. Obesity is 40% more common among people living in deprived areas. 11.9m people in the UK are currently at risk of developing T2DM, but more than half could delay or even prevent a diagnosis by improved diets and lifestyles. This requires effective education that engages people and encourage them towards healthier lifestyles. About 10% of the cases are Type-1, which usually develops in childhood, and is often inherited. The NHS spends £10.3bn every year on treating diabetes, which equates to 10% of its entire budget. 80% of this is spent on diabetes medication. The annual indirect costs, such as productivity loss and informal care, are estimated to be £13bn. Effective education is cheaper than treatment.

 
The government will not spend more on diabetes

DUK’s repeated calls for the government to do more for diabetes care have been unsuccessful. This is largely because the NHS is struggling to cope with a surge in demand for care while suffering a major budget squeeze. In 2016, the government took back control of overspending semi-autonomous hospitals as part of its crackdown to tackle a NHS deficit of £2.45bn; the biggest overspend in its history.
 
DUK is a significant provider of diabetes education

To look at some aspects of DUK’s educational achievements we have taken a selection of extracts from its 2015 Annual Report. Against each extract is a short comment.

DUK:11,000 people learnt how to better understand and manage their condition through our Type 2 online education course.” 
 
COMMENT: This represents about 0.3% of the people in England diagnosed with T2DM.
 
DUK:Our care line supported 22,361 people who needed encouragement, information or someone to talk to”. 
 
COMMENT: This represents about 0.6% of people in England living with diabetes.
 
DUK:5.9m visits to the Diabetes UK website in 2015 – almost 10 per cent more than the year before – giving people the opportunity to learn more about the condition, what we do and how to get involved.”               
 
COMMENT: The key question here is the quality of the visit to the DUK website. Questions include inter alia: What is the average ‘dwell time’ for each visitor to DUK’s website? How many repeat visits does the website receive? What is the average number of pages viewed by visitors to DUK’S website? What are the most popular website pages viewed? What are the least popular website pages? How many visitors to the website come from the UK? What percentage of the people who visit the website “get involved”? How long do they stay involved? What percentage of the website’s visitors register with the site?
                                            
DUK:15,196 people found out their risk of developing Type 2 diabetes at one of our Roadshows – and can now take steps to avoid it.” 
 
COMMENT: This represents about 0.1% of the people in the UK at risk of T2DM.
 
DUK: “Educated more than 17,000 healthcare professionals to better work with and support those living with diabetes.”
 
COMMENT: Is this cost-effective? Would not online engagement be more appropriate?
 
DUK:11,000 people registered to educate themselves about managing their Type 2 diabetes via our online course Type 2 Diabetes and Me.”
 
COMMENT: This represents about 0.3% of people in England diagnosed with T2DM.
 
DUK:11.9 million people in the UK are currently at risk of developing Type 2 diabetes, but more than half of those people could delay or even prevent a diagnosis . . . In 2015 we worked with NHS England and Public Health England to develop the NHS Diabetes Prevention Programme. This partnership has the potential to help people in England who are at high risk delay – in some cases even prevent – Type 2 diabetes, and is being watched by the rest of the UK with interest.
 
COMMENT: In 2015 the UK government's Public Accounts Committee (PAC) observed that the national prevention initiative, which costs over £35m each year, lacked urgency, and recommended that it should, “develop a better and more flexible range of education support for diabetes patients.
 
A HealthPad Commentary reviewed the national prevention program, described an innovative and successful US diabetes prevention initiative, and concluded that because the UK program employed 19th century technologies to address a 21st century epidemic it would likely fail. The Commentary further argued that preventing T2DM entails winning the battle against obesity, reducing poverty, and changing peoples’ diets and lifestyles. To do this, education programs need to employ modern behavior techniques to engage people and coax them to change their behaviour.
 

A further HealthPad Commentary, described the growing frustration of the government’s PAC and the National Audit Office (NAO) with the country’s diabetes establishment.
 
DUK: Our ‘Know Your Risk’ volunteers helped over 15,000 people find out their risk of Type 2 diabetes at one of our events, while our online tool was used over 240,000 times.”
 
COMMENT: This represents 0.47% and between 6 to 7.5% respectively of people living with T2DM in England.
 
DUK should report costs and outcomes not costs and the distribution of services

Two points about DUK’s statements of its educational achievements:
  1. The majority of the charity’s education and support services only appear to reach a small percentage of the total number of people either at risk of T2DM or those living with diabetes. We have drawn attention to the fact that a large percentage of people with T2DM are over weight and 40% of obese people reside in deprived areas of the UK. To be effective diabetes education must have the Heineken effect.
  2. For the past decade at least, the DUK has tended to report the costs and distribution of its education and support services. More relevant would be for the charity to report costs and the effects its services have had on reducing the burden of diabetes, slowing complications, improving efficiencies, and enhancing patient outcomes.
Diabetes education providers should adopt school performance measures

For years the UK’s state education service has been using pupil outcome measures to rate the performance of its schools. Why is this not the case for diabetes education? Can you imagine if year-after-year millions of children in England were failing their public examinations, and year-after-year education officers only reported the costs and distribution of their services?  Can you imagine if the public education services only taught a very small percentage of the children eligible for education and there was no information about children’s performance in examinations?
 
Would people accept an education report that said, “This year Worthy schools spent £20m on physics teaching, which only reached 0.3% of pupils who would benefit from the subject, and we have no idea what percentage of those that were taught either took or passed the recommended physics exams”?
 
Technologies facilitate and transform diabetes education

With failing education programs people with diabetes are being driven to self-manage their condition with inadequate support. Inexpensive and ubiquitous technologies facilitate this, and increasingly people are demanding tools that track weight, blood pressure, daily exercise and diet. From apps to wearables, healthcare technology lets people feel in control of their health, while also providing health professionals with more patient data than ever before. 
 
With more than 100,000 health apps, rapid growth in wearables, and 75% of the UK population now owning a smartphone, digital technology is well positioned to significantly improve diabetes education and management. Such technologies while ubiquitous, are ineffective if only used as an adjunct to traditional education. Traditional diabetes education programs have failed to introduce widespread digital support strategies, which significantly enhance the quality of care, increase efficiencies, and improve patient outcomes for the majority of people living with diabetes.
 
In the first video below Richard Lane describes how digital technology is helping people self-manage their diabetes. In the second, Lane and a patient diagnosed with T2DM suggest that the biggest challenge for diabetes care is actually engaging people who are either at risk of the condition or living with diabetes. Only once people are engaged do you stand a chance to raise their awareness of the disease, and encourage them to change their diets and lifestyles in order to slow the progression of the condition and even prevent it.
 
How can mHealth help in the management of diabetes?
 
What are the biggest challenges of diabetes care?
 
Changing the patient-educator relationship
 
Self-management of diabetes should not be viewed simply as developing a website and providing a portfolio of techniques and tools to help people living with diabetes choose healthy behaviours. A necessary pre-requisite for effective education to reduce the burden of diabetes is the actual engagement of people who are either at risk of T2DM or living with diabetes. (Where are the national diabetes registers?). Once engaged education should inform and empower people, and provide them with access to continuous self-management support. This is substantially different to the way traditional diabetes education is delivered as it transforms the patient–educator relationship into a continuous, rich, collaborative partnership. A future HealthPad Commentary will describe an innovative and cost effective Mexican mHealth program, which has radically changed the patient-educator relationship by encouraging people, who are either at risk of T2DM or living with the condition, to take ownership of their own health, and become an integral member of their care team.
 
Takeaways

Diabetes is an out of control killer disease, which experts belief could be stemmed, reduced and prevented with effective education that is significantly cheaper than paying for treatment. Current diabetes education programs are failing miserably, and the prevalence of the disease is increasing rapidly, especially in young children.

Diabetes education and support require a radical overhaul to prevent the disease from spiralling out of control and bankrupting the NHS. This needs leadership to shape and drive a new and effective diabetes engagement/education model. Could DUK provide this?
 
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Diabetes wars

  • Failing diabetes services are waisting money
  • Too many people with diabetes develop avoidable complications
  • No one is held accountable for poor diabetes service performance
  • The NHS payment systems do not effectively incentivise the delivery of recommended standards of diabetes care
  • Appropriate incentives for diabetes services could improve diabetes outcomes and save the HNS £170m per year

 

National Audit Office v. NHS

A war is being waged between the NHS and the UK’s National Audit Office (NAO) over the state of adult diabetes services in the UK. Two NAO reviews found that doctors are failing to meet nationally agreed standards of diabetes care, and that they are neither effectively incentivised to deliver and sustain quality services nor accountable for poor service. 

The NHS says it is committed to supporting doctors to deliver high-quality care to people with and at risk of diabetes, but the NAO is not convinced.  It recommends that monies for diabetes services and doctors’ remuneration should be linked more directly to desired patient outcomes in order to promote and sustain accountability, responsibility, learning and the strengthening of local capacity. 

 


Adult or type 2 diabetes (T2DM) is an avoidable chronic condition, which occurs when the body does not produce enough insulin to function properly, or the body’s cells do not react to insulin. This means that glucose stays in the blood, and is not used as fuel for energy. There are currently 3.9 million people living with diabetes in the UK, with 90% of those affected having T2DM. Diabetes is a cause of serious long-term health problems, which include blindness, kidney failure, lower limb amputation, and cardiovascular disease, such as a stroke. Roni Sharvana Saha, Consultant in Acute Medicine, Diabetes and Endocrinology at St Georges University Hospital, London describes why weight control is important for the management of T2DM.

         
            (click on the image to play the video) 


 


Local responsibility for adult diabetes services 

In England the responsibility for diabetes services and support rests with local Clinical Commissioning Groups (CCGs) and GPs. In 2003 the UK government gave primary care trusts the responsibility for commissioning local services on behalf of their local populations, and freedom to decide how to best deliver diabetes services. It is for GP practices to ensure that people with diabetes receive all the nine recommended care processes each year in accordance with agreed clinical guidance (see below). In 2004 the Quality and Outcomes Framework (QOF) was introduced as part of the new GP contract, which includes payments for undertaking specified clinical activities and achieving set clinical indicators.

 


The nine basic processes of diabetes care are: (i) blood glucose level measurement (HbA1c), (ii) blood pressure measurement, (iii) cholesterol level measurement, (iv) retinal screening, (v) foot and leg check, (vi) kidney function testing (urine),  (vii) kidney function testing (blood), (viii) weight check, (ix) smoking status check.
 


 

Failing incentives

QOF awards for GPs initially improved diabetes outcomes in primary care. However, recently there has been little improvement, and according to the NAO the current payment system for GPs is not driving the required patient outcomes. GPs are paid for each individual diabetes test they carry out rather than being rewarded for ensuring that all nine tests are delivered. Similarly, the Payment by Results tariff system for English hospitals does not incentivize the multi-disciplinary care required to treat a complex long-term condition such as diabetes. According to the NAO the NHS needs to review and enhance its payment systems to ensure that they effectively incentivise good care and better outcomes for people with diabetes.
 

National Audit Office’s First Review (2012)

In May 2012 the NAO’s first review of adult diabetes services in England found that the NHS was not delivering value for money, and that it was underestimating its annual spend on diabetes services by some £2.6 billion. “There is poor performance in expected levels of diabetes care, low achievement of treatment standards, and 24,000 people die each year from avoidable causes relating to diabetes”, said the report.

The NAO findings included the following:

    1. "Fewer than one in five people with diabetes in England are being treated to recommended standards, which reduce their risk of diabetes-related complications
    2. Many people with diabetes develop avoidable complications
    3. NHS accountability structures fail to hold commissioners of diabetes service providers to account for poor performance
    4. No one is held accountable for poor performance, despite the fact that performance data exist
    5. The NHS is not effectively incentivising the delivery of all aspects of recommended standards of care through the payments systems
    6. There is a lack of clarity about the most effective way to deliver diabetes services
    7. Payment mechanisms available to GPs are failing to ensure sustained improvements in outcomes for people with diabetes
    8. The NHS does not clearly understand the costs of diabetes
    9. Effective management of diabetes-related complications could save the NHS £170 million a year"

 

The NAO Recommendation

The NAO recommended that the system of incentives for doctors be renegotiated to improve outcomes for people with diabetes in accordance with agreed clinical practice. GPs should only be paid for diabetes care if they ensure all nine care processes are delivered to people with diabetes. Also the NAO recommended that the thresholds at which GPs are remunerated for achieving treatment standards should be reviewed regularly.
 

Public Accounts Committee Chair: “Depressing report”

Margaret Hodge, chair of The House of Commons Committee on Public Accounts, which took oral and written evidence on the NAO Report, said, “This was one of the most depressing Reports I’ve read. Everybody understands the enormity of the problem; nobody is arguing with the figures; everybody accepts both the nature of the checks, and the treatments to prevent complications that should be done; money or lack of it has not been an issue; there appears to be a structure within the Department of Health with a tsar and a group of people whose job it is—and yet we are failing.”
 

Public Accounts Committee’s Conclusion: Higher costs, poorer services

The conclusions of Public Accounts Committee echoed its chair’s opening remarks, “Although there is consensus about what needs to be done for people with diabetes, progress in delivering the recommended standards of care and in achieving treatment targets has been depressingly poor. There is no strong national leadership, no effective accountability arrangements for commissioners, and no appropriate performance incentives for providers. We have seen no evidence that the Department of Health will ensure that these issues are addressed effectively . . . . Failure by it to do so will lead to higher costs to the NHS as well as less than adequate support for people with diabetes.
 

Action for Diabetes: the NHS’s Defence (2014)

In January 2014 the NHS defended its services in Action for Diabetes, a report prepared by its Medical Directorate, which sets out the activities NHS England is undertaking as a direct commissioner of GP and other primary care services, and as a support to secondary and community care commissioners to improve outcomes for people with and at risk of diabetes. The report stated that between 1996 and 2002 there was a, “marked reduction in excess mortality in those with diabetes”, and the UK’s diabetes-related mortality rates were better than 19 other developed economies. 

Action for Diabetes reaffirmed that the NHS was committed to supporting CCGs to deliver high-quality care to people with and at risk of diabetes, and will:

      • “Provide tools and resources to support commissioners in driving quality improvement
      • Ensure robust and transparent outcomes information, and align levers and incentives to facilitate delivery of integrated care across provider institutional boundaries
      • Empower patients with information to support their choices about their own health and care, and support the development of IT solutions that allow sharing of information between providers and between providers and people with diabetes
      • Look to the future of the NHS to deliver continued improved outcomes for people with or at risk of diabetes.”
 

In a foreword to Action for Diabetes Professor Jonathan Valabhji, the UK government’s National Clinical Director for Obesity and Diabetes, said the NHS needs, “new thinking about how to provide integrated (diabetes) services in the future in order to give individuals the care and support they require in the most efficient and appropriate care settings, across primary, community, secondary, mental health and social care, and in a safe timescale”.
 

National Audit Office’s Second Review (2015) 

In October 2015, the NAO published a follow-up review of NHS adult diabetes services, and criticised (I) the still low rates of the delivery of basic diabetes care processes, and (ii) the low rates of attainment of diabetes treatment goals. The NAO pointed to the escalation of avoidable complications, such as amputation, blindness, kidney failure and stroke that consume about 70% of the annual treatment costs of the NHS on diabetes.  The report commented:  “The improvements in the delivery of key care processes have stalled, . . . and this is likely to be reflected in a halt to outcomes improvement for diabetes patients . . . There are still 22,000 people estimated to be dying each year from diabetes-related causes that could potentially be avoidable”.


Ineffective payment systems

The NAO’s 2015 report criticized the way that the NHS distributes money, and sets local incentives for improving the delivery diabetes services. Economists have long argued that bureaucrats distributing monies with loose conditions is not an effective way to achieve transformative change. According to the NAO, “Current financial incentives, funding mechanisms and organisational structures of health services do not support the delivery of integrated diabetes care”. The NAO recommends that the NHS should, “Ensure that its payment systems effectively incentivise good care and better outcomes for people with diabetes”. 


Comment: Reasons for failure

According to market economists aid is at best wasteful, and at worst creates a damaging culture of dependency. Also, aid is often subject to vested interests, and fails to change people’s behaviors and improve wellbeing.
 
Institutions responsible for delivering diabetes services in England have not learned these lessons, and as a consequence poorly incentivized diabetes service providers fail to propel people living with diabetes towards self-management, and fail to slow the onset of devastating and costly complications. 
 

Effective incentives are key for improving diabetes outcomes

This Commentary has suggested that without appropriate incentives diabetes service providers have become chronically dependent on their paymasters, which has stifled innovation, made service providers less focused on patient outcomes, and less likely to innovate and prioritize the generation of other resources. Current incentives for diabetes service providers should be renegotiated.
 
A previous Commentary suggested that effective patient outcomes occur when people and communities are engaged and assume greater responsibility for their own wellbeing. Tried and tested behavioral techniques successfully used by the Cameron and Obama administrations need to be embedded in a range of diabetes services to create offerings that people want and that actually lower the risk of T2DM, propel those living with the condition into self-management, and slow the onset of devastating and costly complications; see Behavioral Science provides the key to reducing diabetes.
 
A related issue, which needs to be addressed to improve patient outcomes further, is the need to reduce the power of the bureaucracies that control the provision of diabetes services and to increase competition among diabetes service providers. Current bureaucratic diabetes service providers present a significant barrier for new entrants, and thereby discourage investments in innovations and new technologies. This will be the subject of a future Commentary.

 
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The importance of measuring the impact of diabetes care

  • Bill Gates says that measurement is key to reducing disease

  • Type-2 diabetes is the fastest growing health threat of our time, it is preventable, but not properly measured

  • Expensive diabetes programs fail to dent the burden of the disease

  • Taxpayers have a right to know the annual impact of diabetes care and education on the incidence, outcomes and costs of the disease

  • Healthcare agencies must agree and report clear goals that drive progress

Bill Gates is right. Measurement is central to the success of reducing the global incidence of diseases. Can we learn something from Bill Gates to help reverse the epidemic of type-2 diabetes: a preventable disease, which is spiralling out of control, and set to bankrupt healthcare systems?

Dr Syed Sufyan Hussain, Darzi Fellow in Clinical Leadership, Specialist Registrar and Clinical Lecturer in Diabetes, Endocrinology and Metabolism, at Imperial College London, describes the challenge:

      
             (click on the image to play the video) 
 

The UK

Similar to other developed nations, diabetes in the UK is the largest and fastest growing health challenge of our time. Since 1996, the number of people living with diabetes in the UK has more than doubled: 3.9 million people now have diabetes, another 9.6 million are at high risk of getting type-2 diabetes, and every year, that number is rising dramatically. If nothing changes, in 10 years time more than four million people in England will have diabetes. This suggests that current diabetes care programmes and education are failing.

Diabetes is expensive, and current annual treatment costs alone are about £10bn - some 10% of the annual NHS budget - and 80% of this is spent on managing avoidable complications. For example, diabetes is the most common cause of lower limb amputations, and over 6,000 happen each year in England alone. The result is frequently devastating in terms of social functioning and mood, and poses a considerable cost to healthcare providers, while the financial burden on patients and their families can be enormous.

The total annual costs of diabetes, which includes both direct and indirect costs, such as the loss of earnings because of illness, are difficult to measure, but are estimated to be about £24bn per year. If nothing changes, these costs are projected to rise to nearly £40bn in 20 years. This further suggests that current diabetes care programmes and education are failing. 
 

Doing more of the same 

In its 2015 State of the Nation Report, Diabetes UK (DUK), a large and influential charity, urged the UK Government and NHS England to do more in order to ensure that people with diabetes get the support and education they need to manage their condition. However, if the UK government and NHS England do more of the same, nothing will change, and diabetes will continue to escalate, destroying lives and costing billions. Let us go back to Bill Gates.
 

Measures to drive progress

I’ve been struck again and again by how important measurement is to improving the human condition. You can achieve amazing progress if you set a clear goal and find a measure that will drive progress toward that goal . . . . This may seem pretty basic, but it’s amazing to me how often it is not done,” says Gates.

The UK government, NHS England, Public Health England and DUK do not share an agreed set of indicators, which measure and report on the impact of diabetes care and education. Given that each year billions are spent on diabetes, these agencies should be obliged to report annually on the impact that their diabetes care and education programs have on the prevalence, outcomes and costs of diabetes. Let us return to Bill Gates, and his efforts to reduce the global burden of HIV.
 

Bill Gates 

The 2013 annual report of the Melinda and Bill Gates Foundation stresses that it, “Enhances, the impact of every dollar invested by improving the efficiency and effectiveness of our HIV program, [which] supports efforts to reduce the global incidence of HIV significantly and sustainably, and to help people infected with HIV lead long, healthy, and productive lives. The global incidence of HIV has declined 20% since its peak in the mid-1990s.” 

Now, tweak the above paragraph to create a gold standard annual report of the state of diabetes in the UK. The government, NHS England, Public Health England and DUK, “Enhances the impact of every pound invested in diabetes by improving the efficiency and effectiveness of our diabetes programs and education [sic], which support efforts to reduce the UK’s incidence of diabetes significantly and sustainably, and to help people living with diabetes to lead long, healthy, and productive lives. [Notwithstanding,] since 1996, the UK’s incidence of diabetes has increased by 110%, complications have increased by 115%, and annual treatment costs have increased by at least £2bn.”
 

Changing demographics

In the above paragraph we used indicative numbers to show direction. Some, but not all, of the reported increases can be explained by demographic changes. For example, over the past 20 years, the UK’s population has increased by 5.5 million and aged, and now more than 18% are over 65, and this cohort is rising. According to the Office of National Statistics, 60% of the population increase is due to immigration. David Coleman, a professor of demographics at Oxford University, suggests that this mass influx of migrants has given the UK, Europe’s fastest-rising percentage of ethnic minority and foreign-born populations, and by 2040 foreigners and non-white Britons living here will double and make up one third of the UK population. 

This has important healthcare implications because type-2 diabetes is more than six times more common in people of South Asian descent, and up to three times more common among people of African and African-Caribbean origin. Studies show that people of Black and South Asian ethnicity also develop type-2 diabetes at an earlier age than people from the White population in the UK, generally about 10 years earlier. All these factors have a knock-on affect for healthcare. According to the Institute of Economic Affairs the changing demographics in the UK has created a “debt-time bomb’ that will require the end of universal free healthcare. 
 

Takeaways

Diabetes plays a prominent role in the health of the UK, and not all of its rising burden can be explained by changing demographics. The escalating burden of type-2 diabetes can be reduced and prevented by effective management and education, which engage people living with, or at risk of diabetes, and changes their behavior. Current education programs fail to do this. 

Instead of asking the government and NHS England to, “do more”, is it not time for those responsible for diabetes care to learn from Bill Gate, and, agree and report annually, measures that inform on the impact that diabetes care and education is having on the incidence, outcomes and costs of diabetes? 

 
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DUK and HealthPad agree on the importance of diabetes education

  • Diabetes in the UK is spiralling out of control
  • People with diabetes are not receiving the care they need
  • Education for people living with diabetes must improve
  • CCGs need to increase the effectiveness of diabetes education
  • Policy makers must be more open-minded about digital health
  • Policy makers should prepare the UK for the digital future

 

DUK and HealthPad

Diabetes UK (DUK) and HealthPad are on the same page in recommending more effective education to reduce the escalating burden of diabetes. DUK insists that, “Clinical commissioning groups (CCGs) need to increase the availability and uptake of a range of diabetes education and learning opportunities”.


Managing My Diabetes

HealthPad has developed a cost effective digital diabetes education service specifically for CCGs to: (i) increase the connectivity between local health professionals and people with diabetes, (ii) enhance patients’ knowledge of the condition, (iii) propel people with the condition towards self management, (iv) slow the onset of complications and (v) reduce face-time with doctors, see: Reducing the burden of diabetes by online video.
 

The state of the nation 

DUK’s 2015 State of the Nation Report laments that the incidence rates of diabetes continues to spiral out of control, and people with diabetes is now at an all time high of 3.9 million, with a further 600,000 estimated to have undiagnosed type-2 diabetes. Further, 2015 National Statistical Office figures, show that 67.1% of adult males and 57.2% of adult females in the UK are either overweight or obese, and therefore at risk of type-2 diabetes. 

There is no way of preventing type-1 diabetes, which occurs as a result of the body being unable to produce insulin, and usually develops in childhood, affecting 10% of sufferers. However, type-2 diabetes is the result of bad diets and sedentary lifestyles, and is preventable with effective education. Left unchecked, diabetes can result in devastating health complications such as kidney and heart disease, blindness and amputations. Also, diabetes costs the NHS nearly £10bn each year, 80% of which is spent on managing avoidable complications.
 

Gaping hole” in effective education

DUK director of policy Bridget Turner said, "There is a gaping hole when it comes to diabetes education . . . . This is despite strong evidence that giving people the knowledge and skills to manage their diabetes effectively can reduce their long-term risk of complications . . . . We must get better at offering education to people who are living with diabetes." Dr Sufyan Hussain, a lecturer and clinical registrar in diabetes, endocrinology and metabolism at Imperial College and Hammersmith Hospital, London, has used HealthPad, a digital platform, to develop a portfolio of educational videos for people with diabetes. Here is one about insulin: 

      
                (click on the image to play the video)
 

Calling on the NHS

DUK said that it is “calling on” the NHS to do more. One difference between NHS England and HealthPad is the emphasis they respectively place on digital platforms for delivering diabetes education. Currently, digital platforms are not widely used by the NHS. One possible reason for this is because the NHS is a sanctuary for technophobes. Patients however are not technophobes. General attitudes towards digital healthcare are rapidly changing. The over 65s are becoming increasingly tech-savvy, and quickly adopting digital channels as a source for healthcare information. Research from the Office of National Statistics shows that, between 2006 and 2013, Internet use of the over 65s more than tripled, and their demand for digital health services grew significantly.

Not all health providers are technophobes, and some acknowledge that the NHS has failed to make the most of digital technologies. Changes that these enlightened health providers suggest are contentious; because of the lack of competitiveness the NHS reflects its fragmented single entity, and NHS policy makers stress harmonization rather than competition. This results in the quality of healthcare in the UK becoming a postal code lottery. The NHS cannot expect to improve while there is still a lack of competition and such fragmentation.
               

Network effects

A significant challenge for the NHS is how to deal with digital healthcare platforms: the search engines and websites that constitute the metaphysical health providers in the digital age. What drives new healthcare platforms are economies of scale in gathering and distributing healthcare data and information, which patients want in order to manage their conditions better. The network effects of digital platforms result in more patients finding digital healthcare services ever more compelling. Platforms engage patients, and encourage them to return for updates and more information about their condition. 


Takeaways

It is time that the NHS started to assess the role that platforms can play in the delivery of healthcare. However, the NHS does not know enough to opine with confidence on digital health and the knowledge economy. This does not only result in NHS policy makers being unable to pick technological winners; it also means that technological losers are picking the NHS.

Healthcare and the educational needs of patients must to be conducted in a more open-minded spirit, not simply reflect the status quo, and fall prey to vested interests. The task of healthcare policy makers should be to prepare the UK for the digital future, not to try to stop it happening. 

 
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Online video education can reduce the burden of diabetes

  • UK treatment costs for diabetes are £10bn per year and rising fast
  • London CCG adopts video education to reduce the burden of diabetes
  • Diabetes educational videos delivered directly to patients’ mobiles
  • Enhances patient satisfaction yet reduces face-time with doctors
  • Videos are peoples’ preferred way to receive healthcare information
  • Videos increase knowledge and self-management, and slows complications
  • Videos deliver 10 times the response rate of text and graphics

      


Managing My Diabetes is a new, evidence-based service, which offers a smarter and better way to engage and educate people with type-2 diabetes. It’s delivered by video directly to patients’ mobiles, and aims to significantly dent the eye watering, and rapidly escalating personal, financial and societal costs of this preventable condition. A London CCG is an early adopter. 

Dr Seth Rankin, co-chair of Wandsworth CCG’s Diabetes Group, Managing Partner of Wandsworth Medical Centre, and a long time advocate of the use of video in diabetes education, says, “In traditional doctor-patient consultations, patients often don’t absorb important information, and videos help to redress this. Managing My Diabetes engages patients, and provides them with trusted and convenient video information about their condition, which is a necessary prerequisite for any behavioural change”.

In addition to being the preferred format for patients to receive healthcare information, videos generate responses that are 10-times greater than that generated by text and graphics. Further, unlike health professionals, videos never wear out, they can be dubbed in any language, they’re easily and cheaply updated.
 

Importance of a patient user-base

Once people with diabetes are familiar with the initial Managing My Diabetes service, health providers can easily bolt on additional services to help people further manage their diabetes. This follows the model of digital champions such as Google and Facebook, which succeeded by using a simple core service, which successfully built a user base, and then, and only then, offered more services, thus continuously increasing the familiarity of their users with their services; and in turn the intensity with which they use them. Recently, the Department of Health failed to establish an online doctor-patient user-base for a £31m telehealth project, and it failed, see, Lessons from an axed telehealth project

Rankin describes the genesis and benefits of Managing My Diabetes:

      

        (click on the image to play the video) 


Video content library

Currently, there is no easy way for people with diabetes to quickly and easily obtain reliable online answers to their FAQs in video formats that they prefer, and there is no easy method for health professionals to post answers to patients’ questions about diabetes in a convenient online video format. 

At the heart of Managing My Diabetes is a content library of some 250 videos contributed by local health professionals, which address patients’ FAQs about managing their diabetes. Each video is between 60 and 80 seconds in duration, which is the average attention span of people seeking online video healthcare information. All videos are linked to bios of the contributors, which help patients judge the validity of the videos. 

Health professionals can cluster and send videos directly to patients’ mobiles to quickly and efficiently address their questions. Also, patients can rapidly access the entire diabetes video content library at any time, from anywhere on any devise. 

Managing My Diabetes is designed to: (i) enhance the connectivity between local health professionals and patients, (ii) increase the knowledge of diabetes among people with the condition, (iii) encourage self-management, (iv) slow the onset of complications, and (v) reduce face-time with doctors. 

Roni Saha, a consultant in acute medicine, diabetes and endocrinology at St George’s University Hospital, London, who contributed a portfolio of educational videos to Managing My Diabetes, describes risks for pregnant women with diabetes: 

       

     (click on the image to play the video) 
 

Traditional diabetes education has failed 

No one knows the true costs of type-2 diabetes, but its treatment costs alone are estimated to be some £10bn per year, and, in 20 years, expected to increase to £17bn; with diabetes complications costing a further £12bn per year. This highlights the pressing need to reduce the burden of the condition, which can be achieved by effective education. 

Traditional diabetes education that cost millions has failed to reduce the burden of diabetes. According to the National Diabetes Audit, less that 2% of people with diabetes attend any form of structured education. Instead, they regularly search the Internet for healthcare information, and use social media to share information they find. This is carried out at lightning speed, 24-7, 365 days a year. 

Health providers must come to terms with the fact that the balance of power has shifted from traditional providers of diabetes education to people living with the condition who are primarily interested in how education affects their outcomes. Failure to provide this link, leads to people disengaging and losing interest. 
 

What do people with diabetes want? 

Understanding the myths and realities about what patients really want from diabetes education is vital to capturing its value. A 2014 study by HealthPad into the efficacy of using videos in diabetes education concluded that there is a significant unmet need for trusted and convenient video educational material to help people manage their diabetes remotely: see: How GPs can improve diabetes outcomes and reduce costs. 
 

Age factor 

Because 63% of people with type-2 diabetes in England are over 60, a question that must be asked is whether delivering educational videos directly to their mobiles is really appropriate. The HealthPad study suggests that it is, and a 2014 McKinsey & Co survey on patients’ opinions of digital healthcare services agrees. Patients over 50 want digital healthcare services as much as younger counterparts. By 2018 smartphone penetration in the UK is expected to be almost 100%. The over 55s are experiencing the fastest year-on-year smartphone penetration, and the difference in smartphone penetration by age is expected to disappear by 2020, and Internet use has shifted from being exceptional to being commonplace.

Mobile devices are ubiquitous and personal, and competition will continue to drive lower pricing and increase functionality. Managing My Diabetes ensures that people living with diabetes will always be part of the doctor-patient network, which increases the variety; velocity, volume and value of educational information patients can receive.
 

Takeaways

Managing My Diabetes has been developed, tested and adopted by a London CCG. It has also a number of clinical champions. The service is designed to be easily and cost effectively embedded in primary care practices, and can be delivered in any language. 

If Managing My Diabetes is to dent the devastating burden of type-2 diabetes it will require national leadership to encourage CCG’s to adopt it, and health professionals to embrace it. Will NHS England and Diabetes UK play this much needed leadership role? If, in five years time, the burden of type-2 diabetes in England has not been significantly reduced, who will be accountable?

 
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4 years ago

Structured educational courses to help people living with diabetes manage their condition are not working.

A few closed service providers dominate diabetes education in the UK, and according to the last National Diabetes Audit, less than 2% of the 3.8 million diagnosed with diabetes attend any form of structured education.

The non-dramatic, insidious and chronic nature of diabetes masks the fact that it has become a global epidemic with the potential to overwhelm national health systems, if education can’t halt its progress.

Although advances in diabetes research are significant, the horizon for a cure is still distant. At this moment in time, the best option to halt the progression of diabetes is convenient, fast and effective education.

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