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Cost-effective asset to relieve growing pressure on GPs

Can the escalating primary care crisis in England be helped with a new and innovative online dashboard, which automatically sends short videos contributed by clinicians to patients’ mobiles to address their FAQs?
 
Dr Seth Rankin, Managing Partner of the Wandsworth Medical Centre, and co-chair of Wandsworth CCG’s diabetes group, who has spearheaded the dashboard, thinks it can. Click on the photo below to view a short video that describes how health professionals can use the dashboard:
 
 
 
New and innovative dashboard
 
A 24/7 fully automated service that never wears out
We were motivated to do something about the increasing pressure on GPs, and the impact this has on the quality of our care. Patients may have to wait a couple of days for an appointment with a GP, but they can receive our videos within minutes of their request,” says Rankin. He continues: “A pilot study we carried out in two London primary care practices suggested that video is a patient’s preferred format if they can’t see a GP. Further, patients often don’t retain what you tell them in a 10-minute face-to-face consultation, and they tend not to read pamphlets, which also are expensive to produce. 53% of patients regularly search the Internet for healthcare information, but 81% can’t differentiate between good and bogus information. 72% prefer healthcare information from their GP, and like healthcare videos delivered directly to their mobiles. 70% want access to healthcare information at any time, from anywhere, on their mobiles.
 
“Unlike the Internet, our dashboard provides premium reliable information, which can be easily consumed and shared among family, friends and carers. Also, the videos can be viewed many times, from anywhere, and unlike pamphlets and doctors, they never get tired, never wear out, and are available 24/7, 365 days a year. The dashboard is fully automated [see figure below], relieves GPs of a lot of unnecessary work, and, importantly, reports on how our patients’ are using the different videos.”
 
Automated system that encourages engagement behaviours
 
Local experts
“We used local medical experts in our videos because we were keen to increase their connectivity with our patients. The videos provide 60 to 80 second talking-head answers to patients’ questions, and are designed to increase patients’ knowledge of their condition, propel them towards self-management, slow the onset of complications, and reduce face-time with GPs, while enhancing the quality of our care,” says Rankin.
 
Diabetes
He continues: “Although the dashboard easily can be used for any disease state, we started with T2DM as it represents our largest group of patients. Also, we know that: (i) T2DM is preventable with effective education that encourages diet and lifestyle changes, (ii) current diabetes education fails, and over the past decade, the incidence rate of the condition has increased by 65%, (iii) only 16% of the 120,000 people diagnosed each year with diabetes in England are offered structured educational courses, and (iv) only 2% of those offered courses actually enrol in them. So, we created our own bespoke dashboard and content library of about 120 videos, which we organised under 10 headings that we know interest our patients. Each heading has a cluster of ‘essential’ and ‘in-depth’ videos. We use the dashboard to relieve some of the pressure on our health professionals.”
 
Unprecedented crisis
 
Saturation point
A 2016 study published in The Lancet suggests that between 2007 and 2014 the workload in NHS general practice had increased by 16%, and that it is now reaching saturation point. According to Professor Richard Hobbs of Oxford University and lead author of the study, "For many years, doctors and nurses have reported increasing workloads, but for the first time, we are able to provide objective data that this is indeed the case . . . . . As currently delivered, the system [general practice in England] seems to be approaching saturation point . . . . . Current trends in population growth, low levels of recruitment and the demands of an ageing population with more complex needs will mean consultation rates will continue to rise.”
 
More than 1m patients visit GP every day
A 2014 Deloitte’s report commissioned by the Royal College of General Practitioners (RCGP) suggests that the GP crisis in England is the result of chronic under-funding and under-investment in primary care at a time when the demand for GP services is increasing as the population is ageing, and there is a higher prevalence of long term conditions and multi-morbidity.
 
According to the RCGP, over the past five years the number of annual GP consultations has increased by 60 million to around 370 million, while over the same period the number of GPs has grown by only 4.1%. More than one million patients a day visit their GP surgeries, with some GPs now routinely seeing between 40 to 60 patients daily.
 
GPs are extremely stressed
Deloitte’s findings are confirmed by a 2016 comparative study undertaken by the prestigious Washington DC-based Commonwealth Fund, which concludes that increasing workloads, bureaucracy and the shortest time with patients has led to 59% of NHS GPs finding their work either “extremely” or “very” stressful: significantly higher stress levels than in any other western nation. GP stress levels are likely to increase. In a speech made in June 2015, the UK’s Secretary of Health said, “Within 5 years we will be looking after a million more over-70s. The number of people with three or more long term conditions is set to increase by 50% to nearly three million by 2018. By 2020, nearly 100,000 more people will need to be cared for at home.” According to Dr Maureen Baker, chair of RCGP, “Rising patient demand, excessive bureaucracy, fewer resources, and a chronic shortage of GPs are resulting in worn-out doctors, some of whom are so fatigued that they can no longer guarantee to provide safe care to patients.”
 
Causes and consequences
 
GP exodus
Trainee GPs are dwindling and young GPs are moving abroad. According to data from the General Medical Council (GMC), between 2008 and 2014 an average of 2,852 certificates were issued annually to enable British doctors to work abroad. We now have a dangerous situation where there are hundreds of vacancies for GP trainees. Meanwhile, findings from a 2015 British Medical Association (BMA) poll of 15,560 GPs found that 34% of respondents plan to retire in the next five years because of high stress levels, unmanageable workloads, and too little time with patients.
 
Suggested solutions
 
5,000 more GPs by 2020
In the run up to the UK’s 2015 General Election the Secretary of Health pledged “to train and retain an extra 5,000 GPs by 2020” to ease the primary care crisis, but doctors’ leaders did not see this as a solution. Dr Maureen Baker said, "Even if we were to get an urgent influx of extra funding and more GPs, we could not turn around the situation [the GP crisis] overnight due to the length of time it takes to train a GP,” And Dr Chaand Nagpaul, chair of the BMA GPs’ committee, warned later that, “delivering 5,000 extra GPs in five years, when training a GP takes 10 years, was a practical impossibility that was never going to be achieved.” After the election the Health Secretary softened his promise and suggested that it would be ‘a maximum' of 5,000 by 2020.

In 2016, Pulse, a publication for GPs, suggested that the Health Secretary knows he cannot deliver his promise of 5,000 new doctors by 2020, and is negotiating with Apollo Hospitals, an Indian hospital chain, to bring 400 Indian GPs to England.
 
A more innovative approach

Better and smarter solutions needed
While searching for an immediate temporary solution to the GP crisis the Secretary of Health seems to understand that a more innovative approach is required for the medium to long term. In his June 2015 speech he said, “If we do not find better, smarter ways to help our growing elderly population remain healthy and independent, our hospitals will be overwhelmed – which is why we need effective, strong and expanding general practice more than ever before in the history of the NHS. Innovation in the workforce skill mix will be vital too in order to make sure GPs are supported in their work by other practitioners.”
 
Pharmacists in GP surgeries
In July 2015 the NHS launched a £15m pilot scheme, supported by the RCGP and the Royal Pharmaceutical Society (RPS), to fund, recruit and employ clinical pharmacists in GP surgeries to provide patients with additional support for managing medications and better access to health checks.
 
Dr Maureen Baker said, “GPs are struggling to cope with unprecedented workloads and patients in some parts of the country are having to wait weeks for a GP appointment yet we have a ‘hidden army’ of highly trained pharmacists who could provide a solution”. Dr David Branford, former Chair of the RPS said, “It’s a win-win situation . . . .  We will be doing everything we can to support the GPs and make sure this pilot is successful. In time, I hope pharmacists will be working in every GP practice in the country.” Ash Soni, president of the RPS suggests that it makes sense for pharmacists to help relieve the pressure on GPs, and says, “Around 18m GP consultations every year are for minor ailments. Research has shown that minor aliment services provided by pharmacists can provide the same treatment results for patients, but at lower cost than at a GP surgery.”
 
Progressive and helpful move
The efficacy for an enhanced role of pharmacists in primary care has already been established in the US, where retail giants such as CVS, Walgreens and Rite Aid have led the charge in providing convenient walk-in clinics staffed by pharmacists and nurse practitioners. Over time, Americans have grown to trust and value their relations with pharmacists, which has significantly increased adherence to medications, and provided GPs more time to devote to more complex cases. Non-adherence is costly, and can lead to increased visits to A&E, unnecessary complications, and sometimes death. According to a New England Healthcare Institute report, Thinking Beyond the Pillbox, failure to take medication correctly, costs the US healthcare system $300 billion annually, and results in 125,000 deaths every year. 
 
Takeaway
 
Introducing pharmacists into GP surgeries is a progressive and potentially helpful move forward, because, as Dr Maurine Baker suggests, “It is in everyone’s best interests to be seen by a GP who is not stressed or fraught and who can focus on giving their patients the time, attention and energy they need”. However, even more could be achieved if the dashboard described by Dr Seth Rankin were more widely introduced. “Videos play a similar role to practice-based pharmacists. Both deal with simple day-to-day patient questions, and relieve pressure on GPs, which allows them to focus their skills where they are most needed,” says Rankin.
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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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Smart insulin and new hope for type-1 diabetes

  • A new smart insulin could improve the lives of people with type-1 diabetes 

  • The smart insulin is easier, faster, and more effective than current therapies

  • The new compound automatically activates in response to rising blood sugar

A new compound, Ins-PBA-F, referred to as ‘smart insulin’, could spare people living with type-1 diabetes the burden of frequently injecting, and constantly monitoring their blood sugar levels.

The new compound, developed by scientists from the University of Utah, USA, and reported in a 2015 edition of the Proceedings of the National Academy of Science, automatically activates when your blood sugar level soars, brings it back to normal, and remains in circulation for up to 24 hours. In the future, people with type-1 diabetes could inject the smart insulin once a day, or even less frequently, overcoming the need for constant self-monitoring, and insulin top-ups after meals.

 

Easier, faster and more effective

Researchers suggest that the speed, and chemical reactions of Ins-PBA-F normalizing blood sugar in diabetic mice is the same as in healthy mice responding to blood sugar changes with their own insulin. Ins-PBA-F could give a faster, more effective response to lowering blood sugar than the current long-acting insulin drug, and could be tested in humans in two to five years.
 

Type-1 diabetes

According to the WHO, in 2014, 9% of all adults have diabetes, and an estimated 10% of these have type-1 diabetes, a significant proportion of which are children. Type-1 diabetes is an autoimmune disease in which the body kills off all its pancreatic beta cells, which produce insulin that regulates blood sugar. Without beta cells, the body’s sugar levels fluctuate wildly. Dr Sufyan Hussain, Senior Lecturer in Diabetes, Endocrinology and Metabolism at Imperial College, London, describes type-1 diabetes:

       

 

Unrelenting regimen

While insulin injections or infusion allow a person with type-1 diabetes to stay alive, and lead a full and active life, they neither cure the disease, nor necessarily prevent the possibility of the disease’s serious effects, which may include: kidney failure, blindness, nerve damage, heart attack, stroke and pregnancy complications. Traditional insulin therapies are a constant management challenge. Patients must carefully balance insulin doses with eating and other activities multiple times a day and night. Hussain describes the genesis, and benefits of insulin therapy:

    

 

Advantages of ‘smart insulin’

Without insulin, the body has no mechanism for moving sugar out of the blood and into cells, where it is used for energy. People with type-1 diabetes are completely dependent on their daily insulin injections for their survival, and have to check their blood-glucose level by pricking their fingers several times a day to assess how much insulin to inject. Any lapse or miscalculation in this unrelenting regimen can run the risk of dangerous high and low blood-glucose levels; both of which can be life threatening.

“In theory, with Ins-PBA-F there would be none of these glucose problems,” said co-author Dr Danny Chou, “A smart insulin drug that automatically activates in response to rising blood sugar would get rid of the need for top-up injections of insulin, and eliminate the danger of incorrect dosing”.

 

Takeaways

Ins-PBA-F closely mimics the way bodies return their blood sugar levels to normal after eating. According to Chou, “This is an important advance in insulin therapy. Diabetic patients still need to guess to some extent how much insulin they need. With Ins-PBA-F you would just inject it, and it wouldn’t matter if you overshot because its activity would stop when glucose levels get too low. Our smart insulin derivative appears to control blood sugar better than anything that is available to diabetes patients right now.”

 
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  • Promising animal study suggests a vaccine for type-1 diabetes
  • Harvard’s Dana Faber Cancer Institute endorses the study
  • Lab spent years detailing the molecular immune system's response to insulin
  • The therapy for type-1 diabetes is insulin, but there’s no cure
  • Living with type-1 diabetes is a constant challenge
  

A molecule that prevents type-1 diabetes in mice has provoked an immune response in human cells, according to scientists from the National Jewish Health and the University of Colorado. The findings, published in the 2015 Proceedings of the National Academy of Sciences, suggest that a mutated insulin fragment could be used to prevent type-1 diabetes in humans.
 

Strategies that work in mice often fail in humans 

Previously, researchers tried administering insulin to people at risk of the disease as a form of immunotherapy similar to allergy injections, but this didn’t provoke an effective response. John Kappler, Professor of Biomedical Research at National Jewish Health says, "Our findings provide an important proof of concept in humans for a promising vaccination strategy." In 2011, researchers from Harvard University’s Dana Farber Cancer Institute reported that Kappler’s strategy prevented type-1 diabetes in mice. However, strategies that work in mice often fail in humans.
 

Promising findings

Kappler’s findings suggest that an insulin fragment with a change to a single amino acid could provoke an immune response. The idea comes from work in Kappler's laboratory detailing the molecular immune system's response to insulin. This suggests that mutating one amino acid in an insulin fragment, and then presenting the insulin to the immune system, might provoke better recognition by the immune system.

Researchers mixed a naturally occurring insulin fragment, and the mutated insulin fragment with separate cultures of human cells. They found that human T-cells responded minimally to the naturally occurring insulin fragment, but relatively strongly to the mutated one. The human T-cells produce both pro-inflammatory and anti-inflammatory chemicals known as cytokines, and scientists believe that healthy immune responses balance pro- and anti-inflammatory factors. Autoimmune disease occurs when the pro-inflammatory response dominates.
                           

Type-1 diabetes

Type-1 diabetes is an autoimmune disease in which a person’s pancreas stops producing insulin, a hormone that enables individuals to get energy from food. It occurs when the body’s immune system attacks and destroys the insulin producing cells in the pancreas, called beta cells. The causes of type-1 diabetes are not fully understood, but scientists believe that both genetic and environmental factors are involved. Dr Sufyan Hussain of Imperial College, London explains:


     

      (click on the image to play the video) 

Type-1 diabetes most typically presents in early age with a peak around the time of puberty. Historically the condition has been most prevalent in populations of European origin, but is becoming more frequent in other ethnic groups. Kuwait, for example, now has an incidence of 22.3/100,000. India and China have relatively low incidence rates, but account for a high proportion of the world’s children with type-1 diabetes because of their large populations. 
 

Living with type1 diabetes

Living with type-1 diabetes is a constant challenge. People with the condition must carefully balance insulin doses (either by multiple injections every day or continuous infusion through a pump) with eating and other activities throughout the day. They must also measure their blood-glucose levels by pricking their fingers for blood six or more times a day. Despite this constant attention, people with type-1 diabetes run the risk of high or low blood-glucose levels, both of which can be life threatening. People with type-1 diabetes overcome these challenges on a daily basis. While insulin injections or infusions allow a person with the condition to stay alive, they don’t cure the disease, nor do they necessarily prevent the possibility of the disease’s complications, which may include kidney failure, blindness, nerve damage, heart attack, stroke, and pregnancy complications. Richard Lane, President of Diabetes UK, and a person living with type-1 diabetes, describes some of the lifestyle changes associated with the condition:

       

        (click on the image to play the video)
 

Takeaways

While Kappler’s results don’t prove that the mutated insulin fragment will work as a vaccine in humans, they do demonstrate a response in humans consistent with the vaccination response in mice. "The new findings confirm that the painstaking work we have done to understand the unconventional interaction of insulin and the immune system has relevance in humans and could lead to a vaccine and a treatment for diabetes," says Kappler. 

 
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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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Preventing diabetes in high-risk people
  • NHS England is to spearhead a national diabetes prevention program
  • The program aims to prevent diabetes in high risk people by 2025
  • 35% of adults in the UK are living with pre-diabetes
  • The program MUST report outcomes NOT delivered services
  • Type-2 diabetes devastates millions of lives and costs billions
  • Big Data strategies can help NHS England improve patient outcomes

Early in 2015, NHS England, Public Health England, and Diabetes UK (the Troika), announced a national joint initiative to prevent diabetes developing in high-risk people by 2025, and declared that England should be, “The most successful country on the planet at implementing a national diabetes prevention programme.” 

Forced to act
About 35% of adults in the UK are living with pre-diabetes, a condition in which your blood sugar level is higher than normal, but not high enough to be classified as type-2 diabetes. It’s caused by obesity, sedentary lifestyles, dietary trends, and an ageing population, and without appropriate action, pre-diabetics will develop type-2 diabetes; a disease that reduces life-expectancy, and can lead to complications such as blindness, and amputation that seriously affect quality of life, and costs billions.       

Dr Roni Saha, a consultant in acute medicine, diabetes and endocrinology at St George’s Hospital, London describes pre-diabetes: 

        
 
Importance of patient outcomes.
It’s important that the Troika uses patient outcomes, and NOT delivered services as an indicator of its performance. Diabetes agencies regularly report services they deliver, while the prevalence and the cost of diabetes continue to escalate. Outcome data help people take an active role in their healthcare, and provide health providers important feedback, which informs the re-allocation of scarce resources to further enhance patient outcomes, and reduce costs.  

Immediately, the Troika announced its initiative, doctors raised concerns about the additional burden it would place on GPs. World renowned heart surgeon Devi Shetty, the founder and Chairman of Narayana Health, India, views doctors as significant obstacles to the introduction of technologies, which can improve significantly patient outcomes:

        

Big data
The Troika might consider using Big Data to enhance the performance of its diabetes initiative. Big Data can pool the experiences of people with pre-diabetes, suggest which regimens work best for which individuals, allow health providers to evaluate diet and lifestyles practices, and compare them within and across organizations and communities. Information about blood sugar levels, and hypertensive blood pressure can be transmitted directly into electronic health records of people with pre-diabetes. Data systems can notify health providers of problematic trends with individuals, which gives them an opportunity to intervene early, perhaps with just a telephone call, rather than waiting for an emergent and costly episode.

NHS England is selectively using the John Hopkins’ Adjusted Clinical Groups (ACGs) system, which should be a contender to support the Troika’s diabetes prevention initiative. ACG is a clinically inspired risk stratification and predictive modeling tool, which draws on demographic, diagnostic, pharmacy, and utilization data from primary and secondary care, to assess the health status of a population in order to plan services, budget and manage resources, and assess patient outcomes. 

Beyond the clinic
Big Data can also monitor people living with pre-diabetes outside the clinic. By linking patients’ shopping histories, social media, and location information through third-party data vendors, health providers can gain a window into peoples’ daily health behavior, thought to determine up to 50% of peoples’ overall health status. This is important for preventing diabetes developing in high-risk groups.

Instead of thinking from the patient level up, there are now enough good data to examine whole populations, and extrapolate what will happen to an individual at risk of developing type-2 diabetes. Big Data can create a convenient, real-time healthcare experience for people living with pre-diabetes. Insights gleaned from the data can improve the quality and accessibility of peoples’ care, and help foster a spirit of cooperation between patients, communities and health providers.

Security 
No data is more personal than health data, and patients expect extra privacy protection if they are to participate in Big Data projects. One simple approach is to anonymize the data. Even for internal reporting and research, providers would not be able to gain access to identity information, and this is reassuring to patients..

Takeaway
Will England become, “The most successful country on the planet at implementing a national diabetes prevention program”? Will the Troika successfully prevent pre-diabetics from developing type-2 diabetes? If the Troika’s program fails to improve patient outcomes, who will be held responsible? 
 
 
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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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