Better Use of Resources Key to Improving Diabetes Care

Liam Davenport

November 17, 2020

The COVID-19 pandemic has shown that the notion of a resource poor environment in diabetes management is a misnomer and already available resources and technologies need to be better used to maximise patient care, say UK experts.

They argue that pharmacists and other members of the care team should be given wider roles and more responsibility not only to make diabetes care more effective but also potentially improve outcomes, while patients should be more readily offered the latest diabetes technology.

They were talking as part of a dedicated session at the Diabetes Professional Care (DPC) Virtual 2020 meeting on November 12.

'Stark Contrast'

Professor Partha Kar, associate national clinical director for diabetes for NHS England and a consultant in diabetes medicine at Portsmouth Hospitals NHS Trust, led the discussion.

He began by saying that the impact of resource availability on the management of diabetes has been thrown into "stark contrast" by the COVID-19 pandemic.

Hannah Beba, clinical pharmacist at County Durham and Darlington NHS Foundation Trust, agreed, saying that her team has been playing "catch-up" recently after all diabetes services were "completely cancelled" at the start of the pandemic.

However, now that the UK has entered the second lockdown, she said that there is "some concern" that we "know who we should be seeing" as a priority, "but we’re still not getting to them".

Beba said she and her colleagues have nevertheless introduced some innovations during the pandemic, such as virtual multidisciplinary meetings for their "frail elderly" patients.

They have also looked at broadened healthcare professionals’ roles, which has meant that she has "got a bit more involved in the team in different ways than I would have previously".

This was achieved partly because they have, for some time, had an integrated care service, which "has been a really great resource during COVID-19" that "kept those lines of communication open" with different members of the diabetes team to help patients "most at risk", Bebe said.

Clinical Leadership

For Prof Kar this highlights his belief that when talking about resource poor environments, "it depends a lot on the clinical leadership where you are", with one example being that resources such as pharmacists are often under-utilised.

He asked Beba: "When we talk about ‘resource poor’, do you think it’s about not thinking wider beyond just fixed roles, that people have always done for years?"

She agreed, but added that she would "expand it beyond pharmacy", as there are "lots of roles that are under-utilised", such as dieticians, podiatrists, and psychologists.

"I think if you managed to get that balance right," diabetes management "would be a really slick machine that would give the patients the ability to self-manage a lot better."

Prof Kar said that it is obvious on his tours of NHS trusts, where he has seen "very clear evidence" that those with pharmacists dedicated to diabetes care are "more effective", with fewer errors and better interaction between care teams.

Beba nevertheless said that one of the "problems" around pharmacists being involved in diabetes care is that it is a "high risk area of practice", and so there has been a desire for pharmacists to prove their competence.

She believes that the introduction of an accreditation system similar to that used for nursing would show what pharmacists "are capable of," as this understanding is "sometimes lacking" among GPs, and they would consequently be more comfortable handing over some responsibilities.

Misnomer

Joining the session, Dr David Strain, clinical senior lecturer and honorary consultant with the University of Exeter Medical School, agreed that the idea of ‘resource poor’ is a misnomer, as it is "about using the facilities you’ve got to the best of your ability".

For example, his team has used practice pharmacists to "escalate therapy and realised we now get to the optimum dose" of drugs in a much better way, "which means that patients are controlled but also…better adherent".

Consequently, Dr Strain is "reluctant to use the term ‘resource poor’" but rather the term "resource appropriate".

Beba said that another aspect of the resource environment is technology, which has been used "really differently" during the pandemic.

Technology

Prof Kar said that, in general, the NHS is "antediluvian" in its approach to technology, in the sense that its attitude is "sorry, it’s not going to work" because things are expected to happen in the same way they always have.

He also expressed frustration with the assumption that "old people don’t use technology", even though "that myth has been buried so many times over" and is "the biggest nonsense I’ve ever heard".

He continued that there is consequently a "big opportunity" for the adoption of technology, but it requires people to "lead the charge" and show that it can achieve results.

Dr Strain agreed technology is "absolutely" underused in frail elderly, as there is a "perception" in which clinicians ask themselves, "Why should I use a [continuous glucose monitor] for a 96-year-old because what is it going to do?"

However, he believes that such patients "probably have the most to gain" from such technology, as HbA1c levels are "not particularly reliable in the frail elderly" due to being "artificially elevated and there are many unexplained symptoms".

Moreover, neither hypoglycaemic nor profound hyperglycaemic episodes "don’t present the way that they often do," and using a continuous glucose monitor such as FreeStyle Libre (Abbott) for 4 weeks "will give you a much better insight into what’s really going on".

Dr Strain said that has the "potential benefit of reducing hospitalisation and admissions, and most importantly, making those patients feel a damn sight better".

Prof Kar added that the COVID-19 pandemic has "forced" the adoption of novel technologies and it has "broken down barriers”, and it is no longer seen as an “alien concept".

However, they may not reach the most deprived populations, and he said his team has spoken to Abbott, for example, to "see" how the company is "reaching out".

He continued: "I don’t think it’s only the responsibility of the clinicians" to make access to technology more equitable.

Another aspect of that is the referral process.

Prof Kar said that clinicians, in effect, tell patients, "you can get technology if you go to the hospital", following a GP referral.

The patients who have "the time" and motivation to go to the hospital, however, are "probably" from a less socially deprived background, he said, whereas "a lot of people" are holding down three jobs and "don’t have time".

"Providers have a big role to play," Prof Kar continued, and "companies, if they want more access, need to have plans for how to reach across the digital divide, so to speak."

No funding declared.

No relevant financial relationships declared.

Diabetes Professional Care Virtual 2020: Abstract Managing Diabetes in Resource Poor Environments & in the face of Pandemic Challenges. Presented November 12.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....