Feature / About diabetes

Our continuing series giving managers a greater understanding of clinical activities looks at diabetes. Seamus Ward reports

Diabetes is well known as a disease linked to high levels of sugar (glucose) in the blood. It is a long-term condition that already takes up about 10% of the NHS budget and the number with the disease is growing fast.

The disease is normally categorised as type 1 or type 2 (see box overleaf). Type 2 diabetes is often seen as a disease of the sedentary, high-calorie Western lifestyle. It is believed that 80% of type 2 cases are preventable. Many forms of the disease also have a genetic component.

High blood sugar is a consequence of a lack of insulin or the body’s inability to use the insulin it produces. Insulin is a hormone produced by the pancreas that metabolises blood sugar – unlocking the energy in glucose (the main energy source) to fuel the body’s cells. If the levels of insulin are insufficient or the insulin produced cannot be used, excess glucose is absorbed by the kidneys and expelled in the urine. Blood sugars must be regulated as they can cause distressing symptoms and badly damage body tissues,

It is thought there are around 2.6 million people with the disease in England, rising to around 3 million across the whole of the UK. According to charity Diabetes UK the prevalence of diabetes is four times that of all the cancers put together. The number of people with the disease is rising rapidly – in England it has doubled in the past 10 years. And there is little sign this growth is abating – over-16s with diabetes accounted for 7.4% of the population of England in 2010, but it is estimated this will increase to 9.5% by 2030.

Cost to the NHS

The York Health Economic Consortium has estimated that it costs the NHS almost £10bn a year and this is likely to rise to just under £17bn by 2035/36.

‘Diabetes doesn’t always get the headlines, but its true cost to individuals and the nation is absolutely enormous,’ says Dr Rowan Hillson, former Department of Health national clinical director for diabetes.

Dr Hillson,  a consultant diabetologist at Hillingdon Hospitals NHS Foundation Trust before she retired this year, says that an estimated 7 million people are at risk of developing diabetes. And 800,000 of these people already have it but are undiagnosed.

She says Diabetes UK’s ‘four Ts’ are often the first indicators of the disease. These are:

• Tired – feeling more tired than usual
• Thirsty – not being able to quench a thirst
• Thinner – losing weight or looking thinner
• Toilet – going to the toilet a lot; or bed wetting by a previously dry child or heavier nappies in babies.

These symptoms may alert a GP to test a patient’s urine. However, diabetes is a complex condition that can affect virtually every system in the body. It may be the manifestation of one of these complications that leads to the diagnosis of the disease. One of the main risks is to the cardiovascular system, as diabetes increases the risk of heart attack and stroke as well as other cardiovascular disorders.

Prolonged high blood glucose levels can damage the small blood vessels in the retina, commonly leading to diabetic retinopathy, which can result in blindness.

The list of complications is long and includes dementia, kidney damage and peripheral vascular disease, as well as reduced lung function and congenital malformations in babies of diabetic mothers. It can affect nerves in the legs, leading to numbness, so problems in the feet, such as ulcers, may not be felt until they have developed. This and poor circulation can lead to amputations. It is estimated diabetic foot disease costs the NHS £600m a year.

‘People with diabetes can be found in every part of the health service and that’s why it’s so difficult to count the cost,’ Dr Hillson explains. ‘People with diabetes are more likely to end up in hospital and finance directors have to realise that 15% (sometimes over 25%) of hospital beds are occupied by people with diabetes. They stay in hospital longer, require more resources and are more likely to be readmitted.’

With such a wide range of complications, it is no surprise that many types of healthcare professional are involved in diabetes care – diabetologists, specialist diabetes nurses, podiatrists and dieticians, as well as cardiologists and vascular surgeons. Dr Hillson insists hospitals will only provide high-quality care if they have multi-disciplinary teams in place, integrated with primary and community care.

While not currently reversible, diabetes is treatable. People with type 1 diabetes can correct their lack of insulin using injections, usually from insulin pens and, increasingly, insulin pumps.

People with type 1 must test their blood glucose at least four times a day to ensure it is at safe levels. They do this by pricking their finger and placing a small amount of blood on a test strip. Dr Hillson says financial pressures have recently led to some commissioners reducing the number of test strips issued to diabetics, but this is dangerous as they play a key role in maintaining safe blood glucose levels. She points out that taking too much insulin can lead to a drop in blood glucose. This can lead to a range of symptoms, such as trembling or fatigue and, if left uncorrected, can lead to seizures and unconsciousness.

‘We know that if you keep glucose under control, you reduce enormously the risk of complications,’ she adds.

A healthy lifestyle is a cornerstone of the treatment of all types of diabetes. For those diagnosed with type 2, sometimes losing weight and becoming more active is enough to counteract the effects of the disease. Others require tablets such as metformin or sulfonylureas, which help the body cope better with glucose. Some people with type 2 diabetes are prescribed insulin.

Dr Hillson says patient education and support is an essential component of routine patient care. Every person with diabetes should also have an annual check-up, covering nine care processes required by the National Institute for Health and Care Excellence, as well as an individual care plan for the next year.

The nine care processes detect treatable risk factors for complications or early signs of those complications. They include stopping smoking, blood pressure and weight measurement, eye screening, foot checks and urine testing.

There is little doubt that diabetes is a growing problem that could place severe strain on NHS budgets in the future. However, with the right resources, it is relatively inexpensive to treat and prevent.