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Feature The New Normal

How routine NHS diabetes care can catch up after covid-19

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1927 (Published 31 August 2021) Cite this as: BMJ 2021;374:n1927

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  1. Emma Wilkinson, freelance journalist
  1. Sheffield
  1. emmalwilkinson{at}gmail.com

Progress may have slipped, but general practices are finding innovative ways to catch up. Emma Wilkinson reports on calls for more guidance on new drugs and more remote monitoring to support self-management

“There will be a need for diabetes management to catch up,” as progress made before the pandemic will have slipped, says Partha Kar, NHS England’s national specialty adviser for diabetes and a consultant at Portsmouth Hospitals NHS Trust.

“There will be a lot of people who have not had checks for two years,” he tells The BMJ, adding that primary care has been under huge pressure during the pandemic and is now at the forefront of the vaccine programme. About 90% of patients with diabetes have type 2—about 3.4 million people in England—and are managed in primary care.

The National Diabetes Audit measures the effectiveness of diabetes care against standards set by the National Institute for Health and Care Excellence (NICE) in England and Wales as a way of driving improvement.1 This includes monitoring how many people with diabetes have eight key checks every year: HbA1c, blood pressure, cholesterol, serum creatinine, urine albumin, foot check, body mass index, and smoking. Early figures indicate about a 35-40% reduction in those checks in 2020. “The worry is the impact of that, and we are tracking to see what impact it has,” says Kar.

Technology and support for self-management will be key after the pandemic, he adds, as the NHS tries to overcome some of the slippage. “This is why we have been pushing so hard for the rollout of remote monitoring devices. We need more of that in the NHS,” he says, as around 45% of all patients with type 1 diabetes in England now have a Libre glucose monitoring system. “The pandemic has put a rocket booster under these programmes, and type 1 diabetes education as well.”

There are plans for more NHS online support tools including the Healthy Living platform, which gives people with type 2 diabetes guidance on managing the condition. “Diabetes is a lot about self-management and peer support, and that is how the NHS will get back,” says Kar.

Avoiding a backlog in primary care

The full picture of the pandemic’s effect on diabetes control won’t be apparent until publication of the next National Diabetes Audit, expected at the end of this year. Anecdotally, however, GPs say that they’re seeing much poorer glucose control and that patients who were considered prediabetic are crossing the threshold.

Stephen Lawrence, GP and an associate clinical professor at Warwick University, says that although practices had to switch to different ways of working to keep patients safe, data from the Royal College of General Practitioners show that many practices managed to provide ongoing care for diabetes.

Physical and psychosocial aspects of lockdown—such as being out of the usual routine, stress and anxiety, or losing motivation and opportunities to be active—will have taken their toll, says Lawrence. “Sadly, I feel that’s going to contribute to greater morbidity and mortality than issues around access to primary care,” he says. “I’ve seen people newly diagnosed with type 2 diabetes: people with non-diabetic hyperglycaemia who were leading up to diabetes over a number of years, and lockdown has brought it on sooner.”

Becky Haines, a GP in Gateshead and the town’s clinical lead for diabetes, says that her practice and others have worked hard to avoid a large backlog and, under a local scheme, to review multiple long term conditions together either face to face or virtually, depending on patient preference.

“By April 2020 [after lockdown in mid-March] we were back up and running,” she tells The BMJ. “Not all practices started that early, but they did what they could. I know of some practices where for multiple reasons they didn’t start until November, and then the second wave hit.”

Haines’s practice is close to having done a normal number of annual reviews and is seeing many patients with high glucose levels. She explains, “I work in a deprived area, and many people have been furloughed or lost their job or had relatives who have been unwell or shielding, and they’re not in a place to make big lifestyle changes.

“We’re going to have to work really hard to support people in the next five years to get their results lowered again. There will need to be extra resources.”

With some nurses currently busy doing covid vaccinations, primary care practices are having to consider different approaches to how they do their annual reviews, including use of technology and avoiding multiple visits and duplicated work. One stop community hubs and training of healthcare assistants to deliver some aspects are potential options. “We’re thinking about what we can do a bit more innovatively,” she says. “Practices may think about group consultations to try to get more peer support.”

But she adds that guidance is also needed from bodies such as NICE on the most appropriate use of newer drugs for type 2 diabetes, such as glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors, which have been shown to reduce the risk of heart disease and stroke and not just to lower HbA1c. The last NICE update on drug management was in 2015.

“At the moment it depends on the individual healthcare professional and how up to date their knowledge is,” says Haines. “NICE guidance is long overdue, so that’s going to need to be looked at as a matter of urgency.”

Link workers tackle inequalities

Selvaseelan Selvarajah, a GP partner in east London, tells The BMJ, “We’re all resuming normal services now, and we are seeing more patients with diabetes and more patients with poor control than before. We’ve seen a lot of HbA1c over 100 [mmol/mol], much more than we would have seen previously.” Those uncontrolled blood glucose readings are put in context when you consider that an ideal target in adults with diabetes is 48 mmol/mol.

It’s more complicated than simply doing the annual review on time, he explains. The Bromley by Bow Health Centre, where he practises, has found the funding to hold extra clinics with healthcare assistants to make sure that blood tests, blood pressure checks, and foot checks can be done before a telephone consultation with the GP.

The practice has invested in link workers, who support people through social prescribing to try to tackle some inequalities in their population. “We have 30 000 patients over three practices in a densely packed area,” he says. “There’s not much outdoor space, a lot of people work in frontline jobs or hospitality, and it’s had a huge impact on them.”

These patients were suddenly having to work in stressful environments at risk of catching covid or were suddenly out of work. Those circumstances don’t make it easy to keep active and motivated in looking after yourself, says Selvarajah. “The pandemic has had an impact on people not being able to exercise and be active, and people’s eating habits have changed—we’ve seen how all the [takeaway] delivery apps have done really well,” he tells The BMJ.

He adds that greater use of technology can help to manage demand. “We purchased 100 blood pressure machines to lend to patients,” he says, so that the practice could keep monitoring when patients couldn’t access health services or didn’t want to.

Remote consultations are here to stay

When the pandemic hit in March 2020, most doctors working in UK diabetes services were pulled into caring for patients with covid. As with other specialties, much routine care stopped for the 12 weeks of the first wave, and the same happened as the alpha variant took hold in the second wave from January to March 2021. Kar estimates that around 60-70% of his team’s work became about looking after patients on covid wards.

Urgent clinics continued to see patients face to face for hypoglycaemia or extreme hyperglycaemia, active foot disease, new diabetes in pregnancy, or insulin initiation. Since then there’s been a large increase in virtual consultations. Most other routine work also shifted online and remains there.

“I’ve just finished a clinic, and of the 11 patients, three were face to face and everyone else was over the phone,” says Kar. “The majority of patients have stayed virtual, and that’s because of the amount of monitoring technology that people have at hand now.”

NHS data also indicate that hospital admissions of younger patients with diabetes and foot complications have fallen, while admissions of middle aged and elderly patients have risen. This may be related to covid, says Kar, and is something to keep an eye on.

Dexamethasone for covid-19

“The use of dexamethasone for covid has had a big knock-on impact,” says Kar, as specialist teams have had to manage virtual wards of patients treated for covid with this steroid, and it can take weeks to get their diabetes back under control. In the first four months of the pandemic a third of covid related deaths (14 000) were in people with diabetes, but dexamethasone can cause substantial hyperglycaemia in people with diabetes.

Retinal screening was suspended during the first lockdown throughout the UK, and as services reopened capacity was low because of distancing rules and the need to clean equipment and rooms between patient appointments. But Public Health England already had plans to change screening to every two years in people at low risk after research showed that this was a safe interval—which Kar says has helped to take pressure off.

And what of new diagnoses of diabetes? In a study of GP records, researchers at Manchester University found a 30% drop in April 2020 when compared with historical trends.2 As the year progressed this recovered but remained well below what would be expected, suggesting that from March to December 2020 some 60 000 diagnoses of type 2 diabetes were missed or delayed in the UK.

The team also found a fall in HbA1c testing, most notably in older people, raising concerns about long term complications as poor control is missed. Part of the reason for this, says the charity Diabetes UK, may have been patients not seeking help because of a fear of contracting covid-19 if they attended healthcare services or not believing that their care was urgent enough.

“I haven’t seen a consultant in more than a year”

Hayley McDonnell, a 47 year old teacher in Cheshire, says, “I haven’t seen a consultant in more than a year now. I haven’t had any invites to have my HbA1c taken, and I haven’t had any feedback on how I’m doing or if I need to make changes.”

It’s been 14 years since McDonnell had type 1 diabetes diagnosed. She also has a thyroid condition and a benign pituitary tumour and is used to regular checks at the hospital. But none of her usual care has happened because of the pandemic.

She’s considered that maybe she should have been more proactive, but she wasn’t sure who to contact. In December 2020 she caught covid-19 and was terrified. She recovered and has since had a vaccine. And she’s been making changes to her insulin doses: taking that little bit more control may be a positive thing, she adds, but she’d like reassurance.

She concludes, “I’ve put on weight this year, and I’m thinking, ‘Is this my thyroid issue or pituitary tumour?’ Usually I have a scan every 18 months, but I really don’t want to go to the hospital.”

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Patient consent obtained.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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