Diabetes is a chronic health condition that is common in the UK. A common condition, but contrary to public assumption, ‘common’ and ‘benign’ are not necessarily synonymous; it is not unusual that a patient with uncontrolled type 2 diabetes will, ten years post diagnosis, find themselves losing a limb because of an ulcer that won’t heal or experience worsening of their vision.
The monetary cost of treating these complications is significant, at £5.5 billion a year. However, money is not all that is lost. Without sight or the ability to walk, there is the risk of losing independence; a luxury that many would argue is priceless.
However, a key word is ‘uncontrolled’.
Individuals with type 2 diabetes can hugely influence the trajectory of their disease with simple interventions such as a healthy lifestyle and good medication compliance. It boils down to how well patients are able to manage their condition.
This said, perhaps it comes as no surprise that last week the government was criticised by the Public Accounts Committee for being ‘too slow’ in preventing and treating diabetes, the finger specifically being pointed at ‘unacceptable variations’ in education, care and treatment of patients.
The government’s response to the criticism, an NHS Diabetes Prevention programme that will aim to limit the number of people becoming diabetic is important and seems a good idea, but perhaps the focus is not quite right. What about those who already have the disease?
Currently, it is the responsibility of any health professional that comes into contact with a patient to educate them about the management of their disease and any potential complications. This is usually the patient’s GP or a practice nurse. A consultation may go a bit like this:
In walks a patient, a relatively young woman, aged 45, with type 2 diabetes. BMI is 36 (in the obese range) and most recent HbA1c, an average measure of long term blood glucose levels, is 75 (high- 48 is the lower limit for a diagnosis of diabetes). She is here for her annual diabetic review.
Doctor smiles and greets the patient. ‘Hello, how are you?’ Yes fine. Standard response. The doctor may then explain to the patient that a ‘marker of their diabetes control’/ HbA1c is high, before subsequently asking whether the patient is taking their diabetes tablet, metformin. To which the patient may explain that they ‘don’t get on with it’ and would ‘rather not’. The doctor may then decide to do some more bloods and explain this to the patient, who may respond something like ‘oh you want to see how gloopy my blood is?’ To which the doctor will reply with another smile, ‘Yes I am afraid you are a bit too sweet’. They will then discuss changing the formulation of metformin to the ‘longer acting stuff’ in the hope of improving compliance. The doctor will type up the prescription request whilst reminding the patient that they will get ‘complications early’ if they continue with poorly controlled sugars. A follow up appointment with the nurse is arranged and the patient will go on their way.
This consultation probably gets 10/10 for rapport.
However, improving lifestyle is first-line in the management of diabetes and even when the patient is on medication, in an ideal world, health professionals should use any opportunity to educate patients with respect to their condition and encourage a healthy lifestyle. This is a patient with a high BMI, who does not get on with tablets… surely there should be some talk about weight loss and exercise.
I acknowledge that GP consultations are unique in that they are a bit like a television series, it can be tricky to understand the whole picture when you’re watching episode four without having watched episodes one, two or three.
Nonetheless, having spoken to a number of doctors, I can predict a likely response… ‘But if I mention that [weight loss], they may be offended, complain and won’t come back.’
This is where my concern lies. I worry that health professionals are inadvertently doing patients a disservice when they don’t remind them of simple interventions such as healthy living and weight loss when it makes such a difference to disease progression as well as a patient’s overall health, well-being and, perhaps most importantly, independence. Besides, surely there are ways of mentioning interventions such as weight loss that won’t offend?
During this example consultation, there was also a lack of patient education about the complications of diabetes.The doctor only mentioned that ‘complications will come earlier’, they did not say what they were, and they did not clarify the patient's understanding. I question whether this patient would have been ostensibly blazé about their ‘gloopy’ blood if they realised that their high sugar levels may lead to an infected foot ulcer and subsequent amputation in ten years time?
Patients have a right to understand the implications of their conditions. They need to be able to make informed decisions; a decision to run high blood sugar levels is okay if the patient knows and fully understands the implications of their decision. However, my worry is that patients are not fully aware of the implications of their disease.
Granted, there is something to the doctors' concern that offended patients are less likely to engage and the notion that this is worse than saying nothing as ‘at least they are being monitored’.
However, accepting this is not good enough and needs to be addressed.
We need to find solutions to take the pressure off health professionals and empower patients. We need to inform without scare tactics. Patients need to be inspired, not fearful, to make positive movements to look after themselves and their chronic conditions. I consider that this may even have a snowball effect since the experience of friends and relatives is an important source of health information (and inspiration).
I question whether health professionals should hand the baton over and the emphasis of healthcare delivery should switch from educating patients in a one-on-one ‘nagging’ manner to aim to motivate patients to take control of their own health, perhaps through the use of multiple mediums to deliver the content.
I understand that not everyone is interested in their health, but most people are interested in their ability to function and their quality of life, and I would argue that this is essentially what the complications of diabetes can take away.
As the number of individuals with diabetes increases, we need to find solutions to educate these patients. Whether it be apps, informational plays or events, I think it’s time we went to the drawing board. It's time to switch the focus and get in control.