'Expert patients cannot do it all – they still need expert care'
Patients with long-term conditions are often experts on their condition, which is why self-management is encouraged in diabetes.
However, it can be extremely difficult to manage blood glucose levels during illness. Viruses, such as those that cause colds and flu, can increase insulin requirements so dramatically that patients need to test blood glucose levels four to six times a day to ensure insulin doses are accurate. In addition, long-term hyperglycaemia not only triggers chronic complications but also leads to diabetic ketoacidosis, a medical emergency due to severe metabolic imbalance.
Because both type 1 and type 2 diabetes can be extremely difficult to self-manage alongside an acute infection, and patients may need expert advice and care from health professionals. However, GPs are overstretched and it can be difficult to get an emergency appointment when blood glucose levels become unstable, while in addition, hospital diabetes clinics are not designed to provide a drop-in centre for diabetes self-management difficulties resulting from illness.
These problems highlight the fact that diabetes care is not seamless and high-risk patients who become ill may not receive the medical attention they need.
The recent top-down reorganisation of the NHS has diverted resources away from care. People with diabetes need to feel confident that services such as NHS 111 will provide correct advice that is appropriate to their condition and situation. However, NHS 111 is not properly resourced, with some advisers receiving only a few weeks’ training. This does not inspire confidence, nor does it ensure advisers have advice and guidance needed to prevent a person with diabetes from being admitted to hospital. Other factors affecting care provision are an ageing population, a shortage of accident and emergency consultants and the crisis in the NHS. Early intervention and an integrated system are urgently needed to avoid acute ill health wherever possible.
This issue is a difficult one. The answer lies with patients being proactive and taking primary responsibility for managing their diabetes. Action can be taken to avoid ketoacidosis due to prolonged hyperglycaemia, reducing hospital admissions. This involves regular blood testing and acting on the results, especially during illness. Having a flu vaccination is essential as a preventive measure.
The National Diabetes Inpatient Audit and the National Paediatric Audit showed there were 8,472 hospital admissions relating to diabetic ketoacidosis in 2011. A large proportion of these were potentially due to deliberate omission or forgetting to take insulin by 10-19-year-olds. An emphasis on patient education is necessary by diabetes teams, in collaboration with GPs, in respect of ketosis prevention and maintaining blood glucose levels to avoid this emergency condition that requires admission to A&E. However, patients must also be able to access seamless diabetes care when they require it.
Val Wilson is a diabetes researcher, lecturer and writer. She has had brittle type 1 diabetes for 37 years.