Raising care standards: Why understanding diabetes matters

Why is understanding diabetes in every social care setting important? Let’s break this down. What is diabetes? Put simply, it is elevated blood glucose (irrespective of the different types of diabetes, it is the causes and management which differ). What does elevated blood glucose do over a period of time? It wreaks havoc and can cause various health problems with numerous parts of the body being affected.

Stark figures

In the UK, the latest figures provided by diabetes charity, Diabetes UK, tell us that more than 5.8 million people are living with diabetes. Of this 5.8 million, 4.6 million have a diagnosis, whilst an additional 1.3 million people could be living with type 2 diabetes but are yet to be diagnosed. On top of this, based on blood glucose levels, an estimated 6.3 million people are at an increased risk of type two diabetes. Putting all this together, approximately 17% (nearly a fifth) of the population in the UK lives with diabetes or ‘pre-diabetes’.

Diabetes is a serious condition: a highly prevalent metabolic and vascular disorder affecting one in four UK care home residents. If your organisation supports people with learning disabilities, data indicates it is around 10%, nearly double the general population. We should also be aware that type 2 diabetes is not just a condition in middle-aged and older adults. Although the numbers being diagnosed in children and younger adults are smaller, the steepest percentage increase of people with type 2 diabetes is in those under the age of 40.

An increasingly complex issue

For people living with type 1 diabetes, care standards, treatments and technology (such as pumps and continuous glucose monitoring or CGM) have had a significant impact, whereby people are living longer and therefore possibly requiring support as they age. Does this mean there is a tsunami of people living with diabetes requiring social care support coming in the not-too-distant future?

Some think so, such as Martin Scivier (a septuagenarian living with type 1 diabetes) who has spoken and written eloquently about his concerns regarding the possibility of requiring care in years to come and whether those providing it will fully understand and have the skills to ensure that his diabetes continues to be well managed. Living with type 1 diabetes, type 2 diabetes or a rarer form of diabetes, is multi-faceted and becomes increasingly complex as someone ages, requiring differing levels of clinical and social care intervention and support.

For older people living with diabetes, do we need a different approach? Depending on individual health status and general wellbeing, including level of frailty, yes, a different approach is absolutely required. Not surprisingly, as some people age, the way they respond to trauma (psychological, physiological or emotional) differs. As we age, frailty is not an absolute. However, in recent years, frailty has emerged as a new complication of diabetes and may affect 32-48% of adults with diabetes over the age of 65. It has a significant impact and is associated with poor outcomes, including reduced survival rate.

For individuals becoming increasingly frail, there is the opportunity to halt the decline and improve health status. But if ignored, frailty will progress and become disabling. Frailty and diabetes have a bidirectional relationship (which is being further researched), so by managing diabetes, this can have a positive impact on frailty, and vice versa. Cognitive ability, nutritional status and acute illness can (along with many other aspects) have an impact on diabetes too.

A care provider’s role

For care providers, doing the basics well is vital. The social care workforce is essentially the eyes, ears and hands of the wider healthcare team. It is in a great position to undertake a range of tasks and spot potential problems in a timely manner, thus contributing to a ‘prevention/proactive approach’ rather than a ‘reactive environment’. Every person living with diabetes will have differing health status, co-existing long-term conditions and medications, all of which will alter over time. As people age, these aspects of care need to be regularly reviewed.

A good place to start is the National Advisory Panel on Care Home Diabetes (NAPCHD) strategic document and associated guidelines, along with the more recent Type 1 Diabetes in Care Homes: A practical guide on management position statement from a NAPCHD Working Group and the recently published Care of Older People with Diabetes: A manual for healthcare practice, particularly chapter 13b. To maintain or improve effective diabetes care, there are some key metrics that care homes should be incorporating into their policies, records, care environment, skills and capabilities of team members, that these resources explain in detail. As a minimum for providing satisfactory care, the NAPCHD identified the following four elements and the essential factors within them.

Evidence that a care home has a diabetes screening policy at admission to a care home that is easily implemented and audited. This is likely to lead to a reduced number of GP callouts for undiagnosed diabetes and associated complications, reduced hospital admissions for undiagnosed diabetes.	This is likely to lead to a reduced number of GP callouts for undiagnosed diabetes and associated complications, reduced hospital admissions for undiagnosed diabetes.
The availability within each care home of a fully stocked and maintained hypoglycaemia kit	This should lead to reduced ambulance callouts for hypoglycaemic episodes and reduced hospital emergency admissions for hypoglycaemia.
Evidence that a care home has a risk calculation/stratification tool for diabetes foot disease	Use of this tool by trained staff should reduce costs associated with unnecessary amputation due to earlier intervention.
Provision of local effective diabetes education and training programmes for care home staff	This should lead to a reduced number of GP callouts for diabetes-related management issues and reduce hospital admissions for hypoglycaemia, infections, and other common medical problems in residents with diabetes.

Essential factors

• Personalised care plan.

• Structured education and training for care staff.

• Responsible and accessible integrated primary and community care.

• Facilitated discharge from hospital.

• Structured medication review.

• Co-ordinated care and information sharing using digital network.

• Responsible and flexible commissioning of services.

• Adult social care needs assessment and critical events risk assessment

• Care home diabetes policy.

• Access to specialised services including laboratory services.

How can you provide individualised, person-centred care if you do not know whether the person is living with diabetes (given the high prevalence in the older population)? Regular blood glucose monitoring is essential. An older person’s blood glucose may indicate an issue prior to presenting with symptoms (of high or low blood glucose). Older people do not always display symptoms in the same way a younger person would (and/or may not be able to communicate them). Improving knowledge and confidence of team members at all levels within the setting is key for not just everyday support of the person living with diabetes but also for identifying potential problems and ‘raising the flag’ to senior colleagues or allied clinical teams.

Having the capability and skills to undertake capillary blood glucose testing is vital – particularly if a care provider is supporting someone being treated with insulin or oral medication which can potentially elicit hypoglycaemia. A suspected ‘hypo’ needs to be confirmed, and if a community nurse usually performs the blood glucose testing, they are not in a position to dash to a care home or individual’s home to carry out a test.

With the advance of technology, an increasing number of older people will be making use of CGM. The use of CGM devices may help to overcome the increased risk of hypoglycaemia for older people, particularly the use of the alarm features (audible and vibrating options). Care teams will need to ensure that they are appropriately trained on these technologies. This is one of the concerns, particularly of the type 1 community, as they age – knowing that whoever is supporting them has the skills and knowledge to assist them. For individuals that have managed their diabetes independently for perhaps 60 years, letting go and accepting help will be a huge step and they will want to have confidence in the team caring for them in their later years.

Be part of the solution

Footcare is an area my colleagues and I spend a lot of time talking about. Over 180 diabetes related amputations take place in this country every week. Approximately 1% of the total NHS budget is spent on diabetic footcare, but let’s put the financial aspect to one side. Just think of the psychological and emotional aspect of living with a diabetic foot ulcer or amputation – the vast majority of which we are told are preventable.

The care sector is in a fantastic position to be part of the solution to improve these statistics by employing preventative footcare measures. For example, realising that a blister should not be ignored, ensuring that good daily footcare takes place, documenting and acting upon any changes in the feet and checking footwear is adequately supportive and that nothing has fallen into a shoe before it is worn – someone with nerve damage may not feel that a Vicks VapoRub lid may be in there by accident (a real example!). Whenever an event or problem occurs, a care team should ‘play detective’ – why did it happen and what can be implemented to avoid a repeat?

A final additional consideration I would like to share relates to the care team – how many are living with diabetes? Think about recruitment and retention. Do you create an environment where people at interview or already in post feel comfortable in disclosing conditions such as diabetes? Reasonable adjustments may or may not be required and if required, may only be temporary. For example, having the time and place to check blood glucose and/or inject insulin, talking about hypos and where they keep their meter and hypo treatment (including what it is). During pregnancy, additional appointments may be required and accommodated. Ultimately, supporting a team member living with a long-term condition may provide extra insight into supporting residents effectively.

Quality of life is paramount for people living with diabetes, irrespective of their age or circumstances. Diabetes is an independent risk factor for admission to a care home and there are multiple considerations to take into account. Residents living with diabetes in care homes are at higher risk of infections, leg and foot ulceration and complications associated with hypo- and hyperglycaemia. Social care providers, together with allied healthcare professionals, must collaborate on how best to meet the clinical, health and wellbeing needs of older people living with diabetes.

Now is the time to act. Strive for excellence with diabetes understanding and care – to empower and benefit the people you employ and support. Education, communication and collaboration are key to making a difference.

How has your organisation kept abreast of the latest developments in effective care and support for people living with diabetes? Leave a comment on this feature or join the conversation to share your thoughts.

Lynne Reedman is the Founder and Service Lead at DUET diabetes Ltd.

Email: [email protected] Linkedin: @Lynne-Reedman-DUET-diabetes-Ltd