Supplement: Think on your feet for the best diabetes care

Ask Sanjay Desai about the consequences of failing to get medicines right in the care for people with diabetes and his answer is pretty grim. “Foot amputations, stroke, heart disease, and much more,” he says. “This stuff is really important.”

Mr Desai, associate director for medicines optimisation at Berkshire West clinical commissioning groups – a federation of several CCGs – has been involved in a radical redesign of the diabetes pathway to improve care for patients and ensure a better deal for the NHS.

As a pharmacist, he knows the value of good medicines management, and believes that patients need support to get the best out of their treatment. Mr Desai says: “Sometimes there can be side effects or dosage problems. A lot of patients simply don’t take their medicines, and we know that the more drugs they are prescribed, the higher the chance they won’t take them all.”

It’s complicated

When it comes to diabetes care, the stakes are high, in financial as well as human terms. Simon O’Neill, director of health intelligence and professional liaison for the charity Diabetes UK, says diabetes accounts for a big part of NHS spending. Most estimates put it at around 10 per cent. Medicines for diabetes are part of that, accounting for around £1 in every £10 in the primary care prescribing budget. But the real cost comes when diabetes is not well controlled.

“Around 80 per cent of the spend on diabetes is actually spent on treating complications, such as amputations and dialysis,” he says. “Good medicines management is part of preventing complications – it’s about prescribing the right thing, and supporting and enabling people to manage their condition.”

‘The real cost comes when diabetes is not well controlled’

But who should be responsible for ensuring that patients get the best out of their drugs? “Five or six years ago, diabetes wasn’t seen as being as much of a priority as it is now,” says Mr Desai. “And 15 years ago, it wasn’t really on the agenda for primary care; it was a secondary care issue. But now I’d say that, along with respiratory [diseases], diabetes is one of the main priorities in primary care.”

People with type 2, the vast majority of those with diabetes, will mostly be looked after in primary care. This has made it vital to upskill primary care professionals, including GPs and practice nurses, he says, as well as supporting patients, through education, for example.

Medicines optimisation

The relatively recent shift to GP practice based care brings its own challenges, he adds. “The primary care workforce is at breaking point. We need to manage care in the most effective way we can. Using pharmacists in general practice can be a good way to help people manage their medicines more effectively.”

Mr O’Neill says CCGs have a vital role in medicines optimisation – but getting prescribing right is part of a bigger picture.

‘Getting prescribing right is part of a bigger picture’

“Some 50 per cent of people with type 2 diabetes don’t take their medicines as prescribed within two years,” he says. “But you’re not going to improve medicines optimisation without lots of other things in place, such as education and care planning, which put patients at the centre of care. If you haven’t got elements like that, then people aren’t necessarily going to understand what the tablets are for.”

The Berkshire West federation – made up of Newbury and District, North and West Reading, South Reading, and Wokingham CCGs – has taken precisely that approach, and it is beginning to pay off, says Richard Croft.

A GP, Dr Croft is diabetes lead across Berkshire West CCGs, and clinical lead for diabetes at the Thames Valley Strategic Clinical Network. “This means I have strategic input to CCGs beyond my own,” he says.

“So I’m aware that in some CCGs, medicines management isn’t aligned with everything else that’s going on – there are people doing their own thing. We’re very fortunate in Berkshire West that medicines management is certainly on board with everything we’re doing to improve care for people with diabetes.”

The approach of Berkshire West’s “Diabetes sans Frontieres” project is relatively new. Service redesign began in 2012, when the then Berkshire West Primary Care Trust was identified as third worst performing PCT on a key measure of diabetes control (HbA1c attainment) in the 2010-11 national diabetes audit.

This shock result drove a major change to the diabetes pathway that has included, among other things, appointment of a consultant community diabetologist who works between primary and secondary care, a focus on patient education, and a shift to a care planning model.

‘Other steps include setting up multidisciplinary virtual clinics and changes to medical records system’

Importantly, however, there is also a strong focus on medicines optimisation. “From the beginning, our medicines management colleagues have been singing from the same hymn sheet,” he says. “For example, there’s heaps of evidence that cheap human insulin to control type 2 diabetes is every bit as good as more expensive insulin analogues, so we should be prescribing it across the whole area.”

Prescribing quality schemes – where GPs are essentially incentivised to prescribe in line with agreed guidelines and use human insulin with the lowest cost – are one way of making it happen, says Dr Croft. “Secondary care is now on board too, so we’re saying the same things across the board.”

Companies selling insulin have been very responsive and happy to engage with the new regime, he says, ensuring a better deal for the NHS and, indeed, for patients.

Results so far are good, with the proportion of patients hitting target HbA1c levels increasing from 46.5 per cent in June 2012 to 59.5 per cent by December last year.

Dr Croft agrees that medicines optimisation, while important, is not the silver bullet to solve every issue. Other important steps in Berkshire West have included setting up multidisciplinary virtual clinics to discuss patients with poor control, and changes to the medical records system to give a clear view of how care is delivered at a practice level.

He points out that getting diabetes care right is hugely important, not just to individual patients, but to the health service budget as well, and that includes making the best use of medicines.

“Renal failure, for example, can cost £35,000 per year [cost of hospital based dialysis]. There’s a big focus at the moment on prevention of diabetes. Well, what we’re doing is secondary prevention - we’re stopping eye disease, kidney failure, foot amputations. Getting medicine right is helping us to do that.”