Structured group education vs diabetes

According to latest reports there are currently around 2.9 million people with diabetes, 90 per cent of whom have type 2, and somewhere in the region of 850,000 people who have diabetes and are unaware of it. This figure currently rises by approximately 150,000 year on year.

Diabetes care consumes 10 per cent of the NHS budget. By 2025, it’s likely to be nearer 20 per cent.

To the general public, and perhaps even to some commissioners in primary care, type 2 diabetes is the Cinderella of serious health conditions – the figures sound incomprehensibly huge, but as a row of numbers on a budget line, they command little attention.

Diabetes does not have the shock public profile of other diseases. Mention the words cancer, heart disease or stroke and immediately the audience understands this is life-threatening stuff.

Because diabetes can be asymptomatic for the first 10-15 years, it’s often referred to as “mild” or “a touch of sugar” – sometimes by healthcare professionals who should know better. Some people with diabetes feel so well they even deny their diagnosis.

However, diabetes is a major cause of heart disease, stroke, kidney failure, blindness, lower limb amputation, erectile dysfunction. Put like that, and diabetes is catapulted into a completely different league. 

Although diagnosis is often earlier these days, thanks to screening initiatives and the advent of incentives to GPs through the Quality and Outcomes Framework, it’s not that long since up to 50 per cent of people presented with at least one complication at diagnosis, complications which are preventable with good management of risk factors.

Whose responsibility is the management of diabetes?

For avid readers of National Institute for Health and Clinical Excellence guidelines, quality standards, and any number of health policy directives and reports, it will come as no surprise that in type 2 diabetes it’s not all down to GPs, practice nurses, dietitians and their colleagues.

‘Often overlooked is the notion that an informed, skilled, motivated, and confident individual with diabetes is key to reducing the enormous human and economic cost of this serious disease’

As with any long-term condition, the 24/7 minute-by-minute decisions on lifestyle, monitoring, food choices, medication taking, and physical activity, all of which affect health outcomes and impact on the local health economy, are made by the person with diabetes. 

For about 90 minutes a year (if they’re lucky), these people will have an opportunity to share this responsibility with their healthcare professional.

In the last 10 to15 years, policy makers, key leaders in the field and patient organisations have come together to champion an increasing body of guidance, recommendations and quality standards to raise the bar in terms of how people with diabetes can best be supported by the NHS.

Embedded in these models of care but often overlooked, is the notion that an informed, skilled, motivated, and confident individual with diabetes is key to reducing the enormous human and economic cost of this serious disease.

Out of the National Service Framework for Diabetes (2001 and 2002) which recognised the centrality of the empowered person to their care, came the concept and development of structured self management education.

Diabetes structured self management education (or DSSME) is the opportunity for people with diabetes to explore their knowledge, gain options and make choices for the kind of self-management that suits them, along with the chance to gain skills for negotiating the day-to-day decisions they will make to control their diabetes in a way that best fits their lifestyle.

What does structured group education offer?

Structured group education programmes are not one-to-one consultations delivered to a group of people. They are a completely different approach to care, with an ultimate goal of promoting self-management to improve clinical outcomes and psychosocial well being. 

Whereas traditional consultations have a way of sustaining dependency – the very attitude current policy is striving to break down – structured group education fosters independence and confidence.

It also increases contact time with healthcare professionals through a cost-effective use of resource management. It increases motivation through the sharing of experiences and learning from each other’s success and challenges.

Peer-to-peer is a powerful mechanism for change, and evidence exists from at least one UK programme that changing illness beliefs as a result of attending such a programme can lead to sustained lifestyle behaviour change.

So why is structured group education not embedded in every healthcare organisation’s diabetes care pathway?

Perhaps our predominant culture of scientific medicine creates the first obstacle. In modern Western healthcare philosophy, it’s unusual for a therapy which is neither a surgical procedure, nor a medical device, nor can be prescribed against a pharmaceutical budget, to be considered as a formal “treatment”.

For example, consider Metformin, a traditional treatment and one of the most common drugs in the pharmaceutical armoury in diabetes, and compare it to structured education, a non-traditional treatment.

Both are low in cost, and the evidence recommends that both should be prescribed as a first line treatment at diagnosis of diabetes for the majority.

Although Metformin is a product of many years of rigorous scientific testing, has a defined and easily understood function in reducing blood glucose levels, it also has limitations. There is no guarantee that the patient will take it as prescribed – and taking a tablet cannot affect aspects of lifestyle which impact on glucose control. 

Structured education on the other hand, can target improvement in a range of biomedical outcomes, including glucose control, as well as addressing health beliefs, motivation and lifestyle change.

This is a model in which we have a traditional treatment and a non-traditional treatment which are complementary and work best when taken together in the recommended doses. 

Why, when the going gets tough in economic terms, is it education programmes that become the victim of budgetary cuts? Why is it that there are still many areas in the country where people with diabetes have never had access to structured education?

Perhaps, despite the potential cost savings and ever-increasing evidence base supporting this approach, healthcare practitioners tread the path of least resistance and opt for a more comfortable, traditional way of delivering diabetes care.

The 2012 Audit Office report on the management of adult diabetes services in the NHS sends a clear warning that continuing in this same old way is no longer tenable, and in the long term, definitely unaffordable.

Join us over the next few weeks to find out, as we explore the evidence, show how current policy and guidance can be more than a set of bullet points, and share with you tried and tested tips for success for effective, economic structured education from around the UK. 

Heather Daly is nurse consultant, research, at University Hospitals of Leicester Trust, on behalf of The Leicester Diabetes Centre Research and Education Writing Group

heather.daly@uhl.nhs.uk

Leicester Diabetes Centre