Improving diabetes care: collaborative efforts to drive better outcomes
Longstanding health inequalities in the Black Country have resulted in unequal access to technologies such as continuous diabetes monitoring but a partnership between industry and a primary care trust has transformed uptake
Diabetes is one of the six major health conditions that affects more than 5.6 million people in the UK,1 with 90% of those with the condition living with type 2 diabetes.2 Every week, diabetes leads to more than 190 amputations, 770 strokes, 590 heart attacks and more than 2,300 cases of heart failure. One in six hospital beds is occupied by a person with diabetes, and it costs 10% of the NHS budget, 80% of which is spent on treating preventable complications.3
In the Black Country (West Midlands) region, which includes areas such as Dudley, Sandwell, Wolverhampton and Walsall, life expectancy is significantly lower than the national average in England.4 The region also has a higher recorded prevalence of diabetes, with more than 108,000 people currently living with the condition, of whom 94% are living with type 2 diabetes.5 In particular, Sandwell is also one of the most deprived local authorities in the country, ranking 12th (out of 317 local authorities) in England.6
More than 25% of the local population identify as Asian or Asian British. The most common languages spoken in Sandwell (other than English) are Punjabi (6.4%), Polish (1.7%), Bengali (1.0%) and Urdu (1.0%).7
In June 2022, in a shift towards improving access to diabetes technology, NICE updated its guidelines to make continuous glucose monitors (CGM) available to selected people with type 2 diabetes. These include individuals who are administering insulin two or more times a day, have recurrent or severe hypoglycaemia (hypos), have impaired hypoglycaemia awareness, can’t monitor their own blood sugar levels, use a scanning device, or are advised to do a finger prick test at least eight times a day. Pregnant women who have type 2 diabetes or gestational diabetes may also be offered CGM if they have several hypos.8
Currently, implementation of the NICE guidelines in primary care in England is varied, resulting in health inequalities and wide variations. However, the local ambition for Your Health Partnership PCN, run by Sandwell and West Birmingham Hospitals NHS Trust, is to increase equitable access to diabetes technology by reducing these levels of variation.
A COLLABORATIVE APPROACH
Historically, there had been longstanding inequality for patients who needed access to diabetes technology in the Black Country Integrated Care Board (ICB).9 This variation was further exacerbated by the COVID pandemic when people with diabetes were unable to get a specialist appointment to access CGM. Recognising these issues, Abbott’s local market access team initiated a safe pathway for the implementation of CGM – the FreeStyle Libre 2 system* (other sensors are available) – in GP practices.
Since then, Sandwell, part of the Black Country ICB, has pioneered primary care implementation of diabetes technology to improve outcomes for local people with diabetes, and to bridge the gap between secondary, primary, and community care to reduce variations in access to CGM.
The Your Health Partnership Practice worked with Abbott’s market access specialist support team to identify these eligible patients and implement pathway process mapping, to identify individuals in agreement with the practice nurse and engaging with multiple stakeholders such as consultants and diabetes specialist nurses in secondary care. The project was also supported by lead pharmacists, commissioners, finance, and medicines management leads in Sandwell.
The initial scheme was implemented from January 2021 to October 2021, and by April 2022, LibreView,** the data management software, was being used by general practice nurses to review and analyse historical glucose data remotely.
The monitoring process showed patients who were scanning more frequently had better control of their glucose levels, lower HbA1c, and lower rates of variability. They also spent less time over the hyperglycaemic threshold and were more likely to spend time in their individualised target range. After 6 months, the mean Glucose Monitor Indicator (GMI) for patients was 54.6mmol/mol, which meant that on average, the group was achieving the treatment target of 58mmol/mol.
Almost 99% of the first cohort of patients reached their individualised glucose target range. This also eased pressure on secondary care services at a time when they were most strained, and this benefit is set to continue through an expected reduction in patient complications in the long-term. Healthcare professionals in secondary care services welcomed this shift as many of the patients didn’t need to be seen in hospital settings.
As a lead diabetes nurse, I was also keen to embrace the knowledge and skill to implement CGM in primary care as I felt patients shouldn’t have to miss out on this valuable piece of technology. The pilot project enabled me to collaborate with the secondary care diabetes team, aiming to introduce a service into general practice that was previously only available to patients living with diabetes attending the consultant-led service in the hospital setting. There were groups of people who were eligible but would never have had the opportunity to benefit due to being lost to follow-up appointments or not engaging with this pathway.
EXPANDING ACCESS ACROSS COMMUNITY CARE
As the guidelines for access to diabetes technology for people living with type 2 diabetes evolved, additional barriers around access for patients who didn’t speak English as their first language also needed to be considered. The prevalence of type 2 diabetes is higher among Asian, Black and minority ethnic groups in the UK,10 and there was a need to ensure those groups in the local area were supported.
As a result, the Abbott team worked closely with general practice nurses and GPs to help them initiate the FreeStyle Libre system and help support these patients, by providing a range of translated videos and telephone translators for different languages, including Punjabi and Urdu. This enabled GPNs to better engage with patients from different ethnic backgrounds.
The practice also took a more tailored approach with vulnerable patients, including those with learning difficulties and house-bound patients assisted by carers, as these groups often found regular finger prick tests difficult. For example, working closely with community nurses, the practice’s housebound lead managed to initiate CGM in these patients, including those who have dementia and require additional support. More recently, in one particular care home, the staff have downloaded LibreView to access data from the readers used to monitor residents’ glucose levels,9 granting access to the local GP so that patient data can be reviewed remotely and recommendations made to improve care, such as adjusting their insulin to reduce the frequency of hypos or improve their HbA1c, which is predicted to lead to a reduction of long-term complications and use of secondary care and emergency services.
This enabled primary healthcare teams to see how data sharing could increase access across different pathways, in a move that could be rolled out across other sites once processes have been streamlined.
Partnership approach to reducing inequalities
It is vital to note that not all of those who are eligible for CGM have access to the technology or are able to use it. For example, vulnerable and elderly people don’t necessarily have compatible smartphones, therefore readers which can be used with the FreeStyle Libre 2 sensors are needed. Workarounds such as screenshots provided by healthcare assistants are in place, but this is not ideal. A streamlined approach to diabetes care across the entire health system is needed that allows full technological access across all electronic platforms, so that information can be shared easily between community nurses, practice nurses and housebound leads, enabling patients to experience the full benefits of the technology.
Practice nurses leading diabetes management in primary care settings are well placed to identify patients for interventions such as CGM and understand some of the barriers facing their local population when it comes to accessing diabetes technology, including being unable to take time off work, care duties and transport costs.
SUCCESS TO DATE
As a result of these local interventions, data were shared with the diabetes clinical learning networks in the Black Country ICB. The ICB’s medicines management team continues to develop guidance to support wider implementation, with a view to ensuring that primary care staff are trained and supported to use CGM in eligible patients. It is likely that anticipatory care, combined with the known efficacy of CGM for improved self-management, will produce clinically significant improvements for people living with diabetes, including a reduction in waiting times for secondary care initiation, fewer hypoglycaemic episodes, improved HbA1c due to increased Time in Range, and ultimately, a reduction of long-term complications and use of secondary care and emergency services.
Diabetes is a burden, and individual patients need differing levels support, however, the results have shown that diabetes technology can be revolutionary and reduce the risk of complications while improving overall health outcomes.
CASE STUDY
Michael Brown, aged 71 years, from Coventry was diagnosed with Type 2 diabetes nearly 30 years ago. He said: ‘Since I’ve had the FreeStyle Libre 2 system, I feel so much better in myself. Not only that, but the nurse said I had lost 18kg since she last weighed me, and my HbA1c had dropped from 68mmol/mol to 58mmol/mol.
‘When I first got the system, it was great being able to get regular readings and seeing how food affected my blood glucose levels, which also meant eating the right things and losing weight without trying or feeling hungry. Since I have lost weight, I’ve noticed I don’t need as much insulin, which is not only better for me, but [is] cutting costs to the NHS.’
CONCLUSION
A proactive nationwide approach for diabetes management could be instrumental in transforming patient outcomes and optimising healthcare resources across the country. The approach taken in Sandwell demonstrates the results that could be achieved on larger scale by implementing a forward-thinking, community-based approach to managing diabetes through closer community collaboration.
THE TECHNOLOGY
FreeStyle Libre 2 and Libre 2 Plus sensors are compatible with FreeStyle LibreLink app and FreeStyle Libre 2 reader, the FreeStyle Libre 2 system has option glucose alarms: to receive alarms notifications, alarms need to be turned on and the sensor kept unobstructed within 6 meters of the reading device. The FreeStyle LibreLink app is only compatible with certain mobile devices and operating systems. Please check the website for more information about device compatibility before using the app. Sharing of glucose data requires registration with LibreView.
LibreView data management software is intended for use by both patients and healthcare professionals to assist people with diabetes and their healthcare professionals in the review, analysis and evaluation of historical glucose meter data to support effective diabetes management.
More information on Abbott’s FreeStyle Libre 2 system at pro.freestyle.abbott
*FreeStyle Libre 2 and Libre 2 Plus sensors are compatible with FreeStyle LibreLink app and FreeStyle Libre 2 reader, the FreeStyle Libre 2 system has option glucose alarms: to receive alarms notifications, alarms need to be turned on and the sensor kept unobstructed within 6 meters of the reading device. The FreeStyle LibreLink app is only compatible with certain mobile devices and operating systems. Please check the website for more information about device compatibility before using the app. Sharing of glucose data requires registration with LibreView.
**LibreView data management software is intended for use by both patients and healthcare professionals to assist people with diabetes and their healthcare professionals in the review, analysis and evaluation of historical glucose meter data to support effective diabetes management. More information on Abbott’s FreeStyle Libre 2 system at pro.freestyle.abbott[/]
Disclaimer: Lynn Broomfield received no financial compensation for this article. The content was reviewed for accuracy by Abbott. The views expressed are those of the author and not necessarily those of Abbott. Professional writing support was provided.
References
1. Diabetes UK. How many people in the UK have diabetes? 2024. https://www.diabetes.org.uk/about-us/about-the-charity/our-strategy/statistics
2. Diabetes UK. How many people in the UK have diabetes? 2024. https://www.diabetes.org.uk/about-us/about-the-charity/our-strategy/statistics
3. Diabetes UK. Diabetes is serious. 2023. https://www.diabetes.org.uk/support-us/campaign/diabetes-is-serious
4. NHS Black Country Integrated Care Board. Our five year Joint Forward Plan; 2023. https://blackcountry.icb.nhs.uk/about-us/our-priorities/our-5-year-joint-forward-plan
5. NHS Black Country Integrated Care Board. Know your risk and be aware of diabetes symptoms; 2023. https://blackcountry.icb.nhs.uk/news-and-events/latest-news/know-your-risk-diabetes
6. Sandwell Trends. Deprivation - Sandwell in a West Midlands Context; 2019. https://www.sandwelltrends.info/deprivation_west_midlands_context/#:~:text=Deprivation%20%2D%20Sandwell%20in%20a%20West,of%20a%20total%20of%20317
7. Sandwell Trends. Ethnic Group & Language; 2021. https://www.sandwelltrends.info/ethnicity-religion-country-of-birth/
8. Diabetes UK. Getting a free CGM, Flash Glucose Monitor (FreeStyle Libre) or insulin pump on the NHS – who should qualify? 2024. https://www.diabetes.org.uk/about-diabetes/looking-after-diabetes/technology/cgm-flash-pump-who-qualifies-on-nhs
9. Data on file. Abbott Diabetes Care
10. Pham TM, Carpenter JR, Morris TP, et al. Ethnic Differences in the Prevalence of Type 2 Diabetes Diagnoses in the UK: Cross-Sectional Analysis of the Health Improvement Network Primary Care Database; 2019. https://www.dovepress.com/ethnic-differences-in-the-prevalence-of-type-2-diabetes-diagnoses-in-t-peer-reviewed-fulltext-article-CLEP