Dr Phil Hammond, broadcaster and sessional GP in Bristol

Diabetes care in hospitals needs improving
 

Last week, I bought the Health and Social Care Bill. I tried reading it online for free,1 but it gave me a migraine, so I popped into the Parliament bookshop and shelled out for a hard copy—£19 for the 353-paged Bill and £13 for 234 pages of ‘explanatory notes’. By page 19, I’d given up the will to live. The Bill is an impossibly complex mix of regulations, substitutions, amendments, and impositions. Then there are the hundred amendments that have already been proposed by the Government post-publication. Andrew Lansley complains that people don’t understand his Bill and for once he’s absolutely right. I’ve yet to meet a GP who has digested it, cover to cover.

Some doctors delight in the minutiae of political reform, but I’m more interested in patients. The reforms have targeted chronic disease as the key area we need to improve on, and that doesn’t come much bigger than diabetes. So how are we doing? GPs have some idea of the quality of care we’re providing thanks to the quality and outcomes framework, but the National diabetes inpatient audit 2010 has raised alarms about the quality of hospital care.2

The audit of 93% of acute trusts in England on a single November weekday found that people with diabetes accounted for 15% of beds with a median age of 75 years; their median length of stay was 8 days, but only 9% had been admitted specifically for diabetes management. The majority (86.7%) had an emergency admission and nearly 40% of inpatients were insulin treated. And now the bad news:2

  • 37.1% of inpatients with diabetes experienced at least one medication error
  • 26.0% of charts had prescription errors and 20.0% had one or more medication management errors
  • Errors were more common with the use of insulin than with the use of oral hypoglycaemic agents
  • Patients with medication errors had twice the rate of severe hypoglycaemia (18.1% compared with 7.9%)
  • 27.5% of patients had their feet examined at any time during admission
  • 2.2% of patients developed a new foot complication during their hospital stay, but 49.6% of these had no input from the multidisciplinary footcare team.

So for all Labour’s billions there is still huge variation, substantial error, and sub-standard care in the inpatient management of patients with the most common, expensive chronic disease. Should GPs gloat or should we ponder our own imperfect practice? And, as the new commissioners of healthcare, should we be trying to improve standards of hospital diabetes care?

It helps, of course, to find a cause for this epidemic of variable care and it seems likely that a lack of expertise could be it. The audit found, rather alarmingly, that:2

  • 29.8% of sites had no inpatient dietetic provision for people with diabetes
  • 26.8% of sites had no inpatient diabetic podiatry service
  • few patients were under a diabetes consultant (9.0%) or on a diabetes ward (4.6%)
  • 69.4% of inpatients with diabetes had not been seen by a member of the diabetes team, including 46% who should have been referred to the team.

These alarming gaps in care are for the mother of all chronic diseases, so I would dread to think what level of expertise awaits patients with rarer diseases. Insulin requirements in sick people vary day by day, sometimes hour by hour, and they need expertise beyond the generalist nurse or the inexperienced junior doctor passing through on a shift. As the future commissioners of care (at the time of writing) we must ensure that specialist services give patients access to just that. There’s no point polishing up a single care pathway for diabetes when patients are arriving via 20 other care pathways. The NHS is about people: training them properly, recruiting them adequately, and giving them a humane environment in which to be humane. That’s what we should be commissioning.

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  1. Parliament. Health and Social Care Bill. Available at: www.publications.parliament.uk/pa/cm201011/cmbills/177/11177.i-vii.html (accessed 5 April 2011).
  2. NHS Diabetes. National diabetes inpatient audit 2010. NHS Diabetes, 2011. Available at: www.yhpho.org.uk/resource/item.aspx?RID=106455 G