Integrating care systems and people living with diabetes – A new hope

From the outside looking in it’s easy to believe the NHS to be a single organisation. Of course it is anything but, with multiple competing (now collaborating) large providers (Trusts), re-aligned contractors (PCNs), NHSE & I, AHSNs, GP Federations, quasi-external regulatory bodies, estates management (NHS Property services and multiple other private landlords), Royal Colleges, professional regulators and the Department of Health and Social care, all having a part to play.

In his 1994 book Fortress NHS, David Seedhouse describes the foundation of our NHS as “little more than a medical service dressed up in fine language”. Rudolf Klein noted the complex politics of how our system was set up and the key role given to the medical profession, particularly hospitals.

It could be argued that this foundation has continued to affect our present. It is our choice whether it continues to affect our future and the populations we serve.

It is well known we spend approximately 10 per cent of our NHS budget on diabetes, with the bulk of this on inpatient stays. As we move from a system of competing interests to true collaboration with a single stated intent, we must ensure that resources are further prioritised to prevent complications of diabetes (and indeed diabetes itself). These are tremendously costly to the individual, their family and to society. The latter is, in my view, underrepresented in our current thinking on the value of diabetes management. For example, Steen Carlsson and colleagues from Sweden showed the effects of microvascular and macrovascular complications on time lost from work as well as hospital care. In their study, neuropathy had high costs of work absence with very low costs of hospital-based care: a stroke has four times the cost of absence from work than hospital costs. Social care costs are likely to add even more to this.

We must ensure we measure what is important to people living with diabetes and the wider society; we must define quality in this context and enact policy, pathways and guidelines accordingly. “If you can’t (or don’t) measure it, you can’t improve it.”

What is the role of healthcare professionals in all of this?

It has been said that in the genesis of type 2 diabetes (and likely outcomes from developing it) there is a much greater relationship to health behaviours (30 per cent) and even more so to the social determinants of health (50 per cent) with clinical care being perhaps directly only responsible for 20 per cent. We can, and will, continue to strive to affect positively the latter in our professional practice but by collaborating across the healthcare divide the effect of our efforts will be greatly magnified: that is leadership.

This alone will not be enough, with expected rises in prevalence of diabetes (suggested as up to one in three adults worldwide by 2050). We simply cannot sit Canute-like and expect by the power of our oratory to turn back the tide. If we are to maximally affect the future we must, with a naivety of purpose, reach far beyond health to forge enduring partnerships with social care, local government, the voluntary sector, business and most importantly the populations we all serve. 

As an eternal optimist I feel we have a tremendous opportunity within the structure of Integrated Care Systems to work with others to create a culture where the promotion of proactive prevention of illness becomes the norm and where we share responsibility for risks, aspirations, challenges, and successes.

See you at the DPC!