Dr Dinesh Nagi, MBBS, PhD
Lond. Consultant in Diabetes and Endocrinology and Chairman, Association Of British Clinical Diabetologists (ABCD)
Coronavirus has impacted on clinical services for diabetes in ways we have not experienced before. Recovery and reshaping of services provides an excellent opportunity for us to innovate.
Impact on individuals with diabetes
- People who have diabetes are likely to be at risk of getting more severe disease.
- Emerging data has shown that high blood glucose in patients with COVID-19 predicts a poorer outcome, as does poor pre-existing metabolic control in those who develop COVID 19.
- Diabetic emergencies such as diabetic ketoacidosis (DKA) may present with atypical presentations which include heightened severity, associated kidney failure and need for higher insulin demands.
- Social distancing and the mobilisation of resources mean most routine appointments have been cancelled and there will a mountain of backlog of these to be dealt with.
- Several diabetes units and GP surgeries have reverted to virtual consultation which is necessary, and a welcome change, but cannot be used in all clinical scenarios to deal with diabetes.
- This crisis has provided an opportunity for us to innovate as never before, to improve clinical services and support those with diabetes in a much-improved way.
Impact on diabetes services
- To deal with this pandemic, a significant number of specialist medical and nursing staff have been seconded to acute general medical duties and in support of Covid wards. This has created a shortfall of workforce to deal with essential services, with the impact on specialist care for diabetes.
- The maintenance of the safe ongoing care of people with diabetes is likely to have been seriously compromised, with less people coming to hospital emergency departments for acute presentations, less access to investigations, and discontinuation of most initial face to face consultations.
- Standard out-patient clinics and regular day case investigations have been lost.
- As a consequence of this reduction in referrals to Diabetes departments raises concerns of important unmet clinical need. There are anecdotal reports of late presentations of people with newly diagnosed type 1 diabetes presenting late with ketoacidosis and associated harm.
- Trainee doctors in diabetes have been seconded solely to acute medical on call duties and have effectively lost access to specialist training given their current work plans. Their contribution and adaptation to service, however, is worthy of recognition by the NHS.
- Although, in many cases, diabetes MDT foot clinics and antenatal clinics have retained face to face clinical services. Many services have abandoned plasma glucose checks for gestational diabetes and/or are running these services virtually as well. Services have adapted to minimise face to face contact and guidelines for the investigation of gestational diabetes screening have abandoned the OGTT, in an attempt to minimise risk.
- People with diabetic foot disease are a high-risk cohort; yet referrals into foot MDT clinics have reached a nadir. Perhaps reflecting, in part a fear from those living with diabetes and, in part, reluctance for primary care teams to refer to hospital.
- A limited number of services have had access to technology and patient information to deliver these activities from home settings.
Innovation during adversity
The new way of delivering diabetes care in the NHS provides several opportunities to deal with issues we have never completely mastered. The lessons we’ve learnt for the NHS include:
- Planning ahead
- Give clear signals to those involved in planning of services
- Support innovation especially adoption of technology to deliver services but all diabetes specific technologies