The NHS medical care improvement programme, Getting It Right First Time (GIRFT), has published its national report on diabetes care within the NHS. The report, Diabetes GIRFT Programme National Specialty Report - November 2020, says that NHS services are failing people who have type 1 diabetes, hospital inpatients with diabetes, and those with diabetic footcare problems at risk of ulceration and amputation. The GIRFT report highlights the NHS Long Term Plan’s stated commitment to diabetic patients: “For those who periodically need secondary care support we will ensure that all hospitals in future provide access to multidisciplinary footcare teams and diabetes inpatient specialist nursing teams to improve recovery and to reduce lengths of stay and future readmission rates.” Despite this promise of support for diabetic patients, GIRFT found that failings in care provision for those at highest risk of footcare problems leading to ‘preventable ulceration and ultimately, needless amputation’ is costing the NHS up to £1 billion in resources and care costs per year. Up to 20 % of hospital inpatients have diabetes, but many are suffering serious harm from insulin errors or lack of specialist diabetic care. Meanwhile, the NHS’s ability to learn from its mistakes is hampered because the total cost of compensation claims arising from negligent diabetes care is unknown, as NHS Resolution does not track diabetes as a claims category. The GIRFT report says urgent action must be taken by the NHS to avoid harm to patients with diabetes, save money and resources and improve patient care. What is diabetes? Diabetes is a common but dangerous condition in which the body’s blood sugar or glucose level becomes too high. Type 1 diabetes occurs when the body cannot produce the insulin it needs to control the blood sugar. Type 1 diabetes is a lifelong, irreversible condition which is often diagnosed in childhood. People with type 1 diabetes must take insulin for life. Around 8% of people with diabetes have type 1. Type 2 diabetes occurs when the body becomes resistant to insulin, resulting in the body not being able to use the insulin that it produces. Type 2 diabetes can often be managed by lifestyle changes including diet and exercise, although for some, medication is needed. Around 90% of people with diabetes have type 2. 2% of people have other types of diabetes, often as a result of other conditions like pancreatic disease or cystic fibrosis. GIRFT’s report describes diabetes as one of the biggest health issues facing the UK. An estimated 4.7 million people have diabetes in the UK. Diagnoses of diabetes have more than doubled over 20 years and the numbers are increasing. 10% of the entire NHS budget is spent on diabetes and its complications, including amputations arising from foot problems, kidney failure, sight loss, heart attacks and strokes, and death. In the UK, every week there are 140-170 amputations, 680 strokes and 530 heart attacks, all related to diabetes. GIRFT says many of these are avoidable. What does GIRFT’s report say about NHS care of diabetes? The report focussed on three key areas of diabetes care that need most attention and where significant improvements can be made. These were type 1 diabetes, inpatient care and diabetic footcare. Key findings from GIRFT’s investigation into NHS diabetes care included: Type 1 diabetes People with type 1 diabetes don’t always get the support they need to manage their diabetes and reduce the risk of serious complications. Fewer than 30% of people with type 1 diabetes meet the target average blood sugar level (HbA1c test) needed to reduce their risk of complications, according to the National Diabetes Audit. In fact, research has shown that the UK has the worst average blood sugar level outcomes compared with 12 other European countries and the USA. Many NHS trusts and CCGs did not know how many type 1 patients in their area were receiving specialist care. Young people who are moving from paediatric to young adult and adult services are not receiving support. As with other serious conditions, support for young adults with type 1 diabetes is vital whilst they leave home, start work or university, to reduce the risk of avoidable harm. Improvements in technology and patient education were recommended to support those with type 1 diabetes. Inpatient care Up to 20% of hospital inpatients have diabetes, of which over 90% are admitted for conditions unrelated to their diabetes, such as pneumonia, fractures and operations. The staff who treat them are from differing surgical and medical disciplines and may not be experienced in diabetes care. Inpatients with diabetes have higher infection rates, longer stays and higher mortality. GIRFT emphasised the importance of dedicated multi-disciplinary diabetes inpatient teams (MDiTs) in hospitals to champion diabetes inpatient care. These MDiTs can ensure that knowledgeable help is provided for patients with diabetes on admission, with specialist referral, in coordinating with outpatient or community services and providing psychological support. They can also raise awareness of how to prevent harm to inpatients with diabetes, whilst supporting and educating other healthcare professionals to provide better care. However, they found that: A quarter of hospitals don’t have a single diabetes inpatient specialist nurse, and this may lead to more frequent hospital acquired harm. 28% of inpatients who needed to see a diabetes specialist during their stay didn’t because none was available. NHS trusts should provide a seven-day service, where at least one member of the MDiT team is available on weekend days, so that urgent cases are seen by a diabetes specialist within hours rather than days. Many hospitals do not have a system in place to identify people with diabetes on admission. Staff often only become aware that a patient has diabetes when a problem occurs. Up to 40% of inpatients with diabetes suffer insulin errors. In 2017, around 9,600 inpatients needed rescue treatment from coma after a hypoglycaemic (hypo) attack, and 2,200 suffered from diabetic ketoacidosis (DKA) from undertreatment with insulin. DKA is a life-threatening condition arising from severe lack of insulin which can lead to diabetic coma and death if not treated quickly. Many NHS trusts have no structured programme to train staff on the safe use of insulin. GIRFT recommends that measures to prevent insulin errors, including training, should be provided for every healthcare professional who dispenses, prescribes and/or administers insulin, including a competency assessment. GIRFT emphasised that understanding and managing a patient’s diabetes is critical when they are having surgery, to avoid hypoglycaemia or hyperglycaemia and post-operative surgical complications including delayed wound healing and infection. Trusts should have clear, audited perioperative (related to surgery) pathways for people with diabetes. People with diabetes who have surgery experience increased length of stay, higher readmission rates and higher morbidity than people without diabetes. Many people who usually manage their own diabetes medication, blood glucose levels and carbohydrate intake, have their insulin and devices taken from them and locked away when they go into hospital. This can be stressful and dangerous if the staff who control the insulin don’t know how to use it safely. GIRFT recommends that trusts have a self-management policy, which supports inpatients to self-manage their diabetes, if safe to do so. Diabetic footcare 20% of people with diabetes have a higher risk of damage to nerves and blood vessels caused by long term high blood sugar levels. If untreated, minor injuries can lead to ulcers and amputation. Around 10% of people with diabetes will have a diabetic foot ulcer at some point in their lives. People with diabetes are 20 times more likely to have an amputation. Amputation and ulcers increase mortality rates. 50% of people die within five years of a diabetic foot ulcer. Up to 70% of people die within five years of an amputation and 50% of those who have a major amputation die within two years. GIRFT believe that many foot ulcers and amputations could be prevented with proper access for diabetic patients with footcare problems to multi-disciplinary footcare services (MDFS). 80% of the UK’s 140 leg, foot and toe amputations per week follow ulceration, and should be preventable. NICE Guideline (NG19) states that everyone with diabetes should have an annual foot examination to check and advise them of their risk of foot ulceration and tell them what to do if they develop a foot wound. People with increased risk should be referred to a community footcare protection service (FPS). Those at high risk or who already have an ulcer should be referred to the MDFS. GIRFT found that: Despite growing evidence that provision of specialist footcare services for people with diabetes dramatically reduces ulceration and amputation, many NHS organisations are not doing enough to improve. Community based staff should be trained to carry out foot screening examinations, but this doesn’t happen in many areas, and most patients are not told their risk or what action to take if they develop a foot lesion. Many hospitals still do not have a fully-established MDFS, and in many areas there is no FPS. GIRFT recommend that all trusts should have a dedicated MDFS, which should be well integrated with the FPS. Smaller hospitals often experience difficulty in obtaining an urgent vascular opinion for patients at risk of diabetic foot ulceration and amputation. GIRFT recommends that everyone with a diabetic footcare emergency needing hospital admission should be assessed the same day by the MDFS. If vascular impairment is identified, they should have access to a vascular opinion the same day. Boyes Turner’s medical negligence lawyers regularly help clients recover compensation for severe injury caused by negligent treatment of diabetes and its complications. Boyes Turner welcomes GIRFT’s call for urgent action from the NHS to improve care of diabetes and reduce avoidable harm. If you have suffered amputation or other severe disability as a result of negligent care of diabetes and would like to find out more about making a claim, contact us by email at mednegclaims@boyesturner.com or call us free on 0800 124 4845.
