Diabetes developments – by Simon O’Neill

Simon O'NeillIn a regular blog series, Simon O’Neill, Diabetes UK’s Director of Health Intelligence and Professional Liaison, rounds up the latest diabetes news.

This week Simon updates on pharmacists, superbugs, epidemics, prescriptions, activity and psychological support.

The pharmacist will see you now…

NHS England is continuing to build on its programme of pharmacists working alongside GPs and practice nurses within primary care clinics. In July they invited applications from a further 520 clinical pharmacists to cover 1,791 GP sites, potentially benefitting an additional 18.5 million patients.

This follows the success of the original pilot schemes which have seen 494 clinical pharmacists working across about 650 GP practices. The plan is for all GP practices to have access to these roles (1,500 in total) by 2018/19.

Initially, clinical pharmacists were recruited by GP practices in areas of greatest need and employed by the practice to provide patient facing, clinical pharmacy services. However, in practice, employment models and the roles and responsibilities vary. Clinical pharmacists are helping practices by alleviating some GP workload pressures, working directly with patients and providing long term opportunities to develop the wider primary care workforce.

Their main role is to help patients manage their medication effectively, including through medicines reviews and prescription management. This improves the quality of care and ensures patient safety as well as freeing up time for GPs to focus on patients with the most complex health issues. However, in addition clinical pharmacists are also triaging and managing common ailments, responding to acute medicine requests and managing long-term conditions (often in conjunction with the practice nurse), as well as undertaking audit and providing education to other staff.

Many who have already taken on this new clinical role find it much more rewarding than being a community pharmacist, where the main role is often dispensing medicines. They feel that this better uses their skills and training and is complementary to the other members of the primary care team.

Microbial resistance

The issue of microbial resistance, where superbugs, such as MRSA, don’t respond to treatment with antimicrobial medicines, has been around for some time. However, there is growing concern that much more needs to be done before we find ourselves without treatment options.

The effectiveness of moulds were written about in Ancient Egypt, where mouldy bread was sometimes applied to wounds to aid healing. But it wasn’t until 1928 that Alexander Fleming was able to demonstrate the antimicrobial properties of penicillin in humans. Until that discovery many microbial infections were untreatable. Even a minor cut could lead to blood poisoning and death and all doctors could do was wait and hope that the patient would pull through.

However, in the nearly 90 years since the first antibiotic was used, we are finding that more and more infections are developing resistance to antimicrobails and we are in danger of moving back to a position where treatment options are limited.

Infections by multidrug-resistant bacteria are estimated to cause 25,000 deaths in the EU every year. Antimicrobial resistance also places a tremendous burden on healthcare systems and society, with an annual cost due to healthcare expenditure and productivity losses estimated at approximately €1.5 billion in the EU alone.

Resistance to antimicrobial medicines can occur naturally when microorganisms replicate themselves badly or when resistant traits are exchanged between them. However, the use and misuse of antimicrobials can accelerate the emergence of resistant strains. Resistance can also spread from animals to humans through the food chain or direct contact and the use of antibiotics in farm animals has probably exacerbated the situation. Historically we have developed new medicines to combat this naturally acquired resistance but there is now a lack of new antimicrobial drugs entering the market.

As a result of this concern, the European Medicines Agency, and others are trying to reduce the unnecessary use of antibiotics in both animals and humans as well as supporting the development of new medicines. One interesting approach is the study of the therapeutic potential of bacteriophages, which are naturally occurring viruses that kill bacteria. Since their mechanism is completely different to that of antibiotics, bacteriophages could be effective against bacteria that have become resistant to antibiotics.

One developing area for many hospitals is Antibiotic Stewardship Programmes, which have been shown to reduce costs and antibiotic use in hospitals. A recent study has been reviewing the evidence to see if such programmes have also had an effect on the incidence of antibiotic resistant bacteria. They have found that implementing such programmes is associated with a 51% reduction in the incidence of multidrug-resistant Gram-negative bacteria, a 48% reduction in extended-spectrum beta-lactamase-producing Gram-negative bacteria (such as Klebsiella and Pseudomonas), a 37% reduction in MRSA, and a 32% reduction in C. difficile infections in hospital inpatients. The reductions were particularly significant in haematology-oncology departments (59% reduction), intensive care units (23%) and medical departments (22%).

A very different approach has been taken with the development of a free educational app aimed at younger children. Dr Bug: Microbe Mayhem teaches children about viruses, bacteria and the use of antibiotics. The game encourages children to use the correct treatment for fighting infections, teaching them than antibiotics kill good bacteria as well as bad; that they don’t work on viruses so you need to boost your own immune system by eating healthily; and that sometimes bugs become resistant. The app is designed to stimulate conversations within families about healthcare choices in an enjoyable way as well as to raise the issue of overuse of antibiotics.

An African epidemic

For many years Sub- Saharan Africa has had very little recorded diabetes. With a lack of insulin for those with Type 1 diabetes (T1D), many probably died before even being diagnosed. And with poverty and famine, the risks for T2D were low. But a new report, published in July, shows that the area is now seeing a rapidly growing diabetes epidemic that could have devastating health and economic consequences.

The Lancet Diabetes & Endocrinology Commission is a multidisciplinary group of more than 70 clinicians, experts in public health and health systems, economists, and social scientists. They worked for three years on the report, analyzing health data from more than 39,000 people from 12 countries, and data on the quality and effectiveness of 6,096 healthcare providers from four countries.

After decades of focusing on infectious diseases such as HIV, tuberculosis, and malaria, health systems are largely unprepared for dealing with the growing burden of diabetes which has now reached almost 22% in the adult population and as high as 30% in men and women aged 55-65 years.

As in other countries, this growth is linked to the transition from lower- to higher-income; a growing and aging population; changes in lifestyle and eating habits; urbanization and changing work practices. Unsurprisingly the greatest growth has been in T2D. Sadly it is estimated that only half the people with diabetes have been diagnosed and, of those, only 1 in 10 is receiving any treatment. This means that there is likely to also be a huge increase in other illnesses such as heart disease, stroke, and kidney failure.

It’s estimated that, if nothing is done to address the problem, the overall cost of diabetes in the region could nearly triple to more than $59 billion by 2030, which they can ill afford.

The Commission has called for a concerted effort from communities, national governments, and international agencies to bring diabetes in sub-Saharan Africa under control. They have also called for more research to better understand the nature and magnitude of diabetes prevalence in each country in the region; financial resources from nations and international partners; training for community-based health workers in diabetes prevention and control and; the use of new technologies to aid in screening, diagnosis, monitoring, and treatment.

Prescription exemption

Many people will remember the fiasco that occurred a few years ago when the NHS Business Services Authority began issuing fines to people with diabetes in England who were claiming free prescriptions without a valid prescription exemption certificate. Diabetes UK lobbied hard at the time for these fines to be reversed and for no further fines to be issued without first informing people of the need for such a certificate and giving them time to apply for one.

However, figures from the BSA, issued in July, show that the number of fines has doubled between 2015/16 and 2016/17 with nearly a million fines being issued across all medically exempt groups, not just those with diabetes. Apparently the BSA makes random checks when they think that a claim for a free prescription has been made incorrectly. However, for people with diabetes, you would think that it would be easy to check if the person should be exempt simply by checking if the prescription is for diabetes related medication.

This is a timely prompt that we need to keep reminding people in England, with medically treated diabetes, that they need not only to get an exemption certificate but also to ensure that it is in date and still valid. Currently exemption certificates are only valid for 5 years, even if you have a lifelong, incurable condition

These boots are made for walking

Researchers from Stanford University published a study in July that used smartphone technology and data to track the physical activity habits of 717,000 men and women from 111 countries over a 95-day period. These people had allowed data from their phones to be shared anonymously.

The study is 1,000 times larger than any previous study on human movement and, by tracking data from phones, rather than asking people to self-report on their activity, is likely to give a truer picture of what is actually happening in real time. Of course, phones only track movement data when the phone is being carried, but in most cases people tended to have their phones with them for the majority of the day.

The team analyzed individuals’ step records along with data on age, gender, height and weight status. They found that, on average, people were only walking about 5,000 steps a day – half of the recommended level of activity. Interestingly they found that in countries with low obesity rates, people walked a similar amount every day, but in countries where people’s pattern of walking was more erratic, there were high obesity levels. Countries also demonstrate ‘activity inequality’ where different groups of people are either regularly active or not. The greater the variation between these groups, the greater the inequality which is a strong predictor of obesity and poorer health outcomes.

The study suggested that the built environment had a great impact on levels of walking. Overall women were the least active, but this may be influenced by cultural differences, where women may have less freedom to move around independently. In more walkable cities, activity was greater throughout the day and throughout the week, regardless of age, gender or BMI with the greatest increases in activity found for females. The findings have implications for global public health policy and urban planning.

It also highlights just how timely our Million Steps challenge is, encouraging people to walk more than 10,000 steps a day for three months!

Psychological support

Many people with diabetes state that they would like better access to psychological support, but often this is lacking in diabetes services. One programme which should be more widely available is the NHS Improving Access to Psychological Therapies (IAPT) service. This normally provides short term (4 sessions) Cognitive Behavioural Therapy either individually or to groups. CBT is a talking therapy that can help people manage their problems by changing the way they think and behave. It is most commonly used to treat anxiety and depression, but can be useful for other mental and physical health problems.

900,000 adults access IAPT sessions every year, but demand still outstrips capacity. Therefore NHS England has announced that it is working with NICE to support a new digitally enabled therapy assessment programme, where up to 14 digital therapy products will be assessed for use within the IAPT service by 2020.

Digitally enabled therapy is psychological therapy that is provided online or through mobile applications, with the support of a therapist. There is evidence to show that these therapies can achieve comparable outcomes to face-to-face therapy, when the same therapy content is delivered in an online format. Providing this online obviously allows the learning to be achieved through patient self-study, at a time that suits them. This is then reinforced and supported by a suitably trained therapist. Many people have indicated that they would prefer to access therapy in this way.

The aim of this programme is to find good quality, evidence-based digital therapy packages for use in IAPT services. There will be an application process and those programmes which are felt to have met a certain standard will then be trialed and evaluated within IAPT services for up to two years. The evaluation will include user and therapists’ feedback, as well as cost effectiveness and performance. After this, reports on each of the different programmes will be made available to allow services to choose the tools which they think will best meet local needs.

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