28 - Applying international best practice in diabetes care

Whilst the UK has already made great steps forward in the management, treatment and care of diabetes, there is always much to learn from the successes of other countries to further improve services.

In my career at Roche, I have been fortunate enough to spend five years working in Latin America, in addition to many years working across Europe. This time spent working internationally, has helped me understand the power of sharing knowledge and learning from one another, from first-hand experience.

Recently, we initiated a project to uncover variations in the approach to diabetes management across the globe. We collated examples of international best practice in diabetes care and reflected upon what the lessons may be for the UK.

The evidence was brought together into three focused themes; access to technology, improving self-management in diabetes, and personalisation of type 2 diabetes management.

From several country examples of international best practice in diabetes care we discovered some key learnings for the UK linked to these three themes. It is my hope that these results and examples will stimulate debate and action, which may ultimately improve the outcomes and experiences for people living with diabetes in the UK.

Digital solutions have the potential to improve outcomes for people living with diabetes in the UK, and are already delivering a great deal of benefits in some settings, across various parts of the NHS. However, there is currently no requirement on individual commissioners to fund approved and proven solutions.

In the Netherlands, where 1.3 million people are living with diabetes, a ‘digital diabetes clinic’ was set up in collaboration between hospitals and industry. The clinic was established for people with diabetes in need of support, changing current care pathways to better suit the individual patient.

Clinic attendees were offered coaching and blood glucose monitoring apps. The project was able to achieve increased treatment adherence and improved outcomes for people living with diabetes. It also allowed easier monitoring of outcomes by clinicians, from a distance.

There is untapped potential in the NHS to integrate individualised digital diabetes solutions into existing care pathways, or to change care pathways to build digital care models around people’s individual needs. Doing so would allow people with diabetes to have more seamless and guaranteed support without having to engage with various healthcare professionals and organisations about their care. Evidence from the Netherlands also suggests it could improve the self-management of their diabetes.
If these health apps and digital solutions were to be delivered at large scale and better integrated into pathways it would enable provision of consistent and streamlined care. However, in order to achieve this, reimbursement pathways for digital apps and solutions need to be put in place to encourage the use of proven digital solutions and enable effective monitoring at all levels.

With appropriate reimbursement pathways and by drawing on inspiration from other countries, we could better integrate digital solutions into existing care pathways and provide people with a consistent offer across the country.

Each person with type 2 diabetes should be supported to manage their condition at every stage of the diabetes journey through enabling personalised management.

In Panama, coaching was used as part of a large-scale integrated diabetes management intervention. The intervention programme ran from 2014 to 2018 and involved 35,000 people with diabetes, of which 95% had type 2 diabetes. Health coaches across Panama were on hand to give guidance on lifestyles issues, nutrition and exercise.

A desktop-based diabetes management system was used as a data registry to record the outcomes of the intervention. It showed that 81% of patients experienced a positive clinical impact from the programme, of whom two-thirds saw a reduction on HbA1c levels. There was also a predicted 6% reduction in both deaths and complications associated with diabetes, and it was estimated that if the programme continued to be implemented, $21 million in direct costs could have been saved over a period of ten years.

A separate coaching intervention in Poland resulted in 67% of participants reporting feeling more motivated when it came to managing their diabetes. Eighty-five percent of patients involved felt that digital coaching gave them a better sense of security, while 82% said that the coaching increased their quality of life.

The examples from Panama and Poland demonstrate how personalised management programmes can better support people to monitor their diabetes and feel confident in managing their condition. By delivering a large-scale integrated Personalised Diabetes Management programme in the UK, the potential impact on both health and economic outcomes is vast. Such programmes can enhance patients’ ability to self-manage their condition through the provision of blood glucose monitoring technology, structured education and lifestyle guidance.

Unfortunately, tools to support the self-management of people living with diabetes in the UK are not as well established but are being delivered in some parts of the NHS. By scaling up such digital interventions we can support more people with diabetes to better self-manage their condition.

Because of the complexity and variable nature of type 2 diabetes, not everyone with the condition always has appropriate, personalised care management plans in place that are tailored to their particular needs.
In the Netherlands, research has identified that there is a need to personalise diabetes management for people with type 2 diabetes but that this is not always carried out on diagnosis. In order to address this, a number of initiatives were undertaken by pharmacists in order to help distinguish between different subtypes of type 2 diabetes and personalise the care available to them.

This included a two-hour survey, asking about their wider environment, behaviour, thoughts and feelings, a discussion with a dietician about their eating and drinking habits in order to support personalised goal setting, and a consultation with a pharmacist about their medication to ensure people are put on appropriate medication for their needs.
These interventions resulted in people with type 2 diabetes being better-screened, and given tailored treatment appropriate to their lifestyle and particular medical needs. They were able to achieve a safe reduction in medication, and many lost weight within the first six months. People were also able to maintain their blood glucose levels with lower insulin requirements, indicating their insulin sensitivity had improved.

These results show us that improved, multidisciplinary personalisation of diabetes management in primary care has the potential to improve outcomes for people living with type 2 diabetes, and help provide tailored treatment and support to them.

It also shows us that community pharmacists can have a crucial role to play in ensuring people with type 2 diabetes receive tailored support.

The evidence from case studies builds a picture of integrating and personalising diabetes management. Diabetes needs to be addressed with an integrated, collaborative and personalised approach in order to cover all the different angles of this complex condition.

This integrated approach cannot be achieved without partnership and collaboration, and pharma companies must co-create with patients and ensure that systems work for them.

Roche Diabetes Care was delighted to recently be awarded Silver standard in the Patient Partnership Index in recognition of progress in this area. There will be a heavier focus from us on co-creation over the next 12 months in the hope of achieving Gold in 2021.

Only by working together can we bring true relief to people with diabetes and create sustainable health structures to deliver the best possible care