Agenda item

To receive a presentation about out of hospital care for adults with diabetes in North Central London.

Prior to the presentation of the report on this issue, Jan Pollock introduced a deputation on the issue of Diabetes Services. She informed the Committee that she was a long-term user of insulin as a Type-1 diabetic. She described experiencing a severe hypoglycaemic attack while under the care of the Royal Free hospital in the 1990s for an operation because blood sugar tests were not carried out. She asked for further details about the current treatment of diabetic people when using NHS services. She also expressed concerns about the current shortage of certain drugs used by diabetic people as they were now being used by non-diabetic people for the purposes of weight loss.

Amy Bowen, Director of System Improvement at NCL ICB, introduced the report of diabetes services informing the Committee that, as a system, a commitment had been made to focus on prevention, early intervention and proactive care. This was challenging in a system with high levels of demand and real pressure on services but the aim was to intervene before a crisis occurred while improving equity of access to services. This required both a focus on the medical elements of the service but also addressing the wider determinants of health.

Referring to the slides, Amy Bowen highlighted progress on outcomes and recovery after the Covid-19 pandemic but acknowledged that there was further work required, including proactive preventative work with young people. She also noted that the comments from the deputation had demonstrated the importance of the individual’s role in managing their health and close collaboration with them as people with diabetes tended to be expert patients.

Amy Bowen then responded to questions from the Committee:

• Referring to page 57 of the agenda pack, Cllr White noted that 8 care processes were referred to but only 7 were listed. Amy Bowen agreed to clarify this in writing. (ACTION) Cllr White also queried why the proportion of diagnosed patients receiving all 8 care processes was relatively low. Amy Bowen acknowledged that the figures were low but explained that there was a new primary care model for long-term conditions based on outcomes and this included the proportion of diabetes patients receiving all 8 care processes and the 3 Treatment Targets referred to on page 59. Four of the five NCL Boroughs had chosen to focus on the 8 care processes as their key outcome for 2024/25.
• Cllr White noted that some diabetes patients were managed by their GPs rather than a diabetes specialist. Amy Bowen said that more specialised support for often needed for Type-1 diabetes patients due to the underlying mechanisms of the condition and complexity of management, so support tended to be provided by secondary care. However, most aspects of Type-2 diabetes could usually be effectively managed by primary care services.
• Asked by Cllr White about the long-term conditions referred to on page 62 and links with psychological services referred to on page 61, Amy Bowen said that these were metabolic diseases including cardiovascular disease, coronary heart disease, chronic kidney disease and high blood pressure as well as respiratory diseases such as asthma or chronic obstructive pulmonary disease. She acknowledged that mental health issues including depression were common comorbidities for people living with a long-term condition such as diabetes.
• Cllr White asked about the NHS availability of automated care including Continuous Glucose Monitoring (CGM) and insulin pumps and whether these could be combined. Amy Bowen said that a lot of work was ongoing nationally to invest in technological solutions to help patients manage their blood sugar levels, but that she was not in a position to provide specific details so would look into this further. (ACTION)
• Cllr Chakraborty requested clarification on what stage CGM was made available to diabetes patients. Amy Bowen explained that CGM could be particularly useful for patients who have blood pressure that fluctuates a lot or who have difficulties in keeping up with a treatment regime so the priority was in providing this to patients who would particularly benefit.
• Asked by Cllr Atolagbe about patient choice, Amy Bowen said that this was fundamental for people with long-term conditions and that there was no one-size-fits all solution. While the aim for a consistent set of outcomes there needed to be flexibility in the service to accommodate people’s individual preferences. The current primary care model was aiming to create more time and support to allow this to happen.
• Referring to the graphs on page 57, Cllr Cohen expressed concern that Barnet was the only Borough where the proportion of Type-2 patients receiving all 8 care processes had declined between 2019 and 2022/23. Amy Bowen confirmed that Barnet was one of the Boroughs that had prioritised this as a key outcome for 2024/25 but would respond in writing about the specific query. (ACTION) Cllr James noted that the figures were lower in Enfield than any of the other Boroughs. Amy Bowen commented that there had been a particular focus in Enfield on the 3 Treatment Targets as a key diabetes outcome which was reflected in the data on page 59. She added that there was always a need to track data such as this further to understand how it impacted on outcomes for different demographic groups.
• Asked by Cllr Atolagbe about Type-2 diabetes, Amy Bowen said that it was often linked to lifestyle related risk factors including obesity, alcohol use and lack of physical activity and was also closely linked to people’s wider determinants of health and economic security. A focus on addressing these issues was therefore as important as clinical care.
• Cllr Revah queried the reasons for the shortage of diabetes medication that had been raised through the deputation. Amy Bowen distinguished between injectable drugs for managing blood sugar such as insulin and a new class of drugs to support people with Type-2 diabetes who were finding it difficult to keep their blood sugar in a healthy range. A side effect of the latter was weight loss and so there was an increased interest in these drugs which had led to a global shortage and therefore a procurement problem for the NHS.
• Asked by Cllr Revah about variations in services across different boroughs, Amy Bowen said that details of how this was being addressed had been included in the report. She added that the single primary care model for NCL set out on page 64 aimed to drive out variation and improve outcomes and that similar work was ongoing for community services.
• Cllr Chakraborty noted from the report that there was a focus on both early intervention and population-level prevention. Amy Bowen clarified that primary prevention (population-level) was about preventing people from developing a condition in the first place whereas secondary prevention (early intervention) was about minimising the risk of a condition worsening by reaching people as far upstream as possible.

Cllr Clarke thanked Amy Bowen for her report and suggested that the Committee should continue to monitor progress on early intervention and population-level prevention. (ACTION)