The International Diabetes Federation (IDF) (2021) has announced that diabetes is ‘a significant global challenge to the health and wellbeing of individuals, families and countries’. The prediction of a 46% rise in the number of people with diabetes worldwide, which equates to 783 million people being diagnosed by 2045, is alarming. This is coupled with a widening gap between rich and poor communities in countries and continents where access to health care can be limited and expensive. South East Asia is facing a 69% rise, Europe a 13% rise and across Africa a 134% rise to 2045 (IDF, 2021), which consequently places great pressure on existing services and further widens gaps in limited diabetes care throughout many continents.
In the UK, more than 5 million people are living with diabetes (Diabetes UK, 2023a). This figure, however, does not include the 13.6 million people thought to be at risk of diabetes (Diabetes UK, 2023b). However around 50% of those could prevent their condition developing through the current diabetes prevention programmes available (Poupakis et al, 2023). The World Health Organization (WHO) (2023) has ranked the UK among the those countries in Europe with high numbers of overweight and obese adults, and 1 in 3 children in the European region are reported to be overweight or obese. It is worrying that NHS Digital (2021) has reported an increased incidence in type 2 diabetes in people under 40.
This exponential rise is concerning as it affects access to services, health care, screening, education and also prevention of diabetes-related complications. There are also many disparities emerging in prescribing practices across populations in the UK (Phillips, 2021). Inequalities are also evident, for example, with access to diabetes technologies among populations from ethnic minority backgrounds and socially deprived areas. This has now revealed a 6-year trend of widening inequalities across the UK, according to the National Paediatric Diabetes Audit (NPDA), 2021-2022 (Royal College of Paediatrics and Child Health (RCPCH), 2023). These examples do not accord with the ethos of national and international organisations such as the WHO (2013), The Health Foundation (Naik et al, 2020), the National Institute for Health and Care Excellence (NICE) (2016), the CORE20PLUS5 programme (NHS England, 2021) and in EuroHealthNet (2023).
Health inequalities and inequities
The term health inequities is described as ‘avoidable inequalities in health between groups of people within countries and between countries’ (WHO, 2013). Equity is sometimes used interchangeably with equality. However, equality is considered to exist when all individuals and groups of people are given equal treatment regardless of need or outcome. Equity refers to the absence of systematic, unfair, avoidable or remedial inequities in health between groups of people, whether these groups are defined socially, economically, geographically or demographically (WHO, 2013). Within human rights law, the use of the term ‘inequalities’ includes the underlying concept of social justice and proportional response to need as in the concept behind equity (WHO, 2013). Health outcomes differ between groups but health inequities are the differences in health outcomes and their risk factors between social groups that are socially produced, systematic in their distribution and are avoidable, unfair and unjust.
During and since the COVID-19 pandemic, the widening gap of health inequalities and health inequities, especially in diabetes care, has become increasingly apparent (Mishra et al, 2021). People with type 2 diabetes from Black and other ethnic minority groups experienced a disproportionately higher risk of COVID-19 and unfavourable outcomes with type 2 diabetes (Office for National Statistics (ONS), 2020). This finding has been reported across the world (McGrail et al, 2022).
People from ethnic minority groups can have weaker access to health care and inferior experiences of diabetes care and treatment (Stead et al, 2019; Seewoodhary, 2021), related to racial discrimination and ostracism (Public Health England, 2018). Ethnic inequalities are not unique to COVID-19 outcomes. Marginalised groups from different ethnic minority groups have higher rates and earlier onset of diabetes, more aggressive deterioration of diabetes, and less favourable survival outcomes (Williams, 2012; Goff, 2019). Empirical analyses show that ethnic differences in health persist even after modification for socio-economic status (Razai et al, 2021).
Consultation conversations
Promoting and enhancing consultation conversations to enable people to have a voice and for their beliefs and opinions to be heard and understood is vital (Odiase et al, 2020; Phillips et al, 2020). Individuals can fear health professionals, therefore creating a friendly and approachable calm consultation conversation can help individuals who may be feeling oppressed or scared to learn to trust and have confidence in their health professional (Phillips et al, 2020). Building an atmosphere of trust will encourage people to work with their diabetes health professionals to plan their care. This can enable people to gain confidence in living with diabetes and to gain knowledge and confidence in self-management of their diabetes (Phillips, 2019).
Some people with diabetes and with comorbidities and/or social complexities may not see their diabetes as a priority. This can interrupt their engagement with structured education or attending review appointments as they do not see it as important. The term ‘patient education’ can cause reduced engagement in some individuals because the terminology may indicate something they do not want to engage with for fear of failure (Ocloo et al, 2021). Landmark work regarding person-centredness and person-centred consultation conversations was published by Stewart (2001). She advised health professionals to ‘walk alongside’ each individual and to understand their individual priorities. This can enable a positive consultation conversation, with outcomes tailored to the individual's needs, helping to reduce their fears and promote engagement.
Ethnic differences
Community practitioners need to be active members of their local communities and listen to the voices of their populations, in order to respond and accord to local health needs and educational approaches. This has become evident since the COVID-19 pandemic highlighted a widening divide between those who experience inequities and those who do not, and also with the significant rise in the numbers of all age groups with both type 1 and type 2 diabetes (Messaaoui et al, 2021; Salmi et al, 2022; Xie and Al-Aly, 2022; McKeigue et al, 2023). The UK, for example, now has the highest prevalence of type 1 diabetes in children and young people across Europe (RCPCH, 2023).
Significant ethnic distinctions in the risk of long-term vascular outcomes among people with type 2 diabetes have been recognised across the UK and European populations (Goff, 2019; Mathur et al, 2020). The extent to which these inequalities originate from changeable aspects, such as use of healthcare services or the quality of diabetes care, remains unclear. Given that variations can accrue over time, it is vital to identify where along the care pathway differences for diverse populations from ethnic minority ancestries may arise. Although equity and inclusivity of health service provisions is a central principle in terms of clear statements and intensions about ‘improving lives’ and ‘everyone counts’, recent evidence has emphasised ethnic differences in access to health care, treatment provision and risk factor control (Burt et al, 2016; Goff, 2019; Phillips, 2021).
This has been further impacted by the disproportionate cost of insulin and the WHO (2021) has reported on the alarming state of global access to insulin and diabetes care. Access is governed by cost and pharmaceutical influence on pricing, which further reinforces inequalities and inequities. The WHO (2021) is working on universal access for insulin as a lifesaving drug.
Impact of diabetes
Type 2 diabetes is becoming a global pandemic, principally due to the increasing incidence of obesity (Hu et al, 2015; Xu et al, 2020; IDF, 2021). Type 2 diabetes is a health disparity that disproportionately impacts minority ethnic groups (Goff, 2019; Nagar et al, 2021). Asian and Black ethnic groups in the UK have approximately two to four times the prevalence of type 2 diabetes compared with White and other ethnic groups (Whicher et al, 2020). All new presentations of diabetes need to have type 1 diabetes ruled out as this autoimmune condition presents in all age groups and is often misdiagnosed or missed in middle age or overweight adults (Thomas et al, 2023). Lean type 2 diabetes (type 2 diabetes that occurs in people with a lean or normal bodyweight) is a particular phenomenon that occurs among South Asian populations (Salvatore et al, 2023) and can be mistaken for type 1 diabetes. Therefore knowledge of this presentation is important for community practitioners so they can be aware of this when caring for their local populations. Efforts to mitigate health disparities of this kind are both a social imperative and a pressing scientific challenge.
Socioeconomic deprivation
Nagar et al's (2021) study confirmed previously identified ethnic disparities in people with type 2 diabetes and found that socioeconomic deprivation is a significant risk factor for type 2 diabetes. They reported that type 2 diabetes is associated with interactions between ethnicity and socio-economic deprivation. Specifically, socio-economic deprivation is a comparatively increased risk factor for type 2 diabetes for individuals with South Asian and/or African ancestry, compared to those with European ancestry (Seewoodhary, 2021). Ethnic minority groups are more likely to face health challenges due to living in urban, deprived communities, often in overcrowded and damp accommodation and often employed in lower-paid jobs, many of which can carry significant health risks (Razai et al, 2021). This finding suggests that more ancestry-specific interventions need to be taken at the policy level to reduce these health disparities, thereby identifying and channelling resources to communities that are at highest risk. This echoes the recommendations of listening to local voices (Phillips, 2021).
Access to diabetes care
There is emerging evidence in the UK that ongoing disruption to routine care may be leading to excess mortality in people with diabetes (Diabetes UK, 2023a). It has been reported that every week across the UK diabetes leads to 184 amputations (Office for Health Improvement and Disparities, 2023a), 770 strokes, 590 myocardial infarctions and 2300 new cases of heart failure (Diabetes UK, 2023a). Additionally, there were 7000 excess deaths in England involving diabetes, which was 13% more than expected (Office for Health Improvement and Disparities, 2023b). A national survey conducted among Diabetes UK members (2023a) reported that a third of respondents found it difficult to make appointments for routine diabetes check-ups and, worryingly, people in the most deprived quintile were 50% more likely to have had no contact with their healthcare teams in over a year compared to those least deprived. This reflects the problem of inequalities and reduced access for those who need access the most. Additionally, the survey highlighted that, in areas of highest deprivation, respondents were more likely to have experienced difficulties in managing their diabetes (57%) as compared to those in the least deprived (45%) (Diabetes UK, 2023a).
People who miss or are late to attend their routine diabetes reviews face unfavourable outcomes, especially those relating to avoidable amputations (McQueenie et al, 2019; Robbie et al, 2022). Additionally, it has been well documented that major lower limb amputation results in early mortality in people with diabetes, especially in those individuals who are male, in their mid-60s with predominantly type 2 diabetes (Jupiter et al, 2016). Whereas 5-year mortality for foot ulceration is 30.5%, that for minor and major amputations is 46.2% and 56.6% respectively (Armstrong et al, 2020). Higher mortality rates are associated with social deprivation and geographical neighbourhood clusters in people with diabetes who have foot ulceration or lower extremity amputation (Hurst et al, 2020). In a study of European healthcare systems, delays in referral to specialist foot care teams were common (Manu et al, 2018). It was further recognised that there should be education for GPs, nurses and people with diabetes to raise awareness of the risk of foot ulceration and the need for prompt referral to specialist diabetes foot care services. NICE (2019) advocates that people with diabetes with acute diabetes-related foot problems should be referred within one working day to their local foot protection service, with triage within one further working day.
Access to GP services
Inequalities in access to GP services are a key policy concern given the role of GPs as gatekeepers to secondary care services. Geographic or area-level factors, including local deprivation and restricted supply of healthcare provision, are important elements of access. In considering how area-level deprivation relates to GP utilisation, two potentially opposing factors may be important. The supply of healthcare services tends to be lower in areas of higher deprivation. However, sub-optimal health status among individuals in deprived areas suggests there is greater need for accessible health care (Barlow et al, 2021). The patient's journey and ‘missed opportunities’ (Kwok et al, 2022) also require reflection and time to undertake regular root cause analyses, to see if improvements in each patient's journey and appropriate ‘lean thinking’ changes to primary care and specialist diabetes services could be made (Anderson et al, 2019). This could increase accessibility for local communities to reduce inequalities and promote inclusivity in diabetes care services.
Coupled with this is the growth of the use of digital technologies in health care across Europe during the pandemic. Although this increased accessibility during lockdowns, it also restricted access to information and education for those from deprived communities who face inequality in terms of accessibility, due to varied access to or competence in the use of digital interventions (Wong et al, 2022).
Strong working relationships between primary and secondary care diabetes services and enablement through the provision of individualised, person-centred diabetes education in accessible formats to meet local community needs is vital (Phillips, 2019). This needs community involvement in terms of timings, formats, need for interpreters or crèche facilities and also multilingual or recorded patient education about diabetes. This must also include meal examples that fit the local community and are not just representing western food groups or meal types. This all takes time and funding from integrated care boards and health professionals, but is vital in working in partnership with local communities. Hearing their local voices and responding to their needs is necessary to promote effective knowledge gain and facilitate self-management (Phillips, 2023).
Organisations across Europe have been established with the aim of working in partnership to understand how people experience care and to listen to local communities to learn how to establish joined-up care (National Voices, 2013). This will be a significant step forward for diabetes care across communities, where this has been the desired outcome for many years (Bain et al, 2021).
Access to dental services
The WHO resolution on oral health (Lamster, 2021) is seeking to increase access to dental services, which highlights vulnerable populations who face inequalities in accessing dental services often due to finances or accessibility. Diabetes is linked to periodontal ill health and cardiovascular disease (Herrera et al, 2023). People diagnosed with diabetes require regular dental reviews; however, this has become increasingly more difficult due to the unaffordability and privatisation of many dental services (Northridge et al, 2020). This is an important area for community diabetes nurses, who should ensure that each individual with diabetes they are working alongside is supported to access dental care.
Cultural competence
Reduced access to, and engagement with, diabetes care is a considerable concern for people from Black, Asian and other minority ethnic groups across the UK, despite health care being free at the point of delivery (Wilson et al, 2012; Bhurji et al, 2016; Goff et al, 2020). Diabetes care is a significant issue for Black British communities in particular, who are disproportionately burdened by type 2 diabetes (Goff et al, 2020). Tackling these health inequalities needs to be a healthcare priority. Health professionals are often sensitive to the issues of providing diabetes self-management education and support to Black African and Caribbean communities but lack confidence and often knowledge in this area (Goff et al, 2020, Zeh et al, 2012).
An institutional lack of resources and a focus on achieving incentivised targets often inhibits and prevents practitioners delivering person-centred and individualised care that is responsive to the needs of their local communities. Goff et al (2020) also reported that responsive care tends to be ‘target driven’ rather person-centred and individualised to local communities. Alongside this, a lack of cultural competence can also cause barriers in accessing effective person-centred diabetes care. Health professionals often require more education, training and resources to improve their cultural sensitivity, awareness and understanding and to enable them to feel more confident in supporting people from minority ethnic ancestries in developing diabetes self-management skills (Attridge et al, 2014).
Conclusion
Health professionals, services and managers need to have a broad perspective on local care and the provision of services to reflect the needs of people in their local communities and work to identify gaps and meet all care needs, but particularly those emerging across diabetes care. As the population ages and diabetes prevalence increases annually, health and social care services need to reflect this growing need and respond accordingly. Listening to and working with the local community can enable more targeted health and social care (Thorstensen-Woll et al, 2021) and the identification of gaps in services. Person-centred education development and planning need to accord with the growing healthcare needs and complexities diabetes can create across communities. Enabling joined-up approaches, as highlighted by Bain et al (2021), can close gaps in care and generate better patient experiences in both primary and secondary diabetes care. Such care can be enhanced by educated health professionals who have regular access to essential updates in diabetes care, which underpins excellence in inclusive diabetes care delivery.
KEY POINTS
- Inequalities need to be recognised in diabetes care provision
- Enhancing each individual's voice within their consultation conversations can promote inclusion and reduce inequalities
- Gaps in diabetes care services have widened since the lockdowns
- Local voices are essential in reshaping services to local communities
- Recognition and acknowledgement of inequalities helps to resolve these issues for people with diabetes
CPD reflective questions
- Think about your last consultation with someone with diabetes. What were your and their priorities?
- Have you ever not understood where a person with diabetes appears to be in their decision making? What steps did you take to understand and help the person?
- What steps to gain understanding about health beliefs and cultural awareness have you undertaken in your role?