Helen Lee, Prevention Team manager discusses inequalities in the provision of eye health services and how to better support self-management of diabetes.
Diabetic eye disease is still one of the leading causes of sight loss amongst people of working age. Between April 2012 and March 2013, over 1,500 people experienced significant irreversible sight loss and were certified as blind and partially sighted because of diabetes. Yet with the right support and treatment sight loss could have been prevented for many of these people.
Currently 3.5 million people are diagnosed with diabetes in the UK and it’s estimated a further 400,000 are living undiagnosed. Here in the UK we have a national diabetic eye screening program where people are invited annually for screening to detect early signs of diabetic eye disease. It's estimated this saves the sight of 400 people a year through early detection and treatment.
At RNIB, with funding from the Department of Health's Health & Social Care Volunteer Fund, we have been working over a number of years to improve access to services and the support that people receive to manage diabetes, because while there are good services, people are also missing out. In the 1970s a GP in South Wales identified that people experiencing socio-economic deprivation, with the greatest health need, tended to have the poorest access to good health services. This effect has become known as the 'Tudor Hart inverse care law’. The effect is far reaching. In England a person living in socio-economic deprivation will on average die eight years earlier than those living in the most affluent socio-economic circumstances. This person will on average have also lived for more years with significant illness and disability compared to their more affluent neighbours.
This inequality also exists in eye health. People living in poverty experience higher levels of sight loss and are less likely to access optometry services and diabetic eye screening. When they do reach secondary care hospital services their eye disease is on average at a more advanced stage compared to more affluent people.
Is this inevitable? Not at all, changes can be made to health services and support can be put in place to ensure people have fair and equal access based on need, in line with the founding principles of the NHS. We are working with communities and health services in areas of Leeds, Liverpool & Manchester where there are high levels of deprivation, to improve the support people receive to manage diabetes and access eye care services.
In some of the areas we are working in, peoples’ risk of eye disease is compounded by their ethnicity. People from South Asian and black African and Caribbean communities are more at risk of developing diabetes and diabetic eye disease. People of all ethnicities who have diabetes are also more at risk of cataracts and glaucoma. Our work is looking to identify effective ways of improving services and community support, mobilising volunteers to improve eye health and prevent avoidable sight loss.
Diabetes is a complex condition for people to manage. It can affect almost every aspect of a person's life. Improving self management is critical to helping people prevent complications such as sight loss from developing. We have been working to test relatively inexpensive interventions that can be rolled out to communities complementing initiatives like the diabetes year of care.
In Bradford we worked with patients and health services to develop a folder which people with diabetes can use as an organiser, to keep a record of appointments, targets around HbA1c, cholesterol and blood pressure. But the most important aspect of the folder is the way it can be used to facilitate a coaching conversation between the health professional and patient. There are prompts to encourage people with diabetes to set realistic lifestyle goals to help manage their condition. The challenge of diabetes can feel overwhelming to health professionals as well as those living with the condition. So, funded by Bradford clinical commissioning groups, we have developed a range of training tools to support professionals to adopt a more patient focused approach using motivational interviewing. These are freely available from RNIB. Email [email protected] for more information.
Managing a complex health condition while struggling with the reality of living in poverty is a huge challenge. Individuals often need to make difficult choices: to prioritise their appointment at the opticians or their children's; to take an extra shift at work to pay essential bills or take time off to attend diabetic eye screening. To effectively prevent sight loss due to conditions like diabetes a whole community approach is required. It is important that individuals are not alone but supported by health professionals, family members, friends and the wider community who have an understanding of these challenges.
If you are a GP, work in a practice or a primary care setting you can find information to enable you to better support your patients with sight loss through our GP Eye Health Network.
More diabetes related content:
To read more about the initiative in Bradford visit: www.rnib.org.uk/systems-approach-diabetes
Read a blog by Liz Wilkinson, president of the Opthalmology Section at the Royal Society of Medicine, about the importance of integrating retinal screening into diabetes care: www.rnib.org.uk/nb-online/integrating-diabetic-eye-care
RNIB has created three new films about diabetes. The first film is about the eye screening process, the second is about how diabetes can be managed if the patient has sight loss and the last film suggests ways people can adjust their diet to suit a healthier lifestyle: www.rnib.org.uk/nb-online/diabetes-film