Written evidence submitted by Diabetes UK (RTR0079)

1. Introduction

1.1.   Diabetes is one of the fastest growing and potentially most devastating health crises of our time. Over 4.9 million people are currently living with diabetes in the UK. Diabetes UK is committed to creating a world where diabetes can do no harm. Our aim is to fund crucial health research, improve healthcare and treatment, and prevent yet more people developing this potentially life-threatening condition

1.2.   Diabetes UK is the UK’s leading funder of medical research for diabetes, and conducts policy and campaigns work to improve the lives and health outcomes for people living with or at risk of diabetes.

1.3.   Diabetes UK’s submission focuses on the need to ensure there are enough condition specific specialists within the NHS, and also that all healthcare professionals are sufficiently trained in diabetes.

2. What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?

What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?

2.1.   The pandemic has given rise to innovation and changed the way that care is delivered across the NHS, and in diabetes care and prevention this has included the rapid rollout of remote consultations and digital pathways. The urgent need to reduce face to face consultations during the pandemic has permanently changed the way the NHS works, but local systems must take care that plans for the future reflect the needs of their patients and communities.

2.2.   It is essential that patients and healthcare professionals are involved in planning new models of care to ensure they meet local needs. New ways to deliver care will affect plans for recruitment, training and retention, and they must take into account the changing needs of the UK population and regional differences. The Government, NHS England and Integrated Care Systems (ICS) should use available data to understand the demographics and needs of different populations as models of delivering care change and develop.

2.3.   Planning the workforce for the future must give due consideration to condition specific specialists. Diabetes, in particular, already affects 1 in 14 people and this number is rising. Prior to the pandemic, diabetes accounted for 10 per cent of NHS spending and 1 in 6 hospital beds was occupied by someone with diabetes. The rise in comorbidities, an ageing population and increasing obesity rates are leading to more complex diabetes cases, and specialists play a vital role in supporting people to manage their condition directly and indirectly, by supporting other healthcare professionals.

2.4.   Due to the complex and demanding nature of diabetes, the impact of the condition on a person’s emotional and psychological wellbeing can be profound. In a Diabetes UK survey in 2019, 7 out of 10 people with diabetes said they felt overwhelmed by the demands of the condition and further studies have also shown that around 40 per cent of people with diabetes experience poor psychological wellbeing at any one time[i]. However, a 2018 survey on emotional and psychological support showed three quarters of people living with diabetes were not able to access the specialist psychological support they needed. Workforce planning for the future must meet both the physical and psychological needs of people living with the condition, and significant focus must be given to development of the mental health workforce to meet the needs of growing numbers of people living with long term and complex conditions such as diabetes.

2.5.   New models of delivering care will be needed to deal with the increasing pressure on the NHS, and they must ensure that there is sufficient specialist knowledge within the system to meet the holistic needs of those with long-term conditions.

3. What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors? In particular:

To what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?

3.1.   There is not an adequate system in place for determining the workforce training requirements to meet long term need of the population. This has been repeatedly highlighted by many organisations including the Kings Funds, Nuffield Trust and Health Foundation, and well as the Health and Care Committee itself.

3.2.   Diabetes UK support the findings of the Committee’s 2021 inquiry into Workforce burnout and resilience in the NHS and social care which highlighted: “There is no accurate, public projection of what health and social care require in the workforce for the next five to ten years in each specialism. Without that level of detail, the shortages in the health and care workforce will endure, to the detriment of both the service provision and the staff who currently work in the sector.”

3.3.   We also endorse the Committee’s recommendation for publication of regular “objective, transparent and independently-audited... reports on workforce projections that cover the next five, ten and twenty years including an assessment of whether sufficient numbers are being trained.”

3.4.   The merger between Health Education England and NHS England/Improvement presents a key opportunity to strengthen the system for workforce planning at a national level with the alignment of workforce, financial and service planning with education and training.

3.5.   The Health and Care Bill also represents a key opportunity to enshrine in law a more robust system for workforce planning. Diabetes UK, along with others in the sector, supports Baroness Cumberlege’s amendment (amendment 170) that would require the Government to publish independently verified assessments every two years of current and future workforce numbers required to deliver care in England.

3.6.   Workforce plans must consider the rapid rise in long-term conditions, including type 2 diabetes, which is transforming the health landscape in the UK. Currently, 4.9 million people are living with diabetes and there are 13.6 million people at increased risk of developing type 2 diabetes. Plans must also consider the increasing complexity of the condition due to an ageing population, increasing co-morbidities and rising obesity rates, and ensure that healthcare professionals have the knowledge and resources to provide excellent care to support people to manage their condition.

4. Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?

4.1.   More training is needed for healthcare workers to understand diabetes. By 2030, it is estimated that 1 in 10 adults will be living with diabetes and before the pandemic 1 in 6 people in hospital had diabetes, it is therefore essential that throughout the NHS, all professionals have sufficient understanding of the condition to treat these patients. Managing diabetes affects all aspects of a person’s physical and mental health, so all healthcare professionals need to understand the condition to be able to offer optimal care. A lack of widespread understanding of diabetes carries significant risk; it leads to medication errors and sub-optimal care, which not only impacts the long-term management of the condition but can also cause acute complications including diabetic ketoacidosis or severe hypoglycaemia. As well as diabetes specialists, training is needed to ensure all those working in the NHS and social care have the knowledge necessary to treat people with diabetes safely.

4.2.   Over 3.1 million people have a diagnosis of type 2 diabetes, which is predominantly treated in primary care. More needs to be done to ensure that the primary care workforce has the skills to deliver high quality diabetes care. Practice nurses carry out most routine care for people with diabetes within the general practice setting and it is essential that they have the support they need to take on leadership roles and feel confident delivering diabetes care as it becomes increasingly complex. Training for practice nurses should focus more on leadership and communication skills to enable them to lead in this growing area and relieve pressure on GPs.

4.3.   Training in diabetes and other complex long-term conditions is also needed within the mental health workforce. More than 1 in ten (10.7%) people with type 1 diabetes, and more than 1 in 20 (5.3%) people with type 2 diabetes accessed IAPT (Improving Access to Psychological Therapies) services in 2019-20, according to the latest figures available in the National Diabetes Audit.

4.4.   However initial apprentice training for Personal Wellbeing Practitioners (PWPs), who deliver a large portion of all IAPT interventions, does not include supporting people with long-term health conditions in its curriculum. Indeed, this learning is not mandatory and is only available to PWPs after a year on the job. Given that nearly 200,000 people with diabetes accessed IAPT services in 2019-20, this demonstrates a gap in PWP training that must be closed. 

4.5.   Diabetes UK is also concerned about the high vacancy rate within the IAPT programme. Results from Higher Education England’s Adult IAPT Workforce Census 2020 reported the vacancy rate was 11% of total funded whole time equivalent posts.

4.6.   Diabetes inpatient care teams are crucial for providing quality care for people with diabetes in hospital. They are key to offering expert knowledge to support quick turnaround of patients in A&E and effective care across the hospital which prevents deaths, and they help to make hospital stays shorter and safer for people with diabetes. In normal times, almost one third of inpatients with diabetes have a medication error during their hospital stay[ii]. Diabetes UK was therefore concerned that in some areas inpatient diabetes teams were disbanded during the first peak of the pandemic, which left some people with diabetes without the specialist care they needed in hospital. These teams offer ongoing support and training to colleagues as well as delivering care themselves. In planning the workforce for the future, specialist teams like inpatient diabetes teams should be prioritised and they must be protected, even in times of crisis.

4.7.   Further training is also needed to tackle weight related stigma in the NHS. The APPG on Obesity’s 2018 survey found that only a quarter of people living with obesity felt that they were treated with dignity and respect when seeking advice or treatment related to their weight. There is a need for healthcare professionals to be better trained on the causes, impacts and treatment of obesity, and learn to challenge stigmatising views in themselves, their colleagues and their patients.

4.8.   Healthcare professionals need to develop a knowledge of and promote the weight management pathway in their local area, including formal services and informal community services. Qualitative insight work conducted with GPs on behalf of Diabetes UK indicates that many healthcare professionals see bariatric surgery as a ‘last resort’ intervention, making them unwilling to make referrals in recently diagnosed people, despite NICE guidance that adults with a body mass index of 35 or more who have been diagnosed with type 2 diabetes within the past 10 years are offered an expedited referral for bariatric surgery assessment.

5. Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?

5.1.   The inverse care law persists, with the least affluent areas having fewer GPs. According to research by The Health Foundation, after accounting for different levels of need, a GP working in a practice serving the most deprived patients will on average be responsible for the care of almost 10% more patients than a GP serving patients in more affluent areas[iii]. People living in poverty are over twice as likely to develop type 2 diabetes and rates of gestational diabetes are twice as high in the most deprived communities compared to the most affluent areas[iv][v]. To reduce disparities in health outcomes, access to care must urgently be improved in deprived areas.

5.2.   Diabetes Specialist Nurses (DSNs) play a crucial role in delivering diabetes care, including offering advice and training to other colleagues. Yet the number of DSNs has been falling and research in 2016 revealed that of the DSN workforce in employment at the time of the study, over 50% were within 10 years of retirement[vi]. It is concerning that alongside the pressure of rising demand and the pandemic, many more will leave the NHS and people with diabetes could suffer as a consequence. The Government, along with NHS England, should develop a national workforce strategy to ensure there are sufficient appropriately skilled DSNs to meet the current and future needs of people with diabetes. This would include developing a competency framework for DSNs in order that they can be consistently assessed and recognised[vii].

5.3.   The development of the mental health workforce to meet the needs of the growing number of people living with long term, complex conditions including diabetes is also an area that requires specific attention. While there appears to be a growing understanding of the interrelationship between effective diabetes management and good emotional and psychological wellbeing, and diabetes services across the country have reported developing business cases for specialist diabetes psychology and psychiatry posts, we regularly hear that these services are struggling to fill these posts due to shortages in the mental health workforce.

5.4.   Providing a key focus on good mental health among people with diabetes should be seen as a strategic priority to ease workload and resource pressures on other parts of the NHS. The NHS’ Five Year Forward View for Mental Health states that the cost of complications stemming from mental health problems in people with long term physical illnesses increases the cost of care by an average of 45%. Additionally, the National Diabetes Audit shows that people who are receiving mental health support have poorer treatment outcomes than those who are not, increasing the risk of potentially devastating diabetes complications.

6. What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?

6.1.   The next iteration of the NHS People Plan must give due consideration to the rise in long-term health conditions, and the need for condition specific specialists. In particular, it is concerning that even as the number of people living with diabetes continues to rise, the number of Diabetes Specialists Nurses (DSNs) is falling. The plan should include steps to recruit DSNs to meet the needs of everyone living with diabetes. Supporting nurses to take on specialist roles also boosts job satisfaction and retention. Our 2016 survey showed that job satisfaction remains high among most DSNs: around 70% of respondents said that they are satisfied or very satisfied with their role overall[viii]. This likely reflects a strong interest in and commitment to diabetes care among the DSN workforce; most respondents (85%) said that a strong interest in diabetes motivated them to specialise in this field.

6.2.   The NHS People Plan must recognise the ongoing changes to how care is delivered, which will likely result in more remote consultations and digital pathways. However, consideration must also be given to the need to maintain face-to-face appointments for those who need them. In our survey of people with diabetes, a third (33%) of respondents said they want all of their appointments to be face-to-face, and another quarter (25%) want most of their appointments to take place this way. This was higher for people from deprived areas, with 36% of people from the most deprived quintile in England wanting all their appointments face-to-face, compared to 31% in the two most affluent quintiles.

6.3.   Government, NHS England and local health leaders should closely monitor the impact of new triage systems and digital pathways to understand the impact on staffing. They should also monitor any changes to who is accessing care and at what stage they come forward for treatment, and use the data to reduce inequalities in access to care and health outcomes.

7. What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?

7.1.   Integrated Care Systems (ICSs) can provide a system-wide view, they therefore have a vital role in workforce planning to meet the needs of the local population without duplicating resources or leaving gaps. It is essential that ICSs facilitate good communication and support between different areas of the health system, including between primary and secondary care. ICSs can help to facilitate greater collaboration and clearer boundaries of responsibility between primary and secondary care, which will reduce bureaucracy and improve diabetes care. One HCP in primary care told us that a lack of access to specialist support and advice risks burn-out. ICSs must ensure collaboration across primary and secondary care so that all staff feel supported. It is critical that ICSs invest in staff training and collaboration between hospitals and GP practices to deliver excellent care and retain staff in both settings.

7.2.   Diabetes clinical networks can facilitate collaboration and education across local health systems. They can also advise on training and workforce needs locally. This essential infrastructure should be supported by ICSs.

7.3.   ICSs must also ensure healthcare professionals have sufficient support to maintain morale and support good staff wellbeing. The Government must give ICSs adequate funding to offer mental health and wellbeing support services to NHS staff, which will in turn promote retention.