Diabetes Mellitus is not a rare condition. The British Diabetic Association tells us that it affects about 2% of the UK population and within that 2% , some groups are affected more than others. The Asian community in the UK have a particularly high incidence. This factor may well have a genetic component but equally may be a reflection of their typically high fat diet. (Nathan 1998)
Genetic factors certainly do play a part in the aetiology of Diabetes Mellitus. A relative with the disease will increase your own chances of contracting it and the closer the relationship, the higher the chance. This is particularly true of Type I diabetes mellitus. Type II diabetes mellitus also has a genetic like but other factors such as increasing age and BMI are also found to be independently relevant factors (Gregg et al. 2003). In the UK, Diabetes Mellitus is ranked as one of the commonest childhood illnesses (except for trivia) with about 20 children per 100,000 being diagnosed each year with the condition (Devasenan Devendra 2004)
Diabetes Mellitus is known to be associated with a number of complications. As a general rule the incidence of complications increases with time. It is also thought to be associated with the degree of control of the Diabetes Mellitus, the better the control the lower the incidence of complications. (Kissebah et al. 1989)
It is said that about 9% of the total NHS budget will be spent on Diabetes Mellitus and its related issues. Its complications will account for about half this sum (Newrick 2000)
In specific relevance to our essay title there are two major complications which link Diabetes Mellitus with erectile dysfunction and they are cardio-(macro)vascular disease and neuropathy. (Wagner et al. 1998)
Neuropathy is typically a late onset complication of the diabetic state. It is found in about 2.4% of the general population. It is also primarily age related and the incidence rises to 8% in the elderly diabetic patient. ( Hughes 2002)
Erectile dysfunction currently occurs in 10-15% of men but there is a distinct variance with age. 40% of men at 40 yrs. report some degree of erectile dysfunction and 70% at the age of 70 yrs. (Gregoire 1999)
Bowering (2001) points out the fact that other factors can also affect the eventual incidence of the cardiovascular complications of Diabetes Mellitus such as blood pressure and smoking. Both of these factors are known to be positively and independently associated with erectile dysfunction so it is not surprising for them to be found in relation to Diabetes Mellitus. Some of the most recent research shows that, as far as Type I diabetes mellitus is concerned, a reduction in HbA1 by 10% will reduce cardiovascular complications (both micro- and macro-vascular) by a factor of between 34-76%. On the face of it, that looks impressive, but the difficulty is that by increasing the insulin dosage to ensure better control, the patient is put at greater risk of potentially having hypoglycaemic attacks.
In direct consideration of our topic, Bowering (2001) also states the fact that atherosclerosis is a major complication of Diabetes Mellitus. Brief consideration of the physiological and anatomy of the erectile mechanism will tell us that the presence of atherosclerotic vessels will seriously impede the blood flow to the penis which clearly will not be as responsive to the triggers to erection as normal.
The need for change
The need for change is highlighted in documents such as the National Service Framework which were produced by the Government after a major review of the NHS service provision. The National Service Framework specifically target areas where the provision was found to be inadequate together with the setting of targets that help those areas where provision is optimal. With regard to the subject of this essay the major sections of relevance to the diabetic are:
The NHS will develop, implement and monitor agreed protocols and systems of care to ensure that all people who develop long-term complications of diabetes receive timely, appropriate and effective investigation and treatment to reduce their risk of disability and premature death.
All people with diabetes requiring multi-agency support will receive integrated health and social care.
There was general agreement that the provision of care across the NHS as a whole was inconsistent. Some areas provided excellent care and others frankly, did not. (Croxson 2002)
The National Service Framework initiative aims to promote a more consistent level of care by publishing guidelines, standards and targets. Standard 11 and 12 are manifestly general in their content but clearly they represent a basic minimum that should be adhered to. Standard 10 suggests that all diabetic patients will receive specific and regular follow up for the possible complications of Diabetes Mellitus.
In addition to the Standards, the National Service Framework also defines intervention for the diabetic patient. It is not appropriate, in the context of this essay, to mention all of the interventions here but the Framework specifically calls for regular surveillance of patients with Diabetes Mellitus to detect the commonly occurring complications, such as erectile dysfunction, depression and cardiovascular disease so that they may be offered the appropriate treatment in a timely fashion. It particularly calls for healthcare professional to ensure that people with Diabetes Mellitus can feel free to discuss problems with their sex lives “such as impotence”.
Very significantly it makes the comment that healthcare professional should be aware that a person suffering from Diabetes Mellitus may also be suffering from depression. If the patient has impotence, there is a distinct possibility that they are more likely to attribute the impotence to their diabetic state than to depression. (Ackerman et al. 1995)
People with Diabetes Mellitus are far more likely to attribute their lack of energy or enjoyment to their diabetes rather than consider that it may be due to depression and the healthcare professionals should be both aware of this and prepared to make positive and tactful enquiries if they suspect that there is a problem. (Gayle Beck J. 1995)
The National Service Framework also makes a very valid point and that is that the management of these conditions (broadly) is the same whether or not diabetes is present. It follows that healthcare professional should endeavour to ensure that patients with Diabetes Mellitus should receive “equitable access” to the services that they need. They quote the example of erectile dysfunction to the extent that men with the problem generally require multidisciplinary assessment to gain a correct diagnosis - whether it is neuropathy, cardiovascular disease or purely psychological in origin. The treatment plan should be formulated on the basis that the problem is the erectile dysfunction. The fact that they have Diabetes Mellitus is merely a complicating factor.
In conjunction with the initiatives of the National Service Frameworks, NICE has also produced guidelines for the specific treatment and investigation of both Type I and Type II diabetes mellitus (2003) which outlined the standards that were to be expected, on a National scale.
There is rarely enough provision for treatment of sexual dysfunction within the NHS (Gregoire 1999) and there is clearly a significant demand considering the figures that we have quoted above
An overview of current practice with up to date research and specialist professional opinion linked to relevant theory.
Some of the most recent papers on the subject have dealt with the issues of patient empowerment and education which are now recognised to be a major tool in the establishment of good diabetic control. Furnell (et al.2004) wrote a particularly illuminating paper on the issue. In terms of the definitive need for change they write:
A gap currently exists between the promise and the reality of diabetes care. Practical interventions that facilitate collaborative relationships and foster patient-centred practices are the key to closing this gap.
The degree to which change is necessary in this respect is a reflection of the change in attitude and management that is necessary to give the patients empowerment and education as this rather flies in the face of old-fashioned management. Collaborative relationships between healthcare professional and patient are the current trend and there is every merit in trying to encourage them. (Dawes RM et al. 1974).
Clearly, with the current trend towards evidence-based medicine, we should look for evidence which would suggest that such collaborative models are more likely to work than perhaps the old didactic approach.
A paper by Norris (et al. 2001) is very helpful in this respect. It is useful because it provides us with a meta-analysis of papers which provide a comparison between patient empowerment and education and good diabetic control. It is a huge undertaking, looking at 72 studies over a 20 year period with a huge number of different outcome endpoints. The majority are not particularly relevant to this article, but the relevant points show that areas of diabetic control that are amenable to self-management were all improved with good patient education. Glycaemic control, dietary management and the acquisition of knowledge all improved which therefore clearly demonstrates the need for change as all three correlate well with better long-term control and therefore reduction in cardiovascular and neuropathic consequences.
Betts(et al. 2002) also make the case for change in a slightly different, but possibly more persuasive way. In accordance with the suggestions in the National Service Frameworks they champion the multi-disciplinary approach for all types of diabetic patient. We have already commented on the advice for implementation for multi-disciplinary team based approach and it is being implemented in some areas at present. Betts comments that “in many areas this approach is still sub-optimal with an unacceptably high incidence of complications still being reported. The authors comment that it is possibly the lack of proper management of change that is an important factor in these areas.
Part of the optimum management of the diabetic state (particularly Type II diabetes mellitus ) is the control of the diet. Once again, patient empowerment and education is a vital tool in this regard. In terms of the multi discipline approach, the dietician is also inevitably involved. (Barnes, 2004)
Following on from the provisions of the National Service Framework, a paper produced by the Nutrition Sub-Committee of the Diabetes Care Advisory Committee of Diabetes UK (2003) gives us an excellent overview of the current provision of the dietetic services available. This is particularly relevant top this essay as it also highlights areas that are in need of change. It is both illuminating and well written. It starts with the unusual step of producing its own validation from both the European Association for the Study of Diabetes (EASD) 1998 and the American Diabetes Association (ADA) 2002. The paper extensively covers just about all aspects of dietetic care and finishes with the statement
“The increasing evidence for the importance of good metabolic control and the growing requirement for measures to prevent Type 2 diabetes in an increasingly obese population will require major expansion of dietetic services if the standards in National Service Frameworks are to be successfully implemented at local level.”
This is clearly true and is in line with the other authorities that we have referred to above.
Managing change, steps in bringing about change.
The proper and efficient management of change is vital in an organisation as large and diverse as the NHS. We have show comments by various authors who have commented on the inability of some areas to effectively introduce the National Service Framework Standards. An authoritative and definitive work on the subject of the management of change is the text by Fred Nickols (2004) which he modestly calls “A Primer”. It is, in fact a comprehensive tour de force on the subject and is particularly relevant to our considerations as he was one of the authors of the critical response on the implementation of the Griffiths Report along with Davidmann.
The whole topic of management of change is vast, and a speciality in its own right, so it clearly is not a viable option to cover all of the theory in this essay. If one has to condense the most important elements of the theories on management of change they would probably come under the headings of:
It is clear that with the National Service Frameworks, the first three elements are catered for. The management style adopted by the NHS in this instance appears to have been both collaborative and coercive. The time scales were defined in the original documents as aiming to be fully implemented ( in the diabetic framework) by 2006
It is obviously a matter of debate as to just how effective the NHS has been in “selling the ideals and communicating the message” as this will doubtless be perceived differently by different healthcare professional in different specialities in different areas of the country. Mechanisms have already been put in place to evaluate the progress and a number of bodies are reporting back to the Department of Health.
Time frame in which the strategy and outcomes can be evaluated.
As we have commented above, the National Service Framework calls for an implementation of the various strategies to have been completed by 2006. It is hard to assess just how effective they have been so far since clearly no one has yet been able to do any sort of study on the final outcome. Any experienced healthcare professional working in the NHS would almost certainly be able to point to some areas of progress, just as they would probably also be able to point to areas where implementation was not yet complete.
The management of erectile dysfunction in Diabetes Mellitus ( specifically) comes down to the good management of the diabetic state. We have established that (specifically) for the diabetic patient, there is an increased incidence of erectile dysfunction and this is largely due to the increased incidence of both cardiovascular disease and neuropathy. Both of these factors have an incidence that is inversely related to the HbA1 level. The better the control the fewer the complications. (Boule et al 2001)
We have examined the need for patients to be empowered and educated in order for the control to be optimum and how this is called for in the National Service Frameworks related to Diabetes Mellitus. In the words of the DCCT research Group (1993):
In broad terms, the ability to recognise and manage the signs and symptoms efficiently comes down, in the last analysis, to patient education. Patients who are aware of what is being done for them and, more importantly, the reasons why it is being done, are generally far more compliant and objective in managing their own condition
Waterlow (1998) echoes this comment with:
The clinician, whether they are a diabetic specialist a specialist diabetic nurse or any other healthcare professional, bears a responsibility to educate the patient in the practicalities of good diabetic control. By doing so, they will help to minimise the likelihood of them subsequently presenting with erectile dysfunction or other related complications. This is an issue that is returned to time and time again in the diabetic literature.
The key to the successful implementation of any change as fundamental as this is the successful management of its introduction. It would be fair to say that the NHS has learnt the lessons of the past few decades and now tends to be far more aware of the importance of good management of change. With the result that many of the more recent initiatives have been implemented with a great deal more efficiency and effectiveness than they have done in the past.