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Exchange of experience: how is diabetes managed in Wales?

The stories of patients and a nurse telling about the peculiarities of medical treatment of diabetes in Wales, what is the difference with treatment in Ukraine and what people have to face - all this was described in her report by the Executive Director of the UDF, Natalia Kozhan
1. Meeting with patient O.D., who lives in Barmos, Wales, UK.

The patient is 43 years old and has type I diabetes mellitus, 23 years old. At the age of 20, in serious condition, he was hospitalized in an inpatient department with a sugar level of 30 mmol/l, in which he was from 18.00 to 2.00. His blood sugar level was lowered to 7 mmol/l and discharged to his home. The next day, the patient was referred to the diabetes school, which operates in the family hospital. In school classes, the patient was taught to keep a diary of sugar levels and food consumed. For half a day, the patient worked with a nutritionist, who talked about nutrition in diabetes mellitus (what foods and drinks should not be consumed, how to use the glycemic index when choosing products). He does not use food tables indicating bread units, because they were not recommended.

Insulin and a monitor for constant monitoring of sugar levels are given to him free of charge, regardless of the level of glycated hemoglobin. This is due to the fact that stress and various other situations lead to fluctuations in sugar levels.

For the first two years, the patient received combined insulin, and then long and short insulin was prescribed separately. For 23 years, he changed the types of insulin three times, this was due to the fact that the state did not purchase the prescribed insulin. Currently, he receives Lantus and Novorapid.

The patient is under the supervision of a family doctor and a nurse. He has not visited an endocrinologist for more than 8 years, because the doctor has retired, and there is no other in the medical institution.

1-2 times a year he is examined. Passes the following tests: glycated hemoglobin, urine and blood tests. During the examination, the manipulative nurse checks the sensitivity of the legs, whether the hair on the toes falls out and examines the feet. Ultrasound of blood vessels, kidneys, liver was not performed. Once a year, check for retinopathy. The patient's eyesight deteriorated after 8 years of illness. Sodium levels are also checked because patients with diabetes have increased sweating.

Indications for immediate hospitalization are a sugar level of 20 mmol/l for more than 6-12 hours and infectious diseases, primarily of the nasopharynx.

For the first two years, the patient had poor blood sugar control, so the nurse called him to the family outpatient clinic every 3 months and told him about the complications of diabetes and possible disability in this regard. "The insurance company, of course, will carry out amputation of a limb, dialysis, kidney transplant free of charge, but medical workers will have serious trouble due to the fact that the patient is in serious condition," repeated the words of the nurse O.D. In Wales, organ transplants are performed on insured patients free of charge, but primarily on young patients.

The patient has two daughters, 18 and 21 years old, who do not have diabetes. During pregnancy, the wife did not undergo any special examinations, but warned the couple about the high risk of giving birth to a child with type I diabetes. They also said that parents should monitor the child and immediately consult a doctor if thrush, thirst, frequent urination, throat infections are detected.

Currently, the patient feels tired from the disease, but the nurse recommended that he fall in love with his illness, because it is for life, and then it will be easier. During a visit to the nurse, she is interested in the state of mental health, the presence of depression.

In Wales, there are psychological support groups where group members support each other, talk about their experience of living with diabetes, and defend their rights.

There is a stigma among some employers for diabetic patients. The patient has a friend who worked as a firefighter. When his boss found out about his diagnosis, he fired him from his job, although according to the law he should have offered him another job. A lawsuit was prepared and the firefighter received compensation.

The patient also noted that he, like other patients with diabetes mellitus, has a fear of the possibility of hypoglycemic coma. His brother, who is a paramedic, made a special board for the patient for the employees of the company where the patient works. On one part of the board, he wrote the signs of a hypoglycemic coma and relief measures, and on the other half, a hyperglycemic coma with relief measures. This helps colleagues to understand the patient's condition and, if necessary, provide assistance.

2. Meeting with a nurse at a family hospital, Harlech, Wales, UK.

I.K., Family Hospital Nurse, Harlech, Wales, UK. She has been working for more than 20 years and provides examination and education to patients with diabetes. In order to organize activities on diabetes mellitus, she underwent special training. Currently, there are many courses for medical professionals of various levels, for leaders on diabetes mellitus, including online training.

For example, on the basis of the University of Brighton, there are courses for medical professionals. These courses cover diabetes complications and their management, diabetes epidemiology, lifestyle interventions and current treatment options, self-management and patient perspective, insulin management, therapy and monitoring and other injectable drugs, evidence-based practice in diabetes management, improving quality, safety and service in clinical settings, leadership and change management in clinical services.

Communicating with patients, the nurse helps them control diabetes mellitus, invites them for examinations, conducts explanatory work if patients do not control their sugar levels. She also tells them about self-support groups and the British Diabetes Federation's website, where they can find a lot of interesting information about diabetes, healthy foods, exercise and a healthy lifestyle. It is recommended that they also register on this site in order to be able to receive individual advice.

Patients with type I diabetes mellitus are told, necessarily, about the signs of hypoglycemia and hyperglycemia, self-help.

Patients with type II diabetes mellitus are told that treatment includes proper nutrition and physical activity. Some people may also need to take diabetes medications, such as metformin or insulin. Type II diabetes can go undiagnosed for many years if symptoms are missed. If left undetected, high blood sugar can cause serious health problems called diabetes complications.

The nurse tells patients about the types of complications in diabetes and their first signs.

The functions of the nurse also include issues related to the prevention of diabetes mellitus, primarily among risk groups (patients with obesity, with diseases of the cardiovascular system, and those belonging to different ethnic groups).

The problem of obesity has now become a serious problem for Wales. Many people consume Coca-Cola, carbonated drinks, chips, fast food from an early age. In this regard, it was decided at the country level to prohibit the advertising of these products. People from African-Caribbean and South Asian countries (Indians, Pakistanis, Bangladeshis) are at higher risk of developing type II diabetes from a young age. To reduce the likelihood of developing type II diabetes, recommendations are provided to eat healthier foods, lose weight if necessary, have a healthy weight and a healthy waist size, and move more. Taking care of your weight and being more active helps your body control your blood sugar levels and helps prevent insulin resistance, which can lead to type II diabetes.

3. Meeting with patient F., who suffers from type I diabetes mellitus and is temporarily, due to hostilities on the territory of Ukraine, in Wales, Great Britain. Patient F. is 44 years old and has been suffering from type I diabetes mellitus since he was 16 years old (28 years old).

Upon arrival in Wales in August 2022, he was assigned a consul who provides advisory services on all issues of interest to patient F. (residence procedure, obtaining a visa, bank card, conditions of employment and learning English, medical care, etc.). Medical care in Wales for immigrants from Ukraine is provided free of charge in a family outpatient clinic, if necessary, in an inpatient setting.

Patient F. said that the main disadvantage of medical care in Wales compared to Ukraine was that the patient was treated with respect and had never felt humiliated. In Ukraine, in order to get a prescription for insulin, it is necessary to make an appointment with a family doctor every month, in advance, and come at the time when you sign up, which requires release from work for this time. Monthly absences from work cause dissatisfaction with management. If you come to the primary health care center when you have time to do so, you need to ask patients from the queue to be allowed to skip the queue, which causes their dissatisfaction, or thank the medical staff (chocolates, candies) to make a prescription and give it to the patient. To receive insulin free of charge, it is necessary to bring the results of a blood test for glycated hemoglobin every three months. Patients understand that this is an uncertain indicator, because the patient may have a high sugar level, then a low one, and the average will be normal. Therefore, in order to receive insulin free of charge, patients bring inaccurate data on the level of glycated hemoglobin.

In Wales, on his arrival, on the third day, he visited the family dispensary. The doctor prescribed him insulin therapy, inquired about his health, wrote a prescription for insulin and a continuous glucose monitoring device (CGM device). Later, if it is necessary to obtain a prescription for insulin or for a device, patient F. comes to the family outpatient clinic, at the reception a medical worker enters the electronic patient registration system, verifies the patient's data and writes out the necessary prescriptions. There is no need to visit a family doctor if there are no changes in the state of health.

Executive Director of UDF Natalia Kozhan
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