There are multiple ways in which to access the specialty due to the wide variety of diabetes and endocrine conditions and the range of ways in which patients can present.
Diabetes is increasingly being managed in the community with close working partnerships with secondary care. Referral from primary into secondary care is recommended for one of the ‘super six’ (inpatient diabetes, foot diabetes (with predefined criteria), poorly controlled type 1 diabetes (including in adolescents), insulin pump services, low eGFR or patients on renal dialysis, and antenatal diabetes). Diabetes clinics are frequently multidisciplinary.
Endocrine referrals can be from primary care or from other specialties suspecting endocrine disease to general endocrine clinics or specialist clinics dealing with the specific condition in question (for example, adrenal or thyroid clinic) or group of patients (for example, antenatal clinics or adolescent and young adult clinics). Specialist endocrine clinics are frequently joint specialty clinics, for example:
- joint pituitary clinics with neurosurgeons or ENT
- joint thyroid orbitopathy clinics with ophthalmology
- thyroid nodule clinics with radiology, histopathology and ENT
- joint reproductive endocrinology clinics with gynaecology
- joint paediatric and adult clinics to support transition
- joint neuroendocrine tumour (NET) clinics with oncology
- joint late effects clinic with haematology and/or neurology.
The Specialised Endocrinology Clinical Reference Group of NHS England has defined service specifications for specialised endocrinology, insulin resistant diabetes, pancreas transplantation, and islet transplantation, and the pathways in and out of these services. Many will run on a ‘hub and spoke’ model with initial assessment and management at the hub and follow up at the spoke in unison with the hub, tailored to the needs of the location. Video conferencing facilitates MDT working and patient flow.
The process of transition from children’s to adults’ services is particularly important for this specialty. NICE guidance has recently become available and NHS England has issued a service specification for diabetes (opens PDF, 648.6KB). The transition of young people diagnosed with diabetes or endocrine conditions in childhood should be a ‘purposeful and planned process of supporting young people to move from children’s to adults’ services’ as defined by the Department of Health. Adult physicians and paediatricians need to work closely together to agree a transition policy that aligns services and supports the young person and their family through the process. The model chosen to support the process of transition may vary but the adult team should meet the young person and their family prior to transfer and ideally care should be delivered in young adult clinics in adult services up to at least the age of 25.
The setting up of young adult clinics also supports care for young people presenting between the ages of 16–25 directly to adult services. For example, the annual incidence of a new diagnosis of diabetes is the same for people aged 16–20 and 20–25 and inevitably there will be higher numbers aged 19–25 in any locality whose care would be in adult services.
Care should be developmentally appropriate, taking into account the broader changes to a young person’s life at this time. As well as dealing with diabetes and their endocrine condition, young people may also be experiencing other concurrent life changes such as the end of full-time education, a potential move away from parents and carers, university, starting work, making career choices, and experimenting with alcohol, sex, drugs and as well as the interchange between primary and secondary care. Young people with a chronic condition are also shown to be more likely to engage in risky behaviours such as alcohol and substance misuse (see article on risk behaviours in adolescents with type 1 diabetes).
Mental health disorders are known to be a significant comorbidity in young people with type 1 diabetes, whereas good emotional and mental wellbeing and support can promote vital resilience. There is a strong correlation between psychosocial issues, including anxiety and depression, and an increase in negative outcomes for young people, including increased HbA1c (glycated haemoglobin) and a longer gap between young people’s appointments. Diabetes has also been linked to increased risk of eating disorders, with some studies suggesting rates as high as 20% in the adolescent population in type 1 and 2 sufferers. Disturbed eating behaviours are common where manipulation of insulin or hypoglycaemic agents are used to manage body weight. In addition, a number of medical treatments used in psychiatry are linked with diabetes.
Transition in diabetes requires specialist adult physician, paediatrician and diabetes specialist nurse input, supported by dietetics and psychology. The team needs to be available for inpatients as well as outpatients as some young people with diabetes may present acutely to adult services with a diabetes emergency during transition. Psychology is also a key component in certain groups of young people with endocrine conditions, for example, those with disorders of sexual development. Some of this group of patients also need the involvement of a gynaecologist and urologist. It is a requirement in the NICE guidance that all young people have a member of the team who is their named worker.
The provision of effective training in transition care for both paediatric and adult higher specialist trainees should be a priority; currently this training is lacking.