2. Futures Scanning

DIABETES MELLITUS

Recent advances (in well resourced countries) include :

Insulin analogues, glucometers, infusion pumps and new advances in prevention of complications.
Posiibility of PREVENTION of Type 1 diabetes (this requires genetic screening.
Genetic diagnosis – impact of genetic developments needs to be evaluated
Need to monitor Type 2 diabetes and obesity and related illness
Investment in drugs for investigation and treatment, more human resources (diabetes educators, dieticians, psychologist, podiatrist, IT re: protocols, advice etc)
Ambulatory care
Adolescent care
Rapid HbAic, microalbuminuria testing
Exploit telemedicine (protocols, review)

ENDOCRINOLOGY

General endocrinology is a fast growing area:

Expanding use of Growth Hormone -?relevance in our S-E environment (but growth hormone is definitely effective and indicated in an expanding group of conditions.
Late effects of cancer treatment (ie as more children survive childhood cancers, so to does the consequences of therapy become apparent eg adrenal and thyroid disorders).
Genetic diagnosis eg molecular endocrinology
Neonatal screening (including metabolic disease)
Adolescent care
Exploit telemedicine (eg Bone Age)

NB - We need a data base to track trends (of diabetes in particular)

MAN POWER
GENERAL :

Demands for subspeciality care is on the rise. Paediatrics is only BEGINNING to take the route to more highly specialized care taken by physicians years ago.

Because of a smaller paediatric population (that need highly specialized ), paediatrics should NOT encourage the movement of subspeciality care into the community.

Subspeciality paediatrics (2^nd or 3^rd tier) , should stay within academic centres.

Need one Paediatric Endocrinologist per million population (optimistically) -

The majority of Paediatric Endocrinologists not only fulfil their duties in their subspeciality, but also do general paediatrics. Perhaps "Specialists with interest in Paediatric Endocrinology " could fulfil dual functions in ? regional hospitals .

In essence, the sub-speciality should be protected, even though the group of patients have complex (and /or rare ) disease. These conditions require the expertise of sub-specialists who can support the regional paediatrician. The managemant of endocrinopathies in childhood should be supervised primarily by the sub-specialist. These patients require GOOD BASIC CARE , but the care needs to be individualized. Rare conditions desrve ADEQUATE CARE which should be initiated at a tertiary institution. Management of these patients at secondary levels should be part of a well planned referral network.

• Identification of likely epidemiological, demographic and socio-economic impacts on need and demand for services in this specialty

There is a definite increase in numbers of new diabetics being diagnosed (previously diabetes was uncommon in the Black child). Need to develop a model to predict how many new diabetics that are likely to be seen in the future.

Urbanisation – diet, obesity, type 2 diabetes (likely to feature as new problems)

Barker hypothesis – implications for health system with high incidence of IUGR

Medical aid transfers to public sector VIZ late transfers after depletion of funds.

Medical aid transfers to the public sector viz late transfers after depletion of funds, and the envisaged plans by some medicalk aids to use state hospitals as the preferred health provider has implications for state services. In addition, there may be conflict of interest when indigent patients and medical aid patients compete for the same service.

IMPACT OF HIV :

• HIV affects service delivery and funding of non HIV related disease
• Ethical issues around managing endocrinopathies in HIV positive patients

• RELEVANCE OF NEW DEVELOPMENTS IN THE SOUTH AFRICAN CONTEXT

There is an increased demand for support services – dieticians, diabetes educators, ophthalmology etc.

HUMAN RESOURCES: --ie urgent priority ; eg need for more nurse educators.

Currently paediatric subspecialities are in their infancy (ie still being developed) and therefore there is no room for contraction. Development of subspecialist services improves efficiency of service delivery. EG if diabetics are managed by subspecialists (or if the care is supervised, then there would be better quality of care , possibly with cost savings eg less complications.)

COST IMPLICATIONS : optimal (eg tight glycaemic control ) care is desirable but comes at a cost (financial and human resources, specifically for glucometers and test strips) that may be prohibitive. Tight control is beneficial in terms of preventing complications – which may burden the health resources later on. Unknown cost of control vs cost of complications ratio. Newer developments are expensive, are they worth it? How best not to compromise well motivated patients (who would benefit from more intensive treatment).

NEED TO :

Establish the adequate minimum adequate care for a child or adolescent with diabetes and then ensure that this is supplied (eg should not every diabetic have access to a glucometer ?). Well motivated patients are not supplied with adequate

Test Strips currently.

National guidelines and reasonable access to specialized services and drugs (eg growth hormone).

Ensure easy access to specialized (/unusual) medication especially in remote areas. (see Policy Document on Chronic non- communicable disease in Childhood)

Invest in existing centres of expertise – including support structures : laboratory, radiology, specialized surgery (eg paediatric urologist).

3. Quality of Care

PROBLEMS:

No formal diabetes teams – inadequate (and sometimes inappropriate) educator, dietetics, psychology (staff performance appraisal)

Conventional treatment regimens may not be as good as (more expensive) "tight control" in terms of preventing complications.

Shortage of food in the context of diabetes or expensive treatment (GH)

Patients who are far away from the service suffer – transport, repeat meds, communication

Availability of specialised drugs in rural areas

Poor patients without telephones or transport to deal with emergencies

Ophthalmology (and other support services) difficult to access; they are also overwhelmed, no special interest in diabetes.

Poor understanding of Type 1 Diabetes on the part of health workers (eg inappropriate advice to a patient). Urgency of the presenting complaint often not appreciated by attending (secondary level doctors). Therefore, better lines of communication and involvement by regional doctors essential.

NEEDS

Paediatric and adolescent focused service / hospital

Transport to health facilities especially children living in remote areas.

Chronic illness grant / specifically diabetes (in the context of the huge nutrition problem overall), consider food support rather than financial (?).

PROPOSALS:

Define paediatric and adolescent diabetes as a tertiary care disease (vs HIV/AIDS as a secondary level) with more appropriate allocation of resources.

Plan a registry of rare endocrine disease

Review of system of approvals for GH (expedite process)

Suggest a national (accessible!) GH budget (possibly include GnRHa, others), allocation of GH regulated by paediatric endocrinologists (appropriate indications)

Chance to think about protocols – For paediatric / adolescent DKA, for cost-effective testing / rational use of laboratory and radiology (and other?) services

Chance to establish early referral to growth clinics (prevent inappropriate and costly investigations) .

Avoid duplication of laboratory facilities eg identify laboratories doing specialized testing (eg one national / regional lab).

Establish implementable policies with respect to availibilty of Test strips and unusual medications.

4. Access to Services

Rural and poor patients are disadvantaged.

Because of the referral system and transport difficulties, patients cannot access drugs.

Health professionals and patients disadvantaged by language barrier

Early consultation (telephonic), no appropriate emergency care of children and adolescents DKA (were should these patients be cared for in our system?)

NEED TO :

Strengthen regional hospital expertise

5. Efficient Use of Resources

Endocrinology resources currently very limited

Liimited manpower / support professionals.

Need to facilitate access to unusual medicines – who should do this?

User friendly and level-appropriate protocols

HIV often over shadows other conditions leading to poor utilization of (limited) resources. If a separate budget is established for HIV related conditions, then current resources may be better utilized.

Staff education (for interested, motivated personnel) is an important priority.

PATIENT EMPOWERMENT / EDUCATION / SATISFACTION

6. Education and Training

• Training at tertiary institution with down referral and networking, with protocols, ‘outreach’ re diagnosis of diabetes, growth (ie Height) monitoring (which is a good indicator of child health anyway!)

7. Public / Private Interaction

Day ward (for diagnostic tests) can be shared by private and public sectors.

Expertise, consultation can be shared .

Access to drugs eg insulin analogues.

Standardising testing between public and private labs

8. Organisation of Services

Currently, paediatric endocrinology is in a state of evolution ie services are being developed in most provinces. Most of the current service is provided by paediatricians who have other commitments. Multidisciplinary clinics are generally not available (because of lack of manpower eg very few psychologists, specialist surgeons). Patients spend time being "shunted " from clinic to clinic. Efficiency can be improved by "joint" multidisciplinary clinics. Each teaching(major) hospital should have a paediatric endocrinology unit (with support staff and other subspecialist services including radiology and surgery).