cohealth welcomes the opportunity to contribute to the House of Representatives Standing Committee on Health, Aged Care and Sport Inquiry into Diabetes.
cohealth is a large Victorian community health services providing integrated physical health, mental health and social support services to people in the inner, western and northern suburbs of Melbourne. Diabetes affects many of the people cohealth works with, reflecting the prevalence of the condition in the broader population. Despite the potential consequences of diabetes, many people cohealth works with describe facing significant barriers to the effective prevention, self-management and ongoing care that would minimise the impact it has on their life, health and wellbeing. These are outlined in this submission.
While commonly associated with individual risk factors and behaviours, the prevalence of diabetes is integrally related to the social determinants of health – the circumstances in which people are born, grow, live, work and age. The risk of developing type 2 diabetes can be reduced by healthy lifestyles, but this can be out of reach for many. Low incomes and cost of living pressures can make nutritious food more expensive; powerful commercial enterprises aggressively advertise less healthy foods; poor urban planning increases reliance on car travel and can leave people living in outer suburbs less time and energy to engage in exercise.
Reducing the incidence and impact of diabetes in Australia will require a concerted, multi-sector response that not only supports individuals and communities, but reduces structural inequalities and the influence of less nutritious products and marketing.
Summary of Recommendations
Diabetes is a chronic health condition that impedes the body’s ability to produce and/or use insulin, a hormone produced by the pancreas to regulate blood glucose levels. This results in high blood glucose levels, which can lead to serious complications such as heart disease; stroke; eye disease, including retinopathy; kidney disease; peripheral vascular disease; nerve damage; foot problems; and gum disease. Diabetes is also associated with serious mental health challenges including treatment-related distress, anxiety and depressive symptoms.
The impact of diabetes can be reduced through diabetes prevention activities and better support for people living with diabetes, improving health outcomes and reducing long-term complications.
The main forms of diabetes are:
Type 1 diabetes – a lifelong autoimmune disease. It often has onset in childhood or early adulthood but can occur at any age. People with type 1 diabetes require daily insulin therapy for survival.
Type 2 diabetes – a condition in which the body becomes resistant to the normal effects of insulin and gradually loses the capacity to produce enough insulin in the pancreas. The condition has strong genetic and family-related (non-modifiable) risk factors and is also often associated with modifiable risk factors. Type 2 diabetes is the most common form of diabetes.
Gestational diabetes – occurs when higher than optimal blood glucose is diagnosed in pregnancy.
‘Other’ diabetes – a name for less common forms of diabetes resulting from a range of different health conditions or circumstances.
Pre-diabetes – characterised by elevated blood glucose, but not meeting the diagnostic criteria for diabetes.
In 2021 more than 1.3 million (1 in 20) Australians were living with diabetes. However, this figure is likely to underestimate the true prevalence of diabetes in the Australian population as studies have shown that many Australians are living with undiagnosed diabetes.
There is a greater incidence of diabetes among some population groups, including Aboriginal and Torres Strait Islanders and people in low socio-economic groups. These groups also experience disadvantage in other areas of life, and poorer health outcomes. To reduce the impact of diabetes it is vital that structural inequalities are addressed, in tandem with improving diabetes health promotion and care.
cohealth is one of Victoria’s largest community health services, operating across nine local government areas in the western, northern and inner suburbs of Melbourne. Our mission is to improve health and wellbeing for all, and to tackle inequality and inequity in partnership with people and their communities.
A primary health service, cohealth provides integrated medical, dental, allied health, mental health and community support services and works directly with communities to understand their needs and develop responses, and deliver programs promoting community health and wellbeing.
Our service delivery model prioritises people who experience social disadvantage and are consequently marginalised from mainstream health and other services – people who have multiple health conditions, experience homelessness and unstable housing, have a disability or mental illness, those engaged in the criminal justice system, Aboriginal and Torres Strait Islanders, refugees and asylum seekers, people who use alcohol and other drugs and LGBTQIA+ communities.
cohealth has had lengthy experience providing a range of health and other supports to people who have, or who are at risk of having, diabetes, working with several thousand clients with diabetes each year. The vast majority of these have type 2 diabetes.
A small team of Diabetes Educators provide specialise diabetes care, including self-management education integrated with clinical care as part of a therapeutic intervention to promote physical, social, spiritual and psychological wellbeing. A range of other health care professionals also support people with diabetes prevention, care and self-management, including general practitioners, practice nurses, dietitians, exercise physiologists, podiatrists, dentists and dental hygienists, pharmacists, allied health assistants and counsellors. Other health and social support programs support the individual clients with diabetes, including linking with specialised services.
Access to best practice diabetes care is unequal
Effective diabetes care requires that all Australians have access to the prevention, early intervention, ongoing care and support the enables them to prevent, understand and manage the disease effectively in the community. However, the conditions and services for this are not available to everyone. The people cohealth works with face significant barriers to good health in general, including accessing best practice diabetes care.
While diabetes is commonly associated with individual risk factors and behaviours, it is vital that policy responses recognise the key role played by the social determinants of health. These are the circumstances in which people are born, grow, live, work and age – and the structural conditions in society which lead to unequal living conditions and affect the chances of a healthy life. They include income, employment conditions, housing, where you live, and experiences of stigma, discrimination and marginalisation.
Ensuring everyone has the foundations for good health, including an adequate income, secure and appropriate housing, access to nutritious food and opportunities for exercise, and are free from experiences of discrimination, must be the starting point for reducing the impact of diabetes in Australia.
Governments meaningfully address the social determinants of health that impact on diabetes, particularly through: significantly increasing social and affordable housing; and ensuring income support payments provide an adequate living, through increasing the rate of JobSeeker and related payments.
The costs associated with treating diabetes, as well as for living the healthy lifestyle that can protect against development of type 2 diabetes, are prohibitive for many of the people cohealth works with. In addition, the current cost of living crisis and escalating housing costs are placing significant pressure on people’s budgets, meaning that many people are unable to afford fresh, nutritious food and participate in exercise.
Medications, consumables and health care appointments can be out of reach for many people. Even telehealth appointments can be inaccessible for people with insufficient phone credit, who don’t have wi-fi or the necessary technology. Self-management of diabetes is compromised when people are unable to afford the cost of care, leading to risk of complications, hospitalisation and poorer health, with significant impacts on individuals, families and the health system.
New technologies have revolutionised diabetes care, particularly continuous glucose monitoring and insulin pumps. However, these are not equitably available in the community due to their cost. Subsidies for some products are available under the National Diabetes Services Scheme (NDSS), but barriers remain for people on low incomes:
Continuous Glucose Monitoring (CGM) assists people with type 1 diabetes to maintain blood glucose levels in their target range and manage their diabetes. Optimising diabetes control can decrease the short- and long-term complications of diabetes, and their associated health care costs. CGM is fully subsidised by the NDSS for people with type 1 diabetes under 21 years of age or who have a Health Care Card or are on a pension. Other people with type 1 diabetes pay a copayment of $32.50 per month.
For many people cohealth works with, a copayment of this amount can be prohibitive. In the current cost of living crisis, where housing and other living costs are increasing dramatically, this is particularly acute. CGM is unaffordable for people in these circumstances, meaning they are unable to realise the benefits from this technology.
CGM subsidies are not available for people with type 2 diabetes who require insulin. Enabling greater use of CGM by people with type 2 diabetes would have significant benefits to individuals and the health system through improving health outcomes and reducing hospitalisations.
Insulin pumps are small electronic devices for people with type 1 diabetes delivering small doses of rapid-acting insulin. They can make life with type 1 diabetes more flexible, and can reduce the frequency of severe hypoglycaemia as well as improve quality of life.7 However, they cost up to $10,000 to buy, or private health insurance may cover the cost. The NDSS covers the cost of monthly consumables. This cost makes insulin pumps unaffordable for people on low incomes, who have to do multiple daily injections.
The use of insulin pumps in combination with CGM can provide optimal control of blood glucose levels and is known to be associated with reduced long-term complications. However, this combination is also unaffordable for people on low incomes, who then miss out on the benefits of this therapy.
Cost barriers for diabetes care, including new technologies, such as continuous glucose monitoring and insulin pumps, should be removed, and the products be available to all who would benefit from them, regardless of income.
Promotion of multidisciplinary care
A multi-disciplinary approach to diabetes care is associated with improved outcomes for clients.9 Community health services, such as cohealth, are well placed to deliver care in this way, with an existing and comprehensive range of multi-disciplinary health providers. Through our experience providing multi-disciplinary diabetes care a range of challenges relating to funding and systems have been identified:
There is no specific Medicare MBS item number to support the work of a multi-disciplinary diabetes clinic, so funding from an array of different sources must be brought together to provide multidisciplinary care.
The Victorian government Community Health Program funding supports diabetes nurses/educators; Medicare, through MBS item numbers, funds general practitioners and nurses; other disciplines such as dieticians and exercise physiologists are paid through HACC/CHSP10 and home care packages.
Clients over 65 years of age need a My Aged Care assessment and referral, which can be a barrier to involvement, and take time to complete.
This multitude of funding sources and accountabilities creates additional work for practitioners, reducing the time they are available to clients.
cohealth Diabetes Educators have identified essential features of multi-disciplinary clinics, including:
Chronic disease management plans under Medicare enable a small degree of multidisciplinary care. However, these only provide for five sessions with allied health providers of all disciplines over a 12-month period, which is not always sufficient to manage diabetes. Increasing the number of session available for people with diabetes would enable them to access the range of supports they need to respond best to their diabetes care needs. The number of sessions available should be determined by clinical need, with clients with more complex needs and at higher risk of complications eligible for 10-15 sessions.
Increase investment in multi-disciplinary models of diabetes care.
Tailoring responses to specific groups
The Australian National Diabetes Strategy 2021-203011 recognises that there are several groups in the community who have a higher risk of diabetes, and for whom efforts should be prioritised. cohealth supports an approach where diabetes prevention and treatment programs are culturally appropriate and tailored for groups facing barriers to health care. Effective programs are those developed, and co-designed, implemented and evaluated in partnership with diverse communities.
cohealth dieticians observe some factors relating to specific groups:
Clients with serious mental illness (eg schizophrenia), have higher rates of diabetes, along with risk factors such as obesity. Some of this may stem from health risk behaviours such as low-quality diet, smoking and physical inactivity. However, these conditions are often a side effect of the medications people take for their mental illness, due to their direct impact on glucose metabolism.
Despite the improved management of symptoms of schizophrenia and other conditions, the rapid and large weight gain that often follows can have marked effects on a patient’s mental health, because of the effect of excess weight on body image, mobility and physical health concerns and experiences of weight stigma. Weight stigma itself has a profound impact on the mental health of people with larger bodies, their participation in society and their utilisation of health services. When people experience this in addition to stigma related to their mental health diagnosis, the social exclusion experienced is compounded.
As the weight gain is usually due to side effects of medication, it is important to work compassionately with people to address the underlying modifiable factors that can support their best management of their health and health goals, such as improving dietary quality and supporting increased movement.
Clients from culturally and linguistically diverse (CALD) backgrounds. Evidence indicates there is a higher prevalence of diabetes in some CALD communities.Factors contributing to this higher level of risk include genetic factors, immigration factors, socio-economic factors, and socio-cultural factors, particularly language barriers, literacy rates and lack of access to culturally appropriate care.
As the progression to chronic disease can occur within six years of migration, early intervention programs with healthy lifestyle messages and practical skills training are encouraged. Ensuring diverse communities are key partners in the development, design, delivery and evaluation of this work is essential to ensure programs are appropriate to different communities. Programs should recognise and address the social, cultural and economic barriers to improving dietary quality and increasing movement. Working with bicultural workers and translators, and providing translated, pictorial and video resources showing multicultural foods is important to convey that traditional diets (compared to ‘western diets’) are preferable. Resources need to be regularly updated to ensure they are relevant for the most recently arrived groups.
cohealth developed a successful program that aimed to intervene early to help prevent the appearance or progression of chronic disease in these communities, by providing education, exercise and practical skills to encourage ongoing healthy lifestyles, however it was funded by a one-off grant, so could not be continued.
Lifestyle modification programs have been demonstrated to be effective in the prevention of type 2 diabetes, but are limited for CALD communities in Australia.
Partner with diverse communities to develop diabetes prevention and care programs that are culturally appropriate and respond to community needs.
Supporting community-based prevention measures
Type 2 diabetes accounts for 85-90% of all diabetes in Australia16, a proportion reflected in the clients with diabetes that cohealth sees. As such, addressing contributing factors at a community level is a vital prevention measure. Healthy eating, nutrition and exercise programs, along with access to dietitians and the like, should be available and targeted to communities at greatest risk. Programs must recognise that people have many competing, and often more immediate, health, economic, education and social support priorities, so should be delivered in ways that reduce barriers. This can include: being provided in communities, free or very low cost, in community languages, particularly those of recently arrived communities, and at times that enable participation. As recommended above, developing responses in partnership with diverse communities will ensure they best meet community needs.
To improve long term health outcomes, program funding must be adequate to provide comprehensive, community designed responses, and be ongoing rather than short term.
Invest in ongoing, community based and led prevention programs.