‘A Diabetic Tsunami’ – The Welsh hospitals grappling with rising diabetes

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“Knife to skin.”

I’d never heard the expression before. Nor had I ever heard the piercing crack of a fibula bone being cut in two. But we all hear it. Knife to skin. Bone-cutter to bone. And now a new sound: the urgent, frenetic buzzing of an oscillating power saw.

Dave Lewis – a vascular surgeon who used to work in Christchurch, New Zealand, until its earthquake in 2011 obliterated his home – moves the saw closer to the newly formed opening in Kay’s solitary, bare leg. He positions it just below the knee.

It resembles a regular hand-held power drill – bar a steel rectangular blade, serrated at the end, in lieu of the drill-bit. In a matter of seconds, it cuts straight through Kay’s remaining tibia bone. More cutting, more cauterising follows. The leg is severed. “Thank you,” Lewis says quietly to his team.

Kay lies motionless, her face and torso hidden under a light blue surgical drape. Shrouded, save for a tuft of her hair at the top, beneath the gaze of an anaesthetist.

Her disembodied leg, with its partially blackened, ulcerated foot, is wrapped in a dull green sterile bag, tied at the top, and dropped into the “limb bin” of Cardiff’s Operating Theatre 15. It bears the instruction: “Destroy by incineration.”

In 2021/22, diabetes was linked to more than 650 amputations in Wales (in England the annual average is more than 9,000). This is Kay’s second. As the number of patients with diabetes continues to soar, so do the myriad demands on health services. “It is a major public health crisis,” says the charity Diabetes UK, “and it’s worsening at breath-taking speed.”

We first met Kay on the vascular ward of Cardiff’s University Hospital of Wales. Of the 38 patients there, astonishingly, nearly half had diabetes – a condition characterised by high blood glucose levels when the body can’t produce any or enough insulin (or the insulin itself doesn’t work properly). Kay has had Type 1 diabetes since childhood. Nearly all the other patients have Type 2, which is often preventable and commonly associated with obesity, low physical activity, and old age.

“All the arteries are furred up inside,” Kay tells me, propped up in her hospital bed, glancing towards her outstretched leg.

The sole of her foot is rough, red and scabrous. Two of her toes are near pitch-black, tissue appears to be missing, sacrificed to gangrene. The risks of further infection poisoning her body leave little option but amputation.

It’s estimated around one in three people with diabetes, like Kay, will at some point develop a foot ulcer, often due to peripheral nerve damage. The loss of feeling in a ‘diabetic foot’ can cause horrific wounds. “We’ve had patients with drawing pins and needles,” says ward manager Rhiannon Joseph. “Or a set of keys in a shoe that he hadn’t realised he’d ended up walking on for a week.”

Rhiannon Joseph’s ward is increasingly populated by the limbless. “There’s been a massive increase especially over the last few years,” she says. “Last week we did six amputations, this week we’re already scheduled to do up to three. Amputation of toes and forefoot we’re doing every day.” She estimates 80% of the patients involved have diabetes.

At least 8% of the adult population in Wales now has diabetes, the highest estimated prevalence rate of the four UK nations (it’s 7.3%, for instance, in England), with more and more hospitalised as a result. Wales is comparatively older and frailer as a nation, with high levels of obesity. But the rate of new diabetes registrations, mostly Type 2, continues to astound.

Over a 12-year period (up to 2021/22), Public Health Wales reported an increase of almost 60,000 people with diabetes in Wales. That amounts almost to a 40% rise. “If current trends continue,” the Welsh government’s health agency warned recently, “we estimate that around 1 in 11 adults will be living with diabetes in Wales… an increase of nearly 48,000 people by 2035/36.”

Amputations happen only in extreme cases, and with support (including from charities like Diabetes UK), many people with diabetes can manage their condition effectively. But clearly this vast diabetic caseload, fuelled in part by rising obesity levels, is stretching an already stretched NHS, from renal to stroke wards, and beyond.

Forty miles away, in a hospital room in Swansea, Richard sits alone, peering out of the window. In truth, it is a largely futile exercise. The 57-year-old school canteen worker can barely see the frame of the window, let alone what’s beyond it. He has diabetic retinopathy, where, over time, excess sugar in his blood has caused an abnormal growth of blood vessels in the retina of his left eye. His vision is now obscured by bleeding from the burst vessels.

“You’re just figures, a blur… that’s all,” he replies when asked what he can see. So much blood has leaked into his left eye, he needs an hour-long ‘vitrectomy’ operation to extract it.

One of the consultant ophthalmologists in Swansea’s Singleton Hospital, Gwyn Williams, refers to a “diabetic tsunami… we’re filling up clinics faster than we can staff them.” In response to a Channel 4 News request, the Welsh government estimated 69,000 people in Wales now have some degree of diabetic retinopathy.

The cruelties of sight loss – among so many other debilitating (in some cases fatal) complications experienced by some of those with diabetes – are compounded by the injustices involved. People from Black African, African Caribbean and South Asian backgrounds, for instance, are at risk of developing Type 2 diabetes from a much earlier age than the white population. Type 2 diabetes is also markedly more prevalent in areas of higher deprivation. Inequality forms a critical backdrop to this crisis.

In a deteriorating picture across the UK, cases of younger people being diagnosed with Type 2 diabetes are accelerating. Clearly, the financial costs to the NHS are vast.

Last month the University of York’s Health Economics Consortium (commissioned by Diabetes UK) published new research which estimated that the direct costs of diabetes in 2021/22 to the NHS, UK-wide, was £10.7 billion.

Across the UK, various national Diabetes Prevention Programmes have been established. In Wales, the government has been pushing ahead with its diabetic eye screening programme. It’s rolling out intervention work through GP surgeries for patients considered ‘pre-diabetic’. In Cardiff, the health board has established new models of care with emergency diabetic foot clinics.

But it’s hard to detect any significant dents in the problem. Meanwhile the obesity epidemic shows no signs of abating.

In the operating theatre in Cardiff, Dave Lewis and his team have been threading stitches around Kay’s newly formed stump. As we leave, I ask him about the projection that, on current trends, there could be nearly 50,000 more patients in Wales with diabetes in just over a decade. “The NHS is always very good at coping,” he replies, “but it’s going to be a big ask, isn’t it?”

And with that, another operating team begins to arrive, waiting for their next slot. Knife to skin. It is relentless.