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Topic on a Page - Diabetes

Data Sources:

Public Health England (PHE):

Data Profiles: Diabetes

NHS England:

Cardiovascular Disease Focus Pack Tool

NHS Digital:

GP2DRS (Diabetic eye screening programme)

National Diabetes Audit

NHS RightCare

Diabetes UK:

Diabetes Facts and Figures

Supporting Information:

National Institute for Care and Health Excellence (NICE):

Rehabilitation after critical illness in adults [QS158] September 2017

Resources: Diabetes: (pathways, guideance, advice, technology appraisal guidance, quality standards, in development)

Clinical Knowledge Summary – Diabetes Type 1

Clinical Knowledge Summary – Diabetes Type 2

Clinical Knowledge Summary – Insulin therapy in type 2 diabetes

Local Government Briefing – Encouraging people to have NHS Health Checks and supporting them to reduce risk factors [LGB15] February 2014

Multimorbidity [QS153] June 2017

Type 2 Diabetes in Adults: management [NG28] Updated May 2017

Type 2 diabetes: prevention in people at high risk [PH38] September 2017

Public Health England (PHE)

Health matters: preventing type 2 diabetes

NHS Evidence:

Diabetes Prevention

Diabetes Type 1

Diabetes Type 2

Diabetes and Cardiovascular disease

Diabetes and Stroke

Diabetes and Pregnancy

Diabetic Retinopathy

Diabetic Feet

Diabetes UK:

NHS Diabetes Commissioning Documents & Guidance

Diabetes UK Midlands

NHS England:

NHS Diabetes prevention Programme (NHS DPP)

Linked Topics:

Topic last reviewed: Apr-19

JSNA Topic: Diabetes

Background

Diabetes is one of the most common chronic diseases in the UK and the proportion of people being affected is continually increasing. In Lincolnshire, it continues to affect an increasing number of the population. Obesity accounts for 80–85% of the overall risk of developing Type 2 diabetes and this is a major public health issue (Source: NICE). In England, obese adults are five times more likely to be diagnosed with Type 2 diabetes than adults of a healthy weight (Source: PHE).

Diabetes is a long term condition that can have a major impact on the person with the condition as well as their family. Diabetes is classified as:

  • Type 1: develops when the insulin producing cells in the body have been destroyed and the body is unable to produce insulin. This type of diabetes accounts for about 10% of all adults with diabetes (Source: Diabetes.org). It can develop at any age but usually before the age of 40. This is the most common type of diabetes in childhood. Type 1 diabetes is becoming more common in the UK.
  • Type 2: develops when the insulin producing cells in the body are unable to produce enough insulin, or when the insulin that is produced does not work properly. It is the most common form of diabetes, accounting for between 85–95% of cases. This type of diabetes usually appears in people over the age of 40, although some groups have greater risk (see below) and in such cases it may appear earlier. An increasing number of children are developing Type 2 diabetes.
  • Gestational: where high blood sugar develops during pregnancy which usually resolves after delivery, although women who have had it are at increased risk of Type 2 diabetes in the future.
  • There are other specific types of diabetes, for example, drug/chemical induced diabetes.

Genetic factors are the main risk factors for Type 1 diabetes. For Type 2 diabetes, the risk factors are more varied and include:

  • Obesity and inactivity (obesity accounts for 80–85% of the overall risk of developing Type 2 diabetes (Source: NICE).
  • Family history.
  • Ethnicity (for example, people of Asian and African descent are 2–4 times more likely to develop Type 2 diabetes).

Diabetes can result in a wide range of complications, for example:

  • Cardiovascular disease (CVD) - is a major cause of death and disability in people with diabetes. People with Type 2 diabetes have a twofold increased risk of stroke within the first five years of diagnosis compared with the general population.
  • Chronic Kidney Disease (CKD) - during their lifetime, approximately 3 in 4 people with diabetes will develop CKD.
  • Retinopathy – diabetes is the leading cause of preventable blindness in people of working age.
  • Chronic painful neuropathy – is estimated to affect a quarter of the diabetes population and people with diabetes are estimated to be up to 30 times more likely to have an amputation compared with the general population.
  • Reduced quality of life – people with diabetes face significant challenges to daily living, for example, managing episodes of hyperglycaemia, self-monitoring of blood glucose and daily administration of insulin.

(Source: NICE)

It is therefore essential that, in addition to diabetes preventative interventions continuing to take place, people are provided with the support to be able to manage their condition to reduce their risk of diabetes complications.

The impact of diabetes on the health and social care sector is significant. It is estimated that diabetes accounts for approximately ten percent of the total health resource expenditure of which 80% are for treating potentially avoidable complications.

Context

National Strategies, Policies & Guidance

There are a wide range of strategic frameworks, plans and guidelines that have diabetes as a key, or related, component.

NHS Long Term Plan – sets out commitments for actions the NHS will take to improve outcomes on the major conditions, which includes diabetes. The Plan sets out a range of actions the NHS will take, for example in relation to the prevention of Type 2 diabetes, a focus on personalised support to enable self care, reducing variation in the quality of diabetes care and delivering digital delivery models for self-management education.

The NHS Mandate has a specific objective to lead a step change in the NHS in preventing ill health and supporting people to live healthier lives. One of the goals for 2020 is to support people to reduce their risk of diabetes through the NHS Diabetes Prevention Programme (NDPP) announced in the NHS Five Year Forward View. It aims to deliver services for people already identified with non- diabetic hyperglycaemia, and who are therefore at high risk of developing Type 2 diabetes. It also has a goal for a measurable reduction in variation in the management and care for people with diabetes, including improving the achievement of the National Institute for Health and Care Excellence (NICE) recommended treatment targets whilst driving down variation between CCGs.

Prevention is Better than Cure – sets a vision for putting prevention at the heart of the nation's health. The mission is to improve healthy life expectancy so that, by 2035, at least five extra years of healthy, independent life are had, whilst closing the gap between the richest and poorest. It recognises the role of healthy lifestyles such us, physical activity and obesity.

Public Health England‘s (PHE) Evidence into Action Plan identifies the need to develop evidence-based NHS preventative services and implement them at scale. Obesity is one of the priorities in the PHE Plan, therefore contributing to the prevention and management of Type 2 diabetes.

The NDPP, Diabetes Treatment and Care Programme and digital innovations in diabetes are three areas of diabetes work for NHS England (Source: NHS England). Diabetes has also been one of the areas in NHS England's Elective Care Development Collaborative (100 day challenge).

The NHS England CCG Improvement and Assessment Framework has diabetes as a key area with a number of indicators.

The NHS Right Care Commissioning for Value programme identifies opportunities to improve outcomes in the highest spending programmes. The Commissioning for Value Focus Packs have a focus on cardiovascular disease which includes diabetes. The NHS Rightcare Diabetes Pathway identifies seven national opportunities with a number of interventions and outcomes

The General Medical Service (GMS) Quality and Outcome Framework (QOF) financially rewards contractors for the provision of quality care, and helps to standardise improvements in the delivery of primary medical services. Diabetes is one of the clinical domains in the QOF, and has a range of associated indicators, including diabetes records/registers and the ongoing management of people with diabetes

NICE provides national guidance and advice to improve health and social care and has a wide range of publications addressing both the prevention and management of diabetes.

The Local Government Association (LGA) has published a wide range of resources to support the delivery of Local Government public health responsibilities. Some of these support the prevention of diabetes, for example: whole systems approach to tackling obesity, healthy ageing, tackling health inequalities and social prescribing.

Local Strategies & Plans

The Lincolnshire NHS System Plan for 2019/20 is currently being developed and this will be followed by a 5 year plan to show the local delivery of the NHS Long Term Plan locally. Diabetes is a system wide priority in Lincolnshire.

Diabetes is a key part of the Lincolnshire Sustainability and Transformation Partnership (STP) and it is identified as a Health and Wellbeing Challenge. STP targets have been set for 2021, for example, in relation to addressing overweight/obesity, NICE diabetes treatment targets and diabetes structured education. Diabetes prevention and management is an area in the STP Prevention Plan.

A number of priorities in the Joint Health and Wellbeing Strategy for Lincolnshire are very relevant to diabetes. Obesity is one of the priority areas and the link with Type 2 diabetes is highlighted in the Strategy. One of the objectives of the Strategy is to establish a whole system wide approach to obesity. Physical activity is another priority of the Strategy and the benefit of physical activity in reducing the risk of Type 2 diabetes is recognised. One of the objectives in the Strategy is to integrate physical activity into pathways and strategic planning.

What is the picture in Lincolnshire?

What the data is telling us

There is a wide range of information on diabetes, for example:

  • PHE Public Health Profiles provide a wide range of information in relation to diabetes (for example, National General Practice Profiles, Public Health Outcomes Framework, Health Profiles, Healthier Lives – Diabetes).
  • The National Diabetes Audit (NDA) measures the effectiveness of diabetes healthcare against NICE clinical guidelines and quality standards. It integrates data from both primary and secondary care sources.
  • The NHS Right Care Commissioning for Value Programme provides information on diabetes, for example, spend and the risk of various conditions for people with diabetes (for example, heart failure and stroke).
  • NHS Digital provides a range of diabetes indicators, for example; mortality from diabetes and emergency diabetes hospital admissions.
  • The Global Burden of Disease (GBD) study provides data on mortality, illness and disability burden and risk factors linked to the burden from 1990 to 2016.

Using these various data and information sources, some of the key findings in relation to Lincolnshire are:

  • The 2017 GBD highlights that diabetes is the eighth highest burden of disease in Lincolnshire, accounting for 2.47% of all disability life adjusted years (DALYs) which equates to 5,804 years (Source: Global Burden of Disease).
  • General practice data shows the registered adult diabetes population. In 2017/18, 50,489 people were on a diabetes register (7.8% of the Lincolnshire population aged 17+). The highest prevalence of diabetes is in Lincolnshire East CCG (8.9%). Some Lincolnshire general practices have nearly twice the Lincolnshire average of recorded diabetes (Source: PHE).
  • It is estimated that in Lincolnshire 12.4% (75,506) of the 16+ population have non-diabetic hyperglycaemia (pre-diabetes) and therefore at risk of developing Type 2 diabetes as well as other cardiovascular conditions. In England it is estimated that the overall prevalence is 11.4% (Source: PHE).
  • In Lincolnshire it is estimated that 63.7% of adults have excess weight (overweight or obese), with all the Lincolnshire local authorities having a higher percentage than the England average of (61.3%) (Source: PHE).
  • All CCGs in Lincolnshire have a higher proportion of people aged over 65 than England. The highest proportion being in Lincolnshire East CCG with 25.8% (Source: PHE).
  • The NDA shows variation across CCGs and general practices in the completion of the eight care processes (includes for example HbA1c, blood pressure, cholesterol, BMI, smoking and foot surveillance) and treatment targets (HbA1c, blood pressure and cholesterol).
  • The NHS Right Care Commissioning for Value 'Where to Look Diabetes Pathway' (January 2017) identifies that Lincolnshire CCGs are 'worse' than their comparator CCGs for diabetes patients receiving all three treatment targets (2014/15).
  • The Lincolnshire Diabetic Eye Screening Programme exceeds the 80% achievable uptake target (Source: NHS England).
  • The Lincolnshire preventable sight loss (diabetic eye disease) is 2.2 per 100,000 population, compared to the national average of 3.1 per 100,000 population (2016/17) (Source: PHE).

Trend

  • The Global Burden of Disease (GBD) study shows how diabetes is causing an increasing burden on the health of the population. Since 2010, the disability adjusted life years (DALYs) due to diabetes has increased by 16.65% (Source: Global Burden of Disease).
  • In Lincolnshire from 2012/13 to 2017/18, the number of adults on a diabetes register has increased by 18.5%. The overall prevalence has increased from 6.90% to 7.77% (Source: PHE).
  • The Diabetes Prevalence Model for Local Authorities and CCGs estimates the impact of obesity on diabetes prevalence using a number of scenarios and estimates diabetes prevalence to 2035. It is estimated that the total adult diabetes prevalence in Lincolnshire could be 10.3% by 2035 (diagnosed and undiagnosed) (Source: PHE Diabetes Prevalence Estimates for Local Populations).

Key Inequalities

There is a range of health inequalities relating to diabetes:

  • Deprivation is closely linked to the risk of both obesity and Type 2 diabetes. Prevalence of Type 2 diabetes is 40% more common among people in the most deprived quintile compared with those in the least deprived quintile.
  • People from black, Asian and other minority ethnic groups are at an equivalent risk of Type 2 diabetes at lower BMI levels than white European populations (Source: PHE).
  • Diabetes prevalence varies across both Lincolnshire general practices and CCGs.
  • People with diabetes are at a greater risk of a range of chronic health conditions including cardiovascular disease, blindness, amputation, kidney disease and depression, than people without diabetes.
  • The findings from the NDA (2017/18) for England show that fewer people with Type 1 than Type 2 and other diabetes receive their annual health checks.
  • Diabetic retinopathy is among the most common causes of sight loss in the working age population (Source: PHE).
  • People with diabetes have a reduced life expectancy.

There are a range of strategies and programmes to address health inequalities. The Marmot Review, a strategic review of health inequalities, identified six policy objectives for addressing health inequalities, for example, strengthening the role and impact of ill health prevention. Diabetes is specifically mentioned in the Review, for example, how diabetes prevalence is inversely related to income.

Current Activity & Services

There is a wide range of interventions to address diabetes which includes the prevention, on-going management and treatment of diabetes complications.

Diabetes Risk Assessment and Prevention

  • The NHS Health Check Programme is a screening and risk management programme that aims to identify people at risk of diabetes (and other conditions) amongst people aged 40-74 years.
  • The National Diabetes Prevention Programme aims to reduce the incidence of Type 2 diabetes, by reducing blood glucose parameters and reducing weight at 12 months and beyond. The service is being provided in Lincolnshire.
  • Making Every Contact Count (MECC) is an approach to encourage behaviour change utilising the millions of day to day interactions that organisations and people have with other people.
  • Public Health England's 'One You' campaign helps adults across the country avoid future disease caused by modern lifestyles.
  • Community Pharmacists provide a wide range of services. Further information on the services that they provide and how they contribute to the prevention and management of diabetes can be found in the Lincolnshire Pharmaceutical Needs Assessment (PNA).

Management of Diabetes and Treatment

  • General practices and NHS community and secondary care providers have a vital role in supporting people to manage their condition. Staff have been able to access training to ensure they are able to provide support to their diabetic patients. This includes foot care, clinical management and lifestyle support.
  • Much of the management and monitoring of diabetic patients, particularly patients with Type 2 diabetes, is undertaken by GPs and members of the primary care team. The general practice QOF includes a range of indicators in relation to the management of diabetes.
  • Lincolnshire is delivering the NHS England Treatment and Care Programme, specifically focusing on the NICE Three Treatment Targets and Multidisciplinary Footcare.
  • Lincolnshire Community Health Service NHS Trust provides specialist diabetes care to patients with complex, intermediate diabetic problems. This includes for example; the promotion of healthy lifestyles, treatment and care plans and patient education.
  • United Lincolnshire Hospitals NHS Trust provides a diabetes specialist service, which includes for example, inpatient diabetes management, managing diabetes related emergency admissions, diabetes education (for Type 1) and a specialist dietetic service. (People from Lincolnshire will also access out of county NHS hospital providers for specialist diabetes services).
  • Lincolnshire has been part of the NHS England Elective Care Development Collaborative (100 day challenge) which has had a focus on diabetes. This has brought together professionals from primary, community and secondary care to deliver diabetes care differently.
  • The National Diabetes Eye Screening Programme offers everyone aged 12 or over who has diabetes an annual screening test for diabetic retinopathy.
  • Diabetes UK provides a range of products and services to help people manage their diabetes.

Unmet Needs & Gaps

  • Estimated diabetes prevalence for Lincolnshire exceeds the actual registered prevalence, suggesting an undiagnosed diabetes population (many people have Type 2 diabetes for years without realising because early symptoms tend to be general). There is a need to continue to raise awareness amongst the population about diabetes and use diabetes screening tools to enable people with a confirmed diagnosis to be appropriately managed to prevent complications.
  • In addition to diagnosing the diabetes population, there is a need to continually identify and offer interventions for people at risk of diabetes, through the NHS Health Check Programme, National Diabetes Prevention Programme and other risk assessment tools.
  • There are some gaps in addressing excess weight and obesity across the four-tiered service model (Tiers 1-4). The JSNA Obesity (All Ages) topic provides further information.
  • The data from the NDA shows variation in diabetes care across general practices and CCGs which needs to be addressed to ensure people are appropriately managed. This is being addressed by the NHS England Treatment and Care Programme.
  • NICE has guidance that includes recommendations for diabetes patient education for both Type 1 and 2. It is known there are gaps in delivering the NICE recommendations in the county.

Local Views

Whilst not specific to diabetes, the Lincolnshire STP has carried out engagement to gain the local views on a wide range of health issues. Some aspects of the engagement programme will include issues that are relevant to diabetes.

Funding from the Health and Wellbeing Grant and the NHS England Treatment and Care Programme has enabled 'Living with Diabetes' days to take place in various locations in the County. These have provided an opportunity for people to share their experiences of living with diabetes. Furthermore, the NHS England Elective Care Development Collaborative (100 day challenge) has included an element of public engagement to ascertain the views of people on their diabetes care.

Risks of not doing something

Diabetes is a long-term condition that is becoming increasingly prevalent. Some of the known risk factors for diabetes can be addressed through preventative measures. Obesity is one of the risk factors for Type 2 diabetes, and therefore it is essential that interventions to reduce obesity continue to be applied to reduce the incidence of diabetes.

Diabetes can lead to serious health complications if the condition is not managed well. Consequently, it is essential that people receive good health care and the skills and knowledge to be able to self-care.

Diabetes accounts for a high proportion of NHS expenditure, which will continue to increase, without preventing diabetes and managing the condition to avoid complications.

What is coming on the horizon?

The NHS Long Term Plan includes diabetes as one of the major health conditions. There are a number of milestones to be achieved over the next ten years. NHS England are launching a national digital education platform called HeLP diabetes by the end of 2019/20.

What should we be doing next?

As a whole system we should continue to:

  • Take action to implement the priorities and objectives in the Joint Health and Wellbeing Strategy for Lincolnshire, specifically in relation to obesity and physical activity.
  • Deliver the National Diabetes Prevention Programme, focusing on those communities with greatest health need.
  • Deliver the NHS Right Care Programme opportunities to ensure that people with diabetes are appropriately managed to reduce complications. Continuing the work of the NHS England Treatment and Care Programme in Lincolnshire will support the Right Care opportunities to be addressed.
  • Take the lessons learnt from the NHS England Elective Care Development Collaborative into the system wide work on diabetes.
  • Provide people with the skills and knowledge to be able to self-care to reduce their risk of diabetes and manage their diabetes when diagnosed.
  • Commission and provide high quality healthcare for those people living with diabetes risk factors or established diabetes.

 

If you need to contact us about this topic, please email JSNA@lincolnshire.gov.uk

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