Diabetes

 Diabetes is a common long-term health condition which results when the body cannot properly control glucose (sugar) levels in the body. There are different types of diabetes but the four commonest are:

  • Type 1 diabetes: where the pancreas doesn’t produce any insulin, or not enough insulin, to help glucose enter the body’s cells.
  • Type 2 diabetes: where the insulin that is produced does not work properly (known as insulin resistance). This could also be associated with overweight and obesity and high blood pressure (NHS Choices).
  • Gestational diabetes: poor control of blood sugar during pregnancy
  • Secondary diabetes: damage to the pancreas due to other medical conditions or treatments

There are over 3.2 million people diagnosed with diabetes in England; 10% of those diagnosed have Type 1 diabetes (T1DM) and 90% have Type 2 diabetes (T2DM). An additional 9.6 million are thought to be at risk of developing Type 2 Diabetes. By 2025, it is estimated that there will be 4 million people with diabetes in England alone (Diabetes UK, 2014).

In addition, people are developing T2DM at a younger age (Holden et al, 2013). Every year around 20,000 people die early due to the complications of diabetes (Diabetes UK, 2014).

Worryingly, the rate of health complications caused by diabetes is rising. Diabetes now accounts for around 10% of the annual NHS budget; around £10 billion a year. Of this, around 80% is spent on managing potentially preventable complications (Diabetes UK, 2014).

What do we know

Risk factors

The risk of Type 1 Diabetes is mainly related to family history and inherited risk factors. The risk of Type 2 Diabetes is also higher in those with family history and those from certain ethnic groups e.g. those of a South Asian or African-Caribbean heritage. Type 2 Diabetes is 6 times more common in people of South Asian origin and up to 3 times more common in people of African and African-Caribbean origin.

Lifestyle factors, however, have the biggest impact on risk of Type 2 Diabetes. It is estimated that the majority of cases could, in fact, be prevented by adoption of healthier lifestyles. Body weight, and particularly waist circumference is strongly related to risk of diabetes.

In some people, blood sugar levels are higher than average but do not reach the threshold for diagnosis of Type 2 Diabetes. This is known variously as ‘impaired glucose tolerance’ (IGT), ‘non-diabetic hyperglycaemia’ (NDH) or simply ‘pre-diabetes’. This group is recognised as an important target group for diabetes prevention as studies show that 50% of those with NDH will develop diabetes within 10 years.

Complications

Both Type 1 and Type 2 diabetes can result in short-term and long term complications. Short-term complications arise from dangerously low or dangerously high levels of blood sugar (hypoglycaemia and diabetic ketoacidosis or hyperosmolar hyperglycaemic non-ketotic syndrome. Poor control of blood sugar over a prolonged time can lead to longer-term complications through damage to blood vessels.

Blood vessel damage can affect very small blood vessels in the eyes, kidneys and nerve endings particularly in the feet. Large blood vessels can also be affected, in fact heart disease and stroke (cardiovascular disease) are the most common cause of premature death in people with diabetes (Source: Diabetes and Cardiovascular Disease: Time to Act)

Facts, figures, trends

Risk factors

Slough has a high proportion of BME (Black and Minority Ethnic) patients: according to the national Census, 54% of Slough’s population is non-White (40% Asian, 9% Black). Over a quarter of adults in Slough are estimated to be obese.

Diabetes prevalence

Diabetes poses a particularly major health problem in Slough, due to a significantly higher than national average proportion of people with diagnosed diabetes, and low physical activity rates. There were 9,500 patients in Slough with diagnosed diabetes in 2014/15 (8.4% of the population) which is significantly higher than the national average of 6.4 % (Figure 1).

Estimations based on a diabetes model developed by the Yorkshire and Humber Public Health Observatory, however, indicate that there may be 770 people in Slough with diabetes who remain undiagnosed
An active pre-diabetes screening programme in Slough over 2014 saw an increase in the recorded prevalence from 8.2% to 8.4% and a resulting 500 more people on the diabetes register.

Figure 1. Percentage of population with a recorded diagosis of diabetes by GP in Slough

Figure 1

Though across Slough the prevalence of diabetes is high, with 11 of the 16 practices having significantly higher levels of diabetes than the national average, as illustrated in Figure 2 there is significant variation in rates of diabetes across Slough’s GP practices, ranging from 6% to over 13% (excluding the walk-in centre).

Figure 2. Diabetes Prevalence (QOF prevalence) according to GP Practice (2014/15)

Figure 2

Based on Office of National Statistics population projections the total population with diabetes in Slough in 2020 will be 14,172. This burden could be even greater, with Public Health estimates suggesting that there could be over 3,000 people with undiagnosed diabetes in Slough.

Non-Diabetic Hyperglycaemia (NDH)

It is estimated that an additional 13,242 (12%) adults in Slough, though not diabetic, meet the criteria for non-diabetic hyperglycaemia Of those attending our Healthy Hearts Programme locally, 10% were found to have NDH.

From April 2016, practices will be encouraged to update their registers again and to screen around 45,000 people to identify who to refer to the exercise and diet programme which will be commissioned from national providers over the next three years (see Local Strategy).

Diabetes treatment and outcomes

In terms of primary care targets for treatment, Slough GP practices perform very well, exceeding the national average for all monitoring and treatment indicators, these include keeping blood pressure, cholesterol and blood sugar measurements within the target range.

39% of people with diabetes in Slough met all three targets for control of blood pressure, blood sugar and cholesterol. This was the third best result in the South Central region, behind only Windsor, Ascot and Maidenhead CCG and Bracknell and Ascot CCG.

Diabetes total complication rate similar to the national average despite a much higher level of diabetes in the borough, though proportion of diabetics admitted to hospital with serious complications (MI, stroke, stage 5 CKD) is higher than national average, suggesting that though total complication rate is controlled, serious complications are not being avoided.

National and local strategies (current best practices)

National Guidelines

NICE Guideline (PH38) Type 2 diabetes: prevention in people at high risk (2012) recommends that risk assessments should be provided to all patients with potential risk factors. Interventions suggested should be matched to the level of risk assessed.

NICE Guideline (PH35) Type 2 diabetes prevention: population and community-level recommends that local action should be taken to reduce the burden of risk factors across the population and not just in high risk groups. Suggestions for action include performing a local joint strategic needs assessment and using this develop a local strategy for prevention. The strategy should include promotion of physical activity as well as healthy diet. Healthy lifestyle messages should be consistent, clear and culturally appropriate.

National Frameworks

There are a number of frameworks in place to ensure a consistent and high standard of care for patients with diabetes. For example, the 2001 National Service Framework for diabetes established 9 standards for the provision of high quality services, which cover the identification, empowerment and care of patients with diabetes. Two main performance measures are the National Diabetes Audit (NDA) and the GP Quality and Outcomes Framework (QOF).

Local

National Diabetes Prevention Programme

The NDPP is a joint commitment from NHS England, Public Health England and Diabetes UK, to deliver at scale, an evidence-based behavioural programme to support people to reduce their risk of developing Type 2 diabetes .The programme is mainly about weight reduction, healthier diet and increasing physical activity. This will have a knock-on effect to reduce a host of other health risks/long-term conditions and dependency on social care services. Slough has been selected as a site for the "first wave" of roll out of the programme.

The programme will target those at high risk only by inviting those with known risk factors e.g. high BMI or those from high risk ethnic groups, to have a screening blood test. Those found to meet the criteria for non-diabetic hyperglycaemia (NDH) will then be referred to the programme.

Based on data from demonstrator sites where the programme has been pilots, it is estimated that in a practice of approx. 10,000 people around 1,500 or 1 in 50 adults will be diagnosed with NDH enabling them to take action.

If eligible for referral to the programme a key message is that if people stay on the programme for 9 months and reach their goals then their risk for conversion to diabetes will be reduced to zero for at least the next five years (comparative data isn’t available for longer than this period).

(Source: National Diabetes Prevention Programme)

Slough Diabetes Network

Diabetes networks are key to ensuring cohesion of the above services and in ensuring clear and consistent communication between teams. The Slough Diabetes Network was established in April 2013 and has the goal of sharing innovation and best practice both within the Clinical Commissioning Group and across the wider federation.

What is this telling us?

Diabetes is one of the major local health concerns as it is a long-term disease with significant effects on morbidity (ill health) and mortality (death). Slough has the highest prevalence of diabetes (8.4%) and largest proportion of non-white BME population (54%) compared to any other local authority across Berkshire and therefore there is a significant burden of disease in the borough.

The local diabetes networks (consisting of GPs, public health specialists, commissioners, consultants, patient groups, providers and managers) have made considerable in-roads in improving the offer rates of the Key Care Processes, including providing more specialist nurses, and improving education and strengthening networks.

What are the key inequalities?

Ethnicity

Type 2 Diabetes is up to six times more common in people of South Asian origin and up to three times more common in people of African/Caribbean origin than the white population.

Socioeconomic status
Those in the most deprived fifth of the population are at 1.5 times greater risk of developing diabetes than those in the rest of the population and are at 3.5 times greater risk of dying from compications.

Disability

People with disabilities are at greater risk of being physically inactive and of having problems with weight, and therefore are at greater risk of developing Type 2 Diabetes.

Gender
Though diabetes is more common in men than in women, it is women that are more likely to die due to diabetes than men,

Age

Over one in twenty people over the age of 65 have diabetes, this rises to one in five people aged over 85.

(Source: Department of Health – Inequalities in Diabetes)

What are the unmet needs/ service gaps?

  • Local primary care management of diabetes is good, prevention of type 2 diabetes however remains a priority
  • There are a significant cohort (>12,000) of adults likely to have NDH (pre-diabetes) in Sough that are at higher risk of developing diabetes and therefore need to be targeted

Recommendations for consideration by other key organisations

  • Implementation of the National Diabetes Prevention Programme
  • Continuation of promotion of NHS Health Checks

 

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