Diabetes

Diabetes is a long-term condition that can have major impacts on a patient and their family. Classifications of diabetes are: 

• Type 1: or Type 1 Diabetes Mellitus (T1DM) develops when insulin producing cells have been destroyed so the body is unable to produce insulin. Type 1 diabetes accounts for about 8% of all people with diabetes (Source: Diabetes.org). It can develop at any age, but usually manifests before the age of 40. It is the most common type of diabetes in childhood. Type 1 diabetes is becoming increasingly common in the UK. 
• Type 2: or Type 2 Diabetes Mellitus (T2DM) develops when the insulin producing cells in the body cannot produce enough insulin, or when insulin sensitive tissues fail to respond to insulin that is produced. It is the most common form of diabetes, accounting for between 85–95% of cases. T2DM usually appears in people over the age of 40, although some groups are at a greater risk, and in such cases, it may appear earlier. An increasing number of children are developing T2DM. 
• Gestational Diabetes Mellitus (GDM): when high blood sugar develops during pregnancy. This usually resolves after delivery, although women who have had GDM are at increased risk of T2DM in the future. 
• There are other specific types of diabetes, for example, drug/chemical induced diabetes. 

Diabetes is one of the most common chronic diseases in the UK. In Lincolnshire and nationally, it continues to affect an increasing number of the population. Genetic factors are the main risk factors for T1DM. For T2DM, risk factors are more varied and include: 

• Obesity and inactivity. Obesity accounts for 80–85% of the overall risk of developing T2DM, which is a major public health issue (Source: NICE). In England, obese adults are five times more likely to be diagnosed with T2DM than adults of a healthy weight (PHE). 
• A family history of diabetes. 
• Ethnicity (for example, people of Asian and African descent are 2–4 times more likely to develop T2DM). 

Studies have shown that people who are lonely are more likely to develop T2DM, independent of other lifestyle risk factors. Isolation (i.e. the absence of social contact) is not a predictor of T2DM, however, loneliness (i.e. a feeling of lack of meaningful relationships) is. This is possibly due to the body’s response to stress (Source: Diabetologia). 

“People with learning disabilities are more likely to be obese or overweight and inactive, both of which are risk factors for type 2 diabetes”, therefore people with learning disabilities are more likely to develop T2DM, and at an earlier age. Additionally, they may suffer inequality of access to regular monitoring, surveillance, and of structural education that they receive (Source: PHE). 

Research also reveals associations between incidence of T2DM and socio-economic status, suggesting that people from lower income groups are more likely to develop T2DM (Source: International Journal of Epidemiology). “Deprivation is strongly associated with higher levels of obesity, physical inactivity, unhealthy diet, smoking and poor blood pressure control, all of which are linked to the risk of developing Type 2 diabetes and the risk of serious complications amongst those already diagnosed with both Type 1 and Type 2 diabetes.” People in more deprived areas are less likely to have regular health checks, further increasing their risk of complications (Source: Diabetes UK).  

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

• Cardiovascular disease (CVD): a major cause of death and disability for people with diabetes. People with T2DM 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 people with diabetes; and 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 can face significant challenges to daily living, for example, managing episodes of hyperglycaemia, self-monitoring of blood glucose, and daily administration of insulin (Source: NICE). 

NHS Long Term Plan – sets out commitments for actions the NHS will take to improve outcomes on major conditions, which includes diabetes. 

The National Institute for Health and Care Excellence (NICE) provide guidance, advice and quality standards.

Prevention is Better than Cure – a vision for putting prevention at the heart of the nation’s health. It recognises the role that healthy lifestyles play, such as increased physical activity to reduce obesity. 

Public Health England‘s (PHE) Evidence into Action Plan identifies the need to develop evidence-based preventative services and implement them at scale. Obesity is one priority in the PHE Plan, therefore contributing to the prevention and management of T2DM. 

The NHS Diabetes Prevention Programme (NDPP); Diabetes Treatment and Care Programme; and digital innovations in diabetes are three workstreams of NHS England (Source: NHS England). Diabetes has been one of the focus areas in NHS England’s Elective Care Development Collaborative (100 day challenge). 

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 General Medical Service (GMS) Quality and Outcome Framework (QOF) financially rewards contractors for the provision of quality care, helping to standardise improvements in the delivery of primary medical services. Diabetes is one of the clinical domains of the QOF. 

The Local Government Association (LGA) has published many resources to support the delivery of Local Government public health responsibilities, including the prevention of diabetes. 

The 2019 Global Burden of Disease (GBD) highlights diabetes as the eighth highest burden of disease in Lincolnshire. Diabetes accounts for 3.48% of all disability life adjusted years (DALYs). 

GP practice data show the percentage of patients with diabetes in Lincolnshire has been consistently higher than the national average. The proportion of patients who have T2DM and are aged 65 years or over is higher than the national average, although, this may be expected given the older age profile of the population.  In Lincolnshire, a higher proportion of people with T2DM are white, and fewer are of minority ethnic origin, compared to the national average.   

In part, the high prevalence of diabetes in Lincolnshire can be attributed to excess weight (overweight or obese). The prevalence of excess weight locally has been consistently worse than the national average, particularly in Boston, South Holland and South Kesteven. The Diabetes Prevalence Model estimates total (diagnosed and undiagnosed) adult diabetes could be 10.3% by 2035 (Source: PHE Diabetes Prevalence Estimates for Local Populations). 

The percentage of people with T2DM offered a structured education programme is better for Lincolnshire than the national average. This leads to better treatment outcomes and fewer foot care complications. The East coast of Lincolnshire currently has some of the highest rates of diabetes nationwide.  Mablethorpe, Sutton on Sea and Trusthorpe have low uptake and engagement with the NHS Diabetes Prevention Programme (NDPP). This must be due, in part, to a lack of awareness of the programme, and a lack of understanding of T2DM. 

The National Diabetes Audit (NDA) shows variation across general practices in Lincolnshire of the completion of the eight care processes (HbA1c measurement, blood pressure, cholesterol measurement, retinal screening, weight check, serum creatinine testing, urinary albumin testing, and foot checks); and treatment targets (HbA1c, blood pressure, and cholesterol). 

The NHS Right Care Commissioning for Value ‘Where to Look Diabetes Pathway’ (January 2017) highlighted that Lincolnshire CCG was ‘worse’ than its comparator CCGs for diabetes patients receiving all three treatment targets (2014/15). 

The Lincolnshire Diabetic Eye Screening Programme exceeds the 85% achievable uptake target (NHS England). 

An Integrated Lifestyle Service (ILS) is commissioned across Lincolnshire, to support residents to lead healthier lifestyles. This includes key measures to prevent T2DM such as weight management, physical activity, reducing alcohol consumption, and smoking cessation. Let’s Move Lincolnshire is another local preventative approach, working to increase physical activity levels. Both approaches align with the Better Health initiative. 

The NHS Health Check Programme is a screening and risk management programme to identify people at risk of diabetes (and other conditions) of people aged 40-74 years. 

The National Diabetes Prevention Programme intends to reduce the incidence of T2DM with interventions that reduce blood glucose parameters and reduce weight over the 12 month programme and longer term. The service is being provided in Lincolnshire. 

Making Every Contact Count (MECC) encourages behaviour change by utilising the millions of day to day interactions that professional have with members of the public. 

Community Pharmacists now provide a wide range of services. The services they provide, and how pharmacists can contribute to the prevention and management of diabetes can be found in the Lincolnshire Pharmaceutical Needs Assessment (PNA). 

Much of the management and monitoring of diabetic patients, particularly those with T2DM, is undertaken by GPs and primary care team staff. The general practice QOF includes a range of indicators related to the management of diabetes. 

Lincolnshire healthcare staff deliver 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 by promoting healthy lifestyles, producing treatment and care plans and educating patients. 

United Lincolnshire Hospitals NHS Trust provides a specialist diabetes service. This comprises inpatient diabetes management, managing diabetes related emergency admissions, diabetes education (for Type 1) and a specialist dietetic service. Some people from Lincolnshire will 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) that has a focus on diabetes. This brought together professionals from primary, community, and secondary care, to deliver diabetes care differently. 

The National Diabetes Eye Screening Programme offers an annual screening test for diabetic retinopathy to everyone with diabetes aged 12 and over. 

Diabetes UK provide products and services to help people manage diabetes. 

The NHS England Elective Care Development Collaborative (100–day challenge) included an element of public engagement to ascertain the views of people on their diabetes care. 

Estimated diabetes prevalence for Lincolnshire is higher than registered prevalence, suggesting many in the population with undiagnosed diabetes. In fact, many people have T2DM for years without realising because early symptoms tend to be general. Raising awareness about diabetes for the whole population, and use of diabetes screening tools, will enable people with a confirmed diagnosis to be offered help and prevent unwanted complications. 

In addition to diagnoses, there is a continual need to identify and offer interventions for people at risk of diabetes. This partly achieved by the NHS Health Check Programme, National Diabetes Prevention Programme, and other risk assessment tools. 

Prevention of obesity is complex and challenging at the population level. The food and physical activity landscape of the UK contribute to an overly obesogenic environment. Nonetheless the known inequalities of childhood obesity demonstrate that weight gain is not inevitable. It is linked to an individual’s resources – their ability to choose less convenient, maybe more expensive option, when making choices of nutrition and activity. There are gaps in addressing excess weight and obesity across the four-tiered service model. The Healthy Weight JSNA topic provides further information. 

Data from the NDA show variation in diabetes care across general practices which need to be addressed if people are to be provided with optimum care. This is somewhat addressed by the NHS England Treatment and Care Programme. NICE guidance includes education recommendations for patients of both T1DM and T2DM. There are known gaps in the delivery of NICE recommendations in the county. 

Take action on obesity and physical activity by implementing the priorities and objectives in Lincolnshire’s Joint Health and Wellbeing Strategy. 

Deliver the National Diabetes Prevention Programme, focusing on communities with the greatest health needs. 

Deliver the NHS Right Care Programme to ensure that diabetes is appropriately managed and complications reduced. Continue the work of the NHS England Treatment and Care Programme in Lincolnshire to support the Right Care opportunities. 

Assign the “lessons learnt” from the NHS England Elective Care Development Collaborative to 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 people living with diabetes risk factors or with established diabetes.