DIABETES HEALTH
NEEDS ASSESSMENT
LUTON BOROUGH
COUNCIL
Produced by Luton
Public Health
Intelligence Team
Contents
Executive Summary................................................................................................................................. 2
Recommendations .................................................................................................................................. 4
1 Introduction ......................................................................................................................................... 5
2. Demographics ..................................................................................................................................... 5
2.1.1 Population .................................................................................................................................. 5
2.1.2
Population projections ........................................................................................................ 6
2.1.3
Ethnicity and migration ....................................................................................................... 7
2.1.4
Deprivation.......................................................................................................................... 8
3. Risk Factors ......................................................................................................................................... 9
3.1 Obesity .......................................................................................................................................... 9
3.2 Physical activity and diet ............................................................................................................. 11
3.3 Family history of diabetes ........................................................................................................... 12
3.4 Ethnic background ...................................................................................................................... 12
4. Prevalence ......................................................................................................................................... 12
4.1 Recorded and Expected Prevalence............................................................................................ 13
4.2 Hospital admissions .................................................................................................................... 15
5. Early Diagnosis and Primary Care Management ............................................................................... 15
5.1 Health Checks.............................................................................................................................. 15
5.2 Diabetic Retinopathy Screening .................................................................................................. 16
5.3 Primary Care Management ......................................................................................................... 18
6. Provision of service and care ............................................................................................................ 26
6.1 Complications of diabetes........................................................................................................... 26
7. Costs of diabetes ............................................................................................................................... 35
8. Mortality due to diabetes ................................................................................................................. 39
9. Service user perspective ................................................................................................................... 40
10. Provider perspectives and what are we doing locally? .................................................................. 41
11. NICE guidelines................................................................................................................................ 45
12. Recommendations .......................................................................................................................... 46
13. References ...................................................................................................................................... 47
1
Executive Summary
Diabetes is a condition that causes a person's blood sugar level to become too high. There
are two main types of diabetes these are type 1 and type 2.
Risk Factors


An increase in the older population is likely to lead to an increase of diabetes within the
borough as age is a risk factor of diabetes.
Prevalence of obesity in Luton adults aged 16 and over in 2014/15 is 9.8%; this is
significantly higher than the England average.

Prevalence of obesity in Luton reception year children in 2014/15 is 10.2%; this is
significantly higher than the England average of 9.1%.

Prevalence of obesity in Luton year 6 children in 2014/15 was 23.4%; this was
significantly higher than the England average of 19.1%.

Proportion of people eating 5 a day (41.3%) in Luton is significantly lower than the
national average (53.5%).

Proportion who meet the recommended level of physical activity in Luton (45.1%) is also
significantly lower than national levels (57%).
Prevalence

Luton (7.6%) has a prevalence of diabetes significantly higher than the England average
6.3%.

Recorded prevalence for diabetes within Luton GP practices for 2014/15 shows there is
wide variation with prevalence ranging from 2.3% to 12.3%. A total of 10 practices have
recorded prevalence significantly lower than the Luton average and the same numbers
have recorded prevalence significantly higher than Luton.
Early Diagnosis and Primary Care Management
 In recent years Luton has consistently has a higher health check uptake compared to the
national average.

Luton (86.8%) has a significantly lower percentage of diabetes patients who have had
retinopathy screening in 2013/14 compared to the national average (90%).

10 practices in Luton have a significantly lower percentage of diabetes patients who
have had retinopathy screening in 2013/14 compared to the Luton average (86.8%). 17
practices have a percentage significantly higher than Luton.
2

The percentage of patients with diabetes, on the register, in whom the last blood
pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less,
2014/15. The proportions range from 70.7% to 98.5%. Six practices had percentages
significantly lower than the Luton average and 11 practices had percentages
significantly higher than Luton.

The percentage of patients with diabetes, on the register, in whom the last blood
pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less,
2014/15. The proportions range from 41.7% to 92.9%. Eight practices had percentages
significantly lower than the Luton average and 13 practices had percentages
significantly higher than Luton.

The percentage of patients with diabetes, on the register, whose last measured total
cholesterol (measured within the preceding 12 months) is 5 mmol/l or less, 2014/15.
The proportions range from 56.4% to 88.8%. Six practices had percentages significantly
lower than the Luton average and nine practices had percentages significantly higher
than Luton.

The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c
is 59 mmol/mol or less in the preceding 12 months, 2014/15. The proportions range
from 35% to 81%. Five practices had percentages significantly lower than the Luton
average and nine practices had percentages significantly higher than Luton.

The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c
is 75 mmol/mol or less in the preceding 12 months, 2014/15. The proportions range
from 51% to 97%. Eight practices had percentages significantly lower than the Luton
average and nine practices had percentages significantly higher than Luton.

Luton diabetes patients have an additional risk of 178% (or 1.7 times more) of
developing angina compared to non-diabetes patients. This is significantly higher than
the national average (136.8%) or 1.4 times more

Luton diabetes patients have an additional risk of 186% (or 1.9 times more) of
developing heart failure compared to non-diabetes patients. This is significantly higher
than the national average

Luton diabetes patients have an additional risk of 139% (or 1.4 times more) of a
myocardial infarction compared to non-diabetes patients. This is significantly higher
than the national average
Costs of Diabetes

The current total spend on diabetes prescribing per person in NHS Luton CCG was
£241.51. This ranks the CCG 12 of 211 CCG’s on the diabetes QOF register nationally
(with 1 representing the CCG with the lowest spend).
3

The CCG’s total spend for this indicator in 2013/14 was £3,020,060. The total spend on
diabetes prescribing per person with diabetes in NHS Luton for this CCG is currently
within the lowest 25% nationally.
Recommendations
Prevention and screening
• Primary and community services should provide brief advice at every opportunity
and refer to lifestyle services where appropriate (NICE PH35)
• Identification and referral to intensive lifestyle support in high risk and vulnerable
groups (NICE PH38) should be systematically rolled out across primary and
community care including pre-diabetes and diabetes
Early Detection and diagnosis /Treatment: improving experiences of care and support
• Reduce variation in primary care of
– Health checks uptake with a focus on quality including referral onto intensive
lifestyle programmes
– Diabetic Retinopathy Screening with NHS England
– Newly diagnosed diabetics and refer to structured education programme
including self-care and foot care (NICE guidance 19)
– BP and cholesterol control in diabetics linked primary care investment
programme
– Hba1c control with a focus in Medics cluster
Aftercare
• Embed within diabetes pathway post treatment lifestyle advice and support for all
patients linked to Enhanced Recovery Programme
Integrated commissioning
• Review current pathway /service offer, to reduce duplication and redistribute to
need (CCS) and develop discharge bundle for repeat admissions. Consider a CQUIN.
• Ensure all diabetes specifications are outcomes focused and linked to other relevant
specifications.
• Embed NICE Quality Standard (QS6, QS125 and QS109) into contracting and monitor
performance to reduce additional risk of complications.
4
1 Introduction
Diabetes is a condition that causes a person's blood sugar level to become too high. There
are two main types of diabetes these are type 1 and type 2. Type 1 diabetes is when the
body is unable to produce insulin. Insulin is a hormone which enables the body to use the
glucose in the blood. Type 1 diabetes accounts for around 10% of all diabetes within adults.
Type 2 diabetes is when the body is unable to produce enough insulin or when the insulin
produced does not work properly (Diabetes UK 2015). Type 2 diabetes is far more common
than type 1. In the UK, around 90% of all adults with diabetes have type 2. There are 3.9
million people living with diabetes in the UK. That's more than one in 16 people in the UK
who has diabetes either diagnosed or undiagnosed (NHS 2014). People with diabetes are
more likely to be at risk from coronary events, strokes and other vascular problems.
Targeted diabetes case finding, together with screening for Chronic Kidney Disease, forms
part of the NHS Health Checks programme (NHS 2014).
The prevalence of diabetes rises steeply with age: one in twenty people over the age of 65
in the UK have diabetes and this rises to one in five over the age of 85 years. People of
South Asian, African, and African-Caribbean descent have a higher than average risk of
developing type 2 diabetes than the population as a whole (Diabetes UK 2015). The
frequency of diabetes in England is higher in men than in women; however, women with
diabetes are at relatively greater risk of dying than men (Diabetes UK 2015). This is possibly
due to how gender compounds other aspects of inequality such as social-economic
differences in the prevalence of diabetes and obesity. In addition, pre-menopausal women
with diabetes do not have the same protection against CHD as women who do not have
diabetes (Diabetes UK 2015).
Women who have had gestational diabetes are also at increased risk of developing Type 2
diabetes (NHS 2014). Having polycystic ovary syndrome increases the risk of diabetes,
especially combined with being overweight or obese (Diabetes UK 2015).
2. Demographics
The health of the population of Luton tends to be slightly poorer than the England average.
The poorer health outcomes are linked primarily to the levels of socioeconomic deprivation
experienced by a significant segment of the population. This section will describe the
numbers and projected growth of the population; demographics (e.g. age, gender, and
ethnicity); population movement in and out of the borough; deprivation and poverty.
2.1.1 Population
The latest (2014) Office for National Statistics (ONS) Mid-Year Population Estimate for Luton
was 211,000. In recent years, there has been convergence between the ONS figures and
those of the Council due, in the main, to improved accuracy of ONS data as a result of
increased enumeration in the 2011 Census and the subsequent rebasing of population
figures.
Figure 2.1 shows the most densely populated areas of Luton are in the centre of the town.
With an area of 4,336 hectares, the official (ONS) population figure translates into a
5
population density of 48 people per hectare. This figure is greater than many London
Boroughs.
Figure 2.1: Luton population density
Source: Census 2011, Office for National Statistics and Ordnance Survey
2.1.2 Population projections
Luton’s population is projected to grow significantly between 2011 and 2031, with the latest
forecasts projecting growth of 25% in the next 20 years (LBC 2015). Key drivers for this are
high levels of natural growth (more births than deaths) and international in-migration.
Luton also has high population churn and a study found that 70% of the population in Luton
in 2010 was either not born or not living in Luton at the time of the 2001 Census (Mayhew
and Waples 2011).
Table 2.1 shows a summary of population projections for Luton. Key changes over the next
20 years are:
 Population of Luton is projected to increase by 50,400, a rise of 25%.
 School age population (5-15 year olds) is projected to increase by 7,850, a rise of
26%.
 Those aged 65-89 is projected to increase by 10,750 people, a rise of 47%.
 Very elderly population (90+) is projected to increase by 1,450 people, a rise of
153%.
An increase in the older population is likely to lead to an increase of diabetes within the
borough as age is a risk factor of diabetes, this will put more pressure on resources within
the borough.
6
Table 2.1: Luton population projections by age from 2011 to 2031
Source: Luton Borough Council using POPGROUP software and a ten year migration average.
Components may not sum to totals due to rounding.
2.1.3 Ethnicity and migration
Figure 2.1.3 shows the board ethnic groups in the Luton population, with approximately 45% of the
population being of Black and Minority Ethnic Origin (BME) or non-white. The ethnic composition of
Luton fits a model known as ‘super-diversity’ in which there is an increasing number of BME
communities within the population each with its own needs and cultures. Luton has a long history of
migration into the area both from elsewhere in the UK and overseas. There have been long-standing
African-Caribbean, Bangladeshi, Indian, Irish and Pakistani communities in Luton as a result of
international migration. More recently, the migration patterns have become more complex. In the
mid-1990s, the opening of the University of Luton (now the University of Bedfordshire) caused a
rapid growth in the student population of the town. This growth has been sustained with an
increase in numbers of overseas students.
In the mid-2000s, the expansion of the European Union led to a significant increase in migration
from eastern European countries, particularly Poland and Lithuania. 7% of Luton’s population is
classed as ‘other white’ which is the group for non-British or Irish Europeans (but this group also
includes people from other parts of the world including Americas and Australasia) (England has 4.6%
of the population in this category). There has also been in-migration from African countries such as
the Congo, Ghana, Nigeria, Somalia and Zimbabwe. There is also a Turkish population in
Luton. More recently, National Insurance Registration data has demonstrated further increases in
international migration with Romanians moving to the town after the change in law allowing them
the right to work in the UK at the beginning of 2014. Analyses of translation service data also
highlighted the levels of diversity in the town by identifying over 120 languages or dialects being
spoken by residents. This provides corroborating evidence of Luton being super-diverse.
5% of the total population of Luton are Black African or Black African heritage (England 2.1%) and
5.9% Black Caribbean or Black Caribbean heritage (England 1.9%). 14.4% of the population are
Pakistani (England 2.1%), 6.7% Bangladeshi (England 0.8%) and 5.2% Indian (England 2.6%).
7
Figure 2.1.3: Ethnic composition of Luton
2.1.4 Deprivation
There is no single generally agreed definition of deprivation. Deprivation is a concept that overlaps,
but is not synonymous with, poverty. Absolute poverty can be defined as the absence of the
minimum resources for physical survival, whereas relative poverty relates this to the standards of
living of a particular society at a specific time.
The Index of Multiple Deprivation 2015 produced by Communities and Local Government (CLG)
combines a number of indicators, chosen to cover a range of economic, social and housing issues,
into a single deprivation score for each small area in England. This allows each area to be ranked
relative to each other according to their level of deprivation.
Luton is ranked as the 59th (out of 326) most deprived local authority. In 2010 Luton was ranked as
the 69th most deprived local authority in 2007 as the 87st (out of 354 authorities) and in 2004 the
101st most deprived local authority. This indicates that Luton is becoming relatively more deprived
in comparison to the other local authorities of England and the trend of has been happening since
2004. (Figure 2.1.3). Luton has nine output areas in the top ten per cent most deprived areas in the
country. Three of these are in Northwell, two in Farley and South wards and one in Biscot and
Dallow wards.
8
Figure 2.1.4: Deprivation in Luton 2015.
3. Risk Factors
Diabetes does not impact everyone equally and inequalities exist in the risk of developing
diabetes, for example, in accessing services and health outcomes. Areas with high levels of
deprivation are associated with a greater prevalence of diabetes (PHE 2014). Those who are
overweight, physically inactive or have a family history of diabetes are at increased risk of
developing diabetes. Obesity is the most important modifiable risk factor (see Section 3.1
for information on obesity in adults in Luton). Smoking is also associated with multiple
complications for people with diabetes (ASH 2012).
3.1 Obesity
Being overweight or obese increases your risk of developing diabetes and high blood
pressure (NHS 2014). The prevalence of obesity has increased in the past 25 years in every
age group, social class, ethnicity and gender. In England, most people are overweight or
obese. Overweight and obese children are more likely to be obese when they reach
adulthood.
9
Figure 3.1.0 Prevalence of obesity in adults aged 16 and over, 2014/15
Prevalence of obesity in Luton adults aged 16 and over in 2014/15 is 9.8%; this is
significantly higher than the England average figure 4.1.0. However in 2012/14 data taken
from the health survey for England (HSE) estimates that in Luton 63.9% of the adult
population are either obese or overweight so the QOF figure is likely to be inaccurate.
Figure 3.1.1 Prevalence of obesity in adults aged 16 and over in Luton GP
practices, 2014/15
10
A total of 10 practices had recorded prevalence significantly lower than Luton and 9
practices had prevalence significantly higher. Figure 3.1.1 shows prevalence of obesity in
Luton GP practices in 2014/15.
Figure 3.1.2 Prevalence of childhood
obesity in reception year, 2014/15
Figure 3.1.3 Prevalence of childhood obesity
in year 6, 2014/15
Figure 3.1.2 shows prevalence of obesity in Luton reception year children in 2014/15 is
10.2%; this is significantly higher than the England average of 9.1%. Figure 3.1.3 shows
prevalence of obesity in Luton year 6 children in 2014/15 was 23.4%; this was significantly
higher than the England average of 19.1%.
3.2 Physical activity and diet
Department of Health latest guidelines recommend that adults (aged 19-64 years) should
aim to be active daily. Over the course of a week, all activity should add up to at least 150
minutes (2½ hours) of moderate intensity activity which should last at least 10 minutes. An
example of this would be to do 30 minutes on at least 5 days a week. Being physically active
can protect against chronic diseases, with regular physical activity key to preventing people
from becomes obese or overweight. See table 3.2.1 below. The guidelines for children refer
to opportunities for moderate to vigorous-intensity physical activity. Children and young
people should undertake a range of activities at this level for at least 60 minutes over the
course of a day. At least twice a week this should include weight-bearing activities that
produce high physical stresses to improve bone health, muscle strength and flexibility. This
amount of physical activity can be achieved in a number of short, 10-minute (minimum)
bouts (NICE 2009).
Dietary modification and regular physical activity are significant elements in CVD prevention
and control. A diet which is high in fat can cause fatty deposits to build inside the arteries
which can lead to high blood pressure and high cholesterols. Therefore a balanced diet
including fruit and vegetables is essential (NHS 2014). Due to the recent rise in obesity in the
UK population the government researched ways of tackling the problem and in June 2014
published a paper outlined action to reverse obesity levels. Part of this action will involve a
sugar tax being applied to sweetened drinks which will begin in 2018. This will help to
reduce the risks of obesity, tooth decay and other life threatening diseases (PHE 2016).
11
Table 3.2.1 shows that 38.7% of children aged 5 and under had more than one decayed,
filled or missing teeth, significantly worse than the national average (27.95) in 2011/12.
Table 3.2.1: Five a day and physical activity performance in Luton and comparator areas in
2014
Source: PHOF
The proportion of people eating 5 a day (41.3%) in Luton is significantly lower than the
national average (53.5%). Similarly, the proportion who meet the recommended level of
physical activity in Luton (45.1%) is also significantly lower than national levels (57%).
3.3 Family history of diabetes
Genetics is one of the main risk factors for type 2 diabetes (NHS 2014). Your risk of
developing the condition is increased if you have a close relative – such as a parent, brother
or sister – who has the condition. The closer the relative, the greater the risk. A child who
has a parent with type 2 diabetes has about a one in three chance of also developing it (NHS
2014).
3.4 Ethnic background
People of south Asian, Chinese, African-Caribbean and black African are more likely to
develop type 2 diabetes. Type 2 diabetes is up to six times more common in south Asian
communities than in the general UK population, and it is three times more common among
people of African and African-Caribbean origin (NHS 2014).
People of south Asian and African-Caribbean origin also have an increased risk of developing
complications of diabetes, such as heart disease, at a younger age than the rest of the
population (NHS 2014).
4. Prevalence
According to QOF registers in 2014/15 the prevalence of diabetes in the adult population in
England is 6%, this equates to around 2.7 million people. Locally in Luton the recorded
prevalence is 7.6% and equates to around 12,900 adults aged 17+. There are also a
substantial amount of people with undiagnosed diabetes. According to Diabetes UK it is
estimated that in England and Wales there is 0.2% diabetes prevalence in children aged 0-9
years and 0.9% prevalence in children aged 10-19 (Diabetes UK 2015). When applied to the
Luton population this equates to around 260 children who also potentially have diabetes in
the borough.
This section looks at the known and undiagnosed prevalence of diabetes in Luton and the
GP practices in the borough. Comparisons are made to comparator CCG’s and National
figures where possible.
12
4.1 Recorded and Expected Prevalence
Figure 4.1.1 Recorded prevalence of diabetes in persons aged 17+, 2014/15
Figure 4.1.1 shows recorded prevalence for diabetes within Luton and comparator CCG’s for
2014/15. Luton (7.6%) has a prevalence significantly higher than the England average 6.3%,
as do all comparator CCG’s. The Luton prevalence equates to a total of 12,889 people
diagnosed with diabetes.
13
Figure 4.1.2 Recorded prevalence of diabetes in persons aged 17+, Luton GP practices
2014/15
Figure 4.1.2 shows recorded prevalence for diabetes within Luton GP practices for 2014/15
there is wide variation with prevalence ranging from 2.3% to 12.3%. A total of 10 practices
have recorded prevalence significantly lower than the Luton average and the same number
have a recorded prevalence significantly higher than Luton.
Figure 4.1.3 Estimated prevalence of diabetes for Luton and England 2016 - 2035
Source: APHO Diabetes prevalence model
Figure 4.1.3 shows estimated prevalence of diabetes for Luton and England from 2016 to
2035. In 2016 the estimated prevalence is 10.2% and this equates to 17,019. This compares
to 12,889 on the recorded disease registers at QOF. Therefore there are potentially around
4,150 people with undiagnosed and therefore uncontrolled diabetes within Luton. As can be
observed the prevalence of diabetes is estimated to rise to 22,614 people in 2035 meaning
approximately 5,000 more people will have diabetes in the borough.
*Please note that QOF is based on persons aged 17+ and the modelled estimates on people
16+ so numbers may vary slightly.
14
4.2 Hospital admissions
Figure 4.2.0 Emergency hospital admissions: diabetic ketoacidosis and coma, 2014/15
Figure 4.2.0 shows emergency admission rates for diabetic ketoacidosis and coma for
2014/15. Luton has a rate of 36.3 per 100,000 population and this is not different than the
national rate of 31.2 per 100,000 population.
5. Early Diagnosis and Primary Care Management
Diabetes needs to be diagnosed as early as possible so it can be treated quickly. Diagnosis of
diabetes can be made using urine and blood tests and a glucose tolerance test (GTT). The
test is simple; as glucose is not normally in the urine the test determines if glucose is
present and specifically how much is present.
These tests’ (to determine diabetes in individuals) form a part of the NHS health checks
programme. The following section has information on health checks in Luton and England
for comparison.
5.1 Health Checks
The NHS Health Check is a check of peoples’ heart health. Aimed at adults in England aged
40 to 74, it checks vascular or circulatory health and works out the risk of developing some
of the most disabling – but preventable – illnesses. Among other things, blood pressure,
cholesterol, and BMI will all be checked and results given to the patient (NHS 2014).
Crucially, an NHS Health Check can detect potential problems before they do real damage.
Everyone is at risk of developing heart disease, stroke, type 2 diabetes, kidney disease and
some forms of dementia.
15
Table 5.1.0: Recent uptake of health checks within Luton compared to national average
Source: NHS Health Checks
Table 5.1.0 above shows that in recent years Luton has consistently has a higher health
check uptake compared to the national average. The total row shows the average numbers
of numbers eligible from 2011/12 to 2015/16.
5.2 Diabetic Retinopathy Screening
Eye screening is a key part of diabetes care. In people with diabetes, eyes are at risk of
damage from diabetic retinopathy, a condition that can lead to sight loss if it's not treated
(NHS 2014). The screening is also part of pre testing at some opticians; this is useful as
damage can be spotted even before a person knows they have diabetes.
16
Figure 5.2.1: Percentage diabetes patients who had diabetic retinopathy
screening 2013/14
Source: QOF 2013/14
Figure 5.2.1 shows that Luton (86.8%) has a significantly lower percentage of diabetes
patients who have had retinopathy screening in 2013/14 compared to the national average
(90%).
17
Figure 5.2.2: Percentage diabetes patients who had diabetic retinopathy screening, GP
practices 2013/14
Figure 5.2.2 shows that 10 practices in Luton has a significantly lower percentage of
diabetes patients who have had retinopathy screening in 2013/14 compared to the Luton
average (86.8%). 17 practices have a percentage significantly higher than Luton.
5.3 Primary Care Management
As well as early diagnoses of diabetes it is also important to control and monitor diabetes
within patients already diagnosed with the disease. This section looks at how GP practices
within Luton perform on diabetes management indicators.
18
Figure 5.3.1: DM002: The percentage of patients with diabetes, on the register, in
whom the last blood pressure reading (measured in the preceding 12 months) is
150/90 mmHg or less, 2014/15
Figure 5.3.1 shows the percentage of patients with diabetes, on the register, in whom the
last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less,
2014/15. The proportions range from 70.7% to 98.5%. Six practices had percentages
significantly lower than the Luton average and 11 practices had percentages significantly
higher than Luton.
19
Figure 5.3.2: DM003: The percentage of patients with diabetes, on the register, in
whom the last blood pressure reading (measured in the preceding 12 months) is
140/80 mmHg or less, 2014/15
Figure 5.3.2 shows the percentage of patients with diabetes, on the register, in whom the
last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less,
2014/15. The proportions range from 41.7% to 92.9%. Eight practices had percentages
significantly lower than the Luton average and 13 practices had percentages significantly
higher than Luton.
20
Figure 5.3.3: DM004: The percentage of patients with diabetes, on the register,
whose last measured total cholesterol (measured within the preceding 12 months)
is 5 mmol/l or less, 2014/15
Figure 5.3.3 shows the percentage of patients with diabetes, on the register, whose last
measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less,
2014/15. The proportions range from 56.4% to 88.8%. Six practices had percentages
significantly lower than the Luton average and nine practices had percentages significantly
higher than Luton.
21
Figure 5.3.4: DM007: The percentage of patients with diabetes, on the register, in
whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months,
2014/15
Figure 5.3.4 shows the percentage of patients with diabetes, on the register, in whom the
last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months, 2014/15. The
proportions range from 35% to 81%. Five practices had percentages significantly lower than
the Luton average and nine practices had percentages significantly higher than Luton.
22
Figure 5.3.5: DM009: The percentage of patients with diabetes, on the register, in
whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months,
2014/15
Figure 5.3.5 shows the percentage of patients with diabetes, on the register, in whom the
last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months, 2014/15. The
proportions range from 51% to 97%. Eight practices had percentages significantly lower
than the Luton average and nine practices had percentages significantly higher than Luton.
23
Figure 5.3.6: DM012: The percentage of patients with diabetes, on the register,
with a record of a foot examination and risk classification: 1) low risk (normal
sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3)
high risk (neuropathy or absent pulses plus deformity or skin changes in previous
ulcer) or 4) ulcerated foot within the preceding 12 months, 2014/15
Figure 5.3.6 shows the percentage of patients with diabetes, on the register, with a record
of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses),
2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses
plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding
12 months, 2014/15. The proportions range from 66% to 100%. Eight practices had
percentages significantly lower than the Luton average and 13 practices had percentages
significantly higher than Luton.
24
Figure 5.3.7 DM014: The percentage of patients newly diagnosed with diabetes, on the
register, in the preceding 1 April to 31 March who have a record of being referred to a
structured education programme within 9 months after entry on to the diabetes register,
2014/15
Figure 5.3.7 shows the percentage of patients newly diagnosed with diabetes, on the
register, in the preceding 1 April to 31 March who have a record of being referred to a
structured education programme within 9 months after entry on to the diabetes register,
2014/15. The proportions range from 0% to 100%. One practice had percentage
significantly lower than the Luton average.
25
Figure 5.3.8 DM018: The percentage of patients with diabetes, on the register, who
have had influenza immunisation in the preceding 1 August to 31 March, 2014/15
Figure 5.3.8 shows the percentage of patients with diabetes, on the register, who have had
influenza immunisation in the preceding 1 August to 31 March, 2014/15. The proportions
range from 73% to 100%. Seven practices had percentages significantly lower than the
Luton average and 11 practices had percentages significantly higher than Luton.
Figure 5.3.9 Baseline Assessment of Diabetes indicators for Luton 2016/17
Source: NHS England.
The figures in figure 5.3.9 will act as a baseline for further work as identified by the CCG
Improvement and Assessment Framework (CCGIAF) 2016/17.
6. Provision of service and care
6.1 Complications of diabetes
Having diabetes brings additional risks of developing other problems such as angina,
myocardial infarction and amputation. This section looks at some of these additional risks
for diabetes patients in Luton and compares to the national average and other similar CCG’s.
26
Figure 6.1.0: Additional risk of diabetes patients having angina, 2009/10-2012/13
Figure 6.1.0 shows that Luton diabetes patients have an additional risk of 178% (or 1.7 times
more) of developing angina compared to non-diabetes patients. This is significantly higher
than the national average (136.8%) or 1.4 times more.
27
Figure 6.1.1: Additional risk of diabetes patients having heart failure, 2009/102012/13
Figure 6.1.1 shows that Luton diabetes patients have an additional risk of 186% (or 1.9 times
more) of developing heart failure compared to non-diabetes patients. This is significantly
higher than the national average.
28
Figure 6.1.2: Additional risk of diabetes patients having major amputation,
2009/10-2012/13
Figure 6.1.2 shows that Luton diabetes patients have an additional risk of 268% (or 2.7 times
more) of a major amputation compared to non-diabetes patients. Although lower this is not
significantly different than the national average.
29
Figure 6.1.3: Additional risk of diabetes patients having minor amputation,
2009/10-2012/13
Figure 6.1.3 shows that Luton diabetes patients have an additional risk of 624% (or 6.2 times
more) of a minor amputation compared to non-diabetes patients. Although lower this is not
significantly different than the national average.
30
Figure 6.1.4: Additional risk of diabetes patients having myocardial infarction,
2009/10-2012/13
Figure 6.1.4 shows that Luton diabetes patients have an additional risk of 139% (or 1.4 times
more) of a myocardial infarction compared to non-diabetes patients. This is significantly
higher than the national average.
31
Figure 6.1.5: Additional risk of diabetes patients having renal replacement
therapy, 2009/10-2012/13
Figure 6.1.5 shows that Luton diabetes patients have an additional risk of 338% (or 3.4 times
more) of a renal replacement therapy compared to non-diabetes patients. Although higher
this is not different than the national average.
32
Figure 6.1.6: Additional risk of diabetes patients having stroke, 2009/10-2012/13
Figure 6.1.6 shows that Luton diabetes patients have an additional risk of 103% of a stroke
compared to non-diabetes patients. This is not different than the national average.
33
Table 6.1.0: Shows indicators for diabetes complications within Luton CCG and compares to
the national average
Table 6.1.0 shows various hospital admission indicators for diabetes complications within
Luton CCG in the three year period 2011/12 to 2013/14 and compares to the national
average.
34
Key findings in the indicators are:







Luton had 17.5 per 1,000 population aged 17+ (n=625) of diabetic episodes of care
and this was significantly lower than the national average (19.2 per 1,000
population.
However of these episodes of care 85.4% (n=534) were accounted for by patients
who had more than one stay, which is significantly higher than the national average.
The number of days in hospital for diabetes foot-care was 5,405 which equated to
151.3 per 1,000 population aged 17+; again this was significantly lower than the
national average (163.2).
A total of 154 patients (62.9%) had more than one episode of care within the three
year time period; again this is significantly higher than the national average (55.4%).
There were 61 amputations a rate of 1.7 per 1,000 people aged 17+ and a total of
1,246 days in hospital (34.9 per 1,000 population aged 17+. Both of these were
significantly lower than the national average (2.6 and 43.4 per 1,000 population
respectively).
There were a total of 26 major amputations 0.7 per 1,000 population aged 17+ and
this was not significantly different to England (0.8).
There were 35 minor amputations 1.0 per 1,000 population aged 17+ and this was
significantly lower than the national average (1.8).
7. Costs of diabetes
The cost of diabetes to the NHS is over £1.5m an hour or 10% of the NHS budget for England
and Wales. This equates to over £25,000 being spent on diabetes every minute. In total, an
estimated £14 billion pounds is spent a year on treating diabetes and its complications, with
the cost of treating complications representing the much higher cost (Diabetes UK 2016).
This section looks at some costs and outcomes of diabetes for Luton using the Diabetes
Outcomes Verses Expenditure Tool (DOVE tool).
The current total spend on diabetes prescribing per person in NHS Luton CCG was £241.51.
This ranks the CCG 12 of 211 CCG’s on the diabetes QOF register nationally (with 1
representing the CCG with the lowest spend). The CCG’s total spend for this indicator in
2013/14 was £3,020,060. The total spend on diabetes prescribing per person with diabetes
in NHS Luton for this CCG is currently within the lowest 25% nationally.
In terms of outcomes for Luton CCG the current percentage of people with diabetes with a
HbA1c of 59mmol/mol or less on the QOF register in NHS Luton was 65.9%. This equates to
7,417 out of 11,254 people on the register. This ranks the CCG 180 of 211 CCGs nationally
for this indicator (with 1 representing the CCG with the best outcomes).
NHS Luton was in the bottom 50% of CCGs in England for the percentage of people with
diabetes with a HbA1c of 59mmol/mol or less . In order to achieve a percentage equivalent
to that of the median (average) CCG, NHS Luton would need to increase the number of
people with diabetes with a HbA1c of 59mmol/mol or less by a further 499, assuming a
static total register size.
35
The percentage of people with diabetes with a HbA1c of 59mmol/mol or less in NHS Luton
was lower than those of the top 25% of CCGs in England. In order to achieve a percentage
equivalent to that of the median (average) CCG, NHS Luton would need to increase the
number of people with diabetes with a HbA1c of 59mmol/mol or less by a further 752,
assuming a static total register size.
*Please note the prevalence here of 11,254 does not the current prevalence stated earlier
as this tool is from 2013/14 and uses earlier data.
Figure 7.1 Total spend on diabetes prescribing compared to people
with diabetes with a HbA1c of 59mmol/mol or less for NHS Luton
Source DOVE tool
Figure 7.1 shows total spend on diabetes prescribing compared to people with diabetes with
a HbA1c of 59mmol/mol or less for NHS Luton. The chart shows that in 2012/13 Luton had a
high expenditure and low outcomes for this indicator and in 2013/14 Luton had a low spend
and low outcomes. This suggests that although outcomes in patients with controlled HbA1c
were low in 2012/13, less money was spent the following year and therefore outcomes
worsened.
36
Figure 7.2 Total spend on diabetes prescribing compared to people with
diabetes with a HbA1c of 64mmol/mol or less for NHS Luton
Source DOVE tool
Figure 7.2 shows total spend on diabetes prescribing compared to people with diabetes with
a HbA1c of 64mmol/mol or less for NHS Luton. The chart shows that in 2012/13 Luton had a
high expenditure and low outcomes for this indicator and in 2013/14 Luton had a low spend
and low outcomes. This suggests that although outcomes in patients with controlled HbA1c
were low in 2012/13, less money was spent the following year and therefore outcomes
worsened.
37
Figure 7.3 Total spend on diabetes prescribing compared to people with
diabetes with a HbA1c of 75mmol/mol or less for NHS Luton
Source DOVE tool
Figure 7.3 shows total spend on diabetes prescribing compared to people with diabetes with
a HbA1c of 75mmol/mol or less for NHS Luton. The chart shows that in 2012/13 Luton had a
high expenditure and low outcomes for this indicator and in 2013/14 Luton had a low spend
and low outcomes. This suggests that although outcomes in patients with controlled HbA1c
were low in 2012/13, less money was spent the following year and therefore outcomes
worsened.
38
8. Mortality due to diabetes
Figure 8.1.0 Mortality due to diabetes in
males all ages, 2012/14
Figure 8.1.1 Mortality due to diabetes in
females all ages, 2012/14
Figure 8.1.0 shows mortality due to diabetes in males all ages in 2012/14 in Luton (19.7 per
100,000 population) was significantly higher than the national average (11.9 per 100,000
population). Figure 8.1.1 shows mortality rate due to diabetes in females all ages in Luton is
13.2 per 100,000 population and this is not different to the national average (8.6 per
100,000 population).
Figure 8.1.2 Mortality due to diabetes in
persons all ages, 2012/14
Figure 8.1.3 Mortality due to diabetes in
persons aged 75 and less, 2012/14
Figure 8.1.2 shows mortality rate due to diabetes in persons all ages in Luton is 16.2 per
100,000 population and this is not different to the national average (10.0 per 100,000
population). Figure 8.1.3 shows mortality rate due to diabetes in persons ages 75 and less in
Luton is 3.9 per 100,000 population and this is not different to the national average 2.9 per
100,000 population).
39
Figure 8.1.4 Mortality due to diabetes, all
ages, recent trends
Figure 8.1.5 Years of life lost due to diabetes
mortality in persons aged 1-74 years,
2012/14
Figure 8.1.3 shows recent trends in mortality rates due to diabetes are falling in males,
females and persons for Luton and nationally. However due to the small numbers involved
locally a small increase in deaths annually can cause a spike in the rate, as seen in the chart.
Figure 8.1.6 shows years of life lost due to diabetes mortality in persons aged 1-74 years in
2012/14; the rate for Luton is 4.6 per 100,000 population and is not different to the national
rate of 3.9 per 100,000 population.
9. Service user perspective
Figure 9.1.0 Patient with long term conditions perspective on support received and their
ability to manage their condition.
*Note: The yellow group contains a younger population with higher than average people
from black and Asian backgrounds and with moderate deprivation.
40
10. Provider perspectives and what are we doing locally?
Diabetes community services in Luton are provided by Cambridgeshire Community Services (CCS).
The services include both clinical interventions and structured education. A list of these can be
located in figure 10.0.
Figure 10.0 Luton Diabetes Services provided by CCS
Source: CCS provider services
The Luton care pathway for diabetes services can be seen in figure 10.1 below, however this
pathway is currently under review.
41
Figure 10.1 Luton Diabetes Services Care Pathway
Source: CCS provider services
Figure 10.2: CCS referrals and activity by month for 2015/16
Source: CCS provider services
Figure 10.2 shows there is variation in CCS activity across the months. There is a pattern of
increased overall activity from Apr 15 to Mar 16.
42
Figure 10.3: CCS activity by GP practice compared to QOF diabetes register
Source: QOF and CSS provider services
Figure 10.3 shows CSS activity in GP practices in 2015/16 and also the prevalence and
numbers on the QOF register (2014/15) in Luton GP practices.
Figure 10.4: CCS activity by activity type 2015/16
Source: CCS provider services
43
Figure 10.4 shows the most common service types used was Diabetes DSN review, DSN non
routine and Insulin start which makes up 54% of total activity. Lower activity levels were for
Hypo follow up, Weight management and walking away, LWD housebound.
As part of the Luton Primary Care Investment Scheme (PCIS) for 2016/17 a new component
was introduced to identify pre diabetes patients. These patients are then kept on a register
and monitored. Personal health plans (PHP) and structured education is also offered to
these patients.
Data submitted to the National Diabetes Audit (NDA) for 2014/15 shows GP practice performance
for treatment targets around diabetes. The results are shown in tables 10.5 to 10.8 below.
Figure 10.5: Diabetes Treatment Targets for Larkside locality for 2014/15
Source: NDA 2014/15
Figure 10.6: Diabetes Treatment Targets for Kingsway locality for 2014/15
Source: NDA 2014/15
Figure 10.7: Diabetes Treatment Targets for Medics locality for 2014/15
Source: NDA 2014/15
44
Figure 10.8: Diabetes Treatment Targets for SEL locality for 2014/15
Source: NDA 2014/15
11. NICE guidelines
This section identifies various guidelines and evidence base which can help underpin
population based diabetes interventions.
Table 11.0 Guidelines and evidence base to assist in diabetes interventions
Guideline name
PH38 Preventing type 2 diabetes: risk
identification and interventions for
individuals at high risk
PH35 Preventing type 2 diabetes:
population and community-level
interventions
Benefit of guideline
Provides guidelines to help identify diabetes
diagnoses in individuals and highlight persons
at risk. Health checks are also mentioned in
here.
Provides guidelines on how to prevent
diabetes in individuals and population level.
PH35 includes recommendations on diet and
physical activity.
This includes recommendations on Asian
population and diabetes
PH46: Assessing body mass index and
waist circumference thresholds for
intervening to prevent ill health and
premature death among adults from
black, Asian and other minority ethnic
groups in the UK.
PH10 Smoking cessation services
Provides guidelines on the best interventions
in order to achieve the most successful
quitters.
45
12. Recommendations
Prevention and screening
• Primary and community services should provide brief advice at every opportunity
and refer to lifestyle services where appropriate (NICE PH35)
• Identification and referral to intensive lifestyle support in high risk and vulnerable
groups (NICE PH38) should be systematically rolled out across primary and
community care including pre-diabetes and diabetes
Early Detection and diagnosis /Treatment: improving experiences of care and support
• Reduce variation in primary care of
– Health checks uptake with a focus on quality including referral onto intensive
lifestyle programmes
– Diabetic Retinopathy Screening with NHS England
– Newly diagnosed diabetics and refer to structured education programme
including self-care and foot care (NICE guidance 19)
– BP and cholesterol control in diabetics linked primary care investment
programme
– Hba1c control with a focus in Medics cluster
Aftercare
• Embed within diabetes pathway post treatment lifestyle advice and support for all
patients linked to Enhanced Recovery Programme
Integrated commissioning
• Review current pathway /service offer, to reduce duplication and redistribute to
need (CCS) and develop discharge bundle for repeat admissions. Consider a CQUIN.
• Ensure all diabetes specifications are outcomes focused and linked to other relevant
specifications.
• Embed NICE Quality Standard (QS6, QS125 and QS109) into contracting and monitor
performance to reduce additional risk of complications.
46
13. References
Action on smoking and health (2012). Smoking and Diabetes. [Online] June 2012. Available
from: http://ash.org.uk/files/documents/ASH_128.pdf
Diabetes UK (2014) Guide to diabetes. Related conditions.[Online]. Available from:
http://www.diabetes.org.uk/guide-to-diabetes/what-is-diabetes/related-conditions/
Diabetes UK (2015) Facts and Stats on Website located at
https://www.diabetes.org.uk/Documents/Position%20statements/Diabetes%20UK%20Facts
%20and%20Stats_Dec%202015.pdf Accessed 06/2015
Diabetes UK (2016) Website http://www.diabetes.co.uk/cost-of-diabetes.html Accessed
05/2016
Department of Health (2011). Who gets diabetes-health inequalities.Available from:
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/
publications/publicationspolicyandguidance/browsable/dh_4899972
NHS (2014) Website located here http://www.nhs.uk/Conditions/Diabetestype2/Pages/Causes.aspx Accessed 05/2016
NHS (2014) Website located here http://www.nhs.uk/Conditions/nhs-healthcheck/Pages/What-is-an-NHS-Health-Check.aspx Accessed 05/2016
NICE (2009) website located https://www.nice.org.uk/guidance/PH17/chapter/Introduction
Accessed 06/2016
PHE (2016) Website accessed 04/2016 at https://www.gov.uk/government/news/levy-onhigh-sugar-drinks-phe-statement
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