Ealing JSNA 2012-13
Chapter 20.2
Diabetes
Version Control
Chapter
Name
Diabetes
Author
Dr Sapna Chauhan
Last
Updated
August 2012
Contact Details for Queries
Name
Dr Sapna Chauhan
Telephone
02088256118
Email
[email protected]
1
Contents
Executive Summary .................................................................................................... 4
What is Diabetes? ....................................................................................................... 5
Prevalence of Diabetes .............................................................................................. 6
Diabetes Prevalence by the Health Networks in Ealing ....................................... 7
Deprivation, Ethnicity and Inequality .......................................................................... 9
Diabetes in Children ................................................................................................... 9
Gestational diabetes ................................................................................................. 10
Lifestyle Estimates for Adults ................................................................................... 11
Management of diabetes in Primary Care ............................................................... 11
Deaths from Diabetes ............................................................................................... 15
Diabetes related complications ................................................................................ 16
Spending on Diabetes Care and Outcomes ............................................................ 24
Evidence based Interventions .................................................................................. 31
Current service provision in Ealing .......................................................................... 32
Recommendations .................................................................................................... 35
Appendix 1: Diabetes Prevalence at practice level by the Health Networks in
Ealing. ....................................................................................................................... 36
2
Index of Tables and Figures
Figure 1: Prevalence of diabetes in Ealing compared with the Cluster group and
England in 2010/11 ......................................................................................................... 6
Figure 2: % Prevalence of recorded diabetes across London in 2010/11 .................... 7
Figure 3: Prevalence of recorded diabetes (%) by the 7 Health Networks in Ealing,
QOF 2010/11 .................................................................................................................. 8
Figure 4: Clinical Management of Diabetes in Ealing, Indigo Group and England in
2010/11 ......................................................................................................................... 12
Figure 5: % of diabetic patients whose last HbA1c was 8% or less (DM24) 2010/11
...................................................................................................................................... 13
Figure 6: Clinical Management of patients with diabetes by the Health Networks in
Ealing 2010/11 .............................................................................................................. 13
Figure 7: Trend in Mortality DSR per 100,000 from diabetes (ICD9 250 adjusted,
ICD10 E10-E14), in 1993-2010 for all ages ................................................................ 15
Figure 8: Mortality from diabetes (ICD10 E10-E14), DSR per 100,000 for less than
75 years in 2008-10 (pooled) ....................................................................................... 16
Figure 9: Prevalence of Diabetes complications in Ealing, Indigo Group and England
...................................................................................................................................... 17
Figure 10: Emergency hospital admissions: diabetic ketoacidosis and coma,
indirectly age and sex standardised rates per 100,000 population in 2009/10 .......... 18
Figure 11: Hospital procedures: lower limb amputations in diabetic patients, indirectly
age and sex standardised rates per 100,000 population in 2009/10 ......................... 18
Figure 12: Annual foot care admission episodes per 10,000 people with diabetes by
PCT, Indigo Group 2008–11 ........................................................................................ 20
Figure 13: Annual amputations (major and minor) per 10,000 people with diabetes by
PCT Indigo Group, 2008-2011 ..................................................................................... 21
Figure 14: Endocrine spend in Ealing compared with other programme budgeting
categories 2010/11 ....................................................................................................... 25
Figure 15: Diabetes Expenditure across Care setting in Ealing compared to ONS
cluster average ............................................................................................................. 26
Figure 16: Spend & outcome for Ealing relative to other PCTs in England in 2010/11
...................................................................................................................................... 28
Figure 17: Diabetes Spend and HbA1c outcomes in 2010/11.................................... 29
Figure 18: Diabetes Spend and Lower Limb amputation in Diabetics ....................... 30
Figure 19: Diabetes Spend and emergency admissions for diabetic complications.. 30
Table 1: APHO Diabetes Estimated prevalence aged >16 years in Ealing ................... 7
Table 2: Lifestyle estimates for adults in Ealing, London and England ...................... 11
Table 3: % of Patients receiving all care processes by age group and diabetes type
in Ealing ........................................................................................................................ 14
Table 4: Ealing Diabetes Foot Disease Profile- Jan 2012. ......................................... 19
3
Executive Summary

The prevalence of diagnosed diabetes among people aged 17 years and
older in NHS Ealing is 6.5% compared to 6.8% in all PCTs with similar
diabetes risk factors. Ealing has the 5th highest prevalence in 2010/11 across
London.

There is substantial variation in prevalenc e of recorded diabetes at the 7
Health Networks level. In 2010/11 the highest prevalence was noted in the
North Southall (9.3%) and lowest in the Central Ealing (4.3%).

In NHS Ealing 48.4% of all people with diabetes aged 17 years have an
HbA1c of 7% or less. This is significantly lower than PCTs with populations
with similar diabetes risk factors and significantly lower than England as a
whole.

Of the people with diabetes included in the National Diabetes Audit in NHS
Ealing 5.7 per 1000 had had a stroke in the previous year compared to 6.9
per 1000 across the whole of England.

In NHS Ealing 6.5 per 1000 of people with diabetes had a myocardial
infarction in 2009/10 compared to 6.0 per 1000 across England.

The emergency hospital admission rate for diabetic ketoacidosis and coma in
2009/10 shows an improvement compared to 2008/09 by 41 percentage
points in Ealing.

The emergency hospital admission rate for lower limb amputation in diabetic
patients in Ealing is 9.35 per 100,000 in 2009/10 lower than the national
average. However, Ealing has the 2nd highest annual amputation rate in the
Indigo Group and its foot care admission rate was the 3rd highest in 20082011.

In 2009/10, of all people with diabetes in the National Diabetes Audit (NDA)
0.98% in Ealing received Renal Replacement Therapy (RRT) compared to
0.38% in England. Ealing has the second highest rate for RRT across
England after Enfield PCT (0.99%).

In Ealing there were 54.5% excess emergency re‐admissions (%) within 28
days among people with diabetes when compared with people without
diabetes by PCT 2009/10. The England value is 59.1%.

Programme Budgeting Marginal Analysis 2010/11 shows diabetes care to fall
within the low spend/worst outcomes category when compared to PCTs
nationally, however when spend on diabetes is compared to outcomes in
Ealing it has a lower spend and improved outcomes for lower limb
amputations in diabetics and emergency admissions for diabetes related
complications.
4
What is Diabetes?
Diabetes is a chronic and progressive disease in which the amount of glucose in the
blood is too high. It affects both children and adults .Diabetes is the leading cause of
blindness in people of working age, the largest single cause of end stage renal
failure, and, excluding accidents, the biggest cause of lower limb amputation.
There are two main types of diabetes.
Type 1 diabetes develops when the insulin-producing cells in the body have been
destroyed and the body is unable to produce any insulin. It accounts for between 5
and 15 % of all people with diabetes and is treated by daily insulin injections, a
healthy diet and regular physical activity.
Type 2 diabetes develops when the body can still make some insulin, but not
enough, or when the insulin that is produced does not work properly (known as
insulin resistance).
Gestational diabetes: affects women during pregnancy though often disappears after
delivery. Women who have had gestational diabetes are at higher risk of developing
diabetes later in life than women who have not had gestational diabetes. 1
The risk factors are different for Type 1 and Type 2. The following groups are
identified as being at increased risk of developing diabetes:
Type 1 diabetes
People with a strong family history of type 1 diabetes
Although the onset of type 1 diabetes is typically in childhood it also occurs in
adults
Type 2 diabetes
People with a family history of diabetes
Ethnicity: Type 2 diabetes usually appears in people over the age of 40,
though in South Asian and black people, who are at greater risk, it often
appears from the age of 25.
Obesity increases the relative risk of developing type 2 diabetes by 12.7
times in women and by 5.2 times in men 2.
Deprivation is strongly linked with higher levels of obesity, physical inactivity,
unhealthy diet, smoking and poor blood pressure control, all factors which are
linked to the development of diabetes or which increase the risk of developing
complications in those who already have the disease 3. Those in the most
deprived fifth of the population are one-and-a-half times more likely than
average to have diabetes at any given age. Both mortality and morbidity are
increased by socio-economic deprivation. 4
1
Definition, diagnosis and classification of diabetes mellitus and its complications : report of a WHO
National Audit Office 2001
3
Diabetes in the UK 2009: Key statistics on diabetes. Diabetes UK, 2009.
4
National Service framework for diabetes: standards. DH 2001
2
5
People with impaired glucose tolerance
Women who have had gestational diabetes mellitus
Diabetes Facts5
A male non-smoker diagnosed with diabetes at the age of 45 years who
maintains HbA1c, blood pressure and cholesterol measurements within
current QOF targets has an 11.5% chance of dying before his 60th birthday.
This equates to a life expectancy of 17.4 years compared to 34.5 years for all
men aged 45 years in the United Kingdom.
A woman diagnosed at the same age has an 8.9% chance of dying before her
60th birthday and has a life expectancy 20.1 years lower than all women of
the same age.
Adjusting the life expectancy for these hypothetical patients to account for the
lower quality of life associated with diabetes results in a Quality Adjusted Life
Expectancy of 13.3 years for the man and 13.6 years for the woman.
Prevalence of Diabetes
In 2010/11 there were 19,634 (6.5%) people aged 17 years and older diagnosed with
diabetes in NHS Ealing. There is also an estimated 1,863 adults with undiagnosed
diabetes. These include patients that are overweight or obese, patients with
gestational diabetes and those with impaired glucose tolerance. The NHS health
check programme provides an opportunity for both early identification of
undiagnosed diabetics and those with modifiable risk factors.
The chart below compares the prevalence of diabetes in NHS Ealing with the cluster
group and England. Ealing PCT is in Indigo group that has a relatively young
population with substantially greater than average proportion of the population
from Black and Asian ethnic groups and higher than average deprivation.
Figure 1: Prevalence of diabetes in Ealing compared with the Cluster group and
England in 2010/11
10.0%
8.0%
6.0%
Diagnosed Diabetes
4.0%
Undiagnosed diabetes
2.0%
0.0%
Ealing
Indigo Group
England
Source: Quality and Outcomes Framework, 2010/11and APHO Diabetes Prevalence Model
5
Source: UK Prospective Diabetes Study Outcomes Model and Government Actuary's Department Life Tables
6
There has been growth in the prevalence of diabetes by 30%, a possibility of growth
in list size over 3 years. This increase is likely to be attributable to an upward trend
in obesity, an aging population and the high prevalence of South Asian and
African-Caribbean people who are more likely to develop diabetes compared to
the white population. Diabetes prevalence is set to continue to increase
dramatically over the next 20 years, according to the model. In Ealing by 2030, it is
estimated that 29,897 people will have diabetes, compared to 21,167 people in 2010.
Table 1: APHO Diabetes Estimated prevalence aged >16 years in Ealing
Number
Prevalence %
21,167
23,070
8.6%
9.2%
25,212
27,380
9.9%
10.5%
29,897
11.2%
Source: Yorkshire and Humber Public Health Observatory APHO Diabetes Prevalence Model (1st Oct. 2010)
Figure 2 shows the diabetes prevalence for the population aged 17+ by PCTs across
London based on the Quality Outcome Framework (QoF) data for 2010/11. Ealing
has the 5th highest prevalence of 6.5% across London.
8
7
6
5
4
3
2
1
0
National
London SHA
Richmond and…
Kensington and…
Camden PCT
Westminster PCT
Wandsworth PCT
Lambeth PCT
Hammersmith…
Southwark PCT
Kingston PCT
Islington PCT
Bromley PCT
City and…
Greenwich…
Sutton and…
Haringey…
Havering PCT
Lewisham PCT
Barnet PCT
Croydon PCT
Bexley CT
Tower Hamlets…
Waltham Forest…
Hillingdon PCT
Hounslow PCT
Barking and…
Enfield PCT
Ealing PCT
Newham PCT
Brent Teaching…
Redbridge PCT
Harrow PCT
% Prevalence
Figure 2: % Prevalence of recorded diabetes across London in 2010/11
Source: Quality outcomes framework 2010/11
Diabetes Prevalence by the Health Networks in Ealing
In Ealing GP practices will group into clusters of 30-50,000 patients to form 7 Health
Networks. These will be community hubs for mutual support, training, insulin
initiation and collaborative health promotion. There is substantial variation in
prevalence of recorded diabetes at the Health Network level. In 2010/11 the
highest prevalence was noted in the North Southall (9.3%) and lowest in the
Central Ealing (4.3%). However, this may not be a true picture of the disease pattern
as a number of cases may remain undiagnosed.
7
Figure 3: Prevalence of recorded diabetes (%) by the 7 Health Networks in Ealing, QOF
2010/11
10
9
% Prevalence
8
7
6
5
2009/10
4
2010/11
3
2
1
0
Acton
West
Ealing
Central
Ealing
North
North
South
North
South
North
Southall Southall
Source: Quality outcomes framework 2010/11
The data from Quality Outcome Framework (QOF) for 2010/11 shows vast
differences in diabetes prevalence at the 7 Health Networks level in Ealing. We
would expect some variation due to the different age, ethnicity and deprivation
profiles of the practices. See Appendix 1.
Within “South Southall” the lowest prevalence is recorded in the Medical
Center (6.9%) and highest in the Sunrise Medical Center (12.9%). Given a
higher proportion of South Asian ethnic groups in the Southall, a greater
morbidity due to diabetes is recorded in this area.
In “North Southall” the prevalence varies from 14.5% in the Health Promotion
Centre to 5.9% in the Greenford Avenue FHP.
In “North North” the highest prevalence is noted in Meadow View (9.7%) and
lowest in Perivale Medical Clinic (5.2%).
Within “South North” the highest prevalence is recorded in the Ribchester
Medical Centre (9.5%) and lowest in the Hanwell Health Center (4.4%).
In “Central Ealing” the highest prevalence is recorded in Cuckoo Lane Health
Center (5.4%) and lowest in Corfton Road surgery (2.9%).
In “West Ealing” the highest prevalence is recorded in Grosvenor House
Surgery (8.1%) and lowest in Ealing Park Health Center (3.4%).
Within “Acton” the prevalence varies from 8.1% in the Burlington Gardens
Surgery to 2.1% in the Bedford Park Surgery
8
Deprivation, Ethnicity and Inequality
There is a strong association between deprivation and Type II diabetes – the most
deprived areas tend to have more obesity and physical inactivity. In the UK the most
deprived fifth of the population has 1½ times the diabetes prevalence of the least
deprived fifth. There is a two-fold difference in complication rates between the least
and most deprived quintiles.
Ethnicity and deprivation are closely associated with higher mortality rates from
circulatory diseases. The relationship is complex and modifiable factors such as
cultural practices, food choices and accessibility of services may contribute to poorer
outcomes.
The Health Survey for England’s special report on ethnicity (2004) identified poorer
health in men from all Black and Minority Ethnic groups (BMEs), particularly from
cardiovascular disease and diabetes, and lower levels of physical activity compared
to “White British” residents. This trend is also seen in children. Diabetes affects all
South Asian groups, but particularly those from a Bangladeshi and Pakistani
background. The age of onset of diabetes is earlier in South Asian and Black, and
the increased duration of disease puts this group at higher risk of complications.
Type II diabetes accounted for the majority of cases of diabetes. Black Caribbean,
Indian, Pakistani and Bangladeshi men and women have a higher risk of type II
diabetes than the general population. The prevalence of type II diabetes increases
with age among all groups. With the exception of the Chinese and the Irish, this
increase with age was greater among minority ethnic groups than among the general
population
Diabetes in Children6
There are about 29,000 children and young people with diabetes in the UK. About
26,500 of them have Type 1 diabetes and about 500 have Type 2 diabetes. There
are a further 2,000 children and young people in the UK with diabetes whose
diagnosis is not known13
Type 1
The current estimate of prevalence of Type 1 diabetes in children in the UK is
one per 700–1,000.
Local authorities and primary care trusts (PCTs) can expect between 100 and
150 children with diabetes to live in their area.
The peak age for diagnosis is between 10 and 14 years of age.
Type 2
In 2000, the first cases of Type 2 diabetes in children were diagnosed in
overweight girls aged nine to 16 of Pakistani, Indian or Arabic origin. It was
first reported in white adolescents in 2002
6
Key Statistics on Diabetes 2012 by Diabetes UK
9
In 2004, children of South Asian origin were more than 13 times more likely to
have Type 2 diabetes than white children.
Within children 0-16 the prevalence of type 2 diabetes is increased through social
deprivation, levels of obesity and ethnicity. For children from the South Asian
community the chances of developing type 2 diabetes are approximately 13 times
that of a white child of similar weight and deprivation level. Recent data from Lead
Consultant at Ealing Hospital indicated a figure of 115 children with diabetes
however this has not been defined and may not include children cared for through
other tertiary centres.
Gestational diabetes7
Gestational diabetes is a type of diabetes that arises during pregnancy (usually
during the second or third trimester). In some women, it occurs because the body
cannot produce enough insulin to meet the extra needs of pregnancy. In other
women, it may be found during the first trimester of pregnancy, and in these women,
the condition most likely existed before the pregnancy.
Gestational diabetes affects up to 5 per cent of all pregnancies.
Women who are overweight or obese are at a higher risk of gestational
diabetes.
The lifetime risk of developing Type 2 diabetes after gestational diabetes is at
least 7 per cent.
The data from Ealing Hospital Maternity Unit indicates the gestational diabetes
prevalence of 6.1% (428 pregnancies) between 1 st Jan 2011 to 29th Feb 2012. Total
diabetes in pregnancy accounted 7.1% (501 pregnancies). These findings suggest
that there is a rapid rise in the number of both pre gestational diabetes as well as
gestational diabetes in Ealing and resources will be required to provide care as
recommended by NICE showing public health advantage for long term maternal and
child health.
7
Key Statistics on Diabetes 2012 by Diabetes UK
10
Lifestyle Estimates for Adults
Obesity and physical activity services –see specific JSNA chapters
Table 2: Lifestyle estimates for adults in Ealing, London and England
Smoking
Ealing
London
Suburbs
England
Adult
obesity
19.2%
19.8%
Increasing and
higher risk of
drinking
19.2%
20.6%
Physically
active adults
18.1%
20.7%
Healthy
Eating
adults
39%
36.4%
20.7%
22.3%
24.2%
28.7%
11.2%
8.8%
9.9%
Source: Modelled Estimates from Health Survey for England, 2006-08, Ealing Health Profile 2012.
Management of diabetes in Primary Care
Indicators of care within the General Medical Services (GMS) contract (Quality and
Outcomes Framework) demonstrate that individuals with diabetes in Ealing are
managed at below average standard compared to individuals in England (QOF data
2010/11). Good quality primary care reduces the occurrence of complications
related to diabetes. These include control of blood glucose (HbAIc level), control
of blood pressure (<145/85) and cholesterol (<5mmol/l).
The chart below provides a breakdown of the key aspects of clinical management of
patients with diabetes and highlights the measurement and attainment of HbA1c,
blood pressure, cholesterol, retinal screening, peripheral pulses and neuropathy
testing in the 15 months ending 1st April 2011. Ealing is compared with Indigo Group
based on the diabetes area classification for PCTs in England. Indigo group has
PCTs with a relatively young population, greater than average proportion of the
population from the Black and Asian ethnic groups and higher than average
deprivation.
11
Figure 4: Clinical Management of Diabetes in Ealing, Indigo Group and England in
2010/11
Source: Quality and Outcomes Framework, 2010/11
Glucose in the blood sticks to haemoglobin in red blood cells, resulting in
glycosylated haemoglobin which is also known as HbA1c. The more glucose there is
in someone’s blood, the greater the amount of HbA1c that is present. While blood
glucose levels vary continuously, HbA1c provides a measure of an individual’s
average blood glucose over the previous two to three months. The main aim of
diabetes care is to enable a patient to normalise their blood glucose levels. 8
Patients who have an HbA1c level of 7.5% or less have a good level of diabetes
control. Under the QOF 2009/10 guidance, three target levels for HbA1c (7%, 8%
and 9%) are included to provide an incentive to improve glycaemic control across the
distribution of HbA1c values, recognising however that the lower level may not be
achievable for all patients. 9 The Ealing PCT average for Hb1Ac less than 8% or less
indicator was 74% compared to an England average of 78%.
8
9
NICE CG87 Type 2 diabetes: the management of type 2 diabetes, May 2009
Quality and Outcomes Framework Guidance for GMS contract 2009/10.
12
Havering
Harrow
Camden
Westminster
Islington
Bromley
Barnet
Croydon
Enfield
Waltham Forest
Kensington and Chelsea
Sutton and Merton
City and Hackney
Southwark
Haringey
Redbridge
Newham
Greenwich
Hillingdon
Barking and Dagenham
Wandsworth
Brent
Ealing
Lambeth
Hounslow
Lewisham
Tower Hamlets
London
England
82.00
80.00
78.00
76.00
74.00
72.00
70.00
68.00
66.00
Kingston
Richmond and…
%
Figure 5: % of diabetic patients whose last HbA1c was 8% or less (DM24) 2010/11
Source: Quality and Outcomes Framework, http://www.ic.nhs.uk/qof
The figure below provides a breakdown of the key aspects of clinical management of
patients with diabetes and highlights the measurement and attainment of HbA1c,
blood pressure and cholesterol targets. There are variations between the Health
Networks in the level of control of diabetes achieved amongst their patients.
Figure 6: Clinical Management of patients with diabetes by the Health Networks in
Ealing 2010/11
90
80
70
Acton
60
West Ealing
50
%
Central Ealing
40
North North
30
South North
20
South Southall
North Southall
10
0
DM-24 HbA1c is < 8 DM12 BP is<145/85 DM17Measured total Exception rate for
in last 15 months
Cholestrol <5mmol/l
diabetes
in last 15 months
Source: Quality and Outcomes Framework, http://www.ic.nhs.uk/qof
13
The National Diabetes Audit
The NHS Atlas of Variation has demonstrated the substantial variation in diabetes
processes and outcomes for patients. This variation is linked to the increasing costs
aligned with treating diabetes, along with late diagnoses and inappropriate care. The
National Diabetes Audit 2010-11 reported that just over half of the increasing
numbers of people diagnosed with diabetes receive all nine necessary care
processes in England (for example, at least annual eye examination).
In NICE guidance it is recommended that all people with Type 2 diabetes should
receive the following care processes at least once a year:
HbA1c measurement;
Cholesterol measurement;
Creatinine measurement;
Micro-albuminuria measurement;
Blood-pressure measurement;
Body mass index (BMI) measured;
Smoking status recorded;
Eye examination;
Foot examination.
In 2010/11 52 practices (63.4%) from Ealing PCT have submitted data to the
National Diabetes Audit (NDA). The overall results of participating practices shows
that only 46.3% of people of all ages with Type 1 diabetes in Ealing had received all
nine care processes between January 2010 and March 2011.
56.6% of people of all ages with Type 2 diabetes had received all nine care
processes between January 2010 and March 2011.
A comparison of results for participating practices in Ealing PCT of patients receiving
all care processes by age group and diabetes type are shown below:
Table 3: % of Patients receiving all care processes by age group and diabetes type in
Ealing
Source: National Diabetes Audit 2010/11
14
Deaths from Diabetes
Life expectancy is reduced on average by more than 20 years in type 1 diabetes and
up to 10 years in type 2 diabetes. Mortality rates are up to five times higher for
people with diabetes compared to those without the disease. It is estimated that
diabetes accounts for one in seven deaths in the UK from diabetes. 10 Although
diabetes is listed as an official cause of death for approximately 7000 people each
year in the UK, death certificates often fail to take diabetes as an underlying cause
into account.
Figure 7 shows that there have been significant fluctuations in deaths from diabetes
during the past 15 years. The mortality from diabetes has decreased between 19932010 in Ealing, however remains higher than England and London.
Figure 7: Trend in Mortality DSR per 100,000 from diabetes (ICD9 250 adjusted, ICD10
E10-E14), in 1993-2010 for all ages
18.00
16.00
14.00
12.00
10.00
8.00
6.00
4.00
2.00
MALES
LONDON
FEMALES
ENGLAND
2009
2007
2005
2003
2001
1999
1997
1995
1993
2010
2008
2006
2004
2002
2000
1998
1996
1994
2009
2007
2005
2003
2001
1999
1997
1995
1993
0.00
PERSONS
Ealing LB
Source:The NHS Information Centre for health and social care
10
Diabetes in the UK 2004, A report from Diabetes UK October 2004
15
Figure 8 shows that the mortality from diabetes in Ealing for both males and females
aged less than 75 years remain higher than London and England in 2008-10.
However, males experienced more deaths from diabetes compared to female
counterparts.
DSR per 100,000
Figure 8: Mortality from diabetes (ICD10 E10-E14), DSR per 100,000 for less than 75
years in 2008-10 (pooled)
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
ENGLAND
LONDON
Ealing LB
Males
Females
Persons
The NHS Information Centre for health and social care
Diabetes related complications
Poorly managed diabetes can lead to a range of complications including amputation,
kidney disease, strokes, heart attacks, depression and blindness. As a result
diabetes increases the chance of a person needing hospital admission by 5 times. 11
The National Diabetes Audit noted that the majority of complications develop after a
long period of exposure to high blood glucose, high blood pressure and high
cholesterol. It is widely accepted that the early diagnosis and treatment can reduce
the risk of complications. The early diagnosis would better enable primary care
health professionals to support patients in avoiding complications and ultimately
emergency admission.
It is estimated that someone diagnosed with diabetes at age 45 who does not smoke
and maintains HbA1c, blood pressure and cholesterol measurements within current
QOF targets and did not have any diabetic complications at diagnosis will require
treatment for complications costing over £14,000. (Source: UKPDS Outcomes
Model)
The figure 9 shows the prevalence of complications. It provides data on emergency
hospital admissions for diabetic ketoacidosis and coma, minor and major lower limb
amputations in people with diabetes aged 17 years and older. A minor amputation is
defined as an amputation of the toe or foot. Any amputation above the ankle is
defined as a major amputation.
11
Turning the Corner: Improving diabetes Care, June 2006. Department of Health.
16
These data have been taken from the Hospital Episode Statistics (HES). HES is a
central database of all NHS hospital admissions in England. The data in this chart is
for the period April 2007 to March 2009. The rate shown is a rate per 1000 people
diagnosed with diabetes. Other sources of data may present similar data as a rate
per 100,000 general population and this may show a different pattern of diabetic
complications.
Figure 9: Prevalence of Diabetes complications in Ealing, Indigo Group and England
Minor lower limb amputation.
0.7
Major Lower Limb amputations
0.6
Diabetic retinopathy treatments
0.9
9.8
Renal Failure
3.6
Ketoacidosis
Ealing
6.5
Myocardial Infarction
Indigo Group
5.7
Stroke
England
14.9
Cardiac Failure
24.1
Angina
0
5
10
15
20
25
30
35
Rate per 1000 population
Source: National Diabetes Audit 2009/10
Diabetic ketoacidosis (DKA) is a dangerous complication of diabetes, and can be
fatal if left untreated. In DKA, the body is unable to break down glucose. It is caused
by a lack of insulin in people with Type 1 diabetes. It is rare in people with Type 2
diabetes. The emergency hospital admission rate for diabetic ketoacidosis and coma
for all ages in 2009/10 shows an improvement compared to 2008/09 by 41
percentage points in Ealing. The rate in Ealing is lower compared to the England
average in 2009/10 (25.44 vs 27.09 per 100,000 population). See figure 10.
17
Figure 10: Emergency hospital admissions: diabetic ketoacidosis and coma, indirectly
age and sex standardised rates per 100,000 population in 2009/10
Lewisham
Barking & Dagenham
Lambeth
Hillingdon
Croydon
Brent
Southwark
Greenwich
Haringey
Bromley
Wandsworth
Hounslow
Havering
Newham
Ealing
Bexley
Islington
Waltham Forest
Hammersmith &Fulham
Richmond
Merton
Redbridge
Kingston
Harrow
Enfield
Kensington&Chelsea
Sutton
Westminster
Camden
Barnet
Tower Hamlets
Hackney
London
England
50.00
45.00
40.00
35.00
30.00
25.00
20.00
15.00
10.00
5.00
0.00
Source: The NHS Information Centre for health and social care
Foot problems in diabetes result from peripheral nerve involvement or peripheral
vascular disease. As many as 1 in 10 people with diabetes are affected by foot
ulcers during the course of their disease. The emergency hospital admission rate for
lower limb amputation in diabetic patients in Ealing is 9.35 per 100,000 in 2009/10
lower than the national average.
20.00
18.00
16.00
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
Lewisham
Hounslow
Lambeth
Greenwich
Kingston
Harrow
Croydon
Merton
Bexley
Brent
Waltham Forest
Hammersmith…
Southwark
Islington
Camden
Ealing
Haringey
Barking &…
Wandsworth
Redbridge
Hillingdon
Havering
Enfield
Richmond
Sutton
Westminster
Tower Hamlets
Bromley
Barnet
London
England
Figure 11: Hospital procedures: lower limb amputations in diabetic patients, indirectly
age and sex standardised rates per 100,000 population in 2009/10
Source: The NHS Information Centre for health and social care
18
Diabetes Foot Disease Profile
Updated figures on amputation rates (major and minor) for 2008–11 have been
produced by the Yorkshire and Humber Public Health Observatory (YHPHO).
Amputation figures require careful interpretation. Amputation rates can be affected
by many factors, including quality of primary care, delays in presentation or referral,
availability and quality of specialist resources, population demographics and
prevailing medical opinion. 12
In Ealing over the 3-year period, there were 148 foot care admission episodes
a year per 10,000 people aged 17+ with diabetes compared with the England
average of 181 per 10,000 people.
In Ealing there were 95 amputations ( major and minor) performed during the
three years, 2008-2011 giving an annual rate of 17 amputations per 10,000
people aged 17+, lower than the national average of 27 per 10,000 adults with
diabetes.
Table 4: Ealing Diabetes Foot Disease Profile- Jan 2012.
Source: Diabetes Health Intelligence for the National Diabetes Information Service (NDIS)
http://www.yhpho.org.uk/diabetesfootprofiles/pdfs2012/5K5_Diabetes_Footcare_Profile.pdf
12
Foot Care for People with Diabetes. The Economic Case for Change. March 2012.
19
The risk of ulceration and amputation is related to factors such as age and ethnicity.
Ealing PCT belongs to the Indigo group, which has relatively young population, a
substantially higher than average proportion of the population from black and Asian
ethnic groups, and higher than average deprivation.
Indigo group foot care admission rates and amputation rates are considerably
lower than the England average.
The average foot care admission rate for the Indigo group PCTs was 129 per
10,000 people with diabetes, and the average amputation rate for the Indigo
group was 16 per 10,000 people with diabetes.
Ealing has the 2nd highest annual amputation rate in the Indigo Group and its
foot care admission rate was the 3rd highest as shown in figure 13 and 14
Figure 12: Annual foot care admission episodes per 10,000 people with diabetes by
PCT, Indigo Group 2008–1113
250
200
150
100
50
0
According to the latest report 14 Brent has the lowest annual amputation rates in the
indigo group (figure 14). The estimated annual saving from lower admission rates,
relative to the average for the rest of the Indigo group, was £201,000. This is
approximately 1.3 times the cost of the MDT and STARRS (Short Term Assessment,
Rehabilitation and Reablement Service) for diabetic foot care. Monetised 5-year
Quality Adjusted Life Year (QALY) gains from lower major amputation rates, relative
to the Indigo average, are estimated at £65,000 for a 1-year patient cohort.
13
Diabetes Health Intelligence
http://www.yhpho.org.uk/default.aspx?RID=116836
14
Foot Care for People with Diabetes. The Economic Case for Change. March 2012.
20
Figure 13: Annual amputations (major and minor) per 10,000 people with diabetes by
PCT Indigo Group, 2008-201115
30
25
20
15
10
5
0
Kidney disease
Diabetes is the commonest cause of end stage renal disease and about 30% of
people with Type 2 diabetes develop kidney disease which accounts for 21% of
deaths in people with Type 1 diabetes and 11% in Type 2 diabetes. 16
End-stage chronic kidney disease (CKD5) is 12 times higher among men and 8
times higher among women with diabetes when compared with people who do not
have the condition. In 2009/10 in Ealing 0.98% compared to England 0.38% of
people of all ages with diabetes in the National Diabetes Audit (NDA) 2011 received
Renal Replacement Therapy (RRT).
Ealing has the second highest rate for RRT across England after Enfield PCT
(0.99%).17The risk of a person with diabetes requiring RRT increases with age.
People with diabetes from Black and Asian ethnic groups are more likely to have
severe chronic kidney disease than those from White ethnic groups. 18 Potential
reasons for variation include ethnicity, population age-structure, and level of
deprivation, capacity for RRT and service delivery (metabolic management).
15
16
Diabetes Health Intelligence
http://www.yhpho.org.uk/default.aspx?RID=116836
Diabetes UK (2010) Diabetes in the UK 2010: Key statistics on diabetes.
National Diabetes Audit 2011
18
Dreyer G et al. The effect of ethnicity on the prevalence of diabetes and associated chronic kidney disease. Q
J Med [Internet]. 2009 [cited 2011 Jan5]; 102(4): 261-9. http://qjmed.oxfordjournals.org/content/102/4/261.long
17
21
Cardiovascular complications
Cardiovascular disease, resulting from prolonged exposure to high blood levels of
glucose and fats, is a major cause of death and disability in people with diabetes and
accounts for 44% of deaths in people with Type 1 diabetes and 52% in those with
Type 2 diabetes. The risk of death from coronary heart disease for women with type
2 diabetes is about 50% greater than for men and the risk of stroke is doubled within
the first 5 years after diagnosis of Type 2 diabetes compared with the general
population. 19
People with diabetes are at greater risk of having a myocardial infarction (MI) or
heart attack than people who do not have the condition. In 2009/10 in Ealing 0.65%
compared to England, 0.60% of people of all ages with diabetes included in the
National Diabetes Audit (NDA) were admitted to hospital for MI. Potential reasons for
variation include:
Ethnicity – people from a South Asian ethnic background have higher rates of
coronary heart disease (CHD);
Deprivation, which is associated with higher rates of CHD;
Service delivery (cardiovascular risk management).
It is important that people with diabetes who have had an MI are offered cardiac
rehabilitation to reduce the risk of further cardiac events.
Eye Diseases
Diabetes is the most frequent cause of blindness in people of working age in the UK.
People with diabetes are up to 20 times more likely to become blind than other
people. This is mostly because of retinopathy resulting from damage to blood
vessels in the retina, but people with diabetes also have double the risk of
developing glaucoma and cataracts compared with the general population. Twenty
years after diagnosis nearly everyone with Type 1 and 60% of people with Type 2
diabetes have some retinopathy. See the JSNA chapter on Screening for details of
the Diabetic Retinopathy Screening Service for Ealing
Use of Inpatient services in Ealing:
The findings for the National Diabetes Audit 2009/10 shows in Ealing, people of all
ages with diabetes stayed in hospital 25.8% longer than would have been expected
if they had had the same length of stay as people of a similar age without diabetes.
The England value is 19.4%:
The main factors involved in longer lengths of stay in people with diabetes are:
diabetes-related morbidities complicating admissions to hospital for other
reasons
Inadequate control and management of diabetes while people are in hospital
for reasons unrelated to diabetes.
19
Diabetes UK (2010) Diabetes in the UK 2010: Key statistics on diabetes.
22
In Ealing there were 54.5% excess emergency re‐admissions (%) within 28 days
among people with diabetes when compared with people without diabetes by PCT
2009/10. The England value is 59.1%:
In Ealing 10.2% fewer than would be expected if people with diabetes underwent a
similar proportion of elective day case procedures as people of a similar age without
diabetes in 2009/10
Prescribing 20
Insulin is used to lower the blood glucose level of people with Type 1 diabetes and
that of people with Type 2 diabetes when non-insulin drugs are not providing
adequate control. For PCTs in England, insulin total net ingredient cost per patient
on GP diabetes registers ranged from £79 to £176 (2.2-fold variation) in 2010/11.In
England, Ealing has the second lowest insulin total net ingredient cost per patient on
GP diabetes registers £84 after Brent £79 in 2010/11. There is a need to ensure that
the recommended treatment regimens in NICE guidelines for people with Type 1 and
Type 2 diabetes are implemented locally.
However across England the degree of variation observed for spending on noninsulin anti-diabetic items is greater than that for spending on insulin items. In Ealing,
the non-insulin anti-diabetic drugs total net ingredient cost per patient on GP
diabetes registers is £113.8 compared to England £110.79 in 2010/11.
In England, the total net ingredient cost per patient on GP diabetes registers for
blood-testing items ranged from £43 to £87 (2-fold variation) in 2010/11. In Ealing
blood-testing total net ingredient cost per patient on GP diabetes register is £55.9.
There is no association that PCTs spending the most on blood-testing items do not
necessarily have the greatest percentage of people with diabetes who have optimal
blood glucose control.
Diabetes outcomes in Children 21
The diabetes prevalence rate in Ealing for 0-18 years is between 75-144 children at
any point. The most likely range is 115-130.22For PCTs in England, the percentage
of children aged 0–15 years in the NDA with diabetes whose most recent HbA1c
measurement was 10% or less ranged from 41.7% to 100.0% (2.4-fold variation).
When the five PCTs with the highest percentages and the five PCTs with the lowest
percentages are excluded, the range is 61.3–92.2%, and the variation is 1.5-fold.
20
The NHS Atlas of Variation in Health care for people with diabetes released in June 2012.
http://www.sepho.org.uk/extras/maps/NHSatlasDiabetes/atlas.html
21
The variation in Child care atlas was released in May 2012
http://www.sepho.org.uk/extras/maps/NHSatlasChildHealth/atlas.html
22
Source: Paediatric team at Ealing Hospital
23
In Ealing only 50.9% (lowest across whole of London and 2nd lowest across
England after Darlington) of children aged 0-15 years with Type 1 diabetes had
HbA1c measurement of 10% (86 mmol/mol) or less in January 2009 to March 2010.
When compared with "Like with like PCTs" the figures are: Hillingdon -74.7%,
Hounslow-61.9%, Brent-64.4%, Harrow-81.7%, Newham-68.8%
Percentage of children aged 0-15 years with previously diagnosed diabetes in the
National Diabetes Audit (NDA) admitted to hospital for diabetic ketoacidosis by PCT,
January 2009 to March 2010: Ealing-25.6%,Hillingdon -28.2,Hounslow-31.9%,Brent38.8%,Harrow-32.1%,Newham-29.8%
This suggests that Ealing has a fewer number of children aged 0-15 years with type
1 diabetes with HbA1c measurement of 10% or less, however diabetic ketoacidosis
admissions remain lowest when compared with most PCTs across London.
Spending on Diabetes Care and Outcomes
The Department of Health Programme budgeting is a method of looking at
how resources are spent in different areas (or programmes) of healthcare, There
are currently 23 programme budgeting categories, which are based on the World
Health Organisation (WHO) International Classification of Disease (ICD10). It is a
retrospective appraisal of resource allocation broken down into ‘programmes’ - with a
view to influencing and tracking future expenditure in those same programmes.
Programme budgeting data are made available in a number of tools which support
effective commissioning, such as the benchmarking spreadsheet, the programme
budgeting Atlas and the Spend & Outcomes Tool.
Programme budgeting data on diabetes is recorded under programme: endocrine,
nutritional and metabolic problems. As diabetes complications have an impact on
other programmes such as the circulatory system, kidneys and eyes the data does
not capture the full financial impact of diabetes.
Ealing spend 8.29 million on Diabetes programme in 2010/11 compared to 8.5
million in 2009/10. Although direct comparisons on spend for 2010/11 should not be
made with previous years due to significant changes in methodology. The estimated
spend in Ealing for diabetes in 2010/11 was £8.29 million and this represents 1.4%
of the total budget. Total Endocrine budget in 2010/11 is 18.84 million, 3.0% of the
total spend on all programmes in Ealing.
24
Figure 14: Endocrine spend in Ealing compared with other programme budgeting
categories 2010/11
100.0
90.0
80.0
Expenditure as selected (£million)
70.0
60.0
Endocrine spend = £18.8 million
50.0
40.0
30.0
20.0
10.0
0.0
Programme
Budgeting
Categories
1 Infectious diseases
2 Cancers and
Tumours
3 Disorders of Blood
4 Endocrine,
Nutritional and
Metabolic problems
5 Mental Health
Disorders
6 Problems of Learning
Disability
7 Neurological
8 Problems of Vision
9 Problems of Hearing
10 Problems of
circulation
11 Problems of the
respiratory system
12 Dental Problems
13 Problems of The
gastro intestinal
system
14 Problems of the
skin
15 Problems of the
Musculo skeletal
system
16 Problems due to
Trauma and Injuries
17 Problems of Genito
Urinary system
18 Maternity and
Reproductive Health
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23a 23x
Programme budgeting category code
Source: Department of Health, Programme Budgeting Data 2010/11
25
The largest proportion of diabetes spent was in Primary care & Prescribing
amounting to nearly £5.77 million23, higher than the ONS cluster average. The
proportional expenditure across secondary care (Inpatient: non elective cases) in
Ealing is higher when compared with the average proportional expenditure for
similar PCTs within the region.
Figure 15: Diabetes Expenditure across Care setting in Ealing compared to ONS
cluster average
80%
Ealing PCT
Percentage of expenditure in selected programme
70%
ONS Cluster
average
60%
50%
40%
30%
20%
10%
0%
Source: Department of Health, Programme Budgeting Data 2010/11
23
Department of Health, Programme Budgeting Data 2010/11
http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Programmebudgeting/DH_075743#_7
26
Ealing PCT spends 2.50 million per 100,000 population in 2010/11, lower than
ONS cluster average of 2.84 million per 100,000 population and ranked 104
nationally.
1st quintile
2nd quintile
3rd quintile
Harrow PCT
Luton Teaching PCT
Croydon PCT
Hounslow PCT
3.0
Ealing PCT
4.0
Enfield PCT
Barnet PCT
5.0
Redbridge PCT
6.0
Waltham Forest PCT
Greenwich Teaching PCT
Expenditure (£million per 100,000 population)
7.0
2.0
1.0
0.0
National Rank Lowest to Highest
Source: Department of Health, Programme Budgeting Data 2010/11
Diabetes Spend in relation to outcomes
Ealing spend £25.05 in 2010/11 per head per year on diabetes compared to £25.89
in 2009/10. The diabetes spend per head in 2010/11 is lower than the England
average of £27.93 per head per year. Whilst programme budgeting allows an
analysis of spend by health programmes to explore high cost areas the natural next
step is to assess the return on the investment with regards to patient and population
health outcomes.
27
Figure 16: Spend & outcome for Ealing relative to other PCTs in England in 2010/11
Endocrine conditions: Ealing has a
higher spend and worse outcomes
Source: Department of Health Spend and Outcomes tool 2010/11
Interpreting the chart:
Each dot represents a programme budget category.
The outcome measures on the chart have been chosen because they are reasonably representative of the
programme as a whole. This means that for some programmes no outcome data is available.
The source data for the outcome measures shown on the chart can be found in the Spend and Outcome Tool.
A programme lying outside the solid pink +/- 2 z scores box, may indicate the need to investigate further. If the
programme lies to the left or right of the box, the spend may need reviewing, and if it lies outside the top or
bottom of the box, the outcome may need reviewing. Programmes outside the box at the corners may need a
review of both spend and outcome.
Programmes lying outside the dotted/thin pink +/- 1 z score box may also warrant further exploration.
Z Score:
A z score essentially measures the distance of a value from the mean (average) in units of standard deviations.
A positive z score indicates that the value is above the mean, whereas a negative z score indicates that the
value is below the mean. A z score below -2 or above +2 may indicate the need to investigate further.
28
Ealing has a higher spend and worse outcomes for Endocrine, Nutritional and
metabolic problems in 2010/11. While this is true for all conditions relating to
endocrine and metabolic problems as a whole, a slightly different scenario is noticed
when looking at lower limb amputation and diabetes emergency admissions
separately. In Ealing there was a lower spend and improved outcomes for lower limb
amputations in diabetics and emergency admissions for diabetes related
complications in 2010/11.
The figure below shows standardised total spend on diabetes care based on
Programme Budgetting data in 2010/11 against the standardised proportion of
people with an HbA1c measurement of 7.5% of less.
Figure 17: Diabetes Spend and HbA1c outcomes in 2010/11
Ealing PCT
Source: SPOT tool
29
Figure 18: Diabetes Spend and Lower Limb amputation in Diabetics
Ealing PCT
Source: SPOT tool
Figure 19: Diabetes Spend and emergency admissions for diabetic complications
Ealing PCT
Source: SPOT tool
30
Evidence based Interventions
The Department of Health published the Diabetes National Service Framework in
2001 which set out 12 national standards for the care of people with diabetes. This
was followed in 2003 with a Delivery Strategy which set out how the Diabetes NSF
could be achieved. 24 In 2010, a six year update on performance on the Diabetes
NSF standards was published, which highlighted progress made on each of the 12
standards. 25
Evidence suggests education and awareness is the key to solving the diabetes
problem in the UK, but tackling obesity when it is still at an early stage is essential in
preventing the spread of the disease.
Benefits of a 10 kg weight Loss (Jung,1997)26
Mortality
Diabetes
Lipids
Blood Pressure
20-25% reduction in total
mortality
30-40% reduction in diabetes
related deaths
Reduced risk of developing
diabetes by >50%
30-50% reduction in fasting
glucose
15% reduction in HbA1c Level
10% reduction in total
Cholesterol
15% reduction in LDL(low
density lipoprotein)
30% reduction in triglycerides
8% increase in HDL(High density
lipoprotein)
10mmHg reduction in systolic
BP(blood pressure)
20mmHg reduction in diastolic
BP.
NICE (2011) Quality Standard 1 defines a patient’s education programme according
to five key criteria: It should be
Evidence based, supporting the learner in developing attitudes, beliefs,
knowledge and skills to self-manage diabetes.
Theory driven, with written supporting materials
Delivered by trained educators
Quality assured
Regularly audited.
24 National Service Framework for Diabetes: Delivery strategy. DH 2003
25
Six years on. Delivering the Diabetes National Service Framework. Department of Health, 2010.
26
Jung RT 1997, Obesity as a disease. British Medical Bulletin 53:307-21
31
All information about treatment and care should be flexible, and take into account
age and social factors, language, accessibility, physical, sensory or learning
difficulties, and ethnically and culturally appropriate (NICE, 2011)
NICE Guidance Type 1 diabetes. Diagnosis and management of type 1 diabetes in
children, young people and adults. http://guidance.nice.org.uk/CG15
NICE Care pathway for diabetes. http://pathways.nice.org.uk/pathways/diabetes
NICE Guidance Type 2 diabetes (partially updated by CG87). Type 2 diabetes: the
management of type 2 diabetes (update). http://www.nice.org.uk/CG66
National Service Framework for Diabetes (2001)
Diabetes Commissioning Toolkit (2006)
Type 2 Diabetes Clinical Guideline: The management of type 2 diabetes – CG87
May 2009 – partial update and replacement of CG66, including newer
pharmacological agents.
NICE Guidance: Diabetes in pregnancy: CG63: management of diabetes and its
complications from pre-conception to the postnatal period – March 2008
Diabetes Health Intelligence – hosted by Yorkshire and Humber Public Health
observatory
NHS Diabetes – Department of Health team with the remit of supporting the
implementation of the Diabetes NSF
Preventing Type 2 diabetes: population and community interventions in high-risk
groups and the general population (May 2011).
Type 2 diabetes: preventing the progression of pre-diabetes to Type 2 diabetes
among high-risk groups published in May 2012.
Current service provision in Ealing
The care pathway for diabetes is complex and moves from prevention, through
awareness raising and diagnosis to management of complications. Healthcare
professionals carrying out diabetes care include general practitioners and practice
nurses, district nurses, diabetes specialist nurses, dieticians, podiatrists, consultant
diabetologists, and renal, vascular and ophthalmic consultants. There are also
implications for local authority social care services, where patients experiencing
diabetes related complications may need residential or home care, occupational
therapy or disability equipment.
In Ealing only 2.8 Whole Time Equivalent Diabetic Specialist Nurses (DSN) are
employed to support the 82 general practices with 19,600 diabetic population. One
additional DSN dedicated to young adults and children . Ealing Clinical
Commissioning Group (ECCG) ratified the new Strategy for Diabetes Care in
December 2011. It includes the following:
32
The establishment of a Diabetes Redesign Board with 3 work streams
(Technical, Clinical, and Commissioning Development), each with objectives
to coordinate and lead change across the whole system
A three tier model of diabetes care. Tier One includes routine care for the
great majority of patients through general practice nurse-led diabetic clinics.
Tier Three is hospital care for the most difficult cases, children and pregnant
women. Tier Two has yet to be developed; it will include community clinics led
by Lead Practices for Diabetes and Diabetes Specialist Nurses to a) Initiate
insulin, b) Case manage complex cases, and c) Support Tier One care
The clustering of general practices into geographic areas of about 30,000
population (termed ‘local health Networks’) to facilitate on-going collaboration
across services in primary care, public health, community groups and others
for social and emotional wellbeing, and between disciplines practice nurses
and diabetes specialist nurses for medical care.
It is proposed that the GP Practices in Ealing will cluster into geographic areas of
about 50,000 population (10-20 general practices) to form local health Networks.
These will be community hubs for mutual support, training, insulin initiation and
collaborative health promotion. General practices within local health Networks will
receive practical advice and support from consultant diabetologists, diabetic
specialist nurses and other diabetes services. They will also receive generic
intermediate care support (e.g. rehabilitation, step-up beds and community nurses),
support for education and leadership development, and academic links for student
attachment, research and collaborative innovation.
Patient Information & Education and Training Programmes
The Public Health lead on Prevention and Education to the general public
contributing to the prevention of diabetes through a range of general public health
programmes. The Public Health role is focussed on helping to prevent people
developing diabetes and supporting those who are at high risk of developing
diabetes. These programmes include:
Diabetic Retinopathy Screening Service
The Diabetic Eye Screening Programme in Ealing offers routine annual digital
photography to all diabetic patients. The uptake rate for diabetic screening has
increased steadily in the last three years. Initial uptake rates hovered around 50%
increased to around 70% in 2010/11. See JSNA chapter on retinal screening.
Choosing Health Projects:
The Choosing Health projects deliver a wide range of activities including health
promotion, advocacy, education, training, direct services and fitness in the
community. The projects cover both national and local priorities under target health
needs: During 2011/12 a total of 17 projects were funded including newly
commissioned services Health Walks Programme; Obesity Prevention 0-5 and
Ealing Health Lifestyle Programme (supporting people post a NHS Health Check).
33
Health Trainers
NHS Health Trainers in Ealing provide advice, motivation and practical support to
adults who want to adopt healthier lifestyles. NHS Health Trainers know the local
area and can help people find relevant services, community groups and projects.
They can also give practical support and advice to help develop and maintain a
healthy lifestyle, and act as a link between professionals and communities
.Individuals can self-refer via email or phone or practices can refer.
The Ealing Healthy Lifestyle Programme was set up to support patients identified
to be at risk of developing long terms conditions following an NHS Health Check.
This is a comprehensive service, integrated with the NHS Health Checks
Programme in Ealing to support patients to change behaviours and sustain a
healthier lifestyle.
Ealing Walks programme
A programme of walks open to all people across the borough. People who would like
to undertake more activity can join on or more of the walks offered across Ealing on
different days of the week at varying times including evenings and weekends.
Awareness Raising / Education Work
Diabetes Talks, Presentations and training across the borough. Undertake diabetes
awareness raising and promotional work on different occasions throughout the year,
for example as part of diabetes week in June.
The Dietetics Service in Ealing in partnership with other health care professionals
in the Integrated Care Organisation (ICO) providing the Right Start Education
Programme for people diagnosed with Type 2 Diabetes. The aim of the Programme
is to increase knowledge and understanding of diabetes and support people
diagnosed with Type 2 to feel more confident managing their own condition.
MEND (Physical Activity & Healthy Eating)
MEND is a 10 – week family based healthy lifestyle programme for children aged 7 –
13 years, who are classified as overweight or obese through the national weighing
and measuring programme in schools and their families. Children attend the
sessions, twice a week, with their parents/carers for a variety of structured practical,
interactive, fun sessions that are based on evidence of effectiveness.
Sessions include physical activity, nutrition and support on motivating behaviour
changes. Evaluation of the programme has shown good progress toward sustained
improvements in diet, fitness levels, self-confidence and personal development;
including body mass index and waist circumference.
34
Recommendations
Proactive identification of diabetics within primary care through the NHS
vascular screening programme and ensure optimum condition management
of those on the diabetes registers.
Support and focus on lifestyle management of those patients in a pre-diabetic
state (Impaired Glucose Tolerance (IGT) /Impaired Fasting Glycaemia (IFG)
to help people avoid developing diabetes.
Continue to develop an education programme for GPs, practice nurse’s and
district nurses, to enable practices and more ‘generalist staff’ to be able to
monitor and manage diabetic patients with the support of more ‘specialist
staff’.
Ensure that activity data from all commissioned services should include
information about age, sex, ethnicity and geography to facilitate monitoring of
equity of access to services and inform future service development.
Continue to support and expand the programme to raise awareness of
diabetes in communities at high risk of disease; to promote prevention,
increase detection and promote timely and appropriate access to services.
Children diabetes teams to work in partnership with children, young people
and their parents to find ways of improving glucose control. Ensure HbA1c
levels for children with diabetes are monitored and develop services to drive
improvements
Engage with the public and patients to increase awareness of the local
diabetes services.
Strengthen links between diabetes services and services which deliver
preventive activities such as physical activity and healthy eating.
Ensure services are able to meet the needs of people with diabetes in care
homes and nursing homes, and those with mental illness and learning
disabilities.
Continue to focus on ‘hard to reach groups’ who are more susceptible to
complications as a result of mismanaging their diabetes. This includes people
with mental health, alcohol, drug misuse problems, pregnant women and
people with diabetes who are in care homes.
35
Appendix 1: Diabetes Prevalence at practice level by the Health Networks in
Ealing.
NORTH SOUTHALL DIABETES PREVALENCE
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
2009/10
2010/11
SOUTH SOUTHALL DIABETES PREVALENCE
14.0
12.0
10.0
8.0
%
2009/10
6.0
2010/11
4.0
2.0
0.0
Y02342
E85656
E85061
E85096
E85049
E85090
E85121
E85006
36
ACTON DIABETES PREVALENCE
9.0
8.0
7.0
%
6.0
5.0
4.0
2009/10
3.0
2010/11
2.0
1.0
0.0
WEST EALING DIABETES PREVALENCE
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
2009/10
2010/11
E85122
E85014
E85034
E85628
E85657
CENTAL EALING DIABETES PREVALENCE
6.0
5.0
4.0
2009/10
3.0
2010/11
2.0
1.0
0.0
E85740 E85091 E85714 E85057 E85120 E85099 E85123 E85726 E85026 E85116
37
NORTH NORTH DIABETES PREVALENCE
10.0
9.0
8.0
7.0
6.0
5.0
2009/10
4.0
2010/11
3.0
2.0
1.0
0.0
E84059 E85050 E85053 E85054 E85098 E85108 E85111 E85112 E85127 E85643 E85725
SOUTH NORTH DIABETES PREVALENCE
12.0
10.0
8.0
6.0
4.0
2009/10
2010/11
2.0
0.0
38
Diabetes Quality and Outcomes Framework Indicators in 2010/11
Source: GP Practice Profiles
39
40