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Diabetes

Introduction

Diabetes is a long term condition that causes a raised blood glucose level, which can be caused by insulin insensitivity and insufficient amounts of insulin released from the pancreas (see footnote 1).

Nationally there were 2.2 million people diagnosed with diabetes in England in 2009 (see footnote 2). More than 1 in 20 people have diabetes in Haringey and in England and this number is predicted to rise, partly due to an ageing population and partly due to the increasing prevalence of obesity (see footnote 3).

There are a number of modifiable risk factors for diabetes – such as obesity – therefore diabetes prevention is a priority (see footnote 1). Diabetes can lead to long term complications such as diabetic retinopathy, nephropathy and neuropathy. Cost effective treatment, close to home is a priority to reduce unnecessary admissions or attendances to hospital.

The risk of death for patients in England with type 2 diabetes is 1.6 times higher than the general population. People with diabetes are at increased risk of other health problems, for example, they are five times more at risk of cardiovascular disease (CVD) compared with those without diabetes (see footnote 4). There were about 24,000 excess deaths each year in people with diagnosed diabetes (type 1 and 2) in 2007/8 (see footnote 5).

Risk factors for diabetes, prevalence of diabetes and mortality from diabetes are not distributed equally within the population. There are higher rates in certain Black and minority ethnic (BME) groups and lower socio-economic groups.

Diabetes is an important contributor to the life expectancy gap in Haringey, both as a risk factor for CVD and as an important long term condition. Outcome 2 of the Haringey Health and Wellbeing Strategy “a reduced life expectancy gap” sets five key priorities: reduce smoking, increase physical activity, reduce alcohol misuse, reduce early deaths from CVD and cancer especially in the east of the borough and support people with long term conditions to live a healthier life (see reference 6). Delivering on these 5 priorities encompasses prevention, early intervention and appropriate treatment and care of diabetes. Diabetes is therefore a priority in Haringey.

This JSNA section links with the following other JSNA sections: life expectancy gap (diabetes is a contributor to this gap), sections on life style factors that are risk factors for diabetes or lead to poorer health outcomes for diabetics (smoking, physical activity, alcohol misuse, adult obesity, childhood obesity, diet and nutrition).

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Key issues and gaps

  • Diabetes is an important contributor to the life expectancy gap in Haringey. Prevention, early intervention and treatment and care of diabetes is central to the Haringey Health and Wellbeing Strategy
  • More than 1 in 20 people in Haringey have diabetes. There are significant numbers of undiagnosed diabetics in Haringey.
  • Age and lifestyle factors, (particularly obesity and physical inactivity) are key risk factors for diabetes. There are a number of preventative programmes in Haringey but some are short term funded (e.g. exercise referral scheme for people with long term conditions) and there are important gaps such as weight management services for adults and children.
  • Diabetes and its risk factors are commoner in certain BME groups and lower socio-economic groups or in areas of deprivation. Service provision therefore needs to be targeted and appropriate for these groups.
  • Data suggests that emergency hospital admissions (for ketoacidosis and coma) are rising, hospital admissions are higher on the east of Haringey and there is variability in complication rates by GP practice. Models of care need to address these issues.
  • Implementation of a systematic care pathway needs to be agreed and implemented encompassing prevention, primary care, intermediate care, secondary care and integrated care. Key elements include: reducing variation in primary care outcomes, strengthening intermediate care and improving patient education.
  • Local intelligence for diabetes needs strengthening to give more accurate information of prevalence, complication rates and service provision. Information by geography, practice, socio-economic group or deprivation and ethnicity would help target services to needs.
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Who is at risk and why

The risk factors for type 2 diabetes are: weight, waist circumference, age, physical activity levels, family history of type 2 diabetes or diabetes in pregnancy. Other existing health conditions also increase the risk of developing Type 2 diabetes such as severe mental health problems, cardiovascular disease and pre-diabetes (see footnote 1).

Age is a key factor in diabetes prevalence. Type 1 diabetes tends to be diagnosed in childhood but the prevalence of Type 2 diabetes increases steadily after the age of 45 years (see footnote 3).

In general, people who are obese are five times more likely to have diagnosed diabetes than those with a healthy weight.  Particular ethnic groups are more likely to be obese and have a raised waist circumference (see footnote 7). Across England the prevalence of obesity is rising and it is projected that by 2025 42% of men and 39% of women will be obese (see footnote 3) (see also Obesity section of JSNA).

Most ethnic minority groups (a notable exception, is the Irish) have a higher standardised risk of having diagnosed diabetes compared to the general population (see footnote 7). Black and Asian ethnic groups have a higher risk of developing type 2 diabetes and tend to develop it at an earlier age (see footnote 1) (see footnote 3). Compared to the general population the following groups have increased risk: Black Caribbean males (twice the risk), Black Caribbean females (three times the risk), Pakistani females (five time the risk) and Bangladeshi women (three times the risk) (see footnote 7). Haringey has much higher proportions of minority ethnic groups than England, especially in the east of the borough.

People from lower socio-economic groups are more likely to develop diabetes (see footnote 1). People living in the 20% most deprived neighbourhoods in England are 56% more likely to have diabetes that those living in the least deprived areas (see footnote 3).

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The level of need in the population

Risk factor prevalence

Adult obesity in Haringey is estimated to be 27.6%, higher than England (23%). Risk factors for diabetes are commoner in certain BME groups and linked with deprivation. Further information can be found in the relevant JSNA sections.

Diabetes prevalence

In 2010/11 there were 11748 people aged 17 years and older diagnosed with diabetes in NHS Haringey. There is also an estimated 1484 adults with undiagnosed diabetes. 5.2 % of the Haringey population were diagnosed with diabetes (compared to 5.5% in England). The estimated prevalence for Haringey and England are 7.4% and 7.5% respectively (see footnote 3).

There is some evidence to suggest that the gap between predicted prevalence and numbers diagnosed is greater in the younger age groups (see footnote 4).

Recorded prevalence of diabetes among Haringey GP practices ranged between 2 and 9% of their adult population (QOF 2010/11). Modelling of expected numbers suggest a significant number of practices had more recorded than expected and others, less than expected. It may be that the model does not adjust appropriately for ethnicity and therefore there are limitations in applying it to Haringey.

Outcomes in primary care

HbA1c is an indicator of better blood sugar control, an important element of diabetes care.

54.1% of all people with diabetes aged 17 years and older in Haringey (excluding those who are excepted from reporting) have an HbA1c of 7% or less (good control). This is similar to England (see footnote 3). The rate of exception reporting in primary care is higher in Haringey than England (QOF 2010/11).

Figure 1 shows that Haringey performance across a range of indicators is roughly inline with achievement in London and England as a whole. However the percentage of diabetics with HbA1c of 7% or less is only just above 50%. There is also variation between GP collaboratives with south east collaborative recording lower rates on a number of indicators.

Figure 1: QOF achievement by collaborative compared to Haringey London and England 2011.

Source (QOF 2011)

Hospital admissions

Figure 2 below maps hospital admissions for diabetes by lower super output area (small areas).  This shows higher rates of admission in east of Haringey.

Figure 2: Likelihood of admission to hospital for diabetes

Source: MOSAIC 2009

Complication rates

The National Diabetes audit reviews the percentage of people with diabetes with a hospital admission that mentions each complication. Angina, cardiac failure, stroke and myocardial infarction in the previous year are the commonest reported complications. 16.8% patients had angina and 5.8% had a stroke in the previous year. Haringey has lower rates than England for most complications although this may be because the data is not age standardised and Haringey has a younger population. Haringey has high reported rates of renal failure and diabetic retinopathy treatments; the latter may be due to increased recall and retinopathy screening in Haringey (see footnote 3).

Figure 3 shows standardised rates of emergency hospital admissions due to diabetic ketoacidosis and coma. In 2008/09 and 2009/10 the rate in Haringey has increased markedly. Reasons for this are not clear.

Figure 3: Emergency hospital admissions: diabetic ketoacidosis and coma, indirectly age and sex standardised rates (2002/03 to 2009/10)

Source:NCHOD

Expenditure on Diabetes

Analysis of total spending on diabetes care against HbA1c outcomes shows that NHS Haringey is not statistically different from England (programme budgeting data (PBMA) 2010/11) (QOF 2010/11) (see reference 3).

Mortality

People with diabetes aged 20-79 are twice as likely to die as people in that age group without the condition. In Haringey if diabetes did not have that impact there would have been 14.1% fewer deaths between the ages of 20 and 79 years (2005) (see footnote 3).

Figure 4 shows recent trends in standardised mortality ratio (SMR) and deaths from diabetes in Haringey. Haringey SMR is generally higher than England or London. The number of deaths in Haringey dropped to 7 in 2009 but rose again to 16 in 2010, but numbers are small.

Figure 4: Standardised mortality ratio for diabetes in Haringey compared to London and England and Wales 1993-2010 (Number of deaths on Haringey line)

Source: NHS Information Centre

4.38 years of life per 100 000 (European standardised) population were lost due to diabetes in Haringey (2008-10). This is higher, though not statistically different, than other boroughs in North Central London, London as a whole and England as a whole (source NHS Information Centre).

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Current services in relation to need

Prevention

NICE recommends developing cost-effective physical activity, dietary and weight management interventions for communities at high risk of type 2 diabetes (see footnote 1).

Interventions can halve the number with impaired glucose regulation who go on to develop type 2 diabetes. The greatest impact on the levels and associated costs of type 2 diabetes is likely to be achieved by addressing these behavioural risk factors in whole communities and populations. Health promoting messages should be delivered in a consistent, clear and culturally appropriate manner, and national messages tailored to local populations (see footnote 1).

In Haringey the modifiable behavioural factors that increase risk of diabetes or complications from diabetes are all more prevalent in certain BME groups, lower socio-economic groups and on the east of the borough. There are a number of specific programmes mainly focusing on the east of the borough including an exercise referral scheme for people with long term conditions and a developing community based weight management service, though both only have one years funding secured. The Health Trainer Service supports clients with lifestyle changes. For more details see JSNA sections on adult obesity, physical activity, smoking and alcohol.

Early Intervention

Key planks of early intervention are early diagnosis and management of disease registers in primary care, education programmes in primary care, community based health champions and the NHS Health Checks programme. The data above suggests there is variability in diagnosis rates between GP practices, although this requires further investigation. Haringey has a strong history of GP education for diabetes; this is currently being refreshed. A Community Health Champions Programme in partnership with Diabetes UK undertakes risk assessments in primary care and raises awareness of disease. NHS Health Checks (see footnote 8) are now being delivered in community and primary care settings in is now strong in east of Haringey; this year we have undertaken 5000 checks with appropriate follow up.

Treatment and Care

Key aims of treatment care for diabetes in Haringey are to deliver: care closer to home, quality care e.g. blood sugar control, effective secondary prevention, reduced complications, cost effective care, integrated health and social care, avoidance of inappropriate hospital admission. Care should be targeted to needs achieving equitable access and outcomes for population sub-groups.

North Central London Cluster has developed a diabetes care pathway outlining a model of care including prevention (as above), primary care, intermediate care, secondary care and patient education. This requires local adaptation and implementation.

The majority of patients with diabetes manage their condition under the care of their GP.

Patients in Haringey are also able to access a nurse-led intermediate diabetes service which provides a tier of care for patients who need specialist input which can be provided by highly trained nurses outside a hospital setting. The service operates from three community health centres across the borough. A pilot ensures patients referred from GPs in north east Haringey are triaged via intermediate care service to avoid unnecessary hospital referrals and support patient management closer to home in primary care or intermediate care as appropriate.

Patients in Haringey will usually be referred for diagnosis and management of an acute condition to Whittington Health or the North Middlesex Hospitals diabetes departments. An integrated care model is in development, this aims to bring together community and hospital services and health and social care services. Local data above suggests that emergency admissions for ketoacidosis and coma are rising; this is of concern. Hospital admission rates are higher on the east of the borough.

Patient education services have been reduced in recent years, particularly DESMOND. A programme is being established with Whittington Health.

Local Intelligence

The above sources, local information on the distribution of risk factors (outlined in other JSNA sections) and national data emphasise the burden, and increasing burden, of diabetes and the higher prevalence of risk factors in certain sub-groups and on the east of Haringey. However, the routine data sources above give limited information on: estimated prevalence of diabetes, complication rates for hospital admissions and expenditure on diabetes services. These are, in part, limited because the models do not adequately take account of the ethnic profile of the population; this would impact greatly on service needs. There has also been limited review of service provision by ethnicity and deprivation. Further understanding would enable appropriate targeting of services according to need.

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Service users and carers opinion

The GP Patient Survey 2010/11 captured the information from patients with a long term condition, not just those with diabetes on: (i) the percentage of all people with a long term condition that have discussed with their doctor or nurse the management of their health problem, and of those, (ii) those who agreed with their doctor or nurse on how best to manage their health problem, (iii) those that feel that they have definitely received enough support for managing their health problem and (iv) those who had been told they had a "care" plan. Haringey was slightly better than England for the first three of these indicators: for example Haringey 84%, England 80% . The proportion who were told they had a “care” plan in Haringey was slightly worse than England (10% against 13%) (see footnote 3). The Diabetes Partnership Group, in Haringey, has had representation from Diabetes UK.

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Expert opinion and evidence base

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Projected service use in 3-5 years and 5-10 years

Figure 5 shows the projected prevalence of diabetes. Between 2009 and 2030 the prevalence is estimated to increase from 7.2% to 9.4 % in Haringey. Approximately half of this increase is due to the changing age and ethnic group structure of the population and about half is due to the projected increase in obesity (see footnote 9).

Figure 5 : Expected Prevalence of diabetes in Haringey, London and England

Source: APHO Diabetes Prevalence Model for England, 2010.

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Unmet needs and service gaps

Diabetes risk factors, prevalence, mortality and other key outcomes are strongly related to ethnicity and deprivation. The following key unmet needs are identified from the information above:

Prevention

  • The exercise referral scheme for patients with long term conditions has only a further one year funding secured and only operates in east of Haringey.
  • There are limited weight management programmes in Haringey for both children and adults. One year funding has been obtained for a service for adults.

Early Intervention

  • Again, key projects only have short term funding e.g. community health champions.
  • The NHS Health Checks programme has developed well to date in the east but needs scaling up, to increase uptake in the east of Haringey and to identify those at risk in west Haringey.
  • There are a considerable number of GP practices with significant numbers of undiagnosed patients with diabetes.
  • Risk identification and interventions for high risk groups aged 25-40 years.

Treatment and care

  • Much good work has been undertaken including some innovative approaches e.g. intermediate care triage of patients in north east Haringey.
  • Emergency admissions are increasing and there is a big variation in hospital admissions between east and west Haringey.
  • Patient education programmes and dietetic and weight management support for patients with diabetes need to be strengthened.
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Recommendations for commissioning

  • To review and implement a multi agency care pathway encompassing: prevention (primary and secondary), primary care, intermediate care, secondary care, integrated health and social care and patient self management, education and information programmes (including welfare advice)
  • To agree key performance indicators and desired outcomes of care for key services including: quality indicators, equity of access and outcomes for different population sub-groups.
  • To review and take forward specific programmes:
    • Exercise referral scheme for patients with long term conditions
    • Obesity prevention programmes and weight management services for adults and children (as a major risk factor for diabetes and to reduce complications for patients with diabetes)
    • Ensure the stop smoking service targets patients with long term conditions
    • Lifestyle programmes for high risk populations (mental health, learning difficulties, BME groups)
    • A sustainable scheme for community champions to raise awareness of diabetes in the community
    • Strengthen and increase resources to the NHS Health Checks programme to achieve full rollout, higher uptake and address inequalities.
    • Review options for risk identification and interventions for high risk groups aged 25-40 years
    • Continue to strengthen GP education
    • Work with primary care to reduce the numbers of undiagnosed cases and ensure equity of outcomes in general practice
    • Evaluation of the north east Haringey triage of GP referrals to hospital. Strengthen the intermediate care service.
    • Additional resource and support to allow a further shift in management of diabetes into the community
    • Continue work with partners to develop an integrated care model
    • Establish a robust diabetes education and self-management programme in Haringey
  • To further develop local intelligence on population needs and service outcomes, particularly in relation to geography, ethnicity and deprivation.
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Recommendations for further needs assessments

  • Practice level profiles for diabetes
  • Equity audit of diabetes services
  • Evaluation of diabetes triage in north east Haringey
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Key contact

Dr Fiona Wright, Assistant Director of Public Health - email: fiona.wright@haringey.gov.uk

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References

1. Preventing type 2 diabetes: population and community interventions. NICE public health guidance 35. NICE, 2011 (external link).

2. Six Years On: delivering the Diabetes National Service Framework. Department of Health, 2010 (external link).

3. Diabetes Community Health Profile – NHS Haringey. Yorkshire & Humber Public Health Observatory, 2012.

4. National Diabetes Audit 2009-10. The NHS Information Centre, 2011.

5. National Diabetes Audit Mortality Analysis 2007-08. The NHS Information Centre, 2011.

6. Haringey Health and Wellbeing Strategy

7. Inequalities in Diabetes and Obesity Prevalence in England. Yorkshire & Humber Public Health Observatory, 2009.

8. NHS Health Check: vascular risk assessment and management best practice guidance. Department of Health, 2009 (external link).

9. Diabetes Health Intelligence. Yorkshire and Humber Public Health Observatory (external link).

10. National Service Framework for Diabetes. Department of Health, 2001 (external link).

11. Preventing type 2 diabetes: risk identification and interventions for individuals at high risk Public Health. Draft Guidance (CG87, CG63, CG66, CG10). NICE, 2011.

12. NHS Diabetes Commissioning Guides (external link).

13. Service improvement guidance from NHS Diabetes (external link).

Page Last Updated: 4 April 2013

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