1. What is diabetes?
Diabetes is a common chronic condition in which the amount of glucose (sugar) in the blood is too high. This is because the body’s way of converting glucose into energy is not working as it should. There are two main types of diabetes: Type 1 where the pancreas does not produce any insulin and Type 2 where the body does not produce enough insulin or the body’s cells do not react to insulin. Insulin is a hormone that enables blood sugar to enter the cells in your body where it can be used for energy. Without insulin, blood sugar cannot get into cells and instead builds up in the bloodstream.
High blood sugar is damaging to the body and leads to diabetes symptoms, like having to go to the toilet more frequently, being incredibly thirsty, and feeling very tired. It may also cause weight loss and infections. Over a long period of time, high glucose levels in your blood can cause complications that can impact on different parts of the body including eyes, heart, kidneys, nerves and feet. With the right treatment and care, people can live a healthy life and there’s much less risk that someone will experience these complications.
Type 1 diabetes is usually diagnosed in children, teenagers, and young adults but it can develop at any age. There is currently no cure for Type 1 diabetes but it is less common than Type 2 Diabetes and can be managed successfully by administering insulin, by following a healthy, balanced diet and getting regular physical activity.
Type 2 diabetes accounts for about 90 per cent of all people with diabetes and can be prevented or delayed through lifestyle changes, such as maintaining a healthy weight, eating well and being physically active. Medication and/or insulin may also be required in order to treat it.
2. Key facts
In 2016/17 there were 13,044 people, aged 17 years or older, who had been diagnosed with diabetes and included on GP registers in NHS Bexley CCG. This equals 7% of the population compared to 6.5% in London and 6.7% in England.
Figure 51: % of patients (17+) with diabetes mellitus, as recorded on GP practice disease registers in Bexley, London and England
Source: Public Health England, Diabetes Profiles
However, the total prevalence of people with diabetes, diagnosed and undiagnosed, is estimated to be 8.2% (15,621 people) in Bexley compared to 8.5% for England. This indicates that on Bexley’s GP practice lists, 2,577 patients potentially remain undiagnosed. In addition, across Bexley GP practices, the diabetes diagnosed prevalence varies between 5.6% and 10.2%.
Figure 52: % of patients (17+) with diabetes mellitus, as recorded on GP practice disease registers in Bexley, 2016/17.
Source: Public Health England, Diabetes Profiles
National Diabetes Audit 2016/17
The National Diabetes Audit (NDA) is a major national clinical audit in England and Wales, which measures the effectiveness of diabetes healthcare against NICE guidelines and quality standards. In 2016/17, 96% of GP practices in Bexley participated in the audit. Data from the 2016/17 audit for NHS Bexley CCG shows that:
- Type 1 and Type 2 diabetes is more common in males than females: 59% of people with Type 1 diabetes are male and 41% are female. 55.7% of people with Type 2 diabetes in Bexley are male and 44.3% are female.
- Type 1 diabetes is usually diagnosed earlier in life than Type 2: 48.9% of people in Bexley with Type 1 diabetes are under the age of 40.
- People with Type 2 diabetes are on average older than people with Type 1: 51.4% of people with Type 2 diabetes in Bexley are aged over 65.
- In Bexley, there are a significantly higher proportion of people from a minority ethnic group with Type 2 diabetes (21.7%), than Type 1 diabetes (8%). This reflects the national picture which shows 19.3% of people with Type 2 diabetes and 8.4% of people with Type 1 diabetes are from a minority ethnic group in England.
Non-diabetic hyperglycaemia (NDH), also known as pre-diabetes or impaired glucose regulation, refers to raised blood glucose levels, but not in the diabetic range. People with non-diabetic hyperglycaemia are at increased risk of developing Type 2 diabetes. They are also at increased risk of other cardiovascular conditions.
In 2015, Public Health England published a report that sought to estimate the prevalence of NDH in England. It was carried out using Health Survey for England data of adults aged 16 and over in England, covering the period 2009 to 2013.
The prevalence model estimated that in 2015 there were five million people aged 16 years and over with NDH. This equals 11.4% of the population of this age group. At local authority level across England, NDH ranged from 8.5% to 14.0%. The study found that local authorities with high estimated prevalence of NDH have high elderly populations, high proportions of Black and Asian ethnic groups or combinations of both.
Bexley’s prevalence of NDH is estimated to be 11.6% of the population aged 16 years and over (22,061). In 2015, there were only approximately 6,000 people on GP registers, which suggests that there are approximately 16,000 people in Bexley who are at high risk of Type 2 diabetes but this is unknown by the resident and the GP. Finding these people before they develop Type 2 diabetes and encouraging them to make healthier lifestyle choices is a key prevention priority, which the NHS Health Check Programme and NHS Diabetes Prevention Programme are helping to address.
 Public Health England, NHS Diabetes Prevention Programme, Analysis of non-diabetic hyperglycaemia prevalence in England, produced by National Cardiovascular Intelligence Network, August 2015
Figure 53: Estimates of non-diabetic hyperglycaemia in local authorities in England in 2015.
Source: Public Health England (NCVIN), NHS Diabetes Prevention Programme, August 2015.
Diabetes in Older People
Bexley has an ageing population, which is likely to have a significant impact on diabetes levels in the future. Figure 54 shows that over 50% of adults, who are predicted to have diabetes, are aged 65 years and over. In addition, we are forecasting demographic growth in BME populations in the Borough. Increased prevalence of diabetes among BME groups means that these populations should also be a focus for diabetes prevention and management.
Figure 54: People predicted to have Type 1 or Type 2 diabetes in Bexley
Source: POPPI, Crown Copyright 2016
3. What are we doing about it?
NHS Health Checks
The NHS Health Check is a key way to identify diabetes and those at high risk of Type 2 Diabetes. It can refer those at risk on to the NHS Diabetes Prevention Programme, which supports behaviour change to enable people to maintain a healthy weight and be more active. In 2017/18, 13,462 people in Bexley aged 40-74 years old were offered an NHS Health Check but only 5,022 people were recorded as receiving one. This means that percentage uptake of the NHS Health Check in Bexley was 37.3%, below the England average of 47.9%. Increasing the uptake of the NHS Health Check will help identify people at high risk of developing Type 2 diabetes and reduce chronic illness and avoidable premature death.
National Diabetes Prevention Programme
There is strong international evidence which demonstrates how behavioural interventions, which support people to maintain a healthy weight and be more active, can significantly reduce the risk of developing diabetes. The Healthier You: NHS Diabetes Prevention Programme (NHS DPP) identifies those at high risk and refers them onto a behaviour change programme.
Those referred to the service receive tailored, personalised support over nine months to reduce their risk of Type 2 diabetes, including education on healthy eating and lifestyle, help to lose weight and physical exercise programmes, all of which together have been proven to reduce the risk of developing the disease.
In May 2018, the Health Innovation Network, NHS England, Public Health England and Diabetes UK confirmed a new contract with ICS Health & Wellbeing to offer 4260 free places on the programme across South London with the flexibility for participants to attend services across multiple locations in London, including at evenings and weekends.
Structured education programmes can help people with diabetes to improve their knowledge and skills and also help to motivate them to take control of their condition and self-manage it effectively. In 2015, 700 people in Bexley were newly diagnosed with Type 2 diabetes. Of these, 535 people (76.4%) were offered structured education within 12 months of diagnosis. This is similar to the percentage for England (77.3%). Only 160 people out of 535 newly diagnosed diabetics in Bexley (22.9%) attended structured education within 12 months of diagnosis. This was a significantly higher percentage than the England average of 7.4%.
Bexley Diabetes, as a part of Bexley Health Ltd, deliver the Diabetes Education Service to patients and health care professionals in Bexley. Their trainers have been delivering the X-PERT Structured Patient Education Programme since January 2010. X-PERT is a six-week group education programme for people with Type 2 diabetes. The programme assists patients in understanding more about diabetes and how to control their blood glucose levels and live a healthier lifestyle. During the programme, patients learn all about the up-to-date treatments and management of diabetes. They also have the opportunity to explore and address any problems or issues that they may have with their diabetes. The programme has been shown to improve diabetes control, reduce diabetes tablets and insulin usage and increase self-management skills.
 The NHS Health Check programme: sharing good practice, Diabetes UK (February 2016)
 More support and choice for south Londoners at risk of Type 2 diabetes, Health Innovation Network (South London), 24 May 2018
Recommended Care Processes for Diabetes
The National Institute for Health and Care Excellence (NICE) recommends nine care processes for diabetes. Five of these care processes relate to risk factors (body mass index, blood pressure, smoking, glucose levels (HbA1c) and cholesterol) and the remaining four relate to tests to identify early complications (urine albumin creatinine ratio, serum creatinine, foot nerve and circulation examination and eye screening). Eye screening is handled by the national NHS Diabetic Eye Screening Programme and reported separately (not as part of the data on the eight care processes referred to below).
Table 13: % of people with diabetes who had eight recommended individual care processes by diabetes type, 2016/17
Source: National Diabetes Audit 2016/17 and Public Health England
In NHS Bexley CCG, 33.7% of people with Type 1 diabetes received the eight recommended care processes in 2016/17 compared to 34.4% in England. 49.4% of people with Type 2 diabetes received the eight recommended care processes in 2016/17 compared to 47.7% in England. This performance is generally considered to be in line with other similar CCGs given the characteristics of our diabetic population but there is still the potential for performance to be improved. For example, Serum Creatinine checks for people with Type 1 diabetes and Urine Albumin checks for people with Type 2 diabetes were completed less frequently in 2016/17.
NHS Diabetic Eye Screening Programme
Diabetic eye screening is a key part of diabetes care. People with diabetes are at risk of damage from diabetic retinopathy, a condition that can lead to sight loss if it is not treated. Everyone aged 12 and over with diabetes is offered screening once a year.
Guy’s and St Thomas’ provide the NHS Diabetic Eye Screening Programme for people living in South East London (Lambeth, Southwark, Lewisham, Bexley, Bromley and Greenwich). The programme manages a register of all patients with diabetes living in the catchment area and seeks to maximise the number of patients attending for screening. Clinics are run at several hospital/community healthcare sites and seven high street opticians, including Erith, Bexleyheath and Sidcup.
Data from the NHS Diabetic Eye Screening Programme for 2016/17 shows that 9,809 people with diabetes aged 12 and over were screened out of 11,306 people from Bexley who were offered routine digital screening (86.8%). This was above the average for both London (83.3%) and England (74%).
Figure 55: % uptake of routine digital eye screening by people aged 12+ with diabetes in London, 2016/17.
Source: Public Health England, NHS Diabetic Eye Screening Programme,14 June 2018
In 2016/17, 99% of people in South East London were offered an appointment within three months of addition to the service register, compared to 95.8% in England. In order to reduce anxiety for people with diabetes, it is important for them to receive their results in a timely manner. It is also important for their GP and relevant health professional(s) to be informed in a timely manner so that they can take appropriate steps in the ongoing care of people with diabetes. In 2016/17, figures for South East London show that 99.9% of results letters were issued to patients and GPs within three weeks, compared to 96.5% in England.
 South East London Diabetic Eye Screening Programme, Guy’s and St Thomas’ NHS Foundation Trust
An important part of the screening programme is that a person with referred proliferative (R3A) diabetic retinopathy is seen in hospital in a timely manner so they can receive appropriate management. In 2016/17, 70.6% of urgent (R3A) referrals from South East London were seen in hospital eye services within four weeks, above the average for London (61.7%) and England (68.4%).
Diabetes Treatment Targets
NICE recommends treatment targets for HbA1c (glucose control), blood pressure and serum cholesterol. In NHS Bexley CCG, 28% of people with Type 1 diabetes achieved all three treatment targets in 2016/17, higher than in 2015/16 (25.4%) but no change from 2014/15 (28.6%). In people with Type 2 diabetes, 45.8% achieved all three treatment targets in 2016/17 but this was lower than in 2015/16 (47.1%) and 2014/15 (50.5%).
Table 14: % of people achieving their treatment targets for Type 1 and Type 2 diabetes, 2016/17
Source: Public Health England, Diabetes Profiles
Diabetes Foot Care
The risk of foot problems in people with diabetes is increased, largely because of either diabetic neuropathy (nerve damage or degeneration) or peripheral arterial disease (poor blood supply due to diseased large and medium‑sized blood vessels in the legs), or both. Peripheral arterial disease affects 1 in 3 people with diabetes over the age of 50, and can also increase the risk of heart attack and stroke. Diabetes is the most common cause of non‑traumatic limb amputation, with diabetic foot ulcers preceding more than 80% of amputations in people with diabetes. If foot problems are detected and appropriately managed at an early stage it is possible to prevent hospital admissions, as well as foot and leg amputations.
Age UK Bexley provide a ‘low-risk’ foot care service for people aged 50 years and over. The service is run by trained healthcare professionals, who can check feet for any problems, such
Age UK Bexley provide a ‘low-risk’ foot care service for people aged 50 years and over. The service is run by trained healthcare professionals, who can check feet for any problems, such as pain or swelling, and help with cutting nails. As well as running three community clinics, the service offers to visit people in their own home if they are housebound.
Oxleas NHS Foundation Trust provides a ’high risk’ podiatry service for adult patients who have a medical condition, such as diabetes, that is affecting their feet and may potentially lead to foot ulceration. The service provides routine treatments and wound care, as well as a nail surgery service to people over the age of 18. The main purpose of podiatry treatment is the prevention of tissue breakdown (ulceration) in individuals whose medical conditions may lead to lower limb tissue viability problems. Podiatry can also help increase mobility and independence, especially in elderly people, and enable patients to wear comfortable shoes, which can protect feet from trauma and help minimise the risk of falls.
In 2017/18, NHS Bexley CCG developed an enhanced diabetic foot network pathway to ensure better local management of people with diabetes and foot-related complications, and to reduce major amputations/hospital stays. This service is designed to ensure that all people with diabetes over the age of 12 years old receive a foot check at least once a year as part of their annual review. This is supported by a structured education project.
4. What works and best practice?
A number of approaches are needed to tackle diabetes at a population level. The overarching priorities are to both prevent or delay the onset of diabetes (for Type 2 diabetes), diagnose people early, and to give people with diabetes the right treatment and care to prevent complications.
Working collaboratively across a number of partners is important for prevention, including the Council, NHS organisations, local service providers, the voluntary and community sector, and with individuals and communities. This can support the delivery of a range of objectives and initiatives, such as:
- Access to information, advice and support (e.g., One You Campaign and Making Every Contact Count).
- Improvements to the design of buildings and public spaces through urban planning.
- Promoting access to and use of parks and open spaces;
- Promoting healthy workplaces.
- Promoting healthy eating and the healthy catering commitment.
- Sport and leisure opportunities to increase physical activity.
- Stop Smoking Service.
- Social Prescribing (e.g., Community Connect in Bexley).
- Obesity prevention initiatives to support weight loss.
- Promoting flu immunisation for people with long-term conditions, such as diabetes.
NICE Guidelines: The National Institute for Health and Care Excellence (NICE) produces pathways (interactive topic-based flowcharts), guidelines (evidence-based recommendations) and quality standards (statements covering priority areas for quality improvement) for use by healthcare professionals about the care people with diabetes should receive. This covers a range of topics, including diabetes in children and young people, preventing Type 2 diabetes, managing Type 1 and Type 2 diabetes in adults, diabetes in pregnancy and diabetes-related footcare.
 Age UK Bexley, Foot Care Service: https://www.ageuk.org.uk/bexley/services/footcare-service/
Diabetes UK – Know Your Risk Tool: NICE public health guidance on preventing Type 2 diabetes in people at high risk, recommended that GPs and other primary healthcare professionals should use validated self-assessment questionnaires or validated web-based tools, such as the Diabetes UK Know Your Risk tool. The tool aims to help individuals find out their risk of developing Type 2 diabetes within the next ten years and was developed in collaboration with the University of Leicester and University Hospitals of Leicester NHS Trust.
National Diabetes Prevention Programme (NHS DPP): Many cases of Type 2 diabetes are preventable through lifestyle changes. The NHS DPP aims to identify those at high risk and refer them onto a behaviour change programme. The programme started in 2016 with a first wave of 27 areas and is being rolled out to the whole country by 2020 with an expected 100,000 referrals available each year. Bexley was part of a successful South London Partnership bid to be a first wave implementation site for the programme. The Health Innovation Network in South London is working with partners to deliver the programme, including supporting the sharing of learning and best practice.
NHS Health Checks include information, advice and signposting to support people to avoid or delay developing diabetes (prevention) and a diabetes risk screening and referral (detection). Diabetes UK have published a number of resources and tools to improve the delivery and uptake of health check programmes, including examples of good practice from across England.
NHS Diabetes Right Care Pathway: The diabetes pathway defines the core components of an optimal diabetes service for people with or at risk of developing Type 1 and Type 2 diabetes. It seeks to reduce variation and improve outcomes and identifies the key evidence-based interventions which the system should focus on for greatest improvement, supported by practice examples from across the NHS.
NHS Diabetic Eye Screening Programme: Diabetic eye screening is a key part of diabetes care. People with diabetes are at risk of damage from diabetic retinopathy, a condition that can lead to sight loss if it’s not treated. Screening is an effective way of detecting the condition early, enabling treatment to be given to stop it from getting worse. Research has indicated that people experiencing socio-economic deprivation tend to have poorer attendance at diabetic eye screening. Minority ethnic groups were also found to be associated with a higher risk of severe diabetic retinopathy. This highlights the importance of targeting diabetes prevention initiatives and promoting take-up of preventative care (e.g., annual eye tests) among high risk groups. It also suggests there is a role for diabetic eye screening programmes to reach out to people with diabetes living in more deprived areas to ensure attendance so that any early signs of eye disease can be detected and treated.
Structured Education for People with Type 2 diabetes: The Health Innovation Network in South London has produced a toolkit to address the causes and barriers to low uptake of structured education for people with Type 2 diabetes and to provide guidance on how to make high quality structured education easily accessible across South London.
5. What are the gaps?
- Bexley has an ageing population and an increasing proportion of the population is from BME populations, which will have a significant impact on diabetes levels in the future.
- In May 2018, a new NICE quality standard was published to prioritise promotion of health and prevention of premature mortality among Black, Asian and other minority ethnic groups. One of the quality statements seeks to improve referral rates of people from minority ethnic groups, who are identified as being at high risk of developing Type 2 diabetes, to an intensive lifestyle change programme. It also advocates provision of advice to those with a lower level of risk.
- The prevalence of obesity in Bexley is higher than the national averages for both adults and children; therefore, significant effort needs to be focused on preventing and managing obesity, including promoting physical activity.
- There is some significant variation between GP practices in terms of diabetes prevalence, completion of recommended care processes, and achievement of treatment targets. Diabetes profiles, showing information at GP practice level are available from Public Health England’s website.
- Whilst offers of structured education for people newly diagnosed with Type 2 diabetes have improved, this is not yet matched by records of attendance.
- Most of the NICE recommended care processes are well completed, though less frequently in Type 1 patients overall. Care processes where the CCG has not achieved as high a rate of completion may benefit from some further investigation.
- Encourage and support healthy lifestyle changes within the population (e.g., healthy diet, weight management and physical activity.
- Continue to target interventions at those at risk of developing diabetes and those who have been diagnosed and need support to manage their condition to prevent development of related conditions.
- Ensure that people from Black, Asian and other minority ethnic groups at high risk of Type 2 diabetes are referred to culturally sensitive and appropriate services that can help them achieve healthy weight and be more active. People who are not currently at high risk of Type 2 diabetes should be given information and further support relevant to their needs.
- Regularly review annual care processes and treatment target results to help select priorities for improvement to reduce variation.
- Commissioners to work with providers, GPs and other health professionals to further improve referrals and take-up of the diabetes structured education programme.
- Commissioners to work with providers, GPs and other health professionals to ensure that care pathways meet NICE guidelines.
 Diabetic eye disease: A UK Incidence and Prevalence Study, Rohini Mathur et al., London School of Hygiene and Tropical Medicine, 2017
 Improving access to structured education for people with Type 1 and Type 2 diabetes, Health Innovation Network, South London