Nottingham Insight

Introduction

Diabetes Mellitus (DM) is a group of disorders that results from the body’s inability to control blood glucose levels. The raised blood glucose levels over time lead to damage to blood vessels and organs. It is a chronic disease which causes substantial premature morbidity and mortality, and imposes a heavy burden on health services.

• 2.8 million adults (6.2% of the adult population) in England had a diagnosis of diabetes in 2013/2014 (HSCIC, 2015), but a high number remain undiagnosed. The true prevalence in 2015 is estimated to be around 3.4 million (7.6% of the adult population) (YHPHO, 2012).
• There are 4 sub-categories of diabetes: Type 1, Type 2, gestational and ‘other’ types. Type 2 is the most common and is usually diagnosed in people over 40. As the symptoms often appear gradually, diagnosis can be delayed.
• Diabetes prevalence is increasing in all age groups and is predicted to continue rising over the next two decades. It is expected to be one of the main diseases accounting contributing to longstanding illness in the elderly.
• Diabetes accounts for approximately 10 per cent of the annual National Health Service budget. This is nearly £10 billion a year, or expressed another way: £192 million a week; £27 million a day; £1 million an hour; £19,000 a minute or £315 a second (Hex, N., et al, 2012)
• The total cost (including direct care and indirect costs) associated with diabetes in the UK is currently estimated at £23.7 billion. These costs are predicted to rise to £39.8 billion by 2035–36 (Hex, N., et al, 2012).
• Eighty per cent of NHS spending on diabetes goes on managing complications, most of which could be prevented (Kerr, M, 2011)
• One in 20 people with diabetes incurs social services costs. More than three-quarters of these costs are associated with residential and nursing care (Kings Fund et al, 2000)
• One in seven hospital beds is occupied by someone who has diabetes, although this may not be the immediate cause of that illness. In some hospitals, it is as many as 30% (HSCIC, 2013).
• People with diabetes are twice as likely to be admitted to hospital as those without (Sampson MJ, Doxio N, Ferguson B et al, 2007).
• One in four people admitted to hospital with heart failure, heart attack or stroke has diabetes. People with diabetes experience prolonged stays in hospital. This results in about 80,000 bed days per year (Sampson MJ, Crowle T, Dhatariya K et al, 2006).
• 42.2 million prescription items were dispensed in primary care units across England in 2012 at a net ingredient cost of nearly £768 million. This is an increase in cost of 7.7 per cent over 2010 (The Health and Social Care Information Centre, 2013).
• People with diabetes in England and Wales are 37.5% more likely to die early than their peers. For Type 1 diabetes, mortality is 129.5% greater than expected and for Type 2 diabetes it is 34.5% greater. The greatest increased risk of death is in younger ages and in females (Diabetes UK 2014).
• Effective control of blood glucose and blood pressure helps prevent the development and progression of complications. As 95% of diabetes management is self-care, this makes patient education essential.

This chapter focuses on Type 2 diabetes.

Unmet needs and gaps

Early local involvement in the national Diabetes Prevention Programme gives a potential opportunity to reduce the numbers of people developing DM, or delaying the onset of diabetes with people remaining healthy for longer, although success is not guaranteed.

• There are currently a comparatively large number of people in Nottingham City with undiagnosed DM, largely type 2. The diagnosed prevalence in 2014 was 5.2% in Nottingham City compared to 6.2% in England (estimated prevalence is 7.2% compared to 7.3%). This means that within the City, only an estimated 72% of people with diabetes have been diagnosed, compared to 85% nationally (PHE: Cardiovascular Disease Profile, Diabetes, 2015).
• For those known to have DM in the City, although care is comparatively good, there is significant room for further improvement, which can be expected to improve clinical outcomes. A key priority is to improve achievement of proven therapeutic goals, such as control of high blood pressure and cholesterol and glucose control, which the new contract incentives. Variability in care delivery across the City may be significant.
• The recent Equity Audit of retinopathy screening to prevent blindness among people with DM found a number of inequities in access, which should be addressed.
• There have been large recent increases in gestational diabetes and the new payment system may not be meeting the full costs of treatment.
• NHS Nottingham City CCG spent £250 on prescribing per person with diabetes. This is lower than the England average of £285. The total spend on prescribing for anti-diabetic items between April 2013 and March 2014 was £3,770,000. This accounted for 9.0% of the total CCG prescribing budget (PHE: Cardiovascular disease profile, Diabetes, 2015).

Recommendations for consideration by commissioners

1. Ensure successful delivery of the National Diabetes Prevention Programme in Nottingham City.
2. Undertake further work with Public Health programmes and Primary Care providers to increase the detection and diagnosis of type 2 DM, particularly among those communities most at risk of the condition.
3. Support the implementation of newly commissioned services, with the aim to ensure that the patient pathway is well-coordinated.
4. Expand the availability and accessibility of culturally-sensitive educational programmes for those with DM and their carers.
5. Consider the provision of psychological care for patients with diabetes, alongside other long-term conditions.
6. Progress and monitor actions to resolve inequity of access to diabetic retinopathy screening identified in the Health Equity Audit.
7. Improve foot care, with pathway improvement and integration with podiatry services, to address avoidable morbidity and hospital admissions.
8. Improve care for young people in transition from children’s’ services to the new, community-based adult services.
9. Work with the medicines management team to develop pharmacist-led services for patients with diabetes, and ensure they are integrated effectively into the care pathway.
10. Ensure that patients and carers continue to be involved in the development and implementation of service changes.
11. Work with the primary care commissioning team to ensure robust performance management and support (including data to highlight clinical variation) to general practices to reduce unwarranted variations in the care of patients with diabetes.
12. Work with providers to review the pre-discharge procedure for patients admitted to hospital with diabetes-related complications and determine how the Nottingham City Diabetes Service can best support community follow up (as indicated by patient need and severity of disease).
13. Pending the completion of the research, consider making use of the findings of the Interim Report Increasing the uptake of primary and community long-term conditions services in Black and Minority Ethnic (BME) communities in Nottingham - an exploratory research study, to improve access to long-term conditions services for people from BME communities.
14. Use Equity Audits to monitor access and utilisation of the new Diabetes Service.

Rachel Sokal, Consult in Public Health, Nottingham City Council, Rachel.Sokal@nottinghamcity.gov.uk

Dawn Jameson, Commissioning Manager, Nottingham City CCG, Dawn.Jameson@nottinghamcity.nhs.uk