Diabetes is a condition where the amount of glucose in your blood is too high. There are two main types of diabetes: Type 1 diabetes (when the body is unable to produce any insulin) and Type 2 diabetes (when the body is unable to produce enough insulin or the body's cells don't respond to insulin). Around 90% of diabetes cases among children and young people are Type 1, but Type 2 is increasing in prevalence. For adults, it is estimated that around 90% of cases are Type 2. In 2017, diabetes ranked as the fifth highest cause of years lived with disability in the UK.
The National Institute for Health and Clinical Excellence (NICE) provides recommendations on annual care processes that adults and children with diabetes should receive, as well as three treatment targets that adults should achieve in order to reduce the risk of diabetic complications. Here we use data from the National Diabetes Audit and National Paediatric Diabetes Audit to look at how the quality of care for diabetics has changed over time.
The National Institute for Health and Care Excellence (NICE) recommends that all people with diabetes aged 12 years and over should receive nine annual care processes. These include:
- HbA1c – blood test for glucose control
- Blood pressure – measurement for cardiovascular risk
- Serum cholesterol – blood test for cardiovascular risk
- Serum creatinine – blood test for kidney function
- Urine albumin/creatinine ratio – urine test for risk of kidney disease
- Foot risk surveillance – examination for foot ulcer risk
- Body mass index – measurement for cardiovascular risk
- Smoking history – question for cardiovascular risk
- Digital retinal screening – photographic eye test for early detection of eye disease
The data shown here does not include the ninth care process – digital retinal screening – because this is not currently available as part of the National Diabetes Audit data.
Fewer people with Type 1 than with Type 2 diabetes receive their annual checks in England. In 2018-19, 41% of people with Type 1 diabetes received eight care processes compared to 54% of people with Type 2 diabetes. Urine albumin and foot surveillance are most often missed out, while blood pressure and smoking history are most often checked. The National Diabetes Audit suggests that a change to the smoking care process calculation and the way that BMI data were collected may account for the increase in percentages for these checks.
NICE recommends treatment targets for HbA1c (glucose control), blood pressure and serum cholesterol. Meeting these targets has the following benefits:
- The HbA1c target (≤58 mmol/mol) reduces the risk of all diabetic complications.
- The blood pressure target (≤140/80) reduces the risk of cardiovascular complications and reduces the progression of eye and kidney disease.
- The cholesterol target (<5mmol/L) reduces the risk of cardiovascular complications.
Over the last six years, the proportion of patients achieving all three treatment targets in England has improved for both Type 1 and Type 2 diabetes, by 3.7 and 4.2 percentage points respectively. The improvements that occurred between 2012-13 and 2013-14 in blood pressure target achievement (Type 1 and Type 2) and glucose control (Type 1) have been sustained. However, glucose control targets are achieved in Type 1 diabetes less than half as often as in Type 2 diabetes.
Younger people with either Type 1 or Type 2 diabetes are less likely to achieve all three treatment targets than older people. The National Diabetes Audit states that this is mostly due to poorer glucose and cholesterol control in those aged under 65 years, and that there has been no change over the past five years.
Measuring changes to this indicator over time is important given that one of the Quality and Outcomes Framework (QOF) indicators aims to address the potential over-treatment of frail patients and under-treatment of patients without frailty.
Guidelines specify that HbA1c and height and weight measurements should be recorded for all children and young people with Type 1 diabetes, and from 12 years of age they should have all seven checks. Thyroid screening should also be performed at diagnosis and annually thereafter.
Since 2004/05, the percentage of children and young people receiving care processes has increased consistently, with 55% of children with Type 1 diabetes receiving all seven care processes in 2018/19. This compares to only 31% of those with Type 2 diabetes (data not shown). HbA1c and BMI are most often checked, while urine albumin and eye screening are most often missed out.
Note that from 2015/16, data were reported separately for children with Type 1 and Type 2 diabetes, so are not directly comparable to previous years. However, the audit states that, as the majority of children and young people have Type 1 diabetes, the improvements in completion rates can be taken to reflect real improvements.
About this data
National Diabetes Audit:
The National Diabetes Audit (NDA) is commissioned by the Healthcare Quality Improvement Partnership (HQIP), funded by NHS England, and managed by NHS Digital in partnership with Diabetes UK. The NDA provides a comprehensive view of diabetes care in England and Wales, and measures the effectiveness of diabetes healthcare against NICE Clinical Guidelines and NICE Quality Standards.
The ninth annual care process for all people with diabetes to receive a digital retinal screen is not presented here, so the 'eight care processes' comprise of eight care processes excluding eye screening. This is because the screening registers are drawn from practice registers, but the outcomes are recorded in screening management systems that presently cannot export data to the National Diabetes Audit.
There was a change in the treatment targets used, from HbA1c, blood pressure and cholesterol (up to 2016-17) to HbA1c, blood pressure and statin prescription (in 2017-18). The 'old' measure has been reported here for purposes of continuity in the time series.
For more information, please see the NHS Digital website.
National Paediatric Diabetes Audit:
The National Paediatric Diabetes Audit (NPDA) is commissioned by the HQIP, funded by NHS England and the Welsh Government, and managed by the Royal College of Paediatrics and Child Health. It compares the care and outcomes of all children and young people up to the age of 24 with diabetes who are receiving care from Paediatric Diabetes Units in England and Wales.
For more information, please see the Royal College of Paediatrics and Child Health website.