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). It is estimated that around 90% of diabetes cases are Type 2. In 2017, diabetes ranked as the fifth highest cause of years of life lost in the UK.
The National Institute for Health and Clinical Excellence (NICE) provides recommendations on nine annual care processes that adults with diabetes should receive, as well as three treatment targets that they should achieve in order to reduce the risk of diabetic complications. Here we use data from the National 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:
1. HbA1c – blood test for glucose control
2. Blood pressure – measurement for cardiovascular risk
3. Serum cholesterol – blood test for cardiovascular risk
4. Serum creatinine – blood test for kidney function
5. Urine albumin/creatinine ratio – urine test for risk of kidney disease
6. Foot risk surveillance – examination for foot ulcer risk
7. Body mass index – measurement for cardiovascular risk
8. Smoking history – question for cardiovascular risk
9. 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 2017-18, 43% of people with Type 1 diabetes received eight care processes compared to 59% 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, and for the eight care processes in the most recent year.
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 eight years the proportion of patients achieving all three treatment targets has improved for both Type 1 and Type 2 diabetes, by 2.1 and 5.0 percentage points respectively. The improvements that occurred between 2010-11 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 new Quality and Outcomes Framework (QOF) indicators aims to address the potential over-treatment of frail patients and under-treatment of patients without frailty.
About this data
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.