DIABETES HEALTH NEEDS ASSESSMENT

LUTON BOROUGH COUNCIL

Produced by Luton

Public Health

Intelligence Team

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Contents Executive Summary ................................................................................................................................. 2

Recommendations .................................................................................................................................. 4

1 Introduction ......................................................................................................................................... 5

2. Demographics ..................................................................................................................................... 5

2.1.1 Population .................................................................................................................................. 5

2.1.2 Population projections ........................................................................................................ 6

2.1.3 Ethnicity and migration ....................................................................................................... 7

2.1.4 Deprivation.......................................................................................................................... 8

3. Risk Factors ......................................................................................................................................... 9

3.1 Obesity .......................................................................................................................................... 9

3.2 Physical activity and diet ............................................................................................................. 11

3.3 Family history of diabetes ........................................................................................................... 12

3.4 Ethnic background ...................................................................................................................... 12

4. Prevalence ......................................................................................................................................... 12

4.1 Recorded and Expected Prevalence ............................................................................................ 13

4.2 Hospital admissions .................................................................................................................... 15

5. Early Diagnosis and Primary Care Management ............................................................................... 15

5.1 Health Checks .............................................................................................................................. 15

5.2 Diabetic Retinopathy Screening .................................................................................................. 16

5.3 Primary Care Management ......................................................................................................... 18

6. Provision of service and care ............................................................................................................ 26

6.1 Complications of diabetes ........................................................................................................... 26

7. Costs of diabetes ............................................................................................................................... 35

8. Mortality due to diabetes ................................................................................................................. 39

9. Service user perspective ................................................................................................................... 40

10. Provider perspectives and what are we doing locally? .................................................................. 41

11. NICE guidelines................................................................................................................................ 45

12. Recommendations .......................................................................................................................... 46

13. References ...................................................................................................................................... 47

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Executive Summary

Diabetes is a condition that causes a person's blood sugar level to become too high. There

are two main types of diabetes these are type 1 and type 2.

Risk Factors

An increase in the older population is likely to lead to an increase of diabetes within the borough as age is a risk factor of diabetes.

Prevalence of obesity in Luton adults aged 16 and over in 2014/15 is 9.8%; this is significantly higher than the England average.

Prevalence of obesity in Luton reception year children in 2014/15 is 10.2%; this is significantly higher than the England average of 9.1%.

Prevalence of obesity in Luton year 6 children in 2014/15 was 23.4%; this was significantly higher than the England average of 19.1%.

Proportion of people eating 5 a day (41.3%) in Luton is significantly lower than the national average (53.5%).

Proportion who meet the recommended level of physical activity in Luton (45.1%) is also significantly lower than national levels (57%).

Prevalence

Luton (7.6%) has a prevalence of diabetes significantly higher than the England average 6.3%.

Recorded prevalence for diabetes within Luton GP practices for 2014/15 shows there is wide variation with prevalence ranging from 2.3% to 12.3%. A total of 10 practices have recorded prevalence significantly lower than the Luton average and the same numbers have recorded prevalence significantly higher than Luton.

Early Diagnosis and Primary Care Management

In recent years Luton has consistently has a higher health check uptake compared to the national average.

Luton (86.8%) has a significantly lower percentage of diabetes patients who have had

retinopathy screening in 2013/14 compared to the national average (90%).

10 practices in Luton have a significantly lower percentage of diabetes patients who have had retinopathy screening in 2013/14 compared to the Luton average (86.8%). 17 practices have a percentage significantly higher than Luton.

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The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less, 2014/15. The proportions range from 70.7% to 98.5%. Six practices had percentages significantly lower than the Luton average and 11 practices had percentages significantly higher than Luton.

The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less, 2014/15. The proportions range from 41.7% to 92.9%. Eight practices had percentages significantly lower than the Luton average and 13 practices had percentages significantly higher than Luton.

The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less, 2014/15. The proportions range from 56.4% to 88.8%. Six practices had percentages significantly lower than the Luton average and nine practices had percentages significantly higher than Luton.

The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months, 2014/15. The proportions range from 35% to 81%. Five practices had percentages significantly lower than the Luton average and nine practices had percentages significantly higher than Luton.

The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months, 2014/15. The proportions range from 51% to 97%. Eight practices had percentages significantly lower than the Luton average and nine practices had percentages significantly higher than Luton.

Luton diabetes patients have an additional risk of 178% (or 1.7 times more) of developing angina compared to non-diabetes patients. This is significantly higher than the national average (136.8%) or 1.4 times more

Luton diabetes patients have an additional risk of 186% (or 1.9 times more) of developing heart failure compared to non-diabetes patients. This is significantly higher than the national average

Luton diabetes patients have an additional risk of 139% (or 1.4 times more) of a myocardial infarction compared to non-diabetes patients. This is significantly higher than the national average

Costs of Diabetes

The current total spend on diabetes prescribing per person in NHS Luton CCG was £241.51. This ranks the CCG 12 of 211 CCG’s on the diabetes QOF register nationally (with 1 representing the CCG with the lowest spend).

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The CCG’s total spend for this indicator in 2013/14 was £3,020,060. The total spend on diabetes prescribing per person with diabetes in NHS Luton for this CCG is currently within the lowest 25% nationally.

Recommendations

Prevention and screening

• Primary and community services should provide brief advice at every opportunity and refer to lifestyle services where appropriate (NICE PH35)

• Identification and referral to intensive lifestyle support in high risk and vulnerable groups (NICE PH38) should be systematically rolled out across primary and community care including pre-diabetes and diabetes

Early Detection and diagnosis /Treatment: improving experiences of care and support • Reduce variation in primary care of

– Health checks uptake with a focus on quality including referral onto intensive lifestyle programmes

– Diabetic Retinopathy Screening with NHS England – Newly diagnosed diabetics and refer to structured education programme

including self-care and foot care (NICE guidance 19) – BP and cholesterol control in diabetics linked primary care investment

programme – Hba1c control with a focus in Medics cluster

Aftercare • Embed within diabetes pathway post treatment lifestyle advice and support for all

patients linked to Enhanced Recovery Programme Integrated commissioning

• Review current pathway /service offer, to reduce duplication and redistribute to need (CCS) and develop discharge bundle for repeat admissions. Consider a CQUIN.

• Ensure all diabetes specifications are outcomes focused and linked to other relevant specifications.

• Embed NICE Quality Standard (QS6, QS125 and QS109) into contracting and monitor performance to reduce additional risk of complications.

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1 Introduction Diabetes is a condition that causes a person's blood sugar level to become too high. There are two main types of diabetes these are type 1 and type 2. Type 1 diabetes is when the body is unable to produce insulin. Insulin is a hormone which enables the body to use the glucose in the blood. Type 1 diabetes accounts for around 10% of all diabetes within adults. Type 2 diabetes is when the body is unable to produce enough insulin or when the insulin produced does not work properly (Diabetes UK 2015). Type 2 diabetes is far more common than type 1. In the UK, around 90% of all adults with diabetes have type 2. There are 3.9 million people living with diabetes in the UK. That's more than one in 16 people in the UK who has diabetes either diagnosed or undiagnosed (NHS 2014). People with diabetes are more likely to be at risk from coronary events, strokes and other vascular problems. Targeted diabetes case finding, together with screening for Chronic Kidney Disease, forms part of the NHS Health Checks programme (NHS 2014). The prevalence of diabetes rises steeply with age: one in twenty people over the age of 65 in the UK have diabetes and this rises to one in five over the age of 85 years. People of South Asian, African, and African-Caribbean descent have a higher than average risk of developing type 2 diabetes than the population as a whole (Diabetes UK 2015). The frequency of diabetes in England is higher in men than in women; however, women with diabetes are at relatively greater risk of dying than men (Diabetes UK 2015). This is possibly due to how gender compounds other aspects of inequality such as social-economic differences in the prevalence of diabetes and obesity. In addition, pre-menopausal women with diabetes do not have the same protection against CHD as women who do not have diabetes (Diabetes UK 2015). Women who have had gestational diabetes are also at increased risk of developing Type 2 diabetes (NHS 2014). Having polycystic ovary syndrome increases the risk of diabetes, especially combined with being overweight or obese (Diabetes UK 2015).

2. Demographics The health of the population of Luton tends to be slightly poorer than the England average. The poorer health outcomes are linked primarily to the levels of socioeconomic deprivation experienced by a significant segment of the population. This section will describe the numbers and projected growth of the population; demographics (e.g. age, gender, and ethnicity); population movement in and out of the borough; deprivation and poverty.

2.1.1 Population

The latest (2014) Office for National Statistics (ONS) Mid-Year Population Estimate for Luton was 211,000. In recent years, there has been convergence between the ONS figures and those of the Council due, in the main, to improved accuracy of ONS data as a result of increased enumeration in the 2011 Census and the subsequent rebasing of population figures. Figure 2.1 shows the most densely populated areas of Luton are in the centre of the town. With an area of 4,336 hectares, the official (ONS) population figure translates into a

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population density of 48 people per hectare. This figure is greater than many London Boroughs.

Figure 2.1: Luton population density

Source: Census 2011, Office for National Statistics and Ordnance Survey

2.1.2 Population projections

Luton’s population is projected to grow significantly between 2011 and 2031, with the latest forecasts projecting growth of 25% in the next 20 years (LBC 2015). Key drivers for this are high levels of natural growth (more births than deaths) and international in-migration. Luton also has high population churn and a study found that 70% of the population in Luton in 2010 was either not born or not living in Luton at the time of the 2001 Census (Mayhew and Waples 2011). Table 2.1 shows a summary of population projections for Luton. Key changes over the next 20 years are:

Population of Luton is projected to increase by 50,400, a rise of 25%.

School age population (5-15 year olds) is projected to increase by 7,850, a rise of 26%.

Those aged 65-89 is projected to increase by 10,750 people, a rise of 47%.

Very elderly population (90+) is projected to increase by 1,450 people, a rise of 153%.

An increase in the older population is likely to lead to an increase of diabetes within the borough as age is a risk factor of diabetes, this will put more pressure on resources within the borough.

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Table 2.1: Luton population projections by age from 2011 to 2031

Source: Luton Borough Council using POPGROUP software and a ten year migration average.

Components may not sum to totals due to rounding.

2.1.3 Ethnicity and migration Figure 2.1.3 shows the board ethnic groups in the Luton population, with approximately 45% of the population being of Black and Minority Ethnic Origin (BME) or non-white. The ethnic composition of Luton fits a model known as ‘super-diversity’ in which there is an increasing number of BME communities within the population each with its own needs and cultures. Luton has a long history of migration into the area both from elsewhere in the UK and overseas. There have been long-standing African-Caribbean, Bangladeshi, Indian, Irish and Pakistani communities in Luton as a result of international migration. More recently, the migration patterns have become more complex. In the mid-1990s, the opening of the University of Luton (now the University of Bedfordshire) caused a rapid growth in the student population of the town. This growth has been sustained with an increase in numbers of overseas students. In the mid-2000s, the expansion of the European Union led to a significant increase in migration from eastern European countries, particularly Poland and Lithuania. 7% of Luton’s population is classed as ‘other white’ which is the group for non-British or Irish Europeans (but this group also includes people from other parts of the world including Americas and Australasia) (England has 4.6% of the population in this category). There has also been in-migration from African countries such as the Congo, Ghana, Nigeria, Somalia and Zimbabwe. There is also a Turkish population in Luton. More recently, National Insurance Registration data has demonstrated further increases in international migration with Romanians moving to the town after the change in law allowing them the right to work in the UK at the beginning of 2014. Analyses of translation service data also highlighted the levels of diversity in the town by identifying over 120 languages or dialects being spoken by residents. This provides corroborating evidence of Luton being super-diverse. 5% of the total population of Luton are Black African or Black African heritage (England 2.1%) and 5.9% Black Caribbean or Black Caribbean heritage (England 1.9%). 14.4% of the population are Pakistani (England 2.1%), 6.7% Bangladeshi (England 0.8%) and 5.2% Indian (England 2.6%).

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Figure 2.1.3: Ethnic composition of Luton

2.1.4 Deprivation There is no single generally agreed definition of deprivation. Deprivation is a concept that overlaps, but is not synonymous with, poverty. Absolute poverty can be defined as the absence of the minimum resources for physical survival, whereas relative poverty relates this to the standards of living of a particular society at a specific time. The Index of Multiple Deprivation 2015 produced by Communities and Local Government (CLG) combines a number of indicators, chosen to cover a range of economic, social and housing issues, into a single deprivation score for each small area in England. This allows each area to be ranked relative to each other according to their level of deprivation. Luton is ranked as the 59th (out of 326) most deprived local authority. In 2010 Luton was ranked as the 69th most deprived local authority in 2007 as the 87st (out of 354 authorities) and in 2004 the 101st most deprived local authority. This indicates that Luton is becoming relatively more deprived in comparison to the other local authorities of England and the trend of has been happening since 2004. (Figure 2.1.3). Luton has nine output areas in the top ten per cent most deprived areas in the country. Three of these are in Northwell, two in Farley and South wards and one in Biscot and Dallow wards.

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Figure 2.1.4: Deprivation in Luton 2015.

3. Risk Factors Diabetes does not impact everyone equally and inequalities exist in the risk of developing diabetes, for example, in accessing services and health outcomes. Areas with high levels of deprivation are associated with a greater prevalence of diabetes (PHE 2014). Those who are overweight, physically inactive or have a family history of diabetes are at increased risk of developing diabetes. Obesity is the most important modifiable risk factor (see Section 3.1 for information on obesity in adults in Luton). Smoking is also associated with multiple complications for people with diabetes (ASH 2012).

3.1 Obesity Being overweight or obese increases your risk of developing diabetes and high blood pressure (NHS 2014). The prevalence of obesity has increased in the past 25 years in every age group, social class, ethnicity and gender. In England, most people are overweight or obese. Overweight and obese children are more likely to be obese when they reach adulthood.

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Figure 3.1.0 Prevalence of obesity in adults aged 16 and over, 2014/15

Prevalence of obesity in Luton adults aged 16 and over in 2014/15 is 9.8%; this is significantly higher than the England average figure 4.1.0. However in 2012/14 data taken from the health survey for England (HSE) estimates that in Luton 63.9% of the adult population are either obese or overweight so the QOF figure is likely to be inaccurate.

Figure 3.1.1 Prevalence of obesity in adults aged 16 and over in Luton GP practices, 2014/15

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A total of 10 practices had recorded prevalence significantly lower than Luton and 9 practices had prevalence significantly higher. Figure 3.1.1 shows prevalence of obesity in Luton GP practices in 2014/15.

Figure 3.1.2 Prevalence of childhood obesity in reception year, 2014/15

Figure 3.1.3 Prevalence of childhood obesity in year 6, 2014/15

Figure 3.1.2 shows prevalence of obesity in Luton reception year children in 2014/15 is 10.2%; this is significantly higher than the England average of 9.1%. Figure 3.1.3 shows prevalence of obesity in Luton year 6 children in 2014/15 was 23.4%; this was significantly higher than the England average of 19.1%.

3.2 Physical activity and diet

Department of Health latest guidelines recommend that adults (aged 19-64 years) should aim to be active daily. Over the course of a week, all activity should add up to at least 150 minutes (2½ hours) of moderate intensity activity which should last at least 10 minutes. An example of this would be to do 30 minutes on at least 5 days a week. Being physically active can protect against chronic diseases, with regular physical activity key to preventing people from becomes obese or overweight. See table 3.2.1 below. The guidelines for children refer to opportunities for moderate to vigorous-intensity physical activity. Children and young people should undertake a range of activities at this level for at least 60 minutes over the course of a day. At least twice a week this should include weight-bearing activities that produce high physical stresses to improve bone health, muscle strength and flexibility. This amount of physical activity can be achieved in a number of short, 10-minute (minimum) bouts (NICE 2009). Dietary modification and regular physical activity are significant elements in CVD prevention and control. A diet which is high in fat can cause fatty deposits to build inside the arteries which can lead to high blood pressure and high cholesterols. Therefore a balanced diet including fruit and vegetables is essential (NHS 2014). Due to the recent rise in obesity in the UK population the government researched ways of tackling the problem and in June 2014 published a paper outlined action to reverse obesity levels. Part of this action will involve a sugar tax being applied to sweetened drinks which will begin in 2018. This will help to reduce the risks of obesity, tooth decay and other life threatening diseases (PHE 2016).

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Table 3.2.1 shows that 38.7% of children aged 5 and under had more than one decayed, filled or missing teeth, significantly worse than the national average (27.95) in 2011/12. Table 3.2.1: Five a day and physical activity performance in Luton and comparator areas in 2014

Source: PHOF

The proportion of people eating 5 a day (41.3%) in Luton is significantly lower than the national average (53.5%). Similarly, the proportion who meet the recommended level of physical activity in Luton (45.1%) is also significantly lower than national levels (57%).

3.3 Family history of diabetes

Genetics is one of the main risk factors for type 2 diabetes (NHS 2014). Your risk of developing the condition is increased if you have a close relative – such as a parent, brother or sister – who has the condition. The closer the relative, the greater the risk. A child who has a parent with type 2 diabetes has about a one in three chance of also developing it (NHS 2014).

3.4 Ethnic background People of south Asian, Chinese, African-Caribbean and black African are more likely to develop type 2 diabetes. Type 2 diabetes is up to six times more common in south Asian communities than in the general UK population, and it is three times more common among people of African and African-Caribbean origin (NHS 2014). People of south Asian and African-Caribbean origin also have an increased risk of developing complications of diabetes, such as heart disease, at a younger age than the rest of the population (NHS 2014).

4. Prevalence According to QOF registers in 2014/15 the prevalence of diabetes in the adult population in England is 6%, this equates to around 2.7 million people. Locally in Luton the recorded prevalence is 7.6% and equates to around 12,900 adults aged 17+. There are also a substantial amount of people with undiagnosed diabetes. According to Diabetes UK it is estimated that in England and Wales there is 0.2% diabetes prevalence in children aged 0-9 years and 0.9% prevalence in children aged 10-19 (Diabetes UK 2015). When applied to the Luton population this equates to around 260 children who also potentially have diabetes in the borough. This section looks at the known and undiagnosed prevalence of diabetes in Luton and the GP practices in the borough. Comparisons are made to comparator CCG’s and National figures where possible.

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4.1 Recorded and Expected Prevalence

Figure 4.1.1 Recorded prevalence of diabetes in persons aged 17+, 2014/15

Figure 4.1.1 shows recorded prevalence for diabetes within Luton and comparator CCG’s for 2014/15. Luton (7.6%) has a prevalence significantly higher than the England average 6.3%, as do all comparator CCG’s. The Luton prevalence equates to a total of 12,889 people diagnosed with diabetes.

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Figure 4.1.2 Recorded prevalence of diabetes in persons aged 17+, Luton GP practices 2014/15

Figure 4.1.2 shows recorded prevalence for diabetes within Luton GP practices for 2014/15 there is wide variation with prevalence ranging from 2.3% to 12.3%. A total of 10 practices have recorded prevalence significantly lower than the Luton average and the same number have a recorded prevalence significantly higher than Luton. Figure 4.1.3 Estimated prevalence of diabetes for Luton and England 2016 - 2035

Source: APHO Diabetes prevalence model

Figure 4.1.3 shows estimated prevalence of diabetes for Luton and England from 2016 to 2035. In 2016 the estimated prevalence is 10.2% and this equates to 17,019. This compares to 12,889 on the recorded disease registers at QOF. Therefore there are potentially around 4,150 people with undiagnosed and therefore uncontrolled diabetes within Luton. As can be observed the prevalence of diabetes is estimated to rise to 22,614 people in 2035 meaning approximately 5,000 more people will have diabetes in the borough. *Please note that QOF is based on persons aged 17+ and the modelled estimates on people 16+ so numbers may vary slightly.

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4.2 Hospital admissions

Figure 4.2.0 Emergency hospital admissions: diabetic ketoacidosis and coma, 2014/15

Figure 4.2.0 shows emergency admission rates for diabetic ketoacidosis and coma for 2014/15. Luton has a rate of 36.3 per 100,000 population and this is not different than the national rate of 31.2 per 100,000 population.

5. Early Diagnosis and Primary Care Management Diabetes needs to be diagnosed as early as possible so it can be treated quickly. Diagnosis of diabetes can be made using urine and blood tests and a glucose tolerance test (GTT). The test is simple; as glucose is not normally in the urine the test determines if glucose is present and specifically how much is present. These tests’ (to determine diabetes in individuals) form a part of the NHS health checks programme. The following section has information on health checks in Luton and England for comparison.

5.1 Health Checks

The NHS Health Check is a check of peoples’ heart health. Aimed at adults in England aged 40 to 74, it checks vascular or circulatory health and works out the risk of developing some of the most disabling – but preventable – illnesses. Among other things, blood pressure, cholesterol, and BMI will all be checked and results given to the patient (NHS 2014). Crucially, an NHS Health Check can detect potential problems before they do real damage. Everyone is at risk of developing heart disease, stroke, type 2 diabetes, kidney disease and some forms of dementia.

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Table 5.1.0: Recent uptake of health checks within Luton compared to national average

Source: NHS Health Checks Table 5.1.0 above shows that in recent years Luton has consistently has a higher health check uptake compared to the national average. The total row shows the average numbers of numbers eligible from 2011/12 to 2015/16.

5.2 Diabetic Retinopathy Screening

Eye screening is a key part of diabetes care. In people with diabetes, eyes are at risk of damage from diabetic retinopathy, a condition that can lead to sight loss if it's not treated (NHS 2014). The screening is also part of pre testing at some opticians; this is useful as damage can be spotted even before a person knows they have diabetes.

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Figure 5.2.1: Percentage diabetes patients who had diabetic retinopathy screening 2013/14

Source: QOF 2013/14

Figure 5.2.1 shows that Luton (86.8%) has a significantly lower percentage of diabetes patients who have had retinopathy screening in 2013/14 compared to the national average (90%).

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Figure 5.2.2: Percentage diabetes patients who had diabetic retinopathy screening, GP practices 2013/14

Figure 5.2.2 shows that 10 practices in Luton has a significantly lower percentage of diabetes patients who have had retinopathy screening in 2013/14 compared to the Luton average (86.8%). 17 practices have a percentage significantly higher than Luton.

5.3 Primary Care Management

As well as early diagnoses of diabetes it is also important to control and monitor diabetes within patients already diagnosed with the disease. This section looks at how GP practices within Luton perform on diabetes management indicators.

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Figure 5.3.1: DM002: The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less, 2014/15

Figure 5.3.1 shows the percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less, 2014/15. The proportions range from 70.7% to 98.5%. Six practices had percentages significantly lower than the Luton average and 11 practices had percentages significantly higher than Luton.

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Figure 5.3.2: DM003: The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less, 2014/15

Figure 5.3.2 shows the percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less, 2014/15. The proportions range from 41.7% to 92.9%. Eight practices had percentages significantly lower than the Luton average and 13 practices had percentages significantly higher than Luton.

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Figure 5.3.3: DM004: The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less, 2014/15

Figure 5.3.3 shows the percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less, 2014/15. The proportions range from 56.4% to 88.8%. Six practices had percentages significantly lower than the Luton average and nine practices had percentages significantly higher than Luton.

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Figure 5.3.4: DM007: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months, 2014/15

Figure 5.3.4 shows the percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 59 mmol/mol or less in the preceding 12 months, 2014/15. The proportions range from 35% to 81%. Five practices had percentages significantly lower than the Luton average and nine practices had percentages significantly higher than Luton.

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Figure 5.3.5: DM009: The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months, 2014/15

Figure 5.3.5 shows the percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months, 2014/15. The proportions range from 51% to 97%. Eight practices had percentages significantly lower than the Luton average and nine practices had percentages significantly higher than Luton.

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Figure 5.3.6: DM012: The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 12 months, 2014/15

Figure 5.3.6 shows the percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 12 months, 2014/15. The proportions range from 66% to 100%. Eight practices had percentages significantly lower than the Luton average and 13 practices had percentages significantly higher than Luton.

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Figure 5.3.7 DM014: The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register, 2014/15

Figure 5.3.7 shows the percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register, 2014/15. The proportions range from 0% to 100%. One practice had percentage significantly lower than the Luton average.

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Figure 5.3.8 DM018: The percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 August to 31 March, 2014/15

Figure 5.3.8 shows the percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 August to 31 March, 2014/15. The proportions range from 73% to 100%. Seven practices had percentages significantly lower than the Luton average and 11 practices had percentages significantly higher than Luton. Figure 5.3.9 Baseline Assessment of Diabetes indicators for Luton 2016/17

Source: NHS England. The figures in figure 5.3.9 will act as a baseline for further work as identified by the CCG Improvement and Assessment Framework (CCGIAF) 2016/17.

6. Provision of service and care

6.1 Complications of diabetes

Having diabetes brings additional risks of developing other problems such as angina, myocardial infarction and amputation. This section looks at some of these additional risks for diabetes patients in Luton and compares to the national average and other similar CCG’s.

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Figure 6.1.0: Additional risk of diabetes patients having angina, 2009/10-2012/13

Figure 6.1.0 shows that Luton diabetes patients have an additional risk of 178% (or 1.7 times more) of developing angina compared to non-diabetes patients. This is significantly higher than the national average (136.8%) or 1.4 times more.

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Figure 6.1.1: Additional risk of diabetes patients having heart failure, 2009/10-2012/13

Figure 6.1.1 shows that Luton diabetes patients have an additional risk of 186% (or 1.9 times more) of developing heart failure compared to non-diabetes patients. This is significantly higher than the national average.

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Figure 6.1.2: Additional risk of diabetes patients having major amputation, 2009/10-2012/13

Figure 6.1.2 shows that Luton diabetes patients have an additional risk of 268% (or 2.7 times more) of a major amputation compared to non-diabetes patients. Although lower this is not significantly different than the national average.

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Figure 6.1.3: Additional risk of diabetes patients having minor amputation, 2009/10-2012/13

Figure 6.1.3 shows that Luton diabetes patients have an additional risk of 624% (or 6.2 times more) of a minor amputation compared to non-diabetes patients. Although lower this is not significantly different than the national average.

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Figure 6.1.4: Additional risk of diabetes patients having myocardial infarction, 2009/10-2012/13

Figure 6.1.4 shows that Luton diabetes patients have an additional risk of 139% (or 1.4 times more) of a myocardial infarction compared to non-diabetes patients. This is significantly higher than the national average.

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Figure 6.1.5: Additional risk of diabetes patients having renal replacement therapy, 2009/10-2012/13

Figure 6.1.5 shows that Luton diabetes patients have an additional risk of 338% (or 3.4 times more) of a renal replacement therapy compared to non-diabetes patients. Although higher this is not different than the national average.

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Figure 6.1.6: Additional risk of diabetes patients having stroke, 2009/10-2012/13

Figure 6.1.6 shows that Luton diabetes patients have an additional risk of 103% of a stroke compared to non-diabetes patients. This is not different than the national average.

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Table 6.1.0: Shows indicators for diabetes complications within Luton CCG and compares to the national average

Table 6.1.0 shows various hospital admission indicators for diabetes complications within Luton CCG in the three year period 2011/12 to 2013/14 and compares to the national average.

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Key findings in the indicators are:

Luton had 17.5 per 1,000 population aged 17+ (n=625) of diabetic episodes of care and this was significantly lower than the national average (19.2 per 1,000 population.

However of these episodes of care 85.4% (n=534) were accounted for by patients who had more than one stay, which is significantly higher than the national average.

The number of days in hospital for diabetes foot-care was 5,405 which equated to 151.3 per 1,000 population aged 17+; again this was significantly lower than the national average (163.2).

A total of 154 patients (62.9%) had more than one episode of care within the three year time period; again this is significantly higher than the national average (55.4%).

There were 61 amputations a rate of 1.7 per 1,000 people aged 17+ and a total of 1,246 days in hospital (34.9 per 1,000 population aged 17+. Both of these were significantly lower than the national average (2.6 and 43.4 per 1,000 population respectively).

There were a total of 26 major amputations 0.7 per 1,000 population aged 17+ and this was not significantly different to England (0.8).

There were 35 minor amputations 1.0 per 1,000 population aged 17+ and this was significantly lower than the national average (1.8).

7. Costs of diabetes The cost of diabetes to the NHS is over £1.5m an hour or 10% of the NHS budget for England and Wales. This equates to over £25,000 being spent on diabetes every minute. In total, an estimated £14 billion pounds is spent a year on treating diabetes and its complications, with the cost of treating complications representing the much higher cost (Diabetes UK 2016). This section looks at some costs and outcomes of diabetes for Luton using the Diabetes Outcomes Verses Expenditure Tool (DOVE tool). The current total spend on diabetes prescribing per person in NHS Luton CCG was £241.51. This ranks the CCG 12 of 211 CCG’s on the diabetes QOF register nationally (with 1 representing the CCG with the lowest spend). The CCG’s total spend for this indicator in 2013/14 was £3,020,060. The total spend on diabetes prescribing per person with diabetes in NHS Luton for this CCG is currently within the lowest 25% nationally. In terms of outcomes for Luton CCG the current percentage of people with diabetes with a HbA1c of 59mmol/mol or less on the QOF register in NHS Luton was 65.9%. This equates to 7,417 out of 11,254 people on the register. This ranks the CCG 180 of 211 CCGs nationally for this indicator (with 1 representing the CCG with the best outcomes). NHS Luton was in the bottom 50% of CCGs in England for the percentage of people with diabetes with a HbA1c of 59mmol/mol or less . In order to achieve a percentage equivalent to that of the median (average) CCG, NHS Luton would need to increase the number of people with diabetes with a HbA1c of 59mmol/mol or less by a further 499, assuming a static total register size.

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The percentage of people with diabetes with a HbA1c of 59mmol/mol or less in NHS Luton was lower than those of the top 25% of CCGs in England. In order to achieve a percentage equivalent to that of the median (average) CCG, NHS Luton would need to increase the number of people with diabetes with a HbA1c of 59mmol/mol or less by a further 752, assuming a static total register size. *Please note the prevalence here of 11,254 does not the current prevalence stated earlier as this tool is from 2013/14 and uses earlier data.

Figure 7.1 Total spend on diabetes prescribing compared to people with diabetes with a HbA1c of 59mmol/mol or less for NHS Luton

Source DOVE tool

Figure 7.1 shows total spend on diabetes prescribing compared to people with diabetes with a HbA1c of 59mmol/mol or less for NHS Luton. The chart shows that in 2012/13 Luton had a high expenditure and low outcomes for this indicator and in 2013/14 Luton had a low spend and low outcomes. This suggests that although outcomes in patients with controlled HbA1c were low in 2012/13, less money was spent the following year and therefore outcomes worsened.

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Figure 7.2 Total spend on diabetes prescribing compared to people with diabetes with a HbA1c of 64mmol/mol or less for NHS Luton

Source DOVE tool

Figure 7.2 shows total spend on diabetes prescribing compared to people with diabetes with a HbA1c of 64mmol/mol or less for NHS Luton. The chart shows that in 2012/13 Luton had a high expenditure and low outcomes for this indicator and in 2013/14 Luton had a low spend and low outcomes. This suggests that although outcomes in patients with controlled HbA1c were low in 2012/13, less money was spent the following year and therefore outcomes worsened.

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Figure 7.3 Total spend on diabetes prescribing compared to people with diabetes with a HbA1c of 75mmol/mol or less for NHS Luton

Source DOVE tool

Figure 7.3 shows total spend on diabetes prescribing compared to people with diabetes with a HbA1c of 75mmol/mol or less for NHS Luton. The chart shows that in 2012/13 Luton had a high expenditure and low outcomes for this indicator and in 2013/14 Luton had a low spend and low outcomes. This suggests that although outcomes in patients with controlled HbA1c were low in 2012/13, less money was spent the following year and therefore outcomes worsened.

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8. Mortality due to diabetes

Figure 8.1.0 Mortality due to diabetes in males all ages, 2012/14

Figure 8.1.1 Mortality due to diabetes in females all ages, 2012/14

Figure 8.1.0 shows mortality due to diabetes in males all ages in 2012/14 in Luton (19.7 per 100,000 population) was significantly higher than the national average (11.9 per 100,000 population). Figure 8.1.1 shows mortality rate due to diabetes in females all ages in Luton is 13.2 per 100,000 population and this is not different to the national average (8.6 per 100,000 population).

Figure 8.1.2 Mortality due to diabetes in persons all ages, 2012/14

Figure 8.1.3 Mortality due to diabetes in persons aged 75 and less, 2012/14

Figure 8.1.2 shows mortality rate due to diabetes in persons all ages in Luton is 16.2 per 100,000 population and this is not different to the national average (10.0 per 100,000 population). Figure 8.1.3 shows mortality rate due to diabetes in persons ages 75 and less in Luton is 3.9 per 100,000 population and this is not different to the national average 2.9 per 100,000 population).

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Figure 8.1.4 Mortality due to diabetes, all ages, recent trends

Figure 8.1.5 Years of life lost due to diabetes mortality in persons aged 1-74 years, 2012/14

Figure 8.1.3 shows recent trends in mortality rates due to diabetes are falling in males, females and persons for Luton and nationally. However due to the small numbers involved locally a small increase in deaths annually can cause a spike in the rate, as seen in the chart. Figure 8.1.6 shows years of life lost due to diabetes mortality in persons aged 1-74 years in 2012/14; the rate for Luton is 4.6 per 100,000 population and is not different to the national rate of 3.9 per 100,000 population.

9. Service user perspective Figure 9.1.0 Patient with long term conditions perspective on support received and their ability to manage their condition.

*Note: The yellow group contains a younger population with higher than average people from black and Asian backgrounds and with moderate deprivation.

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10. Provider perspectives and what are we doing locally? Diabetes community services in Luton are provided by Cambridgeshire Community Services (CCS). The services include both clinical interventions and structured education. A list of these can be located in figure 10.0.

Figure 10.0 Luton Diabetes Services provided by CCS

Source: CCS provider services

The Luton care pathway for diabetes services can be seen in figure 10.1 below, however this pathway is currently under review.

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Figure 10.1 Luton Diabetes Services Care Pathway

Source: CCS provider services

Figure 10.2: CCS referrals and activity by month for 2015/16

Source: CCS provider services Figure 10.2 shows there is variation in CCS activity across the months. There is a pattern of increased overall activity from Apr 15 to Mar 16.

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Figure 10.3: CCS activity by GP practice compared to QOF diabetes register

Source: QOF and CSS provider services

Figure 10.3 shows CSS activity in GP practices in 2015/16 and also the prevalence and numbers on the QOF register (2014/15) in Luton GP practices.

Figure 10.4: CCS activity by activity type 2015/16

Source: CCS provider services

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Figure 10.4 shows the most common service types used was Diabetes DSN review, DSN non routine and Insulin start which makes up 54% of total activity. Lower activity levels were for Hypo follow up, Weight management and walking away, LWD housebound. As part of the Luton Primary Care Investment Scheme (PCIS) for 2016/17 a new component was introduced to identify pre diabetes patients. These patients are then kept on a register and monitored. Personal health plans (PHP) and structured education is also offered to these patients.

Data submitted to the National Diabetes Audit (NDA) for 2014/15 shows GP practice performance for treatment targets around diabetes. The results are shown in tables 10.5 to 10.8 below.

Figure 10.5: Diabetes Treatment Targets for Larkside locality for 2014/15

Source: NDA 2014/15

Figure 10.6: Diabetes Treatment Targets for Kingsway locality for 2014/15

Source: NDA 2014/15

Figure 10.7: Diabetes Treatment Targets for Medics locality for 2014/15

Source: NDA 2014/15

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Figure 10.8: Diabetes Treatment Targets for SEL locality for 2014/15

Source: NDA 2014/15

11. NICE guidelines This section identifies various guidelines and evidence base which can help underpin population based diabetes interventions.

Table 11.0 Guidelines and evidence base to assist in diabetes interventions

Guideline name Benefit of guideline

PH38 Preventing type 2 diabetes: risk identification and interventions for individuals at high risk

Provides guidelines to help identify diabetes diagnoses in individuals and highlight persons at risk. Health checks are also mentioned in here.

PH35 Preventing type 2 diabetes: population and community-level interventions

Provides guidelines on how to prevent diabetes in individuals and population level. PH35 includes recommendations on diet and physical activity.

PH46: Assessing body mass index and waist circumference thresholds for intervening to prevent ill health and premature death among adults from black, Asian and other minority ethnic groups in the UK.

This includes recommendations on Asian population and diabetes

PH10 Smoking cessation services Provides guidelines on the best interventions in order to achieve the most successful quitters.

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12. Recommendations

Prevention and screening

• Primary and community services should provide brief advice at every opportunity and refer to lifestyle services where appropriate (NICE PH35)

• Identification and referral to intensive lifestyle support in high risk and vulnerable groups (NICE PH38) should be systematically rolled out across primary and community care including pre-diabetes and diabetes

Early Detection and diagnosis /Treatment: improving experiences of care and support • Reduce variation in primary care of

– Health checks uptake with a focus on quality including referral onto intensive lifestyle programmes

– Diabetic Retinopathy Screening with NHS England – Newly diagnosed diabetics and refer to structured education programme

including self-care and foot care (NICE guidance 19) – BP and cholesterol control in diabetics linked primary care investment

programme – Hba1c control with a focus in Medics cluster

Aftercare • Embed within diabetes pathway post treatment lifestyle advice and support for all

patients linked to Enhanced Recovery Programme Integrated commissioning

• Review current pathway /service offer, to reduce duplication and redistribute to need (CCS) and develop discharge bundle for repeat admissions. Consider a CQUIN.

• Ensure all diabetes specifications are outcomes focused and linked to other relevant specifications.

• Embed NICE Quality Standard (QS6, QS125 and QS109) into contracting and monitor performance to reduce additional risk of complications.

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13. References

Action on smoking and health (2012). Smoking and Diabetes. [Online] June 2012. Available from: http://ash.org.uk/files/documents/ASH_128.pdf Diabetes UK (2014) Guide to diabetes. Related conditions.[Online]. Available from: http://www.diabetes.org.uk/guide-to-diabetes/what-is-diabetes/related-conditions/

Diabetes UK (2015) Facts and Stats on Website located at https://www.diabetes.org.uk/Documents/Position%20statements/Diabetes%20UK%20Facts%20and%20Stats_Dec%202015.pdf Accessed 06/2015 Diabetes UK (2016) Website http://www.diabetes.co.uk/cost-of-diabetes.html Accessed 05/2016 Department of Health (2011). Who gets diabetes-health inequalities.Available from: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/browsable/dh_4899972

NHS (2014) Website located here http://www.nhs.uk/Conditions/Diabetes-type2/Pages/Causes.aspx Accessed 05/2016

NHS (2014) Website located here http://www.nhs.uk/Conditions/nhs-health-check/Pages/What-is-an-NHS-Health-Check.aspx Accessed 05/2016 NICE (2009) website located https://www.nice.org.uk/guidance/PH17/chapter/Introduction Accessed 06/2016 PHE (2016) Website accessed 04/2016 at https://www.gov.uk/government/news/levy-on-high-sugar-drinks-phe-statement