Diabetes

On 31 March 2015 there were 10,455 people aged 17 and over diagnosed with diabetes registered with a General Practitioner (GP) in Calderdale. This is a prevalence of 6.4%, which is the same as the national prevalence.

There is no recent information about the number of children and young people with diabetes in Calderdale. However, a recent survey undertaken by Diabetes UK (Diabetes UK Review of Paediatric Diabetes Survey) indicated that in November 2015, there were 195 children and young people registered with GPs in Calderdale and Greater Huddersfield who were registered with the local diabetes specialist service.

Most diabetes care takes place in General Practice (GP), and diabetes is a key part of the Quality and Outcomes Framework (QOF). The latest QOF figures (for 2014/15) demonstrate wide variation in achievement for most indicators relating to diabetes. The CCG has recognised the importance of consistency of care, and its clinical associate for diabetes (Dr Fred Mayland) has been working with practices to support and encourage them to benchmark and review their practice.

A new service (the Level 3 service) providing enhanced care and support in primary care for adults stabilised on injectable therapies began in December 2015. This service is being delivered by most GP practices with training / mentoring / support from the local diabetes specialist team. It aims to improve consistency of care in practices across Calderdale for this group of patients, and to develop the skills and knowledge of local GPs and nursing staff. The service will facilitate the managed transfer to primary care of eligible patients currently being cared for in secondary care – this process is likely to be complete by the end of 2016.

Calderdale and Huddersfield NHS Foundation Trust provides paediatric diabetes services to children and young people in Calderdale, including transition clinics for young people moving on to adult services. It also provides care and support to women with gestational diabetes pre- and post-pregnancy and to some adults – mainly those with complex problems.

At present, there is no formal mechanism for collecting the views of people with diabetes and their families in Calderdale although people are encouraged by the CCG and Calderdale and Huddersfield Foundation Trust (CHFT) to provide feedback.

However, there are some specific pieces of work which have informed the CCG’s approach to diabetes:

• Improving Diabetes event (October 2014);
• Specific work with the Diabetes UK Calderdale Diabetes Support Group;
• Work with the Calderdale Health Forum on self-care for people with diabetes;
• Engagement work undertaken with the local South Asian population with diabetes.

The latest estimate of people aged 17 and over with undiagnosed diabetes (from 2012/13) was 3,395 but this will have increased since that time. In addition, Public Health England (PHE) estimates that around 19,584 people in Calderdale have non-diabetic hyperglycaemia (also known as pre-diabetes).

Diabetes prevalence increases with age. The projected structure of the population in Calderdale between 2011 and 2021 indicates that the number of people aged 65 and over will increase by 28%.

Adults

The National Institute for Healthcare Clinical Excellence (NICE) has developed a series of quality standards for adults with diabetes. These are described below:

1. People with diabetes and / or their carers receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education;
2. People with diabetes receive personalised advice on nutrition and physical activity from an appropriately trained healthcare professional or as part of a structured educational programme;
3. People with diabetes participate in annual care planning which leads to documented agreed goals and an action plan;
4. People with diabetes agree with their healthcare professional a documented personalised haemoglobin A1c (HbA1c) target, and receive an ongoing review of treatment to minimise hypoglycaemia;
5. People with diabetes agree with their healthcare professional to start, review and stop medications to lower blood glucose, blood pressure and blood lipids in accordance with NICE guidance;
6. Trained healthcare professionals initiate and manage therapy with insulin within a structured programme that includes dose titration by the person with diabetes;
7. Women of childbearing age with diabetes are regularly informed of the benefits of preconception glycaemic control and of any risks, including medication that may harm an unborn child. Women with diabetes planning a pregnancy are offered preconception care and those not planning a pregnancy are offered advice on contraception;
8. People with diabetes receive an annual assessment for the risk and presence of the complications of diabetes, and these are managed appropriately;
9. People with diabetes are assessed for psychological problems, which are then managed appropriately;
10. People with diabetes at risk of foot ulceration receive regular review by a foot protection service in accordance with NICE guidance;
11. People with diabetes with a limb-threatening or life-threatening diabetic foot problem are referred immediately to acute services, and the multidisciplinary foot care service is informed of this;
12. People with diabetes with an active foot problem that is not limb-threatening or life-threatening are referred to the multidisciplinary foot care service or foot protection service within one working day and triaged within one further working day;
13. People with diabetes admitted to hospital are cared for by appropriately trained staff, provided with access to a specialist diabetes team, and given the choice of self-monitoring and managing their own insulin;
14. People admitted to hospital with diabetic ketoacidosis receive educational and psychological support prior to discharge and are followed up by a specialist diabetes team;
15. People with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist diabetes team.

Children and young people

NICE guidance on Type 1 and Type 2 diabetes in children and young people identifies the following key priorities for implementation:

• Education and information for children and young people with diabetes:

  Take particular care when communicating with and providing information to children and young people with type 1 and type 2 diabetes if they and / or their family members or carers (as appropriate) have, for example, physical and sensory disabilities, or difficulties speaking or reading English (2004, amended 2015);

• Insulin therapy for children and young people with type 1 diabetes:

  Offer children and young people with type 1 diabetes multiple daily injection basal–bolus insulin regimens from diagnosis. If a multiple daily injection regimen is not appropriate for a child or young person with type 1 diabetes, consider continuous subcutaneous insulin infusion (CSII or insulin pump) therapy as recommended in continuous subcutaneous insulin infusion for the treatment of diabetes mellitus (NICE technology appraisal guidance 151) (new 2015);

• Dietary management for children and young people with type 1 diabetes:

  Offer level 3 carbohydrate‑counting (Level 3 carbohydrate counting is defined as carbohydrate counting with adjustment of insulin dosage according to an insulin:carbohydrate ratio) education from diagnosis to children and young people with type 1 diabetes who are using a multiple daily insulin injection regimen or continuous subcutaneous insulin infusion (CSII or insulin pump) therapy, and to their family members or carers (as appropriate), and repeat the offer at intervals thereafter (new 2015);

• Blood glucose and HbA1c targets and monitoring for children and young people with type 1 diabetes:

  • Advise children and young people with type 1 diabetes and their family members or carers (as appropriate) to routinely perform at least 5 capillary blood glucose tests per day (new 2015);
  • Offer ongoing real‑time continuous glucose monitoring with alarms to children and young people with type 1 diabetes who have:
    • frequent severe hypoglycaemia, or
    • impaired awareness of hypoglycaemia associated with adverse consequences (for example, seizures or anxiety), or
    • inability to recognise, or communicate about, symptoms of hypoglycaemia (for example, because of cognitive or neurological disabilities) (new 2015).

    Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimise the risk of long‑term complications (new 2015);

• Hyperglycaemia, blood ketone monitoring and intercurrent illness in children and young people with type 1 diabetes:

  Offer children and young people with type 1 diabetes blood ketone testing strips and a meter, and advise them and their family members or carers (as appropriate) to test for ketonaemia if they are ill or have hyperglycaemia (new 2015);

• Psychological and social issues in children and young people with diabetes:

  Offer children and young people with type 1 and type 2 diabetes and their family members or carers (as appropriate) timely and ongoing access to mental health professionals with an understanding of diabetes because they may experience psychological problems (such as anxiety, depression, behavioural and conduct disorders and family conflict) or psychosocial difficulties that can impact on the management of diabetes and wellbeing (2004, amended 2015);

• Diabetic kidney disease in children and young people with type 2 diabetes:

  Explain to children and young people with type 2 diabetes and their family members or carers (as appropriate) that:

  • using the first urine sample of the day ('early morning urine') to screen for moderately increased albuminuria (ACR 3–30 mg/mmol; 'microalbuminuria') is important, as this reduces the risk of false positive results;
  • if moderately increased albuminuria is detected, improving blood glucose control will reduce the risk of this progressing to significant diabetic kidney disease;
  • annual monitoring is important because, if diabetic kidney disease is found, early treatment will improve the outcome (new 2015);

• Diabetic ketoacidosis:

  Measure capillary blood glucose at presentation in children and young people without known diabetes who have increased thirst, polyuria, recent unexplained weight loss or excessive tiredness and any of the following:

  • nausea or vomiting;
  • abdominal pain;
  • hyperventilation;
  • dehydration;
  • reduced level of consciousness (new 2015).

References

• Health and Social Care Information Centre: Quality and outcomes framework 2014-15.
• NICE: Diabetes in adults.
• NICE: Diabetes (type 1 and type 2) in children and young people: diagnosis and management.