The UK National Diabetes Audit results are in. Change is in the wind, but there’s still a storm in the offing.

Published today, the National Diabetes Audit reports from 2013-2015 are here and have some interesting findings for us. Participation in the audit by Clinical Commissioning Groups (CCGs) and Local Health Boards (LHBs) compared to previous years was down by a third, but from a T1 perspective we can see clear improvements in long term blood glucose levels and access to structured education. A high portion of T1s still struggling with managing blood glucose levels, a low participation rate in structured education and both significant variability of T1 care by CCG and LBH and a reduction in completion of critical care processes indicate areas where improvements are still needed.

But on to the data…

Treatment Targets

On the topic of the all important metrics relating to treatments, how has the population faired since 2013? Firstly let’s take a look at the Hba1C:

It appears that the number of T1s achieving the NICE guideline of lower than 6.5% has definitely improved. Statistically quite a lot. It has gone up from 6.5% to 8.4% of the T1 population, a 30% improvement, which is significant. Also significant is the improvement in those hitting the NDA target of lower than 7.5%, going from 27.2% to 29.9% achieving this. That’s an increase of nearly 10%, so also a good result.

One could question why this has happened. Given the data relating to structured education and the proliferation of the Diabetic Online Community over the past few years, in spite of the pressures on the NHS, access to information seems to be having the desired impact.

In spite of this, the broader T1 population is still struggling to manage their long term blood glucose levels, so while these numbers are an improvement, and statistically significant, in absolute values there are still more than 200,000 people out there with T1 that are at high risk of developing complications, and at a cost to the NHS.

What we can see is that variation across CCGs of Hba1C results is very significant, and further study looking at why some have 50% within NICE guidance and others have none is required.

The table below demonstrates the other key targets, of which blood pressure has also shown a great improvement:

Cholesterol levels have remained constant, and with the ongoing questions that are now being raised as to the validity of Cholesterol research on which targets were based, I question whether this should be ignored. What’s interesting about the table (taken from one of the published presentations rather than the base statistics) is that the NICE Hba1C target is omitted.

Structured Education

The number of people being offered education has dramatically increased over the past two years of the study, with nearly 76% of all diabetics in England and Wales being made this offer. The graph below shows how dramatic that change is.

Whilst showing a fundamental shift in thinking about the importance of structured education in diabetes care, what this graph hides is the disparity of availability of structured education for T1s and T2s.

It was offered to 78% of T2s but only 32% of T1s. What the reports don’t show, and what you need to dig down into the data for is the change in T1s.

In 2012-2013, only 3.7% of all newly diagnosed T1s were offered structured education.
In 2013-2015, 30% and then 32% respectively of newly diagnosed T1s were offered structured education.

The improvement is dramatic and welcome. And absolutely necessary. Now to get those long term T1s that still need education into some.

What’s perhaps more disappointing is the actual participation in Structured Education. In 2012-2013, 23% of those offered took it up. In 2014-2015, only 5.7% took it up. So while there was ten times more on offer, only three times as many people took it up. I think this highlights that delivery of the education on offer perhaps needs re-evaluating so that more participate.

Primary Care Processes

Summarising the key findings, we see that not a lot has changed in terms of the eight critical care processes offered by primary care, Type 1s fair less well than Type 2s, and the percentage of people receiving those checks remains fairly flat since 2009, with if anything, a reduction in both the numbers of T1s and T2s receiving these checks compared to 2009. That’s not a great headline. If you are T1 or T2 under 40, you are less likely to receive all your primary care processes, although whether this is the fault of primary care or lifestyles of the under 40s is not defined in the report.

More disturbingly, as a T1 the variation between CCGs on the completion of primary care processes is fairly wide when compared with that seen for T2s. Again, this may not be solely down to the CCGs and LHBs, but may be much more a reflection of the age and socio-economic status of those diagnosed with T1 compared to T2. We already know that those under 40 have fewer completions, so laying the numbers of under 40s across the reporting CCGs, and adding the socio-economic status of the area may provide some interesting insights.

What is certainly true is that the GP-centred model feeding into mothership hospitals isn’t working and needs to be changed. These metrics aren’t good enough to stop a lot of people ending up in a place that the NHS just doesn’t want and we simply can’t continue in this vain.

Perhaps looking at creating convenient walk in centres that could be used around a working day, feeding data back to key specialists or GPs might make access easier. Making it easy for the patient has to be the key aspect of this. And to do this, patient data needs to be easily shared between centres, which is an ongoing issue at the heart of NHS patient care.

Conclusions

While there have been steps forward in the past two years, notably in the offering of education to both T1s and T2s and in those achieving better glucose measurements, there are also some key points that haven’t changed a lot. The key one of those being that the majority of T1s still struggle to achieve blood glucose levels that will significantly reduce their risks of complications and in the long term will severely reduce their quality of life.

It’s clear that it isn’t those in the top 30% that need help, rather those in the bottom 70%. The big question is how can this be achieved?

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