Diabetes NHS Long Term Plan Commitments 'Met and Exceeded'

Becky McCall

November 11, 2021

Editor's note, 12 November 2021: This article was updated for clarity.

Outcomes in diabetes are something to be proud of, said England’s National Specialty Advisor for Diabetes, addressing the opening session of the Diabetes Professional Conference 2021.

He added that the last decade had seen rates of amputations, cardiovascular disease, and hospital admissions all drop significantly, and much of this had been led by primary care as well as specialty services.

Professor Partha Kar, national specialty advisor for diabetes, together with Professor Jonathan Valabhji, national clinical director for diabetes and obesity, presented the annual update on the NHS England Diabetes and Obesity Programmes at the meeting, held in-person in London.

Prof Jonathan Valabhji & Prof Partha Kar

The update was dominated by the effect of the pandemic on delivery of care from the perspective of both clinicians and patients. Prof Valabhji pointed out that faced with the onslaught of COVID and the desperate need for a solution, the emphasis was on disentangling the unknowns at that time. "In severe outcomes there was a clear association between COVID and HbA1c, and BMI in the obese range. Our rich NHS datasets have provided info that other countries’ can’t do."

QCOVID Risk Prediction Algorithm

He pointed out that in trying to identify the most at-risk patients, they were challenged with creating the QCOVID risk prediction algorithm for risk of hospitalisation and mortality from COVID-19 in adults.

"The QCOVID database stratifies diabetes by type as well as by level of deprivation and provides an absolute and relative risk score," explained Prof Valabhji. "This work fed into prioritisation groupings for roll out of COVID vaccines."

QCOVID was also extended to look at risk of COVID post-vaccination. "The absolute risk of hospitalisation and death was massively reduced by the vaccine, but the relative risk is similar to pre-vaccine times in patients with diabetes," Prof Valabhji pointed out. "For type 2 diabetes after vaccination, there remains a 28% higher risk of COVID mortality with HbA1c below 59 mmol/mol and 76% higher risk in patients with type 2 diabetes and HbA1c above 59 mmol/mol."

Diabetes 8 Care Processes Pre-COVID and Since COVID

Turning to the recovery of routine diabetes care post-COVID, Prof Valabhji pointed out that the surrogate measure for routine diabetes care is the state of delivery of the eight diabetes care processes. "By ethnicity, one would have expected the biggest fall in routine care in Black and Asian communities rather than White populations, but our data show the opposite, so the fall off in routine care was biggest in White patients."

Between 2016-17 and 2020-21 there was a year-on-year modest but steady increase in the completion of all eight care processes up to 2019-20, but this declined in the year of COVID, he said. In 2017-18 (the year in which the highest percentage of patients received all eight care processes), 43% of type 1 diabetes patients received all eight care processes, but this fell to 25% in 2020-21. For type 2 diabetes, 59% received all eight care processes in 2017-18 and this fell to 37% in 2020-21.

"Clinical teams have done their best to prioritise people who need the care," said Prof Valabhji. "We have allocated an additional £5 million to specific areas to support recovery. It won’t solve workforce issues but will go some way to support local teams in routine care."

Pandemic, Body Weight and NHS Weight Loss Programmes

It is widely known that body weight increased during the pandemic. Prof Valabhji highlighted some research that examined baseline weight in people starting the English NHS Diabetes Prevention Programme. "These are very objective data in England. We see weight changing from April 2017 to March 2021, clearly showing an immediate and rapid rise in body weight from the onset of lockdown.

"There is reasonable cause to suspect this effect is seen much more widely across the general population too, the effects were most marked in younger people, in women, and in those from deprived communities," he said.

The NHS has four weight management programmes: NHS Diabetes Prevention Programme; NHS Low Calorie Diet Programme; The NHS Digital Weight Management Programme, and tiers 3 and 4 specialist weight management services.

Data from these weight management programmes will be combined across the National Obesity Audit, which is due to launch in April 2022. It aims to reproduce the success of the National Diabetes Audit, with data on demographics, weight loss trajectories among other participant features. "We need diabetes services to complete data, and with the participant’s NHS number these data will be linked to other datasets including the ONS [Office of National Statistics] and HES [Hospital Episode Statistics]," said Prof Valabhji. "Even after leaving a tier 4 service, by extracting data longitudinally on an individual, we can still look at the longer-term weight trajectory, longer-term complications associated with obesity, and mortality. It’s phenomenally powerful."  

Prof Valabhji referred to early outcomes from the English NHS Diabetes Prevention Programme (DPP). "The findings on weight loss and HbA1c reduction we hope might translate into around a 25% reduction in type 2 diabetes incidence," he reported, adding that they switched to an online programme quickly when lockdown hit.

Now, over 100,000 participants have accessed and completed the digital intervention sessions since the pandemic onset, he said. Of these, 85,000 were remote sessions, which involved trying to reproduce the group dynamic via MS teams and Zoom, for example. Another 21,000 participants used a bespoke digital product that they interacted with on an individual basis.

Prof Valabhji compared these digital participants with 120,000 people who participated in face-to-face group interventions pre-COVID. "Digital resulted in a left shift in the age distribution by around a decade, completion was comparable, while weight loss showed non-inferiority of the digital/remote intervention," he said, reporting original data.

Weight losses across in-person, remote and digital services were all similar: between 2-2.8 kg in the intention-to-treat patients, and 3-4.8 kg in those who completed the programme.

Regarding the NHS Low Calorie Diet Programme, Prof Valabhji said so far, the translation of the DIRECT study had gone well, despite a 6-month delay in start date due to COVID. The pilot covers 25% of areas across the country, with 2000 referrals, and 75% of patients starting the ‘soups and shakes’ diet. "Numbers are small at the moment, but it looks like mean weight loss is about 13kg at 3 months and this was maintained at six months."

The NHS Digital Weight Management Programme (DWMP) is a new tier two weight management service for those with a BMI in the obese range plus a comorbidity – diabetes, or hypertension, or both. "It is for any type of diabetes," he stressed, noting the importance of type 1 diabetes patients having access too. "We wanted people with type 1 diabetes patients to have access to this digital programme during COVID, as the association of BMI with COVID-related mortality is steeper in those with type 1 diabetes compared to those with type 2."

The DWMP is totally digital, due to COVID, and provides three levels of intervention over 12 weeks in tier 2. There are three levels of programme: digital access only; digital access plus 50 minutes of coaching; and digital access plus 100 minutes of coaching and more personalised support and gamification.

NHS Long Term Plan Commitments

Prof Kar turned attention to the NHS Long Term Plan Commitments on diabetes, saying: "We need to challenge ourselves and look at what we’ve done and not done."

He selected a few examples of progress made.

Adoption of Free Style Libre for type 1 diabetes has exceeded target. "We started in 2018 with 0% uptake, we had committed to 20% but currently we are at 50%. This is a fantastic achievement," he said.

One commitment was that all pregnant women with type 1 diabetes will be offered continuous glucose monitoring (CGM). From 2021, 88% of all eligible pregnant women have been offered CGM, and 67% were prescribed a CGM, with 21% declining it.

Prof Kar highlighted the increase in access to Free Style Libre, with 10.7% of type 1 diabetes patients adopting it in April 2019, rising to 17.2% by August that year. By 2021, 50% had adopted the device.

"We are working closely with NICE on access to hybrid closed loop technology. So far around 500-600 patients have closed loop technology across 32 centres, collecting data, and we are waiting for NICE to make a call on this," said Prof Kar, adding that the UK is one of the first countries in the world to do this type of trial across the board.

All type 1 diabetes patients have access to digital tools including DigiBete, or My Way.

Prof Kar pointed out that they want every area to have a multidisciplinary team and diabetes in-patient specialist nurse (DISN) foot team. "Most regions have these now. Back in 2010, in-patient diabetes foot team was gold dust!"

Beyond the commitments

Finally, Prof Kar referred to extra commitments made including new audits of young people with type 2 diabetes. "We also want to ensure that access to diabetes care has to be given irrespective of deprivation and ethnicity. In 2021, a Black child has half the chance of a White child of getting CGM. This is unacceptable in this country. We will close this gap."

Other commitments relate to a specialist survey, peer support for type 1 diabetes everywhere in the NHS, diabetes and ethnicity, as well as improving the gathering of patient feedback to know what needs to change. Prof Kar said that he was working closely with NICE on flash glucose monitoring as well as closed loop technology. "These will be out for consultation soon."

He also noted the work on monogenic diabetes, where NHS genetic testing will aim to spot a rare form of diabetes in people who are unaware they have it. Staff will also be trained on this.

Prof Kar finished with a few top tips. "Focus on the priorities, be guided by the data, target deprivation and ethnicity, which are linked to worse outcomes, and remember deprivation and ethnicity are not the same thing. Work with the regional NHS England diabetes teams."

 

Presented on 10 November, 2021 at the Diabetes Professional Care (DPC) conference.

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