Tailored prevention messaging for diabetes

1 What is Diabetes?

Diabetes is a condition where the level of sugar in the blood becomes too high. There are several types of diabetes, the two main ones are:

• Type 1 diabetes, an autoimmune condition where the body does not produce enough insulin, a hormone which controls the level of sugar in the blood. It is most common in younger people and usually diagnosed in the under 40s. Around 10% of people with diabetes in the UK have type 1. Type 1 diabetes is managed with lifelong insulin replacement treatment. (Source: NHS, Type 1 Diabetes)
• Type 2 diabetes, a condition that occurs where not enough insulin is produced by the pancreas, or the cells in the body become resistant to it. Eventually the pancreas can become worn out from producing increased insulin and will produce less. Around 90% of people in UK with diabetes have type 2 diabetes. Type 2 diabetes can be treated with diet and exercise, but medication and insulin may also be needed. (Source: NHS, Type 2 Diabetes)

2 Prevalence of Diabetes

NHS England reported in May 2019 that approximately 10% of health expenditure in England is associated with diabetes, costing around £10 billion per year in costs to the NHS (source: NHS England, New Online Support, May 2019). NHS England states that the proportion of prescriptions issued by primary care for diabetes increased from 7.3% in 2007/08 to 11.4% in 2017/18. (Source: NHS Digital, Prescribing for diabetes England, 8 November 2018). According to the National Diabetes Audit, in 2013/14 there were 1.6 million people in England registered with diabetes or under the care of a specialist diabetes service, rising to 3.2 million in 2017/18 (Source: Diabetes: Written Question, 28 January 2019, 213365)

It estimated that costs of diabetes to the wider economy in the UK was around £13 billion in 2010/11 (Source: Public Health England, Guidance: Health matters: preventing Type 2 Diabetes, 24 May 2018).

Diabetes UK estimates that 295,800 in Scotland have been diagnosed with diabetes, 195,700 in Wales and 96,100 in Northern Ireland (Diabetes UK, Diabetes Prevalence 2018).

One main modifiable risk factors for the development of type 2 diabetes is obesity. Public Health England state that:

• There is a 7 times greater risk of diabetes in obese people compared to those of a healthy weight, and a threefold increase in risk for overweight people. Severely obese people, with a BMI of 40 or over, are at an even greater risk than obese people with a lower BMI ranging from 30 to 39.9.
• Men with an increased waist circumference are 5 times more likely and women are over 3 times more likely to have diagnosed Type 2 diabetes than those without a raised waist circumference.

Other risk factors for the development of type 2 diabetes include lower socioeconomic status, family history of type 2 diabetes and certain ethnicities. Public Health England state:

• Data from the Health and Safety Executive shows that in 2014 in the most deprived quintile compared to the least, obesity was 13% and 50% higher for men and women, respectively.
• Prevalence of Type 2 diabetes is 60% more common among individuals in the most deprived quintile compared with those in the least deprived quintile in England.
• The South Asian population living in the UK are up to 6 times more likely to develop Type 2 diabetes than that of the white population. People of African and African-Caribbean descent are 3 times more likely to have type 2 diabetes that the white population

(Source: Public Health England, Preventing Type 2 Diabetes, 24 May 2018)

The National Diabetes Audit has reported on the extent of variation within diabetes care in England. It found significant local variation across a range of different aspects of patient care for both Type 1 and Type 2 diabetes. They found that variation could not be explained by demographics and in some cases younger people were achieving treatment targets much less often (Source: National Diabetes Audit 2017-18, 13 June 2019).

The House of Commons Library has also published ‘Diabetes in England: where are the hotspots?’ (November 2017) and the ‘How healthy is your area?’ Dashboard.

3 Diabetes prevention, treatment and care

NHS England has outlined the challenge that diabetes poses to the NHS:

Managing the growing incidences of diabetes in England is set to be one of the major clinical challenges of the 21st century. Estimates suggest that the number of people with diabetes is expected to rise to 4.2 million people by 2030, affecting almost 9% of the population.

(Source: NHS England, Diabetes treatment)

In April 2018, Lord O’Shaughnessy, Parliamentary Under Secretary of State for Health and Social care, set out the national approach to preventing diabetes and improving care for people with diabetes:

The long-term approach to diabetes involves both seeking to reduce the increase in the prevalence of diabetes and, for those with diabetes, seeking to reduce the likelihood of developing complications and improving overall levels of treatment and care. Work to reduce the increase in future prevalence of type 2 diabetes is being delivered through the NHS Diabetes Prevention Programme. By 2020, the programme will support up to 100,000 people at high risk of type 2 diabetes each year across England. Those referred will get tailored, personalised support over at least nine months to achieve a healthy weight, improve nutrition and increase levels of physical activity in order to reduce risks of developing type 2 diabetes. Work on reducing the likelihood of those with diabetes developing complications is through the diabetes treatment and care programme. This focuses on four key interventions:

1. Increasing attendance at structured education by both those newly diagnosed with diabetes and those who have had the condition for a longer period;
2. Increasing achievement of the diabetes treatment targets and reducing variation in achievement of these targets between clinical commissioning groups and between general practitioner practices;
3. Reducing the levels of amputations by increasing the availability of multidisciplinary footcare teams; and
4. Reducing lengths of inpatient stay for people with diabetes by increasing the availability of diabetes inpatient specialist nurses

(Source: Diabetes, Written Question, HL6831, 16 April 2018)

Generally, diabetes treatment is commissioned by local clinical commissioning groups (CCGs), although NHS England is responsible for commissioning insulin-resistant diabetes services (adults and children), and specialist diabetes services in children.

4 The NHS Long Term Plan

The then-Prime Minister, Theresa May, asked the NHS to produce a long-term plan to improve access, care and outcomes for patients, in return for a five-year funding settlement announced in June 2018. Under this settlement, the NHS England budget will grow on average by 3.4% in real terms each year from 2019/20 to 2023/24, increasing by £20.5 billion in total by 2023/24.

The NHS Long Term Plan was launched on 7 January 2019. It set out a range of actions the NHS will be taking to prevent type 2 diabetes and reduce the variation in the quality of diabetes care:

2.15. The NHS Diabetes Prevention Programme supports those at high risk of type 2 diabetes to reduce their risk. A joint commitment by NHS England, Public Health England (PHE) and Diabetes UK, the programme is the largest undertaking of its kind in the world and over 100,000 people have already benefited since its introduction in 2016. In many areas demand has outstripped supply, and it has proven highly effective. We are now committing to fund a doubling of the NHS Diabetes Prevention Programme over the next five years, including a new digital option to widen patient choice and target inequality.

2.16. The risk of developing type 2 diabetes is up to six times higher in certain Black, Asian and Minority Ethnic (BAME) groups. Expanding the Diabetes Prevention Programme is a key vehicle for tackling health inequalities, with a significantly higher take up from BAME groups than the general population. We will also continue to support local health systems to address inequality of access to multidisciplinary foot care teams and specialist nursing support for people who have diabetes.

2.17. Medical research has shown that some people with type 2 diabetes can achieve remission through adoption of a very low calorie diet. This allowed nearly half of patients to stop taking anti-diabetic drugs and still achieve non-diabetic range glucose levels [37]. We will therefore test an NHS programme supporting very low calorie diets for obese people with type 2 diabetes.

(Source: NHS Long Term Plan (Chapter 2), 7 January 2019)

In June 2019, the NHS Long Term Plan Implementation Framework was published. It stated that additional funding would be made available for the following:

• Central reimbursement arrangements are in place for 2019/20 and 2020/21 to enable up to 20% of people living with Type 1 diabetes who are eligible under the clinical criteria for that funding, to access flash glucose monitoring devices;
• There will be targeted funding for MDFTs [Multidisciplinary Foot Teams] and DISNs [Diabetes Inpatient Specialist Nurses] transformation projects. In the first instance, continued funding will be provided in 2019/20 for currently established MDFTs and DISN transformation projects, supporting them to become sustainable from 2020/21 onwards. Thereafter, targeted funding will be available for systems that have not had access to MDFTs and DISNs by this point, to help improve equality of access and ensure universal coverage
• Targeted funding from 2019/20 to 2023/24 to support delivery of the three recommended treatment targets and to continue funding for existing structured education projects. This funding is tapered to reduce across the period as improvements are embedded;
• Targeted funding to test low calorie diets for obese people with Type 2 diabetes, working with demonstrator sites covering up to 5,000 people from 2019/20;
• Ensuring that pregnant women with Type 1 diabetes are offered continuous glucose monitoring from April 2020, where clinically appropriate. Funding arrangements will be confirmed later in 2019/20 (p.20).

5 The Diabetes prevention programme (DPP)

The DPP is a joint commitment from NHS England, Public Health England and Diabetes UK, to deliver at scale, evidence based behavioural interventions for individuals identified as being at high risk of developing Type 2 diabetes.

The programme is open to individuals over 18 years of age with nondiabetic hyperglycaemia.

The DPP was first announced in NHS England’s 2014 Five Year Forward View publication:

We also need to make different investment decisions - for example, it makes little sense that the NHS is now spending more on bariatric surgery for obesity than on a national roll-out of intensive lifestyle intervention programmes that were first shown to cut obesity and prevent diabetes over a decade ago. Our ambition is to change this over the next five years so that we become the first country to implement at scale a national evidence-based diabetes prevention programme modelled on proven UK and international models, and linked where appropriate to the new Health Check. NHS England and Public Health England will establish a preventative services programme that will then expand evidence-based action to other conditions.

(Source: NHS England, Five Year Forward View, October 2014)

Seven demonstrator sites were selected in March 2015 to pilot and develop the programme, before the first wave of the programme was launched in 27 areas in May 2016, under the name Healthier You (Source: Diabetes: Health Services, Written Question, 828, 2 June 2015). Additional areas went live as part of the second wave in June 2017.

The DPP overview document sets out the interventions an individual should receive:

The NHS DPP behavioural intervention is underpinned by three core goals:

1. achieving a healthy weight
2. achievement of dietary recommendations
3. achievement of CMO physical activity recommendations

Whilst models between providers vary slightly, the programme must be made up of at least 13 sessions, with at least 16 hours face to face contact time, spread across a minimum of 9 months, with each session lasting between 1 and 2 hours. People will be supported to set and achieve goals and make positive changes to their lifestyle in order to reduce their risk of developing Type 2 diabetes. Sessions will be delivered predominantly in face to face groups.

NHS England has commissioned four providers (Pulse Healthcare, Ingeus UK, Living Well Taking Control and Reed Momenta) to deliver the programme, and local areas select the most appropriate provider to meet their area’s needs. As well as the face-to-face stream, the DPP also has a digital stream, providing the following interventions:

1. wearable technologies that monitor levels of exercise
2. apps which allow users to access health coaches
3. online peer support groups
4. the ability to set and monitor goals electronically

(Source: NHS England, NHS Diabetes Prevention Programme – digital stream)

Five providers have been commissioned to offer the digital stream across eight pilot areas. At the launch of the DPP, it was estimated that when the programme was fully rolled-out across the country, there would be approximately 100,000 referrals per year by 2020. NHS England has provided the following figures for coverage in the first waves:

The programme, which is run collaboratively by NHS England, Public Health England and Diabetes UK, was officially launched last year with 27 areas covering 26 million people – almost half of the country. The latest figures reveal the programme is making good progress, with just under 50,000 people referred in Wave 1 and more than 18,000 on the programme at the end of April. This exceeds the original target set in the NHS Mandate of 10,000 referrals during 2017/18. Wave 2 areas will cover another 25% of the population, with an estimated 130,000 referrals and up to 50,000 additional places made available thanks to the expansion. Funding has also been agreed for another 12 months in the 27 sites currently up and running. The ambition is for the programme to eventually cover the whole of the country and these figures could rise to as many as 200,000 referrals and more than 80,000 people on programmes by 2018/19.

(Source: NHS England, New parts of the country set to benefit from expansion of diabetes prevention programme, 16 June 2017)

NHS England commissions the DPP directly, and according to a March 2017 PQ, the cost of implementing the programme across wave one areas was £12 million. It has also provided implementation funding to local health authorities of £1.47 million in 2016/17 (Sources: PQ 60779, 27 January 2017 and PQ 65591, 7 March 2017).

For areas that joined the programme in 2017/18, NHS England provided implementation funding of between £30,000 and £60,000. The Government’s mandate to NHS England for 2018/19 set a target of at least 60,000 people referred to the DPP, with 100,000 supported through the DPP by 2020 (this is the same target as in the 2017/18 mandate).

It its 2016 report into Management of adult diabetes services in the NHS, the Public Accounts Committee raised concerns about whether this 100,000 target was sufficiently ambitious:

We welcome the introduction of the new NHS Diabetes Prevention Programme but, by itself, this will not be enough to stem the rising number of people with diabetes. An estimated 200,000 people are newly diagnosed with diabetes every year. In March 2015, NHS England, Public Health England and diabetes UK launched the NHS Diabetes Prevention Programme, which targets people at high risk of developing type 2 diabetes. In 2015– 16 the programme aims to support up to 10,000 people, through local initiatives on weight loss, physical activity and cooking and nutrition. NHS England told us that the programme will eventually help 100,000 people a year. The Department, NHS England, and Public Health England will need to move at pace and at scale to stem the rising number of people with diabetes. Recommendation: NHS England and Public Health England should, by April 2016, set out a timetable to ramp up participation in the national diabetes prevention programme to 100,000 people a year, set out what it will cost, and how the programme will target those areas with the highest prevalence of diabetes. Public Health England should also set out how its other public health activities, such as marketing campaigns, will contribute to preventing diabetes.

(Source: Committee of Public Accounts, Management of Adult Diabetes Services in the UK: Progress Review, HC 563 2015-16, 22 January 2016, p. 6.

In September 2017, National Institute for Health Research-funded researchers launched a four year study to evaluate the rollout of the DPP.

In answer to a PQ in May 2018, Steve Brine said that there is evidence to show that the DPP had been successful in targeting patients in the most deprived communities:

Analysis of the first year of the programme showed significantly higher attendance rates in the most deprived quintile compared to the least deprived quintile, 72 per 100,000 population versus 60 per 100,000 population. This suggests that the programme is reaching those who are most at risk of developing type 2 diabetes.

(Source: Diabetes: Written Question, 144307, 15 May 2018).

The 2019 NHS Long Term Plan committed to “fund a doubling of the NHS Diabetes Prevention Programme over the next five years, including a new digital option to widen patient choice and target inequality.” (section 2.15). The commitment was restated in the Government’s Green Paper on Prevention in the 2020s (July 2019).

6 News, Press Releases and Further Reading

‘Type 2 diabetes prevention programme to offer fitness trackers’, Diabetes Times, 13 August 2019.

‘New “intelligent” NHS health checks to be driven by predictive analytics’, Digital Health, 16 August 2019.

‘Personalised health checks to be considered in new review’, Department for Health and Social Care, 16 August 2019.

‘Digital diabetes prevention rolled out as part of NHS Long Term Plan’, NHS England, 12 August 2019.

‘Meeting Type 2 treatment targets could save NHS millions’, Diabetes UK, 8 August 2019.

‘Our research shows Type 2 diabetes develops differently depending on ethnicity’, Diabetes UK, 28 June 2019.

‘New NHS online support for Type 2 diabetes’, NHS England, 28 May 2019.

‘Patients on NHS type 2 diabetes prevention programme lose 60,000kg between them’, NHS England, 1 April 2019.

‘Patients diagnosed with type 2 diabetes to be put on 800-calorie diet in NHS Pilot’, The Pharmaceutical Journal, 30 November 2018.

‘NICE impact diabetes’, NICE, September 2018.

‘Research: Effectiveness of text message based, diabetes self-management programme’, British Medical Journal, 17 May 2018.

‘Promoting health and preventing premature mortality in black, Asian and other minority ethnic groups’, NICE, May 2018, Quality Statement 3.

‘Progress on the Healthier You: NHS Diabetes Prevention Programme: referrals, uptake and participant characteristics’, Diabetic Medicine, 20 December 2017.

‘Men “develop diabetes more easily”, NHS England, 5 October 2011.

‘Diabetes risk factors’, Diabetes UK.

7 Devolved Policy

Scotland

‘Diabetes survey 2018’, Diabetes in Scotland, 18 June 2019.

‘A healthier future: type 2 diabetes prevention, early detection and intervention: framework’, Scotland Healthcare Quality and Improvement Directorate, 16 July 2018.

‘Illness and long-term conditions’: Diabetes’, NHS Scotland.

‘Diabetes’, Scottish Public Health Observatory.

Northern Ireland

‘Patient education/self-management programmes for people with long term conditions 2018/19’, Department for Health, 14 August 2019.

‘New diabetes prevention programme launched in NI’, Public Health Agency, 1 April 2019.

‘Number of people with diabetes in Northern Ireland increases by 62.5% in a decade’, Diabetes UK, 28 February 2018.

Wales

‘Minister launches ambitious new plan to halt obesity rise in Wales’, Welsh Government, 17 October 2019.

‘Healthy weight: Healthy Wales’, Welsh Government, 12 April 2019.

‘Petition P-04-682: Routine screening for type 1 diabetes in children and young people’, National Assembly for Wales Petitions Committee, July 2018.

‘A picture of diabetes in Wales’, Senedd Research, 27 April 2017.

‘Diabetes delivery plan 2016 to 2020’, Welsh Government, 12 December 2016.

‘Healthcare policy in Wales’, Diabetes UK.

8 Recent UK Parliamentary Material

UK Parliament: Diabetes, 9 January 2019, Westminster Hall, 122WH-144WH