Diabetes mellitus

Diabetes is a condition where the amount of glucose in blood is too high because the body cannot use it properly. This is because the pancreas does not produce any insulin, or not enough, to help glucose enter the body’s cells – or the insulin that is produced does not work properly (known as insulin resistance).

There are three main kinds of diabetes: Type 1 diabetes is commonly treated with insulin and often diagnosed in people aged under 30.  Type 2 diabetes can be treated with diet alone, tablets or insulin injections and can be diagnosed at any age, but most commonly from middle-age onwards.  Type 2 diabetes can be associated with being overweight.  Gestational diabetes affects pregnant women and often goes away after birth.  Women who’ve suffered gestational diabetes have an increased risk of going on to develop type 2 diabetes in later life.

Diabetes is a common life-long health condition. There are 2.8 million people diagnosed with diabetes in the UK and an estimated 850,000 people who have the condition but don’t know it.

Health spending on people with diabetes is typically higher than average.  With type 2 diabetes particularly affecting older people, and the number of older people set to rise, having robust plans to meet the future needs of people with this illness is essential.

This topic is associated with the following JSNA topics:

Last updated: 2012-07-06 10:10:13
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1. What are the key issues?

  1. Increasing prevalence of diabetes risk factors obesity, reduced physical  activity, poor nutrition and smoking.
  2. Increasing prevalence rates of diabetes will create subsequent increased demand on services.
  3. Evidence suggests that there are high numbers of people with undiagnosed diabetes.  Undiagnosed diabetes may lead to complications that could be avoided with treatment.
  4. High numbers of people identified as having pre-diabetes are progressing to diabetes.
  5. Middlesbrough has higher than the England average number of emergency admissions due to ketoacidosis and coma.  Middlesbrough also has low scores for diabetes care processes and management to target indicators.
  6. Access to self-management education programmes is limited to those newly diagnosed.
  7. There is variation in treatment, quality of care and outcomes at a general practice level.
Last updated: 06/07/12

2. What commissioning priorities are recommended?

Further develop, implement and monitor strategies to identify and offer effective management to patients with pre-diagnosed diabetes or who are at high risk of developing diabetes.

Prevent diabetes and tackle health inequalities by:

  • Developing population wide, multi-agency and multi-faceted approach to address the risk factors for diabetes (obesity, nutrition, physical activity, smoking)
  • Investing in evidence-based services which support people to reduce the risk of developing diabetes (including gestational diabetes) especially targeting at risk groups.
  • Develop, implement and monitor strategies to reduce the risk of developing type-2 diabetes and to reduce the inequalities in the risk of developing type-2 diabetes.  NICE guidance expected in 2012 on preventing the progression from pre-diabetes is expected to support this progress.

Ensure diabetes services have the capacity and capability to cope with the increasing prevalence of diabetes:

  • Develop a systematic and integrated approach to prevention and effective management of diabetes and other related long term conditions with primary care, public health, secondary care, community services, voluntary and community sector and the community
  • Ensure existing commissioned services are sufficiently resourced to accommodate increase in diabetes population.

Reduce diabetes complications by developing, implementing and monitoring protocols to further reduce and effectively manage complications of diabetes.

Provide more life-long opportunities for education and self-management for those with diabetes.

Improve quality of diabetes care by:

  • Reducing variation in quality of care by encouraging and promoting peer review among general practices.
  • Ensuring that there are clear referral pathways between services for people with diabetes (including structured education courses and antenatal care) and services supporting lifestyle behaviour change.

Ensure the emotional wellbeing and mental health needs of patients with diabetes are addressed in a systematic way as part of the care pathways.

Ensure that all women of reproductive age with diabetes receive appropriate advice, treatment and support. (NICE clinical guideline 63: diabetes in pregnancy).

Last updated: 06/07/12

3. Who is at risk and why?

Gestational diabetes is an additional risk factor for women.  Other forms of diabetes are not strongly linked to gender.

Type 1 diabetes is most commonly diagnosed in people aged under 30.  Increasing age raises the risk for developing type 2 diabetes.  Women of child-bearing age, particularly those who are overweight, are at risk of developing gestational diabetes, should they become pregnant.

It is known that people from South Asian and African-Caribbean ethnic groups are more likely to have diabetes and tend to develop the condition at younger ages.

Socioeconomic status
Diabetes prevalence is higher in areas experiencing deprivation. People living in the 20% most deprived neighbourhoods in England are 56% more likely to have diabetes than those living in the least deprived areas.  This may be due to higher proportions of people in ethnic minorities living in deprived areas, and higher levels of lifestyle risk factors in deprived populations.

Obesity is the main risk factor for developing type-2 diabetes.  Diabetes is also associated with low levels of physical activity and poor diet and nutrition.

Family history
Those with a family history of diabetes are more likely to develop diabetes themselves.  This may be influenced partly by genetics and partly by social norms.

Risks associated with diabetes
People with diabetes have reduced life expectancy.
Diabetes is a leading cause of cardiovascular disease.
Diabetes is the leading cause of blindness in the working-age population.
Diabetes is the second most common cause of lower limb amputation (trauma being the most common).
Diabetes can impact on mental health and emotional wellbeing ranging from psychological problems dealing with the diagnoses to complex mental illness. The prevalence of depression is twice as high in people with diabetes compared to the general population.

Last updated: 06/07/12

4. What is the level of need in the population?

Key Points

  • In Middlesbrough the estimated prevalence of diabetes is 7.9%, but only 5.3% of the population has been diagnosed with diabetes.  It is likely that over 2,200 people with diabetes remain undiagnosed.
  • Some general practices within Middlesbrough have identified fewer than expected people with diabetes.
  • There is variation between general practices within Middlesbrough in terms of identification of people with diabetes, and treatment of those with diabetes.
  • Middlesbrough spends more than the England average on diabetes care, and has similar outcomes.  Although costs in Middlesbrough are not significantly high, there is clear scope to improve outcomes

Prevalence of Diabetes

The prevalence of diabetes in Middlesbrough is below the England average.  Crude prevalence rates have increased from 4.2% in 2005/6 to 5.3% in 2009/10.  NHS health checks introduced in October 2008 included checking for diabetes in people aged 40-74 years.

Middlesbrough diabetes prevalence trend


In Middlesbrough, prevalence models suggest that 7.9% of the population (95% confidence interval 5.7%-11.4%) has diabetes (Source APHO Diabetes Prevalence Model).  Current registers of people with diabetes in Middlesbrough include 5.3% of the adult population (6,200), suggesting around 2,200 people have undiagnosed diabetes.  However, this could be as few as 430 or as many as 6,000.

Middlesbrough quantifying diabetes 


Diabetes in General Practices

There is considerable variation between general practices in identification of people with diabetes.  Five practices in Middlesbrough have identified the expected number of people with diabetes or more. Six practices have identified fewer than 80% of the people expected to have diabetes.

Middlesbrough GP observed to expected diabetes


There is variation in emergency admissions for diabetes between practices.  Using 3 years of pooled data from 20 practices, emergency admissions were 3 times higher in some practices compared to others.

Middlesbrough diabetes emergency admissions


A comprehensive range of practice-level indicators is available on the APHO practice profiles website: www.apho.org.uk/pracprof


Diabetes Care

Care process measures in Middlesbrough are broadly in line with similar areas, although tend to be slightly worse.

 Middlesbrough diabetes care processes

* Patients may be ‘excepted from measurement’ if they do not attend for review or where there is a clinical contra-indication or side effect.

** Purple Group is one of five groups in the Diabetes Area Classification, which clusters PCTs together that have similar risk factors for diabetes.

Middlesbrough diabetes service provision

Additional data show that 93% of diabetic patients received retinal screening (England=91%) and 83% had their blood pressure at 145/85 or less (England=81%).  (source: nww.indicators.ic.nhs.uk/)

Complications of Diabetes

Emergency admissions for ketoacidosis and coma have been higher than England for the past eight years.  These differences are significant for the past three years.  There is a trend towards increased admission rates, with the most recent data being significantly higher than both regional and ONS comparator group rates.

 Middlesbrough admissions ketoacidosis and coma


Lower limb amputations in Middlesbrough are similar to national rates, although they have been below the England rate for the five most recent years.  In 2009/10 there were 10 admissions for lower limb amputation (including toe amputations).  There appears to be a declining trend in amputation rates.

 Middlesbrough diabetes amputations


Middlesbrough diabetes complications  


Spending on diabetes care

Middlesbrough spends more than the England average on diabetes care, and has similar outcomes.  Prescribing costs are above the England average. While costs in Middlesbrough are not significantly high, there is clear scope to improve outcomes.

Middlesbrough spend on diabetes


Children with Diabetes

Care for children with diabetes is predominantly hospital-based.  Admissions for children in South Tees are above England rates, but the difference is not statistically significant.

James Cook Child Diabetes Number


South Tees Child Diabetes Admissions


Last updated: 26/11/13

5. What services are currently provided?

Primary Care
General practitioners continue to provide most of the medical care to people with type 2 diabetes. The complexity of care for this common disease requires systematic care from the practice team and the timely referral to community and hospital-based specialists.   Practices deliver day-to-day care based on locally developed and agreed primary and secondary shared care pathways.  They also ensure they have systems and processes in place to facilitate annual review, usually run by a lead practice nurse.  People diagnosed with diabetes are issued with an information booklet and a handheld record in order to document agreed goals and an action plan.   Screening for diabetes is provided routinely as part of the Healthy Heart Check CVD screening programme for adults aged 40-74.

Community Care
South of Tees has a diabetes community service which offers a range of multi-disciplinary clinics across the South Tees area.  The multi-disciplinary team providing this service include diabetes specialist nurses, doctors with a special interest in diabetes, dieticians and podiatrists.
The diabetes community service provides clinical management of complex diabetes needs, including insulin initiation and titration in type 2 diabetes and initiation of new treatments. The specialist team also deliver structured education for those newly diagnosed with type 2 diabetes (DESMOND), empowering the person to take responsibility for the management of his or her own condition.
The South Tees area has an established diabetes retinal screening programme (DRSS) delivered by James Cook University Hospital from community locations across Middlesbrough and Redcar & Cleveland.

Secondary Care
Specialist care diabetes services are delivered by the South Tees Foundation Trust at two sites: Friarage Hospital, Northallerton and James Cook University Hospital, Middlesbrough.
Consultants manage those people who have developed significant complications from their diabetes as well as any acute or planned admissions for adults and children.  There are specialist clinics for:

  • pregnant women and those planning a pregnancy
  • adolescents and young adults
  • patients treated with insulin pump therapy
  • patients with diabetic renal disease
  • patients with diabetic foot disorders
  • patients with increased cardiovascular risk.


The specialist team also deliver structured education programme (DAFNE) for adults with type 1 diabetes.  This programme aims to provide participants with the skills of carbohydrate counting and insulin dose adjustment.

Map of Medicine
Full details of all local services and clinical guidelines are available on the Tees Map of Medicine website.  This is only available to healthcare professionals.

Last updated: 06/07/12

6. What is the projected level of need?

Diabetes prevalence is forecast to rise.  This is due to factors such as people living longer, an increase in the proportion of people aged over 50 and the rise of obesity as a major risk factor for diabetes.

The chart below shows forecast rates of diabetes for the next 20 years.  Although the confidence interval is wide, there is a clear rise expected in diabetes rates.  In 2010 it is estimated that 8,500 people in Middlesbrough have diabetes (we only know about 6,200 of these).  This will rise to 9,700 by 2020 and up again to 11,000 in 2030.  Diabetes care services will need to plan to cater for this expected rise in need.

Middlesbrough diabetes prevalence projection

 Source: APHO Diabetes prevalence model


Last updated: 06/07/12

7. What needs might be unmet?

Self-management is recognised as the cornerstone of diabetes care but currently there is no routine, ongoing assessment of educational need.  Structured education programmes limited to those newly diagnosed.

People at risk of developing diabetes are not being systematically identified and their risks managed appropriately. When they are, many people still continue to progress to develop diabetes.

Despite the introduction of systematic review for patients, diabetes complications rates remain high.

Focused work needs to be carried out to further understand the high rate of diabetic complications (i.e. diabetic ketoacidosis and coma) and what can be done to reduce them.

The needs of children and young people with diabetes need to be assessed in detail and the information used to inform service improvements.

Last updated: 06/07/12

8. What evidence is there for effective intervention?

NICE Clinical Guidelines  Available from www.nice.org.uk


NICE Diabetes in Adults Quality Standard 2011  Available from www.nice.org.uk/guidance/qualitystandards/diabetesinadults/diabetesinadultsqualitystandard.jsp

Joint Department of Health and Diabetes UK Care Planning Working Group (2006) Care Planning in Diabetes. Available from www.dh.gov.uk

Joint Department of Health and Diabetes UK Patient Education Working Group (2005) Structured Patient Education in Diabetes: Report from the Patient Education Working Group. Available from www.dh.gov.uk

Guidance on the use of patient-education models for diabetes. NICE technology appraisal 60 (2003; NHS Evidence accredited). Available from www.nice.org.uk/TA60


Diabetic foot problems: inpatient management of diabetic foot problems. NICE clinical guideline 119 (2011; NHS evidence accredited). Available from www.nice.org.uk/CG119

Liraglutide for the treatment of type 2 diabetes mellitus. NICE technology appraisal 203 (2010; NHS Evidence accredited). Available from www.nice.org.uk/TA203

Type 2 diabetes: the management of type 2 diabetes. NICE clinical guideline 87 (2009; NHS Evidence accredited). Available from www.nice.org.uk/CG87

Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period. NICE clinical guideline 63 (2008; NHS Evidence accredited). Available from www.nice.org.uk/CG63

Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus. NICE technology appraisal 151 (2008; NHS Evidence accredited). Available from www.nice.org.uk/TA151

Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. NICE clinical guideline 15 (2004; NHS Evidence accredited). Available from www.nice.org.uk/CG15

Type 2 diabetes: prevention and management of foot problems. NICE clinical guideline 10 (2004; NHS Evidence accredited). Available from www.nice.org.uk/CG10


from  Tees map of medicine http://tees.mapofmedicine.com (accessed via password from Athens)

Last updated: 06/07/12

9. What do people say?

Diabetes Survey: 2010

Patients & Carers

A survey targeted at the diabetes population was distributed through the diabetes community and secondary care clinics, the retinal screening service and Diabetes UK throughout August 2010. 

Overall the results around access, choice and support for diabetes patients were very positive.  DESMOND education in particular received a lot of positive comments and people stated they would like further access to ongoing DESMOND education at regular intervals.

A report of the survey was produced and is available at:

www.middlesbrough.nhs.uk following the links to MY NHS

Last updated: 06/07/12

10. What additional needs assessment is required?

Identify the diabetes education needs of the local population.

Work with all providers to understand the root causes of diabetes complications at an individual case level.

Understand the reasons why some people don’t attend health screening opportunities.

Assess public awareness of the signs and symptoms of diabetes.

Last updated: 06/07/12

Key contact: Sue Prout

Job title:  Commissioning Manager

e-mail:  sue.prout@tees.nhs.uk

Phone: 01642 746552


NHS Diabetes (2009) Commissioning Diabetes Without Walls. Available from www.diabetes.nhs.uk

Department of Health (2008) Five years on: delivering the diabetes National Service Framework. Available from www.dh.gov.uk

Department of Health (2006) Diabetes Commissioning Toolkit. Available from www.dh.gov.uk

Department of Health (2004) The way ahead: the local challenge. Improving diabetes services. Available from www.dh.gov.uk

Department of Health (2003) National Service Framework for diabetes: delivery strategy. Available from www.dh.gov.uk

Department of Health (2001) National Service Framework for Diabetes. Available from www.dh.gov.uk


Other references

Children’s Diabetes Profile for South Tees NHS Trust (May 2010) http://www.yhpho.org.uk/diabetes_profiles_children/pdfs/RTR00_Diabetes%20profile.pdf

Diabetes community health profile for Middlesbrough PCT (2009/10) http://yhpho.york.ac.uk/diabetesprofiles/PDF2011/5KM_Diabetes%20Profile.pdf