Diabetes Nottingham City Joint Strategic Needs Assessment April 2009

Transcription

1 Diabetes Nottingham City Joint Strategic Needs Assessment April 2009 Introduction Diabetes is a group of disorders with common features, raised blood glucose being the most evident. It is a chronic disease which can cause substantial premature morbidity and mortality. It imposes a heavy burden on health services. - There are 4 sub-categories of diabetes: Type 1, Type 2, gestational and other types. Type 2 is the most common. - An estimated 2 million people in England had a diagnosis of diabetes in 2008, but a high number are undiagnosed and prevalence is estimated to be as high as 2.4 million, or 4.67% of the population. i Type 2 diabetes is usually diagnosed in people over 40 and the symptoms often appear gradually, which can delay diagnosis. - People with diabetes are twice as likely to be admitted to hospital and at any point in time at least one in ten people in hospital have diabetes. ii At least 5% of the NHS budget is spent on treating diabetes and its complications iii. Drugs used in diabetes are the second biggest cost on the national drugs bill (7% of all prescription costs). 1 in 20 people with diabetes incur social care costs, around 230m per year i. Key facts on Diabetes iv - Life expectancy is reduced Type 1- by at least 15 years, Type 2- by 5-7 years - Effective control of blood glucose and hypertension prevents the development and progression of complications. 95% of diabetes management is self-care making patient education essential. This chapter focuses on type 2 diabetes. Cardiovascular disease, obesity in adults and children and diet and nutrition are considered elsewhere. Key issues and gaps - Nottingham s high level of deprivation is associated with a higher prevalence of diabetes and its complications, including early death; it is a major health inequalities issue. - Diabetes is increasing in Nottingham through rising levels of obesity and an increase in the BME adult population. - There were 11,364 adults over 17 (4.4%) known to have diabetes in Nottingham in 2007/08 (QOF register). - Anecdotal increase in gestational diabetes. - Diabetic retinopathy service: 1533 patients (13%) did not attend for their annual screen; the poorer uptake by certain groups needs addressing. - Ensure appropriate training and education for professionals. - New services for diabetes are being commissioned (community diabetes service; telephone outreach service; structured diabetes education). - Drugs used in diabetes are ranked second in the top 10 BNF sections by cost for the PCT. Nationally, diabetes drugs are the fastest increasing group of drugs in the NHS. - Information needed on the provision of diabetes services for children and young people. - Information needed on links with the physical and sensory impairment agenda. Recommendations for Commissioning - To work closely with PBC Clusters and other stakeholders, and co-ordinate action plans via the PCT s Diabetes Commissioning Group. - To co-ordinate and support awareness raising initiatives, targeting communities at risk, to 1

2 increase the awareness of diabetes. - To prioritise roll out of the local enhanced service (LES) agreement for CVD screening. - To ensure services for patients with diabetes are integrated with the PCT s programme of CVD health improvement including adult obesity services that are being commissioned. - To ensure the development and co-ordinated implementation of newly commissioned services for diabetes through 2009, working closely with PBC Clusters and other stakeholders. - To address inequity of access to diabetic retinopathy identified in the HEA. - To explore the role of the community pharmacist and the provision of enhanced services under the pharmacy contract. - To review the current service provision to children, young adults and pregnant women with diabetes. - To ensure high quality education and information for patients, including programmes of structured diabetes education. - To ensure high quality diabetes training and education for care providers. 2

3 1. Who s at risk and why Fixed Risk Factors for Type II Diabetes Increasing age, strong family history of diabetes, ethnicity with prevalence higher in people of South Asian and African-Caribbean origin. Modifiable risk factors for Type II Diabetes Obesity (principal risk factor), low physical activity, poor diet and nutrition. These risk factors are associated with deprivation. Diabetes is a chronic disease which can cause substantial premature morbidity and mortality. - Life expectancy is reduced Type 1- by at least 15 years, Type 2- by 5-7 years; times higher risk of death from Coronary Heart Disease and stroke; - Leading cause of blindness in people of working age and renal failure; - Most common cause of lower limb amputation (non-traumatic); - Nerve damage (Diabetic neuropathy) affects 60-70% of people with diabetes; - Pregnancy risk babies of women with diabetes are 5 times more likely to be stillborn, 3 times more likely to die within the first months of life, twice as likely to have a major congenital malformation; - Impotence may affect up to 50% of men with diabetes. 2. The level of need in the population Numbers of residents: 1 Obese / est. with diabetes Overweight / est. with diabetes Patient Numbers (%) 47,000 / ,800 / 5090 Expected adults over 17 (07/08) 2 11,836 (expected prevalence of 4.6%); about 60% women, 40% men 3 People known to have diabetes (QOF register 07/08) Est. people with diabetes not on QOF register ,364 (4.4%) Of those on the QOF register (07/08): - Controlled (ie measured by HbA1C<7.5) - Poorly controlled (i.e. HbA1C>7.5) - Exception reported 4 Using Long Term Conditions modelling: 5 - Est. 80% of diagnosed patients should be able to achieve control - Est. 15% are complex patients - Est. 5% require secondary care - 6,636 (58%) - 3,616 (31%) - 1,112 (11%) - Est. 9,091 patients ie est. 2,455 of the 3,616 poorly controlled require support to achieve control - est patients - est. 568 patients Nottingham s expected prevalence is 11,836 (4.6%); an estimated 500 people are not on the QOF register and potentially living with their diabetes undiagnosed. Of the expected prevalence in adults, about 60% are women and 40% are men. Nottingham s ratio of reported 1 Based on census pop, so likely to be higher figure 2 From NHS Comparators, Expected Prevalence of diabetes calculated using YHPHO model: national age / sex specific rates applied to GP practice list size data. Not adjusted for deprivation. 3 National expected prevalence is 5.7% 4 i.e. on the register but not included in the reporting of this indicator 5 DH Long Term Conditions model Nottingham City Joint Strategic Needs Assessment April

4 to expected prevalence is 0.96, above the national average of 0.84 and the SHA average of There does not appear to be a problem of undiagnosed diabetes in the community. Est. 5% patients require Secondary Care: 568 Potential number of referrals to Community Diabetes Service ( ) = 805 Est. 15% patients have complex diabetes: 1705 Community Diabetes Service targeted practices; patients = 900 Potential group for telephone outreach: 2455 Est. 80% of patients should achieve control: 9091 Patients with poorly controlled diabetes (HbA1C >7.5) who could potentially achieve control: 2455 (22%) Patients with controlled diabetes (HbA1c <7.5): 6636 (58%) Community Diabetes Service targeted practices; patients = 900 Figure 1 MODELLING FOR DIABETES SERVICES Total registered diabetic population = 11,364 (QOF 07/08) Estimated 80% of patients diagnosed with diabetes should be able to achieve control (Department of Health Long Term Conditions modelling): number of people meeting HbA1c Target of <7.5 = 6636 (58%) therefore 2,455 (22%) of the 3,616 poorly controlled require support to achieve control. Community Diabetes Service: targeted at 20 practices with an estimated 1800 patients with poorly controlled diabetes as well as patients with complex diabetes from remaining practices Telephone outreach: targeted at patients with non-complex diabetes that could be supported to achieve control. Complications of diabetes Diabetic retinopathy: Diabetes is the single largest cause of blindness among people of work age in the UK. v Approximately 40% of Type 2 diabetics will have retinopathy at diagnosis about 5,000 people in Nottingham; of these 4-8% ( ) will have sight-threatening retinopathy. Prevalence may be even higher, as prevalence among South Asians is estimated at 47%. Nottingham City Joint Strategic Needs Assessment April

5 Kidney disease: About 30% of people with Type 32 diabetes develop overt kidney disease. Footcare: In there were 5015 lower limb amputations in people with diabetes in England. Complications of diabetes: admissions Local hospital admissions data analysis using diabetes as primary diagnosis code showed: ii - the majority of diabetes admissions were ophthalmic related but probably largely day cases as low numbers of bed days; - peripheral circulation complications accounted for the largest number of bed days; - the numbers of admissions for renal and peripheral circulation complications were low but generated long length of stay; - Complications that appear to have the biggest impact on services in terms of cost, were peripheral circulation and renal, as both had an average length of stay of around 13 days. Length of stay for renal complications was particularly high for the City compared to the County. - The cost of excess beds stay in Nottinghamshire is over and above the expected length of stay according to the Health Resource Group (HRG) national tariff. Diabetes admissions cost 8,855,069, with peripheral circulatory contributing to 39% of the total cost. Fig.1 Nottingham s high rate of admission to hospital compared to Nottinghamshire County (diabetes (E10-E14) in any diagnostic field; ). vi DSR per 1,000 population Ashfield Bassetlaw Broxtowe Gedling Mansfield Newark and Sherwood Rushcliffe Nottingham Bassetlaw Notts County City PCT PCT tpct Issues of Inequality - Nottingham s high level of deprivation is associated with a higher prevalence of diabetes and its complications, including early death vii. The most deprived one-fifth of the population are 1 ½ times more likely to have diabetes. Deprivation is strongly associated with higher levels of obesity, physical inactivity, smoking and poor blood pressure and blood sugar control, worse access to services and lack of confidence in managing their diabetes and associated complications. viii - Nottingham has a significant South Asian (6.5% of Nottingham pop, census 2001) and African Caribbean population (3.4%), with associated increased prevalence of diabetes; as the age of onset of diabetes is earlier in South Asians, and duration of disease is a risk factor for complications, this group is at higher risk of complications. - Mosaic analysis of admissions: As table1 illustrates (below) admissions to hospital for diabetes are higher for different communities as described by Mosaic Types (as shown by an Index over 100, as 100 is average for all Types) see Nomad+ for maps of Mosaic Nottingham City Joint Strategic Needs Assessment April

6 groups. Types particularly at risk of admission: - I50: Older people receiving care in homes or in sheltered accommodation live scattered across the city, with some concentration in Bilborough, Bulwell, Bestwood; - I48: Older people living in small council and housing association flats who live in small, concentrated areas of the city, especially Bilborough. - However, Groups F and G are at risk of admission and represent high numbers of households within the city. Group G - families on lower incomes who often live in large council estates where there is little owner-occupation - live primarily in the outer estates of Aspley, Bilborough, Bestwood wards, and the smaller Lenton Abbey estate; Group F people who are struggling to achieve rewards and are mostly reliant on the council for accommodation and benefits - live primarily in St. Ann s, Sneinton and the Meadows. - Type D26 South Asian Industry (Forest Fields, Hyson Green, Sneinton and the Meadows) and Group F have higher than average proportions of people from Black and Minority Ethnic communities. Table 1: Mosaic index of admission to hospital with diabetes Type % in Nottingham; no. of households Type in Nottingham cf. to England (Index) Admission for Diabetes (Index) I50 2.1%; 2, I48 1.8%; 2, D26 1.1%; 1, F37 8.5%; 11, G43 6.5%; 8, F38 1.9%; 2, F39 2.8%; 3, G42 8.0%; 10, G41 7.5%; 10, Notable changes in need since JSNA April 08 The increasing trend in diabetes: The register in 2006/07 was 10,622, i.e. 742 people were added to the register in one year. This reflects an increase in identification of people with diabetes, as well as the increase in the prevalence of diabetes due to the increasing trend in obesity. Gestational diabetes There has been an increase in City Hospital and QMC in the numbers of women developing gestational diabetes: City campus saw 90 patients in 2007/08, but had already seen 65 patients by October Current services in relation to need Primary care - Identification of undiagnosed diabetes: The PCT has developed a Locally Enhanced Service for Cardiovascular Disease risk assessment and management (CVD LES) which aims to identify people at risk of conditions such as heart disease, diabetes and stroke, and support them in making healthier lifestyle choices. It will also identify those with undiagnosed conditions. While in the longer term, this initiative is expected to reduce the need for healthcare, in the short term, it could create an additional need for services which offer care to people with diabetes. Access to services and education / information is crucial. Nottingham City Joint Strategic Needs Assessment April

7 - Medicines Management: Work is continuing with practices, community pharmacists and other service providers to promote the appropriate prescribing of drugs for people with diabetes and the importance of patients understanding how to best use their medicines. - National Diabetes Audit 2008: The aim is to support implementation of the Diabetes NSF and therefore improve the quality of patient care for people with diabetes; 55 of the PCT s practices participated; the full dataset will be released early in Structured Education Programme A localised (Nottinghamshire) curriculum for a structured education programme for people with Type 2 diabetes has been developed and agreed. The PCT is now seeking expressions of interest for delivery of this service across the greater Nottingham area in partnership with Nottinghamshire County tpct. This will entail a comprehensive procurement process with service implementation anticipated by March Specialist community dietician City Central cluster The City Central PBC Cluster has identified a specific need for further dietetic support for targeting obesity and diabetes within the Asian community. Funding has been gained for a 1 year project to be undertaken by a specialist community dietician. The results of this project will be used to inform the future strategic direction and commissioning plans. Telephone outreach service The PCT is also currently commissioning a large scale pro-active telephone based care management service for people with long term conditions, in the first instance focusing on diabetes and COPD but with a view to including other diseases or other areas e.g. obesity. Community Diabetes Service The PCT is currently commissioning a specialist community diabetes team to address inequalities and access, support self management, and enable people with diabetes to receive high quality care in the most appropriate setting (e.g. support to primary care staff, 1-1 individualised clinical management, education, insulin initiation etc). The first phase should target 1800 poorly controlled diabetic patients in practices targeted by having patients with the highest level of need (Figure 1); the subsequent phase will be targeted at 801 poorly controlled diabetic patients in the remaining practices. Diabetic retinopathy screening PCTs implement the National Diabetic Retinopathy Screening Programme locally to deliver 2 main targets: - 100% of people known to have diabetes will be offered screening using only digital photography within the previous twelve months. - 80% of people offered screening in 2007 will have received it. The (Greater) Nottingham Diabetic Retinopathy Service (NDRS) started in September 2006, and is provided by Nottingham University Hospitals NHS Trust. The programme has a centralised call and recall system and patients are given a set appointment time and date. Patients are identified as eligible for screening through GP practices Diabetic Registers and opportunistically through patients attending the diabetes clinic. Patients who meet the (national) criteria for screening and live within the Nottingham City PCT area (and also parts of Broxtowe, Gedling and Rushcliffe) are invited for retinopathy screening annually. There are two static sites for screening: Nottingham City Hospital and QMC. There are also several temporary community sites, which vary by location according to identified community needs, these areas include, Carlton, Clifton and Stapleford. Issues raised by Health Equity Audit (Dec 2008) Nottingham City Joint Strategic Needs Assessment April

8 Of the Nottingham City diabetic patients eligible for retinopathy screening: (87%) attended for screening; (13%) did not attend (DNA d); there were 2745 DNAs overall to the service; therefore 57% were City residents. Analysis of the DNAs showed: - There are a significantly higher percentage of individuals eligible for in the two most deprived quintiles compared to the remaining quintiles. However, there is also a significantly higher percentage of individuals in the two most deprived quintile groups not attending compared to the more deprived quintiles (41% DNAs from most deprived quintile; 10% least deprived); - Robin Hood cluster had the highest DNA% at 25%; Norcom: 20%; City Central: 9%. User and provider views The PCT held a second local diabetes workshop in October 2008 to update interested parties on the strategic approach and provide an opportunity for comments, questions and suggestions. Notable changes since JSNA April 08 - Implementation of CVD LES - Specialist community dietician City Central cluster - Commissioning of the Structured Education Programme - Commissioning of the Community Diabetes Service - Commissioning of the Telephone Outreach service for Long Term Conditions 4. Projected service use in 3-5 years and 5-10 years The incidence of Type 2 diabetes is growing at 15% a year in some areas of the country i due to the changing population demographics and an increase in lifestyle risk factors: - An ageing population there is a projected increase in the 45 to 55 population by 2016, unlike the national trend, the population will be stable, there is even a projected reduction in the numbers aged An increase in over 85s is anticipated, probably due to improved mortality rates amongst men of that age. ix - The proportion of Nottingham s population from BME groups will grow to at least 27% in 2026, although they will be remain a younger proportion of the adult population. iv - Obesity is one of the key risk factors for developing diabetes the risk is 13 times higher in obese women and 5 times in men x ; 47% of Type 2 diabetes in England is attributable to obesity. xi See Nottingham s trend in adult and childhood obesity By 2025, it is forecast that 3,605,000 people or 6.48% of the population will have diabetes. Approximately half of the predicted rise will be due to the increasing prevalence in obesity and half will be due to the aging population. Type 2 diabetes is starting to be diagnosed in children, likely due to an increase in childhood obesity. xii The incidence of Type 1 diabetes is increasing in all age groups but the rise is particularly steep among children under 5 years old. 5. Expert Opinion and Evidence Base National Service Framework for Diabetes (2001) Greater Nottingham Diabetes Guidelines (2003) Diabetes Commissioning Toolkit (2006) Type 2 Diabetes Clinical Guideline: The management of type 2 diabetes (update) May 2008 NICE Guidance: Diabetes in pregnancy: management of diabetes and its complications from Nottingham City Joint Strategic Needs Assessment April

9 pre-conception to the postnatal period March 2008 Evidence shows: - onset of Type 2 diabetes can be delayed or even prevented by sustained lifestyle changes in diet and physical activity; - early diagnosis and tight control of blood sugar levels and blood pressure, especially early in the disease, can increase life expectancy and reduce complications; eye screening and treatment can reduce severe visual loss. - The impact of diabetes and its complications can be reduced by providing well-organised, integrated care from diagnosis, including, in particular the education and empowerment of patients and their families and the early identification of complications. The Greater Nottingham Diabetes Network Clinical Standards Sub Group and the PCT s Diabetes Commissioning Group provide the structures to ensure the necessary professional expertise and input. User views: The National Patient Survey in 2006/7 focused on people with diabetes. The survey covered diagnosis, check ups, tests, management, education and training, psychological and emotional support, hospital inpatient experience, and GP access. After reviewing the results, the PCT held a workshop to discuss the findings with a group of interested patients. Outcomes included patient views informing the commissioning of structured education for Type 2s (in addition to patients views as part of the piloting of this service), the development of the community diabetes team, a training needs analysis of GP practice staff, and the commissioning of a specific psychological support post for children at NUH. Other structures in place to gather the views of people with diabetes are: - Patient representatives and a representative from Diabetes UK are members of the Greater Nottingham Diabetes Network and its sub groups. Patients have been involved in service planning and care pathway redesign. - There are plans to invite patient representatives on to the PCT s Diabetes Commissioning Group. - There is a need to investigate methods of gathering views from Black and Minority Ethnic communities and other hard to reach groups. 6. Unmet needs and service gaps Newly commissioned services for diabetes should begin to address the unmet needs identified in Section 2, in particular patients known to have poorly controlled diabetes. Further gaps identified: - An estimated 472 people with undiagnosed diabetes. - Anecdotal increase in gestational diabetes; new NICE guidance on diabetes in pregnancy. - Information on diabetes services for children and young people. - Links with the physical and sensory impairment agenda. Few local services regularly collect views from patients. The future service providing structured patient education to patients with type 2 diabetes will collect patient feedback. GP practices and community pharmacies could also be supported in future to collect patient feedback. 7. Recommendations for Commissioning Nottingham City Joint Strategic Needs Assessment April

10 - To work closely with PBC Clusters and other stakeholders, and co-ordinate action plans via the PCT s Diabetes Commissioning Group. - To co-ordinate and support awareness raising initiatives, targeting communities at risk, to increase the number of people who have their diabetes diagnosed. - To prioritise roll out of the local enhanced service (LES) agreement for CVD screening. - To ensure services for patients with diabetes are integrated with the PCT s programme of CVD health improvement including adult obesity services that are being commissioned. - To ensure the development and co-ordinated implementation of newly commissioned services for diabetes through 2009, working closely with PBC Clusters and other stakeholders. - To address inequity of access to diabetic retinopathy identified in the HEA. - To explore the role of the community pharmacist and the provision of enhanced services under the pharmacy contract. - To review the current service provision to children, young adults and pregnant women with diabetes. - To ensure high quality education and information for patients, including programmes of structured diabetes education. - To ensure high quality diabetes training and education for care providers. 8. Recommendations for further Needs Assessment - Analysis of patients being managed by secondary care. - Service provision to children. - Links with the physical and sensory impairment agenda. - Diabetes and pregnancy - Diabetes and renal disease 9. Key Contacts Shirley Smith Assistant Director of Commissioning (Community Services), Nottingham City PCT, shirley.smith@nottinghamcity-pct.nhs.uk Dr Jeanelle de Gruchy Deputy Director of Public Health, Nottingham City PCT, jeanelle.degruchy@nottinghamcity-pct.nhs.uk i PHO-Brent-ScHARR (PBS) diabetes prevalence model Diabetes in England. National Diabetes Support Team. November ii Diabetes in England. National Diabetes Support Team. November iii Roberts S Working together for better diabetes care. Department of Health. iv Nottinghamshire Diabetes Network. Public Health Report on Diabetes. March Figures obtained from YHPHO Diabetes Key Facts March v Diabetes in England. National Diabetes Support Team. November vi Penelope Siebert. Diabetes Healthcare Needs Assessment for the county of Nottinghamshire. vii Williams R, and Farrar H Diabetes Mellitus. In Health Care Needs Assessment, eds A Stevens, J Raftery and JSS Mant, Abingdon, UK: Radcliffe Publishing Ltd viii Nottinghamshire Diabetes Network. Public Health Report on Diabetes. March 2007 ix State of Nottingham Report (2008) x Nottinghamshire Diabetes Network. Public Health Report on Diabetes. March Figures obtained from YHPHO Diabetes Key Facts March xi Department of Health. Turning the Corner: Improving Diabetes Care xii Diabetes in England. National Diabetes Support Team. November Nottingham City Joint Strategic Needs Assessment April