Spotlight on diabetes

The nature of diseases and their consequences have changed hugely over the 70 years of the NHS, as have the experiences and outlooks of the people who suffer those diseases. This is certainly true for diabetes. In 1948, most people with diabetes had Type 1 diabetes, an auto-immune disease that requires insulin injections to sustain life. While it was already over 2 decades since insulin had been first discovered, the devices used to inject insulin back then were fairly primitive by today’s standards. In 1948, insulin could only be obtained from animals and injection was with glass syringes and needles that required washing.

In 1948, Type 2 diabetes was uncommon. Under-nutrition was a common problem then, with food in the post-war era still rationed. Over the ensuing decades, food availability fortunately increased, but by the 1970s food availability was such that the health consequences of over-nutrition were becoming apparent. By 1975, 5-10% of our population were obese. Over 40 years on, and we see 25-30% of the population of England now obese. Being overweight or obese are the major modifiable risk factors for Type 2 diabetes, and we have seen more than doubling of the number of people with Type 2 diabetes over the last 20 years, with around 3.5 million now suffering. Over 90% of all people who have diabetes in England now have Type 2 diabetes.

The advances in healthcare generally and diabetes care more specifically over the 70 years of the NHS have been remarkable. In the 1980s it became possible to manufacture human insulin. By the late 1990s, we saw the development of analogue insulins, with small modifications to the human insulin molecule causing changes to absorption profiles, to produce both quicker and longer acting insulins. The devices to administer insulins have also evolved, as have the devices to monitor glucose levels, with insulin pen devices, insulin pumps, continuous glucose monitoring devices and flash monitoring devices now available.

But the advances have not just been around insulin and its administration. We have seen huge advances in treatments for Type 2 diabetes, such that instead of the choice of just two drug types, aside insulin, in the early 1990s, we now have a choice of eight drug types. We are now not far off half a billion people worldwide with diabetes, so that the market incentives for drug companies to invest in research and development for the management of Type 2 diabetes are huge, with new drugs and drug types now available every few years.

We have also seen rarer forms of diabetes described, that had previously been misidentified as type 1 or type 2 diabetes, such as maturity onset diabetes of the young (MODY).

Advances in human organ transplantation have brought significant benefits to the management of Type 1 diabetes, with islet cell transplantation and whole pancreas transplantation now available in certain situations.

Improvements in treatments and technologies, as well as improvements in the organisation and delivery of NHS care, have been matched by improvements in the outcomes for people with diabetes, such that over the decades, the risks of any individual with diabetes going blind, having a limb amputated, having a heart attack, or having a stroke have reduced, and life expectancy has increased.

We’ve come a long way, but there is still a long way to go. The increase in number of people with Type 2 diabetes now challenges the NHS and all healthcare systems across the world.

The NHS Diabetes Prevention Programme (NHS DPP) is one way we are tackling this. The programme launched in 2015 and reaches full national coverage close to the NHS’s 70th birthday. England will be the first country in the world to achieve full national coverage with a Type 2 diabetes prevention programme.

There has been significant enthusiasm from primary care with over 167,000 people referred and over 71,000 taking up the programme to date. We are still seeing referral and take up rates exceeding our original expectations and attendance rates on the programme have been higher for individuals from Asian, Afro-Caribbean and other ethnic groups, and as high for individuals from the most deprived compared to the least deprived communities, so we are successfully reaching groups that are at higher risk of developing Type 2 diabetes.

Early outcomes data and our provisional analyses suggest that over 50% of those that start the interventions and complete over 60% of the programme achieve an average weight loss of 3.3kg, 3.7kg if those starting with a healthy weight are excluded from the analysis. This is over 1kg higher than our expected figure.

We launched a digital stream of the NHS DPP in November 2017 – with services implemented in eight areas as part of a major evaluation.  To date, around 1,300 people have been referred onto the programme with around 60% logging onto a service.  We aim to have recruited 5,000 people onto these services during 2017/18.

Drawing on the combined efforts of the NHS DPP and population-level interventions such as the sugar tax, changing the trajectory of Type 2 diabetes incidence is a realistic goal over the next few years.

As well as working to prevent Type 2 diabetes, we are also striving to improve treatment and care for people that already have diabetes, Type 1 and Type 2. We invested £42m in funding to help improve outcomes for people with diabetes in 2017/18 and we will make a further £40m available in 2018/19. This funding will create more structured education places, additional posts in new or expanded multi-disciplinary footcare teams and additional inpatient specialist nurses and related staff in inpatient teams. It will also allow 864,000 additional interventions a year to be undertaken with individuals with diabetes to improve glucose, blood pressure and cholesterol levels.

We are embracing the opportunities new technologies offer today. NHS Digital are developing on our behalf a new resource aimed specifically at people with Type 1 diabetes and this month, the new website will be launched that includes advice tailored to living life with Type 1 diabetes, advice on getting emotional support, and educational content which can be accessed in more flexible ways.

In a separate piece of work, we are focussing on digital self-management support for people with Type 2 Diabetes.

Today, we are also much more aware of the psychological support required by people with diabetes. Diabetes UK’s report on the future of diabetes emphasises the importance that people with diabetes place on having their emotional and psychological needs met.  The NHS in England is placing 3,000 therapists into GP surgeries so we can treat people’s mental and physical conditions together, and we’re already seeing positive results for people’s mental health in places where we are trialling these new ways of helping people with diabetes.

It will be fascinating to see where the next 70 years of the NHS will take us, given the amazing advances of the last 70 years.

Jonathan Valabhji

Professor Jonathan Valabhji is National Clinical Lead for Multiple Long-Term Conditions at NHS England, having been National Clinical Director for Diabetes and Obesity between 2013 and September 2023. He is Clinical Chair in Medicine at Imperial College London and Honorary Consultant Diabetologist at Chelsea and Westminster Hospital NHS Foundation Trust.

As well as a practising clinician and researcher, over the last decade he established and led the NHS England diabetes and obesity programmes, with a broad portfolio of national workstreams focusing on lifestyle interventions, clinical care, and technological support for diabetes self-management. He has led rapid translation of high-quality research into national policy and practice and has established models for evaluation to assess translational impact.

He successfully made the case for, and led implementation of, the NHS Diabetes Prevention Programme, the NHS flagship prevention programme. By 2018 England became the first country to achieve universal population coverage with an evidence-based type 2 diabetes prevention programme, with over 1.3 million people now referred in, and latest evidence suggesting reduced type 2 diabetes incidence in both programme participants and at population level associated with programme implementation.

He qualified in 1990 from St Bartholomew’s Hospital Medical College, London, and in 2019 was awarded OBE in the Queen’s New Year Honours List for services to diabetes and obesity care.