LTP Priority: Prevention and Diabetes Care
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: NHS Diabetes Prevention Programme (NHS DPP)
Major driver of health inequalities in your area of work
- Type 2 diabetes is a leading cause of preventable sight loss in people of working age and is a major contributor to kidney failure, heart attack and stroke.
- The prevalence of diabetes in England has increased significantly in recent years, from 2.3 million in 2009/10 to 3.1 million in 2016/17. By 2035, this prevalence is expected to increase to 4.9 million.
- Being overweight or obese is the main modifiable risk factor for type 2 diabetes with the risk of developing the condition 3 times higher in overweight people and 7 times higher for obese people compared to those of a healthy weight. Other non-modifiable risk factors include increasing age and South Asian or black ethnicity; South Asian populations are up to 6 times more likely to develop diabetes than white populations and black populations are 3 times more likely.
- Those of South Asian or black ethnicity have an increased risk of developing the condition at a younger age (from age of 25 not 40) and lower BMI compared to white populations. at a lower BMI.
- Male gender and increased socioeconomic deprivation are also associated with type 2 diabetes, with a prevalence 60% greater in the most deprived quintile compared to the least deprived quintile. Deprivation is also associated with an increased risk of obesity.
- Non-diabetic hyperglycaemia (NDH) refers to raised blood glucose levels (HbA1c 42-47mmol/mol (6.0-6.4%); or fasting glucose 5.5-6.9 mmol/l) that are not in the diabetic range but are associated with an increased risk of developing type 2 diabetes. They are also at increased risk of other cardiovascular conditions. It is estimated that there are 5 million people in England with NDH. The characteristics of people with this condition are broadly similar to the characteristics of people with Type 2 diabetes. However, male gender and high deprivation are associated with Type 2 diabetes but no association has been found with NDH, once other major risk factors are taken into account. Possible explanations for these discrepancies might be that both males (because of greater central obesity) and those from areas of greater deprivation (because of diet, exercise and other environmental factors) are more likely to progress from NDH to type 2 diabetes.
- National Audit Data 2017-18 shows that there are 2.9 million people in England diagnosed with Type 2 diabetes and 1.3 million with recorded non-diabetic hyperglycaemia (at high risk of developing diabetes). The National Cardiovascular Intelligence Network (NCVIN) estimates that there are 4 million people with Type 2 diabetes and 5 million people with non-diabetic hyperglycaemia. There is therefore an underdiagnosis of both type 2 diabetes and people who are at high risk of developing diabetes.
- The National Diabetes Audit 2017-18 15.4% of people recorded with non-diabetic hyperglycaemia are from BAME groups. BAME people with non-diabetic hyperglycaemia have a lower age distribution than white people. The proportion of people with non-diabetic hyperglycaemia in each deprivation quintile is similar but there is a slight gradient from most deprived to least deprived.
- The main observable health inequalities in diabetes relate to who develops diabetes and therefore focusing on prevention, at greater scale forms a key part of our strategy to tackling emerging inequalities.
People living in deprived areas and protected groups – Black, Asian and Minority Groups (BAME)
NHS Diabetes Prevention Programme (NHS DPP)
The NHS Diabetes Prevention Programme (NHS DPP) supports those at high risk of Type 2 diabetes to reduce their risk, via a 9 month supported lifestyle intervention to achieve a healthy weight, improve nutrition and increase physical activity.
To date over 400,000 people have been referred to NHS DPP and in 2018-19 NHS DPP exceeded its Mandate and Five Year Forward View Target of 100,000 people on the programme each year by delivering 105,000 places. Within the NHS Long Term Plan there is a commitment to doubling capacity on the programme from 100,000 places per year to 200,000 places per year by 2023/24.
The main observable health inequalities in diabetes relate to who develops diabetes and therefore focusing on prevention, at greater scale forms a key part of our strategy to tackling emerging inequalities. By improving access and supporting referral and uptake of NHS DPP from deprived and BAME communities who are most at high risk of diabetes will help to address health inequalities.
However, there are emerging inequalities in relation to take up of the NHS Diabetes Prevention Programme. There are significantly lower rates of referrals in those aged <65 compared to those >65. Given the estimated age distribution of people with NDH, this is to be expected. However, individuals aged <65 have a significantly lower uptake to the programme (46% compared to 57%) and a significantly lower completion rate (44% compared to 59%). Moreover, completion is significantly lower in most deprived areas (46% compared to 58%). While take-up rates are significantly higher for people from the BAME group, their completion rate is only 43% compared to 56% for those in the white group. While there is significant confounding between BAME, deprivation and age, this relationship is confirmed through multivariate analysis.
Even though the completion rate is significantly lower for BAME groups compared to white groups, the higher initial take-up rate for BAME, 1.8 times higher compared to white groups, means that the representation of BME vs. white groups in the completing cohorts is commensurate with their respective proportions in the population with NDH (1.2 higher at completion for BAME, which equals the increased prevalence of NDH in that group). It should be noted that these results are based on early outcome data and may change. A full analysis of the causes of poorer retention rates in certain groups will be undertaken as part of the ongoing NIHR funded evaluation of the NHS Diabetes Prevention Programme.
The following actions have been put in place by NHS England and NHS Improvement to address the emerging inequalities:
- Routine quarterly monitoring of take up and retention rates on the programme by BAME, social deprivation and provider will continue to be undertaken by the NCVIN on behalf of NHS England & NHS Improvement;
- From 2019/20, future allocation of programme places for each STP will be linked to both social deprivation and BAME prevalence to ensure that service availability is targeted towards those local health communities with the greatest need;
- Implementing a new provider framework for NHS DPP which aims to encourage uptake and retention on the programme. 20 STPs will move onto the new framework in August 2019, 8 in April 2020 and remaining 16 STPs in August 2020. Under a new provider framework, there will be:
- An outcome based payment for providers focused on both social deprivation and BAME. Providers will receive a higher payment where they are able to retain people from BAME backgrounds, or from postcode areas associated with high deprivation;
- Digital diabetes prevention programme which provides an opportunity to extend uptake of those who decline or do not progress onto the face to face programme. The digital prevention programme also aims to improve uptake from working age people. The digital service is likely to be of a greater benefit proportionally to people from BAME communities as they are on average younger and more likely to be of working age.
- Providers under the current framework have been asked to explore options for improving retention, including Asian language programmes in certain areas. There is a need to evaluate these programmes to determine the extent to which they improve retention rates for BAME.
The modelled impact of the NHS Diabetes Prevention Programme, based on a meta-analysis of the effectiveness of diabetes prevention programme trials internationally is available in ‘NHS England Impact Analysis of implementing NHS Diabetes Prevention Programme, 2016 to 2021’.
Analysis of outcomes from the current programme indicates a mean weight change of -3.7kg for participants who are overweight or obese (mean percentage weight change -4.2%). The mean weight change for all completers of the programme was -3.3kg (mean percentage weight change of -4%). Our original evidence review and impact analysis suggested we should expect an average weight loss of 2.5kg, so outcomes are exceeding expectations.
In addition, the mean reduction in HbA1c for completers of the programme was -2mmol/mol.
Outcomes from the initial evaluation of the Digital Diabetes Prevention Programme (8 Digital pilot sites between January to November 2018) are encouraging:
- 69% uptake with equal proportion of men and women
- Majority of participants were of working age (42% were under 55, 29% aged between 55 and 65) higher than face to face programme
- Good uptake from BAME population resembling local populations
- Same level of uptake as face to face for most deprived group but higher uptake of across the deprivation quintiles 1-3
- Good retention rates and weight loss similar to face to face programme.
Guidance for Commissioners
- Overall Guidance will be due in September 2019
NHS Diabetes Prevention Programme
Note of elements to include in How to Guide:
- STPs to review data on uptake of initial assessment, uptake of the programme and retention on the programme by age group, BAME groups and deprivation.
- STP to undertake a Health Equity Audit to review uptake of initial assessment, uptake of and retention on the programme and develop and implement an action plan to improve uptake and retention amongst priority population groups identified locally.
- Review registers for non-diabetic hyperglycaemia population using NDA 2017-18 data to identify and practices who are under diagnosing people and implementing annual call and review. STPs to support GP practices to undertake audits of practice registers to identify the at-risk population with existing non-diabetic hyperglycaemia e.g. by promoting use of audit tools to assist with case finding.
- Targeting BAME groups at a lower age (from 25 not 40) and lower BMI for case finding for non-diabetic hyperglycaemia.
- Work with Local Authorities to improve uptake of NHS Health Check including diabetes risk assessment amongst people from deprived and BAME communities which will support identification of people at high risk of diabetes and support referral onto NHS DPP.
- STP to work with general practice to encourage referrals into NHS DPP targeting to meet the Long-Term Plan target of doubling number of places on the programme by 2023/24.
- Work with providers to understand uptake and retention within BAME groups and deprived communities and explore opportunities to improve uptake and retention within specific target population groups.
- Targeting specific population groups through community action to raise awareness of risk of diabetes, completion of diabetic UK risk score.
- Case studies:
- ‘Targeted case finding approaches’ – A case study from Salford NHS Diabetes Prevention Programme.
- ‘Community engagement to support uptake amongst specific populations’ – A case study from the Bradford NHS Diabetes Prevention Programme.