Diabetes care - progress against national priorities: commitments - 2021 to 2026

Priority 2 - Type 1 Diabetes

To improve the care and outcomes of all people living with type 1 diabetes

The Diabetes Improvement Plan 2014 set out to improve the care and outcomes for people living with Type 1 diabetes through improving glycaemic control, improving care at the onset of type 1 diabetes, early intensification of therapy and access to high quality patient education. It also highlighted the need to support children and young adults during the education years and during transition from paediatric to adult care settings to minimise disengagement and risk of deteriorating glycaemic control.

Action 2.1 Improve the care for children and young people

Prevention of DKA at diagnosis of Type 1 diabetes

As discussed under Action 1.2 a national campaign was launched to support the early identification and referral of new onset type 1 diabetes.

Using data to support improvements in care

SCI-Diabetes has further enhanced their paediatric pages and these are now being used routinely by all paediatric units in Scotland which gives the ability to harness comparative data. SCI-Diabetes produces quarterly MCN reports which highlights performance against some key measures for people with diabetes and data for under 18s is included within the relevant measures. An adult and paediatric centre level report outlining HbA_1c level within each centres respective patient population is now available on a quarterly basis through SCI-Diabetes. The development of the paediatric diabetes dashboard is supporting teams to further review the care they are providing to children and young people through additional metrics related to this age group and provides opportunities for teams to learn from one another.

Improving Care in Schools

In June 2014, the document Supporting Children and Young People in Education was launched to help provide clarity and promote a team approach for your people with diabetes in schools. A review of this document will take place to ensure support is available for children in pre-school services and those attending out of school care services, such as after school clubs.

Supporting Transition to Adult Services

For young people with diabetes the transfer from child to adult services is a critical transition in their lives and like all transitions it offers both a risk and an opportunity for the young person and their diabetes care. The consensus would suggest that this process should be collaborative and that the young person and their family will require active support throughout this period.

In 2015 the National Standards for Transition were published and in 2017, a national Paediatric and Adolescent Diabetes Transitional Policy was launched to support teams in achieving these standards. Alongside the policy, which could be adapted for local use, a transition standards self-reflection tool was developed to highlight areas that are working well and any areas that might need to be developed.

The diabetes dashboard within SCI-Diabetes now allows teams to review diabetes related process and outcome measures for the 18 – 25 year old population. This gives the opportunity to identify how well people within this age group are doing following their move to adult services and identify where improvements may be required.

Action 2.2 Improve Glycaemic Control

National Standards for Glycaemic Control

Intensive glycaemic control improves short, medium and long term outcomes of type 1 diabetes and is one of the key goals of care. In 2016, the paediatric and adults diabetes teams and the wider diabetes community agreed national guidance for the management of type 1 diabetes in both adults and children. This led to a focus on early intensive glycaemic management for newly diagnosed patients and to support patients with established type 1 diabetes with the aim that every diabetes centre in Scotland gives the same consistent messages about the glycaemic levels to aim for from diagnosis.

In the recent years there has sustained efforts to increase the number of people with HbA_1c < 58mmol/mol (optimal glycaemic control) and reduce the number of people with HbA_1c >75mmol/mol. In the last 6 years the number of people with optimal control has increased with 26.5% of adults having HbA_1c < 58mmol/mol compared to 21.5% as reported in 2013. The gap between those with optimal glycaemic control and poor glycaemic control has also narrowed with the number of adults having HbA_1c >75 has reduced to 31.6% from 37.1% in 2013. Improvements in glycaemic control are down to a number of factors, most notably increasing access to high quality education and access to technology to support self-management.

The graph below demonstrates the improvements that have taken place between 2010 and 2019. It is noted that performance on glycaemic control in 2019 has decreased marginally from the figures reported in 2018. HbA_1c is strongly influenced by age and socioeconomic deprivation and therefore we will explore barriers to meeting HbA_1c targets to help inform targeted intervention in groups not currently benefiting from current care models.

Early Intensification: STEP programme

Funding was provided by the Scottish Diabetes Group to support NHS Forth Valley to develop and pilot patient education tailored to adults newly diagnosed with type 1 diabetes. The aim of the Scottish Type 1 Education Programme (STEP) is to provide people newly diagnosed with type 1 diabetes with the understanding and confidence to carbohydrate count and independently adjust their insulin dose. This education programme has demonstrated significant improvements with 62% of participants achieving an HbA_1c level on <58mmol/ml after 6 months.

Following the pilot in NHS Forth Valley, this programme has been rolled out with NHS Highland, NHS Boards, NHS Lothian, NHS Shetland and NHS Grampian offering this programme while some other boards have expressed an interest in providing this.

The diabetes dashboard in SCI-Diabetes provides detailed information on glycaemic control at national, regional, local and individual level. One key measure is the % of individuals achieving optimal control (HbA_1c <58mmol/mol) at 1 year post diagnosis. The clinical community have set an initial target of 58% of people achieving this. At the end of 2019, 51.6% of people were achieving this.

Access to Technology

In December 2016, the Scottish Government gave a commitment to build on the progress made following the Ministerial commitment in February 2012; which lead to an increase in insulin pump provision for people with type 1 diabetes, particularly in young people. The additional funding commitment was announced to support increased levels of provision of insulin pumps within the adult type 1 population and to support NHS Boards in developing services for Continuous Glucose Monitoring (CGM) provision, embedding this technology into clinical practice in both adults and children.

The number of people with type 1 diabetes using insulin pump therapy in Scotland at the end of 2019 was 4,614, representing 13.8% of the type 1 diabetes population. Within the under 18 type 1 diabetes population, 38.9% are using pump therapy while 11.3% of people with type 1 diabetes over the age of 18 are using insulin pump therapy. This is a significant increase on the number of people using insulin pump therapy as reported in the Diabetes Improvement Plan 2014 where 22.6% of people under the age of 18 and 4.5% of people over the age of 18 had access to this technology (this equates to an additional 2,767 pump users in Scotland). It is noted that the substantial increase in insulin pump therapy use in those under the age of 18 is likely to be a key factor in the substantial improvements in HbA_1c observed in Scottish children over the past decade.

Technology is supporting people to self-manage their diabetes and is now part of standard practice. The advent of flash glucose monitoring (FGM) has transformed how individuals can monitor their glucose levels on a day to day basis. In 2018, the Type 1 subgroup of the SDG produced eligibility criteria for the use of FGM. This was followed by a formal assessment of FGM by the Scottish Health Technology Group. This combined approach has ensured wide spread adoption of this technology and FGM is available across all health boards in Scotland dependent on local eligibility criteria. At the end of 2019, 42% of people of people with type 1 diabetes under the age of 18 and 31.4% of people with type 1 diabetes over the age of 18 had access to this technology.

The funding provided by Scottish Government has also supported an increase in both children and adults having access to Continuous Glucose Monitoring (CGM) systems. These can now be linked to insulin pumps to create sensor augmented pumps and hybrid closed loop systems. These systems significantly reduce the risk of severe hypoglycaemia and improve glucose control.

Diabetes technologies have had a transformative effect for many individuals living with type 1 diabetes but the diabetes community across Scotland must strive to ensure that access is equitable and does not result in greater widening of inequalities in diabetes outcomes.

SIGN Update: Glycaemic Control in Type 1 diabetes

The Scottish Intercollegiate Guidelines Network (SIGN) have committed to producing a new guideline in relation to optimising glycaemic control for people living with type 1 diabetes. This process started in March 2020 but is currently on hold during the COVID-19 pandemic.