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

Priority 4 - Equality of Access

To reduce the impact of deprivation, ethnicity and disadvantage on diabetes care and outcomes

Despite improvements in life expectancy and health outcomes significant differences still exist for people living with diabetes depending on deprivation, where they live, ethnic group and their life circumstances. The Diabetes Improvement Plan highlighted that equality of access to health services for everyone living with diabetes should be a theme that runs through all efforts to improve quality of services. To help assess and address inequity, the Diet and Healthy Weight Team as part of the Type 2 Diabetes Prevention, Early Detection and Intervention Framework are undertaking an Equality Impact Assessment (EQIA) and Fairer Scotland Duty Assessment. They have also asked Boards to undertake EQIA to ensure equality. We will also undertake additional impact assessments as part of the publication of the Refresh Plan.

Action 4.1 Minimise the impact of deprivation, ethnicity and geography

Deprivation and Glycaemic Control

'Glycaemic control trends in people with type 1 diabetes in Scotland 2004–2016' report that deprivation continues to have an impact on glycaemic control of people living with diabetes. It reports that the 20% of people living in the most-deprived areas had HbA_1c levels on average 8.0mmol/mol higher than those of the 20% of people living in the least-deprived areas. While glycaemic control is improving overall the difference between HbA_1c levels for people living in the most-deprived areas and those living in the least-deprived areas has not changed significantly over time and therefore concerted effort is required to make improvements.

Deprivation and Mortality in type 1 diabetes

A recent retrospective cohort study assessing 'Socio‐economic status and mortality in people with type 1 diabetes in Scotland from 2006–2015' demonstrated that deprivation was associated with a steeper mortality gradient in people with type 1 diabetes than in the population without type 1 diabetes in Scotland. Age‐standardized mortality has decreased over time but socio‐economic inequalities may be increasing.

Information on deprivation is available within the diabetes dashboard and there is ongoing work to look at outcomes with individuals from different areas of deprivation.

Tackling Disengagement

One of the quality improvement and outcome measures that health boards report on is the level of disengagement within their population as disengagement from diabetes services is associated with poorer health outcomes. Data available on disengagement (defined as no record of HbA_1c and no retinal screening in the preceding 15 months) highlights that people with both type 1 and type 2 diabetes living within the most-deprived areas are more likely to be disengaged from services than those living in the least-deprived areas.

This data also highlights that people within the 18 – 25 age range across all deprivation levels are most likely to disengage from diabetes services. The annual national diabetes sharing best practice meeting for Managed Clinical Networks is used to highlight areas of activity trying to tackle this issue and support wider roll out where applicable.

Geographical Issues

With one fifth of the Scottish population living in rural areas and a significant number living in remote areas, geographical location can present a significant issue for diabetes services. This includes accessing health services, maximising specialist resources locally and retention or skilled health care staff. New technology solutions such as NHS Near Me to access health care professionals remotely and the use of online areas of support is providing ways for people to engagement with services where they may find it difficult to attend in person.

Evolving Models of Care

In response to the COVID-19 pandemic and given the current restrictions in place, the move towards remote support will be fundamental to the evolving models of care to support the wider diabetes population. Ensuring that people have the education and the tools to self-manage their diabetes as much as possible will is key to developing pathways. At the same time, we must approach redesign while being mindful that technology will not be suitable for all.

The National Clinical Strategy outlines the vision of care delivery in a community setting. This is particularly relevant for long term conditions such as diabetes. Diabetes MCNs have been working with health boards, within their transformational change agenda, to redefine care models for type 2 diabetes. This includes speciality input to support generalist care services which is offered in a community setting rather than in hospitals. In addition, diabetes is data rich and this information can be used to offer virtual review with specialist input where required.

Diabetes technologies increasingly allow the ability for people to share their health data with their healthcare team reducing the need for face to face review and offering a more person centred care approach. COVID-19 has resulted in a rapid adoption of many digital and virtual solutions and all diabetes services have this as a core activity within their existing care models. There are challenges, particularly around IT governance and the provision of suitable equipment, but on the whole a robust infrastructure is now evolving in many diabetes services to embed virtual care and digital solutions within everyday clinical practice.

Key to this area of work is ensuring the principles of person centred care and realistic medicine are considered. The needs of someone living with diabetes will vary from person to person and will be influenced by where they are on their patient journey. There is a need to understand the issues around disengagement and develop our services to meet the needs of the populations we serve to reduce the gap in health inequalities. There is also the need to be mindful that the increasing move toward digital solutions for care will not be suitable for everyone and we cannot disadvantage people as care models develop.

Action 4.2 Improve outcomes for individuals requiring additional support

Access to Psychological Support

People with diabetes experience disproportionately high rates of mental health problems such as depression, anxiety and eating disorders. People with poor mental health are less likely to engage with their diabetes care team and therefore this is linked with poorer health outcomes.

As highlighted earlier the Psychology Provision to Support delivery of 'A Healthier Future: Type 2 Diabetes Prevention, Early Detection and Intervention Framework' highlights that early and appropriate support is crucial to improving service provision, physical health, mental health and well-being, and quality of life for people with a diagnosis of, or at risk of Type 2 diabetes.

As reported in the Diabetes Improvement Plan 2014, the Scottish Government previously supported a study to support Psychology in Diabetes, Psychology and Diabetes (PiD-PaD) to improve self-management of diabetes through upskilling staff. There has been no continuation of the PiD-PaD project in any of the pilot boards and it is recognised that access to psychological support is still inconsistent. In some areas local programmes have been developed, for example ACT now (NHS Grampian) promotes self-management and behaviour change for people with type 2 diabetes and has had positive outcomes. There are also a range of online CBT programmes available for use and while most are not diabetes specific they can be helpful for people who have a long term condition. Diabetes Scotland are currently campaigning for wider psychology to support the general diabetes population with diabetes distress.

There is ongoing work looking to link SCI-Diabetes to data on vulnerable cohorts such as individuals experiencing homelessness, housebound and other disadvantaged groups. This information will be key to considering how care models should be developed to meet the needs of such cohorts.