Diabetes care - Diabetes improvement plan: commitments - 2021 to 2026

Background

Diabetes in Scotland

Diabetes is a chronic disease that occurs when the pancreas cannot make insulin or cannot make sufficient insulin to keep blood glucose within normal limits. This can be associated with resistance to the effect of insulin. Over the long-term, high glucose levels are associated with damage to the body and failure of various organs and tissues. Diabetes is a major cause of coronary heart disease, stroke, kidney failure, blindness, amputation and premature death.

Type 1 diabetes can develop at any age, but occurs most frequently in children and young people. When you have type 1 diabetes, your body produces very little or no insulin. Type 1 diabetes accounted for 10.7% of all cases of diabetes in Scotlandin 2019.

Type 2 diabetes accounted for 87.9% of all cases of diabetes in Scotland in 2019. It starts with resistance to the action of insulin and is associated with older age, being overweight and obesity. The prevalence of type 2 diabetes is increasing in Scotland, as in many other countries, and this is likely to be due to poor diet (specifically excess energy intake), low levels of physical activity and the resulting increase in the levels of obesity.

Gestational diabetes (GDM) is a type of diabetes that results in high blood glucose during pregnancy and is associated with complications to both mother and child. GDM usually disappears after pregnancy but women affected and their children are at increased risk of developing type 2 diabetes later in life. Up to 50% of women diagnosed with gestational diabetes develop type 2 diabetes within 5 years of their baby being born.

The incidence and prevalence of all types of diabetes is increasingly affecting the health and wellbeing of the population, and placing additional pressure on health and community services. The increase in reported prevalence depends on a number of factors, including demographic changes (ageing population), better survival rates and better detection of type 2 diabetes.

The Framework for the Prevention, Early Detection and Early Intervention of Type 2 Diabetes^[2] published by the Scottish Government in 2018, aims to tackle this growing issue. It is possible to prevent type 2 diabetes through targeted weight management interventions, which provide individuals with the support, skills and resources to improve their health and delay the onset of type 2 diabetes. It is also possible to reverse a diagnosis of type 2 diabetes in those 'recently diagnosed' through intensive weight management programmes, which would enable an individual to achieve 'remission'.

Not everyone living with diabetes has been diagnosed. It is estimated that around 10% of cases of type 2 diabetes remain undiagnosed and Diabetes Scotland estimates that over 500,000 people in Scotland are at 'high risk' of developing type 2 diabetes. The implementation of the Framework will support identification of people at risk of developing type 2 diabetes including people who have pre-diabetes (above normal blood sugar levels but not high enough to be diagnosed as having diabetes) or previously unrecognised type 2 diabetes. The Framework also aims to ensure timely access to services to support individuals optimise their health and wellbeing.

Diabetes and Covid-19

Recent Scottish and international data has highlighted that individuals with diabetes are at increased risk of severe COVID including hospitalisation and death^[3]. Many individuals with diabetes have additional risk factors which put them more at risk of poor outcome, like being from a Black, Asian or minority ethnic group, increased age, a BMI over 30, a history of high HbA1c, or complications such as heart failure or kidney disease. Diabetes teams have been using this information to identify those most at risk and provide support for people who would benefit from tailored protective measures.

COVID has also caused unprecedented disruption to all NHS services. Many out-patient diabetes services were suspended to allow resources to focus on acute unscheduled care. In the majority of cases, out-patient and other elective activity has resumed but not to traditional models of care. Care has evolved to ensure it aligns with COVID secure measures and as such a significant proportion of diabetes care is now delivered virtually. While many aspects of care align readily to virtual care models, some, such as group education sessions and initiation of technologies, require ongoing development. We also need to ensure that we have robust mechanisms in place to perform all of the necessary processes of care so that individuals with diabetes have an appropriate level of surveillance to detect and prevent complications. The disruption caused by COVID provides an opportunity to restructure care models to ensure that disease surveillance is a key component of services moving forward. This blended approach of a robust surveillance model linked to person centred care planning, which in many instances will be virtual, ensures a dynamic approach to optimising all aspects of care.

Diabetes Policy Landscape

While the increasing prevalence of diabetes continues to put pressure on the health and wellbeing of the population and on clinical services, considerable progress in care and clinical outcomes has been made in the last decade. This reflects the strength of the healthcare community supporting people with diabetes in Scotland, the active engagement with people living with diabetes and the support of the Scottish Government and the third sector.

The Diabetes Action Plan 2010: Quality Care for Diabetes in Scotland was centred on the principles of the Quality Strategy and was intended to drive up care through genuine involvement of people with diabetes, focus on outcomes of care and learning from best practice. The Diabetes Improvement Plan 2014 built on the progress that had taken place, outlined priority areas for improvement and expectations in the context of new approaches to quality improvement.

This Diabetes Improvement Plan refresh spans across a range of policy areas and will be relevant to wider health and social care reforms. The COVID-19 pandemic has caused unprecedented disruption to health and social care services, but has also driven rapid development in many areas. Post-publication of this Plan, we will continue to collaborate with all relevant policy areas, as well as third sector stakeholders and move into an implementation phase.