1. Diabetes Clinical Advisory Group Strategic Clinical Cardiovascular network, for heart, stroke, renal and diabetes “Bringing people together to advise on what good services look like to improve health care for our population now and for future generations” SEC Strategic Clinical Networks September 2013

2. ] NHS | CVD SCN Diabetes CAG Presentation September 20132

3. The human cost of diabetes Diabetic retinopathy Leading cause of blindness in working ‐ age adults Diabetic nephropathy Leading cause of end ‐ stage renal disease Stroke 2 ‐ to 4 ‐ fold increase in cardiovascular mortality and stroke Cardiovascular disease 8/10 die from CV events Diabetic neuropathy Leading cause of non ‐ traumatic lower extremity amputations ] NHS | CVD SCN Diabetes CAG Presentation September 20133

4. National Priorities The following priorities were identified by, Jonathan Valabhji, NHS England National Clinical Director (NCD) for Diabetes: Tackle obesity Early diagnosis – approximately 750,000 undiagnosed people with diabetes Managing people well – 9 standard primary care processes (54% nationally last year); control glucose, blood pressure and cholesterol Integrated care and proactive management - Efficient management of those with complications Diabetic Foot disease Identify groups at high risk of CVD ] NHS | CVD SCN Diabetes CAG Presentation September 20134

5. SEC CCG Priorities Diabetes integrated care models Footcare for patients with diabetes (being led by Diabetes UK) 9 primary care quality check processes Training and education for both clinicians and patients ] NHS | CVD SCN Diabetes CAG Presentation September 20135

6. CCG Outcome Indicators ] NHS | CVD SCN Diabetes CAG Presentation September 20136 Ensuring people have a positive experience of care Treating and caring for people in a safe environment and protecting them from harm Domain 1 Reducing premature death in CVD patients 1.4 Myocardial infarction, stroke and stage 5 chronic kidney disease in people with diabetes Domain 2 Enhancing quality of life for people with long term conditions 2.4 People with diabetes who have received nine care processes 2.5 People with diabetes diagnosed less than a year who are referred to structured education 2.7 Unplanned hospitalisation for asthma, diabetes and epilepsy (under 19s) 2.8 Complications associated with diabetes, including emergency admission for diabetic ketoacidosis and lower limb amputation Domains 4 and 5 Domain 3 Helping people recover from illness or injury 3.2 Emergency readmissions within 30 days of discharge from hospital

7. Driving forces CVD Outcomes Strategy 2013 CCG Clinical outcome indicators National Diabetes Clinical Director work programme Diabetes National Services Framework Diabetes UK Integrated Care NICE guidance Diabetes UK Foot-care programme ] NHS | CVD SCN Diabetes CAG Presentation September 20137

8. Cardiovascular (CVD) Outcomes Strategy 2013 Manage CVD as a single family of disease Improve prevention and risk management by making benchmarked data about CVD risk factors available Improve prevention and risk management by supporting the successful implementation of the NHS Health Check programme. Improving and enhancing case finding in primary care Better identification of very high risk families and individuals Better early management and secondary prevention in the community Improve acute care Improve care for patients living with CVD Improve end of life care for patients with CVD Improve intelligence, monitoring and research and support commissioning ] NHS | CVD SCN Diabetes CAG Presentation September 20138

9. Challenges for CVD SCN team so far Obtaining legacy information Data Sources / validation No data analyst support in the SCN Organisational start-up and negotiating within the new NHS environment Small team Geographical area ] NHS | CVD SCN Diabetes CAG Presentation September 20139

10. Increasing prevalence It is estimated there are more than 3million people in the UK living with diabetes. 2.5 million people are diagnosed and by 2020 3.8 million are expected to have diabetes If current trends continue these numbers will rise to 5 million, or 8% of the population, by 2025 –10% have Type 1 diabetes –90% have Type 2 diabetes Up to 7 million people at high risk

11. 2006–72007–82008–92009–10 0 1 2 3 4 5 6 7 Diabetes Cancer Coronary Heart Disease Stroke and mini-stroke % Population Cancer > 3m with diabetes today 5m people by 2025 Diabetes is the No.1 health threat in the UK Heart disease Diabetes

12. Increasing prevalence

13. 2013 estimated prevalence of diabetes by local authority 2030 estimate of diabetes, assuming obesity continues to rise at the current rate 2030 estimate of diabetes, assuming obesity stabilises at the 2010 rate Source: Diabetes Prevalence Model for local authorities in England, YHPHO Diabetes Health Intelligence 2012 Contains Ordnance Survey data © Crown copyright and database right 2013 Levels of diabetes in the South East coast area ] NHS | CVD SCN Diabetes CAG Presentation September 2013 13

14. Increase in unnecessary complications 2006-10 Amputations26% Angina33% Cardiac failure 43% Kidney failure 56% Stroke87% Retinopathy118% Source: Derived from National Diabetes Audit Data

15. National Diabetes Audit Participation ] NHS | CVD SCN Diabetes CAG Presentation September 201315

16. Variation in Care Source: NDA 2009/10

17. Quality of diabetes care in the South East coast area There are nine care processes which have been identified as essential in high quality care for people with diabetes. The National Institute for Clinical Excellence (NICE) recommends that all patients age over 12 should have all nine care processes each year. These are: Urinary albumin Eye screening Foot exam Smoking review Body Mass Index (BMI) Cholesterol Blood creatinine HbA1c Blood pressure Source: The information on this poster is taken from National Diabetes Audit 2010-2011 Report 1: Care Processes and Treatment Targets, produced by the Health and Social Care Information Service. Contains Ordnance Survey data © Crown copyright and database right 2013 Percentage of those with diabetes receiving all nine care processes by primary care trust (PCT) for 2010/11 Type 2 diabetes Type 1 diabetes ] NHS | CVD SCN Diabetes CAG Presentation September 201317

18. Quality of diabetes care in the South East coast area Source: The information on this poster is taken from National Diabetes Audit 2010-2011 Report 1: Care Processes and Treatment Targets, produced by the Health and Social Care Information Service. Contains Ordnance Survey data © Crown copyright and database right 2013 ] NHS | CVD SCN Diabetes CAG Presentation September 201318

19. Inpatient activity in the South East coast Acute complications - Diabetic Ketoacidosis (DKA) by primary care trust (PCT) 2010/11 Source: The information is taken from National Diabetes Audit 2010-2011 Report 2: Complications and Mortality, produced by the Health and Social Care Information Service. Contains Ordnance Survey data © Crown copyright and database right 2013 Additional risk of death among people with diabetes compared to the local population by primary care trust (PCT) 2010/11

20. Inpatient activity in the South East coast Source: Hospital Episode Statistics, The Information Centre for Health and Social Care. Contains Ordnance Survey data © Crown copyright and database right 2013 Contains National Statistics data © Crown copyright and database right 2013 Day case rates for people with diabetes compared to those without diabetes 2010/11 by clinical care group (CCG) % difference between observed and expected counts. Surrey Heath NW Surrey NE Hampshire and Farnham Dartford, Gravesham and Swanley Medway Swale Canterbury and coastal Thanet West Sussex Guilford and Waverley Brighton and Hove Eastbourne, Hailsham and Seaford Hastings and Rother S Kent coast W Kent Ashford High Weald Lewes Havens Horsham and Mid Sussex E Surrey Surrey Downs Crawley ] NHS | CVD SCN Diabetes CAG Presentation September 201320

21. Inpatient activity in the South East coast Length of stay for people with diabetes compared to those without diabetes 2010/11 by clinical care group (CCG) % difference between observed and expected counts. Surrey Heath NW Surrey NE Hampshire and Farnham Dartford, Gravesham and Swanley Medway Swale Canterbury and coastal Thanet West Sussex Guilford and Waverley Brighton and Hove Eastbourne, Hailsham and Seaford Hastings and Rother S Kent coast W Kent Ashford Horsham and Mid Sussex E Surrey Surrey Downs Crawley High Weald Lewes Havens Source: Hospital Episode Statistics, The Information Centre for Health and Social Care. Contains Ordnance Survey data © Crown copyright and database right 2013 Contains National Statistics data © Crown copyright and database right 2013 ] NHS | CVD SCN Diabetes CAG Presentation September 201321

22. Inpatient activity in the South East coast Emergency readmissions for people with diabetes compared to those without diabetes 2010/11 by clinical care group (CCG) % difference between observed and expected counts. Surrey Heath NW Surrey NE Hampshire and Farnham Dartford, Gravesham and Swanley Medway Swale Canterbury and coastal Thanet West Sussex Guilford and Waverley Brighton and Hove Eastbourne, Hailsham and Seaford Hastings and Rother S Kent coast W Kent Ashford Horsham and Mid Sussex E Surrey Surrey Downs Crawley High Weald Lewes Havens Source: Hospital Episode Statistics, The Information Centre for Health and Social Care. Contains Ordnance Survey data © Crown copyright and database right 2013 Contains National Statistics data © Crown copyright and database right 2013 ] NHS | CVD SCN Diabetes CAG Presentation September 201322

23. Inpatient activity in the South East coast Emergency length of stay for people with diabetes compared to those without diabetes 2010/11 by clinical care group (CCG) % difference between observed and expected counts. Surrey Heath NW Surrey NE Hampshire and Farnham Dartford, Gravesham and Swanley Medway Swale Canterbury and coastal Thanet West Sussex Guilford and Waverley Brighton and Hove Eastbourne, Hailsham and Seaford Hastings and Rother S Kent coast W Kent Ashford Horsham and Mid Sussex E Surrey Surrey Downs Crawley High Weald Lewes Havens Source: Hospital Episode Statistics, The Information Centre for Health and Social Care. Contains Ordnance Survey data © Crown copyright and database right 2013 Contains National Statistics data © Crown copyright and database right 2013 ] NHS | CVD SCN Diabetes CAG Presentation September 201323

24. Understanding your outcomes and expenditure Increasingly, local areas are finding it useful to compare what they spend on services with the outcomes patients actually experience. The charts below show outcomes and expenditure information 2011/12 for clinical commissioning groups (CCGs) in the South East coast. Source: The Information Centre for Health and Social Care Total spend on prescribing compared to people with diabetes with a HbA1c of 59mmol/mol or less ] NHS | CVD SCN Diabetes CAG Presentation September 201324

25. Understanding your outcomes and expenditure Increasingly, local areas are finding it useful to compare what they spend on services with the outcomes patients actually experience. The charts below show outcomes and expenditure information 2011/12 for clinical commissioning groups (CCGs) in the South East coast. Source: The Information Centre for Health and Social Care Spend on blood glucose testing items compared to people with diabetes with a HbA1c of 59mmol/mol or less ] NHS | CVD SCN Diabetes CAG Presentation September 201325

26. Understanding your outcomes and expenditure Increasingly, local areas are finding it useful to compare what they spend on services with the outcomes patients actually experience. The charts below show outcomes and expenditure information 2011/12 for clinical commissioning groups (CCGs) in the South East coast. Source: The Information Centre for Health and Social Care Average spend on insulin items compared to people with diabetes with a HbA1c of 59mmol/mol or less ] NHS | CVD SCN Diabetes CAG Presentation September 201326

27. Foot care in the South East coast area Source: The information on this poster is taken from Hospital Episode Statistics (HES) and Information Centre for Health and Social Care Episodes of inpatient care for diabetic foot disease per 1,000 people with diabetes ] NHS | CVD SCN Diabetes CAG Presentation September 201327

28. Foot care in the South East coast area Source: The information on this poster is taken from Hospital Episode Statistics (HES) and Information Centre for Health and Social Care Average length of stay for diabetic foot disease per 1,000 people with diabetes ] NHS | CVD SCN Diabetes CAG Presentation September 201328

29. Foot care in the South East coast area Source: The information on this poster is taken from Hospital Episode Statistics (HES) and Information Centre for Health and Social Care Major amputations ] NHS | CVD SCN Diabetes CAG Presentation September 201329

30. Foot care in the South East coast area Source: The information on this poster is taken from Hospital Episode Statistics (HES) and Information Centre for Health and Social Care Minor amputations ] NHS | CVD SCN Diabetes CAG Presentation September 201330

31. Foot care in the South East coast area Source: The information on this poster is taken from Hospital Episode Statistics (HES) and Information Centre for Health and Social Care Number of episodes of inpatient care per patient ] NHS | CVD SCN Diabetes CAG Presentation September 201331

32. % Admitted with foot Disease ] NHS | CVD SCN Diabetes CAG Presentation September 201332

33. Amputation rates CCGMajor amputations per 1000 with diabetes All amputations per 1000 with diabetes National average0.92.6 Eastbourne, Hailsham & Seaford 1.74.2 Hastings & Rother0.92.7 High Weald, Lewes & Havens 0.52.5 Brighton & Hove0.92.9 West Kent0.83.3 Dartford, Gravesham & Swanley 0.83.3 ] NHS | CVD SCN Diabetes CAG Presentation September 201333

34. Amputation rates cont. CCGMajor amputations per 1000 with diabetes All amputations per 1000 with diabetes National average0.92.6 South Kent Coast Canterbury & Coastal0.82.1 Thanet1.63.8 Ashford1.33.4 Swale1.12.2 Medway0.92.8 ] NHS | CVD SCN Diabetes CAG Presentation September 201334

35. Amputation rates cont. CCGMajor amputations per 1000 with diabetes All amputations per 1000 with diabetes National average0.92.6 Coastal West Sussex1.03.0 Horsham & Mid Sussex 0.91.8 Crawley0.72.9 Surrey Downs0.72.0 Guildford & Waverley0.71.8 Surrey Heath0.62.5 East Surrey0.82.7 North West Surrey1.13.0 ] NHS | CVD SCN Diabetes CAG Presentation September 201335

36. KATIE DAFNE LOCAL Type 1 Diabetes Patient Structured Education Programmes SADIE SAILING ] NHS | CVD SCN Diabetes CAG Presentation September 201336 MINT1E

37. DESMOND XPERT LOCAL Type 2 Diabetes Patient Structured Education Programmes ESTER Derek ] NHS | CVD SCN Diabetes CAG Presentation September 201337

38. SEC Inpatient Patient Satisfaction ] NHS | CVD SCN Diabetes CAG Presentation September 201338

39. Emerging Themes Integrated Models of Care Footcare pathways The NICE 9 Primary Care Checks GP and patient education Retinopathy Early diagnosis/misdiagnosis ] NHS | CVD SCN Diabetes CAG Presentation September 201339

40. Cross-network emerging priorities Palliative Care Smooth transition for patients moving between children’s and adult healthcare services Rehabilitation Seven day a week services ] NHS | CVD SCN Presentation to Diabetes CAG September 201340

41. ] NHS | CVD SCN Diabetes CAG Presentation September 201341

42. 2012 Resident population NumberPrevalence Lower uncertainty limit Upper uncertainty limit Diagnosed Prevalence MissingBased On Lower Certainty Upper Certainty 1 NHS Ashford CCG 6,6017.1%5.1%10.6%5.7%1.4%-0.6%4.9% 2 NHS Brighton and Hove CCG 14,0806.2%4.2%9.4%4.0%2.2%0.2%5.4% 3 NHS Canterbury and Coastal CCG 11,7337.2%5.2%10.4%5.5%1.7%-0.3%4.9% 4 NHS Eastbourne, Hailsham and Seaford CCG 12,3528.2%6.1%11.7%5.8%2.4%0.3%5.9% 5 NHS Coastal West Sussex CCG 31,0617.9%5.8%11.5%5.9%2.0%-0.1%5.6% 6 NHS Crawley CCG 5,8386.9%4.5%11.6%5.7%1.2%-1.2%5.9% 7 NHS Dartford, Gravesham and Swanley CCG 14,1507.2%5.0%11.3%5.7%1.5%-0.7%5.6% 8 NHS East Surrey CCG 9,3116.7%4.8%10.7%4.6%2.1%0.2%6.1% 9 NHS Guildford and Waverley CCG 10,5386.4%4.6%10.5%4.3%2.1%0.3%6.2% 10 NHS Hastings and Rother CCG 12,5718.4%6.0%11.9%5.9%2.5%0.1%6.0% 11 NHS Medway CCG 14,1756.7%4.7%10.3%6.6%0.1%-1.9%3.7% 12 NHS Horsham and Mid Sussex CCG 11,6116.5%4.7%10.6%4.7%1.8%0.0%5.9% 13 NHS North West Surrey CCG 18,3316.8%4.7%11.3%5.3%1.5%-0.6%6.0% 14 NHS South Kent Coast CCG 13,0857.9%5.6%11.3%6.4%1.5%-0.8%4.9% 15 NHS Surrey Heath CCG 4,9706.6%4.7%11.1%5.0%1.6%-0.3%6.1% 16 NHS Swale CCG 6,0037.1%5.0%10.2%6.7%0.4%-1.7%3.5% 17 NHS Thanet CCG 8,9168.2%5.7%11.7%6.8%1.4%-1.1%4.9% 18 NHS West Kent CCG24,6226.7%4.9%10.3% 5.1%1.6%-0.2%5.2% 19 NHS High Weald Lewes Havens CCG9,8857.3%5.4%10.9% 5.2%2.1%0.2%5.7% 20 NHS Surrey Downs CCG15,3796.8%4.9%11.4% 4.6%2.2%0.3%6.8% ] NHS | CVD SCN Diabetes CAG Presentation September 201342