Quality statement for diabetes

Diabetes is a major health condition in Wales, affecting around one in twelve adults (approximately 8% of the population), including both diagnosed and undiagnosed cases. An estimated 65,000 people remain undiagnosed, with a further 350,000 at high risk of developing type 2 diabetes.

Diabetes affects the daily lives of those living with it and may result in complications which can profoundly affect health and well-being, such as kidney failure, blindness and amputation. It is also a major contributor to other long-term conditions, including cardiovascular disease, kidney disease, and liver disease, and has widespread implications across the health system.

An updated cost-of-illness analysis estimated the direct cost of diabetes in the UK at £10.7 billion in 2021 to 2022, with over 60% of this spending attributed to managing complications. Diabetes is now estimated to account for more than 6% of the UK health budget. Historic modelling had previously projected that diabetes would represent around 10% of total health expenditure, potentially rising to 17% by 2035 to 2036 if trends continued.

In Wales, projections indicate that an additional 48,000 people could be living with diabetes by 2035, bringing the total to around 1 in 11 adults. The financial burden is significant, with diabetes-related hospital admissions costing an average of £4,518 per spell in 2021 to 2022 (excluding those involving amputations), and prescription costs for diabetes medications reaching £105 million in 2022 to 2023.

Of the 220,000 people known to live with diabetes in Wales, around 90% have type 2 diabetes, 8% have type 1 diabetes, and the remainder live with rarer forms including pancreatic diabetes, gestational diabetes (diabetes arising in pregnancy), monogenic diabetes, and others. The prevalence of type 1 diabetes among all ages is estimated at around 0.32%, with higher rates seen in younger age groups and more deprived areas.

A significant proportion of type 2 diabetes may be preventable. Welsh health policy strongly emphasises primary prevention to ensure everyone can pursue healthy lives with good nutrition, active lifestyles, and maintain a healthy body mass index. People living with type 2 diabetes may enter remission with appropriate intervention, and everyone diagnosed with type 2 diabetes should have an opportunity to explore if this is possible.

There is a strong association between obesity and the likelihood of developing type 2 diabetes. The national approach to addressing the challenge of obesity is set out in the Healthy Weight, Healthy Wales Strategy, and health and social care services should support people to address the risk factors associated with obesity. People with pre-diabetes or at high risk of developing diabetes should be referred the All Wales Diabetes Prevention Programme.

High-quality early diabetes care is essential to preventing complications. Self-management of diabetes is of equal importance to medical management for everyone living with diabetes. Appropriate intervention is essential to preventing progression and complications, including access to regular eye screening in line with best practice. Ensuring people living with diabetes in Wales are treated in line with agreed and approved pathways is a key aspect of delivering high-quality care. Support for psychological well-being and timely access to appropriate help are recognised as important components of effective diabetes management.

Type 2 diabetes is not only rising rapidly in prevalence; there is a changing disease pattern. Increasingly, younger adults and children are developing type 2 diabetes. Type 2 diabetes has a more aggressive course within these age groups, with an increased risk of complications; there is also a marked association with wider socioeconomic factors and minority ethnic backgrounds. Similar associations are present in type 2 diabetes during pregnancy. Pregnancies affected by type 2 diabetes now outnumber those affected by type 1 diabetes. Services should be designed to address these inequalities and contribute to more equitable outcomes.

Type 1 diabetes is a lifelong condition that requires careful balancing of insulin requirements with food intake, activity, and exercise. Technology now plays an important role in the treatment of type 1 diabetes. Hybrid closed-loop systems (semi-automated insulin pumps) have the potential to reduce complications and ease the burden of daily management. Equitable access to these technologies across geography, ethnicity, age and deprivation status in Wales is essential.

Outcomes during pregnancy for people with type 1 diabetes have started to improve and are associated with the use of continuous glucose monitors; hybrid closed loops have the potential to improve outcomes further. Recent trials have shown it is possible to detect type 1 diabetes in a pre-clinical stage, and there is potential for the emergence of treatments to delay the onset of type 1 diabetes. Diagnosing type 1 diabetes in a preclinical stage could have the potential to reduce the trauma of hospital admission at diagnosis and the risk of diabetic ketoacidosis. Services should keep pace with such developments and be ready to introduce new innovations as appropriate.

Children face unique challenges when living with diabetes and benefit from access to specialist care, structured education, support in schools, and guidance for parents and guardians. The Children and Young Persons Wales Diabetes Network supports the delivery of high-quality, equitable care by promoting collaboration across paediatric diabetes teams in Wales. The Network facilitates service improvement through regular review of national audit data, supports professional development through training and education, and encourages the sharing of best practice. It also plays a role in developing consistent pathways and resources, helping to reduce unwarranted variation and improve outcomes for children and young people living with diabetes.

Certain groups living with diabetes may face specific challenges, for example inpatients (23% of inpatients have diabetes), people living in a cared for situation, people without housing, people with learning disabilities or severe mental illness. Dedicated and inclusive services are required to reduce adverse outcomes in these populations.

A knowledgeable and well-trained workforce underpins the delivery of excellent diabetes services. Supporting career progression, encouraging succession planning, and promoting staff retention and recruitment are essential to sustaining high-quality care. Innovation also plays a vital role. Services are increasingly being designed to meet people’s needs closer to home, including in community settings. At the same time, emerging technologies such as artificial intelligence offer the potential to further improve systems, streamline processes, and support service development.

This refreshed quality statement forms part of a strengthened focus on quality in healthcare delivery and will underpin future planning and accountability arrangements across NHS Wales. It sets out key expectations for service planning, supported by national collaboration and leadership through the National Strategic Clinical Network for Diabetes as part of NHS Wales Performance and Improvement.

The quality of diabetes care will be measured and monitored using a range of national audits and data sources. These provide vital insights to inform service planning, drive improvement, and ensure accountability across the system. Key sources include:

• National Diabetes Audit (NDA): monitoring care processes, treatment targets, and outcomes for adults with diabetes.
• National Paediatric Diabetes Audit (NPDA): assessing quality and outcomes of care for children and young people.
• National Diabetes Foot Care Audit (NDFA): measuring performance against the National Institute for Health and Care Excellence (NICE) clinical guidance and to monitor adverse outcomes for people with diabetes who develop diabetes-related foot disease.
• NHS Wales Diabetes Insights & Variation Atlas (DIVA): providing data on outcomes, therapies and costs (NHS access only).
• Primary Care Information Portal (PCIP): supporting local and national monitoring of primary care indicators (NHS access only).
• Patient Reported Outcome Measures (PROMs): capturing the lived experiences and outcomes that matter to people with diabetes.
• Eight High Value Diabetes Metrics: a core set of priority measures used to support benchmarking and service improvement, coordinated by the National Strategic Clinical Network for Diabetes.
• National Pregnancy in Diabetes Audit (NPID): monitoring care and outcomes for women with diabetes during pregnancy.

These datasets will support transparent reporting, continuous quality improvement, and accountability at local, regional, and national levels.

Equitable

1. The National Strategic Clinical Network for Diabetes will bring together stakeholders including clinicians, managers, the third sector, social carers, and people with lived experience of diabetes to develop national resources that support more consistent, equitable, high-quality diabetes care. 
2. The National Strategic Clinical Network for Diabetes will produce data-driven insights using all available resources including national audits, atlases of variation, high value metrics, and other data sources to demonstrate unwarranted variation and drive quality improvement.
3. The National Strategic Clinical Network for Diabetes will support and enable the adoption of diabetes technology, including hybrid closed loop systems, to improve clinical outcomes, with a particular focus on ensuring equitable access. 
4. Health boards will identify and implement targeted actions to improve outcomes amongst groups who face barriers to accessing care. This includes developing tailored approaches for people with type 2 diabetes under the age of 40, adolescents and young adults, and people living in cared-for settings.

Safe

5. Healthcare professionals looking after people living with diabetes will be appropriately trained and knowledgeable to deliver high-quality care whilst minimising harm.
6. Any instances of harm relating to diabetes care in domiciliary, residential, or inpatient settings will be reported through local and national reporting systems in a timely manner. Health boards will use this data to target training, education, and support for staff delivering care in these settings, ensuring that learning is identified and applied to prevent recurrence.
7. Health boards will provide children and young people with diabetes high-quality and enhanced support (the pathway) when transitioning from children to adult services, including psychosocial support and a focus on preventing common harms such as diabetic ketoacidosis (DKA) and T1DE (type 1 diabetes with disordered eating). 
8. All healthcare professionals involved in caring for people with diabetes will provide effective preconception planning. Excellent care throughout pregnancy with pre-existing diabetes will include effective use of technology. Gestational diabetes pathways will be followed with an increased focus on follow-up and intervention to prevent future type 2 diabetes.
9. Health boards apply the All-Wales Referral Pathway for new presentations of type 1 diabetes to prevent diabetic ketoacidosis and hospital admission.

Effective

10. Health boards will support the prevention of type 2 diabetes by identifying those at high risk and referring them to the All-Wales Diabetes Prevention Programme. 
11. Health boards will deliver the national pathway requirements for the provision of remission services for people living with type 2 diabetes.
12. Diabetic Eye Screening Wales will provide accessible appointments at recommended intervals and work towards improving accessibility of results and reducing inequity of access.
13. Health boards will deliver standardised, nationally agreed diabetes care pathways across community and hospital settings.
14. Health boards will develop services for people identified as having pre-clinical type 1 diabetes and offer individuals with newly diagnosed type 1 diabetes and pre-clinical diabetes the opportunity to participate in appropriate research trials.
15. Health boards will optimise the delivery of the eight care processes and treatment targets for people with diabetes.
16. Health boards will implement phased plans to ensure that all people recommended to have hybrid closed loop systems have access to this treatment. 
17. Health boards participate in all national diabetes audits and routinely use these data sources to support quality improvement in service delivery and outcomes.

Efficient

18. Health boards will adopt electronic databases to improve efficiency of diabetes care and communication across primary, community, and secondary care settings, supported by national platforms such as the NHS App.
19. Health boards routinely collect, analyse, and use high-value diabetes metrics to inform quality improvement activity.
20. Health boards will seek to increase nationally agreed high value interventions and reduce low value interventions in diabetes.

Person centred

21. Health boards provide continuous access to a suite of information and educational resources to support diabetes management, including structured diabetes educational programmes and digital peer support.
22. Health boards provide tools and appropriate support in line with the diabetes psychology pathway, including the provision of an appropriately trained workforce.
23. People with diabetes are empowered to collaborate with their healthcare team in their individualised diabetes care planning.
24. Health boards will provide an integrated and holistic service for people with diabetes as part of the national Community by Design programme.
25. Health boards and the third sector work together to provide peer support opportunities for people who live with diabetes.
26. Health boards routinely collect Patient Reported Outcome Measures for diabetes which are used to inform service development and improvement.

Timely

27. Health boards provide timely education to support the effective management of diabetes in the first year of diagnosis.
28. Health boards provide prompt access to care for people who experience diabetes-related foot problems. This includes urgent self-directed access to members of the multidisciplinary foot team for active diabetes foot disease.

NHS Wales Performance and Improvement has developed the following nationally agreed pathways for adoption by NHS organisations:

• Adult Repeat Diabetic Ketoacidosis (DKA) Pathway
• All Wales Diabetes Prevention Programme Pathway
• Diabetes Foot Care Pathway
• Diabetes Pre-conception Pathway
• Diabetes Psychology Pathway
• Transitional and Handover Care for Young Adults
• Type 1 Diabetes Pathway
• Type 2 Diabetes Pathway

These can be found on the pathways and guidelines webpage on the NHS Wales Performance and Improvement website.

More information can be found on the Diabetes NHS Wales Performance and Improvement webpage.