NPDA 2019-20 Executive Summary
Source: data.gov.uk (2024-05-31)

National Paediatric Diabetes Audit 2019 - 2020. National Paediatric Diabetes Audit 2019 - 2020

The excel file contains unit, regional and national level data obtained from the National Paediatric Diabetes Audit 2019-2020.
Specifically, it includes information on patient characteristics, completion of health checks and outcomes achieved (as recommended by the National Institute for Clinical Excellence) for infants, children and young people with type 1 diabetes, under the age of 25, who attended paediatric diabetes units in England and Wales between 1 April 2019 and the 31 March 2020.
Data are included for the seven key health checks:
• Glycated Haemoglobin A1c (HbA1c)
• Body Mass Index (BMI)
• Thyroid
• Blood pressure
• Urinary albumin
• Foot examination
• Eye screening.

Data on other health checks include:
• Psychological assessment
• Offering of immunisation against influenza
• Advice about managing diabetes (‘sick-day rules’)
• Using (or trained to use) blood ketone testing strips and a meter
• Cholesterol
• Additional dietetic support

Data are included for health checks at diagnosis
• Screening for autoimmune disease (coeliac and thyroid disease) 
• Provision of Level 3 carbohydrate-counting education

Data on outcomes of care include:
• HbA1c target measurements
• Small vessel (microvascular) disease
• Large vessel (macrovascular) disease
• Autoimmune disease (coeliac and thyroid disease)

The data were first published in 2021 alongside the National Paediatric Diabetes Audit Report 2019-2020 Data suppressed due to small numbers (<5).

For further information and details on the audit please refer to:
• National Paediatric Diabetes Audit Annual Reports: https://www.rcpch.ac.uk/resources/npda-annual-reports
• NPDA results online: http://npda-results.rcpch.ac.uk/default.aspx
• The RCPCH website: https://www.rcpch.ac.uk/npda

Royal College of
Paediatrics and Child Health
RCPCH
Annual report 2019-20
Care processes and outcomes
Audits
RCPCH
National Paediatric
Diabetes Audit
NPDA

Front cover Image by Emilia Smith, winner NPDA Cover Art Competition

National Paediatric Diabetes Audit
(NPDA) National report 2019/20:
Care processes and outcomes
Citation: National Paediatric Diabetes Audit Annual Report 2019-20: Care Processes and Outcomes.
London: Royal College of Paediatrics and Child Health, 2021.
© Healthcare Quality Improvement Partnership 2021

1.
Foreword
I am delighted to introduce this 2019/20 National Paediatric Diabetes Audit (NPDA) report; the
tenth to be published by the Royal College of Paediatrics and Child Health, and the 17th since
the audit’s inception. The report highlights the care and outcomes of children and young
people living with diabetes in England and Wales in 2019/20. It covers incidence and prevalence,
diabetes-related outcomes and complications, use of diabetes-related technologies, compliance
with health care checks recommended by the National Institute for Health and Care Excellence
(NICE), and recommendations for improvements in care.
This year has been tough for everyone and at one point the production of the annual report
seemed uncertain. The final data submission window for the 2019/20 audit began on the 1st
April 2020, when the first wave of the COVID-19 pandemic was peaking, and the NHS was in a
state of extreme flux. In some parts of the country, members of the paediatric workforce were
relocated to support colleagues working in acute adult medicine, paediatric diabetes teams
were grappling with new ways of supporting their families and discovering new concepts such
as working remotely. Mandatory participation in national clinical audits, including the NPDA was
suspended. Despite these challenges, it is commendable that 96% of paediatric diabetes teams
in England and Wales were able, and chose, to submit data for the 2019/20 audit year. This is
testament to the dedication of the paediatric diabetes clinical community, and their support and
thirst for data–driven improvements in paediatric diabetes care. I would urge all units to submit
data for 2020/21, a year unlike any other, but one from which to use data to learn from, and to
shape future services.
Overall, since 2012/13, the NPDA has shown impressive national improvements in HbA1c outcomes
and rates of completion of health checks fuelled by a more coordinated national, regional and local
approach to diabetes management. Despite the results contained in this 2019/20 report looking
similar to 2018/19, this still represents overall improvement, and I am aware of the fantastic work of
the ongoing National Diabetes Quality Programme. Furthermore, we should not be disheartened
by these results, as international comparisons with other European countries also show dramatic
improvements in one year followed with a plateauing the next year. To quote Martin Luther King
Jr ‘if you can’t fly then run, if you can’t run then walk, if you can’t walk then crawl, but whatever you
do you have to keep moving forward’. The NPDA continues to move forward.
This report continues to show worrying insights into differences in outcomes related to social
deprivation and ethnicity. Those living in more deprived areas continue to lag behind those in the
least deprived areas and minority ethnic children and young people are less likely to achieve lower
HbA1c targets or be using a diabetes technology that could support their management, even
after accounting for other patient factors. In the year where the ‘Black Lives Matter’ movement
has raised the profile of ethnic inequalities across society, this report provides additional impetus
for action to reduce disparities in care outcomes across different ethnicities. Barriers to achieving
excellent outcomes amongst those children and young people living in more deprived areas and
of Black ethnicity must be identified and mitigated if we are to see significant further overall
national progress.
There continues to be a worrying trend for higher numbers of children and young people with
Type 2 diabetes being cared for by paediatric diabetes services. Whilst still a rare disease amongst
children and young people, rising numbers indicate that this is related to the rise in obesity in
England and Wales which requires ongoing attention.

With the pandemic and associated lockdowns ongoing at the time of writing, we are yet to fully
quantify their impact on child health and outcomes, including those reported here. It will be
incumbent on all of us, when we emerge from the worst of it, to help assess the damage, use our
voice to advocate for policies that help repair the damage and address the pre-existing threats to
child health evidenced within this report.
I would like to thank all those involved in writing the report and developing its recommendations,
including the NPDA Project Board, Methodology and Dataset Group, the audit team, and Clinical
Lead, Professor Justin Warner. I would like to thank the paediatric diabetes teams across England
and Wales for their support for the audit in this uniquely challenging year, and for their ongoing
efforts to make improvements in their local services.
Professor Russell Viner
President, Royal College of Paediatrics and Child Health

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NPDA National report 2019/20: Care processes and outcomes
2.
Glossary
Autoimmune disorder – an autoimmune disorder occurs when the body’s immune system
attacks and destroys healthy body tissue by mistake. There are more than 80 types of autoimmune
disorder.
Body Mass Index (BMI) – a measure of someone’s size based on their weight and height. BMI is a
value derived from the weight and height of an individual and is calculated by the weight divided
by the square of the body height, and is expressed in units of kg/m2. BMI is used to determine if
someone is a healthy weight for their height.
Cardiovascular disease (CVD) is a general term that describes a disease of the heart or blood
vessels. Blood flow to the heart, brain or body can be reduced as the result of a blood clot
(thrombosis), or by a build-up of fatty deposits inside an artery that cause the artery to harden and
narrow (atherosclerosis) causing heart disease and strokes.
Care processes – these are the various medical tests that healthcare professionals should take to
measure things in the blood or screen various parts of the body to ensure they are not damaged.
They are also referred to as health checks.
Cholesterol – a fatty substance which is vital for the normal functioning of the body. Cholesterol
levels in the blood should be within a particular range and excessively high levels of cholesterol can
contribute towards diabetes complications.
Coeliac disease – an autoimmune disease caused by the gut’s reaction to gluten. It is treated by
omitting gluten from the diet. Gluten is found in wheat, barley, and rye.
Diabetes mellitus (DM) is commonly referred to as diabetes. It is a condition where the blood
glucose levels remain high because the body cannot use the glucose properly without treatment.
If left untreated diabetes complications will occur, the common ones include eye and kidney
damage, cardiovascular disease, strokes and foot damage.
Glucose – a simple sugar with a specific chemical formula and is classed as a monosaccharide.
Glucose is the sugar that is found in blood and blood glucose acts as a major source of energy for
the body.
HbA1c (Glycated haemoglobin) – The term HbA1c refers to glycated haemoglobin. By measuring
glycated haemoglobin (HbA1c), clinicians are able to get an overall picture of what our average
blood sugar levels have been over a period of weeks/ months. For people with diabetes this is
important as the higher the HbA1c, the greater the risk of developing diabetes-related complications.
(Diabetes.co.uk)
Health checks – the various medical tests that health care professionals should take to measure
things in the blood or screen various parts of the body to ensure they are not damaged. They are
also referred to as care processes.
Key health checks – Seven health checks for children with Type 1 or Type 2 diabetes recommended
for annual completion by NICE guidance (NG18, 2015) that monitor diabetes management and
screen for diabetes-related complications.

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NPDA National report 2019/20: Care processes and outcomes

Macrovascular complications – regular elevation of blood glucose levels over a long period of
time leads to damage of blood vessels. Over time the lining of the large blood vessels (arteries)
become weaker resulting in macrovascular disease. Damage to the large vessels will contribute to
cardiovascular disease and strokes.

Micro/macro albuminuria – as kidney disease progresses, more albumin leaks into the urine, a
condition called microalbuminuria or proteinuria. As the amount of albumin in the urine increases,
the kidneys’ ability to filter the blood decreases.

Mean – a measure of the ‘average’ of a set of numbers. Add up all the numbers, then divide by how
many numbers there are in the sample.

Median – the median is the middle number of a list of numbers when they are sorted from the
smallest to the largest number.

Microalbuminuria – small amounts of protein in the urine. It is the first sign of kidney damage
(nephropathy) caused by many years of high blood glucose levels. Microalbuminuria is reversible if
blood glucose levels are improved.

Microvascular complications – regular elevation of blood glucose levels over a long period of time
leads to damage of blood vessels. Over time the lining of the small blood vessels become weaker
resulting in microvascular disease. This can be found at the back of the eye (retinopathy) and in the
kidneys when they become damaged.

Normoalbuminuria – the presence of the normal amount of albumen in the urine.

Retinopathy – a complication of diabetes, caused by high blood glucose levels damaging the back
of the eye (retina). It usually takes several years for diabetic retinopathy to reach a stage where it
could threaten your sight. Retinopathy can cause blindness if left undiagnosed and untreated.

Thyroid disease – a disease which causes the thyroid to produce either too much or too little of the
thyroid hormone.

Urinary albumin – a test to check urine for the presence of a protein called albumin. Small amounts
of albumin leak into the urine when the kidney is damaged. Therefore, urinary albumin can be
used as a test for kidney disease.

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NPDA National report 2019/20: Care processes and outcomes
3.
Introduction to the National
Paediatric Diabetes Audit
The NPDA is delivered by the Royal College of Paediatrics and Child Health (RCPCH) and has been
reporting for 17 years. Data is submitted by healthcare professionals in Paediatric Diabetes Units
(PDUs) in England and Wales about the care received by the children and young people with
diabetes using their service. The effectiveness of diabetes care is measured against NICE guidelines
(NG18, NICE 2015) and includes treatment targets, health checks, patient education, psychological
wellbeing, and assessment of diabetes related complications including acute hospital admissions,
all of which are vital to monitoring and improving the long-term health and wellbeing of children
and young people with diabetes.
The NPDA is designed to measure and motivate change at local, regional network and national
levels across England and Wales. It also has a role in assuring patient safety, as data from the audit
are used to inform hospital inspections by the Care Quality Commission (CQC) in England and in
Wales by the Healthcare Inspectorate Wales. The audit encourages everyone with an interest in
improving the lives of children and young people with diabetes to work together including
healthcare managers, commissioners, children, young people, and their families as well as all
members of the multi-disciplinary team.
In the last five years, NPDA outcome data have also been benchmarked against certain other
European, North American and Australasian countries, providing insights into areas where
international comparisons can drive improvements (McKnight et al., 2015; Maahs et al., 2015; Sherr
et al., 2016; Anderzen et al., 2020).

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NPDA National report 2019/20: Care processes and outcomes
4.
Background to the audit
Diabetes mellitus occurs when blood glucose levels are elevated because the body is unable to
metabolise it. The UK has the highest number of children and young people aged 0-14 with Type 1
diabetes in Europe (International Diabetes Federation, 2019). Complications associated with
suboptimal diabetes management include damage to small and large blood vessels and nerves
which over time can result in blindness, kidney failure, heart disease, stroke, and amputations. With
good diabetes care and blood glucose management, the risks of complications are reduced,
enabling children and young people to enjoy a healthy and longer life.
Diabetes care is complex and requires collaboration between healthcare professionals, children
and young people and their families, carers and friends. Good quality care requires adequate
resources and training of the workforce (Campbell & Waldron, 2013) to support the medical,
emotional and psychological needs of children, young people and their families. In addition,
families need ongoing and appropriate age-related structured patient education on self-
management to provide knowledge, skills and competencies to manage their diabetes on a daily
basis (Waldron & Campbell, 2014). Ensuring that patients and families are provided with a thorough
understanding of the targets associated with good diabetes management and the need for
regular health checks to prevent complications is an essential part of high-quality care (NICE, 2015).
5.
Commissioners of the NPDA
The RCPCH is commissioned by the Healthcare Quality Improvement Partnership (HQIP) to deliver
the NPDA as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP).
HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing,
and National Voices. Its aim is to promote quality improvement in patient outcomes, and in
particular, to increase the impact that clinical audit, outcome review programmes and registries
have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage,
and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising
around 40 projects covering care provided to people with a wide range of medical, surgical and
mental health conditions. The programme is funded by NHS England, the Welsh Government and,
with some individual projects, other devolved administrations and crown dependencies www.
hqip.org.uk/national-programmes

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NPDA National report 2019/20: Care processes and outcomes
6.
Scope of the 2019/20 NPDA report
This 2019/20 report covers the health checks (care processes) and outcomes for children and young
people with diabetes who have attended PDUs during the period from 1st April 2019 through to
31st March 2020, aged 0 – 24 on the first day of the audit period.
The NPDA achieved a participation rate of 100% of paediatric diabetes units in England and Wales
from 2011/12 until the 2018/19 audit year. Challenges associated with the COVID-19 pandemic meant
that seven out of the 173 paediatric diabetes teams in England and Wales did not submit data for
2019/20.
A comparison was made to the 2018/19 audit where the data was complete (see Appendix 2)
to ascertain whether the data submitted by the 166 PDUs in 2019/20 was representative of all
children and young peopled with diabetes being managed within a PDU.
Analysis showed that the patient cohort for each audit year were similar in terms of demographics
and outcomes, and that the 2019/20 sample was broadly representative of the wider population of
children and young people being managed within a paediatric diabetes unit.
6.1 Key audit questions
The report aims to address a series of questions relating to paediatric diabetes care, which include:
•
What proportion of children and young people with diabetes are reported to be receiving key
age-specific processes of diabetes care, as recommended by NICE?
•
How many children and young people achieve outcome measures within specified treatment
targets?
•
Are children and young people with diabetes demonstrating evidence of small vessel disease
(microvascular) and/or abnormal risk factors associated with large vessel disease
(macrovascular) prior to transition into adult services?
•
Are there inequalities in care and outcomes between PDUs, regional networks, or between
different patient groups?
6.2 Full audit results
An associated Appendix 1 to this publication provides full details of the tables of results and
analyses that inform the key findings and recommendations set out within this report and can be
found at: https://www.rcpch.ac.uk/resources/npda-annual-reports#downloadBox

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NPDA National report 2019/20: Care processes and outcomes
7.
Key messages
1.
Paediatric diabetes teams have demonstrated laudable commitment to data driven quality
improvement by succeeding in submitting their 2019/20 datasets during the first wave of the
COVID-19 pandemic, despite severe disruption to services.
2. National median HbA1c (a measure of blood glucose control) remained constant at 61.5 mmol/
mol between 2018/19 and 2019/20 following several years of year on year decreases
(improvement) in the national median.
Figure 1: Median HbA1c for children and young people with all types of diabetes in England and
Wales 2009/10 to 2019/20
3. Considerable variation in HbA1c target outcomes amongst children and young people with
Type 1 diabetes persists between PDUs even after case-mix adjustment.
4. The completion rates of all recommended health checks for Type 1 diabetes increased
between 2018/19 and 2019/20, except for eye screening.

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NPDA National report 2019/20: Care processes and outcomes
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2004/05
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
All types of diabetes
Type 1 only
% of children and young people who completed
a full year of care
HbA1c
Blood
pressure*
BMI
Urinary
albumin*
Cholesterol*
Eye screen*
Foot Exam*
Thyroid
* health checks completed on children and young people aged 12 or older
* health checks completed on children and young people aged 12 or older

Figure 2: Percentage of children and young people who completed a full year of care recorded as
receiving individual health checks, 2004/05 to 2019/20
8. The proportion of children and young people with Type 1 diabetes who were assessed as
requiring additional psychological or CAMHS support outside of MDT clinics increased from
39.1% in 2018/19 to 43.9% in 2019/20.
9. One fifth (19.4%) of children and young people with Type 1 diabetes were using a real-time
continuous glucose monitor (rtCGM). Children using this technology were found to be more
likely to be meeting lower HbA1c targets.

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NPDA National report 2019/20: Care processes and outcomes
0%
10%
20%
30%
40%
50%
60%
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/ mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
% of children and young people with
Type 1 diabetes
HbA1c target levels
Using CGM
Not using CGM

Figure 3: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by rtCGM usage, 2019/20
7. Increased use of rtCGM was associated with living in less deprived areas and White ethnicity,
with those in the most deprived areas and Black children and young people least likely to be
using this technology.
8.
Those living in more deprived areas were found to have a higher risk of retinopathy,
albuminuria, needing additional psychological support, and higher HbA1c levels.

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NPDA National report 2019/20: Care processes and outcomes
8.
Recommendations
Hospital commissioners, NHS Regional
Offices, Regional Partnership Boards,
NHS England and NHS Wales should:
1.
Read this report alongside the unit level reports within their area to benchmark outcomes
both locally and nationally.
2. Note the inequities in outcomes highlighted by this report and fund care based on case mix in
terms of language, ethnicity and deprivation.
Trusts and Health Boards should:
3. Ensure PDUs have appropriate staffing levels in the paediatric multi-disciplinary teams (MDT)
to provide excellent quality care to young patients with diabetes. This must include dedicated
admin support and IT support to record good quality data.
 4. Ensure that parents and patients have access to appropriate psychological support as
required and in line with NICE guidance.
Paediatric diabetes teams and commissioners
should:
5. Ensure that technologies such as pumps and rtCGM are:
•
Considered in concordance with NICE guidance and,
•
Education programmes are available to support their use.
Paediatric diabetes teams should:
6. Review their NPDA results, in a timely way, within a team meeting and work together to
identify priorities for on-going quality improvement activities.
7. Regularly upload data collected as part of routine diabetes care (monthly) by members of the
paediatric diabetes (MDT) into the NPDA data capture system. Data uploaded should be:
•
Checked for completeness and quality.
•
Used to monitor performance against HbA1c and health check completion targets
throughout the audit year.
•
Used to identify patients at risk of missing key health checks by the end of the audit year, so
that they may be followed up their next clinic appointment.
8. Ensure consistent messages about glucose and HbA1c targets and have a mechanism to
ensure all team members are aware of and communicating the same target to their families.
9. Ensure that all families attending their diabetes service are made aware of the recommended
annual health checks for diabetes.
10. Take steps to improve engagement with children and young people with Type 2 diabetes to
ensure that the NICE-recommended health checks for this cohort are carried out annually.

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NPDA National report 2019/20: Care processes and outcomes
9.
Summary of results
9.1 Overall National HbA1c results
•
In 2019/20 the mean HbA1c was 64.5 mmol/mol, while the median HbA1c was
61.5 mmol/mol.
9.2 Key findings: Type 1 diabetes
9.2.1 Incidence, prevalence, and patient
characteristics
•
In 2019/20, data for 27,653 children and young people with Type 1 diabetes
(52.3% male, 47.7% female) were reported to the NPDA in England and Wales.
•
The prevalence of Type 1 diabetes in children and young people aged 0 to 15
years old in England and Wales was estimated to be 198.3 per 100,000 of the general
population; it is slightly higher among boys (199.0 per 100,000) compared to girls (197.6 per
100,000).
•
There were at least 2,799 children and young people aged 0 to 15 years old newly diagnosed
with Type 1 diabetes in England and Wales in 2019/20, with an estimated incidence of 25.6 per
100,000 general population within this age group. Incidence varies by age group among boys
and girls.
•
There were proportionately more children and young people with Type 1 diabetes living in the
most deprived quintile areas (23.0%), which is consistent with the distribution of the general
population aged 0-19 years old in England and Wales.
9.2.2 Completion of health checks
•
The completion rates of all recommended health checks for Type 1 diabetes
increased between 2018/19 and 2019/20, except for eye screening.
•
The percentage of children and young people with Type 1 diabetes receiving
level 3 carbohydrate-counting education within 14 days of diagnosis increased
from 75.6% in 2018/19 to 82.5% in 2019/20.
•
The percentage of children and young people with Type 1 diabetes receiving flu vaccination,
sick day rules advice and blood ketone testing increased with respect to 2018/19.
•
The percentage of those aged 12 and above with a complete year of care receiving all seven
recommended health checks for Type 1 diabetes decreased from 55.2% in 2018/19 to 54.4% in
2019/20.
•
The percentage of those with a complete year of care receiving four or more HbA1c
measurements during the audit year decreased from 57.5% in 2018/19 to 53.1% in 2019/20.
•
The percentage of children and young people with Type 1 diabetes receiving screening for
coeliac disease and thyroid disease within 90 days of diagnosis in 2019/20 remained in excess
of 80% and was similar to the previous year (83% vs 81% for coeliac disease and 89% vs 85% for
thyroid disease for 2018/19 and 2019/20 respectively).

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NPDA National report 2019/20: Care processes and outcomes
•
The percentage of those with a complete year of care receiving psychological assessment
decreased from 85.7% in 2018/19 to 84.4% in 2019/20.
9.2.3 Blood glucose diabetes control targets (HbA1c)
•
The national mean and median HbA1c were 65.0 and 62.0 mmol/mol
respectively. These results were consistent with those recorded in 2018/19.
•
Higher average HbA1c was associated with female sex, longer duration of
diagnosis, living in a more deprived area, adolescence and Black, mixed and
Asian ethnicity.
9.2.4 Microvascular complications
•
Albuminuria was found in 11.1% of young people aged 12 years and above
with Type 1 diabetes.
•
There was little variation in the presence of albuminuria by duration of
diabetes, age or sex.
•
The presence of albuminuria was associated with poorer HbA1c outcomes.
•
Abnormal eye screening was found in 12.0% of young people aged 12 and
above with Type 1 diabetes.
•
The risk of abnormal eye screening increased with age and duration of
diabetes and was highest amongst adolescent females.
9.2.5 Macrovascular complications
•
High blood pressure (hypertension) was found in 26.7% of young people
aged 12 years and older with Type 1 diabetes, as defined by systolic or
diastolic blood pressure.
•
One fifth (18.9%) of young people aged 12 years and older with Type 1 diabetes
had a total blood cholesterol level exceeding the target of 5 mmol/l.
•
17.5% of children aged 0 to 11 years with Type 1 diabetes were overweight, and
18.6% were obese. In young people aged 12 years and above 18.4% were
overweight and 24.3% obese.
•
In England, 32.5% of children aged 4 to 5 years old with diabetes were overweight or
obese (a decrease from 35.9% in 2018/19) compared to 23.0% in the National Child
Measurement Programme for England.
•
In Wales, 47.2% of children with diabetes aged 4 to 5 years were overweight or obese (an
increase from 37.7% in 2018/19) compared to 26.3% in the Child Measurement Programme for
Wales in 2017/18.
•
The prevalence of overweight and obesity amongst children aged 10 to 11 years old with
diabetes in England was 38.7% (an increase from 37.1% in 2018/19) compared to 35.1% of the
wider cohort within the National Child Measurement Programme for England.
•
A higher proportion of girls aged 12 years and above were overweight or obese compared to
boys of the same age with Type 1 diabetes.
•
The proportion of children and young people who were overweight or obese were higher in
the most deprived quintiles than the least deprived.

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NPDA National report 2019/20: Care processes and outcomes
9.2.6 Outcomes of psychological assessment
•
The proportion of children and young people with Type 1 diabetes who were
assessed as requiring additional psychological or Child and Adolescent
Mental Health Services (CAMHS) support outside of multi-disciplinary team
(MDT) clinics increased from 39.1% in 2018/19 to 43.9% in 2019/20.
•
Nearly two thirds (61.8%) of children and young people with Type 1 diabetes in
Wales were assessed as requiring additional psychological support.
•
Amongst children and young people with Type 1 diabetes, there was a higher proportion of
adolescent girls recorded as requiring additional psychological support compared to
adolescent boys.
•
The percentage of children and young people with Type 1 diabetes assessed as requiring
additional psychological support was highest amongst those who were recently diagnosed.
•
Children and young people with Type 1 diabetes who were recorded as requiring additional
psychological support were more likely to have higher HbA1c.
9.2.7 Hospital admissions
•
The number of units submitting admissions data decreased from 168 in
2018/19 to 155 in 2019/20.
•
Data quality and completeness needs to improve further before PDU submitted admission
data can be considered representative of admission trends in England and Wales.
9.2.8 Treatment regimen
•
Over one third (38.0%) of children and young people with Type 1
diabetes were using an insulin pump.
•
Usage of insulin pumps to deliver insulin therapy in Type 1 diabetes
has increased in all age groups since 2014/15.
•
Increased usage of pump therapy was associated with female sex,
younger age, living in the least deprived areas and White ethnicity.
•
Over a third (39.8%) of White children and young people with Type 1 diabetes
were using an insulin pump compared to 26.7% of Black children and young
people with diabetes.
•
In the least deprived areas, 44.3% of children and young people with diabetes were using an
insulin pump, compared to 31.7% in the most deprived areas.
•
The gap between pump usage amongst children and young people with Type 1 diabetes
living in the most and least deprived areas has widened with time, from 18.4% versus 26.3% (a
difference of 7.9 percentage points) in 2014/15, to 31.7% versus 44.3% (a difference of 12.6
percentage points) in 2019/20. However, the discrepancy reduced from 13.4 percentage points
in 2018/19.
9.2.9 Continuous blood glucose monitoring
•
Almost a fifth (19.4%) of children and young people with Type 1 diabetes
were using a real time continuous glucose monitor with alarms (rtCGM).
•
Almost half of all children with Type 1 diabetes aged 0-4 were using an
rtCGM, compared to 11% of 15-19 year olds.

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NPDA National report 2019/20: Care processes and outcomes
•
One fifth (20.2%) of White children and young people with Type 1 diabetes were using an
rtCGM compared to 15.1% of Asian and 11.7% of Black children and young people with diabetes.
•
In the most deprived areas, 14.0% of children and young people with diabetes were using an
rtCGM, compared to 25.2% in the least deprived areas.
•
Children and young people with Type 1 diabetes using rtCGM with alarms were more likely to
be using insulin pump therapy than insulin injections.
•
Combined pump and rtCGM usage amongst children and young people with Type 1 diabetes
was most strongly associated with achievement of lower HbA1c target outcomes.
9.2.10 Thyroid and coeliac disease
•
One in 20 (5.8%) of children and young people in England and Wales with
Type 1 diabetes had been recommended a gluten-free diet, indicative of
coeliac disease; and 3.1% were receiving treatment for thyroid disease.
•
Prevalence of coeliac disease was higher amongst girls with Type 1 diabetes
(7.0%) compared to boys (4.7%).
•
There were twice as many girls with Type 1 diabetes and thyroid disease (4.3%) compared to
boys (2.0%).
•
The prevalence of coeliac disease was higher amongst children and young people with Type 1
diabetes living in the least deprived areas, and within White and Asian ethnic groups.
9.3 Key findings: Type 2 diabetes
9.3.1 Incidence, prevalence, and patient
characteristics
•
There were 866 children and young people with Type 2 diabetes reported to the audit, of
whom 201 (23.2%) were newly diagnosed within the audit year.
•
There have been year on year increases in the numbers of children and young people with
Type 2 diabetes being managed within a PDU since 2012/13, with the percentage of the total
NPDA sample doubling from 1.3 to 3.0% in this period.
•
Higher risk of Type 2 diabetes was found in girls, those of non-white ethnicity, and those living
in the most deprived areas, consistent with previous NPDA findings.
9.3.2 Completion of health checks
•
The completion rates of all recommended health checks for Type 2
diabetes decreased between 2018/19 and 2019/20, except for urinary
albumin which remained constant.
•
The percentage of those aged 12 and above with a complete year of care
receiving all seven key checks decreased from 30.9% in 2018/19 to 26.7% in
2019/20.
•
The percentage of those with a complete year of care receiving four or more HbA1c
measurements during the audit year decreased from 34.9% in 2018/19 to 33.0% in 2019/20.

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NPDA National report 2019/20: Care processes and outcomes
9.3.3 Blood glucose diabetes control targets (HbA1c)
•
The mean and median HbA1c of children and young people with Type 2
diabetes in England and Wales receiving care in a PDU in 2019/20 were 58.6
and 51.0 mmol/mol.
•
The national mean increased by 1.2 mmol/mol and the national median
increased by 0.5 mmol/mol between 2018/19 and 2019/20.
•
Similarly to Type 1 diabetes, higher average HbA1c was seen in those children
and young people of a female sex, with a longer duration of diagnosis, living
in a more deprived area and Black, mixed and Asian ethnicity.
9.3.4 Microvascular complications
•
Albuminuria was found in 25.7% of children and young people with Type 2
diabetes; more than twice the rate observed in those with Type 1 diabetes,
indicating that children and young people with Type 2 diabetes are at
greater risk of kidney disease.
•
Abnormal eye screening results were found in 6.1% of young people with
Type 2 diabetes; half the rate recorded amongst young people with Type 1
diabetes.
9.3.5 Macrovascular complications and risk factors
•
Hypertension (defined by either systolic or diastolic blood pressure) was
found in 44.3% of children and young people with Type 2 diabetes, almost
double that seen in Type 1 diabetes.
•
Over a quarter (28.8%) of young people aged 12 years and older with Type 2
diabetes had a total blood cholesterol level exceeding the target of 5 mmol/l.
•
Most (84.2%) of children and young people with Type 2 diabetes were obese.
9.3.6 Outcomes of psychological assessment
•
Over half (53.6%) of children and young people with Type 2 diabetes were
assessed as requiring additional psychological or CAMHS support outside
of MDT clinics; an increase from 45.5% in 2018/19.
9.3.7 Treatment regimen
•
More than half (57.7%) of children and young people with Type 2 diabetes were managing their
diabetes with dietary management alone or with diet and blood glucose lowering medication.

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NPDA National report 2019/20: Care processes and outcomes
10. NPDA resources to support the use
of the audit results for quality
improvement
10.1 Reviewing results
•
Comprehensive PDU level reports comparing performance between audit years and against
regional and national averages are available to download from via a pdf generator on the NPDA
website.
•
Unit, regional, and CCG level results are available for comparison on the NPDA’s interactive
reporting web tool, NPDA Results Online. Results for specific measures can be compared
across each reporting level, and between audit years.

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NPDA National report 2019/20: Care processes and outcomes
•
The NPDA also provides Excel files of each audit years results presented at PDU, regional, CCG,
and STP level on the NPDA website.
10.2 Communicating results and planning
improvements as a team
Team work is essential for successful, sustained quality improvement activity, and so the NPDA
has developed a slide deck for clinical leads to use to present their results to their teams, identify
areas of achievement and for improvement, and raise awareness of the audit’s key findings and
recommendations. The slide deck contains links to resources to support quality improvement,
including case studies and presentations from NPDA annual conferences.

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NPDA National report 2019/20: Care processes and outcomes
10.3 Engaging families in improving care
We believe that quality improvement activities are most successful when clinical teams and service
users work together, so our parent and patient focussed outputs are designed to empower them
to recognise good care and meaningfully collaborate with clinicians to support required
improvements where identified. For this core, care process and outcome audit, these include:
•
Parent and carer versions of the report in English and Welsh
•
Bespoke clinic posters showing PDU performance against key audit measures and national
and regional results.
•
Animations explaining the function of the audit, and key results and messages arising from
the audit.
Examples shown relate to the 2018/19 and updated versions will be produced for the 2019/20 report.

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NPDA National report 2019/20: Care processes and outcomes
11. Conclusion
In a uniquely challenging year, paediatric diabetes teams have demonstrated continued
commitment to data-driven improvement by participating in the NPDA 2019/20 data process. This
report demonstrates the maintenance of improvements made year on year over the past seven
years, both in terms of diabetes related outcomes, and the provision of recommended health
checks for those with Type 1 diabetes.
However, this report also shows that there remains much to do to reduce inequalities in outcomes
associated with deprivation, ethnicity, and age, in the use of technologies that can support children
and young people to achieve the best HbA1c possible, and in terms of risk of Type 2 diabetes.
Further, health check completion amongst those with Type 2 diabetes worsened. Teams must
continue to work together with the children and young people that they care for, their families and
healthcare commissioners to identify and tackle barriers to achieving excellent outcomes. Ongoing
national, regional and local quality improvement activities must focus on reducing variation in
care and outcomes between patients and PDUs.

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NPDA National report 2019/20: Care processes and outcomes
12. Acknowledgements
Report Editors
•
Ms Saira Pons Perez, NPDA Analyst, RCPCH
•
Professor Justin Warner, Clinical Lead, RCPCH and Consultant in Paediatric Endocrinology and
Diabetes, Cardiff and Vale University Health Board
•
Ms Holly Robinson, NPDA Manager, RCPCH
•
Ms Karina Green, NPDA Coordinator, RCPCH
Quantitative Analysis
•
Ms Saira Pons Perez, NPDA Analyst, RCPCH
National Paediatric Diabetes Audit Clinical Lead
•
Professor Justin Warner, Clinical Lead, RCPCH and Consultant in Paediatric Endocrinology and
Diabetes, Cardiff and Vale University Health Board
Project Management
•
Ms Holly Robinson, NPDA Manager, RCPCH
Project Support
•
Ms Karina Green, NPDA Coordinator, RCPCH
•
Mr Simon Duncan, Audit Administrator, RCPCH
•
Mr Tom Keiller, Administrative Assistant, RCPCH
•
Mr Calvin Down, Clinical Standards Programme Manager, RCPCH
•
Ms Adele Picken, Information Governance Manager, RCPCH
National Paediatric Diabetes Audit Project Board
•
Professor Nick Bishop, Vice President for Science and Research, RCPCH (Chair)
•
Dr Fiona Campbell, Consultant Paediatric Diabetologist, Leeds Teaching Hospitals NHS Trust
•
Professor Justin Warner, Clinical Lead, RCPCH and Consultant in Paediatric Endocrinology and
Diabetes, Cardiff and Vale University Health Board
•
Dr Kemi Lokulo-Sodipe, Specialty Registrar in Paediatrics, Southampton Children’s Hospital
•
Ms Rachel Harris, Paediatric Diabetes Specialist Nurse, Cardiff and Vale University Health Board
•
Ms Kate Cullen, Parent Representative
•
Mr Simon Lewthwaite, Parent Representative
•
Dr Neil Hopper, Consultant Paediatrician, South Tyneside And Sunderland NHS Foundation Trust
•
Dr Mark Deakin, Consultant Paediatrician, Alder Hey Children’s Hospital NHS Foundation Trust

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NPDA National report 2019/20: Care processes and outcomes
National Paediatric Diabetes Audit Methodology and Dataset Working Group
•
Dr Fiona Campbell, Leeds Teaching Hospitals NHS Trust (Chair)
•
Dr Nivedita Aswani, Consultant in General Paediatrics and Diabetes, Derby Hospitals NHS
Foundation Trust
•
Dr Bill (William) Lamb, Consultant Paediatric Diabetologist
•
Professor Justin Warner, Consultant in Paediatric Endocrinology and Diabetes, Cardiff and Vale
University Health Board
•
Ms Francesca Annan, Dietitian, Clinical Specialist Paediatric/Adolescent Diabetes Dietitian,
University College London Hospital Foundation Trust
•
Dr Halina Flannery, Clinical Psychologist, University College London Hospital NHS Foundation
Trust
•
Ms Kate Fazakerley, Parent Representative
•
Dr Alex De Costa, Specialty Registrar in Paediatrics, Queen Mary University
•
Ms Kate Cullen, Parent Representative
•
Mr Simon Lewthwaite, Parent Representative
•
Ms Rachel Harris, Paediatric Diabetes Specialist Nurse, Cardiff and Vale University Health Board
•
Ms Nicky Moor, Paediatric Diabetes Specialist Nurse, Barts and the London NHS Trust
•
Dr Neil Hopper, Consultant Paediatrician, South Tyneside And Sunderland NHS
Foundation Trust
•
Dr Mark Deakin, Consultant Paediatrician, Alder Hey Children’s Hospital NHS Foundation Trust
•
Dr Evelien Gevers, Consultant Paediatrician, Barts and the London NHS Trust
HQIP Support
•
Ms Vivien Dunne, Project Manager, NCAPOP, Healthcare Quality Improvement Partnership
•
Dr Sasha Hewitt, Associate Director, NCAPOP, Healthcare Quality Improvement Partnership
•
Ms Emma Skipper, Associate Director, NCAPOP, Healthcare Quality Improvement Partnership

The Royal College of Paediatrics and Child Health (RCPCH) is a registered charity in England and Wales (1057744) and in
Scotland (SC038299).
Royal College of Paediatrics
and Child Health
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Healthcare Quality
Improvement Partnership (HQIP)
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London EC3N 2EX
Royal College of
Paediatrics and Child Health
RCPCH
Published by RCPCH May 2021
National Paediatric Diabetes Audit (NPDA)
Annual report 2019-20
Care processes and outcomes