NPDA 2020-21 Appendix 1: Full audit analysis
Source: data.gov.uk (2024-05-31)

National Paediatric Diabetes Audit 2020 - 2021. The excel file contains unit, regional and national level data obtained from the National Paediatric Diabetes Audit 2020-2021.
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 2020 and the 31 March 2021.
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 2022 alongside the National Paediatric Diabetes Audit Report 2020-2021 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 2020-21:
Care processes and outcomes
Audits
RCPCH
National Paediatric
Diabetes Audit
NPDA
Appendix 1 - full audit analysis

NPDA National report 2020/21:
Care processes and outcomes
Appendix 1: Full audit analysis

3.3.5 HbA1c outcomes by deprivation
quintile
42
3.3.6 HbA1c outcomes across PDUs in
England and Wales
43
3.4
HbA1c outcomes of children and
young people with Type 2 diabetes 44
3.4.1 HbA1c outcomes by sex
45
3.4.2 HbA1c outcomes by age group and
duration of Type 2 diabetes
46
3.4.3 HbA1c outcomes by deprivation
quintile
46
3.4.4 HbA1c outcomes by ethnic category 47
3.5
Small vessel (microvascular) disease 48
3.5.1 Diabetic kidney disease
48
3.5.2 Eye Disease
52
3.6
Large vessel disease – Cardio Vascular
Disease (CVD) risk factors
53
3.6.1 Blood pressure and cholesterol
53
3.6.2 Body Mass Index
56
3.7
Psychological assessment
61
3.7.1 Psychological outcomes of children
and young people with
Type 1 diabetes
61
3.7.2 Psychological outcomes of children
and young people with Type 2
diabetes
63
3.8
Hospital Admissions
63
3.8.1 Type 1 Diabetes-related admissions 63
3.8.2 DKA at diagnosis
64
4.
Treatment regimen and
diabetes monitoring
66
4.1
Treatment regimens
66
4.1.1 Treatment regimens of children
and young people with Type 1
diabetes
66
4.1.2 Treatment regimens of children and
young people with Type 2 diabetes 70
4.2
Real Time Continuous glucose
monitoring (rtCGM)
70
4.2.1 rtCGM use among children and young
people with Type 1 diabetes
71
5.
Thyroid and coeliac disease 76
5.1
Thyroid and coeliac disease
amongst children and young
people with Type 1 diabetes
76
6.
List of Tables
79
7. List of Figures
81
8.
References
85
Contents
1.
Characteristics, prevalence,
and incidence
4
1.1
Audit cohort
4
1.2
Characteristics of children and young
people with Type 1 diabetes
4
1.2.1 Age and sex
4
1.2.2 Regional distribution
5
1.2.3 Ethnicity
6
1.2.4 Deprivation
7
1.3
Prevalence and incidence of Type 1
diabetes
7
1.3.1 Prevalence
7
1.3.2 Incidence
9
1.4
Characteristics of children and
young people with Type 2 diabetes
13
1.4.1 Age and sex
13
1.4.2 Regional distribution
14
1.4.3 Ethnicity
15
1.4.4 Deprivation
15
2.
Completion of health
checks (care processes)
16
2.1
Completion of health checks for
children and young people with
Type 1 diabetes
16
2.1.1 Completion of key health checks
16
2.1.2 Variation in key health check
completion
19
2.1.3 Number of HbA1c measurements
received
23
2.1.4 Nutrition and lifestyle education
and support
25
2.1.5 Completion of all other annual
health checks
26
2.1.6 Care at diagnosis
28
2.2
Health checks for children and young
people with Type 2 diabetes
30
2.2.1 Completion of key health checks
30
2.2.2 Number of HbA1c measurements
32
2.2.3 Completion of all other health checks 32
3.
Outcomes
34
3.1
HbA1c
34
3.2
HbA1c outcomes of children and young
people with all types of diabetes
34
3.3
HbA1c outcomes of children and
young people with Type 1 diabetes
36
3.3.1 National and regional unadjusted
HbA1c results
36
3.3.2 HbA1c outcomes by sex
39
3.3.3 HbA1c outcomes by duration of
diabetes
39
3.3.4 HbA1c outcomes by ethnicity
40

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NPDA National report 2020/21: Care processes and outcomes
1.
Characteristics, prevalence, and
incidence
1.1 Audit cohort

A total of 31,615 children and young people with diabetes were included in the 2020/21 audit.

Table 1 shows the breakdown by age group and type of diabetes.

Table 1: Number of children and young people with diabetes by age-group and type of diabetes in
2020/21.
0-4
years
5-9
years
10-14
years
15-19
years++
20-24
years ++
Total
% of
cohort
Type 1 diabetes
1,570
6,331
12,598
9,372
21
29,892
94.6%
Type 2 diabetes
0
17
367
589
0
973
3.1%
Cystic fibrosis-related diabetes
17+
87
88+
192
0.6%
Monogenic forms of diabetes
14
28
59
61
0
162
0.5%
Other specified diabetes mellitus
29
55
128
97+
309
1.0%
Not specified diabetes mellitus
10
17
34
26+
87
0.3%

+ Results merged to mask number <5

++ The NPDA recognises that transition to adult diabetes services usually starts in a patient’s late teenage years. The numbers presented in
these columns represents the number still receiving care from a PDU and does not represent the total number of young people with
diabetes in these age groups in England and Wales.
1.2 Characteristics of children and young people
with Type 1 diabetes
1.2.1 Age and sex

Figure 1 shows the number of children and young people with Type 1 diabetes by sex and age in
whole years at the beginning of the audit period. The distribution by age and sex is consistent with
previous years. The number of children increases with age up to the age of 15, when many young
people start to transition to adult services. Boys account for 52.7% of the sample.

5
NPDA National report 2020/21: Care processes and outcomes
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
Boys
41
94
166
240
307
404
516
641
733
908
1006
1250
1348
1482
1505
1555
1483
1243
699
120
Girls
37
86
141
178
279
383
502
558
760
913
1005
1138
1299
1310
1241
1315
1229
1028
579
132
2020/21
78
180
307
418
586
787
1018
1199
1493
1821
2011
2388
2647
2792
2746
2870
2712
2271
1278
252
2019/20
51
167
273
388
569
742
922
1167
1426
1633
1944
2250
2397
2445
2638
2644
2510
2063
1199
170
0
400
800
1200
1600
2000
2400
2800
3200
Number of children and young people
with Type 1 diabetes reported to the audit
Age, sex and audit year

Figure 1: Total number of children and young people with Type 1 diabetes broken down by age and
sex, 2019/20 – 2020/21
1.2.2 Regional distribution of children and young people with
Type 1 diabetes

Table 2 shows the number of children and young people with Type 1 diabetes by age category
included in the 2020/21 audit overall and by country and regional network. Children and young
people were allocated to a region and country based on the last paediatric diabetes unit (PDU)
that they attended within the audit year.

6
NPDA National report 2020/21: Care processes and outcomes

Table 2: Number of children and young people with Type 1 diabetes by country, region and age
group, 2020/21
Region/Country
0-4
years
5-9
years
10-14
years
15-19
years
20-24
years
Total
(% of
cohort)
England and Wales
1,570
6,331
12,598
9,372
21
29,892
100.0%
England
1,496
6,033
11,905
8,974
21
28,429
95.1%
Wales
74
298
693
398
0
1,463
4.9%
East Midlands
113
449
870
672+
2,104
7.0%
East of England
194
699
1,350
1,007+
3,252
10.9%
London and South East +
327
1,381
2,762
2,106+
6,579
22.0%
North East and North Cumbria
94
358
709
524
0
1,685
5.6%
North West
200
776
1,607
1,093
8
3,685
12.3%
South Central +
143
630
1,145
871
0
2,790
9.3%
South West
121
503
1,002
683+
2,309
7.7%
West Midlands
153
671
1,296
1,012+
3,132
10.5%
Yorkshire and Humber
142
566
1,164
1,019+
2,893
9.7%

+ Results merged to mask numbers <5
1.2.3 Ethnicity

The ethnic breakdown of the children and young people with Type 1 diabetes reported to the
2020/21 audit is shown in Table 3. Percentages are also shown excluding ‘not stated’ and ‘unknown’
categories to allow for comparison with the 2011 census data. The distribution of Type 1 diabetes by
ethnic status is similar to the background population.

Table 3: Ethnic groups of children and young people with Type 1 diabetes in England and Wales,
2020/21
No. of children and
young people with T1
diabetes
Total
(% of cohort)
% of total with
known and
stated ethnicity
% of total
population**
White
23,715
79.3%
83.3%
86.0%
Asian
1,991
6.7%
7.0%
7.5%
Black
1,182
4.0%
4.1%
3.3%
Mixed
903
3.0%
3.2%
2.2%
Other
691
2.3%
2.4%
1.0%
Not stated
799
2.7%
-
-
Not known
611
2.0%
-
-

*Percentage of total population in 2011 England and Wales Census

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NPDA National report 2020/21: Care processes and outcomes
1.2.4 Deprivation

Table 4 shows the number and percentages of children and young people with Type 1 diabetes by
deprivation quintile in 2020/21 based on patient postcode and the English (IMD, 2019) and Welsh
(WIMD, 2019) indices of multiple deprivation. Percentages are also shown excluding missing values
to allow for comparison with the breakdown of the general population aged 0 to 19 years old in
England and Wales (ONS, 2019).

The deprivation breakdown shows a higher proportion of children and young people with Type 1
diabetes living in the most deprived quintile. This is consistent with the distribution of the general
population aged 0 to 19 years old in England and Wales.

Table 4: Percentage and number of children and young people with Type 1 diabetes by deprivation
quintile, 2020/21
Deprivation
quintile
Total
% of cohort
% of total
with known
deprivation
% of children and
young people
aged 0-19 yrs
old (England and
Wales)+
Most deprived
6,786
22.7%
22.7%
23.7%
Second most deprived
6,069
20.3%
20.3%
20.7%
Third least deprived
5,659
18.9%
19.0%
19.0%
Second least deprived
5,682
19.0%
19.0%
18.1%
Least deprived
5,665
19.0%
19.0%
18.5%
Missing
31
0.1%
-
-

+Percentage of general population aged 0 to 19 years old in England and Wales. Calculations made using the “Lower layer Super Output
Area population estimates” from the Office for National Statistics, mid-year 2020.
1.3 Prevalence and incidence of Type 1 diabetes
1.3.1 Prevalence

Figures 2 and 3 show the prevalence rates of Type 1 diabetes in children and young people aged 15
and below by sex and by age group, over the last seven audit years respectively.

The estimated prevalence rate of Type 1 diabetes in England and Wales was 204.5 per 100,000 of
the general population. It was slightly higher among boys (208.3 per 100,000) compared to girls
(200.4 per 100,000), with no appreciable change over the last seven audit years.

8
NPDA National report 2020/21: Care processes and outcomes
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
Boys
199.8
194.9
190.8
196.1
198.1
198.1
199.0
208.3
Girls
175.3
187.2
190.6
192.2
193.8
194.6
197.6
200.4
All
187.7
192.0
195.0
194.2
196.0
196.4
198.3
204.5
0
50
100
150
200
250
Prevalence per 100,000 general
population 0-15 years old
Sex and audit year
y

Figure 2: Prevalence of Type 1 diabetes per 100,000 general population among children aged 0-15
years by age and sex, 2013/14 to 2020/21.
0
50
100
150
200
250
300
350
400
0-4
5 - 9
10 - 14
0 - 4
5 - 9
10 - 14
0 - 4
5 - 9
10 - 14
Boys
Girls
All
Prevalence per 100,000 general
population
Age group and sex
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21

Figure 3: Prevalence of Type 1 diabetes per 100,000 general population by age group and sex,
2013/14 to 2020/21

9
NPDA National report 2020/21: Care processes and outcomes
1.3.2 Incidence

In 2020/21 there were 3,662 children and young people newly diagnosed with Type 1 diabetes, of
whom 3,526 (96.3%) were aged 0-15 years old1. This is 789 more than the average number newly
diagnosed and being managed in a PDU between 2013/14-2019/20 (2873). By comparison, the
mean number of children and young people with all types of diabetes being managed within a
PDU in 2020/21 was 185.

Figure 4a shows the incidence of Type 1 diabetes among boys and girls aged 0-15 years, from
2013/14 to 2020/21. It shows an increase in both girls and boys in 2020/21 (a 27.4% increase in boys
and a 12.6% increase in girls) compared to 2019/20.
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
Boys
24.8
28.0
24.8
25.9
26.0
25.8
26.6
33.9
Girls
20.8
24.4
20.8
24.4
24.2
23.3
24.6
27.7
All
22.8
26.5
22.8
25.4
25.1
24.6
25.6
30.9
0
5
10
15
20
25
30
35
40
Incidence per 100,000 general
population 0-15 years old
Sex and audit year
Boys
Girls
All

Figure 4a: Incidence of Type 1 diabetes per 100,000 general population among children aged 0-15
years by sex, 2013/14 to 2020/21

Figure 4b shows that the consistent seasonal pattern of new diagnoses of Type 1 diabetes amongst
all children and young people receiving care from a PDU observed in previous audit years was
disrupted in 2020/21. The reason for this is not known.
1 The NPDA and the National Diabetes Audit (NDA) have undertaken a quality assurance exercise around case ascertainment of new cases of Type
1 diabetes. The NPDA collects data on children and young people with diabetes from PDUs where care is provided whereas the NDA collects data
from the General Practice Extraction Service (GPES) covering whole populations. Although there are slight differences in the number of new cases
from these two data sources, the increasing incidence is demonstrated in both, thus validating the data for audit and QI purposes.

10
NPDA National report 2020/21: Care processes and outcomes
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2013/14
252
225
190
186
208
245
249
242
224
258
202
134
2014/15
262
224
188
181
213
241
245
207
253
293
236
182
2015/16
240
237
205
224
234
304
296
248
264
300
258
161
2016/17
278
243
227
192
259
264
278
262
251
294
210
180
2017/18
242
253
214
223
243
272
275
216
243
309
229
198
2018/19
245
215
217
203
248
258
274
265
222
312
231
205
2019/20
241
251
221
217
231
268
256
270
293
286
257
146
2020/21
194
281
308
316
302
339
379
320
296
287
301
339
0
50
100
150
200
250
300
350
400
Number of children diagnosed with
Type 1 diabetes
Month of diagnosis
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21

Figure 4b: Number of new cases of Type 1 diabetes amongst children and young people receiving
care from a PDU by month, 2013/14-2020/21

Figure 5 shows the breakdown of the age at diagnosis for both boys and girls with Type 1 diabetes
in 2020/21.

11
NPDA National report 2020/21: Care processes and outcomes
343
638
880
204
291
629
574
96
0
200
400
600
800
1000
0 to 4 years
5 to 9 years
10 to 14 years
15+
Newly diagnosed children and young
people with Type 1 diabetes
Sex and age group
Boys
Girls

Figure 5: Newly diagnosed children and young people with Type 1 diabetes by age group and sex,
2020/21

Figure 6 shows an increase in incidence of Type 1 in 2020/21 compared to all previous audit years in
each age group, and in both boys and girls, with the highest incidence amongst boys aged 10-14 years.
0
5
10
15
20
25
30
35
40
45
50
0 - 4
5 - 9
10 - 14
0 - 4
5 - 9
10 - 14
0 - 4
5 - 9
10 - 14
Boys
Girls
All
Incidence per 100,000 general population
Age group, sex and audit year
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21

Figure 6: Incidence of Type 1 diabetes per 100,000 general population by age group and sex, 2013/14
to 2020/21

Despite the increased incidence, Figure 7 shows no difference in the age profile in new incidence
of Type 1 diabetes between 2019/20 and 2020/21.

12
NPDA National report 2020/21: Care processes and outcomes
0
50
100
150
200
250
300
350
400
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Age
Numbers of new cases of Type 1 diabetes
2019/20
2020/21

Figure 7: Numbers of new cases of Type 1 diabetes presenting in 2019/20 and 2020/21 by age at the
beginning of the audit year

Figure 8 shows the incidence per 100,000 of Type 1 diabetes by CCG in England and LHB in Wales.

Figure 8: Incidence of Type 1 diabetes amongst children and young people aged 0-15 years per
100,000 by CCG (England) and LHB (Wales)

13
NPDA National report 2020/21: Care processes and outcomes
1.4 Characteristics of children and young people
with Type 2 diabetes

In 2020/21, there were 973 children and young people with Type 2 diabetes being cared for in a
PDU, of whom 230 (23.6%) were newly diagnosed within the audit year. Prevalence and/or incidence
rates of Type 2 diabetes cannot be accurately calculated from NPDA data as an unknown number
of children and young people are treated for Type 2 diabetes in primary care and will therefore not
be included in the paediatric audit. However, there appears to be a year on year increase in the
number of children and young people with Type 2 diabetes being managed within PDUs. For
instance, in 2020/21 there was an increase of 107 (12.4%) compared to the total number reported in
20219/20. Figure 9 shows the numbers of children and young people with Type 2 diabetes being
managed within a PDU since 2011/12.
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
Type 2 diabetes
448
326
340
544
621
715
745
790
866
973
% Total Audit
1.8%
1.3%
1.3%
2.0%
2.2%
2.5%
2.5%
2.6%
3.0%
3.1%
448
326
340
544
621
715
745
790
866
973
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
0
200
400
600
800
1000
1200
1400
Number of children and young people
with Type 2 Diabetes
Percentage of total NPDA cohort

Figure 9: Numbers of children and young people with Type 2 diabetes included in the NPDA,
2011/12- 2020/21
1.4.1 Age and sex

Figure 10 shows the age and sex breakdown of children and young people with Type 2 diabetes. The
numbers start to fall from ages 15-16 years due to transitioning to adult services. In every age there
is a higher proportion of girls with Type 2 diabetes. It shows there were higher numbers of young
people with Type 2 diabetes aged 15-17 receiving care from PDUs in 2020/21 compared to 2019/20.

14
NPDA National report 2020/21: Care processes and outcomes
0-9
10
11
12
13
14
15
16
17
18+
Boys
5
8
18
22
43
47
71
77
47
36
Girls
12
16
23
49
65
76
115
114
68
60
2020/21
17
24
41
71
108
123
186
191
115
96
2019/20
22
21
34
59
76
144
165
132
125
86
0
50
100
150
200
250
Number of children and young people with
Type 2 diabetes
Age and sex

Figure 10: Numbers of children and young people with Type 2 diabetes by age and sex, 2019/20 and
changes in numbers between 2019/20 and 2020/21
1.4.2 Regional distribution

Table 5 shows the number of children and young people with Type 2 diabetes by country and region,
based on PDU location.

Table 5: Number of children and young people with Type 2 diabetes by country and region, 2020/21
Region/Country
5-9 years
10-14 years
15-19 years
Total
(% of cohort)
England and Wales
17
367
589
973
3.3%
England
17
354
574
945
3.2%
Wales
0
13
15
28
0.1%
East Midlands
27+
39
66
0.2%
East of England
22+
39
61
0.2%
London and South East
5
127
194
326
1.1%
North East and North Cumbria
0
16
22
38
0.1%
North West
55+
63
118
0.4%
South Central
0
30
34
64
0.2%
South West
12+
29
41
0.1%
West Midlands
48+
94
142
0.5%
Yorkshire and Humber
29+
60
89
0.3%

+Results merged to mask numbers <5

15
NPDA National report 2020/21: Care processes and outcomes
1.4.3 Ethnicity

Table 6 shows the breakdown of children and young people with Type 2 diabetes by ethnic category.
The percentage of the general population in each ethnic category according to the most recent
census is presented to enable comparison of prevalence of Type 2 diabetes within each category.
Most children and young people with Type 2 diabetes were of non-White ethnicity, and the
prevalence of Type 2 diabetes in children of non-White ethnicity was disproportionately higher
than the prevalence of non-White ethnicity in the general population. The breakdown in 2020/21
was similar compared to 2019/20.

Table 6: Children and young people with Type 2 diabetes England and Wales by ethnic group,
2020/21
Ethnicity
Total
% of cohort
% of total with
stated ethnicity
% of total
population*
White
324
33.3%
36.2%
86.0%
Asian
343
35.3%
38.4%
7.5%
Black
129
13.3%
14.4%
3.3%
Mixed
49
5.0%
5.5%
2.2%
Other
39
4.0%
4.4%
1.0%
Not stated
29
3.0%
-
-
Not known
60
6.2%
-
-

*Percentage of total population in 2011 England and Wales Census
1.4.4 Deprivation

Table 7 shows that there were a disproportionate number of children and young people with Type
2 diabetes living in the most deprived areas compared to the least deprived. This trend was
observed in previous audit years.

Table 7: Numbers and percentages of children and young people with Type 2 diabetes by
deprivation quintile, 2020/21
Deprivation quintile
Total
% of cohort
% of total with
known
deprivation*
% of children and
young people
aged 0-19 years
old (England and
Wales)**
Most deprived
406
41.7%
41.9%
23.7%
Second most deprived
273
28.1%
28.1%
20.7%
Third least deprived
157
16.1%
16.2%
19.0%
Second least deprived
81
8.3%
8.4%
18.1%
Least deprived
52
5.3%
5.4%
18.5%
Missing
4
0.4%
-
-

* Percentages within deprivation quintiles have been calculated excluding those without an allocated quintile due to missing data, to
allow comparison to the age group 0-19 years old in England and Wales, 2020.

**Percentage of general population aged 0 to 19 years old in England and Wales. Calculations made using the “Lower layer Super Output
Area population estimates” from the Office for National Statistics, mid-year 2020.

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NPDA National report 2020/21: Care processes and outcomes
2. Completion of annual health checks
2.1 Completion of health checks for children and
young people with Type 1 diabetes
2.1.1 Completion of key health checks

Health checks recommended by NICE for children and young people with Type 1 diabetes (NG18,
NICE 2015; NG19, 2015) should be performed at least once annually.

Prior to 2020/21 the NPDA reported on the following seven to be the ‘key’ annual checks:

1. Glycated Haemoglobin A1c (HbA1c) (blood test for diabetes control)

2. Body Mass Index (BMI) (measure of cardiovascular risk)

3. Blood pressure (measure of cardiovascular risk)

4. Urinary albumin (urine test for kidney function)

5. Thyroid screen (blood test for hyper/hypothyroidism)

6. Eye screening (photographic test for eye risk)

7. Foot examination (foot examination for ulcer risk)

However, disruptions to the diabetic retinopathy screening schedule due to the COVID-19 pandemic
meant that fewer children and young people underwent retinopathy screening. Furthermore,
there was a recommendation to reduce screening from annually to biennially unless retinopathy
was observed at a previous screen, for many services in England. In view of this change, the NPDA
has changed its reporting and now describes six ‘key annual checks’, excluding retinopathy
screening. Guidelines specify a starting age of 12 years for commencing all checks except for HbA1c
and measurement of height and weight, which should be recorded in all ages of children and
young people with Type 1 diabetes, and thyroid screening, which should be performed at diagnosis
and annually thereafter.

In 2020/21, there were 24,138 children and young people with Type 1 diabetes who completed a full
year of care (i.e. who did not transition to adult services, did not die, and were not diagnosed within
the audit year), of whom 14,449 (59.9%) were aged 12 and above. Table 8 shows the percentage of
children and young people recorded as receiving essential healthcare checks in the audit year,
from 2015/16 to 2020/21.

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NPDA National report 2020/21: Care processes and outcomes

Table 8: Percentage of children and young people with Type 1 who completed a full year of care
recorded as receiving health checks, 2015/16 to 2020/21
Age
Health check completion
Audit year
2015/16
2016/17
2017/18
2018/19
2019/20 2020/21
All
ages
No. of children and young people
with T1 diabetes (n)
22,567
22,933
23,130
23,223
22,638
24,138
HbA1c (%)
99.2
99.5
99.4
99.4
99.7
90.6
BMI (%)
97.9
98.7
98.9
99.2
99.3
78.6
Thyroid (%)
77.7
81.8
84
87.2
87.8
77.9
Aged
12 and
above
No. of young people with T1 diabetes (n)
13,313
13,437
13,363
13,391
13,266
14,449
Blood pressure (%)
90.8
92.7
94.6
96.2
96.5
70.4
Urinary albumin (%)
66.0
68.7
74.3
78.3
79.1
64.4
Foot Exam (%)
65.8
72.8
78.2
82.5
84.3
57.1
All seven health checks* (%)
35.5
43.5
49.8
55.2
54.4
N/a
All six health checks (%)*
40.2

* Includes retinal screening- one of the key annual checks until 2020/21

**Excludes retinal screening due to change in screening interval for 2020/21.

Given the suspension of ‘face to face’ clinic visits across England and Wales for much of 2020/21,
and reluctance amongst some families to come to the hospital setting following cessation of
restrictions, it is not surprising that completion rates for 2020/21 have decreased from previous
years. Figure 11 shows completion rates from 2004/05 up until 2020/21. Comparisons of completion
rates prior to 2015/16 should be reviewed with caution as they included both Type 1 and Type 2
diabetes.

Figure 11 shows that the improvement trend from previous audit years reversed in 2020/21, with
smaller percentages receiving each key health check compared to the previous audit year.

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NPDA National report 2020/21: 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
2020/21
All types of diabetes
Type 1 only
Type 1 only
(excluding eye screening)
% of children and young people who completed
a full year of care
Audit year
HbA1c
Blood pressure*
BMI
Urinary albumin*
Cholesterol*
Eye screen*
Foot Exam*
Thyroid

* health checks completed on children and young people aged 12 or older

Figure 11: Percentage of children and young people who completed a full year of care recorded as
receiving individual health checks, 2004/05 to 2020/21

Figure 12 shows that only two fifths (40.2%) of all children with Type 1 diabetes who completed a
year of care in 2020/21 received all six key annual healthcare checks, which is lower than the
percentage receiving all seven in 2020/21 (when retinopathy screening was included),
2.0%
2.6%
3.6%
5.0%
5.2%
4.1%
5.8%
6.7%
12.1%
16.1%
25.4%
35.5%
43.5%
49.8%
55.2%
54.4%
40.2%
0%
10%
20%
30%
40%
50%
60%
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
2020/21
All types of diabetes
Type 1 only
Type 1 only-
six checks*
% of young people aged 12 or older who completed
a full year of care
Audit year

Figure 12: Percentage of young people aged 12 or above who completed a full year of care recorded
as receiving all seven/six key health checks, 2004/05 to 2020/21.

* Retinopathy screening was removed from the ‘seven key health checks’ analysis in 2020/21 due to changes in frequency of screening
during this audit year. The percentage receiving all of the remaining six key annual checks is presented instead for this audit year.

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NPDA National report 2020/21: Care processes and outcomes

2.1.1.1 Retinopathy screening

Retinopathy screening intervals changed for many services in England in 2020/21. Rather than
screening all those with diabetes aged 12 and above annually, many were advised to screen
biennially unless an abnormal result was observed at previous annual screen. In 2020/21, 24.3% of
children and young people with Type 1 diabetes age 12 and above received a screen, a decrease
from 74.5% in 2019/20.

In 2019/20, 1,302 young people with Type 1 diabetes had an abnormal eye screen recorded, of whom
1,056 were also captured in the 2020/21 audit dataset. Figure 13 shows that of those with results in
both years, only half (49.1%) who had an abnormal eye screen result in 2019/20 had an eye screen in
2020/21.
82.2%
50.9%
17.8%
49.1%
0%
20%
40%
60%
80%
100%
Normal eye screen results in
2019/20
Abnormal eye screen results in
2019/20
Didn't have eye screen in 2020/21
Had eye screen in 2020/21

Figure 13: Percentage of children and young people aged 12 and above in 2019/20 receiving
retinopathy screening in 2020/21, by screening result in 2019/20
2.1.2 Variation in key health check completion

2.1.2.1 Variation in completion rates nationally and regionally

Tables 9 and 10 provide a breakdown of the health checks recorded for children and young people
with Type 1 diabetes with a complete year of care in 2020/21 by regional network, country and
overall, in England and Wales. Table 9 contains data on the health checks received by all children
and young people with Type 1 diabetes and Table 10 contains data on the health checks received
by those aged 12 and above.

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NPDA National report 2020/21: Care processes and outcomes

Table 9: Percentage of children and young people of all ages with Type 1 diabetes who completed
a full year of care recorded as having received key health checks by country and region, 2020/21
Country/Region
No. of children
and young peo-
ple with Type 1
diabetes
Percentage completing health checks
HbA1c (%)
BMI (%)
Thyroid (%)
England and Wales
24,138
90.6
78.6
77.9
England
22,965
90.3
78.8
77.9
Wales
1,173
95.2
74.8
78.9
East Midlands
1,660
97.3
82.3
78.5
East of England
2,645
89.9
68.4
57.7
London and South East
5,395
80.4
75.7
79.2
North East and North Cumbria
1,322
97.8
92.5
87.2
North West
3,011
90.5
79.9
78.2
South Central
2,213
97.4
94.3
83.5
South West
1,893
95.4
77.4
83.9
West Midlands
2,512
89.0
66.5
75.6
Yorkshire and Humber
2,314
94.9
86.2
83.5

Table 10: Percentage of young people aged 12 and above with Type 1 diabetes who completed a full
year of care recorded as having received key health checks by country and region, 2020/21
Country/Region
No. of young
people aged 12
and above with
Type 1 diabetes
Percentage completing health checks
Foot
exam (%)
Blood
pressure
(%)
Urinary
albumin
(%)
All six
(%)
England and Wales
14,449
57.1
70.4
64.4
40.2
England
13,765
57.7
70.6
64.1
40.4
Wales
684
43.9
65.2
69.9
35.8
East Midlands
1,000
48.2
76.3
63.0
32.8
East of England
1,542
39.8
58.2
50.9
23.2
London and South East
3,276
55.6
63.7
59.4
38.7
North East and North Cumbria
777
61.0
89.1
77.7
46.6
North West
1,836
62.6
74.9
64.1
43.8
South Central
1,292
59.4
81.7
73.1
46.4
South West
1,120
60.2
70.1
67.0
40.9
West Midlands
1,518
60.6
60.6
61.5
37.7
Yorkshire and Humber
1,404
74.4
81.6
74.9
58.0

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NPDA National report 2020/21: Care processes and outcomes

2.1.2.5 Variation in completion rates across PDUs

The 2020/21 audit year has clearly been a difficult year to complete health checks in children and
young people with diabetes. However, there has been large variation in rates across all the PDUs
submitting data. Figure 14 shows the percentage of eligible children and young people with Type
1 diabetes receiving each specific key annual health check within each PDU from lowest to highest
in 2020/21. It shows huge variation in the percentages receiving each check within different PDUs,
with some services achieving rates of 100% on some, and others achieving rates lower than 10% of
their caseload.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage of children and young peopke with Type 1
diabetes receivimg each health check per PDU
PDUs
HbA1c 1+ in audit
Thyroid
Body mass index
Blood pressure (aged 12+)
Albuminuria (aged 12+)
Foot examination (aged 12+)

Figure 14: Percentage of children and young people with Type 1 diabetes receiving each key health
check by PDU, 2020/21

Figure 15 shows the variation by PDU in the percentage of young people aged 12 years and older
who were recorded to have received all six key health checks in 2020/21. The horizontal navy line
shows the mean completion rate for England and Wales, and the dotted lines indicate PDUs whose
results are within two standard deviations (dashes) or three standard deviations (dots) of the mean.
There remains considerable variation in percentage of young people receiving all six health checks
across PDUs.

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NPDA National report 2020/21: Care processes and outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
50
100
150
200
250
300
350
% of young people with Type 1 diabetes aged 12 and
above receiving all six healthchecks
Number of young people with Type 1 diabetes aged 12 and above who completed a full
year of care
English PDUs
Welsh PDUs
95% level (2 SD)
99% level (3 SD)
Mean (England and Wales)

Figure 15: Percentage of young people aged 12 years and above with Type 1 diabetes who completed
a full year of care recorded as receiving all six health checks by unit, 2020/21

Figure 16 plots overall PDU health check completion rates against the total number of young people
with Type 1 diabetes aged 12 and above who completed a full year of care within each PDU. The
health check completion rate is calculated by dividing the sum of the number of health checks
received by young people with Type 1 diabetes aged 12 and above who completed a full year of care
by the sum of the total expected number of health checks. The total expected number of health
checks is equal to the number of young people, with Type 1 diabetes aged 12 and above who
completed a full year of care, multiplied by six (i.e. the number of health checks that they should have
received within the audit year). This metric is used in the NPDA to determine outlier status, with
PDUs below the bottom dotted line (>3SD) considered ‘alarm’ outliers, as they were recording
significantly fewer key health checks than other PDUs in England and Wales. In 2020/21 outlier status
is for information only as NICE recommendations were difficult to fulfil during the pandemic year.

23
NPDA National report 2020/21: Care processes and outcomes


55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
0
50
100
150
200
250
300
350
Health check completion rate
Number of young people with Type 1 diabetes aged 12 and above who completed a full
year of care
English PDUs
Welsh PDUs
95% level (2 SD)
99% level (3 SD)
Mean (England and Wales)
Figure 16: Funnel plot of key health check completion rates for young people aged 12 years and
above with Type 1 diabetes who completed a full year of care 2020/21, by PDU

Given the overdispersal of results against these compound health check metrics within the 2020/21
audit year, and the fact that provision of health checks was so severely disrupted during this first
year of the COVID-19 pandemic, the NPDA suspended the outlier management process for this
audit year.
2.1.3 Number of HbA1c measurements received

NICE (NG18) recommends that a minimum of four HbA1c measurements are offered to children
and young people with Type 1 diabetes per annum. Figure 17 shows the percentage of children and
young people with Type 1 diabetes receiving a full year of care by number of HbA1c measurements
received in the audit year. It shows that less than a fifth (14.9%) had four or more measurements
recorded in 2020/21, which is 38.2 percentage points lower than in 2019/20, and a quarter (26.0%)
only had one HbA1c recorded in the audit year.

24
NPDA National report 2020/21: Care processes and outcomes
2016/17
2017/18
2018/19
2019/20
2020/21
0
0.5%
0.6%
0.6%
0.3%
9.4%
1
4.5%
4.3%
3.7%
3.6%
26.0%
2
12.9%
11.4%
10.6%
11.7%
28.3%
3
29.1%
29.0%
27.7%
31.2%
21.4%
4 or more
52.9%
54.6%
57.5%
53.1%
14.9%
0%
10%
20%
30%
40%
50%
60%
70%
% of children and young people with Type 1 diabetes who completed a full
year of care

Figure 17: Percentage of children and young people with Type 1 diabetes who completed a full year of
care by number of HbA1c measurements recorded per child or young person, 2016/17 to 2020/21

Table 11 shows the percentage of children and young people with Type 1 diabetes receiving a full
year of care by number of HbA1c measurements in each country and region.

Table 11: Percentage of children and young people with Type 1 diabetes who completed a year of
care receiving 1-4+ HbA1c measurements by country and region, 2020/21.
Country/Region
Total
None (%)
One (%)
Two (%)
Three (%)
Four (%)
England and Wales
24,138
9.4
26.0
28.3
21.4
14.9
England
22,965
9.7
26.3
28.0
21.0
14.9
Wales
1,173
4.8
18.8
32.9
28.2
15.3
East Midlands
1,660
2.7
15.2
28.3
29.7
24.1
East of England
2,645
10.1
28.8
27.3
22.2
11.6
London and South East
5,395
19.6
29.7
25.6
15.4
9.7
North East and North Cumbria
1,322
2.2
19.3
31.9
30.3
16.3
North West
3,011
9.5
32.7
28.8
18.1
10.9
South Central
2,213
2.6
14.8
25.3
27.2
30.0
South West
1,893
4.6
23.7
35.1
25.8
10.8
West Midlands
2,512
11.0
33.5
32.1
16.2
7.2
Yorkshire and Humber
2,314
5.1
24.8
23.7
20.7
25.7

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NPDA National report 2020/21: Care processes and outcomes
2.1.4 Nutrition and lifestyle education and support

NICE (NG18) recommends offering children and young people with diabetes dietetic support to
help optimise body weight and blood glucose control, and NHS England’s Best Practice Tariff
criteria for paediatric diabetes care (NHS Improvement, 2019) include the offering of an additional
dietetic appointment outside of multidisciplinary (MDT) clinic meetings. A lower take up rate of
dietetic appointments outside of appointments with the rest of the MDT should be interpreted
with caution, as it could reflect satisfaction with the advice shared during routine MDT appointments
rather than a lack of engagement with the service.

Of those children and young people with Type 1 diabetes who completed a full year of care 82.6%
were offered an additional dietetic appointment, compared to 89.0% in 2019/20. Table 12 shows the
percentages who were offered an additional appointment and attended the offered appointment
within the audit year.

Table 12: Percentage of children and young people with Type 1 diabetes who completed a full year
of care who were offered and/or attended an additional dietetic appointment by country, 2020/21
Country/Region
Total
Appointment
offered
Appointment
attended
England and Wales
24,138
82.5%
49.1%
England
22,965
83.8%
49.6%
Wales
1,173
57.9%
39.6%
East Midlands
1,660
59.8%
45.7%
East of England
2,645
84.5%
48.5%
London and South East
5,395
83.0%
52.0%
North East and North Cumbria
1,322
83.3%
56.4%
North West
3,011
87.0%
42.1%
South Central
2,213
84.2%
53.3%
South West
1,893
83.1%
34.1%
West Midlands
2,512
87.7%
58.4%
Yorkshire and Humber
2,314
94.4%
53.8%

There was no difference in the percentages of appointments offered across different age groups,
ethnic categories, deprivation quintiles or between girls and boys. The percentage of appointments
attended decreased with age and duration of diabetes, from 56.3% of those four years old or
younger to 44.5% in the group aged 15 years old or older (Figure 18).

26
NPDA National report 2020/21: Care processes and outcomes
56.3%
51.6%
50.4%
44.5%
58.8%
50.7%
48.3%
46.1%
45.5%
38.5%
0%
10%
20%
30%
40%
50%
60%
70%
0 to 4
5 to 9 10 to 14 15 to 19
Less
than 1
year
1-2
years
3-4
years
5-9
years
10-14
years
15+
years
Age group
Duration of diabetes

Figure 18: Percentage of offered dietetic appointments attended by age group and duration of
diabetes, 2020/21
2.1.5 Completion of all other annual health checks

The NPDA also collects data on five additional health checks for children and young people with
Type 1 diabetes as recommended by NICE 2015 (NG18):

1. Psychological assessment (assessment for need of psychological support)

2. Offering of immunisation against influenza

3. Advice about managing diabetes (‘sick-day rules’)

4. Using (or trained to use) blood ketone testing strips and a meter

5. Smoking status check

Results are shown in Table 13.

27
NPDA National report 2020/21: Care processes and outcomes

Table 13: Percentage of children and young people with Type 1 diabetes who completed a full year
of care recorded as receiving health checks by region and country, 2020/21.
Country/
Region
No. of young
people aged 12
and above with T1
diabetes and a
complete year of care
Flu
vaccine
(%)
Sick day
rules (%)
Blood
ketone
testing
(%)
Psychological
assessment
(%)
Smoking
health
check (%)*
England
and Wales
24,138
80.3
82.1
86.9
71.6
88.2
England
22,965
80.7
82.5
86.6
72.1
87.7
Wales
1,173
72.8
72.6
92.8
60.6
99.1
East Midlands
1,660
71.6
91.7
96.0
65.9
86.8
East of England
2,645
69.1
82.8
83.0
62.0
85.0
London and
South East
5,395
77.4
78.1
84.0
74.8
86.2
North East and
North Cumbria
1,322
95.5
94.3
86.2
80.0
78.4
North West
3,011
86.4
82.1
89.3
63.5
97.5
South Central
2,213
77.7
71.4
84.3
81.7
85.1
South West
1,893
81.7
85.6
88.9
64.1
86.5
Wales
1,173
72.8
72.6
92.8
60.6
99.1
West Midlands
2,512
83.0
82.0
82.3
78.1
88.5
Yorkshire and
Humber
2,314
92.1
88.4
91.9
79.7
89.5

*percentage of young people age 12 and above with Type 1 diabetes

Approximately 2.1% young people were recorded as smoking within the audit year and of those,
39.3% were offered a referral to smoking cessation services, compared to 46.0% in 2019/20. The
proportion of current smokers was higher in boys (2.4%) than girls (1.7%), and higher among those
living in the most deprived areas (2.8%) than in the least deprived areas (1.4%).

Figure 19 shows a consistent increase over the previous three audits in the percentage of children
and young people with Type 1 diabetes being offered flu vaccination, “Sick day rules” advice and
blood ketone testing, and a small decrease in the percentage of children receiving psychological
assessment. In 2020/21 there is a marked decrease.

28
NPDA National report 2020/21: Care processes and outcomes
2017/18
2018/19
2019/20
2020/21
Psychological assessment
86.6%
85.7%
84.4%
71.6%
Flu vaccine recommended
75.9%
81.2%
87.6%
80.3%
‘Sick day rules’
77.4%
83.6%
88.7%
82.1%
Blood ketone testing
82.7%
88.0%
91.9%
86.9%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
% of children and young people
who complete a full year of care

Figure 19: Completion rates for psychological assessment, flu vaccine recommendation, “Sick day
rules” advice and blood ketone testing, for children and young people with Type 1 diabetes who
completed a full year of care, 2017/18 to 2020/21
2.1.6 Care at diagnosis

2.1.6.1 Screening for autoimmune conditions

Children and young people with Type 1 diabetes are at greater risk of having other autoimmune
conditions. NG18 (NICE, 2015) and NG20 (NICE, 2015) recommend screening for thyroid and coeliac
disease at diagnosis.

Figure 20 shows the percentage of children and young people diagnosed more than 90 days
before the end of the audit year (n=2,720), who received screening for coeliac and thyroid disease
within 90 days of diagnosis. In 2020/21 the rates of completion of both health checks at diagnosis
saw a small increase with respect to 2019/20.

29
NPDA National report 2020/21: Care processes and outcomes
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
Thyroid
67.8%
78.9%
83.8%
88.8%
85.2%
86.6%
Coeliac
62.3%
72.6%
80.2%
82.9%
81.3%
83.8%
0%
20%
40%
60%
80%
100%
% of newly diagnosed children and young people
with Type 1 diabetes

Figure 20: Percentage of newly diagnosed children and young people with Type 1 diabetes who
received screening for thyroid and coeliac disease within 90 days of diagnosis, 2015/16 to 2020/21

2.1.7.2 Level 3 carbohydrate counting

NICE guidance (NG18, NICE 2015) recommends offering level 3 carbohydrate-counting education
to children and young people with Type 1 diabetes from diagnosis.

Figure 21 shows the percentage of children and young people diagnosed more than 14 days before
the end of the audit year (n=3,526) who received level 3 carbohydrate-counting education within 14
days of diagnosis from 2017/18 to 2020/21.

30
NPDA National report 2020/21: Care processes and outcomes
Carb counting %
2017/18
67.60%
2018/19
75.60%
2019/20
82.50%
2020/21
82.10%
0%
20%
40%
60%
80%
100%
% of newly diagnosed children and young people
with Type 1 diabetes

Figure 21: Percentage of newly diagnosed children and young people with Type 1 diabetes who
received level 3 carbohydrate counting education within 14 days of diagnosis, 2017/18 to 2020/21
2.2 Health checks for children and young people
with Type 2 diabetes

The health checks for children and young people with Type 2 diabetes recommended in NG18 and
NG19 (NICE, 2015) differ slightly from those for Type 1 diabetes. The NPDA includes cholesterol
screening as one of the six essential annual checks for those with Type 2 rather than thyroid
screening. All should be performed annually from diagnosis, except for foot examination, which is
indicated from age 12, and eye screening, which is also indicated from 12, and indicated biennially
from 2020 onwards (previously annually). In 2020/21, there were 618 children and young people
who completed a full year of care (i.e. were not diagnosed, did not die and did not transition to
adult services within the audit year) recorded as having Type 2 diabetes, of whom 577 (93.4%) were
aged 12 years and above.
2.2.1 Completion of key health checks

Figure 22 shows the percentage of children and young people with Type 2 diabetes who completed
a full year of care recorded as receiving each of the six recommended health checks from 2015/16
to 2020/21.

31
NPDA National report 2020/21: Care processes and outcomes
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
% of children and young people with Type 2 diabetes
who completed a full year of care
Audit year
HbA1c
BMI
Cholesterol
Urinary albumin
Blood pressure
Eye screen*
Foot exam*
All 7 care
processes*
All 6 care
processes**
* % refers to young people aged 12 or older with a complete year of care
* % refers to young people aged 12 or older with a complete year of care

*Health check for those aged 12 and above

** Excludes retinal screening for 2020/21 due to change in screening frequency from this year

Figure 22: Percentage of children and young people with Type 2 diabetes who completed a full
year of care recorded as receiving key health checks, 2015/16 to 2020/21.

Table 14 shows the percentage of children and young people with Type 2 diabetes recorded as
receiving recommended health checks in the audit year, from 2015/16 to 2020/21.

Table 14: Percentage of children and young people with Type 2 diabetes who completed a full year
of care recorded as receiving recommended health checks, 2015/16 to 2020/21
Age
Health check completion
Audit year
2015/16
2016/17
2017/18
2018/19
2019/20 2020/21
All
ages
No. of children and young people (n)
412
473
470
501
534
618
HbA1c (%)
97.3
96.6
96.8
97.8
95.3
82.7
BMI (%)
94.4
94.1
94.5
95
94.2
69.1
Cholesterol (%)
59.2
66.4
67.9
70.5
64.4
58.3
Aged
12 and
above
No. of young people (n)
390
436
436
470
499
577
Urinary albumin (%)
51.7
56.7
58.9
62.1
62.1
48.9
Blood pressure (%)
85
86
88.5
90.9
89.6
63.1
Foot Exam (%)
50
50.2
61.7
67
65.1
40.4
All six health checks (%)
16.7
21.3
25.7
30.9
26.7
24.1

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NPDA National report 2020/21: Care processes and outcomes
2.2.2 Number of HbA1c measurements

Figure 23 shows that 10.7% of children and young people with Type 2 diabetes recorded as
completing a full year of care received the recommended four or more HbA1c measurements in
the year, with nearly a fifth not receiving any at all.
2016/17
2017/18
2018/19
2019/20
2020/21
None
3.8%
3.2%
2.2%
4.7%
17.3%
1
15.4%
18.7%
15.2%
11.6%
34.5%
2
22.8%
21.3%
21.2%
24.7%
25.6%
3
27.5%
25.7%
26.5%
26.0%
12.0%
4+
30.4%
31.1%
34.9%
33.0%
10.7%
0%
5%
10%
15%
20%
25%
30%
35%
40%
% of children and young people with Type 2
diabetes who completed a full year of care

Figure 23: Number of HbA1c measurements recorded for children and young people with Type 2
diabetes receiving a full year of care, 2016/17 – 2020/21
2.2.3 Completion of all other health checks

Table 15 shows the percentage of children and young people with Type 2 diabetes completing a
full year of care (n=618) recorded as being offered and attending an additional dietetic appointment
outside of routine MDT clinics with the rest of the MDT present. Lower uptake may be indicative of
satisfaction with advice provided in routine clinics rather than lack of engagement with dietetic
services.

Table 15: Percentage of children and young people with Type 2 diabetes who completed a full year
of care recorded as being offered and attending an additional dietetic appointment, 2017/18 to
2020/21
England and Wales
2017/18
2018/19
2019/20
2020/21
Appointment offered (%)
70.0
80.0
80.0
78.3
Appointment attended (%)
48.7
48.5
56.0
56.3

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NPDA National report 2020/21: Care processes and outcomes

The NPDA also collects data on four additional health checks for children and young people with
Type 2 diabetes:

•
Psychological assessment (assessment for need of psychological support)

•
Offering of immunisation against influenza

•
Advice about managing diabetes during sickness (‘sick day rules’)

•
Smoking status

Results are shown in Table 16 for all children and young people with Type 2 diabetes and a complete
year of care (n= 618).

Table 16: Percentage of young people with Type 2 diabetes who completed a full year of care
recorded as receiving additional health checks by region and country, 2017/18 to 2020/21
Health checks
England and Wales
2017/18
2018/19
2019/20
2020/21
Assessment for need of psychological
support (%)
77.9
75
70.8
60.5
Flu vaccine recommendation (%)
49.4
69.3
67.8
63.3
‘Sick day rules’ advice (%)
41.7
51.5
53
48.5
Smoking status check (%)*
83.3
84.3
85.0
83.7

*percentage of children and young people age 12 and above

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NPDA National report 2020/21: Care processes and outcomes
3. Outcomes
3.1 HbA1c

HbA1c is a marker of overall diabetes blood glucose levels over the preceding six to eight weeks and
is associated with lifetime risk of microvascular complications. There is clear evidence from the
DCCT trial (The Diabetes Control and Complications Trial Research Group, 1994) and the follow up
EDIC trial (Nathan et al., 2005) that good diabetes management in childhood tracks into adulthood
with a lower risk of developing vascular complications and early mortality in the future.

In 2015, NICE (NG18, 2015) introduced a stricter HbA1c target of 48mmol/mol or less to indicate
excellent diabetes management for both Type 1 and 2 diabetes and requested that providers also
report those achieving a level of 53 mmol/mol or below. To allow historical benchmarking, the
NPDA also reports the numbers achieving the previous NICE (2004) target of 58 mmol/mol or
below and an HbA1c level above 80mmol/mol representing considerable increased risk of both
microvascular diabetic complications (eye disease and kidney disease) and cardiovascular disease.

Average HbA1c and the proportion of children and young people meeting specific HbA1c targets
vary depending on the type of diabetes. Children and young people with non-Type 1 diabetes tend
to have a lower HbA1c than those with Type 1 diabetes. Some of the data presented below refer to
children and young people with all types of diabetes whilst other sections detail the results of
those with Type 1 or Type 2 diabetes separately. Numbers of children and young people with other
types of diabetes were too low to enable meaningful analysis.

This section of the report seeks to answer the following audit questions:

1. What are the average HbA1c levels and percentage of children and young people with
diabetes hitting targets in England and Wales for 2020/21, and

2. What are the longitudinal changes?
3.2 HbA1c outcomes of children and young people
with all types of diabetes

Table 17 provides a breakdown of the unadjusted mean and median HbA1c results achieved by
each country, and regional network. The mean HbA1c of children and young people with all types
of diabetes in England and Wales receiving care in a PDU in 2020/21 was 64.0 mmol/mol; this is a
decrease of 0.5 mmol/mol compared to that recorded in 2019/20 (64.5 mmol/mol). The median
HbA1c was 61 mmol/mol, which is a decrease of 0.5 mmol/mol compared to that recorded in 2019/20
(61.5 mmol/mol).

35
NPDA National report 2020/21: Care processes and outcomes

Table 17: HbA1c for all children and young people with all types of diabetes and one or more valid
HbA1c measurements by region, county and overall, 2020/21
Country/Region
No. of children and
young people with
all types of diabetes
Mean
Standard
deviation
Median
Interquartile
range
England and Wales
26,139
64.0
16.8
61.0
18.0
England
24,806
63.9
16.8
61.0
18.0
Wales
1,333
64.7
17.3
62.0
18.0
East Midlands
1,944
61.4
15.0
59.0
16.0
East of England
2,769
64.3
17.2
61.0
18.0
London and South East
5,266
65.1
17.9
62.0
18.5
North East and North
Cumbria
1,576
62.2
15.8
60.0
17.0
North West
3,240
65.3
16.9
62.0
19.0
South Central
2,602
62.1
15.4
60.0
16.8
South West
2,108
63.0
15.9
60.0
16.0
West Midlands
2,662
64.1
16.3
62.0
17.0
Yorkshire and Humber
2,639
64.6
18.0
61.0
18.5

Figure 24 shows the median HbA1c for children and young people with all types of diabetes, in
England and Wales, from 2009/10 to 2020/21. The timeline below the graph highlights key quality
improvement initiatives implemented in England and Wales over the same period.

36
NPDA National report 2020/21: Care processes and outcomes
Internal and
external peer
reviews of Quality
standards and
on-going
participation in
quality
improvement
methodology
training

58
60
62
64
66
68
70
72
74
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19 2019/20 2020/21
Median HbA1c (mmol/mol)
England
Wales
Regional
networks
established,
England
Best
Practice
Tariff
introduced,
England

Quality
Assurance
(peer
review),
England
Diabetes
Delivery Plans,
England &
Wales
Quality
Assurance
(peer
review),
Wales
Regional
networks
established, Self-
assessment QA
started, England
& Wales
Updated
Diabetes
Delivery Plan
published 2016,
Wales
National
Diabetes QI
Programme
introduced,
England &
Wales

Figure 24: Median HbA1c for children and young people with all types of diabetes in England and
Wales 2009/10 to 2020/21, with associated NHS policy and/or paediatric diabetes delivery structural
changes
3.3 HbA1c outcomes of children and young people
with Type 1 diabetes

The results presented in this section pertain to children and young people with Type 1 diabetes and
show the variation in HbA1c outcomes nationally and regionally as well as by patient characteristics.
3.3.1 National and regional unadjusted HbA1c results

Table 18 shows the unadjusted mean and median HbA1c results for children and young people
with Type 1 diabetes achieved by region and country. The unadjusted mean HbA1c was 64.2 mmol/
mol, which is a decrease of 0.8 mmol/mol from 2019/20. The median HbA1c was 61.0 mmol/mol, a
decrease of 1 mmol/mol from 2019/20.

37
NPDA National report 2020/21: Care processes and outcomes

Table 18: HbA1c for all children and young people with Type 1 diabetes with one or more valid
HbA1c measurement, by regional network, country, and overall, 2020/21
Country/
Region
No. of children and
young people with
Type 1 diabetes
Mean
mmol/mol
Standard
deviation
mmol/mol
Median
mmol/mol
Interquartile
range mmol/
mol
England and Wales
24,986
64.2
16.4
61.0
17.0
England
23,693
64.2
16.4
61.0
17.0
Wales
1,293
65.0
17.1
62.0
18.0
East Midlands
1,877
61.7
14.8
59.5
15.5
East of England
2,694
64.6
17.0
61.0
17.6
London and South East
4,939
65.5
17.2
62.0
18.4
North East and North
Cumbria
1,513
62.5
15.7
60.0
16.5
North West
3,077
65.6
16.5
62.5
18.0
South Central
2,518
62.3
15.1
60.0
15.0
South West
2,040
63.3
15.6
60.5
15.0
Wales
1,293
65.0
17.1
62.0
18.0
West Midlands
2,509
64.4
15.8
62.0
17.0
Yorkshire and Humber
2,526
64.6
17.4
61.0
17.5

Figure 25 and Table 19 show the percentages of children and young people with Type 1 diabetes
achieving each of the NICE (2015) treatment targets from 2014/15 to 2020/21.

Figure 25 also includes the percentages of children and young people with Type 1 diabetes who
achieved the NICE (2004) treatment targets of below 58 mmol/mol, between 58 mmol/mol and 80
mmol/mol, and above 80 mmol/mol from 2010/11 to 2013/14.

38
NPDA National report 2020/21: Care processes and outcomes

6.4%
6.5%
7.5%
7.2%
10.3%
10.6%
11.8%
6.8%
8.2%
8.8%
8.9%
11.4%
11.4%
12.6%
10.3%
11.9%
12.6%
12.5%
14.3%
14.1%
13.4%
34.3%
34.8%
34.3%
34.8%
33.3%
33.1%
32.4%
13.4%
14.1%
13.7%
13.7%
11.5%
11.5%
10.6%
7.5%
6.6%
6.7%
6.5%
5.2%
5.3%
6.3%
15.8%
17.4%
15.8%
18.4%
55.5%
57.5%
58.4%
58.3%
28.7%
25.1%
25.9%
23.9%
21.3%
17.9%
16.4%
16.5%
14.1%
14.0%
12.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
% of children and young people with Type 1 diabetes
>58 and ≤69 mmol/mol
>69 and ≤76 mmol/mol
>76 and ≤80 mmol/mol
<58 mmol/mol*
>58 and ≤80 mmol/mol*
>80 mmol/mol
* NICE (2004) treatment targets from 2010/11 to 2013/14

Figure 25: Percentage of children and young people with Type 1 diabetes with an HbA1c result
within current and previous target ranges, 2010/11 – 2020/21

Table 19 shows the percentages of children and young people who achieved HbA1c targets by
country and by region.

Table 19: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by country and regional network, 2020/21
Country/regional
network
≤48
mmol/
mol (%)
≤53
mmol/
mol (%)
<58
mmol/
mol (%)
58-80
mmol/
mol (%)
≥69
mmol/
mol (%)
>75
mmol/
mol (%)
>80
mmol/
mol (%)
England and Wales
11.8
23.7
37.9
49.2
29.7
18.1
12.9
England
11.9
23.8
38.0
49.1
29.6
18.1
12.8
Wales
11.4
22.4
35.5
50.8
32.3
19.6
13.7
East Midlands
14.4
27.8
43.2
47.7
24.0
13.4
9.1
East of England
12.1
23.3
37.9
47.8
30.7
19.6
14.3
London and South East
11.2
22.1
35.3
49.9
32.8
20.7
14.8
North East and North Cumbria
15.1
28.0
42.7
47.1
27.0
15.7
10.2
North West
9.8
20.5
33.8
51.2
33.1
20.9
15.0
South Central
12.9
27.4
42.1
47.6
24.7
14.5
10.3
South West
12.1
24.3
39.5
49.4
26.7
15.9
11.1
West Midlands
10.9
22.6
35.8
52.2
29.5
17.0
12.0
Yorkshire and Humber
11.4
23.5
39.2
47.3
30.4
19.0
13.5

39
NPDA National report 2020/21: Care processes and outcomes
3.3.2 HbA1c outcomes by sex

Figure 26 shows that the mean HbA1c has decreased at a similar rate for both boys and girls with
Type 1 diabetes over the last 18 years. It also shows a consistently higher mean HbA1c in girls
compared to boys.
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010/
11
2011/1
2
2012/
13
2013/
14
2014/
15
2015/
16
2016/
17
2017/
18
2018/
19
2019/
20
2020
/21
Boys
75.9
73.8
73.5
73.5
73.9
74.2
74.6
73.6
72.9
71.4
70.2
69.8
67.5
66.6
67
64.7
64.7
63.7
Girls
77.1
75.5
75.1
75.3
75.6
75.8
76.4
75.4
74.5
72.8
72
71.4
69.1
68.1
68
65.4
65.3
64.8
60
62
64
66
68
70
72
74
76
78
80
Mean HbA1c (mmol/mol)
Boys
Girls

Figure 26: Mean HbA1c for boys and girls with Type 1 diabetes, 2003/04 to 2020/21
3.3.3 HbA1c outcomes by age and duration of diabetes

Figure 27 shows mean unadjusted HbA1c by duration of diabetes in 2019/2020 and 2020/21. Children
and young people of all age groups had higher HbA1c from two years following diagnosis, with the
exception of those aged 0-4 years. After the first year following diagnosis, those aged 15-19 had
consistently higher HbA1c than other age groups.

40
NPDA National report 2020/21: Care processes and outcomes
<1yr
1-2 yrs
2-3 yrs
3-4 yrs
4-5 yrs
5-10 yrs
Age 5 to 9
54.3
67.4
Age 10 to 14
50.7
65.7
67.4
73.5
71.4
Age 15 to 19
58.7
63.2
63.1
70.9
81.2
72.4
50
55
60
65
70
75
80
85
Mean HbA1c (Mmol/mol)
Duration of diabetes
Age 5 to 9
Age 10 to 14
Age 15 to 19

Figure 27: Mean HbA1c for children and young people with Type 1 diabetes in England and Wales
by duration of diabetes and age group, 2020/21
3.3.4 HbA1c outcomes by ethnicity

Figure 28 shows that whilst there have been overall improvements in the average HbA1c amongst
children and young people with Type 1 diabetes in all ethnic categories since 2011/12, there have
been consistent differences in HbA1c outcomes between those in different ethnic categories, with
those of White ethnicity having lower average HbA1c and those of Black ethnicity having the
highest average HbA1c year on year.

41
NPDA National report 2020/21: Care processes and outcomes


2003
/04
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
2020
/21
White
76.4 74.7
73.9
73.6
74.4 74.4 75.0
73.9
73.2
71.6
70.5
69.9
67.7
66.7
67.0 64.6 64.6 63.9
Asian
81.5
78.2
77.0
78.3
76.0 76.7
76.3
74.9 74.3
73.1
72.5
72.2
69.3
68.7
68.8 66.2
65.8
65.2
Black
81.5
80.1
79.8
81.3
80.2 81.3
81.9
81.1
81.0
78.9
78.0 77.8
74.0 74.2
74.9 71.4
71.9
70.9
Mixed
82.5
80.5 75.5
78.6
79.0 77.8
78.1
78.1
77.0
74.5
73.7
73.3
70.6
68.7
69.6
67.5
67.4 67.2
Other
75.1
73.8
75.7
75.4
74.0 74.1
77.5
72.9
73.4
73.2
72.1
72.3
69.6
68.2
67.0 63.7
63.0
63.3
60
65
70
75
80
85
Mean HbA1c (mmol/mol)
White
Asian
Black
Mixed
Other
Figure 28: Mean HbA1c for children and young people with Type 1 diabetes in England and Wales
by ethnic group, 2003/04 to 2020/21

Table 20 provides a breakdown of average HbA1c by ethnic group and deprivation. It shows that
overall, living in a less deprived area was associated with lower HbA1c amongst those of all ethnicities,
except for those of Black ethnicity. It also shows that that the average HbA1c for children and young
people of Black ethnicity living in the least deprived areas was similar to that of children of Asian
and White ethnicity living in the most deprived areas.

Table 20: Mean HbA1c for children and young people with Type 1 diabetes by ethnic category and
deprivation quintile, 2020/21*
Ethnicity
most
deprived
second most
deprived
third least
deprived
second least
deprived
least deprived
White
67.5
64.9
64.3
62.2
60.7
Asian
67.7
64.0
64.4
63.8
60.6
Black
71.9
71.0
69.2
66.9
71.4
Mixed
70.9
67.3
66.1
64.7
63.3
Other
65.2
63.6
63.7
60.2
58.9

*The (red–white–green) colour scale indicates (higher-mid-lower) mean HbA1c levels

Figure 29 shows the percentage of children and young people with Type 1 diabetes meeting HbA1c
treatment targets. It shows that results of those of White or Other ethnicity skew towards the lower
targets, whereas those of Black or Mixed ethnicity skew above these targets.

42
NPDA National report 2020/21: Care processes and outcomes
10%
10%
11%
12%
13%
7%
10%
10%
12%
13%
11%
13%
14%
17%
18%
27%
33%
32%
32%
29%
14%
9%
13%
10%
11%
7%
7%
7%
5%
6%
25%
18%
13%
12%
11%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Black
Mixed
Asian
White
Other
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and ≤58
>58 and ≤69 mmol/mol
>69 and ≤76 mmol/mol
>76 and ≤80 mmol/mol
>80 mmol/mol

Figure 29: Percentage of children and young people with Type 1 diabetes in England and Wales
achieving HbA1c targets by ethnic group, 2020/21
3.3.5 HbA1c outcomes by deprivation quintile

NPDA results have consistently shown an association between higher HbA1c and living in more
deprived areas. Figure 30 shows that in 2020/21 there was a reduction in mean HbA1c within each
deprivation quintile compared to 2019/20.
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
Most deprived
74.7
73.7
71.6
70.7
70.9
68.2
68.3
67.8
Second most deprived
74.0
72.3
69.6
68.7
68.7
66.2
66.1
65.2
Third least deprived
72.2
70.6
68.1
67.0
67.5
65.0
65.1
64.4
Second least deprived
70.4
69.0
66.7
65.6
65.9
63.4
62.7
62.3
Least deprived
69.0
67.2
64.8
64.0
64.2
61.9
62.0
60.7
74
72
70
68
66
64
62
60
Mean HbA1c (mmol/mol)
Second most deprived
Third least deprived
Most deprived
Second least deprived
76
Least deprived

Figure 30: Mean HbA1c for children and young people with Type 1 diabetes by deprivation quintile,
2013/14 to 2020/2021

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NPDA National report 2020/21: Care processes and outcomes

Figure 31 shows the percentages of children and young people with Type 1 diabetes achieving
treatment targets by deprivation quintile. Results of those in the least deprived areas skewed
towards lower targets, whereas those of children and young people living in the most deprived
areas skewed towards the higher cut offs.
9%
11%
11%
13%
15%
10%
11%
13%
14%
15%
11%
13%
13%
15%
15%
32%
32%
33%
33%
32%
12%
12%
10%
9%
9%
8%
7%
6%
5%
5%
18%
14%
13%
10%
8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Most deprived
Second most deprived
Third least deprived
Second least deprived
Least deprived
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and ≤58
>58 and ≤69 mmol/mol
>69 and ≤76 mmol/mol
>76 and ≤80 mmol/mol
>80 mmol/mol

Figure 31: Percentage of children and young people with Type 1 diabetes in England and Wales
achieving HbA1c targets by deprivation quintile, 2020/21
3.3.6 HbA1c outcomes across PDUs in England and Wales

Figure 32 shows the median HbA1c value for all PDUs in England and Wales. Median HbA1c values
by PDU ranged from 54.5 mmol/mol to 69.0 mmol/mol.
50
52
54
56
58
60
62
64
66
68
70
Median PDU HbA1c in mmol/mol
National median
Paediatric diabetes unit
National median= 61 mmol/mol

Figure 32: Median HbA1c per PDU 2020/21

Figure 33 shows the percentage of children and young people with Type 1 diabetes achieving the
HbA1c target of <58 mmol/mol by PDU. The overall percentage achieving this target was 37.9%. The
percentages achieving this target per PDU ranged from 17.8% to 67.7%.

44
NPDA National report 2020/21: Care processes and outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
Overall national %
Paediatric diabetes unit

Figure 33: Percentage of children and young people with HbA1c <58mmol/mol per PDU 2020/21
3.4 HbA1c outcomes of children and young people
with Type 2 diabetes

HbA1c outcomes are jointly reported for England and Wales given the smaller numbers of children and
young people with Type 2 diabetes included within the audit. The mean and median HbA1c of children
and young people with Type 2 diabetes in England and Wales receiving care in a PDU in 2020/21 were 61.0
and 53.0 mmol/mol, respectively: both higher than in 2019/20, with a wider interquartile range. This in
contrast to Type 1 diabetes, where the national mean and medians fell in 2020/21.

Table 21: HbA1c for all children and young people with Type 2 diabetes and one or more valid HbA1c
measurements in England and Wales, 2015/16 – 2020/21
Audit year
No. of children and
young people with
Type 2 diabetes
HbA1c in mmol/mol
Mean
Standard
deviation
Median
Interquartile
range
2015/16
539
59.7
25.4
51
30.5
2016/17
605
60.2
24.6
52
33.5
2017/18
650
61.3
25.3
53
28.5
2018/19
674
57.4
23.5
49.5
26
2019/20
731
58.6
23.6
51
28
2020/21
676
61
24.8
53
33.5

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NPDA National report 2020/21: Care processes and outcomes

Figure 34 shows variation in the percentages of children and young people with Type 2 diabetes
achieving HbA1c targets since 2017/18, with no improvement trend across this period. Two fifths
(40.9%) were achieving the recommended target of lower or equal to 48 mmol/mol, a decrease
from 44.3% in 2019/20.
41%
44%
47%
40%
10%
11%
12%
10%
7%
7%
6%
8%
11%
12%
11%
14%
5%
5%
5%
5%
5%
4%
3%
4%
20%
17%
16%
19%
2020/21
2019/20
2018/19
2017/18
% of children and young people with Type 2 diabetes
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and ≤58
>58 and ≤69 mmol/mol
>69 and ≤76 mmol/mol
>76 and ≤80 mmol/mol
>80 mmol/mol

Figure 34: Percentage of children and young people with Type 2 diabetes with an HbA1c result
within current and previous target ranges, 2017/18 – 2020/21
3.4.1 HbA1c outcomes by sex

Figure 35 provides a breakdown of mean HbA1c amongst children and young people with Type 2
diabetes broken down by sex in each audit year. It shows variation between the audit years, and a
tendency for girls to have higher HbA1c.
2017/18
2018/19
2019/20
2020/21
Boys
60.2
57.5
57.1
60.6
Girls
61.7
57.3
59.3
61.2
54
55
56
57
58
59
60
61
62
63
Mean HbA1c (Mmol/mol)
Boys
Girls

Figure 35: Mean HbA1c for boys and girls with Type 2 diabetes, 2017/18 to 2020/21

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NPDA National report 2020/21: Care processes and outcomes
3.4.2 HbA1c outcomes by age group and duration of Type 2 dia-
betes

Figure 36 shows that mean HbA1c increases within each age group after the first year of diagnosis
of Type 2 diabetes.
<1yr
1-2 yrs
2-3 yrs
3-4 yrs
4-5 yrs
5-10 yrs
Age 5 to 9
54.3
67.4
Age 10 to 14
50.7
65.7
67.4
73.5
71.4
Age 15 to 19
58.7
63.2
63.1
70.9
81.2
72.4
50
55
60
65
70
75
80
85
Mean HbA1c (Mmol/mol)
Duration of diabetes
Age 5 to 9
Age 10 to 14
Age 15 to 19

Figure 36: Mean HbA1c for children and young people with Type 2 diabetes, by age group and
duration of diabetes, 2020/21
3.4.3 HbA1c outcomes by deprivation quintile

Figure 37 shows variation in mean HbA1c by deprivation quintile across audit years. There has been
a weaker correlation between deprivation and mean HbA1c as has been observed amongst those
with Type 1 diabetes.

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NPDA National report 2020/21: Care processes and outcomes
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
Least deprived
55.5
54.1
59.4
50.5
49.1
52.4
Second least deprived
55.6
57.9
61.8
55.6
59.7
56.5
Third least deprived
56.2
60.3
57.7
59.1
56.6
62.4
Second most deprived
59.4
61.2
61.0
54.5
58.7
60.0
Most deprived
62.4
61.4
61.9
59.6
60.0
63.2
45
50
55
60
65
Mean HbA1c (mmol/mol)
audit year
Least deprived
Second least deprived
Third least deprived
Second most deprived
Most deprived

Figure 37: Mean HbA1c for children and young people with Type 2 diabetes in England and Wales
by deprivation quintile, 2015/16 to 2020/21
3.4.4 HbA1c outcomes by ethnic category

Similarly to those with Type 1 diabetes, Figure 38 shows that White children and young people with
Type 2 diabetes had lower mean HbA1c, and Black children with Type 2 diabetes had higher mean
HbA1c than those in other ethnic categories between 2015/16 and 2020/21.
White
Asian
Black
Mixed
Other
2015/16
56.8
58.7
69.9
52.1
61.3
2016/17
55.6
61.3
71.9
64.0
62.9
2017/18
57.9
61.0
75.2
58.6
61.5
2018/19
54.1
58.0
66.9
60.2
56.7
2019/20
54.7
59.4
66.1
59.6
57.0
2020/21
57.1
61.6
72.2
61.7
61.2
45
50
55
60
65
70
75
80
Mean HbA1c (mmol/mol)
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21

Figure 38: Mean HbA1c for children and young people with Type 2 diabetes by ethnic category,
2015/16- 2020/21

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NPDA National report 2020/21: Care processes and outcomes
3.5 Small vessel (microvascular) disease

People with diabetes are at increased risk of microvascular disease including diabetic kidney
disease (nephropathy) and diabetic eye disease (retinopathy). This chapter explores the incidence
and demographics of early signs of microvascular disease in children with diabetes.
3.5.1 Diabetic kidney disease

Annual albuminuria screening is recommended by NICE (2015) in all children with Type 1 diabetes
aged 12 and above, and for all those with Type 2 diabetes of any age. The presence of significant
albuminuria may be indicative of progressive diabetic kidney disease.

3.5.1.1 Albuminuria in young people with Type 1 diabetes

Nearly two-thirds (n = 10,204) of young people with Type 1 diabetes aged 12 years and above were
recorded as receiving an albuminuria screen during the audit period. Of those, 95.9% (n = 9,785)
had a valid interpretation of their urinary albumin level. Increased risk of kidney disease is indicated
by the presence of either micro- or macro-albuminuria. Figure 39 shows that 10.3% of young people
in England and Wales were recorded as having micro- or macro-albuminuria.
89.7%
89.6%
91.1%
92.7%
88.9%
87.2%
93.8%
87.2%
88.8%
84.4%
93.2%
94.3%
10.3%
10.4%
8.9%
7.3%
11.1%
12.8%
6.2%
12.8%
11.2%
15.6%
6.8%
5.7%
0%
20%
40%
60%
80%
100%
England & Wales
England
Wales
East Midlands
East of England
London and South East
North East and North
Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
% of children and young people with Type 1 diabetes
Normo-albuminuria
Micro- or macro-albuminuria

Figure 39: Percentage of young people with Type 1 diabetes aged 12 years and older with
albuminuria by country and regional network 2020/21

Table 22 shows that the percentage of young people with Type 1 diabetes aged 12 years and above
with albuminuria has remained stable since 2015/16.

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NPDA National report 2020/21: Care processes and outcomes

Table 22: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria, 2015/16 to 2020/21
Audit Year
Total (n)
Normo-albuminuria (%)
Micro- or macro-
albuminuria (%)
2020/21
9,785
89.7
10.3
2019/20
11,270
88.9
11.1
2018/19
11,075
90.2
9.8
2017/18
10,631
89.8
10.2
2016/17
9,938
90.0
10.0
2015/16
9,364
90.1
9.9

Figure 40 shows little variation in the presence of albuminuria by duration of diabetes between the
audit years.
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
2016/17
10.6%
9.1%
8.7%
11.4%
9.2%
10.2%
2017/18
10.7%
8.9%
9.9%
10.3%
10.8%
13.5%
2018/19
10.8%
9.8%
10.2%
9.0%
9.9%
11.4%
2019/20
8.6%
10.3%
10.1%
11.9%
12.4%
11.3%
2020/21
11.2%
9.0%
10.1%
10.5%
11.2%
10.3%
0%
3%
6%
9%
12%
15%
18%
% of young people with Type 1 diabetes
Duration of diabetes

Figure 40: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by duration of diabetes, 2016/17 – 2020/21

Figure 41 shows little difference in rates of albuminuria by age and sex, with boys having a marginally
higher rate at every age, with the exception of age 18, however this finding should be interpreted
with caution given the small numbers of young people receiving care from a PDU at this age.

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NPDA National report 2020/21: Care processes and outcomes
12
13
14
15
16
17
18
Boys
12.2%
10.6%
9.0%
12.0%
10.0%
13.0%
9.9%
Girls
9.9%
8.6%
8.5%
9.7%
8.8%
11.1%
12.7%
0%
3%
6%
9%
12%
15%
% of young people with Type 1 diabetes
Age and sex

Figure 41: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by age and sex, 2016/17 – 2020/21

Figure 42 shows that prevalence of albuminuria decreased in nearly all deprivation quintiles in
2020/21, but no clear relationship between prevalence of albuminuria and deprivation.
Most deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least deprived
2016/17
12.0%
11.1%
8.6%
10.0%
8.4%
2017/18
11.2%
11.0%
10.4%
9.5%
9.1%
2018/19
9.8%
10.0%
9.4%
10.4%
9.4%
2019/20
10.3%
10.9%
10.3%
12.2%
11.9%
2020/21
10.2%
10.5%
10.5%
9.9%
10.3%
0%
3%
6%
9%
12%
15%
% of young people with Type 1 diabetes
Deprivation quintile

Figure 42: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by deprivation quintile, 2016/17 – 2020/21

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NPDA National report 2020/21: Care processes and outcomes

Figure 43 shows that young people with Type 1 diabetes and higher HbA1c tend to be more at risk
of albuminuria. It also shows that albuminuria can be present even amongst those meeting the
lower HbA1c targets.
8%
11%
10%
12%
14%
16%
24%
30%
12%
10%
6%
6%
26%
16%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Micro/macro albuminuria
Normoalbuminuria
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and ≤58
>58 and ≤69 mmol/mol
>69 and ≤76 mmol/mol
>76 and ≤80 mmol/mol
>80 mmol/mol

Figure 43: Percentage of young people with Type 1 diabetes achieving HbA1c targets by presence
of albuminuria, 2020/21

3.5.1.2 Albuminuria in children and young people with Type 2 diabetes

Figure 44 shows that albuminuria was present in 23.4% of children and young people with Type 2
diabetes with a valid PDU interpretation of their urinary albumin level (n=346) in 2020/21. The
percentage of children and young people with Type 2 diabetes with albuminuria is over twice that
recorded for young people with Type 1 diabetes (10.3%) – indicating that children and young people
with Type 2 diabetes are at greater risk of kidney disease.
14.6%
21.0%
22.1%
20.6%
25.7%
23.4%
0%
5%
10%
15%
20%
25%
30%
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
Percentage of children and young
people with albuminuria
Audit year

Figure 44: Percentage of children and young people with Type 2 diabetes with albuminuria in
England and Wales, 2015/16 – 2020/21

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NPDA National report 2020/21: Care processes and outcomes
3.5.2 Eye Disease

3.5.2.1 Retinopathy in young people with Type 1 diabetes

There were 4,247 young people with Type 1 diabetes aged 12 years and above recorded as receiving
an eye screen during the audit period. Of those, 97.1% (n = 4,127) had a valid eye screen result
recorded. Table 23 shows that 16.9% of young people with Type 1 diabetes aged 12 and above had
an abnormal eye screen result recorded within the audit period. The NPDA only records an eye
screen as being normal or abnormal. Most abnormal screens in this age group are likely to represent
background retinopathy. The higher rate of retinopathy in 2020/21 could reflect that services were
asked to prioritise screening patients with retinopathy identified at their previous annual screen.

Table 23: Percentage of young people with Type 1 diabetes aged 12 years and above with a normal/
abnormal eye screening result, 2015/16 to 2020/21
Audit Year
Total (n)
Normal %
Abnormal %
2020/21
4,247
83.1
16.9
2019/20
10,852
88.0
12.0
2018/19
11,431
86.9
13.1
2017/18
11,134
87.2
12.8
2016/17
9,938
85.2
14.8
2015/16
9,788
84.7
15.3

Figure 45 provides a breakdown of screening results in 2020/21 of all those who also had a recorded
retinopathy screening result in 2019/20. It shows that of those with a normal result in 2019/20, a
tenth (10.3%) were found to have retinopathy in 2020/21, whilst two fifths (42.4%) of those with
retinopathy in 2019/20 had a normal result in 2020/21.
89.7%
43.4%
10.3%
56.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Normal results in 2019/20 (n=1506)
Abnormal results in 2019/20 (n=514)
Normal results in 2020/21
Abnormal result in 2020/21

Figure 45: Retinopathy screening outcomes of children and young people with Type 1 diabetes on
2020/21 by result of screening in 2019/20

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NPDA National report 2020/21: Care processes and outcomes

3.5.2.2 Retinopathy in young people with Type 2 diabetes

Figure 46 shows that 3.5% of young people with Type 2 diabetes aged 12 years and above with a
valid eye screening result (n=171) had an abnormal result. The rate of retinopathy found amongst
young people with Type 1 diabetes was 16.9% by comparison.
6.2%
4.8%
5.6%
6.7%
6.1%
3.5%
0%
1%
2%
3%
4%
5%
6%
7%
8%
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
% of children and young people with
Type 2 diabetes and retinopathy
Audit year

Figure 46: Eye screening results for young people aged 12 years and above with Type 2 diabetes,
2015/16 to 2020/21
3.6 Large vessel disease – Cardiovascular Disease
(CVD) risk factors

People with diabetes are at an increased risk of cardiovascular disease secondary to macrovascular
risk factors including high blood pressure, abnormal lipid levels and high body mass index. This
chapter examines the prevalence of these risk factors, and patient characteristics associated with
higher risk for them.
3.6.1 Blood pressure and cholesterol

High blood pressure and/or raised blood cholesterol increases lifetime risk of cardiovascular disease,
including stroke and heart disease. In adults with Type 1 diabetes, maintaining normal blood
pressure and cholesterol within target (less than 5 mmol/L) reduces this risk. Although screening
of total cholesterol levels is no longer a mandatory requirement for children and young people
with Type 1 diabetes following NICE guidance NG18 (2015), results are still presented where data
have been submitted. Diastolic and systolic blood pressure measurements were converted to age-
and sex- adjusted centiles using survey data between 1995 and 1998 from the general population
aged between 4 and 24 years old (Jackson et al., 2007).

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NPDA National report 2020/21: Care processes and outcomes

3.6.1.1 Blood pressure and cholesterol in young people with Type 1 diabetes

Table 24 shows the percentages of young people aged 12 and above with Type 1 diabetes with a
recorded blood pressure in the audit period (n=11,702) classified as having ‘high normal’ (91st -98th
centile) or ‘high’ blood pressure (>98th centile). Nearly one third of young people (31.0%) with Type
1 diabetes had high blood pressure (hypertension); this represents an increase compared to the
figure reported in the 2019/20 audit (26.7%).

Table 24: Percentage of young people with Type 1 diabetes aged 12 years and above falling within
blood pressure targets by country and region, 2020/21
‘High normal’ blood pressure
(91st–98th centile)
High’ blood pressure
(>98th centile)
Country/region
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
England and Wales
28.8
10.1
28.9
30.6
4.2
31.0
England
28.8
10.1
28.9
30.3
4.2
30.7
Wales
29.5
10.6
30.4
35.8
4.9
36.9
East Midlands
30.0
11.1
30.0
35.8
4.8
36.9
East of England
28.5
11.3
29.1
30.3
3.5
30.3
London and South East
30.2
9.1
30.5
29.4
3.4
29.7
North East and North Cumbria
25.6
5.7
25.9
28.0
1.7
28.5
North West
27.4
9.5
26.0
30.8
3.7
29.2
South Central
27.1
9.3
28.2
28.3
3.3
29.5
South West
28.7
12.5
25.7
33.4
8.6
33.9
Wales
29.5
10.6
30.4
35.8
4.9
36.9
West Midlands
32.2
10.0
33.6
28.7
5.2
30.1
Yorkshire and Humber
27.7
12.8
29.0
30.1
4.7
31.6

Table 25 shows the percentages of young people aged 12 and above with Type 1 diabetes with a
recorded cholesterol screen (n=10,030) within the target for total blood cholesterol. It shows that
19.8% exceeded the higher (>=5 mmol/l) target for total blood cholesterol. This figure is 0.9% higher
than the one reported in the 2019/20 audit (18.9%).

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NPDA National report 2020/21: Care processes and outcomes

Table 25: Percentage of young people with Type 1 diabetes aged 12 years and above falling within
cholesterol targets by country and region, 2020/21
Country/region
4 mmol/l or more (%)
5 mmol/l or more (%)
England and Wales
61.9
19.8
England
61.6
19.9
Wales
66.1
18.1
East Midlands
60.2
19.2
East of England
61.9
20.4
London and South East
62.7
20.2
North East and North Cumbria
61.1
22.2
North West
64.3
22.0
South Central
61.4
20.7
South West
60.7
18.4
Wales
66.1
18.1
West Midlands
58.4
15.6
Yorkshire and Humber
60.8
20.5

Figure 47 shows the percentages of young people aged 12 years and older with Type 1 diabetes
with ‘high’ blood pressure (>98th centile) and the percentage above the target for total blood
cholesterol (>=5 mmol/l) reported to the audit since 2013/14.
0%
5%
10%
15%
20%
25%
30%
35%
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
% of young people with Type 1 diabetes
Audit year
Cholesterol level (>=5 mmol/l)
High blood pressure (>98th centile)

Figure 47: Percentage of young people aged 12 years and older with Type 1 diabetes with high blood
pressure and total blood cholesterol above the target in England and Wales, 2013/14 to 2020/21

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NPDA National report 2020/21: Care processes and outcomes

3.6.1.2 Blood Pressure and cholesterol in patients with Type 2 diabetes

Table 26 shows the percentage of children and young people with Type 2 diabetes with a recorded
blood pressure in the audit period (n=519) classified as ‘high normal’ (91st -98th centile) or ‘high’
blood pressure (>98th centile). Half (49.3%) of children and young people with Type 2 diabetes had
high blood pressure.

Table 26: Percentage of children and young people with Type 2 diabetes with ‘high’ or ‘high-
normal’ blood pressure, 2016/17 – 2020/21
‘High normal’ blood pressure
(91st–98th centile)
High’ blood pressure
(>98th centile)
Country/region
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
2020/21
21.4
14.6
22.0
46.8
13.5
49.3
2019/20
28.3
16.1
26.8
42.8
10.4
44.3
2018/19
25.4
17.6
39.6
42.5
10.1
44.6
2017/18
22.2
16.9
34.1
42.7
13.1
44.9
2016/17
24.5
15.8
36.2
42.2
13.6
45.6

Table 27 shows the percentage of children and young people with Type 2 diabetes with a recorded
cholesterol screen (n=466) above the target for total blood cholesterol. It shows that 28.0% met or
exceeded the higher target for total blood cholesterol (>=5 mmol/l) in 2020/21, a similar percentage
with respect to 2019/20 (28.8%).

Table 27: Percentage of children and young people with Type 2 diabetes above cholesterol targets,
2016/17 – 2020/21
4 mmol/l or more
5 mmol/l or more
2020/21
71.4
28.0
2019/20
69.1
28.8
2018/19
69.1
28.3
2017/18
74.9
33.8
2016/17
75.9
36.2
3.6.2 Body Mass Index

Higher Body Mass Index (BMI, weight/height2) is associated with increased cardiovascular risk. BMI
has been standardised using appropriate UK 1990 centile charts to allow direct comparisons across
different ages and between sexes. The following categories of BMI are shown based on the UK 1990
standards (Pan & Cole, 2012):

• Underweight: below the 2nd centile

• Healthy weight: between the 2nd and 85th centile

• Overweight: between the 85th and 95th centile

• Obese: above the 95th centile

57
NPDA National report 2020/21: Care processes and outcomes

Comparisons can be made with the National Child Measurement Programme in England (NHS
Digital, 2021) and the Child Measurement Programme in Wales (Public Health Wales, 2019). These
programmes measure the height and weight of all children in Reception class (aged 4 to 5 years
old) in both countries and Year 6 (aged 10 to 11 years old) in England.

3.6.2.1 Body Mass Index and Type 1 diabetes

Figure 48 shows the prevalence of obese and overweight children with Type 1 diabetes compared
against the prevalence within wider population in England and Wales. For 2020/21, in England
40.4% of children aged 4 to 5 years old with Type 1 diabetes were overweight or obese (an increase
from 32.5% in 2019/20) – higher than the 27.7% in the National Child Measurement Programme
(NCMP) for England 2020/21. In Wales, 57.2% of children with Type 1 diabetes aged 4 to 5 years were
overweight or obese (an increase from 47.2% in 2019/20) – more than double the 26.9% recorded in
the Child Measurement Programme (CMP) for Wales in 2018/19 (the latest data available). However,
given the small numbers of children with Type 1 diabetes at these ages in Wales, this increase could
be artefactual. The prevalence of overweight and obesity in children aged 10 to 11 years old with
Type 1 diabetes in England 2020/21 was 42.1% (an increase from 38.7% in 2019/20) compared to
40.9% of the wider cohort within the National Child Measurement Programme for England 2020/21.

These findings indicate that there is a higher prevalence of obesity and overweight among younger
children with Type 1 diabetes compared to children of similar ages in the wider population.
40.4%
27.7%
42.1%
40.9%
57.2%
26.9%
0%
10%
20%
30%
40%
50%
60%
70%
Children with
Type 1 diabetes
Children in
the NCMP*
Children with
Type 1 diabetes
Children in
the NCMP*
Children with
Type 1
diabetes
Children in
the CMP**
Aged 4-5
Aged 10-11
Aged 4-5
England
Wales
% of children aged 4 to 5 or aged 10 to 11
Prevalence of overweight and obese children by country

* National Child Measurement Programme (England)

** Child Measurement Programme (Wales)

Figure 48: Percentage children with Type 1 diabetes with obesity and overweight, aged 4 to 5 and
age 10 to 11 years old, compared to the wider population by country, 2020/21

58
NPDA National report 2020/21: Care processes and outcomes

Figure 49 shows the percentage of children and young people with Type 1 diabetes included in the
audit within each BMI category for 2019/20 and 2020/21. In 2020/21, a higher percentage of those
aged 0-11 years had a healthy weight (63.2%) compared to those aged 12 years and above (56.2%),
and that a higher percentage of children and young people with Type 1 diabetes were overweight
or obese than were underweight. It also shows that in those aged 0-11, a higher percentage were
obese in 2020/21 compared to 2019/20.
1.1%
56.2%
18.4%
24.3%
0.7%
63.2%
17.5%
18.6%
1.0%
57.8%
18.2%
23.0%
1.0%
57.5%
18.3%
23.1%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Underweight
Healthy weight
Overweight
Obese
Underweight
Healthy weight
Overweight
Obese
age 12 plus
age 0 to 11
Percentage of children with Type 1 diabetes in each BMI category
2020/21
2019/20

Figure 49: Percentage of children and young people with Type 1 diabetes within BMI categories by
age group, 2019/20- 2020/21

Figure 50 shows the distribution of BMI of children and young people with Type 1 diabetes for
2019/20 and 2020/21 compared to the 1990 reference population. It shows that overall, children and
young people with Type 1 diabetes have a higher BMI than the general population, and an overall
trend towards higher BMI between 2019/20 and 2020/21.

59
NPDA National report 2020/21: Care processes and outcomes
1st
5th
10th
25th
50th
75th
85th
95th
99th
Centiles
UK1990 reference
2019/20
2020/21

Figure 50: Distribution of body mass index of children and young people with Type 1 diabetes in
2019/20 and 2020/21 compared to the 1990 reference population

Figure 51 shows that the percentage of boys and girls with overweight or obesity increases with
deprivation, and that girls aged under 12 were less likely to be overweight or obese compared to
boys, whereas this trend was reversed in girls and boys aged 12 and above.
0%
10%
20%
30%
40%
50%
60%
Most
deprived
Second
most
deprived
Third
least
deprived
Second
least
deprived
Least
deprived
Most
deprived
Second
most
deprived
Third
least
deprived
Second
least
deprived
Least
deprived
Aged 0-11
Aged 12+
% of children and young people with
Type 1 Diabetes
Boys (Overweight or Obese)
Girls (Overweight or Obese)

Figure 51: Percentage of children and young people with Type 1 diabetes within the overweight or
obese BMI category, by deprivation quintile, age group and sex, 2020/21

Figure 52 shows that a higher percentages of children and young people with Type 1 diabetes and
a healthy weight are meeting lower HbA1c targets compared to children and young people with
overweight or obesity, however the proportions of those in each BMI category with an HbA1c
exceeding 80mmol/mol were very similar.

60
NPDA National report 2020/21: Care processes and outcomes
18.5%
13.2%
12.1%
8.6%
12.9%
13.3%
11.7%
9.3%
15.0%
17.7%
16.7%
15.1%
25.8%
30.1%
32.7%
34.0%
8.2%
8.9%
9.9%
12.5%
3.9%
4.6%
5.1%
6.6%
15.9%
12.2%
11.9%
13.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Underweight
Healthy weight
Overweight
Obese
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and ≤58
>58 and ≤69 mmol/mol
>69 and ≤76 mmol/mol
>76 and ≤80 mmol/mol
>80 mmol/mol

Figure 52: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by BMI category, 2020/21

3.6.2.2 Body Mass Index and Type 2 diabetes

Table 28 shows the percentage of children and young people with Type 2 diabetes in each BMI
category for England and Wales from 2016/17 to 2020/21. It shows that in each audit year, most
children and young people with Type 2 diabetes were obese.

Table 28: Body mass index categories for children and young people with Type 2 diabetes, 2016/17
to 2020/21
Total (n)
Underweight
(%)
Healthy weight
(%)
Overweight
(%)
Obese
(%)
2020/21
648
8.1*
7.4
84.6
2019/20
796
7.2*
8.7
84.2
2018/19
737
7.6*
7.7
84.7
2017/18
677
0.0
5.9
9.5
84.6
2016/17
658
6.5*
8.1
85.4

*results merged to mask number <5

Figure 53 shows similar percentages of children and young people with Type 2 diabetes within
each weight category when broken down by sex.

61
NPDA National report 2020/21: Care processes and outcomes
Healthy Weight
Overweight
Obese
Boys
7.8%
7.8%
83.5%
Girls
7.4%
7.2%
85.2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% of children and young people
with
Type 2 Diabetes
Boys
Girls

Figure 53: Percentage of children and young people with Type 2 diabetes who were in healthy
weight, overweight or obese category by sex, 2020/21
3.7 Psychological assessment

Psychological assessment and access to psychology services should be available to all children and
young people and their families with diabetes as children and young people with diabetes have a
greater risk of emotional and behavioural difficulties. All children and young people with diabetes
and their family members or carers (as appropriate) should be offered emotional support after
diagnosis, which should be tailored to their emotional, social, cultural and age-dependent needs.
3.7.1 Psychological outcomes of children and young people
with Type 1 diabetes

There were 20,204 (67.6%) children and young people with Type 1 diabetes recorded as having a
psychological screening assessment within the audit period, 96.2% (n=19,434) of whom had a
known outcome of the assessment recorded. Of these, 46.5% (n=9,031) were assessed as requiring
additional psychological or CAMHS support outside of multidisciplinary team (MDT) clinics
(hereafter ‘additional psychological support’). Table 29 shows an increase in the number of children
and young people recorded as requiring additional support compared to 2019/20.

Table 29: Outcome of assessment of the need for psychological support and/or child and adolescent
mental health services (CAMHS) support, for children and young people with Type 1 diabetes,
2017/18 – 2020/21
Audit year
No. of children and young people with a known
outcome of psychological assessment
Required additional
support (n)
Required additional
support (%)
2020/21
19,434
9,031
46.5
2019/20
21,137
9,283
43.9
2018/19
20,852
8,153
39.1
2017/18
20,114
5,672
28.2

62
NPDA National report 2020/21: Care processes and outcomes

Figure 54 shows that the percentages of younger boys and girls assessed as requiring additional
psychological support were similar up to age 12. Rates diverged thereafter as more adolescent girls
were recorded as requiring additional support compared to adolescent boys.
0-1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19-
22
Boys 49%
46%
44%
43%
45%
44%
44%
45%
46%
47%
44%
44%
43%
44%
46%
43%
39%
38%
36%
Girls
49%
43%
49%
45%
42%
39%
46%
44%
47%
49%
49%
53%
50%
50%
54%
54%
49%
48%
49%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% of children and young people
with Type 1 diabetes
Age and sex

Figure 54: Percentage of children and young people with Type 1 diabetes who were assessed as
requiring additional psychological support by age and sex, 2020/21

Figure 55 shows that children and young people with Type 1 diabetes who required additional
psychological support were more likely to have an HbA1c in the higher target range compared to
those who did not require additional psychological support.
10%
11%
9%
12%
13%
17%
26%
29%
9%
8%
5%
4%
15%
9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Required additional
psychological support
Did not require additional
psychological support
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and ≤58
>58 and ≤69 mmol/mol
>69 and ≤76 mmol/mol
>76 and ≤80 mmol/mol
>80 mmol/mol

Figure 55: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by outcome of psychological assessment, 2020/21

63
NPDA National report 2020/21: Care processes and outcomes
3.7.2 Psychological outcomes of children and young people
with Type 2 diabetes

There were 559 (64.5%) children and young people with Type 2 diabetes recorded as receiving a
psychological assessment within the audit period, 506 (90.5%) of whom had a known outcome of
the assessment recorded.

Of the children and young people with Type 2 diabetes with a known result, more than half (59.5%)
were assessed as requiring additional psychological or CAMHS support outside of MDT clinics
(Table 30).

Table 30: Outcome of assessment for need of child and adolescent mental health services/
psychological support of children and young people with Type 2 diabetes by country, 2017/18 to
2020/21
England
and Wales
No. of children and young people with a known
outcome of psychological assessment
Required additional
support
(n)
Required additional
support
(%)
2020/21
506
301
59.5
2019/20
534
286
53.6
2018/19
457
208
45.5
2017/18
417
126
30.2
3.8 Hospital Admissions

Diabetes-related hospital admission rates in this section have been calculated from data submitted
by PDUs. Previous hospital admission reports from the NPDA have utilised linked admission data
taken from Hospital Episode Statistics (HES) in England, and the Patient Episode Database for
Wales (PEDW) (RCPCH, 2014 and 2017), hence rates are not directly comparable. NPDA reported
admissions data submitted by PDUs for the first time in the 2016/17 core report to encourage
submission of higher quality admissions data, which permits regional network and unit level
comparisons.

Results in this section are presented for children and young people with Type 1 diabetes only due
to small numbers with other types of diabetes. In 2020/21, 165 out of 171 PDUs submitted admission
data for children and young people with Type 1 diabetes. There were 5,379 diabetes-related
admissions within the 2020/21 audit year reported for 4,370 children and young people with Type 1
diabetes.
3.8.1 Type 1 diabetes-related admissions

Table 31 shows the percentage of children and young people with Type 1 diabetes being managed
within PDUs who submitted admissions data, who were admitted at least once with a diabetes-
related admission, not associated with diagnosis, within the audit year.

64
NPDA National report 2020/21: Care processes and outcomes

Table 31: Percentage of children and young people with Type 1 diabetes admitted at least once for
a diabetes-related reason that was not associated with diagnosis, 2020/21
Country/region
No. of
children and
young peo-
ple with T1
diabetes*
Diabetic
Ketoacidosis
(%)
Hypogly-
caemia
(%)
Ketosis
without
Acidosis
(%)
Stabilisation
(%)
Other
(incl.
surgery)
(%)
England
and Wales
28,976
1.8%
0.6%
0.8%
1.7%
2.8%
England
27,513
1.8%
0.6%
0.8%
1.8%
2.8%
Wales
1,463
2.6%
0.9%
1.4%
1.1%
2.9%
East Midlands
2,104
1.4%
0.5%
0.2%
1.3%
1.7%
East of England
3,252
1.7%
0.6%
0.6%
1.3%
2.6%
London and
South East
6,579
1.8%
0.6%
0.5%
3.2%
2.4%
North East and
North Cumbria
1,685
1.4%
0.2%
0.6%
0.7%
1.9%
North West
3,455
2.3%
0.6%
1.0%
1.0%
2.9%
South Central
2,790
1.6%
0.8%
1.2%
1.2%
5.2%
South West
2,087
1.5%
0.6%
1.2%
1.8%
3.6%
West Midlands
2,668
1.6%
0.5%
0.4%
1.8%
2.6%
Yorkshire and
Humber
2,893
2.3%
0.6%
1.6%
1.3%
2.6%

* Totals shown include only children and young people with Type 1 diabetes being managed by PDUs submitting admissions data.
3.8.2 DKA at diagnosis

Figure 56 shows that for England and Wales combined, 25.8% of the newly diagnosed patients
being managed by PDUs submitting admissions data in 2020/21 (n = 2,737), had DKA at diagnosis
of Type 1 diabetes. This finding is higher than the 23.9% incidence rate reported in the previous
NPDA Hospital Admissions Report (RCPCH, 2017), and the rate (22.9%) reported for 2019/20. There
was significant variation in rates of DKA at diagnosis between regions, which suggests data
completeness and quality issues with incomplete submission of admission data by certain
participating PDUs in the 2020/21 audit.

The 2022 NPDA admissions report will combine HES and PEDW data with admissions data
submitted by PDUs and will include assessment of whether PDU-submitted admission data can
be considered representative of admission trends in England and Wales.

65
NPDA National report 2020/21: Care processes and outcomes
25.8%
25.6%
29.9%
21.8%
25.0%
31.2%
17.4%
21.1%
29.2%
27.7%
17.0%
32.1%
22.9%
22.8%
25.9%
17.5%
22.4%
27.0%
12.4%
12.7%
21.4%
33.5%
18.3%
34.0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
England and Wales
England
Wales
East of England
East Midlands
London and South East
North East and North
Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
% of children and young people with Type 1 diabetes
2020/21
2019/20

Figure 56: Percentage of children and young people with Type 1 diabetes who had DKA at diagnosis
in 2020/21, by region and country

66
NPDA National report 2020/21: Care processes and outcomes
4. Treatment regimen and diabetes moni-
toring

The NPDA collects treatment regimen data and data on usage of real-time continuous glucose
monitors (rtCGM) with alarms amongst children and young people with diabetes. Where a treatment
regimen changes throughout the audit year, the latest regimen recorded is used for the analysis.
4.1 Treatment regimens
4.1.1 Treatment regimens of children and young people with
Type 1 diabetes

There were 27,053 children and young people with Type 1 diabetes with a valid treatment regimen
recorded within the audit period. Table 32 provides a breakdown of the treatment regimens
recorded by nation and region for children and young people with Type 1 diabetes.

Table 32: Percentage of children and young people with Type 1 diabetes, on each treatment
regimen, by country and region, 2020/21
Country/region
No. of children
and young peo-
ple with
T1 diabetes
One – three in-
jections/day
Four or more
injections/day
Insulin pump
England and Wales
27,053
2.4%
59.1%
38.5%
England
25,674
2.5%
59.1%
38.4%
Wales
1,379
0.9%
59.2%
39.8%
East Midlands
1,919
1.3%
54.9%
43.8%
East of England
2,813
1.2%
65.0%
33.7%
London and South East
5,800
3.7%
54.7%
41.6%
North East and North Cumbria
1,603
2.4%
51.8%
45.7%
North West
3,217
3.8%
59.3%
36.9%
South Central
2,586
3.2%
57.7%
39.1%
South West
2,227
2.6%
69.8%
27.7%
West Midlands
2,754
1.6%
61.5%
36.9%
Yorkshire and Humber
2,755
0.9%
59.3%
39.7%

In England and Wales, 1% of children and young people with Type 1 diabetes using insulin injections
were also using other blood glucose lowering medication (BGLM), whereas 0.4% of children and
young people using insulin pump therapy were using other BGLM.

67
NPDA National report 2020/21: Care processes and outcomes

Figure 57 shows the breakdown of insulin regimens amongst those with a recorded sex and age
(n=27,021). Younger children (< 4 years) were more likely to be using insulin pump therapy than
older children, in keeping with the trend seen in other European and transatlantic cohorts (Sherr
et al., 2016), and pump usage was more prevalent in girls.
35%
44%
45%
45%
40%
41%
40% 42%
39%
41%
41%
39% 38% 39%
34% 36%
33% 36%
50%
37%
40%
65%
56%
55%
55% 60% 59% 60% 58%
61%
59% 59%
61%
62%
61%
66% 64% 67% 64%
50%
63% 60%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
Boys Girls
Age
Sex
Insulin pump
Injections

Figure 57: Percentage of children and young people with Type 1 diabetes recorded as using insulin
injections or insulin pump therapy by age and sex, 2020/21

Since 2014/15, there has been an increase in insulin pump usage for all age groups with a
corresponding reduction in use of insulin injections (Figure 58), however the trend for increasing
pump use amongst those aged 0-9 has reversed since 2018/19.
0%
10%
20%
30%
40%
50%
60%
70%
2014/15
2015/16
2016/17
2017/18
2018/19 2019/20 2020/21
% of children and young people with Type 1
diabetes
Audit year
Insulin injections
0–4 years
Insulin injections
5–9 years
Insulin injections
10–14 years
Insulin injections
15–19 years
Insulin pump therapy
0–4 years
Insulin pump therapy 5–
9 years
Insulin pump therapy
10–14 years
Insulin pump therapy
15–19 years

Figure 58: Percentage of children and young people either on daily insulin injections or pump
therapy by age group, 2014/15 to 2020/21

68
NPDA National report 2020/21: Care processes and outcomes

Insulin pump usage increased with duration of diabetes (Figure 59) with 86.1% of those in their first
year of diagnosis of Type 1 diabetes using insulin injections, compared to less than half (48.9%) of
those after 5 to 9 years post diagnosis. The percentage of those using insulin pumps in the first year
of Type 1 diabetes reduced by almost a half, from 24.8% in 2019/20 to 13.9% in 2020/21.
86.1%
65.0%
56.3%
48.9%
47.1%
47.7%
13.9%
35.0%
43.7%
51.1%
52.9%
52.3%
0%
20%
40%
60%
80%
100%
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
% of children and young people
with Type 1 diabetes
Duration of diabetes
Insulin injections
Insulin pump

Figure 59: Percentage of children and young people either on daily insulin injections or pump
therapy by duration of diabetes for England and Wales, 2020/21

Figure 60 shows that White children and young people were more likely to be using a pump compared
to those within Asian and Black ethnic groups. Insulin pump therapy usage was also more prevalent in
those living in the least deprived compared to the most deprived areas of the country.
White
Mixed
Other
Asian
Black
Most
Second
most
Third
least
Second
least
Least
Ethnicity
Deprivation
2020/21
40.2%
37.8%
34.6%
31.1%
27.4%
32.5%
36.3%
38.4%
42.4%
44.0%
2019/20
39.8%
35.0%
34.9%
29.7%
26.7%
31.7%
35.8%
37.5%
42.4%
44.3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
% children and young people with
Type 1 Diabetes

Figure 60: Percentage of children and young people with Type 1 diabetes using insulin pump
therapy by ethnic group and deprivation, 2020/21

69
NPDA National report 2020/21: Care processes and outcomes

Figure 61 shows that despite increases in insulin pump usage compared to insulin injections in all
quintiles of deprivation, the gap between the most and least deprived areas has widened with
time. In 2014/15 the percentage on insulin pump therapy for the most and least deprived areas was
18.4% versus 26.3% (a difference of 7.9 percentage points), whereas in 2020/21 the gap had widened
to 32.5% versus 44.0%, respectively (a difference of 11.5 percentage points). However, the discrepancy
has decreased from 2019/20, when there was a 12.6% difference.

Figure 61: Percentage of children and young people with Type 1 diabetes using insulin injections or
insulin pump therapy by ‘least’ and ‘most’ deprived quintile, 2014/15 to 2020/21

Figure 62 shows a general trend for children and young people with Type 1 diabetes using insulin
pump therapy to achieve lower HbA1c targets compared to those on insulin injections. These data
do not account for the influence of deprivation, age, duration of diabetes or other factors which
may influence the choice of insulin regimen, which have also been shown to impact upon target
achievement.
10.7%
10.5%
9.2%
13.4%
13.1%
18.7%
26.0%
32.2%
9.4%
8.3%
5.4%
3.8%
15.2%
5.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Injections
Insulin pump
>58 and ≤69 mmol/mol
>69 and ≤76 mmol/mol
>76 and ≤80 mmol/mol
>80 mmol/mol

Figure 62: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by treatment regimen, 2020/21

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NPDA National report 2020/21: Care processes and outcomes
4.1.2 Treatment regimens of children and young people with
Type 2 diabetes

Table 33 shows the breakdown of diabetes treatment regimen for children and young people with
Type 2 diabetes. Data was either missing or reported as ‘unknown’ for 33.4% of children and young
people with Type 2 diabetes.

The majority of those with Type 2 diabetes were either managing their diabetes with diet alone
(11.4%) or in combination with another blood glucose lowering agent (48.1%). However, given that
there was a cohort on insulin alone, and missing data, caution should be taken when interpreting
these results.

Table 33: Percentage of children and young people with Type 2 diabetes using each treatment
regimen, England and Wales, 2019/20 and 2020/21
Treatment regimen
2019/20
2020/21
No. of children and young people with Type 2 diabetes
with a recorded treatment regimen (n)
660
648
Dietary management
Only (%)
11.8
11.4
And other BGLM† (%)
45.9
48.1
1 to 3 insulin injections
Only (%)
4.2
2.6
And other BGLM† (%)
13.2
11.6
4 or more insulin injec-
tions
Only (%)
14.1
12.5
And other BGLM† (%)
9.7
11.6
Insulin pump
Only (%)
1.1*
2.2*
And other BGLM† (%)

*Results merged to mask number <5

† And other blood glucose lowering medication
4.2 Real time continuous glucose monitoring (rtCGM)

NICE guidance applicable at the time of the 2020/21 audit (NG18) stated that ongoing rtCGM
monitoring with alarms to children and young people with Type 1 diabetes who:

•
had frequent severe hypoglycaemia or

•
had impaired hypoglycaemia awareness that is associated with adverse consequences (for
example, seizures or anxiety) or

•
couldn’t recognise or communicate about symptoms of hypoglycaemia (for example, because
of cognitive or neurological disabilities).

However, new guidance published in 2022 (NG18- 2022) now recommends that it should be offered
to all children and young people with type 1 diabetes, as long as it is provided alongside education
to support children and young people and their families and carers to use it.

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NPDA National report 2020/21: Care processes and outcomes
4.2.1 rtCGM use among children and young people with Type 1
diabetes

There were 24,184 children and young people with Type 1 diabetes with a negative or positive
indication of use of rtCGM with alarms reported within the audit period. Overall, 27.9% were using
rtCGM in England and Wales (Figure 64)- an increase from 19.4% in 2019/20. These results should
be interpreted with caution given that 19.0% (n = 5,708) of children and young people with Type 1
diabetes had an unknown or missing entry; percentages of missing data also varied by region.
27.9%
27.7%
32.8%
23.7%
22.8%
28.8%
28.9%
30.7%
31.2%
17.5%
33.3%
25.0%
0%
3%
6%
9%
12%
15%
18%
21%
24%
27%
30%
33%
36%
England and Wales
England
Wales
East Midlands
East of England
London and South East
North East and North Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
% of children and young people with Type 1 diabetes

Figure 63: Percentage of children and young people with Type 1 diabetes using rtCGM with alarms
by country and regional network, 2020/21

Figure 64 shows that younger children with Type 1 diabetes were more likely to be using rtCGM
than those who were older.
0 – 4 years
5 – 9 years
10 – 14 years
15 – 19 years
Boys
33.1%
18.6%
11.9%
5.5%
Girls
33.8%
19.9%
11.0%
5.9%
0%
5%
10%
15%
20%
25%
30%
35%
% of children and young people with
Type 1 diabetes
Age and sex

Figure 64: Percentage of children and young people with Type 1 diabetes using a real-time
continuous glucose monitor (CGM) with alarms by age and sex, 2020/21

Figure 65 shows that rtCGM was more likely to be used in the first two years following diagnosis of
Type 1 diabetes.

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NPDA National report 2020/21: Care processes and outcomes
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
CGM use
24.3%
31.2%
30.4%
27.9%
25.1%
23.8%
0%
5%
10%
15%
20%
25%
30%
% of young people with Type 1
diabetes
Duration of diabetes

Figure 65: Percentage of children and young people with Type 1 diabetes using a rtCGM by duration
of Type 1 diabetes, 2020/21

Figure 64 shows variation in use of rtCGM by ethnic group and deprivation quintile. Increased use
was found across all deprivation quintiles and ethnic groups, with the highest percentage increase
between the audit years being amongst Black children and young people with Type 1 diabetes,
from 11.7% in 2019/20 to 21.9% in 2020/21- an increase of 87.2%. However, this was the lowest
percentage out of all ethnic groups, with those of Mixed ethnicity having the highest rate of usage,
at 29.3%.

Figure 66 also shows that children and young people with Type 1 diabetes living in the least deprived
areas were more likely to be using rtCGM compared to those living in the most deprived areas,
although the percentage increase between the audit years was highest amongst those living in
the most deprived areas, with a 70.0% increase in use between 2019/20 and 2020/21.
0%
5%
10%
15%
20%
25%
30%
35%
Mixed
White
Other
Asian
Black
Ethnicity
2020/21
2019/20
Most
Second most
Third least
Second least
Least
Deprivation
2020/21
2019/20

Figure 66: Percentage of children and young people with Type 1 Diabetes using a rtCGM by ethnic
group and deprivation quintile, 2019/20 - 2020/21

Figure 67 shows the usage of rtCGM by ethnic group and deprivation quintile. It shows that rtCGM
use was more prevalent amongst those living in the least and second least quintile within most
ethnic groups, and that Black children and young people typically had lower use than other ethnic
groups irrespective of deprivation status.

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NPDA National report 2020/21: Care processes and outcomes
White
Asian
Black
Mixed
Other
Most deprived
23.1%
23.8%
22.7%
30.3%
29.1%
Second most deprived
25.8%
20.0%
22.1%
26.0%
18.5%
Third least deprived
28.2%
26.0%
17.6%
30.2%
27.6%
Second least deprived
29.7%
31.8%
21.7%
31.1%
36.8%
Least deprived
34.7%
42.5%
25.7%
29.5%
34.7%
0%
5%
10%
15%
20%
25%
30%
35%
40%

Figure 67: Percentage of children and young people with Type 1 Diabetes using a rtCGM by ethnic
group and deprivation quintile, 2020/21

Figure 68 shows that despite increases in rtCGM usage in all quintiles of deprivation, the gap between
the most and least deprived areas has widened with time. However, this trend reversed between the
last two audit years, with the gap decreasing from 11.2% to 10.9% between 2019/20 and 2020/21.

Figure 68: Percentage of children and young people with Type 1 diabetes using a real-time
continuous glucose monitor (CGM) by ‘least’ and ‘most’ deprived quintile, 2017/18 to 2020/21

74
NPDA National report 2020/21: Care processes and outcomes

Figure 69 shows that children and young people with Type 1 diabetes using rtCGM were more
likely to achieve lower HbA1c targets compared to those who were not using rtCGM.
14%
9%
14%
9%
19%
13%
27%
27%
6%
10%
3%
5%
5%
14%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Using CGM
Not using CGM
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and ≤58
>58 and ≤69 mmol/mol
>69 and ≤76 mmol/mol
>76 and ≤80 mmol/mol
>80 mmol/mol

Figure 69: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by rtCGM usage, 2020/21

Figure 70 shows that rtCGM was more prevalent amongst pump users than those using insulin
injections.
47.0%
16.1%
53.0%
83.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Insulin pump therapy
Insulin injections
using CGM
not using CGM

Figure 70: Percentage of children and young people with Type 1 diabetes using insulin injections
or insulin pump therapy by rtCGM usage, 2020/21

Figure 71 shows year on year increase in the use of rtCGM in combination with insulin pump and
insulin injections, for both England and Wales since 2015/16.

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NPDA National report 2020/21: Care processes and outcomes
60% 58% 55%
51%
60% 58% 55%
51%
62% 57% 53%
47%
2%
3%
6%
9%
2%
3%
6%
10%
4%
8%
8%
12%
31% 30% 26% 21%
31% 30% 26% 21%
26% 25%
21%
19%
7%
9%
14%
19%
7%
9%
14%
18%
8%
11%
18% 22%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
17/18 18/xx-xxxx-xxxx
17/18 18/xx-xxxx-xxxx
England and Wales
England
17/18 18/xx-xxxx-xxxx
Wales
Injections alone
Injections and rtCGM
Pump alone
Pump and rtCGM

Figure 71: Percentage of children and young people with Type 1 diabetes using insulin injections
alone, insulin injections and rtCGM, insulin pump alone, insulin pump and rtCGM, by country,
2017/18 to 2020/21

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NPDA National report 2020/21: Care processes and outcomes
5. Thyroid and coeliac disease
5.1 Thyroid and coeliac disease amongst children
and young people with Type 1 diabetes

Children and young people with Type 1 diabetes are at an increased risk of other autoimmune
conditions. This chapter describes the prevalence of such associations in England and Wales.

Table 34 shows that the prevalence of Thyroid disease in 2020/21 for children and young people
with Type 1 diabetes was 2.7%, and 5.2% of children and young people with Type 1 diabetes had
coeliac disease. The figure for coeliac disease is similar compared to 2019/20 (5.8%), but higher
compared to an international collaborative study that found a prevalence rate of 3.5% across three
continents (Craig et al., 2017).

Table 34: Percentage of children and young people with Type 1 diabetes with thyroid or coeliac
disease by country and region in England and Wales, 2020/21
Country
No. of children and young
people with Type 1 diabetes
Coeliac disease
Thyroid disease
England and Wales
29,892
5.2%
2.7%
England
28,492
5.2%
2.7%
Wales
1,463
4.3%
2.3%
East Midlands
2,104
5.4%
3.0%
East of England
3,252
4.7%
3.1%
London and South East
6,579
4.9%
2.9%
North East and North Cumbria
1,685
4.0%
3.3%
North West
3,685
5.6%
2.1%
South Central
2,790
6.7%
2.3%
South West
2,309
4.3%
2.9%
West Midlands
3,132
5.1%
2.3%
Yorkshire and Humber
2,893
6.2%
2.7%

Figure 72 shows year on year variation in prevalence of thyroid and coeliac disease amongst those
with Type 1 diabetes. Prevalence of both coeliac and thyroid disease decreased since 2019/20.

77
NPDA National report 2020/21: Care processes and outcomes
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
Thyroid
3.2%
3.5%
2.6%
3.0%
3.3%
3.1%
2.7%
Coeliac
4.7%
4.0%
4.4%
5.6%
6.5%
5.8%
5.2%
0%
1%
2%
3%
4%
5%
6%
7%
8%
% of children and young people with
Type 1 diabetes
Audit year

Figure 72: Percentage of children and young people with Type 1 diabetes with thyroid or coeliac
disease in England and Wales, 2014/15 to 2020/21

Figure 73 shows that there was a higher prevalence of both autoimmune conditions amongst girls
compared to boys.
1.9%
2.2%
2.0%
1.8%
4.2%
4.5%
4.3%
3.7%
0%
2%
4%
6%
8%
10%
20 17/18
20 18/19
201 9/20
20 20/21
Thyroid disease
4.6%
5.3%
4.7%
4.1%
6.6%
7.8%
7.0%
6.5%
0%
2%
4%
6%
8%
10%
2017/18
2018/19
2019/20
2020/21
Coeliac disease
Boys
Girls
Boys
Girls

Figure 73: Percentage of children and young people with Type 1 diabetes and comorbid coeliac or
thyroid disease by sex, 2017/18 to 2020/21

Coeliac disease prevalence was higher amongst children and young people with Type 1 diabetes
living in the least deprived areas compared to the most deprived areas, but there was no clear
association between prevalence of Thyroid disease and areas of deprivation (Figure 74).

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NPDA National report 2020/21: Care processes and outcomes
Most deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least deprived
Thyroid
2.7%
3.0%
2.6%
2.6%
2.6%
Coeliac
4.5%
5.1%
5.4%
5.6%
5.8%
0%
1%
2%
3%
4%
5%
6%
7%
8%
% of children and young people
with Type 1 diabetes
Deprivation Quintile

Figure 74: Percentage of children and young people with Type 1 diabetes and coeliac or thyroid
disease by deprivation quintile, 2020/21

Figure 75 shows that the prevalence of coeliac disease was highest amongst White children and
young people with Type 1 diabetes, while the prevalence of thyroid disease was highest amongst
Asian children and young people with Type 1 diabetes. Those of Black ethnicity had the lowest rates
of both coeliac and thyroid disease out of all ethnic groups.
White
Asian
Black
Mixed
Other
Thyroid
2.7%
4.4%
1.4%
2.1%
3.3%
Coeliac
5.5%
5.0%
2.9%
3.5%
4.2%
2.7%
4.4%
1.4%
2.1%
3.3%
5.5%
5.0%
2.9%
3.5%
4.2%
0%
1%
2%
3%
4%
5%
6%
% of children and young people with
Type 1 diabetes
Thyroid
Coeliac

Figure 75: Percentage of children and young people with Type 1 diabetes and coeliac or thyroid
disease by ethnic group, 2020/21

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NPDA National report 2020/21: Care processes and outcomes
6. List of Tables
Table 1: Number of children and young people
with diabetes by age-group and type of diabetes
in 2020/21.
4
Table 2: Number of children and young people
with Type 1 diabetes by country, region and age
group, 2020/21
6
Table 3: Ethnic groups of children and
young people with Type 1 diabetes in England
and Wales, 2020/21
6
Table 4: Percentage and number of children
and young people with Type 1 diabetes by
deprivation quintile, 2020/21
7
Table 5: Number of children and young people
with Type 2 diabetes by country and region,
2020/21

14
Table 6: Children and young people with Type
2 diabetes England and Wales by ethnic group,
2020/21

15
Table 7: Numbers and percentages of children
and young people with Type 2 diabetes by
deprivation quintile, 2020/21
15
Table 8: Percentage of children and young
people with Type 1 who completed a full year of
care recorded as receiving health checks,
2015/16 to 2020/21
17
Table 9: Percentage of children and young people
of all ages with Type 1 diabetes who completed a
full year of care recorded as having received key
health checks by country and region, 2020/21
20
Table 10: Percentage of young people aged 12 and
above with Type 1 diabetes who completed a full
year of care recorded as having received key health
checks by country and region, 2020/21
20
Table 11: Percentage of children and young people
with Type 1 diabetes who completed a year of care
receiving 1-4+ HbA1c measurements by country
and region, 2020/21.
24
Table 12: Percentage of children and young people
with Type 1 diabetes who completed a full year
of care who were offered and/or attended an
additional dietetic appointment by country,
2020/21

25
Table 13: Percentage of children and young people
with Type 1 diabetes who completed a full year of
care recorded as receiving health checks by region
and country, 2020/21.
27
Table 14: Percentage of children and young people
with Type 2 diabetes who completed a full year of
care recorded as receiving recommended health
checks, 2015/16 to 2020/21
31
Table 15: Percentage of children and young
people with Type 2 diabetes who completed a
full year of care recorded as being offered and
attending an additional dietetic appointment,
2017/18 to 2020/21
32
Table 16: Percentage of young people with Type 2
diabetes who completed a full year of care recorded
as receiving additional health checks by region and
country, 2017/18 to 2020/21
33
Table 17: HbA1c for all children and young people
with all types of diabetes and one or more valid
HbA1c measurements by region, county and
overall, 2020/21
35
Table 18: HbA1c for all children and young people
with Type 1 diabetes with one or more valid HbA1c
measurement, by regional network, country, and
overall, 2020/21
37
Table 19: Percentage of children and young people
with Type 1 diabetes achieving HbA1c targets by
country and regional network, 2020/21
38
Table 20: Mean HbA1c for children and young
people with Type 1 diabetes by ethnic category
and deprivation quintile, 2020/21*
41
Table 21: HbA1c for all children and young people
with Type 2 diabetes and one or more valid HbA1c
measurements in England and Wales, 2015/16 -
2020/21

44
Table 22: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria,
2015/16 to 2020/21
49
Table 23: Percentage of young people with
Type 1 diabetes aged 12 years and above with a
normal/ abnormal eye screening result, 2015/16 to
2020/21

52

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NPDA National report 2020/21: Care processes and outcomes
Table 24: Percentage of young people with Type
1 diabetes aged 12 years and above falling within
blood pressure targets by country and region,
2020/21

54
Table 25: Percentage of young people with
Type 1 diabetes aged 12 years and above falling
within cholesterol targets by country and region,
2020/21

55
Table 26: Percentage of children and young people
with Type 2 diabetes with ‘high’ or ‘high-normal’
blood pressure, 2016/17 – 2020/21
56
Table 27: Percentage of children and young people
with Type 2 diabetes above cholesterol targets,
2016/17 - 2020/21
56
Table 28: Body mass index categories for children
and young people with Type 2 diabetes, 2016/17 to
2020/21

60
Table 29: Outcome of assessment of the need for
psychological support and/or child and adolescent
mental health services (CAMHS) support, for
children and young people with Type 1 diabetes,
2017/18 – 2020/21
61
Table 30: Outcome of assessment for need of
child and adolescent mental health services/
psychological support of children and young
people with Type 2 diabetes by country, 2017/18 to
2020/21

63
Table 31: Percentage of children and young
people with Type 1 diabetes admitted at least
once for a diabetes-related reason that was
not associated with diagnosis, 2020/21
64
Table 32: Percentage of children and young
people with Type 1 diabetes, on each treatment
regimen, by country and region, 2020/21
66
Table 33: Percentage of children and young
people with Type 2 diabetes using each treatment
regimen, England and Wales, 2019/20 and
2020/21

70
Table 34: Percentage of children and young
people with Type 1 diabetes with thyroid or coeliac
disease by country and region in England and
Wales, 2020/21
76

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NPDA National report 2020/21: Care processes and outcomes
7. List of Figures
Figure 1: Total number of children and young
people with Type 1 diabetes broken down by age
and sex, 2019/20 – 2020/21
5
Figure 2: Prevalence of Type 1 diabetes per
100,000 general population among children aged
0-15 years by age and sex, 2013/14 to 2020/21.
8
Figure 3: Prevalence of Type 1 diabetes per
100,000 general population by age group and
sex, 2013/14 to 2020/21
8
Figure 4a: Incidence of Type 1 diabetes per
100,000 general population among children
aged 0-15 years by sex, 2013/14 to 2020/21
9
Figure 4b: Number of new cases of Type 1 diabetes
amongst children and young people receiving care
from a PDU by month, 2013/14 – 2020/21
10
Figure 5: Newly diagnosed children and young
people with Type 1 diabetes by age group and
sex, 2020/21
11
Figure 6: Incidence of Type 1 diabetes per
100,000 general population by age group and
sex, 2013/14 to 2020/21
11
Figure 7: Numbers of new cases of Type 1 diabetes
presenting in 2019/20 and 2020/21 by age at the
beginning of the audit year
12
Figure 8: Incidence of Type 1 diabetes amongst
children and young people aged 0-15 years per
100,000 by CCG (England) and LHB (Wales)
12
Figure 9: Numbers of children and young
people with Type 2 diabetes included in the
NPDA, 2011/12- 2020/21
13
Figure 10: Numbers of children and young
people with Type 2 diabetes by age and sex, 2019/20
and changes in numbers between 2019/20 and
2020/21

14
Figure 11: Percentage of children and young
people who completed a full year of care
recorded as receiving individual health
checks, 2004/05 to 2020/21
18
Figure 12: Percentage of young people aged
12 or above who completed a full year of care
recorded as receiving all seven/six key health
checks, 2004/05 to 2020/21.
18
Figure 13: Percentage of children and young
people aged 12 and above in 2019/20 receiving
retinopathy screening in 2020/21, by screening
result in 2019/20
19
Figure 14: Percentage of children and young
people with Type 1 diabetes receiving each key
health check by PDU, 2020/21
21
Figure 15: Percentage of young people aged
12 years and above with Type 1 diabetes who
completed a full year of care recorded as
receiving all six health checks by unit, 2020/21
22
Figure 16: Funnel plot of key health check
completion rates for young people aged 12 years
and above with Type 1 diabetes who completed a
full year of care 2020/21, by PDU
23
Figure 17: Percentage of children and young
people with Type 1 diabetes who completed a full
year of care by number of HbA1c measurements
recorded per child or young person, 2016/17 to
2020/21

24
Figure 18: Percentage of offered dietetic
appointments attended by age group and
duration of diabetes, 2020/21
26
Figure 19: Completion rates for psychological
assessment, flu vaccine recommendation, “Sick day
rules” advice and blood ketone testing, for children
and young people with Type 1 diabetes who
completed a full year of care, 2017/18 to 2020/21 28
Figure 20: Percentage of newly diagnosed children
and young people with Type 1 diabetes who
received screening for thyroid and coeliac disease
within 90 days of diagnosis, 2015/16 to 2020/21
29
Figure 21: Percentage of newly diagnosed children
and young people with Type 1 diabetes who
received level 3 carbohydrate counting education
within 14 days of diagnosis, 2017/18 to 2020/21
30
Figure 22: Percentage of children and young
people with Type 2 diabetes who completed a
full year of care recorded as receiving key health
checks, 2015/16 to 2020/21.
31

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NPDA National report 2020/21: Care processes and outcomes
Figure 23: Number of HbA1c measurements
recorded for children and young people with Type
2 diabetes receiving a full year of care, 2016/17 –
2020/21

32
Figure 24: Median HbA1c for children and young
people with all types of diabetes in England and
Wales 2009/10 to 2020/21, with associated NHS
policy and/or paediatric diabetes delivery structural
changes

36
Figure 25: Percentage of children and young
people with Type 1 diabetes with an HbA1c result
within current and previous target ranges,
2010/11 – 2020/21
38
Figure 26: Mean HbA1c for boys and girls with Type
1 diabetes, 2003/04 to 2020/21
39
Figure 27: Mean HbA1c for children and young
people with Type 1 diabetes in England and Wales
by duration of diabetes and age group, 2020/21 40
Figure 28: Mean HbA1c for children and young
people with Type 1 diabetes in England and Wales
by ethnic group, 2003/04 to 2020/21
41
Figure 29: Percentage of children and young
people with Type 1 diabetes in England and Wales
achieving HbA1c targets by ethnic group, 2020/21 42
Figure 30: Mean HbA1c for children and young
people with Type 1 diabetes by deprivation
quintile, 2013/14 to 2020/2021
42
Figure 31: Percentage of children and young
people with Type 1 diabetes in England and Wales
achieving HbA1c targets by deprivation quintile,
2020/21

43
Figure 32: Median HbA1c per PDU, 2020/21
43
Figure 33: Percentage of children and young
people with HbA1c <58mmol/mol per PDU,
2020/21

44
Figure 34: Percentage of children and young
people with Type 2 diabetes with an HbA1c result
within current and previous target ranges, 2017/18 –
2020/21

45
Figure 35: Mean HbA1c for boys and girls with Type
2 diabetes, 2017/18 to 2020/21
45
Figure 36: Mean HbA1c for children and young
people with Type 2 diabetes, by age group and
duration of diabetes, 2020/21
46
Figure 37: Mean HbA1c for children and young
people with Type 2 diabetes in England and Wales
by deprivation quintile, 2015/16 to 2020/21
47
Figure 38: Mean HbA1c for children and young
people with Type 2 diabetes by ethnic category,
2015/16- 2020/21
47
Figure 39: Percentage of young people with Type 1
diabetes aged 12 years and older with albuminuria
by country and regional network 2020/21
48
Figure 40: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by duration of diabetes, 2016/17 – 2020/21
49
Figure 41: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by age and sex, 2016/17 – 2020/21
50
Figure 42: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by deprivation quintile, 2016/17 – 2020/21
50
Figure 43: Percentage of young people with Type
1 diabetes achieving HbA1c targets by presence of
albuminuria, 2020/21
51
Figure 44: Percentage of children and young
people with Type 2 diabetes with albuminuria in
England and Wales, 2015/16 – 2020/21
51
Figure 45: Retinopathy screening outcomes of
children and young people with Type 1 diabetes on
2020/21 by result of screening in 2019/20
52
Figure 46: Eye screening results for young people
aged 12 years and above with Type 2 diabetes,
2015/16 to 2020/21
53
Figure 47: Percentage of young people aged 12
years and older with Type 1 diabetes with high
blood pressure and total blood cholesterol above
the target in England and Wales, 2013/14 to
2020/21

55
Figure 48: Percentage children with Type 1 diabetes
with obesity and overweight, aged 4 to 5 and age
10 to 11 years old, compared to the wider population
by country, 2020/21
57

83
NPDA National report 2020/21: Care processes and outcomes
Figure 49: Percentage of children and young
people with Type 1 diabetes within BMI categories
by age group, 2019/20- 2020/21
58
Figure 50: Distribution of body mass index of
children and young people with Type 1 diabetes
in 2019/20 and 2020/21 compared to the 1990
reference population
59
Figure 51: Percentage of children and young
people with Type 1 diabetes within the overweight
or obese BMI category, by deprivation quintile, age
group and sex, 2020/21
59
Figure 52: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by BMI category, 2020/21
60
Figure 53: Percentage of children and young
people with Type 2 diabetes who were in healthy
weight, overweight or obese category by sex,
2020/21

61
Figure 54: Percentage of children and young
people with Type 1 diabetes who were assessed as
requiring additional psychological support by age
and sex, 2020/21
62
Figure 55: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by outcome of psychological assessment,
2020/21

62
Figure 56: Percentage of children and young
people with Type 1 diabetes who had DKA at
diagnosis in 2020/21, by region and country
65
Figure 57: Percentage of children and young
people with Type 1 diabetes recorded as using
insulin injections or insulin pump therapy by age
and sex, 2020/21
67
Figure 58: Percentage of children and young
people either on daily insulin injections or pump
therapy by age group, 2014/15 to 2020/21
67
Figure 59: Percentage of children and young
people either on daily insulin injections or pump
therapy by duration of diabetes for England and
Wales, 2020/21
68
Figure 60: Percentage of children and young
people with Type 1 Diabetes using insulin
pump therapy by ethnic group and
deprivation, 2020/21
68
Figure 61: Percentage of children and young
people with Type 1 diabetes using insulin injections
or insulin pump therapy by ‘least’ and ‘most’
deprived quintile, 2014/15 to 2020/21
69
Figure 62: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by treatment regimen, 2020/21
69
Figure 63: Percentage of children and young
people with Type 1 diabetes using rtCGM with
alarms by country and regional network, 2020/21 71
Figure 64: Percentage of children and young
people with Type 1 diabetes using a real-time
continuous glucose monitor (CGM) with alarms by
age and sex, 2020/21
71
Figure 65: Percentage of children and young
people with Type 1 diabetes using a rtCGM by
duration of Type 1 diabetes, 2020/21
72
Figure 66: Percentage of children and young
people with Type 1 Diabetes using a rtCGM by
ethnic group and deprivation quintile, 2019/20 -
2020/21

72
Figure 67: Percentage of children and young
people with Type 1 Diabetes using a rtCGM by
ethnic group and deprivation quintile, 2020/21
73
Figure 68: Percentage of children and young
people with Type 1 diabetes using a real-time
continuous glucose monitor (CGM) by ‘least’ and
‘most’ deprived quintile, 2017/18 to 2020/21
73
Figure 69: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by rtCGM usage, 2020/21
74
Figure 70: Percentage of children and young
people with Type 1 diabetes using insulin
injections or insulin pump therapy by rtCGM
usage, 2020/21
74
Figure 71: Percentage of children and young
people with Type 1 diabetes using insulin injections
alone, insulin injections and rtCGM, insulin pump
alone, insulin pump and rtCGM, by country, 2017/18
to 2020/21
75
Figure 72: Percentage of children and young
people with Type 1 diabetes with thyroid or coeliac
disease in England and Wales, 2014/15 to 2020/21 77

84
NPDA National report 2020/21: Care processes and outcomes
Figure 73: Percentage of children and young
people with Type 1 diabetes and comorbid coeliac
or thyroid disease by sex, 2017/18 to 2020/21
77
Figure 74: Percentage of children and young
people with Type 1 diabetes and coeliac or thyroid
disease by deprivation quintile, 2020/21
78
Figure 75: Percentage of children and young
people with Type 1 diabetes and coeliac or thyroid
disease by ethnic group, 2020/21
78

85
NPDA National report 2020/21: Care processes and outcomes
8. References

Craig, M. E., et al. (2017). Prevalence of Celiac Disease in 52,721 Youth with Type 1 Diabetes:
International Comparison Across Three Continents. Diabetes Care 40(8): 1034-1040.

Jackson LV, Thalange NK & Cole TJ (2007) Blood pressure centiles for Great Britain. Arch Dis Child
92: 298–303

Maahs DM, Hermann JM, Holman N et al (2015) Rates of diabetic ketoacidosis: international
comparison with 49,859 pediatric patients with type 1 diabetes from England, Wales, the U.S.,
Austria, and Germany. Diabetes Care 38: 1876–82

McKnight JA, Wild SH, Lamb MJ et al (2015) Glycaemic control of type 1 diabetes in clinical
practice early in the 21st century: an international comparison. Diabet Med 32: 1036–50

Nathan DM, Cleary PA, Backlund JY et al (2005) Intensive diabetes treatment and cardiovascular
disease in patients with type 1 diabetes. N Engl J Med 353: 2643–53

NICE (2004) Diagnosis and management of type 1 diabetes in children, young people, and
adults (CG15). NICE, London. Available at: http://www.nice.org.uk/guidance/cg15

NICE (2015) Diabetes (type 1 and type 2) in children and young people: diagnosis and
management (NG18). NICE, London. Available at: http://www.nice.or.uk/guidance/ng18

NICE (2015) Diabetic foot problems: prevention and management (NG19) NICE, London. Available
at https://www.nice.org.uk/Guidance/NG19

Pan H, Cole TJ. (2012) LMS growth, a Microsoft Excel add-in to access growth references based on
the LMS method (version 2.77). Harlow Healthcare, South Shields. Available at:
http://www.healthforallchildren.com/shop-base/shop/software/lmsgrowth

Randell T, (2012) Developing a best practice tariff in paediatric diabetes: Can we improve services
and outcomes for children and young people with diabetes in England? Diabetes Care for
Children & Young People 1: 23–6

RCPCH (2017) National Paediatric Diabetes Audit 2012-2015, Part 2: Hospital admissions and
complications.

Sherr JL, Hermann JM, Campbell F et al. (2016) Use of insulin pump therapy in children and
adolescents with type 1 diabetes and its impact on metabolic control: comparison of results from
three large, transatlantic paediatric registries. Diabetologia 59: 87-91

Waldron S, Campbell F. (2014) Structured patient education to improve self-management: a
vision for the future. Diabetes Care for Children & Young People 3: 5–7

Welsh Government (2013). Together for Health – Diabetes Delivery Plan.

Appendix 1: Full audit analysis
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
5-11 Theobalds Road,
London, WC1X 8SH
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Improvement Partnership (HQIP)
Dawson House, 5 Jewry Street,
London EC3N 2EX
Royal College of
Paediatrics and Child Health
RCPCH
Published by RCPCH April 2022