NPDA 2018-19 Annual Report
Source: data.gov.uk (2024-05-31)

National Paediatric Diabetes Audit 2018 - 2019. The excel file contains unit, regional and national level data obtained from the National Paediatric Diabetes Audit 2018-2019.
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 2018 and the 31 March 2019.
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 2020 alongside the National Paediatric Diabetes Audit Report 2018-2019 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 2018-19
Care processes and outcomes
Audits
RCPCH
National Paediatric
Diabetes Audit
NPDA

Front cover Image by Katie Lamb, winner NPDA Cover Art Competition
My name is Katie Lamb, I am 18 years old and will be marking 17 years of
type 1 diabetes in a couple of weeks.
As you can imagine, I have attended a fair few paediatric diabetes
clinics over the years, and I have been lucky enough to have the same
DSN since the very beginning. The relationship I have built with her and
all members of the diabetes team is one I will cherish forever- they have
become like a family to me. As I have turned 18 it is time for me to look
to moving to adult care, which is one of the most difficult things I have
ever had to do, because it means saying good bye to people who mean
so much to me.
I was thinking about the theme ‘a good diabetes clinic visit’ and
realised that for me, it didn’t matter what the numbers were, what my
graph looked like or how ‘good’ my HbA1c is (although of course that
helps), what made clinic good was being around people who were there
for me, the best clinics make me feel supported by my team, confident
that they are standing with me through whatever my body might throw
at me.
I have some truly incredible memories in the children’s clinic, I really
have had a lot of fun, but I know that behind it all were the incredible
doctors and nurses and dietitians who never failed to be right there
when I needed them the most. So I decided to draw three figures, myself
with my pump and CGM in the middle, because they always put the
patients first, alongside my nurse and dietitian, literally and symbolically
standing with me and supporting me.

© HQIP 2020
National Paediatric Diabetes
Audit 2018/19
Care Processes and Outcomes

Report produced by the
National Paediatric Diabetes Audit
Royal College of Paediatrics and Child Health
Royal College of
Paediatrics and Child Health
RCPCH

Foreword
I am very pleased to introduce the 2018/19 national report of the National Paediatric Diabetes
Audit; the ninth to be published by the Royal College of Paediatrics and Child Health, and the
16th published since the audit’s inception. The report provides an analysis of data submitted
by healthcare professionals caring for children and young people with diabetes in England
and Wales over 2018/19 and includes information on prevalence of diabetes, diabetes-related
outcomes and complications, use of diabetes-related technologies, compliance with health
care checks recommended by the National Institute for Health and Care Excellence (NICE),
and recommendations for improvements in care.
For the first time in several years, last year’s audit did not show a reduction in national median
HbA1c for children and young people with diabetes, so it is extremely gratifying to see a
reduction in this report. This reflects and validates the commitment shown by paediatric
diabetes teams to improve the care and outcomes of the children and young people with
diabetes within their services both locally and nationally, through participation in the
National Children and Young People’s Diabetes Network and the National Children and
Young People’s Diabetes Quality Programme. It is also pleasing to see evidence of continuing
improvement in the numbers of children and young people receiving the recommended
health checks for diabetes.
However, despite the national improvements shown, the audit continues to show notable
inequalities in outcomes, in the use of technologies shown to improve diabetes management,
and in levels of psychological distress; with children and young people with diabetes living in
the most deprived areas and of non-White ethnicity typically faring worse. Service providers
and commissioners must work with their local communities to understand the challenges
associated with good diabetes management so that these may be targeted, and solutions
funded. This report shows how discrepancies in access to continuous glucose monitoring are
contributing to variation in outcomes, and this must be addressed.
Disappointingly, the 2018/19 audit shows that numbers of children and young people with
Type 2 diabetes receiving care within paediatric diabetes services continue to rise. For many,
the development of Type 2 diabetes can be prevented with lifestyle changes but families
need support to make the changes needed. The increasing numbers of affected children and
young people within the audit highlights the need for urgent action from government to
help them lead healthier lives.
I would like to thank all those involved in writing the report and developing its
recommendations, including the NPDA Project Board, Methodology and Dataset Group, the
audit team, and Clinical Lead, Professor Justin Warner. I would like to thank the paediatric
diabetes teams across England and Wales for their continuing support to the audit and for their
efforts to make improvements in their local services, resulting in the national improvements
evidenced within this report.
Professor Russell Viner, President of the Royal College of Paediatrics and Child Health

Foreword
1
1.
Executive summary
6
1.1
Background to the audit
6
1.2 Audit aims
6
1.3 Audit scope
6
1.4 What the audit measures
6
1.5 Report structure
7
1.6 Overall National HbA1c results
7
1.7 Key findings: Type 1 diabetes
7
1.8 Key findings: Type 2 diabetes
11
2. Recommendations
13
3. Introduction
14
3.1
Commissioning
14
3.2 Background
15
3.3 NPDA outputs and collaborations
15
3.4 Scope of the 2018/19 NPDA report
16
3.5 Key audit questions
16
3.6 Data completeness
16
4. Case studies
18
4.1 Improving clinic HbA1c using quality
improvement methodology and a
whole team approach – Alder Hey
Children’s Hospital
18
4.2 Team work and performance
monitoring key to providing excellent
care at Kingston Hospital NHS
Foundation Trust
19
5. Characteristics, prevalence
and incidence
21
5.1
Audit cohort
21
5.2 Characteristics of children and
young people with Type 1 diabetes
21
5.3 Prevalence and incidence of Type 1
diabetes
25
5.4 Characteristics of children and
young people with Type 2 diabetes
27
5.5 Key findings
31
6. Completion of health checks
(care processes)
33
6.1 Completion of health checks for
children and young people with
Type 1 diabetes
33
6.1.7 Care at diagnosis
44
6.2 Healthcare checks for children and
young people with Type 2 diabetes
46
6.3 Key findings
49
7. Outcomes
50
7.1
HbA1c
50
7.2 Small vessel (microvascular) disease 66
7.3 Large vessel disease - Cardiovascular
disease (CVD) risk factors
76
7.4 Psychological assessment
85
7.5 Hospital admissions
91
8. Treatment regimen and
diabetes monitoring
94
8.1
Treatment regimen
94
8.2 Real time continuous glucose
monitoring (rtCGM)
99
8.3 Assessing the probability of achieving
HbA1c targets according to treatment
regimen and use of rtCGM
103
8.4 Key findings
106
9. Thyroid and coeliac disease 108
9.1
Thyroid and coeliac disease
amongst children and young
people with Type 1 diabetes
108
9.2 Key findings
111
10. Conclusion
112
11. List of figures
113
12. List of tables
117
13. Acknowledgements
119
14. References
121
Contents

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NPDA core report: Care Processes and Outcomes 2018/19
NPDA core report: Care Processes and Outcomes 2018/19
1.
Executive summary
1.1 Background to the audit

Diabetes is a condition where the amount of glucose in the blood is too high because the body
cannot use it properly. High blood glucose levels over time may cause complications associated
with diabetes including damage to small and large blood vessels and nerves. If not managed, this
can result in blindness, kidney failure, heart disease, stroke, and amputations. However, with good
diabetes care and blood glucose control, the risks of complications are markedly reduced, enabling
children and young people with diabetes to live a healthy, happy and longer life.

The National Paediatric Diabetes Audit (NPDA) was established to compare the care and outcomes
of all children and young people with diabetes receiving care from Paediatric Diabetes Units
(PDUs) in England and Wales. The audit is commissioned by the Health Quality Improvement
Partnership (HQIP), funded by NHS England and the Welsh Government, and is managed by the
Royal College of Paediatrics and Child Health. This is the 16th annual report of the audit.
1.2 Audit aims

The audit’s aims are to:

•
Monitor the incidence and prevalence of diabetes amongst children and young people
receiving care from a PDU in England and Wales

•
Establish whether recommended health checks are being received by children and young
people with diabetes

•
Enable benchmarking of performance against standards of care specified by the National
Institute for Health and Care Excellence (NICE) guidance at PDU, regional and national level

•
Determine the prevalence and incidence of diabetes-related complications amongst children
and young people with diabetes
1.3 Audit scope

The 2018/19 NPDA included all 175 PDUs in England and Wales, and captured information on 30,155
children and young people up to the age of 24 years under the care of a consultant paediatrician
between 01 April 2018 and 31 March 2019.
1.4 What the audit measures

The audit collects data submitted by PDUs detailing patient demographics, completion of health
checks recommended for children and young people with diabetes, and their outcomes.

The health checks audited were those recommended by NICE in their guidance for the diagnosis
and management of children and young people with Type 1 and Type 2 diabetes (NG18, NICE, 2015).

7
NPDA core report: Care Processes and Outcomes 2018/19
NPDA core report: Care Processes and Outcomes 2018/19

Prevalence and incidence of diabetes, associated complications, and completion of health checks
(care processes) are broken down by age group, gender, type of diabetes, deprivation (using Indices
of Multiple Deprivation based on patient postcode), region and country. Since gender, ethnicity, age
and deprivation are known to impact upon the level of diabetes control typically achieved by patients
as reflected in mean HbA1c levels, case-mix adjusted mean HbA1c levels are presented so that PDU
performance can be fairly represented and benchmarked taking these factors into account.
1.5 Report structure

This is the fourth year that the audit has reported health check completion rates and outcomes
achieved for children and young people with Type 1 and Type 2 diabetes separately. This executive
summary contains key findings and recommendations from the audit which are presented in
more detail in later chapters. For the third time, a section on admissions has been added to the
Outcomes of Care chapter.
1.6 Overall National HbA1c results

•
There has been a decrease of 2.5 mmol/mol in both the national mean and
median HbA1c for children and young people with all types of diabetes being
treated within a PDU in England and Wales since 2017/18. In 2018/19 the mean
HbA1c was 64.6 mmol/mol, while the median HbA1c was 61.5 mmol/mol.
1.7 Key findings: Type 1 diabetes
1.7.1 Incidence, prevalence, and patient characteristics

•
There were 28,597 (52% male) children and young people with Type 1
diabetes being managed within PDUs in England and Wales in 2018/19.

•
The prevalence of Type 1 diabetes in children and young people aged 0 to
15 years old in England and Wales was 196.4 per 100,000 of the general
population; it was slightly higher among boys (198.1 per 100,000)
compared to girls (194.6 per 100,000).

•
There were 2,769 children and young people aged 0 to 15 years old
newly diagnosed with Type 1 diabetes in England and Wales in 2018/9, giving an incidence of
24.5 per 100,000 of the general population within this age group.

•
There were proportionately more children and young people with Type 1 diabetes living in the
most deprived quintile areas (22.5%, expected 20%), which has been a consistent trend
since 2013.

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NPDA core report: Care Processes and Outcomes 2018/19
1.7.2 Completion of health checks

•
The percentage of those aged 12 and above with a complete year of care
receiving all seven recommended health checks for Type 1 diabetes
increased from 49.8% in 2017/18 to 55.2% in 2018/19.

•
There remains considerable variation in completion rates of health checks
between PDUs, with the percentage of children and young people with Type
1 diabetes and a complete year of care receiving all seven ranging from 3.3 to 95.8%.

•
Completion rates of all key health checks increased between 2017/18 and 2018/19 with the
exception of BMI measurement. However, a high rate of BMI measurement was still found,
with 99.2% of all children and young people with a complete year of care and Type 1 diabetes
receiving this key check in 2018/19.

•
There were no differences in overall health check completion rates associated with ethnicity,
deprivation, or age group.

•
There was a linear relationship between the percentage of those receiving four or more HbA1c
measurements and deprivation quintile, with 56.2% within the most deprived quintile
receiving four or more compared to 58.5% of those in the least deprived quintile receiving four
or more.
1.7.3 Blood glucose diabetes control targets (HbA1c)

•
The unadjusted mean HbA1c was 65 mmol/mol; a decrease of 2.5 mmol/mol
compared to the mean recorded in 2017/18. The median HbA1c was 62 mmol/
mol - 2.0 mmol/mol lower compared to 2017/18.

•
Increasing age, female gender, living in the most deprived areas, non-white
ethnicity and longer duration of diabetes continue to be associated with
higher HbA1c levels in children and young people with Type 1 diabetes.

•
There has been a consistent downward trend in mean HbA1c within each deprivation quintile
since 2013/14 and within each ethnic category since 2015/16. However, on average, Black
children and young people with Type 1 diabetes have had consistently higher HbA1c than
those in other ethnic categories over this period, with those of Afro-Caribbean ethnicity being
the ethnic subcategory with the highest overall HbA1c.

•
Considerable variation in the percentage achieving HbA1c target outcomes amongst children
and young people with Type 1 diabetes persist between PDUs even after case-mix adjustment.
1.7.4 Microvascular complications

•
Albuminuria was found in 9.8% of young people aged 12 years and above with
Type 1 diabetes.

•
There was little variation in the presence of albuminuria by duration of
diabetes, age or sex.

•
The presence of albuminuria was associated with poorer HbA1c outcomes.

•
Abnormal eye screening was found in 13.1% of young people aged 12 and
above with Type 1 diabetes.

•
The risk of abnormal eye screening increased with age and was highest
amongst adolescent females.

•
The risk of abnormal eye screening was higher in young people with higher diastolic blood
pressure.

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NPDA core report: Care Processes and Outcomes 2018/19
1.7.5 Macrovascular complications

•
High blood pressure (hypertension) was found in 25.8% of young people aged 12 years and
older with Type 1 diabetes.

•
19.0% of young people aged 12 years and older with Type 1 diabetes had a total
blood cholesterol level exceeding the target of 5 mmol/l.

•
17.7% of children aged 0 to 11 years with Type 1 diabetes were overweight, and
18.1% were obese. In young people aged 12 years and above 18.4% were
overweight and 23.6% obese.

•
Girls aged 12 years and above had a higher proportion of overweight and
obesity than boys of the same age.

•
The proportions of children and young people with overweight or obesity were
higher in the most deprived quintiles compared to the least deprived.
1.7.6 Outcomes of psychological assessment

•
The proportion of children and young people with Type 1 diabetes who were assessed as
requiring additional psychological or CAMHS support outside of MDT clinics increased from
28.2% in 2017/18 to 39.1% in 2018/19.

•
Amongst children and young people with Type 1 diabetes, there was a
higher proportion of adolescent girls recorded as requiring additional
psychological support compared to adolescent boys.

•
The percentage of children and young people with Type 1 diabetes assessed
as requiring additional psychological support was highest amongst those
who were either newly or recently diagnosed and amongst those living in
the most deprived areas.

•
Children and young people with Type 1 diabetes who were recorded as requiring additional
psychological support tended to have higher HbA1c.
1.7.7 Hospital admissions

•
The number of units submitting admissions data increased from 167 to 168 with only 7 PDUs
failing to submit admissions data in 2018/19.

•
Significant variation in reported admission rates between regions suggests
incompleteness of data submission amongst units who did submit
admissions data.

•
Data quality and completeness needs to improve further before PDU
submitted admission data can be considered representative of admission
trends in England and Wales.

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NPDA core report: Care Processes and Outcomes 2018/19
1.7.8 Treatment regimen

•
Just over a third (36.7%) of children and young people with Type 1 diabetes
were using an insulin pump.

•
Usage of insulin pumps to deliver insulin therapy in Type 1 diabetes has
increased in all age groups since 2014/15.

•
Increased usage of pump therapy was associated with female gender,
younger age, living in the least deprived areas and White ethnicity.

•
The gap between pump usage amongst children and young people with Type 1 diabetes
living in the most and least deprived areas has widened with time, from 18.4% versus 26.3% (a
difference of 7.9 percentage points) in 2014/15, to 29.5% versus 42.9%, in 2018/19, respectively (a
difference of 13.5 percentage points).
1.7.9 Continuous blood glucose monitoring

•
Only 12.6% of children and young people with Type 1 diabetes were using a
real-time continuous glucose monitor (rtCGM).

•
Increased usage of rtCGM with alarms was associated with younger age,
living in the least deprived areas and White Ethnicity.

•
Children and young people with Type 1 diabetes using rtCGM with alarms were more likely to
be using insulin pump therapy than insulin injections.

•
Once patient characteristics were controlled for:

– Children and young people with Type 1 diabetes were more likely to be achieving the HbA1c
targets of <48mmol/mol or <58mmol/mol when using insulin pump therapy combined
with rtCGM

– Use of an insulin pump was only associated with a higher probability of achievement of the
NICE recommended target (48 mmol/mol) with the addition of rtCGM

– Use of rtCGM increased the probability of meeting both targets in combination with either
MDI or insulin pump therapy
1.7.10 Thyroid and coeliac disease

•
6.5% of children and young people in England and Wales with Type 1
diabetes had been recommended a gluten-free diet indicative of coeliac
disease; and 3.3% were receiving treatment for thyroid disease.

•
Prevalence of both autoimmune disorders was higher amongst girls
compared to boys, although the prevalence increased for both sexes in
2018/19 compared to 2017/18.

•
The prevalence of coeliac disease is higher amongst children and young
people with Type 1 diabetes living in the least deprived areas, and within
White and Asian ethnic groups.

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NPDA core report: Care Processes and Outcomes 2018/19
1.8 Key findings: Type 2 diabetes
1.8.1 Incidence, prevalence, and patient
characteristics

•
There were 790 children and young people with Type 2 diabetes being
managed within PDUs in England and Wales in 2018/19; of whom 187 were
newly diagnosed within the audit year.

•
There have been year on year increases in the numbers of children and young people with
Type 2 diabetes being managed within a PDU since 2012/13, with the percentage of the total
NPDA sample doubling from 1.3 to 2.6% in this period.

•
Higher risk of Type 2 diabetes was found in girls, those of non-white ethnicity, and those living
in the most deprived areas, consistent with previous NPDA findings.
1.8.2 Completion of health checks

•
The percentage of those aged 12 and above with a complete year of care
receiving all seven key checks increased from 25.7% in 2017/18 to 30.9% in
2018/19, however this rate remains considerably lower than for those with
Type 1 diabetes.

•
The completion rates for all key health checks for children and young people with Type 2
diabetes improved between 2017/18 and 2018/19.

•
Just over a third (34.9%) of children and young people with Type 2 diabetes had four or more
HbA1c measurements recorded. This is lower than the percentage of those with Type 1 living
in the most deprived areas receiving four or more (56.2%).
1.8.3 Blood glucose diabetes control targets (HbA1c)

•
The unadjusted mean and median HbA1c of children and young people with
Type 2 diabetes in England and Wales receiving care in a PDU in 2018/19 were
57.4 and 49.5 mmol/mol, respectively, with the latter reflecting a 3.5 mmol/mol
decrease since 2017/18.

•
There was variation in mean HbA1c by age and ethnic group, with Black and
adolescent children and young people with Type 2 diabetes having higher
HbA1c level compared to those of other ethnic backgrounds.
1.8.4 Microvascular complications

•
Albuminuria was found in 20.6% of children and young people with Type 2
diabetes; twice the rate observed in those with Type 1 diabetes.

•
Abnormal eye screening results were found in 6.7% of young people with
Type 2 diabetes; half the rate recorded amongst young people with
Type 1 diabetes.

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NPDA core report: Care Processes and Outcomes 2018/19
1.8.5 Macrovascular complications and risk factors

•
Hypertension was found in 44.6% of children and young people with Type 2
diabetes; double the rate seen in Type 1 diabetes.

•
The majority (84.7%) of children and young people with Type 2 diabetes were
obese.
1.8.6 Outcomes of psychological assessment

•
There were 208 (45.5%) children and young people with Type 2 diabetes
assessed as requiring additional psychological or CAMHS support outside of
MDT clinics, an increase from 30.2% in 2017/18.
1.8.7 Treatment regimen

•
Half (50.4%) of children and young people with Type 2 diabetes were managing their diabetes
with diet and blood glucose lowering medication.

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NPDA core report: Care Processes and Outcomes 2018/19
2. Recommendations

1. Trusts/Health Boards should ensure PDUs have appropriate staffing levels (including
dedicated admin support), and IT support to record good quality data.

2. Data collected as part of routine diabetes care should be regularly uploaded (monthly) by
members of the paediatric diabetes multidisciplinary team (MDT) into the NPDA data capture
system and checked for completeness and quality, with summary results generated used to
monitor performance against HbA1c and health check completion targets.

3. PDUs should review their NPDA results within a team meeting and work together to identify
priorities for quality improvement activities.

4. PDUs must collect and submit complete ethnicity data. Patients/families should define their
own ethnicity, which should be asked for at diagnosis.

5. Commissioners of paediatric diabetes services should provide and fund care based on case
mix in terms of language, ethnicity and deprivation.

6. Paediatric diabetes MDT’s should ensure consistent messages about glucose and HbA1c
targets and have a mechanism to ensure all team members are aware of and communicating
the same target.

7. CCGs (England) and Health Boards (Wales) should be aware that variation in funding of real
time continuous glucose monitoring and pump therapy directly causes variation in HbA1c
outcomes at national and local level and should support advancing technologies fully.

8. Trusts and Health Boards need to provide adequate psychology staffing in all paediatric
diabetes centres to ensure that parents and patients have access to clinical psychological
support when needed. Clinical psychologists should be embedded within the paediatric
diabetes MDT.*

9. PDUs need to ensure that families are made aware of the recommended annual health
checks for diabetes by their diabetes care provider.

10. Teams should be aware that completion rates of health checks tend to be higher amongst
children and young people with Type 1 diabetes compared to those with Type 2 diabetes and
take steps to improve engagement with children and young people with Type 2 diabetes to
ensure that these checks are carried out annually.
* NICE (NG18) guidance states “Offer children and young people with type 1 and type 2 diabetes and their family members or carers
(as appropriate) timely and ongoing access to mental health professionals with an understanding of diabetes”. We have specified
that the Psychologist should be embedded within the MDT further feedback from our recommendations workshop, as attendees
suggested that this would guarantee understanding of diabetes and ensure that psychologists are able to participate in PDU service
development. The group also considered that ‘access when needed’ was more amenable to audit than ‘timely’ access.

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NPDA core report: Care Processes and Outcomes 2018/19
3. Introduction

The NPDA is delivered by the Royal College of Paediatrics and Child Health (RCPCH) and has been
reporting for 16 years. Data is submitted by healthcare professionals in all Paediatric Diabetes Units
(PDUs) in England and Wales about the care received by the children and young people with
diabetes using their service. The effectiveness of diabetes care is measured against NICE guidelines
and includes treatment targets, health checks, patient education, psychological wellbeing, and
assessment of diabetes related complications including acute hospital admissions. All of these are
vital to monitoring and improving the long-term health and wellbeing of children and young
people with diabetes.

All 175 PDUs in England and Wales participated in the 2018/19 audit, capturing information on
30,155 children and young people with diabetes up to the age of 24 years remaining in paediatric
care. The vast majority (94.8%) of the children and young people in the audit had Type 1 diabetes.

The NPDA is designed to measure and motivate change at local, regional and national levels across
England and Wales. It also has a role in assuring patient safety, as data from the audit are used to
inform hospital inspections by the Care Quality Commission (CQC) in England. The audit encourages
everyone with an interest in improving the lives of children and young people with diabetes to
work together including healthcare managers, commissioners, children, young people, and their
families as well as all members of the multi-disciplinary team.

In the last four years, NPDA outcome data have also been benchmarked against certain other
European, American and Australasian countries, providing insights into areas where international
comparisons can drive improvements (McKnight et al., 2015; Maahs et al., 2015; Sherr et al., 2016).

Past NPDA reports have recognised wide variation in the quality of care and outcomes achieved by
PDUs in England and Wales. The audit provides an essential baseline for measuring PDU, regional,
commissioning group and national performance, and enables benchmarking of year on year
progress. These results support efforts within PDUs, regions and at a national level to understand
variability, and by doing so focus efforts to improve care within centres performing less well, which
will ultimately contribute to overall national improvement.
3.1 Commissioning

The NPDA is commissioned by the Healthcare Quality Improvement Partnership (HQIP). HQIP is
led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and
National Voices. Its aim is to promote quality improvement in patient outcomes, and in particular,
to increase the impact that clinical audit, outcome review programmes and registries have on
healthcare quality in England and Wales. HQIP holds the contract to commission, manage and
develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising
around 40 projects covering care provided to people with a wide range of medical, surgical and
mental health conditions. The programme is funded by NHS England, the Welsh Government and,
with some individual projects, other devolved administrations and crown dependencies.

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NPDA core report: Care Processes and Outcomes 2018/19
3.2 Background

Diabetes mellitus occurs when blood glucose levels are elevated because the body is unable to
metabolise it. The UK has the largest prevalence of children and young people with Type 1 diabetes
in Europe (Lacobucci, 2013). Complications associated with suboptimal diabetes management
include damage to small and large blood vessels and nerves which over time can result in blindness,
kidney failure, heart disease, stroke, and amputations. With good diabetes care and blood glucose
management, the risks of complications are reduced, enabling children and young people to enjoy
a healthy and longer life.

Diabetes care is complex and requires collaboration between healthcare professionals, children
and young people and their families, carers and friends. Good quality care requires adequate
resources and training of the workforce (Campbell & Waldron, 2013) to support the medical,
emotional and psychological needs of children, young people and their families. In addition,
families need ongoing and appropriate age-related structured patient education on self-
management to provide knowledge, skills and competencies to manage their diabetes on a daily
basis (Waldron & Campbell, 2014). Ensuring that patients and families are provided with a thorough
understanding of the targets associated with good diabetes management and the need for
regular health checks to prevent complications is an essential part of high-quality care (NICE, 2015).
3.3 NPDA outputs and collaborations

The NPDA produces the following reports, all of which can be viewed and downloaded from
www.rcpch.ac.uk/npda.

•
The Care Processes and Outcomes Report produced annually compares results across
England (by region) and Wales.

•
A lay summary of the above specifically designed for patients and families will be made
available online and in print shortly following the release of the main report.

•
Individualised unit, region and CCG/Local Health Board level reports provide details of
performance at each level. These are published online shortly following publication of the Care
Processes and Outcomes Report. The online reporting tool enables comparison between
specific units or regions, and contains outlier information.

•
The NPDA Hospital Admissions and Complications Report measures rates of admission to
hospital for complications such as diabetic ketoacidosis (DKA) or hypoglycaemia. The most
recent report (RCPCH, 2017) combined admissions data submitted by PDUs with data
extracted from the Hospital Episode Statistics in England (HES) and the Patient Episode
Database for Wales (PEDW) to identify trends in admissions between 2012/13 – 2014/15.

•
Patient Related Experience Measure (PREM) reports provide each unit with feedback from
questionnaires completed by parents and patients who use their service. The most recent
online PREM surveys were rolled out nationally in 2019, and will be reported in 2020.

•
The NPDA collaborates with the National Diabetes Audit (NDA) for adults to produce a
National Diabetes Transition Audit, tracking the care of young people with diabetes during the
transition from paediatric diabetes services to adult diabetes services. The most recent report
was published in 2019 (NHS Digital, 2019).

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NPDA core report: Care Processes and Outcomes 2018/19

•
The NPDA collaborates with national and international researchers to benchmark UK diabetes
outcomes and co-morbidities.

•
Data from the NPDA are used to provide data to justify PDUs in England receiving the Best
Practice Tariff (Randell, 2012).
3.4 Scope of the 2018/19 NPDA report

The NPDA analyses data provided by healthcare professionals working in PDUs that are defined
as clinics, hospital wards, hospital departments and any other hospital unit diagnosing and
treating children and young people with diabetes mellitus in England and Wales. This 2018/19
report covers the health checks (care processes) and outcomes for children and young people
with diabetes who have attended PDUs during the period from 1st April 2018 through to 31st
March 2019. Whilst it is important to acknowledge improvements in diabetes care made during
this period, this audit also aims to highlight deficiencies in care and make specific recommendations
to commissioners of health services, regional diabetes networks, and PDUs to address the quality
of recording of data relating to patient care and outcomes and the clear inequalities in outcomes
across England and Wales.
3.5 Key audit questions

The report aims to address a series of questions relating to paediatric diabetes care, which include:

•
What proportion of children and young people with diabetes are reported to be receiving key
age-specific processes of diabetes care, as recommended by NICE?

•
How many achieve outcome measures within specified treatment targets?

•
Are children and young people with diabetes demonstrating evidence of small vessel disease
(microvascular) and/or abnormal risk factors associated with large vessel disease
(macrovascular) prior to transition into adult services?
3.6 Data completeness

Over the nine years that the RCPCH has been responsible for delivering the NPDA, there has been
a steady improvement in both the quality and completeness of data submitted. However, there
remains considerable variation across PDUs with respect to their ability to resource adequate IT
systems to collect and submit accurate and complete data during the audit year. NPDA results are
utilised by commissioners to measure performance and PDUs have been urged to improve the
completeness of their record-keeping and data completeness to ensure it reflects their practice.

The 2018/19 audit is the third audit year in which a comprehensive data completeness report was
available upon upload of audit data, enabling detection of missing or incorrectly coded data. It was
also the fourth year that the NPDA asked clinical leads at each unit to provide a signature to confirm
the completeness and accuracy of their data submission. It is expected that these developments
will have had an impact on the overall quality of data submitted to the NPDA.

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NPDA core report: Care Processes and Outcomes 2018/19

For the third time, this report includes analysis of admissions data submitted by PDUs. These data
had not been included in previous reports as the data were considered to be of questionable
quality and completeness. This was confirmed by comparison of admissions identified in both the
NPDA, HES and PEDW datasets as part of the analysis for the NPDA Hospital Admissions Report
(RCPCH, 2017), which found that only 32.3% of all admissions were found in both the NPDA
submitted data and either the HES or PEDW dataset.

All but 7 of the 175 PDUs submitted admissions data in 2018/19. It is therefore not possible to use
these data to calculate representative figures for numbers of diabetes-related admissions in
England and Wales, or to base any recommendations on these data. However, a small amount of
admissions data has been presented in order to stimulate focus on its submission. The NPDA will
continue to work with PDUs over the next audit cycle to identify and resolve barriers to the
submission of complete and good quality admissions data.

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NPDA core report: Care Processes and Outcomes 2018/19
4. Case studies
4.1 Improving clinic HbA1c using quality
improvement methodology and a whole
team approach – Alder Hey Children’s
Hospital

F. Mehta, M. Deakin, A. Ghatak, P. Paul, E. Pointon, L. Carlson, K. Thornborough, K. Millar

NPDA results showed little improvement in HbA1c amongst our ~410 children and young
people with type 1 diabetes (T1DM) over 3 years (median HbA1c 65mmol/mol:2016, 65mmol/
mol:2017 and 64mmol/mol:2018) despite increasing insulin pump and CGM use, mirroring
the national trend (median HbA1c 64mmol/mol, 2017 and 2018, National Paediatric
Diabetes Audit).

Through quality improvement (QI) methodology, priority areas for improvement work were
identified. This was enhanced by QI training for the team through participation in the
National Diabetes Quality Programme offered by the Royal College of Paediatrics and
Child Health.

In January 2018, all team members were involved in a detailed review of service care
delivery and outcomes with workshops to agree shared team purpose, treatment targets
and areas for development. Improving HbA1c through patient education was identified as
a core work stream.

Further to this review, multiple enhancements to current practice were developed and
implemented iteratively by the whole team through fortnightly QI meetings. Examples
include clear streamlined new diagnosis education, structured insulin adjustment training
and an ‘information prescription’ used within clinic. Impact of change was monitored
through monthly median clinic HbA1c measurement. Annual median clinic HbA1c fell from
64 mmol/mol (2018) to 61 mmol/mol (2019), with CGM use increasing from 16% to 22% and
insulin pump use decreasing from 44% to 43% over the same period. Increased CGM use is
unlikely to have contributed significantly to the decrease in clinic HbA1c as this correlation
has not been observed in previous years.

We believe our experience demonstrates that embedding QI methodology in service
development with interventions targeting patient education can improve clinic HbA1c. Key
factors for success included a whole team approach, clear and consistent targets and real
time data review.

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NPDA core report: Care Processes and Outcomes 2018/19
4.2 Team work and performance monitoring
key to providing excellent care at Kingston
Hospital NHS Foundation Trust

S. Calas, J. Miles, V. Pai, J. Gwynne

We are pleased that the National Paediatric Diabetes Audit (NPDA) continues to demonstrate
excellent patient care and outcomes for children and young people treated at Kingston
Hospital. The Trust recognises that these results are based on the hard work and dedication
of the energetic and dedicated Multidisciplinary Team (MDT) who drive this success by
having a shared sense of purpose and ownership.

Kingston Hospital is already a positive outlier for children and young people with diabetes
receiving all seven essential care processes as defined by best practice, but the MDT is
striving to improve further by empowering patients, their families and carers to manage
their diabetes even better, by employing the latest technologies, by developing and
supporting staff and by continuously monitoring performance as reported by the NPDA.

The diabetes team believe the following initiatives have proved effective:

•
Insulin pump therapy is offered to all suitable type 1 patients as per best practice
recommendations.

•
Continuous glucose monitors (CGMs) providing patients with real-time glucose
readings to tailor their insulin doses are used whenever possible. Patients then take a
more proactive approach to managing and improving their own blood glucose levels
and improve their quality of life.

•
Data from the CGMs is accessed remotely by the paediatric diabetes team and poor
readings are flagged for attention. Patients are then contacted and issues resolved
quickly and efficiently.

•
Retrospective data from insulin pumps, CGMs and other blood glucose meters is
reviewed during every clinic appointment. By reviewing their data with the clinician
patients gain a better understanding of the readings and trends, giving them more
confidence in making changes to better manage their diabetes.

•
The Trust provides a holistic MDT that takes into account a patient’s medical, social and
mental health needs, with patients seen at least four times per year by a medical
professional, a diabetes nurse and a dietitian. The paediatric diabetes team also makes
contact with every patient a minimum of eight times per year, in line with best practice.

•
The MDT review all patients monthly who are experiencing difficulties managing their
diabetes care and those who have had a recent inpatient admission, devising
individualised care plans to address their specific needs.

•
All patients are invited to attend an annual psychology screen where additional support
needs are identified and are then offered an appointment with the psychologist if
needed.

•
The paediatric diabetes team visit local schools at the beginning of each school year to
create individual health plans for pupils with diabetes.

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NPDA core report: Care Processes and Outcomes 2018/19

•
The paediatric diabetes team voluntarily run a number of out-of-hours events for
children and young people with diabetes along with their parents or guardians. These
popular events enable families to meet others in similar situations, encouraging them
to share their experiences and knowledge and teach better diabetes management.
Here are some examples of past events:-

− Rock climbing with teaching on how to avoid low blood sugar when exercising.

− ‘Cook & Eat’ sessions to help educate young people about carbohydrates and insulin
adjustments.

− An inspirational talk from a professional stunt man on how he manages his diabetes
and maintains a healthy lifestyle.

− An annual networking event for families to learn about and discuss diabetes
management.

•
The paediatric diabetes team, along with patients and their families, have also taken part
in a charity walk to raise money to support children and young people with diabetes,
raising over £7000.

•
The paediatric diabetes team deliver training to all new nurses and junior doctors and
the paediatric diabetes link nurses are trained to support ward staff.
A constant review of performance data drives continued progress of improvement and identifies
gaps for focus on new initiatives. The paediatric diabetes team benchmark their annual NPDA
performance against other local Trusts to identify their strengths and weaknesses against peers.
The team also regularly feed into, liaise with and share practice with the National Children and Young
People’s Diabetes Network. This has encouraged ownership of the data and the formulation of a ‘5
year plan’ for improvement.

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NPDA core report: Care Processes and Outcomes 2018/19
5. Characteristics, prevalence and
incidence
5.1 Audit cohort

A total of 30,155 children and young people with diabetes were included in the 2018/19 audit, an
increase of 403 (1.4%) compared to the 2017/18 audit.

Table 1: Number of children and young people with diabetes included in the audit by age and type
of diabetes, 2018/19
0-4
years
5-9
years
10-14
years
15-19
years++
20-24
years++
Total
(% of cohort)
Type 1 Insulin-dependent diabetes mellitus
1,544
6,191
11,822
9,012
28
28,597 (94.8)
Type 2 Non-insulin-dependent
diabetes mellitus
0
19
313
458
0
790 (2.6)
Cystic fibrosis-related diabetes
21+
112
79
0
212 (0.7)
Monogenic types of diabetes
17
22
61
59
0
159 (0.5)
Other specified diabetes mellitus
33
46
96
89
0
264 (0.9)
Not specified diabetes mellitus
9
28
37
55
0
129 (0.4)
Missing type of diabetes
0
0
*
*
0
*

* indicates a number less than 5 which has been suppressed

+ 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 may not necessarily represent the total number of young
people with diabetes in these age groups in England and Wales.
5.2 Characteristics of children and young people
with Type 1 diabetes
5.2.1 Age and sex

Figure 1 shows the number of children and young people with Type 1 diabetes reported to the
audit by sex and age in whole years at the beginning of the audit period. Almost all (99.8%) of the
Type 1 cohort had a known or specified sex.

The numbers increase with age up to the age of 15, when many young people start to transition to
adult services. Boys account for 52% of the sample, which is consistent with previous years.

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NPDA core report: Care Processes and Outcomes 2018/19
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20-2
4
Boys
39
95
136
221
302 404 489 599 730
916
1001 1118 1207 1318 1422 1485 1396 1182 692
108
16
Girls
31
64
134
220
299 347 490 644
721
xx-xxxx-xxxx
1111
1225 1259 1208 1180 1054 582
101
12
2018/19
70
159
270
441
601
751
979 1243 1451 1755 2031 2226 2318 2543 2681 2693 2576 2236 1274 209
28
2017/18
51
150
313
452
617
792 1022 1223 1482 1762 1953 2077 2321 2515 2537 2680 2667 2211 1194
188
15
0
400
800
1200
1600
2000
2400
2800
3200
Number of children and young people reported
to the audit
Age, sex and audit year



Figure 1: Numbers of children and young people with Type 1 diabetes included in the NPDA by age
and gender, 2018/19 and total numbers 2017/18 and 2018/19.
5.2.2 Location

Table 2 describes the number of children and young people with Type 1 diabetes by country,
regional network and age category. Children and young people are allocated to a region and
country based on the last paediatric diabetes unit (PDU) that they attended within the audit year.

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NPDA core report: Care Processes and Outcomes 2018/19

Table 2: Number of children and young people with Type 1 diabetes by country, region and age
group, 2018/19
0-4
years
5-9
years
10-14
years
15-19
years
20-24
years
Total
(% of cohort)
England and Wales
1,544
6,191
11,822
9,012
28
28,597 (100)
England
1,479
5,876
11,161
8,617
28
27,161 (95.0)
Wales
65
315
661
395
0
1,436 (5.0)
East of England
175
685
1,236
1,051+
3,146 (11.0)
East Midlands
102
419
824
602+
1,946 (6.8)
London and South East
362
1,425
2,662
2,029
6
6,484 (22.7)
North East and North Cumbria
96
336
651
522+
1,602 (5.6)
North West
186
753
1,509
1,093+
3,540 (12.4)
South Central
119
547
1,003
740+
2,408 (8.4)
South West
141
473
974
700+
2,287 (8.0)
Wales
65
315
661
395
0
1,436 (5.0)
West Midlands
156
640
1,192
982+
2,968 (10.4)
Yorkshire and Humber
142
598
1,110
908
12
2,770 (9.7)

+ Results merged to mask numbers <5 in the 20-24 age group
5.2.3 Ethnicity

Table 3 (page 23) shows the number and percentage of children and young people with Type 1
diabetes by ethnic category. Percentage ethnicity distribution for children and young people with
Type 1 diabetes are also shown excluding ‘not stated’ and ‘unknown’ categories to allow comparison
with 2011 census data. There was no difference in the ethnicity of children with Type 1 diabetes
compared to 2011 census background population or from the 2017/18 audit.

Table 3: Ethnic group of children and young people with Type 1 diabetes England and Wales, 2018/19
No. of children
and young people
with T1 diabetes
% of total sample
% of total with
known and stated
ethnicity*
% of total
population**
White
22,733
79.5
84.4
86.0
Asian
1,795
6.3
6.7
7.5
Black
1,044
3.7
3.9
3.3
Mixed
836
2.9
3.1
2.2
Other
529
1.8
2.0
1.0
Not stated
965
3.4
-
-
Not known
638
2.2
-
-
Missing
57
0.2
-
-

* Ethnicity percentages have been calculated without the ‘not stated’ and unallocated groups to allow comparison to 2011 census data

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

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NPDA core report: Care Processes and Outcomes 2018/19
5.2.4 Deprivation

Table 4 shows the breakdown of children and young people with Type 1 diabetes by deprivation
quintile, derived by matching postcodes to the English (IMD, 2016) and Welsh (WIMD, 2015) indices
of multiple deprivation data. A small proportion (0.16%) could not be allocated to a deprivation
quintile because their postcode was either missing or invalid, or it didn’t match a lower super
output area (LSOA).

The proportion of children and young people with Type 1 diabetes living in the most deprived
quintile was higher, and this has been a trend across audit years (Figure 2, page 21).

Table 4: Percentage and number of children and young people with Type 1 diabetes by deprivation
quintile, 2018/19
No. of children and young
people with T1 diabetes
% of total sample
Most deprived
6,450
22.5
Second most deprived
5,703
19.9
Third least deprived
5,418
18.9
Second least deprived
5,483
19.2
Least deprived
5,496
19.2
Missing
47
0.2
Most
deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least
deprived
Missing
2015/16
21.6%
20.0%
19.2%
19.4%
19.6%
0.2%
2016/17
21.8%
19.8%
19.0%
19.1%
19.2%
1.1%
2017/18
21.5%
19.3%
18.3%
18.6%
19.0%
3.3%
2018/19
22.6%
19.9%
18.9%
19.2%
19.2%
0.2%
0%
5%
10%
15%
20%
25%
% of children and young people with
Type 1 diabetes



Figure 2: Percentage and number of children and young people with Type 1 diabetes by deprivation
quintile, 2015/16 to 2018/19
Deprivation quintile and audit year

25
NPDA core report: Care Processes and Outcomes 2018/19
5.3 Prevalence and incidence of Type 1 diabetes
5.3.1 Prevalence

Prevalence is calculated for children and young people aged 15 and below given that transition
to adult services typically occurs from this age onwards. Figures 3 and 4 (page 25 and 26) show
the prevalence rates over the last six audit years. In 2018/19, the prevalence of Type 1 diabetes in
children and young people aged 0 to 15 years old in England and Wales was 196.4 per 100,000 of
the general population; it was slightly higher among boys (198.1 per 100,000) compared to girls
(194.6 per 100,000).
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
Boys
199.8
194.9
190.8
196.1
198.1
198.1
Girls
175.3
187.2
190.6
192.2
193.8
194.6
All
187.7
192.0
195.0
194.2
196.0
196.4
0
50
100
150
200
250
Prevalence per 100,000 general p opulation
Sex and audit year
Boys
Girls
All

Figure 3: Prevalence of Type 1 diabetes per 100,000 general population among children aged 0-15
by sex, 2013/14 to 2018/19

26
NPDA core report: Care Processes and Outcomes 2018/19
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

Figure 4: Prevalence of Type 1 diabetes per 100,000 general population by age group and sex,
2013/14 to 2018/19
5.3.2 Incidence

In 2018/19, there were 2,769 children and young people aged 0 to 15 years old newly diagnosed with
Type 1 diabetes in England and Wales, giving an incidence of 24.5 per 100,000 general population
within this age group. Figure 5 shows that the incidence rates have varied little since 2013/14.
2013/14
2014/15
2015/16
2016/17
2017/18
2018/2019
Boys
24.8
28.0
24.8
25.9
26.0
25.7
Girls
20.8
24.4
20.8
24.4
24.2
23.2
All
22.8
26.5
22.8
25.4
25.1
24.5
0
5
10
15
20
25
30
Incidence per 100,000 general population
Sex and audit year
Boys
Girls
All

Figure 5: Incidence of Type 1 diabetes per 100,000 general population among children aged 0-15
by sex, 2013/14 to 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19
0
5
10
15
20
25
30
35
40
45
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 and sex
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19

Figure 6: Incidence of Type 1 diabetes per 100,000 general population by age group and sex, 2013/14
to 2018/19
5.4 Characteristics of children and young people
with Type 2 diabetes

In 2018/19, there were 790 children and young people with Type 2 diabetes reported to the audit
who were being cared for in a PDU in England and Wales; of whom 187 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. All that
can be concluded is that there are year on year increases in the number of children and young
people with Type 2 diabetes being managed within PDUs. This year, the number of children and
young people reported to the audit increased by 45 compared to the number reported in 2017/18.
Figure 7 shows the numbers of children and young people with Type 2 diabetes being managed
within a PDU since 2012.

28
NPDA core report: Care Processes and Outcomes 2018/19
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
Type 2 Diabetes
448
326
340
544
621
715
745
790
% Total Audit
1.8%
1.3%
1.3%
2.0%
2.2%
2.5%
2.5%
2.6%
448
326
340
544
621
715
745
790
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
0
200
400
600
800
1000
1200
1400
Number of children and young people
with Type 2 Diabetes

Figure 7: Numbers of children and young people with Type 2 diabetes included in the NPDA,
2011/12- 2018/19
5.4.1 Age and sex

Figure 8 (page 29) shows the numbers of children and young people with Type 2 diabetes being
cared for in a PDU decreasing from the age of 16, suggesting that young people are either
transitioning to adult services or are being managed within primary care in greater numbers from
diagnosis from this age. At every age there is a higher percentage of girls with Type 2 diabetes.
There has been an increase in 13-14-year olds with Type 2 diabetes between 2017/18 and 2018/19.

29
NPDA core report: Care Processes and Outcomes 2018/19
6-9
10
11
12
13
14
15
16
17
18-19
Boys
7
7
10
10
25
29
46
62
36
16
Girls
12
11
31
30
72
86
81
93
85
38
2018/19
19
18
41
40
97
115
127
155
121
54
2017/18
14
15
28
63
67
86
154
140
101
70
0
20
40
60
80
100
120
140
160
180
Number of children and young people with
Type 2 diabetes
Age and sex

Figure 8: Numbers of children and young people with Type 2 diabetes included in the NPDA by
age and sex, 2018/19 and changes in numbers between 2017/18 and 2018/19.
5.4.2 Location

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

Table 5: Number of children and young people included in the audit with Type 2 diabetes by
country and region, 2017/18
No. of children and young
people with T2 diabetes
% of total
England and Wales
790
100
England
770
97.5
Wales
20
2.5
East of England
40
5.1
East Midlands
44
5.6
London and South East
257
32.5
North East and North Cumbria
23
2.9
North West
95
12.0
South Central
44
5.6
South West
47
5.9
West Midlands
137
17.3
Yorkshire and Humber
83
10.5

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NPDA core report: Care Processes and Outcomes 2018/19
5.4.3 Ethnicity

Table 6 presents a breakdown of children and young people with Type 2 diabetes included in the
audit 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. The results show that most children and young people with Type 2 diabetes
were of non-White ethnicity, and that the prevalence of Type 2 diabetes in children of non-White
ethnicity is disproportionately higher than the prevalence of non-White ethnicity in the general
population.

Table 6: Ethnic group of children and young people with Type 2 diabetes England and Wales,
2018/19
No. of children
and young people
with T2 diabetes
% of total sample
% of total with
stated ethnicity*
% of total
population**
White
291
36.8
40.3
86.0
Asian
281
35.6
38.9
7.5
Black
84
10.6
11.6
3.3
Mixed
42
5.3
5.8
2.2
Other
24
3.0
3.3
1.0
Not stated
28
3.5
-
Not known
35
4.4
-
Missing
5
0.6
-

* Ethnicity percentages have been calculated without the ‘not stated’ and unallocated groups to allow comparison to 2011 census data

** Percentage of total population in 2011 England and Wales Census
5.4.4 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. Figure 9 (page 31)
shows that this trend has been consistent between 2015/16 and 2018/19.

Table 7: Numbers and percentages of children and young people with Type 2 diabetes by
deprivation quintile, 2018/19
No. of children
and young people
with T2 diabetes
% of total sample
Most deprived
361
45.7
Second most deprived
208
26.3
Third least deprived
113
14.3
Second least deprived
68
8.6
Least deprived
38
4.8
Missing
2
0.3

31
NPDA core report: Care Processes and Outcomes 2018/19
Most
deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least
deprived
Missing
2015/16
45.7%
25.0%
14.8%
7.4%
6.8%
0.3%
2016/17
47.0%
23.2%
14.1%
8.8%
5.3%
1.5%
2017/18
45.6%
23.0%
14.2%
7.7%
5.6%
3.9%
2018/19
45.7%
26.3%
14.3%
8.6%
4.8%
0.3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
% of children and young people with
Type 2 diabetes
Deprivation quintile and audit year

Figure 9: Percentage and number of children and young people with Type 2 diabetes by deprivation
quintile, 2015/16 to 2018/19
5.5 Key findings

Type 1 diabetes

•
There were 28,597 (52% male) children and young people with Type 1 diabetes being managed
within PDUs in England and Wales in 2018/19.

•
The prevalence of Type 1 diabetes in children and young people aged 0 to 15 years old in
England and Wales was 196.4 per 100,000 of the general population; it was slightly higher
among boys (198.1 per 100,000) compared to girls (194.6 per 100,000).

•
There were 2,769 children and young people aged 0 to 15 years old newly diagnosed with Type
1 diabetes in England and Wales in 2018/9, giving an incidence of 24.5 per 100,000 general
population within this age group.

•
There were proportionately more children and young people with Type 1 diabetes living in the
most deprived quintile areas (22.5%, expected 20%), which has been a consistent trend since 2013.

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NPDA core report: Care Processes and Outcomes 2018/19

Type 2 diabetes

•
There were 790 children and young people with Type 2 diabetes being managed within PDUs
in England and Wales in 2018/19; of whom 187 were newly diagnosed within the audit year.

•
There have been year on year increases in the numbers of children and young people with
Type 2 diabetes being managed within a PDU since 2012/13, with the percentage of the total
NPDA sample doubling from 1.3 to 2.6% in this period.

•
Higher risk of Type 2 diabetes was found in girls, those of non-white ethnicity, and those living
in the most deprived areas, consistent with previous NPDA findings.

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NPDA core report: Care Processes and Outcomes 2018/19
6. Completion of health checks
(care processes)
6.1 Completion of health checks for children and
young people with Type 1 diabetes
6.1.1 Completion of key health checks

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

The NPDA has considered seven of these to be essential 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)

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 2018/19, there were 23,223 children and young people with Type 1 diabetes included in the audit
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 which 13,391 (57.7%) were aged 12 and above.

Table 8 (page 34) shows the percentage of children and young people recorded as receiving
essential healthcare checks in the audit year, from 2015/16 to 2018/19.

34
NPDA core report: Care Processes and Outcomes 2018/19

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 2018/19
Age
Health check completion
Audit year
2015/16
2016/17
2017/18
2018/19
All
ages
No. of children and young people with T1 diabetes (n)
2018/19
22,933
23,130
23,223
HbA1c (%)
99.2
99.5
99.4
99.4
BMI (%)
97.9
98.7
98.9
99.2
Thyroid (%)
77.7
81.8
84.0
87.2
Aged
12 and
above
No. of young people with T1 diabetes (n)
13,313
13,437
13,363
13,391
Blood pressure (%)
90.8
92.7
94.6
96.2
Urinary albumin (%)
66.0
68.7
74.3
78.3
Eye screen (%)
66.2
74.4
75.9
77.5
Foot Exam (%)
65.8
72.8
78.2
82.5
All seven health checks (%)
35.5
43.5
49.8
55.2

There has been consistent improvement in the percentages of children and young people recorded
as receiving essential health checks since 2004/05; both in terms of the proportion completing
each individual health check (Figure 10), and the proportion completing all seven (Figure 11, page
35). It is important to note that it is not possible to make direct comparisons prior to 2015/16 as
before this date rates for Type 1 and Type 2 diabetes were combined and are now reported
separately. However, given that the majority of children and young people reported to the audit
have Type 1 diabetes, the improvements in completion rates shown can be taken to reflect real
improvements in health check completion and/or completeness of data submitted to the NPDA.
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
All types of diabetes
Type 1 only
% of children and young people who completed
a full year of care
HbA1c
Blood
pressure*
BMI
Urinary
albumin*
Cholesterol*
Eye screen*
Foot Exam*
* health checks completed for children and young people aged 12 or older

Figure 10: Percentage of children and young people who completed a full year of care recorded as
receiving individual health checks, 2004/05 to 2018/19

35
NPDA core report: Care Processes and Outcomes 2018/19
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%
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
All types of diabetes
Type 1 only
% of young people aged 12 or older who
completed a full year of care



Figure 11: Percentage of young people aged 12 or above who completed a full year of care recorded
as receiving all seven key health checks, 2004/05 to 2018/19
6.1.2 Variation in key health check completion

6.1.2.1 Variation in completion rates nationally and regionally

Tables 9a and 9b (page 36) provide a breakdown of the healthcare checks recorded as received by
children and young people with Type 1 diabetes with a complete year of care in 2018/19 by region,
country and overall in England and Wales. Table 9a contains data on the health checks received by
all children and young people and Table 9b contains data on the health checks recommended for
and received by young people aged 12 and above.

36
NPDA core report: Care Processes and Outcomes 2018/19

Table 9a: Percentage of children and young people of all ages with Type 1 diabetes who completed
a full year of care recorded as having received health checks by country and region, 2018/19
No. of children
and young
people with
Type 1 diabetes
Percentage completing
health checks
HbA1c
BMI
Thyroid
England and Wales
23,223
99.4
99.2
87.2
England
22,121
99.4
99.2
86.9
Wales
1,102
99.9
99.8
93.5
East of England
2,641
99.5
99.0
83.6
East Midlands
1,565
99.8
99.4
92.5
London and South East
5,350
99.0
99.2
81.1
North East and North Cumbria
1,307
99.1
98.3
88.8
North West
2,902
99.7
99.3
91.7
South Central
1,941
99.7
99.3
89.8
South West
1,782
99.9
99.3
88.1
West Midlands
2,368
99.7
99.5
86.8
Yorkshire and Humber
2,265
98.4
99.2
90.0

Table 9b: Percentage of young people aged 12 and above with Type 1 diabetes who completed a
full year of care recorded as having received health checks by country and region, 2018/19
No. of young
people aged
12 and above
with Type 1
diabetes
Percentage completing health check
Foot
exam
Blood
pressure
Urinary
albumin
Eye
screen
All
seven
England and Wales
13,391
82.5
96.2
78.3
77.5
55.2
England
12,793
81.9
96.1
77.7
77.1
54.3
Wales
598
94.6
98.7
90.1
86.3
73.7
East of England
1,542
75.6
97.3
75.3
80.7
50.7
East Midlands
890
87.1
94.5
82.0
75.7
59.4
London and South East
3,066
77.8
97.7
72.1
71.5
48.4
North East and North Cumbria
772
75.5
94.6
81.6
81.5
56.1
North West
1,648
88.6
96.2
82.8
75.5
57.3
South Central
1,109
79.6
92.2
79.8
86.2
59.2
South West
1,033
86.1
95.6
78.8
81.8
58.1
West Midlands
1,397
86.4
95.3
75.5
75.1
52.1
Yorkshire and Humber
1,336
84.8
97.7
81.4
76.9
59.1

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NPDA core report: Care Processes and Outcomes 2018/19

There were no differences in completion rates of healthcare checks across different age groups,
ethnic categories or deprivation quintiles.

6.1.2.2 Variation in completion rates across PDUs

Figure 12 shows the variation by unit in the percentage of young people aged 12 years and older
who were recorded to have received all seven key healthcare checks. The horizontal navy line shows
the mean completion rate for England and Wales, and the dotted lines indicate units 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 seven health checks
across PDUs.1 PDUs below the bottom dotted line (>3SD) are considered ‘alarm’ outliers as a
significantly smaller percentage of their patients received all the key checks compared to other
PDUs in England and Wales.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
50
100
150
200
250
300
% of young people with Type 1 diabetes aged 12 and
above receiving all seven 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 12: Percentage of young people aged 12 years and above with Type 1 diabetes who completed
a full year of care recorded as receiving all seven health checks by unit, 2018/19
1 Individual PDU level reports will be published at www.rcpch.ac.uk/npda to detail unit level performance.

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NPDA core report: Care Processes and Outcomes 2018/19

Figure 13 plots 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 in each unit. 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 7 (i.e. the number of health checks that they should have received
within the audit year). PDUs below the bottom dotted line (>3SD) are considered ‘alarm’ outliers as
they were providing significantly fewer key health checks than other PDUs in England and Wales.
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
0
50
100
150
200
250
300
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 13: Health check completion rate of young people aged 12 years and above with Type 1
diabetes who completed a full year of care by unit, 2018/19
6.1.3 Number of HbA1c measurements received

NICE (NG18) recommends that four HbA1c measurements are offered to children and young
people with Type 1 diabetes unless there is concern about suboptimal blood glucose control, in
which case more frequent testing may be appropriate.

Figure 14 (page 39) 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 57.5% had four or more measurements recorded in 2018/19.

39
NPDA core report: Care Processes and Outcomes 2018/19
0
1
2
3
4+
2016/17
0.5%
4.5%
12.9%
29.1%
52.9%
2017/18
0.6%
4.3%
11.4%
29.0%
54.6%
2018/19
0.6%
3.7%
10.6%
27.7%
57.5%
0%
10%
20%
30%
40%
50%
60%
70%
% of children and young people with Type 1 diabetes
who completed a full year of care
Number of HbA1c measurements

Figure 14: 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 2018/19

Table 10 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 10: Percentage of children and young people with Type 1 diabetes who completed a full year
of care by number of HbA1c measurements recorded 2018/19, by country and region
None (%)
One (%)
Two (%)
Three (%)
Four or
more (%)
England and Wales
0.6
3.7
10.6
27.7
57.5
England
0.6
3.8
10.5
27.5
57.6
Wales
0.1
2.1
12.1
30.6
55.2
East of England
0.5
4.5
13.8
34.6
46.6
East Midlands
0.2
2.6
6.8
24.6
65.9
London and South East
1.0
6.3
12.1
27.0
53.6
North East and North Cumbria
0.9
2.5
7.5
20.5
68.6
North West
0.3
3.3
13.6
32.4
50.5
South Central
0.3
1.5
5.7
20.7
71.9
South West
0.1
1.1
7.1
26.3
65.4
West Midlands
0.3
3.5
12.4
29.4
54.5
Yorkshire and Humber
1.6
3.3
8.4
25.1
61.6

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NPDA core report: Care Processes and Outcomes 2018/19

Table 11 shows that the proportion of children and young people with Type 1 diabetes receiving four
or more HbA1c measurements was higher in the least deprived areas.

Table 11: Percentage of children and young people with Type 1 diabetes who completed a full year
of care by number of HbA1cs measurements recorded, by deprivation quintile, 2018/19
None (%)
One (%)
Two (%)
Three (%)
Four or more (%)
Most deprived
0.6
4.2
12.2
26.8
56.2
Second most deprived
0.8
3.9
11.0
27.4
57.0
Third least deprived
0.6
4.0
10.6
27.3
57.5
Second least deprived
0.5
3.2
9.7
28.3
58.4
Least deprived
0.5
3.0
9.3
28.7
58.5
6.1.4 Dietary and nutritional 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 (Randell, 2012) include the offering of an additional dietetic
appointment.

Of those children and young people with Type 1 diabetes who completed a full year of care (N=20,932),
90.1% were offered an additional dietetic appointment, compared to 85.3% in 2017/18. Table 12 (page
40) shows the percentages who were offered an additional appointment (who were recorded as
either being offered an appointment or had attendance of an appointment recorded within the
audit year) and the percentage who attended the offered appointment. Lower take up of offered
dietetic appointments should be interpreted with caution as they could reflect poorer engagement
or greater satisfaction with dietetic input received as part of routine clinic appointments.

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 and
region, 2018/19
Appointment
offered
(%)
Appointment
attended
(%)
England and Wales
90.1
54.0
England
90.7
54.4
Wales
78.2
45.9
East of England
91.0
60.8
East Midlands
97.2
56.9
London and South East
87.5
54.5
North East and North Cumbria
96.3
45.8
North West
91.1
59.4
South Central
91.2
48.4
South West
92.8
55.2
West Midlands
87.2
54.9
Yorkshire and Humber
91.5
47.1

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NPDA core report: Care Processes and Outcomes 2018/19
6.1.5 Smoking

Figure 15 (page 41) shows the percentage of young people aged 12 and above with Type 1 diabetes
completing a full year of care with a smoking status recorded.
85.6%
85.0%
99.5%
74.8%
80.6%
89.3%
82.3%
95.3%
81.0%
85.2%
91.3%
75.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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

Figure 15: Percentage of young people aged 12 and above with Type 1 diabetes with a full year of
care and a recorded smoking status

Table 13 (page 42) shows the percentage of all young people aged 12 and above with Type 1 diabetes
with a recorded smoking result in the audit period classified as ‘current smoker’ and the percentage
of ‘current smokers’ who were recorded as being offered a referral to smoking cessation services.
Approximately one in thirty-four young people were recorded as smoking within the audit year
and of those, 45.5% were offered a referral to smoking cessation services, compared to 40.0% in
2017/18.

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NPDA core report: Care Processes and Outcomes 2018/19

Table 13: Percentage of young people aged 12 and above with Type 1 diabetes recorded as a ‘current
smoker’ who were referred to smoking cessation services by region and country, 2018/19
No. of young people
aged 12 and above
with T1 diabetes
(n)
Proportion recorded
as ‘current smoker’
(%)
Referred to smoking
cessation services
(%)
England and Wales
16,592
3.1
45.5
England
15,777
3.2
45.1
Wales
815
1.1
66.7
East of England
1,136
4.5
32.9
East Midlands
1,824
3.0
52.9
London and South East
3,737
2.7
53.9
North East and North Cumbria
951
3.0
55.2
North West
2,019
3.8
48.7
South Central
1,401
3.0
40.5
South West
1,330
4.1
40.0
West Midlands
1,737
1.8
53.1
Yorkshire and Humber
1,642
3.4
35.7
6.1.6 Completion of all other annual health checks

The NPDA also collects data on four 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

Results are shown in Table 14 (page 43) for all children and young people with a complete year of
care (N=23,223).

43
NPDA core report: Care Processes and Outcomes 2018/19

Table 14: 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, 2018/19
Psychological
assessment
(%)
Flu vaccine
recommendation
(%)
‘Sick day rules’
(%)
Blood ketone
testing
(%)
England and Wales
85.7
81.2
83.6
88.0
England
86.8
80.9
83.4
87.8
Wales
64.2
87.2
89.0
91.7
East of England
75.8
71.6
80.3
80.9
East Midlands
93.9
77.7
94.5
96.7
London and South East
90.9
82.7
84.2
87.8
North East and North Cumbria
90.0
73.1
78.9
89.6
North West
85.8
83.9
86.7
91.4
South Central
88.6
77.2
79.8
81.9
South West
82.5
83.8
82.5
83.7
West Midlands
88.2
87.9
84.1
90.8
Yorkshire and Humber
85.0
83.6
78.4
89.3

Figure 16 shows that there have been increases in the provision of all additional health checks
between 2017/18 and 2018/19, except for psychological assessment.
86.6%
75.9%
77.4%
82.7%
85.7%
81.2%
83.6%
88.0%
68%
70%
72%
74%
76%
78%
80%
82%
84%
86%
88%
90%
Psychological
assessment
Flu vaccine
‘Sick day rules’
Blood ketone testing
% of children and young people who
completed a year of care
2017/18
2018/19

Figure 16: Completion rates for psychological assessment, flu vaccine recommendation, “Sick day
rules” and blood ketone testing, for children and young people with Type 1 diabetes who completed
a full year of care, 2017/18 and 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19
6.1.7 Care at diagnosis

6.1.7.1 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.

Table 15 shows the percentage of children and young people diagnosed within the audit year and
more than 90 days before the end of the audit year (n=2,134) who received screening for coeliac
and thyroid disease within 90 days of diagnosis by country and region.

Table 15: Percentage of children and young people with Type 1 diabetes who received screening
within 90 days of diagnosis by country and region, 2018/19
No. diagnosed
90 days before the
end of the audit (n)
Thyroid disease
screen
(%)
Coeliac disease
screen
(%)
England and Wales
2,134
88.8%
82.9%
England
2,021
88.9%
82.7%
Wales
113
87.6%
86.7%
East of England
214
90.7%
85.0%
East Midlands
155
85.8%
74.8%
London and South East
436
87.6%
80.0%
North East and North Cumbria
116
79.3%
81.0%
North West
275
89.1%
81.1%
South Central
166
94.0%
88.0%
South West
207
91.3%
84.5%
West Midlands
229
89.1%
81.7%
Yorkshire and Humber
223
90.6%
89.7%

Figure 17 (page 45) shows the percentage of children and young people diagnosed more than 90
days before the end of the audit year (n=2,134), who received screening for coeliac and thyroid
disease within 90 days of diagnosis. There has been an improvement in the rates of completion of
both health checks at diagnosis from 2015/16 to 2018/19.

45
NPDA core report: Care Processes and Outcomes 2018/19
Thyroid
Coeliac
2015/16
67.8%
62.3%
2016/17
78.9%
72.6%
2017/18
83.8%
80.2%
2018/19
88.8%
82.9%
0%
20%
40%
60%
80%
100%
% of newly diagnosed children and young
people
with Type 1 diabetes
Autoimmune disease screening and audit year

Figure 17: Percentage of newly diagnosed children and young people with Type 1 diabetes who
received screening within 90 days of diagnosis, 2015/16 to 2018/19

6.1.7.2 Level 3 carbohydrate counting

NG18 (NICE, 2015) also recommends offering level 3 carbohydrate-counting education to children and
young people with Type 1 diabetes from diagnosis. Overall, 75.6% received this, compared to 67.6% in 2017/18.

Table 16 shows variation in the percentage of children and young people diagnosed more than 14
days before the end of the audit year (n=2,801) who received level 3 carbohydrate-counting education
within 14 days of diagnosis by region.

Table 16: Percentage of children and young people with Type 1 diabetes recorded as receiving
carbohydrate-counting education within 14 days of diagnosis by country and region, 2018/19
No. diagnosed
14 days before the
end of the audit
Carb counting
(%)
England and Wales
2806
75.6
England
2663
76.2
Wales
143
64.3
East of England
298
72.5
East Midlands
196
72.4
London and South East
582
71.5
North East and North Cumbria
151
80.1
North West
354
72.0
South Central
215
73.0
South West
263
86.7
West Midlands
325
81.5
Yorkshire and Humber
279
81.7

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NPDA core report: Care Processes and Outcomes 2018/19
6.2 Healthcare checks for children and young
people with Type 2 diabetes

The healthcare checks for children and young people with Type 2 diabetes recommended in NG18
and NG18 (NICE, 2015) differ slightly from those for Type 1 diabetes. The NPDA includes cholesterol
screening as being one of the seven essential annual checks rather than thyroid screening. All
should be performed annually from diagnosis, except for foot examination and eye screening,
which are indicated from age 12. In 2018/19, there were 501 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) recorded as having Type 2 diabetes, of which 470 (93.8%) were aged 12 years and above.
6.2.1 Completion of key health checks

Figure 18 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 seven recommended health checks from
2015/16 to 2018/19.
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2015/16
2016/17
2017/18
2018/19
% of children and young people who
completed a year of care
HbA1c
BMI
Cholesterol
Urinary
albumin
Blood
pressure
Eye screen*
Foot exam*
All 7 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

Figure 18: 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 2018/19

Table 17 (page 47) shows the percentage of children and young people recorded as receiving
essential healthcare checks in the audit year, from 2015/16 to 2018/19.

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NPDA core report: Care Processes and Outcomes 2018/19

Table 17: 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 2018/19
Age
Health check
Audit year
2015/16
2016/17
2017/18
2018/19
All ages
No. of children and young people (n)
412
473
470
501
HbA1c (%)
97.3
96.6
96.8
97.8
BMI (%)
94.4
94.1
94.5
95.0
Cholesterol (%)
59.2
66.4
67.9
70.5
Aged 12
and above
No. of young people (n)
390
436
436
470
Urinary albumin (%)
51.7
56.7
58.9
62.1
Blood pressure (%)
85.0
86.0
88.5
90.9
Eye screen (%)
47.2
54.8
57.3
59.6
Foot Exam (%)
50.0
50.2
61.7
67.0
All seven health checks (%)
16.7
21.3
25.7
30.9
6.2.2 Number of HbA1c measurements

Figure 19 shows that 34.9% of children and young people with Type 2 diabetes recorded as
completing a full year of care received four or more HbA1c measurements.
None
1
2
3
4+
2016/17
3.8%
15.4%
22.8%
27.5%
30.4%
2017/18
3.2%
18.7%
21.3%
25.7%
31.1%
2018/19
2.2%
15.2%
21.2%
26.5%
34.9%
0%
5%
10%
15%
20%
25%
30%
35%
40%
% of children and young people with Type 2 diabetes
who completed a year of care
Number of HbA1c measurements

Figure 19: Number of HbA1c measurements recorded for children and young people with Type 2
diabetes receiving a full year of care, 2016/17 – 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19
6.2.3 Completion of all other health checks

Table 18 shows the percentage of children and young people with Type 2 diabetes completing a
full year of care (n= 501) recorded as being offered and attending an additional dietetic appointment.

Table 18: 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, 2018/19
England and Wales
2017/18
2018/19
Appointment offered (%)
70.0
80.0
Appointment attended (%)
48.7
48.5

Table 19 shows the percentage of young people aged 12 and above with Type 2 diabetes who
completed a full year of care recorded as receiving a smoking status check. It also includes the
percentage of all young people aged 12 and above with Type 2 diabetes with a recorded smoking
result in the audit period classified as ‘current smoker’ and the percentage of those who were
recorded as being offered a referral to smoking cessation services.

Table 19: Percentage of young people aged 12 and above with Type 2 diabetes who completed a
full year of care with a recorded smoking status, and the percentage of current smokers referred to
smoking cessation services, 2018/19
England and Wales
2017/18
2018/19
Percentage of young people with a complete year of
care with a recorded smoking status (%)
83.3
84.3
Young people aged 12
or older with a recorded
smoking status
Total (n)
684
711
‘Current smoker’ (%)
2.6
2.4
Referred to smoking
cessation services (%)
50.0
62.5

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

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

2. Offering of immunisation against influenza

3. Advice about managing diabetes

Results are shown in Table 20 for all children and young people with a complete year of care (n= 501).

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NPDA core report: Care Processes and Outcomes 2018/19

Table 20: Percentage of young people with Type 2 diabetes who completed a full year of care
recorded as receiving health checks by region and country, 2018/19
England and Wales
2017/18
2018/19
Assessment for psychological support (%)
77.9
75.0
Flu vaccine recommendation (%)
49.4
69.3
‘Sick day rules’ (%)
41.7
51.5
6.3 Key findings

This report shows a continuing trend for year on year improvements in completion rates for health
checks recommended for children and young people with diabetes.

Type 1 diabetes

•
The percentage of those aged 12 and above with a complete year of care receiving all seven
recommended health checks for Type 1 diabetes increased from 49.8% in 2017/18 to 55.2% in
2018/19.

•
There remains considerable variation in completion rates of health checks between PDUs,
with the percentage of children and young people with Type 1 diabetes and a complete year of
care receiving all seven ranging from 3.3 to 95.8%.

•
Completion rates of all key health checks increased between 2017/18 and 2018/19 with the
exception of BMI measurement. However, a high rate of BMI measurement was still found,
with 99.2% of all children and young people with a complete year of care and Type 1 diabetes
receiving this key check in 2018/19.

•
There were no differences in overall health check completion rates associated with ethnicity,
deprivation, or age group.

•
There was a linear relationship between the percentage of those receiving four or more HbA1c
measurements and deprivation quintile, with 56.2% within the most deprived quintile
receiving four or more compared to 58.5% of those in the least deprived quintile receiving four
or more.

Type 2 Diabetes

•
The completion rates for all key health checks for children and young people with type 2
diabetes improved between 2017/18 and 2018/19.

•
The percentage of those aged 12 and above with a complete year of care receiving all seven
key checks increased from 25.7% in 2017/18 to 30.9% in 2018/19, however this rate remains
considerably lower than for those with Type 1 diabetes.

•
Just over a third (34.9%) of children and young people with Type 2 diabetes had four or more
HbA1c measurements recorded. This is lower than the percentage of those with Type 1 living in
the most deprived areas receiving four or more (56.2%).

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NPDA core report: Care Processes and Outcomes 2018/19
7. Outcomes
7.1 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.

HbA1c values were included in the outcome analysis if they were within an acceptable range (20-
195mmol/mol), dated within the audit year, and recorded at least 90 days following diagnosis, since
newly diagnosed individuals are unlikely to have established a stable level of control prior to this
cut off and may therefore skew results. Where more than one valid HbA1c was recorded during the
year per patient, the median value for each was used.

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.
7.1.1 HbA1c outcomes of children and young people with all
types of diabetes

Table 21 (page 48) provides a breakdown of the unadjusted mean and median HbA1c results
achieved by each region and country, and the level of variation within them. The mean HbA1c of
children and young people with all types of diabetes in England and Wales receiving care in a PDU
in 2018/19 was 64.6 mmol/mol; this is a decrease of 2.5mmol/mol compared to that recorded in
2017/18 (67.1 mmol/mol). The median HbA1c was 61.5 mmol/mol and is also a decrease of 2.5mmol/
mol compared to the previous year (64.0 mmol/mol).

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NPDA core report: Care Processes and Outcomes 2018/19

Table 21: HbA1c for all children and young people with all types of diabetes and one or more valid
HbA1c measurements by country and region, 2018/19
Audit year
No. of
children
and young
people with
all types of
diabetes
HbA1c in mmol/mol
Mean
Standard
deviation
Median
Interquartile
range
England and Wales
28,277
64.6
17.1
61.5
17.5
England
26,879
64.5
17.1
61.5
17.5
Wales
1,398
64.9
17.3
62.0
18.5
East of England
3,051
64.8
17.8
61.0
18.1
East Midlands
1,940
61.7
15.3
59.0
16.3
London and South East
6,464
65.0
17.8
62.0
18.0
North East and North Cumbria
1,560
64.1
15.4
62.0
16.5
North West
3,521
65.8
18.1
62.5
18.5
South Central
2,365
62.4
15.3
60.0
16.0
South West
2,241
63.7
16.3
61.0
17.0
West Midlands
2,974
65.4
17.0
63.0
18.5
Yorkshire and Humber
2,763
65.2
17.4
62.0
18.0
Missing valid HbA1c
measurement
1,878
-
-
-
-

Figure 20 (page 52) shows the median HbA1c for children and young people with all types of
diabetes, in England and Wales, from 2009/10 to 2018/19. The timeline below the graph highlights
key quality improvement initiatives implemented in England and Wales over the same period.

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NPDA core report: Care Processes and Outcomes 2018/19

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
Median HbA1c (mmol/mol)
England
Wales
Regional
networks
established,
England
Best Practice
Tariff
introduced,
England

Quality
Assurance
(peer review),
England
Diabetes
Delivery Plans
published,
England &
Wales
Quality
Assurance
(peer review),
Wales
Regional networks
established, Wales

Self-assessment QA started,
England & Wales
Updated
Diabetes
Delivery Plan
published
2016-2020,
National
Diabetes QI
Programme
introduced,
England & Wales



Figure 20: Median HbA1c for children and young people with all types of diabetes in England and
Wales 2009/10 to 2018/19 with associated NHS policy and/or paediatric diabetes delivery structural
changes.
7.1.2 HbA1c outcomes of children and young people with
Type 1 diabetes

The data presented in this section refers to children and young people with Type 1 diabetes and
captures the variation in HbA1c outcomes nationally and regionally as well as by patient
characteristics.

7.1.2.1 National and regional unadjusted HbA1c results

Table 22 (page 53) 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 65
mmol/mol; this is a decrease of 2.5 mmol/mol compared to the mean recorded in 2017/18 (67.5
mmol/mol). The median HbA1c was 62 mmol/mol and is 2.0 mmol/mol lower compared to 2017/18
(64.0 mmol/mol).

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NPDA core report: Care Processes and Outcomes 2018/19

Table 22: HbA1c for all children and young people with Type 1 diabetes and one or more valid HbA1c
measurements by country and regional network, 2018/19
n
Mean
mmol/mol
Standard
deviation
mmol/mol
Median
mmol/mol
Interquartile
range
mmol/mol
England and Wales
26,987
65.0
16.8
62.0
17.5
England
25,627
65.0
16.7
62.0
17.1
Wales
1,360
65.2
17.1
62.0
18.8
East of England
2,981
65.0
17.7
61.5
17.6
East Midlands
1,858
62.2
14.9
59.5
15.9
London and South East
6,070
65.7
17.3
62.5
17.9
North East and North Cumbria
1,522
64.4
15.2
62.0
16.0
North West
3,341
66.5
17.7
63.0
18.0
South Central
2,290
62.6
15.1
60.0
15.5
South West
2,158
64.3
16.0
61.0
17.0
West Midlands
2,786
66.1
16.5
63.5
18.5
Yorkshire and Humber
2,621
65.5
17.0
62.0
17.0

Figure 21 and Table 23 (page 54) show the percentages of children and young people with Type 1
diabetes who achieved each of the NICE (2004, 2015) treatment targets from 2015/16 to 2018/19.
Figure 22 also includes the percentages of children and young people with Type 1 diabetes who
achieved the NICE (2004, 2015) treatment targets of below 58 mmol/mol, between 58 mmol/mol
and 80 mmol/mol, and above 80 mmol/mol from 2010/11 to 2014/15.

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NPDA core report: Care Processes and Outcomes 2018/19
6.4%
6.5%
7.5%
7.2%
10.3%
6.8%
8.2%
8.8%
8.9%
11.4%
10.3%
11.9%
12.6%
12.5%
14.3%
15.8%
17.4%
15.8%
18.4%
34.3%
34.8%
34.3%
34.8%
33.3%
13.4%
14.1%
13.7%
13.7%
11.5%
7.5%
6.6%
6.7%
6.5%
5.2%
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%
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
% of children and young people with Type 1 diabetes
<48 mmol/mol
48-53 mmol/mol
54-57 mmol/mol
<58 mmol/mol*
58-68 mmol/mol
69-75 mmol/mol
76-80 mmol/mol
58-80 mmol/mol*
>80 mmol/mol

Figure 21: Percentage of children and young people with Type 1 diabetes with an HbA1c result
within current and historical target ranges, 2011/12 - 2018/19

Table 23 (page 55) shows the percentages of children and young people who achieved HbA1c
targets by country and by region.

55
NPDA core report: Care Processes and Outcomes 2018/19

Table 23: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by country and regional network, 2018/19
≤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
10.3
21.7
36.0
50.0
30.8
19.3
14.1
England
10.3
21.6
36.0
50.0
30.7
19.1
14.0
Wales
10.9
22.6
35.8
48.7
32.1
21.9
15.5
East of England
11.2
23.4
37.3
48.2
29.9
19.2
14.5
East Midlands
12.2
26.4
43.7
46.2
25.0
14.2
10.1
London and South East
10.3
20.8
34.6
50.3
32.5
20.4
15.1
North East and North Cumbria
10.8
20.4
35.4
52.3
30.6
17.3
12.3
North West
8.8
19.2
32.8
51.9
34.0
21.4
15.3
South Central
11.7
24.9
41.2
48.2
25.2
14.6
10.6
South West
10.9
22.9
37.6
48.6
28.8
18.0
13.8
West Midlands
8.5
18.8
32.5
51.9
32.8
21.8
15.6
Yorkshire and Humber
9.5
20.9
34.1
51.4
31.7
19.8
14.6

Figure 22 shows the percentages of children and young people with a complete year of care who
received four or more HbA1c measurements in each PDU against the PDU-level median HbA1c result.
The downward sloping trend line indicates that PDUs with a higher percentage of children and young
people receiving four or more HbA1c measurements tended to have a lower median HbA1c, and this
relationship was signficant. However, there was a lot of variability.
55
57
59
61
63
65
67
69
71
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Median HbA1c (mmol/mol) by PDU,
considering all children and young people
with Type 1 diabetes who completed a full
year of care
% of children and young people with Type 1 diabetes and complete year of care
who received 4+ HbA1c measurements
corr: -0.16397 (p= 0.03)

Figure 22: Scatter plot showing the association between median HbA1c and the percentage of
children and young people with a complete year of care who received 4+ HA1c measurements in
each PDU, 2018/19.

56
NPDA core report: Care Processes and Outcomes 2018/19

7.1.2.2 HbA1c outcomes according to patient characteristics

Figure 23 shows that older children with Type 1 diabetes tend to have higher HbA1c levels compared
to those who are younger, and females tend to have higher HbA1c levels compared to males.
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Boys
61.9
61.6
59.9
59.2
58.1
57.2
58.0
57.6
58.5
59.3
60.2
62.4
63.6
66.4
66.8
67.6
70.2
72.3
71.4
69.3
Girls
60.3
62.2
58.9
59.6
58.3
58.6
57.7
57.5
58.9
60.7
61.9
63.7 64.5
65.4
67.1
69.5
70.9 74.5
76.2
71.9
45
50
55
60
65
70
75
80
Mean HbA1c (mmol/mol)
Age and sex

Figure 23: Mean HbA1c for children and young people with Type 1 diabetes by age and sex, 2018/19

Figure 24 shows that mean HbA1c increases with duration of diabetes.
Less than
1 year
1-2 years
3-4 years
5-9 years
10-14 years
15 or more years
2015/16
59.5
66.6
69.8
71.5
74.6
75.4
2016/17
61.1
65.5
68.7
70.5
74.0
77.3
2017/18
61.4
65.3
68.6
70.7
74.6
75.6
2018/19
59.0
63.4
65.7
68.1
71.2
75.1
45
50
55
60
65
70
75
80
Mean HbA1c (mmol/mol)
Duration of diabetes

Figure 24: Mean HbA1c for children and young people with Type 1 diabetes by duration of diabetes,
2015/16 to 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19

Children and young people with Type 1 diabetes living in the most deprived areas had higher HbA1c
levels compared to those living in the least deprived areas of England and Wales (Figure 25). Despite
overall improvements in HbA1c across all deprivation quintiles since 2013/14, the difference in mean
HbA1c amongst children and young people in the most and least deprived areas has increased
from 5.7 mmol/mol in 2013/14 to 6.3 mmol/mol in 2018/19.
60
62
64
66
68
70
72
74
76
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
Mean HbA1c (mmol/mol)
Most deprived
Second most deprived
Third least deprived
Second least deprived
Least deprived



Figure 25: Mean HbA1c for children and young people with Type 1 diabetes by deprivation quintile,
2013/14 to 2018/19

Figure 26 and Table 24 show the percentages of children and young people with Type 1 diabetes
within each ethnic group achieving NICE HbA1c targets. Children and young people with Type 1
diabetes from Black, Asian and mixed ethnicity groups are over represented in the higher HbA1c
categories compared to White children and young people.

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NPDA core report: Care Processes and Outcomes 2018/19
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/ mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
% of children and young people with Type 1
diabetes
HbA1c target levels
White
Mixed
Asian
Black
Other
Not stated

Figure 26: Percentage of children and young people with Type 1 diabetes in England and Wales
achieving HbA1c targets by ethnic group, 2018/19

Table 24: Mean HbA1c and percentage of children and young people with Type 1 diabetes in
England and Wales achieving HbA1c targets by ethnic group, 2018/19
% of children and young people achieving HbA1c targets
Mean
HbA1c
(mmol
/mol)
Number
(n)
≤48
mmol/
mol (%)
≤53
mmol/
mol (%)
<58
mmol/
mol (%)
≥69
mmol/
mol (%)
>75
mmol/
mol (%)
>80
mmol/
mol (%)
White
64.6
21,580
10.4
22.2
37.0
29.6
18.3
13.4
Asian
66.2
1,684
8.6
17.3
30.4
35.5
20.9
14.1
Black
71.4
967
8.1
14.2
23.7
46.9
32.7
25.6
Mixed
67.5
788
9.3
18.5
30.8
36.9
24.4
18.4
Other
63.7
479
13.8
24.6
38.8
26.9
19.0
13.2
Not stated
63.9
887
12.4
24.7
38.2
29.5
18.3
13.4

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NPDA core report: Care Processes and Outcomes 2018/19

Figure 27 shows the mean HbA1c for each ethnic category between 2015/16 and 2018/19:
62
64
66
68
70
72
74
76
2015/16
2016/17
2017/18
2018/19
Mean HbA1c (mmol/mol)
White
Asian
Black
Mixed
Other
Not stated

Figure 27: Mean HbA1c for children and young people with Type 1 diabetes by ethnic group, 2015/16
to 2018/19

Further breakdown showed that children and young people with Type 1 diabetes of Afro-Caribbean
ethnicity had the highest overall HbA1c of all the Black ethnic sub-categories:

Table 25: Mean HbA1c for children and young people with Type 1 diabetes within Black ethnic
subgroups, 2018/19
N
Mean (mmol/mol)
Standard deviation
Interquartile range
Black Caribbean
136
77.0
21.5
28.5
Black African
588
70.4
18.8
21.0
Black any Other
243
70.6
19.1
24.0

7.1.2.3 Adjusted HbA1c outcomes achieved by paediatric diabetes units (Type 1 diabetes)

Given the variations in HbA1c associated with different demographic and social characteristics, it is
appropriate to adjust HbA1c figures to allow for equitable benchmarking of individual PDU
performance. The case-mix adjustment applied to the 2018/19 data considers the effect of age, sex,
ethnicity, duration of diabetes and deprivation on mean HbA1c and the likelihood of having a HbA1c
lower than the treatment target of 58 mmol/mol or higher than the upper limit of 80 mmol/mol. A
summary of the output of the regression models used to construct the case-mix adjusted measures
can be found in the appendices of this report published on the NPDA website.

Figure 28 (page 60) shows the case-mix adjusted mean HbA1c for each PDU in England and Wales,
and Figures 29 and 30 (pages 60-61) show the case-mix adjusted percentage achieving an HbA1c
result below 58 mmol/mol, and above 80 mmol/mol, respectively. Each graph shows that there
remains considerable variation in HbA1c outcomes achieved by PDUs across England and Wales
once patient characteristics have been controlled for. The horizontal navy line shows the mean

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NPDA core report: Care Processes and Outcomes 2018/19
HbA1c for England and Wales, and the curved lines indicate units whose results are within two
standard deviations (dashed curve) or three standard deviations (dotted curve) of the mean.

HQIP guidance (HQIP, 2017) defines services with a result outside of three standard deviations of
the expected value, after case-mix adjustment, on key quality measures as ‘alarm’ outliers. In Figure
28, PDUs above the top dotted line (>3SD) are considered negative outliers (‘alarms’) as their mean
HbA1c are significantly higher when compared to others in England and Wales.
50
55
60
65
70
75
80
85
0
100
200
300
400
500
600
Mean adjusted HbA1c (mmol/mol)
Number of children and young people with Type 1 diabetes
English PDUs
Welsh PDUs
95% level (2 SD)
99% level (3 SD)
Mean (England and Wales)



Figure 28: Funnel plot of mean adjusted HbA1c for children and young people with Type 1 diabetes
in England and Wales by PDU, 2018/19.
0%
10%
20%
30%
40%
50%
60%
0
100
200
300
400
500
600
Adjusted % of children and young people
with an HbA1c of below 58 mmol/mol
Number of children and young people with Type 1 diabetes
English PDUs
Welsh PDUs
95% level (2 SD)
99% level (3 SD)
Mean (England and Wales)

Figure 29: Funnel plot of percentage of children and young people with Type 1 diabetes in England
and Wales with an adjusted HbA1c <58 mmol/mol by PDU, 2018/19.

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NPDA core report: Care Processes and Outcomes 2018/19

In Figure 30, PDUs above the top dotted line (>3SD) are ‘alarm’ negative outliers as they have a
higher adjusted percentage of patients with an HbA1c > 80 mmol/mol, who are at greater risk of
developing diabetes-related complications.
0%
5%
10%
15%
20%
25%
30%
35%
40%
0
100
200
300
400
500
600
Adjusted % of children and young people with an
HbA1c of above 80 mmol/mol
Number of children and young people with Type 1 diabetes
English PDUs
Welsh PDUs
95% level (2 SD)
99% level (3 SD)
Mean (England and Wales)

Figure 30: Funnel plot of percentage of children and young people with Type 1 diabetes in England
and Wales with an adjusted HbA1c >80 mmol/mol by PDU, 2018/19
7.1.3 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 unadjusted mean and median HbA1c of children and young people with Type 2 diabetes in
England and Wales receiving care in a PDU in 2018/19 were 57.4 and 49.5 mmol/mol, respectively
(Table 26).

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NPDA core report: Care Processes and Outcomes 2018/19

Table 26: HbA1c for all children and young people with Type 2 diabetes and one or more valid
HbA1c measurements in England and Wales, 2015/16- 2018/19
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
51.0
30.5
2016/17
605
60.2
24.6
52.0
33.5
2017/18
650
61.3
25.3
53.0
28.5
2018/19
674
57.4
23.5
49.5
26.0

Table 26 and Figure 31 show that the national median HbA1c of children and young people with
Type 2 diabetes has varied since 2015/16.
51.0
52.0
53.0
49.5
42.0
44.0
46.0
48.0
50.0
52.0
54.0
2015/16
2016/17
2017/18
2018/19
Median HbA1c (mmol/mol)

Figure 31: Median HbA1c for all children and young people with Type 2 diabetes and one or more
valid HbA1c measurements in England and Wales, 2015/16- 2018/19

Figure 32 shows how older children with Type 2 diabetes tend to have higher HbA1c. There is no
difference between boys and girls.

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aged 5 to 9
aged 10 to 14
aged 15 to 19
Boys
47.4
53.6
59.6
Girls
46.3
55.2
59.2
40
45
50
55
60
65
Mean HbA1c (mmol/mol)
Age and sex

Figure 32: Mean HbA1c for children and young people with Type 2 diabetes by group of age and
sex, 2018/19

Figure 33 (page 64) shows that the mean HbA1c improved in almost every deprivation quintile
except for the third least deprived in 2018/19 compared to previous years. Since 2015/16, the mean
HbA1c levels of those in the least deprived quintiles have fluctuated. This may be because the
numbers of children and young people with Type 2 diabetes reported to be living in the least
deprived quintiles are smaller, compared to the numbers reported to be living in the most deprived
quintiles, and therefore they are more sensitive to outlying values and natural variation.

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Least
deprived
Second least
deprived
Third least
deprived
Second most
deprived
Most
deprived
2015/16
55.5
55.6
56.2
59.4
62.4
2016/17
54.1
57.9
60.3
61.2
61.4
2017/18
59.4
61.8
57.7
61.0
61.9
2018/19
50.5
55.6
59.1
54.5
59.6
30
35
40
45
50
55
60
65
Mean HbA1c (mmol/mol)
Deprivation quintile

Figure 33: Mean HbA1c for children and young people with Type 2 diabetes in England and Wales
by deprivation quintile, 2015/16 to 2018/19

Figure 34 shows variation in mean HbA1c in those with Type 2 diabetes by ethnic group, with Black
children and young people having a higher HbA1c level compared to those of other ethnic
backgrounds.

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White
Asian
Black
Mixed
Other
Not stated
2015/16
56.8
58.7
69.9
52.1
61.3
62.3
2016/17
55.6
61.3
71.9
64.0
62.9
60.9
2017/18
57.9
61.0
75.2
58.6
61.5
59.6
2018/19
54.1
58.0
66.9
60.2
56.7
47.1
30
35
40
45
50
55
60
65
70
75
80
Mean HbA1c (mmol/mol)

Figure 34: Mean HbA1c for children and young people with Type 2 diabetes in England and Wales
by ethnic group, 2015/16 to 2018/19
7.1.4 Key findings

All types of diabetes

•
There has been a decrease of 2.5 mmol/mol in both the national mean and median HbA1c for
children and young people with all types of diabetes being treated within a PDU in England
and Wales since 2017/18. In 2018/19 the mean HbA1c was 64.6 mmol/mol, while the median
HbA1c was 61.5 mmol/mol.

•
Variation in national HbA1c has also improved since 2011/12, with the interquartile range for
both England and Wales falling from 20 mmol/mol in 2011/12 to 17.5 mmol/mol for England
and 18.5 mmol/mol in Wales in 2018/19.

Type 1 diabetes

•
The unadjusted mean HbA1c was 65 mmol/mol; a decrease of 2.5 mmol/mol compared to the
mean recorded in 2017/18. The median HbA1c was 62 mmol/mol - 2.0 mmol/mol lower
compared to 2017/18.

•
Increasing age, female gender, living in the most deprived areas, non-white ethnicity and
longer duration of diabetes continue to be associated with higher HbA1c levels in children and
young people with Type 1 diabetes.

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NPDA core report: Care Processes and Outcomes 2018/19

•
There has been a consistent downward trend in mean HbA1c within each deprivation quintile
since 2013/14 and within each ethnic category since 2015/16. However, on average, Black
children and young people with Type 1 diabetes have had consistently higher HbA1c than
those in other ethnic categories over this period, with those of Afro-Caribbean ethnicity being
the ethnic subcategory with the highest overall HbA1c.

•
Considerable variation in the percentage achieving HbA1c target outcomes amongst children
and young people with Type 1 diabetes persist between PDUs even after case-mix adjustment.

Type 2 diabetes

•
The unadjusted mean and median HbA1c of children and young people with Type 2 diabetes
in England and Wales receiving care in a PDU in 2018/19 were 57.4 and 49.5 mmol/mol,
respectively, with the latter reflecting a 3.5 mmol/mol decrease since 2017/18.

•
There was variation in mean HbA1c by age and ethnic group, with Black and adolescent
children and young people with Type 2 diabetes having higher HbA1c level compared to those
of other ethnic backgrounds.
7.2 Small vessel (microvascular) disease

People with diabetes are at increased risk of microvascular disease including diabetic kidney
disease (nephropathy) and diabetic eye disease (retinopathy).
7.2.1 Diabetic kidney disease

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

7.2.1.1 Albuminuria in young people with Type 1 diabetes

More than two-thirds (n = 11,725) 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, 94.5% (n =
11,075) had a valid PDU interpretation of their urinary albumin level. Increased risk of kidney disease
is indicated by the presence of either micro- or macro-albuminuria. Figure 35 shows that 9.8% of
young people in England and Wales were recorded as having micro- or macro-albuminuria; the
percentage varied across regions.

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NPDA core report: Care Processes and Outcomes 2018/19
90.2%
90.1%
92.4%
88.1%
92.4%
89.0%
93.2%
90.7%
86.4%
86.6%
92.1%
93.8%
9.8%
9.9%
7.6%
11.9%
7.6%
11.0%
6.8%
9.3%
13.6%
13.4%
7.9%
6.2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
England & 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
Normo-albuminuria
Micro- or macro-albuminuria

Figure 35: Percentage of young people with Type 1 diabetes aged 12 years and older with
albuminuria by country and region, 2018/19

Table 27 shows that the percentage of young people with Type 1 diabetes aged 12 years and above
with albuminuria remained stable since 2015/16.

Table 27: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria, 2015/16 to 2018/19
Total
(n)
Normo-albuminuria
(%)
Micro- or
macro-albuminuria
(%)
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 36 shows little variation in the presence of albuminuria by duration of diabetes between the
audit years. This is a surprising finding and different to that for presence of retinopathy with
duration of diabetes (Figure 42). Although false positives may be an explanation for this finding,
further longitudinal analysis is required.

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NPDA core report: Care Processes and Outcomes 2018/19
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%
0%
3%
6%
9%
12%
15%
% of young people with Type 1 diabetes
Duration of diabetes



Figure 36: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by duration of diabetes, 2016/17 – 2018/19

Figure 37 shows little difference in rates of albuminuria by age and sex.
12
13
14
15
16
17
18
Boys
9.7%
10.6%
9.3%
10.9%
8.4%
11.7%
14.1%
Girls
9.7%
9.7%
7.9%
7.7%
10.7%
9.5%
10.5%
0%
3%
6%
9%
12%
15%
% of young people with Type 1 diabetes
Age and sex

Figure 37: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by age and sex, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19

Figure 38 shows that in the last three years the prevalence of albuminuria has decreased amongst
children and young people living in the most deprived areas and increased amongst those living in
the least deprived, but no clear relationship between prevalence of albuminuria and relative 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%
0%
3%
6%
9%
12%
15%
% of young people with Type 1 diabetes
Deprivation quintile

Figure 38: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by deprivation quintile, 2016/17 - 2018/19

Figure 39 shows that young people with Type 1 diabetes and higher HbA1c tend to be more at risk
of albuminuria. It shows increased prevalence of albuminuria amongst young people exceeding
the target of 58mmol/mol.
0%
10%
20%
30%
40%
50%
60%
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/ mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
% of children and young people with Type 1
diabetes
HbA1c target levels
% of young people 12+ with Type 1 diabetes and micro- or macro-albuminuria
% of young people 12+ with Type 1 diabetes and normoalbuminuria

Figure 39: Percentage of young people with Type 1 diabetes achieving HbA1c targets by presence
of albuminuria, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19

7.2.1.2 Albuminuria in children and young people with Type 2 diabetes

Figure 40 shows that albuminuria was present in 20.6% of children and young people with Type 2
diabetes with a valid PDU interpretation of their urinary albumin level (n=349) in 2018/19. This
proportion decreased slightly for the first time in the last four years. The percentage of children
and young people with Type 2 diabetes with albuminuria is twice that recorded for young people
with Type 1 diabetes (9.8%) – 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%
0%
5%
10%
15%
20%
25%
2015/16
2016/17
2017/18
2018/19
% of children and young people with Type 2 diabetes
Audit year

Figure 40: Percentage of children and young people with Type 2 diabetes with albuminuria in
England and Wales, 2015/16 - 2018/19
7.2.2 Eye Disease

7.2.2.1 Retinopathy in young people with Type 1 diabetes

There were 11,894 young people with Type 1 diabetes aged 12 years and above recorded as receiving
an eye screen during the audit period. Of those, 96.1% (n = 11,431) had a valid eye screen result
recorded. Figure 42 shows that 13.1% of young people with Type 1 diabetes aged 12 and above had
an abnormal eye screen result recorded within the audit period; the percentage varied by country
and by region. 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.

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NPDA core report: Care Processes and Outcomes 2018/19
86.9%
86.6%
92.4%
85.7%
82.5%
86.8%
90.9%
85.1%
87.3%
83.6%
92.2%
85.0%
13.1%
13.4%
7.6%
14.3%
17.5%
13.2%
9.1%
14.9%
12.7%
16.4%
7.8%
15.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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 aged 12+
Normal
Abnormal

Figure 41: Percentages of young people with Type 1 diabetes aged 12 years and older with normal/
abnormal retinopathy screening results by country and region, 2018/19

Table 28 shows variation in the percentage of young people with Type 1 diabetes aged 12 years and
above with an abnormal eye screening result between audit years.

Table 28: Percentage of young people with Type 1 diabetes aged 12 years and above with a normal/
abnormal eye screening result, 2015/16 to 2018/19
Total
Normal (%)
Abnormal (%)
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

In 2018/19, the prevalence of abnormal eye screening increased with age and was highest amongst
adolescent girls with Type 1 diabetes (Figure 42). The prevalence also increased with longer duration
of diabetes (Figure 43).

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NPDA core report: Care Processes and Outcomes 2018/19
12
13
14
15
16
17
18
Boys
6.2%
8.9%
9.3%
12.4%
14.1%
19.3%
21.7%
Girls
5.6%
9.2%
10.4%
13.9%
19.0%
24.7%
30.4%
0%
5%
10%
15%
20%
25%
30%
35%
% of young people with Type 1 diabetes aged 12+
Age by sex

Figure 42: Percentage of young people with Type 1 diabetes aged 12 years and older with retinopathy
by age and sex, 2018/19
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
2016/17
5.4%
6.0%
8.0%
18.1%
28.6%
36.5%
2017/18
4.2%
4.2%
6.3%
15.3%
27.0%
34.7%
2018/19
4.7%
5.9%
7.4%
14.7%
26.7%
33.5%
0%
5%
10%
15%
20%
25%
30%
35%
40%
% of young people with Type 1 diabetes aged 12+
Duration of diabetes



Figure 43: Percentage of young people with Type 1 diabetes aged 12 years and older with abnormal
eye screening by duration of diabetes, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19

Figure 44 shows little variation in rates of prevalence of abnormal eye screening between audit
years and between deprivation quintiles.
Most deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least deprived
2016/17
14.9%
14.6%
16.4%
14.8%
13.9%
2017/18
13.7%
13.3%
12.1%
12.5%
12.8%
2018/19
13.6%
13.3%
13.1%
12.2%
13.1%
0%
3%
6%
9%
12%
15%
18%
% of young people with Type 1 diabetes
Deprivation quintile

Figure 44: Percentage of young people with Type 1 diabetes aged 12 years and older with an
abnormal eye screening result by deprivation quintile, 2018/19

Figure 45 shows that young people with Type 1 diabetes and higher HbA1c tend to have increased
risk of an abnormal eye screening result.
0%
10%
20%
30%
40%
50%
60%
70%
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/ mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
HbA1c target levels
% young people 12+ with Type 1 diabetes and an abnormal result
% young people 12+ with Type 1 diabetes and a normal result


Figure 45: Percentage of children and young people with Type 1 diabetes with or without an
abnormal eye screening result achieving HbA1c targets, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19

Figure 46 plots both systolic and diastolic blood pressure z-scores (standard deviation score) of
young people aged 12 and above with Type 1 diabetes. The z-scores indicate how many units (of the
standard deviation) a child or young person’s blood pressure is above or below the average value
for their age and sex, using the UK 1990 growth data as reference.

The horizontal blue line indicates the average value for diastolic blood pressure while the vertical
blue line indicates the average systolic blood pressure.

Red dots indicate young people with Type 1 diabetes, aged 12 and above, with an abnormal eye-
screen result at their last check within the audit year.

The concentration of red dots in the upper two quadrants shows that young people with Type 1
diabetes tend to have diastolic blood pressure higher than the average of the population with
same age and sex. Amongst the cohort of young people aged 12 years and above with Type 1
diabetes and an abnormal eye screening result, 61.5% had above average systolic blood pressure,
and 93.7% had above average diastolic blood pressure.
-5
-4
-3
-2
-1
0
1
2
3
4
5
-5
-4
-3
-2
-1
0
1
2
3
4
5
Diastolic Blood Pressure (z scores)
Systolic Blood Pressure (z scores)
Young people aged 12+ with Type 1 diabetes - no retinopathy
Young people aged 12+ with Type 1 diabetes and retinopathy

Figure 46: Scatter plot showing systolic and diastolic blood pressure z-scores of young people with
Type 1 diabetes aged 12 and above, 2018/19.

Figure 47 shows the prevalence of high blood pressure (above centile 98), high cholesterol (above
5mmol/mol), high HbA1c and obesity, among young people with Type 1 diabetes and retinopathy
and those without retinopathy. All four risk factors are more prevalent in those with abnormal eye
screening compared to those without. The risk factor most strongly associated with retinopathy
was high HbA1c (>80mmol/mol), with 30.1% of young people with retinopathy having HbA1c levels
above 80 mmol/mol compared to 16.4% of those without.

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NPDA core report: Care Processes and Outcomes 2018/19
29.5%
22.0%
30.1%
26.7%
25.9%
17.8%
16.4%
23.4%
High Blood Pressure
Cholesterol above 5
mmol/mol
HbA1c above 80 mmol/
mol
Obesity
% of young people aged 12+
with Type 1 diabetes and
retinopathy
% of young people aged 12+
with Type 1 diabetes and- no
retinopathy



Figure 47: Percentages of young people with Type 1 diabetes aged 12 and above with/out retinopathy
with high blood pressure, cholesterol above 5 mmol/mol, HbA1c above 80 mmol/mol and obesity

7.2.2.2 Retinopathy in young people with Type 2 diabetes

Figure 48 shows that 6.7% of young people with Type 2 diabetes aged 12 years and above with a
valid eye screening result (n=326) had an abnormal result. This was almost half the rate of retinopathy
found amongst young people with Type 1 diabetes (13.1%), although the percentage has increased
year on year since 2016/17.
6.2%
4.8%
5.6%
6.7%
0%
1%
2%
3%
4%
5%
6%
7%
8%
2015/16
2016/17
2017/18
2018/19
% of children and young people with Type 2 diabetes
Audit year

Figure 48: Eye screening results for young people aged 12 years and above with Type 2 diabetes,
2015/16 to 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19
7.3 Large vessel disease - Cardio Vascular 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.
7.3.1 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. Unfortunately, the NPDA does not collect data on HDL or LDL cholesterol
which might be helpful in the interpretation of total cholesterol. However, awareness of raised total
cholesterol is important as it may lend itself to lipid lowering therapies in the future. 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).

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

Table 29 (page 77) shows the percentages of young people aged 12 and above with Type 1 diabetes
with a recorded blood pressure in the audit period (n=15,160) classified as ‘high normal’ (91st -98th
centile) or ‘high’ blood pressure (>98th centile). Over a quarter of young people (25.8%) with Type 1
diabetes had high blood pressure (hypertension); this represents a decrease compared to the
figure reported in the 2017/18 audit (26.7%).

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NPDA core report: Care Processes and Outcomes 2018/19

Table 29: Percentage of young people with Type 1 diabetes aged 12 years and above falling within
blood pressure targets by country and region, 2018/19
‘High normal’ blood pressure
(91st–98th centile)
‘High’ blood pressure
(>98th centile)
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
(%)
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
(%)
England and Wales
28.5
9.5
34.0
25.4
3.8
25.8
England
28.3
9.4
33.6
25.3
3.7
25.7
Wales
32.3
11.3
40.4
26.5
4.7
28.3
East of England
28.1
10.1
35.5
26.1
3.7
27.4
East Midlands
31.6
10.8
39.6
30.6
3.1
32.1
London and South East
28.0
7.8
31.8
22.5
2.8
22.6
North East and North Cumbria
30.2
6.7
34.8
21.9
2.2
22.5
North West
26.7
7.9
30.3
24.5
3.0
24.4
South Central
28.2
9.8
33.7
22.1
3.5
22.6
South West
29.6
11.5
32.1
33.2
5.9
30.9
West Midlands
28.4
11.7
37.3
29.1
5.7
31.5
Yorkshire and Humber
27.2
9.9
32.1
22.7
4.4
22.3

Table 30 shows the percentages of young people aged 12 and above with Type 1 diabetes with a
recorded cholesterol screen (n=10,908) within the target for total blood cholesterol. It shows that
19.0% exceeded the higher (>=5 mmol/l) target for total blood cholesterol. This represents a decrease
compared to the figure reported in the 2017/18 audit (21.7%).

Table 30: Percentage of young people with Type 1 diabetes aged 12 years and above falling within
cholesterol targets by country and region, 2018/19
4 mmol/l or more (%)
5 mmol/l or more (%)
England and Wales
59.7
19.0
England
59.7
18.8
Wales
60.5
21.8
East of England
61.0
19.9
East Midlands
54.4
16.0
London and South East
61.7
19.5
North East and North Cumbria
61.8
22.1
North West
60.1
20.0
South Central
56.8
15.4
South West
57.1
17.8
West Midlands
61.1
19.1
Yorkshire and Humber
58.6
18.5

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Figure 49 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. The percentage of young people with
Type 1 diabetes with ‘high’ blood pressure has decreased in most audit years since 2013/14, however
the percentage of young people with high cholesterol has varied over the last six audit cycles.
0%
5%
10%
15%
20%
25%
30%
35%
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
% of young people with Type 1 diabetes
Audit year
Cholesterol level (>=5 mmol/l)
High blood pressure (>98th centile)

Figure 49: 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
2018/19

7.3.1.2 Blood Pressure and cholesterol in patients with Type 2 diabetes

Table 31 shows the percentage of children and young people with Type 2 diabetes with a recorded
blood pressure in the audit period (n=614) classified as ‘high normal’ (91st -98th centile) or ‘high’
blood pressure (>98th centile). Almost half (44.6%) of children and young people with Type 2
diabetes had high blood pressure. Table 32 (page 73) shows the percentage of children and young
people with Type 2 diabetes with a recorded cholesterol screen (n=453) above the target for total

79
NPDA core report: Care Processes and Outcomes 2018/19
blood cholesterol. It shows that 28.3% exceeded the higher target for total blood cholesterol (>=5
mmol/l) in 2018/19, a reduction from 36.2% in 2016/17.

Table 31: Percentage of children and young people with Type 2 diabetes with ‘high’ or ‘high-normal’
blood pressure, 2016/17 – 2018/19
‘High normal’ blood pressure
(91st–98th centile)
‘High’ blood pressure
(>98th centile)
Diastolic
Systolic
Diastolic
and/or
systolic
Diastolic
Systolic
Diastolic
and/or
systolic
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 32: Percentage of children and young people with Type 2 diabetes above cholesterol targets,
2016/17 -2018/19
4 mmol/l or more
5 mmol/l or more
2018/19
69.1
28.3
2017/18
74.9
33.8
2016/17
75.9
36.2
7.3.2 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

7.3.2.1 Body Mass Index and Type 1 diabetes

Figures 50 and 51 (page 74) show the percentage of children and young people with Type 1
diabetes included in the audit within each BMI category by country and region. It shows that a
higher percentage of those aged 0-11 years had a healthy weight (63.5%) compared to those aged
12 years and above (56.7%), and that a higher percentage of children and young people with Type
1 diabetes were overweight or obese than were underweight.

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NPDA core report: Care Processes and Outcomes 2018/19
63.5%
63.7%
59.7%
62.0%
63.0%
65.7%
57.5%
63.9%
66.3%
63.1%
62.7%
63.9%
17.7%
17.6%
18.7%
18.1%
17.4%
17.1%
17.3%
18.4%
17.0%
17.3%
17.3%
18.7%
18.1%
18.0%
21.1%
19.3%
18.9%
16.4%
24.7%
17.1%
16.0%
19.4%
18.8%
16.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 100%
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 aged 0-11 with Type 1 diabetes
Underweight
Healthy weight
Overweight
Obese

Figure 50: Percentage of children aged 0-11 years with Type 1 diabetes within BMI categories by
country and region, 2018/19
56.7%
57.1%
49.7%
59.5%
58.0%
59.7%
53.3%
54.8%
58.7%
56.0%
54.3%
55.2%
18.4%
18.3%
20.3%
17.3%
15.7%
18.1%
17.6%
18.5%
19.6%
19.4%
20.2%
17.9%
23.6%
23.3%
29.2%
20.8%
25.5%
20.9%
27.8%
25.4%
20.9%
23.9%
24.4%
25.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 100%
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 aged 12+ with Type 1 diabetes
Underweight
Healthy weight
Overweight
Obese

Figure 51: Percentage of young people 12 years and older with Type 1 diabetes within BMI categories
by country and region, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19

Figure 52 shows the distribution of BMI of children and young people with Type 1 diabetes since
2016/17 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, with a trend towards
higher BMI amongst children and young people with Type 1 diabetes since 2014/15.
1st
5th 10th
25th
50th
75th 85th
95th
99th
Centiles
UK1990
reference
2014/15
2016/17
2018/19



Figure 52: Distribution of body mass index of children and young people with Type 1 diabetes in
2016/17, 2017/18 and 2018/19 compared to the 1990 reference population

Almost half (49.2%) of girls with Type 1 diabetes aged 12 and above were recorded as being either
overweight or obese compared to just over a third (35.8%) of boys aged 12 and above; the percentage
were lower for girls aged 0 to 11 (34.8%) but higher in boys aged 0 to 11 (36.9%).

Figure 53 (page82) 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.

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NPDA core report: Care Processes and Outcomes 2018/19
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
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 53: Percentage of children and young people with Type 1 diabetes within the overweight or
obese body mass index category, by deprivation quintile, age group and sex, 2018/19

Figure 54 shows that 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.
0%
10%
20%
30%
40%
50%
60%
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/ mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
% of children and young people with Type 1 diabetes
HbA1c target levels
Obese
Overweight
Healthy weight



Figure 54: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by Body Mass Index category, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19

7.3.2.2 Body Mass Index and Type 2 diabetes

Table 33 shows the percentage of children and young people with Type 2 diabetes in each BMI
category for England and Wales in 2016/17, 2017/18 and 2018/19. It shows that in each audit year,
most children and young people with Type 2 diabetes were obese.

Table 33: Body mass index categories for children and young people with Type 2 diabetes, 2016/17
to 2018/19
Total (n)
Underweight
(%)
Healthy
weight
(%)
Overweight
(%)
Obese
(%)
2018/19
737
*
7.1
7.7
84.7
2017/18
677
0.0
5.9
9.5
84.6
2016/17
658
*
6.2
8.1
85.4

*indicates a percentage derived from a number <5

Figure 55 shows similar percentages of children and young people with Type 2 diabetes within
each weight category when broken down by sex.
Healthy Weight
Overweight
Obese
Boys
6.6%
7.9%
84.7%
Girls
7.3%
7.5%
84.8%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
% of children and young people with
Type 2 Diabetes
Boys
Girls

Figure 55: Percentage of children and young people with Type 2 diabetes who were in healthy
weight, overweight or obese categories by sex, 2018/19

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7.3.3 Micro and macrovascular outcomes key findings
Microvascular disease and risk factors

Type 1 Diabetes

•
Albuminuria was found in 9.8% of young people aged 12 years and above with Type 1 diabetes.

•
There was little variation in the presence of albuminuria by duration of diabetes, age or sex.

•
The presence of albuminuria was associated with poorer HbA1c outcomes.

•
Abnormal eye screening was found in 13.1% of young people aged 12 and above with Type 1
diabetes.

•
The risk of abnormal eye screening increased with age and was highest amongst adolescent
females.

•
The risk of abnormal eye screening was higher in young people with higher diastolic blood
pressure.

Type 2 Diabetes

•
Albuminuria was found in 20.6% of children and young people with Type 2 diabetes; twice the
rate observed in those with Type 1 diabetes.

•
Abnormal eye screening results were found in 6.7% of young people with Type 2 diabetes; half
the rate recorded amongst young people with Type 1 diabetes.
Macrovascular disease and risk factors

Type 1 Diabetes

•
High blood pressure (hypertension) was found in 25.8% of young people aged 12 years and
older with Type 1 diabetes.

•
19.0% of young people aged 12 years and older with Type 1 diabetes had a total blood
cholesterol level exceeding the target of 5 mmol/l.

•
17.7% of children aged 0 to 11 years with Type 1 diabetes were overweight, and 18.1% were obese.
In young people aged 12 years and above 18.4% were overweight and 23.6% obese.

•
Girls aged 12 years and above had a higher proportion of overweight and obesity than boys of
the same age.

•
The proportions of children and young people with overweight or obesity were higher in the
most deprived quintiles compared to the least deprived.

Type 2 Diabetes

•
Hypertension was found in 44.6% of children and young people with Type 2 diabetes; double
that seen in Type 1 diabetes.

•
84.7% of children and young people with Type 2 diabetes were obese.

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NPDA core report: Care Processes and Outcomes 2018/19
7.4 Psychological assessment

Psychological assessment and access to psychology services should be available to all children and
young people with diabetes and their families 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.
7.4.1 Psychological outcomes of children and young people
with Type 1 diabetes

There were 22,889 (80.0%) children and young people with Type 1 diabetes recorded as having a
psychological screening assessment within the audit period, 20,852 (91.1%) of whom had a known
outcome of the assessment recorded. Of these, 39.1% (n = 8,153) were assessed as requiring
additional psychological or CAMHS support outside of multidisciplinary team (MDT) clinics
(hereafter ‘additional psychological support’). Table 34 shows an increase in the number of children
and young people recorded as requiring additional support, compared to 2017/18.

Table 34: Outcome of assessment of the need for psychological support and/or Child and
Adolescent Mental Health Services support, for children and young people with Type 1 diabetes,
2017/18 - 2018/19
England and
Wales
No. of children and young people with
a known outcome of psychological
assessment
Required
additional
support
(n)
Required
additional
support
(%)
2018/19
20,852
8,153
39.1
2017/18
20,114
5,672
28.2

Figure 56 (page 86) shows that 39.1% of children and young people in England and Wales were
recorded as requiring additional psychological support or CAMHS. The percentage varied across
regions.

86
NPDA core report: Care Processes and Outcomes 2018/19
39.1%
39.2%
35.7%
48.2%
36.1%
44.0%
35.6%
35.8%
28.3%
29.4%
45.9%
37.9%
0%
10%
20%
30%
40%
50%
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

Figure 56: Percentage of children and young people with Type 1 diabetes assessed as requiring
additional psychological support by country and region, 2018/19

Figure 57 shows that the percentage of younger boys and girls assessed as requiring additional
psychological support varied up to age 11. Rates diverged thereafter as more adolescent girls were
recorded as requiring additional support compared to adolescent boys.

87
NPDA core report: Care Processes and Outcomes 2018/19
0-2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Boys 31.6% 33.1% 35.1% 32.7% 39.3% 34.7% 38.9% 37.9% 35.5% 41.3% 38.3% 39.1% 38.7% 37.3% 36.9% 28.4% 31.7%
Girls 38.2% 25.5% 34.0% 33.2% 38.3% 39.8% 36.4% 37.8% 41.0% 39.6% 42.8% 44.7% 45.9% 45.3% 45.1% 43.5% 37.4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
% of children and young
people with Type 1 diabetes
Age and sex

Figure 57: Percentage of children and young people with Type 1 diabetes who were assessed as
requiring additional psychological support by age and sex, 2018/19

Figure 58 shows that the percentage of children and young people with Type 1 who were assessed
as requiring additional psychological support was highest amongst those who were newly, or
recently, diagnosed.
Diagnosed
in the
audit year
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
Duration
51.6%
43.4%
37.9%
37.0%
36.6%
39.2%
40.8%
0%
10%
20%
30%
40%
50%
60%
% of children and young people with Type 1 diabetes
Duration of diabetes

Figure 58: Percentage of children and young people with Type 1 diabetes assessed as requiring
additional psychological support by duration of Type 1 diabetes, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19

Figure 59 shows that the percentage of children and young people with Type 1 diabetes who were
assessed as requiring additional psychological support or CAMHS support outside of MDT clinics
was highest amongst those who were living in the most deprived areas.
Most
deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least
deprived
Quintile
41.1%
40.8%
38.9%
38.1%
36.1%
30%
32%
34%
36%
38%
40%
42%
% of children and young people
with Type 1 diabetes
Deprivation quintile

Figure 59: Percentage of children and young people with Type 1 diabetes assessed as requiring
additional psychological support or CAMHS support outside of MDT clinics within each deprivation
quintile, 2018/19

Figure 60 shows that the percentage of children and young people with Type 1 diabetes who were
assessed as requiring additional psychological support varied according to ethnic category. Of
those with a stated ethnicity, the percentage was highest amongst those of mixed ethnic group.

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NPDA core report: Care Processes and Outcomes 2018/19
White
Asian
Black
Mixed
Other
Not stated/
unknown
Ethnic group
38.7%
35.1%
40.3%
45.2%
43.3%
44.0%
0%
10%
20%
30%
40%
50%
60%
% of children and young people
with Type 1 diabetes
Ethnic group

Figure 60: Percentage of children and young people with Type 1 diabetes assessed as requiring
additional psychological support within each ethnic category, 2018/19

Figure 61 shows that children and young people with Type 1 diabetes who required additional
psychological support were more likely to be in higher HbA1c target ranges compared to those
who did not require additional psychological support.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/ mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
% children and young people with Type 1 diabetes
HbA1c target ranges
Required additional
psychological support
Did not require additional
psychological support

Figure 61: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by outcome of psychological assessment, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19
7.4.2 Psychological outcomes of children and young people
with Type 2 diabetes

There were 518 (65.6%) children and young people with Type 2 diabetes recorded as receiving a
psychological assessment within the audit period, 457 (88.2%) of whom had a known outcome of
the assessment recorded.

Of the children and young people with Type 2 diabetes with a known result, almost half (45.5%)
were assessed as requiring additional psychological or CAMHS support outside of MDT clinics
(Table 35 ).

Table 35: Outcome of assessment for need of Child and Adolescent Mental Health Services/
psychological support for children and young people with Type 2 diabetes by country, 2016/17
England and
Wales
No. of children and young people with
a known outcome of psychological
assessment
Required
additional
support
(n)
Required
additional
support
(%)
2018/19
457
208
45.5
2017/18
417
126
30.2
7.4.3 Key findings

Type 1 diabetes

•
The proportion of children and young people with Type 1 diabetes who were assessed as
requiring additional psychological or CAMHS support outside of MDT clinics increased from
28.2% in 2017/18 to 39.1% in 2018/19 .

•
Amongst children and young people with Type 1 diabetes, there was a higher proportion of
adolescent girls recorded as requiring additional psychological support compared to
adolescent boys.

•
The percentage of children and young people with Type 1 diabetes assessed as requiring
additional psychological support was highest amongst those who were either newly or
recently diagnosed and amongst those living in the most deprived areas.

•
Children and young people with Type 1 diabetes who were recorded as requiring additional
psychological support tended to have higher HbA1c.

Type 2 diabetes

•
There were 208 (45.5%) children and young people with Type 2 diabetes assessed as requiring
additional psychological or CAMHS support outside of MDT clinics, an increase from 30.2% in
2017/18.

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NPDA core report: Care Processes and Outcomes 2018/19
7.5 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 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 2018/19, 168 out of 175 PDUs submitted admission
data for children and young people with Type 1 diabetes. There were 5,977 diabetes-related admissions
within the 2018/19 audit year reported for 4,595 children and young people with Type 1 diabetes.
7.5.1 Diabetes-related admission

Table 36 shows the percentage of children and young people with Type 1 diabetes admitted at
least once with a diabetes-related admission, not associated with diagnosis, within the audit year.

Table 36: 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, 2018/19
No. of
children
and young
people with
T1 diabetes*
DKA
(%)
Hypogly-
caemia
(%)
Ketosis
without
Acidosis
(%)
Stabilisation
(%)
Other
(incl.
surgery)
(%)
England and
Wales
27,454
2.5%
1.2%
1.3%
1.9%
4.8%
England
26,018
2.5%
1.2%
1.2%
1.8%
4.8%
Wales
1,436
3.1%
1.9%
3.0%
1.9%
5.1%
East of England
3,147
2.9%
1.1%
1.6%
1.7%
7.7%
East Midlands
1,896
1.9%
0.7%
0.4%
2.3%
1.7%
London and
South East
6,092
2.2%
1.2%
0.7%
2.0%
3.8%
North East and
North Cumbria
1,605
2.9%
1.6%
1.5%
0.5%
4.5%
North West
3,541
2.2%
0.8%
0.8%
1.1%
3.6%
South Central
2,409
2.2%
1.4%
1.7%
2.8%
7.2%
South West
2,074
2.5%
1.3%
2.3%
2.2%
4.2%
West Midlands
2,484
2.2%
1.3%
1.3%
1.9%
4.9%
Yorkshire and
Humber
2,770
3.6%
1.5%
1.2%
2.1%
6.1%

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

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NPDA core report: Care Processes and Outcomes 2018/19
7.5.3 DKA at diagnosis

Figure 62 shows that for England and Wales combined, 20.9% of all newly diagnosed patients in
2018/19 (n= 2,789), had DKA at diagnosis of Type 1 diabetes. This finding is lower than the 23.9%
incidence rate reported in the previous NPDA Hospital Admissions Report (RCPCH, 2017), but
higher than the rate (18.2%) reported for 2017/18. There was significant variation in rates of DKA at
diagnosis between regions, which considered alongside the lower national rate compared to
previous analysis suggests data completeness and quality issues with incomplete submission of
admission data by participating PDUs in the 2018/19 audit.

A comprehensive data completeness and quality report is now provided on submission of
admission data to the NPDA which should help to drive improvement in data completeness and
quality of data submitted. Data quality and completeness needs to improve before PDU submitted
admission data can be considered representative of admission trends in England and Wales.
20.9%
20.8%
21.9%
20.0%
19.2%
27.6%
18.2%
9.3%
17.8%
28.3%
16.6%
25.6%
0%
5%
10%
15%
20%
25%
30%
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

Figure 62: Percentage of children and young people with Type 1 diabetes who had DKA at diagnosis
in 2018/19, by region and country

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7.5.4 Key findings

•
The number of units submitting admissions data increased from 167 to 168 with only 7 PDUs
failing to submit admissions data in 2018/19.

•
Significant variation in reported admission rates between regions suggests incompleteness of
data submission amongst units who did submit admissions data.

•
Data quality and completeness needs to improve further before PDU submitted admission
data can be considered representative of admission trends in England and Wales.

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NPDA core report: Care Processes and Outcomes 2018/19
8
Treatment regimen and diabetes
monitoring

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 is used for the analysis.
8.1 Treatment regimen
8.1.1 Type 1 diabetes

There were 27,713 children and young people with Type 1 diabetes with a valid treatment regimen
recorded within the audit period. Table 37 provides a breakdown of the treatment regimens
recorded by nation and region for children and young people with Type 1 diabetes (Table 37 ).

Table 37: Percentage of children and young people with Type 1 diabetes using each treatment
regimen, by country and region, 2018/19
No. of children
and young
people with
T1 diabetes
1 – 3
insulin
injections*
(%)
4 or more
insulin
injections*
(%)
Insulin pump
therapy*
(%)
England and Wales
27,713
3.5
59.7
36.7
England
26,303
3.7
59.5
36.8
Wales
1,410
0.9
63.8
35.3
East of England
3,053
1.6
64.9
33.5
East Midlands
1,853
1.5
57.9
40.6
London and South East
6,306
4.1
57.3
38.5
North East and North Cumbria
1,563
2.8
55.5
41.7
North West
3,377
12.4
53.7
33.9
South Central
2,348
2.9
59.1
38.0
South West
2,213
1.4
68.1
30.5
West Midlands
2,921
1.4
65.5
33.1
Yorkshire and Humber
2,669
0.9
56.2
42.9

* In England and Wales, 3% of children and young people with diabetes using insulin injections were also using other blood glucose
lowering medication (BGLM), and 0.4% of those using insulin pump therapy were using other BGLM.

Figure 63 shows the breakdown of insulin regimens amongst those with a recorded sex and age.
Younger children were more likely to be using insulin pump therapy in keeping with the trend
seen in other European and transatlantic cohorts (Sherr et al., 2016), and pump usage was more
prevalent in females.

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NPDA core report: Care Processes and Outcomes 2018/19
0%
10%
20%
30%
40%
50%
60%
70%
80%
0-1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
% of children and young people with Type 1 diabetes
Age
Insulin pump therapy
Insulin pump therapy
Insulin injections
Insulin injections

Figure 63: Percentage of children and young people with Type 1 diabetes recorded as using insulin
injections or insulin pump therapy by age and sex, 2018/19

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 64).
0%
10%
20%
30%
40%
50%
60%
70%
80%
2014/15
2015/16
2016/17
2017/18
2018/19
% 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 64: Percentage of children and young people either using daily insulin injections or insulin
pump therapy by age group, 2014/15 to 2018/19

96
NPDA core report: Care Processes and Outcomes 2018/19

Insulin pump usage increased with duration of diabetes (Figure 65) with three-quarters (76.8%) of
those in their first year of diagnosis of Type 1 diabetes using insulin injections, compared to just
over half (55.0%) of those after 5 to 9 years post diagnosis.
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
Insulin pump
23.2%
35.9%
42.6%
45.0%
43.2%
39.8%
Insulin injections
76.8%
64.1%
57.4%
55.0%
56.8%
60.2%
0%
20%
40%
60%
80%
100%
% of children and young people
with Type 1 diabetes
Duration of diabetes

Figure 65: Percentage of children and young people either on daily insulin injections or pump
therapy by duration of diabetes, 2018/19

Figure 66 shows that White children and young people were more likely to be using a pump
compared to Asian and Black ethnic groups, and that insulin pump therapy usage is also more
prevalent in those living in the least compared to the most deprived areas.
38.7%
33.9%
30.2%
28.6%
23.1%
29.6%
34.2%
37.3%
41.1%
43.0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
White
Mixed
Other
Asian
Black
Most
deprived
Second
most
deprived
Third least
deprived
Second
least
deprived
Least
deprived
% children and young people with Type 1
diabetes using insulin pump therapy

Figure 66: Percentage of children and young people with Type 1 diabetes using insulin pump
therapy by ethnic group and deprivation quintile, 2018/19

97
NPDA core report: Care Processes and Outcomes 2018/19

Figure 67 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 2018/19 the gap had widened
to 29.6% versus 43.0%, respectively (a difference of 13.4 percentage points).
0%
10%
20%
30%
40%
50%
60%
70%
80%
2014/15
2015/16
2016/17
2017/18
2018/19
% of children and young people with Type 1 diabetes
Audit year
Most deprived - Insulin injections
Least deprived - Insulin injections
Most deprived - Insulin pump therapy
Least deprived - Insulin pump therapy

Figure 67: 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 2018/19

Figure 68 shows the variation in the use of insulin pump therapy by deprivation quintile within
each ethnic category. It shows that Black children and young people with Type 1 diabetes have the
lowest usage in almost every deprivation quintile compared to other ethnic groups.
7.9% difference pump usage
least to most deprived
13.4% difference pump usage
least to most deprived

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NPDA core report: Care Processes and Outcomes 2018/19
36.7%
10%
20%
30%
40%
50%
White
Asian
Black
Mixed
Other
Percentage of children and young people with
Type 1 diabetes using insulin pump therapy
National mean
Most deprived
Second most deprived
Third least deprived
Second least deprived
Least deprived

Figure 68: Percentage of children and young people with Type 1 diabetes using insulin pump
therapy within each deprivation quintile by ethnic category, 2018/19

Figure 69 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.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/ mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
% of children and young people with Type 1 diabetes
HbA1c target levels
Insulin injections
Insulin pump therapy

Figure 69: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by treatment regimen, 2018/19

99
NPDA core report: Care Processes and Outcomes 2018/19
8.2.1 Treatment regimen of children and young people with
Type 2 diabetes

Table 38 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 19.1% of children and young
people with Type 2 diabetes.

The majority of those with Type 2 diabetes were using dietary management, with 50.4% also using
blood glucose lowering medication in combination. However, given that there was a cohort on
insulin alone, and missing data, caution should be taken when interpreting these results.

Table 38: Percentage of children and young people with Type 2 diabetes using each treatment
regimen, 2018/19
Treatment regimen
England and Wales
No. of children and young people with Type 2 diabetes with a recorded
treatment regimen (n)
639
Dietary management
Only (%)
12.5
And BGLM† (%)
50.4
1 to 3 insulin injections
Only (%)
4.4
And other BGLM† (%)
10.6
4 or more insulin injections
Only (%)
10.0
And other BGLM† (%)
9.2
insulin pump
Only (%)
0.6
And other BGLM† (%)
2.2

† blood glucose lowering medication
8.2 Real time continuous glucose monitoring (rtCGM)
8.2.1 rtCGM use among children and young people with Type
1 diabetes

There were 23,547 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, 12.6% were using
rtCGM in England and Wales (Figure 70). These results should be interpreted with caution given
that 17.7% (n = 5,050) of children and young people with Type 1 diabetes had an unknown or missing
entry; percentages of missing data also varied by region.

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NPDA core report: Care Processes and Outcomes 2018/19
12.6%
12.2%
18.5%
7.9%
13.3%
11.3%
15.6%
13.6%
16.4%
10.0%
11.9%
12.2%
0%
3%
18%
21%
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
6%
9%
12%
15%
% of children and young people with Type 1 diabetes using rtCGM with alarms

Figure 70: Percentage of children and young people with Type 1 diabetes using rtCGM with alarms
by country and regional network, 2018/19

Figure 71 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%
40%
% of children and young people with Type 1
diabetes using rtCGM
Age and sex



Figure 71: Percentage of children and young people with Type 1 diabetes using a real-time
continuous glucose monitor with alarms by age and sex, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19

Figure 72 shows that rtCGM was most likely to be used in the first 1-2 years following diagnosis of
Type 1 diabetes.
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
CGM use
14.0%
15.7%
13.6%
12.0%
7.9%
6.5%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
% of young people with Type 1 diabetes
using rtCGM
Duration of diabetes

Figure 72: Percentage of children and young people with Type 1 diabetes using a rtCGM by duration
of Type 1 diabetes, 2018/19

Figure 73 shows that White ethnicity was associated with higher rtCGM usage, and that children
and young people with Type 1 diabetes living in the least deprived areas were twice as likely to be
using rtCGM compared to those living in the most deprived areas.
13.5%
11.6%
10.0%
6.7%
6.5%
8.2%
10.3%
12.7%
16.5%
16.1%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
White
Mixed
Other
Asian
Black
Most
deprived
Second
most
deprived
Third
least
deprived
Second
least
deprived
Least
deprived
% children and young people with
Type 1 Diabetes

Figure 73: Percentage of children and young people with Type 1 diabetes using a rtCGM by ethnic
group and deprivation quintile, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19

Figure 74 shows the usage of rtCGM by ethnic group and deprivation quintile. It shows that usage
was higher amongst children and young people with Type 1 diabetes in the least deprived areas,
across all ethnic groups.
12.6%
0%
10%
20%
White
Asian
Black
Mixed
Other
% children and young people with Type 1
Diabetes using rtCGM
National mean
Most deprived
Second most deprived
Third least deprived
Second least deprived
Least deprived

Figure 74: Percentage of children and young people with Type 1 diabetes using a rtCGM by ethnic
group and deprivation quintile, 2018/19

Figure 75 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 irrespective of mode
of insulin delivery.
0%
10%
20%
30%
40%
50%
60%
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/ mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
% of children and young people with Type 1 diabetes
HbA1c target levels
Using CGM
Not using CGM

Figure 75: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by rtCGM usage, 2018/19

103
NPDA core report: Care Processes and Outcomes 2018/19

Figure 76 shows that rtCGM was more prevalent amongst pump users than those using insulin
injections.
24.1%
5.2%
75.9%
94.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Insulin Pump Therapy
insulin injections
using CGM
not using CGM

Figure 76: Percentage of children and young people with Type 1 diabetes using insulin injections
or insulin pump therapy by rtCGM usage, 2018/19
8.3 Assessing the probability of achieving HbA1c
targets according to treatment regimen and
use of rtCGM

This report has shown that the patient characteristics associated with increased usage of insulin
pumps and rtCGM are similar to those associated with achievement of lower HbA1c targets. In
order to establish whether the better outcomes associated with use of these technologies are
attributable to the technologies or the characteristics of those using them, a binomial logistic
regression model was constructed to examine the effect of treatment regimen type and CGM
usage on the probability of meeting lower HbA1c targets for children and young people with Type
1 diabetes. The model controlled for the effect of the demographic and social characteristics for
which data were available (Table 39, page 96).

The probability of achieving an HbA1c level below the NICE recommended target of HbA1c <48 mmol/
mol was highest for children and young people with Type 1 diabetes who were using both a rtCGM
and an insulin pump. Combined use of these technologies increased the probability of achieving this
target by 5.7 percentage points, compared to children and young people using multiple daily injections
(4+ daily injections) (MDI) without CGM. Use of MDI with rtCGM increased the probability of achieving
this target by 3.0 percentage points, compared to those using MDI without CGM. Children and young
people using insulin pump therapy or MDI alone had a similar probability of achieving an HbA1c of
<48mmol/mol once patient characteristics had been controlled for.

Similarly, the probability of achieving an HbA1c level below the target of <58 mmol/mol was highest
amongst children and young people with Type 1 diabetes who were using rtCGM and an insulin

104
NPDA core report: Care Processes and Outcomes 2018/19
pump. Use of these combined technologies increased the probability of achieving this higher
target by 19.6 percentage points, compared to those using MDI without CGM. In contrast to the
<48 mmol/mol target, use of an insulin pump alone was associated with an increased probability
of achieving an HbA1c <58 mmol/mol, of 8.9 percentage points compared to use of MDI alone. Use
of rtCGM in combination with MDI gave an increased probability of achieving an HbA1c < 58mmol/
mol of 6.2 percentage points.

A linear regression model was also constructed to show the relationships between HbA1c and
patient factors including treatment regimen, controlling for all patient factors included within the
model. This analysis shows that compared to use of MDI alone, use of rtCGM in combination with
an insulin pump gave the largest average reduction in HbA1c (7.62 mmol/mol), with usage of an
insulin pump without rtCGM giving an average reduction of 5.50 mmol/mol, and MDI in combination
rtCGM giving an average reduction in HbA1c of 3.29 mmol/mol. In the linear model, following
treatment regimen, the second largest difference in average HbA1c was associated with deprivation
status, with those living in the least deprived areas having an average HbA1c 5.88 mmol/mol lower
than those living in the most deprived areas.

The analyses also show differences associated with ethnicity, with Black children and young people
with Type 1 diabetes having a lower probability (by 9.0 percentage points) of achieving an HbA1c <
58 mmol/mol, and having higher average HbA1c (by 4.3 mmol/mol) compared to White children
and young people with Type 1 diabetes.

It is important to note that this analysis was conducted using patient-level data collected as part of
the NPDA 2018/19 core audit. NPDA data is descriptive rather than experimental, which means that
we are unable to fully control for all confounding factors. As a result, there are likely other factors
that are not accounted for in the model which are contributing to the difference in outcomes.
Indeed, the regression analyses showed that only 8-15% of the variation in outcomes presented is
explained by the patient factors included within the models.

Table 39: Results of regression analysis of mean HbA1c by taking into account treatment regimen
and measurable socio-demographic co-factors

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NPDA core report: Care Processes and Outcomes 2018/19
Variable
Target < 48 (mmol/mol)
Target <58 (mmol/mol)
Linear regression
(HbA1c mmol/mol)
Marginal
effects (%)
P-value
Marginal
effects (%)
P-value
Coefficient
P-value
Treatment regimen and CGM usage (cf to MDI alone)
On MDI and
using rtCGM
3.0
(1.1 to 4.9)
0.002
6.2
(2.7 to 9.6)
0.000
-3.3
(-4.4 to -2.2)
0.000
On insulin
pump
therapy and
using rtCGM
5.7
(4.4 to 6.9)
0.000
19.6
(17.6 to 21.7)
0.000
-7.6
(-8.2 to -7.1)
0.000
On insulin
pump
therapy and
not using
rtCGM
-0.3
(-1.3 to 0.7)
0.515
8.9
(7.5 to 10.3)
0.000
-5.5
(-5.9 to -5.1)
0.000
Male
(cf female)
1.7
(0.9 to 2.4)
0.000
1.8
(0.6 to 3.0)
0.003
-0.9
(-1.3 to -0.5)
0.000
Age (in
whole years)
0.4
(0.3 to 0.5)
0.000
-0.5
(-0.6 to -0.3)
0.000
0.7
(0.6 to 0.8)
0.000
Duration (in
whole years)
-2.2
(- 2.3 to -2.0)
0.000
-2.5
(-2.7 to –2.4)
0.000
0.8
(0.7 to 0.9)
0.000
Ethnic group (cf White)
Asian
-0.3
(-2.0 to 1.4)
0.707
-2.3
(-4.9 to 0.3)
0.092
-0.1
(-0.9 to 0.7)
0.797
Black
-1.3
(-3.5 to 0.9)
0.280
-9.0
(-12.4 to -5.7)
0.000
4.3
(3.0 to 5.6)
0.000
Mixed
-0.7
(-2.9 to 1.5)
0.533
-5.5
(-8.9 to -2.0)
0.002
2.6
(1.4 to 3.8)
0.000
Other
4.4
(0.9 to – 7.8)
0.004
5.2
(0.5 to 9.9)
0.027
-2.1
(-3.6 to -0.6)
0.006
Not stated or
unknown
0.9
(-0.8 to 2.7)
0.278
0.1
(-2.7 to 2.9)
0.938
-0.1
(-1.1 to 0.8)
0.788

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NPDA core report: Care Processes and Outcomes 2018/19
Variable
Target < 48 (mmol/mol)
Target <58 (mmol/mol)
Linear regression
(HbA1c mmol/mol)
Marginal
effects (%)
P-value
Marginal
effects (%)
P-value
Coefficient
P-value
Deprivation (cf most deprived)
Second most
deprived
1.4
(0.2 to 2.5)
0.019
4.0
(2.2 to 5.8)
0.000
-1.9
(-2.6 to -1.3)
0.000
Third least
deprived
1.6
(0.4 to 2.7)
0.008
6.0
(4.1 to 7.9)
0.000
-2.80
(-3.46 to -2.15)
0.000
Second least
deprived
2.8
(1.6 to 4.0)
0.000
8.7
(6.9 – 10.7)
0.000
-4.27
(-4.91 to -3.62)
0.000
Least
deprived
4.4
(3.1 to 5.7)
0.000
14.4
(12.5 – 16.3)
0.000
-5.88
(-6.51 to -5.25)
0.000
Constant
10.2
(9.8 to 10.6)
0.000
36.2
(35.6 to 36.8)
0.000
58.79
0.000
Adjusted R-squared (Model Target <48): 7.9%
Adjusted R-squared (Model Target <58): 6.5%
Adjusted R-squared (Linear regression): 15.0%
N = 22,460 includes all children and young people with Type 1 diabetes reported to the 2018/19 NPDA
with a valid record for treatment regimen of insulin pump therapy or multiple daily injections; rtCGM
usage; gender; age; duration; ethnicity; and deprivation.
Results found to be statistically insignificant at the p<0.05 level have been greyed out.
8.4 Key findings

•
Just over a third (36.7%) of children and young people with Type 1 diabetes were using an
insulin pump.

•
Usage of insulin pumps to deliver insulin therapy in Type 1 diabetes has increased in all age
groups since 2014/15.

•
Increased usage of pump therapy was associated with female gender, younger age, living in
the least deprived areas and White Ethnicity.

•
Increased usage of rtCGM with alarms was associated with younger age, living in the least
deprived areas and White Ethnicity.

•
The gap between pump usage amongst children and young people with Type 1 diabetes
living in the most and least deprived areas has widened with time, from 18.4% versus 26.3% (a
difference of 7.9 percentage points) in 2014/15, to 29.5% versus 42.9%, in 2018/19, respectively (a
difference of 13.5 percentage points).

•
Children and young people with Type 1 diabetes using rtCGM with alarms were more likely to
be using insulin pump therapy than insulin injections.

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NPDA core report: Care Processes and Outcomes 2018/19

•
Once patient characteristics were controlled for:

– Children and young people with Type 1 diabetes were more likely to be achieving the HbA1c
targets of <48mmol/mol or <58mmol/mol when using insulin pump therapy combined
with rtCGM

– Use of an insulin pump was only associated with a higher probability of achievement of the
NICE recommended target (48 mmol/mol) with the addition of rtCGM

– Use of rtCGM increased the probability of meeting both targets in combination with either
MDI or insulin pump therapy

•
Half (50.4%) of children and young people with Type 2 diabetes were managing their diabetes
with diet and blood glucose lowering medication.

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NPDA core report: Care Processes and Outcomes 2018/19
9. Thyroid and coeliac disease
9.1 Thyroid and coeliac disease amongst children
and young people with Type 1 diabetes

The prevalence of thyroid disease and coeliac disease in 2018/19 for children and young people with
Type 1 diabetes were 3.3% and 6.5%, respectively. The prevalence of coeliac disease is higher
compared to an international collaborative study that found a prevalence rate of 3.5% across three
continents (Craig et al., 2017). The figure for coeliac disease is higher compared to the 2017/18 audit
(5.6%) and the 2016/17 audit (4.4%) (Figure 77).

Table 40: Percentage of children and young people with Type 1 diabetes with thyroid or coeliac
disease by country and region in England and Wales, 2018/19
No. of children and
young people with
Type 1 diabetes
Thyroid disease
(%)
Coeliac disease
(%)
England and Wales
28,597
3.3
6.5
England
27,161
3.2
6.4
Wales
1,436
5.5
8.7
East of England
3,147
4.8
6.8
East Midlands
1,947
3.7
6.5
London and South East
6,484
2.8
5.6
North East and North Cumbria
1,605
3.9
4.4
North West
3,541
2.4
6.2
South Central
2,409
2.3
6.6
South West
2,288
4.1
5.3
West Midlands
2,970
2.5
5.8
Yorkshire and Humber
2,770
3.2
10.3

Figure 77 shows year on year variation in prevalence of thyroid and coeliac disease. The prevalence
of coeliac disease has increased since 2015/16.

109
NPDA core report: Care Processes and Outcomes 2018/19
2014/15
2015/16
2016/17
2017/18
2018/19
Thyroid
3.2%
3.5%
2.6%
3.0%
3.3%
Coeliac
4.7%
4.0%
4.4%
5.6%
6.5%
0%
1%
2%
3%
4%
5%
6%
7%
% of children and young people with Type 1
diabetes
Audit year



Figure 77: Percentage of children and young people with Type 1 diabetes with thyroid or coeliac
disease in England and Wales, 2014/15 to 2018/19

Figure 78 shows that there was a higher prevalence of both autoimmune conditions amongst girls
compared to boys, although the prevalence has increased for both sexes.
4.2%
4.5%
1.9%
2.2%
6.6%
7.8%
4.6%
5.3%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
Girls
Boys
Girls
Boys
Thyroid
Coeliac
% of children and young people with Type 1 diabetes

Figure 78: Percentage of children and young people with Type 1 diabetes and coeliac or thyroid
disease by sex, 2017/18 to 2018/19

110
NPDA core report: Care Processes and Outcomes 2018/19

Coeliac disease prevalence was higher amongst children and young people with Type 1 diabetes
living in the least deprived compared to most deprived areas, but there was no clear association
between prevalence of thyroid disease and areas of deprivation (Figure 79).
Most deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least deprived
Thyroid
3.2%
3.1%
3.7%
3.6%
3.0%
Coeliac
5.6%
5.9%
6.4%
7.2%
7.6%
0%
1%
2%
3%
4%
5%
6%
7%
8%
% of children and young people with Type 1 diabetes
Deprivation quintile

Figure 79: Percentage of children and young people with Type 1 diabetes and coeliac or thyroid
disease by deprivation quintile, 2018/19

Figure 80 shows that the prevalence of coeliac disease is higher amongst White and Asian ethnic
groups; while the prevalence of thyroid disease is higher amongst Asian ethnic groups.
White
Asian
Black
Mixed
Other
Thyroid
3.3%
5.7%
1.3%
2.5%
3.4%
Coeliac
6.8%
5.7%
2.5%
4.5%
4.9%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
% of children and young people with
Type 1 diabetes
Thyroid
Coeliac

Figure 80: Percentage of children and young people with Type 1 diabetes and coeliac or thyroid
disease by ethnic group, 2018/19

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NPDA core report: Care Processes and Outcomes 2018/19
9.2 Key findings

•
6.5% of children and young people in England and Wales with Type 1 diabetes had been
recommended a gluten-free diet, indicative of coeliac disease; and 3.3% were receiving
treatment for thyroid disease.

•
Prevalence of both autoimmune disorders was higher amongst girls compared to boys,
although the prevalence increased for both sexes in 2018/19 compared to 2017/18.

•
The prevalence of coeliac disease is higher amongst children and young people with Type 1
diabetes living in the least deprived areas, and within White and Asian ethnic groups.

112
NPDA core report: Care Processes and Outcomes 2018/19
10. Conclusion

There is much to celebrate in this 2018/19 NPDA report, both in terms of the reduction in national
median HbA1c since 2017/18, and in the increasing numbers of children and young people
receiving the recommended health checks for diabetes. These findings are a credit to the teams
delivering paediatric diabetes care, and the efforts they have made to work with colleagues across
England and Wales to achieve improvements in care through the National Children and Young
People’s Diabetes Network and the National Children and Young People’s Diabetes Quality
Programme. However, this report also shows that there is much to do to reduce inequalities in
outcomes associated with deprivation, ethnicity, and age; and in the use of technologies that can
support children and young people to achieve the best HbA1c possible. Teams must continue to
work together with the children and young people using their service, their families and their
commissioners to identify and tackle barriers to achieving excellent outcomes.

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NPDA core report: Care Processes and Outcomes 2018/19
11. List of figures
Figure 1: Numbers of children and young people
with Type 1 diabetes included in the NPDA by age
and gender, 2018/19 and total numbers 2017/18 and
2018/19.

22
Figure 2: Percentage and number of children and
young people with Type 1 diabetes by deprivation
quintile, 2015/16 to 2018/19.
24
Figure 3: Prevalence of Type 1 diabetes per 100,000
general population among children aged 0-15 by
age and sex, 2013/14 to 2018/19.
25
Figure 4: Prevalence of Type 1 diabetes per 100,000
general population by age group and sex, 2013/14
to 2018/19.
26
Figure 5: Incidence of Type 1 diabetes per 100,000
general population among children aged 0-15
by sex, 2013/14 to 2018/19.
26
Figure 6: Incidence of Type 1 diabetes per 100,000
general population by age group and sex, 2013/14
to 2018/19.
27
Figure 7: Numbers of children and young people
with Type 2 diabetes included in the NPDA,
2011/12- 2018/19.
28
Figure 8: Numbers of children and young people
with Type 2 diabetes included in the NPDA by age
and sex, 2018/19 and changes in numbers between
2017/18 and 2018/19.
29
Figure 9: Percentage and number of children and
young people with Type 2 diabetes by deprivation
quintile, 2015/16 to 2018/19.
31
Figure 10: Percentage of children and young
people who completed a full year of care recorded
as receiving individual health checks, 2004/05 to
2018/19.

34
Figure 11: Percentage of young people aged 12 or
above who completed a full year of care recorded
as receiving all seven key health checks, 2004/05
to 2018/19.
35
Figure 12: Percentage of young people aged
12 years and above with Type 1 diabetes who
completed a full year of care recorded as receiving
all seven health checks by unit, 2018/19.
37
Figure 13: Health check completion rate of young
people aged 12 years and above with Type 1
diabetes who completed a full year of care by
unit, 2018/19.
38
Figure 14: Percentage of children and young
people with Type 1 diabetes who completed a full
year of care by number of HbA1cs measurements
recorded per child or young person, 2016/17 to
2018/19.

39
Figure 15: Percentage of young people aged 12 and
above with Type 1 diabetes who completed a full
year of care recorded as receiving a smoking
health check.
41
Figure 16: Completion rates for Psychological
assessment, Flu vaccine, “Sick day rules” and Blood
ketone testing, for children and young people with
Type 1 diabetes who completed a full year of care,
2017/18 and 2018/19.
43
Figure 17: Percentage of newly diagnosed children
and young people with Type 1 diabetes who
received screening within 90 days of diagnosis,
2015/16 to 2018/19.
45
Figure 18: 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 2018/19.
46
Figure 19: Number of HbA1c measurements
recorded for children and young people with Type
2 diabetes receiving a full year of care, 2016/17 -
2018/19.

47
Figure 20: Median HbA1c for children and young
people with all types of diabetes in England and
Wales 2009/10 to 2018/19 with associated NHS
policy and/or paediatric diabetes delivery structural
changes.

52
Figure 21: Percentage of children and young
people with Type 1 diabetes with an HbA1c result
within current and historical target ranges,
2011/12 - 2018/19.
54

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NPDA core report: Care Processes and Outcomes 2018/19
Figure 22: Scatter plot showing the association
between median HbA1c and the percentage of
children and young people with a complete year of
care who received 4+ HA1c measurements in each
PDU, 2018/19.
55
Figure 23: Mean HbA1c for children and young
people with Type 1 diabetes by age and sex,
2018/19.

56
Figure 24: Mean HbA1c for children and young
people with Type 1 diabetes by duration of diabetes,
2015/16 to 2018/19.
56
Figure 25: Mean HbA1c for children and young
people with Type 1 diabetes by deprivation quintile,
2013/14 to 2018/19.
57
Figure 26: Percentage of children and young
people with Type 1 diabetes in England and
Wales achieving HbA1c targets by ethnic
group, 2018/19.
58
Figure 27: Mean HbA1c for children and young
people with Type 1 diabetes by ethnic group,
2015/16 to 2018/19.
59
Figure 28: Funnel plot of mean adjusted HbA1c for
children and young people with Type 1 diabetes in
England and Wales by PDU, 2018/19.
60
Figure 29: Funnel plot of percentage of children
and young people with Type 1 diabetes in England
and Wales with an adjusted HbA1c <58 mmol/mol
by PDU, 2018/19.
60
Figure 30: Funnel plot of percentage of children
and young people with Type 1 diabetes in England
and Wales with an adjusted HbA1c >80 mmol/mol
by PDU, 2018/19.
61
Figure 31: Median HbA1c for all children and young
people with Type 2 diabetes and one or more
valid HbA1c measurements in England and Wales,
2015/16- 2018/19.
62
Figure 32: Mean HbA1c for children and young
people with Type 2 diabetes by group of age and
sex, 2018/19 58.
63
Figure 33: Mean HbA1c for children and young
people with Type 2 diabetes in England and Wales
by deprivation quintile, 2015/16 to 2018/19.
64
Figure 34: Mean HbA1c for children and young
people with Type 2 diabetes in England and Wales
by ethnic group, 2015/16 to 2018/19.
65
Figure 35: Percentage of young people with Type 1
diabetes aged 12 years and older with albuminuria
by country and region, 2018/19.
67
Figure 36: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by duration of diabetes, 2016/17 - 2018/19.
68
Figure 37: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by age and sex, 2018/19.
68
Figure 38: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by deprivation quintile, 2016/17 - 2018/19.
69
Figure 39: Percentage of young people with Type 1
diabetes achieving HbA1c targets by presence
of albuminuria, 2018/19.
69
Figure 40: Percentage of children and young
people with Type 2 diabetes with albuminuria in
England and Wales, 2015/16 - 2018/19.
70
Figure 41: Percentages of young people with Type
1 diabetes aged 12 years and older with normal/
abnormal retinopathy screening results by
country and region, 2018/19.
71
Figure 42: Percentage of young people with Type
1 diabetes aged 12 years and older with retinopathy
by age and sex, 2018/19.
72
Figure 43: Percentage of young people with Type 1
diabetes aged 12 years and older with abnormal
eye screening by duration of diabetes, 2018/19.
72
Figure 44: Percentage of young people with
Type 1 diabetes aged 12 years and older with an
abnormal eye screening result by deprivation
quintile, 2018/19.
73
Figure 45: Percentage of children and young
people with Type 1 diabetes with or without an
abnormal eye screening result achieving HbA1c
targets, 2018/19.
73
Figure 46: Scatter plot showing systolic and
diastolic blood pressure z-scores of young people
with Type 1 diabetes aged 12 and above, 2018/19. 74

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NPDA core report: Care Processes and Outcomes 2018/19
Figure 47: Percentages of young people with
Type 1 diabetes aged 12 and above with/out
retinopathy with high blood pressure, cholesterol
above 5 mmol/mol, HbA1c above 80 mmol/mol
and obesity.
75
Figure 48: Eye screening results for young people
aged 12 years and above with Type 2 diabetes,
2015/16 to 2018/19.
75
Figure 49: 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 2018/19.
78
Figure 50: Percentage of children aged 0-11 years
with Type 1 diabetes within BMI categories by
country and region, 2018/19.
80
Figure 51: Percentage of young people 12 years
and older with Type 1 diabetes within BMI
categories by country and region, 2018/19.
80
Figure 52: Distribution of body mass index of
children and young people with Type 1 diabetes in
2016/17, 2017/18 and 2018/19 compared to the 1990
reference population.
81
Figure 53: Percentage of children and young
people with Type 1 diabetes within the overweight
or obese body mass index category, by
deprivation quintile, age group and sex, 2018/19. 82
Figure 54: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by Body Mass Index category, 2018/19.
82
Figure 55: Percentage of children and young
people with Type 2 diabetes who were in healthy
weight, overweight or obese category by sex,
2018/19.

83
Figure 56: Percentage of children and young
people with Type 1 diabetes assessed as requiring
additional psychological support by country and
region, 2018/19.
86
Figure 57: Percentage of children and young
people with Type 1 diabetes who were assessed as
requiring additional psychological support by age
and sex, 2018/19.
87
Figure 58: Percentage of children and young
people with Type 1 diabetes assessed as requiring
additional psychological support by duration of
Type 1 diabetes, 2018/19.
87
Figure 59: Percentage of children and young
people with Type 1 diabetes assessed as requiring
additional psychological support or CAMHS
support outside of MDT clinics within each
deprivation quintile, 2018/19.
88
Figure 60: Percentage of children and young
people with Type 1 diabetes assessed as requiring
additional psychological support within each
ethnic category, 2018/19.
89
Figure 61: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by outcome of psychological assessment,
2018/19.

89
Figure 62: Percentage of children and young
people with Type 1 diabetes who had DKA at
diagnosis in 2018/19, by region and country.
92
Figure 63: Percentage of children and young
people with Type 1 diabetes recorded as using
insulin injections or insulin pump therapy by
age and sex, 2018/19.
95
Figure 64: Percentage of children and young
people either using daily insulin injections or insulin
pump therapy by age group, 2014/15 to 2018/19. 95
Figure 65: Percentage of children and young
people either on daily insulin injections or pump
therapy by duration of diabetes 2018/19.
96
Figure 66: Percentage of children and young
people with Type 1 diabetes using insulin pump
therapy by ethnic group and deprivation quintile,
2018/19.

96
Figure 67: 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 2018/19.
97
Figure 68: Percentage of children and young
people with Type 1 diabetes using insulin pump
therapy within each deprivation quintile by ethnic
category, 2018/19.
98

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NPDA core report: Care Processes and Outcomes 2018/19
Figure 69: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by treatment regimen, 2018/19.
98
Figure 70: Percentage of children and young
people with Type 1 diabetes using rtCGM with
alarms by country and regional network, 2018/19. 100
Figure 71: Percentage of children and young
people with Type 1 diabetes using a real-time
continuous glucose monitor with alarms by age
and sex, 2018/19.
100
Figure 72: Percentage of children and young
people with Type 1 diabetes using a rtCGM by
duration of Type 1 diabetes, 2018/19.
101
Figure 73: Percentage of children and young
people with Type 1 Diabetes using a rtCGM by
ethnic group and deprivation, 2018/19.
101
Figure 74: Percentage of children and young
people with Type 1 diabetes using a rtCGM by
ethnic group and deprivation quintile, 2018/19. 102
Figure 75: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by rtCGM usage, 2018/19.
102
Figure 76: Percentage of children and young
people with Type 1 diabetes using insulin
injections or insulin pump therapy by rtCGM
usage, 2018/19.
103
Figure 77: Percentage of children and young
people with Type 1 diabetes with thyroid or
coeliac disease in England and Wales, 2014/15
to 2018/19.
109
Figure 78: Percentage of children and young
people with Type 1 diabetes and coeliac or thyroid
disease by sex, 2017/18 to 2018/19.
109
Figure 79: Percentage of children and young
people with Type 1 diabetes and coeliac or thyroid
disease by deprivation quintile, 2018/19.
110
Figure 80: Percentage of children and young
people with Type 1 diabetes and coeliac or thyroid
disease by ethnic group, 2018/19.
110

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NPDA core report: Care Processes and Outcomes 2018/19
Table 1: Number of children and young people with
diabetes included in the audit by age and type of
diabetes, 2018/19.
21
Table 2: Number of children and young people
with Type 1 diabetes by country, region and age
group, 2018/19.
23
Table 3: Ethnic group of children and young
people with Type 1 diabetes England and Wales,
2018/19.

23
Table 4: Percentage and number of children and
young people with Type 1 diabetes by deprivation
quintile, 2018/19.
24
Table 5: Number of children and young people
included in the audit with Type 2 diabetes by
country and region, 2017/18.
29
Table 6: Ethnic group of children and young
people with Type 2 diabetes England and Wales,
2018/19.

30
Table 7: Numbers and percentages of children and
young people with Type 2 diabetes by deprivation
quintile, 2018/19.
30
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
2018/19.

34
Table 9a: Percentage of children and young people
of all ages with Type 1 diabetes who completed a
full year of care recorded as having received health
checks by country and region, 2018/19.
36
Table 9b: Percentage of young people aged 12
and above with Type 1 diabetes who completed a
full year of care recorded as having received health
checks by country and region, 2018/19.
36
Table 10: Percentage of children and young people
with Type 1 diabetes who completed a full year of
care by number of HbA1cs measurements
recorded 2018/19, by country and region.
39
Table 11: Percentage of children and young people
with Type 1 diabetes who completed a full year of
care by number of HbA1cs measurements
recorded 2018/19, by deprivation quintile.
40
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 and
region, 2018/19.
40
Table 13: Percentage of young people aged 12 and
above with Type 1 diabetes recorded as a ‘current
smoker’ who were referred to smoking cessation
services by region and country, 2018/19.
42
Table 14: 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, 2018/19.
43
Table 15: Percentage of children and young
people with Type 1 diabetes who received
screening within 90 days of diagnosis by
country and region, 2018/19.
44
Table 16: Percentage of children and young
people with Type 1 diabetes recorded as receiving
carbohydrate-counting education within 14 days
of diagnosis by country and region, 2018/19.
45
Table 17: 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 2018/19.
47
Table 18: 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, 2018/19.
48
Table 19: Percentage of young people aged 12 and
above with Type 2 diabetes who completed a full
year of care recorded as receiving a smoking health
check and the percentage of current smokers
referred to smoking cessation services, 2018/19. 48
12. List of tables

118
NPDA core report: Care Processes and Outcomes 2018/19
Table 20: Percentage of young people with Type 2
diabetes who completed a full year of care recorded
as receiving health checks by region and country,
2018/19.

49
Table 21: HbA1c for all children and young people
with all types of diabetes and one or more valid
HbA1c measurements by country and region,
2018/19.

51
Table 22: HbA1c for all children and young people
with Type 1 diabetes and one or more valid HbA1c
measurements by country and regional network,
2017/18.

53
Table 23: Percentage of children and young people
with Type 1 diabetes achieving HbA1c targets by
country and regional network, 2018/19.
55
Table 24: Mean HbA1c and percentage of children
and young people with Type 1 diabetes in England
and Wales achieving HbA1c targets by ethnic
group, 2018/19.
58
Table 25: Mean HbA1c for children and young
people with Type 1 diabetes within Black ethnic
subgroup, 2018/19.
59
Table 26: HbA1c for all children and young people
with Type 2 diabetes and one or more valid HbA1c
measurements in England and Wales,
2015/16- 2018/19.
62
Table 27: Percentage of young people with Type 1
diabetes aged 12 years and above with
albuminuria, 2015/16 to 2018/19.
67
Table 28: Percentage of young people with
Type 1 diabetes aged 12 years and above with a
normal/ abnormal eye screening result, 2015/16
to 2018/19.
71
Table 29: Percentage of young people with Type
1 diabetes aged 12 years and above falling within
blood pressure targets by country and region,
2018/19.

77
Table 30: Percentage of young people with
Type 1 diabetes aged 12 years and above falling
within cholesterol targets by country and
region, 2018/19.
77
Table 31: Percentage of children and young people
with Type 2 diabetes with ‘high’ or ‘high-normal’
blood pressure, 2016/17 - 2018/19.
79
Table 32: Percentage of children and young people
with Type 2 diabetes above cholesterol targets,
2016/17 - 2018/19.
79
Table 33: Body mass index categories for children
and young people with Type 2 diabetes, 2016/17 to
2018/19.

83
Table 34: Outcome of assessment of the need for
psychological support and/or Child and Adolescent
Mental Health Services support, for children and
young people with Type 1 diabetes, 2017/18 –
2018/19.

85
Table 35: 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, 2016/17. 90
Table 36: 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, 2018/19.
91
Table 37: Percentage of children and young
people with Type 1 diabetes using each treatment
regimen, by country and region, 2018/19.
94
Table 38: Percentage of children and young
people with Type 2 diabetes using each treatment
regimen, 2018/19.
99
Table 39: Results of regression analysis of mean
HbA1c by taking into account treatment regimen
and measurable socio-demographic co-factors. 105
Table 40: Percentage of children and young people
with Type 1 diabetes with thyroid or coeliac disease
by country and region in England and Wales,
2018/19.

108

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NPDA core report: Care Processes and Outcomes 2018/19
13. Acknowledgements

Report Editors

•
Ms Saira Pons Perez, NPDA Analyst, RCPCH

•
Professor Justin Warner, Clinical Lead, RCPCH and Consultant in Paediatric Endocrinology and
Diabetes, Cardiff and Vale University Health Board

•
Ms Holly Robinson, NPDA Project Manager, RCPCH

Data Analysis

•
Ms Saira Pons Perez, NPDA Analyst, RCPCH

National Paediatric Diabetes Audit Clinical Lead

•
Professor Justin Warner, Clinical Lead, RCPCH and Consultant in Paediatric Endocrinology and
Diabetes, Cardiff and Vale University Health Board

Project Management

•
Ms Holly Robinson, NPDA Project Manager, RCPCH

Project Support

•
Ms Karina Green, Project Co-ordinator, RCPCH

•
Mr Simon Duncan, Audit Administrator, RCPCH

•
Mr Tom Keiller, Administrative Assistant, RCPCH

•
Ms Adele Picken, Information Governance Manager, RCPCH

National Paediatric Diabetes Audit Project Board

•
Professor Nick Bishop, Vice President for Science and Research, RCPCH (Chair)

•
Dr Fiona Campbell, Consultant Paediatric Diabetologist, Leeds Teaching Hospitals NHS Trust

•
Ms Kate Fazakerley, Parent Representative

•
Ms Helen Thornton, Paediatric Diabetes Specialist Nurse, St Helens and Knowsley Teaching
Hospitals NHS Trust

•
Professor Justin Warner, Clinical Lead, RCPCH and Consultant in Paediatric Endocrinology and
Diabetes, University of Wales Hospital

•
Dr Kemi Lokulo-Sodipe, Specialty Registrar in Paediatrics, Southampton Children’s Hospital

•
Ms Rachel Harris, Paediatric Diabetes Specialist Nurse, Cardiff and Vale University Health Board

•
Ms Kate Cullen, Parent Representative

•
Mr Simon Lewthwaite, Parent Representative

•
Mr Malcom Roxburgh, Statistician, RCPCH

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NPDA core report: Care Processes and Outcomes 2018/19

National Paediatric Diabetes Audit Dataset Working Group

•
Dr Fiona Campbell, Consultant Paediatric Diabetologist, Leeds Teaching Hospitals NHS Trust

•
Dr Nivedita Aswani, Consultant in General Paediatrics and Diabetes, Derby Hospitals NHS
Foundation Trust

•
Dr Bill (William) Lamb, Consultant Paediatric Diabetologist (Retired)

•
Professor Justin Warner, Consultant in Paediatric Endocrinology and Diabetes, Cardiff and Vale
University Health Board

•
Ms Francesca Annan, Dietitian, Clinical Specialist Paediatric/Adolescent Diabetes Dietitian,
University College London Hospital Foundation Trust

•
Dr Halina Flannery, Clinical Psychologist, University College London Hospital NHS Foundation Trust

•
Ms Helen Thornton, Paediatric Diabetes Specialist Nurse, St Helens and Knowsley Teaching
Hospitals NHS Trust

•
Ms Kate Fazakerley, Parent Representative

•
Dr Alex Da Costa, Specialty Registrar in Paediatrics, Queen Mary University

•
Ms Kate Cullen, Parent Representative

•
Mr Simon Lewthwaite, Parent Representative

•
Ms Rachel Harris, Paediatric Diabetes Specialist Nurse, Cardiff and Vale University Health Board

•
Ms Nicky Moor, Paediatric Diabetes Specialist Nurse, Barts Health NHS Trust

•
Mr Malcom Roxburgh, Statistician, RCPCH

HQIP Support

•
Ms Sophia Olatunde, Project Manager, NCAPOP, Healthcare Quality Improvement Partnership

•
Dr Sasha Hewitt, Associate Director, NCAPOP, Healthcare Quality Improvement Partnership

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NPDA core report: Care Processes and Outcomes 2018/19
14. References

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Maahs DM, Hermann JM, Holman N et al (2015) Rates of diabetic ketoacidosis: international
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McKnight JA, Wild SH, Lamb MJ et al (2015) Glycaemic control of type 1 diabetes in clinical
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NICE (2004) Diagnosis and management of type 1 diabetes in children, young people and
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NICE (2015) Diabetic foot problems: prevention and management (NG19) NICE, London. Available
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Pan H, Cole TJ. (2012) LMS growth, a Microsoft Excel add-in to access growth references based on
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Randell T, (2012) Developing a best practice tariff in paediatric diabetes: Can we improve services
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RCPCH (2017) National Paediatric Diabetes Audit 2012-2015, Part 2: Hospital admissions and
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Royal College of Paediatrics
and Child Health
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London, WC1X 8SH
The Royal College of Paediatrics and Child Health (RCPCH) is a registered charity in England and Wales (1057744) and in
Scotland (SC038299).
Healthcare Quality
Improvement Partnership (HQIP)
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Royal College of
Paediatrics and Child Health
RCPCH
Published by RCPCH March 2020
National paedaitric Diabetes Audit (NPDA)
Annual report 2018-19
Care processes and outcomes