NPDA 2019-20 Appendix 1: Full audit analysis
Source: data.gov.uk (2024-05-31)

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

Annual report 2019-20
Care processes and outcomes
Audits
RCPCH
National Paediatric
Diabetes Audit
NPDA

Royal College of
Paediatrics and Child Health
RCPCH
Appendix 1: Full audit analysis

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

NPDA National report 2019/20:
Care processes and outcomes
Appendix 1: Full audit analysis
Citation: National Paediatric Diabetes Audit Annual Report 2019-20: Care Processes and Outcomes.
London: Royal College of Paediatrics and Child Health, 2021.
© Healthcare Quality Improvement Partnership 2021

3.
Outcomes
37
3.1
HbA1c
37
3.2
HbA1c outcomes of children and
young people with all types of
diabetes
38
3.3
HbA1c outcomes of children and
young people with Type 1 diabetes 40
3.3.1 National and regional unadjusted
HbA1c results
40
3.3.2 HbA1c outcomes by sex
43
3.3.3 HbA1c outcomes by duration of
diabetes
43
3.3.4 HbA1c outcomes by ethnicity
44
3.3.5 HbA1c outcomes by deprivation
quintile
47
3.3.6 Adjusted HbA1c outcomes achieved
by paediatric diabetes units (Type 1
diabetes)
48
3.4
HbA1c outcomes of children and
young people with Type 2 diabetes 50
3.4.1 HbA1c outcomes by sex
51
3.4.2 HbA1c outcomes by age group and
duration of Type 2 diabetes
52
3.4.3 HbA1c outcomes by deprivation
quintile
53
3.4.4 HbA1c outcomes by ethnic category 53
3.5
Small vessel (microvascular) disease 54
3.5.1 Diabetic kidney disease
54
3.5.2 Eye Disease
58
3.6
Large vessel disease - Cardio Vascular
Disease (CVD) risk factors
63
3.6.1 Blood pressure and cholesterol
63
3.6.2 Body Mass Index
65
3.7
Psychological assessment
72
3.7.1 Psychological outcomes of children
and young people with Type 1
diabetes
72
3.7.2 Psychological outcomes of children
and young people with Type 2
diabetes
75
3.8
Hospital Admissions
76
3.8.1 Type 1 Diabetes-related admissions 76
3.8.2 DKA at diagnosis
77
Contents
1.
Characteristics, prevalence
and incidence
6
1.1
Audit cohort
6
1.2
Characteristics of children and young
people with Type 1 diabetes
6
1.2.1 Age and sex
6
1.2.2 Regional distribution
7
1.2.3 Ethnicity
8
1.2.4 Deprivation
9
1.3
Prevalence and incidence of Type 1
diabetes
11
1.3.1 Prevalence
11
1.3.2 Incidence
12
1.4
Characteristics of children and young
people with Type 2 diabetes
14
1.4.1 Age and sex
14
1.4.2 Regional distribution
15
1.4.3 Ethnicity
16
1.4.4 Deprivation
17
2.
Completion of health checks
(care processes)
18
2.1
Completion of health checks for
children and young people with
Type 1 diabetes
18
2.1.1 Completion of key health checks
18
2.1.2 Variation in key health check
completion
21
2.1.3 Number of HbA1c measurements
received
24
2.1.4 Nutrition and lifestyle education
and support
26
2.1.5 Smoking
26
2.1.6 Completion of all other annual
health checks
28
2.1.7 Care at diagnosis
30
2.2
Health checks for children and
young people with Type 2 diabetes 32
2.2.1 Completion of key health checks
32
2.2.2 Number of HbA1c measurements
34
2.2.3 Completion of all other health
checks
34
2.3
Case study: High Health check
completion rate for children and
young people with diabetes at
Neath Port Talbot Hospital
36

4.
Treatment regimen and
diabetes monitoring
78
4.1
Treatment regimens
78
4.1.1 Treatment regimens of children
and young people with Type 1
diabetes
97
4.1.2 Treatment regimens of children
and young people with Type 2
diabetes
82
4.2
Real Time Continuous glucose
monitoring (rtCGM)
83
4.2.1 rtCGM use among children and
young people with Type 1 diabetes
83
5.
Thyroid and coeliac
disease
89
5.1
Thyroid and coeliac disease amongst
children and young people with
Type 1 diabetes
89
6.
References
92
7.
List of tables
93
8.
List of Figures
95

6
NPDA National report 2019/20: Care processes and outcomes
1.
Characteristics, prevalence and
incidence
1.1 Audit cohort

A total of 29,242 children and young people with diabetes were included in the 2019/20 audit. For
comparison, 30,155 children and young people were included in the 2018/19 audit when all PDUs
submitted data (please see Appendix 2 for comparison of the two audit cohorts).

Table 1 presents a breakdown of those included by age group and type of diabetes.

Table 1: Number of children and young people with diabetes by age-group and type of diabetes in
2019/20
0-4
years
5-9
years
10-14
years
15-19
years++
20-24
years++
Total
(% of cohort)
Type 1 Insulin-dependent diabetes mellitus
1,450
5,904
11,693
8,595
11
27,653 (94.6)
Type 2 Non-insulin-dependent diabetes
mellitus
0
22
336
508+
866 (3.0)
Cystic fibrosis-related diabetes
20+
100
82
0
202 (0.7)
Monogenic types of diabetes
15
16
56
71
0
158 (0.5)
Other specified diabetes mellitus
30
44
104
93
0
271 (0.9)
Not specified diabetes mellitus
11
20
34
26
0
91 (0.3)
Missing type of diabetes
0
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.
1.2 Characteristics of children and young people
with Type 1 diabetes
1.2.1 Age and sex

Figure 1 (page 7) 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.

The distribution by age and sex is consistent with previous years. The number of children increases
with age up to the age of 15, when many young people start to transition to adult services. Boys
account for 52.3% of the sample.

7
NPDA National report 2019/20: Care processes and outcomes
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
Boys
28
92
158
196
310
374
498
576
702
814
1000
1124
1228
1298
1387
1423
1380
1127
636
82
Girls
23
75
115
192
259
368
424
591
724
819
944
1126
1169
1147
1251
1221
1130
936
563
88
2019/20
51
167
273
388
569
742
922
1167
1426
1633
1944
2250
2397
2445
2638
2644
2510
2063
1199
170
2018/19
70
159
270
441
601
751
979
1243
1451
1755
2031
2226
2318
2543
2681
2693
2576
2236
1274
209
0
400
800
1200
1600
2000
2400
2800
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 sex, 2019/20 and total numbers 2018/19 and 2019/20.
1.2.2 Regional distribution

Table 2 (page 8) shows the number of children and young people with Type 1 diabetes by age
category included in the 2019/20 audit overall and by country and regional network. Children and
young people were allocated to a region and country based on the last paediatric diabetes unit
(PDU) that they attended within the audit year.

In 2019/20 the NPDA received a complete (100%) submission of the children and young people
with diabetes in five regional networks, and more than 90% in the remaining five regions (see
Appendix 2). Table 2 shows little variation between the percentage of children and young people
with type 1 diabetes by regional network between the 2019/20 and 2018/19 audit years.

8
NPDA National report 2019/20: Care processes and outcomes

Table 2: Number of children and young people with Type 1 diabetes by country, region and age
group, 2019/20
0-4
years
5-9
years
10-14
years
15-19
years
20-24
years
Total
(% of cohort)
England and Wales
1,450
5,904
11,693
8,595
11
27,653 (100)
England
1,382
5,599
11,015
8,235
11
26,242 (94.9)
Wales
68
305
678
360
0
1,411 (5.1)
East Midlands
110
396
860
571
0
1,937 (7.0)
East of England *
166
646
1,193
970
0
2,975 (10.8)
London and South East *+
312
1,321
2,497
1,876
6
6,012 (21.7)
North East and North Cumbria
85
331
692
491
0
1,599 (5.8)
North West *
176
710
1,494
1,071++
3,449 (12.5)
South Central +
142
597
1,080
806
0
2,625 (9.5)
South West *
123
427
873
636
0
2,059 (7.4)
West Midlands
142
635
1,221
997++
2,993 (10.8)
Yorkshire and Humber *
126
536
1,105
822++
2,588 (9.4)

* Regional networks affected by a number of PDUs not participating in the 2019/20 audit.

+ Numbers and percentages reported for South Central and London and South East reflect the transition of two units (Worthing Hospital
and St Richard’s Chichester) from the London and South East network to the South Central network in 2019/20

++ Results merged to mask numbers <5
1.2.3 Ethnicity

The ethnic breakdown of the children and young people with Type 1 diabetes reported to the
2019/20 audit was similar to the cohort analysed in 2018/19, and is shown in Table 3. Percentages are
also shown excluding ‘not stated’ and ‘unknown’ categories to allow for comparison with the 2011
census data.

Table 3: Ethnic groups of children and young people with Type 1 diabetes in England and Wales,
2019/20
2019/20
2011 census
Total (% of cohort)
% of total with known
and stated ethnicity*
% of total population**
White
22,155 (80.1)
84.1
86.0
Asian
1,724 (6.2)
6.5
7.5
Black
1,054 (3.8)
4.0
3.3
Mixed
851 (3.1)
3.2
2.2
Other
545 (2.0)
2.1
1.0
Not stated
748 (2.7)
-
-
Not known
576 (2.1)
-
-
Missing
0 (0.0)
-
-

* 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

9
NPDA National report 2019/20: Care processes and outcomes

Figure 2 shows the percentage of children and young people with Type 1 diabetes within each
ethnic category in each regional network, Comparison with previous years data shows a similar
breakdown, despite incomplete submission in 2019/20 (see Appendix 2).
84.4
85.9
65.4
87.6
84.6
85.4
89.9
89.2
74.4
82.3
9.3

11.4
8.4

10.6

8.3

East Midlands
East of England*
London and South East*
North East and North Cumbria
North West*
South Central
South West*
Wales
West Midlands
Yorkshire and Humber*
% children and young people with type 1 diabetes
by ethnic group and region
2019/20
White
Asian
Black
Mixed
Others
Not stated/unknown

* Regional networks affected by PDUs not participating in the 2019/20 audit.

+ Percentages reported for South Central and London and South East reflect the transition of two units (Worthing Hospital and St
Richard’s Chichester) from the London and South East network to the South Central network in 2019/20

Figure 2: Percentage of children and young people with Type 1 diabetes by ethnic group and
regional network, 2019/20
1.2.4 Deprivation

Table 4 (page 10) shows the percentages of children and young people with Type 1 diabetes by
deprivation quintile in 2019/20. Percentages are also shown excluding missing values to allow for
comparison with the breakdown of the general population aged 0 to 19 years old in England and
Wales (ONS, 2019). Deprivation quintiles were based on patient postcode and the English (IMD,
2019) and Welsh (WIMD, 2019) indices of multiple deprivation.

The deprivation breakdown was similar in 2019/20 and 2018/19, with a higher proportion of children
and young people with Type 1 diabetes living in the most deprived quintile. This is consistent with
the distribution of the general population aged 0 to 19 years old in England and Wales.

10
NPDA National report 2019/20: Care processes and outcomes

Table 4: Percentage and number of children and young people with Type 1 diabetes by deprivation
quintile, 2019/20
2019/20
2019/20
Total (% of cohort)
% of total with known
deprivation+
% of children and
young people aged
0-19 yrs old (England
and Wales)++
Most deprived
6,358 (23.0)
23.0
23.7
Second most deprived
5,596 (20.2)
20.3
20.7
Third least deprived
5,269 (19.1)
19.1
19.0
Second least deprived
5,144 (18.6)
18.6
18.1
Least deprived
5,254 (19.0)
19.0
18.5
Missing
32 (0.1)
-
-

+ Deprivation percentages have been calculated without missings and unallocated groups to allow comparison to the age group 0-19
years old in England and Wales, 2019.

++ Percentage of general population aged 0 to 19 years old in England and Wales. Calculations made using the “Lower layer Super Output
Area population estimates” from the Office for National Statistics, mid-year 2019.

Figure 3 shows variation in the percentages of children and young people with type 1 diabetes
within each distribution quintile within each regional network, ranging from 38.5% living in the
most deprived areas in the North West, to about 8.3% in South Central. The breakdown within
networks is consistent across the 2019/20 and 2018/19 audit years.
20.7
12.9
15.8
34.3
38.5
8.3
12.7
24.2
33.4
36.2
19.1
20.6
26.1
22.1
18.2
15.4
19.6
20.1
18.4
16.4
19.3
26.5
19.6
15.2
13.1
20.4
24.7
19.2
17.1
15.8
20.1
19.1
18.2
14.5
15.8
24.0
23.5
18.6
16.5
17.3
20.8
20.9
20.3
13.9
14.3
31.9
19.5
17.9
14.6
14.3
East Midlands
East of England *
London and
South East *
North East and North Cumbria
North West *
South Central
South West *
Wales
West Midlands
Yorkshire and Humber *
% children and young people with type 1
diabetes by deprivation quintiles and region
Most deprived
Second most deprived
Third least deprived
Second least deprived
Least deprived

* Regional networks affected by PDUs not participating in the 2019/20 audit.

+ Percentages reported for South Central and London and South East reflect the transition of two units (Worthing Hospital and
St Richard’s Chichester) from the London and South East network to the South Central network in 2019/20

Figure 3: Percentage of children and young people with Type 1 diabetes by deprivation quintile
and regional network, 2019/20

11
NPDA National report 2019/20: Care processes and outcomes
1.3 Prevalence and incidence of Type 1 diabetes
1.3.1 Prevalence

Figures 4 and 5 (page 12) show the prevalence rates of Type 1 diabetes in children and young people
aged 15 and below by sex and by age group and sex, over the last seven audit years respectively.
Prevalence is calculated up to the age of 14 years of age only, as case ascertainment begins to drop
after this age in the NPDA as young people transition into young adult services. In 2019/20 the
prevalence was estimated by assuming that the seven PDUs not submitting information had the
same prevalence rates - by age and sex - as the previous audit year 2018/19 (see Appendix 2).

The estimated prevalence rate of Type 1 diabetes in England and Wales was 198.3 per 100,000 of the
general population. It was slightly higher among boys (199.0 per 100,000) compared to girls (197.6
per 100,000), with no appreciable change over the last seven audit years.
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
Boys
199.8
194.9
190.8
196.1
198.1
198.1
199.0
Girls
175.3
187.2
190.6
192.2
193.8
194.6
197.6
All
187.7
192.0
195.0
194.2
196.0
196.4
198.3
0
50
100
150
200
250
Prevalence per 100,000 general
population
Sex and audit year
Boys
Girls
All

Figure 4: Prevalence of Type 1 diabetes per 100,000 general population among children aged 0-15
by age and sex, 2013/14 to 2019/20
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
2015/16
2016/17
2017/18
2018/19
2019/20

Figure 5: Prevalence of Type 1 diabetes per 100,000 general population by age group and sex,
2013/14 to 2019/20

12
NPDA National report 2019/20: Care processes and outcomes

Figure 6 shows the prevalence of Type 1 diabetes by CCG in England and overall in Wales. The grey
areas are those where in 2018/19 there were more than 10 children and young people with Type 1
diabetes aged 0-15 attending one of the PDUs that didn’t participate in 2019/20.

Figure 6: Prevalence of Type 1 diabetes per 100,000 (population aged 0-15) by Clinical Commissioning
Group area
1.3.2 Incidence

In 2019/20, 166 out of 173 PDUs in England and Wales reported 2,937 children and young people
newly diagnosed with Type 1 diabetes, of whom 2,799 (95.3%) were aged 0 to 15 years old. Figure 7
provides a breakdown of the age at diagnosis for both boys and girls with Type 1 diabetes included
in the audit.
295 (18.7%)
494 (31.4%)
643 (40.9%)
142 (9.0%)
aged
0 to 4
aged
5 to 9
aged
10 to 14
aged
15+
226 (16.7%)
531 (39.2%)
501 (37.0%)
96 (7.1%)
Newly diagnosed children and
young people
with type 1 diabetes
Boys
Girls

Figure 7: Newly diagnosed children and young people with Type 1 diabetes by age group and sex,
2019/20

13
NPDA National report 2019/20: Care processes and outcomes

Figure 8 shows the incidence of Type 1 diabetes among boys and girls aged 0 to 15, from 2013/14 to
2019/20. In 2019/20 the incidence was estimated by assuming a constant prevalence rate in the
group of units that didn’t participate in the audit, giving an incidence of 25.6 per 100,000 general
population within this age group. Both Figures 8 and 9 show a trend for higher incidence in boys
than girls, with the exception of those aged 5 to 9 years when the number of newly diagnosed
cases in girls is higher.
2013/14
2014/15
2015/16
2016/17
2017/18
2018/2019
2019/20
Boys
24.8
28.0
24.8
25.9
26.0
25.8
26.6
Girls
20.8
24.4
20.8
24.4
24.2
23.3
24.6
All
22.8
26.5
22.8
25.4
25.1
24.6
25.6
0
5
10
15
20
25
30
Incidence per 100,000 general
population
Boys
Girls
All

Figure 8: Incidence of Type 1 diabetes per 100,000 general population among children aged 0-15
by sex, 2013/14 to 2019/20
0
5
10
15
20
25
30
35
40
45
Boys
Girls
Boys
Girls
Boys
Girls
0-4 years old
5-9 years old
10-14 years old
Incidence per 100,000 general
population
Age group and sex
2015/16
2016/17
2017/18
2018/19
2019/20

Figure 9: Incidence of Type 1 diabetes per 100,000 general population among children and young
people by age-group and sex, 2015/16 to 2019/20

14
NPDA National report 2019/20: Care processes and outcomes
1.4 Characteristics of children and young people
with Type 2 diabetes

In 2019/20, there were 866 children and young people with Type 2 diabetes reported to the audit,
of whom 201 (23.2%) were newly diagnosed within the audit year. 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 with Type 2 diabetes reported to the audit and
managed in a PDU increased by 76 (9.6%) compared to the total number reported in 2018/19.
Figure 10 shows the numbers of children and young people with Type 2 diabetes being managed
within a PDU since 2012.

Figure 10: Numbers of children and young people with Type 2 diabetes included in the NPDA,
2011/12- 2019/20
1.4.1 Age and sex

Figure 11 shows that the numbers of children and young people with Type 2 diabetes being cared
for in a PDU decreased from the age of 15. This suggests 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 proportion of girls with Type 2 diabetes.
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
Type 2 Diabetes
448
326
340
544
621
715
745
790
866
% Total Audit
1.8%
1.3%
1.3%
2.0%
2.2%
2.5%
2.5%
2.6%
3.0%
448
326
340
544
621
715
745
790
866
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

15
NPDA National report 2019/20: Care processes and outcomes
`5-9
10
11
12
13
14
15
16
17
18-21
Boys
8
7
11
15
24
50
63
54
50
25
Girls
14
14
23
44
52
94
102
78
75
61
2019/20
22
21
34
59
76
144
165
132
125
86
2018/19
19
18
41
40
97
115
127
155
121
54
0
20
40
60
80
100
120
140
160
180
Number of children and young people with
Type 2 diabetes

Figure 11: Numbers of children and young people with Type 2 diabetes included in the NPDA by
age and sex, 2019/20 and changes in numbers between 2018/19 and 2019/20.
1.4.2 Regional distribution

Table 5 (page 16) shows the number of children and young people with Type 2 diabetes included
in 2018/19 and 2019/20, by country and region, based on PDU location.

16
NPDA National report 2019/20: Care processes and outcomes

Table 5: Number of children and young people included in the audit with Type 2 diabetes by
country and region, 2019/20 and 2018/19
5-9
years
10-14 years
15-19 years
20-24 years
Total
(% of cohort)
England and Wales
22
336
508 +
England
22
321
497 +
Wales
0
15
11
0
26 (3.0)
East Midlands
17 +
29
0
46 (5.3)
East of England *
0
15
29
0
44 (5.1)
London and South East *+
8
92
167
0
267 (30.8)
North East and North Cumbria
0
15
16
0
31 (3.6)
North West *
6
48
55
0
109 (12.6)
South Central +
26 +
33
0
59 (6.8)
South West *
12 +
28
0
40 (4.6)
West Midlands
66 +
95 +
161 (18.6)
Yorkshire and Humber *
38 +
45
0
83 (9.6)

+ Results merged to mask numbers <5

* Numbers and percentages reported for South Central and London and South East reflect the transition of two units (Worthing Hospital
and St Richard’s Chichester) from the London and South East network to the South Central network in 2019/20
1.4.3 Ethnicity

Table 6 (page 17) 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. The breakdown in 2019/20 was similar compared to 2018/19.

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NPDA National report 2019/20: Care processes and outcomes

Table 6: Ethnic group of children and young people with Type 2 diabetes England and Wales,
2018/19 and 2019/20
2019/20
2011 census
Total
% of total sample
% of total with
stated ethnicity*
% of total
population**
White
287
33.1
36.0
86.0
Asian
309
35.7
38.8
7.5
Black
118
13.6
14.8
3.3
Mixed
50
5.8
6.3
2.2
Other
33
3.8
4.1
1.0
Not stated
28
3.2
-
-
Not known
41
4.7
-
-
Missing
0
0.0
-
-

* 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
1.4.4 Deprivation

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

Table 7: Numbers and percentages of children and young people with Type 2 diabetes by
deprivation quintile, 2019/20
2019/20
2019/20
Total (% of cohort)
% of total with known
deprivation*
% of population aged
0-19 yrs old
(England and Wales)**
Most deprived
394
45.7
23.7%
Second most deprived
231
26.8
20.7%
Third least deprived
127
14.7
19.0%
Second least deprived
71
8.2
18.1%
Least deprived
40
4.6
18.5%
Missing
3
-
-

* Percentages within deprivation quintiles have been calculated excluding those without an allocated quintile due to missing data, to
allow comparison to the age group 0-19 years old in England and Wales, 2019.

** Percentage of general population aged 0 to 19 years old in England and Wales. Calculations made using the “Lower layer Super Output
Area population estimates” from the Office for National Statistics, mid-year 2019.

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NPDA National report 2019/20: Care processes and outcomes
2. Completion of health checks
(care processes)
2.1 Completion of health checks for children and
young people with Type 1 diabetes
2.1.1 Completion of key health checks

There are several health 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 describes the following seven to be the ‘key’ annual checks:

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

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

3. Blood pressure (measure of cardiovascular risk)

4. Urinary albumin (urine test for kidney function)

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

6. Eye screening (photographic test for eye risk)

7. Foot examination (foot examination for ulcer risk)

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 2019/20, there were 22,638 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 13,266 (58.6%) were aged 12 and above.

Table 8 (page 19) shows the percentage of children and young people recorded as receiving
essential healthcare checks in the audit year, from 2015/16 to 2019/20.

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NPDA National report 2019/20: Care processes and outcomes

Table 8: Percentage of children and young people with Type 1 who completed a full year of care
recorded as receiving health checks, 2015/16 to 2019/20
Age
Health check completion
Audit year
2015/16
2016/17
2017/18
2018/19
2019/20
All
ages
No. of children and young people with
T1 diabetes (n)
22,567
22,933
23,130
23,223
22,638
HbA1c (%)
99.2
99.5
99.4
99.4
99.7
BMI (%)
97.9
98.7
98.9
99.2
99.3
Thyroid (%)
77.7
81.8
84
87.2
87.8
Aged
12 and
above
No. of young people with T1 diabetes (n)
13,313
13,437
13,363
13,391
13,266
Blood pressure (%)
90.8
92.7
94.6
96.2
96.5
Urinary albumin (%)
66.0
68.7
74.3
78.3
79.1
Retinopathy screen (%)
66.2
74.4
75.9
77.5
74.5
Foot Exam (%)
65.8
72.8
78.2
82.5
84.3
All seven health checks (%)
35.5
43.5
49.8
55.2
54.4

There were increases in the percentage of children and young people with Type 1 diabetes recorded
as receiving all key health checks with the exception of retinopathy screening (Table 8 and Figure
12, page 20). The proportion of those receiving all seven health checks decreased by one percent
compared to the previous year, breaking a trend of consistent improvement since 2009/10 (Figure
13, page 20). It is important to note that it is not possible to make comparisons to completion rates
prior to 2015/16, when the NPDA began reporting rates for those with Type 1 and Type 2 diabetes
separately. However, given that most 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.

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

Figure 12: Percentage of children and young people who completed a full year of care recorded as
receiving individual health checks, 2004/05 to 2019/20
2.0% 2.6% 3.6% 5.0% 5.2% 4.1% 5.8% 6.7%
12.1%
16.1%
25.4%
35.5%
43.5%
49.8%
55.2% 54.4%
0%
10%
20%
30%
40%
50%
60%
2004/05
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
All types of diabetes
Type 1 only
% of young people aged 12 or older who completed a
full year of care
Audit year

Figure 13: 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 2019/20

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NPDA National report 2019/20: Care processes and outcomes
2.1.2 Variation in key health check completion

2.1.2.1 Variation in completion rates nationally and regionally

Tables 9 and 10 provide a breakdown of the health checks recorded for children and young people
with Type 1 diabetes with a complete year of care in 2019/20 by regional network, country and
overall, in England and Wales. Table 9 contains data on the health checks received by all children
and young people with Type 1 diabetes and Table 10 (page 22) contains data on the health checks
received by those aged 12 and above.

Table 9: Percentage of children and young people of all ages with Type 1 diabetes who completed
a full year of care recorded as having received health checks by country and region, 2019/20
No. of children
and young
people with
Type 1 diabetes
Percentage completing health checks
HbA1c (%)
BMI (%)
Thyroid (%)
England and Wales
22,638
99.7
99.3
87.8
England
21,497
99.7
99.2
87.5
Wales
1,141
99.9
99.6
93.4
East Midlands
1,587
99.8
99.2
90.9
East of England
2,425
99.5
99.0
83.8
London and South East
4,907
99.6
99.1
86.0
North East and North Cumbria
1,326
99.9
99.6
88.8
North West
2,851
99.5
99.3
88.6
South Central
2,118
99.9
99.4
88.1
South West
1,683
99.9
99.1
89.8
West Midlands
2,468
99.5
99.3
85.1
Yorkshire and Humber
2,132
99.8
99.6
90.6

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NPDA National report 2019/20: Care processes and outcomes

Table 10: Percentage of young people aged 12 and above with Type 1 diabetes who completed a
full year of care recorded as having received health checks by country and region, 2019/20
No. of children
and young
people with
Type 1 diabetes
Percentage completing health checks
Foot
exam
(%)
Blood
pressure
(%)
Urinary
albumin
(%)
Eye
screen
(%)
All
seven
(%)
England and Wales
13,266
84.3
96.5
79.1
74.5
54.4
England
12,622
83.8
96.5
78.6
74.3
53.7
Wales
644
93.9
97.7
90.2
78.1
68.9
East Midlands
932
87.9
96.8
77.5
67.6
52.9
East of England
1,459
80.5
97.7
74.2
78.2
50.4
London and South East
2,853
75.8
96.7
76.8
69.5
48.0
North East and North Cumbria
768
81.8
94.9
82.2
78.5
57.2
North West
1,671
88.3
96.5
80.6
72.6
53.6
South Central
1,208
84.4
92.1
80.3
76.7
55.9
South West
989
86.8
95.1
79.9
82.4
60.0
West Midlands
1,467
89.5
97.5
74.9
68.6
50.2
Yorkshire and Humber
1,275
88.4
99.3
85.1
82.8
65.4

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

2.1.2.5 Variation in completion rates across PDUs

Figure 14 (page 23) 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 health 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 dashed line (>2SD) reported a significantly smaller
percentage of patients receiving all the key checks compared to other PDUs in England and Wales,
and those above the top dashed line recorded significantly more.
1 Individual PDU level reports will be published at www.rcpch.ac.uk/npda to detail unit level performance.

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NPDA National report 2019/20: Care processes and outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
50
100
150
200
250
300
350
% of young people with Type 1 diabetes aged 12 and
above receiving all 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 14: 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, 2019/20

Figure 15 (page 24) 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). This metric is used in the NPDA to determine outlier status,
with PDUs below the bottom dotted line (>3SD) considered ‘alarm’ outliers, as they were recording
significantly fewer key health checks than other PDUs in England and Wales.

24
NPDA National report 2019/20: Care processes and outcomes
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
0
50
100
150
200
250
300
350
Health check completion rate
Number of young people with Type 1 diabetes aged 12 and above who completed a full
year of care
English PDUs
Welsh PDUs
95% level (2 SD)
99% level (3 SD)
Mean (England and Wales)

Figure 15: 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, 2019/20
2.1.3 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 16 (page 25) 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 53.1% had four or more measurements
recorded in 2019/20, which is 4.4% less than in 2018/19.

25
NPDA National report 2019/20: Care processes and outcomes


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%
2019/20
0.3%
3.6%
11.7%
31.2%
53.1%
0%
10%
20%
30%
40%
50%
60%
% of children and young people with Type 1
diabetes who completed a full year of care
Number of HbA1c measurements
Figure 16: 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 2019/20.

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

Table 11: Percentage of children and young people with Type 1 diabetes who completed a full year
of care by number of HbA1c measurements recorded 2019/20, by country and region
n
None
(%)
One
(%)
Two
(%)
Three
(%)
Four or
more (%)
England and Wales
22,638
0.3
3.6
11.7
31.2
53.1
England
21,497
0.3
3.6
11.5
31.3
53.3
Wales
1,141
0.1
3.9
16.8
30.2
48.9
East Midlands
1,587
0.2
2.6
8.9
28.1
60.1
East of England
2,425
0.5
5.6
16.2
37.0
40.7
London and South East
4,907
0.4
3.7
13.0
32.8
50.2
North East and North Cumbria
1,326
0.1
2.9
6.9
24.1
66.1
North West
2,851
0.5
4.2
13.6
33.0
48.7
South Central
2,118
0.1
1.4
7.4
26.6
64.4
South West
1,683
0.1
2.5
9.2
32.3
55.9
West Midlands
2,468
0.5
5.5
14.7
32.6
46.7
Yorkshire and Humber
2,132
0.2
2.4
6.6
28.0
62.7

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NPDA National report 2019/20: Care processes and outcomes
2.1.4 Nutrition and lifestyle education and support

NICE (NG18) recommends offering children and young people with diabetes dietetic support to
help optimise body weight and blood glucose control, and NHS England’s Best Practice Tariff
criteria for paediatric diabetes care (NHS Improvement, 2019) include the offering of an additional
dietetic appointment.

Of those children and young people with Type 1 diabetes who completed a full year of care 20,151
(89.0%) were offered an additional dietetic appointment, compared to 90.1% in 2018/19. Table 12
shows the percentages who were offered an additional appointment and attended the offered
appointment within the audit year.

Table 12: Percentage of children and young people with Type 1 diabetes who completed a full year
of care who were offered and/or attended an additional dietetic appointment by country and
region, 2019/20
n
Appointment
offered (%)
BMI (%)
England and Wales
22,638
89.0
55.2
England
21,497
89.8
55.2
Wales
1,141
74.6
56.5
East Midlands
1,587
73.2
45.7
East of England
2,425
89.6
54.9
London and South East
4,907
92.9
63.9
North East and North Cumbria
1,326
95.5
48.9
North West
2,851
92.6
60.0
South Central
2,118
83.6
43.2
South West
1,683
89.7
45.6
West Midlands
2,468
85.8
59.8
Yorkshire and Humber
2,132
98.5
53.8

There was no difference in the percentages of appointments offered across different age groups,
ethnic categories, deprivation quintiles or between girls and boys. The percentage of appointments
attended decreased with age and duration of diabetes, from 61.6% of those four years old or
younger to 50.1% in the group aged 15 years old or older.
2.1.5 Smoking

Figure 17 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. The overall percentage for England and Wales
increased to 90.8% in 2019/20 compared to 85.6% in 2018/19.

27
NPDA National report 2019/20: Care processes and outcomes


90.8%
90.4%
99.1%
93.9%
82.7%
90.9%
88.8%
97.3%
90.1%
86.5%
95.0%
85.3%
0%
20%
40%
60%
80%
100%
England and Wales
England
Wales
East Midlands
East of England
London and South East
North East and North Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
% of children and young people with Type 1 diabetes
Figure 17: 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

Table 13 (page 28) 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,
as recommended by NICE (NG18. NICE 2015). Approximately one in thirty-three young people were
recorded as smoking within the audit year and of those, 46.0% were offered a referral to smoking
cessation services, compared to 45.5% in 2018/19.

28
NPDA National report 2019/20: Care processes and outcomes

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, 2019/20
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
16,092
3.0
46.0
England
15,301
3.1
45.6
Wales
791
2.0
56.3
East Midlands
1,112
2.1
43.5
East of England
1,732
4.7
45.7
London and South East
3,498
2.3
59.8
North East and North Cumbria
929
3.9
41.7
North West
2,021
3.4
31.9
South Central
1,503
2.9
59.1
South West
1,197
4.7
37.5
West Midlands
1,771
1.7
43.3
Yorkshire and Humber
1,538
3.3
44.0

The proportion of current smokers was higher in boys (3.3%) than girls (2.7%), and higher among
those living in the most deprived areas (4.4%) than in the least deprived areas (2.1%).
2.1.6 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 29) for all children and young people with a complete
year of care.

29
NPDA National report 2019/20: Care processes and outcomes

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, 2019/20
n
Psychological
assessment
(%)
Flu vaccine
(%)
‘Sick day
rules’
(%)
Blood
ketone
testing
(%)
England and Wales
22,638
84.4
87.6
88.7
91.9
England
21,497
85.5
87.3
88.4
91.7
Wales
1,141
63.7
93.8
93.4
95.6
East of England
2,425
91.9
82.1
88.3
97.9
East Midlands
1,587
74.1
76.4
86.0
76.2
London and South East
4,907
85.1
84.5
86.7
92.9
North East and North Cumbria
1,326
90.5
94.9
93.4
93.7
North West
2,851
84.4
92.0
91.9
94.1
South Central
2,118
88.3
92.7
88.8
93.3
South West
1,683
88.3
88.8
91.3
96.0
West Midlands
2,468
85.0
85.0
87.5
86.9
Yorkshire and Humber
2,132
88.1
94.6
86.0
98.2

Figure 18 shows a consistent increase over the last three audits in the percentage of children and
young people with Type 1 diabetes receiving flu vaccination, “Sick day rules” advice and blood
ketone testing, and a small decrease in the percentage of children receiving psychological
assessment.
Psychological
assessment
Flu vaccine
recommended
‘Sick day rules’
Blood ketone
testing
2017/18
86.6%
75.9%
77.4%
82.7%
2018/19
85.7%
81.2%
83.6%
88.0%
2019/20
84.4%
87.6%
88.7%
91.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
% of children and young people who
complete a full year of care
2017/18
2018/19
2019/20

Figure 18: 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 to 2019/20

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NPDA National report 2019/20: Care processes and outcomes
2.1.7 Care at diagnosis

2.1.7.1 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=2,246) 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, 2019/20
No. diagnosed
90 days before the
end of the audit (n)
Thyroid disease
screen
(%)
Coeliac disease
screen
(%)
England and Wales
2,246
85.2
81.3
England
2,115
84.5
80.8
Wales
131
96.2
90.1
East Midlands
179
74.9
76
East of England
263
78.8
78.8
London and South East
506
81.6
73.7
North East and North Cumbria
113
88.5
82.3
North West
258
87.2
84.1
South Central
219
84.5
85.8
South West
148
90.5
83.8
West Midlands
228
89.5
85.1
Yorkshire and Humber
201
94
88.6

Figure 19 (page 31) shows the percentage of children and young people diagnosed more than 90
days before the end of the audit year (n=2,246), who received screening for coeliac and thyroid
disease within 90 days of diagnosis. In 2019/20 the rates of completion of both health checks at
diagnosis saw a small decrease with respect to 2018/19.

31
NPDA National report 2019/20: Care processes and outcomes


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%
2019/20
85.2%
81.3%
0%
20%
40%
60%
80%
% of newly diagnosed children and young people
with Type 1 diabetes
Autoinmune disease screening and audit year
Figure 19: Percentage of newly diagnosed children and young people with Type 1 diabetes who
received screening within 90 days of diagnosis, 2015/16 to 2019/20

2.1.7.2 Level 3 carbohydrate counting

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

Table 16 (page 32) shows variation in the percentage of children and young people diagnosed
more than 14 days before the end of the audit year (n=2,883) who received level 3 carbohydrate-
counting education within 14 days of diagnosis by region. Overall, 82.5% received this, compared to
75.6% in 2018/19.

32
NPDA National report 2019/20: Care processes and outcomes

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, 2019/20
No. diagnosed
14 days before the
end of the audit
Carb counting
(%)
England and Wales
2,883
82.5
England
2,722
82.4
Wales
161
84.5
East Midlands
231
77.8
East of England
334
75.8
London and South East
619
79.6
North East and North Cumbria
150
90.7
North West
327
75.8
South Central
293
86.3
South West
208
89.9
West Midlands
305
88.9
Yorkshire and Humber
255
85.9
2.2 Health checks for children and young people
with Type 2 diabetes

The health checks for children and young people with Type 2 diabetes recommended in NG18 and
NG19 (NICE, 2015) differ slightly from those for Type 1 diabetes. The NPDA includes cholesterol
screening as one of the seven essential annual checks for those with Type 2 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 2019/20, there were 534 children and young people
who completed a full year of care (i.e. were not diagnosed, did not die and did not transition to
adult services within the audit year) recorded as having Type 2 diabetes, of which 499 (93.4%) were
aged 12 years and above.
2.2.1 Completion of key health checks

Figure 20 (page 33) 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 2019/20.

33
NPDA National report 2019/20: Care processes and outcomes
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2015/16
2016/17
2017/18
2018/19
2019/20
% of children and young people who
completed a full year of care
Audit year
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 20: 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 2019/20

Table 17 shows the percentage of children and young people recorded as receiving essential
healthcare checks in the audit year, from 2015/16 to 2019/20.

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 2019/20
Age
Health check
Audit year
2015/16
2016/17
2017/18
2018/19
2019/20
All
ages
No. of children and young people (n)
412
473
470
501
534
HbA1c (%)
97.3
96.6
96.8
97.8
95.3
BMI (%)
94.4
94.1
94.5
95.0
94.2
Cholesterol (%)
59.2
66.4
67.9
70.5
64.4
Aged
12 and
above
No. of young people (n)
390
436
436
470
499
Urinary albumin (%)
51.7
56.7
58.9
62.1
62.1
Blood pressure (%)
85.0
86.0
88.5
90.9
89.6
Eye screen (%)
47.2
54.8
57.3
59.6
51.5
Foot Exam (%)
50.0
50.2
61.7
67.0
65.1
All seven health checks (%)
16.7
21.3
25.7
30.9
26.7

34
NPDA National report 2019/20: Care processes and outcomes
2.2.2 Number of HbA1c measurements

Figure 21 shows that 33.0% of children and young people with Type 2 diabetes recorded as
completing a full year of care received four or more HbA1c measurements in the year. The
percentage decreased almost 2% with respect to 2018/19.
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%
2019/20
4.7%
11.6%
24.7%
26.0%
33.0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
% of children and young people with Type 2 diabetes
who completed a full year of care
Number of HbA1c measurements

Figure 21: Number of HbA1c measurements recorded for children and young people with Type 2
diabetes receiving a full year of care, 2016/17 – 2019/20
2.2.3 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= 534) 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, 2017/18 to
2019/20
England and Wales
2017/18
2018/19
2019/20
Appointment offered (%)
70.0
80.0
80.0
Appointment attended (%)
48.7
48.5
56.0

35
NPDA National report 2019/20: Care processes and outcomes

Table 19 (page 47) 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 recorded as receiving a smoking health check and the percentage of current
smokers referred to smoking cessation services, 2017/18 to 2019/20
England and Wales
2017/18
2018/19
2019/20
Percentage of young people with a complete year of care with
a recorded smoking status (%)
83.3
84.3
85.0
Young people aged 12 or older
with a recorded smoking
status
Total (n)
684
711
789
‘Current smoker’ (%)
2.6
2.4
2.4
Referred to smoking cessation
services (%)
50.0
62.5
42.1

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=
534). The percentage of children and young people receiving assessment for psychological support
shows a decreasing trend over the last three years.

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, 2017/18 to 2019/20
England and Wales
2017/18
2018/19
2019/20
Assessment for Psychological support (%)
77.9
75.0
70.8
Flu vaccine recommendation (%)
49.4
69.3
67.8
‘Sick day rules’ (%)
41.7
51.5
53.0

36
NPDA National report 2019/20: Care processes and outcomes
2.3 Case study: High Health check completion
rate for children and young people with
diabetes at Neath Port Talbot Hospital

We are very pleased that the National Paediatric Diabetes Audit has shown that Neath Port
Talbot Hospital has yet again achieved a very good health check completion rate.
The MDT and the clinic staff work closely to ensure that all children and young people
with diabetes have the annual health checks as recommended by NICE.

The aspects of the practice that have enabled this are:

•
Setting expectations at diagnosis and through regular education for families, children
and young people emphasising the importance of the annual health checks and
addressing their concerns

•
Prior review of the clinic list to identify children and young people who are due their
annual review

•
Use of specific annual review proforma as a prompt so that all the required data is
captured and this is then entered onto the database

•
Use of specially designed pathology forms agreed across the paediatric, adult and
clinical pathology services in the Health Board that have age appropriate investigation
panel rather than the routine pathology forms and this has been a helpful tool for
both the clinicians and the phlebotomist to ensure that no investigation is missed.
Blood investigations are done on the day and urine is collected as per the
recommendations

•
Entering results promptly into the database.

•
Regular upload to the RCPCH website and review of the data completion report to
identify children and young people who have not completed the health checks and
planning further care in a timely manner

•
Working closely with the retinopathy screening services and discussing missed
appointments in the clinic. The families are supported to access and organise
appointments with the service as needed

•
Discussion of the NPDA data at the All Wales Paediatric Diabetes network meeting to
share good practice and compare with peers. The copies of the NPDA report published
for the parents and carers are available in the clinic for the families to browse when
attending appointments

In summary, regular data review and ownership has helped the MDT at Neath Port Talbot
Hospital to achieve a very good health check completion rate.

MDT

Dr B Mann (Paediatric Consultant and clinical Lead), Lesley Whitehorn (PDSN), K Lewis
(Diabetes Administrator), Dr N D’Souza (Paediatric Consultant)

Clinic Staff

Dawn Jenkins (Clerical Assistant), Barbara Voyce (Healthcare support worker), Gill Thomas
(Paediatric clinic coordinator)

37
NPDA National report 2019/20: Care processes and outcomes
3. Outcomes
3.1 HbA1c

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

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

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 for analysis.

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

This section of the reports seeks to answer the following audit questions: What are the average
HbA1c levels and percentage of children and you people with diabetes hitting targets in England
and Wales for 2019/20, and what are the longitudinal changes?

38
NPDA National report 2019/20: Care processes and outcomes
3.2 HbA1c outcomes of children and young people
with all types of diabetes

Table 21 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 2019/20
was 64.5 mmol/mol; this is a decrease of 0.1 mmol/mol compared to that recorded in 2018/19 (64.6
mmol/mol). The median HbA1c was 61.5 mmol/mol, which is the same as the result recorded in
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 regional network, 2019/20
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
27,427
64.5
17.3
61.5
17.0
England
26,061
64.5
17.3
61.5
17.0
Wales
1,366
64.5
17.0
61.5
18.0
East Midlands
1,895
61.9
15.5
59.2
16.5
East of England
2,880
65.1
18.1
61.5
18.0
London and South East
6,063
64.8
17.9
62.0
18.1
North East and North Cumbria
1,588
64.1
16.1
61.3
16.8
North West
3,467
65.6
18.1
62.0
19.0
South Central
2,559
63.0
16.0
60.0
16.5
South West
2,005
64.2
16.4
61.0
17.0
West Midlands
3,019
65.3
17.1
62.5
17.5
Yorkshire and Humber
2,585
65.2
17.8
61.5
17.0

39
NPDA National report 2019/20: Care processes and outcomes

Figure 22 shows the median HbA1c for children and young people with all types of diabetes, in
England and Wales, from 2009/10 to 2019/20. The timeline below the graph highlights key quality
improvement initiatives implemented in England and Wales over the same period.

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

Best Practice Tariff
introduced,
England

Quality
Assurance (peer
review),
England

Diabetes Delivery
Plans, England &
Wales

Quality Assurance
(peer review),
Wales
Regional networks
established, Self-
assessment QA started,
England & Wales
Updated Diabetes
Delivery Plan published
2016-2020, Wales

National Diabetes QI
Programme introduced,
England & Wales
Internal and external
peer reviews of
Quality standards and
on-going
participation in
quality improvement
methodology training

Figure 22: Median HbA1c for children and young people with all types of diabetes in England and
Wales 2009/10 to 2019/20, with associated NHS policy and/or paediatric diabetes delivery structural
changes.

40
NPDA National report 2019/20: Care processes and outcomes
3.3 HbA1c outcomes of children and young people
with Type 1 diabetes

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

Table 22 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 65.0 mmol/
mol, and the median HbA1c was 62.0 mmol/mol. Both values are equal to those recorded in 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, 2019/20
n
Mean
mmol/mol
Standard
deviation
mmol/mol
Median
mmol/mol
Interquartile
range
mmol/mol
England and Wales
26,121
65.0
16.9
62.0
17.4
England
24,797
65.0
16.9
62.0
17.4
Wales
1,324
64.9
16.9
62.0
18.0
East Midlands
1,826
62.3
15.3
59.5
16.5
East of England
2,808
65.4
17.9
62.0
18.0
London and South East
5,682
65.3
17.3
62.0
17.5
North East and North Cumbria
1,531
64.4
15.8
61.5
17.0
North West
3,264
66.3
17.6
63.0
18.5
South Central
2,473
63.3
15.7
60.5
16.5
South West
1,945
64.5
16.2
61.0
17.0
West Midlands
2,807
66.0
16.5
63.0
17.0
Yorkshire and Humber
2,461
65.6
17.5
62.0
16.6

Improvements in paediatric diabetes care over time should result in lower average HbA1c, and
reduced variation in patient level HbA1c measurements. Figure 23 (page 41) shows a smoothed
representation of the distribution of the HbA1c levels recorded for children and young people with
diabetes within the 2009/10, 2014/15, and 2019/20 audit years. This representation is based on the
probability of achieving specific HbA1c levels within each audit year considering a normal
distribution. The graph shows that there was a clinically significant reduction in mean HbA1c
between 2009/10 to 2014/15, but the variability remained almost constant. However, from 2014/15 to
2019/20 there was also a small reduction in overall variation in addition to a clinically significant
reduction in the mean HbA1c, with the former reflected in the tighter funnel showing higher
numbers of patients achieving scores around the average and the reduction in standard deviation
of HbA1c levels from 18.1 mmol/mol to 16.9 mmol/mol.

41
NPDA National report 2019/20: Care processes and outcomes
0
.01
.02
.03
Probability
0
10
20
30
40
50
60
70
80
90
100 110 120 130 140 150
HbA1c (mmol/mol)
2019/20
2014/15
2009/10
Mean mmol/mol
SD mmol/mol
2009/10
75.4
18.3
2014/15
70.6
18.1
2019/20
65.0
16.9
Figure 23: Distribution of HbA1c values (mmol/mol) of children and young people with Type 1
diabetes in England and Wales, 2009/10, 2014/15 and 2019/20

Figure 24 and Table 23 (page 42) show the percentages of children and young people with Type 1
diabetes achieving each of the NICE (2015) treatment targets from 2014/15 to 2019/20. Figure 24
also includes the percentages of children and young people with Type 1 diabetes who achieved the
NICE (2004) treatment targets of below 58 mmol/mol, between 58 mmol/mol and 80 mmol/mol,
and above 80 mmol/mol from 2010/11 to 2013/14.

42
NPDA National report 2019/20: Care processes and outcomes
6.4%
6.5%
7.5%
7.2%
10.3%
10.6%
6.8%
8.2%
8.8%
8.9%
11.4%
11.4%
10.3%
11.9%
12.6%
12.5%
14.3%
14.1%
15.8%
17.4%
15.8%
18.4%
34.3%
34.8%
34.3%
34.8%
33.3%
33.1%
13.4%
14.1%
13.7%
13.7%
11.5%
11.5%
7.5%
6.6%
6.7%
6.5%
5.2%
5.3%
55.5%
57.5%
58.4%
58.3%
28.7%
25.1%
25.9%
23.9%
21.3%
17.9%
16.4%
16.5%
14.1%
14.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
% of children and young people with Type 1 diabetes
≤48 mmol/mol
49-53 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

* NICE (2004) treatment targets from 2010/11 to 2013/14

Figure 24: Percentage of children and young people with Type 1 diabetes with an HbA1c result
within current and previous target ranges, 2010/11 – 2019/20

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

Table 23: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by country and regional network, 2019/20
≤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
10.6
22.1
36.2
49.8
30.7
19.3
14.0
England
10.6
22.0
36.2
49.9
30.7
19.2
13.9
Wales
11.0
23.3
36.6
48.9
31.8
19.9
14.4
East Midlands
13.1
27.9
43.8
45.9
25.2
14.4
10.3
East of England
11.5
22.7
36.6
48.3
31.3
20.6
15.1
London and South East
10.4
21.8
35.9
50.1
31.8
19.5
14.1
North East and North Cumbria
10.7
22.7
36.5
50.6
30.1
18.4
12.9
North West
9.8
20.0
33.6
50.4
33.3
21.9
16.0
South Central
11.6
24.5
39.3
49.4
26.7
16.1
11.3
South West
11.5
22.6
37.7
48.0
30.1
19.1
14.3
West Midlands
8.5
18.6
31.7
53.5
32.8
20.8
14.9
Yorkshire and Humber
10.0
20.4
34.7
51.0
30.5
19.3
14.4

43
NPDA National report 2019/20: Care processes and outcomes
3.3.2 HbA1c outcomes by sex

Figure 25 shows that over the last 17 years the mean HbA1c has decreased at a similar rate for both
boys and girls with Type 1 diabetes. It also shows a consistent higher mean HbA1c in girls compared
to boys.
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011/
12
2012/
13
2013/
14
2014/
15
2015/
16
2016/
17
2017/
18
2018/
19
2019/
20
Boys
75.9
73.8
73.5
73.5
73.9
74.2
74.6
73.6
72.9
71.4
70.2
69.8
67.5
66.6
67
64.7
64.7
Girls
77.1
75.5
75.1
75.3
75.6
75.8
76.4
75.4
74.5
72.8
72
71.4
69.1
68.1
68
65.4
65.3
58
60
62
64
66
68
70
72
74
76
78
80
Mean HbA1c (mmol/mol)
Boys
Girls

Figure 25: Mean HbA1c for boys and girls with Type 1 diabetes, 2003/04 to 2019/20
3.3.3 HbA1c outcomes by duration of diabetes

Figure 26 (page 44) plots average HbA1c by age group and duration of diabetes. Children and
young people of all age groups had higher HbA1c after up to two years following diagnosis, with
the exception of those aged 0-4 years. After the first year following diagnosis, those aged 15-19 had
consistently higher HbA1c than other age groups.

44
NPDA National report 2019/20: Care processes and outcomes
<1yr
1 yr
2 yrs
3 yrs
4 yrs
5-10 yrs
10-15 yrs
15+ yrs
aged 0 to 4
59.9
60.2
60.1
60.7
aged 5 to 9
55.7
59.6
60.2
59.4
59.4
60.7
aged 10 to 14
57.4
64.8
64.8
65.3
65.4
66.0
67.5
aged 15 to 19
57.3
67.4
70.5
70.0
72.2
72.4
72.4
72.9
50.0
55.0
60.0
65.0
70.0
75.0
mean HbA1c (mmol/mol)
Duration of diabetes
aged 0 to 4
aged 5 to 9
aged 10 to 14
aged 15 to 19

Figure 26: Mean HbA1c for children and young people with Type 1 diabetes, by age group and
duration of diabetes, 2019/20
3.3.4 HbA1c outcomes by ethnicity

Figure 27 (page 45) shows that whilst there have been overall improvements in the average HbA1c
amongst children and young people with Type 1 diabetes in all ethnic categories since 2011/12,
there have been consistent differences in HbA1c outcomes between those in different ethnic
categories, with those of White ethnicity having lower average HbA1c and those of Black ethnicity
having the highest average HbA1c year on year.

45
NPDA National report 2019/20: Care processes and outcomes
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011/
12
2012/
13
2013/
14
2014/
15
2015/
16
2016/
17
2017/
18
2018/
19
2019/
20
White
76.4
74.7
73.9
73.6
74.4
74.4
75.0
73.9
73.2
71.6
70.5
69.9
67.7
66.7
67.0
64.6
64.6
Asian
81.5
78.2
77.0
78.3
76.0
76.7
76.3
74.9
74.3
73.1
72.5
72.2
69.3
68.7
68.8
66.2
65.8
Black
81.5
80.1
79.8
81.3
80.2
81.3
81.9
81.1
81.0
78.9
78.0
77.8
74.0
74.2
74.9
71.4
71.9
Mixed
82.5
80.5
75.5
78.6
79.0
77.8
78.1
78.1
77.0
74.5
73.7
73.3
70.6
68.7
69.6
67.5
67.4
Other
75.1
73.8
75.7
75.4
74.0
74.1
77.5
72.9
73.4
73.2
72.1
72.3
69.6
68.2
67.0
63.7
63.0
60.0
65.0
70.0
75.0
80.0
85.0
mean HbA1c (mmol/mol)
White
Asian
Black
Mixed
Other
Audit Year

Figure 27: Mean HbA1c for children and young people with Type 1 diabetes in England and Wales
by ethnic group, 2003/04 to 2019/20

Table 24 provides a breakdown of average HbA1c by ethnic group and deprivation. It shows that
overall, living in a less deprived area was associated with lower HbA1c amongst those of all ethnicities,
with the exception of those of Black ethnicity. It also shows that that the average HbA1c for children
and young people of Black ethnicity living in the least deprived areas was the similar to that of
children of Asian and White ethnicity living in the most deprived areas.

Table 24: Mean HbA1c for children and young people with Type 1 diabetes by ethnicity and
deprivation, 2019/20 *
most deprived
second most
deprived
third least
deprived
second least
deprived
least deprived
White
68.1
65.6
65.0
62.5
62.0
Asian
68.2
65.7
64.0
64.3
60.5
Black
71.8
73.1
71.4
68.6
68.3
Mixed
70.0
69.4
67.4
64.8
61.9
Other
64.4
65.3
61.3
61.2
60.1

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

Figure 28 (page 46) shows the percentage of children and young people with Type 1 diabetes
meeting HbA1c treatment targets. It shows that results of those of White or Other ethnicity skew
towards the lower targets, whereas those of Black or Mixed ethnicity skew above these targets.

46
NPDA National report 2019/20: Care processes and outcomes
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/ mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
White
10.7%
22.7%
37.2%
29.4%
18.4%
13.4%
Mixed
9.0%
17.5%
29.0%
36.7%
25.0%
17.2%
Asian
8.6%
17.5%
29.5%
34.0%
18.8%
12.9%
Black
7.2%
13.0%
24.2%
49.0%
34.0%
26.3%
Other
15.6%
26.9%
41.0%
29.5%
17.8%
11.9%
0%
10%
20%
30%
40%
50%
60%
% of children and young people with Type 1 diabetes
HbA1c target levels
White
Mixed
Asian
Black
Other

Figure 28: Percentage of children and young people with Type 1 diabetes in England and Wales
achieving HbA1c targets by ethnic group, 2019/20

Even within broader ethnic categories there was variation between subcategories. Table 25 provides
a breakdown of mean HbA1c of children and young people within each ethnic subcategory, and
shows that Chinese children and young people with Type 1 diabetes had the lowest average HbA1c
and those of Black Caribbean ethnicity had the highest average HbA1c, with a difference of 17.2
mmol/mol between these two results.

Table 25: Mean HbA1c for children and young people with Type 1 diabetes by ethnicity, 2019/20
Ethnicity
N
mean HbA1c (mmol/mol)
White British
19,207
64.8
White Irish
51
63.6
White other
1,755
62.6
Mixed White and Black Caribbean
205
69.2
Mixed White and Black African
145
67.7
Mixed White and Asian
156
63.4
Mixed other
301
68.1
Asian Indian
431
63.5
Asian Pakistani
719
66.7
Asian Bangladeshi
105
69.8
Asian other
370
65.7
Black Caribbean
140
78.2
Black African
596
70.5
Black other
265
71.4
Chinese
19
61.0
Other
486
63.1

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NPDA National report 2019/20: Care processes and outcomes
3.3.5 HbA1c outcomes by deprivation quintile

NPDA results have consistently shown a trend for higher HbA1c associated with living in more
deprived areas. Figure 29 shows that in 2019/20 there was similar average HbA1c within each
deprivation quintile compared to 2018/19, with those in the second least deprived quintile coming
closest to closing the attainment gap between outcomes of the next least deprived group.
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
Most deprived
74.7
73.7
71.6
70.7
70.9
68.2
68.3
Second most deprived
74.0
72.3
69.6
68.7
68.7
66.2
66.1
Third least deprived
72.2
70.6
68.1
67.0
67.5
65.0
65.1
Second least deprived
70.4
69.0
66.7
65.6
65.9
63.4
62.7
Least deprived
69.0
67.2
64.8
64.0
64.2
61.9
62.0
60.0
62.0
64.0
66.0
68.0
70.0
72.0
74.0
76.0
Mean HbA1c (mmol/mol)
Most deprived
Second most deprived
Third least deprived
Second least deprived
Least deprived
Audit Year

Figure 29: Mean HbA1c for children and young people with Type 1 diabetes by deprivation quintile,
2013/14 to 2019/20

Figure 30 (page 48) shows the percentages of children and young people with Type 1 diabetes by
deprivation quintiles achieving treatment targets. Results of those in the least deprived areas
skewed towards lower targets, whereas those of children and young people living in the most
deprived areas skewed towards the higher cut offs

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NPDA National report 2019/20: Care processes and outcomes
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
Most deprived
8.1%
16.3%
28.1%
38.9%
25.6%
19.6%
Second most deprived
9.9%
20.1%
33.6%
33.3%
21.0%
15.4%
Third least deprived
10.7%
22.1%
36.4%
30.6%
19.5%
14.0%
Second least deprived
12.1%
25.6%
40.9%
25.2%
14.8%
10.0%
Least deprived
12.9%
27.5%
43.9%
23.7%
13.9%
9.5%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
% of children and young people with Type 1 diabetes
Most deprived
Second most deprived
Third least deprived
Second least deprived
Least deprived
HbA1c target levels

Figure 30: Percentage of children and young people with Type 1 diabetes in England and Wales
achieving HbA1c targets by deprivation quintiles, 2019/20
3.3.6 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 2019/20 data considers the effects of age,
sex, ethnicity, duration of diabetes and deprivation on mean HbA1c, and on 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 31 (page 49) shows the case-mix adjusted mean HbA1c for each PDU in England and Wales,
and Figures 31 and 32 (page 49) 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 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. These graphs,
with individual PDUs identified, are available at NPDA Results Online.

49
NPDA National report 2019/20: Care processes and outcomes

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. The NPDA uses
the adjusted mean HbA1c as its outcome metric for its formal process of identification and management
of outliers. In Figure 30, 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
50
100
150
200
250
300
350
400
450
500
550
600
650
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 31: Funnel plot of mean adjusted HbA1c for children and young people with Type 1 diabetes
in England and Wales by PDU, 2019/20.

In Figure 32, PDUs below the bottom dotted line (<3SD) have a significantly smaller adjusted percentage
of patients achieving a target HbA1c of <58 mmol/mol compared to others in England and Wales
0%
10%
20%
30%
40%
50%
60%
70%
0
50
100
150
200
250
300
350
400
450
500
550
600
650
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 32: 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, 2019/20.

50
NPDA National report 2019/20: Care processes and outcomes

In Figure 33, PDUs above the top dotted line (>3SD) have a significantly 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
50
100
150
200
250
300
350
400
450
500
550
600
650
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 33: 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, 2019/20.
3.4 HbA1c outcomes of children and young people
with Type 2 diabetes

HbA1c outcomes are jointly reported for England and Wales given the smaller numbers of children
and young people with Type 2 diabetes included within the audit.

The mean and median HbA1c of children and young people with Type 2 diabetes in England
and Wales receiving care in a PDU in 2019/20 were 58.6 and 51.0 mmol/mol, respectively (Table 26,
page 51).

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NPDA National report 2019/20: Care processes and outcomes

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- 2019/20
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
2019/20
731
58.6
23.6
51.0
28.0

Table 26 and Figure 34 show that the national median HbA1c of children and young people with
Type 2 diabetes has varied since 2015/16.
44.3%
46.6%
40.5%
10.8%
11.9%
9.8%
6.7%
6.2%
7.7%
12.0%
11.3%
13.8%
5.5%
5.3%
5.4%
3.6%
2.5%
3.8%
17.1%
16.2%
18.9%
2019/20
2018/19
2017/18
% of children and young people with Type 2 diabetes
≤48 mmol/mol
49-53 mmol/mol
54-57 mmol/mol
58-68 mmol/mol
69-75 mmol/mol
76-80 mmol/mol
>80 mmol/mol

Figure 34: Percentage of children and young people with Type 2 diabetes with an HbA1c result
within current and previous target ranges, 2017/18 – 2019/20
3.4.1 HbA1c outcomes by sex

Figure 35 (page 52) shows that boys and girls with Type 2 diabetes had similar HbA1c outcomes
over the past three audit years.

52
NPDA National report 2019/20: Care processes and outcomes
2017/18
2018/19
2019/20
Boys
60.2
57.5
57.1
Girls
61.7
57.3
59.3
54.0
55.0
56.0
57.0
58.0
59.0
60.0
61.0
62.0
63.0
Mean HbA1c (mmol/mol)
Boys
Girls

Figure 35: Mean HbA1c for boys and girls with Type 2 diabetes, 2017/18 to 2019/20
3.4.2 HbA1c outcomes by age group and duration of Type 2
diabetes

Figure 36 shows that those aged 15-19 had higher average HbA1c than those aged 10-14 during the
first year of diagnosis, but after this the averages converged and increased at a similar rate with
each subsequent year.
<1yr
1-2 yrs
2-3 yrs
3-4 yrs
4-5 yrs
5-10 yrs
aged 10 to 14
51.0
57.7
61.5
64.1
aged 15 to 19
55.1
58.3
63.1
64.1
67.0
66.6
40.0
45.0
50.0
55.0
60.0
65.0
70.0
mean HbA1c (mmol/mol)
Duration of diabetes
aged 10 to 14
aged 15 to 19

Figure 36: Mean HbA1c for children and young people with Type 2 diabetes, by age group and
duration of diabetes, 2019/20

53
NPDA National report 2019/20: Care processes and outcomes
3.4.3 HbA1c outcomes by deprivation quintile

Figure 37 shows variation in average HbA1c by deprivation quintile across audit years. There has not
been a consistent positive correlation between deprivation and average HbA1c as has been
observed amongst those with Type 1 diabetes.


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
2019/20
49.1
59.7
56.6
58.7
60.0
40.0
45.0
50.0
55.0
60.0
65.0
70.0
75.0
80.0
mean HbA1c (mmol/mol)
Deprivation quintiles
2015/16
2016/17
2017/18
2018/19
2019/20
Figure 37: Mean HbA1c for children and young people with Type 2 diabetes in England and Wales
by deprivation quintile, 2015/16 to 2019/20
3.4.4 HbA1c outcomes by ethnic category

Similarly to those with Type 1 diabetes, Figure 38 (page 54) shows that typically White children and
young people with Type 2 diabetes had lower average HbA1c and Black children with Type 2
diabetes typically had higher average HbA1c than those in other ethnic categories between 2015/16
and 2019/20.

54
NPDA National report 2019/20: Care processes and outcomes
White
Asian
Black
Mixed
Other
2015/16
56.8
58.7
69.9
52.1
61.3
2016/17
55.6
61.3
71.9
64.0
62.9
2017/18
57.9
61.0
75.2
58.6
61.5
2018/19
54.1
58.0
66.9
60.2
56.7
2019/20
54.7
59.4
66.1
59.6
57.0
40.0
45.0
50.0
55.0
60.0
65.0
70.0
75.0
80.0
mean HbA1c (mmol/mol)
Ethnicity
2015/16
2016/17
2017/18
2018/19
2019/20

Figure 38: Mean HbA1c for children and young people with Type 2 diabetes in England and Wales
by ethnic group, 2015/16 to 2019/20
3.5 Small vessel (microvascular) disease

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

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

3.5.1.1 Albuminuria in young people with Type 1 diabetes

More than two-thirds (n = 11,625) 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, 96.9%
(n = 11,270) had a valid interpretation of their urinary albumin level. Increased risk of kidney disease
is indicated by the presence of either micro- or macro-albuminuria. Figure 39 shows that 11.1% of
young people in England and Wales were recorded as having micro- or macro-albuminuria; the
percentage varied across regions.

55
NPDA National report 2019/20: Care processes and outcomes
88.9%
88.6%
92.9%
89.3%
89.2%
85.9%
93.5%
87.5%
87.7%
86.3%
90.2%
92.5%
11.1%
11.4%
7.1%
10.7%
10.8%
14.1%
6.5%
12.5%
12.3%
13.7%
9.8%
7.5%
0%
20%
40%
60%
80%
100%
England & Wales
England
Wales
East Midlands
East of England
London and South East
North East and North
Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
% of children and young people with Type 1 diabetes

Figure 39: Percentage of young people with Type 1 diabetes aged 12 years and older with
albuminuria by country and region, 2019/20

Table 27 shows that the percentage of young people with Type 1 diabetes aged 12 years and above
with albuminuria has 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 2019/20
Total (n)
Normo-albuminuria (%)
Micro- or macro-
albuminuria (%)
2019/20
11,270
88.9
11.1
2018/19
11,075
90.2
9.8
2017/18
10,631
89.8
10.2
2016/17
9,938
90.0
10.0
2015/16
9,364
90.1
9.9

Figure 40 shows little variation in the presence of albuminuria by duration of diabetes between the
audit years.

56
NPDA National report 2019/20: Care processes and outcomes
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
2016/17
10.6%
9.1%
8.7%
11.4%
9.2%
10.2%
2017/18
10.7%
8.9%
9.9%
10.3%
10.8%
13.5%
2018/19
10.8%
9.8%
10.2%
9.0%
9.9%
11.4%
2019/20
8.6%
10.3%
10.1%
11.9%
12.4%
11.3%
0%
3%
6%
9%
12%
15%
% of young people with Type 1 diabetes
Duration of diabetes

Figure 40: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by duration of diabetes, 2016/17 – 2019/20

Figure 41 shows little difference in rates of albuminuria by age and sex.
12
13
14
15
16
17
18
Boys
9.6%
11.2%
12.7%
11.3%
12.1%
11.7%
16.4%
Girls
9.2%
11.4%
8.7%
9.8%
13.6%
10.2%
8.3%
0%
3%
6%
9%
12%
15%
18%
% of young people with Type 1 diabetes
Age and sex

Figure 41: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by age and sex, 2019/20

Figure 42 shows that in the last four years the prevalence of albuminuria has increased amongst
those living in the least deprived, but no clear relationship between prevalence of albuminuria and
deprivation.

57
NPDA National report 2019/20: Care processes and outcomes
Most deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least deprived
2016/17
12.0%
11.1%
8.6%
10.0%
8.4%
2017/18
11.2%
11.0%
10.4%
9.5%
9.1%
2018/19
9.8%
10.0%
9.4%
10.4%
9.4%
2019/20
10.3%
10.9%
10.3%
12.2%
11.9%
0%
3%
6%
9%
12%
15%
18%
% of young people with Type 1 diabetes
Deprivation quintile

Figure 42: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by deprivation quintile, 2016/17 – 2019/20

Figure 43 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
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 43: Percentage of young people with Type 1 diabetes achieving HbA1c targets by presence
of albuminuria, 2019/20

58
NPDA National report 2019/20: Care processes and outcomes

3.5.1.2 Albuminuria in children and young people with Type 2 diabetes

Figure 44 shows that albuminuria was present in 25.7% of children and young people with Type 2
diabetes with a valid PDU interpretation of their urinary albumin level (n=413) in 2019/20. The
percentage of children and young people with Type 2 diabetes with albuminuria is over twice that
recorded for young people with Type 1 diabetes (11.1%) – indicating that children and young people
with Type 2 diabetes are at greater risk of kidney disease.
14.6%
21.0%
22.1%
20.6%
25.7%
0%
5%
10%
15%
20%
25%
30%
2015/16
2016/17
2017/18
2018/19
2019/20
% of children and young people with
Type 2 diabetes
Audit year

Figure 44: Percentage of children and young people with Type 2 diabetes with albuminuria in
England and Wales, 2015/16 – 2019/20
3.5.2 Eye Disease

3.5.2.1 Retinopathy in young people with Type 1 diabetes

There were 11,116 young people with Type 1 diabetes aged 12 years and above recorded as receiving
an eye screen during the audit period. Of those, 97.6% (n = 10,852) had a valid eye screen result
recorded. Figure 45 shows that 12.0% 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.

59
NPDA National report 2019/20: Care processes and outcomes
88.0%
87.7%
93.1%
90.7%
87.4%
89.0%
89.7%
83.8%
87.7%
86.3%
91.6%
84.2%
12.0%
12.3%
6.9%
9.3%
12.6%
11.0%
10.3%
16.2%
12.3%
13.7%
8.4%
15.8%
0%
20%
40%
60%
80%
100%
England and Wales
England
Wales
East Midlands
East of England
London and South East
North East and North Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
% of children and young people with Type 1 diabetes
Normal
Abnormal

Figure 45: Percentages of young people with Type 1 diabetes aged 12 years and older with normal/
abnormal retinopathy screening results by country and region, 2019/20

Table 28 (page 60) 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. Overall, between
2015/16 and 2019/20 there is a downward trend in the percentage of children and young people
with abnormal retinal screening.

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 2019/20
Total
Normal
Abnormal (%)
2019/20
10,852
88.0
12.0
2018/19
11,431
86.9
13.1
2017/18
11,134
87.2
12.8
2016/17
9,938
85.2
14.8
2015/16
9,788
84.7
15.3

As in previous audits, the prevalence of abnormal eye screening increased with age and was
highest amongst adolescent girls with Type 1 diabetes (Figure 45). The prevalence also increased
with longer duration of diabetes (Figure 46, page 60).

60
NPDA National report 2019/20: Care processes and outcomes
12
13
14
15
16
17
18
Boys
5.2%
6.5%
9.3%
9.9%
14.1%
17.8%
24.1%
Girls
6.1%
7.5%
10.1%
11.5%
19.7%
21.1%
29.7%
0%
5%
10%
15%
20%
25%
30%
35%
% of young people with Type 1 diabetes
Age by sex

Figure 46: Percentage of young people with Type 1 diabetes aged 12 years and older with
retinopathy by age and sex, 2019/20
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%
2019/20
4.3%
4.5%
7.0%
14.8%
23.6%
34.4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
% of young people with Type 1 diabetes
Duration of diabetes

Figure 47: Percentage of young people with Type 1 diabetes aged 12 years and older with abnormal
eye screening by duration of diabetes, 2019/20

Figure 48 shows little variation in rates of prevalence of abnormal eye screening between audit
years and between deprivation quintiles, although there is a downward trend within each quintile.

61
NPDA National report 2019/20: Care processes and outcomes
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
13.3%
13.6%
13.3%
13.1%
12.2%
2019/20
12.9%
12.3%
10.8%
11.4%
12.6%
0%
3%
6%
9%
12%
15%
18%
% of young people with Type 1 diabetes
Deprivation quintile

Figure 48: Percentage of young people with Type 1 diabetes aged 12 years and older with an
abnormal eye screening result by deprivation quintile, 2019/20

Figure 49 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 eye result%
young people 12+ with Type 1 diabetes and a normal eye result

Figure 49: Percentage of children and young people with Type 1 diabetes with or without an
abnormal eye screening result achieving HbA1c targets, 2019/20

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NPDA National report 2019/20: Care processes and outcomes

From 8,355 children and young people with Type 1 diabetes and known albuminuria and eye screen
results recorded, 129 (1.5%) presented both retinopathy and abnormal albuminuria. This percentage
increased with age, from 0.3% at 12 years old to 4.9% at 18 years old. The mean HbA1c of those
children presenting both retinopathy and abnormal albuminuria was 79.4 mmol/mol, compared
to a mean of 65.0 mmol/mol for all children and young people with Type 1 diabetes.

3.5.2.2 Retinopathy in young people with Type 2 diabetes

Figure 50 shows that 6.1% of young people with Type 2 diabetes aged 12 years and above with a
valid eye screening result (n=342) had an abnormal result. This was almost half the rate of retinopathy
found amongst young people with Type 1 diabetes (12.0%).
6.2%
4.8%
5.6%
6.7%
6.1%
0%
1%
2%
3%
4%
5%
6%
7%
8%
2015/16
2016/17
2017/18
2018/19
2019/20
% of children and young people with Type
2 diabetes
Audit year

Figure 50: Eye screening results for young people aged 12 years and above with Type 2 diabetes,
2015/16 to 2019/20

63
NPDA National report 2019/20: Care processes and outcomes
3.6 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. This
chapter examines the incidence and demographics of such risk factors.
3.6.1 Blood pressure and cholesterol

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

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

Table 29 shows the percentages of young people aged 12 and above with Type 1 diabetes with a
recorded blood pressure in the audit period (n=15,026) classified as ‘high normal’ (91st -98th centile)
or ‘high’ blood pressure (>98th centile). Over a quarter of young people (26.7%) with Type 1 diabetes
had high blood pressure (hypertension); this represents an increase compared to the figure
reported in the 2018/19 audit (25.8%).

Table 29: Percentage of young people with Type 1 diabetes aged 12 years and above falling within
blood pressure targets by country and region, 2019/20
‘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
27.6
9.1
28.0
26.1
4.0
26.7
England
27.5
9.0
28.0
26.0
4.0
26.4
Wales
28.3
11.5
29.1
29.8
5.1
32.0
East Midlands
27.3
9.0
28.3
31.9
5.7
33.8
East of England
28.3
9.4
29.3
27.3
4.1
27.8
London and South East
25.6
8.8
26.6
22.5
2.7
23.0
North East and North Cumbria
28.8
4.3
28.9
25.1
2.1
25.6
North West
27.3
8.3
26.6
25.7
3.5
25.3
South Central
31.0
8.0
32.0
21.8
3.9
23.1
South West
28.7
11.4
25.8
32.5
6.5
30.1
West Midlands
28.2
10.5
29.4
28.4
4.3
29.3
Yorkshire and Humber
26.3
9.8
27.0
24.6
5.0
26.3

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NPDA National report 2019/20: Care processes and outcomes

Table 30 shows the percentages of young people aged 12 and above with Type 1 diabetes with a
recorded cholesterol screen (n=10,738) within the target for total blood cholesterol. It shows that
18.9% exceeded the higher (>=5 mmol/l) target for total blood cholesterol. This figure is similar to
the one reported in the 2018/19 audit (19.0%).

Table 30: Percentage of young people with Type 1 diabetes aged 12 years and above falling within
cholesterol targets by country and region, 2019/20
4 mmol/l or more (%)
5 mmol/l or more (%)
England and Wales
59.7
18.9
England
59.5
18.9
Wales
62.8
17.9
East Midlands
55.6
16.7
East of England
56.5
18.2
London and South East
60.1
19.4
North East and North Cumbria
61.7
20.7
North West
62.4
22.0
South Central
58.7
18.2
South West
58.5
18.4
West Midlands
59.1
17.8
Yorkshire and Humber
61.0
17.8

Figure 51 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.
16.1%
21.8%
19.7%
23.0%
21.7%
19.0%
18.9%
27.5%
27.1%
26.3%
25.8%
26.7%
25.8%
26.7%
0%
5%
10%
15%
20%
25%
30%
35%
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
% of young people with Type 1 diabetes
Audit year
Cholesterol level (>=5 mmol/l)
High blood pressure (>98th centile)

Figure 51: 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
2019/20

65
NPDA National report 2019/20: Care processes and outcomes

3.6.1.2 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=684) classified as ‘high normal’ (91st -98th centile) or ‘high’
blood pressure (>98th centile). Almost half (44.3%) of children and young people with Type 2 diabetes
had high blood pressure. Table 32 shows the percentage of children and young people with Type
2 diabetes with a recorded cholesterol screen (n=466) above the target for total blood cholesterol.
It shows that 28.8% exceeded the higher target for total blood cholesterol (>=5 mmol/l) in 2019/20,
a similar percentage with respect to 2018/19 (28.3%).

Table 31: Percentage of children and young people with Type 2 diabetes with ‘high’ or ‘high-normal’
blood pressure, 2016/17 – 2019/20
‘High normal’ blood pressure
(91st–98th centile)
High’ blood pressure
(>98th centile)
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
2019/20
28.3
16.1
26.8
42.8
10.4
44.3
2018/19
25.4
17.6
39.6
42.5
10.1
44.6
2017/18
22.2
16.9
34.1
42.7
13.1
44.9
2016/17
24.5
15.8
36.2
42.2
13.6
45.6

Table 32: Percentage of children and young people with Type 2 diabetes above cholesterol targets,
2016/17 – 2019/20
4 mmol/l or more
5 mmol/l or more
2019/20
69.1
28.8
2018/19
69.1
28.3
2017/18
74.9
33.8
2016/17
75.9
36.2
3.6.2 Body Mass Index

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

•
Underweight: below the 2nd centile

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

•
Overweight: between the 85th and 95th centile

•
Obese: above the 95th centile

66
NPDA National report 2019/20: Care processes and outcomes

Comparisons can be made with the National Child Measurement Programme in England (NHS
Digital, 2020) and the Child Measurement Programme in Wales (Public Health Wales, 2019).
These programmes measure the height and weight of all children in Reception class (aged 4 to 5
years old) in both countries and Year 6 (aged 10 to 11 years old) in England. Figure 52 shows the
prevalence of obese and overweight children with diabetes compared against the prevalence
within wider population in England and Wales since 2015/16. For 2019/20, in England 32.5% of
children aged 4 to 5 years old with diabetes were overweight or obese (a decrease from 35.9% in
2018/19) compared to 23.0% in the National Child Measurement Programme for England. In
Wales, 47.2% of children with diabetes aged 4 to 5 years were overweight or obese (an increase
from 37.7% in 2018/19) compared to 26.3% in the Child Measurement Programme for Wales in
2017/18. However, given the small numbers of children with diabetes at these ages in Wales, this
increase could be artefactual. The prevalence of overweight and obese children aged 10 to 11 years
old with diabetes in England was 38.7% (an increase from 37.1% in 2018/19) compared to 35.1% of
the wider cohort within the National Child Measurement Programme for England.

These findings indicate that there is a higher prevalence of obesity and overweight among young
children with diabetes compared to children of similar ages in the wider population.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Children with
diabetes
Children in
the NCMP
Children with
diabetes
Children in
the NCMP
Children with
diabetes
Children in
the CMP*
Aged 4-5
Aged 10-11
Aged 4-5
England
Wales
% of children aged 4 to 5 or aged 10 to 11
Prevalence of overweight and obese children by country
2015/16
2016/17
2017/18
2018/19
2019/20

* CMP data for Wales is available up to the year 2017/18

Figure 52: Percentage of obese and overweight children with diabetes, aged 4 to 5 and age 10 to
11 years old, and the percentage of obese and overweight children in the wider population by
country, 2015/16 to 2019/20

67
NPDA National report 2019/20: Care processes and outcomes

3.6.2.1 Body Mass Index and Type 1 diabetes

Figures 53 and 54 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 (63.2%) compared to those aged 12 years and above
(56.2%), and that a higher percentage of children and young people with Type 1 diabetes were
overweight or obese than were underweight.
63.2%
63.6%
55.9%
61.8%
64.5%
64.3%
55.6%
63.6%
66.0%
64.6%
63.2%
64.5%
17.5%
17.3%
21.3%
17.4%
17.6%
17.7%
19.2%
17.6%
17.5%
15.7%
16.2%
17.0%
18.6%
18.4%
21.8%
19.8%
17.4%
17.3%
24.4%
18.5%
15.8%
19.1%
20.0%
17.9%
0%
20%
40%
60%
80%
100%
England and Wales
England
Wales
East Midlands
East of England
London and South
East
North East and North
Cumbria
North West
South Central
South West
West Midlands
Yorkshire and
Humber
% of children and young people with Type 1 diabetes
Underweight
Healthy weight
Overweight
Obese

Figure 53: Percentage of children aged 0-11 years with Type 1 diabetes within BMI categories by
country and region, 2019/20
56.2%
56.6%
48.1%
56.4%
58.9%
57.8%
50.9%
55.7%
58.6%
55.7%
56.0%
55.7%
18.4%
18.3%
20.2%
17.7%
19.2%
18.7%
18.1%
18.9%
17.7%
18.1%
17.8%
17.3%
24.3%
24.0%
30.4%
24.8%
20.6%
22.4%
29.7%
24.3%
22.8%
25.6%
24.9%
25.7%
0%
20%
40%
60%
80%
100%
England and Wales
England
Wales
East Midlands
East of England
London and South…
North East and…
North West
South Central
South West
West Midlands
Yorkshire and…
% of children and young people with Type 1 diabetes
Underweight
Healthy weight
Overweight
Obese

Figure 54: Percentage of young people 12 years and older with Type 1 diabetes within BMI categories
by country and region, 2019/20

68
NPDA National report 2019/20: Care processes and outcomes

Figure 55 shows the distribution of BMI of children and young people with Type 1 diabetes since
2015/16 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.
1st
5th
10th
25th
50th
75th
85th
95th
99th
UK1990 reference
2015/16
2017/18
2019/20

Figure 55: Distribution of body mass index of children and young people with Type 1 diabetes in
2015/16, 2017/18 and 2019/20 compared to the 1990 reference population

Figure 56 shows how 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.

69
NPDA National report 2019/20: Care processes and outcomes


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 56: 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, 2019/20

Figure 57 shows how a higher percentages of children and young people with Type 1 diabetes and
a healthy weight are meeting lower HbA1c targets compared to children and young people with
overweight or obesity, however the proportions of those in each BMI category with an HbA1c
exceeding 80mmol/mol were very similar.

70
NPDA National report 2019/20: Care processes and outcomes
0%
10%
20%
30%
40%
50%
60%
≤48
mmol/mol
≤53
mmol/mol
<58
mmol/ mol
≥69
mmol/mol
>75
mmol/mol
>80
mmol/mol
% of children and young people with
Type 1 diabetes
HbA1c target levels
Obese
Overweight
Healthy weight

Figure 57: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by Body Mass Index category, 2019/20

3.6.2.2 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 from 2016/17 to 2019/20. It shows that in each audit year, most
children and young people with Type 2 diabetes were obese. Figure 57 shows similar percentages
of children and young people with Type 2 diabetes within each weight category when broken
down by sex.

Table 33: Body mass index categories for children and young people with Type 2 diabetes, 2016/17
to 2019/20
Total (n)
Underweight
(%)
Healthy
weight (%)
Overweight
(%)
Obese
(%)
2019/20
796
7.2*
8.7
84.2
2018/19
737
7.6*
7.7
84.7
2017/18
677
0.0
5.9
9.5
84.6
2016/17
658
6.5*
8.1
85.4

*results merged to mask number <5

71
NPDA National report 2019/20: Care processes and outcomes
Healthy Weight
Overweight
Obese
Boys
6.4%
7.8%
85.4%
Girls
7.2%
9.1%
83.5%
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 58: Percentage of children and young people with Type 2 diabetes who were in healthy
weight, overweight or obese category by sex, 2019/20

72
NPDA National report 2019/20: Care processes and outcomes
3.7 Psychological assessment

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

There were 21,909 (79.2%) children and young people with Type 1 diabetes recorded as having a
psychological screening assessment within the audit period, 96.5% (n=21,137) of whom had a known
outcome of the assessment recorded. Of these, 43.9% (n=9,283) 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 2018/19.

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 – 2019/20
England and Wales
No. of children and young
people with a known outcome
of psychological assessment
Required
additional support
(n)
Required
additional support
(%)
2019/20
21,137
9,283
43.9
2018/19
20,852
8,153
39.1
2017/18
20,114
5,672
28.2

Figure 59 shows that 43.9% of children and young people in England and Wales were recorded as
requiring additional psychological support or CAMHS. The percentage varied across regions.

73
NPDA National report 2019/20: Care processes and outcomes
43.9%
43.1%
61.8%
58.0%
49.7%
49.4%
49.4%
34.4%
36.9%
27.7%
47.4%
29.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
England and Wales
England
Wales
East Midlands
East of England
London and South East
North East and North Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
% of children and young people with Type 1 diabetes

Figure 59: Percentage of children and young people with Type 1 diabetes assessed as requiring
additional psychological support by country and region, 2019/20

Figure 60 shows that the percentage of younger boys and girls assessed as requiring additional
psychological support varied up to age 12. Rates diverged thereafter as more adolescent girls
were recorded as requiring additional support compared to adolescent boys.
0-1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19-
22
Boys
44.1
42.6 40.7 38.0 38.4
42.4
42.6
43.7 43.0 40.8 43.6 44.8 40.5 42.9 44.0 39.9
41.0
32.1
40.0
Girls
49.1
42.7
44.7
34.5
41.0
40.7
41.5
45.1
44.9
42.5
47.8
45.2 49.9 48.4 50.7 48.8 43.4
42.9 48.6
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
% of children and young people
with Type 1 diabetes
Age and sex

Figure 60: Percentage of children and young people with Type 1 diabetes who were assessed as
requiring additional psychological support by age and sex, 2019/20

74
NPDA National report 2019/20: Care processes and outcomes

Figure 61 shows that the percentage of children and young people with Type 1 who were assessed
as requiring additional psychological support was highest amongst those recently diagnosed.
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
% requiring additional
psychological support
53.0%
42.7%
41.3%
41.2%
42.2%
41.5%
0%
10%
20%
30%
40%
50%
% of children and young people
with Type 1 diabetes
Duration of diabetes

Figure 61: Percentage of children and young people with Type 1 diabetes assessed as requiring
additional psychological support by duration of Type 1 diabetes, 2019/20

Figure 62 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.
The figure also shows that the percentage varied across different levels of deprivation.
37.9%
43.3%
46.2%
49.9%
50.2%
44.6%
45.9%
44.6%
41.0%
43.1%
0%
10%
20%
30%
40%
50%
60%
Asian
White
Black
Other
Mixed
Most
Second
most
Third least
Second
least
Least
Ethnicity
Deprivation
% of children and young people with
Type 1 Diabetes

Figure 62: 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 ethnic
category and deprivation quintile, 2019/20

75
NPDA National report 2019/20: Care processes and outcomes

Figure 63 shows that children and young people with Type 1 diabetes who required additional
psychological support were more likely to have an HbA1c in the higher target range compared to
those who did not require additional psychological support.
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
Required additional
psychological support
Did not require additional
psychological support

Figure 63: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by outcome of psychological assessment, 2019/20
3.7.2 Psychological outcomes of children and young people
with Type 2 diabetes

There were 559 (64.5%) children and young people with Type 2 diabetes recorded as receiving a
psychological assessment within the audit period, 534 (95.5%) of whom had a known outcome of
the assessment recorded.

Of the children and young people with Type 2 diabetes with a known result, more than half (53.6%)
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 of children and young people with Type 2 diabetes by country, 2017/18 to
2019/20
England and Wales
No. of children and young
people with a known outcome
of psychological assessment
Required
additional support
(n)
Required
additional support
(%)
2019/20
534
286
53.6
2018/19
457
208
45.5
2017/18
417
126
30.2

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NPDA National report 2019/20: Care processes and outcomes
3.8 Hospital Admissions

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

Results in this section are presented for children and young people with Type 1 diabetes only due
to small numbers with other types of diabetes. In 2019/20, 155 out of 166 PDUs submitted admission
data for children and young people with Type 1 diabetes. There were 5,978 diabetes-related
admissions within the 2019/20 audit year reported for 4,631 children and young people with Type 1
diabetes.
3.8.1 Type 1 Diabetes-related admissions

Table 36 shows the percentage of children and young people with Type 1 diabetes being managed
within PDUs who submitted admissions data, who were admitted at least once with a diabetes-
related admission, not associated with diagnosis, within the audit year.

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, 2019/20
No. of
children
and
young
people
with T1
diabetes*
DKA
(%)
Hypogly­
caemia
(%)
Ketosis
without
Acidosis
(%)
Stabilisa­
tion
(%)
Other
(incl.
surgery)
(%)
England and Wales
26,455
2.5%
1.1%
1.2%
2.1%
4.8%
England
25,044
2.5%
1.1%
1.1%
2.1%
4.8%
Wales
1,411
2.5%
1.8%
2.6%
2.3%
5.5%
East Midlands
1,886
1.3%
0.5%
0.4%
2.9%
2.6%
East of England
2,975
3.9%
1.4%
1.4%
1.8%
6.5%
London and South East
5,632
2.4%
1.0%
0.8%
1.6%
3.5%
North East and North Cumbria
1,544
2.5%
1.0%
0.7%
1.2%
3.2%
North West
3,316
2.3%
0.8%
1.4%
1.6%
5.8%
South Central
2,625
2.2%
1.6%
1.1%
2.7%
6.6%
South West
2,059
2.7%
1.2%
1.7%
2.4%
5.5%
West Midlands
2,418
2.1%
1.2%
1.2%
2.5%
5.1%
Yorkshire and Humber
2,589
3.1%
1.2%
1.2%
2.7%
4.0%

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

77
NPDA National report 2019/20: Care processes and outcomes
3.8.2 DKA at diagnosis

Figure 64 shows that for England and Wales combined, 22.9% of the newly diagnosed patients
being managed by PDUs submitting admissions data in 2019/20 (n = 2,829), 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 (20.9%) reported for
2018/19. 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 2019/20 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.
22.9%
22.8%
25.9%
17.5%
22.4%
27.0%
12.4%
12.7%
21.4%
33.5%
18.3%
34.0%
0%
10%
20%
30%
40%
England and Wales
England
Wales
East of England
East Midlands
London and South East
North East and North Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
% of children and young people with Type 1 diabetes

Figure 64: Percentage of children and young people with Type 1 diabetes who had DKA at diagnosis
in 2019/20, by region and country

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NPDA National report 2019/20: Care processes and outcomes
4. 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 recorded is used for the analysis.
4.1 Treatment regimens
4.1.1 Treatment regimens of children and young people with
Type 1 diabetes

There were 26,876 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, on a treatment regimen,
by country and region, 2019/20
No. of children
and young
people with T1
diabetes*
1 – 3 Insulin
Injections*
(%)
4 or more
Insulin
Injections*
(%)
Insulin Pump
Therapy*
(%)
England and Wales
26,876
2.7%
59.3%
38.0%
England
25,487
2.8%
59.3%
37.9%
Wales
1,389
0.8%
59.8%
39.4%
East Midlands
1,828
1.9%
54.6%
43.5%
East of England
2,914
1.3%
67.8%
30.9%
London and South East
5,834
4.2%
54.0%
41.8%
North East and North Cumbria
1,585
2.6%
53.1%
44.3%
North West
3,315
4.3%
58.7%
37.1%
South Central
2,578
2.0%
59.7%
38.3%
South West
1,977
1.0%
67.9%
31.2%
West Midlands
2,922
3.7%
62.6%
33.8%
Yorkshire and Humber
2,534
1.4%
58.5%
40.1%

* In England and Wales, 0.8% of children and young people with Type 1 Diabetes using Insulin Injections, also use other Blood Glucose
Lowering Medication (BGLM). Whereas 0.2% of children and young people using Insulin Pump Therapy use other BGLM.

Figure 65 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 National report 2019/20: Care processes and outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
% of children and young people with Type 1
diabetes
Age
Insulin pump therapy (boys)
Insulin pump therapy (girls)
Insulin injections (boys)
Insulin injections (girls)

Figure 65: Percentage of children and young people with Type 1 diabetes recorded as using insulin
injections or insulin pump therapy by age and sex, 2019/20

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 66).


0%
10%
20%
30%
40%
50%
60%
70%
80%
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
% 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 66: Percentage of children and young people either on daily insulin injections or pump
therapy by age group, 2014/15 to 2019/20

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NPDA National report 2019/20: Care processes and outcomes

Insulin pump usage increases with duration of diabetes (Figure 66) with three-quarters (75.2%) of
those in their first year of diagnosis of Type 1 diabetes using insulin injections, compared to just
over half (51.8%) of those after 5 to 9 years post diagnosis.
75.2%
65.0%
56.4%
51.8%
52.6%
57.2%
24.8%
35.0%
43.6%
48.2%
47.4%
42.8%
0%
20%
40%
60%
80%
100%
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
% of children and young people
with Type 1 diabetes
Duration of diabetes
Insulin injections
Insulin pump

Figure 67: Percentage of children and young people either on daily insulin injections or pump
therapy by duration of diabetes for England and Wales, 2019/20

Figure 68 shows that white children and young people were more likely to be using a pump
compared to Asian and Black ethnic groups. Insulin pump therapy usage is also more prevalent in
those living in the least deprived compared to the most deprived areas of the country.
39.8%
35.0%
34.9%
29.7%
26.7%
31.7%
35.8%
37.5%
42.4%
44.3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
White
Other
Mixed
Asian
Black
Most
Second
most
Third
least
Second
least
Least
Ethnicity
Deprivation
% children and young people with
Type 1 Diabetes

Figure 68: Percentage of children and young people with Type 1 Diabetes using Insulin Pump
Therapy by ethnic group and deprivation, 2019/20

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NPDA National report 2019/20: Care processes and outcomes

Figure 68 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 2019/20 the gap had widened
to 31.7% versus 44.3%, respectively (a difference of 12.6 percentage points). However, the discrepancy
has decreased from 2018/19, when there was a 13.4% difference.
0%
10%
20%
30%
40%
50%
60%
70%
80%
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
% of children and young people with Type 1
diabetes
Audit year
Most deprived - Insulin injections
Most deprived - Insulin pump therapy
Least deprived - Insulin injections
Least deprived - Insulin pump therapy
12.6% difference pump usage
least to most deprived
7.9% difference pump usage
least to most deprived

Figure 69: 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 2019/20

Figure 70 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.

82
NPDA National report 2019/20: Care processes and outcomes
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
Insulin injections
Insulin pump therapy

Figure 70: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by treatment regimen, 2019/20
4.1.2 Treatment regimens 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 23.8% of children and young
people with Type 2 diabetes.

The majority of those with Type 2 diabetes were either managing their diabetes with diet alone (11.8%)
or in combination with another blood glucose lowering agent (45.9%). 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, England and Wales, 2018/19 and 2019/20
Treatment regimen
2018/19
2019/20
No. of children and young people with Type 2 diabetes with
a recorded treatment regimen (n)
639
660
Dietary management
Only (%)
12.5
11.8
And other BGLM† (%)
50.4
45.9
1 to 3 insulin injections
Only (%)
4.4
4.2
And other BGLM† (%)
10.6
13.2
4 or more insulin
injections
Only (%)
10.0
14.1
And other BGLM† (%)
9.2
9.7
insulin pump
Only (%)
2.8 *
1.1 *
And other BGLM† (%)

* Results merged to mask number <5 † And other blood glucose lowering medication

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NPDA National report 2019/20: Care processes and outcomes
4.2 Real Time Continuous glucose monitoring
(rtCGM)
4.2.1 rtCGM use among children and young people with Type
1 diabetes

There were 24,289 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, 19.4% were using
rtCGM in England and Wales (Figure 71, an increase of 6.8% with respect to 2018/19. These results
should be interpreted with caution given that 12.2% (n = 3,364) of children and young people with
Type 1 diabetes had an unknown or missing entry; percentages of missing data also varied by region.
19.4%
19.0%
25.9%
16.7%
15.5%
19.6%
23.8%
19.7%
22.7%
14.0%
21.8%
15.6%
0%
3%
6%
9%
12%
15%
18%
21%
24%
27%
30%
England and Wales
England
Wales
East Midlands
East of England
London and South East
North East and North Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
% of children and young people with Type 1 diabetes

Figure 71: Percentage of children and young people with Type 1 diabetes using rtCGM with alarms
by country and regional network, 2019/20

Figure 72 shows that younger children with Type 1 diabetes were more likely to be using rtCGM
than those who were older.

84
NPDA National report 2019/20: Care processes and outcomes
0 – 4 years
5 – 9 years
10 – 14 years
15 – 19 years
Boys
49.5%
28.2%
17.6%
10.7%
Girls
47.0%
27.9%
17.5%
10.7%
0%
10%
20%
30%
40%
50%
60%
% of children and young people with
Type 1 diabetes
Age and sex

Figure 72: Percentage of children and young people with Type 1 diabetes using a real-time
continuous glucose monitor (CGM) with alarms by age and sex, 2019/20

Figure 73 shows that rtCGM was more likely to be used in the first 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
22.4%
21.7%
21.6%
18.8%
14.9%
12.9%
0%
5%
10%
15%
20%
25%
% of young people with Type 1
diabetes
Duration of diabetes

Figure 73: Percentage of children and young people with Type 1 diabetes using a rtCGM by duration
of Type 1 diabetes, 2019/20

Figure 74 shows that White ethnicity was associated with higher rtCGM usage. Whereas children
and young people with Type 1 diabetes living in the least deprived areas were almost as twice as
likely to be using rtCGM compared to those living in the most deprived areas.

85
NPDA National report 2019/20: Care processes and outcomes
20.2%
18.5%
16.0%
15.1%
11.7%
14.0%
17.3%
19.3%
22.3%
25.2%
0%
5%
10%
15%
20%
25%
30%
White
Mixed
Other
Asian
Black
Most
Second
most
Third
least
Second
least
Least
Ethnicity
Deprivation
% children and young people with
Type 1 Diabetes

Figure 74: Percentage of children and young people with Type 1 Diabetes using a rtCGM by ethnic
group and deprivation, 2019/20

Figure 75 shows the usage of rtCGM by ethnic group and deprivation.
19.4%
0%
10%
20%
30%
White
Asian
Black
Mixed
Other
% children and young people with Type 1
Diabetes
National mean
Most deprived
Second most deprived
Third least deprived
Second least deprived
Least deprived

Figure 75: Percentage of children and young people with Type 1 Diabetes using a rtCGM by ethnic
group and deprivation, 2019/20

Figure 76 shows that despite increases in rtCGM usage in all quintiles of deprivation, the gap
between the most and least deprived areas has widened with time.

86
NPDA National report 2019/20: Care processes and outcomes
2017/18
2018/19
2019/20
Most deprived - CGM
6.1%
8.2%
14.0%
Least deprived - CGM
12.8%
16.1%
25.2%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Percentge of children and young
people with Type 1 diabetes
Audit year
6.7% difference rtCGM usage
least to most deprived
11.2% difference rtCGM usage
least to most deprived

Figure 76: Percentage of children and young people with Type 1 diabetes using a real-time
continuous glucose monitor (CGM) by ‘least’ and ‘most’ deprived quintile, 2017/18 to 2019/20

Figure 77 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 77: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by rtCGM usage, 2019/20

87
NPDA National report 2019/20: Care processes and outcomes

Figure 78 shows that rtCGM was more prevalent amongst pump users than those using insulin
injections.
35.0%
9.3%
65.0%
90.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Insulin Pump Therapy
Insulin injections
using CGM
not using CGM

Figure 78: Percentage of children and young people with Type 1 diabetes using insulin injections
or insulin pump therapy by rtCGM usage, 2019/20

Figure 79 shows an increase in the use of rtCGM in combination with insulin pump and insulin
injections, for both England and Wales.

60.0%
57.6%
54.8%
59.9%
57.6%
54.9%
62.0%
56.9%
53.0%
2.3%
3.2%
5.6%
2.1%
2.9%
5.5%
4.3%
7.6%
7.6%
30.5%
29.8%
25.7%
30.8%
30.1%
26.0%
26.0%
24.5%
21.0%
7.2%
9.5%
13.8%
7.1%
9.4%
13.6%
7.8%
11.0%
18.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
17/18
18/19
19/20
17/18
18/19
19/20
17/18
18/19
19/20
England and Wales
England
Wales
Injections alone
Injections and rtCGM
Pump alone
Pump and rtCGM
Figure 79: Percentage of children and young people with Type 1 diabetes using insulin injections
alone, insulin injections and rtCGM, insulin pump alone, insulin pump and rtCGM, by country,
2017/18 to 2019/20

88
NPDA National report 2019/20: Care processes and outcomes

Figure 80 shows that children and young people with Type 1 diabetes using a combination of
insulin pump and real time continues glucose monitoring (rtCGM) have the lowest median HbA1c
(56.0 mmol/mol) compared to injections plus rtCGM (59.0 mmol/mol), pump alone (61.0 mmol/
mol) and injections alone (64.5 mmol/mol). The group using pump and rtCGM also shows lower
variation, with 50% of children presenting HbA1c values between 51.0 and 62.5 mmol/mol, and
outliers between 78.5 and 124 mmol/mol. In contrast, the group showing greater variation of HbA1c
values are those children using injections alone, with 50% of them presenting HbA1c values
between 56.0 and 76.5 mmol/mol, and outliers between 107.3 and 158 mmol/mol.
64.5
76.5
56.0
Median
75th percentile
25th percentile
IQR
Outliers
Outliers
(75th percentile + 1.5*IQR)
(25th percentile - 1.5*IQR)
52.0 59.0
67.0
54.5
61.0 68.0
51.0
56.0
62.0
78.5
34.5
88.3
34.3
89.5
29.5
107.3
25.3
27.9
124.0
30.0
135.0
24.0
130.0
21.0
158.0
0
50
100
150
HbA1c (mmol/mol)
Pump and rtCGM
Pump alone
Injections and rtCGM
Injections alone

(Median= vertical line within grey box, box= interquartile range, whiskers= outlier thresholds, dots= outliers)

Figure 80: Box and whiskers plot of HbA1c (mmol/mol) values for children and young people with
Type 1 diabetes by treatment and rtCGM usage, 2019/20
A boxplot is a standardized way of displaying the distribution of data based on a five number
summary (“minimum”, first quartile (Q1), median, third quartile (Q3), and “maximum”). It can
tell you about your outliers and what their values are. It can also tell you if your data is
symmetrical, how tightly your data is grouped, and if and how your data is skewed.

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NPDA National report 2019/20: Care processes and outcomes
5. Thyroid and coeliac disease
5.1 Thyroid and coeliac disease amongst children
and young people with Type 1 diabetes

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

Table 39 shows that the prevalence of Thyroid disease in 2019/20 for children and young people
with Type 1 diabetes was 3.1%, and 5.8% of children and young people with Type 1 diabetes had
coeliac disease. The figure for coeliac disease is lower compared to 2018/19 (6.5%) (Figure 80), but
higher compared to an international collaborative study that found a prevalence rate of 3.5% across
three continents (Craig et al., 2017).

Table 39: Percentage of children and young people with Type 1 diabetes with thyroid or coeliac
disease by country and region in England and Wales, 2019/20
No. of children and
young people with
Type 1 diabetes
Thyroid disease
(%)
Coeliac disease
(%)
England and Wales
27,653
3.1
5.8
England
26,242
3.1
5.7
Wales
1,411
3.2
7.2
East Midlands
1,937
3.7
6.1
East of England
2,975
3.6
6.4
London and South East
6,012
3.1
5.3
North East and North Cumbria
1,599
3.9
4.4
North West
3,451
2.1
6.0
South Central
2,625
2.4
6.6
South West
2,059
3.9
4.9
West Midlands
2,995
2.6
5.6
Yorkshire and Humber
2,589
3.3
6.1

Figure 81 shows year on year variation in prevalence of thyroid and coeliac disease. In 2019/20 the
prevalence of coeliac disease decreased for the first time since 2015/16.

90
NPDA National report 2019/20: Care processes and outcomes
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
Thyroid
3.2%
3.5%
2.6%
3.0%
3.3%
3.1%
Coeliac
4.7%
4.0%
4.4%
5.6%
6.5%
5.8%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
% of children and young people with
Type 1 diabetes
Audit year

Figure 81: Percentage of children and young people with Type 1 diabetes with thyroid or coeliac
disease in England and Wales, 2014/15 to 2019/20

Figure 81 shows that there was a higher prevalence of both autoimmune conditions amongst girls
compared to boys.
4.2%
4.5%
4.3%
1.9%
2.2%
2.0%
6.6%
7.8%
7.0%
4.6%
5.3%
4.7%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
Girls
Boys
Girls
Boys
% of children and young people with
Type 1 diabetes

Figure 82: Percentage of children and young people with Type 1 diabetes and comorbid coeliac or
thyroid disease by sex, 2016/17 to 2019/20

91
NPDA National report 2019/20: Care processes and outcomes

Coeliac disease prevalence was slightly higher amongst children and young people with Type 1
diabetes living in the least deprived areas compared to the most deprived areas, but there was no
clear association between prevalence of Thyroid disease and areas of deprivation (Figure 83).
Most deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least deprived
Thyroid
2.9%
3.5%
2.9%
3.0%
3.1%
Coeliac
5.0%
5.4%
5.8%
6.7%
6.2%
0%
1%
2%
3%
4%
5%
6%
7%
8%
% of children and young people
with Type 1 diabetes
Deprivation Quintile

Figure 83: Percentage of children and young people with Type 1 diabetes and coeliac or thyroid
disease by deprivation quintile, 2019/20

Figure 84 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
3.1%
4.7%
1.6%
2.4%
3.7%
Coeliac
6.1%
5.6%
2.8%
3.9%
4.4%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
% of children and young people with
Type 1 diabetes
Thyroid
Coeliac

Figure 84: Percentage of children and young people with Type 1 diabetes and coeliac or thyroid
disease by ethnic group, 2019/20

92
NPDA National report 2019/20: Care processes and outcomes
6. References

Anderzen, J, Hermann, JA, Samuelsson, U et al. (2020) International benchmarking in type 1
diabetes: Large difference in childhood HbA1c between eight high‐income countries but similar
rise during adolescence – A quality registry study. Paediatric Diabetes 20(4): 621-627

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

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

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

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

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

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

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

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

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

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

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

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

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

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

93
NPDA National report 2019/20: Care processes and outcomes
7. List of tables
Table 1: Number of children and young people
with diabetes by age-group and type of
diabetes in 2019/20
6
Table 2: Number of children and young people
with Type 1 diabetes by country, region and age
group, 2019/20
8
Table 3: Ethnic groups of children and young
people with Type 1 diabetes in England and
Wales, 2019/20
8
Table 4: Percentage and number of children and
young people with Type 1 diabetes by deprivation
quintile, 2019/20
10
Table 5: Number of children and young people
included in the audit with Type 2 diabetes by
country and region, 2019/20 and 2018/19
16
Table 6: Ethnic group of children and young
people with Type 2 diabetes England and Wales,
2018/19 and 2019/20
17
Table 7: Numbers and percentages of children and
young people with Type 2 diabetes by deprivation
quintile, 2019/20
17
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 2019/20
19
Table 9: Percentage of children and young people
of all ages with Type 1 diabetes who completed a
full year of care recorded as having received
health checks by country and region, 2019/20
21
Table 10: Percentage of young people aged 12 and
above with Type 1 diabetes who completed a full
year of care recorded as having received health
checks by country and region, 2019/20
23
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
2019/20, by country and region
25
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, 2019/20
26
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, 2019/20
28
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, 2019/20
29
Table 15: Percentage of children and young
people with Type 1 diabetes who received
screening within 90 days of diagnosis by
country and region, 2019/20
30
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, 2019/20
32
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 2019/20
33
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,
2017/18 to 2019/20
38
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,
2017/18 to 2019/20
35
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, 2017/18 to 2019/20
35

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NPDA National report 2019/20: Care processes and outcomes
Table 21: HbA1c for all children and young people
with all types of diabetes and one or more valid
HbA1c measurements by country and regional
network, 2019/20
38
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, 2019/20
40
Table 23: Percentage of children and young people
with Type 1 diabetes achieving HbA1c targets by
country and regional network, 2019/20
42
Table 24: Mean HbA1c for children and young
people with Type 1 diabetes by ethnicity and
deprivation, 2019/20 *
45
Table 25: Mean HbA1c for children and young
people with Type 1 diabetes by ethnicity, 2019/20 46
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- 2019/20
51
Table 27: Percentage of young people with
Type 1 diabetes aged 12 years and above with
albuminuria, 2015/16 to 2019/20
55
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
2019/20

59
Table 29: Percentage of young people with Type
1 diabetes aged 12 years and above falling within
blood pressure targets by country and region,
2019/20

63
Table 30: Percentage of young people with
Type 1 diabetes aged 12 years and above falling
within cholesterol targets by country and region,
2019/20

64
Table 31: Percentage of children and young
people with Type 2 diabetes with ‘high’ or
‘high-normal’ blood pressure, 2016/17 – 2019/20
65
Table 32: Percentage of children and young people
with Type 2 diabetes above cholesterol targets,
2016/17 – 2019/20
65
Table 33: Body mass index categories for
children and young people with Type 2
diabetes, 2016/17 to 2019/20
70
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 –
2019/20

72
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,
2017/18 to 2019/20
75
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, 2019/20
76
Table 37: Percentage of children and young
people with Type 1 Diabetes, on a treatment
regimen, by country and region, 2019/20
78
Table 38: Percentage of children and
young people with Type 2 diabetes using
each treatment regimen, England and Wales,
2018/19 and 2019/20
82
Table 39: Percentage of children and young
people with Type 1 diabetes with thyroid or
coeliac disease by country and region in
England and Wales, 2019/20
89

95
NPDA National report 2019/20: Care processes and outcomes
8. List of Figures
Figure 1: Numbers of children and young
people with Type 1 diabetes included in the NPDA
by age and sex, 2019/20 and total numbers 2018/19
and 2019/20.
7
Figure 2: Percentage of children and young people
with Type 1 diabetes by ethnic group and regional
network, 2019/20
9
Figure 3: Percentage of children and young people
with Type 1 diabetes by deprivation quintile and
regional network, 2019/20
10
Figure 4: Prevalence of Type 1 diabetes per 100,000
general population among children aged 0-15 by
age and sex, 2013/14 to 2019/20
11
Figure 5: Prevalence of Type 1 diabetes per
100,000 general population by age group and
sex, 2013/14 to 2019/20
11
Figure 6: Prevalence of Type 1 diabetes per
100,000 (population aged 0-15) by Clinical
Commissioning Group area
12
Figure 7: Newly diagnosed children and
young people with Type 1 diabetes by age
group and sex, 2019/20
12
Figure 8: Incidence of Type 1 diabetes per
100,000 general population among children
aged 0-15 by sex, 2013/14 to 2019/20
13
Figure 9: Incidence of Type 1 diabetes per 100,000
general population among children and young
people by age-group and sex, 2015/16 to 2019/20 13
Figure 10: Numbers of children and young
people with Type 2 diabetes included in the
NPDA, 2011/12- 2019/20
14
Figure 11: Numbers of children and young
people with Type 2 diabetes included in the
NPDA by age and sex, 2019/20 and changes in
numbers between 2018/19 and 2019/20.
15
Figure 12: Percentage of children and young
people who completed a full year of care
recorded as receiving individual health checks,
2004/05 to 2019/20
20
Figure 13: 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 2019/20
20
Figure 14: 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, 2019/20
23
Figure 15: 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, 2019/20
24
Figure 16: 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
2019/20.

25
Figure 17: 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
27
Figure 18: 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 to 2019/20
29
Figure 19: Percentage of newly diagnosed children
and young people with Type 1 diabetes who
received screening within 90 days of diagnosis,
2015/16 to 2019/20
31
Figure 20: 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 2019/20
33
Figure 21: Number of HbA1c measurements
recorded for children and young people with
Type 2 diabetes receiving a full year of care,
2016/17 – 2019/20
34
Figure 22: Median HbA1c for children and young
people with all types of diabetes in England and
Wales 2009/10 to 2019/20, with associated NHS
policy and/or paediatric diabetes delivery
structural changes.
39

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NPDA National report 2019/20: Care processes and outcomes
Figure 23: Distribution of HbA1c values
(mmol/mol) of children and young people with
Type 1 diabetes in England and Wales, 2009/10,
2014/15 and 2019/20
41
Figure 24: Percentage of children and young
people with Type 1 diabetes with an HbA1c result
within current and previous target ranges, 2010/11 –
2019/20

42
Figure 25: Mean HbA1c for boys and girls with
Type 1 diabetes, 2003/04 to 2019/20
43
Figure 26: Mean HbA1c for children and young
people with Type 1 diabetes, by age group and
duration of diabetes, 2019/20
44
Figure 27: Mean HbA1c for children and young
people with Type 1 diabetes in England and Wales
by ethnic group, 2003/04 to 2019/20
45
Figure 28: Percentage of children and young
people with Type 1 diabetes in England and Wales
achieving HbA1c targets by ethnic group,
2019/20

46
Figure 29: Mean HbA1c for children and young
people with Type 1 diabetes by deprivation
quintile, 2013/14 to 2019/20
47
Figure 30: Percentage of children and young
people with Type 1 diabetes in England and Wales
achieving HbA1c targets by deprivation quintiles,
2019/20

48
Figure 31: Funnel plot of mean adjusted HbA1c for
children and young people with Type 1 diabetes
in England and Wales by PDU, 2019/20.
49
Figure 32: 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, 2019/20.
49
Figure 33: 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, 2019/20.
50
Figure 34: Percentage of children and young
people with Type 2 diabetes with an HbA1c
resultwithin current and previous target ranges,
2017/18 – 2019/20
51
Figure 35: Mean HbA1c for boys and girls with
Type 2 diabetes, 2017/18 to 2019/20
52
Figure 36: Mean HbA1c for children and young
people with Type 2 diabetes, by age group and
duration of diabetes, 2019/20
52
Figure 37: Mean HbA1c for children and young
people with Type 2 diabetes in England and Wales
by deprivation quintile, 2015/16 to 2019/20
53
Figure 38: Mean HbA1c for children and young
people with Type 2 diabetes in England and
Wales by ethnic group, 2015/16 to 2019/20
54
Figure 39: Percentage of young people with Type 1
diabetes aged 12 years and older with albuminuria
by country and region, 2019/20
55
Figure 40: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by duration of diabetes, 2016/17 – 2019/20
56
Figure 41: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by age and sex, 2019/20
56
Figure 42: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by deprivation quintile, 2016/17 – 2019/20
57
Figure 43: Percentage of young people with Type
1 diabetes achieving HbA1c targets by presence of
albuminuria, 2019/20
57
Figure 44: Percentage of children and young
people with Type 2 diabetes with albuminuria in
England and Wales, 2015/16 – 2019/20
58
Figure 45: Percentages of young people with Type
1 diabetes aged 12 years and older with normal/
abnormal retinopathy screening results by
country and region, 2019/20
59
Figure 46: Percentage of young people with Type 1
diabetes aged 12 years and older with
retinopathy by age and sex, 2019/20
60

97
NPDA National report 2019/20: Care processes and outcomes
Figure 47: Percentage of young people with Type 1
diabetes aged 12 years and older with abnormal
eye screening by duration of diabetes, 2019/20
60
Figure 48: Percentage of young people with Type 1
diabetes aged 12 years and older with an abnormal
eye screening result by deprivation quintile,
2019/20

61
Figure 49: Percentage of children and young
people with Type 1 diabetes with or without an
abnormal eye screening result achieving HbA1c
targets, 2019/20
61
Figure 50: Eye screening results for young people
aged 12 years and above with Type 2 diabetes,
2015/16 to 2019/20
62
Figure 51: 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
2019/20

64
Figure 52: Percentage of obese and overweight
children with diabetes, aged 4 to 5 and age 10
to 11 years old, and the percentage of obese and
overweight children in the wider population by
country, 2015/16 to 2019/20
66
Figure 53: Percentage of children aged 0-11 years
with Type 1 diabetes within BMI categories by
country and region, 2019/20
67
Figure 54: Percentage of young people 12
years and older with Type 1 diabetes within BMI
categories by country and region, 2019/20
67
Figure 55: Distribution of body mass index of
children and young people with Type 1 diabetes in
2015/16, 2017/18 and 2019/20 compared to the
1990 reference population
68
Figure 56: 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, 2019/20
69
Figure 57: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by Body Mass Index category,
2019/20

70
Figure 58: Percentage of children and young
people with Type 2 diabetes who were in healthy
weight, overweight or obese category by sex,
2019/20

71
Figure 59: Percentage of children and young
people with Type 1 diabetes assessed as requiring
additional psychological support by country and
region, 2019/20
73
Figure 60: Percentage of children and young
people with Type 1 diabetes who were assessed as
requiring additional psychological support by age
and sex, 2019/20
73
Figure 61: Percentage of children and young
people with Type 1 diabetes assessed as requiring
additional psychological support by duration of
Type 1 diabetes, 2019/20
74
Figure 62: 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 ethnic
category and deprivation quintile, 2019/20
74
Figure 63: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by outcome of psychological assessment,
2019/20

75
Figure 64: Percentage of children and young
people with Type 1 diabetes who had DKA at
diagnosis in 2019/20, by region and country
77
Figure 65: Percentage of children and young
people with Type 1 diabetes recorded as using
insulin injections or insulin pump therapy by age
and sex, 2019/20
79
Figure 66: Percentage of children and young
people either on daily insulin injections or pump
therapy by age group, 2014/15 to 2019/20
79
Figure 67: Percentage of children and young
people either on daily insulin injections or pump
therapy by duration of diabetes for England and
Wales, 2019/20
80
Figure 68: Percentage of children and young
people with Type 1 Diabetes using Insulin Pump
Therapy by ethnic group and deprivation, 2019/20

80

98
NPDA National report 2019/20: Care processes and outcomes
Figure 69: 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 2019/20
81
Figure 70: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by treatment regimen, 2019/20
82
Figure 71: Percentage of children and young
people with Type 1 diabetes using rtCGM with
alarms by country and regional network,
2019/20

83
Figure 72: Percentage of children and young
people with Type 1 diabetes using a real-time
continuous glucose monitor (CGM) with alarms
by age and sex, 2019/20
84
Figure 73: Percentage of children and young
people with Type 1 diabetes using a rtCGM by
duration of Type 1 diabetes, 2019/20
84
Figure 74: Percentage of children and young
people with Type 1 Diabetes using a rtCGM by
ethnic group and deprivation, 2019/20
85
Figure 75: Percentage of children and young
people with Type 1 Diabetes using a rtCGM by
ethnic group and deprivation, 2019/20
85
Figure 76: Percentage of children and young
people with Type 1 diabetes using a real-time
continuous glucose monitor (CGM) by ‘least’ and
‘most’ deprived quintile, 2017/18 to 2019/20
86
Figure 77: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by rtCGM usage, 2019/20
86
Figure 78: Percentage of children and young
people with Type 1 diabetes using insulin
injections or insulin pump therapy by rtCGM
usage, 2019/20
87
Figure 79: Percentage of children and young
people with Type 1 diabetes using insulin injections
alone, insulin injections and rtCGM, insulin pump
alone, insulin pump and rtCGM, by country,
2017/18 to 2019/20
87
Figure 80: Box and whiskers plot of HbA1c (mmol/
mol) values for children and young people with
Type 1 diabetes by treatment and rtCGM usage,
2019/20

88
Figure 81: Percentage of children and young
people with Type 1 diabetes with thyroid or coeliac
disease in England and Wales, 2014/15 to
2019/20

90
Figure 82: Percentage of children and young
people with Type 1 diabetes and comorbid coeliac
or thyroid disease by sex, 2016/17 to 2019/20
90
Figure 83: Percentage of children and young
people with Type 1 diabetes and coeliac or thyroid
disease by deprivation quintile, 2019/20
91
Figure 84: Percentage of children and young
people with Type 1 diabetes and coeliac or thyroid
disease by ethnic group, 2019/20
91

The Royal College of Paediatrics and Child Health (RCPCH) is a registered charity in England and Wales (1057744) and in
Scotland (SC038299).
Royal College of Paediatrics
and Child Health
5-11 Theobalds Road,
London, WC1X 8SH
Healthcare Quality
Improvement Partnership (HQIP)
Dawson House, 5 Jewry Street,
London EC3N 2EX
Royal College of
Paediatrics and Child Health
RCPCH
Published by RCPCH May 2021
National Paediatric Diabetes Audit (NPDA)
Annual report 2019-20
Care processes and outcomes
Appendix 1: Full audit analysis