Our Diabetes Partnership: Working together to deliver the best outcomes for people at risk of or living with any form of diabetes
This strategy is a living document that outlines our goals for diabetes prevention and care over the next six years. The Leeds Diabetes Steering Group will develop plans to achieve these goals and will review our priorities annually to ensure they meet the needs of people in Leeds.
We encourage you to read, share, and support this strategy.
Foreword
We are excited to introduce our Leeds Diabetes strategy. This is a team effort to prevent and manage diabetes in our community. We know it is important to involve everyone—individuals, families, healthcare providers, and community organisations.
Why This Matters
Diabetes affects millions of people worldwide, and Leeds is no exception. Whether it is type 1, type 2, or other forms of diabetes, the impact goes beyond physical health. It affects mental well-being, economic stability, and overall quality of life. But together, we can make a difference.
Our Commitment
This strategy is based on evidence, compassion, and inclusivity. We commit to:
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- Prevention: Educating our community about risk factors for cardiovascular disease and type 2 diabetes, healthy lifestyles, and early detection.
- Support: Providing resources for those living with diabetes, their families, and caregivers.
- Collaboration: Partnering with healthcare organisations, schools, workplaces, and faith-based groups to create a supportive environment that meets our community’s needs.
- Advocacy: Amplifying the voices of those affected by diabetes to drive change.
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Your Role
You are a crucial part of this strategy. Whether you are a neighbour, healthcare professional, community provider, or concerned friend, your actions matter.
Together, we can build a strong community where diabetes is easier to control and no longer a barrier to well-being.
Thank you for joining us on this important mission.
1. Introduction
Diabetes is a lifelong condition that makes a person’s blood sugar (glucose) level too high. While high blood sugar is the main issue, diabetes is more complex. Managing diabetes involves many factors, including clinical, psychological, social, and environmental aspects.
In Leeds, over 50,000 people live with diabetes (all types), and 48,000 are at high risk of type 2 diabetes. These numbers are growing. Diabetes can cause serious health problems like sight loss and heart disease.
This strategy aims to address health inequalities in Leeds and meet the rising demand for services. It focuses on the needs of all residents, especially those affected by poverty and inequalities, and aims to reduce pressure on health and care services.
We will focus on scalable, well-resourced actions to improve health outcomes, using national approaches like Core20PLUS5 to speed up progress.
Our goal is to become one of the top diabetes care providers in the country by working together. This involves enhancing collaboration among care providers and adopting a team approach that includes various specialties. We’ll keep track of our performance using established clinical measures and compare it to other successful diabetes services. We’ll also gather feedback from people living with diabetes to help us make necessary changes. Our aim is to improve both short-term and long-term outcomes for people with diabetes.
The goal of this strategy is to improve the quality and consistency of services based on population data, funding, and standards. A Leeds Diabetes Strategy will help achieve this through partnership. The city’s vision is for people to work together to deliver the best outcomes for those at risk of or living with diabetes.
1.1 Leeds Population
The Types of Diabetes
There are three main types of diabetes affecting the Leeds population:
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- Type 1 diabetes (T1D): An autoimmune disease that leads to little or no insulin being available to the body. About 8% of people with diabetes have T1D. In Leeds, over 4,500 people have T1D, including about 350 under 18 years old (Leeds ICB, 2024).
- Type 2 diabetes (T2D): A chronic condition with high blood sugar levels due to impaired insulin secretion or resistance. In Leeds, over 48,000 people have T2D, this includes people under 18 years old (Leeds ICB, 2024).
- Gestational Diabetes Mellitus (GDM): A condition during pregnancy where high blood sugar levels occur. This affects about 1,000 people in Leeds each year. Up to 50% of women with GDM develop T2D within 5 years of giving birth (NICE, NG3, 2020).
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Other types of diabetes exist in smaller populations, such as diabetes from pancreatic disease, type 3c, specific gene defects, Latent Autoimmune Diabetes in Adults (LADA), and drug-induced diabetes.
The High-Risk Population
Non-diabetic hyperglycaemia, also known as pre-diabetes, refers to raised blood sugar levels that are not in the diabetic range. People with this condition are at increased risk of developing type 2 diabetes and other cardiovascular conditions.
People at high risk of developing diabetes include those who have:
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- A blood test showing HbA1c levels between 42 and 48 mmol/mol.
- A Diabetes UK ‘Know your risk’ tool score greater than 16.
- A history of Gestational Diabetes Mellitus.
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The risk of T2D increases with age. People are more at risk if they are white and over 40, or over 25 if from an African-Caribbean, Black African, Chinese, or South Asian background. People are 2-6 times more likely to get T2D if they have a close family member with diabetes. High blood pressure, obesity, and being male also increase the risk. With the right support, up to 50% of T2D cases can be prevented or delayed.
1.2 The Leeds Geography
NHS Leeds Integrated Care Board includes 87 GP practices within 18 primary care networks (PCNs), which work together in Local Care Partnerships (LCPs) to provide coordinated health and social care. There are 15 LCPs in Leeds.
Over 870,000 people are registered with a GP in Leeds, with more than 170,000 living in highly deprived areas. These residents face multiple disadvantages, shorter lifespans, and more long-term health issues (Leeds Joint Strategic Assessment, 2018).
Leeds aims to tackle health inequalities, improve care quality, and address the needs of an ageing population. As a Marmot city since 2023, Leeds is partnering with the Institute of Health Equity to create a Fairer Leeds, focusing on reducing health disparities, especially in deprived areas.
1.3 The Diabetes Leeds Partnership
The Leeds Diabetes Partnership includes healthcare professionals working at board level and in community, primary, and secondary care, along with partners in Leeds City Council, third sector organisations, and the Leeds Health and Care Partnership.
Diabetes care covers a life-course approach, from early years and prevention to living with diabetes. In Leeds, our partnership includes:
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- Services already being delivered locally.
- New locality-based teams and the Integrated Care System (ICS).
- Leeds transformation work.
- Delivery of nationally commissioned/funded programmes at the local level.
- Additional pilot and test bed programmes to test innovative approaches.
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Our partnership aims to create sustainable improvements in the system to reduce variation.
1.4 Key Work Areas
In Leeds, there is significant potential to improve services in both traditional and innovative ways and contribute to national targets in areas such as:
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- Type 2 diabetes prevention.
- Diabetes remission.
- Kidney care.
- Lower limb care.
- Care processes delivery.
- Treatment target attainment.
- Diabetes self-management.
- Other multimorbidity management.
- Green agenda and reducing healthcare waste.
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2. Background
2.1 The Leeds Context
Diabetes diagnoses in England and Leeds have increased in recent years. Over a quarter of Leeds residents will develop diabetes in their lifetime. Currently, over 50,000 people in Leeds have diabetes, and 48,000 are at high risk (Leeds ICB, 2024). Some groups are more affected by diabetes (see Section 7). Diabetes and other health issues are also rising, with about half of those with diabetes experiencing frailty or being at the end of life.
In the past five years, complications leading to A&E visits and hospital admissions have slightly decreased (except for minor amputations). However, spending on diabetes medications has significantly increased, becoming the top drug expenditure in the local health economy, which is a challenge.
2.2 Communication
Communication is essential in health care. Every interaction, from making an appointment to understanding care instructions, depends on effective communication.
In Leeds, we are committed to person-centred care. Through conversations with local people, we know that our approach matters to them. As a result, Leeds has committed to the 3 Cs approach:
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- Better Communication with people
- Effective Coordination of health and care services
- Compassion in delivering health and care services
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This Diabetes Strategy is a live document, shaped by feedback from partners, people, and communities. This ensures we can respond to new developments.
2.3 The Cost of Diabetes
Diabetes is a significant cost to health systems, making up over 6% of the UK health budget. Complications from diabetes are the largest expense, with indirect costs like absenteeism and early mortality estimated at £3.3 billion in 21/22 (Hex, MacDonald, Pocock, 2024).
Leeds is committed to investing in diabetes prevention, care, and treatment to reduce future costs. Improved data capture and outcome tracking are key to this effort.
In the last four years, Leeds’ prescribing costs have risen by £5.5 million, with £2.1 million spent on glucose monitoring technology. Pharmacy expenses include drugs, testing strips, and other appliances. Leeds is open to initiatives like technology to improve cost efficiency, health outcomes, and reduce system burden.
2.4 The Personal Cost of Diabetes
Living with diabetes brings significant personal costs, including emotional and financial burdens. It can reduce quality of life due to complications and the need for constant self-monitoring and lifestyle changes.
A Quality-Adjusted Life Year (QALY) measures the value of medical interventions by considering both life quantity and quality. One QALY equals one year of perfect health.
Cost-effective diabetes treatments based on QALY analysis include self-management education, diabetes remission, exercise, continuous blood glucose monitoring (for type 1 diabetes), and medications for managing kidney disease and glucose levels (Siegel, Ali, Zhou, 2020).
These interventions improve health outcomes and provide value for money, highlighting the importance of integrated care strategies focused on prevention, early intervention, and continuous monitoring to enhance life quality for people with diabetes.
2.5 Multimorbidity
People with diabetes often have other health conditions (multimorbidity). Care for multimorbidity is complex due to interactions between conditions and treatments. In Leeds, common conditions with diabetes include hypertension, depression, cancer, liver disease, osteoarthritis, coronary heart disease, hypothyroidism, chronic kidney disease, and sleep apnoea. Fast-growing conditions include eye disease, liver disease, transient ischaemic attacks, metabolic disorders, fibromyalgia, learning disability, and obesity. In these cases, self-management approaches may need adapting for issues like cognition, physical dexterity, exercise tolerance, and dietary intake.
Leeds is committed to multi-disciplinary specialist meetings to discuss complex cases and ensure safe, consistent care. Leeds will continue to work in partnership to understand population data and lived experiences to improve health outcomes and system working.
2.6 Hospital Admissions
Emergency admissions (non-elective) to hospital make up the highest proportion of admissions. In 2019/20, there were 17,324 hospital admissions/attendances where the primary or secondary cause was diabetes-related; in 2023/24, there was an increase of 7,142 admissions (Leeds ICB, 2024).
Admissions can be avoided by identifying people at risk, primary care services interventions, encouraging better diet and exercise, improving self-monitoring and diabetes control, and supporting people and carers in managing diabetes at home. It needs local health and care services, including local third sector organisations, working effectively together to support people’s health and independence in the community.
3. Vision, Mission, and Goals
3.1 Our Vision
Working together to deliver the best outcomes for people at risk of or living with any form of diabetes.
3.2 Our Mission
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- Prevention: Educating our community about risk factors for cardiovascular disease and type 2 diabetes, healthy lifestyles, and early detection.
- Support: Providing resources for those living with diabetes, their families, and caregivers.
- Collaboration: Partnering with healthcare organisations, schools, workplaces, and faith-based groups to create a supportive environment.
- Advocacy: Amplifying the voices of those affected by diabetes to drive change.
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3.3 Overarching Goals
To achieve our vision, we aim to:
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- Improve early identification of diabetes, cardiovascular disease and those at high risk of developing type 2 diabetes.
- Reduce the number of people at high risk progressing to Type 2 diabetes and, increasing remission rates.
- Improve patient outcomes by optimising care and reducing unnecessary variations.
- Increase the number of people actively managing their condition, treatment, and using technology.
- Provide cost-effective care using population health management approaches.
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3.4 How Do We Achieve It?
The Diabetes Leeds Partnership and the West Yorkshire Integrated Care Board aim to optimise resources for diabetes care and seize opportunities to improve outcomes.
Key actions include:
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- Collaborating with ICS, place-based teams, providers, and other stakeholders.
- Engaging with Leeds’ diverse population through various formats and sectors.
- Providing services universally, with more resources directed to areas with greater needs.
- Reducing preventable complications from poor diabetes management by focusing on regular check-ups, monitoring, and managing risk factors.
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4. Identification and Prevention of Diabetes
4.1 Prevention of Type 2 Diabetes
Diabetes rates have gone up a lot. This is partly because people are living longer, and type 2 diabetes is more common as people age. However, lifestyle changes can also prevent it. Reversing this trend could help fight type 2 diabetes and reduce deaths. Even small changes, like following the national Eatwell Guide and being more active, can help lower the number of type 2 diabetes cases. Leeds will keep working with organisations to prevent type 2 diabetes.
4.2 Identifying Those at Risk of Type 2 Diabetes
More people are being identified early when their blood sugar starts to get worse, which can lead to type 2 diabetes. This is done through systematic checks (like the NHS Health Check Programme) and opportunistic checks (like during hospital visits, high blood pressure, gum disease, or eye changes).
People with high blood sugar levels and non-diabetic hyperglycaemia are at higher risk of developing type 2 diabetes and heart disease, even if they do not develop diabetes.
To improve identification, we will support collaborations with pharmacies, opticians, and dentists. This will include point-of-care testing to find people at risk of type 2 diabetes and those with undiagnosed type 2 diabetes.
4.3 NHS Health Checks
The Global Burden of Disease Study shows that many long-term conditions can be avoided, with 85% of heart disease being preventable. The NHS Health Check invites adults aged 40-74 in England for a check-up every five years to screen for conditions like heart disease, diabetes, kidney disease, and stroke. The aim is to reduce heart disease, health inequalities, and help people manage their heart health through lifestyle changes and access to services.
Since 2019, over 76,000 NHS Health Checks in Leeds have identified 2,010 people at high risk of heart disease, 5,418 at high risk of diabetes, and 3,876 with long-term conditions. Encouragingly, 51% of these people are from high-risk groups, helping to reduce heart disease inequalities.
Following a review, the vision for the Leeds NHS Health Check programme is to offer timely, quality, person-centred checks with high uptake from those most likely to benefit. The programme aims to increase accessibility and reduce health inequalities through flexible appointments, community promotion, and outreach models.
The programme will implement initiatives to empower people, reduce health inequalities, and provide access to wellness initiatives. Partnership working across the Health and Care system and with third sector organisations will ensure better access for communities across Leeds.
GP practices will be supported to identify people at risk of type 2 diabetes. Annual reviews and referrals to the ‘Healthier You’ programme will help manage non-diabetic hyperglycaemia and early type 2 diabetes, reducing heart disease event rates and deaths.
4.4 Diagnostic Uncertainty
Diabetes is a complicated condition with many different forms. Many types of diabetes share similar features, making diagnosis difficult. Sometimes, as the disease develops, a person’s diagnosis can change, or they can be diagnosed with more than one type of diabetes.
It is important to get the diagnosis right to ensure early referral to the right services at the right time for optimal management. Diabetes Leeds is committed to adopting the latest diagnostic tests and improving the skills, knowledge, and confidence of clinicians in identifying cases with diagnostic uncertainty. Efforts will also be made to ensure people are correctly coded in the GP record, sometimes needing more than one diagnostic code.
4.5 Behavioural Interventions
To achieve a sustainable healthcare system, many countries, including England, are focusing on disease prevention and population-level interventions. These are being implemented at scale to help people at high risk of type 2 diabetes change their risk.
Healthier You, the NHS type 2 diabetes prevention programme (NDPP), is a joint effort by NHS England, Public Health England, and Diabetes UK. It aims to reduce the risk of developing type 2 diabetes through evidence-based behavioural interventions. 17,000 people in Leeds are eligible for this programme. Currently, 4,000 places are offered annually in Leeds. Referrals can be made by GPs.
Leeds NDPP data shows an average weight reduction of 4.7 kg after six months. Each kilogram of weight lost reduces type 2 diabetes risk by 16% (Hamman, Wing, Edelstein, 2006). Evidence suggests the programme’s effects diminish over time without follow-up. Therefore, refresher sessions will be considered to sustain improvements.
Public Health prioritises reviewing high-risk populations, including gestational diabetes and NDPP data in Leeds to ensure fair access and set future priorities.
5. Optimal Management of Diabetes
5.1 Workforce
To provide safe and high-quality diabetes care, we need careful planning to ensure we have enough staff. This includes creating care models, training the workforce, and providing education, in line with the NHS Long Term Workforce Plan.
Diabetes Leeds will continue to test and learn from different workforce models to meet the needs of the population. Successful strategies include email advice, guidance, and multidisciplinary team (MDT) clinical drop-in sessions.
5.2 Measuring Quality of Care
Quality of care can be measured in different ways. The National Diabetes Audit (NDA) measures quality by the number of people meeting treatment targets (blood pressure, cholesterol and blood glucose levels (HbA1c)). However, NICE suggests many people with diabetes should aim for lower levels than those used by the NDA.
In the last five years, treatment target management has improved by 3% for people with T1D and stayed the same for T2D (Leeds ICB, 2024). The Leeds Medicines Optimisation Team will create local guidelines for managing diabetes and monitor these guidelines to reduce variation and ensure fairness across West Yorkshire ICB.
Person-centred and connected care will continue to be a focus in improving quality of care.
5.3 Information and Structured Education
Structured diabetes education helps people manage their condition, leading to better health, fewer complications, and improved quality of life. Education should be recommended at diagnosis, emphasising its importance alongside drug therapy. Carers and those living with people with diabetes will be encouraged to attend.
Leeds’ Type 2 Diabetes Structured Education programme (LEEDS Programme) has seen a 17% increase in six years, with over 2,000 referrals in 2023/24, but only 20% complete the course.
For Type 1 Diabetes, Leeds offers DAFNE (Dose Adjustment for Normal Eating) and is exploring VICTOR (Varying Insulin Doses for Changes to Routine) for adults with type 2 diabetes using insulin.
Recent projects have highlighted to need to improve:
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- Education reach through GP practices, employers, and community organisations.
- Access to diabetes information related to poverty.
- Support in accessing diabetes technology.
- Physical activity levels.
- Commitments to the green agenda (e.g., plant diets, reducing medical waste).
- Awareness of test results.
- Inclusion of at-risk individuals in T2D education, especially those facing challenges accessing the NDPP.
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Leeds will continue to provide high-quality information through various channels, including DiabetesLeeds.co.uk, NHS digital offers, and local offers like LEEDS Programme, DAFNE, Confidence with Carbohydrates, and DigiBete (for those under 40 years old).
Structured education will be available to all, focusing on newly diagnosed individuals, those who have not attended before, and those out of recommended targets. An ‘opt-out’ approach will be adopted to improve attendance, making education an integral part of diabetes management. Collaboration with the third sector will address access challenges and support attendance.
Refresher courses, including digital options, will help sustain lifestyle changes and treatment compliance. For those requiring insulin, a structured programme will be provided, like other type 2 diabetes education.
Structured education will be delivered in various formats:
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- Digital (individual)
- Virtual (group)
- In-person (group)
- One-to-one (with reasonable adjustments as needed)
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5.4 Drug Therapy
Diabetes Leeds aims to follow national guidelines for treating people with diabetes and ensure compliance with NICE technology appraisals (TAs). This ensures access to the latest medicines and technologies within the prescribing budget.
We will strive to adopt new drugs and technologies promptly and have a dedicated team to agree on guidelines for glucose management and associated conditions like heart and kidney disease. Working across professions and specialties helps us stay at the forefront of new treatments and guidelines. We will collaborate with medicines optimisation colleagues across West Yorkshire to reduce the ‘postcode lottery’ scenario for neighbouring populations.
5.5 Type 2 Diabetes Remission
Diabetes remission occurs when people with type 2 diabetes achieve normal blood sugar levels without medications, often through significant lifestyle changes like diet and exercise.
Benefits include reduced medication use, improved energy and sleep, better health control, and a lower risk of complications. Economically, it saves on medication costs and reduces long-term health expenses, benefiting the healthcare system.
Leeds aims to make remission a standard practice for eligible people with type 2 diabetes within the first six years of diagnosis. Leeds will also take advantage of opportunities to enrol people onto the national programme.
5.6 Care Processes
People with diabetes will continue to receive healthcare tests per NICE guidance. These include HbA1c, lipids, blood pressure, kidney function tests, eye screening, BMI or waist-to-height ratio, and foot checks. People who smoke will be offered support to quit.
These tests will occur at least annually, with blood sugar control checked twice a year. Leeds aims to improve the proportion of people receiving all care processes annually, with biennial eye screening for those at low risk of sight loss.
An integrated approach across health sectors will improve uptake and follow-up. Patients will be empowered to provide data (e.g., home blood pressure, glucose readings) to clinicians, reducing clinician time. Other measures include home testing kits, better correspondence, fewer visits, group consultations, flexible appointment times, virtual clinics, and an advice service for GPs.
5.7 Maternal Health
Diabetes is common in women, so it’s important to include maternal care in our strategy. Maternity care is expensive for the NHS, especially when there are complications. Diabetes is the most common medical issue during pregnancy, affecting 10-15% of pregnant women in Leeds. Women with diabetes need support before pregnancy to keep their blood sugar levels safe and better access to contraception can help prevent unplanned pregnancies. During pregnancy, joint clinics provide essential support to prevent complications. Women with Type 1 Diabetes (T1D) need advanced technology and expert care, while the number of pregnant women with Type 2 Diabetes (T2D) is rising, often with additional challenges like obesity and language barriers. Gestational Diabetes Mellitus (GDM) cases are increasing by about 20% each year, with around 1,200 cases annually in Leeds. Many of these women come from deprived backgrounds and minority ethnic groups. Whole system, family centred and targeted approaches towards healthy living support for women with a history of gestational diabetes or risk factors for type 2 diabetes development can help prevent Type 2 Diabetes (T2D) in mothers and their children. Women who have a history of GDM need long-term follow-up to manage their health risks, and programs like the Diabetes Prevention Program (DPP) and HENRY can help prevent T2D in these women and their families. Women’s health, including managing diabetes during menopause, should be a priority, aligning with broader government and NHS strategies.
5.8 Transitional Care from Childhood to Adulthood
Blood sugar control often worsens after transitioning from childhood to adulthood, with treatment targets being less likely to be reached. The path to adulthood is continuous, but clinical services may not be smooth. Children and adolescents should take increasing responsibility for their condition as they grow up. This responsibility should start early, for example, with the DigiBete app available in Leeds. Leeds will continue to develop pathways that support effective transition.
5.9 Improving Research and Innovation
The LTHT Diabetes Research team works to improve diabetes care and patient outcomes through new research and teamwork. They use advanced technology, clinical expertise, and patient-focused methods. By partnering with universities, industry, and patient groups, they aim to make substantial changes in diabetes treatment. Their goal is to lead in diabetes research, creating new therapies that improve life for people with diabetes and help fight the disease worldwide. They conduct clinical trials and use data to set new standards in diabetes care and provide innovative solutions for patients.
5.10 Green Agenda
The health of our environment affects human health. Pollution and climate change can make diabetes worse. Supporting the green agenda shows a commitment to personal and community well-being.
Diabetes care often uses disposable products. The green agenda promotes using sustainable materials, reducing waste, and conserving resources. It also supports local, sustainable food systems, providing healthier options for diabetes management.
Green practices can save money for individuals and healthcare systems, which is important because diabetes care is expensive.
By aligning diabetes care with the green agenda, Diabetes Leeds aims to promote a healthier population and planet, while encouraging innovation and sustainability in healthcare.
6. Prevention of Diabetes Related Complications
6.1 Impact
Diabetes complications can seriously affect people, their families, and their jobs. People living with diabetes also face stigma and this is something Leeds wants to address. Serious issues like influenza, heart problems, kidney failure, vision loss, gum disease, or amputations need a lot of support.
People with diabetes often stay in the hospital longer, return more often, and have more emergency calls than those without diabetes.
More details on the impact on specific groups can be found in the High-Risk Groups section.
6.2 Heart and Blood Vessel Problems
Heart disease causes over half of all deaths in people with diabetes. They are about twice as likely to die early from heart disease than those without diabetes. The death rate can be cut in half by better managing heart risk factors. This will be done through personalised care plans, including healthy lifestyle advice, blood pressure control, cholesterol-lowering medicines, stroke prevention, weight management, and appropriate therapies like SGLT2i and GLP-1.
Eye disease, sexual dysfunction, and gum disease may be found during care processes. When found, they will be managed or referred for treatment. We will take steps to ensure more people get the right treatment and follow it.
6.3 Kidney Problems
About 40% of people with diabetes will develop chronic kidney disease (CKD). This can be reduced by good blood sugar control, blood pressure control, and for those with CKD or microalbuminuria, treatment with ACE inhibitors or ARB drugs and SGLT2-I if appropriate.
Diabetes Leeds has found that more needs to be done to inform and educate people with CKD, improve drug management (ACE-I, ARB), and optimise SGLT-2i. System data and professional education will aim to achieve positive outcomes for this group.
6.4 Lower Limb Care
Major amputation is one of the most severe complications of diabetes. In Leeds, while major amputations have stayed the same, minor amputations have increased, showing earlier identification and management. In 2023/24, 167 amputation procedures were done in Leeds, costing just under £2 million (Leeds ICB, 2024).
Diabetic foot ulcers and amputations have high death rates, like some common cancers. Managing foot disease in people with diabetes requires addressing many issues and implementing comprehensive solutions.
Diabetes Leeds will collaborate to develop integrated footcare pathways, working closely with vascular, podiatry, and diabetes specialists. Our goal is to ensure a skilled workforce and provide quick access to specialist teams to reduce the risk of amputations.
Efforts will focus on reducing differences in practice, including infection identification, antibiotic prescribing for diabetic foot infections, offloading management, and population health management to ensure fairness.
Pathways will be developed from diagnosis to ulcer management, with accountability at each step. Leeds-based foot screening training for professionals (both face-to-face and digital) will continue to be promoted to improve foot risk assessments and care.
These strategies aim to create a more consistent and effective approach to diabetic footcare, improving patient outcomes and reducing the risk of severe complications.
High Risk Groups
7.1 High Risk Groups
Some people are more likely to have serious diabetes problems. This can be because they do not understand their condition or do not have the right support. Leeds will work with local groups to help these people.
We want to make our services fair, accessible and easy to use. We will provide information in different languages and formats, like text, audio, and easy-read options.
7.2 Hidden Populations
Leeds aims to find and support people who are under-represented or underserved. These groups are often hard to locate or may not want to be found. Diabetes Leeds will work to identify and build relationships with these groups to include them in care plans.
7.3 Young People with Diabetes
Young adults have a higher risk of diabetes problems because type 2 diabetes is more aggressive in this age group. Risk factors include ethnicity, family history, medical history, and obesity.
Early diagnosis and good management are crucial. Young adults can reduce their risk by getting education, monitoring blood sugar, living healthily, managing weight, and discussing treatments with healthcare providers.
Leeds is part of the NHS England programme ‘T2Day: Type 2 Diabetes in the Young,’ which offers extra health checks and support for those under 40 with type 2 diabetes.
7.4 High Risk Ethnic Groups
Diabetes Leeds will focus on South Asian and Afro-Caribbean communities and other high-risk groups. Engaging with these communities and recruiting community champions will be a priority.
7.5 Serious Mental Illness
People with serious mental illness (SMI) are 2-3 times more likely to have diabetes and die 10-20 years earlier than those without SMI. They also have higher rates of all-cause and cardiovascular deaths and more frequent primary care visits.
Integrated care that addresses both physical and mental health is essential. Currently, half of the 73,000 people with SMI and type 2 diabetes in England and Wales are not getting vital checks to prevent complications.
The NHS and Diabetes Leeds are working to improve care and support for these individuals.
7.6 Learning Disability
About 8.5% of people with learning disabilities have diabetes. They are at higher risk of obesity and other complications. Key issues include complex health needs, communication barriers, and access challenges.
Diabetes Leeds will continually review and implement solutions, including reasonable adjustments, self-management resources, health check promotions, professional training, and policy updates.
7.7 Residential and Nursing Homes
Diabetes is common in residential and nursing homes. We will work with these homes to ensure safe care through clear policies on self-medication, insulin delegation, and managing low blood sugar events.
Challenges include an aging population, training gaps, and resource allocation. Solutions include individualised care plans and appropriate training.
Diabetes Leeds will review solutions against local and national practices, including education, training, diabetes policies, care plans, annual reviews, and audits.
Our focus is to improve the well-being, quality of life, and clinical outcomes of all residents with diabetes. Diabetes Leeds will work towards better integration of care and support.
7.8 End of Life
Managing diabetes at the end of life is complex but there are solutions and guidelines to help. Care in this population is challenging and lacks research. Solutions include developing clinical recommendations, holistic care approaches, relaxing clinical targets, and managing medicines (including deprescribing).
Diabetes Leeds is working to improve end-of-life diabetes care through regular updates to guidelines and providing resources for healthcare professionals. These efforts aim to ensure compassionate and appropriate care for all individuals with diabetes as they approach the end of life.
7.9 Homeless and Vulnerably Housed
Diabetes Leeds is working to improve diabetes care for homeless populations. This includes improving access to care, managing medicines, nutrition, co-existing conditions, education, and literacy, and creating integrated partnership models with outreach.
7.10 Unwarranted Clinical Variations
Healthcare varies due to local needs, individual requirements, and healthcare workers’ skills. Innovative ideas can bring positive changes, but it is important to determine if these differences are necessary.
“Unwarranted clinical variation” refers to care that does not match a person’s needs or preferences, leading to poor outcomes. To minimise these differences, we aim to set basic standards that everyone can expect. By using data on treatment steps, goals, and education, we can identify and address these variations.
7.11 Clinical Workforce Development
We will support the Diabetes Leeds workforce in developing the skills and confidence needed for effective diabetes care. Addressing clinical inertia and enhancing training will prevent treatment delays, improve cardio-renal management, and reduce complications. Diabetes Leeds will explore innovative training and workforce development opportunities.
7.12 Learning from Incidents
Incidents are opportunities to learn and improve. Diabetes Leeds will promote reporting of incidents (including near misses and adverse events) and use recommended models. Learning from incidents will be strengthened by sharing across the system, recognising that pathways and practices are interconnected.
Acronyms and Abbreviations
AF: Atrial Fibrillation
BMI: Body Mass Index
ICB: Integrated Care Board
LHCP: Leeds Health and Care Partnership
CCSP: Collaborative Care and Support Planning
COPD: Chronic Obstructive Pulmonary Disease
CVD: cardiovascular disease
CYP: Children and Young People
DAFNE: Dose Adjustment for Normal Eating
GDM: Gestational Diabetes Mellitus
GP: General Practitioner
IAPT: Improving Access to Psychological Therapies
ICS: Integrated Care Systems
IMD : Indices of deprivation
LADA : Latent Autoimmune Diabetes in Adults
LCC: Leeds City Council
LCH : Leeds Community Healthcare NHS Trust
LCP: Local Care Partnership
LEAP: Leeds Encouraging Activity in People
LTHT: Leeds Teaching Hospitals NHS Trust
MODY: Monogenic Diabetes of the Young
MDT: Multi-Disciplinary Team
NHS: National Health Service
NHS DPP: NHS Diabetes Prevention Programme
NHSE: NHS England
NICE: National Institute of Clinical Excellence
PCN: Primary Care Network
SPA: Single Point of Access
T2D: Type 2 diabetes
T1D: Type 1 diabetes
Contributors
Georgia Blaney | Health Improvement Specialist (Long Term Conditions), Leeds Public Health
Hannah Beba | Consultant Pharmacist: Diabetes, Leeds Health and Care Partnership, NHS West Yorkshire Integrated Care Board (Leeds based)
Nina Davies | Clinical System Pathway Development Lead, Leeds Community Healthcare NHS Trust.
Damian Dawtry | Project Manager – Men’s Health Unlocked, Forum Central
Ali Kaye | Third Sector Development Manager, Leeds Older People’s Forum
Hanna Kaye | Advanced Health Improvement Specialist (Adults and Health), Leeds City Council
Carl Mackie | Head of Public Health, Leeds City Council
Dr Ian McDermott | Diabetes and Diabetes Clinical lead for NHS Leeds ICB and Leeds Community Healthcare NHS Trust
Lindsay McFarlane | Interim Associate Director of Pathway and System Integration | Long Term Conditions, Frailty, End of Life, and Planned Care Populations, Leeds Health and Care Partnership, NHS West Yorkshire Integrated Care Board (Leeds based)
Thomas Lambert | Healthcare Engagement and Systems Change Manager, North of England, Diabetes UK
Martin Lee | Health Program Manager, Leeds City Council
Dr Michael Mansfield | Consultant Physician: Diabetes and Lipid Disorders, Leeds Teaching Hospitals NHS Trust.
Clair Ranns | Diabetes Specialist Pharmacist. Leeds Health and Care Partnership and Leeds Community Healthcare NHS Trust.
Lydia Robson | Health Improvement Specialist (Long Term Conditions), Leeds Public Health
Claire Sert | Service Manager, Diabetes, Speciality and Integrated Medicine Clinical Service Unit, St James Hospital
Emily Turner | Clinical Lead for CVD Prevention, West Yorkshire Integrated Care Board
David Wardman | Associate Director Medicines Optimisation and Clinical Lead, Leeds Health and Care Partnership, NHS West Yorkshire Integrated Care Board (Leeds based)
Jo Volpe | Chief Executive Officer, Leeds Older People’s Forum
Karl Witty | Third Sector Health and Care Development Officer, Volition