The sheer scale of the Long-Term Conditions (LTCs) challenge for
modern healthcare systems means that a shift is needed – away from the
‘medical model’ of illness (which worked efficiently in the 19th and
20th Centuries to bring down mortality and morbidity) towards a model of
care which takes into account the expertise and resources of the people
with LTCs and their communities. This will help to provide a holistic
approach to their care and lives and help them achieve the best outcomes
possible.
The Five Year
Forward View (FYFV) published by NHS England and its partners (2014)
sets out the vision for the future of the NHS. It notes that ’long term
conditions are now a central task of the NHS; caring for these needs
requires a partnership with patients over the longer term rather than
providing single, unconnected “episodes” of care. ’This is particularly
important in supporting the increasing numbers of people with more than
one long term condition, more commonly known as multimorbidity – helping
people with long term conditions to live well, age well and die
well.
NHS systems are expected to work with partner organisations to access
rigorous and validated population health management capabilities that
improve prevention, enhance patient activation and supported self-
management for long term conditions, manage avoidable demand, and reduce
unwarranted variation in line with the Right Care programme.
The 15 million people in England with long term conditions have the
greatest healthcare needs of the population (50% of all GP appointments
and 70% of all bed days) and their treatment and care absorb 70% of
acute and primary care budgets in England. The barriers to great care
for people with long term conditions have been identified by a wide
range of reports and reviews, and can best be summed up as failure to
provide integrated care around the person:
Single condition services: services dealing with single conditions
only and adopting single condition guidelines (with attendant dangers of
polypharmacy and excluding a holistic approach to service users).
Lack of care coordination: people being unaware of whom to approach
when they have a problem, and nobody having a generalist’s ‘bird’s eye’
view of the total care and support needs of an individual.
Emotional and psychological support: in particular, a lack of
attention to the mental health and wellbeing of people with ‘physical’
health problems (as well as failure to deal with the physical health of
people with mental disorder as their primary long term condition).
Fragmented care: the healthcare system remaining within its own
economy, and not being considered in a whole system approach with social
care or other services important to people with long term conditions
(e.g. transport, employment, benefits, housing). Failure to support
people with ‘more than medicine’ offers as provided by, for example,
third and voluntary sectors.
Lack of informational continuity: care records which can’t be
accessed between settings, or to which patients themselves don’t have
access.
Reactive services, not predictive services: failure to identify
vulnerable people who might then be given extra help to avoid hospital
admission or deterioration/complications of their condition(s).
Lack of care planning consultation: services which treat people as
passive recipients of care rather than encouraging self-care and
recognising the person as the expert on how his/her condition affects
their life.
In 2019 the NHS Long Term
Plan was published. This plan aims to support people to live longer,
healthier lives through helping them to make healthier lifestyle choices
and treating avoidable illness early on. The plan sets out a need for
the NHS to work in collaboration with local authorities to deliver
joined up care and to focus prevention programmes on reducing smoking,
obesity and alcohol intake. This approach will reduce the risk of early
ill health and diseases such as cancer, cardiovascular disease, stroke,
respiratory disease and mental ill-health.
1.1 Prevalence and Need
A significant number of people who are classified as fit with between
1 and 4 long term conditions are being admitted to acute care as an
emergency presentation, with an observed growth in the under 65’s.
There is a significant number of unidentified prevalence for
hypertension (5,000 people). Other areas where identification needs to
be improved include diabetes, coronary heart disease, atrial
fibrillation and chronic obstructive pulmonary disease. The figure below
compares Richmond to the 10 most similar CCGs in England, demonstrating
the detection opportunity if Richmond were performing to the level of
its peers.
Identified long-term conditions compared to peer
group, 2017/18
Source: Right Care data 2017/18
This data is then triangulated with GP practice registers and the
figure below shows that there are marked variations in GP registers for
hypertension, obesity, diabetes and depression compared to the 10 most
similar CCGs.
GP Practice registers, recorded incidence of
disease, 2019–20
Source: 2019/20 QOF, NHS Digital
The issue of undetected disease is increasing within Richmond with a
demonstrable growth in morbidity between 2018 and 2019 in these
conditions (the figure below).
Change in population morbidity, 2018–2019
Source: Sollis Clarity 2018/19
People often present with multiple morbidity factors and as the
population ages the incidence of multi-morbidity increases. The table
below shows the likelihood of a particular long-term condition as
multi-morbidity increases, expressed as percentage.
For people with three or more long-term conditions, circa 45% of
people are coded with Hypertension, whereas for people with 9+ LTCs,
this rises to circa 92% of that cohort.
Multi-morbidity in Richmond
Source: Sollis Clarity Partners
The presence of multi-morbidity of long-term conditions manifests in
multiple ways including a rise in A&E attendances, Non-elective or
emergency admissions to hospital, repeated attendance to the GP, a rise
in sickness absence and an impact on overall mental wellbeing (the table
below).
Correlation between unidentified long-term
conditions and hospital attendances
Source: Sollis Clarity Partners
The information in the table above and the table below shows that it
is the presence of multi-morbidity and therefore complexity of a
person’s condition that drives higher usage of hospital attendances and
the number of bed days once a person is admitted, and not necessarily
increased age alone. In all age categories those with a higher number of
conditions will attend hospital more frequently and stay longer once
admitted.
Multi-morbidity by age in Richmond
Source: Sollis Clarity Partners
Within Richmond the identification of long-term conditions is managed
by primary care through a suite of locally commissioned services aimed
at the detection of specific conditions, there are schemes in place
to:
Increase identified prevalence of COPD
Encourage the optimum identification and management of patients with
diabetes in primary care
Identification of people with atrial fibrillation
The community provider works to support primary care through the
community respiratory and diabetes clinics, and the specialist heart
failure nurses to optimise the management of people with long-term
conditions and to support education and training for people to manage
their own long-term conditions.
1.2 Services and Plans in Richmond
Richmond has a predominantly white population, and it is this cohort
that has the highest detected prevalence of long-term conditions and
specifically within the 15–64 age groups, this information correlates
with the age profile of attendance to hospital.
Current services are not as joined up as they need to be which can
lead to fragmentation of pathways of care, people not being actively
managed or followed up in a timely manner resulting in exacerbation and
disease progression.
Addressing long-term conditions in Richmond
Richmond’s model of care supports the development of healthy
behaviours and lifestyles that enable the population to make choices
within a healthy community environment facilitated by the wider
determinants of health. It aims to empower people to self-manage any
long-term health conditions, maintain independence and an enjoyable
lifestyle within the parameters of disease and to prevent the
progression of disease into complexity and frailty.
We will underpin our model with the use of technology and work with
our partners in health, social care and the voluntary sector to maximise
resources and opportunities. The approach is through a framework of
Prevent; Detect; Manage; Optimise
Prevent
To target weight management and support people to make healthy
lifestyle choices by maximising the public health offer to the at-risk
groups starting early in life to build good habits. Supporting mental
health and wellbeing recognising the connectivity between a person’s
mental and physical health specifically in relation to stress and
anxiety
Detect
Develop a service for active opportunistic identification of people
at risk of developing a long-term condition or those who are undiagnosed
working with community pharmacies/ optometrists etc. Optimise the impact
and opportunity for finding people with an undiagnosed long-term
condition through existing annual health checks Opportunistic screening
of identified cohorts of people who may be hard to reach or vulnerable
to developing a long-term condition and may not be picked up through
traditional methods of detection.
Manage
Develop a model of supported self-management whereby a person with a
newly diagnosed long-term condition will be assessed as to their
motivation levels, has a care plan developed and then has access to a
range of interventions to enable them to self-manage their condition,
i.e. information, structured education, buddying, health coaching
regular monitoring and social prescribing (the figure below).
Obesity is a modifiable risk factor for several long term conditions.
Obesity is one of the key behavioural risk factors that the NHS health
checks assesses.
2.1 Prevalence
Overweight
(including obesity) prevalence in adults: In 2022/23, Richmond’s
rate was 55.7%, which was the 13th lowest in London, 13.0% lower than
the England average and 2.6% lower than the London average. The latest
Borough figure for 2022/23 was also 5.8% higher than in 2015/16, in
comparison with 4.4% increase in England’s rate in the equivalent time
period.
Obesity in
early pregnancy: In 2018/19, Richmond’s rate was 10.9%, which was
the 6th lowest in London, 50.5% lower than the England average and 38.6%
lower than the London average. Time series data were not available for
this indicator.
In 2019/20, Richmond’s rate hospital admissions directly attributable
to obesity was 14.0 per 100,000 population, which is the lowest rate in
London, 28.9% lower than the England average and 51.7% lower than the
London average. The latest Borough figure was also 7.2% higher than in
2013/14, in comparison with a 13.8% increase in England’s rate in the
equivalent time period.
Admissions with obesity in primary diagnostic
field by local authority, 2019/20
In this section explores the latest available Richmond-level
information on prevention, prevalence, primary care management,
hospitalisations, and mortality from cardiovascular conditions. The
local coverage and outcomes of the NHS Health Checks, a programme for
adults in England aged 40 to 74, is designed to spot early signs of
stroke, kidney disease, heart disease, type 2 diabetes and dementia,
included in this section. The NHS Health Check helps find ways to lower
cardiovascular risk and has a clear role in delivering preventative and
personalised solutions to ill-health, and empowering individuals to live
healthier and more active lives
Cardiovascular disease (CVD) includes a group of diseases affecting
the heart or blood vessels. The list of specific diseases within the CVD
classification include coronary heart disease (CHD), myocardial
infarction (heart attack), angina, coronary artery diseases and stroke.
Primary prevention of CVD requires patients at risk are identified
before disease has become established. People with hypertension are at
high risk of developing CVD. Controlling blood pressure is therefore a
significant factor that protects the patient from developing serious
circulatory conditions.
3.1 NHS Health Checks Programme
The NHS Health Checks Programme is a mandated service under the
Health and Social Care Act 2012. Local Authorities have a legal duty to
invite 100% of its eligible population over a 5-year period and deliver
at least 50% NHS Health Checks. The annual local targets translate to
20% invitations and 10% NHS Health Checks. The programme is a systematic
vascular risk assessment and management programme, aiming to reduce the
incidence of heart disease, stroke, diabetes and kidney disease. It is
also an opportunity to identify dementia across the population,
particularly high risk and vulnerable groups. It helps people to take
action to avoid, reduce or manage their risk of developing these
conditions It also contributes to the objectives of tackling health
inequalities, including socio-economic, ethnic and gender
differences.
Office for Health Improvement & Disparities estimates the NHS
Health Check Programme could, on average, prevent 1,600 heart attacks
and strokes, and save at least 650 lives each year. The programme aims
to prevent over 4,000 people a year from developing diabetes, detect at
least 20,000 cases of diabetes or kidney disease earlier, allowing
individuals to be better managed and improve their quality of life. It
achieves this by assessing the top seven risk factors driving the burden
of non- communicable disease in England and by providing individuals
with behavioural support and, where appropriate, pharmacological
treatment.
NHS Health Checks logo
Aims and Delivery Model
The NHS Health Checks programme aims to prevent heart disease,
stroke, diabetes, and kidney disease and raise awareness of dementia
both across the local population and within high risk and vulnerable
groups . It also helps people to take action to avoid, reduce or manage
their risk of developing these conditions as well as opportunities to
make progress in tackling health inequalities, including socio-economic,
ethnic and gender inequalities.
The service is available to individuals between 40 and 74 years of
age without existing cardiovascular disease (CVD). Invitations can be
prioritised for residents who are estimated to have a high CVD risk
score (Q-risk) . The aims of the NHS Health Check programme are to offer
an NHS Health Check to 20% of the eligible population every year as part
of a 5-year rolling programme with an uptake level of 50%:
To reduce the prevalence of CVD
To narrow health inequalities in premature death from these vascular
related conditions.
In Richmond 25 GP Surgeries and 2 pharmacies are contracted to
deliver NHS Health Checks. Activity data is automatically extracted from
GP surgeries clinical data system Vision Plus and from pharmacies via
Pharmoutcomes.
Demographics of service users accessing the service via GP surgeries
during 2019/20:
46.20% were aged between 40–50
27.9% were aged between 51–60
17.5% were aged between 61–74
57% were female
40.6% were male
53.7% were BAME
1.3% were Mental Health Patient
0.2% were learning disability patients
0.7% were carers
Demographics of service users accessing the service via pharmacies
during 2019/20:
49% were aged between 40–50
28% were aged between 51–60
23% were aged between 61–74
62% were Female
11 were BAME
45% were Male
The data shows that during 2019/20, females were more likely to
access an NHS Health Check than males. The majority of service users
(46% GP surgeries, 49% pharmacies) were aged 40–50. The BAME population
is slightly overrepresented in comparison with the borough profile for
age range. However, there is a data quality issue with ethnicity not
being recorded in nearly one third of all consultations.
NHS Health Checks Outcomes
During 2019/20 the Richmond NHS Health Check programme outcomes
included:
23 service users were diagnosed diabetic
52 service users were identified with a high QRISK score
(>20%)
69 service users were diagnosed hypertensive
4 service users were diagnosed with chronic kidney disease (CKD) 1
Referrals from an NHS Health Check to lifestyle support services
during 2019/20 included:
59 service users were referred to the National Diabetic Prevention
Programme (NDPP) 2
17 service users were referred to exercise on referral
programme
32 service users were referred to the Health Walks programme
19 service users referred to weight management programme
207 service users were referred to smoking cessation services 3
In July 2020, The Department of Health and Social Care (DHSC) asked
Public Health England (PHE) to carry out an evidence-based review of the
NHS Health Check programme. The review will advise Ministers on how NHS
Health Checks can evolve in the next decade to maximise the future
benefits of the programme in preventing illness and reducing health
inequalities. This may include recommendations on the content of NHS
Health Checks, how the programme is delivered and how it links to the
wider health and social care system 4.
Cumulative percentage of the eligible population aged 40 to 74 offered
an NHS Health Check: In 2018/19 - 22/23, Richmond’s rate was
55.2% (n=35119), which was the 8th lowest in London, 14.7% lower than
the England average and 22.0% lower than the London average. The latest
Borough figure for 2018/19 - 22/23 was also 28.0% lower than in 2013/14
- 17/18, in comparison with 28.8% decrease in England’s rate in the
equivalent time period.
Cumulative percentage of the eligible population aged 40 to 74 offered
an NHS Health Check who received an NHS Health Check: In 2018/19
- 22/23, Richmond’s rate was 54.1% (n=18987), which was the 10th highest
in London, 27.9% higher than the England average and 12.1% higher than
the London average. The latest Borough figure for 2018/19 - 22/23 was
also 6.3% higher than in 2013/14 - 17/18, in comparison with 13.2%
decrease in England’s rate in the equivalent time period.
Cumulative percentage of the eligible population aged 40 to 74 who
received an NHS Health check: In 2018/19 - 22/23, Richmond’s
rate was 29.8% (n=18987), which was the 13th lowest in London, 9.1%
higher than the England average and 12.5% lower than the London average.
The latest Borough figure for 2018/19 - 22/23 was also 23.5% lower than
in 2013/14 - 17/18, in comparison with 38.2% decrease in England’s rate
in the equivalent time period.
NHS Health Checks Programme - Diabetes Risk Assessment
The NHS Health Checks programme provides cardiovascular risk
assessments for people between the ages of 40 and 74 years and are an
important part of type 2 diabetes prevention and diagnosis. The NHS
Health Checks programme includes a diabetes risk assessment or filter,
which should lead onto blood testing for those identified at risk. Those
people identified with NDH following their blood test should be offered
a referral to the NDPP and other lifestyle support services. People
identified as having diabetes are managed through the diabetes care
pathway through primary care.
In 2019/20, Richmond completed 5187 NHS Health Checks; 23 of these
people were diagnosed with diabetes and 59 people were referred to the
NDPP. Nationally, it is estimated that Health Checks could prevent 4,000
people a year from developing diabetes 5 and for every 80 – 200
NHS Health Checks, 1 person is diagnosed with type 2 diabetes
(1.25%–0.5% of checks) 6. Richmond was lower than this range with
0.44% of checks resulting with a diabetes diagnosis.
3.2 Diabetes
Diabetes is a condition where the amount of glucose (a type of sugar)
in the blood is too high. There are many types of diabetes including
Type 1, Type 2, gestational, and other rarer types of diabetes. Type 1
Diabetes accounts for around 8% of cases, other rarer types of diabetes
accounts for 2%, and Type 2 Diabetes accounts for 90%.
Type 1 Diabetes develops when the body is unable to produce insulin.
Type 2 Diabetes develops when the body stops producing enough insulin,
or the body’s cells stop reacting to the insulin produced. This means
sugar builds up in the blood and cannot get into the cells of the body
where it is used for fuel.
This section focuses on type 2 diabetes as it is associated with
lifestyle factors and can be delayed or prevented through support to
change behaviour around lifestyle choices. Other types of Diabetes, such
as type 1 diabetes, are not related to lifestyle issues and cannot be
prevented.
The number of people developing type 2 diabetes has been increasing
globally. Around four million people in the UK have type 2 diabetes and
by 2030 it is estimated that there will be more than 5.5 million people
with it. This is largely due to the rise in obesity, which is estimated
to account for 80–85% of all type 2 diabetes cases in the UK 7. Being
overweight or obese is the major modifiable risk factor for type 2
diabetes.
Impacts of Diabetes
There are many significant impacts on the health and wellbeing of
people living with type 2 diabetes in Richmond. Additionally, there are
large financial impacts on the NHS and wider social and economic costs
due to the rise in type 2 diabetes.
Premature Mortality
Type 2 Diabetes is a major cause of premature mortality, with around
22,000 people with diabetes dying early each year in England. people
with diabetes are more likely to die than their peers of the same age
and sex in the general population. In Richmond, the additional risk of
death in people with diabetes is 50.9%; for England, the additional risk
was 21.8% 8. In England and Wales, people aged 35 to 64
living with type 2 diabetes are up to two times more likely to die
prematurely 9.
Complications /multi-morbidity
Those who develop type 2 diabetes are subsequently at greater risk of
developing complications from the disease: * CVD including heart attack
and stroke – type 2 diabetes leads to an increased risk of CVD. In
Richmond, people with diabetes are 164.8% more likely than people
without diabetes to have a heart attack, and 62.6% more likely to have a
stroke.
* Blindness- leading cause of preventable slight loss among people of
working age * Nerve damage - most often in legs or feet * kidney disease
and failure - diabetes is the leading cause of kidney disease People
with diabetes rarely die as a direct result of diabetes. Most die from
complications such as heart disease, stroke and kidney failure.
Diabetic Foot Disease
Diabetic foot disease is a potential consequence of the complication
of nerve damage and the complication of peripheral vascular disease.
Foot problems are the most frequent reasons for hospitalisation amongst
people who have diabetes. Latest figures for Richmond show that between
2015/2016 and 2017/2018, there were 325 hospital spells for diabetic
foot disease. The median length of stay in hospital was 7 days and the
total number of days spent in hospital for diabetic foot disease was
3,359.
Diabetes is one of the leading causes of amputation of the lower
limbs. From 2015/2016- 2017/2018 there were 35 minor amputation
procedures (removal of toes or feet) performed in Richmond, giving a
directly age and ethnicity standardised rate of 18.7 minor amputations
per 10,000 population-year. This was not significantly different to the
England average. There were only 6 major amputation procedures (above or
below the knee amputation) performed, which was not large enough to
calculate a robust standardised rate for comparison to England.
Hospital admissions
People with diabetes are more likely to be admitted to hospital and
have longer stays than similar people without the condition. One in six
of all people in hospital in England have Diabetes. While Diabetes is
often not the reason for admission, they often need a longer stay in
hospital, are more likely to be re-admitted, and their risk of dying is
higher.
Mental Health
A type 2 diabetes diagnosis can also negatively impact quality of
life and social contact, which can have an adverse effect on mental
health. people with diabetes are more likely to be diagnosed with
Depression. Depression is more prevalent among people living with type 2
diabetes, compared with those who are not. This, as well as many other
complications of type 2 diabetes, increases their risk of premature
death.
A survey 10 conducted by Diabetes UK also found
that:
3 in 5 people (64%) living with diabetes experience emotional or
mental health problems as a result of their condition
just 3 in 10 people living with diabetes said they definitely felt
in control of their condition
nearly a third of people living with diabetes had at some point
relied on self-help materials
one in 5 people living with diabetes had used support or counselling
from a trained professional to help them manage their Diabetes.
Dementia
There is a close association between type 2 diabetes and dementia, in
particular Alzheimer’s Disease and Vascular Dementia 11:
Type 2 Diabetes is associated with a 60% increase in risk for
all-cause Dementia
Individuals with a longer duration and earlier age of onset of
Diabetes have the highest risk
Women with type 2 diabetes have a greater chance of developing
vascular Dementia than men
There is a 56% increased risk of developing Alzheimer’s Disease in
individuals with type 2 diabetes but also people with Alzheimer’s
Disease have an increased risk of developing type 2 diabetes and
impaired glucose tolerance
Social Consequences
In addition to mental health and quality of life, the important
social consequences of type 2 diabetes include impacts on individuals’
family life, education and employment. These are wider consequences that
are just as important as health outcomes, as they have far-reaching
impacts.
Inequalities
Certain Black, Asian and minority ethnic (BAME) groups have a greater
chance of developing type 2 diabetes than people from White ethnic
groups. The South Asian population living in the UK are up to six times
more likely to develop type 2 diabetes than that of the white
population. People of African and African-Caribbean descent are three
times more likely to have type 2 diabetes than the white population. In
Richmond, nearly 22% of people with type 2 diabetes are of ethnic
minority origin.
Costs
Diabetes treatment currently accounts for around 10 per cent of the
annual NHS budget. This is just under £10 billion a year, with 80% spent
on managing preventable complications associated with the condition, and
20% on treatment (e.g. primary care and prescribing).
In 2018/19, costs for diabetes drugs for Richmond CCG amounted to
£1,778,198.6 12. Diabetes prescriptions made up 12.5% of
the total cost of prescribing in England during 2018/19. There are also
major indirect costs, such as loss of productivity due to increased
death and illness and the need for social care.
COVID-19 impact on Diabetes
People with underlying health conditions, such as Diabetes are at a
higher risk of poor outcomes from COVID-19 than people without these
conditions. Recent national data reviews show that Diabetes was
mentioned on 21% of death certificates where COVID-19 was also
mentioned. People with type 2 diabetes are twice as likely to die than
people who don’t have Diabetes when in hospital with COVID-19.
BAME groups are also at an increased risk of death from COVID-19. The
proportion where Diabetes was mentioned on death certificates was higher
in all BAME groups when compared to White ethnic groups and was 43% in
the Asian group and 45% in the Black group.
Due to lockdown periods, many people will have been less physically
active, have unhealthier diets, and not accessing healthcare and
lifestyle services as usual. Some people with non-diabetic hyperglycemia
(high risk of Type 2) may now have Diabetes. There may be a greater
number of people living with undiagnosed Diabetes following
COVID-19.
As people with diabetes can be more vulnerable to becoming seriously
ill from COVID-19, it is important to continue to identify people at
risk of or living with undiagnosed Diabetes. Prevention work to improve
the health and fitness of people, through activities such as exercise,
eating well, losing weight and stopping smoking, will help to minimise
the health impact of COVID-19. People at high risk of Diabetes should be
offered effective support (e.g. Diabetes Prevention Programme) and they
should be monitored for progression to Diabetes, which will support
early diagnosis.
Type 2 Diabetes
Risk of Type 2 Diabetes
The risk of type 2 diabetes is about the chance or likelihood of
developing type 2 diabetes over a period of time. A person’s level of
risk depends on a combination of factors including genetics, which
cannot be changed, and preventable lifestyle factors, with risk levels
varying over the life course. Risk can be reduced in the universal
population through population and community interventions on healthy
eating and physical activity throughout pregnancy, infancy, childhood,
adulthood. Many people will have low risk for type 2 diabetes by
maintaining a healthy lifestyle.
Risk increases with a change in lifestyle factors, such as obesity,
as well as with age. People at increased risk are likely to not be aware
as they may not have symptoms. Without changes to lifestyle, the risk of
type 2 diabetes can progress, leading people to become high risk for
developing type 2 diabetes. People are at high risk of developing type 2
diabetes if their blood sugars are raised, but not high enough to be
diagnosed with type 2 diabetes. They are also at increased risk of other
cardiovascular conditions 13.
The risk factors for being at high risk of type 2 diabetes and
developing type 2 diabetes are the same. These factors include:
Overweight or obesity - there is a seven times greater risk in
people who are obese and three times if overweight
High Blood Pressure - people are more at risk if they have ever had
high blood pressure
Certain ethnicities - People of South Asian origin are six times
more likely to develop Diabetes and Black-Caribbean and Black African
are three times more likely
Age - Risk increases with age. People are more at risk if they are
older than 40 or older than 25 if they are Black Caribbean, Black
African, or South Asian
Family History - People are two to six times more likely to get type
2 diabetes if they have a parent, brother, sister or child with
diabetes
Smoking - Smoking has been proven to be an independent risk factor
for Diabetes, and amongst diabetics it increases the risk of
complications. The highest risk is among heavy smokers and risk remains
elevated for about 10 years after smoking cessation, reducing more
quickly for lighter smokers 14.
Deprivation is strongly associated with higher levels of obesity,
physical inactivity, unhealthy diet, smoking and poor blood pressure
control, all of which are linked to the risk of developing type 2
diabetes. Prevalence of type 2 diabetes is 60% more common among
individuals in the most deprived quintile compared with those in the
least deprived quintile in England
Gestational Diabetes - Gestational Diabetes affects around 5% of all
pregnancies 15. Women who have had Gestational Diabetes
are at a sevenfold increased risk of developing type 2 diabetes later in
life, especially if they gain weight. Children born to mothers with
diabetes during pregnancy tend to have a greater BMI, raised fasting
glucose levels and an increased risk of developing type 2 diabetes later
in life
People at high risk of type 2 diabetes have a greater chance of
developing type 2 diabetes in the future. One out of four people with
high risk will develop type 2 diabetes in the next 10 years 16.
There are various terms used for high risk of Diabetes including:
pre-Diabetes, borderline Diabetes, Impaired Fasting Glucose (IFG),
Impaired Glucose Tolerance (IGT), Impaired Glucose Regulation (IGR), or
Non-diabetic hyperglycaemia (NDH), which all mean that someone is at
high risk of a diagnosis of for developing type 2 diabetes. NDH will be
used throughout this Section to mean high risk of type 2 diabetes.
Once people know they are at risk, they can often prevent or delay
type 2 diabetes from starting by making healthy changes to their diet
and lifestyle. Without lifestyle changes, people with NDH are very
likely to progress to type 2 diabetes. Eating healthy foods,
incorporating physical activity in daily routines, and maintaining a
healthy weight can help bring blood sugar levels back to normal.
Diagnosis
A blood test which detects the level of glucose in your blood is
needed to make the diagnosis of NDH and type 2 diabetes. An HbA1c blood
test is often used and gives an average of how high your blood glucose
levels have been over the preceding few months.
NDH is defined as an HBA1c value between 6.0% (42mmol/mol) and 6.4%
(47mmol/mol) excluding those who had already been diagnosed with
diabetes with an HBA1c value in this range. An HbA1c value of 6.5% (48
mmol/mol) or above is recommended as the blood level for diagnosing
Diabetes. A value of less than 48mmol/mol (6.5%) does not exclude
Diabetes diagnosed using glucose tests.
Diabetes: Level of Need in Richmond
Around 16% of the Richmond population are from BAME groups 17.
Asian/Asian British is the largest BAME group in Richmond (7.3%). In
terms of location, St Margaret’s and North Twickenham had the greatest
proportion of the White/White British ethnic group at 88%, while
Heathfield had the highest proportion of the BAME ethnic group at 30%
(compared to 16% for the Borough). BAME groups are expected to increase
to 17.2% by 2030.
Richmond maintains a rank within the 10% least deprived Local
Authorities (LAs) in England between 2015 and 2019 and remains the least
deprived London borough. In terms of older people, 34% (c. 68,240
residents) of the Richmond population are aged 50 years and over. The
number of older people over 65 in the borough of Richmond is expected to
increase by 6.5% and number of people over age 85 increasing by 7.1% by
2021. Hampton/Teddington, Heathfield/Whitton, and Kew Gardens are areas
with a higher proportion of older people. The most deprived areas in
terms of income deprivation affecting older people are Hampton North,
Heathfield, Barnes, and North Richmond.
In addition to Hampton and Heathfield, Whitton, Hampton North and
Hampton Hill tend to have higher prevalence of heart disease,
respiratory disease and other conditions. These areas are also
relatively more deprived. Nearly one in three people registered with a
GP in Richmond has one or more long-term condition and nearly one in ten
has three or more 18.
There are an estimated 15,000 residents 16 years and over (9.6% of
population) that have NDH in Richmond. In 2018/19, GP Practices
identified around 4,000 of these people (1.3%). This means there could
be around 11,000 people who are unaware they are high risk for
developing type 2 diabetes.
The figure below provides the demographic breakdown of people in
Richmond registered with NDH by their GP Practice. At individual GP
practice level, the percent of people identified with NDH varies,
ranging from around 0.2% to 6%.
NDH prevalence by demographic group, Richmond,
2018/19
Males and females have a similar percent of people registered with
NDH
The 40–64 years and 65–79 years age groups have a similar proportion
of people registered with NDH, together comprising 80% of NDH
prevalence. As risk increases with age, it may be more likely that a
higher proportion of the 80+ age group have already been diagnosed with
diabetes.
Nearly 50% of people with NDH are from the least deprived quintile,
and 13% from the two most deprived quintiles.
Around 69% of people registered with NDH are White and 15% are of
Minority Ethnic Origin (BAME). BAME groups make up around 16% of the
population in Richmond.
As NDH doesn’t tend to have symptoms associated with it,
identification is based on a blood test alone. It is estimated that many
more people have NDH but are unaware of it.
GP Practice Data on Diabetes
At individual GP practice level, the prevalence of diagnosed Diabetes
ranges from around 1% to 6%. In 2018/19, there were 5,770 people
diagnosed with type 2 diabetes.
Diabetes:
QOF prevalence (17+ yrs): In 2022/23, Richmond’s rate was 4.3%
(n=8417), which was the 5th lowest in London, 41.7% lower than the
England average and 36.8% lower than the London average. The latest
Borough figure for 2022/23 was also 17.9% higher than in 2012/13, in
comparison with 23.9% increase in England’s rate in the equivalent time
period.
Type 2 diabetes is more common in males than females; 60% are male.
While there is little difference in the prevalence of NDH by sex, males
have a higher prevalence of diabetes compared to females.
The 40–64 years and 65–79 years age groups have a similar percentage
of people diagnosed with type 2 diabetes. Around 56% of people with type
2 diabetes in Richmond are aged over 65. Richmond has one of the lowest
percentage of people aged 40–64 with type 2 diabetes in London, and the
second highest percentage of people with type 2 diabetes aged 80 and
over.
Around 43% of people diagnosed with type 2 diabetes are from the
least deprived quintile and 18% from the two most deprived
quintiles.
Around 65% of people diagnosed with type 2 diabetes are White, 22%
Minority Ethnic Origin, with a further 13% unknown or not stated. As
BAME groups comprise 16% of the population, this reflects the health
inequality of diabetes among minority ethnic groups.
Geographic Prevalence
There is variation in diabetes prevalence across the borough.
Diabetes is most prevalent in Heathfield and Whitton, followed by
Hampton. This corresponds with having a higher proportion of BAME
groups, older people aged 65+, and deprived areas of the borough, which
are risk factors for type 2 diabetes (the figure below).
It is estimated that 12,553 people in Richmond have diabetes (all
types of diabetes). This includes people that have already been
diagnosed by their GP and those who have diabetes but do not know it
(undiagnosed). Around 55% of people living with diabetes are diagnosed
19.
This is lower than the diagnosis rates for England and London, 78% and
71.4% respectively and is the third lowest in London.
Considering the diagnosed prevalence for Type 1 and Type 2 and other
diabetes, it is estimated that there are 5,649 people living with
undiagnosed diabetes (45%) that are not receiving treatment and are
missing out on vital health checks.
As Richmond has a lower prevalence of some of the risk factors for
diabetes (e.g. obesity, hypertension), higher prevalence of healthy
lifestyle behaviours (e.g. healthy eating, physical activity), and lower
prevalence of people with complications related to diabetes
(e.g. stroke, CHD), it is a possibility that the observed number of
people with undiagnosed diabetes in Richmond is actually lower than the
estimated number. There is the caveat with all modelled data, that there
are data limitations and a degree of uncertainty associated with these
estimates. Nonetheless, the estimates can still be considered
indicative, showing that there is still room for improvement in diabetes
diagnosis in Richmond.
Some of the undiagnosed cases could be within the more elderly
groups. Richmond is one of only six boroughs in London that has more
than 30% of its population aged over age 50 years. It also has the
highest prevalence of type 2 diabetes (39.9%) in people aged 65 to 79
years old compared with all the other London boroughs. Some of the
hidden/undiagnosed diabetes cases could be within the elderly
population.
Projected Diabetes Prevalence
Projections for Diabetes prevalence up to 2035 show an increase in
the number of people living with diabetes in Richmond, as well as in
London and England at a similar rate. By 2035, it is estimated that 7.8%
of people in Richmond will be living with diabetes. This is less than a
1% increase but amounts to a further 3,609 people living with diabetes
in Richmond over the next 15 years (the figure below).
Projected diabetes prevalence in Richmond.
2020–2035
Source: Prevalence estimates of Diabetes, Public Health England,
2016
Treatment Targets
NICE recommends treatment targets for Hba1c (glucose control), blood
pressure and serum cholesterol: Target Hba1c reduces the risk of all
diabetic complications, target blood pressure reduced the risk of
vascular complications and reduced the progression of eye disease and
kidney failure and target cholesterol reduced the risk of vascular
complications. ‘Meeting all three treatment targets’ is achieved where a
patient has HbA1c ≤58mmol/mol, cholesterol <5mmol/L and blood
pressure ≤140/80 (the table below).
In 2018/19, 46.4% of people with type 2 diabetes achieved all three
treatment targets; this is higher than similar CCGs, STP, and England.
Achievement of each treatment target was also higher in comparison.
However, there was variation in the achievement between GP Practices,
ranging from around 30%-60%.
Percentage of people achieving their treatment targets for type 2 diabetes, 2018/2019
The prevalence of diabetes in people with a learning disability is
unknown, but general population data indicate it is around 10%
(including Type 1, but in most cases this is type 2 diabetes) 20.
Applying this figure to the number of people with learning disabilities
in Richmond (695 people with learning disabilities 21) provides a rough
estimate of 70 people with learning diabetes that have diabetes. The
onset of diabetes is seen at an earlier age for people with a learning
disability 22.
People with Severe Mental Illness
People with severe mental illnesses are at substantially higher risk
of diabetes compared with the general patient population. People with
schizophrenia, psychosis, bipolar depression and anxiety are at double
the risk of developing type 2 diabetes 23. In Richmond, 1,896
people were registered with their GP with schizophrenia, bipolar
affective disorder and other psychoses, with 64% of patients over age 40
having a record of blood glucose or HbA1c in the preceding 12 months 24.
Care Homes
Current estimates place the number of older people with diabetes
resident in care homes at one in four 25. Research has shown
that in addition to those with a known diagnosis of diabetes, there are
people with undiagnosed diabetes in care homes whose needs for care are
not being met.
Data limitations
The estimated NDH prevalence is based on modelled data but does not
include confidence intervals. PHOF states a caveat that “with all
modelled data, there is a degree of uncertainty associated with these
estimates therefore should be considered indicative only.” Additionally,
ward level or LSOA breakdown of the data is not available for either
data set, making it difficult to interpret this data beyond borough
level. Like the estimated NDH prevalence data, estimated Diabetes
prevalence is based on modelled data and does not include confidence
intervals.
Current Services on Offer
A range of services are available for people at high risk of
developing type 2 diabetes and for people diagnosed with type 2
diabetes. The services offer support to people to help prevent type 2
diabetes, as well as help identify people with diabetes early, and
ensure quality of care and effective management of their Diabetes.
Primary Care
Much of the management and monitoring of patients at risk of and with
type 2 diabetes is undertaken by GPs and members of the Primary Care
Team, for example through:
Identification through blood test
Maintain register of patients with type 2 diabetes and high risk-
and annual recall
Advice and signposting- GPs and Practice Nurses
Medication- e.g. metformin, insulin
Blood sugar checks (HbA1c)- every 3 months when newly diagnosed and
every 6 months once stable
Annual Diabetic Review (8 care processes recommended by NICE) -
These are five risk factors (body mass index, blood pressure, smoking,
glucose levels (Hba1c) and cholesterol) and four tests to identify early
complications (urine albumin creatinine ratio, serum creatinine, foot
nerve and circulation examination). These important markers ensure
diabetes is well controlled and are designed to prevent long-term
complications.
To support the Enhanced Primary Care Diabetes Service of GP
Practices, the CCG has partnered with the local GP Federations to focus
on quality, support and education for primary care (April 2019-March
2021). This will ensure that all GP Practices have access to the
expertise and support to achieve improvements in the delivery of high-
quality care for patients with, or at risk of, Diabetes.
The NDPP is an intensive lifestyle support programme for people
identified as high risk for developing type 2 diabetes. Individuals are
eligible if they are identified by their GP with NDH, defined as having
an HbA1c 42 – 47 mmol/mol (6.0 – 6.4%) or a fasting plasma glucose (FPG)
of 5.5 – 6.9 mmol/l. The service offers tailored, personalised support
to reduce the risk of type 2 diabetes including education on healthy
eating and lifestyle, help to lose weight and physical exercise
programmes. Local group sessions are delivered in community settings,
and a digital option is offered to those declining face-face group
sessions. Early outcomes of the Service across England demonstrate that
those completing the Programme had a mean weight loss of 3.3 kg and an
HbA1c reduction of 2.04 mmol/mol 26.
From June 2018-November 2020, 1,305 of people in Richmond were
referred to the service. The table below shows the outcomes of the
service.
NDDP outcomes, Richmond, 2018–2020
Source: Richmond NDPP data
Of the people who attended the NDPP Service in Richmond:
59% were male, 41% Female
59% were aged less than 70
30% were of Asian, Black, mixed or other ethnicity (15% of people
with NDH in Richmond are of minority ethnic origin)
21% were from the three most deprived quintiles (although 26% of
people with NDH are from the three most deprived quintiles)
23% were of normal weight (BMI 18–24.9), 39% overweight (BMI
25–29.9), and 36% obese (BMI >30)
Structured Education
Structured education programmes can help adults with type 2 diabetes
to improve their knowledge and skills and help to motivate them to take
control of their condition and self-manage it effectively. A range of
diabetes education programmes exist in London, such as DESMOND and
X-PERT. Remote courses such as Oviva are also available for those who
prefer digital support.
The table below provides an overview of referrals to Structured
Education in 2017 27.
Referrals to Diabetes Structured Education,
Richmond, 2017
The table below provides an overview of referrals to Diabetes Book
& Learn from October 2018-January 2020 for people with type 2
diabetes in Richmond. However, these are rough figures as there have
been issues with recording of attendance by providers on the Diabetes
Book & Learn platform.
Referrals to Diabetes Book & Learn, October
2018-January 2020, Richmond
Specialist Diabetes Service
Wherever possible patients with diabetes are treated by their own GP
with support from a Diabetes Specialist Nurse allocated to the practice.
However, HRCH’s specialist diabetes team can provide specialist care for
cases that are too complex to be dealt with by a patient’s GP practice,
but not complex enough to warrant hospital admission.
The teams work with the patient to agree outcomes and then produce a
care-management plan, which the patient’s GP practice can implement
between visits to the specialist clinic. This approach means that
patients with diabetes are receiving specialised care for their
condition at the most appropriate level and do not have to make
unnecessary trips to acute hospitals.
The HRCH diabetes service in Richmond provides:
A consultant led service
Specialist nurse advice
Specialist diabetes dieticians
Telephone advice line and email service
Podiatry
Retinal screening service, based at Teddington Memorial Hospital and
provided by St. Georges Hospital retinal screening service
Structured education sessions – Nationally accredited programme
DESMOND programmes for Newly Diagnosed and Foundation course FOR THOSE
WITH Established Diabetes.
BERTIE - Diabetes Education Programme for people with type 1
diabetes.
Carbohydrate Counting and Insulin Dose adjustment
Continuous glucose monitoring
Referrals to other local healthy lifestyle intervention
programmes.
Established insulin pump users
Domiciliary visits for housebound clients
Hypoglycaemic Pathway for the prompt treatment and support of
patients calling 999 for hypoglycaemia. This service is provided
alongside London Ambulance Service.
Psychological support and onward referral to Richmond Well-Being
Service where needed. Retinal screening also available at Queen Mary’s
Hospital (in addition to Teddington Memorial Hospital)
Dietetics Service
Having a healthy diet is an important part of living with type 2
diabetes and managing it well. Dietetics can provide individuals with
advice and guidance about their diet. Dietetic services are available
through Kingston Hospital as well as through St. Georges Hospital based
Queen Mary’s Hospital. Additionally, Specialist Diabetes Dietitians are
available in the HRCH Diabetes Team and the Beta Cell Diabetes Team at
Queen Mary’s Hospital.
Foot Care
Podiatry care is offered to patients with diabetes in Richmond to
reduce the risk of lower limb ulceration and early amputation. HRCH
Podiatry and Foot Health team are a registered “Any Qualified Provider”
(AQP) of routine podiatry care, as well as the only NHS provider for
specialist podiatry care to people registered with a Richmond GP.
Referrals can be made by a Richmond GP or other health care
professional.
Secondary Care
Diabetes and Endocrinology departments are mainly accessed by
Richmond residents at Kingston Hospital and Queen Mary’s Hospital. The
clinical needs of patients referred to this service have a greater
complexity or complications. Input may also be required from other
specialities, as clinically appropriate.
The specialist nurse led services, provide care for people with
diabetes requiring additional support and help with their diabetes
management. Consultant led clinics are also provided in their outpatient
departments and outreach centres.
Foot Care
Podiatric foot care is offered to patients in Richmond to reduce the
risk of lower limb ulceration and early amputation. Healthshare Richmond
is the provider of NHS Community Podiatry Services in Richmond.
Referrals can be made by a Richmond GP or other Health Care
Professionals.
Diabetic Eye Screening
Type 2 diabetes increases the risk of having an eye problem called
retinopathy. It is important to have regular eye screening checks for
retinopathy. These are different from normal sight tests and
specifically look for early signs of damage caused by Diabetes. Eye
screening should happen at or around the time of diagnosis and if there
are no concerns, then at least once a year after that. If there are
signs that damage may be developing, individuals may be offered another
check or may be referred to an eye specialist at a hospital.
In 2019, 68.4% of people with diabetes on GP registers had a record
of retinal screening in the preceding 12 months. This is lower than
London and England (73.7% and 77.3% respectively).
Vulnerable Groups
From 2016/17, the National Diabetes Audit has looked at the care of
people with Serious Mental Illness, SMI and Diabetes and compared this
to the care received by the whole population of people with diabetes.
People with SMI and type 2 diabetes are, on average, younger than those
with type 2 diabetes who do not have SMI.
Evidence-based Diabetes Treatment/Interventions
NICE Guidance
NICE provides evidence-based guidance and advice on the prevention,
diagnosis and management of Diabetes:
NICE Guideline PH35- type 2 diabetes prevention: population and
community level interventions (May 2011)
NICE Guideline type 2 diabetes: prevention in people at high
risk
NICE Guideline NG28 – Diabetes in adults: management, example
recommendations
NICE Guideline CG189- Obesity: Identification, Assessment and
Management
NHS RightCare Pathway: Diabetes
The Diabetes
Pathway shows the core components of an optimal Diabetes Service,
evidence of the opportunity to reduce variation and improve outcomes and
the key evidence-based interventions which the system should focus on
for greatest improvement, supported by practice examples from across the
NHS
Lifecourse Approach
Taking a lifecourse perspective is essential for preventing type 2
diabetes, as it is for many health conditions. A lifecourse approach
recognises critical windows for intervention to lessen the risk of
obesity and type 2 diabetes in later life
There are opportunities to prevent and control type 2 diabetes at
key stages of life from preconception, through pregnancy, infancy,
childhood and adolescence, through to adulthood
One review provides an overview of summarised evidence on effective
strategies to prevent Diabetes in the following four cohorts: (1)
pregnant women and young families, (2) children and adolescents (<15
years), (3) working-age population (15–64 years), (4) the elderly
(>64 years), alongside evidence-based communication strategies
(health campaigns, food labelling, etc.) 28
Intensive Lifestyle Intervention
Behavioural interventions conducted in ‘real world’ settings are
effective in reducing weight and reducing the incidence of Diabetes.
Overall, the incidence of Diabetes was reduced by 26% over a period of
12–18 months post-intervention
The NDPP is underpinned by this strong evidence base. The learning
from this evidence review, alongside an Expert Reference Group and
existing NICE guidelines, was used to inform the structure and content
of the NDPP intervention 29.
Diet and Lifestyle Changes
Type 2 Diabetes is preventable by changing lifestyle and the risk
reduction is sustained for many years after the active intervention
Healthy dietary changes based on the current recommendations and the
Mediterranean dietary pattern can be recommended for the long-term
prevention of Diabetes 30
Metformin Compared to Diet or Exercise
Metformin compared with placebo or diet and exercise reduced or
delayed the risk of type 2 diabetes in people at increased risk for the
development of type 2 diabetes
Metformin compared to intensive diet and exercise did not reduce or
delay the risk of type 2 diabetes
The combination of Metformin and intensive diet and exercise
compared to intensive diet and exercise only neither showed an advantage
or disadvantage regarding the development of type 2 diabetes 31
Low Calorie Diets
Findings from the Diabetes Remission Clinical Trial (DiRECT) has
shown that some people with type 2 diabetes can achieve remission
through adoption of low-calorie diets. This allowed nearly half of
patients to stop taking anti-diabetic drugs and still achieve
non-diabetic range glucose levels, with over a third remaining in
remission after two years
NHS England is piloting the Low-Calorie Diet Programme, based on
results from the DiRECT trial, across 10 areas in England, including
North East London and North Central London. Eligible participants will
be offered low calorie, total diet replacement products including soups
and shakes consisting of up to 900 calories a day for up to 12 weeks.
Alongside this, participants will receive support for 12 months
including help to re-introduce food after the initial 12-week
period
Culturally Appropriate Health Education
Culturally appropriate health education has short‐ to medium‐term
effects on glycaemic control and on knowledge of Diabetes and healthy
lifestyles
While pharmacotherapy may appear to achieve greater improvements in
biochemical measures, culturally appropriate Diabetes Education (both
for ethnic minority groups and indeed for all people with type 2
diabetes is vital to compliance with pharmacotherapy 32.
3.3 Hypertension
GP Recorded Hypertension Prevalence
Early diagnosis and treating hypertension significantly reduces the
risk of CVD.
Hypertension: QOF prevalence (all ages): In 2022/23, Richmond’s
rate was 10.2% (n=24768), which was the 11th lowest in London, 29.0%
lower than the England average and 6.2% lower than the London average.
The latest Borough figure for 2022/23 was also 2.4% lower than in
2012/13, in comparison with 5.5% increase in England’s rate in the
equivalent time period.
CHD: QOF
prevalence (all ages): In 2022/23, Richmond’s rate was 2.0%
(n=4755), which was the 14th highest in London, 34.2% lower than the
England average and 5.8% higher than the London average. The latest
Borough figure for 2022/23 was also 1.5% lower than in 2012/13, in
comparison with 10.6% decrease in England’s rate in the equivalent time
period.
Hospital
admissions due to coronary heart disease: In 2022/23, Richmond’s
rate was 386.9 per 100,000 (n=690), which was the 15th lowest in London,
0.0% lower than the England average and 0.0% higher than the London
average. The latest Borough figure for 2022/23 was also 39.4% lower than
in 2003/04, in comparison with 46.2% decrease in England’s rate in the
equivalent time period.
Stroke:
QOF prevalence (all ages): In 2022/23, Richmond’s rate was 1.3%
(n=3112), which was the 8th highest in London, 30.3% lower than the
England average and 16.8% higher than the London average. The latest
Borough figure for 2022/23 was also 12.6% higher than in 2012/13, in
comparison with 8.7% increase in England’s rate in the equivalent time
period.
Hospital
admissions due to stroke: In 2022/23, Richmond’s rate was 163.7
per 100,000 (n=285), which was the 7th lowest in London, 2.8% lower than
the England average and 0.0% higher than the London average. The latest
Borough figure for 2022/23 was also 5.1% lower than in 2003/04, in
comparison with 6.8% decrease in England’s rate in the equivalent time
period.
Mortality
rate from stroke, all ages: In 2020 - 22, Richmond’s rate was
39.1 per 100,000 (n=197), which was the 3rd lowest in London, 22.2%
lower than the England average and 15.5% lower than the London average.
The latest Borough figure for 2020 - 22 was also 59.6% lower than in
2001 - 03, in comparison with 58.6% decrease in England’s rate in the
equivalent time period.
Respiratory diseases include asthma, chronic obstructive pulmonary
disease (COPD), pulmonary fibrosis and pneumonia. In this section the
latest available Richmond-level information on prevalence,
hospitalisations and mortality linked to respiratory conditions will be
explored. Most of the data presented are published for the registered
CCG population (patients registered with Richmond’s GP). In 2019/20 five
South West London (SWL) CCGs merged into a single South West London CCG
which makes it difficult to distinguish information specific to
Richmond. For most CCG indicators the data presented in the chapter is
two years old, as the latest 2019/20 and 2020/21 data is only available
at SWL CCG level.
4.1 COPD
COPD (chronic obstructive pulmonary disease) is a diagnostic term
that captures a variety of serious lung conditions including chronic
bronchitis and emphysema. COPD is usually prevalent in adults over the
age of 35 years. COPD is a serious lung disease for which smoking is the
biggest preventable risk factor.
GP Recorded Prevalence of COPD
COPD: QOF
prevalence (all ages): In 2022/23, Richmond’s rate was 1.0%
(n=2519), which was the 14th highest in London, 43.6% lower than the
England average and 2.0% higher than the London average. The latest
Borough figure for 2022/23 was also 5.1% higher than in 2012/13, in
comparison with 6.0% increase in England’s rate in the equivalent time
period.
Emergency
hospital admissions for COPD (35+): In 2019/20, Richmond’s rate
was 217.6 per 100,000 (n=215), which was the 2nd lowest in London, 47.6%
lower than the England average and 39.2% lower than the London average.
The latest Borough figure for 2019/20 was also 16.6% lower than in
2010/11, in comparison with 1.3% increase in England’s rate in the
equivalent time period.
Asthma:
QOF prevalence (6+ yrs): In 2022/23, Richmond’s rate was 4.8%
(n=10872), which was the 16th highest in London, 26.9% lower than the
England average and 0.9% higher than the London average. The latest
Borough figure for 2022/23 was also 6.2% higher than in 2020/21, in
comparison with 2.3% increase in England’s rate in the equivalent time
period.
MSK conditions are injuries and disorders that affect the human
body’s movement or musculoskeletal system (i.e. muscles, tendons,
ligaments, nerves, discs, blood vessels, etc.). Musculoskeletal
conditions are the largest cause of years lived with disability (YLDs),
accounting for 17% of all YLDs worldwide 33.
5.1 Prevalence of Long-term MSK Problems
Percentage reporting a long-term Musculoskeletal (MSK) problem:
In 2023, Richmond’s rate was 13.1%, which was the 16th lowest in London,
28.8% lower than the England average and 2.3% lower than the London
average. The latest Borough figure for 2023 was also 12.9% lower than in
2018, in comparison with 2.1% decrease in England’s rate in the
equivalent time period.
Percentage reporting at least two long-term conditions, at least one of
which is MSK related: In 2023, Richmond’s rate was 8.5%, which
was the 6th lowest in London, 36.9% lower than the England average and
8.7% lower than the London average. The latest Borough figure for 2023
was also 10.8% lower than in 2018, in comparison with 0.0% decrease in
England’s rate in the equivalent time period.
%
reporting a long term MSK problem who also report depression or anxiety:
In 2016/17, Richmond’s rate was 21.5%, which was the 5th lowest
in London, 10.8% lower than the England average and 17.0% lower than the
London average. The latest Borough figure for 2016/17 was also 19.8%
higher than in 2014/15, in comparison with 7.3% increase in England’s
rate in the equivalent time period.
Rheumatoid Arthritis: QOF prevalence (16+ yrs): In 2022/23,
Richmond’s rate was 0.5% (n=1080), which was the 13th highest in London,
28.2% lower than the England average and 2.5% higher than the London
average. The latest Borough figure for 2022/23 was also 7.7% higher than
in 2013/14, in comparison with 4.6% increase in England’s rate in the
equivalent time period.
Hip
fractures in people aged 65 and over: In 2022/23, Richmond’s
rate was 510.4 per 100,000 (n=170), which was the 11th highest in
London, 8.5% lower than the England average and 1.6% higher than the
London average. The latest Borough figure for 2022/23 was also 15.3%
lower than in 2010/11, in comparison with 9.3% decrease in England’s
rate in the equivalent time period.
People living with mental health problem are more likely to make
unhealthy lifestyle choices and twice as likely to smoke 34. Mental health
problems often lead to alcohol and substance misuse 35; increasing the risk
of obesity, asthma, diabetes, chronic obstructive pulmonary disease
(COPD) and cardiovascular disease 36. This section provides an overview of
nationally available data on mental health in adults living in Richmond,
including GP recorded prevalence of mental illnesses, referral rates to
specialist services, admissions to hospital, employment rates,
accommodation status and premature mortality rates in adults with mental
health problems.
6.1 Key Demographics and Need
GP Recorded Prevalence of Mental Illness
GP Mental Health Registers include patients with a diagnosis of
schizophrenia, bipolar affective disorder and other psychoses.
Mental
Health: QOF prevalence (all ages): In 2022/23, Richmond’s rate
was 0.9% (n=2141), which was the 4th lowest in London, 11.2% lower than
the England average and 22.3% lower than the London average. The latest
Borough figure for 2022/23 was also 6.9% higher than in 2012/13, in
comparison with 18.6% increase in England’s rate in the equivalent time
period.
Estimated
prevalence of common mental disorders: % of population aged 16 &
over: In 2017, Richmond’s rate was 13.2% (n=20430), which was
the lowest in London, 21.9% lower than the England average and 31.4%
lower than the London average. Time series data were not available for
this indicator.
Gap in
the employment rate for those who are in contact with secondary mental
health services and the overall employment rate: In 2021/22,
Richmond’s rate was 70.8 percentage points, which was the 16th highest
in London, 2.0% higher than the England average and 0.6% lower than the
London average. Time series data were not available for this
indicator.
Mental Health Service Users Living In Stable Accomodation
Adults in
contact with secondary mental health services who live in stable and
appropriate accommodation: In 2020/21, Richmond’s rate was
73.0%, which was the 11th highest in London, 25.9% higher than the
England average and 19.7% higher than the London average. The latest
Borough figure for 2020/21 was also 13.3% lower than in 2011/12, in
comparison with 6.2% increase in England’s rate in the equivalent time
period.
6.3 Admissions to Specialist Mental Health Hospitals
Hospital
admissions for mental health conditions: In 2022/23, Richmond’s
rate was 90.9 per 100,000 (n=40), which was the 3rd highest in London,
12.5% higher than the England average and 47.4% higher than the London
average. The latest Borough figure for 2022/23 was also 21.6% higher
than in 2010/11, in comparison with 12.3% decrease in England’s rate in
the equivalent time period.
6.4 Premature Mortality in Adults with Severe Mental Illness
(SMI)
Premature
mortality in adults with severe mental illness (SMI): In 2020 -
22, Richmond’s rate was 61.5 per 100,000 (n=245), which was the lowest
in London, 44.7% lower than the England average and 44.2% lower than the
London average. The latest Borough figure for 2020 - 22 was also 4.4%
higher than in 2015 - 17, in comparison with 22.6% increase in England’s
rate in the equivalent time period.
Sexual health is an important public health issue with health, social
and economic impacts that can affect the people across the life course.
It is a fundamental aspect of human identity and life experience.
Richmond adopts the World Health Organisation’s current working
definition of sexual health which is described as:
“A state of physical, mental and social well-being in relation to
sexuality. It requires a positive and respectful approach to sexuality
and sexual relationships, as well as the possibility of having
pleasurable and safe sexual experiences, free of coercion,
discrimination and violence.” 37
Poor sexual health can lead to sexually transmitted infections
(STIs), HIV and unintended pregnancies which can lead to further
long-lasting and costly impacts for both individuals and wider society.
However, they can be reduced through safer sex practices such as the use
of condoms, regular testing, and access to sexual health and
reproductive services 38. Sexual health services currently focus
on treatment for sexual health transmitted infections, HIV, unplanned
pregnancies as well as prevention.
Prevalence
All new
STI diagnoses rate per 100,000: In 2023, Richmond’s rate was
649.1 per 100,000 (n=1265), which was the 6th lowest in London, 7.7%
lower than the England average and 55.2% lower than the London average.
The latest Borough figure for 2023 was also 6.0% lower than in 2012, in
comparison with 16.6% decrease in England’s rate in the equivalent time
period.
The all new STI diagnosis rate for England is shown as 784/100,000
population and for Richmond as similar at 788/100,000 population for
2018.
Newly diagnosed STIs (excluding chlamydia aged <25) currently
stands at 936/100,000 population in Richmond (2018) which sees a slight
increase on the last two years, but there is no overall increase in
trend since 2012.
In Richmond the diagnostic rate of Gonorrhoea per 100,000 population
is 212/100,000 population, but recent trends are remaining static and is
lower than the London average of 279.4, but significantly higher than
all England (98.5/100,000 population).
Recently, London has witnessed a sharp increase in the rate of
Syphilis. Whilst the latest diagnostic rate (17.9/100,000 population) in
Richmond remains lower than the rest of London, the borough has
nevertheless seen an overall increase in the rate of syphilis since
2012.
In line with the national picture, the number of diagnosis of
gonorrhoea and syphilis are higher in gay men compared to heterosexual
men.
The rate of new HIV diagnosis per 100,000 population among people
aged 15 years or above in the borough was 8.9 compared to 20.9 in the
rest of London and 8.7 in England. Since 2015, Richmond has seen a 7.3%
decrease in new HIV diagnoses.
There has been a good shift to on-line services, however, there
remains an inequality of access to sexual health provision for Richmond
residents with little evidence that the pan-London sexual health
transformation is pushing trends in the right direction fast
enough.
In 2018 the total abortion rate stood at 15.9/1000 15 to 44-year
olds. This is lower than that of both England and London, indicating
women in Richmond have consistently had good access to reproductive care
over the last 6 years.
The percentage of abortions performed under 10 weeks in Richmond was
83.7% which is higher than both England (80.3%) and London Percentage
(82.3%), indicating Richmond residents are getting swift and improved
access to abortion at an early stage of pregnancy.
MSM are among the largest groups diagnosed with a new STI diagnosis
and STI diagnosis is increasing among MSM. BAME communities in Richmond
also experience a significantly higher proportion of STI diagnosis
compared with the proportion of the population from ethnic groups. The
age and gender distribution of new STI diagnoses (Chlamydia, gonorrhoea,
herpes, syphilis, warts) in Richmond in 2018 highlights that the largest
number of newly diagnosed STI’s are in the 25 to 34-year-old age
cohort.
The age and gender distribution of new STI diagnoses (Chlamydia,
gonorrhoea, herpes, syphilis, warts) in Richmond residents in 2018
highlights that the largest number of newly diagnosed STI’s are in the
25 to 34-year-old age cohort (as shown in the figure below).
Age and Gender Distribution of New STI Diagnoses
The age and gender distribution of new STI diagnoses (chlamydia,
gonorrhoea, herpes, syphilis, warts) in Richmond residents in 2018
highlights that the largest number of newly diagnosed STI’s are in the
25 to 34-year-old age cohort (figure below).
Source: GUMCAD
Extracted Feb 2020
Sexual Orientation
People identifying as LGBTQ+ can experience a greater degree of
health inequalities, including sexual health 39. National data shows
where gender and sexual orientation are known. MSM account for 29% of
London residents diagnosed with a new STI in a specialist health clinic.
90% have syphilis and 63% have gonorrhoea. In line with the national
picture, the amount of diagnoses of gonorrhoea and syphilis are higher
in gay men compared to heterosexual men (figure below).
Count of STI diagnoses in Richmond by sexual
orientation
Source: GUMCAD Sep ’18–Oct ’19
When comparing new diagnosis of STIs by ethnic origin and sexual
orientation a larger proportion of white gay/lesbian are newly diagnosed
(the figure below).
Source: GUMCAD
Extracted Feb 2020
New STI Diagnoses (Excluding Chlamydia)
New STI
diagnoses (excluding chlamydia aged under 25) per 100,000: In
2023, Richmond’s rate was 534.6 per 100,000 (n=1042), which was the 7th
lowest in London, 2.8% higher than the England average and 56.5% lower
than the London average. The latest Borough figure for 2023 was also
5.2% lower than in 2012, in comparison with 8.5% decrease in England’s
rate in the equivalent time period.
Genital Chlamydia Trachomatis is the most commonly reported bacterial
STI in England. Infection is asymptomatic in at least 70% of women and
50% of men and as a result most infections remain undiagnosed .
Untreated chlamydia infection has significant health consequences. It is
associated with considerable reproductive morbidity in women including
pelvic inflammatory disease, ectopic pregnancy and infertility. In men,
complications can include urethritis, epididymitis and Reiter’s
syndrome. The chlamydia detection rate is one of the Health Protection
indicators within the Public Health Outcomes Framework (PHOF). In 2013
the department of Health set a recommended chlamydia detection rate of
≥2300 per 100.000 population as this indicates high volumes of screening
and diagnosis.
Gonorrhoea Diagnoses
Gonorrhoea diagnostic rate per 100,000: In 2023, Richmond’s rate
was 130.3 per 100,000 (n=254), which was the 7th lowest in London, 12.7%
lower than the England average and 67.2% lower than the London average.
The latest Borough figure for 2023 was also 160.6% higher than in 2012,
in comparison with 196.9% increase in England’s rate in the equivalent
time period.
London is currently witnessing an increase in the rate of Syphilis.
In response to the rise, Public Health England has formed a “Syphilis
Action Group” to develop and initiate a London wide syphilis action
plan. Richmond has been actively involved in the group since its
creation in 2019.
Syphilis
diagnostic rate per 100,000: In 2023, Richmond’s rate was 19.0
per 100,000 (n=37), which was the 6th lowest in London, 14.0% higher
than the England average and 61.7% lower than the London average. The
latest Borough figure for 2023 was also 200.5% higher than in 2012, in
comparison with 195.7% increase in England’s rate in the equivalent time
period.
HIV
diagnosed prevalence rate per 1,000 aged 15 to 59: In 2022,
Richmond’s rate was 2.1 per 1,000 (n=240), which was the 2nd lowest in
London, 11.9% lower than the England average and 60.9% lower than the
London average. The latest Borough figure for 2022 was also 7.7% lower
than in 2011, in comparison with 19.1% increase in England’s rate in the
equivalent time period.
This year 14 adult residents of Richmond were newly diagnosed with
HIV. The rate of new HIV diagnosis per 100,000 population among people
aged 15 years or above in the borough was 8.9 compared to 20.9 in the
rest of London and 8.7 in England. Since 2015, Richmond has seen a 7.3%
decrease in new HIV diagnoses. The decrease highlights the success of
combination HIV prevention which includes condom provision, pre-exposure
prophylaxis (PrEP), expanded HIV testing and prompt initiation of
treatment after diagnosis.
In Richmond the E-Service during this period had HIV detection rates
for over 24 year olds of non-reactive 7,018 (99.7%) and reactive 21
(0.3%) while the numbers of postal test kits sent out by the newly
commissioned SH:24 service totalled 26 with 11 being processed. Most of
these kits were requested by people in the 25–34 age group (48.39%) and
by males (64.34%). 2 reactive results were produced from those kits
processed.
In Richmond the E-Service during this period had HIV detection rates
for over 24 year olds of non-reactive 810 (99.6%) and reactive 3 (0.4%)
while the numbers of postal test kits sent out by the newly commissioned
SH:24 service totalled 5 with 5 being processed. Most of these kits were
requested by people in the 25–34 age group (40.48%) and by males
(63.16%). No reactive results were produced from those kits
processed.
The vast majority (78.0%) of newly diagnosed patients in the borough
were put on Antiretroviral treatment (ART) within 91 days of their
diagnosis. Successful ART decreases a person’s viral load, significantly
reduces the risk of future transmission and transforms HIV from a fatal
infection to a chronic but manageable condition. However, between 2016
and 2018, 48.5% of HIV diagnoses were made at a late stage of infection
(CD4 count =<350 cells/mm 3). Late diagnosis is the most important
predictor of HIV-related morbidity and short-term mortality and is a key
component of valuating the success of HIV testing efforts.
Contact with Sexual Health Services
Current services In Richmond from Oct 2018 to 19 over 13,000 people
accessed a sexual health service for the first time. Access was greater
amongst females who represented 58% of attendees (Figure 108) 40.
Count of contacts with Richmond’s sexual health
service by age group
Source: GUMCAD Extracted Feb 2020
8. Cancer
Cancer is a group of diseases involving abnormal cell growth with the
potential to invade or spread to other parts of the body. These contrast
with benign tumours, which do not spread. This section presents cancer
prevalence (including new diagnoses), hospitalisations and cancer
survival rates of Richmond’s patients.
Most of the data presented are published for registered CCG
population (patients registered with Richmond’s GP). In the last two
years 5 South West London (SWL) CCGs have merged into a single South
West London CCG which, starting from year 2019/20, makes it difficult to
distinguish cancer information specific to Richmond; for most CCG
indicators the data presented in the chapter is 2 years old, as the
latest 2019/20 and 2020/21 data is only available at SWL CCG level.
8.1 Cancer Diagnosis and Prevalence
Cancer Diagnosed at Early Stages
Percentage of cancers diagnosed at stages 1 and 2: In 2018,
Richmond’s rate was 58.5% (n=418), which was the 4th highest in London,
7.1% higher than the England average and 4.6% higher than the London
average. The latest Borough figure for 2018 was also 3.8% lower than in
2014, in comparison with 1.0% decrease in England’s rate in the
equivalent time period.
Premature and preventable cancer mortality can be found in People
JSNA Chapter. This section presents mortality from main cancer types
including lung, breast and colorectal. There are no mortality indicators
for prostate cancer that can be reported. However, the 2012/16
Richmond’s incidence ratio for prostate cancer was 110.8 (n=695), the
13th highest rate in London, and higher than the England average.
Lung Cancer Mortality
Mortality
rate from lung cancer, all ages: In 2020 - 22, Richmond’s rate
was 32.8 per 100,000 (n=166), which was the 3rd lowest in London, 32.9%
lower than the England average and 24.3% lower than the London average.
The latest Borough figure for 2020 - 22 was also 44.4% lower than in
2001 - 03, in comparison with 24.9% decrease in England’s rate in the
equivalent time period.
Mortality
rate from colorectal cancer, all ages: In 2020 - 22, Richmond’s
rate was 21.6 per 100,000 (n=110), which was the 11th lowest in London,
16.0% lower than the England average and 5.8% lower than the London
average. The latest Borough figure for 2020 - 22 was also 20.0% lower
than in 2001 - 03, in comparison with 18.8% decrease in England’s rate
in the equivalent time period.
Mortality
rate from breast cancer, all ages (Female): In 2020 - 22,
Richmond’s rate was 28.8 per 100,000 (n=86), which was the 10th lowest
in London, 7.8% lower than the England average and 6.0% lower than the
London average. The latest Borough figure for 2020 - 22 was also 33.3%
lower than in 2001 - 03, in comparison with 30.7% decrease in England’s
rate in the equivalent time period.
Cancer
screening coverage: breast cancer: In 2023, Richmond’s rate was
63.8% (n=14667), which was the 6th highest in London, 3.7% lower than
the England average and 14.2% higher than the London average. The latest
Borough figure for 2023 was also 11.7% lower than in 2010, in comparison
with 13.9% decrease in England’s rate in the equivalent time period.
Cancer
screening coverage: cervical cancer (aged 50 to 64 years old):
In 2023, Richmond’s rate was 72.8% (n=16088), which was the 8th highest
in London, 2.1% lower than the England average and 3.1% higher than the
London average. The latest Borough figure for 2023 was also 7.7% lower
than in 2010, in comparison with 5.4% decrease in England’s rate in the
equivalent time period.
Cancer
screening coverage: bowel cancer: In 2023, Richmond’s rate was
70.1% (n=21588), which was the 5th highest in London, 2.6% lower than
the England average and 10.5% higher than the London average. The latest
Borough figure for 2023 was also 22.2% higher than in 2015, in
comparison with 25.7% increase in England’s rate in the equivalent time
period.
Abdominal
Aortic Aneurysm Screening Coverage: In 2022/23, Richmond’s rate
was 73.6% (n=781), which was the 12th lowest in London, 6.0% lower than
the England average and 2.0% lower than the London average. The latest
Borough figure for 2022/23 was also 4.2% lower than in 2013/14, in
comparison with 1.2% increase in England’s rate in the equivalent time
period.
In 2019, 68.4% of people with diabetes on GP registers had a record
of retinal screening in the preceding 12 months. This is lower than
London and England (73.7% and 77.3% respectively) 41. This is lower than
London and England (73.7% and 77.3% respectively).
Vision Plus, Search and Report, accessed securely
online, 2020↩︎
Q-Diabetes is a risk prediction algorithm which
calculates an individual’s risk of type 2 diabetes taking account of
their individual risk factors such as age, sex, ethnicity, and clinical
values↩︎
Vision Plus, Search and Report, accessed securely
online, 2020↩︎
Diabetes UK, Diabetes in care homes: Awareness,
screening, training, September 2017.↩︎
Valabhji J , Barron E, Bradley D et al. Early Outcomes
from the English National Health Service Diabetes Prevention Programme.
Diabetes Care Jan 2020, 43 (1) 152-160; DOI: 10.2337/dc19-1425↩︎
NHS Digital, National Diabetes Audit (NDA) 2018/19
Interactive report for England, Clinical Commissioning Groups and GP
practices, 13 December 2019.↩︎
Timpel, P., Harst, L., Reifegerste, D. et al. What
should governments be doing to prevent Diabetes throughout the life
course?. Diabetologia 62, 1842–1853 (2019). URL: https://doi.org/10.1007/s00125-019-4941-y↩︎
Public Health England, A systematic review and
metaanalysis assessing the effectiveness of pragmatic lifestyle
interventions for the prevention of type 2 diabetes mellitus in routine
practice, August 2015.↩︎
Madsen KS, Chi Y, Metzendorf M, Richter B, Hemmingsen
B. Metformin for prevention or delay of type 2 diabetes mellitus and its
associated complications in persons at increased risk for the
development of type 2 diabetes mellitus. Cochrane Database of Systematic
Reviews 2019, Issue 12. Art. No.: CD008558. DOI: https://doi.org/10.1002/14651858.CD008558.pub2↩︎
Lean, M. E.J. et al. (2019) Durability of a primary
care-led weight-management intervention for remission of type 2
diabetes: 2-year results of the DiRECT open-label, cluster-randomised
trial. Lancet Diabetes and Endocrinology, 7(5), pp. 344-355. (doi:10.1016/S2213-8587(19)30068-3)↩︎
Identified long-term conditions compared to peer
group, 2017/18
GP Practice registers, recorded incidence of
disease, 2019–20
Change in population morbidity, 2018–2019
Multi-morbidity in Richmond
Correlation between unidentified long-term
conditions and hospital attendances
Multi-morbidity by age in Richmond
Admissions with obesity in primary diagnostic
field by local authority, 2019/20
Admissions with obesity in primary diagnostic
field, 2014–2019
Admissions with obesity mentioned in either
primary or secondary diagnostic fields by local authority, 2019/20
Admissions with obesity mentioned in either
primary or secondary diagnostic fields, 2014–2020
Admissions for bariatric surgery by local
authority, 2019/20
Admissions for bariatric surgery,
2014–2020
NHS Health Checks logo
NDH prevalence by demographic group, Richmond,
2018/19
Demographic breakdown of people diagnosed with
type 2 diabetes, 2018/19
Diabetes prevalence in Richmond by LSOA,
2017/18
Projected diabetes prevalence in Richmond.
2020–2035
NDDP outcomes, Richmond, 2018–2020
Referrals to Diabetes Structured Education,
Richmond, 2017
Referrals to Diabetes Book & Learn, October
2018-January 2020, Richmond
Source: GUMCAD
Extracted Feb 2020
Count of STI diagnoses in Richmond by sexual
orientation
Source: GUMCAD
Extracted Feb 2020
Count of contacts with Richmond’s sexual health
service by age group
Social Consequences
In addition to mental health and quality of life, the important social consequences of type 2 diabetes include impacts on individuals’ family life, education and employment. These are wider consequences that are just as important as health outcomes, as they have far-reaching impacts.