Diabetes and an ageing population – are we ready for the future?

Mark Twain once wrote, “There is no such thing as a new idea.” That could easily be applied to the organisation of the NHS, which recently celebrated its 76^th anniversary. When the NHS was formed, there were plans for 30–35 joint authorities to assess the needs of their areas and plan how those needs should best be met (read “integrated care boards” in 2024), and to develop a process to “ensure a proper distribution of doctors” (read “measures to tackle health inequities” in 2024) alongside primacy of leadership roles for members of the medical profession, particularly hospital consultants (Klein, 2013).

In 1950, the population of the UK was around 50 million people. It is now approximately 70 million, with a small further rise expected by 2050 and then stabilisation to 2100 (United Nations, 2024). 

 Alongside this population expansion, there has been a steady life expectancy improvement (in both sexes) at birth from 68 to 80 years, with a narrowing of the gap between women and men. It is predicted that the rise in life expectancy will continue, so that by the end of the century new births can expect to live 90 years (United Nations, 2024). So, we can expect a significant rise in our over 65 years population, as the percentage of younger people declines.

The Health Survey for England (HSE), 2021 reported a diagnosed prevalence of diabetes of 6% across all ages, rising to 15% and 16% of those aged 65–74 and 75+, respectively (NHS England, 2023). HSE also noted that approximately a one third of people with diabetes were undiagnosed, leading to the conclusion that the real prevalence in the population of over 65s is 21%. This is consistent with previous analysis from Public Health England (2016), which suggested an overall prevalence of diabetes of 9.7% by 2035 and around 24% of over 65s. 

By combining the results of the UN population prediction and the HSE, within the next 11 years we can expect around 4.32 million people over the age of 65 years with diabetes. This number has significant implications for the organisation and provision of our health services, particularly noting the rising prevalence of multimorbidity as we age. 

This is particularly so in groups experiencing deprivation (Barnett et al, 2012), the prevalence of which has not improved greatly over the past 15 years (18% of people, as defined by income; Francis-Devine, 2024), and there is concern that this will increase further (Corlett, 2023). This is important, as both prevalence of type 2 diabetes and multimorbidity are associated with deprivation (Barnett et al, 2012; PHE, 2016), and 60% of the direct costs of diabetes in the UK (approximately £10.7 bn p.a.) have been attributed to complications (Hex et al, 2024). In addition, people living with diabetes take up 20% of acute hospital beds, at a cost of £5.5 bn p.a. Those living with type 2 diabetes comprise 66% of hospital attendees over the age of 65 years (Stedman et al, 2020).

The advent of The NHS Long Term Plan (and many attempts prior) was designed to boost primary and community care, make the NHS more proactive in the services provided, and be more joined-up and coordinated, whilst being more differentiated in its support offer to individuals, given the previous focus on acute and emergency care (NHS, 2019). James W. Frick once said, “Don’t tell me where your priorities are. Show me where you spend your money and I’ll tell you what they are.” In this vein, a recent King’s Fund report reminded us that despite the long-term plan aims, and the vast majority of NHS activity occurring in primary and community care, over 80% of NHS funding remains in acute trusts that have seen the largest increases in expenditure (£17 bn) over the past 5 years (Baird et al, 2024). This sum is larger than the total increase in community, ambulance, specialist and mental health trusts combined. 

Unfortunately, data from the Nuffield Trust (2022) indicates a steady rise in 30-day hospital readmissions, from 12.4%–15.5% between 2013/14 and 2020/21. The recent Age UK State of Health and Care in England report indicates a year-on-year drop to 50% (2016–2021) in the proportion of older people (particularly those most deprived) who felt they had sufficient support to manage their long-term conditions (Reeves et al, 2023). 

At the same time, we see a rise (pandemic apart) in A&E attendance, no reduction in emergency admissions that should not require admission (including diabetes), and emergency 30-day readmissions in over 75s at 18%. Meanwhile, there has been no increase in full-time equivalent district nurses (while there has been a 5% rise in community nurses and a greater than 30% rise in overall NHS staff in the same time period; Reeves et al, 2023).

What next? Our new health secretary has recently stated that the NHS is broken, and has appointed Lord Darzi (a consultant surgeon) to lead a review to establish the state of the NHS (Department of Health & Social Care, 2024). For our ageing population, particularly those with diabetes and often multiple other long-term conditions, this needs urgently to establish a way forward that truly focuses on proactive long-term condition management and prevention at every stage, and to enable a parity of esteem between those who work in all sectors of our NHS. I believe this will only occur with a relentless focus on out-of-hospital care, with advancement to leadership positions of those seeking incremental change and allocation of resources commensurate with our stated aims.