Policies play an essential role in improving public health and the quality of care. By studying the way policies are designed, implemented, and evaluated, as well as the overall policy impacts, it is possible to understand whether national efforts to combat public health problems are effective and efficient. Considering this, the present paper will focus on the critical overview of the UK diabetes prevention policy. Diabetes is one of the leading causes of morbidity and mortality worldwide and is associated with such serious health complications as retinopathy, nephropathy, neuropathy, and other comorbidities that reduce one’s functionality and quality of life (British Diabetic Association n.d.). Considering that the incidence of diabetes is currently on the rise (Barron et al., 2017), it is pivotal to address the issue more actively. Noteworthily, in the case of diabetes, special attention must be paid to prevention initiatives because this health condition is largely preventable.
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Before proceeding to the evaluation of the policy itself, the paper will overview the background of the problem with incidence and prevalence statistics for England. Consequently, the history of the national diabetes policy will be discussed along with its core objectives and elements. The analysis of key stakeholders, policy implementation, evaluation, and evidence on its current impacts will be central in the paper. Based on this discussion, it will be possible to state whether the current UK diabetes prevention policy is effective and whether some improvements must be made either in policy formulation or operation.
The terms “policy” and “programme” will be extensively utilised in the present paper. “Policy” is defined here as a combination of principles by which the public is agreed to live and which are formulated in legislation and regulation. Whereas policies reflect the government’s and long-term public commitment to act on eliminating a problem, programmes will be viewed in the paper as short-term interventions that are designed in order to meet certain policy goals.
Importance of the Public Health Topic
Nowadays, the increasing rate of diabetes incidence poses significant challenges to health systems worldwide. Not only does this chronic illness reduces the quality of life and life expectancy, but it also is associated with excess healthcare costs resulting in a substantial economic burden (Howells et al. 2016; Liebl et al. 2015). According to statistics provided by Howells et al. (2016), throughout 2010-2011, the number of UK deaths due to diabetes equated to 23,300, whereas the direct costs of diabetes in the country were £8.8 billion and the indirect costs – £13 billion. For this reason, diabetes and its prevention feature in the UK public health agenda.
According to Barron et al. (2017), “the prevalence of diabetes in England has increased from 2.3 million in 2009/2010 to 3.0 million in 2015/2016” (p. 513). It is also observed that some populations are particularly prone to the development of this adverse condition. According to Penn et al. (2018), its prevalence is higher in regions of socioeconomic deprivation and among Blacks and Asians who are reported to be diagnosed with diabetes two times more often than Whites and people from other racial/ethnic backgrounds: “15.2% vs 8.0%, respectively” (p. 2). In addition, it is noted that a vast majority of diagnosed patients have Type 2 diabetes (Barron et al., 2017; Penn et al., 2018; Xiao & O’Neill, 2017). Compared to Type 1 diabetes that is primarily genetically defined, the development of Type 2 diabetes is closely associated with lifestyle choices and obesity (Howells et al. 2016). It means that the latter variety of the disease is preventable in case the right approach to the identification of risks and patient education is undertaken.
History of the UK Diabetes Prevention Policy
The national diabetes policy was developed in accordance with the St Vincent Declaration, ratified by the World Health Organisation Regional Committee for Europe in 1991 that created a list of objectives for minimising the impact of diabetes (Department of Health n.d.). The National Service Framework for Diabetes published throughout 2001, and 2003 can be regarded as the major document that outlines all UK diabetes policy orientations and standards for the prevention of the disease, care for people with diabetes, management of complications, and so forth (Department of Health n.d.). The framework indicates that the UK authorities are committed to decreasing the risk of diabetes in the population as a whole while are also aimed at eliminating inequalities that currently exist in terms of diabetes prevalence in the county.
The national policy objectives, as well as related standards and guidelines, have evolved over time in accordance with more recent evidence on Types 2 and 1 diabetes, their links to individual’s behaviours, blood glucose, and blood pressure control (Department of Health n.d.). In addition, when suggesting national strategies to combat the problem, new clinical therapies and self-care interventions that have been proved to produce substantial positive outcomes were taken into consideration (Department of Health n.d.). Noteworthily, diabetes prevention initiatives have received more focused attention within the last decade as more high-quality research evidence verifying the correlation between lifestyles and diabetes became available and as the incidence trend and the rate of associated healthcare costs continued to go upward (Public Health England & NHS England 2015).
A specific cultural-social factor that contributed to the formation of the policy is a trend for increasing accessibility of unhealthy food options in UK communities, a higher level of exposure to various stressors, and the general tendency to lead sedentary lifestyles. The National Diabetes Prevention Programme that took into account these trends and research evidence and that was launched by NHS England and Diabetes UK in 2015 can be regarded as a significant milestone in the prevention policy implementation. Before that, the national efforts to prevent diabetes were smaller in scale and often were merely a part of strategies aimed to prevent other adverse conditions, such as obesity (Houses of Parliament 2012). With the first at-scale national programme, England aims to achieve a significant reduction in type 2 diabetes in the UK population as a whole.
UK Diabetes Prevention Policy: Critical Overview
Key Elements, Vision, and Objectives of the Policy
The major goals of the policy are in line with the NHS Five Year Forward View. The governmental plan has the vision to improve the overall quality of care, demonstrate the commitment to prevention, focusing on obesity and diabetes, support healthier behaviours in the population, initiate targeted prevention programmes, and so forth (NHS England 2014). As part of the policy, the National Diabetes Prevention Programme aims to “to significantly reduce the 4 million people in England otherwise expected to have Type 2 diabetes by 2025” (Public Health England & NHS England 2015, para. 1). Besides improving the quality of individuals’ lives, the initiative is expected to lead to such important outcomes as a significant reduction in costs due to diabetes-associated morbidity. As NHS England (2016) reports, even though the total gross cost of targeted prevention activities in a population of 390,000 individuals within five years may equate to £105 million, they may be considered cost-effective and, in the span of the next twenty years, they may save up to £35 million.
Besides the targeted behavioural interventions, the prevention policy includes such components as public education and the identification of at-risk individuals. Another essential element of the national diabetes prevention strategy is the collaboration with manufacturers and retailers to encourage healthier eating in the population (National Institute for Health and Care Excellence [NICE] 2019). Thus, the policy suggests a comprehensive and multi-faceted approach to resolving the identified public health problem.
The main stakeholder responsible for the development of the policy is the Department of Health. At the same time, in the National Service Framework, NHS is identified as the main stakeholders that will “develop, implement and monitor strategies to reduce the risk of developing Type 2 diabetes in the population as a whole and to reduce the inequalities in the risk of developing Type 2 diabetes” (Department of Health n.d., p. 5). However, NHS is not alone in this endeavour and works with multiple partners, including Diabetes UK, a charity organisation dedicated to fighting against a rapidly growing health crisis in England (Diabetes UK n.d.). It is worth noticing that Diabetes UK plays a major role in the dissemination of information about the disease and public awareness-raising along with the NICE that develops guidelines for diabetes prevention, diagnosis, and treatment addressed to healthcare practitioners (NICE 2018). It means that care providers and hospitals take an essential part in the implementation of the policy at a local, community level as well.
Implementation and Targeted Communities
As it was already mentioned before, the prevention policy is actively implemented through multiple campaigns and programmes. The specific elements of those programmes may include the identification of individuals with non-diabetic hyperglycaemia and their consequent engagement in lifestyle interventions with the components of education on how to reduce weight and lead a healthier lifestyle (HNS 2016). Many of these actions have been undertaken by local authorities at the community level before the launch of the National Diabetes Prevention Programme. For example, a six-week South Gloucestershire Diabetes Prevention Programme with a cohort of 300 patients was implemented to educate them on healthy dieting and exercising and provide them with professional support throughout six months post-education (Kok et al. 2019). Another short-term, intensive educational intervention with the elements of group meetings/discussions launched by the commercial Weight Watchers project in Bromley had the purpose of preventing the progression of Type 2 diabetes in those with non-diabetic hyperglycemia (Piper et al. 2017). Both of them were rigorously studied, and the findings proved them successful in improving participants’ diabetes-relevant measures, such as BMI, HbA1c, and mental well-being (Piper et al. 2017; Kok et al., 2019).
When it comes to the National Diabetes Prevention Programme, at the initial phase of implementation, it targeted the communities in Birmingham, Bradford, Durham County, Herefordshire, Medway, Salford, and Southwark (Sood, Maruthappu & Valabhji, 2015). According to Sood, Maruthappu and Valabhji (2015), among 1.8 million eligible individuals covered by the programme in those areas, 1.0–60.9% were people of South Asian origin. The national diabetes prevention strategy and the NICE guidelines emphasise the need to focus on this ethnic minority group because the prevalence of diabetes in people of South Asian descent is about six times higher than in those of European origins (Khunti, Kumar & Brodie 2009; Xiao & O’Neill 2017). By targeting ethnic and racial minorities associated with health disparities, the policy addresses the existing issues of health equity and inequalities.
In accordance with the Public Health England (2018) guidance on evaluation, the UK diabetes prevention policy is assessed based on critical performance indicators, outcomes, and cost effects. In addition, the implementation processes are evaluated in order to measure the effectiveness of interventions (Public Health England 2018). The data from the National Diabetes Audit (NDA) serves as one of the primary sources of information regarding care of those with diabetes and non-diabetic hyperglycaemia alike, as well as the quality of care of those two populations, on the national scale (NSH Digital n.d.). Noteworthily, the data collected throughout 2017 were utilised in order to conduct the first systematic study of the National Diabetes Prevention Programme processes with the purpose to evaluate the efficiency of the reporting system and the quality of information (NHS Digital 2017). Such an initial quality check is important to ensure the reliability of more systematic and long-term evaluation findings that are going to take place in the years to come.
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In addition to regular diabetes audits conducted by NDA and other organisations, such as Diabetes UK, a large-scale and comprehensive research project called DIPLOMA has been designed to assess multiple aspects of the National Diabetes Prevention Programme. The DIPLOMA research comprises eight work packages aimed to study equity of access to the programme, implementation processes, quality and fidelity of service delivery, patient outcomes, comparative effectiveness, validation, long-term cost-effectiveness, and programme management (University of Manchester n.d.). It is valid to say that the results of this study, which will be available after 2021, will help to monitor the policy impact more closely and will prompt the way to make the policy and relevant practices better.
Policy Implementation Progress and Effectiveness
Currently, available epidemiological data and research evidence on the progression of diabetes in England is slightly controversial. Statistics reported by Diabetes UK (2019) indicate that there has been an increase in the number of people diagnosed with diabetes, and the figures reached 3.8 million in 2019 compared to 3.0 million in 2015. In addition, it is estimated that the total number of individuals with this chronic disease, including the undiagnosed ones, maybe as high as 4.7 million (Diabetes UK 2019). At the same time, the NDA data collected during 2016-2017 reveals that over 10% improvements in HbA1c for patients with Type 1 diabetes and in blood pressure for patients with Type 2 diabetes were observed since 2011-2012 (Health and Social Information Centre 2018). It is also observed that 17,000 participants of the NHS Diabetes Prevention Programme have lost 59,000 kg in total, with an average weight loss of 3.4 kg per individual, which is over one kilogram of the originally predicted outcomes (NHS England 2019).
The provided numbers indicate that even though the pre-diabetic and diabetic patients may engage in lifestyle interventions more actively these days, the occurrence of diabetes is still on the rise in the population as a whole. However, actual high-quality evidence on the effectiveness of the policy implementation since 2015, when the government’s prevention efforts intensified and became more proactive, is currently not available. It will be possible to make any conclusions regarding the short-term effects of the existing national policy and programmes merely in a few years, whereas the knowledge of the long-term impacts will likely be formed only by the end of the next decade.
Overall, the National Diabetes Prevention Programme marks a significant improvement in the police operation in England, especially in terms of educating the public, identifying at-risk individuals, and working with them directly. Nevertheless, it seems that the part of the policy concerned with environmental factors, such as accessibility of healthy food options in the population, is not sufficiently addressed at the present moment. As noted by Barrett et al. (2017), “the local food environment is a determinant of both diet and weight status,” and exposure to more healthy food outlets is linked to healthier eating (p. 3317). Black, Moon and Baird (2013) add that healthy foods must be available in neighbourhoods not only physically but also financially because it is observed that lower-income individuals tend to make poorer dietary choices. Therefore, in order to combat the problem of diabetes more efficiently, it may be required to combine awareness-raising campaigns with environmental interventions and improvement of nutrition across organisations: work, school, and others.
The paper provided an overview of the UK diabetes prevention policy, focusing on its implementation, evaluation, and impacts. It was revealed that authorities in England acknowledge the seriousness of all implications linked to recent diabetes incidence trends and pay significant attention to prevention. In fact, the UK national prevention programme is unprecedented as no other states have ever attempted to prevent chronic conditions on such a large scale. It is also worth noticing that various organisations aim to satisfy policy objectives by designing evidence-based interventions. Thus, it may be expected that the policy and implementation processes will indeed lead to positive outcomes. Nevertheless, for attaining more sustainable results, environmental interventions should be implemented as well in order to make it easier for community dwellers to access healthy foods and lead an active lifestyle.
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