Supporting Children and Young People with Diabetes in Wales

2019 Annual Report Supporting children and young people with diabetes in Wales www.cypdiabetesnetwork.nhs.uk/wales @CYPDN_Wales [email protected] Hello, and welcome to our Network’s Annual Report for 2019 This report is being written while NHS Wales faces the huge challenge of a global pandemic. In this unsettling situation it is really worthwhile to look back and reflect on the progress made in calmer times. The NPDA results for Wales again show national improvement. The average HbA1c for young people cared for by teams in Wales has dropped again, with a drop of over 6 mmol/mol since the Network began in 2015. This represents a real improvement in potential health benefits for the young people we care for and teams should feel justly proud about this achievement. More than just data However, life with diabetes is much more than just HbA1c scores – a point that was made by 15 year old Emily, who spoke at our Network Meeting in May 2019. Emily described how she felt about her diabetes in a passionate and moving way. I am so grateful to all the people who have diabetes, or who have family members with diabetes, who have spoken at our events. They inspire us to keep trying to deliver the best care possible. We have all also been inspired by the story of Hypo Dino (see page 3). This great story book was written by Katie, who has Type 1 diabetes, and illustrated by her friend, Ava. Tim Dinosaurus – the Hypo Dino – faces lots of challenges in his job as a spy, and managing his diabetes is one of them! Hypo Dino is a great story that has struck a chord with people with diabetes. It is the first resource published by our Network actually written by a child with diabetes and we are really grateful to Katie and Ava for sharing their creation with us. There is much for us to be proud of as a Network, as you will find out in the pages of this report! With best wishes, Davida Hawkes Dr Davida Hawkes Chair, Children and Young People’s Wales Diabetes Network

Follow the Network on Twitter @CYPDN_Wales Contents Email the network on [email protected] Introduction from Aneurin Bevan University Hywel Dda University Dr Davida Hawkes ...... 2 Health Board ...... 8 Health Board ...... 12

Living with diabetes ...... 3 Betsi Cadwaladr University Swansea Bay University Health Board ...... 9 Health Board ...... 13 2019 in the Wales Network ...... 4 Cardiff & Vale University Brecon Group Report ...... 14 Measuring quality of care for Health Board ...... 10 children and young people with Looking ahead to 2020 ...... 16 diabetes in Wales ...... 6 Cwm Taf University Health Board ...... 11

2 Children and Young People’s Wales AllDiabetes photograhs Network used with (&consent Brecon permission. Group) Living with diabetes

In November 2019, the Children and Young People’s Wales Diabetes Network published ‘Hypo Dino’ - the adventures of Tim Dinosaurus, a heroic dinosaur spy foiling the plans of an evil villain. As well as his superhero style missions, Tim has an additional challenge to overcome, because he also has to manage his Type 1 diabetes. Hypo Dino is the creation of Katie Courtney and Ava Morgan, both age 9. Katie was diagnosed with Type 1 diabetes in June 2017. Shortly after her diagnosis the girls were inspired to start writing and illustrating a book Type 1 diabetes is a challenge, and about Hypo Dino and his adventures can sometimes get in the way, it shouldn’t stop you from having fun after a local author visited their school. and following your dreams.” Written and illustrated by Katie brought the picture book to one Further adventures of Tim Katie Courtney and Ava Morgan of her clinic appointments, and her Dinosaurus may follow as Katie and Ava have already started working Written and team asked if she would be willing to illustrated by on sequels to the original. “We are share it with other children in Wales. Katie Courtney01/11/2019 11:44:13 and Ava Morgan working on a story of when Tim Hypo Dino book v7.indd 1 “Tim is not just a dinosaur, he is a goes on holiday,” says Ava. “And also Hypo Dino book v7.indd 1 dinosaur spy,” explains Katie. “And he another book about Tim having to also has Type 1 diabetes. Sometimes be brave when he goes to get his 01/11/2019 11:44:13 on a mission he has a hypo which blood tests done. I enjoy drawing stops him from battling his enemy, the dinosaur when Katie writes the the evil Doctor Nocter.” stories.” Carol Fraser is a Paediatric Diabetes Specialist Nurse in the Paediatric Hypo Dino is available for Team at Morriston Hospital, and has all children with Type 1 known Katie and her family since diabetes in Wales through Katie was diagnosed. “When Katie their clinics. Copies can showed us her book, we thought it also be requested from the was great,” she says. “It’s funny, and Children and Young People’s we think a lot of children will relate to Wales Diabetes Network hypos sometimes getting in the way of important stuff, like battling evil geniuses and saving the world. “As it’s written by the girls, we’re hopeful that other young children faced with a diagnosis of Type 1 will identify with Hypo Dino. It also sends out the positive message that while

Annual Report 2019 3 2019 in the Wales Network

SEREN Active, a new education module, was launched to help children and young people understand how to manage their diabetes on a day-to-day basis. (In this photo: Claire from the Swansea Bay team and Will from Ysbyty Glan Clwyd)

Parents from Hywel Dda University Health Board who use ‘closed loop’ systems talked about their experiences with members of teams from across Wales, to increase knowledge and understanding among healthcare professionals. (In this photo: Simon and Krystle from the Hywel Dda team with the parent speakers after the meeting)

Several children with Type 1 diabetes, and their families, climbed Pen Y Fan together in April, supported by the Network, 1BloodyDrop, Diabetes UK Cymru and MyLife Diabetes

4 Children and Young People’s Wales Diabetes Network (& Brecon Group) 2019 in the Wales SEREN Connect, a new course about life Network with diabetes, was launched at the NHS Wales Diabetes Professional Conference in September. SEREN Connect has been written by Sara Crowley, the NHS Wales Transitional Care Co-ordinator, and is being rolled out by paediatric and adult diabetes teams across Wales

NHS Wales teams were very successful at the 2019 Quality in Care Diabetes Awards. The new referral pathway for primary care developed in Cardiff & Vale University Health Board (and rolled out nationally by the Network) and the Wrexham Maelor Transition Team both won awards. The Cardiff & Vale Paediatric Diabetes Team were highly commended for a futsal project, and the NHS Wales standard for young people moving to adult services was also highly commended

Our Network established new working groups in 2019. The Schools Group aims to improve care for young people with diabetes in educational settings. The Guidelines Group is working to standardise policies and procedures across Wales. The Psychology Working Group brings together all the psychologists working in paediatric diabetes teams in Wales to share expertise and improve care through working together.

Annual Report 2019 5 Measuring quality of care for children and young people

NPDA core report: Care Processes and Outcomes 2018/19 with diabetes inEngland WalesWales 74

How are we doing in Wales? 72 The National Paediatric Diabetes Audit (NPDA) 70 measures the quality of care we deliver, and the outcomes for children and young 68 people. In this report we have selected some 66 important categories that show how well 64 Median HbA1c (mmol/mol) teams are delivering care and supporting 62 young people. 60 2009/10Fig ure2010/11 1: Radar p 2011/12lot sho win 2012/13g unit, reg2013/14ion an d n2014/15ational per2015/16forman ce 2016/17on the sev2017/18en esse nti2018/19al healt h checks, % achieving A national view an HbA1c of below 58 mmol/mol and % achieving an HbA1c of below 80 mmol/mol PZ011 Wales England and Wales Goal target

We use HbA1c as the main indicator of HbA1c health Regional Quality Quality Updated check (%) networks Assurance Assurance Diabetes successful management of diabetes by established, (peer review), Delivery Plan Thy(peerroid review), England 100%published Unadjusted HbA1c England health chWaleseck 2016-2020, <58 mmol/mol (%) children and young people in Wales. This year (%) 80% the median average HbA1c has reduced to 62 Best Practice Diabetes Wales National Tariff Delivery Plans Regional network60% Diabetes QI introduced, published, established, Wales Programme mmol/mol in Wales. The chart (right) shows England BMI England & 40% introduced, Unadjusted HbA1c health check Wales England & Wales <80 mmol/mol (%) (%) how this means HbA1c has dropped by 10 20% mmol/mol in the past 10 years. The Figure NPDA20: Median also HbA1c published for children and youngtwo people“spotlight with0% all types audits” of diabetes in in England2019. and TheWales 2009/10Technology to 2018/19 with Audit associated showed NHS policy that, and/or paediatricoverall, diabetes insulin delivery pump structural We have published the median HbA1c rates changes.Figure 20: Median HbA1c forBP childrenhealth ch andeck young people with all types of diabetes in England andH ealtWalesh check completion use2009/10 in toWales 2018/19 with is associated less(age dthan NHS12+) policy the and/or average paediatric diabetes for England delivery structural and changes. rate* for each unit on the health board pages. The (%) (aged 12+) Wales.7.1.2 HbA1c However, outcomes there of childrenis variability and young in the peopleNetwork, with with NPDA recommends using the unit median some units exceeding the national average. The Workforce Type7.1.2 1 HbA1cdiabetesoutcomes of children and young peopleFoot examwith heal Typeth check 1 Albuminuria health check HbA1c to review year on year progress, (aged 12+) Audit revealed that (theaged 1 2total+) (%) number of staff in diabetes The data prdiabetesesented in this section refers to children and young people with Type 1 diabetes(%) and because the median score is less affected by teamscaptures thein variationWales in is HbA1c slightly outcomes greater, nationally on and average, regionally as wellthan as byin patient characteristics. Eye screen health check (aged 12+) (%) extreme results. England,The data presented but again in this theresection refersis variability to children and between young people teams with Type in 1 diabetes and 7.1.2.1captures National the andvariation regional in HbA1c unadjustedoutcomes HbA1c nationally results and regionally as well as by patient characteristics. terms ofFi gstaffure 2: Radar numbers. plot showing unit performance in 2017/18 and 2018/19 on the seven key health checks, % achieving an Figure 1: Radar plot showing unit, region and national performance on the sevHbeAn1 ces osfe bnetlioawl h 5eal8 mthm choel/mocks, l %an adc h%iev acinhgiev ing an HbA1c of below 80 mmol/mol an HbA1c of below 58 mmol/mol and % achieving an HbA1c o Tablef b7.1.2.1elow 22 80 (p mNationalagemol /mol53) shows and the regional unadjusted unadjusted mean and median HbA1c HbA1c results results for children and young PZ011 Wales Enpeoplegland a withnd W Typeales 1 diabetesGoal achieved target byPZ region011 - 20 1and8/19 country. ThePZ 0unadjusted11 - 2017/18 mean HbA1cGoal was target 65 Table 22 (page 50) shows the unadjusted mean and median HbA1c results for children and young 2019 Performancemmol/mol; this is a decrease of 2.5 mmol/mol comparedYear-on-year toH thebA1c meanhe aComparisonlth recorded in 2017/18 (67.5 HbA1c heapeoplelth with Type 1 diabetes achieved by region and country. The unadjusted mean HbA1c was 65 checmmol/mol).k (%) The median HbA1c was 62 mmol/mol and is 2.0 mmol/molcheck (%) lower compared to 2017/18 A mmol/mol; this is a decrease of 2.5 mmol/mol comparedA to the mean recorded in 2017/18 (67.5 (64.0 mmol/mol). Understanding the Thyroid mmol/mol). The median HbA1c was 62T mmol/molhyroid and is 2.0 mmol/mol lower compared to 2017/18 (64.0 100% Unadjusted HbA1c 100% Unadjusted HbA1c health check health check J mmol/mol). <5B 8 mmol/mol (%) J B<58 mmol/mol (%) (%) (%) radar plot diagrams 80% 80%

Every unit is measured on 60% 52 55 60% BMI BMI 40% Unadjusted HbA1c 40% Unadjusted HbA1c their performance on key health check health check I C<80 mmol/mol (%)I C<80 mmol/mol (%) (%) (%) areas. Using ‘radar plot’ 20% 20% diagrams we can see whether 0% 0% young people are receivingBP health check HealtBPh hchealectkh comchecpkletion Health check completion (aged 12+) H D (ageratd e12*+) H D rate* the care that they need and (%) (age(%d) 12+) (aged 12+) the outcomes of that care. Foot exam health check Foot exam health check Albuminuria health check Albuminuria health check (aged 12+) (aged 12+) On each diagram there are (aged 12+) (%) G E (aged 12+) (%) G E (%) (%)

four lines. There are two Eye screen hFealth check Eye screen hFealth check radar plots for each unit in (aged 12+) (%) (aged 12+) (%)

Figure 2: Radar plot showingThe unit p ergreenforman clinee in 20 1is7/18 the and 2target018/19 on * –tTh e100%. sevheaeltnh kcheye ckhTheeal cotmhp clheteionck sr,a %te a iThesc hcaievlcuin lagreengt edan b y divi lineding th eis tot theal num targetber of hea lth– c100%.hecks comp leted in each unit by the total expected the network. HbA1c of below 58 mmol/mol and % achieving an HbA1c of below 80 mmonul/molmber of health checks (which is equal to the number of children and young people with Type 1 diabetes aged 12 or older who completed grey line is the average for Englanda full year of c arande mult iplied by 7; 7 iThes the re cosolidmmen dreded nu mlineber of is he ahowlth che ckthes eac hindividual patients should receive.) Wales.PZ011 - 2 0The18/19 blue linePZ0 1is1 - 2the017/18 averageGoal in tthearget unit has scored in the NPDA in 2018-19. HbA1c health Wales Network. Thechec kred (%) line is how the The dashed red line is the individual Thyroid 100% Unadjusted HbA1c individualhealth check unit has scored in the NPDA. unit’s data from the NPDA in 2017-18. <58 mmol/mol (%) (%) 80%

60% 2 of 20 BMI 40% Unadjusted HbA1c health check <80 mmol/mol (%) (%) Children and Young People’s Wales Diabetes Network (& Brecon Group) 6 20%

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*The health check completion rate is calculated by dividing the total number of health checks completed in each unit by the total expected number of health checks (which is equal to the number of children and young people with Type 1 diabetes aged 12 or older who completed a full year of care multiplied by 7; 7 is the recommended number of health checks each patients should receive.)

2 of 20 Figure 19: Adjusted mean HbA1c Figure 19: Adjusted mean HbA1c Figure 9: Health check completion rate for children and young people with Type 1 diabetes aged 12 or older who Figure 9: Health check completion rate for children and young people with Type 1 diabetes aged 12 or older who 90 90 completed a full year of care completed a full year of care

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0% 0 50 100 150 200 250 Aneurin Bevan University Health Board

Figure 1: Radar plot showing unit, region and national performance onF tihgeu resev 1:e Radarn esse pnltoiat ls healowtinhg c huencitk, sreg, %i oanc hainevdi ngat ional performance on the seven essential health checks, % achieving an HbA1c of below 58 mmol/mol and % achieving an HbA1c of below 8a0n m HmbAo1l/molc of below 58 mmol/mol and % achieving an HbA1c of below 80 mmol/mol PZ052 Wales England and Wales GoPZa1l8 t8arget Wales England and Wales Goal target NevillHbA1c he alHallth RoyalHbA1c Gwenthealth check (%) check (%) (87 patients) (206 patients) 6.9 Thyroid 6.9

mmol/l 100% mmol/l Thyroid < > < < > < 100% Figure 1: Radar plot showing unit, regi6.9on and national performance on the sevUen aesdjsuesntetida lH hbealA1cth checks, %6.9 achieving

mmol/l mmol/l Unadjusted HbA1c < > < health che> c < k Figure 1: Radar plot showing uhnealtit, regh chioenc kand national performance on the seven essential health checks, % achieving an HbA1c of below 58 mmol/mol and % achPumpieving an HpatientsbA1c of belo w18.8% 80 mmol<5/mol8 mmol/mol (%) Pump patients 26.6%<58 mmol/mol (%) (%) an HbA1c of below 58 mmol/mol a(n%d) % achieving an HbA1c of below 80 mmol/mol 80% 80% PZ052 Wales (2018:E 17.2%)ngland and Wales GoPZa1l8 t8arget Wales (2018: E24.2%)ngland and Wales Goal target 70mm 50mm 60% 70mm 50mm 60% For large board For small board HbA1c health For large board For small board HbA1c health check (%) BMI BMI check (%) 40% A Unadjusted HbA1c 40% A Unadjusted HbA1c health check health check Thyroid 100% <80 mmol/moTl h(%)yroid <80 mmol/mol (%) (%) Unadjusted Hb(A%)1c 100% Unadjusted HbA1c health check 20% health check 20% J B<58 mmol/mol (%) J B<58 mmol/mol (%) (%) (%) 80% 80% 0% 2019 Performance 0% 60% 60%

BP healtBh MchI eck BP hHeealtalthBh Mc chIheecckk completion Health check completion 40% Unadjusted HbA1c 40% Unadjusted HbA1c (ageheadlt h12 che+) ck (ageheadlt 1h2 +che) ratcke* rate* I C<80 mmol/Imol (%) C<80 mmol/mol (%) (%)(%) (%)(%)(aged 12+) (aged 12+) 20% 20%

0% 0% Foot exam health check Foot exam health check Albuminuria health check Albuminuria health check (aged 12+) (aged 12+) BP heal(ageth cdh e12c+k) (%) Healt(ageh cdh 1e2c+k) (%)completion BP( %)health check (%)Health check completion (aged 12+) (Daged 12+) rate* D rate* (%) H (ageHd 12+) Eye screen health check (%) Eye screen health check (aged 12+) (aged 12+) (%) (aged 12+) (%)

Figure 2: Radar plot showing unit performance in 2017/18 and 2018/19 on the seven key health checks, % achieving an Foot exam health check in 2017/18 and 2018/19 on the sevFoeont kexamey heal hetalh tchh cehcekcks, % achieving an Albuminuria health check Albuminuria health check HbA1c of below 58 mmol/mol and % achieving an HbA1c of below 80 mmol/mol (aged 12+) (aged 12+) (aged 12+) (%) G E (aged 12+) (%) G E (%) (%) PZ052 - 2018/19 PZ052 - 2017/18 Goal target Eye screen hFealth check Eye screen Fhealth check HbA1c health (aged 12+) (%) (aged 12+) (%) cheAck (%) cheAck (%) Figure 2: Radar plot showing unitT pheryrfoormaid nce in 2017/18 and 2018/19 on the seven key health checks, T%h yarcohidieving an 100% Unadjusted HbA1c in 2017100%/18 and 2018/19 on the Usevnaedjnu kseyte dh ealHbtAh1c checks, % achieving an HbA1c of below 58 mmol/mol ahneald %th a cchheckieving an HbA1c of below 80 mmol/molB health check B J <58 mmol/mol (%) J <58 mmol/mol (%) Year-on-year Comparison (%) 80% (%) 80% PZ052 - 2018/19 PZ052 - 2017/18 Goal target 6H0%bA1c health 60% BMI check (%) BMI check (%) 40% Unadjusted HbA1c 40% Unadjusted HbA1c health check health check I Thyroid C<80 mmol/mI ol (%) C<80 mmol/mol (%) (%) 100% Unadjusted HbA(%1c) Thyroid 100% health check 20% Unadjusted HbA1c <58 mmol/mol (%) health check 20% (%) <58 mmol/mol (%) 80% (%) 80% 0% 0%

60% 60% BP healtBh MchI eck BPH healealtthh c chhececkk completion Health check completion 40% UnadBjuMstIed HbA1c (agehealdt h12 c+h) eck (aged 12+)rate* 40% Unadjustreadt eH*bA1c D

0% 0% Foot exam health check Foot exam health check Albuminuria health check Albuminuria health check (aged 12+) (aged 12+) BP heal(ageth cdh e12c+k) (%) Heal(tageh chdec 12k+ )c (%)ompletion G E B(P% h) ealth check G E (%H)ealth check completion (aged 12+) (aged 12+r)ate* rate* (%) (aged 12+) Eye screen hFealth check (%) Eye screen hFealth check (aged 12+) (aged 12+) (%) (aged 12+) (%)

% receiving all 7 % receiving all 7 *The health check completion rate is calculated by dividing the total number* ofTh hee haelthalt chh ceFhckooeckst co ecoxmmapmplel ehtetealidon int rh ae tacech hies ckucnalict ublya ttehde btoty daliv eidxpeingc ttehde total number of health cheFckoos tco emxapmle theeald int he acchhe ucknit by the total expected Albuminuria healtMedianh check HbA1c Albuminuria healtMedianh check HbA1c number of health checks (which is equal to the number of children and yessentialounngu pmeobpelre of w checkshithea Tltyhp ech 1 (edageckiasb de(wt 1eh2si+ ca)hg eisd e 1q2u oarl otold tehre w nhuom cobmer pofle ctedhil dren and yessentialoung people w checksith Type 1 (dageiabedt e12s +a)ged 12 or older who completed (aged 12+) (%) (aged 12+) (%) a full year of care multiplied by 7; 7 is the recommended number of health chae ckfulls yeeaacrh of p actaieren tms ushltouipl(lid%e dr)e bcey 7iv; e7.) is the recommended number of health checks each patients shoul(d% r)eceive.) 66.0 2019 78.8 62.0 2019 66.3 Eye screen health check Eye screen health check 67.8 (ag2018ed 12+) (%) 73.2 63.0 (ag2018ed 12+) (%) 55.7 68.0 2017 68.1 63.0 2017 66.7 *The health check completion rate is calculated by dividing the total number *ofTh hee haelthal tchh cehckecks co commpplelteetdion in r eaatec his u cnailtc buyla thede tboty adliv eixdpeingct tehde total number of health checks completed in each unit by the total expected number of health checks (which is equal to the nu69.5mber of childre2016n and youngn upmeo63.4bpelre ofw ihthe aTlythp ec h1 edckiabs e(wtehs iachg eisd e1q2 uoar lo tlod ethr ew nhu64.5om cobmerp ofle tcedhil dre2016n and young pe50.1ople with Type 1 diabetes aged 12 or older who completed a full year of care multiplied by 7; 7 is the recommended number of health chae ckfusll eyaecahr ofpa ctaierne tms suhltouiplide dre bcey i7v;e 7.) is the recommended number of health checks each patients should receive.)

71.0 20152 of 20 n/a 68.0 20152 of 20 n/a 5 year change: 4 year change: 5 year change: 4 year change: 5 15.4 4 16.2 mmol/mol percentage points mmol/mol percentage points

2 of 20 2 of 20 Unit performance 2019 Unit performance 2018 Wales England and Wales Goal target A - HbA1c health check (%); B - Adjusted % HbA1c <58 mmol/mol ; C Unadjusted HbA1c<80 mmol/mol D - Health check completion rate* (aged 12+); E - Foot exam health check (aged 12+) (%); F - Eye screen health check (aged 12+) (%); G - Albuminuria health check (aged 12+) (%); H - BP health check (aged 12+) (%); I - BMI health check (%); J - Thyroid health check (%)

8 Children and Young People’s Wales Diabetes Network (& Brecon Group) Betsi Cadwaladr University Health Board Figure 1: Radar plot showing unit, region and national performance oFnig tuhree sev1: Radaren es spelontt isahl ohwealintgh unchiet,c regks, i o%n a acnhdiev niantgio nal performance oFnig tuhree sev1: Radaren es spelontt isahl ohwealintgh unchiet,c regks, i o%n a acnhdiev niantgio nal performance on the seven essential health checks, % achieving an HbA1c of below 58 mmol/mol and % achieving an HbA1c of belowa 8n0 H mbmA1ocl /molof below 58 mmol/mol and % achieving an HbA1c of belowa 8n0 H mbmA1ocl /molof below 58 mmol/mol and % achieving an HbA1c of below 80 mmol/mol PZ011 Wales England and Wales PGZoal187 target Wales England and Wales PGZoal132 target Wales England and Wales Goal target

HbA1c health HbA1c health HbA1c health Glanche cClwydk (%) Wrexhamcheck (%) Gwyneddcheck (%) Thyroid Thyroid Thyroid (118100% patients) Unadjusted HbA1c (109100% patients) Unadjusted HbA1c (102100% patients) Unadjusted HbA1c 6.9 health check 6.9 health check 6.9 health check

mmol/l mmol/l mmol/l

< > < > < < > < 6.9 <58 mmol/mol (%) 6.9 <58 mmol/mol (%) 6.9 <58 mmol/mol (%)

Figure 1: Radar plot showing unit, regimmol/lon and national performance onF tihgeu resev 1:e Radarn esse pnltoiat ls healowtinhg c hunecitk, sreg, %mmol/li oanc hainevdi ngat ional performance onF tihgeu resev 1:e Radarn esse pnltoiat ls healowtinhg c hunecitk, sreg, %mmol/li oanc hainevdi ngat ional performance on the seven essential health checks, % achieving

< > < > < (%) > < (%) (%) an HbA1c of below 58 mmol/mol and % achiPumpeving an H 80%patientsbA1c of below 9.6%8a0n m HmbAo1l/molc of below 58 mmol/mol and % achPumpieving an Hpatients80%bA1c of belo w31.7% 8a0n m HmbAo1l/molc of below 58 mmol/mol and % achPumpieving an Hpatients80%bA1c of belo w19.8% 80 mmol/mol

PZ011 Wales (2018:60% En g7.4%)land and Wales GPoalZ18 t7arget Wales (2018:60% E n26.9%)gland and Wales GPoalZ132 target Wales (2018:60% E n16.8%)gland and Wales Goal target

70mm 50mm 70mm 50mm 70mm 50mm For large board BMI For small board HbA1c health For large board BMI For small board HbA1c health For large board BMI For small board HbA1c health 40% Unadjusted HbA1c 40% Unadjusted HbA1c 40% Unadjusted HbA1c health check check (%) health check check (%) health check check (%) A <80 mmol/mol (%) A <80 mmol/mol (%) A <80 mmol/mol (%) (%) (%) (%) Thyroid Thyroid Thyroid 1200%0% Unadjusted HbA1c 1200%0% Unadjusted HbA1c 1200%0% Unadjusted HbA1c health check health check health check J <5B 8 mmol/mol (%) J <5B 8 mmol/mol (%) J <5B 8 mmol/mol (%) (%) (%) (%) 80%0% 80%0% 80%0%

60% 60% 60% BP health check BP heHalealtth chh echckeck completion BP heHalealtth chh echckeck completion Health check completion (aged B12M+)I (aged B12M+)I rate* (aged B12M+)I rate* rate* 40% Unadjusted HbA1c 40% Unadjusted HbA1c 40% Unadjusted HbA1c health check health check health check (%) I C<(%80) mm(oagel/Imdo l1 2(%)+) C<(%80) mm(oagel/Imdo l1 2(%)+) C<80 mm(oagel/mdo l1 2(%)+) (%) (%) (%) 20% 20% 20%

0% 0% 0% Foot exam health check Foot exam health check Foot exam health check Albuminuria health check Albuminuria health check Albuminuria health check (aged 12+) (aged 12+) (aged 12+) (aged 12+) (%) (aged 12+) (%) (aged 12+) (%) BP health check BP h(H%)eealtalthh c chheecckk completion BP h(H%)eealtalthh c chheecckk completion (H%)ealth check completion (aged 12+) H (ageD d 12+) rHate* (ageD d 12+) rHate* D rate* (%) Eye screen health check (%) (aged 12+) Eye screen health check (%) (aged 12+) Eye screen health check (aged 12+) (aged 12+) (%) (aged 12+) (%) (aged 12+) (%)

Figure 2: Radar plot showing unit performance in 2017/18 and 2018/19Fig ounre t h2e: Radar seven p kleyot shhealowthin cgh unecikts p, %er faormachievninceg ainn 2 017/18 and 2018/19Fig ounre t h2e: Radar seven p kleyot shhealowthin cgh unecikts p, %er faormachievninceg ainn 2 017/18 and 2018/19 on the seven key health checks, % achieving an Foot exam health check Foot exam health check Foot exam health check HbA1c of below 58 mAlbmumol/moinurlia a nhed a%lt hac chehievcking an HbA1c of below 80H mbmA1ocl /molof below 58 mAlbmumol/moinurlia a nhed a%lt hac chehievcking an HbA1c of below 80H mbmA1ocl /molof below 58 mAlbmumol/moinurlia a nhed a%lt hac chehievcking an HbA1c of below 80 mmol/mol (aged 12+) (aged 12+) (aged 12+) (aged 12+) (%) G E (aged 12+) (%) G E (aged 12+) (%) G E (%) (%) (%) PZ011 - 2018/19 PZ011 - 2017/18 Goal target PZ187 - 2018/19 PZ187 - 2017/18 Goal target PZ132 - 2018/19 PZ132 - 2017/18 Goal target Eye screen health check Eye screen health check Eye screen health check HbA1cF health HbA1cF health HbA1cF health (aged 12+) (%) (aged 12+) (%) (aged 12+) (%) check (%) check (%) check (%) A A A Thyroid Thyroid Thyroid Figure 2: Radar plot showing unit performance in 2017100%/18 and 2018/19 F oignu trehe 2 sev: URadarneandj ku eypslto ehtd eals hHotbhwA ci1cnhge cunksi,t %p eracformahievinngc ea nin 2017100%/18 and 2018/19 F oignu trehe 2 sev: URadarneandj ku eypslto ehtd eals hHotbhwA ci1cnhge cunksi,t %p eracformahievinngc ea nin 2017100%/18 and 2018/19 on the sevUneandj kueyst ehdeal HtbhA c1checks, % achieving an health check health check health check HbA1c of below 58 mmol/mol and % achievJing an HbA1c of below 80 mHmbAo1l/molc ofB<5 be8l omwm 58o lm/mmolo (l%/mo) l and % achievJing an HbA1c of below 80 mHmbAo1l/molc ofB<5 be8l omwm 58o lm/mmolo (l%/mo) l and % achievJing an HbA1c of below 80 mmol/molB<58 mmol/mol (%) (%) 80% (%) 80% (%) 80% PZ011 - 2018/19 PZ011 - 2017/18 Goal target PZ187 - 2018/19 PZ187 - 2017/18 Goal target PZ132 - 2018/19 PZ132 - 2017/18 Goal target 60% 60% 60% HbA1c health HbA1c health HbA1c health BMI check (%) BMI check (%) BMI check (%) 40% Unadjusted HbA1c 40% Unadjusted HbA1c 40% Unadjusted HbA1c health check health check health check I Thyroid C<80 mmol/ImolT h(%yr)oid C<80 mmol/ImolT h(%yr)oid C<80 mmol/mol (%) (%) 100% Unadjusted Hb(A%1c) 100% Unadjusted Hb(A%1c) 100% Unadjusted HbA1c health check 20% health check 20% health check 20% <58 mmol/mol (%) <58 mmol/mol (%) <58 mmol/mol (%) (%) 80% (%) 80% (%) 80% 0% 0% 0% 60% 60% 60% BP healthB cMhIeck BP hHeealalthtBh cM chhIeecckk completion BP hHeealalthtBh cM chhIeecckk completion Health check completion 40% Unadjusted HbA1c 40% Unadjusted HbA1c 40% Unadjusted HbA1c (ageheald t1h2+ c)heck (ageDheald t1h2+ c)heckrate* (ageDheald t1h2+ c)heckrate* D rate* H <80 mmol/Hmol (%) <80 mmol/Hmol (%) <80 mmol/mol (%) (%) (%) (%) (%()aged 12+) (%) (%()aged 12+) (aged 12+) 20% 20% 20%

0% 0% 0% Foot exam health check Foot exam health check Foot exam health check Albuminuria health check Albuminuria health check Albuminuria health check (aged 12+) (aged 12+) (aged 12+) BP he(alageth dch 1e2c+k) (%) G E BPH heale(alagetthh c dchh ec1e2c+kk) c(%)ompletioGn E BPH heale(alagetthh c dchh ec1e2c+kk) c(%)ompletioGn E Health check completion (%) (%) (%) (aged 12+) (aged 12+)rate* (aged 12+)rate* rate* (%) (%) (aged 12+) (%) (aged 12+) (aged 12+) Eye screen hFealth check Eye screen hFealth check Eye screen hFealth check (aged 12+) (%) (aged 12+) (%) (aged 12+) (%) % receiving all 7 % receiving all 7 % receiving all 7 Foot exam health check Foot exam health check Foot exam health check *The health check complAeltbumion rainteu risia c ahlealtculMedianahted ch beyc kdivi dHbA1cing the total numbe*Trh ofe healthth checks co commpplAeleltbumitoned rianint eua riscia hc ahulealtcnuitl Medianabhtyed c th beyc t kotdivial d HbA1ceinxpeg tchte dtot al numbe*Trh ofe healthth checks co commpplAeleltbumitoned rianint eua riscia hc ahulealtcnuitl Medianabhtyed c th beyc t kotdivial d HbA1ceinxpeg tchte dtot al number of health checks completed in each unit by the total expected essential checks(aged 12+) essential checks(aged 12+) essential checks(aged 12+) number of health checks (whic(hage is edq u12a+l )t o(%) the number of children and younungm pbeeorp ofle hweiathlt hTy cphee 1ck dsia (wbehtiecs(h agea igs eedq u12a +lo )tr o(%) o thlder nu whmob coerm ofp clehtileddr en and younungm pbeeorp ofle hweiathlt hTy cphee 1ck dsia (wbehtiecs(h agea igs eedq u12a +lo )tr o(%) o thlder nu whmob coerm ofp clehtileddr en and young people with Type 1 diabetes aged 12 or older who completed (%) (%) (%) a full year of care multiplied by 7; 7 is the recommen61.5ded number of2019 health cah fueckll yse 62.5eaar cofh cpaarteie mntusl tsihpouliedld b rye ce7; i7v eis.) the recommen55.8ded number of2019 health cah fueckll yse 76.2eaar cofh cpaarteie mntusl tsihpouliedld b rye ce7; i7v eis.) the recommen61.0ded number of2019 health checks 57.5each patients should receive.) Eye screen health check Eye screen health check Eye screen health check 65.5 (ag2018ed 12+) (%) 56.5 60.0 (ag2018ed 12+) (%) 77.1 66.8 (ag2018ed 12+) (%) 26.7 63.0 2017 38.9 59.0 2017 89.1 64.3 2017 10.6 *The health check completion rate is calculated by dividing the total number* ofTh hee haelthalt chh cehckecks co commppleletetidon in r aetaec his ucnalict ublya ttedhe btoty dalivi edxpeingc ttehde total number* ofTh hee haelthalt chh cehckecks co commppleletetidon in r aetaec his ucnalict ublya ttedhe btoty dalivi edxpeingc ttehde total number of health checks completed in each unit by the total expected number of health checks (which is equal to the nu67.0mber of childre2016n and younnug pmeob39.3pelre of w hithea Tltyhp ech 1 edckiasb e(wtehsi cahg eisd e 1q2u oarl otold there w nuho65.0m cobmer pofle ctedhil dre2016n and younnug pmeob85.0pelre of w hithea Tltyhp ech 1 edckiasb e(wtehsi cahg eisd e 1q2u oarl otold there w nuho65.0m cobmer pofle ctedhil dre2016n and young peo0.0ple with Type 1 diabetes aged 12 or older who completed a full year of care multiplied by 7; 7 is the recommended number of health chae ckfulls yeeaacrh of p actaieren tms ushltouiplilde dre bcey 7iv; e7.) is the recommended number of health chae ckfulls yeeaacrh of p actaieren tms ushltouiplilde dre bcey 7iv; e7.) is the recommended number of health checks each patients should receive.) 73.0 2015 n/a 66.1 2015 n/a 65.5 2015 n/a 2 of 20 2 of 20 2 of 20 5 year change: 4 year change: 5 year change: 4 year change: 5 year change: 4 year change: 11.5 23.2 10.3 8.8 4.5 57.5 mmol/mol percentage points mmol/mol percentage points mmol/mol percentage points

2 of 20 2 of 20 2 of 20 Unit performance 2019 Unit performance 2018 Wales England and Wales Goal target A - HbA1c health check (%); B - Adjusted % HbA1c <58 mmol/mol ; C Unadjusted HbA1c<80 mmol/mol D - Health check completion rate* (aged 12+); E - Foot exam health check (aged 12+) (%); F - Eye screen health check (aged 12+) (%); G - Albuminuria health check (aged 12+) (%); H - BP health check (aged 12+) (%); I - BMI health check (%); J - Thyroid health check (%)

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Unit performance 2019 2019 Unit performance A - HbA1c health check (%); B - Adjusted % HbA1c <58 mmol/mol ; C Unadjusted HbA1c<80 mmol/mol D - Health check completion Health- completion D check mmol/mol HbA1c<80 Unadjusted C ; mmol/mol <58 HbA1c % Adjusted - B healthHbA1c (%); check - A health Albuminuria - G (%); health12+) (aged check screen Eye - F (%); 12+) health(aged exam check Foot - E 12+); (aged rate* health (%) check Thyroid - J health (%); BMI check - I (%); health12+) BP (aged - check H (%); 12+) (aged check 10 Cwm Taf University Health Board

Figure 1: Radar plot showing unit, region and national performance onF tighue resev 1: eRadarn esse pnlotita sl hoealwitnhg c unhecitk, sreg, %io anc hanievd inagt ional performance onF tihgeu resev 1:e Radarn esse pnltoiat ls healowtinhg c hunecitk, sreg, %i oanc hainevdi ngat ional performance on the seven essential health checks, % achieving an HbA1c of below 58 mmol/mol and % achieving an HbA1c of below 8a0n m HmbAo1lc/mol of below 58 mmol/mol and % achieving an HbA1c of below 8a0n m HmbAo1l/molc of below 58 mmol/mol and % achieving an HbA1c of below 80 mmol/mol PZ228 Wales England and Wales GPoalZ092 target Wales England and Wales GoaPZ1l8 ta9rget Wales England and Wales Goal target PrinceHbA1c Charleshealth PrincessHbA1c hofealth Wales Royal GlamorganHbA1c health check (%) check (%) check (%) (92 patients) (85 patients) (76 patients) 6.9 6.9 6.9

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mmol/l Figure 1:U Radarnadju pstloetd s HhboAw1cing unit, regmmol/lion and national performance onF tihgeu resev 1:Ue Radarn aesdjsue spntletoidat lsH hbealoAw1ctinhg c hunecitk, sreg, %mmol/li oanc hainevdi ngat ional performance on the sevUen aesdjsuesntetida lH hbealA1cth checks, % achieving

< > < > < Figure 1: Radar plot showing unhealtit, regh cihoenc> < aknd national performance on the seven essential health chheealtcksh, c%h aechkieving health check Pump patients 72.7%an HbA1<5c o8f mbemloowl/ m58ol m (%m)ol/mol and % achPumpieving an HpatientsbA1c of below 26.8% 8a0n m HmbAo1l<5/molc o8f mbemloowl/ m58ol m (%m)ol/mol and % achPumpieving an HpatientsbA1c of belo w50.0% 80 mmol<5/mol8 mmol/mol (%) an HbA1c of below 58 mmol/mol a(n%d) % achieving an HbA1c of below 80 mmol/mol (%) (%) 80% 80% 80% PZ228 Wales (2018:E 75.5%)ngland and Wales GPoalZ092 target Wales (2018:E n29.5%)gland and Wales GoaPZ1l8 ta9rget Wales (2018:E n55.2%)gland and Wales Goal target 70mm 50mm 60% 70mm 50mm 60% 70mm 50mm 60% For large board For small board HbA1c health For large board For small board HbA1c health For large board For small board HbA1c health check (%) check (%) BMI check (%) BMI BMI 40% A Unadjusted HbA1c 40% A Unadjusted HbA1c 40% A Unadjusted HbA1c health check health check health check Thyroid <80 mmol/moTlh (%)yroid <80 mmol/moTl h(%)yroid <80 mmol/mol (%) (%) 100% Unadjusted Hb(%)A1c 100% Unadjusted Hb(A%)1c 100% Unadjusted HbA1c health check health check health check J 20% <5B 8 mmol/mol (%) J 20% <5B 8 mmol/mol (%) J 20% <5B 8 mmol/mol (%) (%) (%) (%) 80% 80% 80% 0% 0% 0% 60% 60% 60%

BP healtBh MchI eck BP hHeealtaltBhh Mc chIheecckk completion BP hHeealtaltBhh Mc chIheecckk completion Health check completion 40% Unadjusted HbA1c 40% Unadjusted HbA1c 40% Unadjusted HbA1c (ageheadlt h12 che+) ck (ageheadlt h12 che+) rcatke* (ageheadlt h12 che+) rcatke* rate* I C<80 mmol/Imol (%) C<80 mmol/Imol (%) C<80 mmol/mol (%) (%)(%) (%)(%)(aged 12+) (%)(%)(aged 12+) (aged 12+) 20% 20% 20%

Figure 2: Radar plot showing unit performance in 2017/18 and 2018/19 F oignu trehe 2 :sev RadarFoeont examk peylo ht eals hheotalwht ichnh gceh uncekcksit, %per acformahievinngc ea nin 2017/18 and 2018/19 F oignu trehe 2 sev: RadarFoeont examk eyplo ht eal shheotalhwt cihnh gceh cunekcksi,t %p eracformahievinngc ea nin 2017/18 and 2018/19 on the sevFoeont examkey heal hetalht chh cehcekcks, % achieving an Albuminuria health check Albuminuria health check Albuminuria health check HbA1c of below 58 mmol/mol and % achieving an HbA1c of below 80 mHmbAo1lc/mol of below 5(8ag memd 1o2l+/mo) l and % achieving an HbA1c of below 80 mHmbAo1l/molc of below 5(8ag medm 1o2l+/mo) l and % achieving an HbA1c of below 80 mmol/mol (aged 12+) (aged 12+) (%) G E (aged 12+) (%) G E (aged 12+) (%) G E (%) (%) (%) PZ228 - 2018/19 PZ228 - 2017/18 Goal target PZ092 - 2018/19 PZ092 - 2017/18 Goal target PZ189 - 2018/19 PZ189 - 2017/18 Goal target Eye screen hFealth check Eye screen hFealth check Eye screen hFealth check (HagebA1cd 1 h2+e)a (%)lth (HagebA1cd 1 h2+e)a (%)lth (HagebA1cd 1 h2+e)a (%)lth checAk (%) checAk (%) checAk (%) Figure 2: Radar plot showing unitT pheryrfoormaid nce in 2017/18 and 2018/19 F oignu trehe 2 :sev Radaren k peylo ht ealshotwh icnhge uncksit,T %pher yarcfoormahidievinngc ea nin 2017/18 and 2018/19 F oignu trehe 2 sev: Radaren k eyplo ht ealshothw cinhge cunksi,t T %ph eryarcfoormahidievinngc ea nin 2017/18 and 2018/19 on the seven key health checks, % achieving an 100% Unadjusted HbA1c 100% Unadjusted HbA1c 100% Unadjusted HbA1c health check HbA1c of Bbelow 58 mmol/mol ahneald %th a cchheckieving an HbA1c of below 80 mHmbAo1l/molc ofB below 58 mmol/mol ahneald %th a cchheckieving an HbA1c of below 80 mmol/molB HbA1c of below 58 mmol/mol and % achievJing an HbA1c of below 80 mmol/mol<58 mmol/mol (%) J <58 mmol/mol (%) J <58 mmol/mol (%) (%) 80% (%) 80% (%) 80% PZ228 - 2018/19 PZ228 - 2017/18 Goal target PZ092 - 2018/19 PZ092 - 2017/18 Goal target PZ189 - 2018/19 PZ189 - 2017/18 Goal target 60% 60% 60% HbA1c health HbA1c health HbA1c health BMI check (%) BMI check (%) BMI check (%) 40% Unadjusted HbA1c 40% Unadjusted HbA1c 40% Unadjusted HbA1c health check health check health check I Thyroid

0% 0% 0% Foot exam health check Foot exam health check Foot exam health check Albuminuria health check Albuminuria health check Albuminuria health check (aged 12+) (aged 12+) (aged 12+) (aged 12+) (%) (aged 12+) (%) (aged 12+) (%) BP health check G E BP(%H h)ealealtthh c chhececkk completioGn E BP(%H h)ealealtthh c chhececkk completioGn E (%H)ealth check completion (aged 12+) (aged 12+)rate* (aged 12+)rate* rate* (%) (%) (aged 12+) (aged 12+) (%) Eye screen hFealth check (aged 12+) Eye screen hFealth check Eye screen hFealth check (aged 12+) (%) (aged 12+) (%) (aged 12+) (%)

% receiving all 7 % receiving all 7 % receiving all 7 *The health check completion rate is calculated by dividing the total number* Tofh eh ehaelathlt hch ceFhckooeckst co coexmmapmplel ehtteealidon int rh ae tacech ihes ckucanlict ublya ttedhe btoty daivil edxpeingc ttehde total number* ofTh hee haelthalt chh ceFhckooeckst co ecoxmmapmplel ehtetealidon int rh ae tacech hies ckucnalict ublya ttedhe btoty dalivi edxpeingc ttehde total number of health cheFckoost co exmapmle hteeald inth e acchhe ckunit by the total expected Albuminuria healtMedianh check HbA1c Albuminuria healtMedianh check HbA1c Albuminuria healtMedianh check HbA1c number of health checks (which is equal to the number of children and yessentialounnug pmeboperle of w hchecksithea Tltyhp ceh 1e (dageckiasb d(wet 1eh2si+ ca)hg eisd e 1q2u oarl otold there w nuhom cobemr pofle cthedild ren and yessentialounnug pmeobpelre of w hichecksthea Tltyhp ech 1 (edageckiasb de(wt 1eh2si+ ca)hg eisd e 1q2u oarl otold there w nuhom cobmer pofle ctedhil dren and yessentialoung people w checksith Type 1 (dageiabdet 1e2s+ a)ged 12 or older who completed (aged 12+) (%) (aged 12+) (%) (aged 12+) (%) a full year of care multiplied by 7; 7 is the recommended number of health chae fckulls yeeaacrh of p actaireen mts ushltouipli(led%d r) ebcey 7iv; e7.) is the recommended number of health chae ckfulls yeeaacrh of p actaieren tms ushltouipli(ld%e dr)e bcey 7iv; e7.) is the recommended number of health checks each patients shou(ld% r)eceive.) 61.3 2019 92.2 64.3 2019 76.3 63.0 2019 91.4 Eye screen health check Eye screen health check Eye screen health check 61.0 (ag2018ed 12+) (%) 58.7 71.5 (ag2018ed 12+) (%) 71.7% 65.0 (ag2018ed 12+) (%) 22.2 58.5 2017 86.4 66.0 2017 51.4% 61.0 2017 97.8 *The health check completion rate is calculated by dividing the total number* Tofh eh ehaelathlt hch cehckecks co commppleletteidon in r aetaec ihs ucanlict ublya ttedhe btoty daivil edxpeingc ttehde total number* ofTh hee haelthalt chh cehckecks co commppleletetidon in r aetaec his ucnalict ublya ttedhe btoty dalivi edxpeingc ttehde total number of health checks completed in each unit by the total expected number of health checks (which is equal to the nu60.0mber of childre2016n and younnug pmebo58.5perle of w hithea Tltyhp ceh 1e dckiasb (wetehsi cahg eisd e 1q2u oarl otold there w nuho65.0m cobemr pofle cthedild re2016n and younnug pmeobn/apelre of w hithea Tltyhp ech 1 edckiasb e(wtehsi cahg eisd e 1q2u oarl otold there w nuho62.0m cobmer pofle ctedhil dre2016n and young peo95.6ple with Type 1 diabetes aged 12 or older who completed a full year of care multiplied by 7; 7 is the recommended number of health chae fckulls yeeaacrh of p actaireen mts ushltouipliledd r ebcey 7iv; e7.) is the recommended number of health chae ckfulls yeeaacrh of p actaieren tms ushltouiplilde dre bcey 7iv; e7.) is the recommended number of health checks each patients should receive.)

61.0 20152 of 20 n/a 71.5 20152 of 20 n/a 66.0 20152 of 20 n/a 5 year change: 4 year change: 5 year change: 3 year change: 5 year change: 4 year change: 0.3 33.7 7.2 24.9 3.0 4.2 mmol/mol percentage points mmol/mol percentage points mmol/mol percentage points

Annual Report 2019 11 Hywel Dda University Health Board

Figure 1: Radar plot showing unit, region and national performance onF tihgeu resev 1:e Radarn esse pnltoiat ls healowtinhg c hunecitk, sreg, %i oanc hainevdi ngat ional performance onF tighue resev 1: eRadarn esse pnltoita ls healowtinhg c hunecitk, sreg, %io anc hainevd inagt ional performance on the seven essential health checks, % achieving an HbA1c of below 58 mmol/mol and % achieving an HbA1c of below 8a0n m HmbAo1l/molc of below 58 mmol/mol and % achieving an HbA1c of below 8a0n m HmbAo1l/molc of below 58 mmol/mol and % achieving an HbA1c of below 80 mmol/mol PZ185 Wales England and Wales GPoalZ0 56target Wales England and Wales GoPZa190l target Wales England and Wales Goal target BronglaisHbA1c health GlangwiliHbA1c health WithybushHbA1c health check (%) check (%) check (%) (31 patients) (114 patients) 57 patients 6.9 6.9 6.9

mmol/l mmol/l mmol/l

< > < > < < > < Thyroid Thyroid Thyroid 6.9 100% 6.9 100% Figure 1: Radar plot showing unit, reg6.9ion and nationa1l00% performance on the seven essential health checks, % achieving

mmol/l Figure 1: Radar plot showing unit, regmmol/lion and national performance on the seven essential health checks, %mmol/l achieving

< > < > < Figure 1: Radar plot showing unit, region> < and national performance on the sevUen aesdjsuesntetida lH hbealA1cth checks, % achieving Unadjusted HbA1c Unadjusted HbA1c health check health check an HbA1c of below 58 mmol/mohealtl anhd c h%e acckhieving an HbA1c of below 80 mmol/mol an HbA1c of below 58 mmol/mol and % achPumpieving an HpatientsbA1c of below 48.3% 8a0n m HmbAo1l<5/molc o8f mbemloowl/ m58ol m (%m)ol/mol and % achPumpieving an HpatientsbA1c of below 55.0% 80 mmol<5/mol8 mmol/mol (%) Pump figures: 61.4%<58 mmol/mol (%) (%) (%) (%) 80% 80% 80% PZ185 Wales (2018:E n37.5%)gland and Wales GPoalZ0 56target Wales (2018:E n50.0%)gland and Wales GoPZa190l target Wales (2018:E n46.2%)gland and Wales Goal target

70mm 50mm 70mm 50mm 70mm 50mm For large board For small board For large board For small board For large board For small board HbA1c health 6H0%bA1c health 6H0%bA1c health 60% check (%) check (%) check (%) BMI A BMI A BMI A 40% Unadjusted HbA1c 40% Unadjusted HbA1c 40% Unadjusted HbA1c health check health check health check Thyroid Thyroid <80 mmol/moTl h(%)yroid 100% <80 mmol/mol (%) 100% Unadjuste

0% 0% 0% Foot exam health check Foot exam health check Foot exam health check Albuminuria health check Albuminuria health check Albuminuria health check (aged 12+) (agBPe hde 1al2+th) check (agedH 1ealt2+)h check completion BP heal(ageth cdh e12c+k) (%) BP hHeealtal(agethh c cdhh e1e2cc+kk) (%)completion Healt(ageh cdh 1e2c+k) (%)completion (%) ((%)aged 12+) (%) rate* (aged 12+) (ageD d 12+) rate* D rate* D H H (%) H (aged 12+) (%) (%) (aged 12+) (aged 12+) Eye screen health check Eye screen health check Eye screen health check (aged 12+) (%) (aged 12+) (%) (aged 12+) (%)

Foot exam health check Figure 2: Radar plot showing unit performance in 2017/18 and 2018/19 F oignu trehe 2 sev: RadarFoeont examk eyplo ht eal shheotalhwt cihnh gceh cunekcksi,t %p eracformahievinngc ea nin 2017/18 and 2018/19 F oignu trehe 2 sev: RadarFoeont examk peyloA htl beal shhumeotalhwit nichnuh gcrehia cunek hecksit, a%pler tahcf cheormahievciknngc ea nin 2017/18 and 2018/19 on the seven key health checks, % achieving an Albuminuria health check Albuminuria health check (aged 12+) HbA1c of below 58 mmol/mol and % achieving an HbA1c of below 80 mHmbAo1l/molc of below 5(8ag medm 1o2l+/mo) l and % achieving an HbA1c of below 80 mHmbAo1l/molc of below 5(8ag medm 1o2(l+age/mo) dl a12n+d) %(%) achieving an HbA1c of below 80 mmol/mol (aged 12+) (%) G E (aged 12+) (%) G E G E (%) (%) (%) PZ185 - 2018/19 PZ185 - 2017/18 Goal target PZ056 - 2018/19 PZ056 - 2017/18 Goal target PZ190 - 2018/19 Eye screPenZ 19he0al -t h2 0c1h7eck/18 Goal target Eye screen hFealth check Eye screen hFealth check F (aged 12+) (%) (HagebA1cd 1 h2+e)a (%)lth (HagebA1cd 1 h2+e)a (%)lth HbA1c health checAk (%) checAk (%) checAk (%) Figure 2: Radar plot showing unit performance in 2017/18 and 2018/19 on the seven key health checks, % achieving an Figure 2: Radar plot showing unitT pheryrfoormaid nce in 2017/18 and 2018/19 F oignu trehe 2 sev: Radaren k eyplo ht ealshothw cinhge cunksi,t T %ph eryarcfoormahidievinngc ea nin 2017/18 and 2018/19 on the seven key health checks, T%h yarcohidieving an 100% Unadjusted HbA1c 100% HbA1c ofU bnealodjwu s5t8e dm HmboAl1c/mol and % achieving an HbA100%1c of below 80 mmol/molUnadjusted HbA1c HbA1c of below 58 mmol/mol ahneald %th a cchheckievJing an HbA1c of below 80 mHmbAo1l/molc ofB below 58 mmol/mol ahneald %th a cchheckievJing an HbA1c of below 80 mmol/molB health checkJ B <58 mmol/mol (%) <58 mmol/mol (%) <58 mmol/mol (%) (%) 80% (%) 80% (%) 80% PZ185 - 2018/19 PZ185 - 2017/18 Goal target PZ056 - 2018/19 PZ056 - 2017/18 Goal target PZ190 - 2018/19 PZ190 - 2017/18 Goal target HbA1c health 6H0%bA1c health 6H0%bA1c health 60% check (%) check (%) BMI check (%) BMI BMI 40% Unadjusted HbA1c 40% Unadjusted HbA1c 40% Unadjusted HbA1c health checkI Chealth checkI Chealth checkI Thyroid C Thyroid <80 mmol/mol T(%hy) roid 100% <80 mmol/mol (%) 100% Unadjuste

0% 0% 0% Foot exam health check Foot exam health check Foot exam health check Albuminuria health check Albuminuria health check Albuminuria health check (aged 12+) (ageBPd h 1e2al+)th check (agedH eal12+t)h check completion BP heal(ageth cdh e12c+k) (%) G E BPH healeal(tagethh c chdhec e12ck+k )c (%)ompletioGn E Heal(tageh chdec 12k+ )c (%)ompletioGn E (%) (%(age) d 12+) (%) rate* (aged 12+) (aged 12+)rate* rate* (%) (%) (aged 12+) (aged 12+) (%) Eye screen hFealth check (aged 12+) Eye screen hFealth check Eye screen hFealth check (aged 12+) (%) (aged 12+) (%) (aged 12+) (%)

% receiving all 7 % receiving all 7 % receivingFoo allt ex a7m health check *The health check completion rate is calcuMedianlated by divi dHbA1cing the total number* ofTh hee haelthalt chh ceFhckooeckst co ecoxmmapmplel ehtetealidon int rh ae tacech hies ckucnalict ubMedianlya ttedhe btoty dalivi e dxHbA1cpeingc ttehde total number* ofTh he ehaelthalt hch ceFhckooeckst co coexmmapmpAlel lehtbumetealidon int rhi nae tacuechr hiiaes cku chnaealtlict ubMedianlyah tt edchhe ebtotcyk daivil e dxHbA1cpeingc ttehde total number of health checks completed in each unit by the total expected Albuminuria health check Albuminuria health check (aged 12+) number of health checks (which is equal to the number of children and yessentialounnug pmeobpelre of w hichecksthea Tltyhp ech 1 (edageckiasb de(wt 1eh2si+ ca)hg eisd e 1q2u oarl otold there w nuhom cobmer pofle ctedhil dren and yessentialounnug pmeobperle of w hichecksthea Tltyhp ceh 1e (dageckiasb de(wt 1eh2si+ c(aage)hg eisd de 1q 21u2 oa+rl) ot(%)old there w nuhom cobemr pofle ctedhild ren and yessentialoung people w ichecksth Type 1 diabetes aged 12 or older who completed (aged 12+) (%) (aged 12+) (%) (%) a full year of care multiplied by 7; 7 is the recommended number of health chae ckfulls yeeaacrh of p actaieren tms ushltouipli(ld%e dr)e bcey 7iv; e7.) is the recommended number of health chae fckulls yeeaacrh of p actaieren tms ushltouipli(lde%d r) ebcey 7iv; e7.) is the recommended number of health checks each patients should receive.) 55.0 2019 58.8 64.0 2019 59.5 57.5 2019 40.0 Eye screen health check Eye screen health check Eye screen health check (aged 12+) (%) 4.0 (ag2018ed 12+) (%) 53.3 65.8 (ag2018ed 12+) (%) 34.5 62.0 2018 45.5 66.1 55.0 62.0 72.5 62.0 39.1 2017 2017 *The health check completion rate is calculated by dividing the tot2017al number of health checks completed in each unit by the total expected *The health check completion rate is calculated by dividing the total number* ofTh hee haelthalt chh cehckecks co commppleletetidon in r aetaec his ucnalict ublya ttedhe btoty dalivi edxpeingc ttehde total number of health checks completed in each unit by the total expected number of health checks (which is equal to the number of children and young people with Type 1 diabetes aged 12 or older who completed number of health checks (which is equal to the number of children and younnug pmeobpelre of w hithea Tltyhp ech 1 edckiasb e(wtehsi cahg eisd e 1q2u oarl otold there w nuhom cobmer pofle ctedhil dren and young people with Type 1 diabetes aged 12 or older who completed 63.4 2016 30.0 64.0 2016 a full 37.2year of care multiplied by 7; 7 is the recomme67.3nded number of2016 health checks en/aach patients should receive.) a full year of care multiplied by 7; 7 is the recommended number of health chae ckfulls yeeaacrh of p actaieren tms ushltouiplilde dre bcey 7iv; e7.) is the recommended number of health checks each patients should receive.) 66.0 2015 n/a 65.0 2015 n/a 70.3 2015 n/a 2 of 20 2 of 20 2 of 20 5 year change: 4 year change: 5 year change: 4 year change: 5 year change: 3 year change: 11 28.8 1 22.3 12.8 0.9 mmol/mol percentage points mmol/mol percentage points mmol/mol percentage points

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A scr 1 e 17

ed t h Hb A scr m scr e al

t ed t ch m scr al

t u ch g e 20 l u an Hb g e (64 patients) n

n 20 Eye of l on an Hb

i p n

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comp

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y e

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e g g

h h

d b

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ll mm

e e g g on h e t d

h / 18 ll

e on e t n Fi Hb Fi an eck h / p h

fu cks

n eck Fi Hb Fi an eck p

mm h 80 a fu cks T 17 h

of eck

mm g 80 a a num * h T 17 h on of

e ) g r a num * h on c d h ) r c c e ch d e 20 h h 80 h

) c

e ow lt n ch

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t ) (%

ow lt n - lt oun

18/19 h 4 year change: b h c t a ) % (%) (% - lt oun 18/19 t el h y l a a ) ) essential checks %) % (%) l al

ea t 20 el + y ( % receiving all 7 l a ) %) alt l al

f ow b ea e 20 20 + a g ( ( percentage points percentage e d

2 alt

f ow k b e 20 a g ( e e d 1

e 2+ 2

k k n h num el n

e 001 1 1 e d 2+ F F

k 2 o n h h of num el h n

A A 001 l a 1 d

ec b 2 o h

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Z l a n

ec b

E Z orman n n ed

n an of % 1c orman P 2019 2018 2017 2016 2015 n ed hec A1c h n an ch of e of % 1c ota P bA1c h 0% hec ee A1c h 0 r 0% 0%

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4 A r 2 c e 6 80% t 00% b 0% H ee 0% ( 0% 0% erf ag aged

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A scr 1 17

t h Hb A scr scr m al

t ch scr m al

u ch g 20 u an Hb g n

n 20 Eye of on an Hb

i n

(132 patients) i

n Eye Eye of on

n (2018: 44.1%) i r g i d Eye i n r g d e i an e at n

e an e at n Morriston e b ivid

d n es e g b ivid

d c n 3.4 3.4 l d es n g

c evi l d n

n d i

k 66.0 70.3 68.0 66.0 69.4 evi y n d /19 G G i k Pump patients 42.6% y h /19 Swansea Bay Bay Swansea Health Board University k J J b k num h k b k an

Wa ec evi

eck num

i an

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i id ec h

ed ac h id ec Unit performance 2018 2018 Unit performance h

mmol/mol o id t ed h 2018 orman ch the on c

mmol/l

6.9 % o id t r

) comme 2018 a orman chec ch the on o

c % l r ac

- ) comme ch a chec y h o (%) o

r e

l ac - ch % d y 50mm Median HbA1c h t (%) o r e

h 5 year change: erf y h ( r % d t h l (%) erf cu % y h ( r For small board For lt l regi

T p ) h l (%) cu % a

(%) lt l regi

T p ) an h , ealth a T

ealt

) t

d (%) k 001 an u , t ealth T the ealt ca ) t

d k 001 2+ u t ealth h the ca q Z 1 k 2+ k ealth h s s I I

2+ q Z 1 k ec H H h an k eck e s s 1 )

2+ i

i P ec uni h ia h an eck e

uni 1 )

i h

i P h ec uni s ia h r 7 e

uni )

ia hea /mol h h ) ec s r 7 t e

I ; i g 2+ ) ia hea /mol h r u c ) g c t I ; i g a 1 2+ 7 h r u c g ol c % I

chec a 1 n 2+ h 7 n h c i ( 001 ol %

ch n

aged chec i 1 y n 2+ h BM /mol n h c i i ( 001 %) (

ch nu aged i 1 y h BM /mol h Z i aged ( %) (%) ( b

h BM (

h Z aged alt ( ol (%) b on r < > < lt BM (

P ow i alt ol (%) on r d ow e lt mm ealt t P ow i alt (%) (wh d ow e mm ealt t aged alt

h e (wh umi h e bumi ( aged l sh

lie h e umi h sh e bumi

( aged l

mmol/l sh

6.9 8 lie

b h hea 5 sh p

mm ( p aged

b h i hea 5 p mm ( p cks

Al ot t i Al BP ot cks 70mm l l 8 ot t e l Al BP ot l l 8 e 5 l u BP p For large board large For ow

p 5 u BP p com ow

p ch com

m ch el

m el h

ow b e ck t h

ow b r l e ck t e

r l el a e of el a ca e

b Radar of ch Radar

b Radar

h ch Radar

h of h 2: 1: of 1c of t h 2: 1:

A of r l of t

A r l of a a r re re 1c a a r e re re e 1c e u u Hb e A e y e

h u u b Hb A y

g g

h b ll

g g e ll e Fi Hb Fi an h fu Fi Hb Fi an

h fu T

a num * T Unit performance 2019 2019 Unit performance a num * port 2019 Annual Report A - HbA1c health check (%); B - Adjusted % HbA1c <58 mmol/mol ; C Unadjusted HbA1c<80 mmol/mol D - Health check completion Health- completion D check mmol/mol HbA1c<80 Unadjusted C ; mmol/mol <58 HbA1c % Adjusted - B healthHbA1c (%); check - A health Albuminuria - G (%); health12+) (aged check screen Eye - F (%); 12+) health(aged exam check Foot - E 12+); (aged rate* health (%) check Thyroid - J health (%); BMI check - I (%); health12+) BP (aged - check H (%); 12+) (aged check Brecon Group Annual Report 2019 The Brecon Group of clinicians representing all paediatric diabetes services in Wales was established in 1995 with the aim of informing the then Welsh Office about the needs for clinical services for children and teenagers with diabetes. An early agreed priority was to establish the Brecon Cohort which is a diagnostic data-set of all people aged <15 years diagnosed in Wales, so that we could establish how many such people required clinical care and in which regions in Wales (Tables 1 & 2).

Table 1. Under 15 year old incidence rates per 100,000 <15yr old population (ONS) Population Incidence Year Cases Age (105) rates 1999 131 5.57 23.5 U15 2009 143 5.18 27.6 U15 2019 167 5.29 31.6 U15

Table 2. Under 15 year old newly diagnosed cases by Health Board where diagnosed in 2019 Health Board Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec t1 Total Date nk T2* Mody ABUHB 4 2 3 3 3 3 5 1 1 1 2 1 29 0 1 0 BCUHB 3 0 3 6 5 2 1 4 4 4 1 3 36 0 3 1 CAVUHB 3 2 1 1 4 3 2 1 1 1 3 1 23 0 2 1 CTMUHB 2 1 3 5 3 3 4 4 4 3 2 3 37 0 0 0 HDUHB 4 0 1 1 2 2 0 0 1 0 2 5 18 1 1 0 SBUHB 1 1 2 1 4 1 3 2 2 2 1 2 22 0 0 0

Our registrations of newly diagnosed cases have allowed us to capture data on the presence of diabetic ketoacidosis (DKA) at presentation of T1D. This allows us to monitor the effect of interventions designed to raise both public and primary care awareness of the symptoms suggestive of developing diabetes, in an effort to promote an earlier diagnosis. We have published data showing that our patients develop symptoms and present to primary care many months before diagnosis, suggesting that opportunities for an earlier diagnosis occur (Townson, 2019). Latest data show evidence that recent initiatives promoted by Welsh Government, Diabetes UK Cymru and critical case reviews of those presenting in DKA, have not significantly impacted rates of presentation in DKA at diagnosis (Table 3).

Table 3. DKA rates over last 3 years Type 1 2017 2018 2019 DKA under 15 50 51 53 DKA 15 and 16 5 3 3 Total DKA 55 54 56 Total Type 1 165 166 177 % total type 1 33% 32.5% 32% Numbers subject to 3 presentations ‘not known’ in 2019

The quality and power of what we can do with our database is dependent on the completeness of returns of new cases. Table 4 shows the numbers of notifications of new

14 Children and Young People’s Wales Diabetes Network (& Brecon Group) cases by month. We thank those colleagues responsible for returning numbers of newly diagnosed cases and are pleased to note only a relatively small number of missing registrations. We would warmly encourage those centres with incomplete 2019 registrations to send to the Brecon Group office as soon as possible to help us maintain the high quality of our database.

Table 4. Monthly notifications of newly diagnosed Type 1 diabetes under 15 years old Jan Feb Mar Apr 17 6 13 17 May Jun Jul Aug 21 14 15 12 Sep Oct Nov Dec 13 11 11 15 Numbers subject to 1 missing date of diagnosis

In the last year we have also published data on the pregnancy outcomes of our cohort, many of whom are now in their young adult lives (Allen, 2019). These analyses have shown that, encouragingly, our young women with diabetes are less likely to become pregnant during their teens than those without diabetes. However, poor glycaemic control continues to be associated with an increased risk of a whole range of adverse outcomes. The babies of our teenage mothers are more likely to be admitted to hospital during their first year of life, suggesting that support for these vulnerable families is important. An unpublished analysis of data on alcohol-related admissions from the Brecon Cohort was presented to a recent meeting of the Children & Young People’s Wales Diabetes Network. This shows that those with diabetes experience a marked increased risk of hospital admission due to alcohol-related problems, compared to those without diabetes. Those with diabetes have maximum admission rates at a younger age (mid-teens) than the peak risk for admission in those without diabetes (18-22 year olds). These findings highlight the importance of improving the education and support provided by clinical services, to help young people with diabetes drink safely. The recent publication of SEREN guidance about alcohol for young people is therefore timely. References Allen LA, Cannings-John RL, Evans A, Thayer DS, French R, Paranjothy S, Fone DL, Dayan CM, Gregory JW. Pregnancy in teenagers diagnosed with type 1 diabetes mellitus in childhood: a national population-based e-cohort study. Diabetologia 2019;Dec 20. doi: 10.1007/s00125-019-05063-w Townson J, Cannings-John R, Francis N, Thayer D, Gregory JW. Presentation to primary care during the prodrome of type 1 diabetes in childhood: A case-control study using record data linkage. Pediatr Diabetes 2019;20(3):330-338. doi: 10.1111/pedi.12829

Dr Kamal Weerasinghe, Brecon Officer Prof John W Gregory & Heather O’Connell

*Numbers of type 2 under 15 years subject to incomplete data regarding date of birth

• Not counted were 2 newly diagnosed and transferred in Type 1 diabetes (T1D) cases from outside Wales in 2019, or the 15 previously diagnosed type 1 cases that transferred in to Welsh units from elsewhere in 2019. Also not included were the 9 type 1 cases diagnosed at 15 and 16 years.

Annual Report 2019 15 n en t c o d m o s e r y l r r l e t s a e t i s n a b P w e e o l o c p a c f r i a e u v t m i t r o E Q y e n Our Network S has agreed we want our services to display these values

2020 – looking forward to a milestone 2020 will mark the 5th anniversary of our Network and we hope to celebrate this and take stock of all we have achieved together.

Children and Young People’s Wales Diabetes Network (& Brecon Group) Contact us Hosted by Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff CF14 4XW

(029) 2074 5163 [email protected] @CYPDN_Wales