PrescQIPP

Addressing Health Inequalities in Early-Onset Type 2 Diabetes: Improving Nine Key Care Processes Completion

St Wulfstan Surgery, Coventry and Warwickshire ICB

Project summary

Early-Onset Type 2 Diabetes Mellitus (EOT2DM) disproportionately affects younger adults from socioeconomically deprived communities, those with higher BMI, ethnic minorities, learning difficulties. Not only do these individuals face stigma, mental health issues and work and family stressors they experience higher complication rates (CVD, nephropathy, retinopathy) due to aggressive disease progression and poorer engagement with healthcare providers.

In our GP practice, a retrospective audit of all 16 eligible EOT2DM patients revealed only 37.5% completed all nine NICE NG28 key care processes within 12 months of diagnosis—well below NDA national averages (~60%). Critical gaps were observed in the following processes: urine ACR (62.5%), foot checks (68.75%), eye screening (75%), and structured education (DESMOND uptake just 12.5%, with 81.25% declining). Non-completion was markedly higher in patients with BMI >40 kg/m² and the one patient with documented learning difficulties, directly highlighting health inequalities in access for this hard-to-reach cohort.

To close these gaps and align with NHS England’s world-first T2DAY programme for under-40s, we implemented:

  1. Automated EMIS recall reminders (pop-ups at 3, 6, and 9 months post-diagnosis) flagging incomplete processes, prioritising ACR, foot/eye screening, and DESMOND referrals.

  2. Extended initial appointments (≥30 minutes) for comprehensive education, motivation, and shared decision-making.

  3. Strengthened referral pathways to local diabetes services.

These low-cost, systems-level changes promote equitable uptake of preventative care, enabling timely risk stratification and optimised prescribing (e.g., earlier GLP-1 agonists, statins). A repeat audit is scheduled for October 2026; we target >80% completion of all nine processes and >50% DESMOND uptake, reducing long-term complications and NHS costs in this high-risk group.