Experiences of people living with diabetes of the eight care processes (checks) - Kingston

Executive summary

This report presents insights from people living with diabetes in Kingston, focusing on their experiences with the eight care processes (known together as an annual review) recommended by the NHS. It combines local engagement findings from activity during March and April 2025 with national and South West London research from 2022–2024. The aim is to understand barriers to accessing these checks and inform future service improvements and communications.

The findings across both national and south west London research and local engagement highlight some variability, unmet needs, and opportunities for more proactive, inclusive, and informed care. The key themes are:

Access and uptake of care processes National research by Diabetes UK (2022–2024) found that fewer than half of people with diabetes in England received all eight recommended care checks, with access significantly lower in deprived areas. Locally, in Kingston for 2024/25 uptake across the 8 care checks ranged from the lowest uptake of 67% to the highest uptake of 89%. Though the survey responses was a small sample, nearly all participants had received a review in the past two years, but some had not discussed results or next steps with a healthcare professional.

Health inequalities National findings indicate that people in deprived areas and from non-White ethnic backgrounds face greater challenges in accessing care and managing diabetes. This is echoed in South West London insight, which shows variation in care quality across GP practices and a lack of referrals for newly diagnosed patients. The local survey also revealed underrepresentation of Black ethnic groups, suggesting potential barriers to engagement.

Quality and consistency of care South West London reports and local survey responses both highlight inconsistencies in diabetes care. While some patients praised their GP or diabetes nurse for thorough and supportive reviews, others described the process as a “tick-box exercise.” Concerns were raised about inconsistent advice on medication and a lack of signposting to support services.

Communication and engagement the online conversation revealed variability in how test results are discussed with patients. Participants were happy to receive results over the phone; however, it could also be a barrier to patients asking questions and healthcare professionals having a more in-depth conversation about results – examining result trends over time and what it means for the patient.

Support for lifestyle and self-management Local engagement showed that while patients received initial advice on diet and exercise, ongoing support was limited. Many relied on self-management or external organisations like Diabetes UK. South West London insight also found that patients wanted more structured support, such as supervised exercise classes and better dietary information.

Mental health and emotional support Mental health challenges were highlighted in the online conversation, where participants expressed concern about the need for greater focus on emotional support in diabetes care. National research supports this, noting that stigma and emotional distress are common, particularly among younger individuals and those with Type 1 diabetes.

Referral and access to other services South West London insight and local survey responses identified gaps in referrals, particularly for newly diagnosed patients. While some praised specialist services like the Diabetic Eye Unit at Kingston Hospital, others faced long waiting times and administrative challenges. Accessing GP practices was also described as difficult due to issues with phone systems.

Education and training for healthcare professionals Both national and local insights suggest that healthcare professionals need to keep their diabetes knowledge up to date. In the online conversation, one participant felt more informed than their doctor, which undermined confidence in the care received. There was also a call for professionals to be aware of local resources and support options.

Prevention and early intervention Prevention was a recurring theme in national research and local engagement. Participants advocated for early intervention through education, regular monitoring, and community-based support. Support groups for both diabetic and pre-diabetic individuals were seen as valuable for promoting healthier lifestyles and preventing complications.

Technology and innovation Participants in the online conversation expressed interest in using technology such as wearables and apps to monitor their health. While they saw potential in linking this data to their GP practice systems, they expressed concerns about privacy and data use. Virtual consultations and online support groups were viewed positively, especially for those facing barriers to in-person appointments.

This report will be shared with Kingston’s public health team to agree next steps and will be available on the NHS South West London ICS Insight Bank.

Introduction

The findings in this report are in response to Kingston Place and Public Health senior leads wanting to better understand the take up of the eight care checks for people living with Type 1 and Type 2 diabetes in Kingston and any potential barriers to access. The aim is to use the insight to inform future service improvements at a neighbourhood level and communications.

Background

Over 10,000 people in Kingston have been diagnosed with diabetes (6% of the adult population). This number has risen by almost 3,000 people in the past decade. It is thought that around 1,400 people have undiagnosed diabetes and another 8,500 (5%) have non-diabetic hyperglycaemia (high blood sugar levels, also known as ‘pre-diabetes’).

Diabetes is the fourth-largest cause of ill-health in 20–69 year-olds, in Kingston, and the fifth largest in those aged 70 and over. Higher levels of diabetes are seen in Asian and Black residents, more than in other ethnic groups. It is also seen more often in people living in areas with greater deprivation.¹

As part of NHS diabetes care patients should be offered certain tests and checks (care processes) every year. These include HbA1c (average blood sugar levels over the last 3 months), feet, blood pressure, cholesterol, blood, urine, smoking status and BMI. These 8 care processes are together also known as an annual review and may happen over several appointments. After the annual review, a healthcare professional will follow up with the individual to talk through the results and if any further support is needed.

These checks help healthcare professionals identify problems early, inform treatment plans and support patients in managing their condition.

During 2024/25 uptake across the 8 care checks in the borough ranged between 67% and 89%. ²

Methodology

The approach to gather insight included a review of national and local insight across South West London between 2022 and 2024 which includes Healthwatch Kingston’s 2022 Pulse Check Report on services for people with diabetes. An online survey for people living with diabetes to answer questions about their experience of the 8 care processes; offer of telephone interviews and online group conversations. These engagement opportunities were promoted via local health and care partners including primary care networks and local community organisations. The survey ran for four weeks, and two dates were offered for online group discussions. There were 33 survey responses, and two participants took part in an online conversation. The level of responses though low is in line with those for Healthwatch Kingston’s Pulse Check Report.

Key themes emerging from national and local insight

National research

The insight below highlights findings of research by Diabetes UK between 2022– 2024.

Access to 8 care processes Diabetes is it fair enough? Diabetes Uk report highlights the experiences of people with diabetes regarding the eight recommended care processes. It shows that less than half of people with diabetes in England received all eight vital checks in 2021-2022. Access was significantly lower for those in the most deprived areas. As a result of the pandemic, disruption to routine care has led to increased mortality and complications. People with diabetes faced difficulties managing their condition due to lack of access to healthcare teams. Some were not as physically active or able to exercise for others eating habits changed and the increasing costs of living had an impact.³

Inequalities in care the same report from Diabetes UK found that people in deprived areas were more likely to have no contact with healthcare teams and faced greater challenges in managing their diabetes. Significant variation was also identified in the completion rates of care processes across different regions.⁴

Blame and Stigma has been found from research into other health conditions can prevent people from engaging with treatment and care.⁵

Research by Diabetes UK to explore impact of stigmatising attitudes, language and behaviour on diabetes patients found that the proportion of respondents who reported negative attitudes from others was higher in those with type 1 than type 2. This is in line with other research and possibly due to the condition being more visible.⁶ Respondents aged 18-64 years were more likely to report experiencing negative attitudes than those over 65 years. Those from non-White ethnic backgrounds reported higher levels of negative attitudes than those from White backgrounds.

The Diabetes UK report, Reverse the trend: reducing type 2 diabetes suggests that the approach taken by decision makers to focus over time on changing individual behaviour has failed when it comes to reducing obesity and its health impacts. This approach can reinforce stigma with people feeling judged or blamed for their condition. It can negatively impact wellbeing and prevent people from accessing the support they need. There is a need for decision makers to recognise health is informed by people’s circumstances.⁷

South West London insight

The insight below highlights findings of publications by local authorities, voluntary and community sector organisations and NHS Place-based community engagement teams.

Support in primary care the role of GPs was mentioned in some reports on services for people with specific conditions⁸ such as diabetes. There were some concerns about treatment being a postcode lottery due to inconsistencies between GP surgeries on the way diabetic conditions were treated. Some newly diagnosed respondents had not been referred to available NHS services. There was a degree of cynicism about annual diabetes checks at GP surgeries being a “tick box” exercise. Some participants felt that they knew more about their condition than their GP. However other respondents found annual reviews to be useful, particularly in relation to food and dietary matters.⁹

The Healthwatch Kingston report suggested respondents said they felt uncertain as to whether they were on the right medication or the correct dosage, with advice on medication being sometimes inconsistent. However, pharmacies were praised for being helpful.¹⁰

Prevention and self-care Healthwatch Kingston’s report¹¹ found 40% of respondents to the survey would make use of diabetes-specific supervised exercise classes. Whilst patients accepted that diabetes care represented the patient taking control of their condition, they felt that needed to build on a partnership of care between patient and doctor. Too few newly diagnosed patients were referred to the available NHS services, leaving respondents to feel alone in coping with diabetes.  The same report suggested participants wanted better information about a healthy diet.¹²

Referrals and waiting times Although there was a positive response to survey questions about access to care, services, and support after referral to Kingston hospital services, Healthwatch Kingston identified a lack of referrals for people in early diagnosis to NHS diabetes services.¹³

Local engagement

Who did we hear from?

Most survey respondents were aged between 55 – 84 years of age with 4 aged 25 – 44 years of age. There were more male respondents at 65% than female which is not usually the case from previous survey responses. Most respondents were either in full time paid work or retired from work. This reflects the older age profile of responses.

Most borough wards were represented in the responses including wards with Core 20+ populations i.e. Berrylands (most responses), Norbiton and Green Lanes & St James (previously Beverley).

In line with the local population most respondents 53% were from a White – English, Welsh, Scottish, N Irish, or British background. This was followed by other White background at 21%, Asian ethnic backgrounds (including Indian and Chinese) at 15% and then Arab at 3%. People from a Black ethnic background were not represented in the responses.

Most respondents are living with Type 2 diabetes having been diagnosed more than 5 years ago. Half identified as having a health condition other than diabetes that was expected to last more than 12 months. Two participants took part in an online conversation, both male with Type 2 diabetes.

Key themes – survey

Take up of the annual review

Nearly all respondents had the opportunity to discuss their results with a healthcare professional however, 9% of respondents had not. Many respondents had spoken to either a GP or nurse at their last review with four indicating they had seen another healthcare professional but did not specify who.

Of the checks undertaken as part of their review the most common were blood tests and blood pressure checks, followed by urine test, weight and BMI and foot check. Less common was smoking status. A few respondents mentioned the diabetic eye check which is not part of the annual review.

Most respondents were able to discuss the results of their annual review and next steps for their diabetes care with their GP or other health professional. However, six said that they had not discussed their results with a healthcare professional and one did not know. Eight respondents indicated that they had not had a conversation about what would happen next with their diabetes care.

Many respondents said that a healthcare professional had talked to them about potential complications of living with diabetes, however six indicated that this had not happened and two did not know.

The most common issues respondents had received support for in the last 12 months were monitoring blood sugar levels, taking medication, eating well, physical activity and using a device (such as an insulin pen). Fewer respondents had received support for their emotional and mental health, connecting with others (peer support) or joining a diabetes course. This may be because respondents did not require support for these issues.

Diabetes support including the annual review

Quality of care and support: Several respondents said that their review was comprehensive and thorough, “allowing time for questions and to check my understanding.” That the GP they see is helpful and they feel supported by them. That the diabetes nurse is experienced and helpful and “in the past offered courses in physical activity and diet and is never judgmental.” Another respondent highlighted that they were happy with the support given by their GP but had not been offered a diabetic eye screening.

One respondent was positive about the “hardworking and dedicated professionals” at the Diabetes and Endocrinology Team at St Helier Hospital. Another respondent explained that their GP had helped them understand that Type 2 diabetes can be reversed when they thought it was inevitable that the condition would progress.

One respondent receives regular visits from healthcare professionals to monitor and manage their condition. However, one respondent highlighted that the review could come across as a “tick-box exercise for the practice and not very helpful, especially when the nurse lacks proper diabetes knowledge.” There was not enough signposting to local support groups.

Monitoring and lifestyle: A few respondents said that were confident in managing their blood sugar levels by regular monitoring at home and taking the health care professionals advice on maintaining a healthy diet and undertaking regular moderate exercise. “The doctor advised avoiding sweets and jogging 3 miles every day”.

A couple of respondents emphasised the importance of having regular checks to help them manage their condition. One said that they only discovered how high their blood sugar was after having a sudden stroke “My advice is not to overlook the importance of annual health check-ups”.

Access to other health services

Most respondents did not find it difficult to access other local health services. However, three said that they did find it difficult and four did not know. The most common reasons given for finding it difficult to accessing services were long waiting times for appointments and concerns about services being too busy. A respondent commented that they had not received an appointment for their diabetic eye screening, and another had concerns about practice staff not being helpful “Staff in the surgery are not helpful. They are not doing anything if you tell them that you can’t make your appointment.”

Key themes – online conversation

The online conversation covered the same questions as the survey plus questions on prevention and use of digital in health. Similar themes to the survey were identified plus the following:

Communication Participants received their diabetes check results over the phone which was seen as an effective method of sharing results, however how they were communicated varied. One participant would find it helpful to know any trends – are the results better or worse than last year, is there anything else I could be doing? Such information was not provided proactively by the healthcare professional unless they asked for them. They felt seeing the health care professional in person could allow for more detailed discussion and the opportunity to ask questions. “Sometimes I would like it to be face to face, but if it’s good news and it’s about making best use of time, then there’s no need for in person appointment.” However, this was not the case for the other participant who was informed about how their results compared to previous years without having to ask.

Diabetic eye checks Though eye checks are not included in the 8 care processes they were viewed as an important check for people living with diabetes. Participants’ experience was that the eye checks had changed from yearly to every 2 years.

Lifestyle support from healthcare professionals about lifestyle changes, diet, and exercise was limited after patients were given initial advice and support following diagnosis. Due to the length of time since their diagnosis the participants tended to rely on self-management, and one mentioned using resources from support organisations like Diabetes UK.

“The information and support that I’ve received really comes in a number of different ways… from actually being part of Diabetes UK.”

Mental health challenges Need for greater consideration by healthcare professionals of the potential mental health challenges associated with diabetes as many are impacted by this. Participants were aware from others about the need for greater mental health support for people living with diabetes.

Education and knowledge of health care professionals Ensuring healthcare professionals keep their knowledge about diabetes care up to date. This includes being aware of links to other health conditions and about what local support and activities are available for people living with diabetes.

Proactive support for patients who are not engaging with healthcare One participant wanted to understand how GP practices support patients who have additional health needs preventing them from engaging with health services. There is a need for support systems to prevent individuals being missed and their health deteriorating further due to isolation, poor mental health, or other barriers to engaging with health services.

Accessing other health services Generally, both participants found the referral process for other health issues effective with timely appointments. “I’ve just had a minor operation… I went to the doctor and … I was referred. Within a couple of months, I had an appointment.”

They were positive about using community pharmacies as these encouraged you “to check your blood pressure while you were there which is easy to do and important if you have diabetes.”

There was also positive feedback about accessing specialist services such as the Royal Eye Unit at Kingston Hospital which is good at sending reminders and making things as easy as possible and the Diabetic Eye Unit. “The diabetic day unit at Kingston Hospital led by Claire Neely, I think is absolutely wonderful. If anybody has a difficult question, she’s always very responsive and helpful.”

However, there were also challenges with one participant having difficulties with administrative processes and timely follow-ups waiting for a knee replacement at South West London elective orthopaedic centre (SWLEOC). “Getting an appointment that’s going to be held to and going to be done in a timely fashion has been really quite ridiculous and the admin at Epsom Hospital has been pretty disgraceful”

Accessing their GP practice was also highlighted as challenging by one participant explaining having to ring the surgery at 8 am and having to wait for a long time before someone answers the call, you are likely to give up and find your own solution. The planned changes to booking GP appointments were welcomed.

“The whole experience [of accessing health services] I think it goes from being absolutely first class to sometimes really being quite lamentable.” 

Making better use of technology

Wearables and Apps: potential of wearables like Fitbits to monitor physical activity and health metrics. However, there were concerns about data security and privacy and the reasons for data collection. “I have a Fitbit, and I target myself 10,000 steps a day… If that was linked somehow so that my GP could see what I’m doing, I wouldn’t have an issue.”

Online support: Virtual consultations and support groups were suggested as beneficial, especially for individuals who experience barriers to attending in person appointments.

Prevention

Education and Awareness: Emphasis on educating both patients and medical professionals about diabetes management and prevention. Regular updates and training for healthcare providers are needed. “Updating of medical professionals sometimes I’ve been in a situation where I’ve gone to a meeting with a doctor and I’ve known more about diabetes than the person that was actually sitting in front of me.”

Lifestyle Changes: Encouraging healthier lifestyles through diet, exercise, and moderation in alcohol consumption. Technology can play a role in promoting and supporting these changes in patients. “I think technology can help you with that because it gives you something you have a target.”

Early intervention: The importance of proactive measures by health services and regular monitoring to prevent complications and manage diabetes effectively. Support groups and community activities were highlighted as possible preventative support. “One of the ways that that can actually be addressed is through the support groups, which are open to both pre-diabetic and diabetic people.”

Next steps

Headline survey findings were shared at Kingston Place Committee and Kingston Health Improvement Group in April 2025. The full findings will be shared with Kingston’s public health team to agree next steps.

It will be published on the NHS South West London ICS Insight Bank.