England 2015/16 to 2020/21

Published 26 August 2021

Key findings

in 2020/21, there were 57.9 million drugs used in treating diabetes prescribed in England for a cost of £1.19 billion, 12.5% of the total spend on all prescription items prescribed in England. This was an increase from 2015/16 where 49.7 million diabetes items were prescribed in England for a cost of £958 million, representing 10.4% of the total spend on all prescription items.
antidiabetic drugs were the most prescribed drugs used in treating diabetes in England in 2020/21 with 43.1 million items at a cost of £686 million. The costs of antidiabetic drugs have increased by 62% since 2015/16 from £423 million.
there were 3.05 million identified patients that were prescribed drugs used in diabetes in England in 2020/21. This was a 1.5% increase from 3.00 million identified patients in 2019/20, and a 12.7% increase from 2.70 million in 2015/16.
the median age of identified patients for drugs used in diabetes was 64 in 2020/21, this has remained consistent since 2015/16. The most common age group in 2020/21 was 70 to 74, this has increased from 2015/16 where the most common age group was 65 to 69.
areas of greater deprivation have the highest number of identified patients being prescribed drugs used in treating diabetes in 2020/21, with the number of patients receiving prescribing in the most deprived areas of England being 264% of the least deprived areas.

1. Introduction

1.1. Scope

Diabetes is a lifelong condition that causes a person’s blood sugar level to become too high. There are 2 main types of diabetes, type 1 diabetes where the body’s immune system attacks and destroys the cells that produce insulin, and type 2 diabetes where the body does not produce enough insulin, or the body’s cells do not react to insulin. Another form of diabetes is gestational diabetes, where diabetes develops during pregnancy and usually disappears after childbirth.

Chapter Three of the NHS Long Term Plan sets out the NHS’s priorities for care quality and outcomes improvement for the decade ahead. There are also 5 long term highlights for diabetes in the long term plan, aimed at prevention and treatment of this condition. These are:

type 2 diabetes prevention as a priority
expanding access to diabetes professionals for optimum treatment and care
emphasising self-management of diabetes as a key role in ‘upstream prevention’
exploring low calorie diets as a potential treatment option for type 2 diabetes
continuing digitisation of diabetes prevention, treatment, and care services.

This publication aims to describe the prescribing of medicines and appliances used for the treatment of diabetes in England that are dispensed in the community. This does not include data on medicines prescribed and dispensed in secondary care, prisons, or issued by a private prescriber as this is not held by the NHSBSA.

These statistics detail:

the total number of prescription items issued for drugs used in diabetes
the number of identified patients that have received prescribing for these drugs
demographic breakdowns of prescribing by age group
demographic breakdowns by sex
demographic breakdowns by a measure of deprivation.

These statistics use the BNF therapeutic classifications defined in the British National Formulary (BNF) using the classification system prior to BNF edition 70. Each January the NHSBSA updates the classification of drugs within the BNF hierarchy which may involve some drugs changing classification between years of this publication. Four paragraphs of the BNF are covered within these statistics:

Insulin
Antidiabetic drugs
Treatment of hypoglycaemia
Diabetic diagnostic and monitoring agents

These medicines are classified by their primary therapeutic indication. However, it is possible that they can be prescribed for other reasons outside of this primary therapeutic indication. For example, metformin which is used to reduce blood sugar for those with type 2 diabetes is also used to treat infertility caused by polycystic ovarian syndrome (PCOS). The clinical indication of a prescription is not captured by the NHSBSA during processing, and therefore we cannot determine the reason that a prescription was issued. Insulin can be prescribed to those with type 1 and type 2 diabetes; therefore, we are unable to distinguish between patients with either type of diabetes, and drug types should not be used as a proxy for diabetes types. Due to these reasons, these statistics may not give an accurate estimation of the population who are receiving drugs specifically for diabetes and the diabetes type of the population, any inferences made from this data should take this into consideration.

The BNF sub-paragraph for hypodermic needles is not included as part of this publication as these are often used for other clinical conditions and would unnecessarily skew the data. This is consistent with previous publications released by NHS Digital.

1.2. Definitions

Throughout this publication the term ‘item’, short for ‘prescription item’, means a single instance of a drug that is listed as a separate entry on a prescription form. For example, Fluoxetine 20mg tables x56.

There are many costs incurred when a dispensing contractor fulfils a prescription. The costs reported in this publication represent the basic price of the item and the quantity prescribed. This is sometimes called the ‘Net Ingredient Cost’ (NIC). The basic price is given either in the Drug Tariff or is determined from prices published by manufacturers, wholesalers or suppliers. Basic price is set out in Parts VIII and IX of the Drug Tariff. For any drugs not in Part VIII, the price is usually taken from the manufacturer, wholesaler or supplier of the product.

In this release the term ‘patient/s’ is used to mean a unique, valid NHS number that has been captured from a prescription form and subsequently verified by the NHS Personal Demographics Service (PDS). Across 2020/21, use of the Electronic Prescription Service (EPS) has increased considerably during the COVID-19 pandemic. As this process captures NHS numbers digitally rather than through scanned paper forms, this has naturally led to an increase in the proportions of identified patients in 2020/21 than seen in previous years.

Where patients are identified, their age is calculated on 30 September of the given financial year to assign them to a single age band. For patients where date of birth has not been captured, they have been included in a category of unknown.

Sex information was not available from PDS for a small number of patients in each year, typically fewer than 100. This may be because it was not disclosed by the patient or not recorded by the organisation that collected the data. These patients have been omitted from the respective figures but can be found in the Statistical Summary Tables for the respective BNF Chapter.

The English Indices of Deprivation 2019 have been used to provide a measure of patient deprivation. This provides an Index of Multiple Deprivation (IMD) looking at different factors such as income, employment and health deprivation and ranks areas of England in deciles based on their score, where 1 is the most deprived and 10 the least deprived. For our publication, the IMD is derived from the location of the practice where an item has been prescribed.

1.3. Patient identification

When the NHSBSA processes prescriptions, the NHS number of the patient is identified for most, but not all, prescriptions. The proportion of items for which a patient could be identified is shown in Table 1. This means that data relating to patient counts represents most, but not all, patients.

These statistics do not contain any personally identifiable data. More details on the statistical disclosure control applied to these statistics is available in section 5 of this summary. More information about how the NHSBSA protects personal information can be found in the statement on confidentiality and access.

Where data is provided “per patient”, this refers to only costs or items attributable to identified patients. Therefore, these will not total overall costs or items which refer to all known costs or items.

Table 1: The proportion of items for which an NHS number was recorded for listed BNF sections 2015/16 to 2020/21

Source: Prescribing for diabetes summary tables - Costs and items (Patient identification rates)

2. Results and commentary

2.1. Volume and cost

Source: Prescribing for diabetes summary tables - Costs and items (Table 1)

There were 57.9 million items for drugs used in diabetes prescribed in 2020/21. This was a 16.4% increase from 49.7 million in 2015/16, and a 0.3% increase from 57.7 million items in 2019/20. The increase in items between 2019/20 and 2020/21 was much smaller than seen in previous yearly increases which between 2015/16 and 2019/20 was an average of 3.79%.

The number of identified patients that have received prescribing for drugs used in diabetes was 3.05 million in 2020/21. This was a 12.7% increase from 2.70 million identified patients in 2015/16, and a 1.48% increase from 3.00 million in 2019/20. The increase in identified patients between 2019/20 and 2020/21 was the smallest increase observed in the period, with yearly increases between 2015/16 and 2019/20 averaging 2.65%.

Source: Prescribing for diabetes summary tables - Costs and items (Table 1)

Costs for drugs used in diabetes also increased to £1.19 billion in 2020/21. This was a 24.4% increase from £958 million in 2015/16, and a 3.46% increase from £1.15 billion in 2019/20. The increase in costs between 2019/20 and 2020/21 was smaller than the previous 2 years increases, and was less than the average yearly increase between 2015/16 and 2019/20 of 4.73%.

Source: Prescribing for diabetes summary tables - Costs and items (Table 1)

The proportion of all prescription items that drugs used in diabetes have accounted for has increased each year, from 4.57% in 2015/16 to 5.22% in 2020/21.

In 2020/21, the cost of drugs used in diabetes accounted for 12.5% of the total spend on all items prescribed in England. This is an increase from 2015/16 when drugs used in diabetes accounted for 10.4% of the total spend.

Source: Prescribing for diabetes summary tables - Costs and items (Table 2)

Antidiabetic drugs remain the most prescribed treatment for diabetes with 43.1 million items in 2020/21. This was a 21.5% increase from 35.5 million items in 2015/16, and a 1.50% increase from 42.5 million items in 2019/20. The increase in antidiabetic drug items between 2019/20 and 2020/21 was smaller than seen in previous yearly increases which between 2015/16 and 2019/20 was an average of 4.61%.

The 3 remaining BNF paragraphs observed decreases in prescribing between 2019/20 and 2020/21. Prescribing of diabetic diagnostic and monitoring agents decreased by 3.40% from 7.19 million items in 2019/20 to 6.94 million in 2020/21, while insulin items decreased by 2.55% from 7.71 million to 7.52 million. Finally, medicines used for the treatment of hypoglycaemia decreased by 6.75% from 343,000 items in 2019/20 to 319,000 in 2020/21.

Source: Prescribing for diabetes summary tables - Costs and items (Table 2)

In 2020/21, antidiabetic drugs had a cost of £686 million. This was an increase of 62.0% from £423 million in 2015/16, and an 11.5% increase from £615 million in 2019/20. These increases in cost are much greater than the respective increases in the number of prescribed items. The increase in cost for antidiabetic drugs between 2019/20 and 2020/21 was less the previous 2 years increases, however it was still larger than the average yearly increase between 2015/16 and 2019/20 of 9.86%.

In line with the number of prescribed items, the 3 remaining BNF paragraphs all observed decreases in cost between 2019/20 and 2020/21. The cost of prescribing of diabetic and diagnostic and monitoring agents was £148 million in 2020/21, a 20.5% decrease from £187 million in 2015/16, and a 10.7% decrease from £166 million in 2019/20. The cost of Insulin items decreased from £366 million in 2019/20 to £353 million in 2020/21, a decrease of 3.51%. Lastly, the cost of items for the treatment of hypoglycaemia was £4.31 million in 2020/21, a 5.09% decrease from £4.54 million in 2019/20.

Source: Prescribing for diabetes summary tables - Costs and items (Table 1)

The average number of items per patient increased each year between 2015/16 and 2019/20, from 17.5 diabetes items per patient to 19.0. However, between 2019/20 and 2020/21 the average number of diabetes items per patient decreased for the first time in the period observed, from 19.0 items to 18.9.

This measure only includes prescribing of drugs used in diabetes and does not include any items prescribed from other BNF sections.

Source: Prescribing for diabetes summary tables - Costs and items (Table 4)

See section 4.7. Interpretation of a box plot for guidance on interpreting this chart.

Prescribing that is dispensed in the community can occur in multiple settings, including from practices and costs centres linked to Clinical Commissioning Groups (CCGs), hospital trusts, and Independent Sector Healthcare Providers (ISHPs) amongst others. Figure 6 displays data relating to prescribing that has occurred in CCGs only.

The cost per patient varied across CCGs in 2020/21, from £281 to £499 with the median cost per patient per CCG being £396. This was a 2.93% increase from a median cost per patient of £384 in 2019/20, and a 17.1% increase from £338 in 2015/16.

In 2020/21, Northumberland CCG and North Tyneside CCG had costs per patient significantly lower than other CCGs and are classed as outliers - that is, their cost per patient is more than 1.5 times the interquartile range below quartile 1. For the first time in the period there was an outlier for higher cost per patient, this being North Lincolnshire CCG.

It should be noted that the number of CCGs decreased in April 2020/21, from 135 to 106, following a number of CCG mergers.

2.2. Patient demographics

Source: Prescribing for diabetes summary tables - Patient demographics (Table 3)

While the overall number of identified patients receiving drugs used in diabetes prescribing has increased year-on-year, the overall split of male and female patients has remained consistent. In 2015/16, 45.3% of identified patients were female and 54.7% were male. This is similar to 2020/21 where 45.2% of identified patients were female and 54.8% were male. However, there are an additional 152,000 female identified patients than there were in 2015/16, and an additional 190,000 males.

Identified patients where their sex was unknown or indeterminate have been grouped together and can be found in the summary tables that accompany this release.

Source: Prescribing for diabetes summary tables - Patient demographics (Table 4)

The median age of identified patients receiving drugs used in diabetes has remained constant at 64 between 2015/16 and 2020/21. The most common age group in 2020/21 was 70 to 74 with 387,000 identified patients followed by 60 to 64 with 370,000 identified patients, and 65 to 69 with 367,000.

More information on how we calculate a patient’s age can be found in section 4 of this summary.

Source: Prescribing for diabetes summary tables - Patient demographics (Table 4)

The proportions of each age group have stayed broadly the same since 2015/16, with the biggest change occurring between 2015/16 and 2020/21 for the 65 to 69 and 70 to 74 age groups. The proportion of identified patients that were 65 to 69 has decreased by 1.21 percentage points from 13.3% to 12.0%, while the proportion that were 70 to 74 has increased by 1.08 percentage points from 11.6% to 12.7%.

Table 2: Number of child and adult identified patients receiving diabetes prescribing (millions of patients)

Source: Prescribing for diabetes summary tables - Patient demographics (Table 6)

There were 34,700 identified patients aged 17 and under that received prescribing for drugs used in diabetes in 2020/21. As a proportion of all identified patients with a captured age this was 1.14%. Between 2015/16 and 2019/20 there had been 4 consecutive years of decreases of the proportion of identified patients that were aged 17 and under, from 1.22% to 1.13%.

Source: Prescribing for diabetes summary tables - Patient demographics (Table 7)

In 2020/21, there were 481,000 identified patients prescribed drugs used in diabetes from practices in the most deprived areas in England, 264% of the 182,000 identified patients that received prescribing from practices in the least deprived areas. In general, more people were prescribed drugs used in diabetes from practices in more deprived areas in 2020/21. This pattern has remained consistent since 2015/16.

The English Indices of Deprivation have been used to provide a measure of patient deprivation. The deprivation deciles reported are those of the prescribing practice that a patient has received a prescription item from. More information on this measure can be found in section 4 of this summary.

3. Background

3.1. Antidiabetic drugs

Antidiabetic drugs are generally used to treat type 2 diabetes. They are taken by mouth and work in a number of different ways depending on the type of drug, for example by increasing the amount of insulin made in the body or by decreasing the production of glucose in the body and so lowering blood glucose levels. Patients may be prescribed a single antidiabetic drug or may be prescribed several to work together to achieve the desired control of their diabetes in combination with diet, exercise and lifestyle advice and interventions.

One of the most commonly used antidiabetic drugs is metformin which is usually the first antidiabetic drug a patient with type 2 diabetes will be prescribed. Depending on the response to treatment, additional antidiabetic drugs may be added, and the patient may be prescribed insulin further into treatment if the desired control of the diabetes is not achieved with antidiabetic drugs and diet and lifestyle management alone.

You can find out more information on type 2 diabetes medications on the NHS website.

3.2. Insulin

Insulin is a hormone that plays a key role in the body’s metabolism, including regulating blood glucose levels. In those with type 1 diabetes, the body produces insufficient insulin to undertake this role effectively. For those with type 2 diabetes, the body does not respond effectively to insulin (known as insulin resistance) or the body does not make enough insulin. People with type 1 diabetes will be prescribed insulin, while only a proportion of those with type 2 diabetes will be prescribed this.

Insulin can be injected or delivered by an insulin pump which regularly infuses insulin into the body. Synthetic insulin or non-synthetic animal insulin are available depending on the needs of the patient. Insulin preparations also vary in how quickly they act and are often used in combinations, depending on the individual requirements of a patient.

You can find out more about insulin on the NHS website.

3.3. Diabetes diagnostic and monitoring agents

Diabetes diagnostic and monitoring agents cover a range of monitoring equipment and testing strips that can be used by a person with diabetes to check their diabetic control. Self-monitoring is not routinely suggested for type 2 diabetes, but it is an integral part of treatment for people with type 1 diabetes. This can be monitoring blood glucose levels or monitoring ketones (a by-product of the breakdown of fats) in either the blood or urine.

By being able to monitor blood glucose levels, patients can manage their health effectively and prevent hypoglycaemia or hyperglycaemia.

Diabetic patients can be at risk of diabetic ketoacidosis, a serious condition, where the body starts to run out of insulin and ketones build up in the body. Checking ketones levels can be an important early warning of this and monitoring agents allow people to check these levels themselves.

3.4. Treatment of hypoglycaemia

Hypoglycaemia is a lower than normal blood glucose concentration. It is the most common side effect of insulin treatment and can cause acute symptoms such as feeling tired and sweating, drowsiness and confusion. This can progress to seizures or unconsciousness if untreated.

Hypoglycaemia can be treated with a sugary drink or snack, though this is not always enough. Fast-acting carbohydrates are prescribed for patients to keep at hand in case of hypoglycaemia, these can be oral liquids and gels, capsules or even injectables.

The NHS website has additional information on symptoms and treatment of hypoglycaemia.

4. About these statistics

Further information on the methodology used in this publication and further background information is available in our Background Information and Methodology supporting document.

4.1. Patient counts

The patient counts shown in these statistics should only be analysed at the level at which they are presented. Adding together any patient counts is likely to result in an overestimate of the number of patients. A person will be included, or counted, in each category or time period in which they received relevant prescriptions. For example, if a patient received a prescription item for a diabetes product in 2018/19 and another in 2019/20, then adding together those totals would count that patient twice. For the same reason, data on patient counts for different BNF paragraphs should not be added together.

4.2. Patient age and sex

The age and sex of patients used in these statistics is derived from data provided by the NHS Personal Demographics Service (PDS) for NHS numbers that have been successfully verified by them. A patient’s age, used to assign them to an age group, has been calculated on 30 September for the given financial year. It is possible that a patient’s PDS information may change over the course of the year, in these cases patients may be subject to multiple counting in these analyses.

4.3. Index of deprivation

The English Indices of Deprivation 2019 have been used to provide a measure of patient deprivation. The English Indices of Deprivation are an official national measure of deprivation that follows an established methodological framework to capture a wide range of individuals’ living conditions.

The reported IMD decile, where 1 is the most deprived and 10 the least deprived, is derived from the location of the practice where an item has been prescribed. There are a small number of items each year that we have reported as having an unknown IMD decile. These are items that have been attributed to an unidentified practice within a Primary Care Organisation (PCO), or where we have been unable to match the practice postcode to a postcode in the National Statistics Postcode Lookup (NSPL) - May 2021.

IMD deciles are calculated by ranking census lower-layer super output areas (LSOA) from most deprived to least deprived and dividing them into 10 equal groups. These range from the most deprived 10% (decile 1) of small areas nationally to the least deprived 10% (decile 10) of small areas nationally.

4.4. Geographies included in this publication

The patient deprivation measures given in these statistics are based upon the LSOA of the postcode of the prescribing organisation as matched to the May 2021 NSPL file. However, higher geographies included in the statistical summary tables of this publication, such as CCG, STP and NHS England Region use NHSBSA administrative records, not geographical boundaries, and more closely reflect the operational organisation of practices than other geographical data sources.

4.5. Changes made to this publication

In previous releases of this publication the number of identified patients per IMD decile had been standardised using mid-year population estimates released by the Office of National Statistics (ONS). However, due to moving the publication date of this release from November to August these mid-year population estimates were not available at the correct level to map them to individual deciles. Therefore, these measures have been amended to show only the number of identified patients and not a standardised rate.

4.6. Planned changes to this publication

This is an experimental official statistic release. Experimental statistics are newly developed or innovative statistics. These are published so that users and stakeholders can be involved in the assessment of their suitability and quality at an early stage. More information on how users can give us their feedback can be found in section 7 of this summary. We will regularly be reviewing the methodology used within the statistics.

4.7. Interpretation of a box plot

Box plots are used to help visualise not just averages, but also how data is spread out. If all data points were arranged from the smallest to the biggest, halfway along this line in the middle would be the median. The middle line in the box is the median. The top section of the box includes the 25% of numbers directly above the median, the bottom includes the 25% directly below the median.

The remaining lowest 25% and highest 25% are usually captured by the whiskers; the whiskers are set to have a maximum length of 1.5 interquartile ranges (the length of the box), the end of each whisker is the most extreme value within this range. Any points that are further than 1.5 interquartile ranges from the top or bottom of the box are classified as statistical outliers and are shown as small circles on the box plot.

The length of the whiskers away from the median show how similar the data is compared to the average; short whiskers indicate that there are no areas extremely different to the average whereas long whiskers show the data is much more spread out and there are bigger differences between the highest and lowest numbers.

5. Statistical disclosure control

Statistical disclosure control has been applied to these statistics. Patient count, items, and net ingredient cost (NIC) have been redacted in the supporting summary tables if they relate to fewer than 5 patients. Further information about our statistical disclosure control protocol can be found on our website.

The high-level figures in this statistical summary have been rounded where appropriate for clarity, in most cases to three significant figures. This is to make this narrative as accessible as possible to all readers. The summary tables released with this publication allow users to investigate this data at lower levels of granularity. Figures in the supplementary tables have not been rounded.

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