Diabetes is one of the biggest long-term health challenges facing NHS Wales. More people are living with the condition, costs are rising, and services are under increasing pressure. As well as helping people with diabetes, the NHS needs to prevent more people from developing it in the future.

We are planning two reviews of diabetes across NHS Wales during 2026 and 2027. This article explains why we are looking at diabetes and the issues our work will explore. 

About diabetes

Diabetes is a serious condition where blood sugar levels are too high. It is usually classed as Type 1 or Type 2, although less common forms include gestational diabetes during pregnancy.

• Type 1 diabetes is an autoimmune condition which means the body cannot produce insulin. Insulin helps the body control blood sugar levels.
   
• Type 2 diabetes is more common and happens when the body does not produce enough insulin or when insulin does not work properly. Type 2 causes include genetic, lifestyle, and environmental factors such as built-up areas which discourage exercise. Type 2 can be delayed or prevented.

Diabetes can have a major impact on people's health and well-being if it is not managed well. It can lead to serious complications affecting the eyes, kidneys, nerves, heart, and other parts of the body (Exhibit 1). More information about diabetes, its complications, and living with the condition is available from the national charity Diabetes UK. 

Exhibit 1: how diabetes can affect the body

Source: Audit Wales using information available from NHS.UK 

More people are facing diabetes

The number of people living with diabetes in Wales has increased significantly over recent years. Public Health Wales reports that the number of adults with diabetes increased by about 40% from 2009-10 to 2021-22 (Exhibit 2). 

Source: Public Health Wales 

Without effective prevention, the number of people living with diabetes is likely to rise further. Current projections suggest that by 2035-36 there could be around 266,000 adults living with the condition (one in 10). 

Rising levels of childhood obesity could increase the number even more quickly. Indeed, the latest data shows that the number of adults with diabetes is already rising quicker than previously projected, with around 230,000 reported to have diabetes in 2025 (Exhibit 2).

Many other people are at risk of developing diabetes. Public Health Wales suggest that currently around 59,000 people might have undiagnosed Type 2 diabetes. And almost 270,000 people have prediabetes, with blood sugar levels higher than normal and putting them at higher risk of developing the condition. Overall, around one in five adults is thought to be living with diabetes or prediabetes currently.

Costs are rising and the NHS is struggling to prioritise prevention

Diabetes UK estimates that the condition currently costs health boards in Wales around £501 million each year, based on 2022 figures. This is about 5% of health boards’ total revenue spend of £10.5 billion.

Over half of the £501 million is associated with managing complications (Exhibit 3).

Exhibit 3: breakdown of current cost of diabetes in Wales in 2022

Source: Diabetes UK

Diabetes UK has forecast that the cost of diabetes could rise to more than £800 million annually by 2035 if current trends continue. Exhibit 4 shows how the current estimated and projected costs break down by health board.

Exhibit 4: estimated cost of diabetes by health board in 2021 and projected cost in 2035 (£ million).

Source: Audit Wales presentation of figures reported by Diabetes UK

Note: we have not audited the figures presented, and the figures do not sum due to rounding.

Most spending is directed towards treating diabetes and managing its complications rather than prevention. Only a small proportion goes towards preventing diabetes from developing in the first place. 

Prevention is essential for improving health outcomes and reducing future demand. National policies and programmes aim to support healthier lifestyles, tackle obesity, and help people at higher risk of developing Type 2 diabetes. However, turning this ambition into practice is still challenging.

The NHS, as well as its public sector partners, must balance the long-term benefits of investing in prevention against immediate pressures on financial resources and capacity, including the growing demand from patients who require treatment today. Also, diabetic specific prevention programmes often rely on short-term funding, do not always achieve full population coverage, and it can take years to see the impact.

While these issues are not unique to diabetes, they are important given the projected increase in the number of people living with diabetes and how much this will cost NHS Wales. This is without considering the wider cost to the economy due to ill health. 

Concerns about diabetes services in Wales are not new

A 2003 review by the Audit Commission in Wales identified several problems, including limited work to prevent diabetes, gaps in care, differences in access to services, staff shortages, poor coordination between primary care and hospital services, and a lack of data to support planning and improvement.

Wales now has a well-developed policy framework for diabetes. The Welsh Government's Quality Statement for Diabetes sets out what good diabetes services should look like. It sets expectations for NHS Wales and is supported by national pathways which describe the recommended approach to care and performance measures. It is also backed up by networks which bring together clinicians and other experts.

Public Health Wales also leads two national programmes: the Tackling Diabetes Together programme and the All-Wales Diabetes Prevention Programme. Both aim to improve health outcomes by preventing diabetes and identifying people at risk earlier.

A recent evaluation of the All-Wales Diabetes Prevention Programme found positive results, including lower blood sugar levels among participants. However, the evaluation recognised challenges in making sure the programme reaches people consistently and delivers long-term benefits.

Twenty years on from the Audit Commission in Wales review, a Senedd All-Wales Cross-Party Review on Diabetes raised many of the same concerns. Finding out why these issues continue, despite sustained policy attention, will be an important part of our work.

Care varies across Wales

Differences in diabetes care across Wales are still a key issue. Data from the National Diabetes Audit, run by NHS England, shows clear differences between health boards in the proportion of patients receiving all eight annual health checks recommended by the National Institute for Health and Care Excellence (NICE).

These checks help people manage their diabetes and reduce the risk of complications (Exhibit 5). A further check for eye problems is provided through the Diabetic Eye Screening Wales programme run by Public Health Wales. 

Exhibit 5: NICE recommended annual health checks for people with diabetes.

Source: Audit Wales presentation of NICE recommended checks

The 2024-25 national diabetes audit found wide variation in the proportion of patients receiving all eight annual health checks. Rates ranged from 33% in Betsi Cadwaladr University Health Board to 43% in Powys Teaching Health Board.

Foot and kidney function checks were the least likely to be completed across Wales as a whole. Rates ranged from 53% for foot checks to 58% for kidney function checks.

There were also differences between patient groups. Only 20% of people with Type 1 diabetes received all eight checks, compared to 37% of people with Type 2. 

The system depends on strong data, good governance, and enough staff

Many organisations play a role in preventing and managing diabetes. These include the Welsh Government, health boards, Public Health Wales, the Strategic Clinical Network for Diabetes, Digital Health and Care Wales, and local government.

The 2023 Senedd All-Wales Cross-Party Review highlighted the need for clear governance arrangements to help drive improvement across the system.

The evidence we have seen so far also highlights ongoing staff shortages, and problems with the quality of data that bodies hold across different systems. These issues can make it harder to monitor performance, target resources effectively, and demonstrate value for money. 

Meanwhile, digital tools such as MyDESMOND, the Diabetes Audit Plus Module and the Diabetes Consultation Note can help people manage their condition, increase patient engagement, and improve information sharing. But these tools are not yet being used consistently. 

What we will be looking at

Our work will look in more detail at how well NHS Wales is doing to prevent diabetes, support people living with the condition, and deliver sustainable services for the future.

We will consider the issues that health boards are facing when delivering diabetes services, and the action they are taking to overcome them.  

The first of our reviews will focus on the management of diabetes. We expect to publish findings in Spring 2027, initially through reports for each health board.

The second review will focus on preventing those at risk from developing diabetes. This work will start in late 2027. 

Across both reviews, we want to highlight what is working well and where services could improve. We want our work to help health boards improve diabetes care, so people with diabetes can live healthier and more independent lives.

We also want to make sure public money is used well to achieve the best possible outcomes for patients. 

Beyond the NHS, we will also consider whether our forward work programme should look at how the wider public sector is supporting healthier lifestyles.