Summary
In 2023, the Mile End Young Adult Diabetes (YAD) service identified inequities in insulin pump access: 68% of White, 14% of Black, and 0% of Asian Type 1 diabetes patients were on pumps. Surveys and interviews revealed barriers faced by ethnic minority groups. The service used its high-risk pathway to engage vulnerable young people (disproportionately from ethnic minority backgrounds). A dedicated young adult diabetes pump nurse was appointed to deliver tailored education, start individuals on pumps, and provide close follow-up. By 2025, 65% of White, 62% of Black, and 52% of Asian patients were on hybrid closed loop (HCL) therapy.
Innovation/Novel approach to an existing problem
The service supports a diverse population of 16–25-year-olds: 30% White, 27% Black, 22% Asian, 8% Mixed, and 13% Other. In 2023, a review of insulin pump access within the service revealed stark inequities and disengagement from diabetes care was disproportionately high among ethnic minority groups. A proactive, community-focused high-risk pathway was introduced. A youth worker and a social worker joined the diabetes team to conduct community outreach and home visits, identifying and building trust with young people. They supported patients to access the service and improved readiness for diabetes technology. Surveys and one-to-one interviews were co-designed with patients from minority backgrounds to understand cultural and structural barriers to pump uptake, ensuring an approach rooted in lived experience. A dedicated young adult diabetes pump nurse was appointed to provide tailored education, initiate pump therapy for high-risk individuals, and deliver personalised follow-up. Objectives were to reduce disparities in access to HCL therapy and ensure the safe and effective use of diabetes technology. All patients received tailored education from the pump nurse before starting therapy, with close monitoring and follow-up. Regular multidisciplinary reviews ensured the pathway remained responsive, safe, and equitable. This initiative combines clinical excellence with social care, embedding equity, outreach, and co-design. Unlike traditional pump programmes, it targets disengagement at the root. It is a scalable, replicable model.
Equality, Diversity and Variation
Key barriers to uptake were lack of knowledge about insulin pump therapy and HCLs, fear of technology failure, limited diabetes literacy, and stigma/not wanting to be identified as living with diabetes. All members of the MDT made a point to discuss the benefits of diabetes technology to ensure that each individual had been introduced to the concept. Peer support technology sessions were held, where young people could meet other young people living with diabetes to see how the technology looks and the benefits their peers had had, with all technology available laid out in the MDT clinics. A dedicated young adult pump nurse delivered tailored education, initiated therapy for high‑risk individuals and provided consistent follow‑up. The youth worker and social worker conducted outreach and home visits to engage young people who were not attending, introducing HCL therapy early.
Impact to Patient Care
Through the high-risk pathway, personalised support, and community outreach, access to HCL therapy increased dramatically by 2025: 65% of White patients, 62% of Black patients, 52% of Asian patients. This represents a major step towards equity. Inclusion of a youth worker and social worker enabled the team to reach disengaged patients in their own environments. Through home visits and community outreach, trust was built with vulnerable young people who were not accessing care. This relational approach helped patients feel seen, supported, and empowered. The young adult pump nurse demystified diabetes technology and helped patients feel confident in managing their condition. Patients reported feeling more in control, less anxious, and more connected to their care team.
Results
In 2023, 35% of the cohort used insulin pumps and 13% were on HCL. Pump use was: 68% White; 0% Asian; 14% Black; 0% Mixed, and 75% Other. In 2025, 60% of the cohort was on HCL (65% White; 52% Asian; 62% Black); 43% Mixed and 57% Other were on pump. There was a significant improvement in the number of young people from Black and Asian backgrounds achieving an HbA1c 53mmol/mol. There was also a significant reduction in the percentage of people with a very high HbA1c in the Asian and Mixed populations. HbA1c 53mmol/mol: White population 47% in 2023 vs 40% in 2025; Asian population 12% in 2023 vs 24% in 2025; Black population 7% in 2023 vs 30% in 2025; Mixed population 0% in 2023 vs 0% in 2025; Other population 37.5% in 2023 vs 29% in 2025. Regarding HbA1c >70mmol/mol, results were: White population 26% in 2023 vs 30% in 2025; Asian population 64.2% in 2023 vs 30% in 2025; Black population 41% in 2023 vs 43% in 2025; Mixed population 60% in 2023 vs 43% in 2025; Other population 37.5% in 2023 vs 29% in 2025. The high-risk pathway allowed the team to be more proactive, actively finding young people struggling to engage and introducing them to new technologies. The pump DSN then tailored education according to need, encouraging and chasing specific requirements, such as eye screening and following up with the most vulnerable patients closely post on-boarding. Following the introduction of the high-risk pathway, pump DSN, peer support, group psychology, drop-in education sessions in youth centres, the service has reduced hospital admissions, reduced DNA rates, significantly reduced HbA1c. It is economically viable, with a Barts Health finance business case estimating an annual net saving of £60,000.
User Feedback
Questionnaires and semi-structured interviews found that over 80% of respondents had previously discussed diabetes technology and expressed interest in using it. However, substantial knowledge gaps remained. A total of 52% were considering insulin pump therapy but reported uncertainty about who to speak to or how to access it. Common concerns included fear of the physical burden of wearing a device, restriction to physical activity, plus fear of malfunction. These findings led to technology sessions for peer support groups, introducing young people on MDI to those using pump technology. Technology was discussed in every consultation and the information above enabled the team to ask young people the right questions about their concerns around using technology. The MDT initiated early conversations around technology and offered follow-up to ensure patients felt supported in their choices.
