National Diabetes Week 2025

Diabetes in our region: A persisting clinical and public health challenge

Diabetes — particularly type 2 diabetes — remains a critical chronic health issue in the Central and Eastern Sydney Primary Health Network (CESPHN) region. Whilst there has been a reduction in hospitalisation rates, local data highlights persistent challenges around the underdiagnosis of diabetes, low uptake of care plans, and rising mortality and diabetes related amputations.

The diabetes burden: What the data shows

According to the CESPHN 2025 Needs Assessment:

• In 2024, there were 99,777 people in the CESPHN region registered on the National Diabetes Services Scheme (NDSS), representing 4.25% of the population.
• The majority (85%) had type 2 diabetes (n=84,817), followed by type 1 (11%), gestational (2.9%), and other types (1.1%).
• Aboriginal people in the CESPHN region are three times more likely to develop diabetes than non-Indigenous counterparts.
• Pre-diabetes is under-identified, with national guidelines recommending validated risk scoring tools (e.g., AUSDRISK) and annual HbA1c testing for high-risk patients.

Adverse outcomes are still significant:

• Diabetes-related hospitalisations:
  – Total: 97.3 per 100,000 population (2021–22)
  – Type 2 diabetes accounts for 67.1 per 100,000
• Amputations due to diabetes:
  – Toe/Foot/Ankle: 10.5 per 100,000
  – Below-knee: 1.3, Above-knee: 0.5
• Mortality:
  – 519 diabetes-related deaths in 2021, up from 428 in 2019
  – Underlying cause of death rate: 51.2 per 100,000, higher in Sydney LHD (56.0)
• Cycle of care gap: In 2021–22, only 3,169 patients received a complete annual diabetes cycle of care — just 0.20 per 100 people, compared to 0.45 nationally

Notably, while hospitalisation rates for diabetes in CESPHN fell from 116 per 100,000 in 2018 to 97.3 per 100,000 in 2022, this is only a partial success given persistent underdiagnosis, inadequate self-management, and low uptake of structured care.

The Role of Primary Care: Early detection, equity, and team-based care

The data is clear: clinicians in general practice and allied health are central to preventing complications, reducing mortality, and managing the diabetes burden more equitably.

How can GPs and Primary Care Teams help:

• Screen early and regularly, particularly in high-risk groups: multicultural groups, Aboriginal, older adults, and low-income populations.
• Use HbA1c testing and AUSDRISK to identify undiagnosed and pre-diabetic individuals.
• Implement structured care including Chronic Disease Management (CDM) plans and regular follow-up.
• Refer to diabetes educators, dietitians, exercise physiologists, and culturally appropriate services.
• Prioritise language services and culturally competent communication with Arabic, Chinese, Vietnamese, and Pacific Islander communities.

What’s new: Supports for health professionals

NDSS enhancements

• CGM subsidies (FreeStyle Libre 2 Plus) from 1 April 2025
• Insulin pump access for all with type 1 diabetes from 1 July 2025
• Aboriginal Health Practitioners can now certify NDSS forms
  🔗 ndss.com.au

MyMedicare reforms

• New Chronic Condition Management Plan replaces GPMP/TCA from 1 July 2025
• Up to 8 group services/year for type 2 diabetes (education, dietetics, EP)
• Incentives linked to MyMedicare registration
  🔗 health.gov.au/mymedicare

NSW IDC program

• Joint care planning with GPs, LHDs, PHNs, and Aboriginal services
• Focus on early detection, self-management, and localised care pathways
  🔗 health.nsw.gov.au/integratedcare

This National Diabetes Week, let’s move beyond awareness toward bold, local action. Together, we can reduce preventable complications and close the diabetes equity gap across the CESPHN region.