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JSNA Live Well

Last updated October 2026. The charts and most of the figures in the text refresh automatically from OHID, GLA, ONS, NHS England, DfE and other national data. Strategies and service descriptions are as at the date shown.

Introduction

The sheer scale of the Long Term Conditions (LTCs) challenge for modern healthcare systems means that a shift is needed away from the traditional medical model of illness towards a model of care which takes greater account of the expertise, strengths and resources of people living with long-term conditions and their communities. This supports a more holistic approach to care and wellbeing and helps people achieve the best possible outcomes throughout their lives.

The NHS Long Term Plan reinforced the importance of prevention, personalised care and supporting people to manage their health and wellbeing. It recognised that long-term conditions are now a central focus of the health and care system and that improving outcomes requires a partnership between services, individuals, families and carers. This is particularly important in supporting the growing number of people living with multimorbidity, where individuals experience two or more long-term conditions at the same time, helping them to live well, age well and maintain independence for as long as possible.

Across Richmond, health and care partners are working through integrated, place-based approaches to improve prevention, support earlier identification of disease, reduce health inequalities and provide more coordinated care for people living with long-term conditions. Effective management of long-term conditions requires collaboration across primary care, community services, social care, mental health services, acute providers and the voluntary and community sector.

1. Obesity

Obesity is a modifiable risk factor for several long term conditions. Obesity is one of the key behavioural risk factors that the NHS health checks assesses.

1.1 Prevalence

Overweight (including obesity) prevalence in adults, (using adjusted self-reported height and weight): In 2024/25, Richmond’s rate was 43.1%, which was the 2nd lowest in London, 33.3% lower than the England average and 24.8% lower than the London average. The latest Borough figure for 2024/25 was also 18.1% lower than in 2015/16, in comparison with 5.6% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

1.2 Obesity in early pregnancy

Maternal obesity increases the risk of complications in pregnancy and birth, including gestational diabetes, pre-eclampsia and the need for caesarean section, and is associated with higher birthweight and an increased risk of childhood obesity. The indicator on maternal BMI recorded at the time of maternity booking is no longer published at local-authority level by OHID, so a current comparative chart for Richmond is not available.

1.3 Hospital Admissions for Obesity

Obesity increases the risk of type 2 diabetes, heart disease, some cancers and musculoskeletal conditions, and hospital admissions give one measure of its impact on health services. NHS England reports admissions in three ways: admissions where obesity was the main reason (primary diagnosis), admissions where obesity was recorded as a factor (primary or secondary diagnosis), and bariatric (weight-loss) surgery. Rates are age-standardised per 100,000 population, and local counts are rounded to the nearest 5. The latest published figures are for 2022/23, and the charts show 2019/20 to 2022/23.

Admissions directly attributable to obesity

In 2022/23 there were around 25 admissions with a primary diagnosis of obesity among Richmond residents, an age-standardised rate of 13 per 100,000 population. This was lower than both London (22) and England (15.7), and the 4th lowest of London’s 32 boroughs. The rate was similar to 2021/22 (12 per 100,000), and is similar to the pre-pandemic rate of 14 in 2019/20.

Source: NHS England, Statistics on Public Health (Hospital Episode Statistics)

Source: NHS England, Statistics on Public Health and Statistics on Obesity, Physical Activity and Diet (Hospital Episode Statistics)

Admissions where obesity was a factor

In 2022/23 there were around 2,180 admissions where obesity was a factor among Richmond residents, an age-standardised rate of 1,196 per 100,000 population. This was lower than both London (2,215) and England (2,225), and the 2nd lowest of London’s 32 boroughs. The rate has risen from 1,059 per 100,000 in 2021/22, and is higher than the pre-pandemic rate of 895 in 2019/20.

Source: NHS England, Statistics on Public Health (Hospital Episode Statistics)

Source: NHS England, Statistics on Public Health and Statistics on Obesity, Physical Activity and Diet (Hospital Episode Statistics)

Bariatric surgery

In 2022/23 there were around 15 bariatric surgery episodes among Richmond residents, an age-standardised rate of 8 per 100,000 population. This was lower than both London (12) and England (9.2), and the 6th lowest of London’s 32 boroughs. The rate was similar to 2021/22 (9 per 100,000), and is similar to the pre-pandemic rate of 7 in 2019/20.

Source: NHS England, Statistics on Public Health (Hospital Episode Statistics)

Source: NHS England, Statistics on Public Health and Statistics on Obesity, Physical Activity and Diet (Hospital Episode Statistics)

 

2. Cardiovascular Disease

This section explores the latest available Richmond-level information on prevention, prevalence, primary care management, hospitalisations, and mortality from cardiovascular conditions. The local coverage and outcomes of NHS Health Checks are also included. The NHS Health Check is a programme for adults in England aged 40 to 74, designed to spot early signs of stroke, kidney disease, heart disease, type 2 diabetes and dementia. The NHS Health Check helps find ways to lower cardiovascular risk and has a clear role in delivering preventative and personalised solutions to ill-health, and empowering individuals to live healthier and more active lives

Cardiovascular disease (CVD) includes a group of diseases affecting the heart or blood vessels. The list of specific diseases within the CVD classification include coronary heart disease (CHD), myocardial infarction (heart attack), angina, coronary artery diseases and stroke. Primary prevention of CVD requires patients at risk are identified before disease has become established. People with hypertension are at high risk of developing CVD. Controlling blood pressure is therefore a significant factor that protects the patient from developing serious circulatory conditions.

2.1 NHS Health Checks Programme

Note: Some figures and service descriptions in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The charts and the five-year uptake figures are current; the local activity, demographic and outcome figures in this section and its subsections date from 2019/20.

Over the five years 2021/22–25/26, 36.1% of Richmond’s eligible population aged 40 to 74 received an NHS Health Check (22,663 checks), compared with 47.8% in London and 36.7% in England. Checks were offered to the equivalent of 96.1% of the eligible population over the same period; this figure can exceed 100% because some people are invited more than once 1.

The NHS Health Checks Programme is a mandated service under the Health and Social Care Act 2012. Local Authorities have a legal duty to invite 100% of its eligible population over a 5-year period and deliver at least 50% NHS Health Checks. The annual local targets translate to 20% invitations and 10% NHS Health Checks. The programme is a systematic vascular risk assessment and management programme, aiming to reduce the incidence of heart disease, stroke, diabetes and kidney disease. It is also an opportunity to identify dementia across the population, particularly high risk and vulnerable groups. It helps people to take action to avoid, reduce or manage their risk of developing these conditions It also contributes to the objectives of tackling health inequalities, including socio-economic, ethnic and gender differences.

Office for Health Improvement & Disparities estimates the NHS Health Check Programme could, on average, prevent 1,600 heart attacks and strokes, and save at least 650 lives each year. The programme aims to prevent over 4,000 people a year from developing diabetes, detect at least 20,000 cases of diabetes or kidney disease earlier, allowing individuals to be better managed and improve their quality of life. It achieves this by assessing the top seven risk factors driving the burden of non- communicable disease in England and by providing individuals with behavioural support and, where appropriate, pharmacological treatment.

NHS Health Checks logo NHS Health Checks logo

Aims and Delivery Model

The NHS Health Checks programme aims to prevent heart disease, stroke, diabetes, and kidney disease and raise awareness of dementia both across the local population and within high risk and vulnerable groups . It also helps people to take action to avoid, reduce or manage their risk of developing these conditions as well as opportunities to make progress in tackling health inequalities, including socio-economic, ethnic and gender inequalities.

The service is available to individuals between 40 and 74 years of age without existing cardiovascular disease (CVD). Invitations can be prioritised for residents who are estimated to have a high CVD risk score (Q-risk) . The aims of the NHS Health Check programme are to offer an NHS Health Check to 20% of the eligible population every year as part of a 5-year rolling programme with an uptake level of 50%:

  • To reduce the prevalence of CVD
  • To narrow health inequalities in premature death from these vascular related conditions.

In Richmond 25 GP Surgeries and 2 pharmacies are contracted to deliver NHS Health Checks. Activity data is automatically extracted from GP surgeries clinical data system Vision Plus and from pharmacies via Pharmoutcomes.

Demographics of service users accessing the service via GP surgeries during 2019/20:

  • 46.20% were aged between 40–50
  • 27.9% were aged between 51–60
  • 17.5% were aged between 61–74
  • 57% were female
  • 40.6% were male
  • 53.7% were from ethnic minority groups
  • 1.3% were Mental Health Patient
  • 0.2% were learning disability patients
  • 0.7% were carers

Demographics of service users accessing the service via pharmacies during 2019/20:

  • 49% were aged between 40–50
  • 28% were aged between 51–60
  • 23% were aged between 61–74
  • 62% were Female
  • 11 people were from ethnic minority groups
  • 45% were Male

The data shows that during 2019/20, females were more likely to access an NHS Health Check than males. The majority of service users (46% GP surgeries, 49% pharmacies) were aged 40–50. The ethnic minority population is slightly overrepresented in comparison with the borough profile for age range. However, there is a data quality issue with ethnicity not being recorded in nearly one third of all consultations.

NHS Health Checks Outcomes

During 2019/20 the Richmond NHS Health Check programme outcomes included:

  • 23 service users were diagnosed diabetic
  • 52 service users were identified with a high QRISK score (>20%)
  • 69 service users were diagnosed hypertensive
  • 4 service users were diagnosed with chronic kidney disease (CKD) 2

Referrals from an NHS Health Check to lifestyle support services during 2019/20 included:

  • 59 service users were referred to the National Diabetic Prevention Programme (NDPP) 3
  • 17 service users were referred to exercise on referral programme
  • 32 service users were referred to the Health Walks programme
  • 19 service users referred to weight management programme
  • 207 service users were referred to smoking cessation services 2

In July 2020, the Department of Health and Social Care (DHSC) asked Public Health England (PHE) to carry out an evidence-based review of the NHS Health Check programme. The review, published in 2021, advised Ministers on how NHS Health Checks could evolve over the following decade to maximise the benefits of the programme in preventing illness and reducing health inequalities, including recommendations on the content of NHS Health Checks, how the programme is delivered and how it links to the wider health and social care system 4.

Cumulative percentage of the eligible population aged 40 to 74 offered an NHS Health Check: In 2021/22 - 25/26, Richmond’s rate was 96.1% (n=60359), which was the 11th lowest in London, 0.7% lower than the England average and 18.9% lower than the London average. The latest Borough figure for 2021/22 - 25/26 was also 25.3% higher than in 2013/14 - 17/18, in comparison with 6.5% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Cumulative percentage of the eligible population aged 40 to 74 offered an NHS Health Check who received an NHS Health Check: In 2021/22 - 25/26, Richmond’s rate was 37.5% (n=22663), which was the 16th lowest in London, 0.9% lower than the England average and 6.9% lower than the London average. The latest Borough figure for 2021/22 - 25/26 was also 26.2% lower than in 2013/14 - 17/18, in comparison with 22.2% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Cumulative percentage of the eligible population aged 40 to 74 who received an NHS Health check: In 2021/22 - 25/26, Richmond’s rate was 36.1% (n=22663), which was the 12th lowest in London, 1.6% lower than the England average and 24.5% lower than the London average. The latest Borough figure for 2021/22 - 25/26 was also 7.5% lower than in 2013/14 - 17/18, in comparison with 17.2% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

NHS Health Checks Programme - Diabetes Risk Assessment

The NHS Health Checks programme provides cardiovascular risk assessments for people between the ages of 40 and 74 years and are an important part of type 2 diabetes prevention and diagnosis. The NHS Health Checks programme includes a diabetes risk assessment or filter, which should lead onto blood testing for those identified at risk. Those people identified with NDH following their blood test should be offered a referral to the NDPP and other lifestyle support services. People identified as having diabetes are managed through the diabetes care pathway through primary care.

In 2019/20, Richmond completed 5187 NHS Health Checks; 23 of these people were diagnosed with diabetes and 59 people were referred to the NDPP. Nationally, it is estimated that Health Checks could prevent 4,000 people a year from developing diabetes 5 and for every 80 – 200 NHS Health Checks, 1 person is diagnosed with type 2 diabetes (1.25%–0.5% of checks) 6. Richmond was lower than this range with 0.44% of checks resulting with a diabetes diagnosis.

2.2 Diabetes

Diabetes is a condition where the amount of glucose (a type of sugar) in the blood is too high. There are many types of diabetes including Type 1, Type 2, gestational, and other rarer types of diabetes. Type 1 Diabetes accounts for around 8% of cases, other rarer types of diabetes accounts for 2%, and Type 2 Diabetes accounts for 90%.

Type 1 Diabetes develops when the body is unable to produce insulin. Type 2 Diabetes develops when the body stops producing enough insulin, or the body’s cells stop reacting to the insulin produced. This means sugar builds up in the blood and cannot get into the cells of the body where it is used for fuel.

This section focuses on type 2 diabetes as it is associated with lifestyle factors and can be delayed or prevented through support to change behaviour around lifestyle choices. Other types of Diabetes, such as type 1 diabetes, are not related to lifestyle issues and cannot be prevented.

The number of people developing type 2 diabetes has been increasing globally. Around four million people in the UK have type 2 diabetes and by 2030 it is estimated that there will be more than 5.5 million people with it. This is largely due to the rise in obesity, which is estimated to account for 80–85% of all type 2 diabetes cases in the UK 7. Being overweight or obese is the major modifiable risk factor for type 2 diabetes.

Impacts of Diabetes

Note: The figures and service descriptions in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The mortality, complication and foot care figures in this section and its subsections date from 2015/16 to 2020.

There are many significant impacts on the health and wellbeing of people living with type 2 diabetes in Richmond. Additionally, there are large financial impacts on the NHS and wider social and economic costs due to the rise in type 2 diabetes.

Premature Mortality

Type 2 Diabetes is a major cause of premature mortality, with around 22,000 people with diabetes dying early each year in England. People with diabetes are more likely to die than their peers of the same age and sex in the general population. In Richmond, the additional risk of death in people with diabetes is 50.9%; for England, the additional risk was 21.8% 8. In England and Wales, people aged 35 to 64 living with type 2 diabetes are up to two times more likely to die prematurely 9.

Complications /multi-morbidity

Those who develop type 2 diabetes are subsequently at greater risk of developing complications from the disease:

  • CVD including heart attack and stroke – type 2 diabetes leads to an increased risk of CVD. In Richmond, people with diabetes are 164.8% more likely than people without diabetes to have a heart attack, and 62.6% more likely to have a stroke.
  • Blindness- leading cause of preventable sight loss among people of working age
  • Nerve damage - most often in legs or feet
  • kidney disease and failure - diabetes is the leading cause of kidney disease People with diabetes rarely die as a direct result of diabetes. Most die from complications such as heart disease, stroke and kidney failure.
Diabetic Foot Disease

Diabetic foot disease is a potential consequence of the complication of nerve damage and the complication of peripheral vascular disease. Foot problems are the most frequent reasons for hospitalisation amongst people who have diabetes. Latest figures for Richmond show that between 2015/2016 and 2017/2018, there were 325 hospital spells for diabetic foot disease. The median length of stay in hospital was 7 days and the total number of days spent in hospital for diabetic foot disease was 3,359.

Diabetes is one of the leading causes of amputation of the lower limbs. From 2015/2016- 2017/2018 there were 35 minor amputation procedures (removal of toes or feet) performed in Richmond, giving a directly age and ethnicity standardised rate of 18.7 minor amputations per 10,000 population-year. This was not significantly different to the England average. There were only 6 major amputation procedures (above or below the knee amputation) performed, which was not large enough to calculate a robust standardised rate for comparison to England.

Hospital admissions

People with diabetes are more likely to be admitted to hospital and have longer stays than similar people without the condition. One in six of all people in hospital in England have Diabetes. While Diabetes is often not the reason for admission, they often need a longer stay in hospital, are more likely to be re-admitted, and their risk of dying is higher.

Mental Health

A type 2 diabetes diagnosis can also negatively impact quality of life and social contact, which can have an adverse effect on mental health. People with diabetes are more likely to be diagnosed with Depression. Depression is more prevalent among people living with type 2 diabetes, compared with those who are not. This, as well as many other complications of type 2 diabetes, increases their risk of premature death.

A survey 10 conducted by Diabetes UK also found that:

  • 3 in 5 people (64%) living with diabetes experience emotional or mental health problems as a result of their condition
  • just 3 in 10 people living with diabetes said they definitely felt in control of their condition
  • nearly a third of people living with diabetes had at some point relied on self-help materials
  • one in 5 people living with diabetes had used support or counselling from a trained professional to help them manage their Diabetes.
Dementia

There is a close association between type 2 diabetes and dementia, in particular Alzheimer’s Disease and Vascular Dementia 11:

  • Type 2 Diabetes is associated with a 60% increase in risk for all-cause Dementia
  • Individuals with a longer duration and earlier age of onset of Diabetes have the highest risk
  • Women with type 2 diabetes have a greater chance of developing vascular Dementia than men
  • There is a 56% increased risk of developing Alzheimer’s Disease in individuals with type 2 diabetes but also people with Alzheimer’s Disease have an increased risk of developing type 2 diabetes and impaired glucose tolerance
Social Consequences

In addition to mental health and quality of life, the important social consequences of type 2 diabetes include impacts on individuals’ family life, education and employment. These are wider consequences that are just as important as health outcomes, as they have far-reaching impacts.

Inequalities

Certain ethnic minority groups have a greater chance of developing type 2 diabetes than people from White ethnic groups. The South Asian population living in the UK are up to six times more likely to develop type 2 diabetes than that of the white population. People of African and African-Caribbean descent are three times more likely to have type 2 diabetes than the white population. In Richmond, nearly 22% of people with type 2 diabetes are of ethnic minority origin.

Costs

Note: Some figures in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The figures quoted in this section date from 2018/19 or earlier.

Diabetes treatment currently accounts for around 10 per cent of the annual NHS budget. This is just under £10 billion a year, with 80% spent on managing preventable complications associated with the condition, and 20% on treatment (e.g. primary care and prescribing).

In 2018/19, costs for diabetes drugs for Richmond CCG amounted to £1.78 million 12. Diabetes prescriptions made up 12.5% of the total cost of prescribing in England during 2018/19. There are also major indirect costs, such as loss of productivity due to increased death and illness and the need for social care.

Type 2 Diabetes

Risk of Type 2 Diabetes

This section is based on sources from before 2022. It summarises national evidence and policy published up to 2016 and has not been revised for this edition. Newer guidance and evidence may now be available.

The risk of type 2 diabetes is about the chance or likelihood of developing type 2 diabetes over a period of time. A person’s level of risk depends on a combination of factors including genetics, which cannot be changed, and preventable lifestyle factors, with risk levels varying over the life course. Risk can be reduced in the universal population through population and community interventions on healthy eating and physical activity throughout pregnancy, infancy, childhood, adulthood. Many people will have low risk for type 2 diabetes by maintaining a healthy lifestyle.

Risk increases with a change in lifestyle factors, such as obesity, as well as with age. People at increased risk are likely to not be aware as they may not have symptoms. Without changes to lifestyle, the risk of type 2 diabetes can progress, leading people to become high risk for developing type 2 diabetes. People are at high risk of developing type 2 diabetes if their blood sugars are raised, but not high enough to be diagnosed with type 2 diabetes. They are also at increased risk of other cardiovascular conditions 13.

The risk factors for being at high risk of type 2 diabetes and developing type 2 diabetes are the same. These factors include:

  • Overweight or obesity - there is a seven times greater risk in people who are obese and three times if overweight
  • High Blood Pressure - people are more at risk if they have ever had high blood pressure
  • Certain ethnicities - People of South Asian origin are six times more likely to develop Diabetes and Black-Caribbean and Black African are three times more likely
  • Age - Risk increases with age. People are more at risk if they are older than 40 or older than 25 if they are Black Caribbean, Black African, or South Asian
  • Family History - People are two to six times more likely to get type 2 diabetes if they have a parent, brother, sister or child with diabetes
  • Smoking - Smoking has been proven to be an independent risk factor for Diabetes, and amongst diabetics it increases the risk of complications. The highest risk is among heavy smokers and risk remains elevated for about 10 years after smoking cessation, reducing more quickly for lighter smokers 14.
  • Deprivation is strongly associated with higher levels of obesity, physical inactivity, unhealthy diet, smoking and poor blood pressure control, all of which are linked to the risk of developing type 2 diabetes. Prevalence of type 2 diabetes is 60% more common among individuals in the most deprived quintile compared with those in the least deprived quintile in England
  • Gestational Diabetes - Gestational Diabetes affects around 5% of all pregnancies 15. Women who have had Gestational Diabetes are at a sevenfold increased risk of developing type 2 diabetes later in life, especially if they gain weight. Children born to mothers with diabetes during pregnancy tend to have a greater BMI, raised fasting glucose levels and an increased risk of developing type 2 diabetes later in life

People at high risk of type 2 diabetes have a greater chance of developing type 2 diabetes in the future. One out of four people with high risk will develop type 2 diabetes in the next 10 years 16.

There are various terms used for high risk of Diabetes including: pre-Diabetes, borderline Diabetes, Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT), Impaired Glucose Regulation (IGR), or Non-diabetic hyperglycaemia (NDH), which all mean that someone is at high risk of developing type 2 diabetes. NDH will be used throughout this Section to mean high risk of type 2 diabetes.

Once people know they are at risk, they can often prevent or delay type 2 diabetes from starting by making healthy changes to their diet and lifestyle. Without lifestyle changes, people with NDH are very likely to progress to type 2 diabetes. Eating healthy foods, incorporating physical activity in daily routines, and maintaining a healthy weight can help bring blood sugar levels back to normal.

Diagnosis

A blood test which detects the level of glucose in your blood is needed to make the diagnosis of NDH and type 2 diabetes. An HbA1c blood test is often used and gives an average of how high your blood glucose levels have been over the preceding few months.

NDH is defined as an HBA1c value between 6.0% (42mmol/mol) and 6.4% (47mmol/mol) excluding those who had already been diagnosed with diabetes with an HBA1c value in this range. An HbA1c value of 6.5% (48 mmol/mol) or above is recommended as the blood level for diagnosing Diabetes. A value of less than 48mmol/mol (6.5%) does not exclude Diabetes diagnosed using glucose tests.

Diabetes: Level of Need in Richmond

Note: Some figures and service descriptions in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The OHID figures are current, but other figures quoted in this section date from 2019 or earlier.

Around 16% of the Richmond population are from ethnic minority groups (excluding White minorities) 17. Asian/Asian British is the largest ethnic minority group in Richmond (7.3%). In terms of location, St Margaret’s and North Twickenham had the greatest proportion of the White/White British ethnic group at 88%, while Heathfield had the highest proportion of residents from ethnic minority groups at 30% (compared to 16% for the Borough). Ethnic minority groups are expected to increase to 17.2% by 2030.

Richmond ranked within the 10% least deprived Local Authorities (LAs) in England on the 2015 and 2019 Indices of Deprivation and, on the 2025 Indices, remains the least deprived London borough. In terms of older people, 39% (c. 76,700 residents) of the Richmond population are aged 50 years and over. The number of older people over 65 in the borough of Richmond is expected to increase by 21.0% and the number of people over age 85 to increase by 47.8% by 2036. Hampton/Teddington, Heathfield/Whitton, and Kew Gardens are areas with a higher proportion of older people. On the 2019 Indices, the most deprived areas in terms of income deprivation affecting older people were Hampton North, Heathfield, Barnes, and North Richmond.

In addition to Hampton and Heathfield, Whitton, Hampton North and Hampton Hill tend to have higher prevalence of heart disease, respiratory disease and other conditions. These areas are also relatively more deprived. Nearly one in three people registered with a GP in Richmond has one or more long-term condition and nearly one in ten has three or more 18.

There are an estimated 15,000 residents 16 years and over (9.6% of population) that have NDH in Richmond. In 2018/19, GP Practices identified around 4,000 of these people (1.3%). This means there could be around 11,000 people who are unaware they are high risk for developing type 2 diabetes.

The figure below provides the demographic breakdown of people in Richmond registered with NDH by their GP Practice. At individual GP practice level, the percent of people identified with NDH varies, ranging from around 0.2% to 6%.

NDH prevalence by demographic group, Richmond, 2018/19 NDH prevalence by demographic group, Richmond, 2018/19

Source: NHS Digital. National Diabetes Audit. 2018/19

GP Practice Data on Diabetes

Note: Some figures and service descriptions in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The charts are current, but other figures quoted in this section and its subsections date from 2018/19 or earlier.

At individual GP practice level, the prevalence of diagnosed Diabetes varies widely across the borough. In 2024/25 there were 8,956 people aged 17 and over on a Richmond GP diabetes register. 19

Diabetes: QOF prevalence: In 2024/25, Richmond’s rate was 4.6% (n=8956), which was the 6th lowest in London, 42.3% lower than the England average and 36.9% lower than the London average. The latest Borough figure for 2024/25 was also 23.6% higher than in 2012/13, in comparison with 31.3% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

The figure below provides the demographic breakdown of people diagnosed with type 2 diabetes.

Demographic breakdown of people diagnosed with type 2 diabetes, 2018/19 Demographic breakdown of people diagnosed with type 2 diabetes, 2018/19

Source: NHS Digital. National Diabetes Audit. 2018/19

  • Type 2 diabetes is more common in males than females; 60% are male. While there is little difference in the prevalence of NDH by sex, males have a higher prevalence of diabetes compared to females.
  • The 40–64 years and 65–79 years age groups have a similar percentage of people diagnosed with type 2 diabetes. Around 56% of people with type 2 diabetes in Richmond are aged over 65. Richmond has one of the lowest percentage of people aged 40–64 with type 2 diabetes in London, and the second highest percentage of people with type 2 diabetes aged 80 and over.
  • Around 43% of people diagnosed with type 2 diabetes are from the least deprived quintile and 18% from the two most deprived quintiles.
  • Around 65% of people diagnosed with type 2 diabetes are White, 22% Minority Ethnic Origin, with a further 13% unknown or not stated. As ethnic minority groups comprise 16% of the population, this reflects the health inequality of diabetes among minority ethnic groups.
Geographic Prevalence

There is variation in diabetes prevalence across the borough. Diabetes is most prevalent in Heathfield and Whitton, followed by Hampton. This corresponds with having a higher proportion of ethnic minority groups, older people aged 65+, and deprived areas of the borough, which are risk factors for type 2 diabetes (the figure below).

Diabetes prevalence in Richmond by LSOA, 2017/18 Diabetes prevalence in Richmond by LSOA, 2017/18

Source: DataRich

Undiagnosed Diabetes

Applying the 2018 estimated diagnosis rate (the latest published) to the 2024/25 GP registers, it is estimated that 16,137 people in Richmond have diabetes (all types of diabetes), against 8,956 on GP practice registers. This includes people that have already been diagnosed by their GP and those who have diabetes but do not know it (undiagnosed). Around 55.5% of people living with diabetes are diagnosed 20. This is lower than the diagnosis rates for England and London, 78.0% and 71.4% respectively, and is among the lowest in London.

Considering the diagnosed prevalence for Type 1 and Type 2 and other diabetes, it is estimated that there are 7,181 people living with undiagnosed diabetes that are not receiving treatment and are missing out on vital health checks.

As Richmond has a lower prevalence of some of the risk factors for diabetes (e.g. obesity, hypertension), higher prevalence of healthy lifestyle behaviours (e.g. healthy eating, physical activity), and lower prevalence of people with complications related to diabetes (e.g. stroke, CHD), it is a possibility that the observed number of people with undiagnosed diabetes in Richmond is actually lower than the estimated number. There is the caveat with all modelled data, that there are data limitations and a degree of uncertainty associated with these estimates. Nonetheless, the estimates can still be considered indicative, showing that there is still room for improvement in diabetes diagnosis in Richmond.

Some of the undiagnosed cases could be within the more elderly groups. Richmond is one of only six boroughs in London that has more than 30% of its population aged over age 50 years. Some of the hidden/undiagnosed diabetes cases could be within the elderly population.

Projected Diabetes Prevalence

Projections for Diabetes prevalence up to 2035 show an increase in the number of people living with diabetes in Richmond, as well as in London and England at a similar rate. By 2035, it is estimated that 7.8% of people in Richmond will be living with diabetes. This is less than a 1% increase but amounts to a further 3,609 people living with diabetes in Richmond over the next 15 years (the figure below).

Projected diabetes prevalence in Richmond. 2020–2035 Projected diabetes prevalence in Richmond. 2020–2035

Source: Prevalence estimates of Diabetes, Public Health England, 2016

Treatment Targets

NICE recommends treatment targets for Hba1c (glucose control), blood pressure and serum cholesterol: Target Hba1c reduces the risk of all diabetic complications, target blood pressure reduced the risk of vascular complications and reduced the progression of eye disease and kidney failure and target cholesterol reduced the risk of vascular complications. ‘Meeting all three treatment targets’ is achieved where a patient has HbA1c ≤58mmol/mol, cholesterol <5mmol/L and blood pressure ≤140/80 (the table below).

In 2018/19, 46.4% of people with type 2 diabetes achieved all three treatment targets; this is higher than similar CCGs, STP, and England. Achievement of each treatment target was also higher in comparison. However, there was variation in the achievement between GP Practices, ranging from around 30%-60%.

Source: National Diabetes Audit (NDA) 2018/19

Vulnerable Groups

Note: The figures and service descriptions in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The learning disability and mental illness figures date from 2019.

People with Learning Disabilities

The prevalence of diabetes in people with a learning disability is unknown, but general population data indicate it is around 10% (including Type 1, but in most cases this is type 2 diabetes) 21. Applying this figure to the number of people with learning disabilities in Richmond (695 people with learning disabilities 22) provides a rough estimate of 70 people with learning disabilities who have diabetes. The onset of diabetes is seen at an earlier age for people with a learning disability 23.

People with Severe Mental Illness

People with severe mental illnesses are at substantially higher risk of diabetes compared with the general patient population. People with schizophrenia, psychosis, bipolar depression and anxiety are at double the risk of developing type 2 diabetes 24. In Richmond, 1,896 people were registered with their GP with schizophrenia, bipolar affective disorder and other psychoses, with 64% of patients over age 40 having a record of blood glucose or HbA1c in the preceding 12 months 25.

Care Homes

Current estimates place the number of older people with diabetes resident in care homes at one in four 26. Research has shown that in addition to those with a known diagnosis of diabetes, there are people with undiagnosed diabetes in care homes whose needs for care are not being met.

Data limitations

The estimated NDH prevalence is based on modelled data but does not include confidence intervals. PHOF states a caveat that “with all modelled data, there is a degree of uncertainty associated with these estimates therefore should be considered indicative only.” Additionally, ward level or LSOA breakdown of the data is not available for either data set, making it difficult to interpret this data beyond borough level. Like the estimated NDH prevalence data, estimated Diabetes prevalence is based on modelled data and does not include confidence intervals.

Current Services on Offer

Note: The figures and service descriptions in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The services, referral figures and programme dates described date from 2017 to 2021.

A range of services are available for people at high risk of developing type 2 diabetes and for people diagnosed with type 2 diabetes. The services offer support to people to help prevent type 2 diabetes, as well as help identify people with diabetes early, and ensure quality of care and effective management of their Diabetes.

Primary Care

Much of the management and monitoring of patients at risk of and with type 2 diabetes is undertaken by GPs and members of the Primary Care Team, for example through:

  • Identification through blood test
  • Maintain register of patients with type 2 diabetes and high risk- and annual recall
  • Advice and signposting- GPs and Practice Nurses
  • Medication- e.g. metformin, insulin
  • Blood sugar checks (HbA1c)- every 3 months when newly diagnosed and every 6 months once stable
  • Annual Diabetic Review (8 care processes recommended by NICE) - These are five risk factors (body mass index, blood pressure, smoking, glucose levels (Hba1c) and cholesterol) and four tests to identify early complications (urine albumin creatinine ratio, serum creatinine, foot nerve and circulation examination). These important markers ensure diabetes is well controlled and are designed to prevent long-term complications.

To support the Enhanced Primary Care Diabetes Service of GP Practices, the CCG has partnered with the local GP Federations to focus on quality, support and education for primary care (April 2019-March 2021). This will ensure that all GP Practices have access to the expertise and support to achieve improvements in the delivery of high- quality care for patients with, or at risk of, Diabetes.

Healthier You: NHS Diabetes Prevention Programme (NDPP)

Note: Some figures in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The figures quoted in this section date from before 2022.

The NDPP is an intensive lifestyle support programme for people identified as high risk for developing type 2 diabetes. Individuals are eligible if they are identified by their GP with NDH, defined as having an HbA1c 42 – 47 mmol/mol (6.0 – 6.4%) or a fasting plasma glucose (FPG) of 5.5 – 6.9 mmol/l. The service offers tailored, personalised support to reduce the risk of type 2 diabetes including education on healthy eating and lifestyle, help to lose weight and physical exercise programmes. Local group sessions are delivered in community settings, and a digital option is offered to those declining face-face group sessions. Early outcomes of the Service across England demonstrate that those completing the Programme had a mean weight loss of 3.3 kg and an HbA1c reduction of 2.04 mmol/mol 27.

From June 2018-November 2020, 1,305 people in Richmond were referred to the service. The table below shows the outcomes of the service.

NDPP outcomes, Richmond, 2018–2020 NDPP outcomes, Richmond, 2018–2020

Source: Richmond NDPP data

Of the people who attended the NDPP Service in Richmond:

  • 59% were male, 41% Female
  • 59% were aged less than 70
  • 30% were of Asian, Black, mixed or other ethnicity (15% of people with NDH in Richmond are of minority ethnic origin)
  • 21% were from the three most deprived quintiles (although 26% of people with NDH are from the three most deprived quintiles)
  • 23% were of normal weight (BMI 18–24.9), 39% overweight (BMI 25–29.9), and 36% obese (BMI >30)
Structured Education

Structured education programmes can help adults with type 2 diabetes to improve their knowledge and skills and help to motivate them to take control of their condition and self-manage it effectively. A range of diabetes education programmes exist in London, such as DESMOND and X-PERT. Remote courses such as Oviva are also available for those who prefer digital support.

The table below provides an overview of referrals to Structured Education in 2017 28.

Referrals to Diabetes Structured Education, Richmond, 2017 Referrals to Diabetes Structured Education, Richmond, 2017

The table below provides an overview of referrals to Diabetes Book & Learn from October 2018-January 2020 for people with type 2 diabetes in Richmond. However, these are rough figures as there have been issues with recording of attendance by providers on the Diabetes Book & Learn platform.

Referrals to Diabetes Book & Learn, October 2018-January 2020, Richmond Referrals to Diabetes Book & Learn, October 2018-January 2020, Richmond
Specialist Diabetes Service

Wherever possible patients with diabetes are treated by their own GP with support from a Diabetes Specialist Nurse allocated to the practice. However, HRCH’s specialist diabetes team can provide specialist care for cases that are too complex to be dealt with by a patient’s GP practice, but not complex enough to warrant hospital admission.

The teams work with the patient to agree outcomes and then produce a care-management plan, which the patient’s GP practice can implement between visits to the specialist clinic. This approach means that patients with diabetes are receiving specialised care for their condition at the most appropriate level and do not have to make unnecessary trips to acute hospitals.

The HRCH diabetes service in Richmond provides:

  • A consultant led service
  • Specialist nurse advice
  • Specialist diabetes dietitians
  • Telephone advice line and email service
  • Podiatry
  • Retinal screening service, based at Teddington Memorial Hospital and provided by St. Georges Hospital retinal screening service
  • Structured education sessions – Nationally accredited programme DESMOND programmes for Newly Diagnosed and Foundation course for those with established diabetes.
  • BERTIE - Diabetes Education Programme for people with type 1 diabetes.
  • Carbohydrate Counting and Insulin Dose adjustment
  • Continuous glucose monitoring
  • Referrals to other local healthy lifestyle intervention programmes.
  • Established insulin pump users
  • Domiciliary visits for housebound clients
  • Hypoglycaemic Pathway for the prompt treatment and support of patients calling 999 for hypoglycaemia. This service is provided alongside London Ambulance Service.
  • Psychological support and onward referral to Richmond Well-Being Service where needed. Retinal screening also available at Queen Mary’s Hospital (in addition to Teddington Memorial Hospital)
Dietetics Service

Having a healthy diet is an important part of living with type 2 diabetes and managing it well. Dietetics can provide individuals with advice and guidance about their diet. Dietetic services are available through Kingston Hospital as well as through St. Georges Hospital based Queen Mary’s Hospital. Additionally, Specialist Diabetes Dietitians are available in the HRCH Diabetes Team and the Beta Cell Diabetes Team at Queen Mary’s Hospital.

Foot Care

Podiatry care is offered to patients with diabetes in Richmond to reduce the risk of lower limb ulceration and early amputation. HRCH Podiatry and Foot Health team have been a registered “Any Qualified Provider” (AQP) of routine podiatry care and the NHS provider of specialist podiatry care to people registered with a Richmond GP, and Healthshare Richmond has provided NHS community podiatry services. Referrals can be made by a Richmond GP or other health care professional.

Secondary Care

Diabetes and Endocrinology departments are mainly accessed by Richmond residents at Kingston Hospital and Queen Mary’s Hospital. The clinical needs of patients referred to this service have a greater complexity or complications. Input may also be required from other specialities, as clinically appropriate.

The specialist nurse led services, provide care for people with diabetes requiring additional support and help with their diabetes management. Consultant led clinics are also provided in their outpatient departments and outreach centres.

Diabetic Eye Screening

Note: Some figures in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The figures quoted in this section date from 2019 or earlier.

Type 2 diabetes increases the risk of having an eye problem called retinopathy. It is important to have regular eye screening checks for retinopathy. These are different from normal sight tests and specifically look for early signs of damage caused by Diabetes. Eye screening should happen at or around the time of diagnosis and if there are no concerns, then at least once a year after that. If there are signs that damage may be developing, individuals may be offered another check or may be referred to an eye specialist at a hospital.

In 2019, 68.4% of people with diabetes on GP registers had a record of retinal screening in the preceding 12 months. This is lower than London and England (73.7% and 77.3% respectively).

Vulnerable Groups

From 2016/17, the National Diabetes Audit has looked at the care of people with Serious Mental Illness, SMI and Diabetes and compared this to the care received by the whole population of people with diabetes. People with SMI and type 2 diabetes are, on average, younger than those with type 2 diabetes who do not have SMI.

Evidence-based Diabetes Treatment/Interventions

NICE Guidance

NICE provides evidence-based guidance and advice on the prevention, diagnosis and management of Diabetes:

  • NICE Guideline PH35- type 2 diabetes prevention: population and community level interventions (May 2011)
  • NICE Guideline type 2 diabetes: prevention in people at high risk
  • NICE Guideline NG28 – Diabetes in adults: management, example recommendations
  • NICE Guideline CG189- Obesity: Identification, Assessment and Management
NHS RightCare Pathway: Diabetes

The Diabetes Pathway shows the core components of an optimal Diabetes Service, evidence of the opportunity to reduce variation and improve outcomes and the key evidence-based interventions which the system should focus on for greatest improvement, supported by practice examples from across the NHS

Lifecourse Approach
  • Taking a lifecourse perspective is essential for preventing type 2 diabetes, as it is for many health conditions. A lifecourse approach recognises critical windows for intervention to lessen the risk of obesity and type 2 diabetes in later life
  • There are opportunities to prevent and control type 2 diabetes at key stages of life from preconception, through pregnancy, infancy, childhood and adolescence, through to adulthood
  • One review provides an overview of summarised evidence on effective strategies to prevent Diabetes in the following four cohorts: (1) pregnant women and young families, (2) children and adolescents (<15 years), (3) working-age population (15–64 years), (4) the elderly (>64 years), alongside evidence-based communication strategies (health campaigns, food labelling, etc.) 29
Intensive Lifestyle Intervention
  • Behavioural interventions conducted in ‘real world’ settings are effective in reducing weight and reducing the incidence of Diabetes. Overall, the incidence of Diabetes was reduced by 26% over a period of 12–18 months post-intervention
  • The NDPP is underpinned by this strong evidence base. The learning from this evidence review, alongside an Expert Reference Group and existing NICE guidelines, was used to inform the structure and content of the NDPP intervention 30.
Diet and Lifestyle Changes
  • Type 2 Diabetes is preventable by changing lifestyle and the risk reduction is sustained for many years after the active intervention
  • Healthy dietary changes based on the current recommendations and the Mediterranean dietary pattern can be recommended for the long-term prevention of Diabetes 31
Metformin Compared to Diet or Exercise
  • Metformin compared with placebo or diet and exercise reduced or delayed the risk of type 2 diabetes in people at increased risk for the development of type 2 diabetes
  • Metformin compared to intensive diet and exercise did not reduce or delay the risk of type 2 diabetes
  • The combination of Metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of type 2 diabetes 32
Low Calorie Diets
  • Findings from the Diabetes Remission Clinical Trial (DiRECT) has shown that some people with type 2 diabetes can achieve remission through adoption of low-calorie diets. This allowed nearly half of patients to stop taking anti-diabetic drugs and still achieve non-diabetic range glucose levels, with over a third remaining in remission after two years
  • NHS England piloted a Low-Calorie Diet Programme from 2020, based on results from the DiRECT trial, in 10 areas in England, including North East London and North Central London; it has since become the national NHS Type 2 Diabetes Path to Remission Programme. Eligible participants are offered low calorie, total diet replacement products including soups and shakes consisting of up to 900 calories a day for up to 12 weeks. Alongside this, participants receive support for 12 months including help to re-introduce food after the initial 12-week period
Culturally Appropriate Health Education
  • Culturally appropriate health education has short‐ to medium‐term effects on glycaemic control and on knowledge of Diabetes and healthy lifestyles
  • While pharmacotherapy may appear to achieve greater improvements in biochemical measures, culturally appropriate Diabetes Education (both for ethnic minority groups and indeed for all people with type 2 diabetes) is vital to compliance with pharmacotherapy 33.

2.3 Hypertension

GP Recorded Hypertension Prevalence

Early diagnosis and treating hypertension significantly reduces the risk of CVD.

Hypertension: QOF prevalence: In 2024/25, Richmond’s rate was 10.7% (n=25992), which was the 11th lowest in London, 29.8% lower than the England average and 5.2% lower than the London average. The latest Borough figure for 2024/25 was also 1.9% higher than in 2012/13, in comparison with 11.4% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

2.4 Coronary Heart Disease (CHD)

GP Recorded CHD Prevalence

CHD: QOF prevalence: In 2024/25, Richmond’s rate was 2.0% (n=4979), which was the 13th highest in London, 31.2% lower than the England average and 8.9% higher than the London average. The latest Borough figure for 2024/25 was also 2.6% higher than in 2012/13, in comparison with 10.8% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

CHD Admissions

Hospital admissions due to coronary heart disease: In 2024/25, Richmond’s rate was 326.1 per 100,000 (n=605), which was the 2nd lowest in London, 15.7% lower than the England average (no London comparison is published for this indicator). The latest Borough figure for 2024/25 was also 49.0% lower than in 2003/04, in comparison with 46.3% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

2.5 Stroke

GP Recorded Prevalence of Stroke

Stroke: QOF prevalence: In 2024/25, Richmond’s rate was 1.4% (n=3302), which was the 7th highest in London, 28.1% lower than the England average and 19.5% higher than the London average. The latest Borough figure for 2024/25 was also 18.9% higher than in 2012/13, in comparison with 11.2% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Stroke Admissions

Hospital admissions due to stroke: In 2024/25, Richmond’s rate was 179.5 per 100,000 (n=325), which was the 12th lowest in London, 3.9% higher than the England average (no London comparison is published for this indicator). The latest Borough figure for 2024/25 was also 4.0% higher than in 2003/04, in comparison with 4.4% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Stroke Mortality

Mortality rate from stroke, all ages: In 2022 - 24, Richmond’s rate was 35.5 per 100,000 (n=184), which was the 4th lowest in London, 26.7% lower than the England average and 21.2% lower than the London average. The latest Borough figure for 2022 - 24 was also 63.3% lower than in 2001 - 03, in comparison with 60.1% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

3. Respiratory Diseases

Respiratory diseases include asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis and pneumonia. In this section the latest available Richmond-level information on prevalence, hospitalisations and mortality linked to respiratory conditions will be explored.

3.1 COPD

COPD (chronic obstructive pulmonary disease) is a diagnostic term that captures a variety of serious lung conditions including chronic bronchitis and emphysema. COPD is usually prevalent in adults over the age of 35 years. COPD is a serious lung disease for which smoking is the biggest preventable risk factor.

GP Recorded Prevalence of COPD

COPD: QOF prevalence: In 2024/25, Richmond’s rate was 1.1% (n=2568), which was the 13th highest in London, 44.2% lower than the England average and 2.7% higher than the London average. The latest Borough figure for 2024/25 was up from 1.0% in 2012/13, in comparison with 8.8% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Emergency Hospital Admissions for COPD

Emergency hospital admissions for COPD (aged 35 and over): In 2023/24, Richmond’s rate was 193.6 per 100,000 (n=204), which was the 2nd lowest in London, 45.7% lower than the England average and 35.1% lower than the London average. The latest Borough figure for 2023/24 was also 25.8% lower than in 2010/11, in comparison with 12.9% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

3.2 Asthma

Asthma Recorded Prevalence

Asthma: QOF prevalence: In 2024/25, Richmond’s rate was 4.9% (n=11347), which was the 13th highest in London, 24.9% lower than the England average and 4.2% higher than the London average. The latest Borough figure for 2024/25 was also 9.7% higher than in 2020/21, in comparison with 2.8% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

4. Musculoskeletal (MSK) Conditions

MSK conditions are injuries and disorders that affect the human body’s movement or musculoskeletal system (i.e. muscles, tendons, ligaments, nerves, discs, blood vessels, etc.). Musculoskeletal conditions are the largest cause of years lived with disability (YLDs), accounting for 17% of all YLDs worldwide 34.

4.1 Prevalence of Long-term MSK Problems

Percentage reporting a long-term Musculoskeletal (MSK) problem: In 2023, Richmond’s rate was 13.1%, which was the 16th lowest in London, 28.8% lower than the England average and 2.3% lower than the London average. The latest Borough figure for 2023 was also 12.9% lower than in 2018, in comparison with 2.1% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Percentage reporting at least two long-term conditions, at least one of which is MSK related: In 2023, Richmond’s rate was 8.5%, which was the 6th lowest in London, 36.9% lower than the England average and 8.7% lower than the London average. The latest Borough figure for 2023 was also 10.8% lower than in 2018, in comparison with no change in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

% reporting a long term MSK problem who also report depression or anxiety: In 2016/17, Richmond’s rate was 21.5%, which was the 5th lowest in London, 10.8% lower than the England average and 17.0% lower than the London average. The latest Borough figure for 2016/17 was also 19.8% higher than in 2014/15, in comparison with 7.3% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

4.2 Rheumatoid Arthritis

Rheumatoid Arthritis: QOF prevalence: In 2024/25, Richmond’s rate was 0.6% (n=1180), which was the 11th highest in London, 25.0% lower than the England average and 5.8% higher than the London average. The latest Borough figure for 2024/25 was also 15.8% higher than in 2013/14, in comparison with 7.6% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

4.3 Hip Fractures

Hip fractures in people aged 65 and over: In 2024/25, Richmond’s rate was 434.1 per 100,000 (n=150), which was the 9th lowest in London, 19.0% lower than the England average and 7.3% lower than the London average. The latest Borough figure for 2024/25 was also 28.0% lower than in 2010/11, in comparison with 12.9% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

5. Mental Health

People living with mental health problem are more likely to make unhealthy lifestyle choices and twice as likely to smoke 35. Mental health problems often lead to alcohol and substance misuse 36; increasing the risk of obesity, asthma, diabetes, chronic obstructive pulmonary disease (COPD) and cardiovascular disease 35. This section provides an overview of nationally available data on mental health in adults living in Richmond, including GP recorded prevalence of mental illnesses, admissions to hospital, employment rates, accommodation status and premature mortality rates in adults with mental health problems.

5.1 Key Demographics and Need

GP Recorded Prevalence of Mental Illness

GP Mental Health Registers include patients with a diagnosis of schizophrenia, bipolar affective disorder and other psychoses.

Mental Health: QOF prevalence: In 2024/25, Richmond’s rate was 0.9% (n=2298), which was the 8th lowest in London, 7.0% lower than the England average and 18.8% lower than the London average. The latest Borough figure for 2024/25 was also 14.1% higher than in 2012/13, in comparison with 20.9% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Estimated Prevalence of Common Mental Disorders

Estimated prevalence of common mental disorders: % of population aged 16 & over: In 2017, Richmond’s rate was 13.2% (n=20430), which was the lowest in London, 21.9% lower than the England average and 31.4% lower than the London average. Time series data were not available for this indicator.

Source: OHID: Public Health Profiles

5.2 Social Factors

Employment of Mental Health Service Users

Gap in the employment rate for those who are in contact with secondary mental health services and the overall employment rate: In 2021/22, Richmond’s rate was 70.8 percentage points, which was the 16th highest in London, 2.0% higher than the England average and 0.6% lower than the London average. Time series data were not available for this indicator.

Source: OHID: Public Health Profiles

Mental Health Service Users Living In Stable Accommodation

Adults in contact with secondary mental health services who live in stable and appropriate accommodation: In 2020/21, Richmond’s rate was 73.0%, which was the 12th highest in London, 25.9% higher than the England average and 19.7% higher than the London average. The latest Borough figure for 2020/21 was also 13.3% lower than in 2011/12, in comparison with 6.2% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

5.3 Hospital Admissions for Mental Health Conditions (under 18s)

Hospital admissions for mental health conditions (under 18 years): In 2023/24, Richmond’s rate was 68.3 per 100,000 (n=30), which was the 16th highest in London, 14.9% lower than the England average and 7.6% higher than the London average. The latest Borough figure for 2023/24 was also 8.7% lower than in 2010/11, in comparison with 12.9% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

5.4 Premature Mortality in Adults with Severe Mental Illness (SMI)

Mortality for people referred to secondary mental health services (aged 18 to 74): In 2022 - 24, Richmond’s rate was 62.3 per 100,000 (n=245), which was the lowest in London, 43.3% lower than the England average and 40.1% lower than the London average. The latest Borough figure for 2022 - 24 was also 5.8% higher than in 2015 - 17, in comparison with 21.1% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

6. Sexual Health

6.1 Sexually Transmitted Infections

Sexual health is an important public health issue with health, social and economic impacts that can affect the people across the life course. It is a fundamental aspect of human identity and life experience. Richmond adopts the World Health Organisation’s current working definition of sexual health which is described as:

“A state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.” 37

Poor sexual health can lead to sexually transmitted infections (STIs), HIV and unintended pregnancies which can lead to further long-lasting and costly impacts for both individuals and wider society. However, they can be reduced through safer sex practices such as the use of condoms, regular testing, and access to sexual health and reproductive services 38. Sexual health services currently focus on treatment for sexually transmitted infections, HIV, unplanned pregnancies as well as prevention.

Prevalence

All new STI diagnoses rate per 100,000: In 2025, Richmond’s rate was 580.1 per 100,000 (n=1141), which was the 7th lowest in London, 1.8% higher than the England average and 51.9% lower than the London average. The latest Borough figure for 2025 was also 16.0% lower than in 2012, in comparison with 32.5% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

STIs key findings for Richmond:

  • The all-new STI diagnosis rate (2025) was 570/100,000 population for England and 580/100,000 for Richmond.
  • Newly diagnosed STIs (excluding chlamydia aged <25) stood at 501/100,000 population in Richmond (2025).
  • In Richmond (2025) the diagnostic rate of gonorrhoea was 105.8/100,000 population, lower than the London average of 323.2 and broadly in line with England (109.1/100,000 population).
  • The latest diagnostic rate of syphilis in Richmond (14.7/100,000 population, 2025) remains well below the London average (38.3/100,000); syphilis rates have risen across London in recent years.
  • In line with the national picture, the number of diagnoses of gonorrhoea and syphilis are higher in gay men compared to heterosexual men.
  • The rate of new HIV diagnosis per 100,000 population in the borough was 6.6 (2024), lower than both London (16.3) and England (9.0).
  • In 2023 the total abortion rate stood at 16.4/1,000 women aged 15 to 44. This is lower than both England (23.4) and London (24.3), indicating women in Richmond have consistently had good access to reproductive care.
  • The percentage of abortions performed under 10 weeks in Richmond was 89.0% (2023), broadly in line with England (89.0%) and London (88.0%), indicating Richmond residents continue to access abortion at an early stage of pregnancy.

MSM are among the largest groups diagnosed with a new STI diagnosis and STI diagnosis is increasing among MSM. Ethnic minority communities in Richmond also experience a significantly higher proportion of STI diagnosis compared with the proportion of the population from ethnic groups.

Age and Gender Distribution of New STI Diagnoses

Note: The figures and service descriptions in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The figures are from GUMCAD data for 2018/19.

The age and gender distribution of new STI diagnoses (chlamydia, gonorrhoea, herpes, syphilis, warts) in Richmond residents in 2018 highlights that the largest number of newly diagnosed STI’s are in the 25 to 34-year-old age cohort (figure below).

STI diagnoses by age group in Richmond, 2018/19 Source: GUMCAD Extracted Feb 2020

Sexual Orientation

Note: Some figures in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The figures quoted in this section date from before 2022.

People identifying as LGBTQ+ can experience a greater degree of health inequalities, including sexual health 39. National data shows where gender and sexual orientation are known. MSM account for 29% of London residents diagnosed with a new STI in a specialist health clinic. 90% have syphilis and 63% have gonorrhoea. In line with the national picture, the amount of diagnoses of gonorrhoea and syphilis are higher in gay men compared to heterosexual men (figure below).

Count of STI diagnoses in Richmond by sexual orientation Count of STI diagnoses in Richmond by sexual orientation

Source: GUMCAD Sep ’18–Oct ’19

When comparing new diagnosis of STIs by ethnic origin and sexual orientation a larger proportion of white gay/lesbian are newly diagnosed (the figure below).

STI diagnoses by ethnicity and sexual orientation in Richmond, 2018/19 Source: GUMCAD Extracted Feb 2020

New STI Diagnoses (Excluding Chlamydia)

New STI diagnoses (excluding chlamydia aged 24 years and under) per 100,000: In 2025, Richmond’s rate was 501.3 per 100,000 (n=986), which was the 7th lowest in London, 13.6% higher than the England average and 52.2% lower than the London average. The latest Borough figure for 2025 was also 11.1% lower than in 2012, in comparison with 22.4% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Gonorrhoea Diagnoses

Gonorrhoea diagnostic rate per 100,000: In 2025, Richmond’s rate was 105.8 per 100,000 (n=208), which was the 7th lowest in London, 3.0% lower than the England average and 67.3% lower than the London average. The latest Borough figure for 2025 was also 111.4% higher than in 2012, in comparison with 117.0% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Syphilis

London saw a rise in the rate of syphilis in the late 2010s. In response, Public Health England formed a “Syphilis Action Group” in 2019 to develop and initiate a London-wide syphilis action plan, and Richmond was actively involved in the group.

Syphilis diagnostic rate per 100,000: In 2025, Richmond’s rate was 14.7 per 100,000 (n=29), which was the 8th lowest in London, 4.6% higher than the England average and 61.5% lower than the London average. The latest Borough figure for 2025 was also 133.4% higher than in 2012, in comparison with 150.2% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

HIV Prevalence

Note: Some figures and service descriptions in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The charts and the new and late diagnosis figures are current; the treatment and e-service figures date from 2018/19.

HIV diagnosed prevalence rate per 1,000 aged 15 to 59 years: In 2024, Richmond’s rate was 2.0 per 1,000 (n=229), which was the 2nd lowest in London, 17.3% lower than the England average and 60.7% lower than the London average. The latest Borough figure for 2024 was also 11.2% lower than in 2011, in comparison with 22.1% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

In 2024, 13 adult residents of Richmond were newly diagnosed with HIV. The rate of new HIV diagnosis per 100,000 population in the borough was 6.6, compared with 16.3 in London and 9.0 in England. Combination HIV prevention – including condom provision, pre-exposure prophylaxis (PrEP), expanded HIV testing and prompt initiation of treatment after diagnosis – continues to support these comparatively low rates.

In Richmond the E-Service during this period had HIV detection rates for over 24 year olds of non-reactive 810 (99.6%) and reactive 3 (0.4%) while the numbers of postal test kits sent out by the newly commissioned SH:24 service totalled 5 with 5 being processed. Most of these kits were requested by people in the 25–34 age group (40.48%) and by males (63.16%). No reactive results were produced from those kits processed.

The vast majority (78.0%) of newly diagnosed patients in the borough were put on Antiretroviral treatment (ART) within 91 days of their diagnosis. Successful ART decreases a person’s viral load, significantly reduces the risk of future transmission and transforms HIV from a fatal infection to a chronic but manageable condition. In 2022–24, 20.0% of HIV diagnoses among Richmond residents were made at a late stage of infection (CD4 count below 350 cells/mm³), compared with 39.2% in London and 43.3% in England 40. Numbers of new diagnoses in a single borough are small, so this percentage can change considerably from one period to the next. Late diagnosis is the most important predictor of HIV-related morbidity and short-term mortality and is a key component of evaluating the success of HIV testing efforts.

Contact with Sexual Health Services

Note: The figures and service descriptions in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The figures date from October 2018 to September 2019.

From October 2018 to September 2019, over 13,000 people in Richmond accessed a sexual health service for the first time. Access was greater amongst females who represented 58% of attendees 41.

Count of contacts with Richmond’s sexual health service by age group Count of contacts with Richmond’s sexual health service by age group

Source: GUMCAD Extracted Feb 2020

7. Cancer

Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumours, which do not spread. This section presents cancer prevalence (including new diagnoses), hospitalisations and cancer survival rates of Richmond’s patients.

Most

7.1 Cancer Diagnosis and Prevalence

Cancer Diagnosed at Early Stages

Percentage of cancers diagnosed at stages 1 and 2: In 2022, Richmond’s rate was 61.6% (n=417), which was the 2nd highest in London, 8.5% higher than the England average (no London comparison is published for this indicator). The latest Borough figure for 2022 was also 1.3% higher than in 2014, in comparison with 2.9% increase in England’s rate in the equivalent time period. Missing time series data for Richmond have been estimated using linear interpolation.

Source: OHID: Public Health Profiles

7.2 Cancer Mortality

Premature and preventable cancer mortality can be found in People JSNA Chapter. This section presents mortality from main cancer types including lung, breast and colorectal. There are no mortality indicators for prostate cancer that can be reported. However, Richmond’s standardised incidence ratio for prostate cancer was 106.0 in 2015–19 (718 cases), statistically similar to England (100) 42.

Lung Cancer Mortality

Mortality rate from lung cancer, all ages: In 2022 - 24, Richmond’s rate was 32.0 per 100,000 (n=169), which was the 4th lowest in London, 31.0% lower than the England average and 22.0% lower than the London average. The latest Borough figure for 2022 - 24 was also 45.7% lower than in 2001 - 03, in comparison with 28.7% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Colorectal Cancer Mortality

Mortality rate from colorectal cancer, all ages: In 2022 - 24, Richmond’s rate was 21.9 per 100,000 (n=117), which was the 13th lowest in London, 14.3% lower than the England average and 4.6% lower than the London average. The latest Borough figure for 2022 - 24 was also 19.0% lower than in 2001 - 03, in comparison with 19.4% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Breast Cancer Mortality

Mortality rate from breast cancer, all ages (Female): In 2022 - 24, Richmond’s rate was 27.5 per 100,000 (n=85), which was the 13th lowest in London, 9.1% lower than the England average and 4.4% lower than the London average. The latest Borough figure for 2022 - 24 was also 36.3% lower than in 2001 - 03, in comparison with 33.0% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

7.3 Cancer Screening Programmes

Breast Cancer Screening

Cancer screening coverage: breast cancer: In 2025, Richmond’s rate was 72.9% (n=17515), which was the 5th highest in London, 1.7% higher than the England average and 11.9% higher than the London average. The latest Borough figure for 2025 was also 0.9% higher than in 2010, in comparison with 6.8% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Cervical Cancer Screening

Cancer screening coverage: cervical cancer (aged 50 to 64 years old): In 2024, Richmond’s rate was 73.4% (n=16564), which was the 6th highest in London, 1.2% lower than the England average and 3.8% higher than the London average. The latest Borough figure for 2024 was also 7.1% lower than in 2010, in comparison with 5.7% decrease in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

Bowel Cancer Screening

Cancer screening coverage: bowel cancer: In 2025, Richmond’s rate was 74.6% (n=23846), which was the 2nd highest in London, 2.3% higher than the England average and 14.4% higher than the London average. The latest Borough figure for 2025 was also 29.9% higher than in 2015, in comparison with 27.3% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

8. Other Adult Screening

8.1 Abdominal Aortic Aneurysm Screening

Abdominal Aortic Aneurysm Screening Coverage: In 2024/25, Richmond’s rate was 80.2% (n=891), which was the 7th highest in London, 2.4% lower than the England average and 5.8% higher than the London average. The latest Borough figure for 2024/25 was also 4.4% higher than in 2013/14, in comparison with 6.2% increase in England’s rate in the equivalent time period.

Source: OHID: Public Health Profiles

8.2 Diabetic Eye Screening

Note: Some figures in this section have not been updated and may not reflect the latest available data. They are retained to provide context and should be interpreted alongside the more recent indicators presented elsewhere in this chapter. The figures quoted in this section date from 2019 or earlier.

In 2019, 68.4% of people with diabetes on GP registers had a record of retinal screening in the preceding 12 months. This is lower than London and England (73.7% and 77.3% respectively) 43.

Acronyms

  1. OHID Fingertips, Public Health Profiles. Indicators: Cumulative percentage of the eligible population aged 40 to 74 offered, and who received, an NHS Health Check↩︎

  2. Vision Plus, Search and Report, accessed securely online, 2020↩︎

  3. Q-Diabetes is a risk prediction algorithm which calculates an individual’s risk of type 2 diabetes taking account of their individual risk factors such as age, sex, ethnicity, and clinical values↩︎

  4. NHS Health Check Programme Review↩︎

  5. Public Health England, NHS Health Check Best practice guidance, March 2016.↩︎

  6. Public Health England, Emerging evidence on the NHS Health Check: findings and recommendations, 2017.↩︎

  7. Diabetes UK, Us, Diabetes and a lot of facts and stats↩︎

  8. OHID. Diabetes Profile↩︎

  9. NHS Digital, National Diabetes Audit 2018-10, Report 2a: Complications and Mortality↩︎

  10. Diabetes UK, Engaging People with diabetes in the Future of Diabetes project: Methodology and summary of findings↩︎

  11. TREND-UK, For Healthcare professionals: Diabetes and Dementia: Guidance on Practical Management, 2018.↩︎

  12. NHS Digital, Prescribing for Diabetes in England 2008/09–2018/19, Nov 2019.↩︎

  13. NHS Diabetes Prevention Programme (NHS DPP) Non-diabetic hyperglycaemia, Produced by: National Cardiovascular Intelligence Network (NCVIN), Date: August 2015↩︎

  14. World Health Organization, Global Report on Diabetes, 2016.↩︎

  15. NICE, Diabetes in pregnancy: management from preconception to the postnatal period, last updated August 2015.↩︎

  16. Diabetes UK↩︎

  17. Richmond Story 2017–18↩︎

  18. The London Borough of Richmond upon Thames Health and Care Plan, 2019–2021↩︎

  19. OHID Fingertips, Public Health Profiles. Indicator: Diabetes: QOF prevalence (17+ yrs). Covers all recorded diabetes, not type 2 alone. Charted below.↩︎

  20. OHID, Public Health Profiles, Estimated diabetes diagnosis rate (2018).↩︎

  21. Diabetes UK, Improving care for People with diabetes and a learning disability- Fact Sheet 1, January 2018.↩︎

  22. Public Health England, Learning Disability Profiles, November 2019.↩︎

  23. NHS England, NHS Right Care Pathway: Diabetes, July 2017.↩︎

  24. NHS England, NHS Long Term Plan, January 2019.↩︎

  25. NHS Digital, QOF Mental Health Indicator, 2019.↩︎

  26. Diabetes UK, Diabetes in care homes: Awareness, screening, training, September 2017.↩︎

  27. Valabhji J , Barron E, Bradley D et al. Early Outcomes from the English National Health Service Diabetes Prevention Programme. Diabetes Care Jan 2020, 43 (1) 152-160; DOI: 10.2337/dc19-1425↩︎

  28. NHS Digital, National Diabetes Audit (NDA) 2018/19 Interactive report for England, Clinical Commissioning Groups and GP practices, 13 December 2019.↩︎

  29. Timpel, P., Harst, L., Reifegerste, D. et al. What should governments be doing to prevent Diabetes throughout the life course?. Diabetologia 62, 1842–1853 (2019). URL: https://doi.org/10.1007/s00125-019-4941-y ↩︎

  30. Public Health England, A systematic review and metaanalysis assessing the effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes mellitus in routine practice, August 2015.↩︎

  31. Prevention of Type 2 Diabetes by Lifestyle Changes: A Systematic Review and Meta-Analysis↩︎

  32. Madsen KS, Chi Y, Metzendorf M, Richter B, Hemmingsen B. Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2019, Issue 12. Art. No.: CD008558. DOI: https://doi.org/10.1002/14651858.CD008558.pub2 ↩︎

  33. Lean, M. E.J. et al. (2019) Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes and Endocrinology, 7(5), pp. 344-355. (https://doi.org/10.1016/S2213-8587(19)30068-3)↩︎

  34. WHO. Musculoskeletal conditions. 2021↩︎

  35. GOV.UK↩︎

  36. Langås, AM., Malt, U.F. & Opjordsmoen, S. Comorbid mental disorders in substance users from a single catchment area - a clinical study. BMC Psychiatry 11, 25 (2011). https://doi.org/10.1186/1471-244X-11-25 ↩︎

  37. WHO (2006) Defining sexual health: Report of a technical consultation on sexual health, 28-31 January 2002, Geneva↩︎

  38. Department of Health (2001) The national strategy for sexual health and HIV.↩︎

  39. Government Equalities Office (2018) LGBT Action plan 2018 – improving the lives of lesbian, gay, bisexual and transgender people.↩︎

  40. OHID Fingertips, Public Health Profiles. Indicator: HIV late diagnosis↩︎

  41. GUMCAD (accessed Feb 2020), Richmond Patients attending all GUM and non-GUM services (Oct 18-Sept 19)↩︎

  42. OHID Public Health Profiles. Cancer incidence: prostate cancer, indicator 93238.↩︎

  43. QOF 2019↩︎

Up to: Joint Strategic Needs Assessment (JSNA)

Updated: 06 October 2026

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