Background: Our aim was to identify and compare modifiable risk factors associated with adverse pregnancy outcomes in women with type 1 and type 2 diabetes and to identify effective maternity clinics. Methods:We included 17,375 pregnancies in 15,290 women with diabetes in a populationbased cohort study across 172 maternity clinics in England, Wales and the Isle of Man.Obstetric complications (preterm delivery, large birthweight) and adverse pregnancy outcomes (congenital anomaly, stillbirth, neonatal death) were obtained for pregnancies completed between 01 January 2014 and 31 December 2018. We assessed associations between modifiable (glycaemia, obesity, clinic) and non-modifiable risk factors (age, deprivation, ethnicity) with pregnancy outcomes.Results: Of 17,375 pregnancies, 8,690 (50.0%) were in women with type 1 and 8,685 (50.0%) in women with type 2 diabetes. The rates of preterm delivery (42.5% type 1, 23.4% type 2), and large birthweight (52.2% type 1, 26.2% type 2) were higher in type 1 diabetes (p<0.001).The prevalence of congenital anomaly (44.8/1000 type 1, 40.5/1000 type 2; p=0.175), and stillbirth (10.4/1000 type 1, 13.5/1000 type 2; p=0.072) did not differ but neonatal death rates (7.4/1000 type 1, 11.2/1000 type 2; p=0.013) were higher in type 2 diabetes. Independent risk factors for perinatal death were third trimester HbA1c > 48mmol/mol (OR 3.06, 95% CI 2.16 to 4.33), living in the highest deprivation quintile (OR 2.29 95% CI 1.16 to 4.52) and having type 2 diabetes (OR 1.65 95% CI 1.18 to 2.31). Variations in glycaemia and large birthweight were associated with maternal characteristics (diabetes duration, deprivation, BMI) without substantial differences between clinics.Interpretation: Our data highlight persistent adverse pregnancy outcomes in type 1 and type 2 diabetes. Maternal glycaemia and obesity are the key modifiable risk factors. No clinics were achieving appreciably better outcomes, suggesting that healthcare system changes are needed

Collecting patient experience information is now very important for the NHS. A detailed questionnaire to record patient experience of diabetes services has been developed and piloted in paper form. However, the costs of using a paper-based system means that this cannot be used nationally. The questionnaire has therefore been put into a web format and this paper reports on a pilot feasibility study asking patients to fill out their experiences using their home computers. Patients recruited from general practice and hospital diabetes clinics were able to successfully complete the questionnaire online. Compared with national prevalence figures, more people with type 1 diabetes than with type 2 diabetes took part in the study. Br J Diabetes 2017;17:11-13

There are 30 national clinical audits in England, most of them solely in secondary care, where participation is mandatory. The National Diabetes Audit (NDA) is the major national clinical audit to include general practice. Data on 42 items of diabetes annual care processes and intermediate outcomes are collected mainly from primary care, but also from specialist services. This information is collated and reported annually in 'report 1'. There are national, clinical commissioning group (CCG), hospital, and individual practice level (from 2014-2015) reports. In 'report 2' the NDA provides information on the number of diabetes complications, diabetes-related hospital utilisation, and diabetes-related mortality. It does this by using NHS numbers of individual people with diabetes to interrogate hospital episode statistics (HES) and the national mortality databases. BENEFITS OF PARTICIPATION IN THE NDA Practices that participate in the NDA get reports on how many people with diabetes in their practices are meeting National Institute for Health and Care Excellence (NICE) clinical guideline standards for diabetes care and treatment. Practices can assess how they are performing compared to similar practices throughout England or to local practices. Data are separated into type 1 and type 2 and where relevant case mix adjusted for the practice patient population to take into account age, sex, ethnicity, and socioeconomic differences from other practices. Benchmarking is therefore valid. Participation in the NDA helps practices to identify priorities for improvement in diabetes care and to identify relationships between patient characteristics and care and or outcomes. This is only possible because the NDA uses individual patient data. Reports can therefore separate type 1 and type 2 diabetes, by age group and can look at 'bundled' care process or treatment achievements. Similarly, individual records enable day-today care to be linked to longterm diabetes complications and outcomes. Throughout primary and specialist care participation in national audits is regarded as a mark of excellence. Discussions of the