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How our CCG has increased the number of people diagnosed with NDH from 2,000 to 60,000

How our CCG has increased the number of people diagnosed with NDH from 2,000 to 60,000

The North West London Collaboration of Clinical Commissioning Groups (CCGs) is working on transforming the treatment and care of diabetes and increasing awareness in order to help prevent more people developing the condition, as part of the North West London health and care partnership.
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The North West London Collaboration of Clinical Commissioning Groups (CCGs) is working on transforming the treatment and care of diabetes and increasing awareness in order to help prevent more people developing the condition, as part of the North West London health and care partnership. 

It as increased the number of people diagnosed with non-diabetic hyperglycaemia (NDH) from 2,000 to 60,000 among other achievements.

The problem

Diabetes accounts for a significant proportion of our local population's health and social care costs.

There are 142,000 people living with Type 1 and Type 2 diabetes in North West (NW) London, which represent £598m of the NHS budget being spent on the condition in this area.

In addition to this, around 190,000 people are living with NDH, also known as pre-diabetes, which means these people’s blood sugar levels are higher than normal and they’re at high risk of developing Type 2 diabetes.

One of the most life-threatening diabetes-related complications is foot ulcers, which costs the NHS more than the top three cancers combined.

Reducing complications could free up between £10 and 20m over the next five years that could be reinvested in other NHS services in NW London. 

We’ve also found that there is a variation in NW London’s provision of diabetes services and patient’s outcomes for three diabetes treatment targets, including HbA1c, which is a test that measures patient’s average blood glucose levels, blood pressure and cholesterol. 

The solution

We want to ensure that patients have enough support to improve their condition and prevent any complications developing.

We‘re transforming diabetes care by working more closely with patients to develop care plans and goals and put them in control of their health.

The challenges

The number of people diagnosed with diabetes is increasing year on year. Traditionally, NHS care has been reactive instead of pro-active, focussing on medication.

For many people with Type 2 diabetes and NDH, the key challenge is the need to adopt a healthier lifestyle, such as reducing weight, getting more active and eating less refined sugar and starch.

These changes are extremely challenging and require a different set of skills and roles from the traditional medical model of care.

With new medicines, research and technology being introduced all the time, we need to ensure our clinicians are well trained to offer the support needed.

IT systems have also been part of our challenge. In NW London, the IT systems haven’t always been joined up so it can be difficult for clinicians to get a complete picture on an individual’s health.

The results

Improving diabetes care helps to reduce patient’s blood pressure, cholesterol and HbA1c.

As a result, this reduces the risk of complications significantly. Complications include heart disease, stroke, eye damage and amputations, which are the main reasons why diabetes patients make up 41% of people admitted to hospital.

We managed to drive forward some quality improvement work, with an initial focus on primary care. So far in NW London we have:

  • Increased the amount of people meeting the three diabetes treatment targets – HbA1c less than or equal to 58 mmol/mol, blood pressure less than or equal to 140/80 mm Hg and cholesterol less than or equal to 5 mmol/L
  • Increased the amount of people attending their annual diabetes check-up and being referred to diabetes structured education
  • Improved collaborative care planning with patient-focussed goals and actions. As a result, more than 50,000 patients now have a care plan
  • Increased work on pre-diabetes care. So far, more than 10,000 referrals have been made to the national NHS Diabetes Prevention Programme (NDPP). This has also increased in areas with the highest deprivation, where people need the support most
  • Increased the number of people diagnosed with NDH from 2,000 to 60,000. We’re identifying more people at high risk of Type 2 diabetes and offering them support to reduce their risk of the condition progressing.
  • Launched the ‘Know Diabetes NW London’website, which provides information, videos, tools and tips to help our residents know, prevent and manage diabetes, change their health and live life to the full

The future

We’ll continue to transform diabetes care and address all our current challenges by:

  • Developing new educational resources for patients and raising awareness of the materials and resources available to clinicians, patients and the public that will increase proactive management of diabetes, supporting people to make positive lifestyle changes and better manage their own health
  • Increasing awareness and supporting training for GPs and specialist nurses and developing a single diabetes service across NW London. The aim of the training and single service will be to reduce variation in NW London’s provision of diabetes services and improve patient’s outcomes for the three diabetes treatment targets, increasing compliance from 40 to 52% by 2021
  • Improving foot care for patients with diabetes by recruiting more podiatrists and tackling the cliché around the role of podiatrists in the diabetes field, as it’s currently perceived negatively and predominately associated with amputation
  • Increasing referrals across NW London into NDPP
  • Increase the use of digital apps and the Know diabetes NW London website to help patients to self-care and manage their diet and weight

CCG comment

Dr Tony Willis, clinical director for diabetes, North West London Collaboration of CCGs, said: ‘Diabetes is a massive problem for individuals and the health system as a whole.

‘We’re aiming to create an NHS system that supports all patients with diabetes or at high risk of Type 2 diabetes to get the best experience and care outcomes.’

NHS North West London Collaborative of Clinical Commissioning Groups are a collaboration of NHS Brent CCG, NHS Central London CCG, NHS Ealing CCG, NHS Hammersmith & Fulham CCG, NHS Harrow CCG, NHS Hillingdon CCG, NHS Hounslow CCG, and NHS West London CCG.

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