With diabetes on the rise nationally, NHS systems have a role to play in preventing and managing this chronic disease. NHS Norfolk and Waveney, Leicester, Leicestershire and Rutland, Humber and North Yorkshire, Hampshire and Isle of Wight ICBs share their work – from virtual consultations and bringing care closer to home, to education and prevention – with Kathy Oxtoby
Rates of diabetes are at ‘an all-time high’ with more than 5.6 million people in the UK estimated to be living with the chronic disease, according to Diabetes UK.
The charity’s data shows that 4.4 million people in the UK live with diabetes. Additionally, 1.2 million people could be living with type 2 diabetes who are yet to be diagnosed.
People with diabetes can develop chronic complications, including eye and foot problems, heart attack and stroke, kidney problems, and nerve damage. There can also be acute complications such as when blood sugars are too high or too low.
Factors that put people at greater risk of developing type 2 diabetes include high blood pressure, age, ethnicity and family history.
Living with overweight or obesity is the ‘most significant modifiable risk factor for developing type 2 diabetes’ – around 90% of people with newly diagnosed type 2 diabetes are living with overweight or obesity, says Diabetes UK.
Diabetes ‘really embodies a lot of the challenges we talk about for patients, the public and systems’, says Professor Aruna Garcea, chair of the NHS Confederation’s primary care network.
Professor Garcea says the trend, more broadly, for the population in England is an ageing population, one that is rising in numbers, is increasingly obese, and increasingly managing more than one long-term condition. From a medical perspective diabetes will often be managed alongside respiratory, heart and other conditions including mental health as well,’ says Professor Garcea. This is typical of the impact of advances in medical care on a prevalent long-term condition, where people are living for longer and co-morbid conditions impact on the complexity of care that needs to be received.
Good diabetes care involves simple measures
In terms of patient experience, diabetes is primarily a nurse led, and general practice led condition area. Important aspects of good diabetes care for patients involve simple measures such as making sure they are getting annual checks, including BMI, cholesterol, diabetic control indices like HbA1c, and urine and kidney function.
In general practice, the Quality and Outcomes Framework specifies the need for a register of patients with diabetes and annual targets for a check, and treatments such as a target for optimal glucose control.
However, where a patient declines input or does not respond to invitations, they can miss out on this key opportunity to optimise their long-term condition and prevent or reduce the impact of progress of the condition, says Professor Garcea.
Optimising care effectively also needs expertise in GPs and nurses providing care, which is not always uniformly available. The annual long-term condition review in general practice is also a key opportunity to support early intervention and prevention of associated co-morbidities such as hypertension, she says.
General practice can also support the impact of having a long-term condition through the uptake of NHS Health Checks, which look for diabetes, hypertension, and evaluates a person’s exercise and alcohol intake for improvements in well-being and health. Prediabetes can also be detected and diabetes prevented through a diet programme, says Professor Garcea.
The importance of patients understanding and managing their medication and condition is ‘vital’. ‘This health literacy of patients is an increasing aspect of good care for long-term conditions which empowers patients and carers,’ she says.
The lack of good prevention, early detection, patient education and optimising control can create significant impact on an individual and the healthcare system, says Professor Garcea. This can lead to patients falling through the cracks and result in A&E admissions, with consequences like heart attacks, amputations, blindness and kidney disease. This is compounded now by the complexity of medical treatments and the challenge of expertise in the general practice clinic, she says.
‘If GPs and primary care nurses are not confident enough, or do not have the knowledge, skills, understanding and capacity to support patients, some patients can fall through the cracks and have worse outcomes,’ says Professor Garcea.
The NHS spends at least £10 billion a year on diabetes which is about 10% of its entire budget, according to Diabetes UK. Almost 80% of the money the NHS spends on diabetes is on treating complications. In some hospitals more than a quarter of beds are used by people with diabetes.
With an ageing and growing population, and patients with more complex needs, the cost of diabetes could rise still further. ‘It is important for systems to be really focused on managing diabetes holistically and as an integrated system,’ says Professor Garcea.
As well as cost, there are pressures on the acute system. ‘Specialist diabetes provision in hospitals faces a lot of pressure. Sometimes, this is because consultant and specialist clinicians who have dedicated time for diabetes care, often have to spend time in A&E and other parts of the hospital and less time supporting patients with diabetes,’ she says.
Then there are workforce challenges. ‘It is well recognised that nationally there are shortages in specialist nursing and podiatry. Attracting people to diabetes nursing roles can be challenging. And there is a shortage of podiatrists around the country,’ she says.
There are also funding and capacity pressures in general practice, and workforce, recruitment and retention issues, she says.
Holistic wrap around care
Some of the opportunities where these challenges are being addressed, and some of the answers as to what the future will look like for diabetes care, are in providing more holistic wrap around care for patients, particularly those with increasingly complex needs, says Professor Garcea.
Some primary care networks (PCNs) are, for example, providing more support, such as through dietitians managing diet for patients alongside the more direct diabetes care.
Local lifestyle clubs are being set up for people with prediabetes to prevent them developing the condition, or to put diabetes in remission.
Virtual care is also on offer for patients to access clinical support from home. This approach ‘allows patients to access care in different ways which means services can reach more patients in a more equitable way’, says Professor Garcea.
And population health data is allowing systems to identify at risk population groups and engage with them as early as possible, she says.
A large part of diabetes services is structured education such as DESMOND and DAFNE. ‘Education is important so that patients better understand the risk of diabetes, how they can prevent becoming diabetic, and also become better at spotting the risk factors of complications related to diabetes,’ says Professor Garcea.
Innovative treatments are also coming into the market, such as hybrid closed loop technology – the “artificial pancreas” – which is being funded by systems, and rolled out nationally.
More needs to be done to address the issues with diabetes. ‘General practice needs to be resourced and funded appropriately with staff and skills to support patients in their communities,’ says Professor Garcea.
And more holistic wrap around care is also needed to meet patients increasingly complex needs, she says.
Prevention is key. ‘Driving greater collaboration between the NHS, local government and the voluntary, community and social enterprise sector is important for delivering those preventative programmes,’ she says.
There is also a growing trend and interest in how to support patients with complex needs, which might involve having more joined up commissioning approaches across long term conditions, she says.
Given the increasingly complex needs of patients, and the aging and growing population, without change, the pressure on services will increase, the cost of diabetes to the NHS will rise, and services for patients could worsen, she says.
And Professor Garcea suggests ICB and ICS leaders ask the question: ‘How can we be really ambitious in providing better care for diabetes patients and the wider range of complex needs they are presenting with, to give them a better experience?’
NHS Norfolk and Waveney ICB: direct patient engagement
Older populations are more at risk of developing complications, such as hypoglycaemia, kidney failure and heart disease, and often require greater support than younger age groups.
‘This is challenging in Norfolk and Waveney due to the high number of older populations and relative prevalence of diabetes in that population group,’ says Elizabeth Barnett, clinical programme manager for diabetes, NHS Norfolk and Waveney ICB.
Providing interventions close to patients homes in Norfolk and Waveney is also challenging, mainly because of the geography and rurality of the ICS.
There are three acute hospital trusts and two community trusts that provide specialist diabetes services. Routine care for diabetes is provided by 105 GP practices. And there are a range of providers of preventative interventions across the ICS.
Incidence of prediabetes and type 2 diabetes is increasing in the region. In 2020, there were 61,000 with prediabetes. By 2024, this has risen to 116,800 people. And in 2018, there were 58,000 with type 2 diabetes, which by 2023 had increased to 70,000 people.
The NHS Diabetes Prevention Programme (NDPP) and digital structured education initiatives – services commissioned by NHS England – are available to eligible patients in the ICS. ‘The focus of these initiatives was to optimise access to preventative interventions that are available at very low cost to Integrated Care Systems,’ says Mrs Barnett.
Norfolk and Waveney has a large non-diabetic hyperglycaemia (NDH) register of 116,800 patients. There are multiple projects to optimise the use of NDPP in the region, says Mrs Barnett.
Projects include direct patient engagement – with patients with NDH and previous gestational diabetes mellitus (GDM) – and the development of a health inequalities focussed marketing plan. They also include improving access for people with previous gestational diabetes working with maternity services, proactive recruitment to rural venues, such as community centres in small towns and villages, and targeted practice engagement to “fill” courses that are undersubscribed. These courses are to support people to reduce their risk of developing type 2 diabetes or better manage their diabetes.
The ICB has co-delivered patient and public community events with providers of diabetes prevention and diabetes support services, and charities including Diabetes UK and Diabetes Norfolk, for example the Norfolk Show.
Since 2020, more than 29,000 referrals have been made to the National Diabetes Prevention Programme. 73% of these referrals have been made since late 2022 when the initiative to optimise use of the programme commenced.
‘More practices who have previously had limited engagement with the programme are continuing to refer patients, says Mrs Barnett.
‘More NDPP venues continue to be offered locally to rural, coastal and communities and in areas of higher deprivation areas where they were never offered before.’
There has also been a ‘sustained improvement’ in GDM referrals (125% increase) and people starting on the NDPP programme (160% increase).
Regarding digital structured education, the ICB contacted all patients in the region with diabetes, inviting them to find out more information about digital structured education programmes- free online services designed to provide advice and information to people living with diabetes, to help them better manage their condition. The programmes are user-led and offer an alternative means of accessing support to the more traditional, group-based structured education programmes, and to self-refer MyType1 Diabetes and Healthy Living for Type 2 Diabetes.
Between February and July 2024: 40,497 SMS messages were sent to patients with type 1 and type 2 diabetes. Some 3,975 people (8.9%) of patients who were contacted, responded to the questionnaire and clicked on the link to register with a digital structured education programme.
‘Sending SMSs and directing patients to an educational landing page is a cost-effective method to increase patient engagement and increase referrals for digital programmes,’ says Mrs Barnett.
Patient benefits of ‘optimising access’ to NDPP and digital structured education initiatives include greater access to a range of preventative services available for patients close to home, says Mrs Barnett.
There is also ‘increased engagement in preventative interventions, which reduces or delays risks of either developing type 2 diabetes or risks of additional complications for those with diabetes. This results inbetter quality of life and reduced risk of associated poor health and wellbeing outcomes’.
Leicester, Leicestershire and Rutland (LLR) ICB and Salutem PCN: diabetes care closer to home
Leicester, Leicestershire and Rutland (LLR) ICB has ‘a diverse population and big health inequalities’, says Dr Raj Than, the ICB’s clinical lead for diabetes, long term conditions and health inequalities. Dr Than is also clinical director of Salutem PCN, which covers north west Leicester, and a GP partner at Humberstone Medical Centre, in Leicester.
He says Leicester has one of the highest prevalence of diabetes in the country – up to 13 percent of the population in the inner city, which is double the national average.
While new technologies and treatments for diabetes are emerging, ‘that in itself poses a huge challenge’ in terms of how this is funded in the most equitable way, he says.
Ten years ago, primary and secondary care clinicians and managerial leads came together to design an enhanced diabetes service that would provide care in community settings and closer to home.
Initially the service was offered to communities where diabetes prevalence was highest, but it now covers almost the whole of Leicester City.
Patients with diabetes – apart from the areas of diabetes care that it was agreed must be managed by consultant specialists in hospital – are looked after in the community with the help of specialist guidance from consultants.
GPs can access Consultant Connect – a diabetes consultant specialist advice line, which reduces the need to refer patients to secondary care. And primary and secondary care clinicians attend a monthly meeting to discuss difficult cases.
The ICB has heavily invested in an upskilling programme to ensure GPs and clinical pharmacists can confidently provide, for example, injectable treatments and start patients on insulin.
‘About 85 percent of LLR is covered by practices providing an enhanced diabetes service and this is slowly expanding,’ says Dr Than.
This approach has achieved better outcomes in three treatment targets, not only regarding sugar control but also blood pressure and cholesterol control, he says.
The ICB is ‘one of the pioneers in providing this enhanced service model’, he says, ‘and this has been achieved because of integration between primary and secondary care and investment in upskilling and training primary care clinicians.’
LLR ICB, through a commissioning enhanced diabetes service, has been ‘very actively involved’ in referring patients to the NDPP, and carrying out opportunistic screening in high risk populations.
Patients who take part in the programme are given advice and training to understand and follow healthy lifestyle measures through behavioural counselling.
Type 2 diabetes patients can also be referred to an ICB-wide diabetes remission programme which includes replacement with low calorie diet and lifestyle modifications.
The ICB is also piloting a service for people aged 18-40 with early onset type 2 diabetes. ‘We are giving this population more time and more resources, and dedicated education programmes, which can be attended remotely,’ says Dr Than.
The pilot service has been ‘well received’, and now has about 3,800 patients, he says.
Early results of a programme evaluation show better outcomes of diabetes control in this age population, he says.
Dr Than says the PCN will shortly start a pilot to provide a cardio renal metabolic (CRM) approach to managing diabetes. This will involve monthly multidisciplinary team meetings where high risk patients are discussed. And rather than a “one disease” treatment approach, patient care will be focussed on managing and optimising cardiovascular risks in a holistic approach.
He says services need to be ‘more integrated into community settings, working with specialists and primary care together, rather than traditional boundaries’.
‘The biggest challenge will be that this requires a different way of funding, thinking and a more patient centred service.’
Dr Than is passionate about diabetes care. ‘We know we can make a difference in this population. By identifying diabetes early and treating it properly we can prevent or postpone complications.’
Pathfields Medical Group: virtual clinics for patients with diabetes
Since 2018, Pathfields Medical Group – a one practice PCN based in Plymouth – has been offering virtual clinics to patients with diabetes with input and support from consultant diabetes specialists from University Hospitals Plymouth NHS Trust, and community nurses.
Consultants help primary care to manage the greater complexity of delivering diabetes care, and hold clinics with GPs and practice nurses. The most complex patients receive specialist hospital care, explains Dr Patrick English, a consultant in diabetes at University Hospitals Plymouth NHS Trust, who developed and helped drive the initiative.
GPs and consultants discuss cases, setting plans and structuring diabetes management, says Dr English. A specialist nurse team has an advisory and supportive role, for example, helping practice nurses to carry out insulin starts.
Patients also had input into the model. ‘Patients said very clearly: “We want to be seen by the GPs at our practice, but we want to know that our GPs have access at their fingertips to specialist support should they require it,”’ says Dr English.
Over time, new diabetes referrals to the trust have fallen by 70%. ‘Patients are being seen by community nurses and primary care practitioners,’ says Dr English.
Through this model it also became clear that there was ‘a whole group of patients in the community who might normally have been seen in specialist care’, says Dr English.
‘We’ve got quite complex insulin regimens for patients who do not go to the hospital,’ says Dr English. Increasingly nursing time in the community is being taken up supporting a more complex case load than was anticipated, he says. ‘These are not patients you would normally expect standard primary care to be able to support.’
Another area that has developed over time are IT tools to support diabetes care. Dr James Boorer, a GP partner and clinical network director at Pathfields Medical Group has developed Target Health Solutions (THS) – a software suite within the GP electronic patient record system SystmOne. The tool supports the virtual clinics, and has helped shape how the PCN sees its diabetes population. It is a template for obtaining such data as weight, blood pressure, blood sugar reading, and kidney function. All of this data is pulled into an easy to read format for the diabetes specialist consultants supporting the PCN. ‘All of that information is available on the screen, and it enables me to make a more rapid review of cases,’ says Dr English.
Dr Boorer says THS has also developed an online questionnaire, which it is now testing, to check patient engagement and understanding of their diabetes treatment, and to ask if they are taking their medicines as prescribed.
He says a challenge is to get patients with diabetes to attend for testing. ‘Traditionally primary care has used “month of birth” recall.’ However with diabetes, this approach would generally mean patients were being undertested, he explains. The PCN now regularly requests patients to come in for their tests, using the THS software, ‘and we’ve seen good outcomes with that approach’, says Dr Boorer.
The PCN also uses semi-automated messaging to tell patients about their HbA1c results, and as a result, for the first time the PCN has started to see a decline in people with chronic poor control of their diabetes, says Dr Boorer.
He says one of the key challenges in delivering diabetes care is related to funding. ‘ It costs hundreds of pounds to deliver good care and yet QOF remunerates at only £26 per year. This is on a background of declining GMS funding in real terms and rising disease prevalence and costs. It makes no business sense to deliver good diabetes care – it is delivered purely based on goodwill and that is running thin.
‘The only way we can deliver results is via automation and removing low value appointments, but even so, delivering diabetes care is a loss making activity,’ he says.
‘We urgently need to review what we expect general practice to do and ensure that the funding for this work is commensurate to work involved.’
Humber and North Yorkshire ICB: ‘Prevention is key to holding back the tide’
In NHS Humber and North Yorkshire ICB the population is ageing and will contain a greater percentage of people over 75 years of age then many other areas, says Dr Naomi Chinn, NHS Humber and North Yorkshire ICB’s clinical lead for diabetes.
‘Our geography is also a challenge,’ she says. ‘Our ICB covers the second largest geography in the country. Within our area we have cities with inner-city diversity and deprivation, but also huge rural areas and coastal stretches which means any centralisation of services would be simply inaccessible for most people.’
Prevention of type 2 diabetes is ‘a key to holding back the tide’, she says. The ICB works with Xyla, its local provider for the NHS Diabetes Prevention Programme (NDPP) throughout the ICB. ‘We also support with funding of a dedicated engagement lead to support GP practices in referring patients through to this service,’ says Dr Chinn.
One specific area of focus where the ICB has achieved ‘significant progress’ is with patients who suffer from pregnancy-related diabetes, she says. ‘We know that women who experience diabetes in pregnancy not only risk complications in their current pregnancy, but also have an increased risk of diabetes in future pregnancies and in later life. By supporting dedicated admin time to identify and then refer these women into the diabetes prevention programme we hope to minimise these future risks.’
Initially the programme did not allow for women to be referred into the prevention programme while they were pregnant. ‘This has now been amended so that the referral can be accepted during pregnancy, hopefully preventing people being lost to follow up because of waiting until confirmation of delivery,’ says Dr Chinn.
The ICB’s diabetes team is in a period of transition following staff changes ‘and is therefore embracing this as an opportunity to refocus the diabetes work stream’, says Dr Chinn.
This started with initial stakeholder identification and informal meetings to gain an understanding of the current situation.
The ICB has gone on to hold a design workshop with wide participation from all sectors. Concurrently it is being supported by Diabetes UK and its internal communications team ‘to engage patient voices and lived experience in our future plans’, says Dr Chinn.
‘Alongside these we are redesigning the Diabetes Locally Enhanced Service for the whole ICB. Notwithstanding ongoing GP collective action, this also aligns with the Darzi report with the opportunity to integrate and enhance community focused provision,’ she says.
Dr Chinn hopes that by producing a new co-designed work programme ‘we will have the momentum to enhance diabetes care through all ages alongside prevention where possible’.
‘We have the opportunity to “turn the tanker”, and as we all know that’s a huge challenge. I hope by working together with patients, providers and commissioners we can make a start on this.’
Hampshire and Isle of Wight ICB: a team identifying patients with non-diabetic hyperglycaemia (NDH)
‘We all know that the number of patients living with type 2 diabetes is significantly increasing, the range of treatments for all types of diabetes widening, and the technology to help patients obtain good control becoming ever more available. With a wide range of diseases that we call “diabetes” and an increasing number of drugs available, the challenges are huge,’ says Dr Paul O’Halloran, GP and diabetes path to remission champion for Hampshire and Isle of Wight ICB.
As an ICB ‘we decided that we would need several strands to our diabetes priorities’, he says. ‘There can be a risk that we focus on the “new and innovative” whilst the older pathways become less of a priority. So, we specifically identified several prevention areas that we added as priorities.
‘As always, outcome data from QOF, implementation of hybrid closed loops, development of pathways to cope with diabetes medication shortages and the overstretching of all services because of increase patient numbers will always be challenges and will feature in any sensible priority list.
‘However, we wanted to make sure that we supported the prevention strategy for patients living with type 2 diabetes,’ he says.
The ICB developed a team that could easily identify patients in a GP practice with non-diabetic hyperglycaemia (NDH) who hadn’t been referred to the NHS diabetes prevention programme (NDPP).
‘The rationale behind this was to increase the offer of referral into the NDPP for appropriate patients and increase attendance at the NDPP. It was also to have a legacy effect of increasing the knowledge of NDH and NDPP in the practice, and of regular searches for patients with NDH, to be cost effective and minimal cost to the host practice, and scaleable through the use of communication technology.
‘We achieved this and our referral rate increased significantly. Feedback from practices and patients was excellent,’ says Dr O’Halloran.
Practices and PCNs ‘needed to be convinced that we were not just going to identify more work for them to undertake. So our offer was clearly a “no additional work for the practice”’, says Dr O’Halloran.
The ICB team undertook the searches, sent out AccuRx invites, fielded the responses and dealt with any queries. The team consisted of an HCA, a doctor with a specialist interest in diabetes, and project management support.
The ICB identified all practices or PCNs within the ICB area that had not made a referral, or were low referrers into the NDPP. The programme had been available for two years at the time of the project initiation. ‘Not every practice took up our offer, despite sending emails, phone calls and letters. We were surprised at this. But we were pleased with an almost 95% uptake,’ says Dr O’Halloran.
The ICB’s next diabetes initiative builds on the success of the NDPP project. The NHS Type 2 Diabetes Path to Remission Programme (T2DR) is a national service designed to improve the outcomes for patients recently diagnosed with type 2 diabetes and living with obesity. This is a low calorie “soup and shake” replacement diet for three months, dovetailing into nine months of support to maintain healthy eating, encourage regular movement and exercise and help with the psychological support to maintain a healthy lifestyle.
‘We have identified practices in our ICB area who have not referred patients into the T2DR programme six months after referral was available. We are offering a team who will provide education of the programme to the practice team and then search the practice system for eligible patients.’
The ICB then sends out accrRx messages offering patient information sessions and helps the practice undertake any queries. The patient information sessions are provided by the organisation supplying the NHS Type 2 Diabetes Path to Remission Programme. ‘We will then counsel patients before helping the practice make a referral,’ says Dr O’Halloran.
The project went live this November and ‘we anticipate similar benefits and legacy effects’, says Dr O’Halloran.
‘Interestingly many of the practices that we offered the NDPP project to are the same as the practices that we have identified in the T2DR project. Because we had developed a mutual trusting partnership, access for our second project into these practices is much easier.’
Central London Community Healthcare NHS Trust: reducing health inequalities by improving access to diabetes services
Central London Community Healthcare NHS Trust’s (CLCH) diabetes teams work across eight London boroughs, including Brent, Harrow, Barnet, Kensington and Chelsea, Westminster, Hammersmith and Fulham, Wandsworth and Merton.
Teams collaborate with GPs, primary care networks and other local partners to share resources, with CLCH, providing training, running specialist clinics, developing initiatives to educate patients and the public about diabetes and delivering structured education programmes to support patients, says Dr John Rochford, CLCH deputy chief medical officer.
‘There is a key focus on helping reduce health inequalities by improving access to our diabetes services,’ he says.
The Trust is also working more closely with public health and specialist weight management teams in more deprived areas, where access and support can be more challenging, to target and adapt ways of delivering services so that they can provide the right diabetes support and advice for different diets.
In Brent, CLCH teams also work with care homes in the local area, offering education on diabetes management for frail patients to help reduce hospital admissions. The Brent Diabetes Service was recently shortlisted for a Quality in Care (QiC) Diabetes Award for their work to educate both newly diagnosed and existing patients with type 2 diabetes on how best to manage their condition.
In south west London, CLCH provides clinical expertise to GPs, practice nurses, hospitals and district nurses through DCAS (diabetes clinical advisory service) to help avoid hospital admissions and ensure patients receive the correct treatment.
And in Barnet, as part of the project to support people from ethnic minority communities to attend appointments, the service worked with Diabetes UK and a local Asian women’s diabetes network group.
‘A dietician from our diabetes team who spoke Urdu attended the group and as a result of this, the service was able to deliver a diabetes education and self-management session in a more convenient setting to help the women manage their condition confidently,’ says Dr Rochford.
He says this activity contributed to an overall 8.7% decrease in the number of people from ethnic minority groups who did not attend appointments between September 2023 – March 2024.
