Article Text

Service user and community clinician design of a partially virtual diabetic service improves access to care and education and reduces amputation incidence
  1. Alastair Watt1,
  2. Andrea Beacham2,
  3. Lynne Palmer-Mann2,
  4. Amy Williams2,
  5. Jacqueline White1,
  6. Rebecca Brown1,
  7. Ellena Williams1,
  8. Gayle Richards1,
  9. Lyndon White1,
  10. Pauline Budge1,
  11. Katy Darvall1,
  12. Ed Bond3,
  13. Richard Paisey1
  1. 1Integrated Diabetes Care, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK
  2. 2Department of Integrated Care, Northern Devon Healthcare NHS Trust, Barnstaple, UK
  3. 3Integrated Diabetes Care, Bideford Medical Centre, North Devon, Barnstaple, UK
  1. Correspondence to Dr Richard Paisey; richard.paisey{at}


Introduction Design of an integrated diabetes service based on needs of service users (persons living with diabetes) and community clinicians in a semirural low-income health district of the UK.

Research design and methods One hundred and eighty-five service users engaged through public meetings, questionnaires and focus groups. General practice staff contributed views through workshops and questionnaires. Analysis of feedback indicated service user needs for better access to education, dietary advice and foot care. General practice staff endorsed these views and requested regular access to secondary care in the community. Seven hundred persons registered with diabetes attended eight well-being events in the community. From 2017 virtual practice multidisciplinary patient reviews, virtual referral of foot cases and non-face-to-face helplines were developed. A National Health Service (NHS) approved ‘App’ and web-based personalized education support for those recently diagnosed with diabetes was introduced.

Results Engagement in education for those recently diagnosed with diabetes increased from 5% to 71%. Weight and hemoglobin A1c (HbA1c) levels before and 6 months after starting the program were 99.4±25 and 95.5±24.2 kg and 59.3±16 and 54.8±12.9 mmol/mol, respectively, p=0.00003 and 0.003. Of those engaging at well-being events, 44 had missed regular follow-up. One hundred and seventy-five cases were reviewed virtually with practice staff by the secondary care team avoiding referral to the hospital diabetic clinic. One hundred and seventy-six referrals were made to the virtual multidisciplinary diabetic foot team clinic. Major amputation incidence declined from 13 to 3 major procedures/10 000 per annum and minor amputation from 26 to 18/10 000. Percentage bed day occupancy by persons with diabetes fell significantly in the district general hospital.

Conclusions Integrated community-based diabetes care delivery has been achieved with partially virtual reviews. Patient education, secondary care in the community, access to dietetic advice and foot care outcomes have all improved.

  • diabetes mellitus
  • type 2
  • diabetic foot
  • diet
  • diabetic
  • education

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  • Deceased AlW deceased since 13th December 2017.

  • Contributors JW, RB, LW and KD developed and delivered the virtual multidisciplinary foot (MDFT). EW, AmW and LP-M developed and delivered the website, Facebook page and dietetic non-face-to-face service. EB, GR, PB, RP and AB developed and delivered the general practice care plan discussions and virtual general practice clinics. All living authors gave final approval and agreed to be accountable for all aspects of work ensuring integrity and accuracy. AIW designed and initiated the project development. General practice staff have engaged enthusiastically in all aspects of the integrated diabetes care program. Glen Allway, Karen Acott (practice leads), Matt Robert (DUK South West), Mel Hucker (tissue viability service), Pat Doran (service user), Sharon Bates (practice manager and CCG adviser), John Wilkins and Hannah Keigthley (project support managers) contributed to monitoring of the integrated diabetes care development program. Toni Pascoe-Knight provided diabetes specialist nurse support to the MDFT. The Barnstaple branch of Diabetes UK contributed to wellbeing events, service user recruitment for focus groups and participation in questionnaires. Thanks to Melvin Cowie for graphic design and Rosamund Paisey for formatting the manuscript. Nicolas Harrison, principal analyst, North Devon Healthcare, provided data analysis of bed occupancy and education program follow up. Ruth Tapsell initiated and followed up low carbohydrate diet therapy at Hartland general practice, Devon, UK. Statistical advice was provided by Dr Paul Hewson and Dr Christopher Paisey.

  • Funding Funding was received from the Sustainability and Transformation Programme in 2017.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplemental information.

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