Table 1

Problems encountered, interventions and outcomes of integrated diabetes care

Problems identifiedInterventionsActionsOutcomes 2018/2019
1) Specialist support to primary care
Specialists could intervene sooner. Lack of coherent care and advice delivered locallyA multidisciplinary team of specialists delivered 17 annual GP practice support visits.Diabetes therapies discussion of selected patients.176 reviews in general practice (see table 2 for detailed outcomes).
Patients said there was a variation in care between practicesPractice process mapping.Care plan rationalized and delivered through Ardens.*122 patient care plans revised 50/53 GPs described a benefit of the visit.
No audit of whole practice diabetes cohortsTabulation of glycemic control and therapy.6 monthly audits of treatment targets inaugurated.Treatment intensified in 15 cases and relaxed in 36 example cases.
2) Improved access and timely referral to community podiatry services
Delay in recognition of foot problem and referralAppointment of three more community podiatrists.Link podiatrist for each practice. FRAME† training for GP staff.Decrease in minor lower extremity amputations from 26/10 000 to 18/10 000
2014/2017 to 2017/2020.
3) Improved access to multidisciplinary foot (MDFT) care team
Accessibility and frequency of MDFTMDFT strengthened. Referral pathway rationalized. Virtual clinic initiated.176 diabetic foot ulcers reviewed in virtual MDFT.Decrease in major lower extremity amputations from 13/10 000 to 3/10 000, 2014/2017 to 2017/2020.‡
4) Improved access to lifestyle support
Most patients unaware of local exercise or weight loss groupsWell-being events open to all persons in practice with diabetes.700 patients attended eight events. Access to multidisciplinary team and psychotherapy.44 excepted patients attended and engaged.
5) Understanding ‘What Matters to You’
Dietetic appointments not always helpful, long waiting timesService user facing dietetic helpline for advice.Regular dietitian help line, Facebook page and website.3334 Facebook contacts in 2018/2019, 67 regular users/month.24
6) Same standard of diabetes care at home
Housebound, residential home diabetic persons not accessing careCore of community nurses trained as link nurses.QOF examinations and diabetic control advice delivered to hard-to-reach patients.HbA1c and foot examination in 97% and 87%, respectively.
7) Improved and consistent access to targeted patient educations resources
5% uptake of diabetes structured group education in entire districtTelephone and text-based education commissioned for recently diagnosed persons with type 2 diabetes§71% of referrals enrolled, 91% attended, 83% completed, 33% face to face.Weight 99.4±25 and 95.5±24.2 kg, HbA1c 59.3±16 and 54.8±12.9 mmol/mol baseline to 3 m p=0.00003 and 0.003.
No uptake of diabetes structured group education in remote areaLow carbohydrate diet offered for new and established persons with diabetes.¶42 of 162 on diabetic register reduced HbA1c to <48 mmol/mol on low carbohydrate diet over the past 3 years.Weight 110.3±19 to 101.5±20 kg, HbA1c 52.9±7 to 45.3±3 mmol/mol baseline to 12 m p=0.00003 and 0.004.