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Trust introduces a pathway to improve diagnosis and treatment outcomes of patients with diabetes, reducing variation in treatment and exceeding clinical targets


    • Rampant prevalence of diabetes, with 15,000 diagnosed patients and an estimate of 3,458 undiagnosed adults
    • Prevent premature deaths due and enhance the quality of life for people with long-term conditions
    • Help people recover from episodes of ill-health or injury, enhancing patients’ experience of care


    • Designed a programme to improve the diabetes care pathway
    • Used targeted interventions focused on 3 Treatment Target (3TT) delivered at practice/hub level
    • Offered current health management systems for diabetes registration, recall and review
    • Held multidisciplinary team (MDT) meetings, facilitation clinics and trained/reviewed peer staff
    • Developed a clinical searches and dashboards system to identify uncontrolled patients, standardise protocol and upskill staff


    • Exceeded the clinical target of 45.8% across all 3TT indicators
    • Improved engagement of patients with chronic disease, enhancing their experience
    • Resulted in standardisation of call and recall processes in patient management
    • Cross organisation MDTs improved effective clinical and performance management
    • Reduced variation in treatment, reducing diabetic complications and improving overall care


Diabetes is a major public health problem that affects approximately 6% of Lewisham residents. The estimated (diagnosed and undiagnosed) diabetes prevalence was 6.26% (2014/15) of people aged 16 years+, representing over 15,000 diagnosed patients and an estimated further 3,458 adults undiagnosed.

One Health Lewisham (OHL) and NHS Lewisham CCG (LCCG) embarked on a programme to improve the diabetes care pathway in Lewisham in line with the Five Year Forward View national ambitions for transformation in diabetes. Using targeted interventions focused on 3TT delivered through practice and hub level. The programme set to address the following:

• Preventing premature death

• Enhancing the quality of life for people with long-term conditions

• Helping people to recover from episodes of ill-health or following injury

• Ensuring people have a positive experience of care

The programme offered practices detailed analysis of current health management systems for diabetes registration, recall and review, MDTs meetings, facilitation clinics and training/peer review from the local GP federation community team.

Over the last 2 years, the programme has successfully reduced the variation of diabetes treatment, improved overall diabetic care in Lewisham from a requires improvement to outstanding in the CCG improvement and assessment framework, helping to reduce diabetic-related complications.


The target was to increase Lewisham’s 3 Treatment Target (3TT) achievement from 42% to 45.8%. This was an ambitious goal for primary care without direct investment in practices. Engagement would be challenging asking practices to find additional resources to attend MDTs and to invest in working in different ways.

Another key element was practices allowing access to their data, use of a data hub and development of a two weekly dashboard. This was overcome by acknowledging the above and working on systems to target treatment at the most likely to benefit, reviewing systems and automation to reduce waste, standardizing and simplifying protocols and upskilling all practice staff to increase effectiveness of any patient encounter.

MDT meetings at hub level: (case studies, shared learning, promotes collaboration and joint working, practice focused) All of the above improved the patient journey and maximize patient engagement. Our diabetes lead undertook regular audit of diabetes management of all practice staff across Lewisham and providing feedback and learning. Lessons learnt included learning around maintaining well controlled diabetes on the diabetic register as they were still at risk of diabetic complications despite reduced blood sugar.


Clinical target of 45.8% achievement across all 3TT indicators achieved, these were measurement for blood glucose – HbA1c 48mmol/mol, cholesterol < 5.0 mmol/l and blood pressure 140/80.

• An improvement in clinical targets has been driven through the three pronged approach; establishment of the multidisciplinary team meetings

• Clinical audit and review and hands on administrative support

• Administrative and IT support: The service has prioritised supporting the lower performing practices with administrative and GP IT hands-on support. Support includes helping practices to manage their diabetes cohorts through the use of OHL prepared searches and good quality data.

We have found that this administrative support motivates practices to take action on the diabetes recall. All participating practices have been contacted by OHL and had their OHL diabetes search results presented to them. Clinical input: OHL diabetic lead has visited 31 practices on several occasions, discussing their recall and review processes for their diabetic patients.

Offering support, clinical direction and suggestions for change, designing specific EMIS searches as requested by the clinicians. Support in initiating smart ways of working, including virtual clinics, internal practice MDTs. Where required, virtual DSN clinic support for targeted patients.


OHL cascaded and embedded new approaches to diabetic care across 30 practices:

-Our Neighbourhood forums enable practices to share best practices and also allow discussions around good evidence-based practice

-Clinical risks and significant events in Diabetic Care discussed improving patient safety and better outcomes

-Clinicians upskilled in the use of targeted strategies during consultations through protocols

-PMs and practice administrators trained on putting systems and processes in place when handling diabetic patients results.

-Developed Business Intelligence clinical system searches and dashboards resulting in more efficient recall systems

-Our Diabetes Facilitator undertakes practice visits and support

Our searches empower practices to work smarter:

-It identifies patients missing only one indicator across the key 8 care processes.

-Quickly identifies uncontrolled patients across the 3 Treatment Targets.

We provide a robust training to Lead GPs, Practice Managers and Administrators to ensure they can interpret and optimally use our reports. We promote the use of the CDEP education in each practice meeting including the MDT meetings.

Joined up working with LCCG, Lewisham & Greenwich NHS Trust, and all GP Practices enabled cascading of good practice and improving of clinical outcomes in Diabetic patients which will prevent Diabetic complications and improve patient safety.


-Standardisation of call and recall and other systems and processes in the management of Diabetic patients across 30 Lewisham practices.

-Creating a culture of learning from each other’s best practice in Lewisham.

-Setup of cross-organization MDTs and networks to improve effective clinical management and learn lessons about effective approaches.

-Bringing GPs out of silos into larger working groups with joined up vision to deliver excellent Diabetic care

-Business Intelligence Search and Report systems allowing for innovative working including virtual MDTs and Virtual case reviews.

-Risk management through constant audits and performance management.

-A performance monitoring dashboard illustrating the current performance of each practice.

-Percentage of Lewisham diabetics with control across all 3 Key Treatment Targets (measurement blood glucose – HbA1c 48mmol/mol, cholesterol < 5.0 mmol/l and blood pressure 140/80) improved from 42% to 46.7% (exceeding the target of 45.8%)

-Significant improved patient experience by keeping their diabetic care closer to home at their practice; bringing special input where required to the practices providing a broader skill mix; improving engagement of patients with their chronic disease.


Our key stakeholders were GP practices, we engaged with them across a number of levels: -Practice meetings, these were individual meetings that focused on each practice’s specific list of diabetic patients.

-Neighbourhood meetings, these were multi-practice meetings with commissioners which reviewed patients across geographical patches. They considered current service provision and explored new and different options to support practices meet diabetes targets.

-PHS contract meetings, these meetings brought together providers to review performance and data. -Lewisham Transformation meetings, involved all diabetic stakeholders including the hospital trust (Lewisham and Greenwich NHS Trust), podiatry services, DECS (diabetes eye screening) services, voluntary sector (Diabetes UK), Healthwatch Lewisham and people with diabetes.

-MDT meetings, each participating practice is required to attend these meeting every two months. They are attended by the 3TT hub team (OHL), OHL diabetes clinical lead and the lead for the practice, DSN Diabetic Specialist Nurse (when available), practice nurse and Consultant Endocrinologist (when available).

OHL deliberately assigned a named contact to all practices which played a key role in bringing practices on. The meetings and regular contact with the Clinical Lead was crucial to achieving buy-in from practices both for support, advice and pulling the work together across the borough.