Diabetes programme

Long term diabetes patient in the programmeLong term diabetes patient in the programmeJoquam undergoes an eye examinationJoquam undergoes an eye examinationService users give their viewsService users give their viewsService users give their viewsService users give their views

There are around 24,000 people in Lambeth and Southwark with diabetes and an estimated further 16,000 with undetected diabetes. The number of deaths attributed to diabetes in 2008 was 10 per cent in Lambeth and 6 per cent in Southwark, compared with 5.7 per cent nationally . Earlier detection and better management of diabetes is known to prevent future complications, including amputations and the development of renal failure and retinopathy, which can lead to blindness.

The Charity awarded the Diabetes Modernisation Initiative (DMI) £4.5 million in November 2010 to develop an excellent system of diabetes care. Its vision is to enable people to 'live well with diabetes' through consistent and accessible services designed with patients; by offering the right balance of support and independence; and by applying state of the art treatment and care approaches.

The DMI works with clinical champions, health service staff and other professionals, as well as people living with diabetes. The initiative has already had a significant impact on the health and quality of life for people with diabetes in Lambeth and Southwark, in the following ways:

Better detection

It aimed to increase detection of diabetes from 64 per cent to 82 per cent - by indentifying an additional 7400 people with undiagnosed diabetes, (so that 33,800 people were receiving diabetes care locally). Between 2009 - 11 the programme had detected an additional 2, 000 patients.

Better control of blood sugars

HbA1c is a blood test which indicates blood glucose levels over a two to three month period. HbA1c can indicate diabetes, and blood sugar control. The aim was to increase the number of people with an HbA1c under 8 from 67 percent to 75 per cent, which equates to 1950 more people. By 2011 the programme had achieved this in 1,650 patients, well on their way to achieving their goal during the programme.

Care in the right place

The aim was to increase patients receiving care in an appropriate setting, avoiding hospital visits / admissions where possible. This has involved working with GPs, community and hospital teams to provide care closer to home. As a result, Lambeth diabetes community services has seen an increase in their patient numbers of 43 per cent between January and May 2012. Additionally, the number of people seen in hospital only once or twice, had fallen by 9 per cent during 2010 -12.

The programme also set out to reduce emergency admissions by 20 per cent, by December 2013. By autumn 2012 the number of avoidable emergency admissions had fallen by 4 per cent since the same time the previous year.

Partnership

Over 350 local diabetes patients involved in activities to improve their care. This work includes a thriving Patient Forum and a training programme to develop the skills of service users who are working alongside clinical leads and the DMI team to redesign services.

The programme has established a parent support group, links with local faith groups and developed culturally specific education programmes for local patients.

The Diabetes MI team are bringing together paediatric teams and families to design and develop the Paediatric Diabetes Network of Excellence across the Evelina Children's Hospital (part of Guy's and St Thomas' NHS Foundation Trust), King's College Hospital NHS Foundation Trust and Lewisham Healthcare NHS Trust.

The DMI is also sharing knowledge with the Integrated Care Programme on a number of areas of service improvement, such as peer support, workforce training and the integration of primary/community and specialist services.

  • Key facts

    Lead organisation:
    Guy's and St Thomas' NHS Foundation Trust

    Funding amount:
    £4.5 million

    Start date:
    Dec 2010