Revolutionising diabetes care in England’s most deprived communities

This blog is written by Dr Tala Balafshan.

Patients living in the most deprived areas of the country can face barriers in accessing care and engaging with health services, often resulting in poorer health outcomes.

At the diabetes centre located on the St Helens and Knowsley site of Mersey and West Lancashire Teaching Hospitals NHS Trust (MWL), we wanted to tackle these challenges head-on. We planned to use an innovative care model to reduce missed appointments, long wait times and preventable emergency admissions, and improve the personalisation of clinics.

A scalable, patient-centred model

We set out to create a model that would not only address the issues in our own young adults diabetes service but could be scaled up and used as a blueprint for other trusts across the country.

We used data and technology and worked with other services (such as mental health) to engage patients and improve their overall experience.

For example, one of the biggest shifts was the proactive implementation of advanced diabetes technology, empowering patients to self-manage their condition. The service expanded access to continuous glucose monitoring (CGM), with 87.8% of patients now using this technology. CGM allows patients to monitor their glucose levels in real time and share the data with their healthcare team, enabling more informed and personalised management of their condition.

Giving patients more autonomy over their diabetes management and sharing real-time data with their care team allows clinicians to identify issues sooner and intervene before medical emergencies arise. By adopting this technology and following patients up though a dedicated emergency admission audit, the team at MWL reduced its recurrent diabetic ketoacidosis (DKA) admissions by 80%.

Holistic, personalised care

This initiative has a strong emphasis on patient-centred care that is personalised to individual needs. Patients are contacted ahead of appointments to encourage attendance and are given pre-clinic questionnaires so that consultations are focused and tailored to them. Urgent access clinics were set up to bypass traditional appointment barriers. We also introduced a self-reported wellbeing questionnaire, the ‘CORE 10’, every 4 months to prompt and normalise discussion of mental health within our consultations, identifying where psychological support was needed and when referral to mental health services was appropriate.

‘From care that is siloed, inefficient and one-size-fits-all to care that is integrated, timely, personalised and focused on prevention.’

It was important to us that the care we provide be holistic, putting the patients' needs first. We wanted to ‘think outside of the box’, join up services and use data and technology to optimise care and tackle inequalities – all reflected in the vision set out in the RCP’s recent report Prescription for outpatients: reimagining planned specialist care, which highlights the urgent need to transform how outpatient care is delivered.

The success of MWL’s initiative is clear in our patient feedback. In total, 93% of patients rated their care experience as ‘very strongly positive’. ‘Did not attend’ rates reduced from 50% to 18.1%, follow-up waiting times decreased from 5.5 months to 3 months, and eight out of nine care processes now exceed national standards.

Bridging the health inequality gap

The biggest impact of this initiative has been improving the health outcomes of those patients who statistically face more barriers and inequalities in healthcare. It recognises the full spectrum of a patient’s needs, not just the condition that they treat.

Health inequality isn’t just a health issue; there are wider social determinants that contribute to poor health outcomes. Identifying the barriers and working as a multidisciplinary team to address them is key to making healthcare fair and equal for all.

The RCP's Bridging the gap guidance has a range of actions that physicians can take to address health inequalities in their work, and how to make it a priority.

Find out more.