Dr Dinesh Nagi provides insight into an integrated model of care provided by primary care and specialist diabetes teams

nagi dinesh

Read this article to learn more about:

  • why integration of primary care and specialist diabetes services is important
  • the role of GPs and practice nurses in the integrated diabetes service
  • the impact of the new diabetes service on patients and healthcare practitioners.


There is wide recognition that specialist diabetes teams need to provide services in a range of healthcare settings.1,2 Since the introduction of the National service framework for diabetes3 in 2001, significant progress has been made in improving the quality of diabetes services. This, combined with the inclusion of diabetes in the Quality Outcomes Framework (QOF)4 for the delivery of diabetes care in primary care, has meant there has been year-on-year improvement in the processes used to measure the delivery of basic aspects of diabetes care.5

Despite continued improvements in the provision of care for people with diabetes, concerns remain about the lack of good quality care for younger adults with the condition5 and the pace of progress. Furthermore, diabetes-related health outcomes remain variable and true integration of diabetes services has not yet been achieved.6

There are recognised inequalities in the provision of diabetes care in the UK.7 In 2010 a Government white paper suggested that future commissioning of services will be clinically led.8,9 Regardless of the mechanism of commissioning, there is no doubt that specialist and primary care physicians, as well as other stakeholders, should develop a closer-working and partnership approach to help improve the quality of diabetes care6 and various models describing this collaborative approach have emerged.10

This Guidelines in Practice article describes the Wakefield approach to modernising diabetes services to support primary care teams in delivering high-quality diabetes care. The service redesign has been in progress since 2009 and is led by the specialist diabetes teams, but overseen and driven by the Diabetes Managed Clinical Network (DMCN), and supported by the local CCG and the acute trust. The redesign has resulted in a number of changes to the delivery of diabetes services in our locality.

Q What is the demographic of Wakefield?

A Wakefield CCG has a population of approximately 295,000 and there is considerable social deprivation in the area.11 In Wakefield, an estimated 7.1% of the registered population aged over 17 years have diabetes, at least a further 3000 are estimated to have undiagnosed diabetes, and at least 30,000 are considered to be at high risk of developing diabetes.12

Q Who led the diabetes service redesign?

A Planning for the service redesign started in earnest in 2006. An initial outline case for the modernisation of diabetes services was presented by the DMCN to the Professional Executive Committee (PEC) of the then Wakefield Primary Care Trust. The case was accepted in principle and the DMCN was given responsibility for the service redesign. We adopted a whole system solution to ensure that it reflected both the national and local priorities. Figure 1 (below) summarises our options appraisal process.

Figure 1: A diagrammatic representation of the options appraisal process
a diagrammatic representation of the options appraisal process

The focus of the DMCN has been to improve the provision of diabetes services by consolidating existing diabetes services and new infrastructure, keeping patients at the centre of any service re-organisation. The DMCN has been at the forefront of many significant developments over the last 10 years, including:

  • structured retinal screening (prior to roll out of the national programme)
  • insulin pump service (2005)
  • structured education programmes for type 1 and type 2 diabetes (Diabetes Education and Self Management for Ongoing and Newly Diagnosed [DESMOND]13 and Dose Adjustment for Normal Eating [DAFNE]14)
  • developing care pathways (i.e. insulin initiation in primary care)
  • information and technology support (specialist teams and primary care)
  • implementing revised diabetes guidelines (2007, 2009, 2011, 2013, 2015, 2016)
  • active patient involvement in the service redesign
  • fostering and developing links between the specialist diabetes service and primary care GP practices.

Q What were the main aims of the diabetes service redesign in Wakefield?

A The DMCN strives continually to improve diabetes services by building new developments on the excellent infrastructure described above. We believe that without these fundamental building blocks in place, further progress would have been difficult to achieve.

The overarching aim of the diabetes service redesign in Wakefield was to improve the care provided to people with type 2 diabetes through the implementation of an exciting and innovative redesign. We believed that the new model would help us:

  • improve the overall quality of diabetes care delivered in primary care
  • reduce variation in the delivery of diabetes care across GP practices
  • improve clinical and IT integration between primary and specialist diabetes services
  • address existing health inequalities.

The efficacy of the redesign was measured using the following primary outcomes:

  • delivery of most diabetes care nearer to the patient's home
  • timely access to specialist services in primary care
  • up-skilling of practices in delivering diabetes care
  • the provision of ongoing educational support for patients, GPs, and practice nurses.

Q How many GP practices were involved with the redesign?

A At the outset, 41 primary care GP surgeries (all but two of those in Wakefield) and the diabetes service in the high-security HM prison opted in to the redesign. The two GP practices that opted out initially joined the redesign in 2010.

Each practice involved (and the prison) was allocated a specialist team, which included a diabetologist, a diabetes specialist nurse (DSN), and dedicated administrative support. Provision was also made for extra dietetic input to be available to primary care. A new local enhanced service (LES) was developed to encompass various components of the diabetes service and incentivise practices to adopt new models of integrated working.

Q How did you initiate the proposed changes?

A Changes were introduced gradually and tailored to each practice involved in the redesign, following a baseline assessment.

Baseline assessment

Firstly, a baseline assessment was performed to evaluate the level of diabetes service provided by each practice involved in the redesign, using a self-assessment tool (see Figure 2, below).

Figure 2: Baseline self-assessment tool
baseline self-assessment tool

DAFNE=dose adjustment for normal eating

The tool helped us to identify the level of service (graded from level 1 to 5) that the practice was already providing, as well as the level of service that it aspired to deliver in future. The results formed the basis of our discussion with the practices during our initial visits.

The level of services provided by practices developed based on the personalised medical services contract around that time, which stipulated a basic level of diabetes service and a step wise approach, depending on the level of service each practice was able to provide. This focused on insulin initiation, affording primary care follow up to patients who were started on insulin treatment and then specialist diabetes services provided by specialist diabetes teams in secondary care.

The diagram shown in Figure 2 (see above) describes the care provided at each different level; levels 1–4 are provided in primary care, while level 5 is delivered by specialist teams in hospital. A practice at level 3 met the basic requirements and could also offer follow up of patients with type 2 diabetes who were stable on insulin treatment after initiation by a specialist diabetes team. At level 4, practices were able to initiate insulin in primary care along with up-titration. The baseline assessment tool that we developed for this purpose was later described by NHS diabetes for others to adopt when assessing the level of service in their own practice.

Practice visit

An initial visit to each GP practice was arranged, attended by a diabetologist, a DSN, the DMCN manager, the DMCN coordinator, and the lead GP for diabetes. Discussions focused on the logistics of joined-up working, an explanation of the model, and the new LES for diabetes, together with the practice’s own aspirations for developing diabetes services further.

Case note review

Patients were selected for a case note review (CNR) using a triage system based on glycaemic control. A pragmatic decision was made to review patients with the highest HbA1c first. The case discussions focused not only on glycaemic control, but also on cardiovascular risk management and other aspects of the diabetes management. An agreement about location of care was agreed for each patient.

The CNR included patients seen in specialist diabetes centres; this enabled review of the last hospital-based consultation so that informed decisions could be made. The potential outcomes of the CNR are shown in Figure 3 (below). The purpose of the CNR was to identify patients who should be seen in specialist primary care clinics (SPCCs)/joint nurse clinics.

Figure 3: Description of the outcomes of the structured case note review (CNR)
description of the outcomes of the structured case note review (CNR)

PN=practice nurse; DSN=diabetes specialist nurse

Q What are the key components of the revised primary care model?

A The revised primary care model consists of:

  • SPCCs in GP practices:
    • joint clinics, attended by a GP and a diabetologist
    • clinical case reviews
  • joint nurse clinics in GP practices
  • practice-based educational sessions.

Specialist primary care clinics Joint clinics

Patients were informed in writing by the practice prior to their appointment as to why they had been selected for the clinic; patients invited to attend joint clinics were discharged from follow up by specialist teams. After a joint consultation (led by the GP) based on care planning principles, an individualised care plan was agreed with the patient.

The frequency of these clinics was based on the level of service provided by the practice (level 2, 3, or 4). The first clinic took place in May 2009 and to date all 43 practices and the high security prison have been running joint clinics.

Clinical case reviews

GPs and practice nurses were allowed clinical freedom to decide which patients (seen in their routine diabetes clinics) they needed to discuss with the specialist teams. To allow these discussions to occur in a timely manner, a process of e-consultation using the integrated diabetes service IT system was agreed, and implemented in 2012. The system allows GPs to raise a 'clinical task' for a diabetologist, simultaneously granting the diabetologist permission to access the patient record for remote review. The diabetologist can then address the clinical queries; an automated email informs the GP once the review is complete. If the diabetologist feels that they are unable to provide appropriate advice through e-consultation, they can request a face-to-face review with the patient.

Joint nurse clinics

Joint nurse clinics allowed a significant proportion of care to be managed in primary care practices and provided an opportunity to up-skill practice nurses in diabetes management. This process radically improved:

  • timelines for insulin initiation (see Figure 4, below)
  • aggressive insulin titration
  • glucagon-like peptide 1 receptor agonist (GLP-1 RA) treatment initiation
  • regular follow up of patients already stable on insulin treatment.
Figure 4: Insulin initiation in primary care—before and after the implementation of service redesign
Insulin initiation in primary care before and after the implementation of service redesign

DSN=diabetes specialist nurse

Practice nurses had free access to the DSN allocated to their practice via telephone and e-consultation. During the redesign, practice nurses have begun to feel more confident having acquired new skills and are now much less dependent on their DSN for support.

Practice-based education

Early in the redesign it was recognised that there was a need for education and training, in addition to that being provided in the CNR and joint clinics. Ad-hoc training sessions were provided based on practice requests (e.g. insulin regimens, new therapies, etc.); 16 modules were developed covering a wide range of topics in diabetes relevant to daily clinical practices, spanning from prevention of diabetes to early diagnosis, management, and complications of treatment. The responsibility for education and training lies with specialist teams visiting the practices and the clinical champion for diabetes.

Q What obstacles did you face when implementing the service redesign?

A There were no serious obstacles, but the hearts and minds of the people involved in the redesign had to change to accept the new model as a way forward to improve the diabetes services and tackle health inequalities.

Agreeing an incentive for GP practices contributing to the redesign involved some challenging discussions, as some people felt that GPs should do the work without extra incentives. An educational agreement was reached through renegotiations of LES, and this led to increased attendance at educational meetings organised by the DMCN.

Q Was any additional staff training required?

A Little additional staff training was required, other than the education of practice nurses and GPs in insulin initiation and follow up, and the use of new drugs for diabetes (such as GLP-1 RAs).

The specialist teams needed some training in the use of the GP practices' IT system. Subsequently, in 2013 the same IT system was introduced in specialist diabetes centres, creating a diabetes service with IT integration. The patient's record can be quickly and freely shared among the healthcare professionals involved in their care; GP practices using the system can see details of a clinical consultation within minutes of the patient being seen at a specialist hospital-based clinic. Widespread use of the same IT system also enabled the use of e-consultation requests with data sharing, where a consultant’s response can be expected within 48–72 hours of request.

Q What has been the impact of the service redesign to date?

A Benefits of the new diabetes services to the local health economy are listed in Box 1 (see below). Although it is too early for us to produce evidence of the success of this model, there are some indirect indicators that demonstrate that we are beginning to make difference. A review performed 3 years after the start of the redesign shows that the level of services provided by GP practices has changed significantly, with more and more practices taking on insulin initiation, titration, and follow-up (see Figure 5, below). More recent data shows that all GP practices deliver a level 3 service or higher.

Figure 5: Levels of service provision by the practices at baseline (2009) and over the next 6 years after the services redesign showing improved levels of diabetes care provision
Levels of service provision by the practices at baseline (2009) and over the next 6 years after the services redesign showing improved levels of diabetes care provision

Box 1: Benefits of the new diabetes model for the local health economy

Benefits for patients

  • Care is provided closer to home
  • Easier access to GP appointments
  • Improved access to diabetes specialists, through joint consultations
  • More time allowed for a dedicated consultation
  • Consistency in information provided by all healthcare professionals
  • Motivational to see healthcare practitioners working together
  • Greater provision of patient education
  • Faster clinical decision making process
  • Reduced time taken for sharing of information between primary and specialist care.

Benefits for GPs

  • Up-skilling through education and support
  • Access to expertise depending on need
  • Access to structured education programmes (e.g. DESMOND)
  • Access to a community diabetes dietitian (one-to-one appointments for people with diabetes who do not wish to attend group education sessions)
  • Improved management of diabetes including an increase in achieving indicators set by QOF.

Benefits for prison service

  • Diabetes clinics available within the prison
  • Patients no longer need to be escorted to specialist diabetes clinics, leading to massive resource savings.

Benefit for hospitals and specialist teams

    • Avoiding duplications
    • IT access allowed: instant information on care provided in primary care
    • Ability to review medication with knowledge of when a drug was started, changed, or stopped
    • More capacity to see patients with complex needs who need to be seen in the specialist diabetes centre
    • Increased first-hand experience of how primary care works.

DESMOND=Diabetes education and self management for ongoing and newly diagnosed; QOF=quality and outcomes framework

Practices in Wakefield have done well with meeting the indicators set in the QOF; data submitted by practices shows more than 90% engagement.15 The prescribing data for new diabetes drugs has provided indirect evidence that the new way of working is producing the desired results. A review performed from April to December 2010 (only 12–18 months after the start of the redesign), showed a significant increase in the total prescribing of the new drugs compared with other primary care trusts in the locality (see Figure 6, below).

Figure 6: Prescribing costs of new drugs including antidiabetic drugs from April to December 2010. The figure shows the significant increase in prescribing of liraglutide (a GLP1 RA) in Wakefield since the diabetes redesign. (Data supplied by Yorkshire and Humber SHA)
Prescribing costs of new drugs including antidiabetic drugs from April to December 2010. The figure shows the significant increase in prescribing of liraglutide (a GLP1 RA) in Wakefield since the diabetes redesign. (Data supplied by Yorkshire and Humber SHA)

Similar improvements in QOF performance were seen at Wakefield’s high-security prison, and prisoners with diabetes reported a significant improvement in the diabetes care they received.16

Positive feedback from patients and healthcare professionals about their experiences of the new model (see Box 2, below) has provided reassurance that the redesign has been successful and a strong motivator to continue developing the service.

Box 2: Qualitative feedback from service users and healthcare professionals

Feedback from services users

'Less worrying than hospital atmosphere, less anxiety, a hospital appointment is a "big" appointment.'

'Smashing appointment!!'

'Hope we're lucky enough for this new service to continue!'

'Excellent experience seeing everyone together in own practice.'

'Brilliant service!'

'Wouldn't have wanted to go to a hospital even though I knew my control was worsening.'

Feedback from healthcare professionals

'In the 30 years that I have been the diabetes specialist at Pontefract General Infirmary there has been a gradual and continuous improvement in diabetes treatment and care, but this is the most important and exciting development I have been involved in. I am confident that this new co-operation between the specialist hospital diabetes centres and GP surgeries [will] result in much better care for people with diabetes across the district.' Consultant diabetologist

'Fantastic learning opportunity to be able to discuss individual cases with the specialist team at the surgery.' GP

'Seeing patients jointly with a hospital specialist was a novel experience which I found very educational. Combining the different strengths of primary and secondary care clinicians clearly benefited both of us, and more importantly, our patients.' GP

'I have learned more this morning on diabetes working with the consultant than I ever did in the 5 years at medical school! Very enjoyable!' GP

Q What advice would you give to GP practices looking to implement a similar redesign in their own locality?

A Work in collaboration with your local specialist diabetes teams and start discussions about the need for integrated diabetes care. In our set up, leadership was provided by the specialist diabetes consultant, who was the Chair of the DMCN at the start of the redesign, but the approach was very much collaborative and involved all stakeholders, including service users and commissioners. The key is to formulate a vision for future diabetes services, which are based in primary care, closer to patients, and sustainable in the long term. The NHS Five year forward view17 emphasises the importance of integrated working across health and social services. We believe our journey, which started several years ago with clinical integration across primary and specialist care teams several, will pave the way to address and achieve the recommendations set out in the Five year forward view.


  1. Royal College of Physicians, Royal College of General Practitioners, Royal College of Paediatrics and Child Health. Teams without Walls 2008: the value of medical innovation and leadership. London: Royal College of Physicians, 2008. Available at: www.rcplondon.ac.uk/projects/outputs/teams-without-walls-value-medical-innovation-and-leadership (accessed 18 November 2016).
  2. NHS Diabetes. Commissioning diabetes without walls. NHS Diabetes, 2009. Available at: www.yearofcare.co.uk/sites/default/files/images/diabeteswithoutwalls1.pdf
  3. Department of Health. National service framework for diabetes: standards. DH, 2001. Avaialble at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/198836/National_Service_Framework_for_Diabetes.pdf
  4. NHS. Quality and outcomes framework website. Available at: content.digital.nhs.uk/QOF (accessed 21 November 2016).
  5. Health and Social Care Information Centre. National diabetes audit. Available at: content.digital.nhs.uk/nda (accessed 7 December 2016).
  6. Diabetes UK, Association of British Clinical Diabetologists, Primary Care Diabetes Society, Community Diabetes Consultants, Royal College of Nursing. Joint Position Statement. Integrated care in the reforming NHS—ensuring access to high quality care for all people with diabetes. 2007. www.diabetologists.org.uk/Shared_Documents/notice_board/joint_statement_v4.pdf
  7. Marmot M, Allen J, Goldblatt P et al. Fair society, healthy lives. Strategic review of health inequalities in England post 2010. The Marmot Review. London: The Marmot Review, 2010. Available at: www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review (accessed 18 November 2016).
  8. Department of Health. Equity and excellence: liberating the NHS. London: Stationery Office, 2010. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/213823/dh_117794.pdf
  9. Department of Health. Liberating the NHS: commissioning for patients—a consultation on proposals. London: DH, 2010. Available at: webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_117705.pdf
  10. Nagi D, Wilson J. Integrated diabetes care: the Wakefield diabetes service redesign. Practical Diabetes 2011; 28 (7): 310–311.
  11. Public Health England. Public health profiles. Diabetes. Prevalence and risk, 2015–16. NHS Wakefield CCG. Available at: fingertips.phe.org.uk/diabetes
  12. Diabetes UK. Diabetes Watch. NHS Wakefield CCG—2014–2015 data. Available at: diabeteswatch.diabetes.org.uk (accessed 24 November 2016).
  13. DESMOND project website. www.desmond-project.org.uk (accessed 25 November 2016).
  14. DAFNE project website. www.dafne.uk.com (accessed 25 November 2016).
  15. Diabetes UK. Diabetes Watch. Profile for Wakefield Clinical Commissioning Group—England. Diabetes UK, 2015. Available at: diabeteswatch.diabetes.org.uk (accessed 25 November 2016).
  16. Nagi D, Wislon J, Kadis T, Jenkins R. Diabetes service redesign in Wakefield HM high-security prison. Diabetes & Primary Care 2012; 14 (6): 344–350.
  17. NHS. Five year forward view. NHS, 2014. Available at: www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdfG