Diabetes Service

Our integrated diabetes service is based on an increased role for primary care in the delivery of diabetes care

Developed from a project pioneered in Hampshire, a community-based specialist team support GP practices and patients in improving health outcomes.

What it means

The ultimate aim of an integrated diabetes services is to give support to diabetic patients who are constantly managing their condition, with care centred and coordinated around their needs.

This means a clear pathway and easy access from diagnosis through initial treatment, continued self-management and dealing with associated complications.

Achieving this means better care and better outcomes for patients who were empowered to take control of their own conditions, reduced prescribing costs and reduced impact of diabetic patients on secondary care.

How it works

The service centres around a Diabetic Specialist Nurse, or DSN, who is based within secondary care however regularly visits our 12 member GP practices.

As specialists in diabetes, DSNs are able to share their expertise to Practice Nurses, GP and other generalist clinicians.

Typically this will involve reviewing specific cases, identifying at risk patients, offering specific education sessions of self management, or carrying out patient reviews jointly with practice staff.

The result is an upskilling of primary care’s capacity to provide highly specific, personalised care diabetic patients need.

When patients have easy access to improved care and education that meets their individual needs, they are enabled and empowered to manage their own care.

This is all underpinned by integrated IT and shares patient records, an agreed approach to collaborative planning, and clearly defined pathways of routine care in a primary setting, and specialist care in secondary and tertiary services.

How it helps

First and foremost, it helps patients get easier access to better care, which in turn increases their education and ability to self-manage their blood sugar levels.

Optimising medication through regular reviews and monitoring also improves outcomes while reducing prescribing costs.

For practices, the benefit is a specialist service available in their own surgery, with staff members able to develop their own clinical expertise in an area that will increasingly impact the patient population in the future.

Healthier, self-managing patients also make less of an impact on the NHS themselves, as their risk of further complications and need for secondary care decreases.

The original ‘Super Six’ scheme in South East Hampshire and Portsmouth estimated a referred saving of £1.9million to the NHS in 2014/15. This came from reducing the number of blood sugar-related admissions, and fewer patients suffering heart attacks or requiring amputations.


Practice Staff Members Upskilled
Patients’ Conditions Well Controlled*
Lower for Hypoglycemia Admissions
Lower for Hyperglycemia Admissions
Practices delivering Care++, the highest standard service**

* Compared to 60.3% in neighbouring areas

** Compared 89% across neighbouring areas