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.

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.