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Transforming diabetes care

In Buckinghamshire, around 1,000 outpatient appointments every year were made for patients with type 2 diabetes. Many of these patients did not need to see their hospital consultant but instead could be supported better in their local communities.

The challenge was to transform the delivery of diabetes services by shifting care away from hospital-based appointments and empowering patients to make decisions about their own care. The process is ongoing but the majority of these patients have now had their care transferred to their GP practice where they will receive ongoing care for their type 2 diabetes.

Patient education

A patient education programme is in place to help patients understand their type 2 diabetes and how it can be managed through:

  • diet
  • exercise
  • lifestyle changes

There are two free diabetes management courses available which patients can be referred to either by their health care professional or by referring themselves via the Live Well Stay Well service. Patients can attend either small group sessions which are held in a wide number of local venues across Buckinghamshire or remotely through the support of a specialist diabetes dietitian and online resources.

Buckinghamshire CCG has introduced the Healthier You programme which is a NHS National Diabetes Prevention Programme aimed at supporting patients identified as having a higher risk of developing type 2 diabetes. Patients are supported and empowered to make small and manageable changes in their daily lives which will reduce their risk of developing type 2 diabetes. In addition to this, Buckinghamshire CCG is one of the first in the country to offer the online version of the Healthier You programme enabling people to access the programme in a way which best suits their lifestyle.


  • over 3000 people referred to the diabetes prevention programme in last 12 months
  • nearly 1000 have attended training and support sessions

Staff training

Healthcare training and education plays a big part in transforming patient care. Although Buckinghamshire is already one of the best areas in the country for controlling diabetic glucose levels, there is still room for improvement. Using nationally collected data it has been possible to identify GP practices that could improve and provide the necessary support to enable them to do so.

There is an advice and guidance service available, staffed by community nurse specialists, to support with any questions relating to type 2 diabetes.

Care home staff have also been provided with diabetes-specific training to standardise care plans.


  • 100+ care home staff trained to check blood glucose levels
  • extensive range of staff education & training sessions are taking place

Use of technology

Diabetes services are making the most of digital innovations to transform care. Patient records can now be shared between GP practices, hospital consultants and community-based diabetes specialist nurses.

Via a mobile app, patients will be able to record their own medical data which is easily shared amongst their care team. This means that patient records can be reviewed by clinicians and avoids the need for a patient to see their GP or consultant unless medically necessary. Furthermore, multi-disciplinary virtual clinics are being rolled out to give health care professionals access to specialised advice and guidance to enable improved management of patients.

Next steps

  • Increase promotion to, and support for, hard-to-reach groups to address health inequalities.
  • Use social prescribing to signpost to non-medical community organisations and services which will in turn enable patients to better manage their diabetes.
  • To use the diabetes model to support patients with other and multiple long-term conditions.