GPs deliver improved NHS diabetes care in Barking and Dagenham

07 January 2019

People with diabetes in Barking and Dagenham are receiving better care and treatment than ever before, thanks to groundbreaking work by local GPs and NHS commissioners. 

An initiative led by NHS Barking and Dagenham Clinical Commissioning Group (CCG) – and involving all 37 GP practices in the borough – has led to a major improvement in type 2 diabetes diagnosis rates and better advice and support for those living with the condition. 

As a result, the estimated number of undiagnosed diabetes cases in the borough has fallen from 1,642 in 2012-13 to 624 in 2017-18 – a decrease of more than 60 per cent. 

The work started in 2016 when a scheme was drawn up to improve diabetes outcomes and ensure everyone in the borough had access to the same quality of care, wherever they lived. 

A data-gathering exercise was undertaken to highlight where extra support was needed, and GPs were then challenged to improve their diabetes testing rates and the care provided to patients.

To help drive improvement, incentives were offered to practices that met certain National Institute for Health and Care Excellence (NICE) guidelines for diabetes diagnosis, treatment and education.  

More than 12,500 diabetes patients were closely monitored – 12,210 with type 2 and 488 with type 1 – and at the end of the first year, the results showed significant progress. 

The improvements seen included: 

  • More patients were receiving the nine NICE care processes for diabetes (inc blood, weight and cholesterol monitoring and eye examinations) – up from 15.7 per cent to 49.4 per cent
  • More patients with type 2 diabetes were being offered structured education to help them manage their condition – up from 40.7 per cent to 63.1 per cent
  • The percentage of patients in Barking and Dagenham diagnosed with pre-diabetes (at risk of diabetes due to impaired glucose tolerance), increased from 0.62 to 4.7
  • The average blood glucose level for diabetes patients across the CCG fell, and the number achieving the recommended target level rose – up from 45.7 per cent to 53.6 per cent. 

Type 2 diabetes is one of the biggest challenges for the NHS with around 3.5 million people in the UK diagnosed with the condition, which can lead to a number of other health issues. 

The prevalence of long term conditions is closely linked to deprivation and ethnicity, so tackling diabetes is a key priority for health and care partners in Barking and Dagenham: the borough is the third-most deprived in London and has an escalating ethnic population. 

Dr Anju Gupta (pictured), GP and Clinical Lead for Diabetes, Barking and Dagenham CCG, said: 

“The success of this work has led to a significant improvement in our diabetes diagnosis rate and in the treatment and support provided to those living with the condition. 

“Through the coordinated efforts by the CCG and our local GPs and their practice teams, we have been able to make a real difference to the quality of care we offer to our patients.” 

Dr Gupta said networking sessions and discussions between practices allowed them to share ways of using web-based data and this collaborative approach them to optimise the care they provided. 

“This project proves that better organisation of care, clinical leadership, and meaningful use of clinical data can overcome the challenges posed by socioeconomic deprivation and achieve high-quality care,” she said. 

Similar work to improve diabetes care is also taking place in Havering and Redbridge, and the learning from the Barking and Dagenham scheme has been shared with GP colleagues nationwide.