Summary of 17 Feb 2015 AGM talk

By Helen Church Lead Diabetes Specialist Nurse with Hounslow and Richmond Community Healthcare NHS Trust (HRCH)


By 2015 an estimated 5 million people will have diabetes, due largely to the rising prevalence of obesity. At least 24,000 deaths could be avoidable per year and a diagnosis of diabetes approximates to a reduction in life expectancy of about 10 years.

The Case for change in Richmond

In 2013, the Quality and Outcomes Framework (QOF) indicated there were 5,840 patients with diabetes, some 85% with type 2, 7% with Type 1 and 7% unclassified. 

A low %age of people are receiving the nine (including retinal screening) care key processes: 50%+ of Type 2 receive the annual tests but Type 1 is particularly low compared to national statistics.


  • Continue case funding work to identify undiagnosed patients e.g. vascular health checks and Diabetes Risk Score
  • Identification and management of pre-diabetes patients
  • Referral to Livewell Richmond services (lifestyle services)
  • Review GP locally commissioned service
  • Routine implementation of key care processes
  • Reduce the number of emergency admissions
  • Investigate the potential to share diabetes specialist nurses across practices – there are no community based diabetes nurses for domiciliary/home visits (though there is one at Teddington Memorial Hospital)
  • Embed NICE Quality Standards in provider contracts
  • Offer DESMOND as a key component of a diabetes package of care – referrals decreased and attendance dropped in the last year – perhaps this is down to its format – there is a need to work with GP nurses to get them on board.
  • Provide group education for non-English speaking groups
  • Review the provision of dietetic services and referral criteria
  • Offer options for non-face-to-face communication for on-going management
  • Better management in nursing and care homes as these have a high incidence of emergency admissions
  • Review integrated models of care from other clinical commissioning groups
  • Develop integrated community based diabetes services
  • Develop pathways to address multiple morbidity
  • Ensure the diabetes pathway is embedded in future Integrated Care organisation

Helen is now able to concentrate on diabetes services for the people of Richmond, as her team is no longer providing services for Hounslow.  Aimed at a more efficient way of working the pyramid model of care is used.

Tier 1 (base level)            Essential care – annual reviews – provided  by GPs and staff

Tier 2                          Enhanced essential care – some GP practices will provide enhanced care services e.g. initiate insulin, manage Type 1s, and foot care

Tier 3                          Specialist care – a consultant-led team will provide care for patients with more complex needs, (e.g. poor glucose control), provided in the community such as a community-based diabetes clinic, health centre or polyclinic e.g. Teddington Memorial Hospital, Queen Mary’s Roehampton

Tier 4  (upper level)  A consultant led team will provide specialist care and advice for patients with complex needs in hospital  – e.g. emergency admissions

What does the Future hold?

The key word is INTEGRATION, between

Clinical commissioning groups


Care providers

The patient

NICE et all

NHS England


In the pipeline

Helen mentioned

  • The greater liaison with the London Ambulance Service re the hypoglycaemia pathway
  • New initiative with DESMOND to be piloted in Richmond, more along the lines of the Expert Patient programme, being six sessions over a two year period. Do contact Helen if you would like to be involved.
  • Continuous Glucose Monitoring System – CGMS Gold Three Day Tracing – charitably funded to help those having trouble with their glucose control

The system consists of a 10p-sized sensor worn on the skin, and a "receiver" that looks similar to a traditional handheld meter that you wave over the sensor to wirelessly pick up data. Google Abbott FreeStyle Libre  for more information or try Abbott’s website.

Demand for this system, which reduces the need for finger prick testing, has been huge. Costs are around £100 per month