Practice receives RCGP award for successfully targeting patients at risk of diabetes

A practice in Lancashire that has effectively reduced the risk of patients developing diabetes has been recognised by the RCGP.

Darwen Health Centre's business manager Ann Neville (left) and advanced nurse practitioner Debbie Yates receive the RCGP's Bright Ideas award from college president Dr Terry Kemple

Darwen Health Centre is one of four recipients the college’s inaugural Bright Ideas Award, which highlight examples of frontline innovation in general practice that can have a big impact.

The practice started its initiative, which proactively targets patients with pre-diabetes, in 2015 after being incentivised by NHS Blackburn with Darwen CCG. It was initially expected to be a two-year plan, but  Darwen Health Centre business manager Ann Neville said the aim was for the scheme to be as sustainable and innovative as possible and it is now in its third year.

Under the programme all patients with HbA1c results that fall in the pre-diabetic range are invited to attend an appointment to discuss the results where they are given dietary and lifestyle advice. Two further monthly reviews are held and another blood test given in the third month to see if there is any improvement.

The practice put in place steps to identify patients with pre-diabetes. All patients with a pre-existing chronic disease were screened for diabetes and opportunistic screening takes place for people considered at-risk, such as those who are overweight. Monthly EMIS Web searches also capture patients who have bloods within the specified range but haven’t attended an appointment.

These steps saw the number of patients on the practice's register of pre-diabetic patients increase from 85 to 546.

As part of the project, healthcare assistants and practice nurses received training from the DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) programme. Upskilling HCAs allows them to undertake the reviews with pre-diabetic patients, so practice nurses and advanced nurse practitioners can focus on managing patients already diagnosed with diabetes.

Data from July 2017 has shown that, out of bloods completed, 46% of patients had an improved HbA1c level, while 45% saw levels stabilise in the low range. A total of 45 patients saw an increase in their HbA1c level but still remained in the pre-diabetic range and only a handful of patients went on to become diabetic. Overall, 111 patients have moved out of the risk range for diabetes.

Preventive action

Advanced nurse practitioner Debbie Yates who set up the programme said: ‘We wanted to take preventive action, make patients aware that they are at of risk becoming diabetic and give them advice to reduce that risk.’

Ms Yates said the initiative would be straightforward for other practices to adopt. ‘Screening can be incorporated into health checks and chronic disease recall. Group consultations could also help the process,’ she said.

‘We found that our patients have better outcomes attending health education appointments in-house with staff they trust than if they were sent to an external group.’

Darwen Health Care won the RCGP Bright Ideas award for England. Other winners at the awards were:

  • Scotland: Dr Andrew Mackay from St Triduana's Medical Practice in Edinburgh, for introducing a simplified care-planning approach to delivering care to new care home residents who lack the capacity to make decisions concerning their welfare.
  • Northern Ireland: Dr Louise Sands, from the Northern Ireland Medical & Dental Training Agency, who produced an e-booklet for newly-qualified GPs.
  • Wales: Steffan Gimblett, practice manager at Pontardawe Primary Care Centre in Swansea, for introducing QR info pods for patients, including links to online services.

RCGP chair Professor Helen Stokes-Lampard said: ‘We want new approaches to be recognised, celebrated and shared extensively; this will inspire other practices to both adopt and implement Bright Ideas that have proved successful elsewhere, and encourage them to think of new Bright Ideas themselves.’

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