Download: Summary Success Story (PDF 195KB) / Full Success Story (PDF 162KB)

The challenge:

Over 8000 people in Milton Keynes have diabetes. As part of a Health Foundation project that stemmed from a wider practice based commissioning (PBC) initiative, Milton Keynes PCT identified diabetes as a key area to implement evidence-based PBC that would lead to improvements in care and patient outcomes. They wanted to deliver diabetes care closer to patients and retain secondary care services for those patients with more complex needs. This meant they needed to up-skill primary and community care health care professionals and set up an interim team to oversee the process of change.

The aim:

The aims of the project were to replace existing routine diabetes services with a community based programme and to move care from the hospital setting and closer to people’s homes. The PCT wanted to introduce changes to the services which could then be audited, with patients having their say on whether the changes made a difference.

What did they do?

A multidisciplinary interim diabetes team was set up, comprising GPs, a diabetes specialist nurse, a practice nurse and a team manger. They also had input from consultants. The team’s job was to to support the care of people with diabetes in primacy care.  In order to do this they needed to put in place some key elements to up-skill primary care practitioners. These included:

The total cost of the project was £180,000.

What changed?

16 out of 29 practices are now signed up to the care planning locally enhanced service (LES) scheme with five more working towards this. 25 out of the 29 practices are now trained in care planning. 14 practices are signed up to the insulin LES. Health care assistants from 22 practices have received education in diabetes. It is anticipated that more than 500 people with diabetes benefited from the service in 2009/10.