Bringing care closer to home in Bexley

Download: Success Story Summary (PDF 220.2KB) / Award Entry Form (PDF 241.7KB)

The challenge 

Lakeside Medical Practice is a GP surgery in Thamesmead, Bexley serving more than 15,000 patients – 737 of whom have diabetes. Deprivation, ill health and disability are higher in Thamesmead than the rest of Bexley. People with diabetes referred by Lakeside to specialist diabetes services were failing to attend appointments; as a result their diabetes control was poor. The team at Lakeside wanted to develop local services closer to home with a view to improving outcomes for diabetes patients. 

The aim 

The team identified three key objectives:

• Improve essential care by developing practice staff knowledge and skills
  
• Provide structured patient education programmes and create cohesive follow-up care plans for type 2 diabetes patients
  
• Link in with Bexley’s diabetes practice development team and engage with patients/patient groups 
  

What did they do? 

There were key actions for each objective. To improve care by enhancing staff knowledge and skills a diabetes specialist nurse (DSN) was employed to work with practice staff to facilitate insulin conversion clinics and embed learning. The DSN also worked with healthcare professionals in the team to support patients with poorly-controlled diabetes. One nurse practitioner, one practice nurse and two GPs were trained to be able to initiate insulin at the practice and insulin conversion clinics take place regularly at Lakeside. 

To support patient education, Lakeside ran the nationally-recognised structured education programme, XPERT, for people with type 2 diabetes. They were also one of the first surgeries in the borough of Bexley to implement the Year of Care scheme to support the development of care plans. 

To make the most of the support offered by Bexley diabetes practice development, a GP or practice nurse from Lakeside attends the monthly network meeting, giving them the opportunity to discuss diabetes services with consultant, nurses, members of the Bexley practice diabetes team, podiatrists, lead GPs, nutritionists and patient representatives. Lakeside also took part in an insulin audit run by the practice development team. The practice has also improved links with patients. The practice nurse attends the Diabetes UK local patient group, which is attended by more than 100 people. The surgery has carried out patient questionnaires to help them tailor patient-centred services to best meet patient needs. 

What happened? 

727 of 737 diabetes patients are now treated from the surgery. There has also been a dramatic improvement of patients’ HbA1c levels. Before starting insulin initiation at the practice, patients’ mean HbA1c was 9.5%. After six months, HbA1c levels had dropped to a mean of 8.2%. The XPERT programme has been attended by 20% of Lakeside’s type 2 diabetes patients. After attending the course, patients have reduced their HbA1c from an average of 8.6% to 7.8%. 

The results of the insulin audit showed 26% of people with type 2 diabetes are controlling their diabetes without medication. Of these, 87% have an HbA1c below 7%. It also highlighted the need to improve blood pressure (BP) levels and as a result the team implemented more frequent monitoring of blood pressure and titrating medication as per NICE guidelines. 

Bexley diabetes practice team also use Lakeside as an example of best practice when sharing diabetes service redesign ideas at conferences, events and workshops.

Key outcomes

• 98% of diabetes patients treated by the surgery
  
• Following insulin initiation by GP practice, HbA1c levels have fallen on average by 1.3%
  
• Patients completing XPERT programme reduced HbA1c by 0.8%