NHS case studies

Integrated Practice Unit, Camden

Working closely with the Clinical Commissioning Group, Diabetes & Wellbeing helped to reshape diabetes services across Camden.

The goal has been the same from day one: improved patient outcomes.

Our work has incorporated:

  • the development of an enhanced diabetes model in primary care, and
  • clinical work in primary care

We supported the service redesign, project management and implementation of a new service model.

An important part of the project was to ensure all staff were fully involved in the changes and their implementation.

To that end we developed an initial training framework and introduced coaching and mentorship schemes as part of ongoing workforce development.

Meanwhile we developed and delivered education modules tailored to individual GP practice requirements.

We were honoured to represent the IPU at the QIC Diabetes 2015 awards as winners of ‘Best initiative to reduce variation in diabetes care’


Sunderland GP Alliance

Diabetes & wellbeing worked with the GP Alliance to meet specific objectives:

  • Facilitate engagement of primary care clinicians with insulin initiation and management training
  • Provide clinical mentorship and support for clinicians in line with agreed competencies
  • Provide in-house support for patients via facilitated and virtual clinics
  • Support the development and implementation of local diabetes care maps for use on map of medicine
  • Support the GP Alliance to develop a blueprint for ongoing diabetes service model redesign informed by pilot findings

St Martin’s Practice, Leeds

Helen has worked in the practice since 2017. She delivers nurse-led clinics for patients with complex diabetes, and provides mentorship and support to GPs and Practice Nurses.

Ashwell Medical Centre, Bradford

Rebecca worked in the Level 2 diabetes service delivering nurse-led clinics for patients requiring injectable therapy initiation and management. She worked closely with the practice team to achieve clinical outcomes for their patients and those referred by neighbouring practices.

The Caversham Group Practice, Camden

Helen worked in the practice from 2015 to 2017. She delivered nurse-led clinics for patients with complex diabetes, and provided education and training to GPs and Practice Nurses. Helen also carried out audits to identify areas for improvement and supported the practice to achieve clinical outcomes.

County Durham and Darlington NHS Foundation Trust

Diabetes & Wellbeing worked as part of the secondary care team.

Our staff became part of a specialist diabetes multi-disciplinary team for several months, to deliver patient care in in-patient setting.

James Wigg Practice, Camden

We worked with the practice in 2016 to implement treatment plans for high risk patients in nurse-led clinics. We acted as a resource for GPs and Practice Nurses to discuss patient management plans, and advised the practice on improvements to their diabetes services.

Fartown Green Road Surgery, Huddersfield

We worked with the surgery to

  • identify high risk patients with type 2 diabetes
  • set up and deliver designated diabetes clinics
  • advise on management plans
  • and implement treatment changes – both oral and injectable therapies.

Moorlands Surgery, Darlington

This GP practice has its own diabetes team, and was looking for support with complex patients.

We provided mentorship, working alongside practice nurses to create high risk clinics for patients with poorly controlled patients.

By troubleshooting the systems in place we were able to recommend management plans for future diabetes care.

And we researched and audited cost-effective treatment options for the surgery.