This site is intended for health professionals only


Case study: Providing complex diabetes care at PCN level

Case study Providing complex diabetes care at PCN level

Case study: Clinical director of Herne Bay PCN, Dr Jeremy Carter, outlines the diabetes pilot at his network of two practices covering 41,500 patients in coastal Kent.

Herne Bay PCN is currently engaged in an East Kent health and care partnership diabetes multi-disciplinary team (MDT) pilot, looking to provide diabetes care for our more complex and poorly controlled diabetic patients. It combines expertise from all our local providers, in a PCN level service.       

Diabetes has been a clinical priority for our PCN from the outset, predominantly due to the high prevalence of diabetes in our population. We had identified that while there were many services for our diabetic patients, spanning our own PCN GP practices, Kent Community Health NHS Foundation Trust (KCHFT) and East Kent Hospitals University NHS Foundation Trust (EKHUFT), as well as a number of other organisations, such as the Paula Carr Diabetes Trust, often these services were fragmented, and working in isolation, with patients attending multiple independent appointments, assuming they even engaged in the care offer in the first place.    

In 2020, our PCN started a project to provide network level diabetes care with joint working across practices within the PCN, as well as collaborating further with our community provider KCHFT.    

We also looked to adopt a population health approach, with risk stratification and tailored care accordingly. Initially, this PCN project focussed on relationship building within the teams who provide care to our patients in the PCN, namely our practice diabetes nurses, the community diabetes specialist nurses, as well as the community nurses who regularly see our housebound patients.   

With better relationships, we expected to be able to progress to more collaborative working, rather than the often parallel working that existed. At the same time, the East Kent health and care partnership (HCP) – within Kent and Medway ICS) - identified diabetes as a priority area, with a view to developing the entire model of diabetes care, based on a hub and spoke model, that had already been demonstrated in other areas, including an MDT model of care approach for our more complex diabetes patients. Herne Bay was identified as an early adopter of this model of care, on account of the prevalence (third highest in the ICS), and our existing work. 

The HCP diabetes model encompassed a number of aspects, including insulin pumps for example; our PCN was focussed on the MDT element of the diabetes plan. As part of this, the HCP was keen to have comprehensive patient and wider stakeholder engagement in the development of this service.  This extensive work done by the East Kent HCP was subsequently recognised by Healthwatch Kent and Medway with an award for excellence in involving people in commissioning and delivery of services.  

The essence of the MDT model that resulted from the engagement work is to provide diabetes care for our most complex and poorly controlled diabetic patients (case selection set as HbA1c >70) with a collaborative, joint-working approach.  We hold weekly face to face joint clinics based at our local community hospital, Queen Victoria Memorial Hospital, where we have obtained access to consulting space. Both our PCN office and some PCN consulting space, as well as the KCHFT team are based here, and strategically as a PCN we are trying to develop this venue as the centre for our PCN level services where possible. The combined team see patients from across the PCN, involving practice diabetes nurses, community specialist diabetes nurses, dietitians, and access to podiatry, and improving access to psychological therapies (IAPT) services, as well as to our local One You lifestyle support service.  

Housebound cases are also discussed in the MDT, to give the same expertise of care to those who cannot attend; the community nurses who look after the patients usually attend those meetings.     

As far as possible, this is a comprehensive clinic, with all work up investigations carried out before the clinic date, thus ensuring all the diabetes standards of care ​are met for all patients who attend the clinic.    

The clinic has very low non-attendance rates. There is a proactive patient selection and booking system, led by the practice diabetes nurses, who explain the MDT process, and encourage attendance. Our experience is that this direct intervention by clinicians, rather than sending letter invitations for example, has been well received by patients, and has led to good engagement including in those who previously had been harder to reach, or who were not routinely accessing care.  

On a monthly basis, this team comes together for a wider MDT clinic including a PCN GP, and a consultant diabetologist from the acute trust, to discuss the most complex cases, where treatment plans and clinical decisions can be made. 

By doing this, we hope the MDT model will achieve two outcomes. Firstly, diabetes care will improve, resulting in better health outcomes for our patients. Secondly, and in my view just as importantly, is the true collaboration of PCN level clinicians form multiple providers, sharing ideas, learning and developing knowledge and skills. For too long we have talked about breaking down silo working, and collaboration, but this is genuinely providing a team of staff from multiple employing organisations, all with the same goal, namely working together as the ‘Herne Bay Diabetes MDT’ with our patients.​ 

Clinical outcomes for any change in diabetes care have to be viewed on multiple time-lines. Often, the health system will look for near-term savings in order to justify investment, yet for diabetes, many of these savings may not materialise for many years, when the amputation, or dialysis treatment, for example, is then prevented. Of course, this has not been running long enough show any impact on these longer-term outcomes.  We do have a number of near-term outcomes though, which are very encouraging.   

It is hoped that if these results continue, and are maintained, then one could suggest that the longer-term health benefits to our patients (and therefore savings to the health economy) will occur.   

Data from April 2022 show patient reported confidence in managing their diabetes improved 32% after engaging with the MDT clinic. Three month follow up Hba1c data after MDT clinic attendance has shown 62% of patients showing a reduction in HbA1c, with some stand-out reductions of 144 to 60, and 108 to 56. 

Given that the cohort of patients attending this clinic have been the most difficult to control in the framework of the existing service provision, and who often had barriers to accessing this care, this new model of care certainly seems, from early data, to have provided significant benefit to this specified population.      

Importantly, as clinical director of the PCN, the true collaboration and team ethos of all our clinicians, managers and support staff involved in this project is most inspiring. Having developed a genuine relationship-based team, who know each other, working together towards the same objectives regardless of which organisation they are employed by, is extremely encouraging; not only for this project, but for developing collaborative working across other clinical areas moving forward.