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Diabetes care in the NHS through commissioning - Seidu S, Khunti K


In line with the epidemic of overweight and obesity as a result of unhealthy lifestyles, the national burden of type 2 diabetes (T2D) is also high and is increasing rapidly (1). T2D is one of the biggest public health challenges of our time with an estimated 4.5 million people living with the condition in the UK (1). The burden of the disease and its complications are out- stripping the ability of the NHS to cope. In 2010/2011, a total annual cost of about £9.8 billion was attributed to the management Type 1 and Type 2 diabetes in the NHS with about 80% used for managing potentially avoidable long-term complications of the disease (2). Emergency admissions resulting from diabetes or its complications are an unexpected health event and could represent poor outcomes or failure to initiate or augment the management of a patient with diabetes at the appropriate time (3). Driven by the Quality and Outcomes Framework initiative started in 2004, initial improvements (4) in the care of people with diabetes have now reached a plateau across the population (5) and additionally, has not succeeded in reducing the variations in care (6, 7). New models of care are therefore being tested to cope with the increasing prevalence, poor outcomes and rising costs of people with T2D.

The need for primary care centered-models of diabetes care

Integrated specialist-community based clinics are now being trialed in the management of people with some complex diabetes problems. In Australia, an innovative integrated primary–secondary model of care for people with complex T2D demonstrated fewer admissions for diabetes-related complications than those receiving usual care (8). In the UK, this model of care has not been found to produce significant reductions in intermediate outcomes and yet incurring significantly higher primary care and community clinic costs (9). The use of well-trained, well-organised primary care teams, offering enhanced diabetes care, could potentially provide longer lasting benefits as continuity of care for the patient can be guaranteed closer to their home. 

In the Five year forward view of the NHS, the Sustainability and Transformation Plans’ (STP) are meant to set out coherent plans for delivery of integrated services across whole areas. They involve population-based accountable care models such as the Multi-Speciality Community Provider (MCP) model and The Primary and Acute Care System (PACS) model. Both care models are based on the GP registered list. PACS aim to improve the physical, mental and social health and wellbeing of its local population and reduce inequalities. This whole system care model joins up primary care, hospital, community, mental health and social care services to improve the health and wellbeing of the whole population. 

Diabetes as a chronic condition yields itself perfectly to this concept of integrated multidisciplinary model since most people with diabetes usually have several other multi-morbid physical and psychological conditions (10). Multi-disciplinary team collaborations in conjunction with various interventions have been shown to report consistency in improvements in HbA1c (11). In an MCP, practices come together in networks or federations and collaborate with other health and social care professionals to provide more integrated services outside of hospitals. The PACs and MCPs models will avoid the constraints in varying sources of funding for primary and specialist teams. The use of well-trained primary care teams in diabetes and its multi-morbid conditions could potentially be attractive to patients who would be guaranteed continuity of care from their primary care teams (12). 

Some examples of enhanced primary care diabetes models commissioned

Examples of enhanced primary care diabetes services along the principles of new PACs and MCPs models of care include the Leicester and the south Somerset models. 

In Leicester, the City Clinical Commissioning Group recently reconfigured diabetes services. Working together, various stakeholders developed an innovative care model that aimed to achieve an integrated diabetes service across community, primary and acute care resulting in a more cost-effective, accessible and high quality service for all patients. General practices in the city were classified as “enhanced” or “core”. The enhanced practices used well trained general practitioners and nurses to provide the diabetes service in their practices. The core practices provided a primary-specialist care service, delivered by usual general practitioners but supported by diabetes specialist nurses, dieticians and podiatrists, working under the supervision of diabetes specialists in the secondary care units in an integrated manner.  An evaluation of the impact of enhanced primary care diabetes package (a key part of the service redesign) on unplanned hospitalisations and length of stay for patients with diabetes (non-elective bed days) has shown some initial positive results (12). 

The Symphony Project in south Somerset is a model that intends to redesign the way in which patients with multiple needs are cared for; integrating primary care, acute care, social care, community services, mental health services, housing, education, voluntary sector and the local authorities. Enhanced primary care offering a broader range of proactive support at scale for patients with chronic condition such as diabetes is a key feature in that model.  


In the new NHS, commissioning diabetes services needs to be done through innovative models of care that consist of integrated multi-professional units but driven by enhanced primary care diabetes teams. This will ensure a population centred approach is provided close to the patients’ homes without compromising their quality of care. 


1. Diabetes UK. Diabetes in the UK 2016 Key Statistics on diabetes. Website: accessed 11th JAN. 2017. 

2. Hex N, Bartlett C, Wright D, Taylor M, Varley D. Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabetic Med. 2012;29(7):855-62. 

3. Stone MA, Charpentier G, Doggen K, Kuss O, Lindblad U, Kellner C, et al. Quality of care of people with type 2 diabetes in eight European countries: findings from the Guideline Adherence to Enhance Care (GUIDANCE) study. Diabetes Care. 2013 Sep;36(9):2628-38. 

4. Alshamsan R, Millett C, Majeed A, Khunti K. Has pay for performance improved the management of diabetes in the United Kingdom?. Primary Care Diabetes. 2010 Jul 31;4(2):73-8. 

5. Doran T, Kontopantelis E, Valderas JM, Campbell S, Roland M, Salisbury C, et al. Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework. BMJ. 2011 Jun 28;342:d3590. 

6. Millett C, Netuveli G, Saxena S, Majeed A. Impact of pay for performance on ethnic disparities in intermediate outcomes for diabetes: a longitudinal study. Diabetes Care. 2009 Mar;32(3):404-9. 

7. Millett C, Bottle A, Ng A, Curcin V, Molokhia M, Saxena S, et al. Pay for perfomance and the quality of diabetes management in individuals with and without co-morbid medical conditions. J R Soc Med. 2009 Sep;102(9):369-77. 

8. Zhang J, Donald M, Baxter K, Ware R, Burridge L, Russell A, et al. Impact of an integrated model of care on potentially preventable hospitalizations for people with Type 2 diabetes mellitus. Diabetic Med. 2015;32(7):872-80. 

9. Wilson A, O’Hare JP, Hardy A, Raymond N, Szczepura A, Crossman R, et al. Evaluation of the clinical and cost effectiveness of intermediate care clinics for diabetes (ICCD): a multicentre cluster randomised controlled trial. PloS one. 2014;9(4):e93964. 

10. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012;380(9836):37-43. 

11. Seidu S, Walker N, Bodicoat D, Davies M, Khunti K. A Systematic review of interventions targeting primary care or community based professionals on cardio-metabolic risk factor control in people with diabetes. Diabetes Res Clin Pract. 2016. 

12. Seidu S, Bodicoat D, Davies M, Daly H, Stribling B, Farooqi A, et al. Evaluating the impact of an enhanced primary care diabetes service on diabetes outcomes: A before–after study. Primary Care Diabetes. 2016.


Content provided by Seidu S & Khunti K 

Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK 

Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK 

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