A Bath & North East Somerset, Swindon and Wiltshire (BSW) Diabetes Community of Practice was launched in May 2021 to provide support and resources to primary care teams wanting to proactively manage patients through the use of risk stratification and improvement methodology.

The Community of Practice (CoP) is facilitated by GP Champions who are passionate about improving patient care and making changes that improve workflow and staff satisfaction. Set up by the West of England AHSN and the BSW Clinical Commissioning Group (CCG) Diabetes team, the CoP allows all Primary Care Diabetes Practice Teams in BSW to share learning and access support as they redesign routine care to prioritise patients at the highest risk of deterioration.

Dr Julia Hempenstall, Wiltshire GP and BSW CCG Diabetes Champion said:

“This piece of work is vital as we rebuild our diabetes care following the experiences of the COVID pandemic. I couldn’t be more excited that the project is focussed on the practices discussing their own hopes for their diabetes care and setting their own goals.”

Brian Leitch, Commissioning Manager, BSW CCG said:

“As commissioner for diabetes, it’s been great watching practices come together on their own terms in the CoP, to share information and resources and to discuss how to best support their patients”.

What does the BSW Diabetes Community of Practice hope to achieve?

  • The right staff seeing the right patient at the right time – which in turns helps to manage the increasing workload clinicians are faced with;
  • Increased attainment of diabetes care process and treatment targets;
  • Improved access to clinical training and guidance;
  • Increased access to diabetes self-management resources and tools and
  • To build a peer network of primary care colleagues who specialise in diabetes to share problems, find solutions and celebrate successes.

Jo Ross, Diabetes Prevention Coordinator at NHS BSW CCG said:

“The CoP has been really beneficial to increase practice awareness of the National Diabetes Prevention Programme and support practices to refer patients to it”.

How are teams in the Community of Practice supported?

Teams have access to a bundle of free resources to use data to risk stratify diabetes care. The resources include access to training, project management resources and improvement, conversation guides, curated educational material and condition specific risk stratification searches.

This ten minute summary video from UCLPartners outlines the risk stratification approach and resources available in the Proactive Care Frameworks:

What are the Proactive Care Frameworks?

The Proactive Care Frameworks have been developed by UCLPartners to help practices to identify patients with specific long-term conditions who need priority care, and those whose care can safely be delayed to enable management of patients post-COVID-19. The frameworks are freely available and are currently being implemented in General Practices across the country for conditions such as Type 2 Diabetes, Cholesterol, Asthma and COPD. The BSW Diabetes Community of Practice will support practices to access and implement the Type Two Diabetes framework.

Kay Haughton, Director of Service and System Transformation, West of England AHSN said:

“The Proactive Care Frameworks have been a fantastic launch pad for us to support primary care colleagues in BSW and are a great opportunity to consider redesigning delivery of care, providing those with Diabetes greater autonomy and support in self-management. It has been a privilege to work with our CCG and primary care colleagues to help transform services for people who have Diabetes.”

Feedback from those involved in the CoP:

A GP said “Health Care Assistant training can help address the skills gap in Practice Diabetes Teams for screening low risk patients and reduce waiting times to see the Diabetes Specialist Nurse or GP”.

A Health Care Assistant said “The motivational coaching workshops were really useful for all forms of work, and can help me to be a more supportive colleague and friend.”

How do I find out more and get involved?

To find out more about the BSW Diabetes Community of Practice you can watch this 45-minute information webinar:

Read more about our work on Proactive Care Frameworks for long term conditions.

If you would like to join the Community of Practice or have any questions about the project, please contact Kate Phillips, Senior Project Manager: Kate.Phillips17@nhs.net


Posted on August 16, 2021

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