The West of England AHSN and Bath, North East Somerset, Swindon and Wiltshire CCG (BSW CCG) are reaching the end of a 12-month project to improve care for patients with type 2 diabetes.

Since the project launched in February 2021, a community of practice has been established with 174 members from 58 practices alongside secondary care staff.  22 practices have made positive changes as a result of the project thus far, with a further 44 practices continuing to implement changes. Interim results show the percentage of BSW patients with type 2 diabetes in the high-risk category has reduced from 33.3% to 28.9%.

Hear more in this short video from Wiltshire GP and BSW CCG Diabetes GP Champion, Dr Julia Hempenstall:


The project used an innovative care framework which aims to support those living with type 2 diabetes. Multiple long-term condition frameworks, developed by UCL Partners, are freely available and they help practices manage large numbers of patients with long-term conditions, whilst empowering the primary care workforce and the patients themselves. This ten-minute summary video from UCLPartners outlines the approach and resources available.

BSW CCG chose to adopt this approach, utilising education and training, as part of a multidisciplinary team, with a focus on supporting practices with the greatest treatment gap and in areas of greatest deprivation. A treatment gap is the actual versus the target % of the population whose treatment has been optimised.

The AHSN have provided project management, developed local implementation resources and facilitated workshops and virtual events.

So far:

  • 58 practices have joined the community of practice
  • Seven BSW primary care networks have all their practices either implementing or engaged with the approach
  • 22 practices are implementing the approach with more planning to start in April 2022
  • 33 delegates have attended motivational coaching training

The community of practice aims to connect clinicians across the CCG to improve their confidence in diabetes management and add a sense of belonging following two years of changes to usual work practices due to the pandemic.  With these improved connections, practice resilience, workforce capacity and integrated diabetes care can also flourish.

Brian Leitch, Commissioning Manager at BSW CCG said:

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

An Advanced Nurse Practitioner working on the project said:

“This has streamlined how we work, reduced the burden on the practice through calls as well as helped support patients to become more responsible for their care. We have identified issues and improved staff and patient awareness of diagnosis as well as treatment of diabetes”

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

“The care frameworks have been a fantastic launch pad for us to support primary care colleagues in BSW. They offer a great opportunity to consider redesigning delivery of care, providing those with diabetes, and other long-term conditions, 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.”

BSW CCG will continue to progress the improvement programme with longer term impact measures reviewed in the next 12 months, including:

  • Reduced number of practice visits
  • Improvement in patient satisfaction
  • Downward trend in numbers of high-risk patients
  • Changes in medication and potential cost savings

The West of England AHSN will continue to support the roll out of long term condition care frameworks through a new blood pressure optimisation programme. The programme aims to prevent heart attacks, strokes, and vascular dementia in patients with hypertension.

Find out more about the West of England’s work to support those with long term conditions by contacting us.

Posted on March 22, 2022

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