Integrated diabetes care : Coventry and Warwickshire approach

The rapid increase in the prevalence of diabetes is not abating across the world. The cost burden of managing diabetes and its complications is putting significant strain on healthcare resources worldwide. Increasingly large proportions of patients with diabetes, including those with complications, are managed by primary care. This has resulted in disjointed as well as huge variation in care, even in managed care systems and the National Health Service (NHS) in the UK. Several attempts have been made to manage patients in the community, such as the widely adopted GPwSI (GP with special interest) model in the UK but with no real evidence of its clinical or cost-effectiveness. The data on cardiovascular risk factors has been captured comprehensively since the introduction of quality outcomes framework (QoF) in the UK. However, longitudinal data has not been utilised to proactively identify and improve individualised care due to the lack of joined-up care, particularly the digital integration of data. To address these issues, we designed two separate projects: a cluster randomised trial of intermediate care clinics in diabetes and proactive identification and management of diabetes patients through a novel web-based digital integration of the data from 12 general practices. The cluster-randomised trial was an ambitious attempt and highlighted the difficulties of conducting large scale RCTs with a high number of follow-up rates. It did however show the importance of team-change, need for local champions and proactive case-finding approach to drive improvements in chronic diseases such as diabetes. The innovation project showed that proactive case-finding and individualised care plan development is feasible utilising existing resources if technology is adopted and used. For this to be sustainable, upskilling of the primary care with tailor made educational workshops, acceptance by the commissioners and providers in the healthcare economy are needed