Providing the right care every time to prevent serious illness

Cut the risk of NW London residents developing a long-term illness through consistent, proactive and coordinated care, with diabetes and high-blood pressure as early priorities.

What we have achieved so far:

The NW London diabetes transformation programme has:

  • launched a new diabetes self-care website http://knowdiabetes.org.uk/ 
  • helped 3,088 patients control their cholesterol, blood pressure and blood glucose against the NICE targets for diabetes (since June 2017)
  • developed a collaborative care plan​ for 55,000 patients which provides coordinated care
  • won two Quality in Care (QIC) Diabetes Awards for - diabetes team initiative of the year - adults and prevention and early diagnosis. Read more here.
  • won two Healthcare Transformation Awards for - utilising digital transformation to manage population health and innovation in diabetes care. Read more here.
  • set up an advisory panel for people living with diabetes and/or their family and carers to help shape the future of personalised diabetes care across NW London.   

We will continue to:

  • increase proactive management of diabetes, supporting people to make positive lifestyle changes and better manage their own health
  • identify and treat more people with high blood pressure and irregular heartbeats
  • join-up care, data and expertise across GPs, community and social care and hospitals.

It is better for people because:

  • better blood-sugar control for people with diabetes will lead to significant reductions in kidney disease, blindness, amputations, heart attacks, strokes and early deaths
  • getting earlier treatment for high blood pressure and irregular heartbeats will lower people’s chances of having a stroke
  • people can be confident of getting the best care, at the right time, based on latest clinical evidence.

It is better for the health and care system because:

  • reducing diabetes-related complications could free up £10-20m over the next five years to reinvest in other services in NW London
  • better diabetes care would mean 65 people every day could be at home in NW London, and not in a hospital bed.

Key facts:

  • £340m is spent on NW London residents with diabetes  - that’s around ten per cent of our total NHS spend
  • over a quarter of emergency overnight stays in hospital are for people with diabetes
  • diabetes is a significant factor in stroke, heart and kidney problems, and amputations
  • over 2,000 people had a stroke in NW London in 2015-16
  • average NHS costs for treating someone who has suffered  a stroke is around £12,000, and follow-up social care is a further £6,800 a year.

Expected outcomes:

  • prevent over 200 strokes due to irregular heartbeats in year one, and over 400 by year two
  • tackling high blood pressure could prevent a further 358 strokes over next five years
  • 20 per cent fewer deaths, 14 per cent fewer heart attacks and 12 per cent fewer strokes related to diabetes.