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.
- £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.
- 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.