Dr Caz Sayer, Camden Clinical Commissioning Group chair and Dr Lance Saker, Camden Clinical Commissioning Group vice chair, outline how local health, social care and third party partners worked together to create a diabetes integrated practice unit that is improving patient outcomes, preventing hospital admissions and reducing unnecessary system costs.
Camden, North London, has a diverse population with a large ethnic minority community. One in seven people living in the borough has a long-term condition, of which diabetes is the third most common
People living with diabetes in Camden reported fragmented care across a complex number of providers and had poor diabetes control, leading to excess early complications. Diabetes prevalence figures in Camden were low, suggesting an undiagnosed population and significant unmet need. The provision and capability of general practice to offer community-based care was also variable, with a reliance on hospital-based care to access specialist advice.
Population health management work undertaken by the CCG, segmenting populations and looking at how to better tailor services to meet the needs of different groups, showed that supporting people to manage their diabetes well through community services not only improved patient outcomes but also reduced unnecessary hospital attendance and admissions. This approach is reflected in national and international evidence showing three key strands to improving outcomes:
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