Community diabetes in South London

Abstract

Lambeth is an inner-city London borough with an ethnically and economically diverse population with a relatively high prevalence of diabetes. Forty-eight GP surgeries are supported for secondary care by two large, renowned teaching hospitals. A major reorganisation of care was undertaken in 2011, with a shift towards a highly integrated approach to multidisciplinary care delivered wherever possible in the community setting (hospitals continued to care for people with type 1 diabetes, advanced diabetes compilations, or current or planned pregnancy). Structural barriers to care delivery (e.g. bureaucracy relating to referrals) were identified and overcome. The integrated model provides a range of initiatives to improve patients’ self-care, including structured diabetes education. Educational sessions and ‘virtual clinics’ share experience and knowledge among healthcare professionals, and expert support is always available to GP practices. The last four years have seen an improved detection rate of diabetes locally, improved diabetes outcomes, a steady reduction in referrals to hospital diabetes clinics and a reduction in local admissions due to diabetes. Patient feedback is highly positive and the future of the service looks bright.