Pennine GP Alliance (PGPA) is proud to announce the successful progress of its diabetes support project within Primary Care, which helps people living with type 2 diabetes who also have a learning disability (LD) or severe mental illness (SMI). The initiative is increasing patient access to essential diabetes care checks and supporting patients to better manage their condition.
Launched in 2024, the three-year project aims to:
- Improve patient attendance at diabetes care appointments.
- Identify and implement reasonable adjustments for patients with LD and SMI.
- Share learning and improve processes to leave a lasting legacy.
Year 2 Highlights
- The project has expanded beyond expectations, supporting 8 local GP practices across Calderdale.
- PGPA’s Diabetes Nurse and Diabetes Care Coordinator have built strong relationships with patients and staff, supporting better uptake of care processes.
- 6 updated easy-read leaflets ensure patients understand the importance of blood tests, eye checks, foot checks, and urine tests.
- Collaboration with the national Diabetes Eye Screening Programme (DESP) and local foot screening services has improved access and reasonable adjustments for patients.
- Postal urine sample kits with follow-up calls have significantly increased completion of often-missed care checks.
- Patients now have access to one-to-one diabetes education with dietitians, addressing previous inequalities in support and guidance.
- New resources promote practical physical activity, tailored for people with LD and SMI.
Impact Stories
A patient who had missed key urine, foot, and blood tests received coordinated support from the diabetes project team and care home staff, resulting in all checks being completed by January 2026.
Another patient who had not had essential tests since 2018 was supported through phone calls, postal sample kits, and care coordination, successfully updating all blood pressure, creatinine, and urine tests.
Looking Ahead – Year 3
- The project will engage remaining practices, continue supporting lifestyle improvements, and review progress to ensure sustainable improvements across Calderdale.
- Targeted support will be provided for patients whose blood sugar (HbA1c) or blood pressure readings remain above recommended levels.
Will Menzies, PGPA Chief Executive said:
“This project shows how tailored support and collaboration with GP practices can make a real difference for patients with diabetes and additional needs. We are proud to see measurable improvements in diabetes care and confident that the project’s legacy will benefit patients for years to come.”