Pennine GP Alliance is highlighting how its diabetes support service has already been helping GP practices meet new national diabetes care requirements introduced in February this year.
Recent changes to the national Quality and Outcomes Framework (QOF) mean that GP practices must now ensure that all eight diabetes care processes are completed to receive funding for diabetes care. Previously, practices could receive funding even if some checks had not been completed.
The updated requirements place greater emphasis on personalised care and proactive support to help patients attend essential checks – an approach that PGPA has already been delivering for the past 18 months through its diabetes support service for practices across Calderdale.
Supporting practices and patients
PGPA’s diabetes project provides free support to GP practices who choose to opt into the service, helping them identify patients who may have missed important diabetes checks and supporting them to attend appointments.
The service includes a Diabetes Care Coordinator and Diabetes Nurse, working together with GP practices to provide targeted, personalised support for patients – particularly those living with type 2 diabetes who also have a learning disability (LD) or severe mental illness (SMI).
Using digital searches and reporting, PGPA’s team can identify patients who have not completed one or more of the eight required care processes in the last 12 months. The team then works directly with practices and patients to help ensure those checks are completed.
This might include:
- Investigating why patients have not responded to automated recalls
- Contacting patients directly to understand barriers to attendance
- Booking appointments on behalf of practices
- Sending reminders and coordinating follow-up support
- Providing advice and reassurance through clinical input from the diabetes nurse
This proactive and personalised approach helps patients access essential care while also reducing pressure on GP practice teams.
Targeted support for patients with additional needs
The service was launched in 2023 as part of a three-year, health inequalities funded, project focused on improving diabetes care for people living with type 2 diabetes who also have learning disabilities or severe mental illness.
The programme has already supported eight GP practices across Calderdale and introduced a range of improvements to help patients better understand and manage their condition.
These include:
- Easy-read information leaflets explaining diabetes checks such as blood tests, eye screening, urine tests and foot checks
- Collaboration with the national diabetes eye screening programme and local foot screening services to support reasonable adjustments
- Postal urine testing kits with follow-up calls to increase completion of commonly missed checks
- Access to one-to-one diabetes education with dietitians
- Practical physical activity resources designed for people with learning disabilities and severe mental illness
What the data tells us
Data from GP practices participating in the diabetes project between 2024 and 2026 shows a significant improvement in the completion of all eight diabetes care processes.
Before support from the PGPA Diabetes Care Coordinator and Diabetes Equality Nurse, an average of 37.8% of patients had all checks completed. This increased to 47.3% during the intervention period and rose further to 54.2% once new systems and processes were embedded in practice.
Overall, this represents an improvement of 16.4% percentage points, demonstrating the positive impact of practices engaging with the PGPA diabetes project to support their patients.
Real impact for patients
The project has already helped patients who had missed key checks for many years. One patient who had previously missed urine, foot and blood tests received coordinated support from the PGPA diabetes team and care home staff, resulting in all checks being completed earlier this year.
Another patient who had not had essential diabetes tests since 2018 was supported through phone calls, postal sample kits and care coordination to successfully update all their blood pressure, kidney and urine tests.
Supporting practices to meet new requirements
As QOF requirements evolve, PGPA’s service is helping practices ensure that patients receive all eight recommended care processes while also supporting practices to meet the updated indicators. The team can also provide guidance and training on the clinical coding used to record diabetes care processes so that practices can accurately capture the work being completed.
The Practice Manager at Boulevard Medical Practice in Halifax complimented PGPA’s service:
“I will say that the support we have received has been good and helped us to put more hours into recalling this specific cohort of patients.”
Will Menzies, Chief Executive at Pennine GP Alliance, said:
“The recent changes to QOF highlight the importance of personalised, proactive diabetes care.
“Through this project we are already supporting practices and patients in exactly this way – helping people access essential care checks while reducing pressure on busy GP teams.
“We are proud of the progress made so far and look forward to continuing this work with practices across Calderdale.”
Looking ahead
Now that the project is in its third year, PGPA will continue working with practices across Calderdale to improve diabetes care processes, support lifestyle improvements and ensure long-term sustainable improvements for patients living with diabetes and additional health needs.