“I felt that my whole lifestyle was being treated/cared for and that was good. The symptoms of diabetes weren’t something that was treated separately but included in working out how my lifestyle could make management of diabetes better. I left feeling I’d been listened to properly and what I had to say had been heard and not dismissed.”
Patient feedback
Three Years of Improving Diabetes Care for People with Learning Disabilities and Severe Mental Illness
As Pennine GP Alliance’s (PGPA) three-year Diabetes Equalities Champion project draws to a close later this year, it is leaving a lasting legacy for patients, GP practices and the wider health system across Calderdale.
For many people living with type 2 diabetes alongside a learning disability (LD) or severe mental illness (SMI), attending routine diabetes appointments can be challenging. Over the past three years, PGPA’s Diabetes Nurse and Diabetes Care Coordinator have worked alongside patients, carers and GP practices to remove these barriers, helping more people receive the essential diabetes checks they need to stay well.
The project has not only improved access to care for patients but has also helped practices develop more joined-up, sustainable ways of delivering diabetes services that will continue long after the project ends.
Why the project was needed
Around 520 people across Calderdale are eligible for an annual physical health check because they have a learning disability or severe mental illness and also live with type 2 diabetes.
Many of these patients were not receiving all eight recommended diabetes care processes – the tests, examinations and screenings needed to effectively monitor and manage their condition. Missing these essential checks can increase the risk of serious complications, poorer long-term health and avoidable hospital admissions.
Recognising these inequalities, PGPA launched the Diabetes Equalities Champion project to provide personalised support for patients while working with practices to improve processes and reduce barriers to care.
A personalised approach
Working closely with GP practices, the Diabetes Nurse and Diabetes Care Coordinator have provided tailored support for patients who may otherwise have struggled to engage with routine diabetes care.
Support has included:
- Contacting patients to understand barriers to attending appointments.
- Coordinating appointments and follow-up care.
- Identifying and implementing reasonable adjustments.
- Working with carers, families and care home staff.
- Providing accessible, easy-read information to improve understanding.
- Supporting patients to build confidence in managing their diabetes.
Alongside direct patient support, the team has also worked with practice staff to develop more effective systems that improve patient care and reduce administrative burden.
Supporting GP practices
The project has supported eight GP practices across Calderdale, helping teams identify patients who had not completed one or more of their eight diabetes care processes.
Together with practices and partner organisations, the team introduced a number of improvements, including:
- Easy-read patient information explaining diabetes blood tests, urine tests, eye screening and foot checks.
- Closer collaboration with the National Diabetic Eye Screening Programme and local foot screening services to improve access and provide reasonable adjustments.
- Postal urine testing kits with follow-up support to improve completion of commonly missed checks.
- One-to-one diabetes education with specialist dietitians.
- Tailored physical activity resources for people living with learning disabilities and severe mental illness.
- Support for GP practices with clinical coding and recording of diabetes care processes.
The project has also aligned closely with the updated national Quality and Outcomes Framework (QOF), supporting practices to ensure more patients receive all eight recommended diabetes care processes.
Making a measurable difference
The project has delivered significant improvements across participating practices.
Between 2024 and 2026:
- Completion of all eight diabetes care processes increased from an average of 37.8% before the project began to 54.2% once new systems and processes had been embedded.
- This represents an overall improvement of 16.4 percentage points.
- Hundreds of patients have received personalised support to access essential diabetes care that they may otherwise have missed.
These improvements mean more patients are receiving the checks they need to better manage their diabetes, reducing their risk of complications and supporting healthier, more independent lives.
Changing lives through personalised support
Behind every statistic is a person whose health has improved because they received the right support at the right time.
One patient who had previously missed urine, foot and blood tests received coordinated support from the Diabetes Equalities Champion team and care home staff, enabling all outstanding checks to be completed.
Another patient had not completed essential diabetes monitoring since 2018. Through personalised phone calls, postal urine testing kits and coordinated appointments, the team supported them to complete all outstanding blood pressure, kidney function and urine tests.
These stories demonstrate how personalised support and simple adjustments can remove barriers that have existed for years.
A lasting legacy
Although the funded project comes to an end during 2026, its impact will continue.
The programme has shown that personalised, proactive care can reduce health inequalities while creating more efficient ways of working for GP practices. The relationships built with patients, the improvements made to practice processes and the resources developed throughout the project will continue to benefit people living with diabetes across Calderdale.
The learning from the project will also help shape future approaches to supporting people with long-term conditions, ensuring that those most at risk of poorer health outcomes receive the care and support they need.
Will Menzies, Chief Executive of Pennine GP Alliance, said:
“Over the past three years, this project has shown that improving health outcomes isn’t simply about offering appointments – it’s about understanding each person’s circumstances and removing the barriers that prevent them from accessing care.
“The dedication of our Diabetes Equalities Champions, alongside the commitment of our GP practices and partners, has resulted in meaningful improvements for patients while creating sustainable ways of working that will continue to benefit Calderdale long after the project concludes. We are incredibly proud of what has been achieved.”