Improving services for people with long term conditions


Improving diabetes services 

The diabetes modernisation initiative

The 'diabetes modernisation initiative' (DMI) has run for four years, supported by the Guy's and St Thomas' Charity. The project brought together all aspects of diabetes care and treatment with patients, GPs, hospital clinicians, nurses, public health professionals and other care providers. These partners worked together to produce a new model for identifying and supporting people with diabetes.

Last year we rolled out a programme of support for self-management which will continue over the next year. As a result of this work Lambeth is now ranked 9th nationally on blood glucose control for their diabetic patients; GP initiated referrals to hospital continue to decline and there has been a sharp fall in emergency admissions for diabetes in the under 65s.

Paediatric diabetes services 

Over the last year we integrated the three paediatric or child diabetes services at the Evelina hopsital in Lewisham and King's hospital into a single 'networked' service for over 350 children and young people with diabetes. This includes a new out of hours telephone service for advice from doctors and nurses, an enhanced and consistent education programme delivered across the three sites and children up to the age of 14 can now choose where they attend their education sessions and enhanced psychological support. The number of children and young people on pumps has increased from 6% to 12% of the caseload. A new family support group, now affiliated to Diabetes UK, organises its own events, provides support to parents and families and regularly gives advice to the CCG about how we can improve services.

Helping people with cardiovascular disease manage their blood pressure 

To better support people with cardiovascular disease we want to help them manage their blood pressure. To do this we commission support for hypertension and lipid management through patient clinics and primary care education.

Supporting people with breathing problems 

We are making sure that all people with breathing problems in Lambeth access the same services. The care all patients receive from different services in Lambeth is overseen by the same service. The service reviews all patient referrals and triages these to specialist services including chest physicians, lung function clinic, pulmonary rehabilitation, oxygen service, or tier 3 stop smoking support. 

All GP practices have also been provided with 'virtual clinics' with specialist respiratory clinicians visiting practices to review their respiratory patients. Other work has included a review of the pulmonary rehabilitation service to ensure provision is adequate for the needs of Lambeth patients and encouraging continued use of the Integrated Respiratory Team and Home Ward to prevent inappropriate emergency admissions.