Delivering specialist diabetes care in a GP practice in Stockport

Summary

Dr Seabrook and Partners is a GP practice in Stockport. About 530 of its patients have diabetes. Patient stories showed a ‘one-size-fits-all’ approach to diabetes care could lead to poor communication, unmet needs and poor compliance with treatments. Furthermore care needed to be efficient and cost effective.

The team wanted to find innovative ways of working and providing high quality specialist care closer to home. Specifically, they wanted to improve the quality of care for hard to reach diabetes patients who had three or more uncontrolled risk factors outside recommended targets.

Challenge

The aim of the project was to provide specialist care, at the practice, to patients at high risk of diabetes-related complications who had been unable to engage with current systems of care, and to modify their risk factors.

The practice wanted to provide patient-centred care, and to streamline the patient journey, resulting in higher efficiency and lower costs to the patient, practice and health service. 

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