Improving Diabetes Care in York with a Specialist Outreach Team


A short-term Diabetes Specialist Outreach Team (DSOT) was established by York Teaching Hospital NHS Foundation Trust to address the needs of those people with diabetes at the highest risk of complications for any reason. Despite a high-quality diabetes service in the local area, certain people at high risk of hospital admission and diabetes complications do not use or benefit from services as they stand. This project aimed to complement and fill in the gaps in the existing service, preventing complications in the longer term, as well as illness and hospital admission in the shorter term. The project was based on remote searches of GP records to identify people whose outcome measures were falling short of targets and criteria-based direct referral. The project team improved individual measurement of HbA1c (when not taken for over 15 months), achievement of three target measures (HbA1c, blood pressure [BP] and cholesterol), and decreased HbA1c in those over 100mmol/mol (11.3%). In addition, intervention led to a saving of 21 diabetes-related hospital admissions in the first year.

Get the latest updates


In the Vale of York Clinical Commissioning Group (CCG) area there is a well-developed integrated diabetes service, comprising three levels of care. This collaborative provision performs well for the majority of local people. However, there are groups of people who do not ‘fit’ usual services, such as: individuals with Type 1 diabetes who have been discharged due to disengagement from hospital care; people who do not visit the GP for routine monitoring and help with management; those who experience repeated, often preventable, hospital admissions relating to their diabetes and people whose test results show high risk of complications despite attendance. Rather than target specific groups of potentially disadvantaged people, work was based on individual outcomes. The use of remote reviews was another innovative approach, requiring careful consideration of potential issues around confidentiality, sensitivity around sharing of practice, and what should happen in different situations to people that were being reviewed. The DSOT was developed to provide specialist individual support to those people identified as at increased risk.


The Vale of York CCG secured up to two years of NHS England funding to improve the achievement of the recommended treatment targets for HbA1c, cholesterol and BP. The project would be provided by York Teaching Hospitals NHS Foundation Trust. Planning discussions reinforced the need for something different. An integrated model of care was created to address mental health, emotional wellbeing, the social situation and to improve diabetes outcomes. Over the first year the plan was to: put staff in place; engage with primary care to explain the project and encourage them to opt in; start remote searches and actions; engage with secondary care for referral criteria to be used for patients; set up rolling monthly hospital database searches for people who matched the criteria and provide the service to people identified. This was a supplementary service to usual care, with criteria-based searches within primary care records and from direct secondary care referrals. Those with diabetes and HbA1c over 100 mmol/mol, three risk factors all above QOF target: HbA1c > 59mmol/mol, BP > 140/80, Cholesterol >5.0mmol/l and no record of HbA1c in the last 15 months were to be identified through primary care data. Hospital data would identify those with two or more DKA admissions in the last 12 months, two or more admissions for severe hypoglycaemia in last 12 months and two or more admissions for any diabetes-related conditions in last 12 months. Coming from direct referrals through secondary care were those who, after initial intervention, were repeated non-attenders despite invitation, who had been discharged due to non-attendance (DNA) since August 2017, those who had repeated foot ulceration despite intervention and might benefit from psychology/social work support, plus those with repeated hyper/hypoglycaemic A & E attendance after the usual solutions had been tried. The patient objectives were to improve HbA1c to below 100mmol/mol; reduce risk factors so fewer than three were above target; measure HbA1c; reduce hospital admissions due to diabetes; provide attendance/offer of attendance at secondary care where appropriate; ensure longer-term engagement in services to return to ‘routine care’ and establish numbers of people reviewed. By January 2018 the team included a GP (0.2 whole time equivalent [WTE] per week), a Diabetes Specialist Nurse (DSN 0.8 WTE) and a Senior Clinical Psychologist (0.6 for the York area), overseen by a senior diabetes consultant. Social support was planned but not recruited at that point. Practices were approached via CCG and opted in to take part. The people identified were offered intensive support, which could include institution/home or surgery visits; psychology and social support and intervention along with staff/carer education and support. For other people, intervention was deemed inappropriate. Each decision made was recorded in the primary care record.


The plan was achieved in the first year, with excellent individual outcomes for specific people with diabetes. In primary care, practices covering 36.4% of the Vale of York population have been reviewed. Around 4-5% of people with diabetes in general practice met the criteria for remote review and 838 remote reviews were undertaken. Results are available on three group practices, covering 1,010 people with diabetes, as these have the longest post-review time (around 12 months). Regarding those with HbA1c >100mmol/mol (11.3%), 42 of 69 patients in the baseline are no longer above 100, an overall improvement of 61% from baseline, with 36% following DSOT input (15 of 42). Of those who improved, the median value is 80mmol/mol (9.5%). Of those who had no HbA1c recorded in >15 months, 37 out of 54 baseline patients had their HbA1c measured, representing an overall improvement of 69% from baseline (51% of this improvement was as a result of DSOT input [19 of 37]). Of those not achieving three treatment targets, 56 out of 80 were no longer above three targets, representing an overall improvement of 70% from baseline (45% of this improvement was following DSOT input [25 of 56]).

Sustainability and Spread

Funding has been secured for the next 12 months with a stronger emphasis on medicines management at CCG request. Another business case is planned for next year. This project would benefit from further research and should be seen as a pilot, especially in terms of financial benefit.

Regional dissemination has taken place at the ABCD conference.

Back to the top

QiC Diabetes Finalist 2019
Patient Care Pathway - Adults
Improving Diabetes Care in York with a Specialist Outreach Team
by York Teaching Hospital NHS Foundation Trust

Quality In Care Diabetes

QiC Diabetes is partnered by:
Supported by:
  • 2022 KEY DATES
  • Open for entry:
    Monday 28 March 2022
  • Entry Deadline:
    Friday 1 July 2022
  • Judging day:
    Tuesday 6 September 2022
  • Awards ceremony:
    Thursday 13 October 2022