North East Essex integrated pathway hub


The North East Essex Diabetes Service commenced in April 2014 and brings together community diabetes, podiatry, outpatients and education, under a single lead contractor – the Suffolk GP Federation.  The five-year contract, worth £2.5m, involves no additional investment and 25% is contingent on delivering Key Performance Indicators (KPIs). During its first year the service has implemented transformational change at scale across a population of 18,400 patients with diabetes.  This includes creating a Diabetes Services Board which brings together patients, clinicians and managers in a forum which manages the service, and forming a single Diabetes Specialist Team consisting of consultants, specialist nurses, a GP, specialist midwife, dietician and podiatrists.  The role of the team, particularly consultants, has changed from seeing patients to governance and supporting primary care.


North East Essex had a higher than national prevalence of diabetes at 7.3%.  Prevalence was growing at 3.8% per annum and approximately 1.7% of the population had undiagnosed diabetes.  Care outcomes in the area were very mixed, with only 40.1% of patients receiving all 8 care processes. Mortality rates are higher than comparable CCGs as were lower limb amputations.  Major amputation rates were twice the level of England. Patient feedback on the service was generally poor. As a result the service was tendered and Suffolk GP Federation CIC was awarded the contract which commenced on 1 April 2014, with no additional financial resources provided.


The new service’s key objectives are to improve diabetes outcomes so that North East Essex achieves upper quartile nationally against a range of process and clinical indicators. Critically, all patients with diabetes are included in the targets and there is no exception coding.  The targets include a 2% increase in patients who receive all 8 care processes, a 1.17% increase in the percentage with an HbA1c 64mmol/mol or less in the preceding 15 months (baseline 71.3%) and to maintain the percentage with diabetes blood pressure of 140/80 or less at 78.4%. It also aimed to make a 10% increase in: patients with care plans, the number of Type 1 patients receiving a foot check, patients with foot ulcers referred to podiatry and a similar increase in referrals for those with high risk feet referred, and a 50% reduction in outpatient appointments.

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QiC Diabetes Finalist 2015
Best innovation in integrated commissioning, or integrated care, model
North East Essex integrated pathway hub
by Suffolk GP Federation

Quality In Care Diabetes

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  • 2022 KEY DATES
  • Open for Entry:
    Monday 28 March 2022
  • Entry Deadline:
    Friday 1 July 2022
  • Judging Day:
    Tuesday 6 September 2022
  • Voting Deadline:
    Monday 12 September 2022
  • Awards Ceremony:
    Thursday 13 October 2022