Solihull Community MDT Project – Collaboration in Care


Solihull has seen an increase in people with diabetes in the last three years of 11%, compared to the national average of 6%. In addition, diabetes has been identified by Heart of England Foundation Trust as an area where savings on current annual spend could be made. Therefore the challenge has been to effect a redesign of the diabetes pathway achieving financial efficiency while providing quality patient care in general practice. Through collaboration between commissioners, community services, primary and secondary care the team has developed a high quality service which has enhanced the skills of the Primary Health Care Team and delivered improved outcomes and satisfaction for patients but without incurring any appreciable increase in costs.


Solihull has a population of 240,000 and the incidence of diabetes is rising by approximately 3% per year. Diabetes is currently being looked after in primary care both in dedicated GP/Practice Nurse led clinics and in a Community Diabetes Clinic. All GP Practices are signed up to the Locally Enhanced Service although neither the provision nor the quality of this service is audited. Solihull CCG is, like many CCGS across the country, facing increased pressure from cuts in funding. An Effectiveness Review Group (ERG) was set up to review all commissioned services to achieve the financial savings required to maintain statutory requirements. The ERG identified diabetes as an area where savings could be made because of the apparent duplication of expense streams. It was also noted that there was a wide variation in the standard of diabetes management in primary care (the percentage of patients achieving an HbA1c less than 7.5% ranging from 52% to 72%) and that Solihull had a high rate of outpatient appointments for diabetic medicine (ranked 196 out of 211 CCGs). A diabetes working group was therefore set up to look at review and redesign of the whole diabetes pathway. This consisted of members from primary care, secondary care, community care and Public Health as well as Diabetes UK and patient representation. From its inception this group was clear in its desire not to sacrifice patient care in order to achieve savings. It would therefore have to come up with innovative ways to design the pathway which would keep patient outcomes paramount while also being cost effective. The collaboration which resulted has led to the development of a truly integrated diabetes pathway in Solihull, bridging the divide between secondary and primary care and incorporating the patient perspective.


To pilot a specialist diabetes service for the population of Solihull that shifts care from hospital and community out-patient clinics to general practice without incurring major cost. To remove the barriers between primary and secondary care allowing collaborative working for the improvement of patient outcomes.

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QiC Diabetes Finalist 2016
Diabetes Collaboration Initiative of the Year Solihull Community MDT Project – Collaboration in Care
Solihull Community MDT Project – Collaboration in Care
by Heart of England Foundation Trust/Solihull CCG


Dr Rosalind Anfilogoff

Job title:
GP Clinical Assistant and Facilitator
Place of work:
Heart of England Foundation Trust


Quality In Care Diabetes

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  • 2021 KEY DATES
  • Open for entry:
    Tuesday 20 April 2021
  • Extended Entry Deadline:
    Monday 12 July 2021
  • Judging day:
    Tuesday 7 September 2021
  • Awards ceremony:
    Thursday 14 October 2021