The only DSN in the Village


Diabetes care in Medway was improved by providing specialist care within the GP surgery. This reduced waiting times for appointments, duplication, and delays to prescriptions, speeded referrals, and improved communication between services. A diabetes specialist nurse (DSN) was seconded from secondary care into a primary care network as a pilot project for two years. The main requirement was to assess patients with HbA1c above 75 mmol/mol. Within 12 months the HbA1c of 159 patients was reduced by between 9-95 mmol/mol, and at 18 months the DSN had reduced the overall HbA1c by 9 mmol/mol per patient across nine practices.


A new clinical post was developed to replace some of the care usually provided by the community DSN team. The new post worked within Rainham primary care network (PCN), offering specialist diabetes care directly within the GP surgeries. The post was a secondment from secondary care, with access directly to the consultants for complex cases, reducing the lengthy referral process and, in some cases, avoiding referrals to the consultants altogether. The aim was to bring all three services together in one initiative. The clinician had access to all the systems and clinical colleagues in both primary and secondary care, further breaking down barriers. The DSN had EMIS, AccuRX and DXS installed on the hospital laptop to work remotely. A new PARM tool was used to extract data from EMIS to identify patients who required DSN support. Patients were then booked in to virtual appointments. Those who required insulin or GLP-1 starts had video consultations. Patients were given the pen device, equipment and literature in advance so they could complete the steps with DSN support on the video call. For more urgent cases, literature was emailed as a PDF. Those unable to use video calls had a face-to-face appointment with full COVID-19 protection.

Equality, Diversity and Variation

Each month the DSN identified patients across the PCN with a HbA1c above 75 mmol/mol using PARM. The DSN time was spread across the nine GP surgeries, ensuring all had the access they required. The tool also highlighted patients who might need further support from surgery staff and was sent out monthly to the GPs and practice nurse responsible for diabetes each month. This ensured variation in care was minimised as all patients with a HbA1c over 75 mmol/ mol were contacted regardless of location. GPs used the remaining slots for other patients. At least 89 of the 659 people involved in the study were recorded as being from an ethnic minority background on EMIS (13.5%), although the total may be higher. The percentage of ethnic minority participants involved in the study was higher than the amount recorded in the local population (13.5% vs 5%). The PARM tool found the people who needed the most support, irrespective of cultural background. A higher-than-average number of people from a minority ethnic background were identified as requiring DSN support. Demographic data from this study were highlighted across the Kent and Medway Strategic Transformation Partnership to help raise awareness of the needs of people with diabetes from ethnic minority backgrounds in Medway.


At 12 months, 465 patients had accessed the DSN service. A total of 243 patients had follow-up data available at the time and 159 of them saw a reduction of HbA1c (between 9-95 mmols/l), with 93 of those also seeing reduced cholesterol (between 0.2-5.8 mmol/l) and 89 patients having a reduction in blood pressure (between 1-47 mmhg). At 18 months, 659 patients had accessed DSN support. Of these, 359 patients had follow-up data. The average HbA1c reduction calculated for the nine surgeries for those patients was 9 mmols/ mol (0.81%) per practice, with some practices achieving as high as 17.1 mmol/mol (1.9%) average reduction. The initiative has brought many benefits for both patients and GP staff. Questionnaires were sent to 300 participants who had been in the service for over nine months and Canterbury Christchurch University conducted interviews with 12 of the respondents. The patient population valued the specialised service within the GP practice at a time where the risk of death from COVID-19 in people with diabetes dominated the media.

Dissemination and Sustainability

Data from the first 12 months of this project were presented at the diabetes professional care conference. This project shows what can be achieved across a PCN for a minimal cost. Once qualitative data from the patient interviews is analysed findings will be published in peer-reviewed journals and presented at more national conferences. Having a DSN in the practice has highlighted the need for specialist support within GP surgeries. A new ‘Best practice in the delivery of diabetes care in the primary care network’ has been released, and Medway hopes to be one of the first PCNs in the country to adopt the new guidelines by developing a Diabetes Support Team (DiaST). This will be a new enhanced tier taken from the existing PCN workforce providing care with an MDT approach. As a gold standard, practitioners within the team should include: a GP with an extended role in diabetes (GPwER); a Practice Nurse with special interest in diabetes; a Clinical Pharmacist (RPS Advanced Stage 2), and a Community/Intermediate Diabetes Specialist Dietitian.

There should also be access to mental health services and strong communication links with the secondary care integrated team.

User Feedback

Feedback was collected from stakeholders via an anonymous SurveyMonkey survey sent to all clinical staff in the GP surgeries. A total of 59% said the PCN DSN service met their needs ‘extremely well’; 65% said responses to referrals, questions or concerns had been ‘extremely responsive’ and 65% were ‘extremely likely’ to recommend the service to a patient. Regarding referral of patients to the new service, 71% said it was ‘extremely easy’, while 65% reported that their knowledge and confidence in managing people living with diabetes had improved. Patients reported satisfaction with the service too.

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QiC Diabetes Finalist 2021
Patient Care Pathway, Secondary and Community
The only DSN in the Village
by Medway 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