Transforming Diabetes Care at Scale in North West London


Since 2014, this collaborative work has commissioned, implemented and monitored outcomes-based improvements in diabetes care. Key successes have included reducing unwarranted variability, producing printable care plans for patients and introducing digital-supported, self-care apps for patients. The work brought together stakeholders from across North West London, including patients and user group facilitators, public health teams, GP federations, commissioners and senior management teams.

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Although a number of commissioning groups have redesigned diabetes services, there has been no previous attempt in England to undertake a diabetes transformation programme aiming to have significant impact on such a large diabetes population. Also, part of the aim with the OOHS was to begin commissioning primary care at scale, working with federations to deliver population level coverage and work on reducing variability through peer-peer interactions and network-based contracts. Basing performance-related payments on network or federation level achievement has aided this process. We have maximised the capabilities of the GP IT system (SystmOne) to the full in order to drive transformation at scale, publishing content simultaneously in 235 GP practices. We have also developed an integrated data warehouse containing linked primary, community, acute and social care data, and have just introduced the first set of diabetes dashboards, allowing automation of previously manual dashboard update processes.


In 2014, diabetes clinical leads from Central London, West London, Hammersmith and Fulham, Hounslow and Ealing CCGs (CWHHE CCG Collaboration) established regular meetings to share best practice and find new ways to engage with local stakeholder groups, during which we realised we shared the same challenges including:

  • Poor achievement against national quality indices: CWHHE CCGs were some of the worst in London for NICE 3 treatment targets (3TT) HbA1c < 58 in newly diagnosed patients, blood pressure < 140/80 and cholesterol < 4)
  • Wide variability in primary care delivery quality and model (and in achieving NICE 3TT) resulting from variability in organisational processes and clinical knowledge/skills
  • Low levels of structured education uptake and completion
  • Little involvement of patients in decisions about their own care.

This led to the commissioning of the Diabetes CWHHE Out Of Hospital Services (OOHS). The aim was to improve care and outcomes for patients by initially addressing some of the inter-practice differences in monitoring of the nine key care processes and achievement of NICE targets using performance-related payment across GP networks against Key Performance Indicators such as:

  • % of patients with record of nine key care processes
  • % of patients reaching all three NICE treatment targets (HbA1c < 58, blood pressure < 140/80, cholesterol < 4)
  • % of patients with record of care planning consultation (requires results shared with patient prior to appointment, collaborative goal setting and care plan development with the offer of a printed care plan to patient at the end of the consultation).

The contracts were piloted across Hounslow CCG from January-July 2015, and rolled-out widely across CWHHE from August-September 2015.


Between August 2015 and March 2017, there has been significant improvement in diabetes care for over 70,000 patients across CWHHE CCGs. Two stand-out exemplar practices showing the greatest levels of improvement are located in areas of highest deprivation:

  • One GP working in the most deprived ward in NWL (Golborne) with low life expectancy and a large North African population managed to increase her practice’s percentage of patients achieving all NICE 3TT from 13.4% to 30.1% in 9 months. Through clinical leadership, the benefits were spread across the entire locality (15 practices, 3,961 patients with diabetes, average multiple index of deprivation score 38) resulting in a 5.2% increase in patients achieving an HbA1c 58 over a 9-month period (increase from 2066 to 2330)
  • Another GP based on the deprived White City estate ran virtual clinics with a community diabetes consultant where all patients with an HbA1c > 100mmol/mol were reviewed. The average HbA1c reduction for this group of patients 8 months later was 36.5 mmol/mol.

Sustainability and Spread

Following the initial success in working across CWHHE CCGs, resulting in significant improvements in care and in achievement of the NICE 3 Treatment Targets, we are now collaborating on an NWL Diabetes Transformation Programme across the entire STP (eight CCGs). With nearly 200 stakeholders inputting into the NWL Diabetes Treatment and Care bid based on the work above, we were successful in winning £2.4 million funding together with a four-year investment plan from the North West London CCGs. We are now working with MyWay digital health, whose team include developers of the Scottish Diabetes Information system (SCI-Diabetes) and MyDiabetesMyWay (MDMW), to link the patient-facing platform with our NWL Diabetes Information System and to extend its existing capabilities (ePHR viewing, automated decision support, upload of glucometer data and provision of diabetes information).

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QiC Diabetes Winner 2017
Diabetes Team Initiative of the Year – Adults
Transforming Diabetes Care at Scale in North West London
by NHS North West London Collaboration of CCGs


Tony Willis

Job title:
Clinical Director for Diabetes
Place of work:
NHS North West London Collaboration of CCGs


Quality In Care Diabetes

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  • 2023 KEY DATES
  • Open for Entry:
    Thursday 27 April 2023
  • Entry Deadline:
    Friday 7 July 2023
  • Judging Day:
    Tuesday 8 September 2023
  • Awards Ceremony:
    Thursday 12 October 2023