Suffolk & North East Essex Integrated Care System


WHY this is important for people in Suffolk and North East Essex

The best care and quality of life for people with, or at risk of, diabetes is essential if everyone in Suffolk and North Essex is to stat well and live well.

As an Integrated Care System we will ensure that:
  • People at risk of diabetes are supported to prevent developing the condition
  • People have access to the best possible care and support they need to live well with diabetes
  • People living with diabetes can monitor and self-manage their condition effectively


Diabetes is a major public health problem with diabetes diagnosis in the UK having risen from 1.4 million to 3.8 million since 1996.

One in ten people aged over 40 now has Type 2 Diabetes. It is estimated there are around 4.7 million people (including those that have been undiagnosed) living with diabetes in the UK and this is estimated to rise to 5.5 million by 2030. In the UK, around 400 people are diagnosed with diabetes every day.

Diabetes costs the NHS over £1.5m an hour (or 10% of the NHS budget for England and Wales), and an estimated £14 billion a year treating it and its complications. Many cases of Type 2 diabetes could be prevented or delayed by healthy eating, being more active, and losing weight if overweight.

Every week in the UK diabetes leads to more than: 
  • 680 strokes
  • 169 amputations
  • 530 heart attacks and almost
  • 2,000 cases of heart failure
  • More than 500 people with diabetes die prematurely every week

Many people with long-term health conditions are already taking control of managing their condition themselves, supplemented with expert advice and peer support in the community and online.  The King’s Fund has called this ‘shared responsibility for health’.  The NHS Long term Plan has outlined a commitment to increase NHS support for people to manage their own health and has prioritised diabetes prevention and management.

What do we know about people’s local experiences?
  • People want to obtain appointments when they are needed.
  • In diabetic foot care, it is important to have regular foot checks, be given more Information and awareness, how to access toenail cutting services, and improvement in staff attitude/working patterns.

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More than half of all cases of Type 2 diabetes could be prevented or delayed if risk factors are identified early and acted upon.

The NHS Long Term Plan and the 2019 Green Paper ‘Advancing Our Health: Prevention in the 2020s’ both detail the commitment to double the NHS Diabetes Prevention Programme, and introduces a digital version that gives the same advice on healthy eating, exercise and weight management as the face-to-face programme, but through wearable technologies, apps and websites.  it is deigned for those at risk of Type 2 diabetes who find it difficult to attend sessions because of work or family commitments.

NHS Health Checks is a national programme commissioned by local authorities. Health Checks offer people aged 40 to 74 a free check-up of their overall health, every 5 years.  The results can tell people whether they are at higher risk of developing certain health problems such as heart disease or Diabetes and allow for prevention action to take place.

HOW we plan to make a difference 

    1.1 People at risk of Type 2 diabetes, in particular those in high risk populations such as Black and Minority Ethnic (BAME), have support to prevent developing the condition. We will enable this by:

  • Extending the NHS Diabetes Prevention Programme, including a digital option and enabling access to local programmes, by 2024. The Programme reduces risk for people at high risk of Type 2 diabetes. A digital option widens choice and helps target inequality. Anglian Community Enterprise (ACE) and Onelife Suffolk will continue to attend BAME community events in order to promote this prevention programme. In 2018-19 there were 3,470 referrals made to the National Diabetes Prevention Programme and 1,735 Assessments conducted.
  • Improving information, advice and support on weight management for people who are overweight and obese and their carers and families. Information should be available in a range of ways and formats, including online, apps, and when accessing health and care services. Weight management programmes can improve health and reduce health inequalities.
  • Developing community-based services and support to help people change to healthier living. Projects such as community food growing and cookery classes help promote healthy eating. Local free or low cost activities such as Couch-to-5K and park runs help people be more active. In one area we are developing a Community Diabetes Prevention Service known as the “Shotley” project which supports pre-diabetic and overweight people in remote parts of the county through highly tailored local interventions. This project provides people with long-term peer group support and the concept was developed by the local people themselves. Healthy meals and cooking skills are supported by local restaurants to incentivise people to keep good diet self-management.

    2.1 People with diabetes have access to the community-based support they need to live as well as possible with their condition. We will enable this by:

  • Improving equality of access to high quality primary care, multi-disciplinary foot care teams and specialist diabetes support. Improving access will tackle existing health inequalities.
  • People with diabetes having reasonable adjustments for their condition in their homes, work, leisure, health and environments. Reasonable adjustments should enable people to manage their health and wellbeing, and enable places and services to be fully accessible to them.
  • People having the right information and advice about diabetes, both through education and wider Public Health. People with diabetes, local communities and the wider public, should understand what diabetes is and why it is important. We will continue to significantly increase the number of Structured Education places available for face-to-face learning for those with both type 1 and type 2 diabetes as well as procuring and implementing a digital Structured Education pilot, which now has over 400 users and some excellent “good news” stories.
  • People with type 1 diabetes having greater access to new technologies and support from teams experienced in their use. New technologies, which include Insulin pumps and interstitial glucose monitoring, enable people with type 1 diabetes to take greater control of their diabetes. Following national guidelines we introduced Libre devices and will continue to steadily increasing the numbers using these devices.
  • Developing support from mentors or buddies. Peer support is an important tool in living well with a long-term condition. A programme of work is underway to support diabetes patients with learning difficulties and services such as Livewell, Onelife Suffolk and Living life to the Full (LLTF) are providing psychological and emotional support for diabetic patients.

    2.2 People with diabetes can self-manage their condition and receive specialist care during hospital stays.

  • We will provide multi-disciplinary foot care teams and inpatient specialist diabetes teams, improved care pathways, and technologies to improve inpatient diabetes control. Better access to these services in hospital and regular quality audits will help improve recovery, reduce length of stay, reduce future readmissions and improve patient experience. Some areas have been developing inpatient support with very positive results, which we intend to roll out to the wider system.

    2.3 People with Type 2 diabetes have nutritional support to manage their condition or even achieve remission.

  • We will improve information, education and advice on nutrition. The right information and advice helps to support weight loss. Peer support can also help people achieve weight loss goals. This is being achieved across the ICS through the use of Structured Education and linking with lifestyle services such as ACE and OneLife Suffolk.
  • We will provide weight management services in primary care for people with Type 2 diabetes or hypertension and a BMI of 30+ (adjusted for ethnicity). Weight management programmes canonal support helps to prevent worsening of people’s condition, reduces the likelihood of complications and can improve people’s health, leading to better quality of life. We offer an integrated healthy lifestyle service and our ICS is at the forefront of this work in piloting a Very Low Calorie Diet (VLCD) for people prior to the national initiative due in 20/21.

    2.4 Children with Type 2 diabetes have access to high quality care.

  • We will provide high quality treatment and care for children with Type 2 diabetes, which is a complication of obesity. Early treatments will prevent children needing more invasive treatment in the future.

    2.5 People with diabetes have integrated support with their wellbeing. We will enable this by:

      • Providing support to people living with multiple long-term conditions that include diabetes that recognises the complexity of their needs. Holistic care will help improve quality of life and prevent worsening health.
      • Improving access to Improved Access to Integrated Therapies for people with long term conditions. Integrating mental and physical health support for long term conditions supports self-care and improved quality of life. We have embedded mental health link workers and psychologists in diabetes centres for several years; in Essex we plan that the Livewell Service will take over the role of providing mental health support in the coming year.
      • Supporting young people to transition from children to adult diabetes services. Tailored support helps young people maintain their health and wellbeing through their transition to adult services. Using population health data to identify variations in services, and groups and communities who need targeted support. Data helps to identify where there are gaps and variations in services, and additional needs in the population, to ensure resources are targeted in the most effective way. We have been promoting a web-based clinical and workflow support tool called ECLIPSE to primary care in order provide diabetic population health data. This data will support GPs with up to date information on their patients, so that the national nine care processes can be implemented for each patient most effectively.

        2.6 Carers of people with diabetes have support to stay well.

      • Carers will receive information and support. Supporting carers helps them in their role and also helps them maintain their own good health and wellbeing. Alongside people with diabetes, carers are also invited to participate in our face-to-face diabetes Structured Education classes.

    3.1 People with diabetes will have the support they need to self-manage their condition.

  • We will expand access to digital self-management tools such as HeLP Diabetes. Prior to the roll out of the national programme our ICS was one of the first to pilot digital Structured Education which has placed us in a good position to take on the upcoming national programme.
  • We will improve self-management of diabetes improves quality of life and helps prevent health complications.
  • Education and information will be tailored to the needs of different groups and communities. Adapting information to the needs of different cultures, communities, and communication needs, helps ensure it is understood and meaningful to people. Engagement with groups such as the Caribbean & African Community Health Support Forum and Bangladeshi Support Group is already underway with further plans to work with other groups.

    3.2 People with Type 1 diabetes can monitor their diabetes more effectively and obtain the right support when they need it. We will enable this by:

  • Making available flash glucose monitors for everyone with Type 1 diabetes, beginning in April 2019. Digital self-care helps people monitor their condition more easily and effectively, and reinforces the importance of prevention in diabetes. The Libre devices are a significant technological change in diabetes self management.
  • Improving information on symptom response. Improved information enables people to seek support promptly. An ICS wide website is being considered and patient portal will provide advice for patients on their condition and services available.

We will know we are making a difference because we will see:

  • Increase in the number of people supported through the National Diabetes Prevention programme, from 145 in 2018/19 to 3,408 in 2023/24
  • Improved diabetes diagnosis rate for those living with undiagnosed diabetes
  • Fewer people with type 2 diabetes who are of minority ethnic origin
  • Improved access and uptake of education programme within 12 months for newly diagnosed people with type 1 and type 2 diabetes
  • More people with type 1 diabetes and type 2 diabetes who received all 8 care processes and quality health outcomes treatments
  • More people with type 1 diabetes and type 2 diabetes who achieved all three treatment targets , and health outcomes
  • Increased access to IAPT for people with long term conditions
  • Fewer admissions for diabetes in children and young people aged 19 or under

People who have Diabetes live well with it and are able to manage their condition. Structured Education improves patient outcomes by enabling patients to understand what they need to do to keep themselves healthy. However, take-up among patients newly diagnosed with diabetes is very low. As a system we were able to bid for funding from NHS England and Suffolk & North East Essex was awarded NHS England Transformation funds of £955k to transform Diabetes Management (including DESMOND and DAFNE self- care programmes). We developed ICS wide governance and appointed a clinical lead to provide steering and oversight. We have:

  • Recruited and trained DESMOND and DAFNE educators
  • Increased the number of DESMOND and DAFNE places & venues available.
  • Central referral and booking service
  • Introduced a diabetes lifestyle navigator role in North East Essex
  • Developed and implemented the ‘Big Impact’ campaign
  • Commissioned a digital diabetes Structured Education provide to offer an alternative method
  • Promoted better glycaemic control.

As the full expanded Structured Education service did not come into place straight away and year end data is still not available, it is still early days in terms of fully evaluating the outcomes of the service. However, in the last three years the expanded Structured Education service has so far almost doubled the numbers of people attending the programme.

Last Updated on December 10, 2020

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