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How our practice identified an extra 150 diabetes patients in two years

15 May 2019

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Kamaldeep Sahota, operational manager at King Edwards Medical Centre in London, explains how his practice dramatically improved its ability to recognise patients at risk of becoming diabetic 
A few years ago, King Edwards Medical Centre in Barking, east London, was struggling to identify pre-diabetic patients.
The problem was shared by other practices in the area, encouraging NHS Barking and Dagenham CCG to introduce a new initiative in 2016, to help its 37 practices reduce the number of undiagnosed diabetes cases.
As a result of the CCG’s initiative, the number of undiagnosed diabetes cases in Barking and Dagenham decreased by 62%: from 1,642 in 2012/13 to 624 in 2017/18.
Kamaldeep Sahota, operational manager at King Edwards Medical Centre, tells Management in Practice how the CCG’s project helped them identify an extra 150 patients with diabetes in just two years.
The problem
It was very hard for us to identify pre-diabetic patients. Our CCG, NHS Barking and Dagenham, invited our practice and other GP surgeries in our area to join a project that would help us [improve the identification process].
The solution
We followed a structured programme that helped us identify pre-diabetic patients and better manage our diabetic patients. The initiative came with a financial incentive attached, which enabled us to invest in additional resources to help us [improve results].
We worked with a third-party company, Primed, on this. They assisted with building in-house searches that allow us, at the click of a button, to pinpoint different cohorts of patients that we need to focus on.
Within our practice, we selected three leads for this project: me, a GP, and one of our nurses.  
I put the whole operation together. I gave the pre-diabetics list to our nurse to manage and those patients received dietary advice and were referred to our local diabetes education program.
Meanwhile, I focused on our 487 diabetic patients. I started looking at the eight NICE care processes for patients with diabetes, checking those who hadn’t completed all the processes.
The benefits
Thanks to the CCG programme, we were able to identify the cohort of pre-diabetic patients and give them dietary advice and education to ensure they don’t become diabetic.  As a result of the in-house searches we built with Primed, we were able to identify 150 patients that we might otherwise have missed.

The programme also helped us improve the outcomes of the eight NICE care processes with our practice’s diabetes GP lead Dr Miriam John helping us to better cater for our diabetic patients. We monitored the eight processes and closed gaps in the care we were providing.
For example, if a diabetic patient needed support with their diet, we would refer them to a dietician, and if somebody was smoking, we would send them to the smoking cessation clinic. We were trying to be proactive.
We identified 100 patients who were missing something from the care processes. With the support of my administrative staff, we called patients whose weight or BMI data was missing. We also put a blood pressure machine and weighing scales in the reception area.
We told those who needed to have their blood pressure checked to drop by the clinic to have this done.
As a team, we all had our own responsibilities and there were special clinics set up by Dr John. For example, patients with an HbA1c value over 48 were called in and given tips from Dr John on how to lower that value.
In 2017 and 2018, we were able to identify 150 additional patients with diabetes and this project has opened our eyes in terms of managing diabetic patients and everything that involves.
It has allowed us to prevent further [deterioration of the condition of] our diabetic patients, by making sure they are all assessed against the NICE care processes, and to avoid our pre-diabetic patients becoming diabetic.
It’s been an enjoyable and satisfying journey, [one we feel] we’re managing very well.
Our most recent figures, from the 13 December 2018, show that 74% of our diabetic patients have been referred to the local diabetes education programme. Previously, patients were referred to this on an ad hoc basis.
The challenges
One of the challenges we encountered was reaching out to patients who don’t speak English.
However, we have quite a multilingual team here. I speak several languages – Punjabi, Hindi, and Urdu – so I was able to contact some of these patients and explain to them why it’s important to come in and have their blood tests done. 
The scheme added to my personal workload. It took time for me to organise the searches; printing them out and distributing them to different members of staff, and setting up the clinics.
For every patient identified as needing a blood test, I had to ensure the receptionists were inviting them to fill in a blood test form and asking them to come in for the test.
It was less difficult for our staff to adjust to this new way of working. This is because there was funding attached to the programme, which allowed us to pay our nurse and our receptionists to put in any necessary overtime.
Additional reporting by Valeria Fiore