Redesigning diabetes care with the patient at the centre

Diabetes is one of the big health challenges in Liverpool, in common with many areas across the UK.

“Designing our diabetes service around the clinical need of our patients has been key,” explained Dr Janet Bliss, Liverpool CCG, Healthy Liverpool Community clinical director. As part of the Healthy Liverpool vision, healthcare teams are working together to ensure that diabetic patients receive care that is proactive, tailored and provided locally in the community. Technology from EMIS Health is helping to turn the service redesign into reality.

Patient receiving a needle instruction from Collette Kelly, diabetes specialist nurse

A convenient service for patients

Patients with conditions that can be managed by regular appointments are being seen in any of six local clinics across the city. EMIS Web provides a view of up to date medical records from everyone involved in the patient’s care. “When a patient comes to their appointment, clinicians have everything they need in front of them,” explains Jan Fennell-Rutherford, Liverpool diabetes partnership operational manager. “There’s no reason for anything to be missed, so it can reduce errors or delays in care. The clinicians love it. They can make better clinical decisions because they can see the impact of every aspect of the patient’s care plan, rather than just the effects of the individual work they're doing with that patient."



“Patients give us positive feedback about how convenient their appointments are now. Patients can visit a clinic local to home or work. It gives them the flexibility to fit their appointments into their lives”

Jan Fennell-Rutherford, Liverpool diabetes partnership operational manager

Focusing on self-care

“We use these appointments to look at self-management of the patient’s diabetes. Improvements to lifestyles and wellbeing can often lead to a reduction in medication. We can catch any issues early, preventing patients from needing acute hospital care.

“In time we want to be able to see the direct affect this will have on diabetic A&E attendance.”


Better care for the ‘super six’

Diabetics in the city who need more care continue with hospital appointments to manage their health – those who fall under the ‘super six’ categories of diabetes, where the condition has potential to be more complex, for example if they are pregnant, under 24 or diabetic foot care patients.

The initiative is having a positive impact for these patients too. “By concentrating the acute services on the serious cases, everyone is receiving the level of care that’s appropriate to their condition. For example patients on an insulin pump should be seen four times per year: previously they were only being seen twice. Under the new initiative, we can see them four times per year and pick up any issues much earlier.”


Future plans

It doesn’t stop there. “We’ll be looking at improvements to services providing care to patients with other long term conditions, such as respiratory illnesses, building on our experience of redesigning the diabetes service,” said Janet. “As part of our Healthy Liverpool Community Model of Care, more services will be provided to patients out of hospital and in the community using joined-up technology from EMIS Health – it means a more convenient service for patients, provided by clinicians who have all the information they need.”   

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