CF led a collaborative programme of work with NHS Tower Hamlets, to establish primary care networks that would increase integration, scale, peer support and challenge in diabetes care. If the networks were successful in improving patient outcomes, the same approach would be applied to all major long-term conditions.

  • Achieved a 600% increase in people with diabetes care plans
  • An 11% increase in people with blood pressure under 140/80
  • A 10% increase in people with cholesterol under 4.58
  • An 8% increase in blood sugar (HbA1c) under 7.5
  • Estimated savings on non-elective acute spend was 12-14%

Poor diabetes care outcomes

NHS Tower Hamlets commissions care for a deprived borough of London where primary care access and share of spending are low. For long-term conditions, especially diabetes, patient outcomes were poor.

Ambition for closer integration

Closer integration of care via primary care networks was a concept initiated by NHS Tower Hamlets. We worked with them to deliver on this ambition, engaging with clinical working groups to establish best practice care packages and protocols for diabetes care, and testing these with groups of patient representatives.

Organising integrated care

GP practices were organised into networks, with a hub at the centre providing diagnostics, coordinating outpatient appointments, and organising urgent and out-of-hours care. Care plans were managed by primary care nurses working with GPs, secondary care clinicians and others in multi-disciplinary teams. Patients were stratified and assigned care packages to suit their particular needs. An information technology system supported data integration, bringing data together from GP, community, acute and pharmacy sources. Performance management tools were also established.

Ongoing impact

In direct response to the success of the primary care networks, investment in primary care in the borough increased from 9% to 14% of spend. The project also laid the foundations for national adoption of the primary care network model across the NHS.