Audit of patients at risk of pre-diabetes

Glyncorrwg Health Centre – Port Talbot

Highly commended Bright Idea for Wales

The problem

Our network has breached 7.4% prevalence for diabetes. We have enormous numbers of patients risking diabetes and want to offer face to face personalised and robust intervention each a year. We have over 6.3% of patients with pre-diabetes (HBA1C > 41 < 49) and another 4.2% at risk of pre-diabetes (defined as over age 45, obese and hypertensive). 5,500 patients out of the network's 55,000 population could have diabetes in the future unless they are helped to make changes.

The bright idea

We designed an audit to identify those with prior abnormal fasted glucose, GTT/HBA1C, as well as those at higher risk of pre-diabetes (aged over 45, hypertensive and obese). We ask them to the centre to see a trained healthcare worker for an HBA1C and focused dietary and lifestyle intervention on an annual basis. Two healthcare workers per surgery are trained in Foodwise (Welsh Assembly Government accredited course). It cost around £3000 to train staff in the cluster (18 staff, two per GP surgery). The project is now used across four clusters in Wales.

We have seen this simple change have a big impact on patients and practice staff with a network wide drop in patients risking diabetes 12 months after lifestyle intervention. 

The impact


51% drop in pre-diabetic's post lifestyle intervention. Patients enjoy the sessions and attend when asked.


Healthcare workers feel empowered to help and enable patients to take better care of themselves. They are also motivated by seeing the drops in HBA1C.


As a network at the end of year two, 79% of patients have had HBA1C tests and 60% have had lifestyle advice supported by literature in the last 15 months. Some practices are exceeding 90% achievement. There has been a network wide drop in patients still actively pre-diabetic one year post lifestyle intervention. The practice benefits from a payment per patient seen.

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