Improvement plan on developing the pre-diabetic register and managing diabetic patients

Darwen Healthcare - Darwen

The problem

Early in 2015 Blackburn with Darwen CCG offered practices a Long Term Conditions Local Incentive Scheme to develop two improvement plans one for Diabetes and one for Respiratory. We researched websites with information about diabetes and felt that providing education to patients at a much earlier stage would eventually reduce or delay the risk of patients becoming diabetics if they listened to the advice and we were able to engage them in self-education. We also hoped that delaying the diagnosing of diabetes would reduce our medication prescribing budget. We wanted to make a difference and offer quality of care to patients and for them to start to take control of their health.

The Bright Idea

Our idea was to provide lifestyle education for patient who's HBA1C blood tests were within the pre-diabetic range (42-47) and encouraged engagement and motivation of our patients. Our Advanced Nurse Practitioner (ANP) developed an education program to upskill our Healthcare Assistants (HCA) to provide lifestyle advice to patients. Patients were opportunistically invited in for a NHS Health Check and all our existing chronic disease patients were also screened with HBA1C blood tests and if a patient had a HBA1C blood result that fell within the range of 42-47 they were invited in for a 30 Minute HCA appointment to discuss the results and provide lifestyle advice along with lifestyle information leaflets. They were then invited in for two further 10-minute review appointments one month apart followed by a repeat HBA1C blood test after 3 months. This would then be followed by an annual review. The ANP used 10 hours of protected study time to develop the protocols. The secretarial staff formatted the protocols, taking 2 hours. HCA training was provided in 3 weekly sessions of 1.5 hours. The Practice Manager provided oversight to monitor that it could also be sustained for the long term.

The impact


Patients are pleased to be attending these appointments at their own practice rather than having to go out to different areas with staff they do not know.

66% of blood tests completed showed a reduction in HBA1C level keeping them within pre-diabetic range.

A recent audit shows out of 546 patients bloods:

  • 253 (46%) had an improvement in their HBA1C Level
  • 248 (46%) remain with a stable HBA1C in the low range of HBA1C
  • 45 (8%) had an increase in their HBA1C level ranging up to 46-47


The change has allowed the ANPs and Practice Nurses to concentrate on managing the already diagnosed diabetics more effectively with better control.
The NHS Health checks were previously completed by Practice Nurses and the upskilling of HCAs allowed us to free up 190 Practice Nurse Hours allowing them to concentrate on complex long term conditions.

The staff resources were not increased, we just restructured the nursing team appointments and upskilled clinical staff from the bottom up.

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