• Run by Calderdale and Kirklees Primary Care Trusts.
  • Focused on people with diabetes in the Calderdale and Kirklees areas of West Yorkshire.
  • Set out to improve quality of life for people with diabetes and to reduce the burden diabetes presents to public service finances and staff.
  • Following a review of existing services, the PCTs changed how services were commissioned, including extending the remit of community nurses.

There are more than 23,000 people with diabetes in the Calderdale and Kirklees areas of West Yorkshire. Clinicians were concerned that their patients’ annual diabetes review was turning into a perfunctory ‘tick-box’ exercise simply recording whether urinalysis, blood sugar, blood pressure checks etc had been done.

At the start of this project, the primary care trusts (PCTs) produced a results sharing sheet, 'Getting the most from your appointment’, encouraging patients to outline what they would like to discuss. They also produced a care plan pro-forma. Patient focus groups were held to introduce the Year of Care and find out what patients wanted from their diabetes care.

The PCTs reviewed existing levels of diabetes services across health, local authority, social services and the voluntary sector. Representatives were invited to a workshop to compare current and planned Year of Care diabetes services.

The gap between the two led to the PCTs commissioning services differently. They worked with social services to extend the training and remit of community nurses so that patients are supported when monitoring blood sugar levels and foot care.

Both Calderdale and Kirklees ran a systematic review of more than 800 diabetes records.

A spokeswoman for Kirklees PCT said all the improved benefits on patient experience, including practice re-organisation, are cost neutral and data are emerging on reduced service use.

More information on the project can be found in the project reports below.