For senior NHS leaders, addressing health inequalities is no longer just a moral imperative; it is a clinical and financial necessity
This article has been commissioned and funded by Eli Lilly & Company Limited (Lilly). It refers to a joint working project and a panel discussion, both funded by Lilly.
Uncontrolled long-term conditions, particularly diabetes, place an unsustainable burden on the system, a strain magnified by failures in equitable care access. Data from the National Diabetes Audit (NDA) underscores the severity of this systemic failure: while the recorded prevalence of type 2 diabetes in adults across England reached 7 per cent in March 2024,1 the variation in care is unacceptable.
The percentage of people with type 2 diabetes receiving all nine care processes across integrated care boards (ICBs) ranges widely, from 38.4 per cent to 70.6 per cent.1 This gap confirms that standardisation alone cannot deliver equity.
As discussed at the HSJ Reducing Health Inequalities Forum in May 2025, a diabetes project in Frimley ICB discovered that the disease is much more prevalent in the working-age population. Furthermore, young adults with the condition are less likely to achieve all their treatment targets, even when they have been offered all care processes.2
The Frimley team found that the lack of “completeness of care” translated into higher long-term costs. The Frimley ICB recognised this challenge and developed a personalised model of care demonstrating that targeted intervention delivers measurable clinical and systemic benefits.3
Identifying the underserved community in Slough
Sangeeta Saran, Frimley’s associate director of out of hospital care, told the HSJ Reducing Health Inequalities Forum that the health inequality challenge within Frimley ICB resides in Slough, a multiethnic, Core20 area with a high prevalence of deprivation and diabetes.4 Diabetes is a major long-term condition in this area, but clinical teams observed that communities often did not take up the care offers, sometimes failing to attend essential regular HbA1c testing. If people do not present, early intervention and continued progression of care become impossible.
She stressed that these communities are “underserved”, not “hard to reach,” which can be frustrating knowing where the patients are and knowing what they need; however, because the service offered was “so formulaic” it did not suit a population often working multiple jobs. By leveraging local data and linking it to system metrics, the team specifically identified more than 1,500 individuals in their diabetic population who had missed routine HbA1c testing for more than 12 months.5
The Frimley blueprint: personalised and proactive intervention
In partnership with Lilly, four Slough primary care networks (PCNs), and with the support of Frimley Foundation Trust, Point-of-Care Testing (POCT), Frimley implemented a joint working project focused on Point-of-Care (POC) HbA1c testing. The project’s overall aim was strategically aligned with system goals: to reduce health inequalities for working-aged people and achieve a longer-term aim of increasing productivity and employment.6
The resulting service model aligns with the integrated care system’s (ICS) strategic ambitions: enabling healthy neighbourhoods, tackling obesity to prevent illness, and supporting people into employment.6
1. Consolidated care – Berkshire and Surrey Pathology Service POCT: Clinical capacity was rearranged to invite patients to a single “one-stop” appointment at their GP practice, which included the blood test, result review, and medication optimisation. This ensures patients receive the entire care process in one visit, addressing the barrier of requiring multiple appointments.
2. Immediate action: POC HbA1c testing was essential, providing results during the initial engagement. This allowed healthcare professionals to perform immediate clinical interventions (such as making medication changes or providing lifestyle advice), ensuring greater “completeness” and “stickiness” of care.
3. Home-based outreach: Recognising accessibility barriers, the project funded appointments outside of standard hours and utilised the multigenerational household team to deliver home-based care for housebound individuals.
System benefits and measurable outcomes
This commitment to proactively addressing the “missingness in data” yielded clear clinical and operational successes. Ms Saran shared that for the cohort targeted for the new care model, the results were encouraging:
- The test cohort saw a 14 percentage point increase in the uptake of the eight care processes applied.3
- The proportion of patients with HbA1c below 58 mmol/mol rose by 10 percentage points (between November 2023 and March 2024).3
These outcomes indicate that restructuring service delivery around population needs can result in a “reduction in inequalities of access”. Crucially, by increasing intervention and improving glucose control, the project works to reduce the likelihood of long-term comorbidities and complications. This preventative early success directly supports the Slough PCN ambition to build a community-led model and enables healthy neighbourhoods.
The Frimley case study illustrates a practical demonstration of proportionate universalism, providing a foundational service for everyone, while ensuring an essential “add-on for those who need it more”. For system leaders, this model indicates that investing in personalised, accessible care not only honours the duty to address inequity but also strengthens system performance by improving clinical outcomes and could proactively reduce the costs associated with unmanaged chronic conditions.
Job code: CMAT-05730
Date of preparation: February 2026
References:
1. OHID. Available at: https://www.gov.uk/government/statistics/diabetes-profile-update-march-2025/diabetes-profile-statistical-commentary-march-2025 4 March 2025 [Accessed 10 December 2025]
2. NHS England. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-audit-yt2/young-people-with-type-2-diabetes-detailed-report-2021-22/care-processes-and-treatment-targets 14 December 2023 [Accessed 13 January 2026]
3. Eli Lilly and Company. Data on File REF-79187. Dashboard. 2025
4. Slough Borough Council. Available at: https://democracy.slough.gov.uk/documents/s80938/Appendix+1+-+SBC+IHWS+specification.pdf [Accessed 7 January 2026]
5. Lilly. Project Initiation Document Frimley. September 2023
6. Lilly. Available at: https://assets.ctfassets.net/kwv2olrxu6pq/49DeRDyouBxwUvsK1NtCtv/66de033bebc602bc07133c8a8cee0cde/UK_Diabetes_ExecSummary_FrimleyJWA_AUG23_PP_LD_GB_2181_V2.pdf August 2023 [Accessed 7 January 2026]
