North West London Collaboration of CCGs: NW London diabetes transformation programme

The project aimed to improve outcomes for diabetics in the community by reducing variation in the care they received. GP networks received performance related payments according to whether they meet certain quality indicators, including meeting the percentage of patients meeting the three National Institute for Health and Care Excellence treatment targets, cost effective prescribing of glucose strips, and patients referred for structured education.

Data analysis was used to identify performance and changes, and a diabetes dashboard set up. Achievements have included a significant increase in patients getting the nine recommended care processes, 3,088 extra patients achieving the three NICE targets since June 2016, a register of non-diabetic hyperglycaemic patients and digital self-care apps for patients.

The approach, which could be replicated elsewhere, has brought together nearly 200 stakeholders and was developed in partnership with patient groups.

Read a detailed case study about this project at HSJ Solutions 


  • Basildon and Thurrock University Hospitals Foundation Trust: EGGS: a new breed of diabetes antenatal clinic
  • Camden Diabetes Integrated Practice Unit: Supporting Primary Care
  • County Durham and Darlington Foundation Trust and partners: County Durham and Darlington Integrated Diabetes Collaboration
  • East Lancashire Clinical Commissioning Group: Diabetes Integrated Service Transformation
  • Kent Community Health Foundation Trust: Improving the Management and Care of Diabetic Older Adults living in a residential Care Home Setting
  • Modality Partnership: Breaking down barriers in diabetes care
  • Oxford University Hospitals Foundation Trust, The University of Oxford’s Institute of Biomedical Engineering and Drayson Health: The evidence-based, patient app-to-clinician system, transforming the management of diabetes in pregnancy
  • Southern Heath Foundation Trust: The West Hampshire Community Diabetes service
  • Suffolk GP Federation: North East Essex Diabetes Service