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Our plans for diabetes services focus on two areas; creating new models of care and our Bradford Beating Diabetes programme.

New model of care

Creating new models of care is an NHS England scheme. The scheme calls on health leaders to redesign care so it is sustainable and better able to meet the needs of our patient population. As diabetes is a priority area for our CCG, we have focused efforts on developing an end-to-end pathway, from the prevention of Type 2 diabetes to the improved management of people with diabetes.

Our model of care for diabetes looks at a number of different areas, covering adults and children, these include:

Bradford beating diabetes

NEW BBD logo 1Our Bradford Beating Diabetes programme focuses on making our population aware of the condition by highlighting the signs, symptoms and risks of Type 2 diabetes. It supports people to make lifestyle changes to reduce the risk of developing the condition and be in control and healthy. 

In our CCG there are more than 21,000 diabetic patients registered with primary care services. Every year, a person diagnosed with Type 2 diabetes will typically spend over 8,500 hours managing their own condition alongside 3 hours input from a health professional. The Bradford Beating Diabetes programme is centred on prevention and education on self-care and management of the condition so that we reduce the number of people diagnosed with the condition.

Bradford Beating Diabetes was chosen as one of the national demonstrator sites for the NHS England Healthier You: NHS diabetes prevention programme. The programme was chosen as a national demonstrator site due to it's innovative approach to delivery and the aim to get the best outcomes for patients. 

How are we doing? 

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Meeting NICE recommended treatment targets

For adults, these treatment targets include HBA1c, cholesterol and high blood pressure. 

  • nationally, 40% of people who have been diagnosed with diabetes are meeting the NICE recommended treatment targets.
  • in our CCG, we achieve better than this with 41.1% of people diagnosed with diabetes meeting NICE recommended treatment targets. 

You can find information for the public on NICE treatment guidelines for adults with diabetes here.

People diagnosed with diabetes attending a structured education course within a year of diagnosis

If you have been diagnosed with diabetes, you should be offered a place on a course to help you understand more about the condition and how to manage it, within a year of your diagnosis.

  • in West Yorkshire, the number of people attending a structured education course is 5%,
  • in our CCG, 2.6% of people who are newly diagnosed with diabetes attend a structured education course within a year of diagnosis, 
  • this means that our CCG are in the second lowest quartile. 

Diabetes nine care processes

NICE recommends that each year all people with diabetes should receive nine key tests, known as the diabetes nine care processes. The tests help to assess whether diabetes is well controlled and are designed to prevent long-term complications.

The nine key tests include:

  1. blood glucose level measurement (HbA1c)
  2. blood pressure measurement 
  3. cholesterol level measurement
  4. retinal screening
  5. foot and leg check
  6. kidney function testing (urine)
  7. kidney function testing (blood)
  8. weight check
  9. smoking status check
  • we have an aim as part of our local quality premium target for 70% of patients to have all nine of these tests annually.
  • in our CCG for in 2015/16, 52.5% of our patients had all nine of these key tests. 

What you tell us about diabetes services

We make sure that we are listening, engaging and involving patients in the planning and design of their local NHS.

To do this, each programme of work has the infrastructure to engage and collect information from people through:

Diabetes service experienceThe insight and feedback you give us makes sure that we don't just collect information, but that we have the means and ability to use it to inform our commissioning activity and improve quality. All the insight and feedback is pulled together in a system we call grass roots.

Grass roots

Grass roots pulls together information reported through NHS Choices, Patient Opinion, Healthwatch, complaints, local groups and direct patient, family and community feedback so that we can understand experiences of local NHS services. This information helps us inform our CCG planning and decision making. 

What you report through grassroots

Your feedback on the Bradford Beating Diabetes prevention programme

BBD programme feedback

Patient stories



2015/16 - what have we done?

Our efforts during 2015/16 focused on our Bradford Beating Diabetes programme. The programme looks to make our population aware, active, healthy and in control of Type 2 diabetes. 


What we are doing in 2016/17

We are developing a new system in Bradford, specifically to tackle the high numbers of people living with, and at risk of developing diabetes. 

Sustainability and transformation plan

In our local five year forward view we set out our vision to - create a sustainable health and care economy that supports people to be healthy, well and and independent. 

To do this, we will be creating a sustainability and transformation plan (STP) for the district. The STP will use our five year forward view as a starting point. We want to move from a complex system (where organisations work on their own) to a simple system that is designed with indivduals at the centre of their care.

Accountable care system 

One of the main parts of our STP is to create an accountable care system. The accountable care system will facilitate transformation across Bradford and create common approaches to challenges that we all face - such as quality in treatment standards and preventing ill health.

The new accountable care system will at first focus on diabetes and prevention of Type 2 diabetes. This will involve providers working together to create an end-to-end system for both Type 1 and Type 2 diabetes that incorporates primary prevention, secondary prevention, care and treatment. 

We chose to start with diabetes as we need to reduce the number of people diagnosed with the condition in Bradford, and lower the risks of associated complications. 

We hope to have one contract in place for the newly designed service which will be operational from April 2017. Although we are starting with diabetes, the development of the accountable care system is part of a longer-term development.

What we are doing over the next five years

Over the next five years, as part of our sustainability and transformation plan (STP), we will create an accountable care system for diabetes.

This means that our population will have a single, simple, joined up system for diabetes care, with the patient at the centre. The accountable care system for diabates will focus on education, prevention of Type 2 diabetes, self-care and reducing the number of complications associated with both Type 1 and Type 2 diabetes - so that patients get high quality care, no matter which NHS service they use. 
Diabetes - next five years