Making Diabetes Self-Management Accessible Across South London

As part of Type 2 Diabetes Prevention Week, Faye Edwards, Senior Programme Manager for diabetes at the HIN, writes about the HIN-backed services which are helping improve access to essential support for people living with diabetes.

For those working in the NHS, particularly primary care, the ever-increasing number of people diagnosed with type 2 diabetes can feel like an uphill climb that just keeps getting higher. Across south London around 180,000 people are living with diabetes, over 120,000 have non-diabetic hyperglycaemia (pre-diabetes), and many more people are undiagnosed.

"For those newly diagnosed with diabetes it can feel overwhelming, confusing and even isolating."

For those newly diagnosed with diabetes it can feel overwhelming, confusing and even isolating. As with any new diagnosis it can take a while for people to understand the implications, and how they should manage their future health. Diabetes education and personalised, supported self-management are vital in the prevention and long-term management of type 2 diabetes, which is why they are priorities for the NHS.

The Health Innovation Network has had a focus on diabetes since 2014 and during our work with local people the importance of access to diabetes education and peer support became really clear. In 2017 the HIN convened the 12 south London clinical commissioning groups to collaborate and create Diabetes Book & Learn, a service to help people access diabetes education wherever they choose in south London. This cross-boundary working is a great example of how commissioning can enhance patient care and deliver a wide choice of options, achieving an economy of scale that would be impossible to deliver alone.

Across south London the Diabetes Book & Learn service provides people with type 2 diabetes with a wealth of education options, including group sessions led by a specialist diabetes dietician or nurse, delivered in person or online, depending on individual preference. These group courses include the DESMOND and X-PERT HEALTH programmes, both of which are well established, quality assured  type 2 diabetes education programmes delivered by trained educators. It also includes HEAL-D, which is a culturally-tailored type 2 diabetes education course for people of African or Caribbean heritage, created in partnership with members of the African and Caribbean communities in south London.

Book & Learn Digital also has a range of options that provide diabetes education and self-management support via a mobile app or telephone. These include the Low Carb Program, which provides structured education, coaching and support on how to self-manage your type 2 diabetes and uses AI to provide personalised recipe and exercise suggestions; and Second Nature, which uses behavioural insights to support people with type 2 diabetes to make lifestyle changes and gain knowledge of self-managing the condition.





Screenshot of diabetes book and learn homepage. Large header image of South London overlaid with a search box. Main text reads: delaying your diabetes education means delaying better health. Book your covid-friendly type 2 course today.

Since the launch of Diabetes Book & Learn in 2018 the we have continued to support its development. During the pandemic we support the ICBs with the procurement of new digital services and facilitated the switch of in-person sessions to online delivery, keeping the service going when many other similar services in the NHS had been temporarily stood down. Since Diabetes Book & Learn began, over 14,000 people with type 2 diabetes have been booked into a diabetes education course, with over half of these people choosing our digital or online options.

The establishment of Diabetes Book & Learn at scale across south London provides an unrivalled choice of education options for people with type 2 diabetes. It is playing a vital role in simplifying access to key self-management support and encouragement, and is equipping people with type 2 diabetes to take control of their future health and wellbeing. No one with a diagnosis of type 2 diabetes in south London should feel overwhelmed, confused or isolated by their diagnosis: Diabetes Book & Learn is here to help.

Find out more

People with type 2 diabetes who are registered with a south London GP practice can self-refer at the link below or call our friendly call centre team on 020 3474 5500. Any health care professional can make a referral via our website, call centre or via their practice IT system.

Diabetes Book & Learn

Scaling up diabetes services in south London through partnerships, innovation and supporting choice

Headshot of Neel Basudev

The story of how south London transformed diabetes care for up to 300,000 people is one of care moving from niche to mainstream. The HIN’s Diabetes theme Clinical Director Dr Neel Basudev charts successes across 12 boroughs.

Here is a letter I recently received in the post.

I want to change and transform the care for a disease across a vast geography. I have about 180,000 people that I need to improve things for and probably a further 275,000 who are at risk of this disease. I need to get things moving from an almost non-existent baseline across the entirety of south London. I need to improve lots of things like outcomes, pathways and patient experience. I have tried calling the A-Team but they were engaged, who can I contact to make this happen and has this ever been done before? Help!

Okay, so I made the letter bit up, but if you want to know how this can be done, then I may be able to help. I am always singing the praises of the diabetes workstream at the NHS’s Health Innovation Network (HIN). Apart from the obvious bias of being Clinical Director, I think that the story of diabetes transformation is one that needs to be told. I was lucky enough to get the chance recently at our flagship conference – Diabetes UK Professional Conference.

Scaling up services for the whole of south London

My role here began in 2016. There was already good work happening at the HIN, but it never got the traction it deserved across the vast geography of south London. I was lucky that my starting coincided with regional and national transformation work and funding. The HIN acted as a glue for south London and helped with much of the bid writing, coordination and then onward management. We soon moved on from niche to mainstream.

The kick-start to a lot of this was type 2 diabetes prevention which brought together south east and south west London colleagues in a unified way. We started from the non-existent baseline I have already mentioned in my fictitious letter. That was the partnership, networking and contacts ticked off. We built a strong base of relationships and people got a sense of what we could do and what we could bring to the table.

It was a no brainer when national funding trickled its way into south London that the HIN would help transformation work and build on this impressive start. The next big thing was structured education. This required a complete revamp: a new system, new referrals, a referral hub, make things easy, better data gathering and flow. It was a big ask, but we did it and launched in October 2018 with Diabetes Book and Learn.

Choice in the NHS is a rare commodity

Geographical boundaries were broken and people were accessing support by exerting choice. Choice can be a rare commodity in the NHS. We don’t like choice. What if people choose the wrong thing? That’s like me saying to the kids “listen to me, I’m your dad” – so instructional rather than offering advice and choice. It turns out that people with diabetes like choice and choice helped them get more support for their diabetes.

Building on that, we then moved a bit more into innovation with our NHS Test Bed project called You and Type 2. This married up several different innovators and their offerings to plug a vast care and support planning hole in diabetes care. It has been going strong since 2018 with six boroughs involved, hundreds of health care professionals trained and thousands of care plans done. There is much more that we can do with it and as you can hopefully see, we are not ones to rest on our laurels. We are looking into better integration across primary and secondary care and remote monitoring.

I am really proud of everything the HIN has helped to do for diabetes care in south London and equally excited about the future. For those of you old enough to remember…the future is bright, the future is green. Or is that lime green? With a bit of blue and purple. Watch this space.

HIN Diabetes theme

See a full list of our projects.

Click here to see our Diabetes theme webpage.

Get in touch to find out more.

Contact our Diabetes theme for more info on any of our projects.

E-mail us here.