Community Diabetes Spoke Clinics

In partnership with Maidstone and Tunbridge Wells NHS Hospitals, West Kent Primary Care, has established a community diabetes service as part of the integrated community diabetes service for West Kent residents.

Several clinics run per week in host practices across West Kent, on a four-weekly rota. The clinics are staffed by community diabetes specialist nurses and practice nurses trained in diabetes.

Why the Community Integrated Diabetes Service was established

Historically, any adult patients with diabetes who were unable to be managed by their GP practice, would be referred to the local hospital for care. This led to long waiting times for patients to be seen.

More specifically, patients with type 2 diabetes who required injectable treatments, were either referred to the Diabetes Department at Maidstone and Tunbridge Wells Hospitals or, if their practice had appropriately trained staff, the patients would be managed by their practice.

To improve equity for patients with diabetes across West Kent and to reduce waiting times for appointments at the hospital, the community diabetes clinics were established.

The first clinics went live in March 2019 at eight practices in Tonbridge and Tunbridge Wells. Over the following months a further twenty clinics were set up, with all twenty eight clinics being fully established by October 2019.

Diabetes Spoke Clinic

The service offers appointments between 09:00 – 17:00 Monday to Friday.

Referral to the Community Integrated Diabetes Service Hubs and Spokes

Referrals can made by GPs, practice nurses and hospital doctors using the Electronic Referral System (ERS).

Once received via ERS, the referral is reviewed and triaged by one of the Community Diabetes Specialist Nurses and dependent on patient need and complexity, the patient is sent an appointment at one of the community diabetes spoke clinics. Advice can also be offered at this stage for further management.

Format of the Community Diabetes Spoke Clinic appointments

Patients will be offered either a face to face appointment at a clinic local to them or a telephone call. Following this the patient and Diabetes nurse will decide on next treatment steps.

Patient Records

The establishment of the clinics at practices, has been made possible by the use of EMIS-Web, a patient record system.

EMIS-Web enables the diabetes specialist nurses and practice nurses working in the community diabetes clinics, to access patient records from any practice in West Kent during a clinic appointment and ensures that the nurses have the most up-to-date information available regarding the patient’s clinical history, test results and medication. EMIS-Web also enables the nurses in the community diabetes spoke clinics to update patient records with details from the diabetes consultation that the GPs and other practice staff can easily access.

Patient Feedback

Patients have been very positive about the community diabetes service and the clinics being based at practices.

…since first being diagnosed with diabetes this is the first time that I feel the problems I am having are being addressed.

…at last – people who give me confidence in their advice.

…The best service I have had at any diabetes clinic or hospital, everything explained and all questions answered.

Very clear and easy to understand relevant to my issues