The challenge
With over 3,000 patients on their diabetes register, Long Lane PCN faced a critical challenge: how to deliver effective treatment, management, and monitoring at scale while maintaining quality of care. The practice needed a comprehensive solution that would improve patient outcomes without overwhelming their clinical team.
Our solution
We developed a bespoke online portal that seamlessly integrated with existing systems to transform diabetes care delivery. The Diabetes Dashboard extracted patient data directly from EMIS, providing real-time visibility of patient progress against key performance indicators and enabling clinicians to make data-driven decisions about care priorities.
Exceptional results
Patient engagement: doubled our target
Our targeted approach achieved remarkable engagement rates:
- 487 patients actively participated from a pool of 2,838 eligible individuals
- 16% engagement rate – more than double our initial KPI target
- Created sustainable pathways for ongoing patient involvement
Mental health screening: transformative results
Recognising the vital connection between diabetes and mental health, we achieved:
- Screening rates increased from 14% to 50% across all diabetes patients by the end of March
- Among session attendees, an impressive 78% completed mental health screenings
- Established integrated care pathways linking physical and mental health support
Clinical efficiency: 50% time savings
Through innovative group session design, we delivered:
- 48 structured group sessions throughout the programme
- Average booking rate of 10 patients per session with 6 attending
- Halved clinician time compared to traditional one-to-one appointments
- Maintained quality of care while doubling reach
Impact and legacy
This initiative didn't just meet targets – it fundamentally transformed how Long Lane PCN approaches diabetes care. By combining digital innovation with evidence-based interventions, we created a scalable model that improves patient outcomes while optimising clinical resources. The success of this programme has established a blueprint for managing chronic conditions that prioritises both patient wellbeing and healthcare sustainability.
