Community Diabetes

Specialist Care for Patients

Community Diabetes Spoke Clinics

In partnership with Maidstone and Tunbridge Wells NHS Hospitals, West Kent Health GP Federation, has established a Community Diabetes Spoke Service as part of the Integrated Community Diabetes Service for West Kent residents.

This Community Integrated Diabetes service consists of level 2 Diabetes Spoke clinics provided at host practices across West Kent and level 3 Diabetes Hub clinics provided at the Diabetes Centre at Maidstone Hospital and Abbey Court, Tunbridge Wells.

Community Integrated Diabetes Service

7 community diabetes spoke clinics run per week in host practices across West Kent, on a 4 weekly rota. The clinics are staffed by community diabetes specialist nurses and practice nurses trained in diabetes.

Spoke clinic locations are shown in the map below:

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 Spoke clinics were established.

The first Spoke clinics went live in March and April 2019 at 8 practices in Tonbridge and Tunbridge Wells. Over the following months a further 20 clinics were set up, with all 28 clinics being fully established by October 2019.

Capacity of Community Diabetes Spoke Clinics

Each Diabetes Spoke Clinic has capacity for 5 to 20 patients dependent on whether 1 or 2 nurses are in clinic and the type of appointments that patients are booked in for.

New patients requiring a full assessment or who need to be taught to administer injectable therapies, usually have a 40-minute appointment. Follow up appointments are 20 minutes long.

Referral to the Community Integrated Diabetes Service Hubs and Spokes

Referrals are made by GPs, practice nurses and hospital doctors using ERS (Electronic Referral System). WKH Community Diabetes Referral form

The referral criteria for the Community integrated Diabetes Service are as follows:

  • Unstable/Complex Type 2 Diabetes
  • Management of stable and unstable type 1 diabetes
  • Poor glycaemic control (e.g. HbA1c >69mmol/mol) despite maximal tolerated hypoglycaemic therapy
  • Young Adults (16-25-year olds)
  • Needing assessment and initiation of injectable therapy start (Insulin / GLP‐1)
  • Preconception awareness /Preconception planning Type 1 & Type 2
  • Severe hypoglycaemic episodes (3rd Party assistance) /hypoglycaemic unawareness
  • Weight management (BMI >35 on insulin or BMI>40 if not suitable for community weight management service)

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 of their condition, the patient is sent an appointment for Level 2 diabetes care at one of the Community Diabetes Spoke Clinics or for Level 3 diabetes care at one of the Hub Clinics, at Maidstone Hospital or Abbey Court in Tunbridge Wells.

Most patients wait on average 5 weeks to be seen for their first appointments at a Community Diabetes Spoke Clinic.

Format of the Community Diabetes Spoke Clinic appointments

All new patients have a full assessment via telephone consultation or face to face in a Community Diabetes Spoke Clinic. Subsequent appointments for follow up review are provided face to face in a Spoke clinic, by video consultation or by telephone dependent on patient need, patient choice and nurse recommendation. Patients requiring injectable initiations are offered a face to face clinic appointment or video consultations.

Patient Records

The establishment of the Spoke clinics at practices, has been made possible by the use of ‘Vision Anywhere’, a web-based patient record system that integrates with patient record systems in all the West Kent Practices.

Vision Anywhere enables the diabetes specialist nurses and practice nurses working in the Community Diabetes Spoke 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. Vision Anywhere 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 Spoke service and the clinics being based at practices. Patients have also been very receptive to having telephone consultations and video consultations during the Covid 19 situation and not being expected to leave their house during lockdown for face to face consultations.

Telephone and video consultations have not only been popular with patients, but they have also helped increase capacity in some of the clinics, which has resulted from reduced travel time by the diabetes specialist nurses. Providing telephone consultations has meant that the diabetes specialist nurses have been able to work from their base more frequently as opposed to travelling to practices to run face to face clinics. This means that some clinics can accommodate more patient appointments which will further reduce patient waiting times.

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.

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