Cambridge University Hospitals


Cambridgeshire and Peterborough Managed Care Network for Diabetes

The Joint Cambridgeshire and Peterborough Managed Care Network for Diabetes is a network of a multidisciplinary group of healthcare professionals, patients, commissioners, managers and service providers, who are dedicated to working together to improve care standards and service delivery for people with diabetes, and to work towards the prevention of diabetes complications and the condition itself.

Background and context – diabetes the condition

Diabetes mellitus is an important medical condition with a high public health burden. Diabetes is a chronic and complex multisystem disorder of glucose metabolism requiring medical input throughout the life-course. Diabetes can be associated with serious complications including macrovascular disease (such as heart attack, angina, stroke, and peripheral vascular disease) as well as microvascular disease (with retinopathy or eye disease, nephropathy or kidney disease and neuropathy or problems with the nerves such as lack of sensation). Unsurprisingly, therefore, diabetes is associated with increased medical problems, requiring seeing doctors more frequently, needing hospital admissions, and with reduced quality of life as well as premature death if poorly controlled.

It is important to note that there are two predominant types of diabetes. Type 1 diabetes typically occurs in children and young adults, is due to absolute insulin deficiency (thus insulin treatment is required for survival), and contributes to approximately 10% of total diabetes prevalence; type 2 diabetes makes up approximately 85-90% of total diabetes prevalence, is associated with obesity and insulin resistance, and typically occurs in older adults aged over 35 years. It is estimated that between a quarter to one-half of type 2 diabetes in populations in developed countries is undiagnosed. This means that while biochemically someone may have diabetes (based on a raised glucose level if tested at the time), but clinically they have not developed symptoms, have not sought medical attention, and hence are undiagnosed. Thus prevalence estimates based on self-report or doctor diagnosed disease are underestimates of the total prevalence of diabetes, which includes individuals with both known and undiagnosed type-2 diabetes.

It is now acknowledged that there is an epidemic of diabetes. Global prevalence is set to rise from 336 million in 2011 to 552 million by 2030. In England, the latest modelled estimates demonstrate that for people aged 16 years and older the prevalence is likely to rise from 3.1 million in 2010 to 4.6 million by 2030. The increasing burden of diabetes in the UK is fuelled by the rising prevalence of obesity as well demographic changes (in age and ethnic group structure of the population). The APHO (Association of Public Health Observatories) model of diabetes prevalence estimates that the prevalence of total (diagnosed plus undiagnosed) diabetes will rise from 32,102 in 2010 to 52,592 by 2030 in Cambridgeshire alone, a predicted increase of ~20,000 persons with diabetes in 20 years.

Diabetes is costly (accounting for >10% of NHS costs), and there is compelling evidence that it is only through improvements in both the management of diabetes for individual patients and in organised service provision for it that the individual and health service burden of diabetes can be brought in check.

The Diabetes Network actively works towards better care and service provision for diabetes, with a strong focus on the education of both health professionals and patients with diabetes.

The Diabetes Network and its work

Historically the Diabetes Network has changed its area of coverage between being a locality based Network, then moving to a Countywide Network across Cambridgeshire, and then further expanding to include Peterborough, as the NHS structures have moved from PCGs to PCTs to the Cluster across Cambridgeshire and Peterborough. Until 31st March 2013, the Diabetes Network functioned under the umbrella of NHS Cambridgeshire (Primary Care Trust). Since 1st April 2013, there are new structures in place nationally, with the establishment of the Strategic Clinical Networks (SCN). The condition of diabetes sits within the Cardiovascular SCN. Existing Networks will in time link with the SCNs.

More information about the SCNs can be found here:

The multidisciplinary Cambridgeshire and Peterborough Managed Care Network for Diabetes brings a range of expert health professionals in diabetes as well as patients with diabetes and service providers and commissioners together to help work together for ensuring that NICE standards for diabetes are met, equity is achieved for patients through different localities, and improvements are made to the service within budgetary constraints.

Over the last 5 years, the Network has championed, advised on and delivered on a range of projects focusing on (but not limited to):

  • integrated diabetes care,
  • the Sustainable Health Partnership diabetes workstream,
  • patient education prioritisation,
  • education of health professionals including locally delivered study days and e-learning via the Cambridge Diabetes Education Programme –
  • improvement of information technology and governance issues,
  • guidelines and referral pathways,
  • and formulating and supporting locally enhanced services (LES) for diabetes.

It has specifically achieved implementation of the diabetes integrated care project in the East Cambridgeshire and Fenland (ECF) locality, and worked with the Medicines Management Team (MMT) to enable cost control and implementation of appropriate drugs for diabetes as well as on specific guidance for glucose self-monitoring among patients with diabetes. In addition, it has helped plan and deliver educational events across the patch for meeting some of the update needs for practice nurses and GPs. Most recently, these have focussed on diabetic feet complications and prevention. The network has been working behind the scenes to evolve and improve Diabetes Manager/NHS.Patient software for use by practices and patients, to improve the ability to generate patient held up to date records, usable for virtual advice, education and prioritisation of care, as well as in Accident and Emergency and for out of hours care.

Network meetings and personnel

  • Membership of the Network comprises more than 60 professionals and service users across Cambridgeshire and Peterborough, with an average attendance of over 20 members at meetings.
  • The Diabetes Network has generally held meetings three to four times a year with its full membership, while its Executive Team meets as required and through ‘virtual meetings’ when necessary.
  • Administrative support for the Diabetes Network is provided by the Post Graduate Medical Centre, by Mrs Julie Graham and Carole Mills.
  • The chair of the Diabetes Network is Dr Nita Forouhi, MRCP, PhD, FFPHM, a Programme Leader at the Medical Research Council Epidemiology Unit and a Public Health Consultant Physician. The co-chairs are Dr Arun Aggarwal (Huntingdonshire locality) and Dr John Szekely (East Cambridgeshire and Fenland locality). Dr Jonathan Roland leads on issues related to Peterborough.
  • The primary care lead for the Diabetes Network is Dr Arun Aggarwal.
  • The chair of the Diabetes Network Working Group is Candice Ward, Principal Diabetes Dietitian, Cambridge University Hospitals NHS Foundation Trust.
  • Patient members include Peter Robins and Roger Smith.
  • The network membership included a large number of dedicated and expert individuals, who have given of their time generously

For further information please contact Julie Graham or Carole Mills (Tuesday – Thursday ONLY) 01223 217606