Summary
Monthly Ardens data exports, manually compiled in Excel, are used to track six key diabetes indicators, including HbA1c, blood pressure, and foot screening. These simple, low-cost snapshots inform targeted patient recalls and guide discussion at monthly Diabetes Specialist Nurse (DSN) meetings and bi-monthly multidisciplinary team meetings (MDTs) with the GP diabetes lead. Between July 2024 and July 2025, this approach supported measurable improvements: HbA1c ≤ 58 mmol/mol increased from 65% to 75%, foot screening rose from 78% to 87%, and statin prescribing in high-risk patients improved from 75% to 90% – all without extra software or GP time.
Innovation/Novel approach to an existing problem
This pharmacist-led diabetes model represents a practical, scalable innovation that leverages existing tools and workforce to deliver high-impact, data-driven care, without additional cost or clinical burden. At the heart of the approach is a manual data-monitoring process using monthly Ardens CSV exports, compiled and tracked in Excel. This method provides a clear, flexible, and replicable system to drive continuous quality improvement. Each month, data is extracted on six key diabetes indicators: HbA1c, blood pressure, cholesterol, foot screening, urine ACR, and structured education referrals. These snapshots are used to identify care gaps, target recalls, and shape clinical decision making. This real-time, locally controlled process allows fast responses to trends. The data informs recall lists, ensures reviews are clinically relevant, and supports dynamic agenda-setting for meetings. Complex cases, prescribing challenges, or emerging patterns are flagged in advance, enabling proactive problem-solving and shared learning. What makes this approach novel is how simple, accessible analytics have been embedded into the daily operations of the general practice team. This model can be rapidly adapted to any practice using Ardens or similar systems. Crucially, it allows small teams to act quickly, track progress visually, and maintain clear accountability for outcomes. From July 2024 to July 2025, this system directly supported measurable improvements in care quality. These gains were achieved through ARRS-funded pharmacist clinics, without increasing GP sessions. Pharmacist reviews are tailored based on data insights, enabling more focused consultations and better patient outcomes. Safety and governance are integral. Duty GP support is available in real time during clinics, and all pharmacist activity is documented and reviewed through regular audit cycles. New pharmacists undergo intensified monitoring.
Equality, Diversity and Variation
Patients can book appointments online 24/7 in nine languages, to date. Responses are in the language of the patient wherever possible. Diabetics with acute symptoms are already clinically approved and fast tracked. Clinics are split into hot (acute) and cold (chronic) so chronic disease and preventative actions are never interrupted by acute patient overload. Group treatment of patients with hypertension and diabetes from the same community has helped to ensure healthcare actions are understood better and reinforced and encourages others in the community to come forward. Often, the HCP leads for these groups understand the language and beliefs of the patients. GP Pathfinders Clinics (GPC) also runs active outreach to schools, places of worship, etc. The management board has a patient representative who also chairs a patient group that reflects Brent’s diversity. This meets regularly to discuss improvements.
Impact to Patient Care
The model has shown consistent improvements across key clinical indicators, increased patient engagement, and enhanced operational safety and efficiency. Over the 12-month period from July 2024 to July 2025, patients experienced more timely, structured, and holistic care delivered through a scalable model that maximises the role of trained pharmacists while maintaining safety and clinical oversight. Patient care has benefited from more focused and timely reviews, thanks to a streamlined operational process. Ardens CSV exports monitor key indicators and identify patients needing intervention. This targeted recall approach ensures pharmacist appointments are used efficiently. It also shapes meeting agendas, ensuring complex cases and system gaps are addressed promptly. In addition, quarterly audits maintain data accuracy, consistency in documentation, and oversight of new team members. Reviews are not limited to diabetes metrics, ensuring patients receive joined-up, personalised care.
Results
Between July 2024 and July 2025, the pathway delivered measurable improvements. Across eight key indicators, there were strong gains in disease control and preventative care: HbA1c ≤ 58 mmol/mol increased from 65% to 75%, a 10% improvement that exceeds the 3% aim. HbA1c ≤ 75 mmol/mol rose from 87% to 91% (+4%). Foot screening completion increased from 78% to 87% (+9%). Diabetes education referrals improved from 81% to 87% (+6%), indicating a stronger emphasis on patient self-management. Statin prescribing for patients with QRISK2 ≥10% (no CVD history) rose from 75% to 90% (+15%), while uptake in patients with established cardiovascular disease increased from 88% to 96% (+8%). Use of ACE inhibitors or ARBs in patients with nephropathy improved from 89% to 96% (+7%), contributing to reduced progression of diabetic kidney disease. Blood pressure control (≤ 140/90 mmHg) increased modestly from 80% to 81% and has been prioritised for further optimisation. All improvements were delivered through ARRS-funded pharmacist clinics, with no additional GP sessions. Monthly Ardens CSV exports were manually analysed in Excel to identify gaps in care, guide patient recalls, and optimise clinic scheduling. This efficient, low-cost data system supports high-value activity without reliance on new platforms or administrative overhead. No prescribing incidents or adverse events were recorded. Pharmacists operated under real-time supervision, with immediate access to duty GPs during every clinic session. This provided a safety net for clinical decision-making and enhanced patient confidence in the model.
User Feedback
The model has shown consistent improvements across key clinical indicators, increased patient engagement, and enhanced operational safety and efficiency. Ardens CSV exports monitor key indicators and identify patients needing intervention and record feedback. This shapes agendas for team meetings. More comprehensive formal patient feedback is planned for Q3 2025. Initial indicators suggest improved care quality and confidence. Positive feedback has been received from the patient council, which is a key component of the management of GPC. Briefings have also been provided to Lord Darzi which referred to the GPC model very favourably. Similar presentations have been given to the Health Foundation and The Kings Fund, who were extremely complimentary.
