Summary
In one of England’s most deprived regions, St Helens Hospital revolutionised diabetes care for 18–25-year-olds through a co-designed, multidisciplinary model. Delivered without extra funding, the service integrates flexible access, embedded psychological support, and advanced diabetes technology. Outcomes include sustained HbA1c improvement, 80% reduction in Diabetic Ketoacidosis (DKA) readmissions, 50% reduction in Did Not Attend (DNA) rates, and all nine care processes delivered above national benchmarks. Mental health prevalence dropped from 32% to 18% through proactive screening and timely intervention. Recognised by NHS England, GIRFT, and winner of the RCP Medicine 2025 ‘Best Overall Presentation’ award, the model sets a national benchmark.
Innovation/Novel approach to an existing problem
Since 2023, the team has integrated proactive outreach, patient empowerment, rapid access clinics, mental health support, a dedicated transition service, and a successful DKA reduction initiative, all without additional funding. This proactive outreach approach began with comprehensive pre-clinic questionnaires exploring personal circumstances and challenges, fostering holistic understanding. This empowers patients to prioritise concerns ahead of consultations, enabling personalised discussions. Digital communication tools ensure timely contact that anticipates patient needs. A quick-access clinic, supported by a dedicated email service, gives patients direct, timely access to healthcare professionals. A dedicated transition clinic was introduced for 16–17-year-olds to bridge paediatric and adult diabetes care. Young adults are supported using Continuous Glucose Monitoring (CGM), with nearly all insulin pump users transitioned to hybrid closed loop (HCL) systems. Technology is integrated in a person-centred care framework, complementing rather than replacing therapeutic relationships and encouraging self-management. Routine mental health screening is embedded alongside early psychological interventions.
Equality, Diversity and Variation
Located in one of England’s most ethnically diverse and socioeconomically deprived regions, the service addresses multifaceted barriers faced by vulnerable young adults. Language differences, financial insecurity, unstable housing, and social isolation often impede diabetes management, deepening health inequalities. These obstacles are countered through proactive, human-centred outreach. Healthcare assistants contact patients before appointments, reducing DNA rates, building trust and ensuring timely access. Through culturally tailored education, personalised support, and advocacy, 87.8% of young adults use CGM, with nearly all pump users on HCL systems. Diabetes care transcends glycaemic control. Cultural competence and social awareness are embedded throughout. Multilingual resources and professional interpreters ensure clear communication. Mental health screening with CORE-10 and early psychological support are delivered with cultural sensitivity. This holistic, patient-centred approach fosters resilience and well-being. Routine audits stratify outcomes by ethnicity, deprivation, and gender, uncovering disparities and guiding targeted actions. Transparent data monitoring ensures continuous improvement and system learning. Leadership in NHS England’s Getting It Right First Time (GIRFT) review highlights the team’s success embedding equity in diabetes care and influencing broader reforms. Peer support and community initiatives create safe spaces where young adults feel valued, heard, and motivated.
Impact to Patient Care
The service delivers a patient-centred, accessible, and empowering model tailored to the unique needs of young adults. Beyond measurable clinical improvements, the true impact is seen in how patients experience their care, engage with services, and gain confidence in managing their diabetes independently. Young adults have traditionally faced fragmented care, high non-attendance rates, and feelings of disengagement from health services. The proactive outreach approach has drastically reduced DNA rates, rebuilding trust and fostering stronger therapeutic relationships. Embedding digital communication tools supports timely, responsive interactions. With nearly 90% of young adults using CGM and nearly all pump users transitioned to HCL systems, patients experience unprecedented control, safety, and freedom. Culturally tailored education and ongoing technical support ensure that technology integration is effective and meaningful. The Transition Clinic ensures continuity and personalised support through a structured, gradual handover with familiar clinicians, easing anxiety and preventing disengagement. It provides tailored education on adult diabetes management, encourages self-advocacy, and addresses the complex psychosocial challenges often faced during this life stage. The two-year Inpatient (DKA) project has been transformative in reducing avoidable admissions. This enhances patient safety, reduces emotional distress, and minimises disruption to education, employment, and personal lives. Integration of routine mental health screening (CORE 10) and timely psychological support addresses stigma and improves uptake of services. Rapid-access clinics and dedicated communication channels enable timely advice and intervention, reducing anxiety and reinforcing self-management. Collaborating with DUK and Digibete facilitates peer-support networks and community initiatives. The diabetes department received the People’s Choice Award 2025. Young adults feel supported, confident, and motivated, embodying a new standard for diabetes care that is equitable, personalised, and deeply impactful.
Results
Continuous data collection and monthly audits ensure accountability and responsive adaptation. A key achievement is reducing DNA rates from 50% in 2022 to 18.1% in 2025. Proactive outreach by healthcare assistants has been crucial in overcoming engagement barriers and building trust. Follow-up waiting times have fallen from 5.5 months to three, enhancing access and reducing risk from delayed care. The median HbA1c improved from 67 mmol/mol in 2023 to 62 mmol/mol in 2025, 31.3% of patients had an HbA1c at the NICE recommended target of <53mmol/mol and 40% of patients had an HbA1c <58mmol/mol indicating enhanced glycaemic control and positioning the service among the top nationally. By 2025 the service exceeded national benchmarks in nine key care processes essential for comprehensive diabetes management: eGFR recorded at 83%; Lipid profile at 77%; eye screening at 89.4%; annual urine albumin-to-creatinine ratio completion at 89%; foot screening at 74%; BMI recorded at 86%; blood pressure monitoring 86%; non-smokers at 92%. Over a two-year period, the Inpatient DKA project achieved an 80% reduction in recurrent DKA admissions as well as overall admission spells, driven by personalised discharge planning, patient education, rapid post-discharge follow-up, and coordinated multidisciplinary care. In 2023-2024, there were 33 DKA admission spells involving 15 patients. In 2024-2025, there were 20 admission spells affecting 12 patients. Using CORE 10 screening, 34% of patients were identified as needing psychological support and promptly referred. The holistic approach reduced it to 18%.
User Feedback
Feedback is gathered separately from two groups: patients attending the transition clinic and those engaged in the ongoing young adult clinic. The surveys are available digitally and on paper. Feedback consistently demonstrates high satisfaction and patient insights directly inform service improvements. Feedback data is reviewed quarterly and action plans are developed.
