Winner

GP Pathfinder Clinics – Improvements in Diabetes Care Using Data

by GP Pathfinder Clinics

Executive Summary

We use monthly Ardens data exports, manually compiled in Excel, 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 meetings and bi-monthly 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.

Judges’ comments:

The GP Pathfinder Clinics initiative is an excellent use of audit data to improve outcomes, with demonstrable results and use of groups to reinforce the healthcare messages and the outreach services. There is also a good explanation on economic viability and cost-efficiency. The equity and inclusion are great with languages, and also meets the needs of patients. The use of pharmacist’s roles was good.

Highly Commended

Juliana Dike

by East London NHS Foundation Trust

Executive Summary

There are a number of service users who are reliant on the Community Nursing Teams to administer their insulin. These service users remain on the caseload indefinitely whilst the case load continues to increase year on year. The project will look at how to empower service users and their carers to self-administer insulin and thereby reduce the District Nursing caseload. This can be done by training them at the point of diagnosis and by working with partner organisations to reduce the number of diabetic patients on the district nursing caseload by 20% by January 2025.

Judges’ comments:

The extremely important area of reducing the district nurse time spent on insulin administration; an aspect set to increase, therefore initiatives like this from East London NHS Foundation Trust are timely. They have demonstrated a clear understanding of the underlying issues and employs a wide range of straightforward measures to deliver significant outcomes. As the case examples show, enabling patients to self-manage their insulin injections is not only a service efficiency gain but also a form of rehabilitation, restoring independence and quality of life.

Commended

PRISM

by Promatica Health & Care

Executive Summary

PRISM is a population health tool developed to help NHS teams identify and prioritise people with diabetes who may be missing from official registers or at risk of deterioration. By integrating with EMIS and SystmOne, PRISM combines national datasets (QOF, NDA) with local records to highlight gaps in care, drive clinical prioritisation, and support proactive interventions. Designed by clinicians, for clinicians, PRISM enables data-led decisions that improve operational efficiency and outcomes. NHS teams have used PRISM to redesign services, better target resources, and ensure high-risk patients receive timely care when they need it most.

Judges’ comments:

PRISM is a data service to find patients not on the correct register. The example used was funded by Dexcom to find patients recommended to have CGMS. There was support for those who did not have smart phone access. There was a good approach to overcome language and cultural barriers. Very well-designed entry which clearly described how data was utilised by identifying and prioritising high risk patients. The project had a clear objective and has achieved positive clinical and non-clinical outcomes, addressing unwarranted variation in diabetes technology.

Executive Summary

Mid and South Essex Integrated Care Board was a pilot site for Implementation of Type 2 Diabetes Path to Remission Programme from Feb 2022 to March 2024.This initiative was funded by NHS England based on Diabetes UK research which demonstrated Remission(where blood sugars return to normal range ) for patients who have Type 2 diabetes and obese or overweight through low calorie diet programme.This submission demonstrates successful turnaround of the implementation of this pilot programme in Mid and South Essex ICB with clinical leadership using available technology in a resource constrained environment.

Judges’ comments:

The entry from Mid and South Essex ICB was a topical project which has demonstrated utilisation of data available to primary care. A good project to increase referrals to the remission service and the results for the remission programme are good. This initiative helps people living with type 2 diabetes provided from the ICB, providing good outcomes for people.