Diabetes Outpatients

Guy's and St Thomas' look after approximately 8,000 patients who have a long term diabetes condition.

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To manually review each patient would take 10-15 minutes per patient - which makes it an impossible task to do each month.

Our methodology - clinical intent

Factor 50 worked with leading clinicians to define their diabetes-specific risk criteria and then to identify what useful data was available for the patients under their care.

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The rules were tested in a rigorous clinical evaluation - which we would be happy to share in more detail upon request.

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We then had high confidence to apply the clinician's rules to the patients to identify which needed to be seen sooner and which looked stable.

Embedding in Diabetes processes

As confidence in this new approach has grown, it has become more and more embedded within the diabetes service

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• Prioritised rebooking of patients in cancelled clinics and DNAs: when clinics are cancelled (e.g. due to a clinician absence), or when a patient does not attend a previous appointment, appointments are re-booked in order of decreasing clinical risk segment, with high risk patients being re-booked within 4 weeks. Early outcomes indicate that a high proportion of cases prioritised in this way might have come to further clinical harm had they not been seen in such a timely manner (as may otherwise have been the case).

• Proactive clinic review and management: this is now being adopted in both Type 1 and Type 2 clinics as a guide for clinicians to place patients on the most suitable pathway to ensure that:

  • Any patients newly identified as high risk are seen more frequently

  • Any low risk patients are booked in appropriately, thereby leaving clinic capacity available for the higher risk patients​

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