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Our work
Our work

Establishing digital diabetes care services

Working with Cambridgeshire and Peterborough STP and five early adopter Primary Care Networks, we designed a ‘digital first’ type 2 diabetes pathway.  This involved looking at ways technology could improve care and make things simpler and more efficient for patients and staff. 

The challenge

Cambridgeshire and Peterborough sustainability and transformation partnership (STP) wanted to deliver a digital first type 2 diabetes pathway to support their ambitions for diabetes remission and care. The STP asked us to work with five primary care networks with some of the highest levels of deprivation and poorest outcomes. The aim was to develop a methodology that could be replicated across the region.

To do this successfully involved:

  • proactively identifying  patients with diabetes who had care gaps
  • automating  pathway management and finding gaps in care processes
  • offering suitable digital (alongside face to face) tools for education and self-help for weight management, diet, exercise and mood
  • establishing the uptake of online consultations both between patients and primary care clinicians and virtual care review discussions between primary, community and secondary care clinicians.

Our approach

Kaleidoscope worked in partnership with Edge Health to design and deliver a programme of support. It was based on making the most of new and existing digital opportunities, while ensuring legacy problems wouldn’t prevent change. Above all, our focus was to create real change for patients.

We did this by focusing on three key issues:

  • Ensuring digital technology follows need – listening to patients and staff and hearing their priorities for improving diabetes care; understanding the digital landscape, current tools and platforms available to staff and patients; finding potential solutions which fit this need and build on existing digital skills and knowledge; and working with them to help identify practical, realistic ways to overcome barriers
  • Recognising this is a very busy time for everyone in primary care.  Even when we started this pre-Covid,  we sought to use existing opportunities for discussions wherever possible, making the programme easy for people to participate in and shifting to digital engagement after initial face to face meetings
  • Providing organisational development support for PCNs –  this has been key for PCNs as they move from ‘nice idea’ to needing to deliver change, and supporting clinical directors and other PCN staff to work into their roles.

The work then evolved in three phases.

1. Understanding the starting point 

We went to each of the five PCNs meeting local leaders including PCN Clinical Directors and diabetes leads. We attended staff meetings to understand operational pathways,  current use of digital tools and barriers to digital adoption. We conducted interviews and discussions with people from local practices, community staff and heard feedback from patients via surveys and group discussions to understand their needs and goals.

Alongside this we conducted desktop research and analysis to understand population health needs and PCN/practice performance to build up a full picture of the local context. We used this information to identify the main challenges to improving local diabetes care and inform actions to address them.

2. Process mapping an outline pathway highlighting potential digital opportunities

We used the information gathered in our research to map a realistic operational primary care pathway. We identified a long list of potential digital solutions that could address the challenges, testing this with key stakeholders along the way. To support this development we looked at current best practice from other regions and at future opportunities for digital pathways. We agreed a criteria to judge the potential solutions against.

3. Clinical summit 

We hosted a clinical summit with PCN leaders to agree a shortlist of digital opportunities to pursue. The  discussion focused on how to make digital change stick with their PCNs. We shared an assessment of the potential solutions and proposed a shortlist of the most promising opportunities which we agreed with summit participants to pursue further.

We produced a detailed implementation plan including a set of recommendations for action following this agreement for the STP to take forward. We also provided early implementation support for the programme, including appointing an evaluation team from the University of Cambridge and agreeing an evaluation protocol in order to judge the success of delivery.

What is happening?

PCN change and implementation workshops 

We recognised that there was significant potential to improve diabetes care for those living in Cambridgeshire and Peterborough, but it was clear from PCN and practice engagement that the opportunity was largely about overcoming variation of existing practices.  There wasn’t a consistent pathway in place across practices and there was variation in practice performance in meeting the type 2 diabetes treatment targets.

Digital interventions hold great appeal, yet without dealing with the existing variation the potential benefits would be significantly reduced. The PCNs were in place but were largely working as individual practices without a clear strategy for improvement as a network.

We held two workshops in each PCN area to support operational implementation of the new pathway. 

The first workshop was for all relevant PCN staff, including GPs, nurses, HCAs, social prescribers and admin teams to support the development of a shared understanding of the proposed pathway and consider what could be implemented immediately, what barriers there were and what action or support was needed. We then asked PCNs to complete implementation proformas following the first workshop so they could make the pathway operational locally. We worked with the STP to support needs that had been identified, for example training.

The second workshop invited wider provider staff from local acute, community and local authority lifestyle teams to come together with PCN staff to embed joint working opportunities.

A blueprint for the digital first pathway redesign

We developed a final document which brought together learning from the programme overall – setting out the approach we had taken, lessons learned and changes that had been put in place as a result. The intention is that the STP will use this to implement digital first pathway redesign for other pathways.

The Kaleidoscope team were great to work with, fitting in with our existing diabetes team really well. They brought structure, pace and expertise to our digital diabetes project that we couldn’t have provided in-house with the lead-in time.

Rob Murphy, North Alliance Programme Director and Diabetes SRO, Cambridgeshire and Peterborough CCG


The digital diabetes project has been really ambitious in changing the way we transform care for patients with type 2 diabetes – I’m really impressed by Kaleidoscope’s commitment to managing the complexity and getting results.

Rozelle Kane, Clinical Lead for Digital and Innovation, Cambridgeshire and Peterborough STP

Our work