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Our work
Our work

Establishing digital diabetes care services

We worked with Cambridgeshire and Peterborough STP and five early adopter primary care networks to design a ‘digital first’ type 2 diabetes pathway. This has resulted in improved care for patients and more efficient processes for both 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 (PCNs) 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
  • recognising the pressures on primary care
  • providing organisational development support for PCNs.

The work then evolved in 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 interviewed  local practices and community staff and gathered  feedback from patients via surveys and group discussions to understand their needs and goals.

2. Process mapping an outline pathway

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.

3. Agreeing the digital opportunities

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 produced a detailed implementation plan including a set of recommendations 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 to judge the success of delivery.

4. Supporting implementation  

We recognised that there was significant potential to improve diabetes care but it was clear from PCN and practice engagement that overcoming variation of existing practices was essential to get the most benefit from digital tools. 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. The PCNs 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, and the second invited staff from local acute, community and local authority lifestyle teams to come together with PCN staff to embed joint working opportunities.

We produced a document that  brought together learning from the programme – setting out our approach, lessons learned and resultant changes that had been put in place. The STP intends to use this to implement digital first pathway redesign for other pathways.


There has been progress across the PCNs in all the areas of action we identified that could have the biggest impact on improving care. This includes the agreement of a consistent pathway and approach to care; introduction of virtual care reviews with community, acute and lifestyle staff; practices making better use of existing technology; and PCNs increasingly dedicating social prescribing time to support patients less able to manage their diabetes.

Frontline PCN staff say the support they received during this programme has helped build trust and relationships between staff across practices and other providers. This has enabled teams to better manage patients, especially during the challenges of the pandemic.

The impact of Covid makes it hard to demonstrate quantitative improvements in key measures. Despite this, since the beginning of the implementation phase (July 2020), pilot PCNs have improved their attainment on the eight care processes by 3% more than non-pilot PCNs.

Some PCNs improved their attainment of the eight care processes considerably, by up to 8-13%. Their improvement was also greater in comparison to the national position. Three of the pilot PCNs showed a larger improvement in patients receiving all three treatment targets compared with GP practices not in the pilot.

As a result of the success in the five early adopter PCNs, the STP expanded the programme to a further four PCNs in June 2021, again focusing on those areas with high levels of deprivation and prevalence. Given its positive impact, the STP is following the same methodology set out by Kaleidoscope and Edge.

The use of technology that was introduced as part of the type 2 diabetes pathway has also been extended to other elements of care. For example, Ely PCNs have extended the ‘bulk texting’ of patients to those with pre-diabetes and as a result saw a 17% increase in patient take up of referrals to the National Diabetes Prevention Programme.

Many of the outputs of this programme have also been spread across all 21 PCNs and practices in the STP.

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