Transforming Diabetes and NDH Management in Hillingdon
Introduction
In Hillingdon, managing diabetes and NDH across PCNs presented a complex challenge. Primary Care IT was engaged to implement digital solutions to improve clinical outcomes and financial performance across the federation.
Background/Challenge
Managing long-term conditions such as diabetes and NDH requires robust tracking of care and compliance with KPIs. Prior systems were insufficient, causing missed income and care gaps. PCIT was tasked with improving data capture, funding accuracy, and patient outcomes.
Objectives included:
- Improve diabetes and NDH indicator performance
- Maximise LES income recovery
- Streamline admin and reduce clinical burden
- Achieve measurable population health benefits
Solution
- Dashboards in OneAnalytics showing live practice and PCN-level performance
- Automated protocols and alerts to identify missed activity or coding gaps
- Monthly performance narratives with actions and insights
- Templates aligned to LES contract wording for precise compliance
Outcome
- 34% of diabetic patients achieved all 3 Treatment Targets (vs 30.2% NWL ICB average)
➤ Equivalent to 1,254 additional healthy years of life for Hillingdon patients - 71.2% of NDH patients reviewed (vs 63.9% NWL ICB average)
- 98% of diabetes LES funding achieved (vs 89% NWL ICB average)
- 100% of NDH LES funding achieved (vs 76% NWL ICB average)
Conclusion
Primary Care IT enabled Hillingdon PCNs to exceed expectations for diabetes and NDH management. Improved care, higher income, and efficiency gains were achieved through custom-built digital tools. This scalable model is ready to replicate across other regions.