Community Diabetes Specialist service

Surrey Downs Health & Care (SDHC) Community Diabetes Specialist Team serves a population size of over 300,000 in Surrey Downs (2017). The prevalence of diabetes in Surrey Downs is thought to be around 6% and it is estimated that 34% of people with diabetes remain undiagnosed

Service overview

The Community Diabetes service consists of a multidisciplinary team (MDT) of Diabetes Specialist Consultant, Nurses, Dietitians, Podiatrist and a Clinical Psychologist, delivering specialist clinics for adults over 25 years old across various locations in Surrey Downs. Adults with diabetes, aged between 17 and 25 years, are followed-up in Epsom Hospital.

Individuals with diabetes are referred by their GP or by other healthcare practitioners to the most appropriate specialist service based on their individual needs and expertise of the service, which are set out in the “Care Model” of the service.

The Community Diabetes service work closely with the diabetes team at Epsom Hospital to allow smooth transition of patient care from and into the hospital specialist service, as and when clinically indicated.

The team are supported by an administrative team who help manage incoming referrals, emails and telephone messages which are passed onto the Clinician of the Day. They are operational between 08:00-16:00 Monday-Friday.

Specialist clinics

Multidisciplinary team (MDT) clinics are held across various locations in Surrey Downs:

Leatherhead Hospital

Tuesday afternoons – MDT clinics

Monday to Friday – daily Diabetes Specialist Nurse (DSN) - led clinics

Address: Poplar Road, Leatherhead, KT22 8SD

Dorking Community Hospital

Alternate Monday afternoons – MDT Clinics

Address: Horsham Road, Dorking, RH4 2AA

Emberbrook Community Centre for Health

Friday mornings – MDT clinics

Address: 14 Raphael Drive, Thames Ditton, KT7 0EB

Nork Clinic, Banstead

Tuesday afternoons – DSN led clinics

Address: 63 Nork Way, Banstead, SM7 1HL

Services provided

The Community Diabetes Specialist service provides the following services:

  • Community Diabetes Specialist MDT Clinics.
  • Daily Community DSN-led clinics.
  • Diabetes Specialist Dietitians provide specialist clinic as part of MDT clinics or on ad-hoc basis.
  • Diabetes Specialist Podiatrist provides 3 sessions a week in Leatherhead Hospital, Dorking Hospital and Emberbrook Community Centre, Thames Ditton.
  • Diabetes Specialist Clinical Psychologist runs 2 clinics a week.
  • Type 1 Diabetes Structured Education (BERTIE).
  • Type 2 Diabetes Structured Education (Empower).
  • Freestyle Libre 2 assessments, training and support.
  • Pre-conception advice and review.

GP referral process

Adults with diabetes who are over the age of 25, are registered with a Surrey Downs GP practice and fulfil the referral criteria can be referred using the Diabetes Tier Three referral form, which should be completed and emailed directly to the service.

The Clinician of the day will triage all referrals, prioritising according to clinical need.

Appointments are booked according to the clinical urgency and appointment details are sent by post, followed by text messages as reminders nearer the appointment date.

After the clinical review, the management plans are sent to the GPs within 24 hours.

Consultation is by appointment only.

Service referral criteria

To refer your patient into the Community Diabetes Specialist Service, note the following inclusion criteria.

Primary Care led by GP or Practice Nurses with advice and support from Diabetes Specialist Nurses (DSN):

  • 9 care processes should be jointly completed but remains responsibility of the Primary Care
  • Uncomplicated Diabetes
  • Diabetes with stable complications

DSN input may be appropriate for ANY diabetes-related issue, but may be required for:

  • GLP1 initiation or titration
  • Insulin initiation or titration
  • HbA1c target not achieved
  • Ad-hoc encounter with the specialist services, e.g., diabetes related admission, Tier 4/3 step-down
  • Patient’s individual needs, e.g., poor engagement, patient requesting the specialist input
  • Significant co-morbidity interfering with the glycaemic management, e.g., learning difficulties,
  • Episode of disabling hypoglycaemia or any SECAmb attendance related to Diabetes.

Integrated Community Diabetes Specialist team (referred by the local DSN):

All 9 care processes should be completed within the community service.

  • Unable to achieve the Treatment targets*
  • Planning pregnancy*
  • Referred by hospital*
  • Altered hypoglycaemic awareness
  • Progression of diabetes complications / Advanced complications, e.g., retinopathy or eGFR <45, and requiring active specialist input
  • Type 1 Diabetes using technology or requiring technological assessment, e.g., FSL, CGM or CSII
  • Pancreatic Diabetes / GP seeking to clarify diagnosis
  • Advanced co-morbidities, e.g., heart failure, cirrhosis

Hospital based specialist care

All 9 care processes should be completed within the hospital.

  • Inpatient Diabetes care*
  • Hypo-unawareness with disabling symptoms
  • Pump (CSII) initiation and follow-up
  • Adolescent / Transitional care for Type 1 Diabetes
  • Antenatal Diabetes*
  • Active Foot disease*
  • Diabetic Nephropathy (Progressive decline in eGFR or patients on Dialysis)
  • Genetic Diabetes / Rare Syndromes / Community team seeking to clarify diagnosis.

* May be stepped down to lower tier once stabilised / suitable to be managed in lower tier.