Developing a Value-Based, Multidisciplinary Community Diabetes Team
Cardiff and Vale University Health Board
Introduction:
Cardiff and Vale UHB saw an urgent need to transform diabetes care. Over 1 in 20 residents live with diabetes, and 1 in 6 hospital beds are occupied by someone with the condition. Type 2 diabetes accounts for 90% of cases and is strongly linked with deprivation and ethnicity. Care was fragmented, with long waits, limited access to community support, and poor achievement of key care processes, especially in deprived areas.
Methods:
With Value in Health funding, a multidisciplinary Community Diabetes Team was established to reduce variation and improve care closer to home. A steering group brought together GPs, consultants, dietitians, pharmacists, finance, and data analysts. A triage system redirected suitable referrals from secondary to community care or returned them to primary care with advice. Clinics, group sessions, domiciliary visits, and education sessions were launched across community settings.
Outcomes:
- Secondary care referrals reduced from 100% to 30%
- Secondary care waiting times dropped from 11 weeks to 6
- Monthly community consultations grew from under 100 (Dec 2022) to 400+ (April 2025)
- Waits for dietetic support halved, from 16 to 8–9 weeks
- In the lowest-performing cluster, HbA1c control improved from 52.5% to 55%
- Completion of care processes rose from 27% to 38%
- Missed diagnoses reduced in target clusters
Learnings:
Multidisciplinary working, good data analysis, and a shared vision were critical. Qualitative feedback highlighted the value of education and patient empowerment. Demand for the improved service increased rapidly, requiring resource planning. PREM data collection should have started earlier.
What Next?
The model is now an exemplar across Wales. Plans include team expansion to meet rising demand, continued data-driven development, and sustained focus on equity and holistic, community-based diabetes care.
