Project PEDS07

Prevention and management of diabetes across Suffolk and North East Essex

This project is investigating how population health management approaches can be applied to diabetes prevention pathways.


Central to the development of local Integrated Care System (ICS), population health management (PHM) is an approach that uses linked data to plan and deliver care that achieves maximum impact on the health and wellbeing of a population. Historical and current data is used to understand the drivers of poor health outcomes in different population groups, to understand current health and care needs, and to predict future ones. This detailed local population insight is in turn used to design new proactive models of care, or target existing ones, to improve health and wellbeing today and in the future. PMH has a strong focus on prevention and the wider determinants of health as well as on the involvement of communities and organizations with a mandate to improve population health.

To build the evidence base for PHM, regional PHM colleagues hosted by East Suffolk and North Essex Foundation Trust, within the Suffolk and North East Essex (SNEE) ICS, have developed this discrete project focusing on the prevention and management of diabetes.

Project activity 

To highlight priority areas to focus on, descriptive cross-sectional analysis is being carried out with available aggregate-level routinely collected and nationally reported data and indicators across the diabetes prevention and management pathway by locality (where information is available), sociodemographic characteristics and time. This includes risk factors for type 2 diabetes, uptake of the NHS diabetes prevention programme, prevalence of diabetes, uptake of structured education, completion of treatment and care processes, and complications resulting in secondary care attendance.

The project is also mapping out the insight that can be obtained through currently available routinely collected data and what population health questions related to diabetes prevention and management can and cannot be answered. This will inform local priorities for PHM analysis via recommendations on a) what and how current data can be used to address specific questions; and b) what questions can only be answered with additional data/linked data. 

The project has identified diabetes-related lower limb amputations as an initial focus area. Diabetes is one of the leading causes of lower limb amputations, which are both seriously detrimental to a person’s quality of life and costly to the NHS. Yet, many lower limb amputations could be prevented through early intervention. With a PHM lens and using locally linked primary and secondary care datasets, multivariable analysis will be carried out to identify and interpret variation in diabetes-related lower limb amputations. This will feed into the identification of cohorts at increased risk of lower limb amputation, a review of existing care pathways and identification any changes to implement which may reduce the risk. Once these changes are agreed, a theory of change, and an implementation and evaluation plan will be developed to assess processes and outcomes. Formative and summative reviews will be carried out and findings written up and disseminated.

Who is involved 

  • Principal Investigator: Helen Green (OHID)
  • Louise Lafortune (University of Cambridge)

Contact us

Helen Green