North West London Collaborative

North West London Clinical Commissioning Groups Collaborative

From April 2017, the CWHHE Collaborative has been extended to become eight CCGs by the inclusion of Brent, Hillingdon and Harrow CCGs. This area is home to 134,000 people with diabetes.

CWHHE Clinical Commissioning Groups Collaborative

In 2014/15 five London CCGs, Central London, West London, Hammersmith and Fulham, Hounslow and Ealing, began working together to improve diabetes care outcomes. They had identified a number of is­sues which required improvement, including variation in the quality of primary care provision, low uptake of structured education, high cost prescribing with poor outcomes and a need for unified guidance for diabetes management.

New contracts were developed for GP practices working together as networks to improve diabetes care for a minimum population of 30,000, which attract payment according to the level and quality of care provided.

The contracts have a range of key performance indicators (KPIs). The Level one contract includes payment-related KPIs for the number of people with diabetes receiving all nine care processes, reaching national standards for blood glucose control, blood pressure and lipids, having a written care plan and being monitored for symptoms of hypoglycaemia if they are on sulphonylureas and/ or insulin.

The Level two contract is for practices trained to provide injectable therapy initiation and optimisation with requirements for recording of an individualised HbA1c target and sufficient improvement in glycaemic control following initiation.

There is also an incentive to provide annual monitoring for people at high risk of developing Type 2 diabetes and referral to intensive lifestyle management or structured education courses.

Each GP practice will have a lead GP and nurse for diabetes care who are appropriately trained in diabetes management.

All practices are on a single IT system (SystmOne), and are supported by local diabetes guidelines, a care plan template and a diabetes dashboard showing performance at practice, network and CCG level. Practices need to attend locally organised diabetes training and network meetings.

The community service contracts have been changed to support this work and to align their performance indicators with the same improvements in the population’s diabetes care.

Clinical Commissioning Group Diabetes Lead Email
NW London CCGs Collaborative   Dr Tony Willis
Central London CCG Dr Andy Goodstone
West London CCG Dr Rachael Garner
Hammersmith & Fulham CCG Dr Tony Willis
Hounslow CCG Dr Raquel Delgado
Ealing CCG Dr Raj Chandok
Brent CCG Dr Ajit Shah
Harrow CCG Dr Mathi Woodhouse
Hillingdon CCG (coming soon) (coming soon)

Central London CCG’s territory equates roughly to Westminster.

West London CCG’s territory equates roughly to Kensington & Chelsea.

CCG Websites