The Barnet Community Diabetes Service is delivered by a dedicated multi-disciplinary team (MDT), including diabetes specialist nurses, dietitians, pharmacist, and diabetes consultant. The team provides support to adults living with diabetes across a range of community settings, including clinic locations and home visits for housebound patients.

This holistic service is designed to empower patients with type 2 diabetes to effectively manage their condition within the community. The team supports individuals with complex health needs who require multiple therapies, aiming to reduce hospital admissions and minimise the risk of long-term complications.

Patients are equipped with the knowledge, skills, and confidence to self-manage their diabetes and make informed decisions about their care.

In addition to clinical support, the service provides access to a number of structured pathways tailored to individual patient needs, including:

DESMOND Structured GROUP Education Programme

The diabetes service offers the DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) structured education programme, available both face-to-face and online.

This programme is specifically designed for adults with type 2 diabetes - whether newly diagnosed or already living with the condition but in need of further support and information.

Sessions are jointly delivered by a diabetes specialist nurse and a dietitian, ensuring a comprehensive approach to diabetes management.

Audit results following participation have shown significant benefits, including improved blood glucose control, weight loss, and, in some cases, a reduction in diabetes medication.

Diabetes GLP-1 Agonist GROUP Support education session

This session is specifically designed for patients prescribed injectable, non-insulin treatments - GLP-1 receptor agonists (GLP-1 RAs).

Its aim is to improve patients' understanding of how GLP-1 medications work and to provide practical guidance on dietary and lifestyle adjustments to help optimise blood glucose control.

The session is delivered by a diabetes dietitian, and patient feedback has been consistently excellent, highlighting the session's value in supporting effective diabetes self-management.

Type 2 Diabetes and Insulin GROUP Support education session

This session is specifically designed for patients with type 2 diabetes who are prescribed insulin treatment.

The aim is to increase patients' understanding of how insulin works, and to provide practical support on the adjustments needed to diet and lifestyle to optimise blood glucose control. The session also covers healthy eating guidelines and addresses common myths and misconceptions related to insulin and diabetes management.

Delivered by a Diabetes Specialist Nurse (DSN) and a dietitian, the session also offers an opportunity for patients to ask questions and gain confidence in managing their diabetes with insulin. 

Coffee Mornings at Edgware Community Hospital 

Coffee Mornings are friendly, informal weekly sessions open to all patients visiting Edgware Community Hospital who are interested in learning more about the Barnet Community Diabetes Service.

These drop-in sessions provide an opportunity for patients to:

• access key information about the service, including clinic locations, referral pathways, and team structure
• ask questions in a relaxed environment
• watch a short promotional video about the service via a convenient QR code
• enjoy a complimentary cup of coffee

Sessions are hosted by our welcoming team of volunteers and a Health Care Assistant, who are on hand to guide patients and provide helpful resources. 

Diabetes Specialist Clinics

This pathway is designed for patients referred to the service for:

• optimisation of diabetes control
• initiation or adjustment of insulin therapy
• initiation of non-insulin injectable medications, such as GLP-1 receptor agonists

These clinics provide comprehensive assessment and support for patients who may be struggling to achieve target blood glucose levels despite current treatment or who are starting more advanced therapies.

Patients attending the clinics benefit from a multi-disciplinary team approach, with access to:

• diabetes specialist nurses for medication management, titration, and self-injection education
• dietitians for personalised nutritional advice to support treatment changes
• pharmacists for medication review and optimisation
• consultant diabetologists for more complex cases requiring specialist oversight

This service also helps to reduce pressure on secondary care by supporting safe discharge and ongoing diabetes management in the community. 

Professional Support and Training

In addition to direct patient care, the Barnet Community Diabetes Service offers support, advice, and training for healthcare professionals who wish to enhance their knowledge and skills in diabetes management.

Service QR code for patients

The below QR code provides patients with an overview of the structure and offerings of the service. This resource can be shared directly with patients to support their understanding of what the service provides.

In addition, the video link contains the same information and can be played in GP practice waiting areas, if appropriate.

Eligibility Criteria

Inclusions

• patient with Type 2 Diabetes with acute or persistent hyperglycaemia (on 3 or more glycaemic agents at maximum tolerated dose)
• steroid-induced diabetes
• initiation of insulin or GLP-1
• review of insulin regime OR change of regime
• supporting discharge from the hospital
• acute or persistent hypoglycaemic episodes
• patient education programme DESMOND (newly diagnosed OR never had education before - not for pre-diabetes)
• dietetic individual assessment: for poorly controlled Type 2 diabetes/education re: carb
• awareness; and those unsuitable for group patient education programme i.e. language barriers, learning disabilities
• patient education group session for insulin titration support (suitable for multiple daily injection regimens, such as twice daily mixed insulin or basal bolus regimen)
• patient education group session for patients receiving GLP-1 or GLP-1/GIP medication (not for initiation, suitable for patients already taking Victoza, Trulicty, Rybelsus, Ozempic, Mounjaro)

Exclusions

• Type 1 Diabetes, LADA and MODY
• pregnancy
• insulin pumps
• CKD 4 and 5

How to Refer