Commissioned by Brent Clinical Commissioning Group
Transcription
Commissioned by Brent Clinical Commissioning Group
Brent Integrated Diabetes Service Commissioned by Brent Clinical Commissioning Group Contents Acknowledgements……………………………..…………………………………………………………………………………………………………………………………..3 What’s New in Brent Integrated Diabetes Service? ……………………………………….………………………………………….…….…..5 How do I make a referral to the new Brent Integrated Diabetes Service? ………..………..……....…..…………...…………….5 What will happen in the Community Clinics..............................................................................................................5 What will happen after the Community Clinic appointment?...................................................................................4 The Link Diabetes Specialist Nurse ……………………………………………………………………………………………………………………..7 In-Practice Joint Consultation Clinics……………………………………………………….…………………………………….…………….………5 Link Nurse Allocation List by Locality……………………………….…………………………………………………………….……………….…….8 Your Diabetes Service is changing Virtual Clinics…………………………………………….…..…………………….….……….………………..……...…..9 Clinic Arrangements……………………………………………………..…..…………….………….……..…..………9 Diabetes Patient Groups………………………………………..……..…….………….…….………….…..…..…….9 Diabetes Themes and Topics…………………………..…..…………….……….………….….….….….…….…..9 New enhanced Primary Care-led Integrated Diabetes Pathway……………..…….……………….10 Diabetes Referral Information Referral Criteria……………………………………………………………………………………….…..………..…12 Referral Forms Tier 3……………………………………………………………………….…………...…..…..…13 Referral Forms Tier 4…………………………………………………………………………………...…….…....14 Diabetes Clinic Addresses Wembley Clinic………………………………………………………………………………………..……...……...16 Willesden Clinic…………………………………………………….……………………………….……...…..…...16 Monks Park Clinic……………………………………..……………………………………………….….…………17 Jeffrey Kelson Centre for Diabetes Endocrinology………………………………………..………..…17 Clinic Location, Day, Times………………………………….…………………………..…………………………………….……….…….………18 Diabetes Education Courses Desmond Course Overview………………………..………………………………..………….……19 Desmond Referral Form……………………….…………………..………………….…………..…..21 Diabetes Podiatry Information…………………..…………..……………………………………….……………...…….23 Brent Integrated Diabetes Service Team Members Contact Details……………….…………..……………………24 2 Acknowledgements I would like to extend my profound thanks and gratitude to Yvonne Leese, Vince Baxter, Nina Patel, Dr Koteswara Muralidhara, Dr Ajit Shah, Dr Daniel Darko, Jonathan McInerny, Rakhee Shah, Farhat Hamid, Maeve Quinn, Nikesh Karunanithy, Tony Afuwape, Melissa AllisonForbes, Michele Nelson, Jeanette Downer, Dr Joan St John and all of the new Brent Integrated Diabetes Team. I would also like to humbly acknowledge the dedication and commitment of the Brent Primary Care Teams and the Specialist Diabetes Team at the Jeffrey Kelson Centre, Central Middlesex Hospital who continually improve the health and lives of all our diabetic patients in Brent. 3 New Service Overview 4 This pamphlet serves as a point of reference to enable everyone to use the new Brent Integrated Diabetes Service effectively. Brent CCG has commissioned a new Consultant led diabetes service aimed at providing high quality specialist diabetes care in the community and closer to the homes of patients. The new diabetes service is designed to provide the same level of specialist care, as can be expected from secondary care but closer to the homes of patients. This service will offer Specialist Diabetes Clinics across all Brent localities and aims to support GP Practices in providing enhanced diabetes care.This service will be run by The Brent Integrated Diabetes Team and work in partnership with Jeffrey Kelson Diabetes Centre at Central Middlesex Hospital. What’s New in Brent Integrated Diabetes Service? The new Brent Integrated Diabetes Service (BIDS) aims to support both the diabetes patient and also the Practices more comprehensively and seeks to reduce the high volume of diabetes numbers in the borough of Brent. The existing diabetes services are well attended and currently offers a range of services which includes Specialist Diabetes Clinics in Wembley Centre for Health and Willesden Centre for Health as well as the weekly DESMOND education sessions. The BIDS Service aims to fully integrate the diabetes services in Brent. The focus will be on managing most of Type 2 diabetes patients in Primary Care and Community settings using optimal use of resources and innovative models of care, which includes:• • • • • • • • • In-Practice Joint Consultations Diabetes Virtual Clinics Link Diabetes Nurse Email/telephone support for GPs,Practice Nurse,Patients Group insulin starts Enhanced Specialist Dietician Psychology Support Additional Desmond Educational Classes Patient Forum and much, much more The new BIDS Team consists of a Diabetes Consultant in the Community, 2 General Practitioners with Special Interest in Diabetes (GPwSI), 5 Diabetes Specialist Nurses, Dietician, Podiatrist, Psychologist, Associate Specialist Consultant, Specialist Diabetes Consultant and Diabetes Service Management Team. How do I make a referral to the new Brent Integrated Diabetes Service? All patients are referred to the BIDS team by the patient’s GP. Once the referral form is received a letter offering an appointment to attend the nearest clinic to the patient’s home address. It is possible to request an alternative Community Clinic, if more convenient. A telephone or text reminder is sent to the patient a few days before the clinic appointment day. What will happen in the Clinic? The first appointment with the BIDS team enables the patient to be seen by a Diabetes Specialist Dietician who will discuss the patient’s diet. At the same appointment, all of the multidisciplinary team members will screen the patient and offer lifestyle changes advice and determine a clinical direction for the patient follow. After the initial diabetes screening process all the information gathered will be tailored to support the individual patient’s needs with a clear care plan. What will happen after the Community Clinic appointment? All patients will be discharged back to the GP with a clear tailored care plan and it is likely that most patients will only need to be seen once. Follow-up appointments will be arranged in the Community Clinics for people with complications as necessary. The appointment will be made at one of our Community Clinics or in the GP Practice jointly seen by the Practice Nurse and one of the Diabetes Specialist Nurses. An onward referral to the local hospital would be made by the General Practitioner as necessary. 5 Your Diabetes Service is Changing 6 Link Nurses Allocated to each locality in Brent Nina Patel Kingsbury Lucy Ogida Willesden Julia Anthony Wembley Margaret Carroll Kilburn Fiona Hughes Harness No of diabetes patients:4592 No of diabetes patients:4255 No of diabetes patients:4098 No of diabetes patients:4110 No of diabetes patients:4160 Forty Willows Surgery St Andrews Medical Centre Sudbury and Alperton M/C The Lever Medical centre Church End Medical Practice Stag Hollyrood Surgery Willesden Medical Centre Stanley Corner Medical Centre The Law Medical Group Acton Lane Surgery Ellis Practice Gladstone Medical Centre Lancelot Medical Centre The Windmill Medical Practice The Stonebridge Practice Chalk Hill Family Practice The Sheldon Practice Hazeldene Medical Centre Park House Medical Centre Harness Harlesden Practice Fryent Way Practice Primary Care Medical Centre Lanfranc Medical Centre The Lonsdale Medical Centre Askyr Medical Practice Brampton Health Centre Neasden Medical Centre The Sunflower Medical Centre Kilburn Park Medical Centre Brentfield Medical Practice Stag Lane Medical Centre Crest Medical Centre Alperton Medical Centre The Clarence Medical Centre Church Lane Surgery Beechcroft Medical Centre St Georges Medical Centre The Eagle Eye Staverton Surgery Freuchen Medical Centre Preston Road Surgery Chamberayne Road Surgery Preston Medical Centre Blessing Medical Centre Oxgate Gardens Surgery Tudor House Medical Practice The Village Medical Centre Integrated Health CiC Chichele Road Surgery Park Road Surgery Kings Edge Medical Centre Burnley Practice SMS Medical Practice Peel Precinct Surgery The Surgery Uxendon Crescent Surgery Roundwood park Medical Centre Pearl Medical Centre Willesden Green Surgery Hilltop Medical Practice Wembley Park Drive Medical Centre Willow Tree Family Practice Premier Medical Centre WCHC Walm Lane Surgery Fryent Medical Centre Brent GP Access Unit Buckingham Rd Surgery 7 The Link Diabetes Specialist Nurse A named Diabetes Nurse per locality will be helping the Practices to manage more diabetes patients within the Practice utilising the following methods: • • • • • • • • • Virtual Clinics with Practice Nurse Joint Consultation with Practice Nurse Providing a Care Plan for complex patients by discussing with Diabetes Consultant/s Facilitating a locality diabetes Monthly Diabetes Group session. This will be in the form of Virtual Diabetes Clinics which will be attended by the diabetes Consultant and will be held once a month at each locality. Each MDG will have time slots for 3-4 sessions in neighbouring Practices so that each Practice will be able to attend the MDG once every 3 - 4 months. If the LCGs or Networks prefer Virtual Clinics in individual Practices rather than neighbouring small locality groups, the number of clinics per Practice would be reduced to 2-3 sessions per year. Upskilling Practice Nurse/s in insulin initiation / GLP-1 starts Helping the Practice to identify patients who can be stepped up to Tier 3 (MDT locality HUB clinics ) or Tier 4 (Secondary Care)or stepped down from Specialist Care to in-Practice Management The Link DSN will provide telephone and email support to the Practice Nurse and patients as required The Link Diabetes Nurse will be visiting each Practice once every 6-8 weeks (this may be more or less based on the amount and type of support needed) Each Practice to identify a 2-3 hour slot, between 9am and 5pm between Monday and Friday, either in the morning or afternoon for the Link DSN visit. Please see the Link Diabetes Nurse allocation list for details below. In – Practice Joint Consultation Clinics The purpose of these clinics is to engage and encourage Practice Nurse and GPs to manage more complex diabetes patients and to increase the uptake of in-house insulin and GLP-1 starts.Joint Consultation should be Practice led with support from DSN and doctors for BIDS Diabetes Team as requested.The Link DSN would facilitate these clinics and ensure that they blend well with the overall pathway and do not create unnecessary additional work. Clinical Governance The Implementation Plan for each locality will be agreed with the Locality Diabetes Lead and the participation from each Practice will be reported to the Locality Lead and the CCG Lead for Diabetes. Prospective and retrospective data analysis will be done using various tools that will be reported to the Practice and the relevant leads in a timely manner to discuss and implement remedial measures as required. 8 The new and enhanced Integrated Diabetes Service introduces the use of Virtual Clinics to Brent, as detailed below:- Virtual Clinics These are clinics where Primary Care colleagues can discuss patients with a diabetes expert, without the patients present. The aim is to plan the management of more complex patients in Primary Care settings. Clinic Arrangements GP Practices will identify patients suitable for discussion in the Virtual Clinic. This could be patients with poor glycaemic control, poor blood pressure control or any other diabetes patient who the Practice thinks may benefit from discussion with diabetes experts. The locality Link DSN will liaise with neighbouring 3-4 GP Practices to arrange a Virtual Clinic with a diabetes Consultant 3-4 times a year. The Link DSN will facilitate preparation of a list of patients for discussion in advance. It may be possible to discuss up to 15-20 patients in 2-2.30 hours. This time can be divided to discuss different diabetes themes or topics. As this is a clinical session akin to managing patients, it is preferable to allocate a dedicated 2-3 hour period in a morning or afternoon session. Here are some examples of high-risk patient groups and diabetes topics that have been found useful for discussion in Virtual Clinics: 1) Diabetes Patient Groups • • • • • • • High HbA1c Recurrent Hypoglycaemic episodes Poor compliance or poor specialist clinic attenders Diabetic renal disease – CKD stage 3 or other co-morbidities Poor BP or Lipid control GLP-1 non-responders Housebound patients 2) Diabetes themes and topics • • • • • Newer medications Renal complications of diabetes Management of Diabetic Neuropathy Hypoglycaemia and driving regulations Managing diabetes in patients with co-morbidities 3) Diabetes Psychology Support • • • Providing a direct clinical service for patients with diabetes and their families / Carers, should there be complex management or psychological issues. Provision of expert advice to other clinicians re the psychological management of patients with diabetes to enable them to improve their wellbeing and facilitate their ability to self-care management. Provision of organisational consultation from a psychological perspective to enable those that currently deliver in the diabetes pathway to refine the pathway, understand gaps and improve outcomes. 9 WHAT’S CHANGED? KEY QUALITY IMPROVEMENTS Enhanced DSN capacity & role in localities to build capability in Primary Care Improved patient experience & equity of access to care Reduction in unscheduled A&E attendances & admission Reduction in New: Follow Up ratio Faster through-put of patient GP informed within 24 hours Discharge summaries 48 hours Improved electronic communication links – DOCMAN Evidence-based packages of care Outcome-based clinical care Improve access/capacity for DESMOND Rapid access to clinical advice Equitable access for all patients e.g. disabilities, housebound Improved self-management Psychological support Enhanced Podiatry & Dietetics services NICE compliant care plans Local Diabetes Managed Clinical Network (LDMCN) – at the Centre of Clinical Care. Focus on safety, quality, effectiveness, patient experience & access TIER 3 Community Services Managed Intermediary Care Multidisciplinary Clinics; Consultant- led support; Access to Specialist Diabetes Dieticians, Podiatrists or other Specialists; Patient Education (DESMOND); Insulin titration; Family Planning &Pregnancy Planning Advice; Psychological Support; Research & Development and Training; Healthcare Professional Education. Tier 3 Referral Criteria: Education (DESMOND) CKD 3 (e-GFR 30 – 45) with Poor glycaemic &/or BP control (poor glycaemia control defined according to co-morbidities & age) R3 retinopathy with Poor glycaemic &/or BP control Preconception, Women of Child Bearing Age & HbA1c > 48 mmol/L (6.8%) Dietician/Weight Management for BMI >35 (or for South Asian BMI > 30) with Poor glycaemic&/or BP control Podiatry – Grade 2 and those with previous Grade 3: for foot care plan (refer patient via Traffic Light Chart) Housebound for home visit by DSN – poor glycaemic control & related co-morbidities Agreed at MDG LAS call out for Hypoglycaemia (fax urgent) – DSN to contact patient within 2-3 days Psychology Services Discharge Criteria: 1.Max. 1 – 4 visits in intermediary care OR 2.Referral to Tier 4 OR 3 Non-attendance without cancellation (at clinician’s discretion) At discharge, all patients will have: 1.Care Plan modified / updated 2.Insulin Titration formulated 10 Diabetes Referral Information 11 Referral Criteria Tier 3 Referral to Community Intermediary Care: Tel: 020 8453 5965. Fax: 020 8453 5972 Education (DESMOND) CKD 3 (e-GFR 30-45) with *Poor glycaemic &/or BP control R3 retinopathy with *Poor glycaemic &/or BP control Preconception, Women of Child bearing age & HBA1c >48mmol/L (6.8%) Dietician/Weight Management for BMI>35 (or for South-Asian BMI >30) with *Poor glycaemic &/or BP control Podiatry -Grade 2*** and those with previous Grade 3: for foot care plan. House bound for Home visit by DSN * poor glycaemic control & related co-morbidities Agreed at MDG LAS call out for Hypoglycaemia (Fax urgent) for DSN to contact patient within 2-3 days Psychology Services Tier 4 Referral To Secondary care: e.g. Central Middlesex Hospital: Tel: 020 8453 2401, Fax: 020 8453 2415 or By Choose and Book NWLH NHS trust Education (DAPHNE) Children Adolescent/ Transitional Type 1 Diabetes Hypo-unawareness CSII Pump Therapy Antenatal CKD4-5 (e-GFR <30) with Poor glycaemic &/or BP control: Complex multiple co-morbidities *Poor glycaemic &/or BP control Agreed at MDG Podiatry -Grade3*** Please call 020 8453 2401 or Fax: 020 8453 2415 for advice/ referral*** 12 REFERRAL FORM FOR DIABETES CARE Tier 3 GP details / stamp (including, patient, name, address, telephone number, fax): Brent Community Services Diabetes Care Long Term Conditions Centre - Diabetes Monks Park Primary Care Centre Monks Park, Wembley. HA9 6JE Tel: 0208 453 5965, Fax: 020 8453 5972 E-mail: [email protected] or: [email protected] Referral made by: Patient Name: DOB: Signature: Date: Sex: Male Female Contact Tel Number/s: NHS Number: Address: Postcode: Ethnicity: Type of Diabetes Housebound? Language: Interpreter Required: Yes No Year of Diagnosis of Diabetes Type 1 Type 2 Others Medications: Please enclose: Oral Anti-glycaemics Insulin/s Other medications (Please enclose full details: name, doses and frequency) Tier 3 Referral to Community Intermediary care: Tel: 020 8453 5965. Fax: 020 8453 5972 1- A copy of completed care plan from GP (mandatory section 1 and section 5) Education (DESMOND) CKD 3 (e-GFR 30-45) with *Poor glycaemic &/or BP control R3 retinopathy with *Poor glycaemic &/or BP control Preconception, Women of Child bearing age & HBA1c >48mmol/L (6.8%) Dietitian/Weight Management for BMI>35 (or for South-Asian BMI >30) with *Poor glycaemic &/or BP control Podiatry -Grade 2*** and those with previous Grade 3: for foot care plan. 2- Copy of House bound for Home visit by DSN * poor glycaemic control & related co-morbidities all Agreed at MDG medications / LAS call out for Hypoglycaemia (Fax urgent) for DSN to contact patient within 2-3 days prescription Psychology Services printout or enter below / separately Specific questions / Other Medical Conditions: problems: ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Clinical Findings: Weight: BMI: Waist Circumference: Blood Pressure: Please see discharge criteria in Brent Community services Diabetes Care chart. Please repeat bloods if not done in the past 3 months and kindly enclose results below : HBA1c: Creatinine: e-GFR Urine Albumin/Creatinine: Total Cholesterol: HDL: LDL: AST (LFT’s): Smoking status: Triglycerides: TSH: Never smoked Current ___ / day: Stopped (date) __ /__ /__ ***PODIATRY – Refer patient via Traffic Light Chart RETINAL SCREENING – Refer NEW patients to Brent Screening Programme Tel: 020 8795 6499 13 14 Diabetes Clinic Addresses 15 Wembley Centre for Health & Care http://www.localdatasearch.com/search?Loc=HA0+4UZ&Key=Wembley+centre+for+health Wembley Centre for Health & Care, 116 Chaplin Road, Wembley, Middlesex HA0 4UZ Tel: 0208 7955 6001 The designated DSN for Wembley Locality is Julia Anthony on 07919046765 Willesden Centre for Health & Care http://www.streetmap.co.uk/map.srf?X=522710&Y=184161&A=Y&Z=110 Willesden Centre for Health Robson Avenue London NW10 3RY The designated DSN for Willesden Locality is Lucy Ogida on 07789906168 The designated DSN for Kilburn Locality is Margaret Carroll on 07767671322 16 Monks Park Clinic Brent CCG Long Term Conditions Centre Monk’s Park Primary Care Centre Monks Park Wembley HA9 6JE Tel: 0208 453 5971 To find out more about Desmond, please contact - Mimoza Kola Tel: 0208 453 5965, Fax: 0208 453 5972 New Email Address : [email protected] New e-mail : [email protected] Please contact Julia Anthony DSN for Wembley on 07919046765 for further information Jeffrey Kelson Centre for Diabetes and Endocrinology, Central Middlesex Hospital http://www.localdatasearch.com/search?Loc=HA0+4UZ&Key=Wembley+centre+for+health Jeffrey Kelson Centre for Diabetes and Endocrinology Central Middlesex Hospital, Acton Lane, London NW10 7NS Telephone: 020 8453 2401 Fax: 020 8453 2415 Or By Choose and Book LNWH NHS Trust To contact the Diabetes Lead Consultant – Dr Koteswara Muralidhara, please call 0208 453 5965 / 07944068563 17 Clinic location, days and time Location Time Days Levels of Service Wembley Centre for Health and Care, 9.00am -13.00pm Fridays Multidisciplinary Diabetes Clinic – Tier 3 Diabetes Consultant GPwsi DSN Dietician Podiatry Psychology 9.00am -13.00pm Tuesdays Multidisciplinary Diabetes Clinic – Tier 3 Diabetes Consultant GPswi DSN Dietician Podiatry Psychology 9.30 - 4.30pm Mon - Fri 116 Chaplin Road, Wembley, Middlesex HA0 4UZ Tel: 0208 795 6001 Willesden Centre for Health, Robson Road, London NW10 3RY Tel: 0208 438 7006 Jeffrey Kelson Centre, Diabetes and Endocrinology, All Tier 4 Clinics Central Middlesex Hospital, Acton Lane, London NW10 7NS Tel: 020 8453 2401 18 Desmond Educational Courses 19 DESMOND Diabetes Educational Courses in Brent - Overview The DESMOND Diabetes Education courses was originally developed five years ago to help and support people with diabetes and their Carers to understand and manage the long term condition. The Desmond courses are designed to empower the patient to cope more effectively with a greater emphasis on self- management and the long term benefits of altering their lifestyle to include healthier diet and exercise. At present, there are three sessions delivered each week by the BIDS Nursing Team but due to the high demand for these educational courses more will be delivered in the near future. The majority of the DESMOND educational courses take place at Monks Park Clinic on Mondays and Thursdays. The Saturday DESMOND courses are held at Wembley Centre for Health & Care. Each course is intensive and starts at 9.30am – 3.30pm.The courses are accessed by GP referral only using the referral form below. Venue Time Mon Monks Park 9.30am-3.30pm X Wembley 9.30am-3.30pm Tues Wed Thurs Fri Sat X X The Desmond educational course is facilitated by the Diabetes Specialist Nurses, Dietician, and in the near future the BIDS Team Psychologist. Desmond is a provision of training for patients/carers to support them in managing their diabetes possibly in collaboration with other educators. The course offers patients a range of diabetes care modules to support and empower them to cope and manage their long term condition more effectively. The Desmond course content emphasises the need to put into effect a balanced and controlled diet which is supported by the Specialist Dietetic Service within the Diabetes Pathway Diet is the cornerstone of diabetes care, and as such the Specialist Diabetes Dietician makes a significant contribution within the multidisciplinary team. Following dietetic consultation (either through DESMOND or 1:1 support), the patient will develop their selfmanagement skills. Examples of when a patient will benefit from dietary advice include: Newly diagnosed with diabetes Patient wishing to improve their diabetes control Change in management of their diabetes e.g. insulin initiation. Overweight and motivated to lose weight Related co morbidities such as diabetic nephropathy Dyslipidemia • • The dietary resources are all evidence-based and appropriate for Brent’s diverse population. The Specialist Diabetes Dietician is an expert resource for the whole of the Diabetes Team and Primary Care to make sure consistent dietary messages are given. Another key part of the course is the clinical psychological management of diabetes and the provision of training in the psychological impact of diabetes. The course aims to help patients come to terms with their diagnosis and enable them to self- care to improve their wellbeing. In addition, the Desmond course offers the provision of training for patients/carers to support them in managing their diabetes in collaboration with other educators. 20 Referral Form Desmond Educational Long Term Conditions Centre - Diabetes Monks Park Primary Care Centre Monks Park, Wembley. HA9 6JE Tel: 0208 453 5965, Fax: 020 8453 5972 New Email Address:[email protected] New e-mail:[email protected] Patient Name: Patients Address: Telephone No: Date of Diagnosis: Date of birth: Ethnicity: Male/Female NHS Number: Referred by English Spoken Yes HbA1c: Date: Biomedical Data *All must be completed or attach result print out BP: Total Cholesterol HDL Cholesterol: LDL Cholesterol: Height: Waist Circumference: Smoking Status: Fructosamine: Body Weight: Medication and Dose Specific questions / problems: 21 Diabetes Podiatry Information 22 23 Brent Integrated Diabetes Service Team Members Contact Details Title Name Telephone No Email Address DSN Kingsbury Nina Patel 07747751902 [email protected] DSN Wembley Julia Anthony 07919046765 [email protected] DSN Willesden Lucy Ogida 07789906168 [email protected] DSN Kilburn Margaret Carroll 07767671322 [email protected] DSN Harness Fiona Hughes 0208 453 5965 [email protected] Dietician Julia Freshwater 0208 453 5965 [email protected] GPwSI Dr Joan St. John 020 8903 4848 [email protected] GPwSI Dr Sangita Godambe 020 8453 2401 [email protected] Hospital Consultant Dr Daniel Darko 020 8453 2401 [email protected] Diabetes Lead Consultant Dr Koteshwara Muralidhara 07944068563 0208 453 5965 [email protected] Associate Specialist Dr Camelia Kirollos 020 8453 2401 [email protected] Admin Team Lead Mimoza Kola 0208 453 5965 [email protected] Administrator Dilani Wanniarachchige 0208 453 5963 [email protected] Service Manager Margaret Mclennan 07771816131 020 3114 7246 [email protected] General Manager Vince Baxter 020 3114 7272 [email protected] For further information contact Melanie Britton on 0203 114 7196 or [email protected] http://www.lnwh.nhs.uk/services/brent-community-services/diabetes-service-brent/ 24