In Hounslow;

  • Over 31,000 Hounslow residents are at high risk of Type 2 Diabetes (people living with blood glucose levels above relaxed target values (HbA1c > 64mmol/mol)
  • Over 25,000 Hounslow residents have diabetes, of which approx. 23,000 have a Type 2 diagnosis.
  • Over the last 5 years, an average of 1,500 Hounslow residents have been diagnosed with Type 2 diabetes per year

The ambition of the Hounslow Diabetes programme;

  1. Reduce the number of people being diagnosed (or delaying a diagnosis) with Type 2 diabetes, i.e. reducing the growth of diabetes prevalence in the borough.
  2. Reduce health inequalities and improve the outcomes of those living with Diabetes.

Hounslow Diabetes Programme

To reduce the growth of Type 2 diabetes prevalence in the borough. By helping residents to live healthier lifestyles and reducing obesity levels across Hounslow. The prevention offer will be bolstered by working, as appropriate, with LB Hounslow Community Solutions. Delivery of a successful focused diabetes campaign across Hounslow that promotes the risks of diabetes and that highlights the importance of lifestyle changes.  (To view the percentage of Hounslow residents with the estimated prevalence of diabetes please click here.)

Gestational Diabetes and T2 Prevention Campaign

  • Improve diabetes prevention understanding and access to NDPP particularly for those from a South Asian, Black, African-Caribbean or Middle Eastern background.
  • Improve uptake (10%) and completion (25%) of the prevention programme from the Hounslow targeted cohort.
  • Education of maternity / antenatal staff in GDM and the increased risks of T2 diabetes at the WMUH maternity unit.
  • Education of pregnant women with a diagnosis of GDM about their increased risk of T2 diabetes later in life.

Hounslow Diabetes Proactive Care Hubs

The Proactive care teams will; Support Level 1 diabetes delivery, reduce variation and tackle health inequalities, improves patient outcomes and upskill integrated neighbourhood teams.

  1. Reduction in the growth of Type II diabetes prevalence.
  2. An increase in patient completion rates for lifestyle interventions/ preventative programmes such as the National Diabetes Prevention Programme (NDPP) as a comparison to previous years.
  3. Delivery of a successful focused diabetes campaign across Hounslow, that promotes the risks of diabetes and that highlights the importance of lifestyle changes to those at high risk of Type II diabetes.
  4. Offer Primary Care Network (PCN) level delivery of specialist diabetes care across an integrated team as part of the Integrated Neighbourhood teams programme. 

Gestational Diabetes (GDM) and T2 Prevention Campaign

(Q1/2) The project aims to reach out to women with a history of GDM in the past 5 years and offer participation in the NDPP. Clinical system data searches were completed in Q1 and 1040 eligible women were identified for contact.

93 NDPP referrals have been received from the GDM cohort up to end of July. 12 drop outs have been recorded, others are awaiting assessment or have transferred to the bespoke digital programme (where patient has agreed). 1 person has completed the programme since they started in January.

(Q3) XYLA (NDPP provider) exited the national contract on 30th November, a new provider THRIVE TRIBE started on the 1st December. The local diabetes team have been mobilising the contract with TT to offer the prevention programme to Hounslow residents. There were a significant amount of referrals on the waiting list which were transferred to TT. There is commitment from TT to have all outstanding referrals processed by 31st March 2024.

Over 100 NDPP referrals were received from the GDM cohort up to end of Nov, with at least 70+ starters seen in year.

Great West Road PCN Diabetes Engagement Events – Autumn 2023  

(Q1/2) Planning started in Q1 and into Q2. A clinical outreach healthcare team will be present at local religious locations to take bloods/ BP testing and advise residents accordingly, provide suggestions in diet + benefits of taking insulin, spreading awareness on what changes they can make to their lifestyle.

There will be a local GP/Nurse speakers at the event for the local community to identify with and mitigate any language barriers. The team will use information leaflets with diet changes that they can relate to such as south Asian foods/ leaflets in languages they can understand. There is an ambition to create Videos/TikTok's with more information that they can watch on the day/ links to such videos.

Confirmed dates now include:

  • Friday 10th November – 11am – 2pm - Jamia Masjid & Islamic Centre, 367 Wellington Rd S, Hounslow TW4 5HU
  • Friday 17th November – Mandir – 11:30am – 2pm. Lakshmi Narayan Temple, 60 Neville Cl, Hounslow TW3 4JG.  
  • Friday 24th November - 11am – 2pm- Gurdwara Sri Guru Singh Sabha, Alice Way, Hounslow TW3 3UA.

(Q3) Great West Road PCN - Raising Awareness on Health Inequalities Engagement - In late October GWR PCN were invited to speak on Desi Radio (a registered charity organisation) to promote to the Punjabi community the health inequalities events that they would hold in local religious centres across November. 

The 3 events focused on raising diabetes awareness, principally concentrating on prevention of Type 2 diabetes and reducing complications. The events provided an opportunity to answer any questions the public had on diabetes medication, exercise, and diet changes.

Diabetes Prevention and Community Engagement

(Q1) included a variety of engagement events held for diabetes week (12th June – 18th June) with multiple community partners. Engagement was combined with Men's health week messages. Events were held at the local Gurdwara. A diabetes focused talk with the United Caribbean Society was provided. The Healthy Hounslow outreach health check team met office workers at the Hampton Business Park to discuss diabetes and offer health checks. A meeting was held with the West London Ghanaian Association to discuss Diabetes awareness within their local community and offer support.

(Q2) included further diabetes engagement in the community; The BBP held the first ‘Health in the Park’ event on Saturday 29th July, to support residents in long-term health, including diabetes. On the day there were outdoor health activities from yoga, football, food workshops, painting, competitions, outdoor games, meditation, treasure hunts, singing from the brain, tennis. A range of health professionals were available on the day to provide helpful advice and guidance to support long-term health. Further information and feedback on the event is on the BBP website here.

A Public Health ‘Men’s Newspaper’ was issued in July, which included diabetes messages on T2 prevention and the specific health risks that men may not be aware of; including their age, weight, eating and exercise. Copies were provided in pubs across the borough.

Proactive Diabetes Care Hubs

The Proactive care hub teams have been established within 4 PCNs across the borough in Q2. The hubs will give specific focus to those patients with diabetes that are experiencing health inequalities in the PCN. 

Patient cohorts that will be contacted by the PADC teams and asked to come to a clinic, include;

  • All T2DM living in hostels or are homeless
  • Asylum seekers
  • T2DM aged over 18 years with a learning disability and HbA1c> 58mmols
  • T2DM aged over 18years with HbA1>58 and have mental health diagnosis (those on the SMI register)
  • All young adults with T2DM 18-39yr olds
  • T2DM adults diagnosed in the last 6 years with Hba1c >58mmols

The team will reach out to these groups and review their diabetes care to-date. The will offer regular diabetes checks as well as review a care packages of support that aim to improve their health outcome.

(Q3) PCNs continued to provide the Diabetes Proactive care clinics to the patients that had experienced health inequalities. With particular focus on all T2DM living in hostels or are homeless, Asylum seekers and Early-On Set T2 diabetes (under 40s). As part of the Diabetes priorities for the ICB – Early on-set T2 patients are being reviewed and given support. Up to end of Q3 – 16 patients in Hounslow had been seen.

An audit of the Feltham Proactive care pilot was carried out in Oct; 71 of 225 pts now have blood glucose in range.

Pro-active Diabetes model 2023.jpg


Counterweight Path to Remission (previously REWIND)

(Q3) There were a number of early mobilisation meetings with the new “Counterweight Path to Remission” provider. In Q4, Counterweight will go-live offering T2DM patients across NWL opportunity to join a 12 month T2DM remission programme. Awareness webinars are being held from December to February for Hounslow PCN/ practice staff to familiarise themselves with programme details.

The service offers a Total Dietary replacement for 12 weeks, at no cost to the patient, which is a different offer to the previous provider. The programme is delivered in different languages and local support F2F classes will be provided from locations within the borough. 

Progression of the Hounslow diabetes programme plan, including:

  • Engagement events with the Hounslow public making them aware of the risks of diabetes. 
  • Thrive Tribe mobilisation and delivery of the prevention programme. 
  • Mobilisation and go-live of the Counterweight Path to Remission programme.
  • Continued delivery of the Proactive diabetes care hubs across all PCNs. 
  • Continue to reduce growth of diabetes prevalence in the borough as set-out in the BBP Health and Wellbeing strategy.

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