Diabetes

The Community Diabetes Service provides high quality expert care to patients with diabetes to help them manage their condition more effectively.

Overview of the service

The Community Diabetes Service consists of a multidisciplinary team of Consultant Diabetologist, specialist diabetes nurses and specialist diabetes dietitians that work across primary care, community settings and secondary care.

We support patients who are predominantly with Type 2 Diabetes, in order to empower them to self-manage their condition and maintain an independent lifestyle.

We also offer DESMOND (diabetes education and self-management for ongoing and newly diagnosed) for all newly diagnosed Type 2 Diabetes patients or patients who have had diabetes for a year. The programme provides patients with more information about their diagnosis and the skills to be able to better self-manage their diabetes. Delivered in small groups over two half days or one full day, DESMOND is led by trained educators at local venues.

Who can access this service?

  • Registered with a Sutton GP
  • The patient must have a clear diagnosis of diabetes
  • Patients with Type 2 Diabetes not achieving HbA1c targets in primary care
  • Patient with recurrent Hypoglycaemia
  • Patient who require Insulin initiation (when insulin competency is not present in the practice)
  • Patient who require Insulin intensification
  • Patient who require initiation of GLP-1 agonists
  • Assessment and management of early diabetes complications
  • Home visits - Private homes, Residential and nursing Homes
  • Patients receiving intermittent steroids
  • Individualised dietary advice (HbA1c >58mmol/mol)
  • Women with Type 2 Diabetes planning pregnancy

This service isn't suitable for:

  • Children, adolescent and patients who are newly diagnosed with Type 1 Diabetes or have ongoing Type 1 Diabetes.
  • People with severe and/or unstable complications of diabetes, or with new symptoms or complications that require immediate medical attention.
  • Pregnant women with a diagnosis of established or gestational diabetes. In this situation, these should be referred to Tier 4 services at local acute Trusts.

Team members who could be involved in patient care

  • Consultant Diabetologist 
  • Specialist Diabetes Nurses
  • Specialist Diabetes Dieticians

Is patient self-referral available?

For all patients referral, we require a complete referral form from a Health Care Professional, such as your GP or Practice Nurse.

Is transport provided?

No, patients will need to provide their own transport.

Are home visits available?

Appointments are provided in local clinics, though home visits are available, where they meet the relevant criteria. Please contact the team on the details below to find out more about home visits.

What can I expect from the service?

We are a team of Consultant Diabetologist, Specialist Diabetes Nurses and Specialist Diabetes Dietitians. When you are referred to us we will offer you an appointment with the most suitable team members.

Your first appointment will consist of an assessment to identify your needs. We may ask you to bring a food diary and your blood glucose monitor/monitoring diary showing records of any blood glucose monitoring that you currently do.

We will then work with you to decide on treatments. This may include further education, dietary advice, changes to medications, or further tests. The number of appointments you will have will depend on your requirements. During your care with us we will keep your GP informed.

What does the service expect from me?

We would like you to be fully involved with planning your care and setting goals. Helping you to self-manage your diabetes is the key to improving your health. With this in mind we will work with you to help you understand your condition fully, and decide on the best treatment.

Please contact us as soon as possible if you cannot make an appointment. This allows us to rearrange an appointment to suit you, and someone else can be offered your old appointment. Missed appointments cost the NHS £700 million per year, so if you miss an appointment without letting us know, we will discharge you from our service and inform your GP.

Is there a cost for this service?

You do not have to pay a fee to attend our service. Your local clinical commissioning group pays for this service to be provided to local people.

What happens when my treatment ends?

We will discharge you to the care of your GP. We will send them a report detailing your care with us. They will then manage your Diabetes on a day-to-day basis. They can refer you back to us if required in the future. Some patients may require further services. If that is the case, we will refer you on accordingly.

Contact us

For all enquiries from both patients and healthcare professionals, please contact:

The Royal Marsden Community Services
Carew House
Floor 2
Railway Approach
Wallington
SM6 0DX
Tel: 0208 661 3908
Email: rmh-tr.rmcsreferral@nhs.net
Fax: 0208 661 3910