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City of York

'Living Well with Diabetes in York' project

In February 2021, we commenced a pilot project in York, using a population health management approach to tackle inequalities in York and improve the health of people living with Diabetes.

What we found out was that over 10,000 people live with Type 2 Diabetes in York, and the data showed that for people who had more than one long term condition, Diabetes was the most common first condition.

A group of partners from the NHS, local authority and voluntary sectors came together to look more closely at the data on our diabetic population, choosing a 'cohort' of people to work with, and building a 'logic model' of change by which we hoped we could support people to live well with diabetes and avoid progression into living with multiple long term conditions.

We then worked through social prescribing link workers within GP practices to proactively reach out to our cohort, helping them build a personalised asset-based plan for their care, making sure they were aware of good resources to manage their diabetes, and helping them get the support they need to live healthy lives.

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NHS Healthchecks

Everyone between the ages of 40 and 74 is eligible for an NHS Healthcheck every five years, which is a cardiovascular health risk assessment that aims to identify early signs of disease and help people improve their chances of staying healthy.

In York, we knew that if we didn't take a population health approach to NHS Healtchecks, the people taking up their offer may not be those most in need of the intervention. Working with Nimbuscare, the public health team at City of York Council Public Health co-designed a model for Healthchecks which used a population health management approach to:

  • Ensure NHS Healthchecks are targeted to the people most likely to benefit, through using primary care data and proactive GP text /letter invites
  • Develop onward pathways from a healthcheck into preventative services
  • Use our local assets to make sure the checks are done in the most deprived areas of the city, as well as using digital and other tools to make them more efficient

This new service was launched in October 2021.

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