Why I set up a pharmacist-led one-stop diabetes clinic in my GP practice

The number of patients with type 2 diabetes mellitus (T2DM), especially within the black, Asian and ethnic minority community, continues to rise, with the International Diabetes Federation estimating that by 2050, approximately 853 million people will be living with diabetes — an increase of 46% on current incidence rates^​1​. The prevalence among the black, Asian and ethnic minority community became more prominent after the COVID-19 pandemic, which exacerbated existing healthcare inequalities^​2​.

In 2020, when I started working at my GP local practice, located in a diverse community in north west England, approximately 120 out of 215 patients with T2DM did not have an annual urine albumin-creatinine ratio (ACR) in place, despite having up-to-date blood testing. This seems to be a common occurrence with other primary care practices^​3​. ACR screening is important in helping to identify kidney disease early in patients with diabetes^​4​; however, a quality improvement assessment revealed that many patients were unaware of the importance of kidney health as part of their diabetes review.

As of November 2021, there were less than 40 patients without annual ACR in place. The practice has since reduced the number of patients with outstanding ACR results down to single digits. 

In implementing regular urine ACR testing for a greater number of people with diabetes, common complaints among patients included having to visit the GP for five to six diabetes-related appointments in a year, seeing different clinicians each time. There were also complaints about waiting up to a year to be referred to a secondary care diabetes clinic.

These complaints served as my motivation to create a one-stop diabetes clinic within the GP practice. The clinic involved a strong working relationship between myself and the healthcare assistant (HCA). We would also seek advice from the GP or secondary care diabetes team in complicated cases. 

The diabetes clinic review initially involved patients being booked in with the HCA for routine blood testing, including HbA1c, urea and electrolytes, liver, lipids and full blood count. Patients will also have their feet, blood pressure and weight checked, and an early morning urine sample requested for ACR testing. Patients are then booked into my clinic the following week to review their results.

As a prescribing pharmacist, with a special interest in diabetes, I will sit with each patient for a 15-minute consultation, going through each of the nine ‘key care processes’ for diabetes recommended by the National Institute for Health and Care Excellence (NICE; see Box^​5​). These results can help to identify those at higher risk of cardiovascular disease (CVD), as well as guide the type of medication prescribed to each patient.

Once the comprehensive review is done, the patient is booked in for a follow-up consultation, either to repeat their blood test after 12 weeks, depending on the medication they were taking, or they may be referred to a secondary care diabetes clinic if they are already on and compliant with the maximum dose of diabetes medication, with no changes to their results. If all nine of NICE’s key care areas are complete, I will code the patient in our IT system as ‘satisfactory’. 

Setting up this one-stop diabetes clinic has benefited patients, as well as the GP practice. Offering a pharmacist-led consultation enables patients to speak to a medication expert about all diabetes-related issues in one appointment, reducing the number of appointments they need to attend, while facilitating patient education on NICE’s nine key care processes.

Part of the education is in helping patients to understand that having a good HbA1c level is as important as a good kidney health or regular eye screening. This has helped empower our patients to take ownership of their diabetes health. Patients having all their reviews completed within a maximum of two or three clinic appointments has also been beneficial to our GP practice, freeing up more time for the GPs to deal with complicated acute cases, while enabling the nurses to focus on other long-term conditions. While enhancing my own skills as a specialist pharmacist, the clinic has helped reduce overall hospital admissions from diabetes-related complications. By January 2025, the GP practice had acquired mostly all diabetes-related points under the Quality and Outcomes Framework (QOF).