North East London
Case Study: The new NHS primary care diabetes injectables, GLP-1 and insulin clinic at Goodman's Field Health Centre
Operose Health is committed to delivering care closer to communities aligned with NHS England’s 10-Year Plan. The DIGI (diabetes injectables, GLP-1, and insulin) Clinic at our Goodman's Field Health Centre in London demonstrates how innovative NHS primary care can address unmet needs and tackle health inequalities, supporting NHS England’s 10-Year Plan by keeping care in the community.
By training pharmacist prescribers Niyyah Sharif and Sumaiyah Tahseen to manage diabetes care that would traditionally require hospital referral, the practice is not only improving access for patients but also building workforce capacity and resilience in primary care diabetes. Investing in our workforce, including local residents, helps to address skills gaps and offers added social value.
The challenge: A gap in diabetes outcomes
Pharmacists Niyyah and Sumaiyah identified a significant gap in diabetes outcomes for their patient population. At Goodman's Field Health Centre, which serves a predominantly Bangladeshi community in Tower Hamlets, many patients with type 2 diabetes were struggling with weight management and cardiovascular complications despite being started on an appropriate medication regimen.
'Over the past couple of years, we spoke to a lot of diabetic patients, particularly from the Bangladeshi community, who have a history of cardiovascular disease, like stroke, heart attacks, and high blood pressure, who really struggled with things like food and weight,' explains Niyyah.
The challenge was compounded by access barriers. Rising demand for GLP-1 medications outstrips hospital capacity across the country, resulting in long waits. This leaves a substantial group of patients with unmet clinical needs and no pathway to treatment. 'We knew there were patients who could benefit from treatment but couldn’t access it,’ says Niyyah. Some patients ended up paying privately for GLP-1, for example, at considerable cost, while others could not afford this treatment.
The approach: Building a primary care diabetes clinic from the ground up
After completing an intensive programme for injectable therapies, Niyyah and Sumaiyah worked to establish a dedicated diabetes injectables clinic at their practice. The course, taught by experienced diabetes nurses, provided case-based learning that prepared the pharmacists to manage complex diabetes in primary care.
With support from a local experienced diabetes hospital consultant, the pharmacists developed comprehensive clinic guidelines combining NICE guidance, SIGN recommendations, and local protocols. They created patient pathways, appointment templates, screening criteria, and a detailed tracking system - all built from scratch with patient safety at the heart.
The clinic operates with a structured three-consultation model:
- Initial face-to-face appointment (30 minutes): Comprehensive and holistic assessment, educating the patient on their medication, and shared decision-making
- Telephone follow-up (10 minutes): Check-in to monitor tolerance, side effects, and adherence at 3-4 weeks
- Face-to-face review (3 months): Blood tests, weight, and blood pressure checks to assess progress
For this first phase of the project, the pharmacists are focusing on two cohorts: younger patients and those from Bangladeshi backgrounds, to address health inequalities. Both pharmacists speak Bengali (Bangla), removing language barriers and building trust with their community.
'We want to at least offer the opportunity to be on GLP-1 or insulin to everyone who is eligible. But we are prioritising and targeting young patients and Bangladeshi patients specifically,' explains Sumaiyah.
The impact: Care closer to home
The DIGI Clinic represents a shift to community-based diabetes care aligned with the NHS 10 Year Plan. The project has been developed collaboratively with the local hospital diabetes consultant, ensuring patients receive safe care closer to home. Patients who previously faced long waits for hospital appointments - or couldn't access treatment at all - can now receive specialist care in their local practice.
'We have two clinics a week, one each, to help improve access,' says Niyyah.
The benefits extend beyond clinical outcomes. Patients appreciate seeing the same clinician over the course of three months and building trusting relationships with them. Face-to-face initial consultations address any initial hesitations like needle-phobia by acknowledging concerns and showing patients the small size of the needle to remove the fear of the unknown.
'A lot of patients are really happy that the initial consultation is face-to-face. They find it easy to speak to people face-to-face rather than over the phone, especially about something that is quite invasive,' notes Niyyah.
The clinic has also become a knowledge hub for the wider practice team. Colleagues now approach Niyyah and Sumaiyah with questions about insulin and diabetes management, extending the impact beyond the dedicated clinic slots.
The service represents a sustainable approach for patients and the system. By supporting patients in primary care, the clinic improves access for those with unmet needs, including underserved groups, while reducing referrals to stretched hospital services.
Personal impact: Building expertise and confidence
Beyond patient outcomes, the DIGI Clinic has been transformative for Niyyah and Sumaiyah’s professional development. The project has expanded their clinical expertise, built their confidence in managing complex cases, and positioned them as diabetes specialists within their practice and wider network.
'It's definitely ignited me to want to learn more,' says Sumaiyah. 'We've worked very hard to come up with these lists outside of our clinics because we're so passionate about it.'
The pharmacists have since attended additional training in advanced clinical practice and diagnostics, with plans to pursue further qualifications. Their commitment to continuous learning ensures the clinic consistently delivers high-quality, evidence-based care.
Lessons learned: Patient-focus, persistence and partnership
For clinicians looking to develop similar initiatives, Niyyah and Sumaiyah emphasise several key lessons:
Patient focus: Taking time to understand concerns and tailoring the service has been crucial. For example, the team addresses misinformation sensitively and manages needle phobia with empathy. 'It's about balancing the risks and benefits. We work with the patient to provide the correct information and do whatever's right for them,’ explains Niyyah.
Adapt care to address inequalities: Speaking Bangla removes language barriers and builds trust with the local Bangladeshi community. Creating bilingual feedback forms and patient materials ensures everyone can engage with the service, helping remove access barriers for those facing health inequalities.
Strong relationships matter: Building connections with specialists like the local hospital consultant provided essential clinical support and mentorship. 'When you have that relationship, you feel more comfortable asking them about cases and learning new things,’ says Niyyah. That connection enabled the pharmacists to manage more complex cases without needing to make unnecessary referrals, keeping care closer to home.
Be resourceful: From contacting an injectable supplier for patient education materials to developing bilingual feedback forms, the pharmacists leveraged every available resource. It's about pulling the right people in and making the most of opportunities. This can-do mindset helped the pharmacists establish a successful new clinic in a short timeframe.
Persistence pays off: ‘From first seeing that unmet patient need, we’ve been committed to making a change. We built a case as to why and how this will benefit the practice, how it will benefit the local population - consistency is key here,' explains Niyyah. Building a new clinic from the ground up takes time and dedication, but the rewards are worth it.
Looking ahead: Measuring impact
While it’s still early days, Niyyah and Sumaiyah have already built the foundations to capture the impact on patients at their three and six-month reviews. A comprehensive tracking system monitors the nine diabetes care processes and measures progress against targets, including HbA1c reduction and weight loss.
'In six months, we expect to see significant improvements to your HbA1c and then your weight to reduce by 3%. That's a worst case scenario. We always hope for more,' explains Niyyah.
Ready to shift care closer to the community in your practice?
The DIGI Clinic reflects our commitment to investing in the workforce to deliver innovative models of care. As part of Operose Health, you gain access to advanced digital tools, a community of like-minded professionals, and operational support that frees you to focus on what matters most - delivering outstanding care to your patients.
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