By making smarter use of technology, we identify earlier those at risk of developing diabetes, and are helping them to stay out of hospital unless they really need to be there. They get more support to manage their own health too, for example through the ‘Carbaware’ course that teaches them about type 1 diabetes and how to live with it more healthily. We have also begun to identify those with more complex diabetes, giving them targeted support to help avoid A&E visits for common side-effects such as hypoglycaemia.

Over the next three years, people will be able to get more of their diabetes care and treatment in the local community. It should be easier for them to see a specialist when they need to, and they will get a support plan more personal to them; which for example, considers any other conditions they have. In time, we expect to improve diabetes patients’ health outcomes and experience of care, and reduce the number of related complications.

People in Berkshire West with a range of persistent pain and spinal problems were being referred unnecessarily for further tests and consultant appointments in areas such as rheumatology, trauma and neurology, as well as pain. So, clinicians and other staff across the system worked together with expert patients to design the ‘Integrated Pain and Spinal Service’, which gives them one seamless care plan. This removes duplication, and offers them treatments such as one-to-one physiotherapy as well as referral to relevant specialists.

This has reduced by one-third the number of people having these unnecessary appointments in two or more specialties. Before the system began, waiting times for outpatient appointments were between seven and nine months; now, the average waiting time is about four weeks, with 92 per cent of people seen in six. This has also saved the NHS £200,000 to reinvest elsewhere.

Watch video: Integrated Pain and Spinal Service

Our family doctors, hospitals, ambulance teams and others are working together to support more vulnerable people who often use services most heavily. In 2017/18, we reduced the number of emergency department attendances for these ‘high intensity users’ by 47 per cent, with fewer 999 calls too.

Central to this is the enhanced role of specialist paramedics, who are trained to identify high intensity users, to give prescriptions and to help give end-of-life care. Because they can do more, these patients can avoid visiting hospitals or emergency departments when it is not the best place for them to be. Instead, these services can focus on doing more for patients who need them most.