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The Sugar Fix

South Eastern Sydney Local Health District
Project Added:
14 April 2015
Last updated:
22 April 2015

The Sugar Fix


The project focused on planning, coordinating and integrating diabetes services in the local community and primary healthcare system. Newly diagnosed patients with Type 2 Diabetes Mellitus (T2DM) will be managed using appropriate referral pathways led by their GP.

Poster from the Centre for Healthcare Redesign graduation, April 2015. Poster from the Centre for Healthcare Redesign graduation, April 2015


To improve access to care and health outcomes for patients with T2DM by planning, coordinating and integrating services in South Eastern Sydney Local Health District (SESLHD).


  • Improved patient satisfaction with the journey from diagnosis and referral to support.
  • Improved individual and population health outcomes.
  • Improved patient self-management.
  • Potential reduction of admissions and re-admissions to emergency departments.
  • Improved satisfaction for GPs who refer patients to the clinic.
  • Improved timeliness of communication between acute services and referring GP.
  • Improved staff satisfaction in clinic, with streamlined processes and reduced numbers of inappropriate referrals requiring follow up and/or further action.
  • A strengthened partnership between South Eastern Sydney Medicare Local (SESML) and St George Hospital Outpatient Diabetes Clinic.

Project status

Project status: Implementation - the initiative is ready for implementation, is currently being implemented, piloted or tested.

Project started:  23 July 2014.


Diabetes is expected to increase more rapidly than any other chronic condition in Australia, with an expected increase of 60% between 2003 and 2033, according to the Australian Burden of Disease study and related projections. There are an estimated 40,000 people within SESLHD who have diabetes mellitus, with 81% diagnosed with T2DM. 16.2% of the population in the Southern Sector Local Government Areas have a diagnosis of T2DM, which is significantly higher than the NSW average of 4.6%.

In the South Eastern Sydney area, there is currently an increase in demand and a growing waitlist for hospital-based outpatient diabetes services for people newly diagnosed with T2DM. There is also a demonstrated need to establish timely clinical pathways and clear referral guidelines for GPs, who should be leading care from the start in order to maintain sustainability and the provision of patient-centred care.

Current data from the St George Hospital Outpatient Diabetes Clinic shows average wait times from ‘referral received’ to ‘booked’ appointments, of 159 days. This is well outside the maximum 90-day triage time currently in place. Current ‘Did Not Attend’ (DNA) rates are 20-30 patients per month. These wait times and DNA rates significantly impact the health and wellbeing of patients.

Wait times have been found to be caused by a number of factors, including:

  • unclear or unknown referral pathways
  • no established feedback or lines of communication for referrers or patients
  • no documented clinical pathways for patients
  • no clear service description of the clinic or its role
  • no current exit or referral function from the clinic
  • clinic not meeting expectations of patients and referrers.


The St George Hospital Outpatient Diabetes Clinic is implementing a new referral procedure, which will improve navigation of the system and triage to endocrinologists, as well as reduce wait times for diabetes specialist services.

The referral redesign is targeting three focus areas: referrals; communication; and clinic purpose. A list of solutions for improving access to the St George Outpatient Diabetes Clinic was developed using staff and GP forums, as well as documenting patient stories. These solutions include:

  • the redesign of a referral form which is added to GP patient systems 
  • defining triage guidelines and clinic purpose
  • GP education provided in small groups, around referral changes and clinic purpose
  • changing the functionality and use of electronic medical record (eMR) functionality, to enhance communication to referrers and patients.

Implementation sites 

St George Hospital Outpatients Diabetes Clinic, General Practice, St George Hospital Outpatient Department. 


South Eastern Sydney Medicare Local (SESML)


Evaluation planned for early 2015 will include an audit of waiting lists, as well as surveys to measure patient experiences and GP and diabetes clinic staff satisfaction. Expected outcomes include:

  • a decrease in patient waiting times
  • improved GP use of new referral form instead of existing form, allowing for information on the patient and the reason for referral to be shared
  • new referral guidelines approved by the Clinical Council
  • a reduction in DNA rates.

Lessons Learnt

  • Communication is key, networking is vital and maintaining relationships with those networks is important for implementing change.
  • Carefully selecting members of the project team is critical to the success of the project.
  • The extent of the issue was underestimated by the project team, highlighting the importance of collaboration with stakeholders.
  • Earlier engagement of GPs is recommended.




Daniel Shaw
Chronic Care Integration Clinical Nurse Consultant
South Eastern Sydney Local Health District
Phone: 02 9113 3999

Michael Russo
Community Engagement Officer
South Eastern Sydney Medicare Local
Phone: 02 9330 9900

Andrew Coe
Director of Partnerships and Planning
South Eastern Sydney Medicare Local
Phone: 02 9330 9900

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