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Support for the CCG Improvement and Assessment Framework

This resource is designed to support diabetes care improvement against key targets that are measured in the CCG Improvement and Assessment Framework. It includes:

What is the CCG Improvement and Assessment Framework?

It is the mechanism by which NHS England conducts an annual assessment of each Clinical Commissioning Group (CCG) in England. Its focus is on supporting improvement in key areas and driving the implementation of the Five Year Forward View. There are 6 clinical priority areas, one of which is diabetes. In 2016 a baseline assessment was carried out - results can be seen here. In November 2017 the first full results will be published.

Find out more about the CCG Improvement and Assessment Framework.

What is measured for diabetes?

  1. Diabetes patients that have achieved all the NICE-recommended treatment targets (HbA1c, blood pressure and cholesterol in adults and children achieving HbA1c target)
  2. Attending structured education within 1 year of diagnosis

How can Diabetes UK help?

Scrutiny of achievement against these targets will become a focus of attention at the highest levels both locally and nationally. Diabetes UK have a large number of resources that are ideally designed to help CCGs address these specific areas. We have focused on simple steps you can take to improve.

Know your numbers

The diabetes-specific CCG Improvement and Assessment Framework results (on the My NHS website) for 2017/18 are searchable by CCG.


Quick wins to improve care

Treatment targets

Diabetes UK has developed a set of bespoke information prescriptions to transform the standard diabetes consultation.

The clinically accurate resources are designed help healthcare professionals and people with diabetes to make decisions together about how to improve their treatment targets.

The patient gets a personalised single side of A4 to take away with them which includes easy-to-read explanations, clear images and individual goals. 

'Individuals report a clearer understanding of the concepts and relevance of HbA1c, lipids and blood pressure and an enhanced motivation to adopt lifestyle modification specific to their own needs.'
Nicola Milne, practice nurse


'Information prescriptions put patients in the driving seat and that is the key to driving successful behavior change. The feedback I’ve had from patients is that they feel more in control and like having clear goals set out to help them improve their health. This is a revolutionary step in diabetes care.'
Dr Stephen Lawrence, General Practitioner

Find out how to embed Information prescriptions in your practice

Structured education

It is important to note that the measure is attendance at structured education, not simply referral. These top tips have been gathered from areas across the UK that are achieving great attendance at structured education and can help you frame discussions with your patients to increase attendance:

  • Be positive.
  • Get to know the course (or ensure your support staff do) so that whoever discusses the course with patients can answer questions and provide reassurance.
  • Explain to your patients that diabetes education will help give them the confidence to manage their diabetes day-to-day.
  • Consider using motivational interviewing techniques to help patients see the value of attending a course.
  • Avoid the term ‘structured education’ as some patients find it off-putting. Try words like ‘course’, ‘knowledge’ or ‘training’.

Good practice

Learn how other areas have improved by reading our detailed case studies that show the power of service redesign to impact achievement of treatment targets or brief bright ideas that show new approaches to structured education.

Resources – structured education

We have resources that will help with everything from a bit of inspiration, to a large scale transformation of your structured education available:

Resource library: Diabetes education and self-management

Resources - treatment targets

Many factors will influence the achievement of treatment targets. Explore our resource library for ideas on how to improve care planning, our guide to insulin delegation (PDF, 241KB), guidance on how to use a network to drive improvement (PDF, 75KB) and much more.

Explore our resources library

Highlights from our library include:

Diabetes UK Support for improvement

The Regional Heads or Improving Care Managers from Diabetes UK’s regional teams work regularly with CCGs and other NHS bodies in their area to support service developments and improvements. To discuss the level of support available please contact them. 

Diabetes UK Regional Support


The Diabetes Service Redesign and Improvement Consultancy is a new ‘arm's length’ part of Diabetes UK, designed to offer practical support to the health and social care system. The Consultancy works in close partnership with CCGs to take simple steps to achieve the maximum improvement in diabetes health outcomes.

The team also specialises in supporting the uptake and impact of diabetes education, motivational interviewing training, leadership coaching and effective redesign of diabetes pathways and services. As a third sector Consultancy, any professional fees are ploughed back into improving the health of people with diabetes.

The Diabetes Service Redesign and Improvement Consultancy

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