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Type 2 Diabetes Mellitus (T2DM) – the silent epidemic

Diabetes prevalence in the Western and Far West NSW region is 6.1 percent of the population. This is higher than the national average of 5.5 percent and is increasing annually. T2DM is also being diagnosed at younger ages, often presenting as a more aggressive disease leading to complications at a younger age. People in the WNSW PHN region are 40 percent more likely to die as a result of their diabetes than the rest of NSW. Our Indigenous population are at particular risk as 20 percent of people living with T2DM identify as Aboriginal.

We need to find better ways to do diabetes care in our region.

How will we do this?

The major health organisations in our region have come together to form Care Partnership – Diabetes, working together to find ways to improve the system. We have designed the Diabetes – Living Better and Stronger program to do this work.

By working together with general practitioners, health providers, patients and carers, we learn what works best for our communities and find out how we can do diabetes care better.

As someone living with Type 2 Diabetes, or their carer, we need your help!

We need to understand where people with Type 2 Diabetes access health care, where the gaps are in care, and where there are patients whose care needs are not being met. We also need to know what works well, and what opportunities there are to find new models of care. We need to know how well diabetes is managed in our region. Over time, we will monitor and assess these things to see if the changes we make create better access to care and ultimately, better outcomes for people with Type 2 Diabetes.

By enroling in the Diabetes – Living Better and Stronger program, you can help us improve diabetes care for everyone in Western and Far West NSW living with Type 2 Diabetes.

About Care Partnership – Diabetes

Care Partnership – Diabetes focuses on enhancing health outcomes for people living with T2DM living in Western and Far West NSW. We know that when detected earlier and when comprehensive and evidence-based care is provided, there is opportunity for remission and a reduction in the development of secondary complications.

Frequently Asked Questions

I have diabetes. Can I enrol in the Diabetes – Living Better and Stronger program?

Anyone currently living with Type 2 Diabetes in Western and Far West NSW whose last blood test (HbA1c) is 7% or more is eligible to enrol in this program. Your doctor can also use their clinical judgment to enrol you into the program.

I am happy with my diabetes care, or I see my team privately. Why would I join?

Every patient’s Type 2 Diabetes journey is important to us. The more people with Type 2 Diabetes who enrol, even those getting all the care they need, the better we will understand where the health system works – and importantly, where it does not work.

I am happy to help, but what benefits will I get?

We are working to improve the system as a whole, and do it in ways that work best in your community. A lot of the work we will do is behind the scenes. Your participation helps improve the system for everyone – including you in the future.

This program aims to improve:

  • health outcomes
  • coordination of care, and
  • linking to services

How do I enrol?

Your doctor will ask for your permission to participate, and if you consent, they will complete your enrolment form and send this to NSW Health for you.

What happens after I enrol? What do I need to do as part of the program?

After enroling into the program, you will be invited to complete some surveys. This keeps your healthcare team up to date with how you’re feeling and coping during your Type 2 Diabetes journey.

What personal information do you need?

We collect your identification details on the consent form that you fill in with your doctor. The consent form will be sent to the Local Health District (LHD) who keep a list of patients who sign up, and your form will be kept in your LHD record. If you receive care in the Western and Far West NSW region, some people (such as the doctors and nurses treating you) may be able to see that you have signed up for this program.

What data do you collect?

We are using data that would be collected about you anyway. Whenever you seek care, data is collected and used to build and fund our health system. Some of this data is about behaviour – for example, how many times you are admitted to hospital in a year; some of it is about the health of our population – for example, the ages and last recorded HbA1c of all the patients who visit a GP practice.

If you already collect this data, why do you need my consent?

We need your consent to follow the data that is collected from your doctor and match it to the data that is collected if you go to hospital. This is done by computers – no one reads your confidential health information for this process. No one is keeping data they would not already have access to, we simply follow the data between GP practices and LHD services (like hospitals). We also need your consent if you are happy for us to use this information in research.

What is the difference between consenting to the Program and to Research?

When you consent to the program, you are agreeing to be enrolled in the Diabetes – Living Better and Stronger Program. When you consent to the research, you are giving permission to use your de-identified data for a better understanding of diabetes. Your participation in research is voluntary. You can choose to participate in the program without participating in research and this will not affect your care.

Will my data and personal information stay confidential?

In this program, we are not able to tell which information came from a specific person or tell whose data we are looking at – it will be de-identified and pooled together.

Will my information be safe?

Yes. All data for this program is stored within the existing health system structures that already store your health care information safely and securely – your GP practice, as well as the four partner organisations: Western NSW Local Health District, Far West Local Health District, Western NSW Primary Health Network, and NSW Rural Doctors Network.

Patient Story  |  Mitchell Cain

Meet Mitchell Cain, a proud Kamilaroi man who now lives in Dubbo.

Mitchell lives with type 2 diabetes and he lost his leg due to complications, so he’s encouraging people to take simple steps to stay healthy, identify diabetes early and manage the condition.

Building healthy habits is one of the simplest steps people can take to manage type 2 diabetes, and ‘Healthy Habits’ is also the theme for Men’s Health Week this year.

To mark 2023 Men’s Health Week, as part of the Diabetes: Living Better & Stronger and Care Partnership – Diabetes program Mitchell is telling his story to help people take those steps, like seeing a GP for a health check.

Information for healthcare providers

We can improve outcomes by working together

Working in the rural and remote primary health environment is both rewarding and challenging. We also recognise that there are gaps in access to and consistency of services that impact on patient care and outcomes.

This is why NSW is initiating a Collaborative Commissioning funding model for chronic disease to better support a more agile and responsive health sector across our regional footprint. Care Partnership – Diabetes is a collaboration between Western and Far West Local Health Districts, Rural Doctors Network and Western NSW Primary Health Network to work together to build on existing services and strengthen local pathways to enhance access to multidisciplinary diabetes care teams.

Over the next three years, Care Partnership – Diabetes will work with you in a place-based rollout to support better:

  1. Engagement of people and communities in understanding T2DM and making positive health changes.
  2. Identification of T2DM earlier through increased opportunities for screening and point-of-care testing.
  3. Shared quality care to improve communication and coordination between health care providers and patients, following an agreed T2DM pathway of care with improved access to specialist care.
  4. Workforce uplift and engagement to enhance health practitioner experiences of delivering care to people living with T2DM by increasing access to training, support and resources for the workforce.

What does this mean for you?

Your patients living with T2DM and a HbA1c >7% will be able to:

  • Have more timely access to diabetes-related services.
  • More opportunities for patient-facing education via variety of platforms.

As a GP, you and your practice/ACCHS will have free access to:

  • Locally relevant point of care T2DM guidelines, accessible via Western NSW Health Pathways.
  • Funding support for Practice Nurse/Aboriginal Health Practitioner hours focusing on T2DM.
  • A Western Diabetes Hub to assist with linking clinical services, education and mentoring opportunities.
  • Case conferencing with endocrinologists and other health providers.
  • INCA, a shared health record that permits patients’ healthcare providers shared visibility of health conditions, medications, test results and management plans. Click here to learn more about INCA.
  • Patient Reported Measures using the Health Outcomes and Patient Experience (HOPE) system. Click here to learn more about HOPE.
  • Education provided via ECHO (Enhanced Clinical Health Outcomes) learning sessions and Rural Health Pro.
  • NSW Health data about your patients, via an electronic platform called LUMOS.

Refer to the following downloadable resources for more information:



What's next?

Let us know if you would be interested in or would like more information about becoming one of the practices participating in Care Partnership – Diabetes.

Simply fill out and submit your details below and we'll be in contact shortly.


Diabetes: Living Better & Stronger and Care Partnership – Diabetes is part of the Collaborative Commissioning Program, a collaboration between the Western NSW Local Health District, the Far West Local Health District, the Western NSW Primary Health Network, and Rural Doctors Network.