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Diabetes Alliance

The Diabetes Alliance Program Plus (DAP+) aims to improve health outcomes and the experience of care for patients with Diabetes within their own general practice.

Sharing and Caring for Diabetes

Jodie Reynolds - Artist

My Artwork tells the story in my cultural way of the specialist Diabetes medical staff travelling across NSW to deliver their message to communities about Diabetes, their services, support, learning and listening, and treatment. It depicts this with the Diabetes medical team in the centre meeting place who travel and share their knowledge with other professionals, as well as the public. The yarning circles of various sizes display the many communities visited. The walking trails illustrated across the artwork shows the shadows of the many people walking and talking, spreading their newfound knowledge with the rest of their families and friends. This is all about getting the message out to the wider community.

To read the artist's full story of her artwork click here

The Diabetes Alliance Team works closely with our Aboriginal Health Access Team colleagues from the Primary Health Network

Diabetes in the Hunter Region

Around 1 in 8 people (12 per cent of the population) in the Hunter Region are estimated to have type 2 diabetes. Currently only 5.4 per cent (76,000 people) are diagnosed and registered with the National Diabetes Services Scheme (NDSS). This means around another 100,000 people are living with undiagnosed and untreated diabetes, while their disease is progressing (Source: HealthStats NSW - Diabetes prevalence in adults)

Accessing the best available care for people with diabetes in our region can at times be challenging. Due to the complex pathophysiology of diabetes, many patients require a broad multi-disciplinary team to minimise the potential development of long-term morbidity. DAP+ aims to improve health outcomes and the experience of care for patients with diabetes within their own general practice.

Prior to the introduction of the Diabetes Alliance Program roll out in 2015, people living with diabetes in regional and remote areas relied either solely on their local GP and community health services for care provision or were required to travel to metropolitan centres to access care. Lifestyle changes, including a healthy diet and regular physical activity, coupled with regular blood glucose self- monitoring, early diagnosis and medical management is the key to avoiding disease progression and secondary complications.

Some of our friendly Diabetes Alliance team members

The Diabetes Alliance initiative story

The Diabetes Alliance Initiative was a program developing since 2016 in a partnership between Hunter New England Local Health District (HNELHD) and the Hunter New England and Central Coast Primary Health Network (PHN) and other external stakeholders. This collaboration has allowed the cross-organisational sharing of skills, knowledge and resources to develop a person centred model of care that is efficient, cost effective and sustainable.

The Initiative is a tangible example of how integrating care can lead to a seamless, person centred approach that can be delivered in a flexible manner to benefit patients, clinicians and healthcare systems.

In 2023 the Diabetes Alliance Initiative expanded to become the Diabetes Alliance Program Plus (DAP+) thanks to a generous philanthropic gift from the Colonial Foundation. 2 new partners joined the collaboration and expanded the partnership to include Hunter Medical research Institute (HMRI) and the University of Newcastle (UoN).

This gift is to:

  • Focus on regional and rural communities
  • Primarily within HNELHD for first 3 years with a view to offer the program to other parts of NSW
  • Continue the existing DAP model but extend it to create a whole of community engagement, access and education program
  • Incorporate robust research into DAP+

The initiative supports the valuable role played by GPs and practice nurses as the basis for improving clinical outcomes, by ensuring primary care clinicians have access to the tools they need to provide the best evidenced care.


Since the commencement of the Diabetes Alliance Initiative in 2015:

  • Over 145 general practices across our region have participated in the program
  • More than 560 GPs and 250 Practice Nurses have taken part in consultations
  • More than 4,000 patients have been seen in clinics

The end goal of the Alliance is for all people with diabetes in our region to have access to gold standard care that leads to improved clinical outcomes.

One of our Diabetes Educators working with a patient at a GP Clinic

Diabetes Alliance Clinic Team

Diabetes Alliance Program Plus Case Conference Clinics in GP practices

General practice-based clinics are the cornerstone of the Diabetes Alliance program.

The program combines the specialist skills of the public sector Diabetes Educators and Endocrinologists who travel to a patient’s own practice to work with the patient’s own GP and Practice Nurse.

General Practice staff may indicate interest to participate in the program and a DAP+ team member will visit your practice and:

  • Discuss the program workflow of case conferencing integrating care with your team
  • Book dates that suit your practice and clinicians
  • Assist in selection of patients
  • Provide pre-clinic education for nurses

What is required of the GP practice:

Prior to the clinic the patients and their carers work with their GP. This involves the following:

  • Informing the patient about the program and what to expect at the appointment
  • Providing information to the patient and collecting their written consent to participate
  • Collecting clinical measures and asking the patient to complete a 3-day blood glucose and food diary

Benefits for your practice and patients:

For the Practice:

  • Data driven quality improvement activity, report presented during lunchtime education of case conference days
  • Accredited CPD for Doctors and nurses with lunchtime education held for all staff
  • Case conferences – specialist teams consult patients together with patients GP and practice nurse at the GP practice providing significant upskilling and collegial networking

For Patients:

  • Care provided with their primary care team in an environment they are familiar with
  • One on one consultation with their primary care team AND the specialist team to develop an individualised care plan
  • Empowerment to manage own health in a supported team
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