ℹ️ Introduction
This article explains how to use the Ardens Manager Diabetes dashboards to understand prevalence, stratify clinical risk, monitor activity and evaluate the quality of diabetes care across Type 1, Type 2, Gestational Diabetes and pre‑diabetes. By the end of this guide, you will be able to use these insights to support proactive planning, targeted interventions and quality improvement across your practice, PCN or ICB.
Background
Diabetes is a long‑term condition with significant impact on morbidity, mortality and health inequalities. Effective care relies on timely diagnosis, structured reviews, medicines optimisation and regular monitoring of clinical indicators. Diabetes care is underpinned by NICE guidance and QOF indicators, requiring consistent population‑level oversight.
In addition to established Type 1 and Type 2 Diabetes, services must also:
Identify and monitor pre‑diabetes (non‑diabetic hyperglycaemia) to reduce progression.
Ensure appropriate follow‑up and post‑partum review for patients with Gestational Diabetes.
Monitor patients at increased cardiovascular and renal risk.
For GP practices, PCNs and ICBs, it is important to:
Understand prevalence across all diabetes sub‑types.
Monitor control measures such as HbA1c, blood pressure and lipids.
Ensure completion of annual reviews and care processes.
Identify unwarranted variation in outcomes, access and workforce activity.
Target intervention to higher‑risk cohorts.
How Ardens Can Help
The Ardens Manager Diabetes Dashboards bring together insights for:
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes
Pre‑diabetes / Non‑Diabetic Hyperglycaemia
Each dashboard follows a consistent structure, enabling organisations to:
Analyse prevalence and demographics.
Review activity and demand.
Stratify clinical risk.
Evaluate quality and safety of care delivery.
The Ardens Manager Diabetes dashboards work alongside existing Ardens Clinical resources to support delivery of high‑quality diabetes care. To learn more about the clinical resources, access the support articles below:
✅Included in Ardens Manager National Content package: Interested in finding out more or requesting a trial? Contact accounts@ardens.org.uk
📍 Access the Dashboard
Log into Ardens Manager.
Go to Services on the left-hand pane.
Open to Conditions folder.
Click on Diabetes.
Click on the required condition tab.
📊 Plan & Forecast Demand
The Overview section enables organisations to analyse coded registers, identify population trends, and plan workforce and recall activity accordingly.
Understand Your Population
The diabetes registers provide visibility of patients coded with a diabetes condition.
These reports help organisations understand:
Recorded prevalence
Population characteristics
Coding patterns and register accuracy
Size of the cohort requiring review or follow‑up
Condition‑specific risk
This insight supports informed workforce planning and recall scheduling.
To review registers:
Click the View button next to the required register report.
Review the Demographic tab to understand age distribution and deprivation.
Review the Conditions tab for breakdown by long-term condition and multimorbidity.
Review the Risk tab to identify patients in vulnerable or higher-risk groups.
Further insights allow organisations to review diagnosis patterns by clinician and by patient geography, supporting identification of variation and unmet need.
Analyse Trends
Understanding how registers change over time allows organisations to anticipate workload and monitor the impact of case-finding and prevention activity.
To analyse trends:
Click View next to the required report.
Click on the Timeline tab.
Choose Year (or another timeframe) from the drop down below the chart
This allows you to:
Analyse trends in diagnosis rates.
Identify an increase in demand.
Inform capacity considerations vs potential demand.
Condition Specific Risk Stratification
Risk stratification helps identify people at higher clinical risk so teams can prioritise recalls, target proactive interventions, and focus workforce capacity where it will have the greatest impact. In the Diabetes dashboards, risk stratification is based on HbA1c control and related indicators, enabling you to identify people with suboptimal glycaemic control (for example, HbA1c above target thresholds) who may need review, treatment optimisation, or additional support.
🔎 Monitor Activity & Safety
The dashboards provide tools to support clinical governance, patient safety and service oversight.
Last Month Activity
All diabetes dashboards include a summary of activity for the previous month, including:
New diagnoses.
Reviews and monitoring completed.
Workforce involvement by role.
To review activity:
Click View next to the activity report.
Review the Demographic, Conditions, Risk and Staff tabs.
Analyse the Timeline tab to understand recent trends.
Safety Alerts
Safety Alerts highlight patients who may require urgent review, such as:
Very poor glycaemic control.
Missing essential monitoring.
Potential medicines‑related risk.
For each report:
Click View.
Select PATIENTS tab.
Review each patient and take appropriate action.
This supports monitoring of workload, capacity and delivery against local priorities.
Case Finders
Case Finder reports identify patients who may have diabetes or pre‑diabetes but lack an appropriate diagnosis code, often due to missed or inconsistent coding.
Using case finders:
Click View.
Select PATIENTS tab.
Review each patient record.
If diagnosis is confirmed:
Add the appropriate diagnosis code in the clinical system.
This will move the patient onto the register and remove them from the case finder.
If inclusion is due to a data error:
Amend or remove the incorrect coding in the clinical system.
Performance Indicators
Performance Indicators monitor completion of key care components across diabetes pathways, including:
Diagnosis coding.
Annual reviews.
Monitoring of HbA1c, blood pressure and lipids.
Screening and target achievement.
Reviewing performance indicators:
Indicators are grouped by diagnosis, review, target or screening.
Green bars display percentage completion.
The Remaining column highlights outstanding care.
Click View and select Show remaining only to support follow‑up.
⚠️ Please note: Patient data can be exported. Refer to this support article for further information.
Patient View for Follow-up
The Patient View functionality enables clinicians and teams to review outstanding elements of care at an individual patient level.
To access Patient View:
Click View next to the patient’s NHS number
Within the patient view:
View all Ardens Manager findings for the patient across relevant reports
Highlight what still needs action
Use this as a prompt list, then review clinical details (history, repeat/long-term use, appropriateness) in the clinical system record
To take action:
Click Open in EMIS/SystmOne to review the full clinical record
Assess suitability of alternatives
Consider patient preference and clinical need
Complete any required medication changes
❓FAQs
What time period does 'Last month activity' refer to?
This reflects activity recorded in the previous calendar month and is updated regularly as data refreshes.
How do case finder reports work?
Case finders identify patients who may meet criteria for diabetes or pre-diabetes but are not coded. These should be clinically reviewed and coded appropriately if confirmed.
How do the dashboards support proactive care?
By highlighting high-risk patients, unmet care needs, and trends, they enable targeted interventions rather than reactive care.
🏫 Additional Support
To further your understanding of the Ardens Manager platform:
Book training for your GP Practice, PCN or ICB.
Contact our Support Team for support in real time.