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Western Sydney Diabetes: An integrated program for diabetes prevention, management, and control in Sydney, Australia


Glen Maberly

Western Sydney Local Health District, AU
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The Problem - Theory

Type 2 diabetes is the leading burden of disease in Australia, with rates more than tripling in just 20 years. Western Sydney is particularly vulnerable, with its large socio-economically and culturally diverse population of >1 million people.  Approximately 12% of the Western Sydney population have diabetes, 35% are at high risk of diabetes and >50% are overweight/obese, far higher than both the state and national averages.

The Initiative - Description/Aims/Timeline

Western Sydney Diabetes (WSD) initiative was established in 2012, and is led by Western Sydney Local Health District (hospital care), Western Sydney Primary Health Network (primary healthcare), Diabetes NSW and ACT (NGO), and PricewaterhouseCoopers, as well as a range of partners from healthcare and non-healthcare sectors.

WSD represents an embedded integrated healthcare initiative that is world-leading in several areas of practice, including both primary prevention, secondary prevention, management of diabetes, and efforts to mobilize the public. Underpinning this is a rigorous data effort to measure and demonstrate the benefits of the initiative.

Since inception, WSD has brought together the Diabetes Alliance, which now has over 130 dedicated members. These include organisations within government, health, and the private sector, as well as NGOs and other charities.

The WSD programs are a unique blend of primary/secondary prevention and management efforts, including:

Primary Prevention - healthy urban design, healthy eating, physical activity programs, advocacy and public awareness campaigns, employee wellness efforts

Secondary Prevention/Management -  HbA1c testing to identify the burden of diabetes, General Practice (GP) support, health pathways, practice nurse training, diabetes masterclasses, complex diabetes clinics, joint-specialist case conferencing, high-risk foot services, CGM for diagnostics, a bariatric obesity clinic, a new community diabetes clinic, and many more.

The Impact - Discussions/Lessons Learned

WSD represents an integrated initiative that is imbedded into regular practice, drawing together the hospital and community, for more than half a decade. While the efforts are not yet enough to cool the western Sydney diabetes hotspot, WSD has demonstrated benefits in a number of areas. The joint-specialist case conferencing work has led the way in healthcare innovation in the state, with demonstrable benefits to both individual patients and GP clinics. WSD has made great strides in identifying the diabetes burden, with published evidence that >20% of patients in hospital in the region have diabetes, numbers which are echoed in GP clinics nearby. This research has also shown that more than 20% of patients are unaware that they have diabetes. A recent research initiative between WSD and the Ministry of Health for NSW has shown that people whose GPs are unaware of their diabetes status have more than double the risk of unplanned hospitalization compared to people who are aware of their disease. With PricewaterhouseCoopers, WSD has developed business cases for funding opportunities, as well as integrated diabetes dashboards that display essential information to a wide range of partners.

WSD represents a fully developed model that can transfer across regions, with a structure and framework that can be applied in many areas.

We can beat diabetes, together.

How to Cite: Maberly G. Western Sydney Diabetes: An integrated program for diabetes prevention, management, and control in Sydney, Australia. International Journal of Integrated Care. 2021;21(S1):125. DOI:
Published on 01 Sep 2021.


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