Download as PDF


NSW Health and the NSW Primary Health Networks (PHNs) are committed to working with partners in a "one health system" approach to improve the health outcomes and experiences of care for people living with diabetes.

The Statewide Initiative for Diabetes Management (the Initiative) has been collaboratively developed in consultation with patients, clinicians, researchers, districts and networks, PHNs, ACCHOs, and non-Government Organisations (NGOs).

The Initiative will focus on providing an integrated and coordinated approach to diabetes management across NSW to keep people well and out of hospital. Key to this is understanding the patient's perspective and organising care around their needs. Supporting people to manage their diabetes, and reducing the impact of diabetes related complications.

A value based healthcare (VBHC) approach is being used to develop and implement this statewide Initiative. This approach strives to improve outcomes that matter to patients, the experiences of receiving and providing care, and the efficiency and effectiveness of care. It focuses on placing the patient at the centre of care and measuring outcomes that matter to them.

The Initiative aims to support the alignment and coordination of activities to achieve improved outcomes across the system, rather than to stop or replace existing work. It is supported by a strong focus on measurement and evaluation to demonstrate impact.

The Statewide Initiative has six focus areas:

  • partnerships with people living with diabetes
  • capability building for health professionals in general practice, primary, community, and aged care settings to promote best practice
  • tailored strategies for priority communities
  • agreed processes for identification of diabetes, referral pathways, and escalation of care
  • shared information and data
  • identified governance and leadership with a focus on partnerships.

A statewide governance structure will oversee four workstreams that focus on developing, implementing, and scaling system wide enablers and solutions to address key focus areas of the initiative. The four workstreams are:

  • governance and partnerships
  • capability development
  • access to care
  • coordinating care.


A working group is being established for each of the four workstreams.

We are seeking nominations from people with an interest and expertise across the following areas for each of the four working groups:

  • clinicians with experience in diabetes management (public and private practitioners)
  • health service managers with experience in planning and delivering diabetes care
  • NGOs and advocacy groups
  • research
  • consumers and carers with lived experience of diabetes.

Working group members will be selected to ensure diversity and representation across geographical areas, roles and expertise.

Desired skills, experience and capabilities

Capacity to contribute to the working group for a period of at least 12 months

The expected commitment is for members to provide continuous input, feedback, and support to achieve the objectives under the priority area. This will include providing information and facilitating access to stakeholders within their network throughout the project. More information about the expected time commitment is included below.

Capability to influence and contribute to the achievement of the Initiative objectives

Each working group will have broad representation across the sector. Each member is expected to bring experience, knowledge, passion, and commitment from their sector or area of expertise to influence genuine change within the specific focus areas of the working groups.

Other information

  • Participation is voluntary and representatives can choose to exit at any time.
  • This role does not involve working with patients.

To assist you in identifying which working group aligns with your expertise and interest we have included an overview of the function and expected activities for each working group below.

Working group objectives

The focus of each working group aligns with one or more of the six focus areas.

The key objectives for each working group have been set, however each group will develop and agree on a more detailed implementation plan. Working groups will be responsible for prioritising proposed solutions as well as identifying and building on existing activities.

Working group 1: Governance and partnerships

The Governance and partnerships enabler working group will focus on strengthening the partnerships and system supports needed for ongoing collaborative improvement in diabetes management across all regions of NSW.

Key objectives include:

  • Encourage regions to formalise partnerships and joint governance.
  • Support regions to develop integrated local strategies and implementation plans.
  • Develop processes at the service level to enable clinical systems data to be used in monitoring the effectiveness of diabetes care.
  • Establish statewide oversight and an authorising environment.

Working group 2: Access to care

The Access to care enabler working group will focus on innovative service models that support people living with diabetes to receive timely, best practice, culturally responsive care.

Key objectives include:

  • Identify innovative service models, including accelerated access to specialist care.
  • Co-design strategies for priority communities, with a focus on Aboriginal peoples.
  • Coordinate statewide activities to support the scale and spread of effective models of care, including enhancing the use of virtual care.

Working group 3: Capability development

The Capability development enabler working group will determine ways to improve uptake and access of programs and resources for both consumers and healthcare providers.

Key objectives include:

  • Develop consistent and accessible pathways for upskilling healthcare staff in best practice diabetes management across the healthcare system.
  • Enhance uptake of consumers and carer resources, peer support, education and coaching.

Working group 4: Coordinating care

The Coordinating care enabler working group will progress the development of tools and processes that support person centred and coordinated care across service providers.

Key objectives include:

  • Identify and promote tools to enable shared care planning across primary, acute and community settings, including the use of inter-operable electronic systems.
  • Coordinate the agreement of consistent processes for early identification of diabetes, risk screening, referral pathways and escalation of care.


The working groups will be accountable to the Statewide Initiative for Diabetes Management Steering Committee. Working group leads will also coordinate activities across workstreams at the Project Implementation Working Group.

Updates will also be provided to other external agencies for noting, such as the Agency for Clinical Innovation (ACI) Diabetes and Endocrine Network.

Time commitment and location of meetings

Each working group will decide on the frequency and duration of meetings. However it is expected that working groups will be meeting monthly for approximately one hour.

Working group meetings will commence in late 2022 or early 2023.

Meetings can be attended in person at 1 Reserve Road, St Leonards, Sydney or virtually via Microsoft Teams.

It is expected that members will review, provide input and consult within their networks to support implementation activities outside of scheduled meetings.

Please let us know if you are interested

If you are interested in joining the Statewide Initiative for Diabetes Management Steering Committee, please complete the online Expression of Interest.

Alternatively you can email

If you have any questions, please do not hesitate to email:

  • Working group 1: Governance and partnerships – Johanna Alaban, Principal Policy Officer Strategy and System Priorities Unit, Ministry of Health at
  • Working group 2: Access to care – Marina Sarkis, Network Manager Diabetes and Endocrine, Agency for Clinical Innovation at
  • Working group 3: Capability development – Kate Tye, Executive Manager Primary Care Development, Nepean Blue Mountains Primary Health Network at
  • Working group 4: Coordinating care – Sandra O’Malley, Manager Integrated Care Implementation, Ministry of Health at

Find our more about the Statewide Initiative for Diabetes Management.

Current as at: Wednesday 9 November 2022
Contact page owner: Strategic Reform and Planning