Background <p>Patients with diabetes receiving haemodialysis are often frail with multiple co-morbidities. Our typical standard model of diabetes care did not meet the needs of this patient cohort. In response we developed a multidisciplinary mobile clinic in 2018, bringing care to the bedside in the Belfast City Hospital dialysis unit. Standard diabetes outpatient clinic appointments were replaced by a consultant delivered diabetes assessment at the bedside in the dialysis unit with diabetes specialist nurse and dietitian input. Dialysis nurses performed monthly foot assessments with rapid access to podiatry input. The retinal screening service brought the screening camera to the dialysis unit annually. We describe our model of care and the results from six years of follow-up after establishment of the clinic.</p> Aims <p>To evaluate the implementation and outcomes of a novel integrated diabetes-dialysis clinic delivered between January 2018 to December 2024. The service provided coordinated care at the bedside by incorporating retinal screening, foot surveillance and consultant led diabetes review. This evaluation focuses on patient engagement, complication screening, and glycaemic management over six years. We also describe the impact of the service on patients and clinical characteristics of those attending during this six-year period.</p> Methods <p>This was a retrospective service evaluation and quality improvement initiative evaluating a novel integrated diabetes- dialysis clinic established in January 2018 at Belfast City Hospital. Data on patient demographics, clinical characteristics and laboratory data was collected from online health care records (NIECR and Encompass/EPIC). The model incorporated monthly foot surveillance by dialysis nursing staff supported by a referral pathway to podiatry, annual digital retinal imaging delivered within the dialysis unit, and consultant led diabetes reviewed supported by specialist nurses and dietitians with access to continuous glucose monitoring where appropriate.</p> Results <p>At initiation 59 patients were reviewed; the majority had type 2 diabetes mellitus and long-standing disease. 16% of patients did not have a diabetes review within the last year, 24% had not attended eye screening in the last year and 20% had not attended foot screening. Common co-morbidities included cardiovascular disease, neuropathy, retinopathy and foot disease. At six years, 56 patients were receiving care in this clinic with similarly high rates of complications and complex treatment needs. Uptake of retinal screening and foot surveillance was maintained through integration into the dialysis pathway. Use of continuous glucose monitoring increased steadily, supported by the service. High mortality was observed across the period, reflecting the frailty of this population, but the clinic continued to deliver care to successive patient cohorts and has since been scaled to all dialysis units in Northern Ireland.</p> Summary <p>The cohort of patients attending the dedicated clinic present with significant co-morbidities, poor quality of life and challenging long-term outcomes. Patients attending this clinic benefit from an integrated care model which addresses multiple aspects of their diabetes in a single, comprehensive setting. All patients now receive the three essential care processes of diabetes review, eye screening and foot screening. This service evaluation demonstrates that a multidisciplinary, integrated diabetes clinic within the dialysis unit is feasible, sustainable and addresses barrier to patients accessing care and has been successfully expanded regionally. </p>