Type 2 Diabetes - framework for prevention, early detection and intervention: evaluation

Executive Summary

The Scottish Diabetes Survey 2020, shows that, in Scotland, 5.8% of the population (317,128) diagnosed with diabetes were recorded on local diabetes registers at the end of 2019 of which 87.7% (278,239) had type 2 diabetes.

The incidence and prevalence of all types of diabetes has been steadily growing in Scotland, as in many other countries, in part due to better care and better detection. For type 2 diabetes, also in part due to unhealthy diet, low levels of physical activity and an increase in levels of obesity. Excess weight is the most significant modifiable risk factor for type 2 diabetes.

The Framework for the Prevention, Early Detection and Intervention of Type 2 Diabetes

The evidence about preventing or delaying the diagnosis of type 2 diabetes (or promoting remission) through targeted weight management interventions,^[1] combined with the cost to the NHS for the treatment of people with type 2 diabetes, helped to inform the decision to create the framework.

The Framework for the Prevention, Early Detection and Intervention of Type 2 Diabetes (referred to throughout this report as "the Framework") builds on the prevention work within the 2014 Diabetes Improvement Plan^[2] (DIP). It is designed to provide guidance to NHS boards and other delivery partners on the implementation of a specific weight management pathway for those at risk or those diagnosed with type 2 diabetes.

Early adopter sites

Three early adopter areas were approached to implement the framework ahead of the national rollout. These were, NHS Ayrshire & Arran, NHS Lothian, NHS Fife and NHS Borders working in partnership as the East Region, and NHS Tayside. They agreed, with additional support from Scottish Government funding and professional advisors,^[3] to begin work ahead of other board areas to redesign and deliver services in line with the Framework. Any learning from these would then be shared with other boards to inform the general roll out of the Framework.

The Framework identified the actions that boards and others needed to take to develop an integrated system. This included: the scoping of services delivery; agreeing local approaches to co-production and service re-design; agreeing the delivery of programmes under each tier and funding allocation; and how data and evidence would be used to identify, target and reduce local health inequalities. It also recommended the adoption of a tiered approach to weight management for those at risk of and with type 2 diabetes.

Evaluation

In November 2019, the Scottish Government commissioned Blake Stevenson to carry out an independent qualitative process evaluation of the adoption and implementation of the Framework in the three early adopter areas to contribute to the first stage of the evaluation of the Framework, in parallel with the national monitoring of patient outcomes. The work aimed to:

• assess whether the Framework was delivered as intended
• identify effective strategies for reaching target groups
• identify potential barriers to implementation as well as enablers of success
• identify the impacts to implementation caused by COVID-19 and the steps taken to adapt services.

The methodology used to evaluate the early adopter sites is captured in the diagram below.

Figure E1: Approach to the evaluation

Phase 1. Set Up Period

• Inception meeting
• Initial contact with early adopter areas
• Desk based activity
• Production of local evaluation and sample plans
• Design of research tools
• PBPP application and Health Board permissions

Phase 2. Fieldwork

• Interviews with programme delivery leads
• Interviews and survey with primary, secondary, community care staff and weight management providers
• Interviews with local stakeholders
• Interviews with patients

Phase 3: Analysis and Reporting

• Updates for and meetings with Scottish Government
• Analysis of all data
• Internal team analysis meeting
• Draft final report
• Final report

This process evaluation of the implementation in the early adopter areas was intended to inform the future rollout of the Framework. However, delays associated with the requirement for Public Benefit and Privacy Panel (PBPP) approval and the COVID-19 pandemic meant that information gathering did not start until January 2021, more than a year after the evaluation was commissioned. During this time, the Framework has been rolled out across Scotland. This report has been written in year four (2021/22) and to date all (14) territorial NHS boards, and one special NHS board have implemented the Framework. Although delayed, learning presented within this report provides valuable insights for those areas in the process of implementing this Framework, and more broadly for the roll out of other healthcare frameworks or policy that need to be implemented at a health board or partnership level. It is based on a combined total of 83 participants across the three areas, 45 health care professionals and 16 patients via interview and 22 health professional survey respondents.

Findings - delivery

The Framework recommended two specific approaches to interventions: one was to improve structured education for those with or at risk of developing type 2 diabetes or pre-diabetes; and the adoption of a tiered approach to weight management for those at risk of or with type 2 diabetes or pre-diabetes.The early adopter areas were expected to meet the Standards for the delivery of tier 2 and tier 3 weight management services for adults in Scotland (healthscotland.scot) for weight management services so that there was some consistency. The Framework allowed areas to use outputs from local needs assessment and existing service provision to design the most appropriate services for their population. This meant that there was variation in the implementation between areas.

Although different delivery approaches were implemented across the early adopter areas, each took steps to map services and pathways to identify gaps in provision and where further development in services was needed. Local factors played a role in how services were designed or expanded - in Ayrshire & Arran the existing midwifery service informed the delivery of gestational diabetes mellitus (GDM) services, the three NHS boards collaborative approach shaped East Region's design and a digital first approach in Tayside resulted in the Oviva suite of programmes used in that area.

The funding that accompanied the implementation of the Framework in the early adopter areas was used to fund new roles and invest in pilot programmes and tools that could be rolled out across the areas. The diagram below summarises the key programmes introduced or expanded across each area, as a result of the Framework.

Figure E2: Summary of key programmes introduced or enhanced across each area as a result of the Framework

Level 2 Early detection and early intervention

Ayrshire & Arran

• Let's Prevent Diabetes introduced, (including post-partum intervention for reducing risk in women with history of GDM)
• Plans underway to pilot and expand LEAN beyond just East Ayrshire

Tayside

• Introduction of new diagnostic pathway using HbA1c (Feb 2021)
• Introduction of Oviva Prevent pre-diabetes education programme

East Region

• Planned introduction of Let's Prevent Diabetes across all three boards
• Expansion of dietitian led gestational diabetes post-partum treatment pathway linking into Let's Prevent

Level 2 Weight management programmes

Ayrshire & Arran

• Weigh to Go introduced

Tayside

• Plans in progress to introduce Second Nature, Slimming World and Football Fans in Training tier 2 weight management services

East Region

• Get Moving with Counterweight tier 2 weight management programmes enhanced or introduced so now in all three boards
• Specialist dietetic-led weight management service enhanced with additional dietetic support and leadership

Level 3 Targeted intervention GDM

Ayrshire & Arran

• Diabetes specialist midwife and HCSW-led advice and treatment service expanded, and new midwife IT platform introduced
• GDM BMI threshold lowered from 35 to 30 kg/m²

Tayside

• New midwife post developed; new GDM pathway; and new midwife IT platform introduced
• GDM Health introduced
• GDM BMI threshold lowered from 35 to 30 kg/m²

East Region

• Introduction of specialist digital/virtual dietetic –led education and treatment sessions for those diagnosed with GDM
• Post-partum pathway links into Let's Prevent and tier 2 and 3 weight management

Level 3 Targeted intervention high risk

Ayrshire & Arran

• Counterweight Plus introduced for type 2 diabetes remission

Tayside

• Counterweight Plus piloted Jan 2021 for type 2 diabetes remission
• Expansion of staff and resourcing for general weight management services
• Plans to introduce Oviva Weigh to Wellness

East Region

• Counterweight Plus extended across the region for type 2 diabetes remission
• Enhanced psychology service at tier 3 weight management and for remission. Increase in service leadership and dietetic resource for tier 2 and 3 weight management

The early adopters adapted their plans to overcome the challenges presented by COVID-19, some producing virtual versions of their programmes and others fast tracking planned digitalisation. This early introduction or adaptation enabled the continuation of some services. It also meant that face to face individual and group work moved to telephone or online platforms and, although staff adapted quickly to use the new technology, the logistics of remote delivery, IT infrastructure and information governance systems often presented problems.

Findings - Perceptions and experiences of the services

Although not a representative sample, the perspectives of patients who accessed the programmes provided some insights to patient experiences. They described the key motivations for joining the programme: a diagnosis of pre-diabetes, and referral or recommendation by a professional; the concerns of the impact of COVID-19; pregnancy and an overall desire to improve their health.

The patients also identified various factors that deterred their take up or completion of programmes, for example work and care commitments that reduced the time available to attend services, their established eating habits and discomfort with group settings.

Overall, the patients interviewed were positive about their experience and the health changes that they made by participating in the programmes and receiving tailored support and advice. This resulted in weight loss and behaviour change so that they made more informed choices about their diet and physical activity.

These experiences, and the experiences of those delivering services, provided some key learning about the weight management programmes. These included:

• consideration of a wider range of evidence-based programmes for managing type 2 diabetes to meet varying needs and preferences
• recognising the established culture of unhealthy eating and its impact on eating habits
• the valuable role of psychological support, both for patients and staff in the programmes and ensuring the appropriate balance between psychology and dietitians
• the importance and need for more general support groups to increase motivation to continue with a programme.

Enablers and barriers to Framework implementation

Early adopters implemented the Framework in ways that best met the needs and existing infrastructure of their areas. Whilst this produced similar and differing programmes, there was commonality of enablers and barriers across all the areas. The key factors that influenced implementation are summarised in the diagram below.

Figure E.3 Enablers and barriers to implementation

Enablers and Barriers

• Technology
• Information Governance
• Resources
• Personnel
• Partnership Working
• Primary Care

Technology

Technology was an important element in the implementation of the Framework in the early adopter areas. All three areas used digital technology to enhance service delivery, especially once the pandemic hit. Some of these initiatives, such as the Oviva programmes in Tayside, were already at the planning stage before COVID-19 but in other areas the pandemic accelerated their introduction.

Information governance

Information governance acted as a barrier. Although one area was able to obtain approval relatively quickly for some of its programmes, others experienced extensive delays. Such delays to approval to use IT packages or to establish information sharing agreements with weight management providers meant having to find workarounds in the interim period, like staff delivering the equipment to patients.

Resources

The funding, documentation and the role of the professional advisors were valuable resources that supported the early adopter areas to implement the Framework. The main challenge was the allocation of funding on a year-on-year basis and its impact on retaining staff and long term planning.

Personnel

Key personnel involved in the Framework's implementation played pivotal roles in service development or motivation and encouragement of partners in each area and were key enablers. However, the challenge of staff turnover experienced by all areas also impacted on implementation and delivery of services. This was caused in part by redeployments during COVID-19 but also when posts were for a fixed term.

Partnership working

The design and delivery of the Framework required formalised structures and processes to plan and deliver the programmes from across a multi-disciplinary team and across primary and secondary care. Navigating these relationships and strengthening partnership working could be a challenge and this was amplified when working across more than one local authority area, health and social care partnership or NHS board. Although challenging, the implementation of the Framework created opportunities to build and strengthen partnership working, increase interactions and collaboration across different teams and disciplines and share learning across areas and regions.

Primary care

The role of primary care professionals emerged as a key determinant of success for effective referral pathways. As part of implementation of the Framework it was important to build the relationships with primary care and in each area various methods were used to do this. A need was recognised to continue to communicate with GPs to clarify referral pathways, provide feeback on patients referred and to help maintain the profile of type 2 diabetes programmes. Some felt that additional levers were needed to encourage this engagement and maintain GP involvement in order to drive forward the changes associated with the Framework's delivery.

Conclusions and considerations

The learning from the implementation of the Framework in the early adopter areas has provided insights to the design and delivery of weight management services, and some wider considerations for implementing the Framework and introducing change on this scale across primary and secondary care. Key areas that would improve implementation or increase consistency across services related to:

• a wider range of programme options – the 2019 weight management standards and gap analysis tool were viewed as helpful, but more choice of evidence-based programmes for managing type 2 diabetes was requested. Guidance was also wanted on the level and type of evidence required to provide robust information about the outcomes for individuals on weight management programmes
• financial support - the resources and financial support enabled the areas to redesign services and work with colleagues to develop programmes. However, the short term nature of the funding restricted future planning and recruitment and retention of staff. A longer financial commitment would provide the security to embed changes and maintain staffing levels
• partnership working - the early adopter areas had clear guidance as to the steps needed to develop an integrated system. Completing these steps needs to be robust with meaningful co-production and service redesign with the key stakeholders and deliverers. This was the most effective way to ensure a shared vision and common understanding of the new pathways and service
• systems – all areas experienced challenges in relation to information governance and sharing information with weight management providers when introducing or adapting services. A better understanding of what would be needed and the time required to develop appropriate agreements would have reduced some of the delays created by the information governance requirements and there was a plea for a national solution to the information governance challenges
• building relationships with primary care - the importance of effective working across primary and secondary care was highlighted in the redesign of services and pathways and the continued strengthening of relationships and understanding across teams. The key role of GPs and Practice staff in effective delivery of services emphasised the need to engage primary care and ensure understanding and buy-in to the new pathway and their role within it.

A common approach across Scotland

The early adopter areas welcomed the opportunity to vary their approach to implementation but also valued the Framework and national standards for promoting consistency between and across areas. However, there were different views about what should have been delivered and how much influence the Scottish Government should have had over implementation.

Some wanted more autonomy to choose programmes and approaches, others were frustrated that areas appeared to be doing things differently when a common approach could have generated more learning, led to national approaches to procurement and avoided repetition. There were particular frustrations about the IT platforms that could be used in one NHS board but not another and more clarity and consistency about IT platforms across Scotland was requested by some.

The aspiration in Scotland to promote and embed best practice in healthcare through a Once for Scotland approach is relevant to these discussions. The tension between local and regional approaches that reflect the context and population needs and a national approach that supports consistency was evident. There was no consensus.

The Modernising Patient Pathways programme aims to identify best practice, understand and, where appropriate, address variation, collectively review and optimise current service pathways and associated primary/secondary care communication across key clinical areas. Although type 2 diabetes is not a speciality network for this programme, the work of the early adopter areas and the further rollout of the Framework provides opportunities to draw together collective experiences and knowledge and highlight where key challenge areas still exist.