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

3. Findings - delivery of the Framework in the early adopter areas

3.1 Introduction

The Framework identified the actions that the early adopter areas 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 level and funding allocation and how data and evidence would be used to identify, target, and reduce local health inequalities.

For those at risk of and diagnosed with type 2 diabetes, the Framework recommended the adoption of a tiered approach to weight management which relates to the level of risk for an individual.

Figure 3.1 Levels of a tiered approach

Tiered approach to weight management services for those at risk and with type 2 diabetes

Level 1 Public health awareness and early detection

Universal services, health promotion and early detection of type 2 diabetes through:

• Public health campaign
• Targeted messaging with core messages
• "At risk' stratification
• Case finding
• Local level action

Level 2 Early detection and early intervention

Early detection and early intervention for those at moderate or high risk through:

• Pre-diabetes education programmes
• Metabolic antenatal clinics
• Maternal and infant nutrition pathways
• Weight management programmes

Level 3 Targeted intervention

Targeted intervention for those diagnosed with type 2 diabetes, at high risk, with pre-diabetes or gestational diabetes:

• Structured education for those with diabetes
• Intensive weight management for remission
• Weight management programmes
• Psychological support

Level 4 Complex case management

Advanced weight management input and specialist interventions:

• May include the use of drugs as part of intensive weight management
• Considers bariatric surgery

The tiered approach was expected to be delivered as part of a broader weight management pathway which also incorporated: programmes for those not at high risk but with higher BMIs; psychological support; child healthy weight interventions; and the provision of wider support to enable people to manage their health conditions.

The introduction of population-level health promotion (Level 1) was on hold pending

the implementation of services for the other levels; therefore levels 2-4 were within the scope of this evaluation. During interviews, respondents focussed only on Levels 2 and 3, thus no information is provided on Level 4 in the remainder of the report.

A key aim of the evaluation was to understand the experience of implementing the Framework; this chapter summarises the approach taken in each of the early adopter area to target high-risk target groups, deliver services, and the impact of COVID-19 on delivery plans.

3.2 Targeting high-risk groups

Each area took steps to improve the targeting of those at risk of type 2 diabetes.

Reducing inequalities is one of the Framework's guiding principles and so interviews with stakeholders and those delivering weight-loss programmes explored the strategies being used to engage those most at risk. Actions included:

• high deprivation groups - focusing the initial rollout of the new diabetes prevention pathway in seven GP practices in areas of higher deprivation in Ayrshire & Arran
• pregnant or planning pregnancy - supporting women with or at risk of gestational diabetes mellitus (GDM) across all three early adopter areas, for example in Ayrshire and Arran, women at risk who attended an oral glucose tolerance test (OGTT) then took part in a group education session
• men - football clubs within Ayrshire and Arran were commissioned to deliver additional Weigh to Go for men. Football Fans in Training (FFiT) programme in Tayside was planned but delayed due to the pandemic
• ethnic minority groups - in East Region, work was underway to remove literacy and language barriers by translating key resources and the delivery of a Let's Prevent Diabetes group specifically for the Polish community was trialled with three patients. Oviva resources in Tayside were available in 22 languages.

Interviewees recognised the need to do more to engage those who may not be accessing services (for example, homeless and traveller populations). Equality impact assessments were expected to identify whether additional targeting was needed.

3.3 Delivering services

The early adopter areas were expected to meet the minimum standards for weight management services so that there was some consistency in referral criteria, referral pathways, provision, length and frequency of follow-up, quantity and type of dietary and physical activity intervention, behavioural change components and provision of specialist interventions. However, the prevention Framework did not prescribe the type and content of the interventions which allowed for variation in implementation between areas. The next section looks at each adopter area in turn and summarises their approach, delivery under the Framework and the impact of COVID-19 in each area.

3.4 Ayrshire & Arran

Local context

Planning and delivery in Ayrshire & Arran were shaped by the existing gaps and access to weight management provision. There are three HSCPs in the region, East Ayrshire, North Ayrshire, and South Ayrshire. This was widely perceived to have created a difference in the weight management provision.

Although there was no level 3 provision in the region, East Ayrshire offered an enhanced level 2 weight management programme: Lifestyle, Exercise and Nutrition (LEAN). This dietitian-led programme offered support for those with higher BMIs and more complex health needs, but an equivalent service was not available to residents outside East Ayrshire.

More broadly, the lack of a level 3 weight management programme in Ayrshire & Arran was identified as a risk in the weight management standards gap analysis. The lack of support from a multidisciplinary team meant that appropriate provision could not be provided for all patients with complex needs. As the following quote illustrates, the absence of psychology input in particular meant that psychological comorbidities could not be reduced:

"The key difference is psychology input, if they're not resolved or strategies given to deal with them, when they try and follow a programme that requires them to fight against their feelings and thoughts, it's almost like you are setting them up to fail. You're not treating the issue, it's not about diet and exercise, more deep-rooted psychological issue that needs addressed. That's why they keep yo-yoing. Can't be sustained, so weight goes back on and in constant dieting cycle because underlying issue never resolved." Health and social care staff, Ayrshire & Arran

Weight management implementation post-framework

Taking account of the local factors, implementation in this early adopter area centred on three workstreams:

• people at high risk
• women with GDM
• a total diet replacement (TDR) pilot.

There was no diabetes prevention pathway prior to the early adopter status being granted, but there were plans for its development and these plans provided the foundations for the implementation of the high risk workstream. For women with GDM, the Framework was used to expand and develop what was already an established and award winning service.^[7] A specialist midwifery team supported women with GDM throughout their pregnancy and because they held prescribing qualifications, all care was provided within one service. The approach used a combination of support and advice from midwives and health care support workers (HCSWs) alongside encouragement and tools for women to self-manage their health.

The third workstream, a small TDR pilot, was introduced following guidance from the professional advisor supporting the early adopters and was new to the region.

The diagram summarises what changes were made in Ayrshire & Arran as part of the Framework's implementation.

Figure 3.2 Key changes as a result of Framework implementation in Ayrshire & Arran

Level 2 Early detection and early intervention

Pre-framework:

• Plans were in place for the development of a diabetes prevention pathway.
• LEAN, an enhanced weight management programme, in East Ayrshire.

Current:

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

Level 3 Targeted intervention GDM

Pre-framework:

• A diabetes specialist midwifery service was in place, steered by a lead midwife for diabetes

Current:

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

Level 3 Targeted intervention High risk

Pre-framework:

• None

Current:

• Counterweight Plus for type 2 diabetes remission

The impact of COVID-19 on service delivery

The Framework helped to shape the development and delivery of the services. Some were being piloted before the pandemic hit and others were in development.

The delivery of workstream 1, that focused on people at high risk, was limited to seven GP practices piloting the Let's Prevent Diabetes programme pre-COVID. From September 2020 the referral pathway opened up to all 54 GP practices who could then refer patients with a pre-diabetes diagnosis to diabetes prevention dietitians. Where appropriate to patient needs and preferences, patients were referred to Let's Prevent and, following its completion, Weigh to Go. Delivery of these programmes throughout COVID-19 had been via online and telephone methods.

A delay in securing psychology input meant that workstream 3 (TDR pilot) had not yet commenced but delivery of the small TDR pilot began in January 2021 with three GP practices invited to refer patients with type 2 diabetes to the Counterweight Plus programme. Initially the 1:1 appointment took place via telephone then shifted to NHS Near Me virtual clinic option.

In contrast, delivery of GDM – which built on an established specialist midwifery service – began in May 2019. The Framework was used to increase the capacity of the service to meet the additional demand created by the reduction of the BMI criteria from 35 to 30 kg/m² for GDM screening. Although the service continued throughout the pandemic, some elements were changed – most notably, the group education for all women attending an OGTT was stopped. Instead, fasting bloods were used to diagnose women and any with GDM were then invited to participate in a 1-1 education session. These women were then supported by the specialist midwives throughout their pregnancy through regular telephone calls.

Future plans

At the time of the fieldwork, plans were being developed to use the funding from the Framework to carry out a small test of change in East Ayrshire and expand the existing specialist level 2 service (LEAN). Additional psychology and dietetic hours had been secured and the recruitment of physiotherapy was underway. Following the test of change, the programme team planned to develop a business case to secure the funding for a pan-Ayrshire service.

3.5 East Region

Local context

The East Region brings together three health boards: NHS Lothian, NHS Fife and NHS Borders. The partnership evolved from initial multi-agency work undertaken in the Borders and a wide-ranging change management programme led by the then Chief Executive of Scottish Borders Council. The three NHS boards, six IJBs and six local authorities in the East Region agreed to work collaboratively for a major prevention and reversal partnership for type 2 diabetes. The multi-level approach was driven by leadership from all senior officers across these organisations. It built on work already underway in different parts of the region and capitalised on the leverage that regional collaboration could bring.

Weight management implementation post-framework

When the East Region became an early adopter area, the programme team was created so that the Partnership provided effective strategic oversight and joint decision making with representation from public health, diabetes specialist teams, weight management services and other health and social care partners.

The Partnership established a number of workstreams^[8] to take forward the programme of work to support the prevention, early intervention and reversal of type 2 diabetes. The first of these was the weight management workstream which held two workshops in Autumn 2018 to develop proposals that would reflect the different levels described in the Framework. A parallel aim was to support a common approach to weight management services and pathways across the East Region, reflecting regional priorities and seeking to maximise outcomes.

As part of the weight management workstream, four intervention programmes were delivered across the region to standardise programmes.

Figure 3.3 Key changes as a result of Framework implementation in East Region

Level 2 Early detection and early intervention

Pre-Framework:

• No structured education programmes in any board areas for pre-diabetes or those at moderate or high risk
• Antenatal metabolic clinic with specialist dietitian and multi-disciplinary team (MDT) in Lothian

Current:

• Planned introduction of Let's Prevent Diabetes (pre-diabetes structured education) in all three boards
• Expansion of dietitian led gestational diabetes post-partum treatment pathway linking into Let's Prevent

Level 2 Weight Management

Pre-Framework:

• Weigh to Go in Borders
• Patients triaged to general dietetics in Fife
• Get Moving with counterweight in Lothian
• All boards had a specialist dietetic-led multi-disciplinary weight management service in place at tier 3 weight management level

Current:

• 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

Pre-Framework:

• No specialist GDM or post-partum education service in any board
• GDM managed in secondary care in all boards
• No post-partum pathway

Current:

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

Level 3 Targeted Intervention intensive weight management for remission

Pre-Framework:

• No type 2 diabetes remission programme in any board

Current:

• Counterweight Plus for all three boards
• 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

Level 2 programmes

The Let's Prevent programme, a lifestyle improvement programme for people at risk of developing type 2 diabetes, was planned to be introduced in all three NHS boards in the region. This evidence-based education programme run by Leicester Diabetes Centre aims to increase healthy eating and physical activity and reduce weight to prevent or delay type 2 diabetes. The East region used SCI diabetes^[9] to identify those eligible for Let's Prevent.

All three NHS boards established service level agreements (SLAs) with sport and leisure providers in the region to run Get Moving with Counterweight, an evidence based and efficient weight management programme. A core component of the Tier 2 programme is physical activity, and a weekly physical activity group session was provided for all patients within the first 12 weeks, normally in the same venue as the Counterweight education sessions.

NHS Lothian had pre-existing SLAs with leisure providers and the revised SLAs set out requirements for an enhanced service. NHS Fife established an SLA with Fife Sport & Leisure to provide the programme in their area and NHS Borders did the same with Live Borders. Referrals were sent to the weight management team in each NHS board (GPs provided information on suitability for physical activity) and a senior dietitian triaged and then forwarded details on to leisure providers.

Level 3 programmes

The third intervention introduced across the region was the GDM programme, community-based education sessions for women diagnosed with GDM, and a subsequent programme for pregnant women with a BMI>30 kg/m² to minimise weight gain. Dietitians worked closely with midwifery services to identify and treat GDM and to promote optimal blood glucose control during pregnancy. They also provided postpartum assessment and ongoing weight management support. By expanding dietitian-led metabolic antenatal clinics it was hoped that this would also support pregnant women with BMI>40 kg/m² or with polycystic ovary syndrome (PCOS).

The final programme extended across the region was Counterweight Plus, a proven weight loss programme delivered by health professionals for managing severe and complicated obesity. This 12-month programme provides people with the skills to lose and then maintain a low weight. It starts with total diet replacement to help with weight loss and is followed by food reintroduction and behavioural techniques to support the maintenance of the lower weight.

The impact of COVID-19 on service delivery

As in other areas, staff were redeployed during the pandemic and delivery plans had to be revised to ensure that patients already participating in programmes continued to receive support.

For Get Moving with Counterweight the group classes delivered in leisure centres were cancelled and instead non-interactive, pre-recorded sessions on YouTube were offered along with a follow up call with a health coach for 1:1 support. Those that had enrolled but not yet started a programme were signposted to motivational materials and a national self-directed online 12-week programme.

For those on GDM group or 1:1 sessions, these moved online to non-interactive, pre-recorded sessions on YouTube with follow up calls with the dietitian for 1:1 support, pharmacies also provided support to manage medicines.

Counterweight Plus programmes, that were delivered 1:1 in a variety of venues pre-COVID, moved online using Attend Anywhere/Near Me, or Skype for Business when restrictions came into place. Education materials and meal replacements were delivered directly to participants from Counterweight. Equipment, like scales, blood pressure monitors and blood glucose monitors, was ordered and distributed to patients to facilitate self-monitoring at home.

Despite these challenges, staff interviewees described how COVID-19 created an opportunity to overcome some of the difficulties associated with the multi-area approach. The pandemic presented a common challenge, and the NHS boards came together to find a solution. The shift to remote delivery was new for all areas and enabled a shared approach to be implemented.

The break in service provision was also used as an opportunity to set up a new database and data dashboard to help manage delivery. The improved data management enabled staff to identify gaps in referrals and therefore enable more targeted approaches to awareness raising.

3.6 Tayside

Local context

The approach to implementation of the framework in Tayside was informed by an extensive co-production process using service design methodologies with the Digital Health and Care Innovation Centre (DHI). This reflected a desire to take a service user needs and service design approach to identifying the needs and solutions in Tayside. The reports from the co-production process identified a range of user needs and new pathways of care including in digital solutions and key recommendations around improved digital information and resources, education and weight management support, lifestyle interventions, prevention and supporting health professionals.

While the co-production process continued to inform the redesign of pathways, initial work focused on enhancing existing pathways by, for example, increasing physiotherapy and psychology input into weight management. The calculation of Know your Risk scores in Nutrition and Dietetic clinics was also introduced in the earlier stages of delivery but paused from March 2020, once patients were being seen remotely.

Weight management implementation post-framework

Figure 3.4 Key changes as a result of Framework implementation in Tayside

Level 2 Early detection and early intervention

Pre-framework:

• People are diagnosed with impaired glucose intolerance using fasting glucose or OGTT at GP and offered Tayside Diabetes Education Programme (TDEP)

Current:

• New diagnosed pathway using HbA1c (introduced Feb 2021)
• Oviva Prevent pre-diabetes education programme
• Plans made for introduction of tier 2 weight management services with Second Nature, Slimming World and Football Fans in Training (FFiT)

Level 3 Targeted intervention GDM

Pre-framework:

• Anyone diagnosed with GDM offered the chance to attend group education
• All called weekly to discuss blood glucose monitoring
• BMI threshold 35kg/m²

Current:

• Development of midwife post new GDM pathway and new midwife IT platform introduced to give access to information on GDM
• GDM Health
• GDM BMI threshold lowered to 30kg/m²

Level 3 Targeted Intervention High risk

Pre-framework:

• Tier 3 general weight management services
• Tayside Diabetes Education Programme (TDEP)

Current:

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

*The co-production process identified changes to pathways that were sometimes funded from within Board's own budget rather than funding attached to the Framework e.g. GDM health (a remote health pathway) and Oviva Weight to Wellness for remote Tier 3 weight management services.

Patients newly diagnosed with type 2 diabetes could be referred to the 12-week Oviva Diabetes Support programme, an interactive digital programme. In the early stages of the programme those recently diagnosed with type 2 diabetes received a letter from the Diabetes Managed Clinical Network (MCN) to promote the new programme and then the Nutrition and Dietetics team followed up to sign them up to the programme. This temporary approach enabled the MCN to pick up patients diagnosed since October 2019. More recently the process shifted from GP referrals to the Nutrition and Dietetics team.

GDM pathways were revised so that women diagnosed with GDM could receive timely support:

• the BMI criteria for a glucose tolerance test was reduced from 35 to 30 kg/m² in 2019
• the midwifery service's new IT platform BadgerNet was used to provide access to videos and information on GDM
• post-natal letters were sent to women (copied to GP) to encourage six weeks fasting glucose test uptake.

The impact of COVID-19 on service delivery

To support those at higher risk of type 2 diabetes, the nine-month digital Oviva Diabetes Prevention programme was introduced for patients with pre-diabetes. This was piloted with six GP practices in Dundee and Angus during COVID-19 and has now been rolled out to all GP Practices in Tayside. GPs identified patients using the HbA1c test and referred them to the Nutrition and Dietetics team who then referred the patients to Oviva.

The Tayside Diabetes Education Programme (TDEP) group education sessions were paused during COVID-19 and women with a GDM diagnosis received education on a 1:1 basis supported by videos and online information. Women were diagnosed via fasting bloods, rather than an OGTT. Following an initial 1:1 education session delivered by a health care assistant, women were supported throughout their pregnancy via frequent telephone calls by the specialist midwife team.

Future plans

Remobilisation of services began in late 2020 as staff returned to their posts and saw the start of a new service, Counterweight Plus. Patients diagnosed within six years were referred from the weight management waiting list and 34 started this TDR programme in January 2021. They were supported via Near Me rather than in a group setting.

More recently, the early detection work was broadened to include a pilot programme based in community pharmacies to identify people at high risk of type 2 diabetes. This workstream will include three phases, encompassing point-of-care HbA1c testing, appropriate referral to services, evaluation of staff and user acceptability and assessment of how HbA1c results compare with the Diabetes UK risk tool.

The co-production process identified family-based interventions as a potentially valuable approach and opportunities to deliver these through the extension of the Scottish Professional Football League's (SPFL's) Football Fans in Training (FFiT) programme were being explored but, because of the pandemic, were not in place at the time of the evaluation's fieldwork. Similarly, a new Slimming World programme (its offer was to include a specialist programme for pregnancy) and Second Nature programme will also be commissioned once the information governance issues about sharing patient information can be resolved.

3.7 The impact of COVID-19 on delivery across the early adopter areas

The restrictions imposed by COVID-19 had a profound impact on service delivery. Pilots were paused and those not already on programmes re-directed to self-management material, while existing programmes moved to remote support. This section reviews in more detail the challenges and opportunities faced by the early adopters in redesigning their delivery plans.

Group work

Enabling a shift to remote delivery was the most significant challenge brought about by COVID-19. Group work had been a key feature of the planned approach for many of the programmes and the early adopters have had mixed success in retaining this via the new online approach.

The lack of an appropriate group IT platform was a key limitation here; Near Me was most commonly used to continue the delivery of programmes but participation was limited to much smaller groups of two to four patients. This meant that group interaction, and the peer support this provided, was restricted, which was a concern for some:

"We're actually removing something that we know is so valuable." Health and social care staff, Ayrshire & Arran

Although group programmes were not the preferred delivery approach for all patient interviewees, others commented that they would have benefited from an IT platform that allowed more group interaction. The smaller numbers participating in each group also meant that the programmes' throughput was reduced, as emphasised by one staff member:

"[We are] drowning because we can't mobilise to operate in a most effective way." Health and social care staff, Tayside

Information governance restrictions

Information governance policies were highlighted as restricting the use of a more appropriate platform for online delivery. For example, a weight management provider reported that they could not download Zoom onto a local authority laptop and had to purchase a new laptop to enable them to deliver a weight management programme. Permission to use Microsoft Teams took several months to secure and therefore further delayed delivery. In contrast though, Tayside interviewees described how COVID-19 had meant that the use of Oviva was approved at "unheard of" speeds.

Staff interviewees recognised the unprecedented demands faced by local information governance teams during the pandemic and, reflecting this, there was consensus that a national solution should be put in place to enable the continuation of group education online.

Consideration: better understanding of information governance requirements and a possible national approachThe logistics of remote delivery

Logistical challenges were also created; firstly, the presentation content had to be amended to ensure its suitability to online delivery and more limited group interaction. In one of the early adopter areas, a WMP described how it took several months to adapt and then pilot the new presentation content to ensure its suitability.

Staff also had to identify a means of providing patients with the equipment needed to support remote delivery. For example, patients taking part in Counterweight Plus had to be closely monitored throughout the programme but instead of doing this via face-to-face appointments, scales, blood pressure monitors and blood glucose monitors were sent to patients' homes. This was perceived to have the unexpected benefit of enabling patients to self-manage from the outset of the programme.

Patient engagement

There were mixed views on how the shift to online delivery affected patients. It was recognised as a barrier for those with low levels of digital skills; reported action to address this included walking patients through the log in process. In contrast, for those patients with work commitments or who lived in a more rural area, the removal of the need to travel to an appointment or session was thought to have enabled participation, as a respondent described:

"A very positive impact with patients being allowed to attend appointments virtually in work's time without the need to travel to an appointment." Health and social care staff, Tayside

Online delivery was also perceived by staff interviewees to benefit those patients who may be uncomfortable in a group setting, a view which was echoed by a few patients:

"If there was no COVID, I would have been invited to go to Kilmarnock for weight sessions. I don't know if would have, I'm actually happy with what's happened… I don't know if I'd have been keen to have gone on a group. I'd suggest that they maintain this way for people like me who are happy to do it this way rather than a group." Patient, Ayrshire & Arran

However, different views were expressed by staff on how remote delivery could support those patients with more complex needs:

"Weight is such an emotive topic, it's easier to do it when they're in a safe and confidential environment and knowing that they are supported when they leave. You don't know what's going on when people are at home." Health and social care staff, East Region

In contrast, another interviewee from the same NHS board felt that remote support may be appropriate for patients with body image issues:

"Working on the phone really suits people, particularly if they are very concerned and have unhelpful thoughts about what they might look like. Done some intense work that's been made possible on the phone. It's about offering different ways of working with people that meets where they are." Health and social care staff, East Region

This highlights how experiences of delivering during COVID-19 have reinforced the importance of a person-centred approach and that there was no 'one-size-fits' all approach.

Reduced footfall in GP practices

In addition to the challenges early adopter areas faced in engaging patients via online platforms, the reduction in footfall in GP practices throughout the pandemic meant that opportunities to identify those at risk were reduced.

Wider use of IT

In each early adopter area, adjustments to programme delivery and a move to online support enabled patients to access services during the pandemic. Those changes have been described throughout this chapter and include examples like the new app in Ayrshire & Arran. Although planned pre-COVID, it was perceived by staff to have been particularly valuable to enhance wider weight management activity. Various teams could manage their own tile in the app, and the family activity challenges set by the children's team was highlighted as being particularly successful. The digital Oviva programmes in Tayside, again planned before the pandemic, became a workable solution to continue delivery. Even existing platforms like YouTube were used to deliver some content in East Region and Tayside.