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

5. Barriers and enablers to effective implementation

5.1 Introduction

Early adopter areas had the freedom to implement the Framework in ways that best met the needs and existing infrastructure of their areas. Whilst this produced contrasting approaches or differing programmes, there was commonality of enablers and barriers across all the regions. These are summarised in this section.

5.2 Enablers and barriers

The key factors are summarised in the diagram and discussed in more detail.

Figure 5.1 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 online programmes and platforms to enhance service delivery, especially once the pandemic hit. Examples included:

• a weight management app developed in Ayrshire & Arran, with individual content being owned and updated by different groups including Early Years, Dietetics and Bariatrics
• use of NHS Near Me video conferencing to deliver 1:1 sessions during the COVID-19 pandemic
• use of the interactive digital Oviva programmes in Tayside
• introduction of Microsoft Teams as a platform for group sessions
• posting videos on YouTube to explain how equipment worked
• using IT platforms like BadgerNet, enabled notifications and information to be sent to women with a recent history of GDM
• Zoom was chosen by one East Region weight management provider to deliver Get Moving with Counterweight
• use of geocoding data about patients on the programme to identify the best location to hold the clinics in East Region.

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.

The reliance on technology did create barriers for those patients and staff for whom some IT was unfamiliar and for others who were digitally excluded because of a lack of internet connectivity or appropriate devices.

Information governance

Information governance was a barrier. As noted in Chapter 3, the process for obtaining approval for the use of the Oviva platform in Tayside was completed promptly. In contrast there were delays in the other areas in receiving approval to use Microsoft Teams for group sessions. In East Region, it took over a year for the Information Governance team to approve a process for delivering resources directly to patients. During that period staff members had to load up their own cars and drive around their NHS board area, delivering the equipment.

Another aspect was data reporting requirements related to the Framework. This meant that new information sharing agreements were needed between weight management providers and the NHS board. Some interviewees reported that establishing these agreements took far longer than expected. In Tayside the introduction of some of the programmes like Second Nature and Slimming World were delayed whilst this was resolved. There was also a practical challenge about data transfer, with one provider explaining that they had to print out the data and physically hand it over in order to work within the restrictions.

Resources

There were a number of resources that supported the early adopter areas to implement the Framework; funding, documentation and the professional advisors.

Funding provided by the Scottish Government enabled service delivery, providing resources for local teams to recruit new staff members and deliver new services.

For example, in Ayrshire & Arran, funding was used to pay for five psychology sessions a week and the involvement of psychology was described by staff as an important shift towards multi-disciplinary weight management. However, the allocation of funding on a year-on-year basis was identified as a challenge because it meant that staff were appointed on short term contracts, creating recruitment, retention issues and higher training costs. More broadly though, it restricted longer term planning:

"As with many of these things, a lot of the times we're dealing with finite pockets of resource for limited period of time which makes meaningful change different. I guess Scottish Government have to do it that way, but it's frustrating not to have mainstream funding for these interventions." Project staff, Tayside

In terms of other support available to early adopter areas, there was a suite of resources designed to support implementation of the Framework. These included Public Health Scotland's 'Standards for the Delivery of Tier 2 and Tier 3 Weight Management Services in Scotland'. Some staff in project teams found this document helpful in planning and designing services and in ensuring consistency across areas both regionally and nationally and others felt that the document gave a "credibility and value" to the work they were carrying out.

Interviewees also identified close links with professional advisors at the Scottish Government as important enablers providing practical support like help in designing services and a dedicated source of advice. Representatives of the early adopter areas also met regularly with the advisors, particularly in the earlier stages of the Framework's implementation, and this provided an opportunity to work to solve some of the "teething problems" and share their learning and experiences.

Consideration: a longer financial commitment would provide security to embed changes and maintain staffing levels

Personnel

Several interviewees identified key personnel involved in the Framework's implementation as playing a pivotal role in either service development or motivation and encouragement of the team and colleagues. For example, the Midwifery Lead for Diabetes in Ayrshire & Arran had created a midwife-led service for women with GDM prior to the Framework's implementation, which was a strong foundation upon which to expand the programme.

In the East region, several interviewees identified the programme lead as instrumental in driving change and facilitating agreement on a common approach:

"There was an excitement here, I think that came from people who led it. It was the way that [the lead] commanded that room when there were some massive egos… Success because of some initial leadership. It blew me away. It was a sense of, we've got this money, we can do something different." Project team, East Region

However, while the importance of individual staff was identified, several interviewees across all areas noted challenges in staff turnover. This was caused, at least in part by redeployments during COVID-19, but also when posts were for a fixed term. Staff sometimes then moved into permanent posts or into teams that were part of a core structure rather than a partnership model.

The staff capacity to deliver elements of the programme either at a management or service delivery level as a result of staff turnover or vacancies was acknolwedged by interviewees across all areas. This was then exacerbated with the high demand for diabetes support services, sometimes as a result of the more effcient referral pathways leading to more referrals plus COVID-19 delays that contributed to the backlog.

Interviewees described how the implementation was planned to try to manage the balance between the promotion of the programmes and the capacity to deliver. The at risk pathway in Ayrshire & Arran, for example, was meeting patient needs at the time of data collection but the programmes had not been actively promoted since remobilisation because of the concerns about meeting any increased demand. Furthermore, one of the three Diabetes Prevention dietitians was leaving their post and this gap, alongside an increasing number of patients reaching their three and six month follow up appointments, meant that the service was now perceived to have reached a "tipping point".

An interviewee in East Region described a similar challenge:

"It's a balancing act about singing it from the roof tops and getting everyone referred. It's working at the moment; word is getting out and there's a steady stream and we can manage that. If there's a mass influx, there would be a waiting list for assessments and for them to start on the programme. At the moment, the balance seems to be working." Health and social care staff, East Region

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 spanning primary and secondary care. The programme teams worked closely with colleagues in primary and secondary care, not only to increase awareness of the Framework and its implementation, but also in the co-production and re-design of services.

Navigating these relationships and strengthening partnership working could be a challenge. There were comments from health care staff about the hierarchical structure within the NHS and 'gatekeepers' of information that needed to be on board with the redesign of pathways and services. These interviewees were realistic about how long it would take for changes to embed, for relationships to develop and logistical difficulties to be overcome.

Some of these challenges were amplified in the East Region by the fact that it covered three NHS boards, six IJBs and six local authorities meaning there were several working cultures to understand and three different approaches to weight management to consider and enhance or redesign. Each NHS board had a governance group with varying levels of engagement. Even with the profile of the Framework and regular partnership working with the MCNs and diabetes groups to develop the new pathway, the relationships and activities in each NHS board required a concerted effort to sustain them. In practice, this meant that programmes came on stream at different times across the East Region reflecting the different stages of local action and ability to move things forward.

Although partnership working could be challenging, the implementation of the Framework was described by staff interviewees as having created opportunities to build and strengthen their working relationships. This was thought, by some, to have improved the quality of services:

"It has provided the opportunity for us all to get together (albeit more recently on teams only) to develop pathways to link our services. This can only be a positive for our service users to have good communication and links being developed across different healthcare areas." Health and social care staff, Ayrshire & Arran

This partnership working was also important for the three health boards involved in the East Region. They worked closely together, and the frequency of communication enabled sharing of learning and experiences. An interviewee in NHS Fife explained that they had met with colleagues from NHS Lothian who provided peer support throughout the establishment and initial delivery of the Counterweight Plus. Another health and social care interviewee described how psychologists in the East Region worked together to identify how best to use psychology input into the programme.

More specific examples on the changes to partnership working included:

• new opportunities for increased interaction with dietitians and therefore a more joined up approach:

"It feels more robust than previously, I think it's the relationships with dietitians now, previously we had dietitians who devised the programme and would help with bits and pieces. Now we have links to diabetes prevention dietitians, we're singing from the same hymn sheet. It feels more robust, it does feel different. It's got more value now." Weight management provider, Ayrshire & Arran

• improved working relationships between different disciplines and between MCN and primary care
• supportive relationships established amongst key staff through regular informal contact to share advice and work collaboratively.

Consideration: to support development of an integrated system, allocate sufficient time and resources to enable meaningful co-production and service redesign with the key stakeholders and deliverers to ensure a shared vision and common understanding of the new pathways and service.

Primary Care

The role of primary care professionals emerged as a key determinant of success for effective referral pathways. Within Ayrshire and Arran, for example, GP practices maintained a register of people at risk of diabetes. Again in Ayrshire and Arran and also Tayside, the GPs carried out the HbA1c tests for patients and then identified the relevant programme to refer them on to:

"we depended on GPs to help with obtaining biochemistries which would normally be carried out in the hospital setting." Health and social care staff, Ayrshire & Arran

As part of implementation of the Framework it was therefore important to build the relationships with primary care. Interviewees from the early adopter areas described the various methods used to do this, which included regular communication via bulletins, emails and meetings to explain the redesign of service and the role that GPs played in the referral process. In the East Region, dedicated Primary Care Leads helped to develop relationships and provide relevant support, this included updating the NHS Lothian Ref help tool used by GPs and other clinicians to refer patients.

The important role that primary care staff play in facilitating access to the new weight management programmes has been highlighted. As described within the Framework (p34), discussing weight sensitively with patients in a way that motivates them can be challenging. Reflecting this, interviewees also made the point that more could be done to improve the confidence and the skills to undertake weight management conversations:

"I think we should get better at having conversations with people who are at risk. There's a sense that GPs don't like to tell people they're overweight. We need to get better at that as a society." Health and social care staff, East Region

Although improved relationships were reported, several interviewees recognised the need to continue to communicate with GPs in individual practices and clusters to:

• clarify referral pathways (some GPs felt that the referral pathway on SCI Diabetes was not easy to find)
• provide feedback on patients referred
• help maintain the profile of type 2 diabetes programmes.

A few interviewees involved in the work with GP practices felt that additional levers were needed to encourage them and, as the GP contract directed their work, an SLA with GP clusters would help to drive forward the changes associated with the Framework's delivery.

There was some recognition amongst health and social care staff interviewees about the time it took to build these relationships and for changes to become embedded. Indeed, there were examples of how a lack of capacity for change within one part of the integrated system could delay delivery: in one area, Counterweight Plus was on hold and in another Let's Prevent Diabetes, both because GP practices were not able to support them, reinforcing the important role of primary care and the need for good working relationship for the success of the redesigned service.

Consideration: ensure sufficient time and opportunity to develop the relationship with primary care as vital in implementing and promoting the new referral pathways