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

6. Conclusion and considerations

The implementation of the Framework in the early adopter areas has led to the development and expansion of existing services, as well as the introduction of specific new weight management pathways for those at risk of or those diagnosed with type 2 diabetes.

In these areas they have identified gaps in provision or where further service development was needed and:

• brought clarity to shared priorities
• built strategic and operational partnerships to enable service re-design
• identified and tried to tackle barriers to change.

Whilst the Scottish Access Collaborative^[10] was not referenced by any interviewees, elements of the key principles had taken place, or were planned such as referrals via a system wide agreed pathway or a clear understanding of demand and capacity that should form the basis of redesigned services. In all three areas this focus and investment has resulted in some services continuing and expanding and new evidence-based programmes being piloted and then introduced on a wider scale.

The implementation of the Framework has brought consistency to previously fragmented approaches to delivery in or across an area. The pandemic clearly affected the momentum of implementation. It brought both obstacles and opportunities, halting or postponing some programmes but also forcing digital innovation to enable remote delivery or accelerated rolling out of online versions of programmes.

Early adopter areas have adapted and updated their plans to ensure that delivery continued amidst the ongoing challenges of COVID-19. The flexibilty of the Framework meant that some areas have used the learning from creating a digital offering to maintain a hybrid service and broadened their output and audience.

6.1 Considerations

The learning from the implementation of the Framework within the early adopter areas provides 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. Some of this learning is reflected in the enablers and barriers discussed in Chapter 5 but the key areas that would improve implementation or increase consistency across services related to:

More options for evidence-based programmes

The 2019 weight management standards and gap analysis tool were viewed as helpful but there were requests for a wider range of evidence-based programme options to meet the needs of individuals for managing type 2 diabetes. 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 to inform which programmes to implement.

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 and continuity.

Partnership working

The early adopter areas had clear guidance as to the steps needed to develop an integrated system, but completing these steps needs to be robust with 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. Sufficient time and resources need to be allocated to enable this process.

Systems

The early adopter 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. There was also a call for a national solution to the information governance challenges.

Building relationships with primary care

Primary and secondary care services must work together to ensure that support is available to people at a time when they are ready and able to engage. For these partnerships to develop, there needs to be realistic time and opportunities to build relationships, a common understanding of the new policy or practice and the resources to plan and implement the required changes. The key role of GPs and practice staff in the redesigned services highlighted the need to engage primary care and ensure understanding and buy-in to the new pathway and their role within it, to ensure the services run smoothly and effectively.

6.2 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 and the tension between local and regional approaches that reflect the context and population needs and a national approach that supports consistency was evident but 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.