QiCD CaseStudies 16-smaller€¦ · Diabetes Research & Wellness Foundation Untitled-1 1 24/02/2015...

This programme has been made possible with sponsorship from Sanofi. Sanofi has had no editorial control over any of its contents.

2016

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Diabetes Research &Wellness Foundation

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case studies

www.qualityincare.org/diabetes 2

Introduction 3

Sponsor: Sanofi Diabetes 4

Supporters 5

Chair of Judges and Judges 6

Prevention and Early Diagnosis 7

Prevention and Early Diagnosis for Secondary Complications in Diabetes 13

Digital and Technology Solutions in the Treatment and Management of Diabetes 17

Diabetes Collaboration Initiative of the Year 33

Patient Care Pathway – Children, Young People and Emerging Adults 41

Patient Care Pathway – Adults 47

Involving the Diabetes Service User and Families/Carers 53

Empowering People with Diabetes – Children, Young People and Emerging Adults 57

Empowering People with Diabetes – Adults 61

Diabetes Team Initiative of the Year 71

Contents


IntroductionWelcome,

Prevention, diagnosis and treatment of diabetes in the UK have never been more important and the 60% increase in the condition’s incidence over the last decade serves as a stark reminder of the need for good care.

Meanwhile, as financial constraints continue to impact on an already overstretched health service, there has never been a better time to recognise and share good practice that improves patient outcomes and drives efficiency.

Launched in 2011, Quality in Care (QiC) Diabetes exists to recognise, reward and share innovative and outstanding clinical practice across the UK and highlight the vital contribution made by local teams and individuals.

The award winning case studies are listed under the relevant categories:- Prevention and Early Diagnosis- Prevention and Early Diagnosis for Secondary Complications in Diabetes - Digital and Technology Solutions in the Treatment and Management of Diabetes - Diabetes Collaboration Initiative of the Year - Patient Care Pathway – Children, Young People and Emerging Adults - Patient Care Pathway – Adults - Involving the Diabetes Service User and Families/Carers - Empowering People with Diabetes – Children, Young People and Emerging Adults - Empowering People with Diabetes – Adults - Diabetes Team Initiative of the Year

Further information about the programme, its judging process and how to enter can be found at: www.qualityincare.org


Sponsor: Sanofi Diabetes

Going beyond the expected in diabetes

Sanofi is delighted to introduce these case studies of the excellent winners, highly commended, commended and finalists from the Quality in Care (QiC) Diabetes 2016 programme.

At this time, it is more important than ever before to be able to share innovative practice, and to learn from what other healthcare teams are doing around the UK.

Sanofi Diabetes is proud have been supporting the QiC Diabetes programme since 2011 and will continue to work hard with those dedicated to developing diabetes care.

These examples of innovative practice, ingenuity and patient focused projects can help support improved patient experience and outcomes in your community, surgery, hospital, health economy, charity, patient organisation and other healthcare settings.

We hope you will find them useful for your clinical practice.

“As the Diabetes Marketing Director of Sanofi Diabetes, I am delighted to welcome back QiC Diabetes to Sanofi for a sixth year. Sharing best practice has never been more important across the NHS and we are honoured to facilitate the sharing of the ideas put forward by you and your colleagues. It is important also, to commend and recognise the achievements

of those people who work in the NHS and whose passion to make these projects happen are the driving force behind delivering inspirational change.”

Karen Stoddart, Diabetes Marketing Director, Sanofi UK & Ireland

“As the new General Manager of Sanofi Diabetes and Cardiovascular I am very pleased to welcome you all to the UK headquarters of Sanofi. We are delighted to be supporting the QiC Awards again this year – an initiative we believe is a great way of highlighting and sharing some of the fantastic projects you and your colleagues have developed to benefit

people with diabetes. It is a great opportunity to recognise your hard work and achievements and we hope you have a successful and enjoyable evening.”

Dr Tunde Falode, General Manager, Diabetes & Cardiovascular, Sanofi UK & Ireland


Supporters


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Chair of Judges and Judges

Chair of Judges Simon O’Neill, Diabetes UK

Dr Paru King, Consultant Physician, Derby Hospitals

Dr Sheridan Waldron, Education Lead for Children and Young People with Diabetes, Children and Young People’s National Diabetes Network

Nour Ajjan, Band 6 Rotational Pharmacist, Sheffield Teaching Hospital

Dr Marc Atkin, Consultant Diabetes & Endocrinology, Royal United Hospital Bath NHS Trust

Andy Broomhead, Blogger, Member of the Council of People Living with Diabetes

Thomas Butler, Healthcare Projects - Professional Relations, Sanofi

Dr Mark Chamley, Partner, Crown Dale Medical Centre

Anne Claydon, Nurse Consultant, Barts Health

Debbie Cook, Vice Chair, National Obesity Forum Nurse Practitioner, Diabetes and Obesity

Anne Cooper, Director of Clinical Safety and Chief Nurse, Health and Social Care Information Centre

Dr Kate Fayers FRCP, Consultant Diabetologist, West Hampshire Community Diabetes

Service, Southern Health NHS Foundation TrustDr Paul Grant,

Editor-in-Chief, British Journal of DiabetesDr Roselle Herring,

Consultant Diabetologist and EndocrinologistSallianne Kavanagh,

Lead Pharmacist - Diabetes and Endocrinology, Sheffield Teaching HospitalsShantell Naidu,

Diabetes Nurse Consultant, Central and North West NHS Foundation TrustPhilip Newland-Jones,

Advanced Specialist Pharmacist Practitioner, University Hospital Southampton NHS Foundation TrustDr Muna Nwokolo,

Clinical Research Fellow and Chair of YDEF, King’s College HospitalDr Mayank Patel,

Consultant Physician in Diabetes and Acute Medicine, University HospitalRebecca Reeve,

Head of Professional Relations, SanofiMichelle Stafford,

Podiatrist - Diabetes Lead, CSH SurreyTarja Stenvall,

General Manager, UK & Ireland, SanofiBob Swindell,

BloggerKev Winchcombe,

Blogger


Prevention and Early Diagnosis

Type 2 Diabetes: Know Your Riskby Diabetes UK

With 11.9 million people at increased risk of type 2 diabetes in the UK, and awareness of type 2 diabetes still low across the population, it is vital more people understand their risk – particularly those in the highest risk categories due to their age or background.

To help up to 1 million people find out their risk of type 2 diabetes. To increase awareness of the risk factors, especially among the highest risk groups. To encourage those at risk to visit their GP and make changes to their diet or levels of physical activity.

In 2015, Diabetes UK identified three development areas to increase the reach and impact of the campaign: development of the Know Your Risk online tool, creation of a new roadshow app, and improvements to ‘journey’. Clearer information was provided on the landing page, including what is needed to complete the questions and who should use the tool, and content was personalised on the results page, to highlight modifiable and non-modifiable risk factors, and with information tailored to the person’s risk category to encourage them to take action. Navigation was simplified. A standalone app to be used at the roadshow was developed, replicating the online Know Your Risk tool, with additional functionality to print an individual’s results and a letter for their GP if they are referred for further tests. This additional print out is an important prompt to encourage action. The app was designed to sync data immediately with the organisation’s email broadcast system, meaning we could send a follow up email to roadshow visitors within 24 hours, again to prompt action. Using feedback from previous campaign activity, as well as additional user insight, the team developed new resources that were easy to understand and evidence-based, including emails with follow up information, signposting and support and an A Z-card with top tips for healthy eating and getting active.

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Know Your Risk is Diabetes UK’s national multi channel campaign to raise awareness of type 2 diabetes and its risk factors. At its centre is the Know Your Risk questionnaire, a validated risk assessment tool developed in partnership with the University of Leicester and University of Leicester NHS Trust. The Know Your Risk campaign encourages people to use the tool to find out their risk of ype 2 diabetes and what to do next – reaching thousands of people every year who go on to receive support to reduce their risk. The approach combines targeted community outreach activity via a roadshow, alongside digital and printed resources to help people understand more about their risk and what they can do to reduce it. Those in the highest risk communities are encouraged to take steps on their diet, levels of physical activity and to visit their GP.


Type 2 Diabetes: Know Your Riskby Diabetes UK

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The app has had additional benefits, including reducing data protection risk and reducing the staff resource needed for processing data by two days per month. The new design and content developed for our follow up email journeys for people at risk led to increased engagement from users, with click through rates increasing from 3.5% to 8.2%.

In 2015 the evaluation was carried out by ICM, an external agency, with a sample of 1,000 people who visited a roadshow between July and October 2015. People were asked a series of questions over the phone which covered topics such as their knowledge of diabetes, their experience of the roadshow event, follow up communications and GP visit, if applicable. They were also asked about the changes that they have made since attending.

rESultSAverage number of users per month completing the online tool increased by 10% following the changes and users spent 73% more time on the page. Following a Facebook ad campaign in late 2015, there were 99,364 completions of the tool in the first four months of 2016, a 28% increase on the same four months in 2015 (77,748). Use of the app at roadshow events has enabled more people to have a consultation and find out their risk by making the process more efficient. The 15,000+ visitors to the roadshow in 2015 all commenced their follow up journey within days of their consultation, compared to an average of four weeks before the development work. There was a 13% increase in the information take home from roadshow events. In total, around 280,000 people were helped find out their risk - of these, 44% were in a high or moderate risk category and were referred to their GP. 73% of those referred to their GP from a roadshow visited for follow up tests, enabling them to access support on their risk (and in some cases receiving a diagnosis of type 2 diabetes). 53% of roadshow visitors reported a change to their diet and/or levels of activity. These figures increased by 4-6% if they recalled the follow up communications, highlighting the impact of our content and messaging in encouraging people to take action. Awareness of risk factors has increased compared to 2014.

This is a really well-designed campaign, with clear and deliverable objectives. The numbers of people this project has touched is impressive and the implementation and results are first class. The tool is easy to use and has often been delivered in deprived communities where over half of those involved have taken it up.



Preventing diabetes by turning research into practiceBy Leicester Diabetes Centre

The Impact Diabetes report in 2012 projected that the NHS’s annual spending on diabetes in the UK will increase from £9.8bn to £16.9bn over the next 25 years. The cost of treating diabetes complications was also predicted to almost double from the current total of £7.7bn to £13.5bn by 2035/6. Type 2 diabetes is mainly linked to lifestyle and largely avoidable, yet the number of people with the condition is spiralling, with national figures predicted to rise from 2.5 million to more than four million by 2025. There is a lack of evidence investigating how to effectively translate prevention research into a UK primary care setting.

To establish whether the use of a structured lifestyle modification programme (based on the DESMOND programme) prevents those with pre-diabetes going on to develop type 2 diabetes. To provide an appropriate structured education programme to target lifestyle modification and behaviour change and a culturally sensitive structured education for the Black Minority and Ethnic (BME) community.

A screening programme was run on 44 different GP practice databases to identify those 40-75 of European origin or aged 25-75 of South Asian origin or those who have previous Impaired Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT). Those most at risk received a letter from their GP inviting them to attend a screening session to see if they have pre-diabetes. Each practice was randomised to either the educational intervention (structured lifestyle modification programme) or control arm of the study and patients from the practice received treatment accordingly. The first group of patients was invited to attend an educational session of either one six-hour or two three-hour sessions initially, followed by an optional yearly refresher session. Those in the control arm received standard patient care and information. The educational sessions were held in small groups and, where necessary, an interpreter was available. All participants within the study received annual health checks for three years and the information was passed on to their GP for their records.

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The Leicester Diabetes Centre (LDC) was selected as a provider, together with public sector contract specialist Ingeus, for NHS England’s Healthier You: NHS Diabetes Prevention Programme which will eventually be rolled out across the entire country. The centre’s group education programme Let’s Prevent is set to become the one of the first interventions in the UK that demonstrates that a structured educational programme reduces the number of people at high risk of type 2 diabetes. It was originally piloted across two Leicestershire towns where 3,000 people at high risk of type 2 diabetes received tailored, personalised help, including education on healthy eating and lifestyle, losing weight and bespoke physical exercise programmes, all of which together have been proven to reduce the risk of developing the disease. LDC was selected to become a provider, together with public sector contract specialist Ingeus, for NHS England’s Healthier You: NHS Diabetes Prevention Programme. The programme was based on DESMOND, the first national structured education programme for type 2 diabetes to meet NICE criteria.



Preventing diabetes by turning research into practiceBy Leicester Diabetes Centre

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Researchers compared the study with other programmes that have been rolled out across the rest of the world and concluded: “While we know programmes have worked in other countries such as the US and Finland – they have been very costly and in the USA they have really struggled to implement the programme with only, with very small numbers of at risk people attending. Let’s Prevent provides a cost-effective model of diabetes prevention that can be directly implemented and commissioned within a community setting.” Many patients said they had adapted long-term changes to their lifestyles which were having positive effects on their health and their diet, which in many cases will be enough to delay the diagnosis or completely prevent type 2 diabetes from developing. Once the programme is rolled out nationally the findings will be reported as part of the NHS Prevention Programme which will be accountable for national figures and will be subject to vigorous audit reports.

The research was published in the Journal of Public Health which reported on the progress on the development of the Let’s Prevent programme. An abstract of the study ‘A Community Based Primary Prevention Programme for Type 2 Diabetes in the UK: A Cluster Randomised Controlled Trial’ was also featured at the World Diabetes Congress in Vancouver last year.

rESultSThe uptake was hugely popular as a total of 880 people from 44 GP surgeries took part. People who attended the main session and one other reduced their risk of the condition by 60% and these who attended all of the programme were 80% less likely to develop type 2 diabetes. Research has shown Let’s Prevent has the potential to reduce the chances of one in four people at risk of type 2 diabetes from getting the condition.

This was well-structured, cost-effective, with strong evidence of outcomes and the patient feedback is great.



Lambeth is an inner-city borough with a population of 310,000 and is one of the most deprived boroughs in London. The demographics are diverse, with large numbers of people of African-Caribbean and Portuguese heritage and more than 100 languages spoken. Based on GP registers, 15,200 people with diabetes live in Lambeth. Although the population is younger, on average, than most of the UK population, a high prevalence of diabetes is related to high levels of obesity and also the substantial BME population. There are 48 GP surgeries in Lambeth and specialist diabetes services are provided in community settings by the Lambeth Diabetes Intermediate Care Team, which includes consultants, GP specialists, diabetes specialist nurses and dieticians.

To offer a short, education course to people in Lambeth found to be at high risk of developing type 2 diabetes. To reduce the number of high risk people in Lambeth who go on to develop the condition.

In 2011 it was decided to promote the use of HbA1c to diagnose type 2 diabetes in Lambeth. It was recognised that there would be people found to have an HbA1c between 43 – 47 mmol/mol who were therefore at high-risk of developing type 2 diabetes. It seemed important to be able to offer these people an opportunity to attend a course to provide information about diabetes and how to prevent it. This led to the development of the “STEPS to prevent diabetes” course, jointly designed by a DSN and Specialist Diabetes Dietician who were experienced in providing structured education and self-management programmes to people living with diabetes. The current evidence relating to diabetes prevention programmes and the content of existing programmes were reviewed. This suggested our approach should consist of a combination of information about diabetes, healthy food choices, increased physical activity and how to sustain lifestyle changes. To promote increased physical activity, we decided to provide each person attending a course with a pedometer. During the planning stage, inclusion and exclusion criteria were agreed and designed to be very simple. GP referrals were accepted for people with an HbA1c 43- 47mmols with no restriction to BMI or age. If people did not speak English they could be accompanied by an appropriate adult who could translate for them.

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Lambeth Diabetes Intermediate Care Team developed a short prevention course called STEPS – focused on increased activity through walking and aimed at local people who are at high risk of developing type 2 diabetes. STEPS was planned and implemented by a Diabetes Specialist Nurse and Dietician who are skilled and passionate about the delivery of accessible structured education for people living with diabetes. The programme is funded by Lambeth CCG. The course has proved very popular with GP referrals increasing year-on-year and almost 900 people have attended in the past three years. No significant changes in HbA1c, total serum cholesterol, blood pressure, weight and body mass index were found after the course and there was no progression to type 2 diabetes for most participants.

STEPS to prevent diabetes: a diabetes prevention course in Lambeth, South East Londonby Lambeth Diabetes Intermediate Care



The programme curriculum was designed and written with specific aims and learning outcomes equally weighted to the following components:

1. Information on diabetes, risk factors and prevention.2. Information regarding Healthy Food Choices

and achieving a balanced diet.3. Value of physical activity, primarily walking supported by a pedometer.4. Personal Goal Setting.

Each STEPS course was designed to last for three hours, accommodating 15 participants, with one trained health professional to facilitate each group (either a DSN or specialist dietician). It was regarded as essential that facilitators were experienced in self and peer reflective practice. All attendees at STEPS were offered a support telephone call two weeks after the course.

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The STEPS course has proved to be very popular – although not all people referred respond to an invitation to attend. An audit aimed to assess whether STEPS attendance was associated with improvement in diabetes-relevant clinical variables between baseline at referral and post-STEPS follow-up. A service evaluation aimed to elicit participants’ views of the programme. Participants exhibited high levels of satisfaction in terms of content, presentation, venue, and likelihood of making behavioural change. The majority of participants highlighted the general positive experience and/or clarification of dietary, lifestyle, and diabetes-related information as the most valuable element of the course.

In 2016 a clinical audit and service evaluation for STEPS were undertaken. Data from participants attending five STEPS courses in 2014 were selected for analysis. Data from 106 participants was reported.

rESultSFor the period March 2013 – March 2016 3,152 people were referred to STEPS and 897 attended a course. Baseline and follow-up data (at least 3 months after the course) for the following clinical variables were obtained from participants’ GP practices: HbA1c, total serum cholesterol, blood pressure, weight and body mass index. No significant changes were found for the clinical variables. 20% of people were found to have progressed to type 2 diabetes. The lack of significant change in clinical variables is encouraging as there was no progression to type 2 diabetes for most participants.

A great and well-designed project that fits in well with the national agenda. The project clearly recognises its limitations, but also identifies the potential impact.

STEPS to prevent diabetes: a diabetes prevention course in Lambeth, South East Londonby Lambeth Diabetes Intermediate Care



Peer review of diabetes foot services in the South Westby South West Cardiovascular Clinical Network

The population of South West (SW) England is of more than 90% white British ethnicity with good longevity and a legacy effect of retirement to much of the area. These characteristics are associated with high prevalence and incidence of diabetic neuropathy and its consequences. Currently 6% of the population in the SW are living with diabetes which amounts to 169,444 persons and the numbers are increasing due to obesity and an ageing population. 768 amputations took place in the SW as a result of diabetic complications over the last year with amputation twice as likely for patients in the region as in London - it is estimated 80% of amputations are potentially avoidable. The commissioning of the care pathway is fragmented.

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Reduction of lower limb amputations as a result of diabetes has been a main priority of the South West (SW) Cardiovascular (CV) Strategic Clinical Network (SCN). National statistics have highlighted high lower extremity amputation rates in diabetes (LEAD) in South West England. Improvements in care processes in other parts of England with similar ethnicity and rurality have resulted in sustained reduction in the LEAD. A standardised Peer Review of foot care services for diabetes patients across all 14 acute trusts and 11 Clinical Commissioning Groups (CCGs) within the South West SWSCN has evolved over four years. Its aim was to understand the variation in practice, establish compliance with NICE standards, identify and share good practice and make recommendations for change and improvement. Provisional data shows a significant reduction in the number of major amputations across the South West in 2015.

To reduce major and minor lower extremity amputation rates in the SWSCN footprint to below the average of demographically similar areas in England by 2018. To deliver a peer review programme involving local clinicians expert in their field to review the care pathway for diabetic patients at risk of a foot amputation across all CCGs.

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Definitive peer review visits were undertaken during an eight month period from October 2014 to April 2015 to each district general hospital in the region. The review team comprised a consultant diabetologist, a NHS Diabetes representative, and two podiatrists. Reviews centred on the Multi-Disciplinary Team (MDT) hospital clinic and a report was developed with local providers to endorse good practice and to support plans for service improvement. A formal review process included the following: a governance process to define terms of reference; preliminary information from the CCG and Trust detailing the provision of key services and variation in amputation rates; and a set timetable with one hour initial discussion with all reviewers and providers.

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rESultS122 sets of notes were audited concerning patients with diabetes-related foot problems in the preceding 12 months. Summary data sheets with description of problem, neuropathy, vascular status and co-morbidity were found in 20 sets of notes. Electronic access to community podiatry notes by the MDT, and vice versa was only achieved in a minority of centres. There were excellent examples across the region of good GP practice annual

Prevention and Early Diagnosis For Secondary Complications in Diabetes


Peer review of diabetes foot services in the South Westby South West Cardiovascular Clinical Network

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The Foot Peer review was a useful mechanism to engage clinicians and commissioners to identify issues within their own locality and to unite in addressing these problems. It was also an excellent vehicle to identify, share and promote best practice. There was good co-operation and engagement from both CCGs and providers of services and in total 120 clinicians took part.

Evaluation of the first round of peer reviews identified the need for a more systematic approach the process. By utilising a small team for all the visits, the first review team had been consistent but by involving a wider group of clinical experts in the second round it helped to encourage a wider review of the total pathway. The reviews benefited from strong clinical leadership by a consultant diabetologist but it would have been beneficial to have had greater involvement from GPs as part of the review teams. Practice nurses gave invaluable insights to the primary care part of the care pathway which is key in ensuring timely access to the right care.

This demonstrated a good investment in staffing and it was excellent to see patient involvement via in depth interviews to give the patient perspective. There have been amazing changes in services since the audit, which has resulted in reduced amputations. Peer review of service is something to actively encourage.

review protocols and patient education - but these were not practised throughout the region, nor co-ordinated within many CCG areas. Commissioning processes had not addressed details of staffing levels or skill mix in community podiatry services. Hospital podiatry was often at full stretch with much time spent on non-clinical tasks. Some Trusts were not compliant with NICE guidance to provide a full MDT weekly. Job plans did not include diabetic foot MDT work in many cases. Information sharing is only slowly being developed. Following the peer reviews many CCGs have established working groups for diabetes to deliver the action plans:

• 10areashavestartedtoplaneducationforprimarycarestaff• 8haveincreasedpodiatrystaffing• 6haveconsolidatedorstartedMDTs• 6rotatepodiatristsbetweencommunityandMDT• 5havejobplanningforMDTteam• 8haverationalisedinformationtrails.

Provisional data for 2015 shows 178 major amputations coded across the South West compared to an average of 251 in the preceding three years suggesting that the peer reviews have had a significant impact.



Cardiovascular disease is the major cause of death in diabetes patients, accounting for 52% of deaths. Abnormality of glucose metabolism is widely prevalent in acute coronary syndrome (ACS) patients. Hyperglycaemia on admission in ACS patients has been considered an acute stress response, and is associated with a less favourable outcome in patients with/without known diabetes. Even in the absence of manifest diabetes, long-term glucometabolic dysregulation increases the risk of mortality of ACS patients both in hospital and after discharge. A screening strategy using HbA1c as the preferred test would be pragmatic and improve early detection and management of glucose intolerance in acute cardiology practice. However, data for screening new onset diabetes with Hba1c in patients presenting with ACS to hospital has not been routinely validated nor previously shown to be consistently utilised on a practical level. An initial pilot project for screening included fasting blood glucose (FPG) as well as HbA1c measurement. Unfortunately, FPG was being undertaken in less than 50% of post-ACS patients.

To screen high risk patients presenting with acute coronary syndrome (ACS) for diabetes (if not previously diagnosed). To offer early referral to our one-off specialist clinic and EXPERT education course to improve long-term outcome of these patients including raising awareness and reducing further cardiovascular burden.

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Disturbances of glucose metabolism and diabetes are widely prevalent in acute coronary syndrome (ACS) and relate to adverse outcome, irrespective of presence or absence of previously diagnosed diabetes. The City Hospital (SWBHT) team developed a protocol incorporating a random HbA1c diagnostic blood test on day 2/3 post admission for every such admitted patient with ACS. All HbA1c results were sent directly through to Diabetes Department via Think Glucose (TG) electronic system on iCM and patients were subsequently invited for a repeat HbA1c at 2 weeks. As a result of this simple, inexpensive yet innovative tweaking of an electronic system on iCM, the team managed to accurately estimate new onset diabetes (10.7 %, nationally 5-7%) in high-risk post ACS patients, who would otherwise have been missed. Every such patient receives counselling about their new diabetes diagnosis, future cardiovascular risks, management plan for their GP and are enrolled into X-PERT diabetes structured education programme. All this fits in with the new CCG and National drive towards screening and detecting new onset diabetes in high-risk populations.

After a period of consultation with cardiology doctors and nursing staff, the screening procedure was rolled out. All patients admitted to a cardiology unit with an initial diagnosis of ACS (excluding those patients with pre-existing diabetes mellitus) underwent a random HbA1c test on day two or three following admission and were referred to the diabetes team via Think Glucose (TG), an electronic referral system using iCM software. Any patient with Hb variant had fructosamine test (levels). Subsequent management followed a protocol. As per ADA guidelines, HbA1c was repeated after two weeks to confirm diagnosis of diabetes in those with HbA1c >48 and those with 42-47

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Screening for new onset diabetes following Acute Coronary Syndrome – the way forward?by Sandwell & West Birmingham Hospitals NHS Trust



Screening for new onset diabetes following Acute Coronary Syndrome – the way forward?by Sandwell & West Birmingham Hospitals NHS Trust

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The Trust has acquired a significant reputation for the development of a niche, and previously untested, screening service. Multi-disciplinary working and increased referrals to ACS diabetes clinic at an early stage were much appreciated by the cardiology team who jointly manage these patients. Increased detection (double national average) of diabetes in an ethnically mixed cohort will result in earlier education and aggressive management of CV risk factors and hopefully better outcomes.

The project has been presented locally within the Trust in our diabetes/cardiology directorate following formal evaluation and ratification by the Trust Clinical Effectiveness Committee. It was also presented as a poster and as an oral presentation in Diabetes UK March 2016 in Glasgow.

rESultSThis prospective observational screening was conducted at a single-centre (SWBHT) over a one-year period (June 2014 - June 2015). Three hundred and ninety nine patients with a mean age 65±5 years were screened: 268 (67%) male, 290 (73%) Caucasian, 95 (24%) South-Asian and 14 (3%) Afro-Caribbean; with an initial HbA1c test over a one-year period. Results of initial HbA1c were normal in 248 (62.1%) patients. Of those patients with an initial abnormal HbA1c, two patients had HbA1c levels of 99 and 127 and were diagnosed with diabetes off the result of these levels plus the presence of symptoms. Of 142 patients due for repeat HbA1c at two weeks, results of the repeat HbA1c were normal in 23 (16%) patients, intermediate in 57 (39.6%) patients, and diagnostic of diabetes in 36 (25%) patients. There were 28 (19.4%) patients that did not have a repeat test; 5 (3.5%) patients died and 21 (14.8%) patients did not attend for follow up HbA1c. Meanwhile there were 62 patients with intermediate HbA1c that had an OGTT at three months. The end result of the screening process diagnosed pre-diabetes in 57 (14.3%) patients and diabetes in 43 (10.7%) patients.

(intermediate) to rule out stress hyperglycaemia. Patients with intermediate repeat HbA1c were subsequently invited for an oral glucose tolerance test (OGTT) at three months to rule out variability in hyperglycemia and ensure we are not missing out on the intermediate, highrisk patients. Patients were contacted following each investigation, using templated letters which included the result of each test, whether normal or abnormal and the subsequent next stage of investigation/management as required. Every newly diagnosed diabetes patient received counselling about their diagnosis and future cardiovascular risks.

Screening for high risk individuals is important. This is a good project and has been done well, especially picking up people with undiagnosed diabetes, or those with poor glycaemic control. Wider recognition of this simple intervention should be encouraged.



A technology-enabled service to optimise insulin managementby Hygieia Medical

Achieving good glycaemic control in type 2 Diabetes is important to prevent mortality and costly complications. Unfortunately achieving good glycaemic control in people with type 2 Diabetes is a worldwide challenge. Standard UK clinical practice is to start with dietary and lifestyle modification, progressing to antidiabetic drug therapy when glycaemic control is no longer achieved and intensifying drug therapy if the patient remains above target. Yet even when using insulin many patients still fail to achieve glycaemic control targets - many patients are only seen for dosage adjustment every six months.

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The d-Nav Insulin Guidance Service is a technology-enabled managed service providing automated insulin dosage titration for patients using basal, premixed, and basal-bolus insulin regimens with and without carb counting. When implemented in a Trust in Northern Ireland mean Hba1c decreased and patient satisfaction was high. Meanwhile, cost effectiveness analysis demonstrates that d-Nav is cheaper than the current standard of care.

To improve glycaemic control using the technology-enabled d-Nav insulin guidance service for patients with type 2 diabetes using insulin in South Eastern HSC Trust. To show that d-Nav is more cost effective than the current standard of care, making better use of insulin and reducing use of concomitant medications.

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The d-Nav Insulin Guidance Service is a technology-enabled managed service which simplifies insulin management by automatically providing dose-by-dose and weekly insulin titration to help patients achieve their glycaemic control targets. The patient uses d-Nav to receive dose recommendations before each injection based on their blood sugar readings. The technology to analyse the readings is built into the device which automatically titrates insulin dosage and then recommends each insulin dose on the screen. It currently supports patients using four insulin regimens – basal only, premixed, and basal bolus with or without carb counting. The new service was phased in to initially test the hypothesis that it would improve glycaemic control and also to allow the clinical team to grow in experience and confidence with the service. This began with an initial pilot evaluation involving 96 patients, data from which informed a business case supported by the commissioners to extend the service to 270 patients. Further data was collected to enable service roll out to 700 users across the Trust including development of a GP Direct Referral Pathway to embed the service in the community. Patients enrolled on the service were asked to use d-Nav before every insulin injection and any time they suspected the occurrence of hypoglycaemia. They were then asked to follow the insulin dose recommendation made by d-Nav or use the device to record the dose taken if not following the recommendation. Patients received telephone support from specialist nurses according and were followed up at three-monthly face-to-face clinic visits where an HbA1c was measured and data on blood glucose measurements and insulin dosage were downloaded from the device.

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Digital and technology Solutions in the treatment and Management of Diabetes


A technology-enabled service to optimise insulin managementby Hygieia Medical

rESultSA total of 96 patients completed phase 1 of the evaluation. The mean (± SD) HbA1c for active users decreased from 9.2 ± 1.4% (77 ± 15 mmol/mol) at baseline to 7.8 ± 1.2% (62 ± 13 mmol/mol) at the 3 - 5 month clinic visit and to 7.5 ± 1.2% (58 ± 13 mmol/mol) at the 6 - 12 month clinic visit. In patients for whom paired data were available, the decreases were statistically significant at both post-baseline visits (both p<0.001). This represented an increase in patients achieving goal HbA1c from 13% at baseline to 39% at 3 – 5 months and 60% at 6 - 12 months. In phase two the cumulative HbA1c data for 270 patients showed that 85% achieved and maintained HbA1c at goal. After three months on the service patients’ average HbA1c was 7.5 ± 1.2% (58 ± 13 mmol/mol) and after 9 months average HbA1c was 7.2 ± 1% (55 ± 11 mmol/mol). A phase 3 service rollout is currently underway with 561 patients using the service as of 31 May 2016. Only 18% of patients were achieving HbA1c ± 8% (64 mmol/mol) at baseline whereas 69% are achieving this target after a minimum of 3 months on the d-Nav Service. Based on UKPDS data a 1% reduction in HbA1c decreases risk of diabetes related death by 21%; risk of MI by 14%; risk of microvascular complications by 37% and risk of peripheral vascular disease by 43%. This clearly demonstrates the impact of the d-Nav insulin guidance service on patients, who experience a mean HbA1c reduction of 1.78% thereby reducing their risk of life changing complications and helping them remain healthy. Data from phases one and two of the project showed the d-Nav service is cheaper than the standard of care. Health economic modelling carried out by the York Health Economic Consortium on the effect of improved glycaemic control on prevalence and healing rates of diabetes foot ulcers predicts that using the d-Nav Insulin Guidance Service for all patients using insulin in Northern Ireland (approx. 12,636) would save the healthcare system £12.7m over three years. Applying this to the entire UK (600,110 insulin users) could save the NHS £600m over three years.


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EvaluatIon

Results from the patient survey show they are highly satisfied with the d-Nav service and the improvements in glycaemic control they have achieved. They also report feeling empowered by achieving glycaemic control and this has led to improvements in lifestyle and diet for some patients. The d-Nav service shows short term cash savings in lancets, test strips and concomitant antidiabetic drugs and efficiency gains through reduced Consultant and DSN visits, with medium and long term savings through reduced complication rates.

Prescribing data was used to demonstrate the real cash savings in lancets, test strips and medications while Trust data was used to demonstrate the efficiency gains in Consultant and DSN visits. HbA1c data was collected prospectively to demonstrate improvements in glycaemic control compared with standard of care. In the Service Expansion phase, data was gathered to demonstrate sustainability of improvements in glycaemic control and cost savings as the service was scaled up.

The team targeted their most hard to reach patients in Northern Ireland and improved their self-management, with a great use of technology and appreciation for the current and emerging situation to support an ever-increasing cohort of patients. They have already produced exceptional audit results.


Type 2 Diabetes and Me – E-learning guideby Diabetes UK, in partnership with Bupa

Most people with diabetes spend approximately three hours per year with their healthcare professional. It is vital that they are able to manage their condition on a daily basis. Diabetes education has been shown to improve health outcomes and reduce the onset of serious complications. However, the National Diabetes Audit found that only 16% of those diagnosed are offered structured education course, resulting in only 3.8% of newly diagnosed type 2 Diabetes patients attending them. Research by the digital sector shows a rapid expansion in internet use, with 90% of adults going online in any location, including for health related guidance, with 78% of respondents having used the internet for this purpose. 87% of people with type 2 diabetes are aged over 50 and there is an increase in the proportion of people aged 65-74 going online in any location. The availability of online education for diabetes in the UK is sparse, with initiatives being offered on a commissioned basis in a local area rather than being freely available nationally.

ChallEngE

A type 2 diabetes diagnosis can be overwhelming. There is so much information available, it can be difficult to take it all in. Diabetes UK’s free type 2 Diabetes and Me online guide allows patients to get all the facts, at their own pace, in their own time. The online guide is for anyone who has recently received a type 2 diabetes diagnosis and those living with or affected by type 2 diabetes who want a refresher about their condition and the options available to support them.

To create a guide to type 2 diabetes that will be relevant to people who have been newly diagnosed - and a refresher for anyone living with type 2 diabetes. The guide will support people with type 2 diabetes to better understand and manage their condition.

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The final project, which can be accessed at www.type2diabetesandme.co.uk, contains five modules providing a comprehensive guide to type 2 diabetes. They cover what diabetes is, complications, eating well, medication and monitoring and practical advice on living with it. Each module then contains bitesize topics for people to complete in their own time. The resource involves quizzes, reveal pages - for users to click on images and icons for more information, interactive multiple choice questions and videos to engage the user and support different learning styles. Transcripts are provided for audio and video content, and non-decorative images include alternative text. Videos can also be paused and re-played. The guide is mobile responsive to give users the opportunity to access the site while on the go, on tablets or phones, adding to the convenience of its use and supporting the increasing number of internet users who go online in any location, not just at home. To gain a greater level of understanding and support for people living with type 2 diabetes, the guide provides information on Diabetes UK’s peer support services, such as an online forum and local support groups. Users also begin a customer email journey to receive more information on the support Diabetes UK offers.

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Type 2 Diabetes and Me – E-learning guideby Diabetes UK, in partnership with Bupa

rESultSSince the launch of the Type 2 diabetes and Me online guide there have been 36,000 registrations and 3,149 service users have been surveyed to gain feedback. A regular online survey is sent out to service users to gain a random sample, to help effectively monitor the guide. 40% of users surveyed are newly diagnosed (one year or less since diagnosis) and 60% have had type 2 diabetes for over one year. 71% of all users found the guide either easy or very easy to use and navigate and 82% stated that they would recommend the guide to a friend. 86% of users who had completed the guide had a positive experience of using Type 2 Diabetes and Me. Sixty seven percent of service users completing the guide said that their knowledge of their condition had increased as a result and 57% felt more confident managing their diabetes. Of those completing the guide 79% said that they would look after their type 2 diabetes more. As of May 2015, 13,000 more users had opted to receive further mailings from Diabetes UK.


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EvaluatIon

The impact has exceeded expectations in terms of the number of people registering. There are approximately 800 new sign-ups per month. Seventy percent of users surveyed had never received any other form of education to support living with their condition. Analysis of the project has shown a broad reach across a range of socioeconomic groups. In January and February 2015, 35% of people accessing the guide were ‘well off,’ 29% ‘comfortable’ and 32% ‘financially stretched’. This indicates that the guide is inclusive and accessible to all.

Data is analysed on a monthly basis to enable the team to report on the service and user satisfaction. The majority of survey respondents find the guide beneficial in increasing their knowledge and confidence in managing their diabetes in addition to enjoying using the guide. Feedback showed that users would like to be able to skip some modules, for example, pregnancy, and questions related to topics that users tend to skip should not be included in the quiz at the end of the module. As such the content of the guide was adapted to reflect this. Users happy to be contacted regarding their experience of using the guide were followed up on a one-to- one basis to gain in-depth knowledge of their experience and to assist with marketing of the guide.

This guide is changing lives and reaching out to a huge amount of people. It is scaleable, sustainable and replicable, with good data on the results. The scale is impressive and it is great to see such a good, free, simple, easy to use, education tool for Type 2.



Transforming Diabesity Care: Institution of an NHS Endobarrier Serviceby Sandwell & West Birmingham Hospitals NHS Trust

UK spending on type 2 diabetes at £8.8bn will rise to £15.1bn by 2035 - and complication costs exceed treatment costs threefold. With sufficient weight loss, there is improved glycaemic control, but diets have not worked on a population-level and have a high individual failure rate. It is counterintuitive to use diabetes medications associated with weight gain (insulin, sulphonylureas) in obesity. Some agents, such as GLP-1 receptor agonists, reduce weight but 75% of patients do not respond sufficiently. Many are reluctant to try bariatric surgery, given its invasive nature. Such surgery has limited availability, is expensive and permanent.

ChallEngE

Endobarrier is a 60cm intestinal liner inserted by mouth (endoscopy) to mimic weight-reducing and diabetes-improving gastric bypass surgery less invasively. The REVISE-Diabesity study has shown that treatment with the device can dramatically improve diabetes, obesity, fatty liver and cardiovascular risk, while having an acceptable safety record and high patient satisfaction levels. Having acquired the practical skills for inserting and removing Endobarriers, Sandwell & West Birmingham Hospitals (SWBH) NHS Trust set out to establish an NHS Endobarrier service for selected patients with diabesity and ‘nowhere else to go’. A one-year service evaluation found it is working well and referrals are increasing from across primary care and multiple secondary care specialties. There is a large number of NHS patients with diabesity who have exhausted treatment options, which suggests that the service could be established widely in the NHS.

To establish a fully operational effective, safe, innovative and cost-effective Endobarrier service for the benefit of patients with diabesity in an NHS setting.

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Endobarrier is an innovative 60cm intestinal liner device inserted by via the mouth. When placed, its forced re-routing of food achieves intestinal ‘bypass’ of bariatric surgery less invasively. It is potentially cheaper and could be made widely available. An advantage in its reversible nature is that it can simply be removed should any device-associated complications arise. Its temporary presence - rather than lifelong anatomical disruptions - empowers patients to make significant positive behaviour alterations over one year (rather than the few weeks of a diet). This aspect is crucial as there is good evidence that a large one year weight loss is a strong determinant of maintenance. The team’s experience from leading the randomised controlled REVISE-Diabesity trial has informed this initiative of transforming the care of those with diabesity, by providing the Endobarrier treatment to selected patients in an NHS setting. The chief executive backed the project, providing strategic advice and asking the team to formalise the service protocol and identify and attach appropriate NHS payment by results (PBR) codes to all activities. He invited a negotiation to reduce costs of 20 Endobarrier devices from the manufacturers (financial year 2014-2015) and another 35 Endobarrier devices (2015-2016), and undertook to find funding for them. Several service planning meetings with the multidisciplinary and multispecialty team resulted in protocol formalisation and identification of all activities. Meetings were minuted with specific action

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plans for specific individuals. All NHS service documentation was reviewed by several team members. The following elements were devised:

• adefinedpatientpathwayhavingdissectedthepatient journey to identify what would operate best within our NHS Trust

• visitproformasdesignedtocapturespecificdatatheservicecouldbeevaluatedon• a1-pagesimple‘troubleshooting’guideforpatientsandgaveacreditcardsized

‘safety alert’ with safety advice and contacts to carry on their person.

The Emergency department was informed of the new service. The team undertook efficacy and safety analyses of the randomised controlled trial data which informed this service, eg use of combination Endobarrier+GLP-1RA is superior at weight and HbA1c reduction than Endobarrier alone.

rESultSThe first NHS Endobarrier clinic was undertaken in October 2014. Since then, 96 patients have been referred (41 accepted, 12 awaiting assessment, 44 excluded). 70% of patients achieved an HbA1c target<58mmol/mol, 40% are no longer obese. Weight fell by 12.3 ± 7.5kg (n20 P<0.0001) at 6 months and by 17.9 ± 9.7kg (n10, P<0.001) at 1 year. HbA1c fell by 14.2 ± 18.7mmol/mol (P=0.003) and by 23 ± 16.7mmol/mol (P=0.002) at respective intervals. Ninety five percent of patients receiving Endobarrier would be “extremely likely” to recommend it (NHS friends and family test). Even with these small numbers the positive impact is clear and there is now an established infrastructure to provide this novel treatment. There was one early Endobarrier removal due to a gastrointestinal bleed and the patient made a full recovery.

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EvaluatIon

The key thing was to get the backing of the Trust’s chief executive. He provided strategic advice and kick started the project by sourcing funding for reduced-cost Endobarriers. It is clear that the service is providing effective results, starting as early as three months and in a group of patients with refractory diabetes. We have acquired experience in how to advise patients to make best use of the device. There are considerable reductions in weight, BMI, HbA1c, systolic BP, ALT (a marker of fatty liver) and high patient satisfaction levels.

The SWBH Endobarrier NHS service was formally evaluated after the pilot case (April 2014) and after one year of initiation (November 2015). The measures evaluated included: referrals, numbers, sources, outcomes, demographics, HbA1c, weight, diabetes medications, safety aspects and patient satisfaction.

Transforming Diabesity Care: Institution of an NHS Endobarrier Serviceby Sandwell & West Birmingham Hospitals NHS Trust

This is an interesting project, tackling a real problem and the outcomes are significant. Patient feedback was impressive.


Good self-management is key to improving health outcomes for people with diabetes. However, despite NICE recommending that everyone with type 2 diabetes should be offered structured education at diagnosis with annual reinforcement, and incentivisation of GPs to refer through QOF, take-up remains low with only 5.3% of eligible patients attending in 2014–15 (National Diabetes Audit). One reason for this may be that most of the current education offered by the NHS is delivered in a group setting, which is not convenient or suitable for some people.

ChallEngE

HeLP-Diabetes has around 800 users and is an evidence-based programme which takes a holistic view of self-management, focusing on medical, emotional and role management. The University College London project offers ongoing support for patients and carers. Features include behaviour change support (with goal setting, action plans, reminders and feedback); emotional support (computerised cognitive behavioural therapy tools, mindfulness, online moderated forum); an online health record where patients can input their own health related information and set text/email reminders for themselves; and regular newsletters, emails and SMS alerting users to updated content, new research findings, and directing them to specific (seasonally relevant) areas of the website. Benefits for patients include reduced diabetes-related distress, improved glycaemic control, accessibility, convenience, privacy and access to clinically informed and trusted information. Developed as a research programme, it is now being rolled out nationally and has been adopted in four London CCGs.

To develop, evaluate and implement a web-based self-management programme for people with type 2 diabetes (at any stage of their illness journey) with the goal of improving access to, and uptake of, structured education and self-management support, hence improving health outcomes in a cost-effective manner. To enable people with type 2 diabetes to take control of their health and lead happier, healthier lives.

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The development of the intervention was informed by: literature reviews; theoretical frameworks; de novo research with patients and HCP to establish user needs and wants; a process of participatory design with patients and HCP; and commercial software and web designers. A pilot study in three practices demonstrated reduced diabetes-related distress (measured by the Problem Areas in Diabetes scale, PAID) after six weeks use. An individually randomised controlled trial was undertaken in primary care to determine effectiveness and cost-effectiveness. The joint primary outcomes were glycated haemoglobin (HbA1c) and PAID. The trial recruited to target and achieved follow up at 12 months (the primary outcome point) for 85% of HbA1c and 90% of PAID data. An implementation study was undertaken in 1 CCG to determine the best method of implementing HeLP-Diabetes into routine NHS care. The implementation plan was theoretically informed, iterative, and evaluated with mixed methods (quantitative data on uptake and use; qualitative data on benefits and challenges). This resulted in a programme that was highly acceptable to commissioners, HCPs and patients, as well as incorporating the latest evidence and best practice in promoting self-management of diabetes.

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HeLP-Diabetes: a proven online solution for diabetes self-management supportby University College London


rESultSThe trial was successful, recruiting to target (n = 374) and achieving good follow-up. The analysis of primary outcomes showed a significant improvement in HbA1c amongst those randomised to HeLP-Diabetes (mean difference -0.23%; 95% Confidence Interval -0.42 to -0.041; p=0.017) but no difference between groups for the PAID (p=0.25). Sub-group analysis suggested a beneficial impact on PAID in patients diagnosed within the last five years. In the implementation study, 22 out of 34 practices adopted HeLP-Diabetes and signed up 205 patients. Of these, around half (47%) were from Black or other Minority Ethnic groups, one third left school at 16 with no further formal education and one-third described their computer skills as basic.


HeLP-Diabetes: a proven online solution for diabetes self-management supportby University College London

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EvaluatIon

The research programme is completed and it is now transitioning into a service delivery model. HCP facilitation appears to be an important factor in overcoming the digital divide. In practices which did not offer HCP facilitation but required patients to self-register, users were more likely to be highly educated and describe their computer skills as good or expert. The team has set up a not-for-profit community-interest company (CIC) called HeLP Digital, which aims to disseminate HeLP-Diabetes across the UK. The CIC was one of seven successful ventures on the 2015 Health and Social innovators Programme (funded by the Government’s Health and Social Innovation fund backed by the Cabinet Office) and to date, has contracts with four CCGs to make HeLP-Diabetes available to all patients with type 2 diabetes in their locality, thus improving availability and range of support for self-management. Usage data show that most visits occur outside normal working hours, confirming the convenience of online access.

The pilot showed that patients (n = 18) who used HeLP-Diabetes over six weeks showed significant improvement (reduction) in their level of diabetes-related distress (PAID). There was also a non-significant trend toward improvement in self-efficacy for diabetes management, as measured on the Diabetes Management Self-Efficacy Score. Data from qualitative interviews suggested that users felt better informed and more aware of how to manage their diabetes, reporting improved self-efficacy and confidence.

This is a great project which focuses on self-management – a much neglected area of care and has good user feedback.


My Diabetes My Way: online support for diabetes self-management by University of Dundee

In 2008, a report by Diabetes UK estimated that diabetes accounted for around 10% of NHS expenditure, equating to £9bn per year, or £1m every hour. This was double a 2001 estimate (Department of Health, 2001), showing the impact of a rising prevalence across the UK. A subsequent report in Diabetic Medicine predicts NHS annual spending on diabetes will increase from £9.8 to £16.9bn by 2035, reaching 17% of the entire NHS budget. The challenge of supporting self-management in the expanding population of people with diabetes can be assisted through the use of technology, for example, by improving learning and education, much of which can be facilitated electronically. Internet based self-management support and electronic personal health records (ePHRs) have the potential to change the balance of power from healthcare providers to healthcare users and reduce the burden of care – but most existing ePHR systems present data residing on single silos, such as GP systems or hospital clinic records.

ChallEngE

My Diabetes My Way (MDMW) is the NHS Scotland interactive website for people with diabetes and their carers. It contains multimedia resources aimed at improving self-management, including traditional information leaflets, interactive educational tools, videos describing diabetes-related complications and testimonials from people with diabetes talking about their experiences. MDMW also offers users access to their clinical data via its novel electronic personal health record (ePHR). The ePHR sources data from primary care, secondary care, specialist screening services and laboratory systems; including diagnostic information, demographics, process outcomes, screening results, medication and correspondence. These data provide a more complete overview of diabetes than is available from any single data source. Over 9,000 patients across Scotland have logged in and user evaluation shows that they find it a useful tool to aid self-management by improving knowledge and motivation to make positive changes.

To assess the levels of usage and uptake of the MDMW ePHR. To find out users’ opinions and experiences of online diabetes data access and to assesss the impact on routine clinical outcomes for MDMW ePHR users.

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A project Editorial group consisting of patients, healthcare professionals and IT professionals oversees the design, development and management of the MDMW ePHR. The system exchanges data with SCI-Diabetes, NHS Scotland’s flagship diabetes record. This system includes data from primary and secondary care, specialist screening systems (eg retinopathy screening, podiatry) and laboratories. Data include diagnostic information, demographics, process outcomes, screening results, medication and clinical correspondence. The system provides a more complete overview of diabetes than would be available from any single data source, such as an isolated primary care or hospital clinic database. Alongside these data is descriptive text explaining each assessment, detailing why they are recorded and what normal range values are. Further educational materials are presented alongside clinical results and are tailored to those using the service. History graphs and tables allow individuals to Patients can set and log their own personal goals and manually enter home-recorded information (weight, blood pressure, etc), or automatically upload blood glucose results through Diasend.

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My Diabetes My Way: online support for diabetes self-management by University of Dundee


rESultSAt the end of 2015, 7,464 patients (43% of registrants) had logged in (102% increase since end 2014; n=3,696). Levels of engagement remain high amongst active users. 3,164 (42.4%) logged in at least once during the final 3 months of 2015; 5,916 (79%) during the full calendar year. There were 42,396 total logins during 2015 (average=5.7/patient; median=3). During December 2015, 1,576 people with diabetes accessed their records (131% increase from December 2014; n=682). Analysis of patient measurements prior to using MDMW and one year after first log-in show encouraging findings. Users of MDMW show a highly statistically significant improvement of 1.53 mmol/mol in HbA1c (p<0.001) among active users. Statistically significant improvements are also shown in albumin/creatinine ratio (p=0.015), body mass index (p=0.022), total cholesterol (p=0.002), HDL cholesterol (p=0.012), LDL cholesterol (p=0.001), diastolic blood pressure (p=0.007) and weight (p=0.003). 696 patients registered to use Diasend alongside MDMW during the first year of availability (March 2015 - February 2016). 123 patients accessed blood glucose data via MDMW and Diasend 647 times (5.3/patient). As of May 2016, over 9,000 people with diabetes have now logged in to MDMW, covering all health boards across Scotland and individuals aged 14 to 94. Around 1,000 of these patients are using Diasend to upload home blood glucose data.

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EvaluatIon

Raising awareness of the service remains a challenge, particularly in primary care, but the project team has ensured that all hospital diabetes clinic waiting rooms contain advertising materials. Over 70,000 MDMW leaflets were distributed to healthcare teams in 2015. The Retinopathy Screening Service ensures that letters sent to patients contain the MDMW web address. Diabetes structured education programmes (DAFNE, TIM, TDEP, etc) actively encourage patients to register for MDMW as part of their course, engaging newly-diagnosed patients early. A further step to streamline the enrolment process has been to allow healthcare professionals to sign-up patients directly through SCI-Diabetes.

An evaluation survey was sent to all active users in early 2015. This questionnaire aimed to capture qualitative and quantitative data using a series or open and closed questions. Patients completed the questionnaire online using Survey Monkey and provided information detailing the impact the system had on their satisfaction and how it enhanced their ability to self-manage. System audit trails monitor usage and uptake using events such as user logins and pages viewed, along with date and time of access.

This programme is “on the money” and is a good, modern approach to support self-management, linking traditional care models to information and ease of access for patients.


The Florence (FLO) telehealth texting systemby Derbyshire Community Health Services NHS Foundation Trust

With the increasing numbers of patients developing diabetes (Diabetes UK states it will increase to five million in 2025 from 3.2 million in 2012) and without additional resources for clinical staff, new ways of working need to be embraced by the health service. The use of digital technology is an additional tool that can be used effectively as part of a diabetes care package.

ChallEngE

Community Diabetes Nurses at Derbyshire Community Health Service have embraced the Florence (FLO) telehealth texting system to support the patients that they see with diabetes. This is a free texting service for the patient and has been used for medication reminders and glucose results; with impressive results both in terms of patient outcomes and in changing the way that the diabetes nurses are working. Over 250 patients with both type 1 and type 2 diabetes are using this technology following identification from the community team. The system allows the specialist nurses to monitor patients remotely, to set individual target ranges for patients and receive e mail alerts if the patient is out of an agreed individual target range. Patients have responded positively to this cost-effective system and it has reduced the number of face-to-face contacts required. Patients report that they feel more supported.

To use technology to support patients managing their diabetes and how this would impact service delivery. To see how and whether the telehealth service could improve patient experience and outcomes, and reduce the number of face-to-face contacts needed.

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FLO was designed by professionals within the NHS, to provide clinically approved remote support and guidance to patients. The community diabetes nurses developed local protocols on the system for patients with diabetes, with support from the project team. Before any patients were added to the system the diabetes nurses added themselves as “a patient” to test the system and familiarise themselves with it. Initially 12 patients were identified and started as a pilot to see how this could work locally and if any modifications were needed following feedback. Governance issues were highlighted at this time and were progressed and resolved prior to the roll out on a wider scale. The enthusiasm of the community diabetes team was shared during their support visits to GP practices when they could highlight the benefits to the clinicians, significantly increasing the number of practices using the system.

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rESultSThe Community Diabetes Team in North Derbyshire have been using this system for the past two years, with over 250 patients registered, aged from 18 to 80. Coverage is across 39 GP practices and the Derbyshire Florence project is issuing over 23,000 text messages a month. The workload of one of the community diabetes nurses was assessed over a one month period with 70 patient contacts due to the system, to understand the impact on their workload. The outcomes were:




• 18face-to-faceconsultationsthatwerenotrequiredandreleased nine hours of specialist nurse time

• 42patientswereadvisedtochangetheirtreatmentby text or phone eg increase their dose

• 45patientshadearlierintervention• Sevenpatientsthatwouldhaveexpectedtohaveto

phone were avoided as the system demonstrated they had good control

It also showed the impact on other health providers:• Twohospitaladmissionswereavoided

• SixavoidedGPappointments.

Data shows that 68% of patients on the system have had a repeat HbA1c. From these patients 78% have had a reduction in their HbA1c and 18% had an increase, 3% planned increase. However caution is needed as this is not a controlled study and 32% have not had data collected.

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EvaluatIon

The use of FLO has been widespread across different age ranges: the eldest is an 80 year old who learnt how to text. Feedback from an experienced diabetes specialist nurse has been surprise at the effectiveness of a telehealth system. In its simplest form medication reminders can be used to prompt patients to take their medication, requiring no other input from the clinician apart from setting the individual up on the system. Patients often report forgetting their medication so a text reminder can make a big difference to their compliance. The issue of responsibility and governance was of concern to the organisation, in case a patient misunderstood the message. A text response advises the patient to contact their GP or diabetes nurse as the default and initial concerns voiced have proved not to be a problem.

Following the initial audit and patient feedback the diabetes nurses changed several aspects of the service. The national protocols were not used as some of the motivational messages were inappropriate and not well received by patients. The high alert levels were too low, highlighting the need for local protocols to be written by the DSNs with the project manager. Although this felt time consuming, verbal feedback from patients improved. DSNs recorded their experience of the system and any practical issues they had which were fed back to the project team - for example, it was not clear if a patient had been added or not and easy for the patient to be added several times, so a message was set up to inform that the patient had been successfully added. Patients also found the # symbol complicated to use, this was changed to “yes”.Timing of receiving the messages was also highlighted from the audit and this changed the set up so the first text for a glucose reading was set up for the morning and, if the patient had not replied, a further text was sent in the day rather than some patients receiving messages late at night. One of the unexpected benefits of the system is its use by those over 65 years of age, who report feeling comforted and reassured that someone is looking after them and reducing their sense of isolation.

A good project representing clear and realistic objectives. It had strong planning and implementation and considered the local impact with the results they were achieving.

The Florence (FLO) telehealth texting systemby Derbyshire Community Health Services NHS Foundation Trust


The Scottish Diabetes Action plan emphasises the need for a ‘person-centredness’ approach to support people with diabetes in managing their own condition. Diabetes care in Scotland relies on a series of managed clinical networks supported by a national informatics platform - SCI-Diabetes. Regional and national audits are regularly published using this data on a series of quality performance indicators (QPIs), which allow regional and international comparisons to be drawn. Despite some encouraging trends in adherence to QPIs, there is clearly room for improvement.

ChallEngE

Clinician Decision Support Systems (CDSS) provide HCPs with automated advice about best practice patient care, and have been shown to effectively influence behaviour in terms of adherence to guidelines and avoidance of drug errors. The Evidence Based Medicine electronic Decision Support (EBMeDS) system is a CDSS that was developed in conjunction with health care providers and successfully implemented within SCI-Diabetes, the Scottish national electronic health record for diabetes. EBMeDS has been ‘live’ to users within NHS Tayside and NHS Lothian since December 2013: evaluation found that use of the EBMeDS system has resulted in a dramatic improvement in adherence to national guidelines, with modest improvements in glycaemic control. Future work will aim to develop and implement additional rule-based algorithms based on user feedback and roll out CDSS to all users of SCI-Diabetes across NHS Scotland.

To implement decision support scripts within the SCI-Diabetes system in NHS Tayside and West Lothian, with a view to informing recommendations for a national decision support system. To demonstrate that there are no unintended adverse effects, and to quantify changes in clinical processes and/or outcomes.

obJECtIvES

When a patient’s electronic health record (EHR) is opened, coded data is sent to the EBMeDS engine consisting of a series of algorithms (or ‘scripts’). Results are transmitted back to the EHR for the user to view. Scripts aligned to diabetes care in Scotland were selected. Significant amendments were required to conform to national guidelines and local context. Initial prompt consists of a short decision support message. Navigating to a “long message” provides further details and a hyperlink to the relevant evidence that can be emailed for future reference. The appearance/behaviour of the system was decided in consultation with users and underwent a number of iterations. A ‘pop-up’ dialogue box that automatically disappears was felt to offer the correct balance between improving access whilst avoiding user fatigue. The SCI-Diabetes architecture allows EBMeDS to be switched on to specific user groups. Awareness raising/training of HCPs was undertaken via departmental meetings. Questionnaires were distributed and focus groups were held prior to implementation that followed a phased approach.

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Clinical Decision Support for Diabetes in Scotlandby NHS Tayside and University of Dundee


rESultSWith regards to clinical outcomes, the presence of an EBMeDS message was associated with small improvements in glycaemic control – which are associated with considerable long-term savings due to reduced complications. For example, if the current UK type 1 diabetes population reduced their HbA1c by 4mmol/mol (0.4%) the estimated saving is £39m over five years (£995m after 25 years). QPIs were based on national guidelines e.g. foot screening is recommended annually - QPI was the percentage of patients who have received foot screening in the past 15 months. For each QPI, the number of patients who received screening following a clinic appointment was compared to the control population. The odds (adjusted for demographic factors) of a patient receiving a screening investigation following a clinic appointment were significantly increased. For example, patients in the intervention group who were due foot screening were approximately three times more likely to receive this after their appointment, compared to controls attending clinic elsewhere. Clinical outcomes included: glycaemic control (HbA1c); cardiovascular risk factors (blood pressure and cholesterol); and kidney function (urinary protein and serum creatinine). Overall, the analysis demonstrated small but significantly greater improvement in HbA1c within cases compared to controls. This resulted in greater numbers falling within the target range for HbA1c within the study population. Kidney function deteriorated in cases and controls, however this deterioration was significantly less marked in cases. The use of the EBMeDS system had no adverse effects on patient experience, clinic consultation or working practices. Quantification of system usage supports users’ assertion that the system encourages more efficient working practices.


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EvaluatIon

For clinical processes, the odds of a patient receiving an appropriate screening investigation following a clinic appointment were significantly raised. Aside from the health benefits afforded by early intervention, there are considerable potential economic savings in areas such as foot screening (where it is possible to extrapolate health savings of £1m per year for NHS Scotland).

Evaluation adopted a mixed methods approach, based upon the NHS Scotland Knowledge into Action framework. The ambition of this strategy is to embed knowledge in care processes in real-time, making the EBMeDS system an ideal exemplar of this approach. Two ‘improvement cycles’ ran over the course of an 18-month period: phase one at Ninewells Hospital and one primary care practice in Dundee (16 weeks); and phase two in the Tayside area and St John’s Hospital, Livingston (16 weeks). A post-implementation questionnaire and focus groups were held towards the end of each improvement cycle. Patient Reported experience measures (PREMs) were collected via questionnaires distributed during each improvement cycle.

This was a very professional submission and what this hospital have achieved is extremely hard to do and do successfully, especially the clinical algorithms. Great initial results, especially with the foot care reviews and it will be interesting to see where this goes in the future.

Clinical Decision Support for Diabetes in Scotlandby NHS Tayside and University of Dundee


An “IDEA” to deliver inpatient diabetes safety messages in bite-sized animations by University Hospitals of Leicester

The National Diabetes Inpatient Audit (NaDIA) in 2013 showed that up to 25% of inpatients have diabetes of whom ~40% are on insulin therapy. For the majority (> 90%) of these admissions diabetes is a secondary diagnosis and not the primary reason for admission and hence often cared for by non-diabetes specialty teams. NaDIA has highlighted sub-optimal care quality across several areas of inpatient diabetes care. Despite emphasis on the need to develop knowledge and skills in managing complex medical conditions including diabetes, there is a lack of confidence and knowledge among trainee doctors in managing inpatients with diabetes. NaDIA 2015 data for Leicester Royal Infirmary showed that on the day of data collection there were 129 patients with diabetes in hospital and of those 27.5% patients reported at least one episode of mild hypoglycaemia, 14.8% at least one episode of severe hypoglycaemia and 26.9% experienced an insulin medication error.

ChallEngE

IDEA (Inpatient Diabetes Education through Animation) is intended to improve inpatient diabetes care. A review of serious diabetes incidents and DATIX incidents was used to identify recurring safety themes. These were then incorporated into a suite of animations. The innovation is aimed at delivering key safety messages to healthcare professionals (HCPs) in memorable bite-sized (3-4 min) animations. IDEA may be used to disseminate key learning messages to all HCPs who care for patients who have diabetes and are admitted to hospital. The videos focus on key areas identified where mistakes have been made, with the aim of learning from these experiences, improving care and patient experience. IDEA can be found on a variety of platforms to widely disseminate shared learning.

To develop an innovative teaching tool for doctors in training which incorporates key safety themes taken from analysis of real-life incidents affecting inpatients with diabetes. To make the tool accessible to all, memorable, produced within a finite budget and easy to disseminate.

obJECtIvES

Analysis of serious untoward incidents (SUI) and DATIX incident reporting of inpatient diabetes/insulin errors from Nov 2013 to Oct 2014 was undertaken. A survey of sub-consultant grade trainee knowledge was also carried out. Recurring diabetes errors and safety themes (medical, nursing, dispensing and administrative) and areas of sub-optimal knowledge in inpatient diabetes care were identified. A robust pathway for reviewing DATIX errors within monthly diabetes morbidity and mortality meeting was implemented. Recurring themes were identified. Discussion within the multidisciplianry team nurtured a culture in which reporting clinical incidents and shared learning are is openly encouraged. A series of real life scenarios were selected to illustrate common preventable harms and animations - IDEA (Inpatient Diabetes Education through Animation) - were created around these scenarios to be used as an adjuvant teaching tool for doctors in training and other staff members (nursing and pharmacy) to improve quality of care for inpatients with diabetes and in turn improve patient safety and experience. These are short (~4 min) videos hosted on IDEA YouTube channel (https://goo.gl/SD56kY), IDEA Vimeo (https://vimeo.com/album/3947654) and also feature on Twitter @IDEA_UHL.

SolutIon



An “IDEA” to deliver inpatient diabetes safety messages in bite-sized animations by University Hospitals of Leicester

rESultSIDEA videos were shown to a group of doctors and pharmacists as a pilot project. Feedback was very positive with 89% respondents scoring four or higher (range 1(poor)-5(excellent)) in evaluation. Around 94% of doctors in training (n=19) rated IDEA relevant, 83% rated useful and would change practice. Pharmacists (n=17) rated IDEA useful and relevant (94%) and would change practice (76%).


They are also incorporated into an interactive web-portal INDIE (http://leicesterdiabetescentre.org.uk/INDIE) which provides a platform for doctors to undertake a short self-assessment (10min) using modified pre-validates questionnaire to identify knowledge gaps and provides easy access to educational resources (links to educational material, IDEA videos and guidance).

lEarnIngS

EvaluatIon

IDEA appeals to the current generation of trainees who are training in a culture of technology and bite size information delivery. The animations are easily viewed on either smartphone, tablet or PC. The rating we have received from medical and other staff members on the usefulness and relevance of these videos is excellent. The pilot suggests that ~80% of IDEA viewers report it would change their practice. This initiative will also show that the IDEA can be easily adopted by more than one Trust.

IDEA was evaluated in the ‘real world’ setting as teaching tool during trainee teaching sessions on insulin safety and inpatient diabetes care. IDEA videos were used to explain topics alongside conventional teaching tools like power-point/prezi slides/frames. The evaluation took place between April 2015 and Nov 2015 and was undertaken with groups of FY1s and Specialist registrars (ST3 and above). Around 98% of Specialist registrars (n=41) rated the content of the teaching session ≥ 4 on a scale of 5 and 95% of FY1s (n=36) rated the content of teaching with IDEA videos ≥ 4 on a scale of 5 (1= strongly disagree, 2= disagree, 3=Unsure, 4 =Agree, 5=Strongly agree).

Great, simple idea and judges loved the fact that untoward incident data was used to focus on what mattered most. This is fresh, different and has potential.


Diabetes Collaboration Initiative of the Year

Information Prescriptions: The Key to Unlocking Behaviour Changeby Diabetes UK

ChallEngEData shows that we are not effectively supporting self-care: the latest National Diabetes Audit (2014-15) showed that only 39.5% of people with diabetes achieve the targets for blood pressure, cholesterol and HbA1c. This is despite these being the factors that place people at risk of devastating complications and the fact they are treatable with routine drugs (eg statins) and lifestyle interventions. There was frustration among doctors and patients that the number of tests and the pressures on time mean that diabetes care becomes nothing but a process of ticking boxes with no opportunity to explore what matters to the patient or to change behaviour and therefore clinical outcomes.

obJECtIvESTo develop a tool that could reach patients across the UK and enable them to better understand and engage with their diabetes care, with the ultimate goal of changing behaviour and clinical outcomes.

SolutIonTwo co-production workshops were set up to design and develop the tool. Involved in the workshops were: Diabetes Consultants, a GP, practice nurse, psychologist, health academics who specialised in behaviour change interventions and people with diabetes. They established the design of the tool, key medical content was agreed and the language used to describe clinical concepts was thoroughly tested to ensure maximum clarity. The workshops created IPs for HbA1c, blood pressure and cholesterol. Four GP surgeries piloted the IPs in practice prior to launch to ensure that they worked as expected. Simultaneously a specification was agreed with the IT suppliers that would meet the objectives of clinicians – in particular agreeing clinical parameters for electronic alerts so that clinicians would be proactively prompted to use the IPs for patients who were outside NICE targets. IPs are now launched on the three main primary care IT systems (EMIS January 2015, Vision April 2015, and SystmOne February 2016) meaning that they are available to over 98% of registered patients in the UK.

The resource was developed by Diabetes UK to change both clinical and patient behaviour. Collaborative design was used to ensure it was easy for clinicians to use as a brief behaviour change intervention with patients who have diabetes and are at higher risk of complications. The tool consists of three information prescriptions (IPs), relating to the key targets in diabetes - HbA1c, blood pressure and cholesterol. To maximise impact and reach, the team worked collaboratively with the primary care IT companies to embed it in their systems. This enabled the proactive targeting of high-risk patients as clinicians receive real-time alerts for patients with diabetes who are outside the NICE targets. It also significantly increases the speed and effectiveness of the intervention as key patient data can be automatically populated on the IPs and a completed IP is saved on the medical record to support continuity of care.



Information Prescriptions: The Key to Unlocking Behaviour Changeby Diabetes UK

rESultSPhase one of the pilot tested the IPs as a paper document in practice to check acceptability to both clinical and patient audiences. Phase two piloted the technological intervention to ensure that all the clinical objectives were fulfilled. The pilot gave the team the confidence to launch nationwide with the following measures in place to allow ongoing measurement of impact:

• IPscontainauniqueURLdirectingpatientstofurtherinformationandsupport.Monitoringtheuseof this unique URL allowed us to track the number of people who had not only received an IP, but had also been motivated to take action and find out more about managing their condition.

• Collectionofpatientcasestudiesfromclinicians.• Individualpracticeaudits.

lEarnIngSThe IPs automatically alert clinicians to patients who have diabetes and are outside the targets for blood pressure, HbA1c or cholesterol. Case studies show this is prompting clinicians to intervene more proactively and identify patients who have slipped through the net for many years. Many patients say the IP was the first time anyone explained their condition to them (clinicians are clear that it is not, but evidently the IP was the first explanation that hit home). Anecdotally we are hearing of patients significantly improving clinical outcomes. The IPs include a unique link to more information on Diabetes UK’s website, and over 13,000 patients in 2015 were sufficiently motivated by the receipt of an IP to access more information on managing their diabetes.

EvaluatIonFormal evaluation of the initiative was carried out by Newcastle University and presented at Diabetes UK Professional Conference in March 2016. This focused on evaluating the usefulness of the IPs and identifying key factors (eg cognitive, behavioural and environmental) that impact on their implementation. The evaluation concluded that behaviour change approaches to implementation science provide new ways of improving patient care. The IPs account for cognitive, behavioural and environmental factors that influence professional behaviour and in doing so can help to improve quality of care. In addition, at the conference two clinicians presented evaluations of the impact of IPs on their individual practice. One focussed on patient experience while the other included an audit of HbA1c results before and after the introduction of IPs which demonstrated a significant improvement. Of the 13,000 visitors to the unique URL, 85% are female (compared with Diabetes UK site average of 65%), showing the resource is particularly resonating with a female audience. It also showed 50% of visitors were aged 45-64 (and a further 42% under 45) – suggesting that the resource is reaching people relatively early in their diagnosis – supporting the ambition that the IPs enable people to take control and prevent complications.

This is a simple, low cost and robust initiative that could have a real national impact for minimal cost. It is totally patient focussed and demonstrates true collaborative working. It has been designed with sustainability in mind and has impressive leverage.


Research for the Future: The ‘Help BEAT Diabetes’ Campaign by Salford Royal NHS Foundation Trust, NIHR CRN: Greater Manchester and NorthWest EHealth

ChallEngEA survey of the public’s attitude towards health research showed high levels of confidence in NHS research (HRA, 2013) and willingness to participate. However many people are unaware of what research takes place locally or how to get involved. One barrier in recruitment to diabetes studies is that most people with the condition are managed in primary care whilst research centres are frequently based in secondary care. Research for the Future is a collaboration between NIHR CRN:GM, NWEH and SRFT who host the campaign. All have close links with the Manchester Academic Health Science Network (AHSN) who are experienced in the development of health informatics technology and Manchester Academic Health Science Centre (MAHSC) who are committed to providing research leadership and increasing public involvement in research. Partners in the project include Diabetes UK who have significantly helped raise awareness of the campaign and Novo Nordisk who supported the pilot with an educational grant.

obJECtIvESTo improve recruitment to research studies to time and target by building a database of volunteers who consent to be approached in the future about studies they are both eligible for and interested in.

SolutIonActions included piloting a feasibility and recruitment tool, ‘FARSITE’ (‘Feasibility Assessment and Recruitment System for Improving Trial Efficiency) and creating a diabetes consent for approach volunteer database. An NHS contact centre was set up within the existing diabetes team and 18 pilot sites with FARSITE were started in three geographically different regions.

rESultSThere are more than 3,700 people on the Help BEAT Diabetes database with 1,600 living in the target area corresponding to NIHR CRN: Greater Manchester footprint. The most successful advertising method is general practice using FARSITE to identify and invite their diabetes population (29% of database registrations). This can be time consuming to implement. NHS diabetes healthcare staff play a valuable role in encouraging people to register (20%) and the campaign website accounts for 15% of registrations as well as providing general information. To date, 14 practices have invited 4,045 patients to join Help BEAT Diabetes. 263 have signed up (5.4%) at a cost of £2,785 (£10.50 per patient). Should those registering go on to participate in one or more studies, the project may be highly cost-effective.

To improve NHS care and focus resources effectively, we need a ‘research active nation’ where people actively help deliver high quality research. Research for the Future is an innovative collaboration between NIHR CRN: Greater Manchester (NIHR CRN:GM), North West EHealth (NWEH) and Salford Royal NHS Foundation Trust (SRFT). It consists of a series of ‘Help BEAT’ campaigns, of which diabetes is the first. Each campaign invites people with a particular health condition to register their details and research interests on a database. In doing so, they give their ‘consent for approach’ and can be contacted in the future about a range of research opportunities. This method of linking research teams with people interested in participating helps recruit to time and target.



Research for the Future: The ‘Help BEAT Diabetes’ Campaign by Salford Royal NHS Foundation Trust, NIHR CRN: Greater Manchester and NorthWest EHealth


lEarnIngSKey learnings from pilot and roll out to date include: targeted marketing from a respected health care professional or organisation is the most successful method of recruitment to the volunteer database (eg GP, diabetes healthcare professionals, Diabetes UK), while radio advertising is the next most successful method. Also, ongoing, planned communications and publicity are vital to encourage new registrations and maintain engagement of existing members. Database maintenance (eg contact details) is time consuming but worthwhile – and ongoing promotion to researchers is essential. FARSITE relies on standardised GP coding of disease and drugs (which is not always the case) and ongoing GP/FARSITE validation is required. GP practice staff also require ongoing FARSITE training and support. Finally, using the database as a ‘first screen’ for key protocol criteria is currently the most cost effective and efficient method of informing people about research opportunities, until volunteer numbers increase sufficiently to utilise the link from database to medical record.

EvaluatIonThe number of diabetes studies which have been helped with recruitment and the number of patients taking part has continued to increase each year. The role of the Research for the Future team has also expanded and helping people engage with their health condition in the broadest sense is now an integral part of the service. Volunteers are regularly informed about local Trust events, Diabetes UK education days and local wellbeing courses.

A really interesting and different project with good patient outcomes. A strong collaboration, with many groups coming together, especially IT. Connecting patients to research is great for diabetes. This has the potential to be totally scalable, as the take-up rate so far has been pretty amazing!


The Health Innovation Network Diabetes Improvement Collaborative by Health Innovation Network

ChallEngEType 1 diabetes affects more than 370,000 adults in the UK. People with the condition are wholly reliant on insulin delivered through multiple daily injections or an insulin pump. Evidence indicates that between 15-20% of adults with type 1 diabetes would benefit from this technology and in comparable countries outside the UK the uptake figure is between 20% and 40%. However in June 2014 data supplied to the HIN from South London service providers indicated that the uptake of this technology in South London was between 3-15% depending on borough. Barriers to insulin pump therapy included lack of capacity within services - including adequately trained staff – and lack of access to type 1 NICE-approved structured education (usually a pre-requisite for starting pump therapy).

obJECtIvESIncreasing insulin pump uptake to at least 15% of the type 1 population in South London by 2018. To create an effective and sustainable network of providers, to identify and develop opportunities for collaboration across the network. To engage local teams in service improvement activities, by providing training and skills in relevant techniques, and to develop an effective collaboration between the NHS and industry to deliver the above aims.

SolutIonThe Diabetes Improvement Collaborative was established under joint working arrangements with three industry providers - Roche Diabetes Care, Boehringer Ingelheim and Johnson & Johnson. Workshops were launched in November 2014 and brought together ten secondary care diabetes teams including over 60 doctors, nurses, allied health professionals, managers, administrators and service users. Over a ten-month period participants attended four workshop events and received tailored on-site support in learning the service improvement tools and techniques required to streamline patient pathways and tackle the barriers. This approach created opportunities for new collaborations to improve services. Between each of the workshops the participating teams were supported by an online platform established to provide resources, ideas and a forum to share action plans.

The Health Innovation Network (HIN) is the Academic Health Science Network for South London. Established across 10 multidisciplinary acute diabetes teams and with three industry partners, the Diabetes Improvement Collaborative had the aim of increasing the uptake of insulin pump therapy for adults with type 1 diabetes. Research cited by NICE stated that 15-20% of people with type 1 could benefit from pump therapy, however a local South London audit undertaken by the Health Innovation Network (HIN) in 2014 revealed that in South London this figure was between 3-15% depending on borough and the average was 8.8%. Results have shown that since the project started in June 2014 there has been an increase of over 370 people accessing insulin pump therapy from sites in South London, equating to a rise from 8.8% to 11.9% of the South London adult type 1 population.



The Health Innovation Network Diabetes Improvement Collaborative by Health Innovation Network


rESultS HIN achieved 100% participation and commitment to the project from all multidisciplinary diabetes teams within South London and three from North London, with attendance at each workshop in excess of 60 participants including provider teams and insulin pump users. Between June 2014 and April 2016 insulin pump uptake at South London trust grew by over 30%. This increase was delivered through improvements such as improving access to structured education, sharing and standardising service protocols and ensuring tasks are undertaken by the most appropriate person. Within South London, over 370 more people are now using an insulin pump and uptake among the South London type 1 population has increased from 8.8% to 11.9%. Across London it has led to greater equity of care, reduction of waiting times, the creation of several new roles within participating sites including Diabetes Specialist Nurse and administration posts, and directly influenced local commissioning decisions. Acute diabetes teams have been empowered to discover how their services could be improved and provided with the skills and knowledge to deliver positive change. Recommendations and findings from the project have been presented to the All Party Parliamentary Group for Diabetes, following an invitation from Diabetes UK.

lEarnIngSThis project has managed to achieve a significant lasting impact on service delivery for individual trusts with a strong emphasis on the importance of access to high quality structured education, and has encouraged a holistic, whole pathway approach to pump therapy. Success has been primarily down to uniting local service providers in a better understanding of local demand and how to work smarter to enable their local pathways to meet this demand more efficiently. There has been no additional central or CCG funding for services themselves.

EvaluatIonThe HIN Diabetes Improvement Collaborative has delivered a substantial increase in uptake, putting South London as a region on track to deliver at last 15% uptake by 2018, with associated significant benefits to local people with type 1.

A well presented project, with clear and measurable objectives. It is a great example of patients, NHS and industry working together across Trusts to improve pump usage.


ChallEngESolihull has a population of 240,000 and the incidence of diabetes is rising by approximately 3% per year. Diabetes is currently being looked after in primary care both in dedicated GP/Practice Nurse led clinics and in a Community Diabetes Clinic. All GP Practices are signed up to the Locally Enhanced Service although neither the provision nor the quality of this service is audited. Solihull CCG is, like many CCGS across the country, facing increased pressure from cuts in funding. An Effectiveness Review Group (ERG) was set up to review all commissioned services to achieve the financial savings required to maintain statutory requirements. The ERG identified diabetes as an area where savings could be made because of the apparent duplication of expense streams. It was also noted that there was a wide variation in the standard of diabetes management in primary care (the percentage of patients achieving an HbA1c less than 7.5% ranging from 52% to 72%) and that Solihull had a high rate of outpatient appointments for diabetic medicine (ranked 196 out of 211 CCGs). A diabetes working group was therefore set up to look at review and redesign of the whole diabetes pathway. This consisted of members from primary care, secondary care, community care and Public Health as well as Diabetes UK and patient representation. From its inception this group was clear in its desire not to sacrifice patient care in order to achieve savings. It would therefore have to come up with innovative ways to design the pathway which would keep patient outcomes paramount while also being cost effective. The collaboration which resulted has led to the development of a truly integrated diabetes pathway in Solihull, bridging the divide between secondary and primary care and incorporating the patient perspective.

obJECtIvESTo pilot a specialist diabetes service for the population of Solihull that shifts care from hospital and community out-patient clinics to general practice without incurring major cost. To remove the barriers between primary and secondary care allowing collaborative working for the improvement of patient outcomes.

SolutIonInterest was expressed by five practices to join this pilot. The diabetes leads and practice nurses met for an exploratory meeting together with the Diabetes Consultant, GP Facilitator, Community DSNs, Pharmacy lead, CCG Project Manager and Patient representative. After discussion, it was agreed that a ‘virtual clinic’ would take place in each practice monthly for four months. The members would form a community multidisciplinary team. Using the computer patient records the team would together formulate an action plan for each patient discussed. The duration of the pilot was dictated by the requirements of the ERG and this meant that the outcomes needed to be realistic for such a short time frame.

Solihull has seen an increase in people with diabetes in the last three years of 11%, compared to the national average of 6%. In addition, diabetes has been identified by Heart of England Foundation Trust as an area where savings on current annual spend could be made. Therefore the challenge has been to effect a redesign of the diabetes pathway achieving financial efficiency while providing quality patient care in general practice. Through collaboration between commissioners, community services, primary and secondary care the team has developed a high quality service which has enhanced the skills of the Primary Health Care Team and delivered improved outcomes and satisfaction for patients but without incurring any appreciable increase in costs.


Solihull Community MDT Project – Collaboration in Care by Heart of England Foundation Trust/Solihull CCG



Solihull Community MDT Project – Collaboration in Care by Heart of England Foundation Trust/Solihull CCG

rESultS Over the four months the total number of patients discussed at the MDTs was 316. At the end of the four month period 102 patients had had a post pilot HbA1c. Mean change in HbA1c was -1.3% while mean improvement in glycaemic control was -1.8%. There were also significant cost savings in terms of drugs stopped or switched.

lEarnIngSHaving successfully shown that this model of providing diabetes care is effective and cost efficient it is now the intent of the CCG to role out the model to all practices in Solihull. In fact six more practices have already expressed their interest in joining. The model will continue to be reviewed and it is hoped in the future to add other members to the MDTs including dieticians. By upskilling clinicians in more complex diabetes management, the team can reduce referrals to community and secondary care clinics with no major outlay in cost. This has been largely due to the use of a pharmacy adviser to rationalise and optimise medication at the time of the MDT. This should make the initiative adaptable to all CCGs, including those where other integrated care models already exist, and particularly attractive in this time of financial constraint.

EvaluatIonThe pilot was evaluated both quantitatively and qualitatively achieved all stated objectives. GPs and PNs taking part in the pilot were asked to complete pre- and post-pilot questionnaires, with responses showing an increase in confidence in all parameters.

This was another very collaborative project which had a good impact in the local area and demonstratated improvement in glycaemic control.


Introducing dedicated annual review clinics for children with T1DM by Paediatric Diabetes Team, Gloucestershire Hospitals NHS Foundation Trust

ChallEngEPrior to 2014, annual reviews for children and young people with type I diabetes in Gloucestershire were conducted during routine clinic appointments. These were done on an ad hoc basis at yearly intervals for each individual patient, with no extra time allocated for structured education. Some patients were having annual review bloods taken in the adult hospital phlebotomy service and some in primary care. This variation resulted in difficulty in complying with the seven key care processes in the 2013-2014 National Paediatric Diabetes Audit, with just 22% of patients having their cholesterol measured.

obJECtIvESTo develop a dedicated annual review clinic for children and young people in Gloucestershire with type 1 diabetes.

SolutIonThe vision was to set up a streamlined and dedicated annual review clinic where patients receive all necessary physical checks, blood test investigations and standardised structured education in a single afternoon clinic visit. Planning began in January 2014 with the first annual review clinic held in April that year. The Lead PDSN liaised with the nursing lead for outpatient services to arrange a paediatric nurse-led phlebotomy service for each clinic. It was also arranged for retinal screening to attend the clinics in order to provide a mop-up clinic to capture patients who had not attended in primary care. Patients were sent a letter inviting them to an age specific pump or injection annual review clinic and explaining the purpose of the new clinic. In the 2014 clinics, education sessions were conducted with families rotating through 15-minute stations covering different topics with different professionals. This was then changed in 2015 following feedback from the 2014 evaluation such that the nurses and dieticians ran a combined 1-hour education session to improve peer support and minimise the time spent waiting. A structured feedback questionnaire was developed for patients attending the 2014 clinics and this was modified following the first annual service evaluation project for the 2015 clinics in order to capture more information from service users.

In 2014 the diabetes multidisciplinary team at Gloucestershire Royal Hospital Foundation Trust introduced a dedicated annual review clinic for children with type 1 diabetes over the age of eight years. This takes the form of a three-hour afternoon clinic visit, facilitated by the diabetes multi-disciplinary team, retinal screening and an onsite nurse-led phlebotomy service. Children are offered their consultant appointment, foot check, retinopathy screening and annual review bloods. Furthermore they are encouraged to participate in structured education sessions with other patients and families attending. Sessions are delivered by specialist nurses and diabetes dieticians and have evolved throughout the process by questionnaire evaluation from our patients and families, who are encouraged to share ideas, experiences and questions about their diabetes. Service users and families have indicated they value the service highly.

Patient Care Pathway – Children, Young People and Emerging adults


Introducing dedicated annual review clinics for children with T1DM by Paediatric Diabetes Team, Gloucestershire Hospitals NHS Foundation Trust

rESultS26 annual review clinics were delivered in 2014-2015 and 20 in 2015-2016. In 2014-2015 147 patients attended annual review with a DNA rate of 11.5% (17 patients). In 2015-2016 176 patients attended annual review in 2015 with a DNA rate of just 6% (11 patients). 91% of respondents positively to the question “Is an annual review clinic useful” with 78% answering ‘yes definitely’. The most noticeable area for improvement from the 2014 evaluation was around time management during the clinic and education sessions with a quarter of respondents giving low satisfaction scores of 1-3 out of 5 the question “Do you feel the timing of the session was right”. As a result the timing of education sessions were re-configured for 2015 as detailed previously. The majority of 2015 respondents had high satisfaction scores on a strength of agreement and disagreement scale when asked about the relevance of material covered in education sessions, how useful the education sessions were and the ability of annual review to answer their questions. Importantly, 85% of patients and families attending annual review and completing the evaluation form either agreed or strongly agreed that they would use what they had learnt to improve their health.

lEarnIngSBoth quantitative and qualitative data from service users support the success of the initiative. 91% of patients felt the concept of annual review clinics was either definitely or probably useful during its first evaluation and 88% of patients surveyed during both clinic cycles (91% in cycle 1 and 85% in cycle two) felt they would use what they learnt at the clinics to improve their future health.

EvaluatIonThe project has achieved its primary aim, but there are some objectives which have not been fully delivered due to service constraints. Firstly psychology screening is not currently being undertaken during annual review clinics, however this is undertaken throughout the year in routine clinic appointments. Secondly, retinal screening did not attend all the clinics but the team is continuing to try and facilitate their presence at future annual reviews. Results from the professionals’ evaluation in 2014 and patient feedback from 2014 and 2015 helped improve clinic time management and structure of the education sessions. Analysis of attendance rates for the clinic shows reduction in non-attendance rates from 2014 to 2015, supporting the fact that patients value the clinic.

Excellent aims and planning, particularly regarding the content and style of education based on user views and acknowledging that parents and young people have different oppinions. This is a solid initiative in service redesign for young people and has also improved glycaemic control, thus preventing further complications.



Diabetes transition from paediatrics to adult services by Isle of Wight NHS Trust

ChallEngEThe transition service used to take the form of one appointment with the paediatric team and adult clinicians at a time dictated by age (usually 16-18 years) rather than by what the young adult themselves wanted. There was very little input from patients into the service design, and the meeting was held in a room which was rather intimidating. In short, it felt like an interview panel.

obJECtIvESTo improve the transition experience so that the young adult became engaged with adult services and that this continued in the long term. Change the transition appointments and process to make the process more user friendly.

SolutIonIt was agreed that rather than meeting the whole team the individual should just meet the adult DSN, the dedicated facilitator, in the paediatric DSN clinic and discuss if transition was still appropriate. When the young adults meet the adult DSN for the first time they have an opportunity to ask questions about the service and what will happen. The idea is to make the whole process as non-threatening as possible and so that the young adult is in the driving seat but given information to make their own decisions whilst still having the support of a team. Education is also delivered on a one to one basis but also is available in groups depending on their choice. The main issues which are discussed are alcohol, recreational drugs, sick day rules, prevention of DKA and hypoglycaemia and driving and these are all discussed in a non-judgemental way. This is critical not only in relation to these subjects but any part of living with diabetes. Otherwise individuals either dread coming or will not attend and so disengage. The main original aim was to just improve the person’s experience of this service and keep as many young adults engaged, so attending, as possible. However because of the new approach, this has had other added benefits of improving diabetes control and engaging in other services as well.

rESultSPatient experience reports high satisfaction on being treated as an adult, age appropriate advice and a more Transition is now an individual appointment with the PDSN and adult DSN to agree if the timing is right for the person to transition. Ninety four percent of people have successfully engaged at transition and there has been an increased attendance rate to adult services post transition.

Those who transitioned from paediatric to adult diabetes services at Isle of Wight NHS Trust were largely lost to follow-up and many found the whole process was intimidating. The healthcare professionals now work together as a multi-disciplinary team to ensure the transition is a smooth, planned, supported change process at an age-appropriate time. Joint transition clinics with the PDSN and adult DSN are provided throughout the year which allows the young adult transitioning through to adult services to meet the DSN to discuss any issues or concerns they may have regarding transition. The young adult is communicated with as an equal and information is shared to enable an informed decision. Six months following transition young adults are invited to meet the consultant in a joint clinic with the DSN. Since this process began in 2010, 94% of young adults have successfully transitioned.



Diabetes transition from paediatrics to adult services by Isle of Wight NHS Trust

lEarnIngSAttending clinic appointments enables young adults to feel supported in all areas of their insulin management. Young adults feel able to disclose and discuss issues, such as drugs and alcohol without fear of being judged, and therefore obtain safe accurate information relating to these issues and diabetes to keep them safe. Discussions on all aspects on life is also encouraged in clinic to provide a holistic approach to care as transition occurs when concurrent life changes are occurring and young adults report that this is extremely beneficial to discuss issues that are concerning them rather than focusing on HbA1c and diabetes management. The open communication has resulted in further benefits and an increase in successful self-care and management. This has been particularly identified in the number of hospital admissions for diabetes emergencies and unplanned pregnancy in those people who have transitioned through in this model.

EvaluatIonAttendance to the specialist service has improved as well as attendance to local screening programmes. It has shown improvements in HbA1c of 16mmol/mol (some of these are only six months post transfer). Rates are improving for ACR screening (87%) and are higher than the national average for England which has an ACR rate yearly of 56.7% in people with type 1 diabetes (National Diabetes Audit 2015). Lower limb assessment screening rate is comparable to the rest of the country for all adults. This could still be seen as a success given the age group and the fact that they may assess their feet on a daily basis themselves and so may not acknowledge the need for official screening.

This is a good transition model and great to see the patient “in the driver’s seat” when planning the service, as well as consulting young adults who had already been through the process. The audit results were very impressive.




Diabetes services for adolescents and young adults – transition and beyond by ENHIDE (East and North Herts Institute of Diabetes and Endocrinology) – East and North Herts NHS Trust

ChallEngECare of adolescents and young adults with diabetes remains challenging for those supporting this vulnerable, frequently disenfranchised group, and a national priority. Young people with diabetes aged 16-30, and their families, experience many difficulties. These include poor capture of basic care processes and adherence to standards of care, lack of access to psychological and nutritional support, a lack of ‘join up’ between health, social service and education services and delayes in provision of services, therapy and equipment. There is patchiness in good practice, such as variable provision of a key worker to help with coordination and navigation of the health, education and social care.

obJECtIvESTo provide integrated seamless care across sites. To create new processes for transfer from transition to young adult services with consistency of adult consultant and DSN personnel, and to enhance care of disengaged young people aged 16-30.

SolutIonA unitary team was created with senior clinical (medical, nursing, dietetic, and latterly psychology) and managerial representatives developing a strategy to improve care for this target group. Having recognised through audit and shared information that the transfer to adult services was a poorly implemented process, and that a significant number of previously well managed patients ‘disappeared’ at age 19 years, services were revised to create a transition (to adult service) clinic. Discharge to adult services at 19 years was renamed ‘transfer’ to newly-established dedicated young adult diabetes clinics, provided on three clinic sites.

Collaborative working between paediatric and adult diabetes services remains fragmentary and successful transfer onto adult diabetes services is the exception rather than the rule. However, East and North Herts NHS Trust has evolved joint Child and Adult Diabetes services from two under-resourced teams in separate acute Trusts (using paper records and with poor coverage of care processes) to a unified model of transitional care for young patients aged 16-19. The single Trust’s diabetes information systems capture both out-patient and emergency hospital activity. The evolution of this service has taken over 20 years of close collaborative working and has demonstrably improved health outcomes into adulthood. A telehealth project will utilise text and Skype technology and be led by a young persons’ worker and diabetes specialist nurse to enable an innovative out of clinic approach to supported care, working closely with primary care.


Diabetes services for adolescents and young adults – transition and beyond by ENHIDE (East and North Herts Institute of Diabetes and Endocrinology) – East and North Herts NHS Trust

rESultSPrimary Outcome of HbA1c improved in all age groups especially 16-19 year olds. There was also better capture of data and improved care processes (NPDA and Peer review findings), improved access to psychology and reduced DKA admission rates. There were 6 DKA admissions (in 6 cases) in 2014-15 and 11 in 2015-16 (in 11 cases) - lower than historical admission date and comparing favourably with the NPDA figures

lEarnIngSA ‘lost to follow-up’ audit revealed the need for a new approach: the CCG has commissioned a two-year pilot of a non-medical provided model of care by diabetes nurse and young adult worker using telemedicine to enable re-engagement of a significant number of the 250 identified disengaged young patients. More generally, staff have developed and used new skills to enhance care through transition into young adult services - including improvements in medical and psychological care, with wider use of open questioning during consultations from all team members. The diabetes best practice tariff (BPT) has enabled the appointment of two psychologists, and audits of the transition service and transfer of care to adult services has led the CCG to support a pilot telemedicine service. Collaboration between two ‘tribes’ - Paediatric and Adult - has broken down traditional barriers, and established a truly seamless service. The traditional skill mix of paediatric and adult diabetes specialist nurses working together has improved specialist care - in particular the use of complex insulin delivery and glucose monitoring systems.

EvaluatIonAs this is a continuing evolution of a service, and is part of the comprehensive children, young people and adult diabetes service it is not possible to specifically identify cost savings - or indeed additional expenses. The service is fully funded from BPT Tariff and through the separate CCG funding of the telemedicine pilot. Income generated from BPT has helped expand psychology, dietetic and specialist nursing posts. Infrastructure changes have enabled clinics to take place for those in further education or work at more convenient times. The transition pump service has also been enabled in this group, with an evolution of care from child, through transition to transfer to adult services now a reality. Currently 19% of those in transition use insulin pumps. By strategic goal sharing the service has adapted quickly to policy changes, for example adoption of updated NICE Guidelines, technological advances and the changing demographic of our patient groups.

This is a great initiative focusing on a complex area of care. It is a strong example of adopting best practice, showed good collaborative work and has been well-evaluated.



Patient Care Pathway – adults

Improving glycaemic outcomes in newly diagnosed Type 1 diabetes adults by Sheffield Teaching Hospital NHS Foundation Trust

A 2014 audit of Sheffield Teaching Hospital NHS Foundation Trust found that glycaemic outcomes for ype 1 diabetes (T1DM) patients were sub-standard and potentially damaging. Even at one-year post-diagnosis, only 23% of patients were achieving the NICE target of <58mmol/mol vs 27% for all durations of T1DM in the 2012 National Diabetes Audit. The existing patient care pathway was reviewed, and a consensus exercise undertaken to develop a clear evidence-based protocol. Results show significant improvements in glycaemic control compared with those diagnosed 2012-2013, and there is a more than two-fold increase in the proportion of patients achieving the NICE target. Staff and patient feedback has been highly positive, with expectations of staff often exceeded, and 85% of patients being on the recommended insulin regimen.

ChallEngESheffield T1DM patients were found to be at increased risk of complications compared to the national average – therefore the Trust’s service was not as effective as it ought to be. Good glycaemic control is the cornerstone of T1DM management, in order to reduce devastating microvascular complications of diabetes, as shown by the Diabetes Control and Complications Trial (DCCT). Results from the EDIC study (a follow-up of DCCT) showed that there is a legacy effect, ie good control from diagnosis is beneficial, even if control in later years is poorer.

obJECtIvESTo reduce the mean 12-month HbA1c of newly diagnosed T1DM patients, by establishing a clear and consistent pathway which could be implemented across the two acute hospitals within the Trust.

SolutIonMost of the initial care of the newly diagnosed T1DM patient is undertaken by DSNs and dieticians, with back up of doctors - so the DSNs created the new pathway, with dieticians and doctors commenting on it and refining it as necessary. The first hurdle was to get buy-in from the DSN team: data were presented illustrating the poor glycaemic outcomes of Sheffield patients diagnosed within the service over the preceding 2 years, and published evidence of the benefits of achieving tight glycaemic control were discussed. All agreed that the outcomes presented were unacceptable and that there needed to be a new approach. This included:

• AformalisedMDTapproach• Analogue-basedMDIregimenfeaturingtwice-dailybasal• Clearguidelinesforinitiationandtitrationofinsulinandformonitoringofglucoseandketones• Scheduleofminimumappointments/contactwithhealthcareprofessionals(HCPs)• AtargetofHbA1cof42-48mmol/molwithinthefirstthreemonths• ‘Fast-track’systemtoaDAFNEcourse

This was then presented to consultants and dieticians for further comment and amendments. The final version of the new pathway was circulated to the entire diabetes team.



Improving glycaemic outcomes in newly diagnosed Type 1 diabetes adults by Sheffield Teaching Hospital NHS Foundation Trust

rESultSUtilising an in-house database, a spreadsheet of all newly confirmed diagnoses of T1DM from 2012-2015 was constructed. Results from those diagnosed in 2012-13 inclusive were compared to those diagnosed in 2014-15. Statistical analysis of HbA1c outcomes was regularly reviewed. Quantitative feedback was given to the DSN team at their quarterly time-out days, and suggestions for improvement sought. The initial results of the new T1DM pathway were presented at the annual team meeting in April 2015 and follow-up results at the same meeting in April this year. There is a significant improvement in HbA1c at 6, 12, and 24 months, and the proportion of individuals achieving the previous NICE target of <58mmol/mol at 12 months has significantly improved (50.0% for those diagnosed ’14-’15 compared to 23.1% for those diagnosed ’12-’13, p=0.048). In relation to the new NICE guidelines (August 2015) more patients reach the target HbA1c of 48mmol/mol or better at 12 months, 24.1% vs 11.7%, p=0.21.

lEarnIngSGetting buy-in from all stakeholders is integral to the success of implementing change. This service redesign initiative has been driven by a clear strategy, including continual audit of outcomes. It has illustrated that effective teamwork, even in the absence of extra resources, can lead to significant improvement in standards and has raised staff morale. Early indications are that the outcomes are sustainable. The team has already commenced sharing its experience with other diabetes centres.

EvaluatIonA review of diabetes literature shows it is possible for the average HbA1c at 12 months (within a clinical trial) to be 57+12mmol/mol (7.3%). Other data presented at Diabetes UK meetings from paediatric diabetes teams show similar results can be achieved in routine clinical care. In order to achieve this evidence suggests that it is best to have consistency of approach, targets, and messages given to patients/parents. Thus the team chose a 12-month HbA1c target of 42-48mmol/mol, in the hope that a larger proportion of patients would actually achieve 48mmol/mol or less (24.1% 2014-15 vs 11.7% 2012-13). Equivalent outcomes have been achieved compared to the best published evidence (mean 58+18 mmol/mol) but at a fraction of the cost.

This is a great example of engagement and the innovation is the ability to implement a whole team change in mentality. The pathway is patient centred and takes a common sense approach to Type 1, leading to big improvements in patient experience. This pathway should be distributed around the country.



Save Sight – Impact of dedicated diabetes eye nurse specialist in diabetes retinopathy by The Hillingdon Hospital

ChallEngEDiabetic retinopathy is the second most common cause of vision loss and the leading cause of visual impairment and blindness among working-age adults in the UK. There is sufficient evidence linking chronic suboptimal blood sugar control with development and worsening of diabetic retinopathy in both type 1 and type 2 Diabetes. Currently there are no best practice tariffs or initiatives to improve diabetes control once diabetic retinopathy is diagnosed. The current model of diabetes care existent across UK supports more community based diabetes care and many patients with known microvascular disease do not have access to specialist care. Separating diabetes specialist appointments from the ophthalmology appointment perhaps does not clearly highlight the importance of improving blood sugar control as the mainstay of treatment to this patient group.

obJECtIvESTo identify diabetic patients with suboptimal glycaemic control who have referable diabetic retinopathy in a district general hospital eye clinic. Offering intervention in the form of education, treatment intensification or early referral to secondary care. To measure the efficacy of intervention using A1c as surrogate marker of glycaemic control.

SolutIonA formal meeting was arranged with managers of both diabetes and ophthalmology divisions, along with ophthalmology lead and consultant diabetologist. Funding was agreed for two sessions, one paid by the ophthalmology directorate and the other from the diabetes medical directorate. A diabetes nurse specialist was recruited to work alongside the ophthalmologists on the same day of the diabetes retinal clinics to identify and recruit patients for this project. The referral criteria to the dedicated diabetes eye nurse specialist (DDENS) was set to an HbA1c >75 with referable diabetes retinopathy to ensure that the service was sustainable within limited resources and not overwhelmed at the outset. The role of DDENS was to review the patient’s diabetes management plan and offer education. Wherever possible, no change was made to the pre-existing arrangement of the diabetes care provider.

The Hillingdon Hospital set up a service embedding a dedicated diabetes eye nurse specialist within the retinopathy treatment eye clinic, obviating the need for referring all patients with suboptimal glycaemic control. A Dedicated Diabetes Eye Nurse Specialist (DDENS) educated these patients and reviewed their diabetes treatments. In the cohort of 116 patients seen between March and December 2015, there was a reduction in median A1c from 89mmol/mol to 72mmol/mol in 102 patients. These results came in patients followed up for three months up to 12 months. Patients found the service acceptable, accessible and convenient. The caregivers found it more satisfying and efficient also. It is projected to save both the ophthalmology and diabetes specialist services money in the medium to long term while improving outcomes for patients.



Save Sight – Impact of dedicated diabetes eye nurse specialist in diabetes retinopathy by The Hillingdon Hospital

rESultSBetween March and December 2015, 116 patients were seen on at least one occasion by the DDENS. (79 male and 37 female, with age ranging between 27-84 years, median 59 years). 74 were of Asian ethnicity, 34 Caucasian and 6 Afro-Caribbean patients - broadly representing the ethnic diversity expected in the coverage area. The majority were under GP-led diabetes care (71%), while 16% were known to hospital based specialist diabetes teams. Another 11% were known to community specialist diabetes services and 2% to both community and hospital specialist team. Most patients (109/116) required some intervention from the DDENS. Education as the only intervention was used in seven patients. 102/116 needed additional therapeutic intervention. 15 patients were commenced on insulin, insulin doses were titrated in 51 patients and oral hypoglycaemics were changed in 34 patients (31%) and timing of medication was adjusted in two patients (2%).

lEarnIngSHayes is a relatively socio-economically deprived area and provided nearly half (46%) of subjects who benefited from this service. Their average A1c 92.7 (median 89.5) at referral reduced to 75.1 (median 69). There is a very successful retinal screening programme that refers and recalls diabetic patients in the UK it does not necessarily feed into the local diabetes services. Patients who were seen from between 1-5 times by the DDENS showed an improvement in their overall diabetes control as demonstrable by the HbA1c 17.3 average reduction. In those followed up, with a repeat HbA1c from 3-6 months of being seen initially (n=41), their median HbA1c improved by 19 (average 15.8). This improvement was sustained in those followed up for longer: 7-9 months (n=35) and 10-12 months (n=26), with median HbA1c improvement of 16 (average 19) and 15.5 (average 17) respectively. 71% of the cohort had GP-led diabetes care, and have been able to achieve significant improvement in glycaemic control, potentially averting referral to secondary or community led diabetes services. The heightened perception by patients of risk to eyesight in the setting of a retinopathy treatment centre may also make them more receptive to education and intervention generally.

EvaluatIonThere has been significant reduction in A1c in the cohort, and some evidence of reversal of retinopathy with improving glycaemic control. Data on actual intervention for retinopathy is required over a 12-month period, so is not yet available.

This is a simple, but effective, intervention that shows a good working relationship between ophthalmology and the diabetes team. The HbA1c reductions are impressive in a group that really matters.



Successful outcomes in gestational diabetes through group education pathwayby Basingstoke and North Hampshire Hospital NHS Foundation Trust

The rising incidence of gestational diabetes and inconsistent patient and foetal outcomes in Basingstoke and North Hampshire Hospital NHS Foundation Trust led to a redesign of its patient pathway for women with a positive oral glucose tolerance test. All women with a positive OGTT are invited to an afternoon session with education delivered by a diabetes nurse, diabetes specialist midwife and dietician. Women are taught home blood glucose monitoring. Review of monitoring data is carried out in a midwife led clinic that runs in parallel to our routine joint antenatal/diabetes clinic. A number of benefits have been demonstrated, with patient-reported outcomes showing the shared learning experience reduced anxiety and became a positive drive to improve diet and lifestyle. Group education is extremely cost effective and peer support, standardisation of educational materials and quality control of education are now embedded.

ChallEngEThe number of women being diagnosed with gestational diabetes is rising. Women require a multidisciplinary approach to their antenatal care. Each member of the team seeing patients individually was not sustainable without reduction in quality of information and support given. A lack of dietetic time was a main driver to change. The Trust’s previous programme tended to over medicalise the experience and was not always viewed as a positive experience.

obJECtIvESTo deliver a group education programme for women diagnosed with gestational diabetes with input from diabetes, obstetrics and dietetics which delivered comparable obstetric and maternal outcomes to existing program and made best use of the limited resources of our health care professionals.

SolutIonAll women diagnosed with gestation diabetes are invited to a two-hour group education session. If they are unable to attend this session due to special circumstances – such as language barrier or educational needs - a 1:1 session will be offered. The session covers issues such as effects gestational diabetes can have on the woman and the foetus; potential treatment pathway; healthy diet and necessary lifestyle changes; how to monitor blood glucose levels correctly; and what follow-up care to expect. Partners are encouraged to attend to support the learning process. Outcome data for all women with a positive oral glucose tolerance test was collected and compared to previous internal and nationally available audit data sets. The Trust pathway was designed within the existing staffing resources. The lesson plan was created based on NICE recommendations, and previous knowledge of structured education programmes, eg Expert and DESMOND.



Successful outcomes in gestational diabetes through group education pathwayby Basingstoke and North Hampshire Hospital NHS Foundation Trust

rESultSSeventy nine patients were diagnosed with gestational diabetes with pregnancies ending in 2014-2015. Sixty five percent achieved good glycaemic control with diet/lifestyle change alone (51/79), 29% achieved good glycaemic control following addition of metformin (23/79) and 6% required insulin treatment +/- metformin (5/79). This showed significant improvements when compared to previous practice despite increased numbers of patients and is higher than national reported averages of <30-55% for lifestyle alone. Mean birth weight was 2.971kg (range 1.9-4.3kg) with 4% of babies >4kg. Nationally 12% of babies are born >4kg. Maternal weight data with booking weight compared to last recorded weight pre delivery was only 5.5kg (range -3kg to +23kg). This data set is incomplete but shows and encouraging signs of reduction in maternal weight and lowering of future diabetes risk. Seventy seven percent of woman attended post natal follow-up and had HbA1c or oral glucose tolerance test recorded. No cases of diabetes were diagnosed. This compares to <30% follow up in previous practice. This reflects the value patients had for service and gave further opportunity of continuing lifestyle change, preconception advice and allows development of prevention strategies for future. Patient reported outcomes where all positive important themes reported where decrease in anxiety, able to talk freely, non-judgemental, empowering, and supportive. Patients were able to talk openly about adjustments made and willingness to take on further dietary modification if needed. The new pathway has demonstrated efficiency in use of time and resource and increased access to advice as all women received advice on diabetes, obstetrics and diet. Extra time created by avoidance of 1:1 encounters has been reallocated within service improving outcomes for other patients.

lEarnIngSThe results demonstrate a significant improvement in our numbers of patients achieving good glycaemic control with diet/ lifestyle and metformin alone. Fewer women required insulin therapy, further reducing the burden of insulin safety education, dose titrations and so on. Outcomes for mothers and babies have improved from baseline and a trend towards less maternal weight gain has also been observed. The most important impact has been on patient experience. Peer support and group discussions time has empowered women to voice anxieties and made significant lifestyle change.

EvaluatIonThe programme evaluation was measured against the team’s own internal audits, published audits from other centres and national pregnancy data. The aim of care in pregnancy is to achieve St Vincent declaration goals that maternal and foetal outcomes should be comparable to women without gestational diabetes. Clear improvements in outcome have been seen and feedback was extremely positive. Efficiency in service and a multi-professional approach has improved training opportunities and proved cost effective.

We are all facing a rising tide of GDM with limited resources. This intiative is an excellent attempt to provide quality care with efficiencies. It is simple, low tech, easy to transfer and has one of the most fantastic websites!


Expanding Type 1 Kidz Project and introducing simple telehealth by Investing in Children

Investing in Children (IiC) is concerned with the human rights of children and believes every child and young person should have a say in all matters affecting them which should bring positive changes. In 2001 IiC started to work with children and young people with type 1 diabetes in County Durham and Darlington to have discussions about the care that they received. It became apparent that the children, young people and parents IiC worked with appreciated the support they got from each other – and monthly support group Type 1 Kidz was started in October 2012. With more funding, two further Type 1 Kidz groups were created across four paediatric services: an over 14s ‘T1ZY – Type 1 StudentZ & Youth’ Group was developed, Simple Telehealth text messaging was introduced and there has been continuous dialogue leading to changes within services.

ChallEngEThe North East has the highest incidence of DKA in the UK with approximately 250 children and young people being admitted to hospital every year for treatment, costing the local NHS £750,000 yearly. Many children and young people are not engaging with their care, resulting in more unplanned hospital admissions and more potentially-avoidable short- and long-term complications.

obJECtIvESExpanding T1KZ across the region to create an environment where children, young people and families can support and learn from each other and improve their health outcomes. To make significant long-lasting changes to Paediatric Diabetes Teams and to design Simple Telehealth Pathways with children and young people for children and young people.

SolutIonA Professional Steering Group and Children & Young People’s Steering Group were set up to oversee planning and implementation of the project. Children, young people and families were invited to a ‘Taster Day’ in May 2014. Young people facilitated discussions to see what children, young people and families would like to gain from T1KZ and get their opinions of how it should be established. The two groups were established in September 2014 and January 2015. All work was carried out in partnership with clinical teams. An IiC Project Worker and young people attended clinics to promote the project and Simple Telehealth Pathways were created.

rESultSThere are three monthly Type 1 Kidz Groups spread across North East England where 114 children and young people with T1 have attended. Discussions have included carb counting, pump sessions, ‘bugs in a box,’ and why it’s important to keep healthy. It is believed that more knowledge will lead to better diabetes management and improved health outcomes now and in the future. In group discussions families are able to have conversations about the care that they receive from their Diabetes Service, which is fed back to clinical teams. IiC has a quality assurance process which encourages good practice where services listen to children & young people and changes are made as a result - they are re-evaluated yearly. Changes have included a psychologist being employed, more initiatives for children and young people to meet their targets in clinic and more reliable, age-appropriate

Involving the Diabetes Service user and Families/Carers


Expanding Type 1 Kidz Project and introducing simple telehealth by Investing in Children


information being given. So far two pathways have been identified and designed in telehealth: Motivational Pathway & Reminder Pathway. Young people designed a motivational pathway where interactive text messages would be sent every other day for a period of six weeks. The aim of the pathway would be to motivate young people who were identified to be struggling to manage their diabetes better. A reminder pathway was also developed where messages can be sent on particular dates and times to remind them to test their blood and take insulin.

lEarnIngSThe initiative was found to have a significant impact on service users and with engagement from clinical teams. IiC has engaged with 446 children and young people through clinical visits and events, which is approximately 63% of children and young people with T1 Diabetes in the region. Furthermore 119 children and young people have specifically attended Type 1 Kidz Sessions which is 17% of all children & young people. Further to this teenagers expressed a desire to meet outside of the ‘Type 1 Kidz’ group sessions and talk about specific age-related topics, such as travelling, university, alcohol, sexual health etc. and therefore ‘Type 1 StudentZ & Youth’ was created. This group meets once a month and is especially for young people over the age of 14. This group also continues to explore telehealth – which currently has 79 young people using Motivational and Reminder pathways across the region. Further funding from Sunderland CCG and Gateshead CCG was achieved this year, allowing all three groups to continue. Families have donated approximately £5,000 to the project.

EvaluatIonChildren, young people and families were asked what was important to themselves in terms of diabetes and what would they like to achieve by attending Type 1 Kidz. Topics included confidence, emotional wellbeing, knowledge and support networks. A 23-question survey was given to children and young people on their first visit to Type 1 Kidz and then six months later. Due to practical issues it was agreed by the Steering Group that the evaluation would look at ‘Low attenders’ and ‘High attenders’ as opposed to ‘Before’ and ‘After’ responses. High attenders are more likely to be more motivated to lead a healthy lifestyle and be less reliant on others. The success of using Simple Telehealth has also been evaluated: it increased the average number of blood glucose readings and HBA1C results within target range, reduced DNAs and cancellations and improved young adult experience.

This is a fantastic project which has clearly achieved a lot in 18 months. It is a true multidisciplinary effort, with young people driving the agenda and a multidisciplinary team of health professionals and youth workers making it happen. All working together, supporting peer learning to ensure there is factually correct information available.



Integrated group psychotherapy for adults living with diabetes by Betsi Cadwaladr University Health Board

ChallEngEIn 2009, as part of a new locality based diabetes team (total population 50,000), the DSN and dietitian implemented a variety of interventions to support patients to self-manage their diabetes. But by 2011, a sub-group of patients still found their diabetes management and control challenging due to co-existing emotional or relational difficulties which usual care was not addressing. This meant patients were ‘held’ in usual care making little improvement, or discharged where their diabetes management deteriorated, and so would be referred to re-enter the usual care over again. There were some patients also reluctant to enter usual care, or those who accessed regular contact through unplanned phone or clinic visits, were reluctant to be discharged by health professionals or their self-care (eating behaviour, glucose testing, and administration of medication/insulin) became sabotaged. Patients who were offered referral to the local CMHT would often decline (due to stigma) or dropped out of the treatment offered, and the waiting times were around 18 months for a longer therapy which would be usual when treating emotional/relational difficulties in a psychoanalytic way. This was both unsatisfactory for the patients and difficult to time manage for the diabetes professionals.

obJECtIvESTo provide an intervention which would be accessible to patients with the full spectrum of diabetes phenotypes, when usual care was rejected, or not successful, and whose commonality would be having emotional or relational difficulties making their diabetes self-management difficult. To develop an integrated psychotherapeutic approach to treat mental and physical health concomitantly.

SolutIonDuring 2011 and 2012 the dietitian and DSN arranged in-house training to observe and experience psychotherapists delivering group intervention based on therapeutic community and group analytic principles. They also joined a supervision group run by the lead for personality disorders services for multi-professionals within the local CMHT. In 2011, the dietitian undertook a Foundation training in group analysis (through Institute of Group analysis, IGA) and in 2013 undertook a Diploma in group work through the IGA, which involved setting up and conducting a training group to be executed under scrutiny of the IGA as well as the local supervision provided. This framework provided an opportunity for the dietitian (as therapist) to set up a therapy group for 1.5 hours a week, for up to eight patients as a pilot for 30 weeks. All patients sign a confidentiality agreement and understand the boundaries

In 2013, a weekly psychotherapy group was developed within Betsi Cadwaladr University Health Board’s locality diabetes team for diabetes patients for whom self-management was very challenging. Some were reluctant to engage at all, and those discharged were repeatedly referred back to begin the cycle of usual care once again. A group was developed with supervision of the lead psychotherapist for personality disorders, and led by the dietitian as therapist in the group. Patients leave when they are ready, based on their personal outcomes. The diabetes dietitian has supervision from the lead psychotherapist in the personality disorder service. The DSN also works “on the boundary”, maintaining appropriate communication whilst ensuring the safety of the patient. To date 14 patients have been active in the group and reported outcomes and acceptability are very positive and demonstrate individual clinical improvements and reductions in weight and medications.



Integrated group psychotherapy for adults living with diabetes by Betsi Cadwaladr University Health Board

and expected commitment to the group as a whole. All patients were invited to be weighed weekly by an assistant, in order that the conductor has some understanding of the situation a patient with both type 1 and type 2 in terms of what they are working for, and also the patient can talk about the difficult feelings towards this in the group in real time.

rESultSPatients’ outcomes are agreed by the patients themselves when thinking about joining the group, and the group helps patients understand their progress and whether leaving or staying in the group is most helpful. Self-measured outcomes for the patients included: subjective /objective binge eating reducing, reducing or maintaining weight and being able to monitor blood glucose appropriately. Patients who have left the group have enjoyed a variety of their desired outcomes: Funding for bariatric surgery (x1); no longer requiring bariatric surgery (x1); stopping insulin (x2); maintaining > 9% weight loss (x5); and one decided to return to work. The psychological benefits have not been directly measured but anecdotally the patients are able to relate more satisfactorily in their outside lives.

lEarnIngSFifteen patients have been part of the group in all, including the six current members and a new member who was preparing to join in June 2016. As a slow-open model, the duration of stay can vary, although a minimum of 30 sessions would be desirable. This model enables a wide spectrum of diabetes difficulties and also range of psychological, emotional or relational difficulties to be explored simultaneously.

EvaluatIonThis model demonstrates that an inter-disciplinary approach can be provided in a single intervention, if professionals with varying specialist knowledge and skills are prepared to work in a truly integrated way to share appropriate cross discipline skills within a safe governance framework.

This is an innovative solution driven by the vulnerable service users it supports, by defining objectives and supporting each other to achieve them. Judges were impressed with the governance arrangements, the innovation and the evaluation, which looks at process as well as looking at qualitative themes.


YES (Youth Empowerment Skills): A stepping stone for diabetes self care and empowermentby Guy’s and St Thomas’ NHS Foundation Trust

ChallEngEAdolescence is when a person’s identification with a disease is formed. This is a high risk period in which diabetes is often poorly controlled and there is a high incidence of unplanned hospital admissions. In addition, in this period many young people acquire maladaptive coping styles that can have enduring harmful consequences. In the local population of 232 young people between age 14-21, 35 patients were not attending any diabetes care appointments or retinal screening. The remaining 192 patients attended at least one appointment over the last two years however, 26% missed more than 50% of their appointments. The team recognised that a new approach was needed that would reach out and appeal to young people.

obJECtIvESTo co-design and co-deliver with young people an innovative model of education to enhance engagement, promote positive coping styles and resilience, provide social resources and support, and improve health outcomes for young people with diabetes.

SolutIonThe team ran four focus groups with young people, facilitated by a young adult with type 1 diabetes and a youth worker, to consider their thoughts and experiences to develop the content and structure of the programme. Three main themes emerged: the programme should be delivered in a youth friendly environment - not in the hospital; sessions needed to be interactive and give young people the opportunity to meet together to share experiences; and some sessions should be delivered by people with diabetes and not just health care professionals. The name Youth Empowerment Skills (YES) emphasised that the programme was not just about diabetes. A key feature of the programme was to identify the young people and to work with them so that they would feel interested and confident in joining. To this end the programme begins with outreach work from a community youth worker, who identifies disengaged young people and works with them to develop their interest in the programme. This role is pivotal as the youth worker facilitates the group to develop social cohesion within the group. The content of the programme needed to be based on a more interactive social form of experiential learning and needed a holistic health approach: important adolescent health topics such as sexual health, pregnancy and eating disorders were included. Simulation elements of the programme were delivered by actors to replicate life-like scenarios where they experienced scenarios such as treating an episode of severe hypoglycaemia and

Guy’s and St. Thomas’ NHS Foundation Trust’s Youth Empowerment Skills (YES) programme works with young people with diabetes, who have low levels of engagement with diabetes care, from socially deprived areas in South London. YES was co-designed and co-delivered by young people and aims to foster self-confidence and strengthen engagement with diabetes care. The programme contrasts with traditional education models for diabetes as it uses novel educational strategies: key features include outreach work and innovative learning styles, including simulations, peer-led sessions and fun activities (such as climbing or going out for a meal). It uses social media to keep young people in touch with each other, encouraging social networking and the delivery of peer-to-peer support. A clinically important fall in HbA1c has been seen in participants so far.

Empowering People with Diabetes – Children, Young People and Emerging adults


wearing a body suit that restricted their physical functionality. There were also “fun” activities to build confidence such as rock climbing. Peer-to-peer delivery was important with some sessions being led by other young people with diabetes. The sessions were held in a community-based youth centre during the school holidays, over a three-day period. In between sessions and after the programme peer support and interaction was maintained through a WhatsApp group and a closed Facebook page.

rESultSThe youth worker has had contact with 71 young people through the project. Most of these referrals were directly from clinics, with members of the diabetes team identifying patients not engaging with their diabetes care. Additional referrals came from parents, schools and local youth centres. Mean age of the participants was 17 ( ± 1.60) years, eight were male and seven female. They all attended the full programme except for one who became unwell. The mean pre-YES HbA1c was 11.3% (± 2.8) and post-YES it was 9.8% (± 2.5) (p <0.02), with two thirds of participants achieving a clinically significant reduction in their HbA1c (± 0.5%). In terms of participant satisfaction, all participants would recommend the programme to others and 12 participants rated the usefulness of programme for their day to day life as 5/5, with the other three rating the impact as 4/5.

lEarnIngSThe YES programme’s youth worker continues to support the graduates of the programme and they now organise their own meetings and activities and help in peer delivery. They continue to communicate and interact with each other in an ongoing social network for support. This outreach activity is developing robust systems to engage young people with the YES programme – and the social bond that has emerged seems to have had a very powerful impact on the lives of these young people.

EvaluatIonThe evaluation of the YES programme began with the initial focus groups followed through with assessment of the pilot. Reach, utility and acceptability were measured, but the most powerful part of the evaluation was the interviews with the participants a few months after the programme, conducted and analysed by independent researchers.

Social bonding is a vital support mechanism and this initiative - which was co-led by someone with diabetes - was a powerful inspiration. The judges felt it had the patients at its heart and was a great pilot programme that they would like to see spread nationwide.

YES (Youth Empowerment Skills): A stepping stone for diabetes self care and empowermentby Guy’s and St Thomas’ NHS Foundation Trust



Making Transition Better – the Newham Experience by Newham University Hospital

Newham, east London is the youngest borough in the UK with 40% of the population under 25 years old and more than 60% from ethnic groups. This leads to a high prevalence of type 2 diabetes, in young people. As a national pilot site for You’re Welcome (DH 2010), Barts Health obtained feedback from patients and carers through focus groups and found that the three contributors to poor self-management were: poor/inflexible access to care; need for peer support; and lack of patient champions. To address this, the team pioneered the use of online diabetes follow-up via Skype, developed a local peer-support group funded by UCLPartners to provide a social platform for young people to discuss issues affecting self-management, and obtained funding for a youth champion to facilitate the peer-groups and help redesign the clinical service.

ChallEngEThe prevalence of diabetes in Newham is around 5-6 times the national average, due largely to the local BME population. It is also the youngest borough in the UK and the sixth most deprived in the UK. A paediatric diabetes service had provided excellent diabetes care for children in Newham since 1986. However, transition to adult services was poor. The complex needs of adolescents and young adults with a chronic illness like diabetes was difficult to address in routine clinics. Non-attendance rates were high with increasing levels of patient and staff dissatisfaction. Even after the establishment of a monthly diabetes clinic in 2005, DNA rates continued to remain high (33-50%) with poor clinical outcomes.

obJECtIvESTo make the transition from paediatric care more user-centred by improving access to services, developing a more holistic model of care that addresses the complex needs of young people and strengthening young people’s ability to manage their diabetes.

SolutIonFollowing a small technology audit with NHS Choices (2010), funding was obtained to examine the scope and feasibility of web-based consultations via Skype, where physical examination was not required. The success of the work led to a programme grant funded by the Health Foundation (DREAMS 2013-15), which specifically explored the role of Skype-based follow-up in those labelled ‘hard to reach’. Young people were encouraged to initiate online contact as required and we began to provide a more open-access service, which was constantly modified based on patient/carer feedback. A core working group, involving outpatient administration staff, ICT managers and clinicians was set up and met regularly during the project allowing operational problems to be addressed immediately. Funding was obtained from UCLPartners (the academic health sciences network) in 2014 to set up and evaluate the role of peer support groups for young people. A launch meeting was held with attendance from multiple organisations (local providers, academia, Newham CCG, Community Links and Newham Council) to initiate the project and discuss the project plan, research questions and collaborative working. A co-design workshop was held in May 2014 with patients, carers, and a range of local partners including active Newham, the Food Academy, local employers, elected councillors and council-funded services like the local Stratford Arts Centre, to



Making Transition Better – the Newham Experience by Newham University Hospital

plan a programme of events. We were fortunate to be able to involve two students from the local sixth-form Chobham Academy, who worked with the project team and designed promotional material, attended some of the peer-group meetings and advised about the activities. In 2015, funding was obtained from the CCG for a Youth Champion, who has now been appointed jointly with the University of East London. The aim of the post is to facilitate the peer groups, raise awareness of diabetes and work with young people locally to help re-design services, making them more user-friendly.

rESultSWe currently have 219 young people between 16 and 25 years attending the clinic: 162 with type 1 diabetes, 46 type 2 diabetes and 11 other. The work highlighted the adaptive use of Skype in order to fit consultations around young people’s daily lives, which was made possible through the technical functionality of Skype (messaging, ‘online status’) and their existing relationship with the clinician. This reflected in a lower DNA rate for Skype appointments compared to that of face-to-face outpatient appointments. For the majority of Skype consultations, the patient used Skype at home (86%). The second most frequent location was work or university (10%), followed by outdoors (3%). One Skype consultation was carried out during the patient’s trip abroad.

lEarnIngSYoung people live very varied lives. The use of Skype therefore needs to be aligned with the wider social and contextual factors in the patient’s lives, as well as their clinical and technical knowledge and capabilities. However, there needs to remain a healthy mix of face-face and online contact. Patient champions, the use of digital and social media and peer-to-peer support are crucial to success. Collaborative working among all partner organisations (including those not traditionally involved in healthcare) is essential. Establishing and maintaining a service of this type requires a high level of commitment and support from staff.

EvaluatIonA quantitative data and process evaluation was used for patients receiving Skype-based follow up, while qualitative data was obtained from eight patient focus groups, 26 questionnaires and 8 in-depth interviews.

A fantastic project with good local context that had a huge local, national and global impact, and is particularly usable for engaging with a younger demographic.



An educational resource for women with Gestational Diabetes Mellitus by Queen’s University Belfast; Belfast Health and Social Care Trust; South Eastern Health and Social Care Trust; Central Manchester University Hospitals NHS Trust Foundation

GDM is associated with increased perinatal morbidity and a 7-fold risk of developing type 2 diabetes in later life compared with normoglycaemic pregnancies. Approximately 5% of UK pregnancies are diagnosed with GDM. Funded by the International Diabetes Federation the aim of Queen’s University Belfast’s resource ‘GDM: Things you need to know, but maybe don’t!’ is to improve the patient experience of every woman diagnosed with GDM during their pregnancy. Originally produced as a DVD in four languages (English, Urdu, Arabic and Somali) and later converted to a website (www.womenwithgestationaldiabetes.com), it was evaluated in a multi-centre randomised controlled trial among 150 multi-ethnic women with newly diagnosed GDM in three UK hospitals. It is now used routinely in patient education and, via the use of social media, usage of the website is growing from patients globally.

ChallEngEGDM is associated with increased perinatal morbidity and a seven-fold risk of developing type 2 diabetes in later life compared with normoglycaemic pregnancies. Approximately 5% of UK pregnancies are diagnosed with GDM. There is a dearth of patient-friendly support material on this serious condition.

obJECtIvESTo design, develop, pilot and evaluate an effective educational tool for improving the patient experience of every woman diagnosed with GDM, leading to a sense of empowerment and allowing woman to regain control of their lives. To educate women to make changes to their diet and lifestyle to prevent type 2 diabetes.

SolutIonDVD design and development centred on two key stakeholders (‘DVD user group’ and ‘professional advisory group’) working alongside a professional multimedia company. Five design focus groups were conducted in multi-ethnic women in Manchester and Belfast. Data from these was then used to steer the DVD design. The DVD user group also provided feedback on preferred DVD style, informing modifications and improvements during the development and pilot stages. The resource, a DVD or website, features five women with GDM from different ethnic backgrounds sharing their views and experiences throughout pregnancy. These interviews are accompanied with an evidence-based commentary and user-friendly graphics to assist in the understanding of the condition.

rESultSThe DVD was evaluated in a multicentre randomised controlled trial (RCT) in Northern Ireland and Manchester, 2 distinct populations with regard to ethnic mix. 150 women with GDM were recruited and randomised to receive the DVD in addition to standard care or standard care alone. Impact of the DVD on maternal anxiety and stress and blood glucose control were assessed. The aim of the RCT was to evaluate the impact of an innovative patient-centred educational DVD on anxiety and glycaemic control in newly diagnosed women with GDM. They were asked to complete a series of validated questionnaires on maternal anxiety and stress and were followed up at their next scheduled clinic visit and asked to repeat the same questionnaires. In addition,

Empowering People with Diabetes – adults


An educational resource for women with Gestational Diabetes Mellitus by Queen’s University Belfast; Belfast Health and Social Care Trust; South Eastern Health and Social Care Trust; Central Manchester University Hospitals NHS Trust Foundation


self-monitored capillary blood glucose on day prior to clinic visit was documented and those in the DVD group were asked to complete a feedback questionnaire. Primary outcomes were mean one-hour postprandial blood glucose and state anxiety. Unfortunately, no significant difference was reported between the DVD group and standard care for anxiety or mean 1-hour postprandial self-reported capillary blood glucose at visit 2. However, patient feedback on the resource produced positive results. Using a scale of 0-10, 84% rated the DVD 7 or above for usefulness (10 being very useful), and 88% rated it 7 or above when asked if they would recommend to a friend (10 being very strongly recommend). To maximise impact, the DVD was converted to a website - www.womenwithgestationaldiabetes.com - which went live at the end of January 2016.

lEarnIngSAlthough patient anxiety or self-reported glycaemic control (primary outcomes) remained unchanged between those women randomised to receive the DVD and the control group, feedback indicated that the DVD still had a beneficial impact on this patient group. Indeed many healthcare professionals informed the team on many occasions that this resource was an excellent and much needed educational tool in busy clinics. Subsequently, additional DVDs were allocated to all three trial centres after the trial for use as patient education tools. Meanwhile website traffic is monitored on a monthly basis.

EvaluatIonAlthough the team did not see a difference in patient anxiety or self-reported glycaemic control between women randomised to receive the DVD and the control group, the DVD had a beneficial impact on this patient group. This qualitative data proves that the resource is an informative and user-friendly tool for educating women, and their families about GDM and its management. While the website is in English, foreign language videos (Urdu, Somali and Arabic) can be accessed from the website. This resource, designed by women with GDM for women with GDM, could easily be utilised by other clinics and healthcare professional, both in primary and secondary care throughout the UK, and beyond.

The judges loved the principle of this entry and that it truly empowered patients and their families by aiding them in asking the right questions to gain valuable answers. The translation into four languages was impressive, particularly considering the cost of translators for a project that was provided free-of-charge. Well-conceived and delivered, it had great impact and the judges would put it straight into practice in their areas.


ACT Now! Guided self-help for adults with Type 2 diabetes to improve self-management and emotional wellbeing by NHS Grampian

A team in NHS Grampian developed a brief, guided self-help programme designed to improve glycaemic control and alleviate anxiety and depression in people struggling to manage type 2 diabetes. ACT Now! consists of between 5-8 appointments, a participant manual and web-based support. The web support incorporates five core modules that promote key self-management behaviours, and three optional modules for those experiencing significant levels of anxiety, depression, or emotionally-driven eating. All modules contain a mixture of video, audio and text material that aim to reinforce weekly discussion topics, provide patient stories, and deliver top tips from experts in the topic areas. Results showed improvement in all areas for participants, including glycaemic control, and anxiety and depression levels fell significantly from baseline to follow-up, as did diabetes-related distress. Participants increased their walking markedly.

ChallEngEDespite regular appointments and good quality education, about half of people with type 2 diabetes do not achieve recommended levels of glycaemic control. Markedly changing complex, long-established lifestyle behaviours that influence glycaemic control and health outcomes, and adhering to treatment regimens that may induce significant side effects can be extremely challenging. Clinical and subclinical anxiety and depression are common, and are associated with poorer glycaemic control. Research indicates that treating anxiety and depression alone does not lead to better diabetes control. Prior to this project there were not any specific guided self-help programmes available for people with Type 2 diabetes in NHS Grampian, or across the UK.

obJECtIvESTo create an intervention that consisted of a small number of 1:1 appointments, a participant and therapist manual, and a web-based resource. To engage a number of primary care practices and the local specialist diabetes outpatient service. To recruit 30 people with type 2 diabetes who meet pre-specified criteria.

SolutIonACT Now! Is a manualised 5-8 appointment programme. It consists of five core modules focused on key aspects of self-management, and three optional modules for people who have specific difficulties with anxiety, depression or emotionally-driven eating. The modular design of ACT Now! is reflected in the web-based support consisting of video footage, text, and sign posting to external material to:

1. Reinforce weekly discussions on pertinent diabetes-related topics2. Link weekly themes to the overall programme aim3. Provide patient stories4. Link weekly themes and goals to health outcomes5. Provide top tips from experts.

The team targeted people whose last HbA1c was among the highest 40% of our type 2 diabetes population because this group benefits most from improvements in glycaemic control. Letters were sent to all those eligible, inviting them to self-refer via email or phone. We also provided leaflets for health professionals to facilitate self-referral.



ACT Now! Guided self-help for adults with Type 2 diabetes to improve self-management and emotional wellbeing by NHS Grampian


rESultSOverall, 60 people were recruited to ACT Now! and three month follow-up data is available on 30. The dropout rate was 13%. Most (86%) were recruited in primary care, and 76% had co-morbid conditions. The initiative was successful in attracting men (48%), who typically do not engage in these kinds of services. There were no significant differences between participants and the overall type 2 population in Grampian (N=23 829) in terms of sex; BMI, and deprivation. However, participants were both significantly younger and had been diagnosed longer (both p < 0.05). Qualitative interviews were conducted with 9 participants and 3 health professionals. Participants reported that the programme had encouraged them to take ownership of their lives and health, had developed skills, and was enjoyable and accessible. All commented that the time and effort devoted had been worthwhile. Three-month follow-up data (N=30) indicated that glycaemic control had improved by a clinically significant degree, dropping from a mean baseline value of 83.5 to 72.6 mmol/mol (p=0.01). Anxiety and depression levels measured using the Hospital Anxiety and Depression Scale similarly fell significantly from baseline to follow-up (p=0.005 and p=0.002, respectively). The same was true for diabetes-related distress, measured using the Problem Area in Diabetes scale (p<0.001). Participants increased their walking by more than the distance of the London Marathon per month (26.7 miles).

lEarnIngSPrimary care were keen to have access to ACT Now! and there little trouble attracting the general practices and roll out to new primary care sites continues. The NHS Grampian Diabetes Managed Clinical Network (responsible for the regional strategic delivery of care to people) supports its delivery. ACT Now! has also been accepted in to the Scottish Health Technologies Group Innovative Medical Technologies Overview programme. This provides its place in treatment pathways subsequent to a critical evaluation of product performance, economic, safety, organisational and patient issues on behalf of NHS Scotland. The report will be available later this year. Perhaps the key message of the innovation project is that people with type 2 diabetes may feel there is little practical support available to help them - but given the right kind of support they can and do make substantial changes to the way they live their lives.

EvaluatIonThe quantitative and qualitative results presented have been very positive, with the programme proving attractive to primary and secondary care medical and nursing staff, and most importantly engaging to people with diabetes. The low dropout rate provides further evidence that people with diabetes found the programme useful. While not measured, people will almost certainly have experienced a sense of greater physical and emotional wellbeing, and improved quality of life. Moreover, as most had co-morbidities, improvements in these conditions may also have occurred.

Novel and impactful, this programme is an empowering extra offer for the diabetes community. Patient input in its design was included from the get go, which is highly impressive and clearly shows the patient-centric focus of the project. A very well-designed study with good outcome measurements and great potential.



Structured group education for people with new onset Type 2 diabetesby Dorset Healthcare University NHS Foundation Trust

Structured education in diabetes has been delivered for more than thirty years in Dorset in collaboration between three local NHS Trusts: Dorset Healthcare University Hospital NHS Foundation Trust, Bournemouth and Christchurch Hospitals NHS Foundation Trust, and Poole Hospital NHS Foundation Trust. The programme serves 66 GP surgeries across nine Dorset localities. It is delivered as part of the patients’ treatment pathway, blending with care from their GP, rather than a stand-alone education programme. After patients are diagnosed with type 2 diabetes in primary care, they are then offered open access to the programme at the venue of their choice. Each of the three sessions takes two hours and is run by a secondary care diabetes specialist nurse and dietitian.

ChallEngEMaintaining good diabetes management is essential to reduce the risk of life-changing complications. Poor control is associated with complications leading to disability, premature mortality and significant financial costs.

obJECtIvESTo empower people who are newly diagnosed with type 2 diabetes, and their family members/carers, to take active responsibility for the day to day control of the condition. To achieve desirable diabetes control (measured as HbA1c) and adjust medications if appropriate. To alert patients about their blood cholesterol levels in relation to targets.

SolutIonThe intervention is designed as a group education programme and the written curriculum is tailored to suit a broad range of participants using Diabetes UK resources to supplement the education. The programme consists of three 2-hour education sessions spread over an average of two months and is facilitated by two health care professionals: a diabetes specialist nurse and a specialist dietitian. The sessions have a relaxed and informal atmosphere. The initial session is a drop-in and the two follow-up sessions are booked appointments. The curriculum is based on adult learning, empowerment and self-efficacy theories. These methods facilitate patients to understand their own risks and to choose personal, achievable goals. The curriculum includes topics related to changing diet and lifestyle, information about diabetes, such as an explanation of diabetes and complications, and straightforward advice for good foot and eye care. Throughout the programme, the diabetes specialist nurse regularly assesses an individual’s need for medication and will liaise with the patient’s GP regarding alterations if necessary. It works in liaison with Dorset Retinal Screening Programme by providing the names of people who access our education. This enables Dorset Retinal Screening Programme to cross-check with their database to identify any patients that may be missing from it and improve the reliability of their records. This programme is designed as the initial step of clinical and self-management in the life-long journey of diabetes care. After the programme is completed, patients are returned to the usual care carried out by their GPs. Since 2010 the team have made several changes to the programme based on internal and external peer reviews and feedback from patients. It is audited quarterly: a recent evaluation of four years of data demonstrates high completion rates and significant reductions in HbA1c and weight. Additionally, the feedback collected after the programme has established it to be positively evaluated by patients.



Structured group education for people with new onset Type 2 diabetesby Dorset Healthcare University NHS Foundation Trust

rESultSFrom 2011-2014, 4,631 patients (57.1% males; age 63 ± 13years; BMI 32 ± 6.6kg/m2; HbA1c 65 ± 23.6mmol/mol) were referred to the programme. 4,121 (89% of referrals) patients completed the programme, 99 were unsuitable referrals, five died and 400 dropped out. Mean completion time was 63 ± 25.2days. Throughout the programme, average HbA1c reduced by 9.3 ± 15.0mmol/mol (p<0.001), 68% of patients achieved HbA1c less than 58mmol/mol and weight reduced by 1.8 ± 2.8kg (p<0.001). An additional audit in 2015 assessed the proportion of people with new onset type 2 diabetes that attended the programme from 2013-2014. Of the sixty-six local GP practices, eight participated in the audit. According to GP surgery records, there were 286 people newly diagnosed with the condition, which indicated 76.9% of patients attended the programme within twelve months of diagnosis - and of those 88.6% went on to complete the programme. Variation in attendance rates existed across different GP practices.

lEarnIngSThe programme has been well regarded by Dorset GPs with 76.7% of their newly diagnosed patients attending the programme. Patient feedback and evaluations are collected at the final session, which indicate the programme is very well received. The drop-out rates are minimal at 8.9%. The programme works as part of the integrated care pathway for diabetes, rather than being offered as an optional extra. Specialist nurses review and change treatment as part of the programme. Patients mentioning foot problems are discussed with the podiatry team. Anyone presenting at the first session with complex type 2 diabetes or suspected type 1 diabetes is immediately re-directed to the appropriate care pathways.

EvaluatIonThe UKPDS showed that tight blood glucose control from the time of diagnosis reduce the rate of complications and early intervention leads to long term benefit to the patient – the ‘legacy effect’. Mean HbA1c reduction was 9.3mmol/mol (3%). The reduction was even higher at 19.9mmol/mol (4%) for those who started the programme with HbA1c of 58mmol/mol or above. The National Diabetes Audit shows that nationwide less than 4% of all newly diagnosed people with type 2 diabetes attend structured education - by contrast, 76.9% of all patients attend the Diabetes Education Programme and the majority complete it within 12 months.

A very successful programme, where the innovation was in the fantastic programme completion results. Good design and integration of existing services with impressive data and evaluation.



The feasibility of delivering a physical activity intervention for adults within routine diabetes careby NHS Grampian

Physical activity consultation has been shown to be effective in promoting physical activity levels for adults with diabetes within controlled research settings – but few interventions have been implemented into routine care. NHS Grampian delivered a 12-month intervention for adults with diabetes within the region over 30 months. Significant improvements were observed in physical activity levels, BMI and several aspects of psychological wellbeing at 12-month follow up. The low-cost intervention was feasible with high protocol fidelity, adoption by staff, positive participant feedback. It proved to be a useful method of supporting people with diabetes and multiple co-morbidities to increase their levels of physical activity and improve psychological wellbeing. This is an encouraging finding in relation to the translation of research findings into everyday practice.

ChallEngERegular physical activity (150 minutes per week) provides substantial health benefits to people with type 2 diabetes, including better control of their condition, an improved cardiovascular risk profile, weight loss and an improved quality of life. Promoting the benefits of physical activity (PA) requires no expensive resources as it merely uses the dissemination of knowledge and experiences - but over 60% of patients with diabetes do not meet the recommended levels of PA. The majority of published physical activity interventions have been performed in a controlled research setting, with short duration and lack of long-term follow-up. It is important to develop and evaluate interventions that are feasible and affordable within routine care.

obJECtIvESTo explore the feasibility of delivering a physical activity intervention for adults within routine diabetes care. To conduct a process evaluation to assess its impact, areas for improvement and consideration for wider spread.

SolutIonThe 12-month intervention was based on Physical Activity Consultation (PAC) guidelines for adults with type 2 diabetes. Recruitment to the service was via posters, leaflets, media and recommendation by health professionals in a hospital-based diabetes clinic and two general practices. Interested patients self-referred by contacting a physical activity consultant directly (by phone or email). This method of recruitment was chosen to reach people with diabetes who were ready to change thus improve retention rates, and minimise the input required by health professionals. Participants received an initial 30-min face-to-face consultation followed by five monthly follow-up consultations (face-to-face, email or telephone). Two further face-to -face 30-min consultations were undertaken at six and 12-months. Between six and 12-months no formal contact with participants was made; however, participants were encouraged to make contact with the activity consultant for advice if needed. Maintenance of behaviour change was encouraged via the use of specific behaviour change strategies (eg relapse prevention).Participants were encouraged to increase their physical activity to meet the current UK recommendations of 30-mins of moderate physical activity on at least five days per week. Walking was encouraged as a cheap and effective form of activity. Pedometers (SilvaEx10) and step diaries were provided and participants were asked to self-monitor their daily step count and set achievable walking goals.



The feasibility of delivering a physical activity intervention for adults within routine diabetes careby NHS Grampian

rESultSParticipants (n=89) were 49% female, mean age 59.5±11.3 years, mean BMI 34.1 ± 7.8, 82.0% with type 2 diabetes, and 58.0% with multiple co-morbidities. Significant improvements were observed in physical activity levels, BMI and several aspects of psychological wellbeing. Fifteen percent (n=13 of 89) met current physical activity guidelines prior to intervention which increased to 69% and 78% at six and 12 month follow up (p=0.004). An increase was observed from baseline in positive affect (PANAS) at six and 12-months (30.5 vs 32.1 vs 34.6, p=0.018). At 12-months an improvement from baseline was observed in BMI (33.1 vs 32.kg/m2, p<0.005) and perceived depression (HADS) (5.1 vs 2.7, p=0.006). No further significant changes were recorded.

lEarnIngSThe intervention was successful and was integrated with other aspects of routine diabetes care (eg podiatry appointments). It was also championed by the Diabetes service lead and was well received and adopted by health professionals within both primary and secondary care – a suggestion reflected in the rate of referrals received from health professionals. It helped people achieve greater levels of physical activity, health benefits and improvement in psychological wellbeing. All participants found the intervention beneficial and would recommend the service to other people with diabetes. Insight was gained from ten health professionals regarding their adoption of the intervention: they considered the protocol to be of a high standard; the service integrated well with current care; referral was not time-consuming; and positive feedback was received from patients attending the service. They also valued the expertise of the physical activity consultant and identified the important role of ‘champions’ working within the diabetes service who helped to promote and endorse the intervention.

EvaluatIonAn independent process evaluation highlighted high protocol fidelity, adoption by staff, positive participant feedback. Three minor amendments were made to the protocol to provide extra support for patients who required more input: an additional phone call after baseline appointment; an optional three-month consultation for participants with complex needs; and an increased consultation duration of 30-45 minutes.

The judges really liked the evidence-based focus of this entry, which presented good measurable outcomes and sustainable costing. Well-written and interesting, the physical aspect of the programme was both attractive and highly motivational.


Royal Bournemouth Hospital’s BERTIE structured education programme is an appropriate means by which people with type 1 diabetes can learn the knowledge and skills necessary for optimal self-care. Started in 1999, it is run over four weekly sessions. Effectiveness has been measured since its inception by collecting biomedical data and a patient satisfaction questionnaire, with a robust quality assurance programme in place.As a result of continued monitoring of the programme, it has evolved to reflect the needs of patients and improve our outcomes. It has shown sustained biomedical improvement over five years, reduction in emotional distress and reduction in hypoglycaemia and hypoglycaemia awareness. Patients also achieve their self-management goals.

ChallEngEPeople with type 1 diabetes require knowledge and skills to enable them to understand the effects of lifestyle on their diabetes and vice versa, and how they can manipulate their treatment to enable them to lead the lifestyle of their choice while maintaining stable blood glucose control. They also need information on the consequences of poor control of their diabetes so they can make informed choices in setting appropriate personal goals for the management of their diabetes. In 1997, patients with Type 1 diabetes had little knowledge about carbohydrate content of food, insulin dose adjustment, management of hypoglycaemia and hyperglycaemia, and the effect of exercise and other factors on blood glucose levels. There was no structured programme and average HbA1c in 1997 for patients under 40 years was 9.9%. A local survey showed 60% of patients never adjusted their insulin.

obJECtIvESTo provide support to people with diabetes to enable them to develop realistic short term and long-term management goals. To help them acquire the knowledge and skills necessary to achieve those goals.

SolutIonIn 1998, the Bournemouth Diabetes Team observed a five day structured type 1 education programme in Dusseldorf, Germany. The team adapted the aims and objectives to develop their own structured programme called BERTIE. The first programme began in May 1999. BERTIE is a standard part of all type 1 care pathways and is offered to anyone who wants to improve their control. We run 7-8 courses a year in a local community centre on four consecutive Mondays from 9am to 3pm. There are 6-8 patients in each group and it is facilitated by a Diabetes Nurse and Dietitian with contributions from a Clinical Psychologist and Consultant Physician. Following referral to the programme patients receive a written invitation. Each educator is BERTIE trained, peer reviewed and follows an Educator mentoring plan. The programme which is quality assured, has a defined Philosophy and written curriculum derived from social learning theory. Patients identify barriers to behaviour change and develop strategies to overcome those barriers. The course is supported by a workbook. Self-management goals are set at week 1 and reviewed at the end of the course. There is emphasis each week on insulin dose adjustment and carbohydrate counting. There is on-going data collection – biomedical and patient satisfaction. Demographics and HbA1c are collected at baseline, six months and one year until five years after completion. Patients are reviewed by a consultant in the hospital six month post course and at one year when further data is collected.


Continued success and evolution of BERTIE; Bournemouth’s Type 1 education programmeby Bournemouth Diabetes & Endocrine Centre, Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust



rESultSA total of 565 patients have attended BERTIE (aged 16-84 years with duration of diabetes from six months to 54 years). Results show a significant reduction in HbA1c maintained for at least five years. 61% (n=276) of the 452 patients with HbA1c >58mmol/mol showed a reduction in HbA1c. Mean HbA1c reduced from 76.9mmol/mol to 73.9mmol/mol at 1 year (p=0.000) and to 72.4mmol/mol at five years (p=0.000). Mean PAID scores reduced from 23.02 to 16.42 (p=0.000). 80 participants reported third-party assistance for hypoglycaemia prior to BERTIE. At one year, 47 provided information of whom 35 (74%) reported no further such episodes after BERTIE.

50 people reported reduced hypoglycaemia awareness prior to BERTIE. Twenty seven provided information at one year of whom 16 (60%) had regained awareness after BERTIE. 95% of patients ‘completely’ or ‘mostly’ achieved their self-management goals.

lEarnIngSBERTIE continues to be an effective intervention leading to a significant reduction in HbA1c and diabetes-related distress which helps patients achieve their self-management goals. The reduction in HbA1c is maintained for at least five years. Following the success of the course, training for healthcare professionals from all over the country is offered to learn the skills to run a similar programme in their locality.

EvaluatIonPre course data collection:

• (from1999)HbA1c,weight,BMI,hypoglycaemiaandhypoglycaemiaawareness;• (from2005)PAID,HADS;• (from2010)HFS.Allmeasuresarerepeatedatsixmonthsandoneyear. HbA1c is collected for five years. BERTIE is audited annually against defined criteria:• reductioninHbA1candPAID,• achievementofpatientmanagementgoals,• reductioninfrequencyofseverehypoglycaemiaand• increasedhypoglycaemiasymptomawareness.

Patients complete an evaluation form at the end of the course

The BERTIE programme ticks all boxes of the empowerment criteria. The substance is good, as is the evaluation and ongoing refining of the project, plus the significant replication is impressive.

Continued success and evolution of BERTIE; Bournemouth’s Type 1 education programmeby Bournemouth Diabetes & Endocrine Centre, Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust


Hypoglycaemia simulation training to address serious untoward incidents in a hospital setting by Cornwall Partnership NHS Foundation Trust

Diabetes team Initiative of the Year

Cornwall has a diabetes population of 28,000, with a high in-patient diabetes prevalence of 16.4%. Diabetes healthcare is increasing in complexity and, with changing team dynamics and restructuring of healthcare organisations, comes a need to provide high quality safe clinical practice in diabetes management. Cornwall Partnership NHS Foundation Trust’s DISN team created a Hypoglycaemia Simulation Training programme following three Serious Untoward Incidents (SUIs) of hypoglycaemia, two of which resulted in deaths. The programme enabled teaching of the management of hypoglycaemia according to the Trust guideline within the ward situation, at the point of care. Following the session, participants undertake a structured team de-brief that analyses learning points, response to the event, team communication and working integration, appropriate and timely use of ward and hypoglycaemia resources. Open and interactive dicussion provides feedback for development and any remedial measures are identified and actioned.

ChallEngEThe hospital had experienced three hypoglycaemia management SUIs - despite an up-to-date Trust wide hypoglycaemia guideline, the introduction of hypoglycaemia ward boxes, regular face to face training and access to national e-learning modules. These educational methods alone appeared to be ineffective. Simulation training, widely used by the aviation industry, has received significant endorsement by the Department of Health and the General Medical Council and it was decided to develop a Hypoglycaemia Simulation module designed to be delivered at the POC. The idea was that challenging human factors in the work environment allows the multi-disciplinary team to learn together, improving performance, with consequent delivery of safer patient care, better outcomes and improved productivity.

obJECtIvESTo address failings in the clinical area following hypoglycaemia SUI and reduce their occurrence. Also, to improve management of hypoglycaemia within the hospital and develop effective multi-disciplinary teams.

SolutIonThe DISN team met with the hospital Simulation team to collaboratively work with and write a Hypoglycaemia Simulation module based on the key points within one of the recent SUIs. The ward manager and governance lead within the area the SUI occurred agreed to the training which established engagement from all major stakeholders. The ward manager, Simulation team and DISN team agreed training dates. The ward manager took responsibility for advertising the training and ensuring availability of staff, and allocation of bed space. The ward team had to respond within real time to the event using the ward resources available, with minimal instruction enabling staff to independently make decisions - thus exposing any system and process errors or latent safety issues. A structured formal team debrief was undertaken, promoting reflection and transfer of knowledge for application to real clinical situations.



rESultSMis-managed hypoglycaemia incidents on the ward where the SUI had occurred were reduced by 100% following training. Anecdotal evidence of correct hypoglycaemia management obtained from DISN patient clinical ward reviews, along with verbal feedback imparted from staff, verified that knowledge and confidence had increased and improved. A post-simulation report was formulated and sent to the ward manager and medical governance lead, copying in the DISN team, outlining recommendations from the training. This was actioned and formally reported back to the Trust governance board.

lEarnIngSPrevalence of SUIs and reported incidents of mismanaged hypoglycaemia throughout the Trust was subsequently reviewed one year on and had significantly decreased. Incidences of both mild and severe hypos throughout the Trust had decreased following initiation of the rolling Hypoglycaemia Simulation programme as per NaDIA results 2015. Staff knowledge and confidence in diabetes management has increased, with 75.2% of patients reporting that all or most staff looking after them knew enough to care about diabetes to meet their needs”. This is above the national average of 65.5 %. Other diabetes teams throughout England have adapted and replicated our Hypoglycaemia Simulation module and further enquiries have been received from other Trusts wishing to develop their own Hypoglycaemia Simulation Training, using our model. The team received national recognition as a DISN team for its work, receiving two prestigious awards – QiC 2014 Judges Special award ‘Highly Commended’ and The Rowan Hillson Insulin Safety Award 2015 – runner up for the ‘Best UK Inpatient Hypoglycaemia Prevention Initiative’.

EvaluatIonOne year post-delivery of Hypoglycaemia Simulation Training, local audit of hypoglycaemia incidents & SUIs was undertaken. This demonstrated 100% reduction in hypoglycaemia incidents seen on the pilot ward, 63% reduction in hypoglycaemia incidences and 100% reduction of SUIs throughout the Trust. 2015 NaDIA outcomes showed reduction in mild hypoglycaemia by approximately 20% and a remarkable reduction in severe hypoglycaemia by just over 50%. Comparing hospital NaDIA 2015 hypoglycaemia data to the national average in 2015 demonstrates a below the national average incidence in both mild and severe hypoglycaemia. Continued analysis of feedback received post Simulation Training illustrates ongoing positive and favourable learning outcomes and experiences across seven evaluation questions.

The judges were highly impressed by the way this team assessed the local situation and delivered what was really needed by the community. The level of engagement with service users was great to see, resulting in some fantastic satisfaction feedback. With clear objectives, a definitive service improvement model and excellent long-term evaluation, this high impact initiative is adaptable and highly replicable - the judges hope to see it disseminated across the country’s NHS trusts.

Hypoglycaemia simulation training to address serious untoward incidents in a hospital setting by Cornwall Partnership NHS Foundation Trust


Introducing a specialist diabetes sports service at Oxford Children’s Hospitalby Oxford Children’s Hospital, Oxford University Hospitals NHS Foundation Trust

Regular exercise is important in maintaining both physical and mental health for children and young people (CYP) with type 1 diabetes (T1DM) – but the great challenge is avoiding potentially disabling hypos, while avoiding highs which can adversely affect performance. To support young sportspeople in the area, Oxford Children’s Hospital’s specialist Diabetes Sports Clinics are now held twice a year. There has been a 73% reduction in hypos and information is provided on exercise and physiology, diet and food choices and managing insulin doses. Each patient gets a personalised care summary and the team has recently held its first Family Sports Management education session. On user evaluation 93% of families ‘strongly agreed’ or ‘agreed’ that they were able to make improvements to their child’s care using information from the clinic while 100% were ‘very likely’ or ‘likely’ to recommend the clinic to family or friends with T1DM.

ChallEngEThere is growing recognition of the importance of sports and exercise in CYP with T1DM. Regular exercise helps maintain a healthy cardiovascular system and results in increased insulin sensitivity. The Oxfordshire Paediatric Diabetes Service recognised that there are significant numbers of CYP who are ‘elite sportspersons’ – performing at competitive levels, or at regional or national level. They train for many hours, and compete regularly, but a number were struggling with hypoglycaemia and this was affecting their confidence in taking part in sport.

obJECtIvESTo establish a supportive environment to nurture the CYPs enthusiasm for sport, helping them become more independent and confident in managing the challenges of sport and diabetes. Establishing an MDT clinic specifically to focus on management of diabetes in those CYP who are competitive sportspeople. To reduce overall occurrence of hypos and aim for an improved/stable HbA1c so that sports performance is optimised.

SolutIonThe team identified members within the Paediatric and Adults Diabetes service with an interest in diabetes sports management. The Diabetes and Sports MDT held focus group discussions with the rest of the members of the diabetes team to get ideas on the challenges facing CYP doing lots of sport. Family information leaflets were developed for children on multiple daily injections (MDI) and on insulin pumps focusing on how they could manage exercise/sport. A pilot clinic in 2014 was well received, and in 2015 the team attended the inaugural UK JDRF Performance in Exercise and Knowledge conference. The clinic was refined following knowledge gained at this conference.

rESultSClinic has been established and individualised care plans with recommendations for insulin dosage before, during and after sports, as well as carbohydrate/protein intake, are given to each patient. There was a reduction in hypo episodes in 73% of patients who attended the clinic while there was no significant rise in the HbA1c 3-4 months after for those attending the clinic. Education has been provided to CYP and their families on the effect of different exercise on blood glucose levels, along with tailored diet advice.



Introducing a specialist diabetes sports service at Oxford Children’s Hospitalby Oxford Children’s Hospital, Oxford University Hospitals NHS Foundation Trust


lEarnIngSFollowing clinics in 2014 and on further reflection and discussion we noted that we were getting more and more referrals for the general clinic for children who were not competitive sportspeople but instead were modestly active children experiencing some issues with blood glucose control. We felt that these were not quite the patients we wanted to see in the Diabetes Sports Clinic and therefore:

• Revisedthereferralcriteriaandmadeitclearerwhichpatientsshouldbeconsideredforreferraltotheclinic• DecidedtohostaFamilySportsManagementEducationmorningforCYPandfamilies

who wished to learn more about managing sport/exercise and diabetes. This was very successful, with 100% of attendees finding the sessions ‘very useful’ or ‘useful’

• Wethereforedevisedapersonalisedcareplansummarywhichisemailedtofamilieswithin24-48hoursof the clinic consultation (families also receive a copy of the full clinic letter which goes out to the GP)

EvaluatIonReduction in hypoglycaemic events in 73% of patients within the 3-4 month period from attending the clinic, with significant impact on the wellbeing of the CYP and their families as hypoglycaemia is the biggest worry for this cohort of patients. In patients where hypos have been significant there is a risk that once control is improved and the frequency of hypos reduces there could be an exponential rise in the HbA1c. However there has been no significant rise in the average HbA1c of the group - so long-term glycaemic control has been maintained while achieving lower hypo frequency.

This is an amazing, much-needed service and a great example of taking an innovative idea and replicating it in a local area. The involvement of the service users in the later stages was brilliant - especially the use of existing social media platforms to capture feedback from the younger demographic. While elite-focused, the judges felt it was a patient-centric initiative that offers vital encouragement for children with type 1 diabetes.


Operation Pharmacist: Ending the Highs and Lows of Diabetesby St George’s University Hospitals NHS Foundation Trust

Patients with diabetes have complex medical needs, which are heightened when faced with surgical intervention. St George’s University Hospitals NHS Foundation Trust introduced a diabetes specialist pharmacist to the pre-operative setting, in order to optimise and pre-empt medicines management issues pre-surgery, and to collaborate and better utilise skill sets of other healthcare professionals. From pre-operative care to theatres, recovery, ward and finally discharge, pharmacists ensured bespoke plans were actioned and communicated, with excellent feedback from surgeons, anaesthetists and diabetes team. Since completion of this work, the data has been fed back to the Trust chief executive with the creation of permanent pharmacist support. There has since been a drive to upskill pharmacy workforce through specialist diabetes workshops and simulation projects to support patients.

ChallEngEDiabetes is one of the most common chronic disorders, affecting at least 6% of people in the UK with the prevalence rising. Patients with diabetes have complex medical needs, but often overlooked are the increased risk of surgical interventions in this group due to diabetes related co-morbidities. As a result at least 10% of patients undergoing surgery will have diabetes and in some hospitals as many as 30%. Failure to identify patients before admission increases the risk of errors. Service provision delivered to the elective surgical diabetes patient did not separate and highlight their specific needs or recognise numerous benefits diabetes patients would receive from dedicated input.

obJECtIvESThese were numerous, and included 100% of peri-operative management plans to be created and implemented with active patient participation, preventative screening and meal plan to reduce fasting period and requirement for intravenous insulin. Also, to highlight and manage patients with poor glycaemic control and encouraging patients to self-manage confidently by promoting patient ownership and control. Other aims included preventing cancellations, reducing delayed discharges from hospital and reducing overall length of stay.

SolutIonFor the first time a pharmacist-led specialist diabetes pre-operative clinic was introduced for two days a week over four months from September 2014 with support of the South West London Small Grants Scheme. Patients were referred directly to the specialist pharmacist by pre-operative care HCPs. During consultation with the pharmacist, patients were for the first time:

• Assessedusingaspeciallydesignedproformatoidentifysurgicalneedsandtroubleshoot,• Optimisedglycaemiccontrolpre-surgerytoacceptablelimits,• PerformedNICE-guidedpreventativescreening• Providedwithaplanwitheducation/adviceforpatientsandHCPs

on interruption of diabetes treatment for surgery.

Patients identified as high risk were directly referred for more specialist input from the diabetologist. Other key HCPs were liaised with as necessary in the surgical pathway. Any pre-surgical actions were communicated as appropriate to the patient/HCPs to complete prior to surgery. The outcomes were dependent on implementation of the specialist pharmacist designed plan by other HCPs.



Operation Pharmacist: Ending the Highs and Lows of Diabetesby St George’s University Hospitals NHS Foundation Trust


rESultSOne hundred and five patients were seen, with 100% receiving a written management plan with active patient/carer participation, glycaemic control scrutinised, then optimised, given preventative health screening and interventions performed. Pre-made clinical decisions helped reduce length of fasting time, reduce prescribing of unnecessary insulin infusions and selecting appropriate insulin scale in advance where required. Admission blood sugars were within 4-12mmol/L and patients were actively placed on the first third of the operating list as recommended, avoiding unnecessary admission night before, therefore intravenous insulin need. This lead to active avoidance of 10 cancellations due to poor glycaemic control contrasting with 2-3/month prior to intervention. Cancellation avoidance and promotion of same day admission led to estimated savings of upward of at least £35,000. Patient safety improved as diabetes medication related error reporting subsided.

lEarnIngSThe work captured the interest of a variety of HCPs and uniquely bridged the gap between the wider multidisciplinary team. The identification and referral of patients by pre-operative staff to the specialist pharmacist meant clinical issues as a direct result of diabetes and medication were able to be proactively resolved well in advance of the planned surgery, as opposed to previous practice of troubleshooting on the day by inexperienced clinical staff. Patients identified as complex had specialist input from an experienced diabetologist. This previous reactive approach lead to inefficient working practices affecting patient flow and potential risk surrounding inappropriate medication interruption. With the new approach, pre-operative staff highlighted the benefits of being able to refer to a specialist and focus attention to their area of expertise. This positively impacted both patient and clinician satisfaction. A greater emphasis is required on referral process across all surgical areas in order to target patients requiring support and optimisation. During the initiative HCPs came to learn the importance of properly managing diabetes patients as the benefits directly impacted their working practices. However in order for this to have a greater impact across the Trust, the benefit of the referral process needs to be shared. This requires a strong focus on education and training to promote the service to the wider hospital group.

EvaluatIonAlthough the aims and objectives appear to be extensive, they are highly achievable due to the simple notion behind the service – to engage the patient proactively and prospectively provide clinical management plans for the peri-operative period. This straightforward idea has impacted directly on improving clinical objectives thereby in turn, service outcomes and user satisfaction. One of the more challenging aspects was to achieve for 100% of patients to maintain glycaemic control within a range of 4-12mmol/L throughout the perioperative period. Although the admission blood glucose could be targeted pre-operatively, in practice maintaining control thereafter is a difficult clinical outcome to achieve as it is subject to various clinical influences. However it is thought with a focus on education and training to the relevant staff, the impact on the variations may be minimised.

A very successful and innovative pilot programme with clear objectives and outcomes. The proactive use of the wider multidisciplinary team was impressive and highlighted pharmacists as an underused key resource. The judges would love to see the initiative rolled out nationally.


This joint project between Queen Alexandra Hospital and Portsmouth NHS Trust involved the diabetes team, maternity team and community midwife team collectively improving outcomes in diabetes-related pregnancies through a redesign of existing diabetes maternity and midwifery services - incorporating better seamless service infrastructure and education, diabetes pregnancy awareness for patients and service delivery. The international St Vincent’s Declaration of 1989 for Diabetes declared that health care professionals should achieve pregnancy outcomes in women with diabetes that approximate that of women without diabetes. The team believes its outcome measures, achieved through substantive service redesign and collaboration of several multi-disciplinary teams, demonstrate that health care professionals can step up to the challenge set by the St Vincent’s Declaration.

ChallEngEThe diabetes, antenatal and community midwife teams recognised the following challenges needed to be addressed in order to deliver a high quality ante-natal diabetes service for the population of Portsmouth: an exponential rise in the number of patients with diabetes related pregnancies; significant under-utilisation of glucose tolerance tests to diagnose gestational diabetes (GDM) and reliance upon a fasting glucose level to diagnose GDM; limited interaction between the community midwifery service and the specialist diabetes ante-natal team; and better utilisation of limited resources within the diabetes ante-natal team and the requirement to demonstrate need and quality outcome to support a service redesign/expansion.

obJECtIvESTo build a new model of collaborative and innovative multi-disciplinary team working involving diabetes and antenatal HCPs as well as community midwifery team to enhance patient continuity; improve mother and fetal/neonatal outcome; manage an ever growing diabetes maternity population; and enhance confidence in local diabetes maternity care.

SolutIonService requirements have grown exponentially. From 2002-7, 324 diabetes-related pregnancies were recorded. This compared with 371 diabetes related pregnancies within the last 12 months alone. Diabetes complications such as macrosomia were also high at baseline (4.6%). In order to overcome these challenges, the team substantively redesigned its diabetes ante-natal services with an eight point plan which included:

• developmentofacommunitydiabetesmidwiferynetworkusingexistingmidwivesskilledtoidentifypatients with (or at risk of) diabetes to ensure appropriate screening and management

• developmentoftwodedicateddiabetesspecialistmidwives(redesignofexistingmidwifery funding) as a pivotal link between the diabetes and antenatal teams

• extensiveeducationthroughoutthedistrictontheimportanceofGTTvsafastingglucoselevel in the diagnosis of GDM, paralleled by an increase in GTT resource availability

• developmentofgroupeducationalsessions(PADDLE,PregnancyandDiabetes,DevelopinginaLearningEnvironment) – a weekly multi-disciplinary education group attended by newly diagnosed GDM mothers

Diabetes pregnancy care – achieving similar outcomes to non-diabetes related pregnancies?by Diabetes Antenatal Team, Queen Alexandra Hospital Portsmouth NHS Trust



Diabetes pregnancy care – achieving similar outcomes to non-diabetes related pregnancies?by Diabetes Antenatal Team, Queen Alexandra Hospital Portsmouth NHS Trust


• identifyingandprovidinginformationtowomenwithdiabetesof child-bearing age the importance of pre-pregnancy counselling (over 900 women received a mail shot)

• establishingadedicatedpre-pregnancycounsellingserviceforwomenwithdiabetes• developmentofanextensiveeducationprogrammetoeducateallhealthcareprofessionalslocallyon

the importance of diabetes pregnancy counselling, management and after care (part of the Diabetes Multi-Health care Programme of Learning) developed in affiliation with the University of Portsmouth

• extensivere-organisationofexistingdiabetesmaternityprotocolssotheymetNICEguidelines.

rESultSBetween 2010 and 2015, diabetes-related pregnancies rose progressively from 210 to 371 per year, an increase of 177%. In part this increase was due to a successful campaign to increase GTT screening (increased 7.5 fold) to identify GDM after we demonstrated that a fasting glucose measurement missed up to 95% of GDM diagnoses. In spite of this huge increase in diabetes pregnancies, we achieved the following outcomes in 371 deliveries during the last 12 months:

a) 3/371 (0.8%) babies with a weight greater than 4.5 kgb) 1/371 (0.3%) intra-uterine deathsc) 0% neonatal deathsd) 2/371 (0.6%) congenital abnormalitiese) 16/371 (4.3%) intra-uterine growth retardationf) 16/371 (4.3%) neonates transferred to the neonatal unit with hypoglycaemia g) 284/371 (76.5%) mothers were breast feedingh) a progressive increase in mothers receiving pre-pregnancy counselling (1.8 fold increase).

lEarnIngSAll aspects of the eight-point plan are now deeply embedded within the diabetes pregnancy service and despite the rapid increase in diabetes related pregnancies, and the team is confident it can maintain these benefits for our diabetes mothers and newborn. Annual data between baseline and the data for the last 12 months shows these trends in improved outcome have been progressive.

EvaluatIonHow do these figures evaluate alongside the general population for deliveries? Where comparable data is available: intra-uterine deaths were lower (0.3 vs 0.47 %); much lower neonatal death rates were observed (0 vs 0.26%); and congenital abnormalities were over seven times lower (0.6 vs 2.27%).

A truly worthwhile project with fantastic results and very effective team integration.

www.qualityincare.org


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