County Durham & Darlington (CDD) Integrated Diabetes Service implemented a five-year model in 2016/17, recognising that North Durham, Durham Dales, Easington and Sedgefield (DDES) and Darlington Clinical Commissioning Groups (CCGs) needed to improve the uptake of patients being referred and attending structured diabetes education programmes. Capacity to deliver sessions had been problematic, with declining numbers of educators and long wait times. In 2017 NHS England funding was secured to double the places from 720 to 1,440 in County Durham and Darlington, with the County Durham and Darlington NHS Foundation Trust (CDDFT) Diabetes Information and Education Team (DIET) providing a single point of access. All referrals for structured education would come through this hub.
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Prior to 2016, GP practices had little understanding of structured education opportunities and benefits, referral processes were confusing, courses were inflexible, waiting lists were long and uptake of places was poor. The main objectives of DIET were to: double the places for patients with Type 2 diabetes; provide more flexible delivery options and contracting arrangements (commencing 2018/19), and provide a single hub for referrals for structured education from GP, health improvement and community services; provide personal contact with patients, offering a holistic needs assessment. Education and support options included X-PERT, DESMOND, electronic and written information, signposting to Diabetes UK’s Learning Zone online modules, plus signposting and onward referral to health trainer services, food banks, stop smoking services and employment counselling. Patients were contacted in advance to encourage attendance. Programmes were adapted, such as for deaf adults and non-English speakers. For working-age adults, letters were sent to employers explaining the benefits of structured education, with evening and weekend courses delivered flexibly in local community venues. Patient-led groups were implemented in 2019 in collaboration with the local Wellbeing For Life service. In primary care a new referral pathway was developed in October 2017. Effective communication was ensured via a network of 78 practice diabetes leads, attendance at practice nurse meetings and ‘time out’ sessions. X-PERT manuals were given to diabetes lead nurses and primary care lead nurses attended sessions to better understand and explain the programmes.
New indicators were incorporated into the local diabetes monitoring monthly dashboards to monitor the extent to which GP practices were referring patients to structured education. These reported at county, CCG, locality and practice level and were shared widely to drive service improvement. Posts were recruited to, and a new team formed. A new patient pathway was developed with a single hub to receive referrals from all 78 GP practices and support personalised assessment and choices for diabetes self-management. A telephone contact service helped understanding of what people with diabetes wanted and needed to support self-managemennt. Options were developed to meet as many needs as possible, including face-to-face programmes, programmes delivered over different timescales, programmes that supported patient choice around dietary approaches and setting individual goals, referral to health trainer services for those who were unable to access group education, provision of written and electronic information and resources, including easy-read formats for people with a learning disability, and information in different languages. Participants were contacted two days prior to the course to encourage attendance. They were followed up by telephone one month and six months post-course. Many received a bi-monthly email newsletter plus details of events or patient engagement activities. The service has an active social media presence @cddftdiabetes to support self-management.
In 2018/19, 1,280 places were offered against a profile of 1,440 (89%). Conversion was good, with over 85% of patients who attended at least one session completing the course. Contacting participants prior to the course by telephone reduced non-attendance. Patients completed empowerment questionnaires pre- and post-course plus an evaluation. Patient empowerment for courses delivered in 2018/19 increased by 22.7% from a mean baseline of 3.79 to a post-course rating of 4.65. The programmes have shown strong clinical and self-management outcomes, and patient follow-ups show that they enjoy sustained benefits. The service operates waiting lists for people who have specific requirements, such as attending a particular day, time, and venue. This is particularly helpful for people with work/caring responsibilities who have limited flexibility. Weekend and evening sessions have been provided, plus sessions in more remote parts. Patient ‘what’s next’ referrals are made to group or individual support around health goals, to peer support, further information and telephone support, and to physical activity sessions in the community.
Sustainability and Spread
The success of the structured education transformation from 2016-2018 has resulted in the DIET service being commissioned from April 2019. In CDD the foundation to success is the maturity of the infrastructure around diabetes integration. This affords access to a wide range of stakeholders and a sense that preventing and managing diabetes is ‘everyone’s problem’, across CCGs, GP practices, regional diabetes networks, the diabetes specialist teams across three acute trusts, community organisations, and with the Health Navigator role supporting community and voluntary organisations. A culture of listening and innovative and responsive solutions to local problems has been created. Feedback has contributed to planning for 2019/20, to include: groups for learning disabilities, 1-1 X-PERT, different languages, cultural appropriateness such as all female in known places such as GP practices; an XPERT First Steps taster sessions to encourage attendance on the full programme; widening access to any patient with an education need – not just those newly diagnosed; dietary advice training for health care assistants in local GP practices; a ‘Dragon’s Den’ (June 2019) to evaluate diabetes digital apps to offer alternative structured education or to supplement the existing face-to-face offer. The learnings have been shared regionally via the NHS England North East and North Cumbria diabetes network, and contributed to developing region-wide approaches to understanding the barriers to uptake of structured education, and a region-wide communications strategy around diabetes education and self-management.
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