Film prescriptions produced by behavioural change media experts and developed by health professionals and patients in Wales have been deployed nationally. Over 30 films are now available for type 2, type 1, gestational and prediabetes, covering all aspects of diabetes care. They were recently incorporated into the National Direct Enhanced Service (DES) for Diabetes in Wales and are viewed by approximately 1,000 patients each month. Initial evaluation of the system demonstrated improvement in disease control as measured by HbA1c.
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Data from a 2015 national audit indicated that only 0.9% of the 186,000 patients with diabetes in Wales had attended a recognised self-management course. With a growing number of individuals developing diabetes it is imperative that effective and scalable solutions become available that allow generations of patients to become experts in their own health needs. A working group (Swansea University, Diabetes UK Cymru, Welsh Endocrine and Diabetes Society, Diabetes Research Unit Cymru, Abertawe Bromorgannwg University Health Board, Hywel Dda University Board with eHealth Digital Media), established in the summer of 2014, oversaw the creation of eight initial short films. The content focused on basic condition information, contained numerous patient-delivered commentaries and followed the principles of behavioural change through self-determination. The films were then reviewed by patient reference groups in the localities described and reviewed by two separate Health Board Research and Development departments, which deemed the project to be service development. The initial sets of films were tested in two large GP practices (Winch Lane in Haverfordwest and Clydach Surgery in Swansea). Following initial patient feedback, further content was generated, particularly around dietary advice, increasing the number of films to ten. Evaluation of the initial data set showed encouraging results, with significant improvements in HbA1c in the watchers that correlated with the number of films watched. The system has now been incorporated into the all-Wales standards for managing diabetes as well as the DES as part of the funded compulsory Gateway module (£22 per patient per year). Healthcare professionals and patients from all over Wales have been involved in the work. Following changes to the deployment method in line with Plan, Do, Study, Act (PDSA) cycle methodology, viewings of the film content have increased to around 1,000 patient views per month, with 40% returning for more viewings.
The film content on PocketMedic was shot in an engaging way; patients are seen at home and presenters are in domestic or familiar environments. The films are broadcast standard and illustrated with high quality graphics to make them accessible to people with low health literacy. The initiative was implemented by clinical commissioners working closely with eHealth Digital Media to create the film content. Clinicians introduced the production team to patients directly or via patient groups. Relationships were built with patients and their stories continue to develop, such as during the filming of ‘Sick Day Rules’ for people with T1 diabetes, when one of the contributors (who had been filmed before) fell ill and allowed the film crew to film at her house and capture the management of her illness. This is a result of building trust with contributors. How many people watch the films, and how many watch again, is documented and data is reported regularly. This quantitative measure is complemented by qualitative feedback via feedback forms.
A paper published in Primary Care Diabetes in 2017 describes the effectiveness of using films to drive behavioural change in patients: ‘We undertook a pilot service-evaluation of prescribed internet-based patient education films for patients with type 2 diabetes. The uptake was 28% and film watching was associated with a relative mean difference in HbA1c of −9.0mmol/mol in the film watchers compared to non-watchers over a three-month period (P = 0.0008)’. This service evaluation helped the idea of film-based education gain momentum and respect among clinicians. PocketMedic became part of the mandatory central gateway module of the DES package for type 2 diabetes in primary care for Wales. Approximately 1,000 patients a month access the films. It is anticipated that they will help people change their behaviour.
Sustainability and Spread
The Diabetes Network Wales has committed funding for three years, beyond which costs are limited to the commissioning of new films and subscription for the distribution and upkeep of film content to patients to ensure it is up to date. It is a low-cost, simple innovation with the potential to extend across the UK. The production team is in conversation with healthcare professionals in other countries who can see the potential for their patients. Now that PocketMedic is built in to the NHS Wales DES, it gives further impetus to drive distribution and reach as many patients as possible. Other chronic conditions have followed the lead of the Diabetes Network, such as the Lymphoedema Network Wales. There is support from the Welsh Government, Diabetes UK and the Welsh Endocrinology Society (WEDS). Nursing groups encourage their members to use the resource for patients. There is support from primary, community and secondary care. The production team would like to work with Vision to put text templates on the GP desktop to make it easier to send texts to patients as an administrative function. As patients’ permission must be given for them to be sent medical information, the texts must come from clinicians rather than using the NWIS (Welsh Informatic Service) lists of mobile numbers, which would be an efficient way to reach large numbers of patients. Scotland benefits from SCI-Diabetes, which will simplify distribution. There is interest in working with PocketMedic there. PocketMedic’s films cover a range of chronic conditions and it makes sense to provide them for other condition groups. The reach and distribution of the films is growing steadily, driven by the quality and effectiveness of the content.
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