Driving clinical engagement in diabetes prevention in Luton
The NHS Diabetes Prevention Programme has seen high rates of referral from every GP practice in Luton.
The Luton NHS DPP team: (from l to r) Amanda Flower, Dr Chirag Bakhai (author), Fahad Matin, Lisa Hudson
Summary
Luton’s GP practices responded extremely positively to the NHS Diabetes Prevention Programme (NHS DPP) with impressive engagement and high rates of referral from every practice. More than 3,000 adults with non-diabetic hyperglycaemia, representing over 2% of Luton’s adult population, were referred to the programme in its first 6 months.
Background
Luton has a total population of around 230,000 and is highly diverse with more than 55% of its residents being of BAME origin. The recorded prevalence of Type 2 diabetes is higher than the national average (7.7% vs 6.7%) and Public Health Outcomes Framework data show higher levels of physical inactivity (27.1% vs 22.2%) and a higher proportion of adults classified as overweight or obese (64.0% vs 61.3%).
The NHS DPP mobilised in Luton in May 2017. This is the first nationwide programme of its kind: an evidence-based intervention, with a minimum of 13 face-to-face sessions over at least 9 months, designed to help people with non-diabetic hyperglycaemia make lasting behavioural change to avoid progression to type 2 diabetes.
The NHS DPP relies on referrals from GP practices. Adults with non-diabetic hyperglycaemia may be found through NHS Health Checks, routine clinical care or retrospective searches of clinical systems. Primary care engagement, both in identification of non-diabetic hyperglycaemia and subsequent referral, is therefore key to the success of the programme.
What was involved
In the run up to mobilising the NHS DPP, it was recognised that awareness of NICE PH38 – ‘Type 2 diabetes: prevention in people at high risk’ was suboptimal in Luton. An audit of NHS Health Check practice across Luton showed they were not always performed in line with guidance and sometimes used random glucose testing. This presented issues for the DPP as NHS Health Checks must use either fasting glucose or HbA1c testing to be able to identify non-diabetic hyperglycaemia.
Luton’s clinical lead delivered training on national guidance, diabetes prevention and the NHS DPP to clinicians through webinars, protected learning events and cluster meetings, as well as training on NHS Health Checks to nurses and healthcare assistants and presenting at the practice managers’ forum. Work with the local pathology department resulted in updated reporting, not only reflecting national guidance but also reminding clinicians receiving results indicative of non-diabetic hyperglycaemia to consider referral to the NHS DPP.
Care was taken to streamline the referral and READ coding processes for the NHS DPP as much as possible. A ‘10 second template’ was developed which automated READ coding, populated the referral form and allowed recall for an annual review to be set-up with a minimal administrative burden. A template for NHS Health Checks was also produced to guide practitioners and promote best practice.
Retrospective searches for people eligible for the NHS DPP, and the accompanying letter for invitation, were produced centrally by the Clinical Commissioning Group (CCG) with each GP practice only needing to add its letterhead. Prior to launch, CCG commissioning managers visited every practice to make sure they were ready to refer and all forms, letters and templates were working and easily accessible. A ‘How to’ guide, with screenshots of every stage, was sent physically and electronically to all practices so clinicians could remind themselves of the referral process whenever necessary.
Once the NHS DPP had mobilised, the clinical lead monitored referral numbers by practice to allow for early identification of barriers or problems and appropriately supported colleagues. Where referral rates suggested possible issues, clinician to clinician conversations were helpful in highlighting areas needing development, addressing any learning needs or providing gentle prompts regarding the programme.
At cluster meetings, feedback was sought for improving the experience of the NHS DPP for both clinicians and the people referred. Referral rates to the programme would be openly discussed and a spirit of friendly competition soon developed between practices, with each aiming to outdo their peers and gain the title of top referrer to the NHS DPP.
What works well
Repetition, repetition, repetition! Key messages around guidance, eligibility and the programme were delivered on multiple occasions through multiple channels – protected learning events, newsletters, clusters meetings, bulletins, training sessions and emails – meaning that it was almost impossible not to know about the NHS DPP in Luton.
Aligning pathology reporting was also extremely helpful. Although some clinicians might not regularly attend meetings or read directed communications, most look through pathology results. Having the pathology reporting specifically mention the NHS DPP acted as a prompt for clinicians to offer referral when ‘eligible results’ were received and helped sustain impact through continued messaging.
Clinical leadership was important for securing engagement. Having all templates, letters and processes designed by a local GP likely increased acceptability to other clinicians. A GP leading the NHS DPP enhanced credibility for the programme and allowed for greater scope to support peers, educate and influence change, particularly where referral rates were lower than expected or existing practice was not aligned with guidance.
Financial incentives in the early stages of the programme were helpful in countering clinical inertia and establishing referral behaviours. Despite later cessation of these incentives, all GP practices have continued to refer to the programme at an impressive rate, suggesting that the processes behind identification of non-diabetic hyperglycaemia and subsequent referral to the NHS DPP are now ‘business as usual’.
What could be improved
The considerable engagement of Luton GP practices resulted in some challenges in managing the flow of referrals. While the Luton system worked closely with the provider, the effect of local preferences for glycaemic testing had not been fully anticipated. The preponderance of fasting plasma glucose testing over HbA1c was problematic; the NHS DPP monitors HbA1c over time and needs baseline readings. People referred with only a fasting plasma glucose result, therefore, had HbA1c measurement arranged by the provider before booking onto NHS DPP sessions, introducing an extra step in the pathway and accompanying delay. Other sites could learn from Luton’s experience - moving to primarily using HbA1c testing when checking for type 2 diabetes locally, unless clinically inappropriate, would largely prevent such issues developing.
Early data for Luton has suggested that working-age men and the more deprived population are underrepresented in referrals to the NHS DPP. In response to this, as well as data showing inequity in uptake of NHS Health Checks, the local authority has recently commissioned an outreach provider to target working-age men and the South Asian community.
As well as the inequity in referral to the NHS DPP, the data also showed some inequity in uptake with lower levels seen in people aged under 65 and in the most deprived populations. Further research suggested that needing to take time off work to attend sessions, the cost and effort of travel (disproportionately affecting the most deprived) and language and cultural barriers were limiting uptake. The provider has responded by increasing the provision of evening NHS DPP sessions, investing in a greater number of NHS DPP venues around Luton to reduce travel burden and organising Urdu-language and women-only sessions.
Next steps
It is hoped that the experiences and learning from Luton can help other NHS DPP sites to enhance primary care engagement and make optimal use of the opportunity presented by the Programme. Through clinical leadership, streamlined referral processes and repeated multi-channel communication, a site can effectively engage all GP practices with the NHS DPP and encourage high rates of identification and referral.