Summary

CWHHE CCG Collaborative created an annual review programme and offered referral into the National Diabetes Prevention Programme. The aim was to achieve reduction in weight, blood glucose parameters and progression to type 2 diabetes, and to maximise completion rates for attendees and ensure good data capture allowing detailed evaluation of the intervention. Evaluation has shown positive feedback from participants, GPs and commissioners, and the CCGs have been selected as the only Wave 1 site for the NHS Digital Diabetes Prevention Pilot.

Innovation

There were several innovative aspects to the project. For instance, the CWHHE diabetes prevention team has worked with commissioners, public health teams, GP practices, patients and ICS to implement a successful diabetes screening and prevention programme across a population of 1.4 million patients. We set out in 2014 (before announcement of the NDPP) to create a systematic primary care approach to the management of patients at high risk of diabetes through the use of a local incentive scheme (LIS) and have achieved our key aims. Numbers of appropriately coded patients on the NDH register have risen by nearly 50,000 patients over a two-year period, and most of these patients are receiving at least an annual HbA1c, blood pressure, BMI calculation and offer of referral into an intensive lifestyle management programme. The model also balances dietary advice and health psychology: ICS model incorporates a proven dietary programme, X-POD, coupled with a bespoke maintenance programme derived from the successful Life Balance programme. Participants are equipped with tools from health psychology to help them overcome obstacles and sustain their health improvements. This approach helps people stay motivated, and to put into action their dietary learning. By ICS working with X-PERT Health and Heidelberg University it ensures its service delivery model meets the standards of these peer-reviewed programmes.

Results

Since 2015, the CWHHE Diabetes Prevention Team has overseen the establishment of an NDH register of over 50,000 people across a population of 1.4m citizens, 235 GP practices and 5 CCGs. Since February 2016, over 75% of the NDH register have had a check of their HbA1c, and more than 85% have had blood pressure and BMI checked. Since September 2016, over 28,000 people have been offered an invitation to the NDPP with over 7,500 receiving a referral or contacting ICS and over 3,200 initial assessments already performed. We estimated that 2,461 citizens would undergo initial assessment over the two-year period of the programme. However, we were able to achieve that number within the first six months and have subsequently managed to receive a doubling of our allocation to 4,922 initial assessments for the two-year period. We are now on track to receive a further 100% uplift in numbers in July to allow 7,383 initial assessments (300% of the initial estimate).
Assuming these are completed, we expect to prevent approximately 309 new diabetes diagnoses over a five-year period with a cumulative five-year NHS cost saving of £929,157.

Dissemination and Sustainability

Our sustainability plans include the following:

• Work to maximise the numbers of citizens with NDH who are identified through risk stratification, HbA1c testing and added to the register. Our aim is to increase the NDH register in CWHHE by a further 20,000 in 2017-18 and ultimately to at least 130,000 in the next five years.
• Encourage people on the NDH register to attend annual review in their practice (at least 75% of the 50,000 so far identified are receiving an annual HbA1c)
• Maximise referrals into the NDPP for face-to-face interventions, continuing with the current successful model in conjunction with ICS
• Offer a single point of referral for all lifestyle interventions for diabetes and NDH in North West London, using a diabetes information hub.

Method

In 2014, the diabetes clinical leads began developing a contractual framework to improve primary care identification and management of patients at high risk of diabetes. The contract was implemented in August 2015 with the aim of increasing numbers of patients with a standardised coding for being at high risk of diabetes, maximising patients that underwent annual review including HbA1c, blood pressure, BMI, smoking status, lipid measurement and brief lifestyle advice, and encouraging referral into more intensive lifestyle management courses. The CCGs were made part of Wave 1 of the NDPP in July 2016. From then to commencement of initial assessments (October) and groups (November) ICS undertook a phased and structured mobilisation. ICS developed a pool of 26 coaches, and invested in additional technology and resources to assist delivery in the face of unexpectedly high demand.