Summary
In line with the Scottish Government’s ‘A Healthier Future’ framework, NHS Grampian developed psychology provision within its prevention and early intervention pathway for type 2 diabetes (T2D). ACT Now! is a brief supported self-management intervention designed to improve glycaemic control and emotional well-being in people who are at risk of, and living with, T2D. Based on the principles of acceptance and commitment therapy, the 1:1 sessions focus on promoting self-management behaviours (eating, physical activity), exploring the links between cognitions, emotions and behaviours and introducing strategies to support individuals to better manage barriers to self-management.
Innovation
Education regarding nutrition, physical activity and treatment regimens is essential. However, research demonstrates that psychological distress (anxiety, depression and/ or diabetes distress) reduces engagement in self-management behaviours, in turn reducing glycaemic control. NHS Grampian developed psychology provision within its prevention and early intervention pathway for T2D. The aim was to embed evidencebased and innovative brief 1:1 intervention, based on the principles of acceptance and commitment therapy (ACT) and delivered digitally across the Grampian region, for the target populations. ACT teaches individuals to accept their thoughts, feelings, sensations and internal experiences (acceptance and mindfulness-based strategies) and to behave in ways consistent with their own valued goals and life direction (commitment and behaviour change strategies). The hypothesis was that an ACT intervention could help improve glycaemic control and health-related behaviours and reduce levels of stress, anxiety, low mood and diabetes-related distress. ACT Now! comprises six-to-eight weekly appointments, each lasting approximately 50 minutes. Sessions are delivered 1:1 with a psychologist via NHS Near Me, with an in-person option. Six core sessions focus on self-management and health-related behaviours, with two optional sessions on anxiety and depression. Sessions explore personal values and how they relate to diabetes/health, using ACT techniques for managing stressful thoughts and feelings. Weekly goals promote changes. A participant manual reinforces content and provides links to further information. Baseline and postintervention measures monitor individuals’ progress and evaluate the programme.
Equality, Diversity and Variation
Diabetes psychology provision was commissioned by NHS Grampian in 2019/20 to widen access and provide new options for self-management support. In collaboration with primary care, this service is available to all individuals at risk of or living with T2D in Grampian. The NHS Near Me video appointment system was adopted to expand reach and accessibility of the ACT Now! programme and reduce travel and time off work. While most participants were happy with digital-first appointments, in-person appointments were also available. Patients could self-refer or be referred by a healthcare professional. Promotional materials were developed, with posters and business cards for primary care practices and third sector supports. Service and referral information was shared at local diabetes conferences and training sessions.
Results
From April 2020-March 2023, 81 individuals had an initial assessment with a psychologist and joined ACT Now!, with 71% completing the programme. The average number of sessions attended was 8.6 and the average time taken to complete the programme was 12.7 weeks. Findings showed clinically and statistically significant improvements in participants’ glycaemic control (mean decrease in HbA1c of 8.6mmol/mol), anxiety (mean decrease in HADS-A score of 3.9), depression (mean decrease in HADS-D score of 3.9) and diabetes-related distress scores (mean decrease in PAID score of 16.0), plus physical activity levels post-intervention (mean increase of 2,685 steps and 2.2 days where a participant was moderately active for at least 30 minutes). ACT Now! was funded by the Scottish Government. Independent evaluation in 2017 found it was cost-effective and cheap to deliver, with a reported +0.21 gain in quality-adjusted life years, as well as a lower lifetime cost of diabetes complications of £248 per patient.
User Feedback
Anonymous feedback forms were sent to all participants after their final session. They were also invited to an interview with a member of the diabetes psychology team. A total of 24 survey responses were received and nine interviews conducted. ACT Now! helped participants to feel more confident and motivated to make and maintain changes, focus their thinking and goals into something manageable, and feel better equipped to manage their diabetes. Participants described improvements in emotional well-being post intervention and felt that the interventions, session content and materials used were wellstructured and relevant. Some participants said a follow-up session would be beneficial, while others wanted content in more depth. There were some challenges experienced with digital delivery but most participants enjoyed its flexibility. Several participants reported that email contact between appointments was beneficial to reinforce their learning. Following feedback, a ‘postcard’ completed in the final session is emailed to the participant three-months post intervention as a reminder of helpful strategies.
Dissemination and Sustainability
ACT Now! focuses on initiating and maintaining changes in key health behaviours, developing skills and responsibility. Moreover, 82% of participants had other chronic medical problems, which the lifestyle changes can help too. HbA1c is an important indicator of long-term glycaemic control, and correlates well with the risk of diabetesrelated complications. It is hoped that ACT Now! will delay the intensification of diabetes drug treatment and thereby decrease overall healthcare spend. At baseline, nearly three quarters (73%) of participants were already on at least one diabetes medication. Up to 50% of these would next move on to the DPP-4 inhibitor class of diabetes medication, which costs an average £431 per patient per year (NICE, 2015). ACT Now! is supported with participant and therapist manuals. Future delivery requires only one direct recurring cost, associated with the salary of a psychology practitioner(s) to deliver the 1:1 sessions. Ways to sustain and spread the innovation include: continuing to embed signposting with general practice; facilitating engagement with third sector and community groups in the region, targeting difficult-to-reach groups and those at increased risk of developing T2D, plus developing audio/video materials to improve accessibility
