Summary
Young people with diabetes are a high-risk group with poor clinical outcomes and subject to significant health inequality. A pilot project was implemented to improve engagement and clinical outcomes. This included: a cross-site Young Adult Diabetes (YAD) team to work across all four Barts health sites; a high-risk YAD pathway to find young people not engaging, understand their barriers and address their priorities; peer support and education, plus support for psychosocial factors like housing, financial resources and mental health.
Innovation
As part of an NHSE-funded pilot, Barts Health set out to deliver equitable care across all four sites and develop a cost-effective service to improve clinical outcomes. A mobile, cross-site YAD team was set up, comprising a diabetes nurse, dietitian, psychologist, youth worker and social prescriber. Baseline data demonstrated that 40% of the cohort was high risk (recurrent DNAs, frequent DKA admissions, homeless, learning disabilities, mental health, HbA1c over 100mmol/mol). Feedback from young people in the service and the paediatric diabetes teams led to the creation of a high-risk pathway to improve engagement and reduce DNAs, a robust transition process from paediatric to adult care, joint appointments with the paediatrics and YAD team, close working with community services to deliver healthcare and education outside the hospital in youth centres and cafes, maximising the impact of each clinical appointment, plus promoting self-management and independence.
Equality, Diversity and Variation
This project delivered equitable YAD services across all the sites through the cross-site YAD team and implementing the initiative for young people in Tower Hamlets, Newham, Waltham Forest and Redbridge. The high-risk pathway allows understanding of the individual needs of young people and having a psychologist, social prescriber and youth workers in the team directly addresses the challenging psychosocial factors that stop them accessing care. Meaningful contact has been achieved with 68% of them. Staff in three day centres have been trained to offer better support. In the low-risk cohort, care has been streamlined and treatment enhanced using diabetes technology, resulting in an HbA1c improvement from 71.5mmol/mol to 67.9mmol/mol in people with T1D and a reduction in HbA1c from 67.7mmol/mol to 62.1mmol/mol in people with T2D.
Results
The high-risk pathway helps understand the needs of individual patients and cater to them. MDT appointments can fast-track patients on to technology, with pump assessments offered straight after the clinic appointment. The initiatives have supported young people with diabetes by addressing their priorities first. This has built their trust with the team and given them the time and space to start thinking about, and working on, diabetes management. The initiatives encourage independence, improved diabetes education and knowledge and promote and encourage the use of diabetes technology. Baseline data from April 2022-April 2023 and outcome data from April 2023-April 2024 from two sites have shown an increase in the number of young people being seen in the service. There are now 156 people with T1D across the two services compared to 109 at end of December 2022 and 46 people with T2D, compared with 26 a year before. Clinic DNA rates have reduced from 39% to 12% and the number of clinic appointments per month has risen. There has been a reduction in average HbA1c for people with T1D from 71.5mmol/mol to 67.9mmol/mol and a reduction in HbA1c for people with T2D from 67.7mmol/mol to 62.1mmol/mol. Meaningful contact has been made with 33 of the 44 individuals who were not previously accessing healthcare services. Findings from all four sites showed: 30% of the cohort had completed structured education compared with only 10% at the end of December 2022; a 36% reduction in the number of hospital admissions with DKA across the three Barts Health sites at Whipps Cross, Newham and Royal London; 20 were helped into safe housing, 15 into employment and 28 receive financial benefits; the service is cost effective, saving the trust £62,597 per year in direct costs.
User Feedback
Feedback is collected by anonymous post-clinic questionnaires, a scrap book for young people to write in after peer support/education sessions, written and video testimonials, invitations to contribute to away days, plus informally in person.
Dissemination and Sustainability
This project included the four Barts Health sites and was a proof-of-concept project aimed at expanding across the whole of North East London. MDT appointments minimise time away from university or work and allow young people to start newer diabetes technologies faster. Recognising that diabetes is not always the patient’s priority and that poor engagement is usually a symptom of bigger psychosocial problems allows more compassionate care delivery. Having a social prescriber, youth workers and psychologist embedded in the service to address the patient’s priorities, like mental health, financial concerns or homelessness, allows the young person to feel listened to and supported. This helps them to trust the service, giving them more time and space to think about their health. Bringing together secondary care, primary care, social workers and mental health is a useful way of making sure everyone involved in a young person’s care is part of the discussion. It is an effective way of communicating between professionals and aligning care, making sure the specific needs of the young person are met. Peer support is used to disseminate education, build independence, discuss mental health and build networks for these young people. It has helped some of them to feel more confident and secure with the service and their diabetes, plus allowed the team to hear their voices and connect better. This project has demonstrated financial viability. Provided that the NHS trust/ICS agree to fund a YAD team, the implementation of this service in other diabetes teams across the UK would be straightforward and much more efficient. These interventions could be implemented across other specialities as the focus is on engagement and personalisation of care.
