Summary

The resource was developed by Diabetes UK to change both clinical and patient behaviour. Collaborative design was used to ensure it was easy for clinicians to use as a brief behaviour change intervention with patients who have diabetes and are at higher risk of complications. The tool consists of three information prescriptions (IPs), relating to the key targets in diabetes - HbA1c, blood pressure and cholesterol. To maximise impact and reach, the team worked collaboratively with the primary care IT companies to embed it in their systems. This enabled the proactive targeting of high-risk patients as clinicians receive real-time alerts for patients with diabetes who are outside the NICE targets. It also significantly increases the speed and effectiveness of the intervention as key patient data can be automatically populated on the IPs and a completed IP is saved on the medical record to support continuity of care.

Results

Phase one of the pilot tested the IPs as a paper document in practice to check acceptability to both clinical and patient audiences. Phase two piloted the technological intervention to ensure that all the clinical objectives were fulfilled. The pilot gave the team the confidence to launch nationwide with the following measures in place to allow ongoing measurement of impact:

• IPs contain a unique URL directing patients to further information and support. Monitoring the use of this unique URL allowed us to track the number of people who had not only received an IP, but had also been motivated to take action and find out more about managing their condition.
• Collection of patient case studies from clinicians.
• Individual practice audits.

Challenge

Data shows that we are not effectively supporting self-care: the latest National Diabetes Audit (2014-15) showed that only 39.5% of people with diabetes achieve the targets for blood pressure, cholesterol and HbA1c. This is despite these being the factors that place people at risk of devastating complications and the fact they are treatable with routine drugs (eg statins) and lifestyle interventions. There was frustration among doctors and patients that the number of tests and the pressures on time mean that diabetes care becomes nothing but a process of ticking boxes with no opportunity to explore what matters to the patient or to change behaviour and therefore clinical outcomes.

Objectives

To develop a tool that could reach patients across the UK and enable them to better understand and engage with their diabetes care, with the ultimate goal of changing behaviour and clinical outcomes.

Solution

Two co-production workshops were set up to design and develop the tool. Involved in the workshops were: Diabetes Consultants, a GP, practice nurse, psychologist, health academics who specialised in behaviour change interventions and people with diabetes. They established the design of the tool, key medical content was agreed and the language used to describe clinical concepts was thoroughly tested to ensure maximum clarity. The workshops created IPs for HbA1c, blood pressure and cholesterol. Four GP surgeries piloted the IPs in practice prior to launch to ensure that they worked as expected. Simultaneously a specification was agreed with the IT suppliers that would meet the objectives of clinicians – in particular agreeing clinical parameters for electronic alerts so that clinicians would be proactively prompted to use the IPs for patients who were outside NICE targets. IPs are now launched on the three main primary care IT systems (EMIS January 2015, Vision April 2015, and SystmOne February 2016) meaning that they are available to over 98% of registered patients in the UK.

Learnings

The IPs automatically alert clinicians to patients who have diabetes and are outside the targets for blood pressure, HbA1c or cholesterol. Case studies show this is prompting clinicians to intervene more proactively and identify patients who have slipped through the net for many years. Many patients say the IP was the first time anyone explained their condition to them (clinicians are clear that it is not, but evidently the IP was the first explanation that hit home). Anecdotally we are hearing of patients significantly improving clinical outcomes. The IPs include a unique link to more information on Diabetes UK's website, and over 13,000 patients in 2015 were sufficiently motivated by the receipt of an IP to access more information on managing their diabetes.

Evaluation

Formal evaluation of the initiative was carried out by Newcastle University and presented at Diabetes UK Professional Conference in March 2016. This focused on evaluating the usefulness of the IPs and identifying key factors (eg cognitive, behavioural and environmental) that impact on their implementation. The evaluation concluded that behaviour change approaches to implementation science provide new ways of improving patient care. The IPs account for cognitive, behavioural and environmental factors that influence professional behaviour and in doing so can help to improve quality of care. In addition, at the conference two clinicians presented evaluations of the impact of IPs on their individual practice. One focussed on patient experience while the other included an audit of HbA1c results before and after the introduction of IPs which demonstrated a significant improvement. Of the 13,000 visitors to the unique URL, 85% are female (compared with Diabetes UK site average of 65%), showing the resource is particularly resonating with a female audience. It also showed 50% of visitors were aged 45-64 (and a further 42% under 45) – suggesting that the resource is reaching people relatively early in their diagnosis – supporting the ambition that the IPs enable people to take control and prevent complications.