Summary
In 2016, NHS England commissioned Healthier You: the NHS Diabetes Prevention Programme (NDPP). NDPP is an early intervention service designed to support people at risk of type 2 diabetes mellitus (T2DM) to make long-standing changes to their health and well-being and prevent them developing the condition. Ingeus, in partnership with Leicester Diabetes Centre (LDC), delivers NDPP in 18 areas across the UK, accounting for 38% of all programme referrals commissioned so far. It is the largest single provider of NDPP services across the country, with over 62,000 referrals. It has achieved exceptionally high performance for uptake, retention and participant outcomes (average HbA1c reduction of -4.4mmol/mol after six months, LDC analysis, February 2018).
Innovation
The approach draws on the combined strengths of Ingeus, a specialist provider of complex public services, and LDC, a global leader in diabetes prevention programme design. This partnership delivers an evidence-based intervention at an unprecedented scale. The NDPP behavioural intervention builds on LDC’s seven years’ work to design, implement and evaluate its Let’s Prevent Diabetes (LPD) intervention in primary care. It is the only such intervention shown to be effective through a large-scale randomised controlled trial (RCT). The RCT found that, after three years, participants who attended the first session achieved a 35% lower risk of developing T2DM, participants who attended all sessions achieved an 80% reduction and there were reductions in HbA1c. LDC’s multidisciplinary team adapted LPD for NDPP to align with NICE guidance and Public Health England’s evidence review. All key theoretical concepts and behaviour change techniques (BCTs) of the original intervention remain. To ensure the programme’s success it had to be bespoke for the user, tailored to the cultural backgrounds of participants and easy for GPs to refer on to. Educators were trained to focus on personal circumstances, helping participants understand the health consequences of their diabetes risk in the context of their own lives. Curriculums were tailored to South Asian, Afro-Caribbean and Eastern European participants. These included discussion on healthy alternatives to common Asian food practices (eg baking bhajis instead of frying them and reducing the use of ghee), the discussion of religious health beliefs (eg the role of ‘destiny’ in health), and education around the healthiest way to control diabetes during culturally important events (eg Ramadan). The NDPP referral form was embedded in GP systems (EMIS, Vision, SystmOne and Prism).
Results
Referral targets are consistently exceeded, achieving 113% against profile nationally. Ingeus is the best providerto convert referrals to attendance at intervention sessions of any NDPP provider and has the highest Milestone 1 to Milestone 2 retention rate (NHS England, 2017), with 75.2% of participants who commence NDPP achieving Milestone 2. LDC analysis shows highly successful results. On average, Ingeus participants achieve an HbA1c reduction of -4.4mmol/mol after six months on the programme. The mean Hb1Ac for participants at the six-month point is 39.9mmol/mol – below the pre-diabetic range. Participants who complete the programme achieve an average weight loss of - 4.1kg (LDC Analysis, Feb-2018). Multilingual educators meet the language needs of BME communities and support retention, while the website includes materials in key languages (eg Bengali, Polish, Urdu). Ingeus-run blood clinics ensure faster access for participants who require a test on referral and minimise barriers to uptake and retention. ‘Rolling’ maintenance sessions allow participants to attend any session they want, rather than having a prescribed date and time. LDC’s evaluation team conducts RCTs to support efficiency improvement.
Dissemination and Sustainability
Ingeus and LDC are contracted to deliver NDPP across the UK until July 2020. NHS England will launch the next iteration of the programme this year and it hopes to have an even larger role and continue provision across the country. Strong relationships have been developed with 1,144 GP practices. Different healthcare systems have been integrated to ensure wider access. In each LHE , NDPP was embedded into wider local systems of service delivery, contributing to health promotion by improving access. Partnership with LDC ensures a platform for scientific dissemination of the results of the programme. In summer 2018, LDC is making two submissions to the World Congress for the Prevention of Diabetes and its Complications. Additionally, it produces an ‘Outcomes Paper’ focused on HbA1c and weight loss and shares findings with NHSE, Public Health England and Diabetes UK to inform contract-wide efficiency improvements. In 2016, when the Wave 1 Regions were assigned, Ingeus delivered in two out of 11 regions (18%). Today, of the 47 regions where the NDPP has been contracted, it delivers in 18 of them (38%).
Method
The intervention is a structured education programme targeting lifestyle and behaviour change. It involves 13, 90-minute sessions, split into four weekly core sessions and nine monthly maintenance sessions. Sessions are held in groups of up to 15 participants, with accompanying friends or family, conducted by an Ingeus-employed, LDC-trained educator. Every session includes goal-setting, action-planning and weigh-ins. All participants receive resources to support behaviour change, including pedometers, activity diaries and personalised health profiles. The core sessions equip participants with an understanding of risk factors, helping them make lifestyle changes and commence the process of long-term behavioural change. Maintenance sessions reinforce the behaviour change methodology through a supportive group environment. All sessions are quality assured by the LDC.
The initial two-month establishment period uses a ‘trailblazer’ site in each contract area to prove the concept of the service to local GPs, which drives rapid uptake later. A Rapid Deployment Team (RDT) leads mobilisation in each new area, contacting every GP practice in 30 days and providing one-click referrals on to the programme using EMIS and SystmOne. Educators capture participant outcome data during the intervention sessions, using an encrypted portable electronic device to submit data (attendance, weight) via an HTTPS online form. LDC trains every educator. These educators perform point-of-care blood tests in accordance with NICE guidelines.
