COVID-19: Innovation Key to Keeping NHS Diabetes Prevention on Track

Liam Davenport

November 13, 2020

The transformation of the national type 2 diabetes prevention programme into a remote and online intervention in just 2 weeks, and the loosening of the referral criteria, in response to the COVID-19 pandemic allowed it to continue supporting all participants and quickly recover referral rates, say UK experts.

The data were presented at the Diabetes Professional Care Virtual 2020 meeting on November 11.

UK Diabetes Risk

It is estimated that currently 5 million people in England are at high risk of developing type 2 diabetes, and if current trends persist, 1 in 3 people will be obese by 2034 and 1 in 10 will develop the condition.

In response, the NHS Diabetes Prevention Programme offers a primarily group-based, face-to-face series of behavioural interventions to help individuals maintain a heathy weight and reduce their risk of type 2 diabetes.

Professor Jonathan Valabhji, national clinical director for diabetes and obesity, NHS England, said that results published in January showed that, up to December 2018, 324,699 people had been referred to the programme, of which 96,442 had attended at least one of 13 group-based intervention sessions.

Intention-to-treat analyses in more than 17,000 individuals demonstrated it was associated with a mean weight loss of 2.3 kg and an average HbA1c reduction of 1.26 mmol/mol.

The impressive results achieved by the programme led to its inclusion in the NHS Long Term Plan, launched in 2019, which states that its capacity should be doubled by 2024 to include 200,000 participants per year.

The target for 2019/2020 was to support approximately 120,000 people on the programme, "which we did achieve, in the nick of time, before the lockdown started in March," Prof Valabhji said.

The COVID-19 pandemic had a huge impact on the programme however.

Referrals decreased dramatically at the start of the pandemic and, "of course…we had to adapt very rapidly over the course of March to shift the entire delivery mechanism from group-based, face-to-face to remote or digital delivery," Prof Valabhji said

User Journeys

Enlarging on the programme’s response to the pandemic, Tom Newbound, director of NHS England’s Diabetes Programme, said that, in the run-up to the first wave, there were around 100,000 individuals in the programme, at different stages of their "user journey".

"So the challenge was very much how best to continue to support these patients," while providing "a safe service…that reduced social contact".

They worked with all of their providers to put in place a fully remote and digital service nationwide, with "exactly the same curricula, the same approach, the same facilitators, for which we’d got good evidence worked well and was achieving the outcomes we wanted".

Newbound said that, within 2 weeks, a series of technologies, such as video conferencing tools, were deployed to support all the individuals currently in the programme.

He also noted that before the COVID-19 pandemic struck, the programme had some digital services, such as wearable technologies, apps, and online support groups, available across "broadly 50% of England, and the aim was that we would bring the other 50% on-stream" during 2020.

In normal circumstances, he continued, digital services "sit alongside" face-to-face interactions, so that individuals have some choice over how to engage with the programme.

However, the pandemic meant that they "immediately" made their digital services available across the remaining 50% of England, "to make sure that there were different routes of access for patients".

COVID-19 Changes

There have also been changes to the way patients are referred to the programme in response to COVID-19.

Eligibility for referral to the programme was previously based solely on a blood test result showing the presence of non-diabetic hyperglycaemia, with the referral made via primary care.

"In that first wave of COVID-19, we saw quite a significant reduction in referrals from primary care," Newbound said.

This meant that the average number of referrals to the programme each month fell from 20,000 pre-COVID-19 to less than 5000 when the first lockdown started.

While there has been a slow increase since then, the rate of referrals from primary care remains below pre-pandemic levels.

Newbound envisages that will continue for the foreseeable future due to, "quite understandably, the capacity and clinical pressures that are present across primary care, and the limits on routine blood testing".

Consequently, the team explored the possibility of self-referral, with the aim of focusing on more vulnerable individuals, such as those from Black, Asian, and Minority Ethnic backgrounds, via social media and other campaigns.

In July, they introduced a "temporary pathway" that does not replace primary care referrals but allows individuals to use the Diabetes UK Know Your Risk Tool to self-assess their likelihood of having type 2 diabetes.

Those who have a moderate or high score are offered support via the Diabetes Prevention Programme, linking them to providers "as if they were referred from primary care", said Newbound.

The Programme also extended the eligibility period for individuals who had previously undergone a blood test to confirm the presence of non-diabetes hyperglycaemia from 12 months to 24 months.

Finally, the team re-contacted individuals who had declined participation in the programme to ask if they would like to re-engage. This yielded approximately 7300 referrals from 70,000 people contacted up to September 2020.

Taken together, these measures have allowed the programme to "top up" the reduced number of referrals from primary care, so that, "to date, we’re back at around 15,000 referrals into the programme", or 75% of pre-COVID-19 levels.

"We’ll need to wait and see, clearly, what the impact of wave two [of the pandemic] is, but I think it shows that these activities we’ve taken up played a really important role to supplement primary care referrals through the year," Newbound said.

The research was funded by NHS England.

No relevant financial relationships declared.

Diabetes Professional Care Virtual 2020: Abstract Healthier You NHS Diabetes Prevention Programme – preventing Type 2 diabetes virtually during a global pandemic. Presented November 11.

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