Addressing health inequalities through co-developing the Healthy Eating & Active Lifestyles for Diabetes (HEAL-D) programme

A case study on how co-production and partnership working were utilised in London to develop an innovative self-management education programme that promoted healthy eating and active lifestyles for patients with Type 2 Diabetes, in line with local needs.

Themes: Health Inequalities, Partnership Working

Case study summary

HEAL-D is a diabetes self-management support and education programme for people living with Type 2 Diabetes (T2D) from African-Caribbean communities in south London, to help them achieve diet and lifestyle goals through supporting and motivating the development of self-management skills. It successfully combines lifestyle education and exercise into a 7-week curriculum, which was co-designed with local communities and healthcare professionals. It is delivered in collaboration with HEAL-D creator King’s College London (KCL), Guy’s and St Thomas’s NHS Foundation Trust (GSTT), the Health Innovation Network (HIN – the Academic Health Science Network (AHSN) for south London), and both south London ICSs (south East London (SEL) and south West London (SWL)).

What was the problem or opportunity?

HEAL-D was developed by KCL between 2015 and 2019 with funding from the National Institute for Health and Care Research (NIHR). Based on the positive HEAL-D design and feasibility trial results there was local support for spread and adoption of the innovative programme. Originally developed as a face-to-face programme, due to the COVID-19 pandemic, it was adapted to be delivered virtually (‘HEAL-D Online’), with work ongoing to increase uptake across south London.

The initial HEAL-D study was conducted in south London and HEAL-D Online is now commissioned as a pilot across both local ICSs. The curriculum is delivered within interactive group activities, including cooking demonstrations and group exercise, to support long term behaviour change. Topics include carbohydrate management, weight management, cardiovascular risk management and healthy cooking practices.

How did this support innovation adoption and spread?

Across London, 7.0% / 4.2% of the population are Black African / Black Caribbean ethnicity. In the UK, people of African or Caribbean descent are disproportionately impacted by type 2 diabetes (T2D) and its associated complications.

HEAL-D was developed by KCL to address inequalities in T2D structured education attendance and outcomes among black African and Caribbean adults, and to be sensitive to the needs of the NHS as well as of people living with T2D. Co-production methods were used to design a self-management programme that would promote engagement, healthful behaviour change and therefore improve diabetes management.

Following the design and feasibility study, KCL worked with GSTT to deliver the programme which was commissioned as a pilot by SEL and SWL ICS and supported by the HIN. HEAL-D was presented at a meeting convened by the HIN for all south London diabetes/long term conditions commissioners and public health teams. The London diabetes clinical network also championed the programme. Implementation of the HEAL-D programme was part of SEL and SWL ICS diabetes strategies and aligns with NHSE diabetes transformation plans and the NHS Long Term plan goal of increasing access to diabetes structured education. The HIN has worked with providers and provided project management expertise to support the local ICS teams to work together.

HEAL-D was initially implemented in community venues in four south London boroughs. GP Practices with a high number of black African or Caribbean individuals with Type 2 diabetes were invited to refer to the programme as part of this pilot. In response to COVID-19 restrictions HEAL-D pivoted to online provision.

Patient and public involvement

The team worked with key stakeholder groups including people living with T2D, healthcare practitioners, and members of the community. The aim was to identify barriers and enablers that motivate lifestyle behaviour change, to improve healthcare access and engagement amongst local communities and to identify appropriate cultural adaptations for a T2D self-management programme. Co-creation methods involved gathering experiences from stakeholders, through interviews and group discussions and then working together to develop a programme. This included going into mosques and churches to foster engagement and connect with community ‘gatekeepers’ such as faith leaders. Ongoing feedback from a small stakeholder group consisting of people with T2D and healthcare practitioners, supported the development of programme materials to ensure appropriate messaging and literacy.

What were the results?

The development of a co-designed, culturally tailored diabetes education programme has proved a hugely significant step forward in addressing health inequalities in south London. It has affirmed that a co-designed approach to diabetes self-management education enables cultural nuances to be acknowledged and respected; and ensures the curriculum and associated peer support is meaningful, worthwhile, and valued by those who attend the course.

The number of participants who attended and completed the HEAL-D course (attended 5 or more sessions), is exceptionally high compared to other diabetes structured education courses. 85% of participants who underwent the face-to-face version of HEAL-D and 71% of online attendees completed the course, which demonstrates the acceptability and importance of this culturally tailored approach.

To ensure equitable access across south London, HEAL-D is now accessible through the Diabetes Book & Learn platform which provides a single point of access for both people living with T2D and referrers to book diabetes education across south London.

What were the learning points?

The key learnings from this work are summarised below and a number are generalisable to the development and implementation of innovations more broadly:

  • Co-designed culturally tailored diabetes education is well received and appreciated by communities and has proven to be a much-needed resource. A ‘one size fits all’ approach to diabetes structured education that does not appreciate cultural nuances will not engage and motivate all participants. ICSs should consider how to adapt their local diabetes education offers to support the local needs of their community.
  • Implementing innovation does take time and effort and requires good relationships between stakeholders to support this process. HEAL-D was developed with local communities and once the proof of concept had been realised it was rapidly spread across south London by the AHSN.
  • Short and rapid cycles of improvement and evaluation have been vital to enhancing the referral and booking processes for HEAL-D across these two ICSs.
  • Having funding available to support the scale and spread of innovation is key.
  • Local champions support promotion and spread of an innovation.  In this instance the training of local ‘lay educators’ provides a legacy of skills and expertise in the local community, and ongoing peer support for participants, which could be replicated in other clinical areas.
  • Group education is an effective way to deliver ongoing peer support and participants value the relationships they establish between themselves in the process.
  • The HIN as the local AHSN has delivered a valuable role in logistically transforming HEAL-D from a feasibility study to a commissioned pilot programme. This includes providing administration and practical support to develop project and evaluation plans, creating the service specification, establishing referral processes, developing local communication plans, and authoring supporting documentation. Information governance assurance is vital for the delivery on the online version of the HEAL-D programme, and this was also provided by the HIN.

Next steps and sustainability

The HIN and South London Applied Research Collaborative (ARC) were awarded National Insights Prioritisation Programme (NIPP) funding to strengthen and evaluate HEAL-D as an innovation that will support COVID-19 recovery plans, address health inequalities and be suitable for rapid scale up and spread within the NHS. The team is evaluating the feasibility and acceptability of the current HEAL-D model, developing key resources, examining potential operating and commissioning models and providing recommendations for systems planning to adopt HEAL-D.

SEL and SWL ICS will continue to work closely with the HIN, KCL and GSTT to support and monitor the progress.

Find out more

You can find out more about the HEAL-D programme at the following links: 

Contact details

  • Dr Louise Goff 
    Reader in Nutritional Sciences at King’s College London and Study Chief Investigator
  • Sally Irwin
    Project Manager, Health Innovation Network