LTP Priority: Diabetes
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: Improved access to and uptake of Diabetes Structured Education for people with diabetes
Major driver of health inequalities in your area of work
In the UK, approximately 12% of deaths of people between the ages of 20 – 79 years are attributable to diabetes. Diabetes and its complications cost over £10 billion every year to treat and one in six patients in hospital has diabetes. It is a leading cause of limb amputation, kidney disease and renal failure, stroke and heart attack. Further, recent analysis by British Heart Foundation suggested that the growing diabetes epidemic will trigger a sharp rise in heart attacks and strokes by 2035 with a 29% increase in the number of people living with diabetes suffering heart attacks or a stroke. In practice this is likely to mean an additional 9,000 heart attacks and 11,000 strokes annually unless further preventative action is taken.
80 per cent of spend on diabetes is associated with spend on complications, many of which can be prevented through good day-to-day diabetes management. Diabetes education equips people with the skills and confidence they need to take control of their condition, live well and avoid costly complications. As such, it is key to successful day-to-day diabetes management.
Even when allowing for coding issues, it is estimated that currently only between 15-30% of people newly diagnosed with diabetes attend structured education, despite high referral rates by GPs.
Uptake of self-management services including structured education is sub-optimal for people with both Type 1 and Type 2 diabetes. People from South Asian and black ethnic groups are at up to 6 times higher risk of developing Type 2 diabetes and they are also more likely to be diagnosed with Type 2 diabetes at younger ages and therefore their lifetime risk of developing complications associated with diabetes is high. By improving uptake in structured education and in particular from people from deprived and BAME communities this would help to improve outcomes for people with diabetes and help to address health inequalities.
As part of the Long Term Plan, the NHS will be taking action to prevent type 2 diabetes and reduce the variation in the quality of diabetes care. For those people living with a diagnosis of type 1 or type 2 diabetes the NHS will enhance its support offer. We will support people who are newly diagnosed to manage their own health by further expanding provision of structured education and digital self-management support tools, including expanding access to HeLP Diabetes an online self-management tool for those with type 2 diabetes.
STPs are asked to set out plans to deliver improved services in line with the Long Term Plan commitments:
- Expanded provision of structured education and digital self-management support tools for people with Type 1 and Type 2 diabetes to improve access and of support
- Provide access for those living with Type 2 diabetes to the national HeLP Diabetes online self-management platform, which will commence phased roll out in in 2019/20
In addition, NHS England and NHS Improvement has piloted digital structured education approaches through test beds projects and transformation funding building the evidence base for expansion of digital services alongside face to face services.
The aim is to increase the number and proportion of people newly diagnosed with diabetes attending structured education within one year of diagnosis. We also propose to expand the options for accessing structured education and self-management support and developing evidence about the relative effectiveness of different approaches.
People living in deprived areas and people from Black, Asian and ethnic minority community.
Improved access to and uptake of Diabetes Structured Education for people with diabetes.
Local healthcare systems are asked to:
- Implement mechanisms for proactively identifying those at risk of developing Type 2 diabetes, or those living with Type 1 or Type 2 diabetes;
- Support GP practices and other NHS Health Check providers to refer people at risk of developing diabetes into the local Healthier You Provider (NB the NHS Diabetes Prevention Programme is centrally commissioned by NHS England)
- Expand the provision of structured education to support people with a diagnosis of diabetes, giving consideration to:
- Expanding provision for people with both Type 1 and Type 2 Diabetes;
- Introduce a range of methods for accessing structured education (e.g. digital) and support GP practices to refer people with a diagnosis of Type 2 diabetes to HeLP Diabetes (NB HeLP Diabetes is provided free to local system by NHS England).
Evidence supports Structured Education resulting in improved glycaemic control and psychosocial wellbeing.
NHS England will be rolling out HeLP Diabetes from early 2020 to all STPs and will be available at no cost to local systems. HeLP Diabetes is an online self-management support programme and accompanying Structured Education pathway for adults with type 2 diabetes. HeLP was developed by a team at University College London (UCL), and provides information about type 2 diabetes and its treatments, offers emotional support, and helps with adopting and maintaining healthy behaviours (e.g. diet, exercise).
HeLP Diabetes has a strong evidence base proving its effectiveness. A randomised control trial (RCT), funded by the National Institute of Health Research (NIHR) demonstrated modest but significant improvements amongst the group using the HeLP diabetes tool in HbA1c levels. In trials HeLP also delivered savings of £111 per person over 12 months. In addition to this, the UCL team also designed an implementation study demonstrating the feasibility of rolling HeLP out at scale. 11 STPs have been identified as early engagement sites supporting testing of the and their feedback will inform the development and implementation of the tool. HeLP will be offered for access by patients at any time after diagnosis. HeLP is one of several digital structured education interventions available and is intended as an addendum to face to face structured education rather than a replacement for it. Referral to and uptake of HeLP Diabetes will count towards QOF and CCG IAF.
NHS England and NHS Improvement have sustained investments through the diabetes transformation funding in 2019-20 in structured education in 137 CCGs, reducing on a tapered basis as savings emerge. It is planned to expand this in 2020-21 to the 16 CCGs rated red for structured education provision in the CCG IAF. NHS England and NHS Improvement plan to also expand access to digital self-management services to improve access for working age populations and look to further boost uptake and retention to services.
Diabetes education improves health outcomes and reduces the onset of serious complications. As a result, it is recommended by NICE. A systematic review of group-based education for people with Type 2 diabetes assessed 21 randomised controlled trials. It concluded that group-based education improves a range of clinical, lifestyle and psychosocial outcomes – including significant improvements in:
- glycaemic control (significantly reduced fasting blood glucose levels and HbA1c, the latter by 0.46 percentage points at one year)
- self-management skills
- diabetes knowledge
- patient satisfaction
- body weight at 12 months.
Diabetes structured education, improve key outcomes, reduce the onset of complications and are cost effective or even cost saving.
RCTs suggest that attendance at structured education results in a reduction in Hba1c levels. There is also a wide body of evidence that suggests that each 1% reduction in HbA1c level result is associated with a risk reduction of 21% for deaths related to diabetes mellitus and a 37% risk reduction for microvascular complications
Given that each 1% reduction in HbA1c level is associated with a Modelling suggests that for every 100,000 people that attend structured education lowered Hba1C results in the following health benefits:
- 190 heart attacks avoided over the first two years (cumulative), 430 over the first five years (cumulative) and 520 over ten years (cumulative).
- 100 strokes avoided over the first two years (cumulative), 230 over the first five years (cumulative) and 290 over ten years (cumulative).
A randomised control trial (RCT) into the effectiveness of DAFNE (a major structured education course for type 1 diabetes) suggested that it led to improved glycaemic control, with HbA1c reductions of 1%. Similarly, the findings of a RCT into X-PERT (for type 2 diabetes) found HbA1c reductions of 0.6%. When this was linked to the UKPDS outcomes model, it indicates a significant reduction in complications risk over 10 years.
A randomised control trial (RCT) of HeLP Diabetes, funded by the National Institute of Health Research (NIHR) showed a significant improvement in HbA1c levels at 12 months in the intervention group compared to the control group (mean difference –0.24%); this difference is clinically meaningful, given the reduced risk of complications such as heart attack, stroke, IHD and heart disease above. With NHS England and NHS Improvement commissioning of HeLP for national implementation it can be delivered at low cost and at scale in England, the potential for population benefit is therefore considerable. Further, a small, single-arm, mixed-methods study examining the impact that the HeLP-Diabetes had on psychological well-being in people with type 2 diabetes demonstrated a significant reduction in (type 2) diabetes-related distress, as measured by the PAID scale. tool in HbA1c levels. In trials HeLP diabetes also delivered savings of £111 per person over 12 months.
NHS England and NHS Improvement investments in structured education will generate a modelled net saving of £8m after 10 years and more in later years as benefits of programmes in reduced rates of deterioration from improved glycaemic control and psychosocial wellbeing emerge.
A recent study conducted in North West London suggested that use of a digital structured education app by Oviva delivered to 100,000 patients per year could generate savings over 5 years of between £164m and £189m. This requires further modelling, but makes the case for looking at expansion of digital approaches.
Diabetes education could be delivered to everyone in the UK diagnosed with Type 2 diabetes – over 3.1 million people – for £40 million per year over five years. This is just under 0.6 per cent of the £7 billion that the NHS spends every year on Type 2-related complications. Moreover, this is likely to overestimate the investment required, as economies of scale mean that course costs would fall with high levels of provision.
For a summary of the published evidence on structured education download Diabetes UK’s report Diabetes Education: the big missed opportunity in diabetes care
NICE (2015). NG17: Type 1 diabetes in adults: diagnosis and management; NICE (2015). NG28: Type 2 diabetes in adults: management
Guidance for commissioners
- Additional guidance will be produced by Mid July 2019
Things to include in the How To Guide:
- STPs should work with the QOF data and National Diabetes Audit to review performance of local practices in terms of offers and take up of Diabetes Structured Education. Performance data at practice level should be disseminated to practices and practices encouraged to increase referrals to Diabetes Structured Education.
- STPs should develop a strategy to engage potential referrers such as GPs and other primary care staff to realise the benefits of locally run Diabetes Structured Education programmes.
- STPs should ensure that attendances and outcomes at Diabetes Structured Education are tracked so that courses are accessible; i.e. in the right places and times for their diverse communities and are delivered well, including supporting patients to understand the personalised actions they can take to self-manage and control their diabetes.
- Local contracts for the provision of Diabetes Structured Education should include reporting requirements on uptake and completion of the SE programmes and the submission of uptake and completion data to the National Diabetes Audit via the CAP system.
- STPs should develop systems locally for following up referrals to ensure that people understand the benefits of the course and any logistical worries are addressed. There is emerging evidence from some of the transformation projects that having a referral hub and a co-ordinator who contacts participants to remind them of the education programme and encourage attendance has helped to improve the uptake of Diabetes Structured Education.
- STPs to consider the commissioning of digital Diabetes Structured Education/self management programmes for people with type 2 diabetes who decline or are unable to attend face to face programmes in order to increase the proportion of patients receiving Diabetes Structured Education. NHS England will be rolling out HeLP Diabetes at no cost to STPs from early 2020. HeLP Diabetes is an online self-management support programme and accompanying Diabetes Structured Education pathway for adults with type 2 diabetes.
- The diabetes self management education resource gives healthcare professionals and local decision makers more information about patient education options. It includes resources to use with your patients and advice on improving uptake.
- Lambeth and Southwark, increased structured education attendances by 80 per cent over three years. As part of this, materials for patients were designed in collaboration with the local Healthwatch and dropped the term ‘education’ altogether, instead using the phrase ‘learn about your diabetes’. Diabetes Modernisation Initiative (2014). Living well with diabetes: Learnings report from the Diabetes Modernisation Initiative
- In Bexley improving access to diabetes education courses was made a priority during a diabetes service redesign. Local healthcare professionals were engaged and people with diabetes consulted to identify convenient venues. As a result, the CCG achieved its target of reaching 50% of people with Type 2 diabetes who were in the first year of diagnosis. Attendance at X-PERT increased from only 40 people in 2009 to over 1,000 in 2010, on average reducing attendees’ HbA1c level by 1.3 percentage points. Cotter B, Grumitt J (2011). GP commissioning: Shaping diabetes care in Bexley. Diabetes & Primary Care 13 (6); 375–80
- Barriers to Uptake of Diabetes Education (BUD1E) study.
- Diabetes Toolkit for Structured Education. A group of diabetes healthcare professionals called the Health Innovation Network for South London and the London Strategic clinical network have developed a toolkit to help with structured education. This toolkit is aimed at providers, commissioners and referrers into structured education for Type 2 Diabetes with the objective of providing best evidence guidance and very practical resources to help teams provide structured education and increase uptake.
- Boosting attendance of diabetes self-management education. Diabetes UK.