Learning lessons from implementation of a national diabetes prevention programme in England
Lisa Brunton, Jonathan Stokes, Judith Gellatly, Pete Bower, Matt Sutton, Paul Wilson
The University of Manchester
Background: The increasing number of people being diagnosed with Type 2 Diabetes Mellitus (T2DM) and at risk of complications has made the disease a major public health concern. Diabetes prevention programmes aim to deliver personalised help to people to reduce their risk of T2DM, including education on healthy eating and lifestyle; help to lose weight; and tailored exercise programmes. The NHS Diabetes Prevention Programme (NHS DPP) commenced during 2016 and by 2018 the NHS DPP had spread to the whole country with a target of making 200,000 places available in the NHS DPP annually by 2023. We report on the implementation of the NHS DPP in England, and identify lessons learned in addressing the challenges of implementation.
Methods: A longitudinal telephone interview study with the designated lead(s) responsible for local implementation of the NHS DPP is being undertaken. In 2017/18, we conducted 20 semi-structured interviews across 16 sampled case sites; in late 2019/early 2020 we extended our sampled case sites to 19 and conducted 24 semi-structured interviews; we plan to conduct final interviews with the local designated lead(s) in spring 2020. Early interviews explored how the programme was organised locally, expectations and attitudes towards the programme, funding, meeting the needs of local target populations and local pathways to generate referrals to the programme in general practice. Later interviews have explored transition to the new contractual delivery framework. To complement our qualitative interview data we also conducted two email surveys to explore variation across sites in the use of financial incentives/resource support given to general practice to encourage referral into the NHS DPP. We first conducted the survey in 2018 and then repeated it towards the end of 2019 to identify any changes over-time.
Results: Five over-arching areas of learning when implementing this large-scale disease prevention programme have been identified: 1) managing new providers; 2) promoting awareness of services; 3) recruiting patients; 4) incentive payments; and 5) mechanisms for sharing learning. In first interviews, tensions appeared to be caused by a lack of clear roles/responsibilities and lack of communication between stakeholders. Both local sites and the national NHS coordination team gained experience through learning by doing. Initial tensions with roles and expectations have been worked out during implementation and at second interviews, designated leads discussed the importance of developing good relationships with their provider, GP practice staff and CCGs and ensuring easy referral pathways for primary care. Challenges were encountered with switching from outgoing to incoming providers, usually in terms of managing the transition of people on waiting lists. Sites were now focused on undertaking initiatives to target high needs populations but most felt they had a long way to go. Receiving monthly data from providers in a user friendly format helped them to target their local population needs. Some sites were attempting to get to ‘business as usual’ regarding referral into the programme and reported either stopping incentive payments or working towards stopping them as they moved on to new contracts.
Implications: Implementing a national disease prevention programme is a major undertaking and our study provides practical learning opportunities for the wider uptake and sustainability of prevention programmes. We will discuss implications for future implementers including the need to define clear responsibilities for stakeholders prior to implementation, ensure engagement with new providers/between providers, offer mechanisms/forums for sharing learning and prioritise public and professional awareness of the programme.
Acute hospitals managing general practice services in the UK: why, how and what are the consequences for primary care delivery?
Manbinder Sidhu(1), Jack Pollard(2), Jon Sussex(2)
(1)Health Services Management Centre, University of Birmingham, (2)RAND Europe
Background: Fostering greater integration between primary and secondary care, sustaining primary care in the face of workforce shortages, and managing patient flows to acute hospitals are recurring themes in United Kingdom (UK) health care policy. One approach which might address such challenges is acute hospitals taking over the running of general practices, a form of ‘vertical integration’ in health care. In this approach, the acute hospital or health board is contractually responsible for the delivery of core general medical services to patients in the practices concerned.
Internationally, examples of vertical integration models have been identified in the United States (Kaiser Permanente Community Health Initiative, Schwartz et al. 2018), Spain (the Alzira model, Comendeiro-Maaløe et al. 2019), and in Denmark (Blom & von Bülow 2013). Little is known about this model of integration in a UK setting: how it is being implemented; the rationale locally; whether and how services offered in primary care settings change as a result; and the impacts of such changes.
Method: We undertook a rapid evaluation using a qualitative approach to understand the implementation of vertical integration in three case study sites across the UK. In particular, we analysed: the rationale for acute hospitals taking over the management of general practices; the governance arrangements they adopted; the challenges experienced during implementation; consequent changes in health care delivery; and impacts upon primary and secondary workforces.
Following an initial rapid review of the literature supported by interviews with key informants and a project design workshop with policy makers and external researchers, we undertook (between August 2019 and January 2020) semi-structured interviews with 52 participants, four non-participant observation of meetings, and analysis of key documentation. Our thematic analysis of interview transcripts, observations and documents followed Braun and Clarke’s (2006) six stage approach. We then developed a theory of change for each case study site as well as for vertical integration overall.
Results: We found that the adoption of vertical integration was prompted by the risk of General Practitioner (GP) practices closing due to difficulties in recruiting permanent GPs, rising costs and growing demand. Acute hospitals offered the prospect of being able to ‘shore up’ primary care with greater financial resilience, increased back office support functions (legal, governance, estates, human resources) and other economies of scale allowing more efficient use of primary care staff. Central to achieving this was GP partners becoming salaried GPs directly employed by the acute hospital/health board, with consequent impacts on their autonomy.
Implementation challenges have included continuing difficulties recruiting and retaining GPs; and differences between primary care and secondary care staff’s understanding of the pressures, processes and challenges of delivering primary care. Clinical secondary care staff have had only limited involvement in the integration with primary care.
There were signs of innovation and increased multidisciplinary working (increased use of advanced nurse practitioners, pharmacists, physiotherapists to fill the absence of GPs), with clinical staff moving across practices, an extended range of primary, community, secondary care services delivered in a single location, and more efficient sharing of data to help manage patient care.
Implications: The introduction and implementation of vertical integration has sustained primary care delivery in locations facing particular challenges. But it remains to be seen whether it truly achieves integration across the care interface. Key to the success of vertical integration is the ability of secondary care providers to foster relationships with primary care staff and provide a long term strategic direction for sustainable care provision and taking advantage of a new era which encourages primary care collaborative working. A follow-up evaluation will reveal more about impacts on patients and on local health economies.
Blom, AB, & L Lene von Bülow. 2013. 'Vertical integration across Hospital Acute Care and on-call General Practitioners. An evaluation of a cross sectional Cooperation Model at Odense University Hospital, Southern Region of Denmark.' International Journal of Integrated Care 13(8).
Braun, V., & Clarke, V. 2006. Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101.
Comendeiro-Maaløe, Micaela, Manuel Ridao-López, Sophie Gorgemans & Enrique Bernal-Delgado. 2019. 'Public-private partnerships in the Spanish National Health System: The reversion of the Alzira model.' Health Policy.
Schwartz, Pamela M, Cheryl Kelly, Allen Cheadle, Amy Pulver & Loel Solomon. 2018. 'The Kaiser Permanente Community Health Initiative: A decade of implementing and evaluating community change.' Elsevier.
'Going the Distance' - An analysis of engagement and drop out among the first 100,000 referrals into the NHS Diabetes Prevention Programme.
Sarah Cotterill, Elizabeth Howarth, Peter Bower
University of Manchester
Background: The NHS Diabetes Prevention Programme (DPP) is a behaviour-change intervention aimed at those at high risk of developing Type 2 Diabetes in England. It offers education on healthy eating and lifestyle, help to lose weight and bespoke physical exercise programmes, providing at least 16 hours of contact over nine to twelve months. Using data collected by service providers we investigate the extent of participation in the NHS DPP intervention and report patient health outcomes. We consider how participation and health outcomes vary with patient and service characteristics.
Methods: Using data collected by DPP service providers, we report overall levels of uptake and attendance, and use multilevel logistic regression models to estimate associations of patient and service characteristics with uptake and attendance of the DPP. We report overall change in glucose levels, weight and well-being, and use multilevel linear regression models to estimate associations of patient and service characteristics with health outcomes. Models account for clustering by site. Multiple imputation by chained equations is used to handle missing data.
Results: During April 2016 to September 2017 99,473 people at risk of diabetes were referred from primary care to the DPP, of whom 55,275 (56%) took up a place. The median number of sessions attended was 4 out of a possible 16. Of those who took up a place on the programme 34% were retained to 60% attendance (regarded by NICE as completion) and 22% completed the full course.
Uptake of the DPP increased with age up to 70 (OR 1.17 (1.15 1.20) per five years) and decreased with older age. Uptake decreased with deprivation, OR 0.65 (0.61, 0.68) for the most deprived compared with the least deprived quintile. Gender and weight had little association with uptake.
Similar associations with age, deprivation, gender were seen for retention as for uptake. Retention to 60% attendance was lower among Asian (OR 0.75 (0.63, 0.91)) and black (OR 0.83 (0.71, 0.99)) compared with white participants, and lower among employed (OR 0.74 (0.69, 0.80)) than retired people. People with a disability were less likely to be retained than those with none (OR 0.81 (0.77, 0.86)). Where some out-of-hours provision was offered retention was higher (OR 1.32 (1.25, 1.39)). Variation across service providers is partly explained by variation in case mix in terms of ethnicity and deprivation, and partly by differences in service provision. Weight and blood glucose were not associated with retention.
Health outcomes (blood glucose, weight and well-being) and how they vary by patient sub-groups and service characteristics will be reported at the conference.
Implications: Over half of the people referred from primary care to the NHS Diabetes Prevention Programme took up a place, and a third of those who started went on to attend the proportion of sessions recommended by NICE. The DPP has been able to retain people regardless of differences in baseline weight and blood glucose. Extending flexible service provision such as out-of-hours sessions may improve retention rates. Measures to improve uptake among minority ethnic and deprived groups; and uptake and retention among those with a disability and people in work may be needed.
An evaluation of an asset-based community development approach to reducing alcohol harm: exploring the barriers and facilitators impacting on community mobilisation at initial implementation stage.
Cathy Ure(1), Suzy Hargreaves(1), Margaret Coffey(1), Liz Burns(1), Suzanne Audrey(2), Penny Cook(1)
(1)University of Salford, (2)University of Bristol
Background: Engaging communities in addressing issues relating to alcohol in their local environment is a recommended strategy to reduce alcohol related harms (McGrath et al., 2019; WHO, 2018). One such approach is Communities in Charge of Alcohol (CICA). CICA takes an Asset Based Community Development (ABCD) place-based approach to reducing alcohol harm. Its approach draws on previous interventions that have been found to reduce alcohol harm, namely the restriction of alcohol availability and through early identification and brief advice (IBA) at a personal level. This novel intervention explores the potential to reduce alcohol harm through engaging volunteers or alcohol health champions (AHCs) at a community level and providing them with the tools, knowledge and capacity to lead brief advice conversations with friends, family and neighbours. At the same time, by providing volunteers with greater understanding of licensing processes, it seeks to empower them to engage in licensing conversations with licensing authorities to address local concerns and needs.
CICA utilises a cascade training model whereby volunteers become accredited AHCs following participation in a 2-day 'Train the Trainer' Royal Society for Public Health Level 2 programme. Then, supported by a designated local co-ordinator, they train other local volunteers to become accredited AHCs. Volunteers were recruited to train as AHCs from eighteen Lower Super Output Areas (LSOAs) across Greater Manchester. Areas were selected at authority level. Each local authority (LA) utilised their own indicators of alcohol related harm to identify which communities within each borough might benefit most from CICA. This presentation reports on the barriers and facilitators experienced during the initial implementation phase of CICA - the period pre-AHC training through to three months post training - by key stakeholders.
Methods: Twenty semi-structured interviews were held with key local stakeholders (Service Commissioners; Operational Local Leads; and, Local Licensing Leads) from the ten Local Authorities. Interviews were held within three months of the initial AHC training input in their area. All interviews were audio taped, transcribed verbatim, and analysed using Framework Analysis.
Results: Nine out of ten local authorities completed the initial implementation phase of CICA. Mobilising pre-identified communities to participate in this complex alcohol harm intervention was impacted by a range of barriers and facilitators. These included: local strategic, political and policy contextual alignment; the impact of local contextual variables; operational issues affecting delivery; the local licensing context; the successful recruitment of Alcohol Health Champions; the effective delivery of appropriate training for community assets; understanding the role of Alcohol Health Champions; and addressing communication challenges.
Implications: This is the first study to explore the factors which impact on the successful setting up of a local community-based volunteer approach to reducing alcohol harm. Although the evidence indicates that providing brief advice at a one to one level and reducing the availability of alcohol can reduce alcohol harm, these findings demonstrate that establishing a successful local, alcohol health champion led programme to drive this health promotion activity requires a robust infrastructure to support it. If other local authorities or devolved regions were interested in establishing and rolling out a similar programme, consideration should be given to the footprint for the intervention and the type and level of training provided, both in relation to the provision of brief advice and the building of self-efficacy in relation to licensing knowledge. Working with good providers who are already integrated into local communities and supported by stable commissioning arrangements is essential.
McGrath et al., (2019). Identifying opportunities for engaging the 'community' in local alcohol decision-making: A literature review and synthesis. International Journal of Drug Policy, 74, p.193-204.
World Health Organisation. (2018). Global report on alcohol and health. https://apps.who.int/iris/bitstream/handle/10665/274603/9789241565639-eng.pdf?ua=1
The NHS Diabetes Prevention Programme delivery and service user experience: An observational study
Rhiannon E. Hawkes(1), Elaine Cameron(2), Sarah Cotterill(1), David P. French(1)
(1)University of Manchester, (2)University of Stirling
Background: The ‘Healthier You’ NHS Diabetes Prevention Programme (NHS-DPP) is a nation-wide behavioural intervention for adults in England at risk of developing Type 2 diabetes. NHS England commissioned four independent provider organisations to deliver the NHS-DPP in localities (sites) across England, stipulating delivery in groups of no more than 15-20 adults over at least 13 sessions, with the central aim of achieving weight loss to prevent progression to Type 2 diabetes.
Currently, there is a lack of reliable information on how the NHS-DPP is delivered, and we do not know the extent of variation between providers and different sites delivering the programme. Furthermore, there are no studies on service user experience specific to the NHS-DPP. Previous research has provided qualitative data on service user experiences of other behavioural programmes, which have the strength of eliciting in-depth views of participants, but tend to be sampled from few geographical sites and can be biased due to only volunteers participating. Gaining information on a larger, more representative sample of service users’ experiences of the NHS-DPP could provide valuable insight into the success of the programme. Our observational data of the NHS-DPP in the field will provide a representative insight into the programme delivery, and does not rely on self-report. Therefore, our research has the following aims: 1) to provide a description of NHS-DPP delivery in eight locations across England, including variation between sites and providers and any discrepancies between what was planned and what was delivered; 2) to describe service user experience of the NHS-DPP as observed in the field.
Methods: We observed the whole NHS-DPP intervention delivery in eight locations, sampling sites with the aim to achieve variation in geography, socio-economic status and ethnicity, and consenting 455 participants in total (36 staff, 419 service users). NHS-DPP delivery was described using the Template for Intervention Description and Replication (TIDieR) framework. One-hundred-and-eighteen sessions were audio-recorded. These audio recordings were supplemented with additional 1-2 pages of contemporaneous observational notes, capturing views spontaneously expressed by participants, non-verbal aspects of delivery and any other notable observations. Service user experience, derived from notes and recordings, was content analysed and summarised into categories.
Results: Some deviations from providers’ intervention designs and NHS England specifications were observed; some providers had a longer gap between sessions than was specified in their designs, and some group sessions exceeded 20 adults. Activities somewhat varied across providers, with some delivering more education-based activities and other providers delivering interactive activities. Some sites also tailored or modified the intervention content (e.g. handing out additional leaflets to supplement the session). Overall, three positive and three negative service user experience categories were observed. Generally, service users reported engagement and satisfaction with the programme (n=58), good relationships with facilitators and peers (n=51), and behavioural changes made (n=18). However, there were observed issues with the scheduling and size of group sessions (e.g. cancelled sessions not communicated, large groups; n=41), factors influencing disengagement or dissatisfaction with session content (e.g. lack of resources, difficult activities; n=25) and the venue (e.g. accessibility issues; n=15).
Implications: Generally, service users demonstrated engagement with the NHS-DPP and developed good relationships within their groups, but there were problems with the scheduling of sessions and some of the site venues which could be addressed to further improve service user experience. By assessing effectiveness of the programme and addressing these acceptability issues, this could increase uptake, reduce service user drop-out and increase the overall effectiveness of the NHS-DPP. In particular, modifying aspects of the NHS-DPP at the organisational level (e.g. session scheduling, group sizes and venues) may ultimately improve service user experience and thereby increase effectiveness and retention.
This work is independent research funded by the National Institute for Health Research (Health Services and Delivery Research, 16/48/07 – Evaluating the NHS Diabetes Prevention Programme (NHS DPP): the DIPLOMA research programme (Diabetes Prevention – Long Term Multimethod Assessment)). The views and opinions expressed in this briefing are those of the authors and do not necessarily reflect those of the National Institute for Health Research or the Department of Health and Social Care.
The impact of management and leadership styles on implementing changes in long-term care: a systematic scoping review
Jo Day(1), Krystal Warmoth(2), Naomi Shaw(2), Charlotte Hewlett(2), Iain Lang(1)
(1)NIHR ARC South West Peninsula, University of Exeter, (2)College of Medicine and Health, University of Exeter
Background: Leadership and management is a key influence on the implementation of evidence-informed practices and included as a factor in many implementation science theories, models and frameworks. Understanding how leadership and management styles impact on improving services is a cross-sector issue and there is a need to better enable leaders and managers at all levels to implement evidence into practice to benefit people receiving health and social care services. Within the long-term residential and nursing care sector, the role of senior managers and leaders is central to the creation of the culture and ethos of a home. They are also an overlooked group in research of the workforce for older people’s care. We sought to understand the research undertaken on the impact of management and leadership styles on implementing evidence-informed changes in the context of improving practice and the quality of life for older people living in long-term care.
Methods: Systematic scoping review using a structured search of databases. All identified titles, abstracts and full-texts were double-blind screened by two researchers. Disagreements were resolved by discussion. Two researchers extracted relevant information from each study capturing the studies’ aim, methods, settings and contexts, participants, data collected, key findings and implications for implementing changes in long-term care practice. All researchers discussed findings and developed interpretations.
37 studies were included. Studies’ methods ranged from qualitative approaches, mixed-method evaluations, systematic reviews and descriptions of models of leadership and management interventions. A focus on transformational, distributed and relationship-oriented leadership and management practices was emphasised. At the micro-level, both personal qualities and technical skills are required to enable leaders and managers to implement improvements. Difficulties in rigorously researching leadership and management within long-term residential care for older people are highlighted.
Implications: Further work is needed to attend to (1) the, constantly shifting wider context and organisational culture in which leaders need to make changes and (2) supporting leadership and management development at all levels within organisations to implement changes to long-term care for older people.