Shared learning database

Greater Manchester CLAHRC (Linda's) Salford Royal Foundation Trust Diabetes Team (Katherine)
Published date:
June 2012

Working together the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester and NHS Salford developed a six month, telephone based, quality assured intensive lifestyle change intervention programme for people at high risk of developing type 2 diabetes (high risk: those with oral glucose tolerance test result between 7.8-11mmol/l and a fasting plasma glucose result 6.1-6.9 mmol/l and diagnosed as having 'impaired glucose tolerance [IGT]'). Delivered by a team of trained health advisors, the programme provided motivation, support and evidence based education via a series of electronic scripts developed and maintained by the specialist diabetes team.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The overall aim of the initiative was to deliver a patient focused intensive lifestyle change service that would provide regular telephone support to motivate and enable people to make positive lifestyle and behaviour changes that would ultimately prevent or delay the onset of type 2 diabetes. The agreed project aims between the NIHR CLAHRC for Greater Manchester, NHS Salford and the Salford Diabetes Team were:
1. To deliver a telephone based support service in which 75% of service users achieve and sustain one or more lifestyle goals
2. To deliver a telephone based support service that 75% of service users rate as assisting them in achieving one or more lifestyle goals
Measures of quantitative success were identified as:
- Clinical outcomes (pre and post programme measurement of fasting glucose and OGTT; weight, BMI and FINDRISC score [Finnish diabetes risk score])
Measures of qualitative success were identified as:
- Self reported behaviour change (goals achieved/not achieved)
- Service user feedback (focus groups, questionnaires)
- Feedback from participating GP practice staff
- Feedback from health advisors delivering the service. Salford Diabetes Care-Call is a well established telephone based service delivered by health advisors trained in motivation interviewing techniques, primarily designed for providing education and support to people with type 2 diabetes.

Utilising the existing Care-Call, a new quality assured intensive lifestyle change service for people identified as being at high risk of developing type 2 diabetes was developed. New scripts and resources were designed by the specialist diabetes team specifically for this population, this included a patient information leaflet and a DVD both designed in house. A six month pathway was designed and agreed.

The objectives of the IGT Care-Call service were:
- To help people at high risk of developing type 2 diabetes better understand their diagnosis and how to reduce their own risk.
- To support self care, improve general well-being and prevent or delay the onset of type 2 diabetes.
- To provide participants with regular telephone support to enable them to acquire the necessary skills and knowledge to make positive lifestyle and behaviour changes and sustain those changes.
- Understand how to engage with and use local NHS and community services effectively.

Reasons for implementing your project

There is overwhelming evidence from randomized control trials to show that modification of lifestyle, in particular weight and physical activity, can prevent or delay the onset of type 2 diabetes. This is of particular relevance to Salford as approximately half of the 220,000 population have a recorded BMI of greater than 25 meaning they are overweight or obese.

Both the International Diabetes Federation and Diabetes UK recommend lifestyle interventions as first choice therapy for people at risk of developing type 2 diabetes. The NHS has long shown its commitment to the prevention of diabetes in the first two standards of the Diabetes National Service Framework (2007).

Since 2007 people diagnosed with impaired glucose tolerance (IGT) (fasting plasma glucose of 6.1-6.9 mmo/l and a 2 hour oral glucose tolerance test result of between 7.8-11 mmol/l) in Salford have been invited to attend a 3 hour group lifestyle education session, delivered by the specialist diabetes team. In addition to the high costs incurred sessions may be inconvenient to the younger working population, suitable rooms were difficult to resource and increasing numbers of new patients diagnosed with diabetes placed continual demands on the specialist diabetes team.

It was decided to see if an alternative method of healthcare delivery could be developed and implemented.

How did you implement the project

The pathway commenced at the GP practice. The project identified that there was variation across the district in how registers and recall systems were set up for this population. The 7 GP practices who participated in the project were known to maintain an IGT register and had an annual recall system in place.

Following referral to Care-Call, participants received an initial introduction call from their personal health advisor to outline the IGT Care-Call programme. A 'patient pack' was sent in advance of the next 'action planning' call which included a copy of the patient's blood results. The action planning call was performed by a qualified health professional (with relevant postgraduate training e.g. Warwick Certificate in Diabetes Care; x-pert trainer) and lasted approximately 40 minutes. The aim of this call was to ensure the person understood their diagnosis and blood result, the importance of preventing type 2 diabetes and how they may be able to reduce their own risk. The patient's current lifestyle was explored with the health professional before the person set themselves an overall goal they wished to achieve over the next six months, together with a smaller specific goal (achievable in one month) on how they would embark on this. Five further calls on the pathway were made each lasting 20 minutes and delivered by the personal health advisor.

Motivational interviewing techniques were used to facilitate behaviour change and the health advisors signposted and referred patients to local services that could help with achievement of goals. On completion of the 6 month programme, repeat blood tests were performed at the GP practice and the results collected and analysed for an evaluation report. Feedback from participant focus groups identified that service users felt they would benefit from additional support after the six month programme. In response to this, the new project offers additional follow up at 9 and 12 months.

Key findings

Patient demographics reflected that of the population in Salford. Patients were predominantly white and aged over 45.
An anonymised database was designed to record success in achieving goals. Key results of the IGT care-Call project demonstrated:
-52% (n=26) of patients reverted to normal fasting glucose and normal oral glucose tolerance test (OGTT) 10% (n=5) reduced their risk to impaired fasting glucose.
-75% (n=38) of patients had a confirmed weight loss on completion of the six month project, and lost an average of 4.8kg (5.3%) per person.
-Of those with an initial BMI >30, 66% (n=22) reduced BMI by an average 2.0 points per person. Seven of this group reduced to BMI 25-30 category.
-61% (N=31) reduced FINDRISC score by average 2.1 points per person.
-88% (n=48) of patients achieved or partially achieved their overall lifestyle goal.
-91% (n=250) mini lifestyle goals (each patient has 5 mini goals) were achieved or partially achieved.
-88% (n=36) patients reported increased understanding of their blood results.
-78% (n=32) patients felt more confident about how they could reduce their own risk of developing type 2 diabetes
-90% (n=37) patients felt they received relevant up to date information on how to reduce their risk of developing type 2 diabetes.
Practice staff reported high confidence levels that IGT Care-Call provided evidence based, dietary and lifestyle advice and increased motivation in their patients. High levels of satisfaction with supporting patient information leaflets and resources were also reported.
The project was awarded a 'Highly commended' award in the Health Service Journal Care Integration, Diabetes Care category on 4/7/2012.

Key learning points

To ensure all aspects of the project were appropriately addressed key people including trust senior management, diabetes service lead and CLAHRC programme managers.were involved from the initial planning stage. Approval was also sought from the Salford Diabetes Commissioning strategy group. The diabetes team provided essential ongoing support being responsible for writing and updating scripts and designing key resources (patient information leaflet, DVD). Using the existing service and staff to deliver this project enabled us to keep costs to a minimum.

For project evaluation purposes the FINDRISC assessment tool was used each practice nurse having an electronic version installed on their computer to record as part of the pre and post assessments. Feedback from practice nurses highlighted that this was time consuming, generated work and did not enhance service delivery as the information required for a FINDRISC was available elsewhere in the referral (e.g. weight/BMI) Using this feedback we are omitting FINDRISC in the next phase of our project.

At a time when the NHS is under considerable financial pressure, using band 4 health advisors to deliver a telephone service frees up capacity in the specialist team, and offers an effective use of resources. The Care-Call concept appears transferable and could be easily adapted to provide lifestyle advice to a wide variety of people and medical conditions.

A cost benefit analysis of the project and future expansion was favourable showing positive return on investment during year three with further (increasing) savings beyond five years. A new project which commenced in April 2012 offers the choice of two services; group education plus telephone follow up or an entirely telephone delivered service and will include people who have a diagnosis of IGT or IFG (impaired fasting glucose).

Contact details

Linda Savas and Katherine Grady
Knowledge Transfer Associate (linda's title) Care-Call Manager (Katherine's title)
Greater Manchester CLAHRC (Linda's) Salford Royal Foundation Trust Diabetes Team (Katherine)

Primary care
Is the example industry-sponsored in any way?