In 2012 NICE published guidance PH38: Preventing Type 2 diabetes. The implementation of this guidance locally was hindered by a number of factors including the lack of existing lifestyle-intervention programmes to deliver this service and the financial constraints limiting the capacity of CCGs to commission new services.
This project aimed to promote the implementation of this guidance utilising existing Tier 2 and Tier 3 weight management services, including commercial providers. As a practicing bariatric physician I knew that these services were already widely commissioned but poorly targeted clinically, so this approach would not only have no requirement for addition funding, but could also improve the clinical effectiveness of already funded services.
Aims and objectives
The aim of this project was to assist commissioning bodies to utilise already funded Tier 2 and Tier 3 weight management services for diabetes prevention.
Tier 2 services, although achieving a lower mean weight loss, have the potential to deliver clinical and cost effective diabetes prevention and to a potentially substantially greater number of patients, although the evidence base for this remained to be established.
Tier 3 Medical weight management services conform fully to the requirements of an intensive lifestyle-intervention programme as specified by PH38 and so already had an evidence base for efficacy and cost-effectiveness.
An objective was to utilise these existing services by means of including the criteria for being at high risk for the development of type 2 diabetes (HbA1c 42-47 mmol/mol) as a required referral criteria for these services. By auditing outcome in terms of diabetes prevention this would also produce an evidence base for the clinical and cost effectiveness of Tier 2 services, informing their further commissioning.
A further aim was to establish quality assured training and competency for the delivery of Tier 2 interventions, which is currently lacking.
Reasons for implementing your project
In 2012 most commissioning regions were funding tier 2 and 3 weight management services. The outcomes recorded related solely to weight loss and not any clinical outcomes. This was because the spectrum and prevalence of weight related co-morbidities was so variable within the populations referred. Because of this, the cost and clinical effectiveness of these services, particularly at Tier 2, was not established.
There existed a strong evidence base that Tier 3 services were cost and clinically effective at preventing type 2 diabetes in a high risk population. It was postulated that Tier 2 services would also be effective at diabetes prevention but the evidence base remained to be established. By including being at high risk for the development of type 2 diabetes as a referral criteria for these services this would, in the case of Tier 3 services, allow better clinical use of these services in compliance with best evidence while implementing PH38 at no addition cost to the commissioners.
Although Tier 2 services did not fulfil the requirements of diabetes prevention/lifestyle intervention programmes as detailed in PH38, they did have an evidence base of weight loss. If this was extrapolated into diabetes prevention, this offered not only a potentially cost effective way of providing diabetes prevention, but a means of extending this service to a much greater population than the capacity of a multi-disciplinary Tier 3 service would allow. Therefore, by extending the referral criteria of already funded Tier 2 services to include an HbA1c 42-47 mmol/mol, this would not only maximise the clinical impact of these services but also allow their cost and clinical effectiveness at diabetes prevention to be fully evaluated. This would enable commissioners to implement a diabetes prevention service to comply with PH38 within their existing funded services and at no additional cost.
A major barrier to this proposal was convincing commissioners that these already existing services could be utilised as diabetes prevention programmes to fulfil PH38. Often, diabetes and weight management services were separate entities within a health economy and were commissioned separately. In these circumstances it was usual for the secondary care diabetes teams to be charged with establishing diabetes prevention programmes to deliver PH38, often being unaware of the already existing Tier 2 and Tier 2 weight management services and their potential to deliver this. Establishing the paradigm that diabetes prevention was a function of weight management was a major barrier to implementation.
How did you implement the project
A key element of this project was to encourage CCGs to better target services that were already established and funded (i.e. Tier 2 and 3 weight management services) for diabetes prevention in line with PH38. Education around the clinical potential of these services, based on already exiting clinic data, was fundamental to achieving this.
To facilitate this I utilised key note lectures at national conferences (e.g. the National Public Health and Primary Care Conference 2014) to raise awareness of this initiative and its supportive evidence base. In addition, I published the details of implementing this proposal in the widely-read journal ‘Diabetes and Primary Care’.
As a result of this I was invited to discuss this proposal with specific CCGs around the country and thereby directly helped them to implement. This usually took the form of direct face-to face meetings with those commissioners directly involved in commissioning and funding this service. There were also educational workshops with other key stakeholders such as Secondary Care Diabetes teams. Many CCGs commission commercial organisations (e.g. Slimming World, Weight Watchers) to provide Tier 2 weight management services. I worked with both of these commercial companies to develop their services for diabetes prevention in line with PH38. This involved meeting with the national clinical leads for these organisations to help refine their exiting services to be compliant with PH38.
Key to these proposals, to CCG commissioners, was that existing and already funded weight management services at Tiers 2 and 3 were being used to implement PH38 and this was being achieved simply by refining the referral criteria for these services. Existing criteria referred only to body weight and BMI (body mass index) and no clinical criteria were stipulated. By including a clinical criterion (HBA1c 42-47 mmol/mol) it allowed these services to deliver intensive lifestyle intervention/diabetes prevention programmes in line with PH38 within the existing funding and clinical capacity of these services, thereby implementing PH38 without requiring any funding in addition to that already allocated to these weight management services.
To meet the then un-met requirement for a quality assured training for deliverers of Tier 2 services, working with the accreditation service ASFI (Accredited Skills for Industry) and Walsall College, a Level 2 qualification course for weight management/diabetes prevention was developed and established with a facility for this to be accessed nationally
In 2016 the NHS Diabetes Prevention Programme was launched. Prior to the launch of this initiative I worked directly with 2 of the 7 demonstrator sites (Birmingham South and Central CCG and Herefordshire CCG) as part of my NICE Fellowship project.
In the first full wave of implementation of the NHS Diabetes Prevention Programme 27 areas were involved covering a population of 26 million people. By April 2017 over 48,000 people had been referred to the service, with 18,000 having commenced the programme. By year 5 of the programme it is projected that 1800 cases of type 2 diabetes will have been prevented or delayed out of a population cohort of 390,000. This represents a number-needed-to-treat of 1:20 for a high risk population. Over a 20 year period, in addition to this clinical benefit, its net cumulative financial impact would be an estimated saving of £35 million.
I consider that my NICE Fellowship project contributed to raising awareness of ways to successfully implement PH38 in a cost and clinically effective way, which has contributed to the setting up and delivery of diabetes prevention through the NHS Diabetes Prevention Programme.
Key learning points
An important factor in the success of my Fellowship was the ability to ‘publicise’ my project. I used invitations to speak at national and local meetings, and well as offers to write articles in key publications, in order to do this. To facilitate this, I pro-actively contacted the organisers of suitable meetings offering my services as a potential speaker. I found that many organisers were grateful for the offer.
Once awareness of the project was raised, it was then important to contact and work with the key commissioners and decision makers in interested CCGs. This can be a difficult and arduous task as it is not always clear precisely where responsibilities and financial resources lie. This may require frequent meetings with each CCG. However, this offers the greatest likelihood of successful implementation.
To be as efficient as possible with time resources, I sought to first identify those individuals within a CCG who could directly influence commissioning. In retrospect, one aspect I might do differently would be to try to garner as broad a support base as possible e.g. by presenting to Senates, etc. Although this is considerably more time consuming, the pressure of an influential support base can be a useful ally in commissioning negotiations.