The Walking Away from Type 2 Diabetes is an evidence-based person-centred diabetes prevention programme that is focused on a holistic approach to lifestyle and health. It is centred on a 3.5 hour group-based structured education programme, delivered to 8-10 participants, aimed at promoting increased physical activity and a healthy lifestyle through targeting perceptions and knowledge of diabetes and diabetes risk, self-efficacy beliefs around lifestyle change, barriers to change and self-regulation. The programme meets criteria for structured education and is specifically designed for implementation within primary care; this includes a full educator training and quality development infrastructure.
Aims and objectives
The aim of the project was to implement the Walking Away from Type 2 Diabetes programme within primary care in diverse settings across the UK.
The objectives were:
- To work with a few diverse primary care organisations nationally to implement the Walking Away programme and identify and address key barriers to implementation.
- Gather detailed feedback from educators and patients at each site, through focus groups and semi-structured qualitative interviews.
- To establish the likely overall 'real world' cost of running the programme.
- To work with further primary care organisations nationally to implement the Walking Away programme once the initial phase was complete.
- To increase capacity for diabetes risk management within the context of the NHS Health Checks Programme or other local initiatives, by using risk score technology to set up systems for identifying and referring high risk individuals onto the Walking Away programme.
Reasons for implementing your project
Type 2 diabetes is a leading cause of disability and mortality nationally and exerts a huge financial cost. Over the last decade there has been a realignment of health care priorities to address this need; this has included a greater emphasis on prevention. For example, the NHS Health Checks Programme was aimed at identifying and treating vascular disease risk in all individuals between 40 and 74 years of age; the prevention of diabetes is a primary aim of the programme. Subsequently, NICE commissioned guidance on the prevention of type 2 diabetes in high risk populations.
The identification of high risk individuals and referral into a lifestyle intervention are the central components of both the NHS health checks programme and the new NICE guidance. There is unequivocal evidence that physical activity in particular and a healthy lifestyle in general are of fundamental importance in the prevention of type 2 diabetes and that lifestyle intervention programmes can reduce the risk of type 2 diabetes by 30-60%. Our group have demonstrated that around 15% of the adult population in primary care have impaired fasting glucose or impaired glucose regulation, the precursors of type 2 diabetes, and that screening for and treating diabetes risk is likely to be highly cost-effective.
The Walking Away from Type 2 Diabetes structured education programme and associated educator training and quality assurance infrastructure was developed to address this urgent health care need. The programme was developed using gold standard methodology for complex interventions and structured education programmes and is consistent with international guidelines and best practice for diabetes prevention. Clinicians, lifestyle and behaviour change experts, representatives from commissioners, policymakers and lay people all contributed to the development of the programme in order to ensure it was both effective and suitable for implementation within the NHS.
How did you implement the project
Implementation occurred in two phases. The first phase was to implement the programme in 3 diverse primary care trusts nationally. This work was then used to inform a more extensive national roll out.
The initial 3 project sites in Southern, Central and Northern England identified at least 3 health care professionals with a previous experience of delivering structured education programmes to attend a two-day Walking Away residential training course designed to enable educators to become fully conversant with the content, philosophy and theory of the programme and to ensure the integrity of programme delivery. In addition, where required, training was provided for using the automated Leicester Diabetes Risk score. This risk score uses a simple evidenced-based algorithm within primary care datasets to identify those with a high risk of type 2 diabetes.
Within most sites implementation is being conducted to be consistent with the NHS health checks programme, therefore the age range targeted was largely 40-75.
Having been trained, educators worked within their own administrative teams to identify those with a high risk of diabetes and refer them onto the Walking Away programme.
Six months after their initial training educators and other stakeholders were invited back to provide feedback on their success to date and share their experiences of running the programme. This was used to measure progress and to gain an insight into the issues faced for primary care teams delivering a diabetes prevention programme as part of usual care.
Focus groups were held with participants attending the education programme to gain an insight into their perception of the programme, what key messages they took away with them and the extent the programme influenced their subsequent health behaviour.
The above work was used to amend and improve the programme. The programme was then rolled out nationally to sites looking to commission an evidence-based diabetes prevention pathway.
All three sites reported moderate to high take-up rates to the programme, with two sites reporting that more than 80% of those referred to the programme attended.
Feedback from educators helped identify several key areas where the Walking Away programme curriculum could be simplified and/or improved in a primary care setting. Furthermore, the effect of institutional structure was explored. For example educators from one site in Southern England reported lower take-up rates than the other sites. This was attributed to the fact the programme was initially attempted to be run on too large a scale with no specific training given to those referring participants. In contrast, other sites started on a small scale and spent several months ensuring the programme was supported by a solid administrative infrastructure.
Feedback from patients during the planned focus groups was highly positive. In particular participants thought the course was very informative and were motivated to try and modify their health behaviour through increased physical activity and the adoption of a healthy diet. A common theme was that the pedometers used in the programme were highly motivational and key to helping individuals become more physically active. However, inaccurate cheap pedometers used in some sites acted as a strong demotivating factor. Individuals reported finding the group-based environment supportive and appropriate to their needs.
The automated Leicester Risk Score was found to be a highly feasible, low resource-intensive, method of identifying diabetes risk.
One site collected a detailed financial breakdown. The total projected cost to the commissioner of running 72 Walking Away courses per year was estimated to be £22,720 in the first year and £19,620 thereafter (2010 costs). Given that the programme is designed to be run with between 8-10 participants, this works out at just under £40 per patient (Figures presented at the Diabetes UK annual conference, London, 2011).
Key learning points
- The main barrier encountered was around teams that tried to implement the programme without adequate support and dedicated areas of responsibility among staff. It is essential to have a systematic joined-up approach to the prevention of diabetes with a clear referral framework where all individuals involved in facilitating the referral pathway have full knowledge of the programme and its importance.
- Where diabetes prevention programmes are initiated, it is important to set up the infrastructure needed within a few pilot sites generating local specific learning before the programme is implemented on a larger scale.
- Risk score technology (Leicester risk score) can effectively be used within the community and primary care to identify those with a high risk of diabetes.
- Group-based education can be used to engage individuals in the prevention of diabetes with a good take-up rate and low cost per patient.
- Pedometers appear really helpful in the promotion of physical activity, one of the most important lifestyle factors linked to the development of diabetes. However, inaccurate cheap pedometers can lead to demotivation and disengagement from the programme.
- This success has now led to the adoption of the programme in other sites nationally and internationally (Ireland). To date over 50 educators have been trained from over 8 sites with more sites planned in the future.
- This initiative was implemented prior to publication of the NICE guidance and contains useful learning points. All aspects of this intervention are not in line with what NICE recommends and users should always refer to the original guidance as the only definitive statement of the guidance.