Background
Structured self-management education programmes help to manage type 2 diabetes mellitus
While pharmacological interventions can support people with type 2 diabetes mellitus (T2DM) management, lifestyle and self-care behaviours are critical to achieving and maintaining glucose control.1
Structured self-management education (SSME) programmes include support and upskilling in T2DM to empower people to engage with healthier behaviours. They are cost-effective and result in improved outcomes, including glycated haemoglobin (HbA1c), weight, blood pressure, depression, quality of life and smoking cessation.2–7 SSME for people with T2DM is recommended by the UK National Institute for Health and Care Excellence (NICE), the American Diabetes Association and the European Association for the Study of Diabetes.8,9
In England, a Clinical Commissioning Group (CCG) commissions a provider organisation to provide T2DM SSME in their local population. The choice of SSME programme rests with the provider. Primary care healthcare professionals then refer people with T2DM to the locally provided SSME programme. In some areas, people with T2DM can also self-refer to SSME.
There are established criteria for high-quality SSME programmes to fulfil NICE requirements (Box 1).10 SSME programmes should be deliverable in a group by default, in addition to routine support from healthcare teams.9 NICE recognises several UK programmes for people with T2DM as meeting these criteria (e.g. DESMOND, X-PERT, Diabetes Manual).2,3,11 Additionally, since this research programme began, Quality Institute for Self-Management Education and Training (QISMET) accreditation for SSME was introduced in the UK. This focuses on accrediting providers and commissioners and not the education programme.
Throughout this report, the term SSME includes all programmes for people with T2DM meeting the criteria in Box 1 or delivered by providers with QISMET accreditation, regardless of delivery modality.
- Be evidence-based.
- Have a structured, written curriculum that is:
- person-centred
- reliable, valid, relevant and comprehensive
- theory driven
- flexible and able to cope with diversity
- uses different teaching media
- resource effective with supporting materials.
- Be delivered by educators:
- with an understanding of education theory appropriate to the age and needs of the participants
- who are trained and competent in the delivery of the programme being offered.
- Be quality assured by trained, independent assessors against agreed criteria.
- Be audited for outcomes.
Uptake of structured self-management education is poor
When this research was planned, an indicator for SSME referral had been recently added to the NHS Quality and Outcomes Framework.12 We assumed that this might improve referrals but was unlikely to impact uptake. This was evident in the latest National Diabetes Audit figures, which, using primary care data, suggest that while 75% of people with T2DM were offered SSME within 12 months of diagnosis, only 11% attended within 12 months.13 Attendance any time from diagnosis is not routinely reported for primary care data, but self-report data suggest a higher, albeit still suboptimal, figure of 49%.14
Multiple patient, healthcare professional and organisation factors probably drive poor referrals/uptake, including:15
- insufficient investment/trained educators
- lack of staff capacity
- absence of public health marketing for diabetes awareness
- lack of integration into patient pathways
- healthcare professionals not advocating for, or recognising, positive SSME outcomes
- misperception that education is expensive
- lack of consideration of patient access issues
- inconvenient locations/timings of sessions.
Such situations may arise from competing funding priorities, absence of clinical engagement, or lack of knowledge about available programmes or benefits. Even when SSME programmes are available/offered, data on uptake and effectiveness are often not routinely collected, which makes evaluation challenging. Consequently, SSME is often regarded negatively among commissioning priorities, due to a lack of information on costs and benefits.
How to embed or ‘routinise’ improvements in everyday healthcare practice remains poorly understood, and is as much a matter of networks of influence and knowledge of priorities and incentives frameworks as of clinical or cost-effectiveness in themselves.16
Aim
Develop and test an intervention (‘Embedding Package’) to increase SSME uptake by people with T2DM in primary care by addressing barriers and supporting enablers to uptake at patient, healthcare professional and organisational levels.
Objectives
The following original objectives, were delivered through four workstreams (WS), aligned with the Medical Research Council (MRC) framework for complex interventions.17,18 These objectives developed over the programme as described in later sections. Figure 1 shows the final set of tasks.
FIGURE 1 Research pathway diagram showing the development, refinement and evaluation of an intervention (‘Embedding Package’) to improve uptake to SSME for people with T2DM. (Figure not reproduced here; see the original article.)
Workstream 1 (develop intervention)
- 1.1. Synthesise evidence from existing literature and data sets, and identify experiential practices, procedures, strategies and plans that represent best practice.
- 1.2. Develop and tailor intervention.
- 1.3. Build capacity and develop resources.
- 1.4. Establish stakeholder and public involvement reference groups.
Workstream 2 (feasibility study)
- 2.1. Pilot the intervention to assess feasibility and suitability of components.
- 2.2. Assess feasibility of collecting data with sufficient accuracy and completeness.
- 2.3. Conduct an ethnographic study to evaluate the intervention and inform its refinement.
- 2.4. Refine the intervention.
- 2.5. Assess progress of research and report to funders on agreed milestones.
Workstream 3 (evaluate intervention for effectiveness)
- 3.1. Conduct a wait-list randomised controlled trial (RCT) to compare impact of the intervention on uptake to SSME with usual care.
- 3.2. Continue ethnographic study to evaluate the intervention and inform the implementation toolkit.
Workstream 4 (evaluate cost-effectiveness and sustainability of intervention)
- 4.1. Assess cost-effectiveness of the intervention.
- 4.2. Assess sustainability of intervention.
- 4.3. Conduct final stage of ethnographic study.
- 4.4. Develop a ‘toolkit’ to enable widespread implementation of the intervention.