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Welcome to the NIHR CLAHRC Community e-newsletter 
 

Welcome to the community e-newsletter for the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) bringing you the latest news and interesting developments from across the nine collaborations and the health service research community. This edition coincides with World Diabetes Day, and showcases the work the CLAHRCs are doing in this area. The CLAHRCs are funded by the NIHR and form part of the NIHR infrastructure. 

World Diabetes Day


The International Diabetes Federation estimates that more than 371 million people in the world have diabetes with half of them not knowing they have this potentially life threatening condition. In the UK alone there are three million people diagnosed with diabetes whilst there are a further 850,000 undiagnosed. Diabetes is a leading cause of blindness, lower limb amputation and cardio-vascular disease. The majority of people, 90 per cent, have type 2 diabetes, which is often considered as purely a “lifestyle” disease; caused by people being overweight and unfit. Although these are contributory other serious risk factors are age and ethnicity with people from black and minority ethnic communities more likely to have diabetes. It is calculated that type 2 diabetes already costs the NHS £10 billion a year and with all the identified risk factors increasing across the population urgent measures need to be taken to tackle the challenge to people’ health and the NHS.
 

The NIHR CLAHRCs have focused a considerable amount of energy on the prevention, early detection and self-management of diabetes and the examples in this newsletter are just a snapshot of the work that has been done. Further information is also available on the NIHR Focus on diabetes website. 

 
Diabetes Risk Score
The Diabetes Risk Score was developed in partnership with Diabetes UK as a quick and easy way of seeing how at risk people are of getting type 2 diabetes. By answering just seven questions anyone can get an accurate reading of how high their risk is. It is available both in paper form and on the Diabetes UK website where it has been taken by more than 300,000 people. As part of the biggest ever diabetes awareness campaign run by Diabetes UK, it includes a downloadable version available to GPs and is also widely used in pharmacies offering diabetes risk screening. Bridget Turner from Diabetes UK said "The diabetes risk score has been a great success and is a core part of our strategy of raising awareness of diabetes and the risk that people have of getting it."
 
Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND)
DESMOND is the pre-eminent diabetes education and self-management programme in England and is also used extensively world-wide including in Australia. It is one of the few diabetes education programmes that meet National Institute for Health and Care Excellence (NICE) criteria. Malcolm Bigg attended a DESMOND course and said “For the first time I understood the effect of diabetes and the pills I was taking on me. I began to understand the difference between food groups and I began to experiment with food and monitor their effect on my blood sugar levels.” With the CLAHRC for Leicestershire, Northamptonshire and Rutland’s (LNR) support, the DESMOND team have expanded their portfolio of programmes to meet the needs of people with specific diabetes educational requirements. This includes people who have had diabetes for some time and people from the black and minority ethnic communities that have a greater prevalence of diabetes. With the support of the Muslim community in Leicester they developed the Safer Ramadan toolkit which supports people with diabetes who wish to fast during the holy month. Eating at the right time to compliment any medication is one of the core methods of diabetes self-management fasting that poses particular challenges at this time of the year.
 
Major successes for Impaired Glucose Tolerance (IGT) care call and diabetes prevention
Working collaboratively, the CLAHRC for Greater Manchester (GM) and the Salford diabetes team have designed, implemented and evaluated IGT Care Call; a six month, telephone-based, pro-active lifestyle education and support programme to prevent type 2 diabetes. Delivered by trained Health Advisors, the project provided motivation, support and evidence-based education via a series of electronic scripts developed and maintained by the specialist diabetes team. Participants also received education leaflets, DVDs and information on local services and groups. Positive six month results demonstrated just over half of participants reverted back to normal glucose levels after completing the programme; 75 per cent of participants reduced their weight by five per cent or more; and, at 12 months, 66 per cent maintained or achieved additional weight loss. Results and cost-benefit analysis enabled the project to expand until December 2013. In addition to being invited to display posters and present at major international conferences in 2014, IGT Care Call has appeared on BBC lunchtime news, won the Quality in Care Diabetes ‘best type 2 diabetes prevention initiative’ award, achieved ‘highly commended’ in the 2012 Health Service Journal Care Integration Awards and has been used as an example of ‘see this guidance in practice’ in NICE guidance on prevention of type 2 diabetes (PH38, July 2012).
 
Reducing diabetes risk in South Asian communities
The CLAHRC for Nottinghamshire, Derbyshire and Lincolnshire (NDL) Step Out study is providing members of the South Asian community in Nottingham and Derby with the skills, knowledge, training and experience to facilitate and deliver a community informed, culturally appropriate intervention to enhance physical activity for South Asian people at high risk of developing diabetes. Eleven bilingual community members – who between them speak Punjabi, Urdu, Hindi, Mirpuri and English – have been engaged as Community Link Workers (CLWs) from inner city localities of Nottingham and Derby to recruit South Asian participants from community settings to the study. In order to prepare them with the necessary skills and knowledge to recruit participants, deliver the intervention, and conduct follow, they were given comprehensive training. Link workers report their involvement with the project to have yielded a range of benefits, both personal and professional. For example, the majority have described developing increased confidence and improved self-esteem as a result of being involved, and others, having enjoyed and discovered an aptitude for this kind of work, have made a decision to pursue an education or career in health promotion or community development.
 
Increasing diabetes awareness in South Asian communities
In total 315 participants were recruited to the CLAHRC for NDL Step Out Study and received the intervention, which involved a group education session about the importance of physical activity in preventing diabetes; an informative DVD containing local ‘stories’ to help engage participants; provision of a pedometer to measure steps; and advice on setting daily activity goals. Whilst it is too early to say whether or not the intervention has had an effect on physical activity, it has given the project team the opportunity to provide information and support to help these 315 people embark on lifestyle change to improve their health. In particular it has demonstrated a highly promising method of engaging more ‘difficult to reach’ South Asian communities at high risk into health promotion intervention.

Read more about these two stories
 
Reducing variation in the identification and management of diabetic foot complications
Variation in the identification, management and subsequent clinical outcomes related to Diabetic Foot (DF) has been demonstrated, despite the existence of guidelines from both NICE and Diabetes UK. The Diafoot project team at West Middlesex University Hospital developed a nurse-led screening tool to identify patients with potential DF on admission and a “care bundle” to improve the consistency of medical management of DF based on these national guidelines. Initial low uptake of the screening tool in the acute medical setting was subsequently improved through the engagement and training of nursing staff, resulting in the screening of more than 15 patients per week, on average. Over a 12 month period more than 900 patients were screened and 58 patients (six per cent) were identified with potential signs and symptoms of diabetic foot and fully assessed. On further examination 64 per cent of these patients were identified to have one or more signs or symptoms associated with diabetic foot and managed appropriately, thus reducing variation in the identification and management of DF through the application of guidelines. Find out more.
 
WICKED - Working with Insulin, Carbs, Ketones and Exercise to manage Diabetes
WICKED is a structured education programme for young adults with Type 1 diabetes in transition from paediatric to adult care, developed by Sheffield Teaching Hospitals NHS Foundation Trust and The University of Sheffield. WICKED was created following evaluation of age appropriate DAFNE (Dose Adjustment for Normal Eating) courses. Feedback from educators and participants identified the need for more focus on issues meaningful to young people at this time in their lives; employment, leaving home, driving, travel, eating out and the risks of alcohol, smoking and recreational drugs. Relationships, sexual health and pregnancy are also discussed in a confidential environment where participants can share experiences of living with diabetes. The five-day WICKED course covers key concepts of physiology, carbohydrate counting and insulin dose adjustment and the management of health complications. Sessions are delivered with peer support to identify personal targets and goal setting. WICKED aims to engage young people with their condition and provide them with competencies needed to self-manage their diabetes effectively and safely, for life. Find out more here or contact Vanessa Whitehead at Vanessa.e.whitehead@sth.nhs.uk
 
Impact of a local enhanced service for diabetes care in Birmingham
Due to the increase in the prevalence of diabetes and the devastating effects it can have, researchers in the CLAHRC for Birmingham and Black County (BBC) have evaluated a new model of diabetes service delivery and found it is likely to have better outcomes for patients. Getting blood sugars, cholesterol, and blood pressure to be better controlled has a significant impact on reducing the complications of diabetes. In the UK general practice, the Quality Outcome Framework (QOF) was established with the aim of improving patient care and service delivery for chronic diseases such as diabetes and control of these important parameters. Researchers in the CLAHRC for BBC have found that a Locally Enhanced Service (LES) model for diabetes is likely to be beneficial. LES have been developed to improve further on QOF achievements by providing further financial incentivisation and training to general practices. The impact of commissioned LES on diabetes outcomes has not been previously investigated. Researchers therefore evaluated this service in a large UK primary care trust area, the results of which are in press. They observed that a diabetes LES performed better regarding glycaemic QOF diabetes outcomes. Furthermore, LES practices were less likely to refer patients to secondary care. This suggests that the LES approach is beneficial and needs to be further explored in order to ascertain whether the impact exerted was due to LES.
 
App to help diabetic youngsters get the most out of clinics
Discussions with doctors at diabetes clinic appointments have often been regarded by young people with diabetes as lacking in relevance, and therefore providing ineffective support for diabetes self-management. A team supported by the CLAHRC for South West Peninsula (PenCLAHRC) is developing and testing the feasibility and use of an app with which young people will engage with their clinician and focus diabetes clinic appointments on their own agenda. Find out more.
 
Whose Diabetes is it?
In 2011-12 the User-centred Healthcare Design theme of the CLAHRC for South Yorkshire (SY) worked with young people with type 1 diabetes and their families in Rotherham and Barnsley. This innovative work led to a proposed information and support service that puts young people at its centre. This service was co-created by the young people, their families and key staff from the Rotherham Hospital Adolescent Diabetes Service through a creative design-led process. The proposed service streamlines all that is positive about the existing provision into one brand and information resource ”Whose Diabetes is it?” that brings in expertise from both inside and outside the NHS, in the form of peer support groups and clinical staff. This information is delivered via means that better fit young people’s lifestyles such as text messaging, websites and in person. Finally it allows for young people and families to receive reassurance from others who know “what it’s like”.  View the service visualisation and final report.
 
Peer led prevention and self management for diabetes 
The CLAHRC for Northwest London (NWL) supported project Diabetes Improvement through Mentoring and Peer-Led Education (DIMPLE) continues to engage new volunteers and has become established as Know Diabetes in the year since the main research was completed. The service provides peer advice and education across the three boroughs of Inner North West London and it is affiliated to Diabetes UK and sponsored by NHS Hammersmith and Fulham. 
In the last 12 months:

  • Peers in Champion roles have raised awareness of the condition and advice services in the community at over 200 events, involving 7,500 people;
  • Mentors provided peer-to-peer support about the condition and wider health and social issues to 140 individual patients;
  • Peer educators have taught 30 courses to train Champions and Mentors.
In addition to the community outreach, the Know Diabetes groups are now working with six GP practices; three diabetes specialist teams and are discussing the redesign of diabetes education with local Clinical Commissioning Groups (CCGs). The Champions work has already spread to one neighbouring London borough, and there is interest in developing the mentor scheme from another one.  A conference about diabetes mentorship is planned for the spring of 2014. The service has an ongoing commitment to using health outcomes data to evaluate improvements in patient health and effectiveness of the service. Find out more
 
Less frequent diabetic retinopathy screening saves costs without compromising patients’ health
Research supported by the PenCLAHRC has concluded that it would be a safe and cost-effective strategy to screen people with type 2 diabetes who have not yet developed diabetic retinopathy, for the disease once every two years instead of annually. For just one hospital, the Royal Devon & Exeter Hospital, there would be an estimated reduction in costs from £1.83 million a year to £1.36 million. Savings of around 25 per cent are predicted. Find out more.
 
Walking Away from Diabetes supported by the CLAHRC for LNR
This is a new intervention for those at risk of diabetes. Many of the issues and challenges in health care are around chronic illness and these can only be addressed through a different approach to health management. Although many of the gains can come from a more proactive management of health, which can save money in the long term, but frequently these improvements are restricted by patient behaviour and their initial high investment costs. Walking Away from Diabetes attempts to overcome these challenges by directly empowering patients to make their own decisions. It is a three-hour structured group education programme delivered by two trained Educators. The course offers participants the opportunity to explore their personal risk and to identify the changes they need to make to remain healthy. The programme utilises an approach to promoting behavioural change and is compatible with the infrastructure and resources available to the NHS. Walking Away from Diabetes is highly successful at promoting increased physical activity, and behaviour changes necessary in reducing the risk of progressing to type 2 diabetes. It has been widely adopted across Leicestershire, Northamptonshire and Rutland.
 
Health Trainers have positive impact on diabetes prevention
The CLAHRC for GM has supported NHS Wigan Borough CCG in finding a community-based service model for type 2 diabetes prevention. The IGT Health Trainer service offered behaviour change support and lifestyle advice to people who are at increased risk of developing type 2 diabetes and spreads the model originally developed with NHS Bolton CCG. The pilot project began in January 2011 and lasted until the end of January 2013. The evaluation of the project has revealed outcome data that is extremely positive: 
  • 74 per cent of Health Trainer participants lost weight (on average 4.2 per cent of their bodyweight);
  • 71 per cent increased their daily consumption of fruit and vegetables by 1.8 portions per day;
  • 49 per cent increased their number of 30 minute moderate exercise sessions per week (on average by 4.2 sessions);
  • Participant feedback was 100 per cent positive: 88 per cent rated the service as ‘very good’ and 12 per cent rated the service as ‘good’.
Read the full evaluation report.
 
A complex intervention to enhance self-management in adolescent diabetes; development and evaluation (phase II)
The care of young people with type 1 diabetes is challenging. For patients, achieving and maintaining good glycaemic control whilst coping with the psychological challenge of a major illness in formative years is not easy. The Diabetes Theme of the CLAHRC for SY, along with collaborators at the University of Sheffield, are nearing the end of phase II of a five year programme of research to develop novel care packages for adolescents with type 1 diabetes. Part of this approach is to improve consistency of care before, during and after the adolescent clinic. Diabetes Specialist Nurse-led Multidisciplinary pre- and post-clinic meetings were implemented, and a standard care planning proforma put in place. The proforma has been designed by the research team to show ‘at a glance’ relevant clinical details about each patient. This avoids inaccuracies, shows up to date relevant clinical and important psychosocial information, and promotes consistent care from the diabetes clinicians. It also serves as a safeguarding tool to ensure vulnerable patients are being followed up correctly. After the clinic, it is used to document a care plan for the patient, which is in turn followed up at their next appointment. Data collection has now stopped for the study, as the team are moving into the analysis phase. The care planning proforma has been very useful and popular amongst the clinicians and so has been kept on as a method of care in the adolescent clinic.
 
CLAHRC Partnership Programme website
The new CLAHRC Partnership programme website is www.clahrcpp.co.uk. This is a new and expanded website which includes latest news and events from the CLAHRCs and the CLAHRC Partnership Programme alongside alongside publications and the BITEs library.


Further information
Further information on the nine CLAHRCs, including links to their own web resources, is available on the NIHR website at www.nihr.ac.uk/infrastructure. This newsletter is produced by the CLAHRC Partnership Programme based at Universities UK on behalf of the CLAHRC community- see www.clahrcpp.co.uk. If you have any ideas or suggestions for the newsletter, please contact Jenny Hawkins at jenny.hawkins@universitiesuk.ac.uk.