How will the framework be implemented?
1. First year of implementation and the role of the early adopters.
For the first year of implementation – five early adopter sites have been approached.
The East Region (working in partnership as NHS Lothian, Fife, Border), Ayrshire and Arran, and Tayside have agreed, with additional support from Scottish Government funding, to begin work to redesign and deliver services in line with this framework. The board areas which have been chosen represent a broad selection of population demographics and geography. Learning from this first year of implementation will be shared with remaining IJBs and NHS boards throughout the year. This is in keeping with Berwick’s seven rules for disseminating innovation in health care as outlined in the Scottish Government’s approach for Practising Realistic Medicine:
1. Find sound innovations
2. Find and support innovators
3. Invest in early adopters
4. Make early adopter activity observable
5. Trust and enable reinvention
6. Create slack for change
7. Lead by example
Early adopter sites have also agreed to champion a whole-systems approach to diet and healthy weight including supporting actions outlined in the ‘A healthier Future: Scotland’s Diet and Healthy Weight Delivery Plan’.
The Scottish Government will appoint a professional advisor will be appointed to work not only with the early adopters but with all IJBs to support them with the planning and preparation for implementation including building the necessary strategic and operational partnerships.
In the East Region Partnership, in an ambition to drive a whole systems approach and as part of a wider interagency partnership the three NHS Boards will work in collaboration with six Integrated Joint Boards and six local authorities. A priority focus will be standardised weight management programmes and prevention pathways, building on the currently recognised effective services and good foundation work in respective areas. Their aim is to fully deliver a whole systems approach to public health working alongside community planning with wider citizen engagement, ensuring collaboration and partnership. They will be adopting this framework as part of the action taken to achieve these wider ambitions.
2. Development of an integrated system
For the first phase of implementation, early adopters should set up an oversight group that will oversee the planning and delivery of the framework over the next five years.
These oversight groups should include representation from public health, diabetes specialist teams, weight management service delivery team, health and social care partners in leisure, local authorities, integrated joint boards, primary care, health visiting and education.
Actions to carry out:
1. Initial scoping of service delivery – understanding current delivery and identifying gaps.
2. Agreeing the local approach to co-production and redesigning of services and integration of weight management teams and diabetes specialists.
3. Decisions on the delivery of programmes under each level.
4. Use data and wider evidence to identify, local health inequalities and action required to reduce them, and how progress will be measured.
5. Funding decisions based on the central funding allocation.
6. Support in redesign, implementation and training to build capacity for health and social care professionals to support the type 2 diabetes weight management services.
7. Monitoring and evaluation of services with use of SCI diabetes and GP clusters.
8. Report on delivery and share best practice.
3. GP Clusters and primary care
GP clusters will support the implementation of the framework by engaging with evaluation and monitoring of referrals and outcomes based in primary care. Working with GP clusters to understand their primary care improvement plans could be valuable in influencing the priority of type 2 diabetes prevention.
By monitoring the referral routes and identification of at risk individuals it should be possible to make small adjustments to local systems to improve operation of referral routes and improve the options available to individuals to achieve healthier outcomes.
Oversight groups in each NHS board area should explore what relationship GP clusters can have in relation to this framework.
With the new GP contract and in time the development on community care treatment centres the potential for these hubs to play significant roles identifying at risk individuals could be highly beneficial.
4. Training for professionals.
The implementation oversight group should use existing networks, such as diabetes MCNs, primary care support teams and child health teams to ensure that information is disseminated to raise awareness of the framework. Local events could also be run for the range of health care professionals involved in the pathways.
It has been recognised that training for health professionals on initiating a sensitive behaviour change conversation related on weight management would be highly beneficial. Health professionals can struggle to talk to patients about their weight in a sensitive manner that motivates the individual. Barriers include concern about upset, time, extent of their role, lack of knowledge of what to say and of knowledge of local services. It is the intention to develop resources for health care professionals to assist with these conversations.
Online training on general health behaviour change related to long term conditions and weight management conversations is currently available to all NHS boards. NHS Education for Scotland currently provides online and face-to-face MAP (motivation, action, prompts) training for health and social care professionals, and others working in prevention, including local government and third sector employees.
Small Talk Big Difference is a one hour training course aimed at anyone who is regularly treating patients with type 2 diabetes (primarily GPs and practice nurses). It focuses on the benefits of weight management in type 2 diabetes, how to have a conversation about weight with a patient and how to motivate a patient towards readiness to change, treating diabetes safely during weight loss and links to further training resources. It comes in a package with a patient leaflet, discussion tool, practice checklist and posters. It is currently being evaluated in a randomised controlled trial to see the effect on weight management referral rates with results in Autumn 2018. If successful the resources will be made freely available across the NHS and could be easily adapted to cover the primary prevention of type 2 diabetes.
5. Data collection and IT infrastructure
Work is on-going to increase the utility of SCI Diabetes to integrate those ‘at risk’, those ‘at high risk’ into the current databases. This will be achieved by assigning read codes to records held in GP systems for those in these groups.
Those who are recorded onto SCI diabetes will also have access to MyDiabetesMyWay to help them better understand their risk and recognise what is required to manage this.
SCI diabetes will need to be able to pull information from the Acute, Maternity and Community TRAK software used by all healthcare professionals and those delivery weight management interventions. This will help build a picture as to who is being referred to what weight management interventions and the outcomes as a result.
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