A Generalist Approach to Type 2 Diabetes in one Sheffield Neighbourhood

“We want to create a life enhancing approach for people living with T2 Diabetes” (co-produced statement, Nov 2022)

Over the last 3 years at Heeley Plus Primary Care Network we have been refining the role we take as a high performing modern healthcare system, alongside our GP practices. As we emerged from the Covid Pandemic we saw the opportunity to refresh our approach and ensure we create ‘life enhancing’ support, not just pursuing medical targets. People told us good metabolic health can be a key part of living a full life, but it is not the end point in itself.

We worked as a genuine co-production group patient body, local population and widening primary care team, to offer an approach that matches people’s real life context.

Moving away from how things have always been done can be scary. We had confidence that if we focused on two key principles we would improve the quality of our service.

Firstly could we increase ‘participation’ from people living with Type 2 diabetes. At an individual level that means improved self-management, but as a local group also peer support and joining in co-production if they are able.

Secondly do our professional staff feel they are doing meaningful work, changing lives for the better.

We felt if we listened well and respond to both these groups, in the context of continuous learning, we would be ok to pursue something new and different.

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Summary of our approach:

o?? Person Centred- focused on what matters most to them

?o?? Locus of control with the person- empowering and enabling, growing skills, knowledge and confidence

?o?? Assess and explain personal risks, short and long term.

?o?? Personalisation of diet for each individual – core message “Eat Real Food” (ie unprocessed food, low in quick release carbohydrates and containing healthy fats)

?o?? Shared decisions around pros and cons of medication- support effective prescribing and deprescribing, recognising that prescribing can undermine motivation to self manage.

?o?? Encourage and create opportunity for participation – self monitoring, self-management, peer support, peer leadership

?o?? Generate a mutually supportive local community where the value of peer support is championed

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We take a person-centred approach to supporting people living with diabetes. It is important to us to find out what matters most to people and ensure we keep that at the centre of their management plan. How we interact should help people to feel better about themselves, and more confident to pursue the things that matter most to them in life.

?The dilemma we have is how we share medical risk. Studies show us that prolonged periods of poor glucose homeostasis and high insulin levels cause both short- and long-term damage to the body.

?In the short term this can lead to low energy levels, poor concentration (brain fog), increased pain levels, poor sleep, excessive thirst and weeing.

?In the longer term this leads to damage to nerves and blood vessels, and ultimately damage to organs and limbs. In the long term this can lead to excessive suffering, disability and pain.

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So, our approach is to work with people, to understand their personal and social context, and support them in navigating the decisions and trade-offs needed to achieve the right balance of short-term actions to reduce longer term risks.

?However, in line with mission, our highest priority is to offer support that helps people to feel good about themselves. We know this is most likely to happen when people are in control, making decisions for themselves in the context of high-quality information, in a format they can understand.

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A joint practice and PCN approach

?We believe in offering patient choice, whilst ensuring that we optimism the quality of each choice. We observed that medication management tended to be the focus in practices, where they also controlled the prescribing and repeat dispensing.

Therefore, at a PCN level we have focused in developing more robust support for non-medication options, that sits alongside medication management in practices.

?This does present a challenge in offering consistent messaging across practices and PCN staff, this is something we are still working on. We have embarked on an education program for all practice and PCN staff that encourages debate and challenge, to surface and manage differing clinical attitudes.

?This article will go on to outline this wrap around non-medical approach.

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The PCN led Offer to compliment practice management

?From local and national experience of successful programs we have adopted the evidence-based approach championed by Dr David Unwin and the Public Health Collaboration. Key features of the approach:

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• Hold hope that recovery is possible, and in some, full drug free remission.
• Develop understanding and confidence in people to actively self-manage- the things each of us can do ourselves (alongside professional support/prescribing as needed)
• Raise awareness of carbohydrates metabolism (used and stored to support energy generation) normally, and in the context of insulin resistance.
• Understand how to rebalance intake of carbohydrate, healthy fats and protein to suit each individual’s physiology. For most this involves lowering the proportion of carbohydrates and increasing fat and protein.
• Consider periods of fasting or time restricted eating, to support weight loss and lowering insulin resistance.
• Consider the effects of stress, poor sleep, and physical activity in supporting good metabolic health
• Raise awareness of the challenges of carbohydrate and Ultra Processed Food addiction, and how to support in a compassionate way.

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We utilise the resources available on the PHC website, with the real food booklets as hand outs. https://phcuk.org/booklets/

?The message of ‘eat real food’ feels centrally important to our dietary approach. It is simple, accessible, and easy to share peer to peer. It encourages unprocessed foods that are naturally low in quick release carbohydrates and contain healthy fats. We pursue this approach considering how to adapt this guidance in the context of culture and budget.

?We also encourage use of the free resources (app and website) from the Freshwell GP practice in Essex https://lowcarbfreshwell.com

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Delivery of PCN approach

?Having experimented with a clinic-based approach, we have shifted to offer a mix of practice based ‘road shows’, central education sessions, and community events

?Running a PCN clinic risked creating confusion over medication management between practices. Patients and practice staff articulated a preference for delivery in their own practices.

?Diabetes clinics led by a GP and practice nurse also maintained the focus on medical management and risked undermining the value of peer led activities.

?We did however run a series of co-led education events as part of these clinics – the outcomes of which are shared below.

Our current approach therefore now consists of:

1.???? Practice based roadshows- Patients on T2D or prediabetes registers are invited to attend a peer-led session to explain the nature and value of the non-medication approaches. These consist of 1 hour of group work, with 30 mins of opportunity for 1:1 conversations with peer leaders. The group work consists mostly of story telling and open discussion to raise confidence and hope for improvement.

2.???? Local Education sessions- These are heavily promoted at the roadshows (but also in practices). Patients are invited to a set of 4 x 2 hour educations sessions. These are located close to their GP practice and delivered by a clinician working in partnership with peer leaders.

?3.???? Follow up sessions and community events- All graduates from the education sessions are invited to join a range of options – digital and in person – to maintain contact and mutual support. These also provide opportunity to refresh motivation and understanding. These also include twice annual ‘Bring and Share’ cooking events

?4.???? Offer of 1:1 support sessions with PCN Health Coach or Social Prescribing Link worker, to either support self-management or help unlock social barriers (or both!)

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Our PCN digital lead, with support from a team of Care Co-ordinators and GP assistants operate a targeted invitation processes using text messages and phoning.?

Practices continue to offer inhouse blood tests, and annual checks with feedback of results. As we progress our co-ordinated approach we hope the messages in these practice contact with nurses, HCAs, and GPs will reinforce the choices have to live well with T2D, including the best chance of putting it into remission.

Results - We have initial results from our first round of education sessions - 6 months on 25% of people with f/u bloods available have an Hba1c 47 or lower , with 66% of people improving their hba1c without new medications. But these are medical results. What matters most to us is hearing what people are doing now, walking more, playing snooker with the kids, playing the guitar again, eating with the family. Human flourishing is our end goal ........We are gaining patient consent and intend to share more details as we progress (maybe we'll be able to reproduce the results already seen in Dr Unwin's practice https://nutrition.bmj.com/content/early/2023/01/02/bmjnph-2022-000544

The Freshwell Team https://journals.lww.com/co-endocrinology/fulltext/2021/10000/brief_intervention_of_low_carbohydrate_dietary.11.aspx

and throughout The Lifestyle Club https://www.thelifestyleclub.uk

......and many many other groups now.