Agenda Document Pack - Clinical and Care Governance Committee - 27/02/2025
Moray Council · 27 February 2025
Back to Clinical and Care Governance Committee — 27 February 2025 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
Page 1
Clinical and Care Governance Committee Thursday, 27 February 2025 Council Chambers NOTICE IS HEREBY GIVEN that a Meeting of the Clinical and Care Governance Committee, Council Chambers, Council Office, High Street, Elgin, IV30 1BX on Thursday, 27 February 2025 at 13:30 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minute of meeting of 28 November 2024 5 - 8 4. Action Log - 28 November 2024 9 - 10 Effective Communication and Information 5. Complaints Report for Quarter 3 2024-25 11 - 28 Safe and Effective Practice 6. Health and Social Care Moray Clinical and Care Governance Group Escalation Report 29 - 42 Accessible, Flexible and Responsive Services 7. Developing a digitally-enabled universal service model to reduce Type 2 diabetes related Risk 43 - 74 8. Items for Escalation to MIJB Page 1
Page 2
Item(s) which the Committee may wish to consider with the Press and Public excluded Leadership and Accountability 9. CONFIDENTIAL Primary Care Update • 13. Information, which if disclosed to the public, would reveal that the Authority proposes, for the purposes of consultation, make an order or direction under any enactment which might allow an individual or organisation to defeat the purpose of the notice or order; Watching the Meeting You can watch the webcast live by going to: http://www.moray.gov.uk/moray_standard/page_43661.html Webcasts are available to view for 1 year following the meeting. You can also attend the meeting in person, if you wish to do so, please come to the High Street entrance door and a member of staff will be let into the building. Page 2
Page 3
MORAY INTEGRATION JOINT BOARD SEDERUNT Mr Derick Murray (Chair) Councillor Peter Bloomfield (Voting Member) Councillor Scott Lawrence (Voting Member) Mr Alex Stephen (Voting Member) Mr Ivan Augustus (Non-Voting Member) Professor Duff Bruce (Non-Voting Member) Mrs Sheila Brumby (Non-Voting Member) Ms Helen Chisholm (Non-Voting Member) Mr Sean Coady (Non-Voting Member) Dr Robert Lockhart (Non-Voting Member) Mr Jim Lyon (Non-Voting Member) Ms Deborah O'Shea (Non-Voting Member) Ms Judith Proctor (Non-Voting Member) Ms Elizabeth Robinson (Non-Voting Member) Dr Malcolm Simmons (Non-Voting Member) Mr Kevin Todd (Non-Voting Member) Clerk Name: Caroline O'Connor Clerk Telephone: 07779 999296 Clerk Email: committee.services@moray.gov.uk Page 3
Page 4
Page 4
Page 5
MINUTE OF MEETING OF THE CLINICAL AND CARE GOVERNANCE COMMITTEE Thursday, 28 November 2024 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Mr Ivan Augustus, Councillor Peter Bloomfield, Mrs Sheila Brumby, Mr Sean Coady, Councillor Scott Lawrence, Dr Robert Lockhart, Mr Jim Lyon, Mr Derick Murray, Ms Deborah O'Shea, Ms Judith Proctor, Ms Elizabeth Robinson APOLOGIES Professor Duff Bruce, Ms Helen Chisholm, Dr Malcolm Simmons, Mr Alex Stephen, Mr Kevin Todd, Ms Janette Topp IN ATTENDANCE Allied Health Professional, Sector Lead Moray; Corporate Manager; Business Manger, Mental Health and Drug and Alcohol Services; Consultant Practitioner, Adult Support and Protection Lead; Integrated Service Manager, Community Learning Disability Service; Lesley Attridge, Locality Manager and Caroline O'Connor, Committee Services Officer. SUBSTITUTES Mr Sandy Riddell (for Mr Alex Stephen) 1. Chair The meeting was chaired by Mr Derick Murray. 2. Welcome and Apologies The Committee joined the Chair in thanking Mr Sandy Riddell for continuing to substitute for Mr Alex Stephen and welcomed Cllr Kirby to her first meeting of the Committee. 3. Order of Business Item 3. Page 5
Page 6
In terms of Standing Order 2.2, the meeting agreed to vary the order of business as set down on the Agenda and take Item 7 "Health and Social Care Moray Clinical and Care Governance Group Escalation Report" after Item 5 "Complaints Report for Quarter 2 2024-25" followed by Item 6 "Drug Related Deaths in Moray" in order to allow the Allied Health Professional, Sector Lead Moray to vacate the meeting at the earliest opportunity. 4. Declaration of Member's Interests There were no declarations of Member's interests in respect of any item on the agenda. 5. Minutes of meeting of 29 August 2024 The minutes of the meeting of 29 August 2024 were submitted for approval. In respect of Item 9 "Inspection of the Moray Supported Lodgings Project in May 2024", Mr Riddell noted the wording in the third paragraph should read "progressed" rather than "progress". Subject to the amendment above, the Committee agreed the minutes of the meeting. 6. Action Log - 29 August 2024 The Action Log of the meeting of 29 August 2024 was discussed and updated accordingly. 7. Complaints Report for Quarter 2 2024-25 The meeting had before it a report by the Allied Health Professional - Sector Lead, Moray informing the Committee of complaints reported and closed during Quarter 2 (1 July 2024 - 30 September 2024). Following consideration the Committee unanimously agreed to note the totals, lessons learned, response times and action taken for complaints completed within the last quarter. 8. Health and Social Care Moray Clinical and Care Governance Group Escalation Report The meeting had before it a report by the Chief Nurse, Moray informing the Committee of progress and exceptions reported to the Clinical and Care Governance Group since the last report to Committee in August 2024. Following consideration the Committee unanimously agreed to note the contents of the report. 9. Drug Related Deaths in Moray The meeting had before it a report by the Business Manager, Mental Health and Drug and Alcohol Services updating the Committee about drug-related deaths in Moray. Following consideration the Committee unanimously agreed to note:- Page 6
Page 7
(i) the drug related death figures for Moray; (ii) the ongoing work of the service in relation to the Multi Agency Risk System (MARS) process; (iii) the National Benchmarking report on the implementation of the Medication Assisted Treatment (MAT) Standards: Scotland 2023/24; (iv) the work being done on the Moray residential rehabilitation pathway; and (v) the development of a strategic group and lived experience panel to align the Moray strategy and the National Mission. 10. Joint Inspection of Adult Support and Protection - Progress Review Summary and Findings The meeting had before it a report by the Consultant Practitioner, Adult Support and Protection Lead Officer providing a summary and overview of the findings of the Moray Joint Inspection of Adult Support and Protection - Progress Review that took place between August - October 2024. The Board joined the Chair in commending the work of the team and partners in relation to the significant progress highlighted in the Progress Review. Following consideration the Committee unanimously agreed to:- (i) note the Joint Inspection of Adult Support and Protection - Progress Review Report; and (ii) acknowledge the hard work and commitment demonstrated by the Moray Adult Protection Committee, Leaders and Front-Line Practitioners throughout the Partnership in supporting people at risk in the Moray community. 11. Adult Support and Protection Multi Agency Improvement Plan The meeting had before it a report by the Consultant Practitioner, Adult Support and Protection Lead Officer updating the Committee on progress against the Adult Support and Protection Multi-Agency Improvement Plan since the last update provided in March 2024. Following consideration the Committee unanimously agreed to:- (i) note the Multi-Agency Improvement Plan and progress to date; and (ii) note the systems in place to monitor and progress actions within the plan. 12. Learning Disability Services Dynamic Support Register - Update The meeting had before it a report by the Integrated Service Manager, Community Learning Disability Service informing the Committee of the requirements of the Scottish Government directive relating to the Coming Home Report, and of the actions and progress made by the Learning Disability Service in response to the directive. Assurance is also given that planning and development continues which will address future anticipated needs associated to the directive. Page 7
Page 8
Following consideration the Committee unanimously agreed to:- (i) note the requirements of the Scottish Government in relation to the Coming Home Report and Dynamic Support Register and the actions taken by the Learning Disability Service to respond to the Scottish Government Directive as set out in paragraphs 4.1-4.6, and in doing so; (ii) continue to support the housing projects that are to be utilised by adults with a Learning Disability which is integral to meeting the requirements of the register and which was previously agreed at the Moray Integration Joint Board on 30 March 2023 (para 12 of the minute refers). 13. End of Life Care Home Beds The meeting had before it a report by the Locality Manager informing the Committee of the termination of block funded End of Life Beds within Moray. Following consideration the Committee unanimously agreed to:- (i) homologate the termination of End of Life (EOL) Care Bed block funded contract from March 2024; and (ii) the new EOL Care Bed Provision Strategy; transitioning to a spot-purchase through the Resource Allocation meeting (RAM) process, ensuring continued access to EOL care for Moray residents. 14. Items for Escalation to MIJB The Committee noted there were no items for escalation to the Moray Integration Joint Board. Page 8
Page 9
MEETING OF MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE THURSDAY 28 NOVEMBER 2024 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE FEBRUARY 2025 1. Strategic Risk Register Update to be provided detailing the impacts of recruitment of dentists on dental services. Discussion to take place between Chief Officer and Unpaid Carer Officer on whether specific mention of Unpaid Carers Strategy should be included in controls section. November 2024 November 2024 Corporate Manager Chief Officer MIJB Development Session took place 31 October 2024 to review and update current Strategic Risk Register. To be presented to MIJB early 2025. Item 4. Page 9
Page 10
Page 10
Page 11
REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 27 FEBRUARY 2025 SUBJECT: COMPLAINTS REPORT FOR QUARTER 3, 2024/2025 BY: CHIEF NURSE - MORAY 1. REASON FOR REPORT 1.1 To inform the Committee of complaints reported and closed during Quarter 3 (1 October 2024 – 31 December 2024). 2. RECOMMENDATION 2.1 It is recommended that the Committee considers and notes the totals, lessons learned, response times and action taken for complaints completed within the last quarter. 3. BACKGROUND 3.1 Within Health and Social Care Moray (HSCM), complaints received by NHS Grampian (NHSG) and Moray Council are recorded on 2 separate systems, in accordance with the appropriate policy and procedure of these organisations. 3.2 At the meeting on 27 February 2020 (para 7 of the minute refers), it was agreed that a combined report from NHSG and Council complaints systems be submitted to future meetings of the Committee. At the Committee meeting on 27 August 2020 (para 14 of the minute refers) it was requested that the procedures be explained to demonstrate the similarities and differences, if any. 3.3 NHS and Local Authority (LA) Complaint Handling Procedure/Policy requires all staff to deal with feedback and complaints in a person/client-centred way. The procedure has been developed working closely with the Scottish Public Services Ombudsman (SPSO). There is a standard approach to handling complaints across the NHS and Local Authority, which complies with the SPSO's guidance on a model complaint handling procedure and meets all of the requirements of the Patient Rights (Scotland) Act 2011, and accords with the Healthcare Principles introduced by the Act. 3.4 The complaints process followed by both NHSG and Moray Council have the same target response timescales. Early resolution, or front line, complaints will be responded to within 5 working days and complaints handled at the Item 5. Page 11
Page 12
investigation stage have a response time of 20 working days. Where it is not possible to complete the investigation within 20 working days an interim response should be provided with an indication of when the final response should be provided. 3.5 The decision as to whether the complaint is upheld or not will be made by the manager or Head of Service. If the person raising the complaint is not satisfied with the outcome, then they may contact the Scottish Public Services Ombudsman (SPSO) for an independent review and assessment, however prior to this, every effort is made to engage with the complainant to resolve the matter to their satisfaction. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The CCG Committee is presented with quarterly complaints performance information using the mandatory Key Performance Indicators (KPIs), published by SPSO in March 2022. These are: Indicator One The total number of complaints received The sum of the number of complaints received at Stage 1 (this includes escalated complaints as they were first received at Stage 1), and the number of complaints received directly at Stage 2. Indicator Two The number and percentage of complaints at each stage which were closed in full within the set timescales of five and 20 working days The number of complaints closed in full at stage 1, stage 2 and after escalation within MCHP timescales as % of all stage 1, stage 2 and escalated complaints responded to in full Indicator Three The average time in working days for a full response to complaints at each stage The average time in working days to respond at stage 1, stage 2 and after escalation Indicator Four The outcome of complaints at each stage The number of complaints upheld, partially upheld, not upheld and resolved at stage 1, stage 2 and after escalation as % of all complaints closed at stage 1, stage 2 and after escalation 4.2 The qualitative indicator on learning from complaints has been removed. However, Part 4 of the SPSO Model Complaints Handling Procedure on Governance stresses the importance of learning from complaints, and the requirements to record and publicise learning. Therefore, learning from complaints will continue to be included in quarterly complaints performance reports and annual complaints reports. 4.3 HSCM Complaints performance data for Quarter 3 is attached at Appendix 1. Page 12
Page 13
4.4 Information about complaints referred to the Ombudsman are also included along with any complaints relating to the actions and processes of Moray Integration Joint Board (MIJB). 4.5 Figures reported do not include complaints raised regarding the vaccination appointments or processes as these are being dealt with through a dedicated team covering the Grampian area. Any complaints or comments regarding the Moray Vaccination Centre in Elgin are included in reported figures. 4.6 Out of Hours Primary Care Service (known as GMED) is hosted by the Moray Integration Joint Board for the whole of Grampian. GMED service cares for patients who have urgent care needs and cannot wait until their GP Practice is open. GMED operates 18:00 until 08:00 each weekday, all weekends and each public holiday including the festive period. Therefore, figures presented for GMED are for a Grampian wide service that on average sees around 90,000 contacts annually (1/6 of the Grampian population). 4.7 Following ministerial approval, Children and Families and Justice Social Work Services were formally delegated by the Local Authority to MIJB on 16 March 2023. All complaints and enquiries received regarding these services and recorded on Lagan are captured in Appendix 1 and the figures below. Complaints 4.8 Overall, a total of 36 complaints were received during Quarter 3. Total Rec’d Q3 23/24 Total Closed Q3 23/24 Total Rec’d Q4 23/24 Total Closed Q4 23/24 Total Rec’d Q1 24/25 Total Closed Q1 24/25 Total Rec’d Q2 24/25 Total Closed Q2 24/25 Total Rec’d Q3 24/25 Total Closed Q3 24/25 LA 26 20 22 16 13 12 18 10 12 16 NHS 16 17 15 22 15 10 17 15 24 21 42 37 37 38 28 22 35 25 36 37 4.9 The table below sets out HSCM complaints received and closed by Quarter. Children and Families and Justice Social Work services figures are included from Q1 2023/24 onwards: 21 18 15 23 32 18 17 26 32 24 25 31 37 42 37 28 35 36 25 15 14 19 24 22 22 21 21 35 29 34 34 37 38 22 25 37 0 5 10 15 20 25 30 35 40 45 Q2 20/21 Q3 20/21 Q4 20/21 Q1 21/22 Q2 21/22 Q3 21/22 Q4 21/22 Q1 22/23 Q2 22/23 Q3 22/23 Q4 22/23 Q1 23/24 Q2 23/24 Q3 23/24 Q4 23/24 Q1 24/25 Q2 24/25 Q3 24/25 Received Closed Page 13
Page 14
4.10 There have been no complaints or enquiries received in Q3 in relation to changes implemented, by HSCM, due to financial decisions. MP/MSP Enquiries 4.11 There were 8 MP/MSP enquiries received regarding council services, under HSCM (including Children and Families and Justice), and recorded on the Council system, Lagan. These were allocated as follows: Service Number of Enquiries Access Team 2 Care at Home 3 Children and Families Area Teams 1 Community Care Finance 2 4.12 7 cases have been resolved with one still under investigation, at the time of reporting. 4.13 As of 1 April 2024, all general MP/MSP enquiries received by NHS Grampian Chief Executive Office, regarding health services, and specific to Moray, are forwarded direct to Service Managers in Moray to handle, in their entirety. To support this change HSCM have streamlined their operational procedures for handling enquiries which has improved efficiency, management oversight, consistency in responses, time management and data collection. 4.14 There was one MP/MSP enquiry received regarding health services, under HSCM, during this reporting period. It was in relation to vaccination appointments. 4.15 Any patient specific MP/MSP enquiries continue to be logged on Datix, and processed by NHS Grampian, either as a complaint, concern or comment, and captured in figures presented today. Concerns and Comments 4.16 There were 11 concerns received during Quarter 3 and recorded on Datix, 10 of these related to parking, signage and location of the Moray Vaccination Centre. One concern was for the Adult Mental Health team. 4.17 There were 8 comments and 1 suggestion received during Quarter 3 and recorded on Datix, these were all in relation to signage for the Moray Vaccination Centre. 4.18 NHS Grampian are in talks with Springfield Properties regarding a continuing agreement for the lease at Southfield Drive. HSCM are awaiting an update and continue to look at future options for the Moray Vaccination Centre. Whilst this work is ongoing temporary signage is positioned daily by the vaccination team to aid those attending. HSCM have also reached out to Moray Council to look at signage options for the centre. Page 14
Page 15
Learning 4.19 Communication continues to be the main theme arising from complaints received, across the partnership. When this involves individual staff members reflective practice is undertaken which is the process of thinking critically about one’s experiences, actions and decisions - to learn and improve future performance. 4.20 As verbally reported at the last Committee, Children & Families Social Work department held two half day Learning & Development sessions in November 2024 titled Learning from Practice. Sessions were attended by 111 front line social work staff to address findings from complaints and professional practice. The events were well received and feedback included: ➢ The sessions were ‘meaningful and snappy’ ➢ It was good to hear the Head of Service’s views and vision ➢ The sessions felt positive and boosted morale ➢ Networking opportunities were welcomed ➢ Staff want to see things moving on – change to be seen and evident A report from the sessions has been circulated to the workforce and an action plan will follow. A report shall be brought forward to Committee in due course. 4.21 The GMED Senior Management Team (SMT) is mindful of the cases currently going through the Datix system (complaints and incidents) and is committed to reviewing its internal clinical governance processes. The SMT will meet in March to discuss this in further depth. In the meantime, the Advanced Nurse Practitioner (ANP) leads will be working with their direct reports at an individual level, to review and reflect on randomly selected cases to identify any learning and development needs. An aim is to normalise this reflective process and remove any stigma attached to identifying times when things have not gone so well. 4.22 The Clinical Risk Management Group meets fortnightly and part of their role includes ensuring investigations are carried out appropriately, learning opportunities are identified and learning is shared with all relevant services. 4.23 Part of the Commissioning Team’s contract monitoring work involves reviewing complaints to external providers and actions taken. Reasons include quality assurance, service improvement, contract compliance and performance monitoring. Feedback 4.24 HSCM has a straightforward process for submitting complaints or feedback. With just two clicks on the Health and Social Care Moray website members of the public can find information about how to provide feedback or lodge a complaint. There are also Feeback Cards throughout NHS sites that can be completed and submitted using the business reply paid envelopes. Some internal social care day services have comments/suggestion boxes or books for people to leave feedback. Improvement Actions 4.25 HSCM’s Communications & Engagement Officer will review and update the ‘How to Complain’ leaflet and ensure all services have copies. Page 15
Page 16
4.26 The importance of effective communication and a timely response is recognised by HSCM; it builds trust and confidence, improves peoples’ experience and supports learning and service improvement. Complaints Handling training is to be arranged for HSCM’s Operational Management Team with a focus on cross service handling and process. 4.27 GMED clinicians continue to attend the monthly Continuing Medical Education (CME) sessions which cover a wide range of topics. The next CME is on 12 March 2025 which, in part, will focus on the complaints process, offering some guidance to clinicians as to the kind of information service managers are seeking when asking them to give a statement regarding a patient they have treated. This aims to improve the quality of response and time taken to respond. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” As set out within Annex C of the Health and Social Care Integration Public Bodies (Joint Working) (Scotland) Act 2014 Clinical and Care Governance Framework. Effective handling of complaints is used to ensure the efficient and sustainable delivery of services to meet priorities. (b) Policy and Legal Clinical and Care Governance requirements are set out within the Moray Health and Social Care Integration Scheme. Appropriate arrangements must be in place to ensure and evidence good governance in meeting duties under the Public Bodies (Joint Working) (Scotland) Act 2014. (c) Financial implications None directly associated with this report. (d) Risk Implications and Mitigation There are systems and processes in place across service areas to support clinical governance, providing assurance to the HSCM Senior Leadership Team and to the Clinical and Care Governance Committee. There are platforms within Health and Social Care to discuss and share good practice, learning and challenges. MIJB, Moray Council and NHS Grampian could find themselves exposed to significant risks if good governance is not in place. The purpose of this report is to oversee the processes to ensure that appropriate action is taken in response to adverse events, scrutiny reports/action plans, safety action notices, feedback, complaints and litigation, and those examples of good practice and lessons learned are disseminated widely. (e) Staffing Implications This activity is core to all practitioners in the front line both in terms of their professional competence and assurances in care delivery. Page 16
Page 17
(f) Property None directly arising from this report. (g) Equalities/Socio Economic Impact Not required as there are no changes to policy. (h) Climate Change and Biodiversity Impacts None directly arising from this report. (i) Directions None directly arising from this report. (j) Consultations Consultations have been undertaken with the following staff who are in agreement with the content of this report where it relates to their area of responsibility: • Corporate Manager, HSCM • Caroline O’Connor, Committee Services Officer, Moray Council • HSCM Clinical and Care Governance Group • Communication and Engagement Officer, HSCM • Lead Nurse, GMED 6. CONCLUSION 6.1 This report provides a summary of HSCM complaints and enquiries received and closed during Quarter 3 (1 October – 31 December 2024). The governance and monitoring of complaints forms part of core business for teams and services and the provision of a good quality, effective and safe service is a key priority for all. Author of Report: Isla Whyte, Corporate Business Support Manager Background Papers: with author Ref: Page 17
Page 18
Page 18
Page 19
APPENDIX 1 Complaints Data (by closed complaints) Quarter 3 (01/10/24 – 31/12/2024) Learning from complaints Teams and services actively review all forms of feedback to see where improvements can be made and share any learning. The tables 1, 2, 3, 4, 5 and 6 below set out the outcomes of closed complaints, what service received the complaint and any actions taken /learning. Table 1 Complaints Information Extracted from Datix – 21 complaints were closed during Quarter 3, 2024/25. Actions Taken/Outcome of complaints closed during Quarter 3, 2024/25: Fully upheld: Complaint is accepted Partially upheld: Complaint is partly accepted Not upheld: Complaint is not accepted Consent not received: Consent form not received from patient Total Access - Improvements made to service access 1 0 0 0 1 Communication - Improvements in communication staff-staff or staff-patient 3 6 0 0 9 Waiting - Review of waiting times 1 2 0 0 3 No action required 0 0 8 1 9 Action plan(s) created and instigated 0 1 0 0 1 Total 5 9 8 1 23* *this figure does not represent number of complaints closed as complaints may have more than one action Item 5. Page 19
Page 20
Table 2 Complaints Information Extracted from Lagan: 16 complaints were closed during Quarter 3, 2024/25 Directorate Department Service Upheld Partially Upheld Not Upheld Resolution Grand Total Health and Social Care Moray Children and Families and Criminal Justice Access Team 1 3 0 0 4 Justice 0 1 0 0 1 Fostering and Adoption and Supported Lodgings 0 1 0 0 1 Health and Social Care Moray Access Team 2 2 2 0 6 Care at Home 0 1 1 0 2 Learning Disability 1 1 0 0 2 Table 3 Complaints Information Extracted from Datix: 21 complaints were closed during Quarter 3, 2024/25 Fully upheld: Complaint is accepted Partially upheld: Complaint is partly accepted Not upheld: Complaint is not accepted Consent not received: Consent form not received from patient Total Allied Health Professionals 1 2 1 0 4 Community Hospital Nursing 0 0 1 0 1 GMED 1 2 0 0 3 Mental Health - Adult Mental Health 2 3 4 0 9 Mental Health - Old Age Psychiatry 0 0 0 1 1 Vaccination Transformation Programme 1 0 2 0 3 Total 5 7 8 1 21 Page 20
Page 21
Table 4 Complaints Information Extracted from Datix – Action Taken by Service (complaints closed during Quarter 3, 2024/25) Access - Improvements made to service access Action plan(s) created and instigated Waiting - Review of waiting times Communication - Improvements in communication staff-staff or staff-patient No action required Total Allied Health Professionals 0 0 0 3 1 4 Community Hospital Nursing 0 0 0 0 1 1 GMED 0 1 1 2 0 4 Mental Health - Adult Mental Health 0 0 2 4 4 10 Mental Health - Old Age Psychiatry 0 0 0 0 1 1 Vaccination Transformation Programme 1 0 0 0 2 3 Total 1 1 3 9 9 23* *this figure does not represent number of complaints closed as complaints may have more than one action. Page 21
Page 22
Active review of complaints through reporting and investigation is a useful tool to identify learning and improve services. Below are some of the actions and learning from complaints closed in Quarter 3, 2024/25. Information provided is kept brief to ensure no patient identifiable information is shared. Table 5 Actions and Lessons Learned (Datix) Communication Complaints Continue to ensure all contacts / telephone calls etc are recorded in case notes by clinicians and admin Communication – staff members to reflect Action Plan Reintroduction of safety calling to ensure patients are aware when there are delays (GMED) A thematic analysis shows, Communication Improvements (staff to staff or staff to patient) continues to be the most common theme arising from complaints. Table 6 Learning Outcomes (Lagan) Process / Procedure Team to review relevant guidelines and establish appropriate protocols Ensure parents are informed of their rights Consideration required in relation to how communication can be improved Complaint Against Service Enhance communication between professionals involved Communication and following procedure continue to be the main themes arising from complaints. Page 22
Page 23
Indicator 1 – The total number of complaints received The sum of the number of complaints received at Stage 1 (this includes escalated complaints as they were first received at Stage 1), and the number of complaints received directly at Stage 2. Table 7 – Total number of complaints received in Quarter 3, 2024/25 System recorded Early Resolution / Frontline (Stage 1) Investigation (Stage 2) Not Marked Total NHS – Datix 19 5 0 24 Moray Council - Lagan 3 5 4 12 Total 22 10 4 36 Table 8 – Allocation of complaints received in Quarter 3, 2024/25 NHS Service - Datix Allied Health Professionals 2 GMED 7 Community Nursing 2 Community Hospital Nursing 2 Mental Health - Adult Mental Health 5 General Practice 1 Vaccination Transformation Programme 5 Total 24 Table 9 – Allocation of complaints received in Quarter 3, 2024/25 MC Service - Lagan Children and Families and Criminal Justice Access Team 2 Children and Families Area Teams 3 Health and Social Care Moray Access Team 5 Care at Home 2 Total 12 Page 23
Page 24
Indicator 2 - The number and percentage of complaints at each stage which were closed in full within the set timescales of five and 20 working days The number of complaints closed in full at stage 1, stage 2 and after escalation within MCHP timescales as % of all stage 1, stage 2 and escalated complaints responded to in full. There were 21 Complaints closed on the NHS system Datix during Quarter 3, 2024/25 – breakdown as follows: Early Resolution/Stage 1 4 Investigation/Stage 2 8 Escalated Stage 2 8 SPSO 1 There were 16 Complaints closed on the MC system Lagan during Quarter 3, 2024/25 – breakdown as follows: Early Resolution/Stage 1 5 Investigation/Stage 2 9 Escalated Stage 2 2 Table 10 – number and percentage of complaints at each stage closed within timescales (based on complaints closed during Quarter 3, 2024/25) Frontline/Early Resolution within timescale Investigation within timescale Escalated Investigation NHS - Datix 2 out of 4 (50%) 1 out of 8 (12.5%) 3 out of 8 (37.5%) Moray Council - Lagan 0 out of 5 (0%) 0 out of 9 (0%) 0 out of 2 (0%) Whilst HSCM aim to respond to complaints within timescales this is not always achievable. Complaints received are often multi-faceted and include more than one service and other sectors, which can impact on response times due to the level of investigation and coordination required. Internal processes for managing complaints have been refreshed and discussed with teams and it is hoped an improving picture on response times can be presented next quarter. Overdue complaints are reported to the Senior Management Team (SMT) on a fortnightly basis for appropriate oversight. This ensures that more complex cases are highlighted and helps SMT identify patterns and address recuring issues. Page 24
Page 25
Indicator 3 - The average time in working days for a full response to complaints at each stage Table 11 – average time in working days to respond at stage 1, stage 2 and after escalation (based on complaints closed during Quarter 3, 2024/25) Frontline Investigative Escalated Investigative NHS - Datix 11 days 64 days 44 days Moray Council - Lagan 41 days 74 days 27 days Page 25
Page 26
Indicator 4 - The outcome of complaints at each stage The number of complaints upheld, partially upheld, not upheld and resolved at stage 1, stage 2 and after escalation as % of all complaints closed at stage 1, stage 2 and after escalation. Graph 2 below shows the number of complaints fully upheld, partially upheld and not upheld as recorded in Datix during Quarter 3, 2024/25. 21 complaints were closed during Quarter 3: 1 was closed as no consent was received. From the remaining 20: 25% were upheld, 35% were partially upheld and 40% were not upheld. 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Early Resolution Investigation Escalated Investigation SPSO Complaints Outcome (Datix) Fully Upheld Partially Upheld Not Upheld Consent not received Page 26
Page 27
Complaints Information Extracted from Lagan: 16 complaints were closed during Quarter 3, 2024/25: 25% were fully upheld, 56% partially upheld, 19% were not upheld. Graph 3 below shows the number of complaints upheld, partially upheld and not upheld as recorded in Lagan from the 16 closed complaints during Quarter 3, 2024/25. 0 1 2 3 4 5 6 7 8 Frontline Investigation Escalated Investigative Complaints Outcome (lagan) Fully Upheld: Complaint is accepted Partially Upheld: Complaint is partly accepted Not Upheld: Complaint is not accepted Resolution Page 27
Page 28
Page 28
Page 29
REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 27 FEBRUARY 2025 SUBJECT: HEALTH AND SOCIAL CARE MORAY CLINICAL AND CARE GOVERNANCE GROUP ESCALATION REPORT BY: CHIEF NURSE - MORAY 1. REASON FOR REPORT 1.1 To inform the Committee of progress and exceptions reported to the Clinical and Care Governance Group since the last report to Committee in November 2024. 2. RECOMMENDATION 2.1 It is recommended that the Committee: i) consider and note the contents of the report; and ii) agree that the Clinical and Care Governance Group will monitor progress of the Multi-Agency Adult Support and Protection Improvement Action plan going forward, reporting only by exception to Committee. 3. BACKGROUND 3.1 Health and Social Care Moray (HSCM) Clinical Governance Group was established as described in a report to this Committee on 28 February 2019 (para 7 of the minute refers). 3.2 The assurance framework for clinical governance was further developed with the establishment of the Clinical Risk Management Group (CRM) as described in a report to this Committee on 30 May 2019 (para 7 of the minute refers). 3.3 As reported to this Committee on 29 October 2020 (para 5 of the minute refers) Social Care representatives attend the Clinical Governance Group, so the group was renamed HSCM Clinical and Care Governance (CCG) Group. 3.4 A refresh of the Terms of Reference for the HSCM CCG Group was undertaken in 2023 and reported to this Committee on 30 November 2023 (para 6 of the minute refers). Item 6. Page 29
Page 30
3.5 This report contains information reported to HSCM CCG Group from Clinical Service Groups / departments. This report also contains further information relating to incidents / adverse events reported via Datix and areas of concern / risk and good practice shared during the reporting period. 3.6 The reporting schedule of the CCG Group does not always align to quarterly reporting to the committee. It has been agreed that the Escalation Report should include the CCG Group meetings between committee scheduling; this may not always be quarterly. 3.7 The CCG Group have met 2 times during this reporting period. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Audit, Guidelines Reviews and Reports 4.1 Relevant Audits, Guidelines Reviews and Reports are presented and discussed. These include local and national information that is relevant to HSCM, for example, recommendations from Health Improvement Scotland (HIS) reports from other areas which require to be discussed, and assurance given that services in Moray are aware of these and have processes in place to meet / mitigate the report recommendations. Overview of items discussed during this reporting period are listed below: • CRM Minutes • External Reports • Service Updates • Adverse Events and Duty of Candour • HSCM Risk Register • Complaints / Feedback • Update from Practice Governance Group Areas of achievement / Good Practice Aberlour Health Hub 4.2 Fleming Hospital in Aberlour is currently being utilised as a Health Hub and alongside providing work space to various services including District Nurses and the Community Response Team, is now delivering drop in and appointment based clinics and services to over 150 people weekly from immunisations through to specialised Third Sector services. 4.3 The Fleming Health Hub is a new initiative for HSCM and has not only created opportunities for delivering services but has created a larger and more diverse Multi-Disciplinary team and enabled new collaborative working and delivery opportunities. 4.4 The Health Hub can be utilised by anyone in Moray and it provides services closer to home for some of our most rural communities who otherwise would have to travel or be unable to access certain services. The rurality of Speyside often meant it was difficult for teams to deliver services due to lack of available space that could be accessed free or to hire. The Health Hub has now changed this and in addition, it also provides a base to encourage specialised Page 30
Page 31
Third Sector organisations to deliver services. A list of clinics and services currently available can be found on HSCM’s website: Keith & Speyside - HEALTH & SOCIAL CARE MORAY Mental Health 4.5 NHS Grampian Mental Health and Learning Disability services (across all the partnerships) are embarking on their "Pathway to Excellence" journey. Pathway to Excellence is a framework for nursing excellence, which is hosted by the American Nurses Credentialing Centre (ANCC). There are 6 standards within the framework; shared decision-making, leadership, safety, quality, wellbeing and professional development. HSCM are currently working towards reaching our goal, and our "Pathway to Excellence" designation by the middle of 2026. Moray Pharmacotherapy 4.6 All Band 7 and Band 8a Pharmacists employed by NHS Grampian and working in GP practices in Moray are now independent prescribers. This is a great benefit to practices, allowing pharmacists to consult with patients and prescribe where appropriate without having to involve GP time. 4.7 Pharmacist involvement in Community Hospitals has decreased discharge time and enhanced the safety and quality of medication provision for the patients. This invaluable service allows a pharmacist to perform a medication review with the patient as they arrive and on discharge, which also frees up primary care capacity. 4.8 Pharmacy First Plus is a service now provided at 9 Community Pharmacies in Moray, with a further 2 starting soon. This position is improved 50% on last year and provides the patient with enhanced medication access for minor conditions from community pharmacy. 4.9 A medication review in frailty patients aimed to investigate the benefit of giving targeted, in-depth medication reviews to frail patients, with a view to minimising medication burden, confusion and falls risk. A cohort of 77 patients were reviewed. In total, 58 medication changes were made; 25 stopped medication, 20 dose changes and 13 frequency alterations. In conclusion, polypharmacy reviews assisted patients into an anecdotally improved position, with an increased awareness of their conditions and greater confidence in managing their medication. 4.10 A high number of individuals in Moray receive Medicines Management as part of their assessed home care package, with some visits only for medication prompting or administration. A medication review into those receiving Care at Home aimed to utilise the opportunity to review complex medication when Page 31
Page 32
people are assessed for high level care packages, with a focus on enabling independence and reducing time spent dealing with medication by those caring for them. Two review methods were used, with 200 patients reviewed in total, resulting in a reduction in 74 potential daily medication visits, 39 reviews stopped at least one medication, amounting to 68 total medications stopped. The review highlighted a need for regular polypharmacy reviews. 4.11 Posters were created detailing the review methodology and results shared at a national Pharmacy Conference in Glasgow as well as at a national HIS webinar. Joint Inspection of Adult Support and Protection 4.12 A summary and overview of the findings of the Moray Joint Inspection of Adult Support and Protection Progress Review was provided to Committee at the meeting on 28 November 2024 (para 10 of the minute refers). The Care Inspectorate commended the Partnership in the findings of the Progress Review where signification progress was found in all 7 of the recommended areas for improvement in the 2022 Joint Inspection. The Partnership will continue to have in place a Multi-Agency Improvement Plan and this will continue to be utilised as a tool to track progress and further improvement moving forward. GMED 4.13 GMED clinicians continue to benefit from monthly Continuing Medical Education (CME) sessions which cover a wide range of topics and are usually delivered by external experts in the field. December's session covered chronic/end stage renal failure and the clinical implications of this, particularly in the out of hours (OOH's) setting. There were almost 50 staff members present with high engagement in a Q&A session and a large focus on safety netting, escalation and knowing who to turn to outside of the GMED team. The popularity of these sessions demonstrates the need and desire for staff to use an evidence-based approach to clinical care and they will continue to be delivered every month. 4.14 GMED is about to re-start the popular 'Case-based Discussion’ (CBD) where a GP will facilitate a group discussion around cases that clinicians have found challenging or particularly interesting. It is open to GP's and Advanced Nurse Practitioners (ANP's) and uptake has been very popular. It will afford not just reflection around the clinical aspects of the case in hand, but will also enable discussion around the quality of documentation and safety netting. Clinical Risk Management (CRM) 4.15 The CRM group continues to meet every 2 weeks to discuss issues highlighted on the HSCM Datix dashboard. This includes Level 1 and Level 2 investigations, Complaints, Duty of Candour and Risks. 4.16 The group is attended by members of the Senior Management Team, Clinical Leads, Chief Nurse and relevant Service Managers. The purpose is to ensure that senior managers are assured of the standards of services and that where necessary investigations are carried out appropriately, and learning opportunities identified and shared following adverse events and complaints. Page 32
Page 33
4.17 Any learning identified is presented and discussed at all relevant operational meetings. 4.18 The CRM group have agreed to review all High and Very High risks on the Risk Register on a monthly basis and will invite risk owners to join CRM meetings to offer constructive challenge and support. Complaints and Feedback 4.19 HSCM complaints information for Quarter 3, 2024/25 is included in a separate report on today’s agenda. Adverse Events (AE) 4.20 Information about AE reported on Datix during Quarter 3, 2024/25 is available at Appendix 1. 4.21 There was a significant rise in AE recorded on Datix during Q3 of 2023/24. The increase can be attributed to our mental health inpatient areas. Some inpatients can display higher levels of distress, violence and aggression, and this results in more recorded incidents. Findings and Lessons Learned from incidents and reviews 4.22 A Level 1 review consists of a full review team who have been commissioned to carry out a significant event analysis and review, reporting findings and learning via the division/service governance structures. 4.23 There are currently 3 Level 1 reviews in progress (at the time of reporting). HSCM Risk Register 4.24 Each Clinical Service Group/Department highlights risks associated with their service, which are then discussed at CRM. The risk register is routinely reviewed with leads with guidance and support provided regarding updates. Work is ongoing to review and improve this process and this will be discussed at OMT every month. 4.25 All new risks identified on Datix are discussed at CRM. There is an ongoing review of the operational risk registers. At the time of reporting, there are 44 risks on the risk register. These are monitored and reviewed as appropriate, by the service managers. As reported above CRM will also review all High and Very High risks on a monthly basis. Duty of Candour 4.26 At the time of reporting there are no ongoing Duty of Candour (DOC) incidents. 4.27 CRM requested a DOC incident reporting review to assess the accuracy, completeness and systemic quality of incident documentation for the 2023/24 reporting period. Variations in incident reporting quality were found. These findings were reported to the CCG Group in February 2025 and a number of recommendations have been agreed. A local improvement plan around DOC understanding and reporting will be developed and overseen by CRM. An update report will be presented to CCG Group in May 2025. Items for escalation to the Clinical and Care Governance Committee 4.28 There are no items to escalate to Committee. Page 33
Page 34
5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” As set out within Annex C of the Health and Social Care Integration Public Bodies (Joint Working) (Scotland) Act 2014 Clinical and Care Governance Framework. (b) Policy and Legal Clinical and Care Governance requirements are set out within the Moray Health and Social Care Integration Scheme. Appropriate arrangements must be in place to ensure and evidence good governance in meeting duties under the Public Bodies (Joint Working) (Scotland) Act 2014. (c) Financial implications None directly associated with this report. (d) Risk Implications and Mitigation There are systems and processes in place across service areas to support clinical governance, providing assurance to the HSCM Senior Leadership Team and to the CCG Committee. There are platforms within Health and Social Care to discuss and share good practice, learning and challenges. Moray Integration Joint Board (MIJB), Moray Council and NHS Grampian could find themselves exposed to significant risks if good governance is not in place. The purpose of this report is to oversee the processes to ensure that appropriate action is taken in response to adverse events, scrutiny reports/action plans, safety action notices, feedback, complaints and litigation, and those examples of good practice and lessons learned are disseminated widely. Adverse events and complaints provide significant information on trends relating to risk and an encouraging opportunity for learning across the system. Regular monitoring of this is critical to ensure continuous improvement and the ambition of achieving excellence in our delivery of high quality care and treatment. The local CRM group reviews all events logged on Datix, ensuring risk is identified and managed. (e) Staffing Implications This activity is core to all practitioners in the front line both in terms of their professional competence and assurances in care delivery. (f) Property None directly arising from this report. (g) Equalities/Socio Economic Impact There is no requirement for an equality impact assessment because there is no change to policy required as a result of this report. Page 34
Page 35
(h) Climate Change and Biodiversity Impacts None directly arising from this report. (i) Directions None directly arising from this report. (j) Consultations Consultations have been undertaken with the following staff who are in agreement with the content of this report where it relates to their area of responsibility: • HSCM Clinical and Care Governance Group members • Sonya Duncan, Corporate Manager • Caroline O’Connor, Committee Services Officer, Moray Council • Locality Manager, Keith/Speyside • Lead Pharmacist, Primary Care • GMED Service Manager • Consultant Practitioner – Adult Support and Protection 6. CONCLUSION 6.1 The HSCM CCG Group are assured that issues and risks identified from complaints, clinical risk management, internal and external reporting, are identified and escalated appropriately. The group continues to develop lines of communication to support the dissemination of information for action and sharing of good practice throughout the whole clinical system in Moray. This report aims to provide assurance to this Committee that there are effective systems in place to reassure, challenge and share learning. Author of Report: Isla Whyte, Corporate Business Support Manager, HSCM Background Papers: with author Ref: Page 35
Page 36
Page 36
Page 37
APPENDIX 1 Adverse Events by Category and Level of Review Reported on Datix (Quarter 3, 2024/25) Table 1 Level 3 - local review by line manager in discussion with staff Level 2 - local management team review Level 1 - significant adverse event analysis and review Part of joint review (single review into multiple events) Total Abusive, violent, disruptive or self-harming behaviour 112 1 0 0 113 Access, Appointment, Admission, Transfer, Discharge (Including Absconders) 10 1 0 0 11 Accident (Including Falls, Exposure to Blood/Body Fluids, Asbestos, Heat, Radiation, Needlesticks or other hazards) 78 1 1 1 81 Consent, Confidentiality or Communication 12 1 0 0 13 Diagnosis, failed or delayed 1 0 0 0 1 Fire 3 0 0 0 3 Implementation of care or ongoing monitoring/review (inc. pressure ulcers) 19 0 1 0 20 Infrastructure or resources (Staffing, Facilities, Environment, Lifts) 4 0 0 0 4 Medical device/equipment 2 0 0 0 2 Medication 56 0 0 0 56 Other - please specify in description 25 1 0 0 25 Patient Information (Records, Documents, Test Results, Scans) 7 1 0 0 8 Security (no longer contains fire) 2 0 0 0 2 Treatment, Procedure (Incl. Operations or Blood Transfusions etc.) 2 0 0 0 2 Total 333 6 2 1 342* *10 Incidents do not yet have a level of review assigned Item 6. Page 37
Page 38
Adverse Events by Type and Result Reported on Datix (Quarter 3, 2024/25) Graph 1 0 20 40 60 80 100 120 140 160 180 200 Breach of Information / IT Security Patient / Client / Resident Staff (including Volunteers) Student or Trainee Visitors, Relatives or member of the Public Provision of Service Audit Property / Equipment Adverse Events by Type and Result Near Miss (event prevented) Event resulted in NO injury, harm or ill-health Event resulted in injury, harm or ill-health Page 38
Page 39
Adverse Events by Service and Level of Review Reported on Datix (Quarter 3, 2024/25) Table 2 Level 3 - local review by line manager in discussion with staff Level 2 - local management team review Level 1 - significant adverse event analysis and review Part of joint review (single review into multiple events) Total Allied Health Professionals 11 0 0 0 11 Community Hospital Nursing 58 2 1 0 61 Community Nursing 37 1 1 1 40 Community Pharmacy 1 0 0 0 1 Community Therapy Services 1 0 0 0 1 Continence Service 1 0 0 0 1 General Practice 7 0 0 0 7 GMED 14 0 0 0 14 Mental Health - Adult Mental Health 54 0 0 0 54 Mental Health - Learning Disabilities 1 0 0 0 1 Mental Health - Old Age Psychiatry 98 0 0 0 98 Mental Health - Specialisms 5 0 0 0 5 Primary Care Contracts Team 0 2 0 0 2 Public Dental Service 5 0 0 0 5 Vaccination Transformation Programme 40 1 0 0 41 Total 333 6 2 1 342 Page 39
Page 40
Adverse Events by Type and Severity Reported on Datix (Quarter 3, 2024/25) Table 3 NEGLIGIBLE: Negligible/no injury or illness, negligible/no disruption to service, negligible/no financial loss MINOR: Minor injury or illness, short term disruption to service, minor financial loss MODERATE: Significant injury, externally reportable e.g. RIDDOR, some disruption to service, significant financial loss EXTREME: Death or major permanent incapacity, permanent loss of service, severe financial loss Total Breach of Information / IT Security 7 0 0 0 7 Patient / Client / Resident 204 40 0 0 244 Staff (including Volunteers) 22 13 1 0 36 Student or Trainee 1 1 0 0 2 Visitors, Relatives or member of the Public 4 0 0 1 5 Provision of Service 15 2 0 0 17 Audit 1 0 0 0 1 Property / Equipment 40 0 0 0 40 Total 294 56 1 1 352 Page 40
Page 41
Table 4: All adverse events by result by Quarter on Datix 2021/22 Quarter 4 2022.23 Quarter 1 2022/23 Quarter 2 2022/23 Quarter 3 2022/23 Quarter 4 2023/24 Quarter 1 2023/24 Quarter 2 2023/24 Quarter 3 2023/24 Quarter 4 2024/25 Quarter 1 2024/25 Quarter 2 2024/25 Quarter 3 Occurrence with NO injury, harm or ill-health 189 218 214 283 200 210 270 327 235 217 225 252 Occurrence resulting in injury, harm or ill-health 79 89 98 78 60 73 76 71 70 69 59 70 Near Miss (occurrence prevented) 31 29 40 38 20 22 26 50 31 27 41 30 Property damage or loss 0 0 0 0 0 0 0 0 0 0 0 0 Death 0 0 0 0 0 0 0 0 0 0 0 0 Total 299 336 352 349 280 305 372 448 336 313 325 352 Table 5: Adverse Events by Severity Reported by Quarter on Datix 2021/22 Quarter 4 2022/23 Quarter 1 2022/23 Quarter 2 2022/23 Quarter 3 2022/23 Quarter 4 2023/24 Quarter 1 2023/24 Quarter 2 2023/24 Quarter 3 2023/24 Quarter 4 2024/25 Quarter 1 2024/25 Quarter 2 2024/25 Quarter 3 Negligible 231 259 264 283 226 240 305 388 274 256 278 294 Minor 64 70 78 60 48 58 61 52 53 50 43 56 Moderate 2 4 8 5 6 5 6 8 9 6 3 1 Major 2 1 2 0 0 1 0 0 0 1 1 0 Extreme 0 2 0 1 0 1 0 0 0 0 0 1 Total 299 336 352 349 280 305 372 448 336 313 325 352 Page 41
Page 42
Page 42
Page 43
REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 27 FEBRUARY 2025 SUBJECT: DEVELOPING A DIGITALLY-ENABLED UNIVERSAL SERVICE MODEL TO REDUCE TYPE 2 DIABETES-RELATED RISK BY: LEAD DIETITIAN MORAY 1. REASON FOR REPORT 1.1 To inform the Committee of work undertaken by Primary Care Team at Maryhill and the Moray Dietetic Department in the testing of a digitally-enabled, low cost prevention and support model for reducing type 2 diabetes-related risk and improving readiness for lifestyle change in high priority patient groups. 2. RECOMMENDATION 2.1 It is recommended that the Committee: i) scrutinise and note the proposed model in the “Developing a Digitally-Enabled Universal Service Model to Reduce Type 2 Diabetes-Related Risk: Impact of the Prevent the Progress of Diabetes App and Brief Dietitian Call on Patient Readiness for Lifestyle Change” report attached as Appendix 1; and ii) acknowledge this Test of Change may offer further transformation opportunities, with a focus on Prevention and Proactive Care. 3. BACKGROUND 3.1 The proposed model (Appendix 1) has been developed jointly by NHS Grampian Moray Dietetics department, Maryhill Practice within Moray Health and Social Care Partnership (HSCP), the Digital Health and Care Innovation Centre (DHI) and the Right Decision Service (RDS) – the national decision support service managed by Healthcare Improvement Scotland (HIS). It is based on an 8-week pilot of the RDS Prevent the Progress of Diabetes app combined with an optional 10 minute signposting and referral call with a dietitian. 3.2 Scottish Government may be providing limited matched funding to support a test of change in Primary Care Dietitians. Item 7. Page 43
Page 44
3.3 Cardio vascular disease (CVD) Prevention and Proactive programme has 5 key pillars to preventing early death from CVD. This includes obesity, hyperglycaemia, hypertension, hyperlipidaemia and smoking. Four out of five of these key pillars have diet and lifestyle components which will require dietetic interventions. Hyperglycaemia links directly to this RDS project. Policy Context 3.4 A Healthier Future highlights the public health crisis emerging from the steady growth in incidence and prevalence of all types of diabetes over the past 10 years. In 2021, 287,551 people in Scotland were living with Type 2 diabetes – 6% of the total population. Around 10% of cases of type 2 diabetes remain undiagnosed, over 500,000 people in Scotland are at high risk of developing type 2 diabetes and treatment for people with type 2 diabetes entails significant cost – approximately 9% of the NHS budget and this is expected to grow as population ages. 3.5 A Healthier Future calls for action by NHS Boards and partners to reverse this trend and avert the emerging crisis through targeted weight management interventions - the evidence-based approach which is central to both prevention and remission of type 2 diabetes. The report describes a digitally-enabled intervention to facilitate this lifestyle change and improved weight management, based on the RDS Prevent the progress of diabetes web and mobile app. 3.6 Development to date and the future recommendations for implementation align closely with the aims and principles underpinning A Healthier Future, a whole systems approach based on multidisciplinary and multi-organisational partnership working, co-production with communities, a person-centred and shared decision-making approach to choosing the best approach for the individual and psychological support alongside management of physical health 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 This is a national tool which will be key to new digital innovations going forward locally and nationally e.g. digital remission for type 2 diabetes, CVD proactive and prevention programs. 4.2 This recommendation highlights that dietitians in Primary Care can be used to support primary care teams to identify and deliver prevention and proactive type 2 diabetes care using new digitally enabled tools. 4.3 Funding for a test of change for Primary Care Dietetics may come from Scottish Government in 2025. Funding will be matched funding. 4.4 Scottish Government CVD prevention and proactive care will be using RDS for information sharing for HCP. 4.5 RDS is where the new SIGN Prevention and Remission of type 2 Diabetes will be placed for HCP. 4.6 RDS and National Primary Care Informatics Team are working together to identify coding for Primary Care and creating additional content within the STU dashboard. This allows easy identification of pre-diabetes mellitus, history of Gestational Diabetes Mellitus (GDM) and patients appropriate for remission. Page 44
Page 45
5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” Recommendations supports Moray HSCP meet LOIP with regards to, focus on preventing and tackling health inequalities, using digital as a means of reducing carbon footprint and working with Moray Growth Deal (DHI) to develop digital technology solutions, ensure robust training and support for staff. Implement Digital Records where possible, develop ways people can access and use digital systems. (b) Policy and Legal Supports Scottish Government Healthier Futures Policy and Digital Health Policies. (c) Financial implications Unless the NHS supports a greater focus on prevention and early interventions for type 2 diabetes the cost for the NHS will continue to escalate. The health economics of preventing type 2 diabetes and delivering higher rates of remission have been identified by the Scottish Health Technologies Group and digital interventions are planned for Scotland via the Accelerated National Innovation Adoption (ANIA) programme in 2025/26 - Digital prevention programme for people at risk of developing type 2 diabetes (d) Risk Implications and Mitigation None arising directly report this report. This will be kept under consideration as work develops. (e) Staffing Implications Currently there are no implications, however as transformation progresses then there may be opportunities for consideration. (f) Property None arising directly from this report. (g) Equalities/Socio Economic Impact Using digital technologies as shared decision making tools which can be viewed in many different languages reduces language inequalities and supports many people who cannot manage face to face appointments e.g. those living in Scottish Indes of Multiple Deprivation (SIMD) 1 and 2, housebound. This increases the reach and reduces inequalities within current type 2 diabetes interventions. (h) Climate Change and Biodiversity Impacts Supports reduction in CO2 as patients receive the information digitally which reduces the need for travel and paper. (i) Directions None arising directly from this report. Page 45
Page 46
(j) Consultations Audrey Steele-Chalmers, Lead AHP Moray Clinical and Care Governance Group Dr Lockhart, Maryhill Primary Care team 6. CONCLUSION 6.1 The Committee are asked to scrutinise and note the content of this report and the continued hard work of the Moray Dietetic, Maryhill Primary Care, DHI and NHS HIS Teams in supporting the developments and testing of this new national digital resource. 6.2 Future initiatives / transformation in dietetics in Primary Care should be allowed to progress to allow future Scottish Government funding opportunities and to continue to improve preventative care into the future. Author of Report: Jacqueline Walker MSc BSc RD Lead Dietitian Moray Background Papers: Ref: Developing a Digitally-Enabled Universal Service Model to Reduce Type 2 Diabetes-Related Risk: Impact of the Prevent the Progress of Diabetes App and Brief Dietitian Call on Patient Readiness for Lifestyle Change - Strathprints Page 46
Page 47
The Digital Health & Care Innovation Centre | 1 Developing a digitally-enabled universal service model to reduce type 2 diabetes-related risk Impact of the Prevent the Progress of Diabetes app and brief dietitian call on patient readiness for lifestyle change. Digital Health & Care Innovation Centre APPENDIX 1 Item 7. Page 47
Page 48
The Digital Health & Care Innovation Centre | 2 Authors Michelle Brogan, Jacqueline Walker, Dr Robert Lockhart, Dr Ann Wales, Clara Carr, Yvonne Maclean, Jamie Savage, DOI number https://doi.org/10.17868/strath.00091677 Disclaimer Readers are responsible for assessing the relevance and accuracy of the content of this publication. University of Strathclyde acting through the Digital Health & Care Innovation Centre will not be liable for any loss, damage, cost or expense incurred or arising by reason of any person using or relying on information in this publication for their own context. Copyright Published: This report has been published and distributed under the terms of Creative Commons Attribution License version 4.0 (CC-BY): https://creativecommons.org/licenses/by/4.0/ This document has been written and prepared by the Digital Health & Care Innovation Centre. The DHI was established as a collaboration between the University of Strathclyde and the Glasgow School of Art and is part of the Scottish Funding Council’s Innovation Centre Programme. The DHI is also part-funded by Scottish Government. DHI supports innovation between academia, the public and third sectors, and businesses in the area of health and care. © 2024 University of Strathclyde acting through Digital Health & Care Innovation Centre. Page 48
Page 49
The Digital Health & Care Innovation Centre | 3 Executive summary This report proposes a digitally-enabled, low cost prevention and support model for reducing type 2 diabetes-related risk and improving readiness for lifestyle change in high priority patient groups. The proposed model has been developed jointly by NHS Grampian Moray Dietitics department, Maryhill Practice within Moray HSCP, the Digital Health and Care Innovation Centre (DHI) and the Right Decision Service (RDS) – the national decision support service managed by Healthcare Improvement Scotland (HIS). It is based on an 8-week pilot of the RDS Prevent the Progress of Diabetes app1 combined with an optional 10 minute signposting and referral call with a dietitian. The pilot focused on three groups of patients in Maryhill Practice: 1. Those at high risk of type 2 diabetes due to a diagnosis of pre-diabetes 2. Women at high risk of developing type 2 diabetes as indicated by a previous diagnosis of gestational diabetes. 3. Patients already diagnosed with type 2 diabetes who met the criteria for remission interventions. Methods Development of the app was based on consultation and co-design with patients and healthcare professionals, underpinned by review of the evidence base around design and implementation of digital tools for diabetes prevention and management. Key findings from the pilot included: Patients in the agreed priority groups were identified through case-finding searches, and the practice contacted them via a text message to invite them to complete a pre-intervention questionnaire and to use the app. A reminder to use the app was sent after 3 weeks. Patients were given the option to request a dietitian call in addition to using the app, and 65 out of 82 patients (79%) chose to do so. A post-intervention questionnaire to assess impact of the app and call on knowledge, confidence and motivation was issued at 8 weeks after the pre-intervention questionnaire. This follow-up questionnaire was also sent to patents who had not responded to the pre-questionnaire. 3 Key findings 1. Of the participants who completed the post- questionnaire (n=83), the majority (62.7%; 52)) used the app at least once, while 37.3% (n=31) did not use it at all. 2. Almost all participants (92.3%) who had used the app rated the app as easy to use (score 3 or higher on a Likert scale of 1-5), with 38.5% of participants rating it at the maximum 5. 3. 94% of patients who used the app said that their knowledge had improved at least a little, and 88% said that their confidence and motivation had improved at least a little. 54% of participants reported that their knowledge had increased “somewhat” or “ a lot.” 52% said that their confidence had improved at these levels, and 56% that their motivation had also improved at these levels. The t-test of knowledge found the mean self-reported knowledge post-intervention as measured by a Likert scale to have increased significantly (P=0.004). 4. T-tests showed that knowledge, confidence and motivation increased equally among patients who used the app in conjunction with a dietitian call (66%) or without a call (34%). 5. Of the respondents who did not use the app, the main reasons provided were lack of awareness, competing priorities, and no access to technology. 5 responses about future improvements to the app also asked for a consultation with a healthcare professional alongside use of the app. 6. The dietitians provided patients with orientation to navigating the app, and made a total of 96 referrals/ information provisions, principally to tier 1, 2 and 3 weight management services (e.g. Prevent IT, Control It, Second Nature Prevent, Counterweight and Counterweight Plus, Oviva) and self-management resources. 56% of patients found the call very helpful, 31% found it somewhat helpful. 7. Almost all respondents who answered the question about behaviour change (46 out of 52) had made or planned to make a change. Of these 67.4% had a dietitian call, and 32.6% did not. This suggests that use of the app alone combined with personal motivation was sufficient for a third of participants to reach the stage of making or planning behaviour change. 1: Website: https://preventdiabetes.scot.nhs.uk or download from the Right Decision Service mobile app - Apple and Android .Page 49
Page 50
The Digital Health & Care Innovation Centre | 4 The most common change was a change in diet or eating habits (n=34), followed by increasing physical activity (n=15), then starting a weight management programme (n=4). Proposal for a future digitally-enabled service model Based on the pilot findings, the pilot proposes a service model which recognises that patients with high, medium and low digital self-efficacy will benefit from different elements of a digitally- enabled prevention and support “bundle.” The bundle elements can be localised and delivered flexibly as a core minimum or extended service approach, to align with local needs and service constraints and contribute to NHS Boards’ Tier 1 universal weight management services, Tier 2 early intervention and Tier 3 targeted intervention services as described in A Healthier Future . We envisage this support bundle aligning with and augmenting current and planned weight management services. For example, it can complement the tightly defined referrals to the forthcoming ANIA digital coaching remission pathway by offering readily available support to a wider range of people who meet the criteria for remission. This report describes the detailed results of the pilot and makes recommendations for future development, implementation and further evaluation of the proposed service model. Recommended next steps include: 1. Make the app available for use across NHS Grampian and more widely. 2. Implement and evaluate the proposed digitally- enabled service model. 3. Engage with the Digital Health & Care Innovation Centre Weight Management Living Lab to define a roadmap for delivery of an integrated service that combines the strengths of the two projects. 4. Support continuous improvement of the app, and implement other key technical improvements – e.g. a national case-finding approach and provision of alerts in the context of the patient record. 4 Page 50
Page 51
The Digital Health & Care Innovation Centre | 5 1. Project aims and scope This project aimed to determine whether the Prevent Progress of Diabetes app, in conjunction with support from a trusted health service and specialist dietitians, can be used as part of a digitally-enabled service model to reduce type 2 diabetes-related risk in three high priority groups – a. patients diagnosed with pre-diabetes b. women with a previous history of gestational diabetes mellitus (GDM) c. patients already diagnosed with type 2 diabetes who met the criteria for entry to a remission programme: • Diagnosed within the last 6 years • 8-65 years old • BMI >= 27 for white Caucasians, or >= 25 or above for people from South East Asian, African-Caribbean or Black African backgrounds. • Latest HbA1c within 12 months >= 48 mmol/ mol if not taking diabetes medication; or > 43 mmol/mol if taking diabetes medication Specifically, the project aimed to assess: 1. Impact of the Prevent Progress of Diabetes app on • patients’ knowledge and understanding about diabetes • their confidence in managing and reducing their diabetes-related risk • their motivation to make lifestyle changes. 2. Impact of augmenting the call with a 10 minute call by phone or NearMe with a dietitian. During this call, the dietitian: • Where possible – for example, through screen-sharing with Near Me - showed the patient through how to use the app • Recommended the most appropriate weight management service in line with NHS Grampian diabetes pathways (e.g. Second Nature Prevent) and made a referral with the patient’s agreement. • Offered practical advice and support on management of diabetes risk – for example, recommending diet sheets. This report outlines the three stages of the project: • Co-design and development of the app in collaboration with patients and healthcare professionals. • Piloting and evaluation of the app with support from healthcare professionals. • Recommendations for a service model for delivery at scale and maximising impact, accompanied by further evaluation and refinement of the approach. 2.Context 2.1 Policy context A Healthier Future highlights the public health crisis emerging from the steady growth in incidence and prevalence of all types of diabetes over the past 10 years. In 2021, 287,551 people in Scotland were living with Type 2 diabetes – 6% of the total population (1). It notes further concerns that: • around 10% of cases of type 2 diabetes remain undiagnosed • over 500,000 people in Scotland are at high risk of developing type 2 diabetes. • treatment for people with type 2 diabetes entails significant cost – approximately 9% of the NHS budget and this is expected to grow as population ages. A Healthier Future calls for action by NHS Boards and partners to reverse this trend and avert the emerging crisis through targeted weight management interventions - the evidence-based approach which is central to both prevention and remission of type 2 diabetes. This report describes a digitally-enabled intervention to facilitate this lifestyle change and improved weight management, based on the RDS Prevent the progress of diabetes web and mobile app. Development to date and the future recommendations for implementation align closely with the aims and principles underpinning A Healthier Future: • A whole systems approach based on multidisciplinary and multi-organisational partnership working • Co-production with communities Page 51
Page 52
The Digital Health & Care Innovation Centre | 6 • A person-centred and shared decision-making approach to choosing the best approach for the individual. • Psychological support alongside management of physical health. 1.2 Local context – Moray and NHS Grampian A Healthier Future calls for GP clusters to deliver the action plan by engaging with evaluation and monitoring of referrals and outcomes in primary care and by integrating type 2 diabetes prevention into primary care improvement plans. DHI jointly funded this project with NHS Grampian Public Health, to address this need for stronger primary care support in the Moray HSCP and NHS Grampian more widely. Through collaboration with the Healthcare Improvement Scotland Right Decision Service, the project aims to equip these primary care teams and patients with digital capabilities and processes for diabetes prevention and remission. The project responds to evidence of need for prevention and support services for type 2 diabetes in NHS Grampian. A Pre-diabetes and Type 2 Diabetes Support Services Survey in Autumn 2023 revealed that a significant proportion of the 900 respondents – 10% with pre-diabetes, 70% with diabetes - want support in the form of weight management and dietary advice and that they do not know about the services that are available. Within the Maryhill Group Practice in Moray, which came forward to serve as the pilot for this project, searches in the Vision primary care electronic health record system showed tat January 2024 22,424 patients in MaryHill Group Practice • 1240 are diagnosed with type 2 diabetes (incidence of 5.5%) • 270 had a diagnosis of pre diabetes and have not progressed to Diabetes ( 1.1%) • 89 have a past diagnosis of gestational diabetes (0.4%) This project aligns with the DHI Rural Centre of Excellence’s Living Lab for Supported Self- Management, which focuses on digital innovations which will encourage use of community assets and cross-sectoral care and support, underpinned by use of personal data stores, to facilitate weight management and reduction of risk from conditions including type 2 diabetes and cardiovascular disease. 3.Methods 3.1 Development of the Prevent the Progress of Diabetes app The web and mobile app were co-designed and developed within the national Right Decision Service platform. Originally piloted and evaluated within DHI, this platform is now led and managed by Healthcare Improvement Scotland. The development process followed three stages, described in an earlier report to DHI (see annex 1.) 3.1.1 Rapid evidence review Sixteen decision support tools were identified in published studies at the time of conducting this review – autumn 2023. Thematic analysis across these studies indicates that: • Developing decision support tools for prevention and remission in the three target groups identified is innovative and addresses a current gap in digital support • •Decision support web and mobile apps for citizens and for shared decision-making by citizens and professionals can deliver clinically significant reduction in diabetes risk. • Decision support prompts embedded in electronic health record systems to identify people with prediabetes can achieve significant improvement in practice – e.g. ordering of HbA1c tests, lifestyle counselling. Key enablers of successful implementation of decision support include: • Personalise self-management advice • Actively support behaviour change through design of the decision support tool, and embedding interaction and dialogue with professionals and peers. • Target individuals most likely to benefit – e.g. those with medium self-efficacy who recognise gaps in their capability for managing diabetes. • Build in continued communication over time to sustain impact. • Integrate decision support into care pathways and clinical processes • Provide training and support for professionals and citizens Page 52
Page 53
The Digital Health & Care Innovation Centre | 7 A key study identified was the observational evaluation (2) of the ‘Healthier You’ NHS England digital diabetes prevention programme. This concluded that a digital intervention in conjunction professional support for behavioural change could be an effective and wide-ranging component of a population-based approach to prevention. This pilot aimed to incorporate, within limited available resource, key elements shown to be effective in this programme. 3.1.2 Consultation with professionals in NHS Grampian Consultation involved two virtual workshops, and four key informant interviews with professionals in Moray and NHS Grampian, using an early prototype of the app and a series of personas and scenarios as the basis for discussion on design and implementation. Professional representation covered: GP and consultant physicians, dietitians, psychologists, public health. 3.1.3 Consultation and co-design with professionals and citizens nationally This Grampian-focused consultation was followed by two virtual workshops open nationally to all healthcare professionals and citizens. Citizens were identified through the Healthcare Improvement Scotland and Health and Social Care Alliance patient and public networks, with support from Diabetes Scotland. Participants included: GPs; consultants; dieticians; nurses from across multiple NHS Boards; students; women with current or previous gestational diabetes mellitus (GDM); people with pre-diabetes, type 1 and type 2 diabetes; people with family members with diabetes or pre-diabetes; and people with learning difficulties. There was representation from Scottish, Southeast Asian and South Asian groups. These workshops used an updated version of the app prototype, building on the input from Moray and NHS Grampian stakeholders. Personas and scenarios were again used to stimulate discussion about how the app could be developed to optimise support for different users and contexts. 3.2 Findings Two major common themes were identified across the evidence base and the consultation workshops: 1. The app should facilitate communication and interaction with trusted healthcare professionals and on the need for access to training and support. Text message notifications to prompt action by the citizen and to open up communication with healthcare professionals were one of the most requested features. This concords with the evidence base indicating that this approach has good potential for increasing long-term use. 2. The app should go beyond physical healthcare support – e.g. diet and exercise – to incorporate psychological support for mental and emotional wellbeing. This was recognised as essential to build individual readiness for change. The consultation stage also drew out a number of more specific technology, content and support requirements, including: • App presentation • Use visual content, including pictures and videos, wherever possible. • Include more interactive elements • Ensure content is easy to read for people with visual impairments and accessible using a screen reader • Shortening lists of links and embedding user- friendly content directly in app pages. • Features • Suggested features included options for goal setting, and appointment related questionnaires or information to support shared decision-making. • Implementation and ongoing support • Stakeholders noted that implementation of the app will require a multi-faceted approach, including: Ƽ Signposting and orientation to the app by healthcare professionals. Ƽ Awareness-raising and support from support services and community services including link workers, Healthpoint, public libraries, leisure services and third sector organisations. Page 53
Page 54
The Digital Health & Care Innovation Centre | 8 3.3 App development The Prevent the progress of diabetes app delivered by the Right Decision Service responds as far as possible within limited resource and at this early stage to these stakeholder requirements: • Tailors content specifically and clearly for the three high priority groups identified for the pilot: • Patients with a diagnosis of pre-diabetes • Women with a previous diagnosis of gestational diabetes • Patients with an existing diagnosis of type 2 diabetes who meet the criteria for remission interventions. • Implemented in conjunction with SMS messaging from the pilot practice (Maryhill Group.) • Supported with the option of a 10-minute signposting call with a specialist dietitian. • Combines a range of interactive psychological assessment and support tools with guidance and advice on weight management, diet, exercise and other lifestyle factors. • Incorporates video and other visual resources • Supports users to navigate the combination of local services and resources within Moray and NHS Grampian and national sources such as Diabetes UK and My Diabetes My Way. User feedback showed confusion over the multiple sources available, difficulties in navigating some websites, and gaps in key content – e.g. My Diabetes My Way does not include resources for pre-diabetes. • Complies with W3C AA accessibility standards. The app can be accessed online as a website, or downloaded from the app stores as a mobile app for offline usage. This multi-channel approach affords the convenience of mobile app access for those who are confident using this approach, and also supports people who have basic skills in Internet usage but are less familiar with downloading mobile apps. 4. Piloting and evaluation methods The Clinical Lead for Primary Care in Moray HSCP put forward the Maryhill Practice to be the test site for this pilot project. 4.1 Patient identification – case finding searches Patients in each of the three high priority groups (pre-diabetes, previous GDM, candidates for remission) were identified by running case-finding searches on the Maryhill Practice electronic health record system (Vision). Searches were conducted in January 2024, using Read codes combined with inclusion and exclusion criteria as follows: General exclusion criteria applied to all groups were: • Not able to speak English (needing translator) • Hearing impairment (given that a key part of the intervention was a phonecall) • Severe kidney or liver disease • Active cancer • Palliative or end of life care. »..l, Heahhcare nt I Righ~ Decision f'Jiii, Scotland Service Right Decisions for Health and Care Menu T Search 'Prevent the progress of diabetes. NHS --._,.- Grampian What is gestational diabetes ) mellitus (GDM)? What matters to me about reducing ) my risk of diabetes? What is my risk of developing type 2 ) diabetes? Building my ability to change ) r Page 54
Page 55
The Digital Health & Care Innovation Centre | 9 Patients who had not provided mobile phone numbers or who had not consented to receiving text messages from Maryhill Medical Practice were also excluded from the study. Pre-diabetes Read codes IGT (impaired glucose tolerance), IFHG (impaired fasting hyperglycaemia) or NDHG (non- diabetic hyperglycaemia) Inclusion criteria: HbA1c over 41mmol/mol and less than 48 mmol/mol BMI >27kg/m 75 year old or under Exclusion criteria: HbA1c>48 (they were transferred to the Diabetes remission group) or <41mmol/mol BMI <27kg/m2 >75years old Palliative care/end of life care. 270 patients were found in the initial search. 149 patients were excluded, leaving 121 to be invited to participate in the pilot. Gestational diabetes Read codes L180 - L180800 (diabetes mellitus arising in pregnancy) and 180900 (gestational diabetes mellitus) - excluding other types of diabetes such as Type 1 or MODY (maturity onset diabetes of the young) or Type 3. Exclusion criteria: • 1 of the patients was no longer at the practice at the time of going through the list on 20/3/24 • We also excluded patients who were over 75 or who were a normal or underweight (BMI<25) • Prediabetes or diabetes diagnoses. 9 were transferred to the prediabetes group and 9 to the remission group • Pregnant 110 patients were found in the initial search. 29 were excluded, leaving 71 who were invited to participate in the pilot. Remission group Read code C10F (type 2 diabetes mellitus) Inclusion criteria: • diagnosed from April 2019 onwards. (within 6 years of diagnosis with type 2 diabetes according to coding on Vision) • HbA1c>48mmol/mol if not on diabetes medication or HbA1c >43 mmol/mol if on diabetes medication • BMI>27 • <75 years old Exclusion criteria: most recent HbA1c <42 mmol/mol 166 patients were initially identified. 48 patients were excluded and 118 were invited to participate in the pilot. Page 55
Page 56
The Digital Health & Care Innovation Centre | 10 4.2 Process As outlined in figure 1 below, patients in each high risk group were sent an SMS message signposting them to the web version of the app and asking them to complete a pre-intervention questionnaire. All patients retrieved through the Vision searches – whether or not they responded to the initial questionnaire - were sent a reminder SMS to look at the app at 3 weeks after the initial text message. Those patients who responded to the initial questionnaire were subsequently sent a follow-up questionnaire at 8 weeks after the original text message to assess whether their knowledge, confidence and motivation had improved. The dietitians called those who did not respond to the follow-up questionnaire to invite them to respond by email or to complete the questionnaire with them over the phone. Patients who did not respond to the initial questionnaire were also sent the follow-up questionnaire. This increased the sample size within which we could compare users versus non-users of the app. Pre-intervention questionnaire Reminder SMS Post-intervention questionnaire Pre-diabetes 121 texted Gestational diabetes 71 texted Eligible for remission 118 texted 30 respondents 17 respondents 35 respondents 23 opted for dietitian call 28* had call 12 opted in for dietitian call 10 had call 29 opted in for dietitian call 27 had call Text reminder about app sent to all pre-intervention respondents at week 3 (81) Text reminder about app sent at week 3 to non-respondents to pre-intervention questionnaire (233) Post-questionnaire sent to all pre-intervention respondents at 4-8 weeks after dietitian call or 8 weeks after initial text.** 60 respondents Post-questionnaire sent by text to all those who did not respond to pre-intervention questionnaire at 8 weeks after initial text. 23 respondents *2 patients rang the surgery to book a diabetes call rather than complete the questionnaire online. 3 further patients were contacted in response to comments in their questionnaires. **The dietitians proactively called those patients who had responded to the pre-intervention questionnaire but initially did not respond to the post-intervention questionnaire and worked through the questionnaire by phone or sent an email copy when requested Annex 2 provides the wording of the text messages sent to patients. 7 .... 7 .... 7 -----... -----------... -------- \ I I I I I I I , \ I I , 7 .... 7 .... 7 -- -- -- 7 .... -- -- -- -... ---... \ I I I I I I I , \ I I , -------- Page 56
Page 57
The Digital Health & Care Innovation Centre | 11 4.3.1 Demographic information Participants were asked to provide their date of birth, gender, ethnicity, age, weight, and height. They were also asked to provide their postcode for assessing level of deprivation using the Scottish multiple deprivation index. Postcodes were mapped to the Scottish Index of Multiple Deprivation (SIMD) to determine the SIMD quintile for each participant. 4.3.2 Improvement in readiness for change – self- rating In the post-questionnaire, participants were asked to rate to what their extent their knowledge, confidence, and motivation had increased since using the app (“Has using the Prevent the Progress of Diabetes web resource improved your [knowledge about managing/confidence about managing/motivation to manage] your diabetes condition?”) from 1 (“Yes, a lot”) to 4 (“No not at all”). 4.3.3 Pre/post comparison of readiness for change using Likert scales In both the pre- and post-questionnaire, participants were asked to rank: • Their knowledge about type 2 diabetes. • Their confidence in managing diet and lifestyle • Their motivation to improve diet and lifestyle • Their current prioritisation of diabetes relative to other things in their life All these aspects were measured on a Likert scale of 1-5, with 1 being the lowest score and 5 the highest. 4.4 Dietitian call Dietitians called those patients who had opted for this support via Near Me where possible, or alternatively by phone. This was not a full dietitian consultation but a brief ten-minute intervention comprising four elements: • Orientation to navigate the app, where possible with a demonstration using screensharing with Near Me. • Referral with patient agreement to the appropriate NHS Grampian service – including: Prevent It, Control It, Second Nature Prevent, Counterweight (face to face), Counterweight Plus, Balance Near Me group and Oviva (digital Tier 3.) • Self-management advice and support, including (for 3 patients) provision of a diet sheet or meal plan. • Where appropriate, recommendations for action to the Maryhill general practice team – for example, to refer for smoking cessation support, test for coeliac disease or IBS, provide updated HbA1c or weight information. 4.5 Power analysis A sensitivity power analysis was conducted G*Power, to identify the largest effect size that could reliably be detected with a two-tailed matched pairs t-test using (n=43, alpha=.05, power=.80). It was found that this sample could detect an effect with a Cohen’s d of 0.43 (approx. a medium effect size) at a power of .80. 4.6 Statistical tests Within-subjects t-tests (or Mann-Whitney U-tests were data was distributed non-parametrically) were used to compare: • Self-rated knowledge, confidence and motivation at the end of the study among those who used the app more or less frequently, and those who did or did not have a dietitian call. The impact of SIMD score on self-rated knowledge, confidence and motivation was also assessed. • Pre- and post-Likert scale results for knowledge, confidence, motivation, and priority among those who completed both the pre- and the post-questionnaires. The difference in pre- and post-results was also compared for those who did and did not have a dietitian call and across groups with low and high SIMD scores. • Pre- and post-intervention BMI scores. Comparisons across the three high risk groups were not possible due to the low sample sizes in some groups. Missing values were filled via mean imputation (there were no more than 3 missing values per comparison). Page 57
Page 58
The Digital Health & Care Innovation Centre | 12 5.Results 5.1 Participants A total of 82 respondents completed the pre-questionnaire, while total of 83 respondents completed the post-questionnaire. In the pre-questionnaire group, 21 respondents did not complete the post- questionnaire; for the post-questionnaire, 23 of the respondents had not completed the pre-questionnaire. This left 60 respondents who completed both the pre- and post-questionnaire. 5.2 Demographics Demographic information for participants is presented in Tables 1 and 2 below, broken down by whether they responded to the pre-questionnaire, the post-questionnaire, or both. All respondents to pre-questionnaire All respondents to post-questionnaire Responded to both pre and post questionnaires Gender 26 male, 55 female, 1 no response NA 19 male, 41 female Ethnicity 76 White 2 South Asian, 1 Black, 1 Chinese, 2 no response 77 White 1 South Asian, 1 Black, 1 Chinese, 1 Mixed, 2 no response 56 White 1 South Asian, 1 Black, 1 Chinese, 56 White, 1 Mixed Diabetes group 31 pre-diabetes, 16 GDM, 35 remission NA 23 pre-diabetes, 11 GDM, 26 remission Age bands 36 [< 55 band], 45 [≥55 band], 1 no response 31 [< 55 band], 52 [≥55 band] 26 [< 55 band], 34 [≥55 band] Had dietitian call 80.5% (66) 61.45% (51) 85% (51) Deprivation (SIMD quintile 1=most deprived, quintile 5=least deprived) Quintile 1 – 4 (4.9 %) Quintile 2 – 14 (17.1%) Quintile 3 – 16 (19.5%) Quintile 4 – 25 (30.5%) Quintile 5 – 15 (18.3%) No postcode – 4 (4.9%) NA Quintile 1 – 4 (6.7%) Quintile 2 – 13 (21.7%) Quintile 3 – 12 (20%) Quintile 4 – 16 (26.7%) Quintile 5 – 12 (20%) No postcode – 3 (5%) Where a variable is listed as NA, it was not measured in that questionnaire. In line with the literature on patients in deprived areas being least likely to engage with health services, the response rate was lowest among patients in the most deprived areas. However, it is noticeable that, while numbers were low, all respondents in this group replied to the follow-up questionnaire as well as the pre-intervention questionnaire. This may have been influenced by the proactive follow-up phone-calls by the dietitians (see note in figure 1 above.) Table 2: Means and standard deviations for age, weight, height, BMI for participants who completed both the pre- and post-questionnaires Mean SD Age 55.8 11.8 Weight (Kg) 98.8 24.7 Height (m) 1.68 0.095 BMI 34.9 0.43Page 58
Page 59
The Digital Health & Care Innovation Centre | 13 5.3 App usage rates Of the participants who completed the post- questionnaire (n=83), the majority (62.7%; 52)) used the app at least once, while 37.3% (n=31) did not use it at all. Usage levels are reported below for all participants who used the app (n=52). Table 3: Participants’ app usage levels for all respondents to the post-questionnaire 5.4 Ease of use Participants were also asked to rate the app’s ease of use on a scale from 1 (Not easy) to 5 (Very easy). Almost all participants (92.3%; n=48) who had used the app rated the app at 3 or higher, with 38.5% of participants (n=20) rating it at the maximum 5. Table 4: Ease of use of the app 5 (Very easy) 4 (Easy) 3 (Neither or) 2 (Not Easy) 1 (Not easy at all) 38.5% 30.8% 23.1% 5.5 Self-rating of improvement in readiness for change Table 5 below displays participants’ self-reported ratings of the app’s effectiveness in improving knowledge, confidence, and motivation. Data includes all participants who responded to the post- questionnaire and used the app at least once (n=52). The great majority of participants reported that the app improved all three aspects of their readiness to change. 94% said that their knowledge had improved at least a little, and 88% said that their confidence and motivation had improved at least a little. Focusing on the higher levels of impact - 54% of participants reported that their knowledge had increased “somewhat” or “a lot.” 52% said that their confidence had improved at these levels, and 56% that their motivation had also improved at these levels. More than once a week Once a week About once a fortnight Once or twice Never 37.3% 42.2% Not at all A little Somewhat A lot Knowledge 3 (5.8%) 21 (40.4%) 15 (28.8%) 13 (25%) Confidence 6 (11.5%) 19 (36.5%) 19 (36.5%) 8 (15.4%) Motivation 6 (11.5%) 17 (32.7%) 17 (32.7%) 12 (23.1%) 5.6 Pre/post comparisons of readiness to change using Likert scales The t-test of knowledge found the mean self-reported knowledge at post-test (M=3.53, SD= .96) to be sig- nificantly higher than knowledge at pre-test (M=2.95, SD=1.02; p=.004, t=-2.99). T-tests of pre/post priority, confidence, and motivation for all respondents who responded to the pre- and post-questionnaire (n=43) did not find a significant difference between pre and post measures (two-tailed p=0.29, 0.11, and 0.45 respectively). Table 5: Participant ratings of app effectiveness in improving knowledge, confidence, and motivation of diabetes management ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Page 59
Page 60
The Digital Health & Care Innovation Centre | 14 5.7 Referrals following a dietitian call Of the 53 participants who used the app at least once, 35 (66%) had a call with a dietitian. 18 (34%) used the app without having a dietitian call. The dietitians observed that of the 66% they spoke to, a number had not used the app at that point. The dietitians’ introduction to using the app as part of the call is likely to have been helpful in prompting future usage. Table 6 below shows the specifics of the total 96 referrals/ advice offerings made as a result of this call. Outcome after dietitian call GDM Pre-diabetes Remission Self-management 2 7 2 Prevent It 6 9 NA Control It NA NA 8 Second Nature Prevent 7 3 NA Oviva (digital Tier 3) 0 2 4 MLC – counterweight (F2F) 1 11 3 Balance (Near Me group) 0 0 1 Counterweight Plus NA NA 12 Dietitian 1:1 consultation 2 3 6 Other – see below* 1 3 3 Number of patients called 10 28 27 Total outcomes 19 38 39 Most popular outcome (% of patients called who chose this option) Second Nature Prevent -digital (70%) MLC-Counterweight F2F (39%) Counterweight Plus (44%) Table 6: Referrals and advice provided in dietitian call *Other options: • GDM –Culturally appropriate diet sheet requested • Pre-diabetes – diet sheet in post • Remission – 900kcal meal plan requested /bariatric surgery waiting list • Requests to complete questionnaire over the phone or via email rather than text. The dietitians also made a number of recommendations for action to the Maryhill general practice team. As outlined in table 7 below, these included updating of clinical parameters around HbA1c or weight, and recommendations for referral – e.g. for smoking cessation or tTG testing. Page 60
Page 61
The Digital Health & Care Innovation Centre | 15 Further Action for primary team GDM Pre-diabetes Remission Other: smoking cessation 1 Annual HbA1c/update 7 4 2 Update Weight 3 3 1 To check tTG for coeliac disease – pos- sible IBS 1 1 To request bone scan/coeliac review 1 Table 7: Recommendations for action to the primary care team as a result of the dietitian call 5.8 Effect of deprivation Participants were asked for their postcode in the pre-intervention questionnaire only. As post-questionnaire responses were needed to assess app effectiveness, only participants who completed both the pre- and post-questionnaire, used the app at least once and entered a valid postcode could be included in an analysis of app effectiveness by deprivation (n=40). Table 8: SIMD quintiles for participants who completed both the pre- and post-questionnaire, used the app, and provided a valid postcode (n=40) To compare the most and least deprived groups, participants were collapsed into 2 bands: most deprived including quintiles 1 and 2 (n=11) and least deprived including quintiles 4 and 5 (n=20). Partici- pants in quintile 3 were excluded from this analysis. More than once a week Once a week About once a fortnight Once or twice Never 37.3% 42.2% A Mann-Whitney U-test was used to compare knowledge and motivation pre- and post-interven- tion, as this data had a non-parametric distribution. No significant differences were detected (p=.312 for knowledge, p-0.421 for motivation). Confidence data was normally distributed, and a t-test again showed no significant difference in values between deprivation groups (p=0.581). 5.9 BMI pre- and post-intervention The average BMI among those who responded to both pre- and post-intervention questionnaires was 34.9 prior to use of the app with or without dietitian call, and 35.1 post-intervention. Two-tailed T-tests showed no significant difference in pre- and post-intervention data, or on comparison of groups who: a) did or did not use the app; b) did not did not have a dietitian call. Realistically, we would not expect to see a large-scale change in BMI only 8 weeks after an intervention 5.10 Qualitative analysis of freetext responses 5.10.1 Pre-intervention responses a) Use of diabetes information resources 74 out of 82 participants answered the question “What resources (e.g. diet sheets, websites, apps) have you used so far?” Many respondents said that they had not used any resources (n=33), although almost all respond- ents (n=77) also answered that wanted to lose weight on a separate question. The most popular resources were websites/apps (n=23), weight loss programmes, plans, or groups (n=9), dietary sheets (n=9), or a specific diet/ meal replacement (n=6). ■ ■ ■ ■ ■ Page 61
Page 62
The Digital Health & Care Innovation Centre | 16 b) Priorities and issues In the pre-intervention questionnaire, respondents identified the following issues as priorities for them at that time – see table 10 below. Table 10: Priorities identified pre-intervention (freetext responses) What are the main priorities in your life at the moment? GDM Pre-diabetes Remission Physical health 7 24 24 Weight 10 16 26 Diabetes 1 8 22 Wellbeing 7 17 18 Mental health 6 14 11 Other (free text)* 2 4 1 One GDM respondent highlighted the difficulty in focusing on her own wellbeing with a new baby to look after: ‘Honestly all of that has been put to the side due to the baby but I really want to make it a priority again.’ Other comments in the pre-intervention questionnaire related to co-occurring health issues, medications and reduced mobility leading to weight gain, and issues with confidence: • ‘Although I am motivated, I have also lost confidence in losing weight as every time I try, I put weight on. • ‘I am very overweight and can’t seem to find the motivation to lose weight. I have lost a few stone in the past but I mostly did diet with miles of walking. Now I can only walk short distances and have to use a rollator.’ Three respondents in the pre-diabetes group highlighted that prior to the text message they were unaware of a diagnosis of pre-diabetes. 5 5.10.2 Post-test responses Eighty-three respondents completed the post questionnaire. a) Priorities and issues In the post-intervention questionnaire, participants were asked “Is there anything else you want to ask or tell us?” as a free text question; 28/82 responded. Due to the overlap with this question, the responses from the question “What are the main priorities in your life at the moment?” (n=7) were combined with this question. In descending order of frequency, key themes emerging from responses to this question are: • 18 participants discussed the other competing factors in their life which made it harder for them to manage diabetes. • For 12 of these participants, co-occurring health issues were a challenge for them. • Lack of support in managing diabetes (n=7). Some participants felt that they had been given a diagnosis and then left to their own devices, while others were unhappy that they only found out about their diagnosis through text. Page 62
Page 63
The Digital Health & Care Innovation Centre | 17 • 3 participants felt that they had lost motivation or confidence after previous failed weight loss attempts, making it harder to keep trying. • 2 participants were glad that they were now getting more support, even if they had felt a lack of support previously. b) Reasons for not using the app 31/83 respondents did not use the app. 29 provided reasons, the most common being: • Not knowing about the app (n=6) • Competing priorities or lack of time (n=7) • No access to technology (n=6). • Self-treating/not concerned/in remission (n=5) • Ill health (n=2) • Not confident in using the app (n=2) • Specific learning need or visual impairment made it difficult to use the app (n=2) c) Behaviour change Participants were asked “Since using the web resource, what (if anything) have you changed - or are you considering changing - to prevent the progress of diabetes?”. All participants who used the app (n=52) answered this question. Almost all (n=46) had made or planned to make a change. Of these 46, 31 (67.4%) had a dietitian call, and 15 (32.6%) did not. This suggests that use of the app alone combined with personal motivation was sufficient for a third of participants to reach the stage of making or planning behaviour change. The most common change was a change in diet or eating habits (n=34), followed by increasing physical activity (n=15), then starting a weight management programme (n=4). 4 participants also commented that it was difficult to make changes due to other demands in their life, including a busy lifestyle or competing health problems. Table 11 below summarises the behaviour change responses across the three patient groups. Table 11: Behavioural changes indicated in freetext responses Patient group Number of comments Improve diet Increase exercise Lose weight Pre-diabetes 24 46% 4% 21% GDM 11 82% 27% 18% Remission 26 31% 27% 8% d) Dietitian call A total of 51 participants had a call with a dietitian, 32 of whom answered the question “How helpful was it to speak to a dietitian? Please explain.” Of these 32, 18 (56%) found the call very helpful, 10 (31%) found it somewhat helpful, 2 found it not very helpful and 1 (3%) found it not at all helpful. 1 participant did not provide a score. Page 63
Page 64
The Digital Health & Care Innovation Centre | 18 Key themes about the benefits of the dietitian call included • Referred to online resources (n=10) • Provided a call to action or improved motivation (n=9) • Provided confirmation, support or encouragement (n=8) • Signposted to digital programme (n=7) • Knowledge gained about pre/diabetes, risk and progression of diabetes (n=5) • Review of clinical picture e.g. bloods, weight (n=2) Seven participants also gave more negative feedback. Some participants found the call too impersonal, mainly being directed to self- management resources when they desired more direct or tailored support (n=3). Others felt that the information provided only covered what they already knew, or that they did not retain new information from the dietitian (n=3). One participant advised that they would prefer a face to face meeting with the dietitian. e) Improvements to the app 44 participants responded to the question “How could we improve the Prevent the Progress of Diabetes web resource?” Forty-four responded. The most common responses were that nothing needed to be added (n=11) or that they couldn’t think of anything more to add (n=9). Five respondents advised that the app should be used alongside face to face appointments. Four respondents asked for additional dietary information – including personalised menus, more cultural variation, more diet sheets . Three asked for simplification, summarising and streamlining of the content. Two said that they would like the content as a mobile phone app – indicating a need to raise awareness of the mobile app option. Two indicated that the app did not work for them personally. f) Additional comments There were 45 responses to the question “Is there anything else you want to tell us?”. As this was a very open question, it had the most varied and idiosyncratic responses. The themes identified from these responses were: Expressing thanks or a positive attitude towards the support offered (n=8) – e.g. “Brilliant work and thank you for helping myself.” Wanting more face-to-face contact (n=5) One respondent in the GDM group shed light on how some patients may see a move towards using a web resource as a first means of support - “women like me need actual human support and not just a website…….Apologies for the brutal honesty but it just feels like another way for the NHS to try and save money that just pushes human interaction away.” Finding there to be a lack of follow up from initial diagnosis (n=3). Wanting to join groups to be motivated by others (n=2). Being unaware they had pre-diabetes before this research (n=2). Disliking online resources in general (n=2). 5.11 How does the dietitian call augment use of the app alone? 79% of respondents to the pre-intervention questionnaire opted for a call with a dietitian, demonstrating the value that a majority of patients place on direct communication and support with healthcare professionals. This is underlined by the finding that 5 out of 42 patients (12%) who responded to the freetext question about improvements to the app requested that the app be accompanied by face to face contact. The positive reports around the experience of the 10 minute dietitian call in the freetext responses (section 6.10.2 d)) confirms that the great majority (87%) of patients benefited from this brief interaction, finding it very helpful or somewhat helpful. The main objective of the call was to identify services, support and next actions that would help the individual patient. Page 64
Page 65
The Digital Health & Care Innovation Centre | 19 As shown in table 6 above, the dietitians provided a total of 96 referrals and advice or support interventions. They also made 20 recommendations to the primary care team for follow-up clinical checks and actions (see table 7.) As illustrated in Table 5 in section 5.5 above, 94% of participants reported that use of the app improved their knowledge, confidence, and motivation to address diabetes-related. 52-56% reported a substantial increase – “somewhat” or “a lot.” T-tests using the data in tables 12 and 13 below indicate that knowledge, confidence and motivation increased equally among patients who had a call (66%) or did not have a call (34%). Moreover, as indicated in point c within section 5.10.2, around a third of patients committed to behaviour change following use of the app alone, without any dietitian call. Together, these results indicate that there is a group of patients with high digital self-efficacy for whom use of the app alone, along with their internal motivation, is sufficient to improve readiness for lifestyle change and to take action accordingly. However, the freetext comments also indicate that patients who did opt for a dietitian call then found it helpful in enabling behaviour change and in improving knowledge, confidence and motivation (see section 5.10.2 points c) and d) above.) The dietitian feedback that a number of patients saw the app for the first time during the call, and the patient responses about use of online resources following the call also suggest that the dietitian call was helpful for these patients in increasing their use of the app. Overall, These results suggest that there is a second group of patients - with medium digital self-efficacy – who benefit from professional support and orientation to using the app in order to achieve the state of readiness necessary to effect behavioural change. Table 12: Participants who used the app at least once and had a dietitian call (n=35) Table 13: Participants who used the app at least once and didn’t have a dietitian call (n=17) Rating Knowledge % Confidence % Motivation % 1 = Yes, a lot 10 (28.6%) 6 (17.1%) 10 (28.6%) 2 = Yes, somewhat 8 (22.9%) 12 (34.3%) 11 (31.4%) 3 = Yes, a little 14 (40.0%) 13 (37.1%) 9 (25.7%) 4 = No not at all 3 (8.6%) 4 (11.4%) 5 (14.3%) Rating Knowledge % Confidence % Motivation % 1 = Yes, a lot 3 (17.6%) 2 (11.8%) 2 (11.8%) 2 = Yes, somewhat 7 (41.2%) 7 (41.2%) 6 (35.3%) 3 = Yes, a little 7 (41.2%) 6 (35.3%) 8 (47.1%) 4 = No not at all 0 (0.0%) 2 (11.8%) 1 (5.9%) Page 65
Page 66
The Digital Health & Care Innovation Centre | 20 6. Limitations and areas for future improvement in study design. This pilot has two main limitations which can be addressed in future larger-scale implementation: 6.1 Small sample size While the study was sufficiently powered to detect moderate and large differences between comparison groups, the sample size was too small to detect small differences. This may account for the inability to detect additional impact of the dietitian call on knowledge, confidence and motivation compared with use of the app alone, and for the absence of significant differences between pre- and post- intervention Likert scale data for confidence and motivation although participant self-rating indicated improvement in both these aspects. 6.2 Questionnaire design and delivery For future larger scale studies, it will be helpful to consult with research and improvement experts on questionnaire design for larger scale studies. Questionnaire tools should be tested for reliability and validity prior to large scale use. Consideration should be given to reducing number of questions to improve response rate and to using published validated ‘gold standard’ questionnaires rather than self-made ones. Several patients expressed a preference for completing questionnaires by email rather than via a text message, and this option should be built into future studies to improve response rate. 7. Conclusions and recommendations 7.1 Make the app available for use across NHS Grampian The primary recommendation arising from this pilot is to make the app available for widespread use across NHS Grampian and more widely across NHS Scotland. The results of the pilot make it clear that it can offer significant benefit to many patients in terms of improved knowledge, confidence and motivation to change lifestyle behaviour. The following recommendations provide pointers as to how to maximise the benefits of the app in terms of patient safety, patient experience and service efficiency. The suggestions are intentionally flexible in nature, being respectful of the resource constraints and capacity challenges within the system. However, regardless of which specific approaches are adopted in different parts of NHS Grampian, the core principle applies of raising awareness and encouraging use across professional and patient groups. 7.2 Deliver a flexible and sustainable digitally- enabled service model This pilot project points to the potential for a sustainable, low-cost digitally-enabled service model with wide reach and high impact across tier 1-3 weight management services outlined in A Healthier Future: • Tier 1 – universal services • Tier 2 – early intervention • Tier 3 – targeted intervention This service model aims to: • Deliver core elements within existing staff and financial resources. • Be flexible, to operate within local service constraints and circumstances. • Build in capacity for development and growth where resource allows, to maximise impact and build on initial successes. Page 66
Page 67
The Digital Health & Care Innovation Centre | 21 The proposed service model is based on a combination of two approaches: 1. Tailored support for patients segmented into three levels of digital self-efficacy, as outlined below. 2. A service bundle approach comprising: • Elements of a core minimum service bundle which can be delivered now, within available resource. • Extended bundle elements which require some investment in technical or service development. A practice or cluster may choose, for example, to focus initially just on the core minimum bundle. Over time, they could extend their focus to wider developments with more impact across all target groups. 7.2.1 Segmentation of patient groups Overall, this study points to three patient groups who are more or less likely to use a digital resource to support prevention and self-management of diabetes: a) High digital self-efficacy These individuals were able to use the app to improve their readiness for lifestyle change without requiring a dietitian call. Their knowledge, confidence and motivation to reduce their diabetes-related risk improved, and the majority also confirmed that they had already changed or planned to change their behaviour. b) Medium digital self-efficacy This group requested a dietitian call and also used the app, in some cases after the dietitian’s explanation of how to navigate the resource. This group also reported improvement in knowledge, confidence and motivation – to the same level as the high digital self-efficacy group who did not request a dietitian call. The majority reported a change or planned change in behaviour, often focusing on actions which reflected the dietitian’s advice and referrals. c) Low digital self-efficacy These patients were not in a position to use the app, whether due to lack of awareness, confidence, motivation, time or digital access. Some (12% of freetext respondents) expressed a strong preference for face to face interaction with healthcare professionals. There was no improvement in readiness for lifestyle change in this group. 7.2.2 Tailored support for the three groups a)High digital self-efficacy For those with high digital self-efficacy, it will be helpful to optimise the capabilities of the app to drive and sustain behavioural change, and using question-based algorithms to guide the user directly to appropriate self-management and self- referral options so that they can independently get the specialist support they require. b) Medium self-efficacy, providing: This group will benefit from: • Signposting and support in using the app from the primary care team and wider community services. This can be facilitated by link workers, support workers, health promotion staff (e.g. Healthpoint) or community agencies such as leisure centre and public library staff. • One or more routes for referral to appropriate self-management and specialist weight management services. For some more confident patients, an algorithmic self-referral route may enable quick and effective referral. Others may need the option to request a short call with a healthcare professional who has a sound knowledge of diabetes prevention and remission, local diabetes pathways and tier 1,2 and 3 weight management services. In this study, dietitians provided this specialist support; in future, other primary care staff could potentially be trained to take this role. Broadening this knowledge and understanding across the primary care team could potentially also help with the communication of diagnosis of pre-diabetes and suitability for remission. Some respondents in this pilot reported that the text message with the study questionnaire was the first communication they had received. Page 67
Page 68
The Digital Health & Care Innovation Centre | 22 c) Low digital self-efficacy: Key interventions for this group include: • Promotion and communication through targeted channels to raise awareness of the app – responding to the finding that a number of non-users did not know about the app. • Guidance and facilitation in using the app for those who lack confidence in digital skills. This could involve, for example, support from link workers and health promotion staff or collaborative arrangements with public libraries, leisure services, support groups and third sector organisations. • Promoting public library services and community services such as Ability.Net which provide free access to digital technology for those who do not have this at home. A supporting document repository is available here to support this report which includes pre and post questionnaires used in the evaluation and free text responses Page 68
Page 69
The Digital Health & Care Innovation Centre | 23 7.2.3 Service bundle elements Table 14 below highlights key elements of a core minimum service bundle and an extended service bundle. Service bundle element W hich patient group (s) will this bundle element support? Healthier Scotland tier Notes Core minimum service – capability already available C1 Running of case reports to identify high risk patient groups (pre-diabetes or previous diagnosis of GDM) and candidates for remission. High, medium and low digital self-ef- ficacy Tier 1 Tier 2 Tier 3 Section 4.1 of this report provides details of how to run these searches manually within Vision and EMIS. For the future, the intention is to make automated reporting possi- ble via the EScro database (see section 8.4 below). C2 SMS text message or email from practice to prompt patient to use the app to support their risk reduction in diabetes. At least one follow-up reminder text or email. • High and medium digital self-effi- cacy • Some low digital self-efficacy users when supported by access and orientation to app. Tier 1 Tier 2 Tier 3 Evidence base and pilot experience indicate that this type of communication and prompting from a trusted health service will improve uptake of digital interventions. C3 Prevent the progress of diabetes app, incorporating local services and resources alongside national support. • High and medium digital self-effi- cacy. • Some low digital self-efficacy users when supported by access and orientation to app. Tier 1 Tier 2 Tier 3 The pilot project confirmed the importance of incorporating com- prehensive information about local service options and support alongside signposting to national resources. The Right Decision Service team will work with local NHS Boards to create their ‘clone’ of the core app, supplemented with local service information. C4 Awareness-raising for the app by primary care professionals. • High and medium digital self-effi- cacy. • Some low digital self-efficacy users – communication by practice will strengthen trust in the service. Tier 1 Tier 2 Tier 3 Evidence base and feedback from pilot underline that direct communication from trusted health professionals will build confi- dence in the app. In this project, dietitians took this role .In other contexts, other healthcare professionals may do so. Light touch awareness and education (e.g. a videoclip) may be needed for healthcare professionals around benefits of the app to patients and how to embed it in their communication with patients. &J Page 69
Page 70
The Digital Health & Care Innovation Centre | 24 Service bundle element W hich patient group (s) will this bundle element support? Healthier Scotland tier Notes Extended service bundle elements (require additional development – technical or service /process redesign) E1 Patient self-referral capability within the app – directing to self-manage- ment resources and tailored services. High digital self-efficacy. Some patients within medium digital self-efficacy group (some will prefer referral by healthcare professional.) Tier 1 (referral to commu- nity services, e.g. exercise classes.) Tier 2 Tier 3 The pilot illustrates the benefits of a seamless user journey from use of the app to build knowledge and motivation through to actioning referral to services in the NHS or commu- nity. RDS team can build self-referral algorithms and forms into the app. Extending capability to enable initial review by pri- mary care team and saving back to patient record will require technical development. W ill require engagement with referral target services to agree processes E2 Provide option (e.g. through the self-referral form) for app users to re- quest a 10 minute call with a healthcare professional to get tailored support and discuss referral options. • Medium digital self-efficacy • Some high digital self-efficacy users will also benefit from the additional advice with healthcare professionals. • Low digital self-efficacy patients may also benefit from the im- proved knowledge and advice from professionals in face to face consultations. Tier 1 (referral to commu- nity services, e.g. exercise classes.) Tier 2 Tier 3 W ill require education and confidence-building for health- care staff around: • Remission, and diabetes prevention for these high risk groups. • Local diabetes pathways, local weight management ser- vices and referral criteria. E3 Provide an interface from the patient record to a direct referral capability which healthcare professionals can use. • High, medium and low digital self-efficacy. Tier 1 (referral to commu- nity services, e.g. exercise classes.) Tier 2 Tier 3 The capability for patients to place direct referrals to NHS and community services (and to copy the referral information into the patient record) can also be made available to health and care professionals as part of the RDS decision support plat- form which already interfaces with patient record systems. E4 Mobilise the wider multi-professional team and community partners to raise awareness of the app and to support people with limited digital and health literacy. Medium and low digital self-efficacy May also help to raise awareness among high digital self-efficacy group. Tier 1 Tier 2 Tier 3 Recognises that signposting patients to the app and helping them to use it does not require healthcare professional input. It involves engagement and some process redesign to involve: • Non-clinical staff such as link workers, health promotion staff or support workers to promote the app and provide patients with basic guidance in its use. • Community services such as public libraries, leisure centres, third sector organisations and support groups to be proactive in raising awareness of the app, providing digital and health literacy support and basic orientation to using the app. &J Page 70
Page 71
The Digital Health & Care Innovation Centre | 25 7.3 A roadmap for collaborative development with the DHI Weight Management Living Lab There is synergy in aims and approach between this Prevent the Progress of Diabetes service model and the emerging service model for the DHI Weight Management Living Lab. Both combine use of a digital app for self-management by a targeted high-risk population group with clinician referral and self-referral to support weight management for prevention of type 2 diabetes and other long term conditions. Each initiative brings unique strengths and areas of focus that could be brought together to maximise overall impact and create an efficient, sustainable approach. This project recommends that the project leads in DHI, Moray and Healthcare Improvement Scotland work together to define a collaborative technical and service development roadmap that will converge these two workstrands and realise the synergies between them. 7.4 Improvements to the app The next phase of implementation should look to apply improvements to the app that will increase utility and patient and professional engagement across all levels of digital self-efficacy. Another round of user consultation and user testing is recommended to design and deliver these improvements. The majority of users had no specific improvements to suggest, the most common feedback being to accompany the app with face to face consultation. The two content and structural areas that some users identified for improvement were: • Personalised menus, more dietary advice, more cultural variation, more diet sheets (4 freetext responses out of 44) • Simplifying and streamlining content (3 freetext responses out of 44) Although not specifically requested, the significant proportion of user feedback indicating the challenges they experience around mood, motivation and feeling unable to make changes suggests that further signposting to emotional and mental wellbeing resources and local support services would be valuable. Beyond this, the broader feedback on the app and the way it lays foundations for a new service model indicate several further opportunities for strategic development which would form part of the extended service model outlined in table 14 above: a) Incorporating question-based criteria linked to logic-based algorithms which will direct users to the appropriate self-referral forms for community and NHS services tailored to their needs. For potentially this self-referral information can be relayed back to the GP practice for initial review and confirmation around appropriateness and safety and incorporation into the patient record before forwarding on. b) Providing links to these referral forms for clinicians to use. These links could be located within the web and mobile app and also within the RDS platform that links with electronic care systems. Creating the algorithmic forms for triaging and referral should be technically straightforward using the Right Decision Service technology. However, negotiation and process redesign work is likely to be needed with the services asked to receive referrals through this route. There would also be a requirement for training and familiarisation of healthcare staff around this new approach. In the short term, an initial step in this direction could involve signposting the available service options on the app, with clear descriptions around what services are on offer and the criteria for referral. 7.5 Improvements to case-finding approach In this study, Vision searches were defined and run manually across Vision patient records. Rather than having to re-create these searches in every practice, and re-run them manually to identify updates, the recommended approach is to embed the searches as stored procedures within the EScro database, which takes an overnight copy of all patient records across primary & secondary care. This will enable all practices to run automated reports using the same criteria when they wish. In particular, it will enable practices to go beyond the retrospective capturing of at risk patients – the study’s approach – regularly identifying and contacting new patients needing support. Page 71
Page 72
The Digital Health & Care Innovation Centre | 26 7.6 Proactive alerting of the clinician in the context of the patient record Building the searches into the EScro database in this way will also enable the Right Decision Service platform integrated with electronic care systems to offer proactive alerting of the clinician to need and opportunity to take action at point of opening the patient record. For example, this could be a prompt to discuss remission support for an eligible patient who is not yet on a remission pathway. 8. Recommendations for future research and evaluation Key recommendations include: • Enlarging the sample size and including a wider diversity of practice populations, including practices from Moray, NHS Grampian and one or two other NHS Boards. This will strengthen the validity and reliability of the evaluation. • Testing the core minimum model outlined above, alongside at least one implementation of an augmented model deploying one or more of the additional support components. 9.Conclusion The pilot has shown how the Prevent the progress of diabetes app from the Right Decision Service, can provide a nucleus of support for a sustainable and flexible digitally enabled service model which increases readiness for lifestyle change to reduce diabetes-related risk in patients with high and medium digital self-efficacy. Potentially, with appropriate digital support, it can also help some patients with low levels of digital self-efficacy. Core elements of this model can be delivered within existing resource. The project also points to a range of extended service options which will further increase impact. These options include technical development, some service redesign or healthcare professional role development to support referral management and support people who are less digitally confident to use this app. Page 72
Page 73
The Digital Health & Care Innovation Centre | 27 10. References 1. Scottish Diabetes Group, 2021: Scottish Diabetes Survey Available from: https://www. diabetesinscotland.org.uk/wp-content/uploads/2023/02/Diabetes-Scottish-Diabetes-Survey-2021- final-version.pdf 2. Ross JAD, Barron E, McGough B, et al Uptake and impact of the English National Health Service digital diabetes prevention programme: observational study. BMJ Open Diabetes Research and Care 2022;10:e002736. doi: 10.1136/bmjdrc-2021-002736 Page 73
Page 74
Page 74