“Delivering results to you”
Share information.
Facilitate diabetes care planning.
Dr Pete Davies; p.davies@nhs.net
Sandwell & West Birmingham NHS Trust
The Problem:
• Diabetes care: often passive
– Are we surprised if appointments & tests are
forgotten or missed?
• Cards stacked against patients
– Professionals have the power & knowledge
and can prepare
– Patients cannot easily be prepared
• We lack shared understanding
– which tests matter?
– What do the results mean?
“Breaking bad news” in diabetes consultations
e.g. HbA1c blood test results
• Similar to hearing
negative feedback at
performance
review/appraisal
• Can’t take it in
• Don’t hear anything else
that is said
There has to be a better way!
To achieve better outcomes in
Long-term Conditions
You need all these components
Engaged
empowered
patient
Organised
proactive
system
Partnership
= Better outcomes
Patients & Partnerships
Overlooked
“Cinderella”
Engaged
empowered
patient
Lots of focus, attention and
investment
Organised
proactive
system
= Better outcomes
Partnership
Service redesign;
QoF, etc.
The average person with diabetes:
spends three hours each year
with a professional
3
= 0.03 %
8,760
The remaining 8,757 hours, they care for themselves.
Historical Diabetes Care
• Passive
– Nurse/doctor agenda
– Telling e.g. results of
tests, examination etc.
– Judging
– Prescribing &
proscribing
• “thou shalt not”
– Often time-constrained
To support Self Care
Get Active!
– Patient-led agenda
– Share information before the
care plan meeting
– Allow time for reflection
– Patient is
• better prepared
• Engaged
• An active partner
Understanding Glucose control- HbA1c Test
We do not make it easy for patients!
• …a surrogate for glucose
control
• …useful clinically
• BUT abstract, not easy to
explain, or understand
• Units of measurement have
changed!
– 7%  53mol/mol
Solution: When blood tests processed
• Send HbA1c result
– direct to person with diabetes
– Do so for everyone
– Make it timely (before the careplanning review)
– Do so in a format that
• communicates meaning
• promotes reflection & care planning
Lean Six-sigma Methodology
Key Moments
Force-field analysis
Voice of the Customer
Survey
Root Cause Analysis
Inventive
problem solving
Helped identify key enablers; helped us
‘manage’ resistors
Game-changer!
Demand high
original idea (text message) NOT popular
Understanding of HbA1c is poor
Identified low health literacy
Product design would be critical
Incorporate low cost AND high qualityThe ‘Personal Mailer’
Health Literacy & patient/user views
• Patient group consultation
• Online communities: DAFNE-online (UK)
& Tu-Diabetes (international)
– Feedback on idea & options for graphics and
text via online survey tool
Professional Help
• One member of patient
group was a graphic
designer!
• Artwork ideas discussed
with 2 independent
graphic designers
Descriptor text
Aim for a low reading age
– Calculated reading age =‘easy to read’ for a
13-15 or 11 year old, respectively
Not bad for an abstract concept 
Design Features
Trend
present and previous results
Number and arrow
Scale
Coloured ruler
3 categories
linked to NICE & QoF targets
Clear advice
“what next” ‘pause, reflect.. bring
to consultation’
Goal setting & individualised
targets
Signpost to lifestyle services
Simple descriptors
Design Features
Trend
present and previous results
Number and arrow
Scale
Coloured ruler
3 categories
linked to NICE & QoF targets
Clear advice
“what next” ‘pause, reflect.. bring
to consultation’
Goal setting & individualised
targets
Signpost to lifestyle services
Simple descriptors
Design Features
Trend
present and previous results
Number and arrow
Scale
Coloured ruler
3 categories
linked to NICE & QoF targets
Clear advice
“what next” ‘pause, reflect.. bring
to consultation’
Goal setting & individualised
targets
Signpost to lifestyle services
Simple descriptors
Outcomes of Design Work
• The result is meaningful
– You don’t have to‘get it’ (i.e. understand A1c)
in order to know how your diabetes treatment
plan is doing
• Now you have the meaning, you might just
assimilate this into
– positive health behaviours,
– Engagement in care planning
Does it work?
Pilot Evaluation
• n=1800
– 8 general practices recruited
– 1 specialist practice (PHD)
• Evaluated by paired questionnaire
• Administered at time of consultation
• Patient and HCP gave their views
• We could match the responses
Healthcare
professionals
People with diabetes
Results to Patients: patient benefits
Statement
% Agreeing/ Strongly
agreeing*
“Getting my HbA1c result
before my appointment
helped me”
73%
“having my HbA1c result
made it easier to talk to my
doctor and/or nurse”
76%
“I would like to receive my
HbA1c result in this way in
future”
89%
“The fact my patient had
their HbA1c result made the
consultation easier”
74%
*n=178 questionnaires returned for analysis
Results to Patients: patient’s behaviour
Domain
People with diabetes
Medication adherence
(concordance)
Dietary adherence
Empowerment
Confidence
Patient comment
“getting my result made me
take my tablets”
“I’ve been trying hard with my
diet, so this really gave me a
boost”
“I will go back to my nurse
and ask to go on a diabetes
course”
“I can now see that my
treatment plan is really
working!”
*n=178 questionnaires returned for analysis
Results to Patients: benefits to diabetes team
Domain
Healthcare professionals
Understanding diabetes
Engagement
Partnership working
HCP comment*
“they wanted to know more
about their result”
“before this it was difficult to
get her to come”
“after we’d discussed their
result, they could see its value
and were all for it”
Did this create time pressures? No extra time pressures
*n=17 professionals across 8 practices
Present State
• Successful roll-out
– December 2011, all Sandwell GP practices
– Available to 20,000 people with diabetes
• Safeguard
– exclude screening for diabetes
• High level of interest, other PCTs/CCGs
and patients
• Support from my Trust
– Sustainable & may be extended
Summary & Conclusions
• Patient involvement enabled product quality

• Sharing information in this way

– Led to positive changes in health behaviours
– Enhanced consultations/care planning,
suggesting partnerships were strengthened
• Suggesting people have understood &
taken greater control of their diabetes

Summary & Conclusions (2)
• We recommend Lean Six-Sigma
methods for Quality improvement work
• Many other applications of this
technology are feasible
• Easily transferable to other areas
• Lots of options for moving this into the
digital health domain




Acknowledgements
Mr Stuart Davis, type 2 diabetes 15 yrs, podiatrist 37 years, Sandwell PCT
Ms Dottie Tipton, Service Improvement Manager, SWBH
Dr Jenny Harding, pharmacist, Director of Clinical Governance Sandwell PCT
Thanks to Lilly UK for providing project support.
Thanks to Sandwell Diabetes Support Group for financial support for the pilot
Understand diabetes. Take control
Maybe initiatives like ours can help achieve that
p.davies@nhs.net