Learning Lessons from Implementation of a National Diabetes Prevention Programme in England

Background: The increasing number of people being diagnosed with Type 2 Diabetes Mellitus (T2DM) and at risk of complications has made the disease a major public health concern. Diabetes prevention programmes aim to deliver personalised help to people to reduce their risk of T2DM, including education on healthy eating and lifestyle; help to lose weight; and tailored exercise programmes. The NHS Diabetes Prevention Programme (NHS DPP) commenced during 2016 and by 2018 the NHS DPP had spread to the whole country with a target of making 200,000 places available in the NHS DPP annually by 2023. We report on the implementation of the NHS DPP in England, and identify lessons learned in addressing the challenges of implementation. Methods: A longitudinal telephone interview study with the designated lead(s) responsible for local implementation of the NHS DPP is being undertaken. In 2017/18, we conducted 20 semi-structured interviews across 16 sampled case sites; in late 2019/early 2020 we extended our sampled case sites to 19 and conducted 24 semi-structured interviews; we plan to conduct final interviews with the local designated lead(s) in spring 2020. Early interviews explored how the programme was organised locally, expectations and attitudes towards the programme, funding, meeting the needs of local target populations and local pathways to generate referrals to the programme in general practice. Later interviews have explored transition to the new contractual delivery framework. To complement our qualitative interview data we also conducted two email surveys to explore variation across sites in the use of financial incentives/resource support given to general practice to encourage referral into the NHS DPP. We first conducted the survey in 2018 and then repeated it towards the end of 2019 to identify any changes over-time. Results: Five over-arching areas of learning when implementing this large-scale disease prevention programme have been identified: 1) managing new providers; 2) promoting awareness of services; 3) recruiting patients; 4) incentive payments; and 5) mechanisms for sharing learning. In first interviews, tensions appeared to be caused by a lack of clear roles/responsibilities and lack of communication between stakeholders. Both local sites and the national NHS coordination team gained experience through learning by doing. Initial tensions with roles and expectations have been worked out during implementation and at second interviews, designated leads discussed the importance of developing good relationships with their provider, GP practice staff and CCGs and ensuring easy referral pathways for primary care. Challenges were encountered with switching from outgoing to incoming providers, usually in terms of managing the transition of people on waiting lists. Sites were now focused on undertaking initiatives to target high needs populations but most felt they had a long way to go. Receiving monthly data from providers in a user friendly format helped them to target their local population needs. Some sites were attempting to get to ‘business as usual’ regarding referral into the programme and reported either stopping incentive payments or working towards stopping them as they moved on to new contracts. Implications: Implementing a national disease prevention programme is a major undertaking and our study provides practical learning opportunities for the wider uptake and sustainability of prevention programmes. We will discuss implications for future implementers including the need to define clear responsibilities for stakeholders prior to implementation, ensure engagement with new providers/between providers, offer mechanisms/forums for sharing learning and prioritise public and professional awareness of the programme