Diabetes Education in England: NHS Healthy Living Does Not Meet the Needs of People with Type 2 Diabetes

Dr Sean Wheatley, MSc, PhD. Science and Research Lead

Sean.Wheatley@xperthealth.org.uk

We have recently published a preprint article* looking at the NHS’s online programme for people with type 2 diabetes. The full article can be accessed here, but this month’s blog provides a quick summary, and outlines why we think the programme will not help people to meet their health goals.

What is NHS Healthy Living?

NHS Healthy Living for People with Diabetes (to give it its full name) is an online education programme. It can be accessed by people in England who have type 2 diabetes. Participants work through it independently, at a pace that suits them.

Why this review was needed – the patient perspective

All healthcare interventions need to be properly appraised, so people who might use them (and healthcare professionals who might refer people to them) are aware of their strengths and limitations. This allows people to make informed choices. It is particularly important that programmes which are promoted nationally through the NHS have been properly reviewed, and it is reasonable to expect high quality evidence to support their use.

Why this review was needed – the commissioner perspective

There are also important implications for those that are responsible for commissioning health services in different parts of the country. Although the NHS is a national service, there are certain decisions that are made on a local level. This includes which education options to make available for people with diabetes.

These commissioners do not have to pay anything to make NHS Healthy Living available in their areas. Other education programmes invariably have some costs attached to them though**. This makes NHS Healthy Living an attractive option, especially as healthcare budgets are being stretched to, and often beyond, their limits.

Healthcare choices should never be made purely based on short-term costs though. The most important reason for this is that the commissioning of ineffective interventions will result in worse outcomes for patients. It is also a false economy though, as people are likely to require more appointments, more medication(s) and more treatments (i.e., to address complications) if they do not receive effective care, and so long-term costs are likely to be higher.

Limitations with NHS Healthy Living

Concern 1: The evidence used to support the national roll out of NHS Healthy Living is based on what is essentially a different programme. NHS Healthy Living is adapted from a programme called HeLP-Diabetes. The original HeLP-Diabetes programme was the subject of a controlled trial, but there have been major changes to the programme since this trial was carried out. This means that the programme that is available to people today has never been properly assessed.

Concern 2: The evidence that is available does not actually suggest that the programme is effective***. On this basis alone, questions can be asked about why this programme was chosen for national implementation.

Perhaps most significantly on this front, engagement with the programme did not lead to a clinically meaningful improvement in blood glucose management (HbA1c was reduced by just 0.8 mmol/mol after 12 months; for comparison, in the most recent audit of X-PERT’s results HbA1c was reduced by an average of 8.4mmol/mol at this timepoint).

There were also:

No improvements to any of the other health markers that were assessed.
No increase in participants’ confidence in looking after their own health.
No evidence that participants were likely to be able to achieve remission.
No decrease in the amount of diabetes medication participants needed.
No reductions in diabetes-related distress.

Concern 3: The content is outdated – a problem that likely contributes to some of the poor health-related outcomes noted above. Contrary to what was previously thought, it is now clear that type 2 diabetes does not need to be a progressive condition. It has also been proven that, for many people, remission of type 2 diabetes is possible. These things are not meaningfully reflected in NHS Health Living.

There have been significant advances in the understanding of how to best manage type 2 diabetes too. Almost all major guidelines now recognise that one size does not fit all, and recommend that individuals should be supported to adopt a dietary approach (from a range of options) that works for them. This is not fairly reflected in NHS Healthy Living either.

Additional concerns: This is not the limit of the issues identified, with other concerns including that the programme…

…does not include any additional support options.

…may not be truly cost-effective.

…is not inclusive (and so may increase health inequalities).

…has been promoted in a misleading way.

It is beyond the scope of this blog to cover these other concerns in more detail (it’d be far too long if it did!), but these points (and more) are all explored further in our article.

Aren’t you biased though?

It’s a fair question, and it would be untrue to suggest that there is no potential conflict of interest here. X-PERT Health relies on NHS organisations commissioning our programmes, and if they turn to other options instead then that will clearly affect us. NHS Healthy Living, as a freely available alternative programme, does have the potential to displace X-PERT Health as a provider of diabetes education in some areas.

Our overarching aim though, as a registered charity and not-for-profit organisation, is to ensure that people have access to good quality education and meaningful support that helps them to improve their health and wellbeing. If programmes that are in competition with ours help to achieve this, then we will applaud that. But if the quality of care people receive is diluted because they are referred to ineffective options (instead of programmes that have been shown to work) then we think it is important to share our concerns and to raise awareness of the potential problem.

Ultimately, we do not think that organisations referring people to NHS Healthy Living helps to achieve our aims as charity or improves patient care. We do however think there is a significant risk that it will be widely promoted despite its limitations because of the advantages it holds, e.g., that it does not cost commissioners anything and that it is branded as an NHS programme (which should be a marker of quality).

So, what’s the bottom line?

NHS Healthy Living has major limitations. As a result, it is unlikely that engaging with this programme will help people with type 2 diabetes to achieve their health goals.

Commissioners (and referrers) should think twice before promoting NHS Healthy Living over other diabetes education options. How and why this programme came to be selected for national use can also be questioned.

* Published research articles have usually been reviewed by people with relevant knowledge and experience, to try and ensure they are of a sufficient quality. The process of having an article reviewed and published can take months though, if not years! A preprint allows a version of a research article to be made widely available much more quickly, to help share important information in a timely manner. Preprints have not therefore been peer-reviewed, but that does not mean the points they make are not valid (nor does an article having been peer reviewed necessarily mean it is any good, though that is a different story!).

** These costs are to the commissioner only – providers of education programmes will have their own expenses to cover, so they cannot realistically provide services without charge, even if they might sometimes like to. All programmes commissioned through the NHS are available to people with diabetes without charge though. On the subject of cost, it is also worth noting that although NHS Healthy Living is free to commissioners and patients, it has NOT been free to the NHS as a whole. NHS England have spent significant sums of money on adapting and implementing it.

*** The evidence used here is from the HeLP-Diabetes trial that was referred to before. In the absence of any direct assessment of NHS Healthy Living we have little choice but to rely on this (as indirect evidence) if we want to make any inferences about the likely impact of the programme.