You and Type 2: digital care plans for type 2 diabetes in South London

The challenge

More and more people are living with long-term conditions, one of the biggest challenges facing health and social care. Type 2 diabetes costs the NHS at least £10bn a year, and people with it account for an estimated 15 to 25% of appointments at a local surgery. The General Practice Forward View says everyone with a long-term condition should have a personalised plan of care, and counts self-care, social prescribing and active signposting among its 10 high impact actions.

South West London Health and Care Partnership and South East London CCG knew that many local people with type 2 diabetes didn’t have access to, or know about, the services they needed to manage their health. They partnered with Healum to:

• build strong relationships between patients and healthcare professionals, to make personalised care plans together
• improve people’s access to services that help them manage their condition
• help people with type 2 diabetes live more easily with their condition, and manage it themselves
• reduce health inequalities in an ethnically diverse population, with multilingual resources, personalised goals and daily actions

What the teams did

Healum’s care planning software and patient app were set up for multidisciplinary primary care teams to create a personalised plan of education, support and motivation for each person, which they could open in the app on their phone. Diabetes nurses and doctors:

• set goals and actions with each patient, through shared decision making
• followed each person’s progress and outcomes against the goals they had set
• shared resources and services that help people make healthy lifestyle choices
• sent people their latest blood test results from EMIS automatically

Before their appointments, people were also sent a personalised video message by text, explaining their test results.

What changed

Lower HbA1c and BMI

For patients who used the app in each of the first 3 months after download, the average HbA1c change was −3.19% and the average BMI change was −2.95%.

A better care experience

The video messages about their test results helped people feel more informed and prepared before their appointments: 98.6% of the videos were opened, and 78.6% were watched to the end.

Goals people made their own

Across 623 app users, 518 goals were agreed together and shared in care plans, and people created 578 goals of their own, such as “Resist pizza on Friday night”. Of the people who set their own goals, 54.6% reduced their BMI and 53.5% reduced their HbA1c, against 35% and 30% of people who didn’t.

More capacity for personalised care

Teams shared resources and information with patients 11,071 times, increasing their capacity to deliver personalised care.

A clearer picture of what people need

App users made over 12,500 healthy choices: 1,355 actions completed, 794 goals joined, 578 goals created, over 1,800 trackers used and 1,719 resource views. They viewed their test results over 3,100 times and their progress over 3,200 times.

Care that fits each person

Staff could tailor the resources, goals and plans they shared to each person’s socioeconomic and cultural background, helping to reduce health inequalities.

In their words

“You & Type 2 has been instrumental in helping us to deliver better outcomes for patients in South London. It’s been a central priority to help reduce health inequalities and decrease variations in care across the region. By embracing digital technologies we have been able to allow our patients access to their results in a way that facilitates care planning. There is much to be learned from You & Type 2 that we can replicate across the health and care system, so that health inequalities can be addressed at a regional and national level.”

Dipti Ghandhi, Diabetes Clinical Lead, Croydon CCG

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You & Type 2 diabetes project helping to transform patient experiences, from our news.