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Health and Wellbeing at Work

Meddbase helps ICB increase referrals to NHS Diabetes Prevention Programme by 1,000%+

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The study was designed to explore whether using the latest digital communications software, and managing it at ICB-level, is more effective than traditional postal invites when it comes to engaging patients in healthy lifestyle programmes. It was conducted by Meddbase, an advanced clinical management system provider, and NHS Humber and North Yorkshire Integrated Care Board.


It found that using patient identification tools and automated text message prompts led to:

● 1,000%+ increase in NDPP referrals – from an average of 32 referrals per month to 363 per month

● 331% increase in the number of patients attending at least one session of the NDPP programme (defined as ‘Milestone 1’) – with the previous monthly average of 16 patients rising to 69 in the first month of the study

● 181% increase in the number of patients attending sessions over a three-month period – with the findings showing an average of 45 patients reaching Milestone 1 each month, compared with the pre-study baseline average of 16

The results from the study and the key learnings for ICBs, including the importance of data quality and the need to facilitate patient choice, are explored in detail in a new white paper report, ‘It’s your GP texting: Utilising technology at ICB level to deliver a tenfold increase in referrals to the NHS Diabetes Prevention Programme’.

The study findings demonstrate how utilising technology at ICB level has the potential to deliver huge increases in patient engagement in healthy lifestyle programmes, such as the NDPP.

The NDPP was developed by NHS England and Diabetes UK and offers patients at risk of type 2 diabetes free support from an evidence-based lifestyle programme. Some two million people in the UK are classed as having pre-diabetes, meaning they are likely to develop the condition if they don’t change their lifestyle. To date, one million people have followed the programme, with data showing that it reduces the chances of developing diabetes by 37% – but it can only have the desired impact with patient participation.

The study was conducted using Meddbase’s software; the system was used to enable the ICB’s Engagement Officer to quickly identify eligible patients, check them against criteria and then schedule text message prompts, while also capturing information to update Electronic Patient Records.

Commenting on the pilot, Scott Walker, Senior Partnership Officer (Diabetes) at NHS Humber and North Yorkshire ICB, said: “We’ve seen phenomenal success with this pilot, which was driven by user need. Previously, we had to wait to achieve the critical mass required to make our diabetes prevention programme viable, but we can now confidently say that we will have enough patients to start a group. In fact, the success of the pilot has given us the confidence to bring in additional human resources to manage patient conversions. That’s the beauty of this solution – the untapped potential is huge.”

Dr Tom Milligan, a GP and the Clinical Lead for Diabetes in Humber and North Yorkshire, said: “Before this study, I thought we were doing NDPP referrals well, but in fact we were missing hundreds of patients with pre-diabetes. The software used for this pilot enabled the ICB to conduct advanced searches for the first time, so they could identify, invite and refer patients that would otherwise have been missed. The result was far greater uptake of the NDPP as well as significant time saved for clinical staff. Given the current capacity challenges within General Practice and the cost to the NHS of lifestyle-related conditions like type 2 diabetes to the NHS, the findings here could have a huge impact.”

Erin Johnston, NHS Product Owner at Meddbase, said: “It has been exciting to work with colleagues at the NHS Humber and North Yorkshire ICB on this pilot, which has achieved brilliant results using our innovative clinical management software to reach patients at-scale as part of an effective and efficient programme. The outcome clearly shows that a strategic ICB-managed approach to patient communications, supported by the right kind of clinical management software, can have a significant impact on uptake of healthy lifestyle programmes.”

About Meddbase

Meddbase is an advanced secure cloud-based clinical management system that integrates Electronic Medical Records (EMR), workflow planning and patient communications as part of a truly end-to-end service to improve patient care, increase efficiencies and support clinicians.

The powerful and flexible software is used across a range of settings including primary care, hospital management and occupational health and customers include the NHS, BUPA and HCA Healthcare UK.

Central to the benefits of the Meddbase system is Pathways, its inbuilt industry-leading workflow management tool that enables custom configuration of a range of tasks, including sending a questionnaire to a patient, using the slot finder to book an appointment for a patient with the right clinician at the right time, attaching a document to a patient record, contacting the patient, making a patient referral, or creating a new task or form and finding a list of patients using filters.

Tasks can also be shared with patients via the Patient Portal, allowing patients to have more choice and control over how their healthcare is planned and delivered, which is the goal of personalised care.

These tasks can be packaged together in a single automated workflow, providing a range of benefits to both clinicians and patients:

● Increases speed and efficiency

● Saves clinicians time and allows for more time with their patients

● Allows organisations to grow without increasing staff costs

● Increases patient engagement through a secure Patient Portal

● Ensures that no task is ever forgotten

About NHS Humber and North Yorkshire Integrated Care Board

NHS Humber and North Yorkshire ICB is a statutory organisation accountable for NHS spend and performance for 1.7million people. The ICB is a core member of the Humber and North Yorkshire Health and Care Partnership, alongside NHS providers, local councils, health and care providers and voluntary, community and social enterprise (VCSE) organisations.

The Health and Care Partnership is one of 42 Integrated Care Boards which cover England to meet health and care needs across an area, coordinate services and plan in a way that improves population health and reduces inequalities between different groups.

The Partnership was first established in 2016 as Humber, Coast and Vale ICS, and since then partners have been working together to look for ways to join up health and care services and to make them work better for local people.

The Partnership works across a geographical area of more than 1,500 square miles including the cities of Hull and York and the large rural areas across East Yorkshire and North Yorkshire, as well as North and North East Lincolnshire, serving the different health and care needs of the population.

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