Title: Can group clinics offer a better way to meet the complex health and social care needs of young adults with diabetes in an ethnically diverse, socioeconomically deprived population?
Funder: Department of Health and Social Care

Abstract: • Background Whilst overall diabetes outcomes in the UK compare well to other countries, serious concerns have been raised about poor outcomes and increasing need in specific populations, e.g. young adults from minority ethnic groups in socioeconomic deprivation. Patient engagement and self-management are key to good diabetes control, yet are often poorly supported by traditional healthcare models and obscured by wider health & social care needs. Group education is used widely in diabetes management, but a recent study found that a group-based education-only intervention for young people with diabetes did not improve outcomes. In contrast, systematic review (2-4) and pilot work in Newham (5-6) suggest culturally-sensitive group clinics that integrate health & social care needs, and are developed through co-design (7) with patients may be effective and well-received by users. The London Borough of Newham has high deprivation, excess diabetes prevalence and reduced life expectancy (8); we propose to evaluate this new model of group-delivered integrated health and social care in this population. Aims To explore the scope, feasibility and potential scalability of group clinics for young adults with diabetes and complex health and social care needs. Strategic objective To contribute to the redesign of NHS services to improve care for people from hard-to-reach groups with long-term conditions. Operational objectives • To perform a scoping exercise and realist review of group clinics and their use in diabetes care (workstream 1) • To use experience-based co-design to design a group clinic-based care model that meets the complex needs of young adults with diabetes within their socio-cultural context (workstream 2) • To implement the co-designed group clinic-based care model (workstream 3) • To conduct a comparative evaluation of the model against current care to elucidate patient and provider perceptions and, mechanisms of action. * To perform preliminary analysis on the potential for group clinics to improve clinical outcomes and patient engagement and/or reduce care costs, in order to inform the design of a future cluster-randomised controlled trial (workstream 4). • To disseminate the outcome(s) of our scoping and realist review, the co-designed new care model and its evaluation to service users and relevant stakeholders and generalize our findings to a wider context (workstream 5) Anticipated outputs • A realist review on the evidence of group clinics in diabetes. • A co-designed group-based new model of care that meets the needs of young adults with diabetes. • An enhanced understanding of the role of experience-based co-design in redesigning conventional NHS services to better meet the health and social care needs of specific hard-to-reach groups with long-term conditions. • A better understanding of the role of participatory research in mobilising academic expertise more effectively • A test of the generalisability of a co-designed new care model evaluated through participatory research methods to a wider context • A platform on which to design future trials to evaluate more definitively the impact of group clinics on clinical outcomes, patient engagement and care costs. References: 1. Christie D, Thompson R, Sawtell M, Allen E, Cairns J, Smith F, Viner R et al. Structured, intensive education maximising engagement, motivation and long-term change for children and young people with diabetes: a cluster randomised controlled trial with integral process and economic evaluation the CASCADE study.. Health Technol Assess 2014;18(20). goo.gl/p7DkBO 2. Attridge M, Creamer J, Ramsden M, Cannings-John R, Hawthorne K. Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus (Review). The Cochrane Collaboration 2014 goo.gl/JoNr0U 3. Taylor S, Pinnock H, Epiphanou E, Pearce G, Parke H, Schwappach A, Purushotham N, Jacob S, Griffiths C, Greenhalgh T, Sheikh A. A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS - Practical systematic Review of Self-Management Support for long-term conditions. Health Services and Delivery Research 2014:2 (53) goo.gl/3YKDiJ 4. Booth A, Cantrell A, Preston L, Chambers D, Goyder E. What is the evidence for the effectiveness, appropriateness and feasibility of group clinics for patients with chronic conditions? A systematic review? Southampton (UK): NIHR Journals Library; 2015 Dec. Health Services and Delivery Research. 5. Greenhalgh T, Collard A, Campbell-Richards D, Vijayaraghavan S, Malik F, Morris J, Claydon A. Storylines of self-management: narratives of people with diabetes from a multiethnic inner city population. J Health Serv Res Policy:2011 16:37-43 goo.gl/nDgbVW 6. Greenhalgh T, Clinch M, Afsar N, Choudhury C, Sudra R, Campbell-Richards D, Claydon A, Hitman G, Hanson P, Finer S. Socio-cultural influences on the behaviour of South Asian women with diabetes in pregnancy: qualitative study using a multi-level theoretical approach. BMC Medicine 2015, in press. Manuscript number 1904899059159406 7. Locock L, Robert G, Boaz A, Vougioukalou S, Shuldham C, Fielden J, Ziebland S, Gager M, Tollyfield R, Pearcey J. Testing accelerated experience-based co-design: a qualitative study of using a national archive of patient experience narrative interviews to promote rapid patient-centred service improvement. Health Services and Delivery Research, 2014 No. 2.4 goo.gl/47civx 8. Data from NHS Health and Social Care Information Centre goo.gl/qsp3Hv

Lay abstract: Revised plain English summary A person with a long-term condition, such as diabetes, usually receives medical care that relies on one-to-one time with health care professionals. This style of health care may not meet a patient’s needs related to their condition or the wider impact it has on their life as a whole. The experience of living with diabetes is a difficult one, and at particular times of life, e.g. young adulthood, a person’s diabetes rarely stands alone from other challenges (e.g. leaving home, starting work, having financial worries). Current NHS care that relies on 1-to-1 appointments with health professionals, may not meet these wider challenges and therefore patients may not attend appointments, find looking after their condition is increasingly difficult, and have unexpected stays in hospital or develop diabetes complications. We would like to design and test out health care services that better meet the needs of people using them. Past research suggests that medical care delivered in a group setting may be one way to do this. The findings of recent research suggest that “group clinics” may be particularly successful for young adults, minority ethnic groups or people who have previously been poor clinic attenders. In the study we have put forward to the NIHR for consideration, we hope to investigate whether group clinics can offer good medical care for people living with diabetes, and if so, how and why they do so. At Newham Hospital, we have already started work that uses peer group support and engages patients in group activities (e.g. learning cooking skills), uses patient champions to lead and educate, and combines clinical care with wider social support, e.g. employment. Patient feedback from this pilot work with young adults suggests group-based care may indeed help individuals cope with challenge of living with diabetes. In this project, we hope to explore further how group clinics might best work for young adults living with diabetes. To do so, we will invite people aged 16-25 years living with diabetes, patient representatives, health care professionals and other organisations (e.g. offering advice and support on healthy eating, exercise, employment or finance) to help us design group clinics for people with diabetes, in a process called “co-design”. We will then run these co-designed group clinics for young adults with diabetes alongside their existing medical care. We will compare the group clinics to ‘traditional’ clinics at Newham (and elsewhere) and researchers will use different tools (e.g. observation, financial analysis, questionnaires and comparison to other studies), to understand the following: • Do group clinics that focus on both health and wider concerns of their patients meet the needs of young people with diabetes? • Do group clinics provide a better way for people living with diabetes and to managing their conditions, and if so, why and how? • What are the ingredients of group clinics that make them different (and/or better) than one-to-one care and are there any particular factors that make them better for some people but not others? • Is it feasible for hospitals to run these kinds of groups and would they work in other settings across the NHS? • Does a larger study of group clinics, compared to traditional clinics, need to be done after this study. If so, how would it be best designed and carried out?

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: METABOLIC AND ENDOCRINE