World Diabetes Day: Celebrating Digital Innovation in Diabetes Care

Every year, on 14 November, World Diabetes Day takes place to celebrate progress in diabetes care, raise awareness about the importance of early detection, and highlight innovative solutions that improve patient outcomes. This year, we take a closer look at a population health led, community-based diabetes prehabilitation programme, launched by One Wirral CIC, in Cheshire and Merseyside, which is helping to reduce surgery postponements, tackle waiting lists, and improve postoperative outcomes for diabetes patients.

Since its launch in April 2023, this groundbreaking service, which uses CIPHA data and waiting list analysis, has shown significant benefits for patients. With a focus on personalised care rather than the traditional clinical model, the programme is providing targeted support for diabetes patients, helping them optimise their health ahead of planned surgeries. This data-driven initiative has proven to be a model for how community health services can be integrated to provide better care at every stage of treatment.

Addressing the Challenge: Surgery Postponements

In the UK, diabetes patients are at high risk of having planned surgeries postponed or cancelled due to uncontrolled blood sugar levels, which can complicate surgical procedures and recovery. Long waiting lists and stretched healthcare systems have further exacerbated this issue, leading to delays in treatment for many patients who are already vulnerable due to their underlying health conditions.

One Wirral CIC’s diabetes prehabilitation service addresses these challenges head-on. By working with Graphnet Health’s population health platform, and CIPHA data, the service analyses hospital waiting lists at Arrowe Park Hospital to identify diabetes patients who are at the greatest risk of surgery delays. Through early identification and a personalised approach to care, patients can receive timely interventions that reduce their risk of complications and ensure they are fit for surgery.

How the Programme Works

The prehabilitation service is designed around the individual needs of each patient, offering personalised support in a community-based setting. Once a patient is identified as being at risk of surgery postponement, they are contacted within 48 hours and scheduled for an appointment with a diabetes prehabilitation health coach. This appointment often takes place in accessible community locations, such as local libraries, which helps break down barriers to healthcare access.

Lucy Holmes, Wellbeing Lead at One Wirral CIC, explains the programme’s approach:

If a person’s HbA1c is over 69, they are automatically booked in for an appointment with a diabetes specialist nurse, who will look at medicines management and optimisation. Once they have seen the health coach and nurse, they commence a personalised prehabilitation lifestyle plan, which they follow up until surgery, whether that is a matter of weeks or months.

The programme combines a holistic approach to care, focusing not only on clinical factors but also on lifestyle changes, including exercise and nutrition. In particular, patients are encouraged to attend free diabetes exercise sessions held weekly in the community. This multi-disciplinary approach ensures patients are well-supported throughout their pre-surgery journey.

Measurable Impact: Patient Outcomes

The results from the first several months of the programme have been impressive. More than 178 patient referrals have been processed through the service, with significant improvements in key health markers:

- Average HbA1c (a marker of long-term blood sugar control) dropped from 73.4 mmol/mol to 63.25 mmol/mol, indicating improved blood glucose management.

- Average BMI dropped from 34.2 to 32.99, reflecting positive changes in weight and body composition.

- Average weight decreased from 98.41kg to 95.45kg, showing tangible progress in weight management, which is essential for improving diabetes control and surgical outcomes.

In addition to these improvements, 58 patients were reviewed by a diabetes specialist nurse as part of the programme. Of these, 37 patients had their medications adjusted, such as adding medications like SGLT2 inhibitors, metformin, or gliclazide. 19 patients received support with their insulin management, and 6 patients began using Libre sensors — a cutting-edge, sensor-based glucose monitoring system that offers real-time insights into blood sugar levels.

Expanding Access: From Local to National

Initially, the service was offered to two Primary Care Networks (PCNs) in the Wirral—Moreton and Meols PCN and North Coast Alliance PCN —funded by the North West Coast Clinical Networks. However, due to the programme’s success, it has now been expanded across the entire Wirral and is being adopted by all local Primary Care Networks. The goal is for this community-centred, data-driven approach to be scaled nationally, ensuring that diabetes patients across the UK have access to the same level of care and support.

The service is also helping to streamline the healthcare process by removing the need for GP referrals for patients who are at risk of surgery postponement. Referrals can now be made directly from secondary care, ensuring patients receive timely interventions and reducing administrative delays.

The Power of Personalised Prehabilitation

One of the key takeaways from this case study is the success of personalised prehabilitation, supported with rich population health data and analysis. Rather than following a one-size-fits-all model, the service adapts to each patient’s unique needs, taking into account their health status, lifestyle, and goals. This approach not only improves preoperative health but also sets patients up for better postoperative recovery.

The impact of this service is a reminder that prevention and early intervention are essential in managing chronic conditions like diabetes. By using data analytics, community engagement, and a holistic, patient-centred approach, we can improve outcomes, reduce healthcare costs, and, most importantly, enhance the quality of life for people living with diabetes.

Looking Forward: A Model for the Future

As the world continues to face increasing rates of diabetes and surgical delays, programmes like the one launched by One Wirral CIC offer a promising solution. By leveraging the power of community-based care, population health platforms, and personalised prehabilitation, we can not only improve the health of individual patients but also create a healthcare system that is more responsive, efficient, and compassionate.

On World Diabetes Day, it is important to celebrate these innovations and recognise the potential for further improvement in the way we manage diabetes care. One Wirral CIC’s prehabilitation service is a shining example of what’s possible when healthcare is driven by data, compassion, and a commitment to holistic patient care.

To learn more about how community health programmes like these are making a difference, follow the conversation on social media with the hashtag #WorldDiabetesDay and #DiabetesCareInnovation.

For more information on Graphnet’s population health solutions, visit graphnethealth.com/solutions/population-health.