Implementing the guideline

There is a national framework for type 2 diabetes prevention, early detection and early intervention, published in 2018, with the aim of supporting NHS boards to implement and enhance the following pathways of care that relate directly to this guideline:⁴³

• type 2 diabetes prevention programmes
• tier 2 and tier 3 adult weight-management programmes
• gestational diabetes and postpartum type 2 diabetes prevention programmes
• type 2 diabetes remission programmes.

Scottish Government has committed to support NHS boards to provide evidence-based programmes as detailed in this guideline. Progress is monitored by local oversight groups at board level as well as a national oversight group at Scottish Government.

Audit tools designed around guideline recommendations can assist in this process.

Central to the implementation of this guideline and underpinning all approaches to design and delivery of services should be the commitment to address the health inequalities well documented in people with type 2 diabetes and obesity. Scottish Government has asked  all health boards to undertake an equality impact assessment (EQIA) on all of the pathways within the framework and develop subsequent plans to address inequalities gaps. This could be in the development of culturally-intelligent resources for people whose first language is not English, or the design of a weight-management programme for those with an intellectual disability. The guideline group encourages health boards to share their experiences, knowledge and resources developed through this process. Support and training is also available from Public Health Scotland for health boards in the development of their EQIAs.

Current outcomes are measured using the core national dataset for weight management and type 2 diabetes prevention and remission, which can be accessed on the NES platform TURAS, with annual analysis of data undertaken by Public Health Scotland.⁹ Using a core dataset enables national trends to develop over time that can inform continuous improvement. NHS-board level reporting means metrics, such as the number of patients referred and completing type 2 diabetes prevention programmes, and their subsequent outcomes, can be seen.

Consultation on this guideline raised concerns about the capacity in primary care to manage any potential increase in testing or diagnosis arising from increased risk assessment. This was acknowledged by the guideline group, with the understanding that primary care resourcing was outwith the remit of the guideline. The emerging developments in point-of-care testing in community pharmacies and the future ability to use home testing kits for HbA1c may offer possible solutions to the testing capacity pressures, together with investment in weight management, and type 2 diabetes prevention and remission programmes.

The implementation of Community Treatment and Care (CTAC) services can support the impact of increased testing. CTAC services are designed and configured around local population need and include basic disease data collection (eg blood pressure) and chronic disease monitoring. Learning for implementation is available from (https://ihub.scot/improvement-programmes/primary-care/community-treatment-and-care/about-community-treatment-and-care/)

The Scottish Government has published a national consensus statement with criteria for the prioritisation of use of GLP-1 RAs/GIP RAs in the treatment of people with obesity in NHS Scotland. It recommends that health boards adopt a phased introduction, initially for adults living with severe obesity and related cardiometabolic conditions. As part of the phased introduction, the consensus statement sets an initial eligibility threshold of body mass index (BMI) ≥38kg/m2 in the presence of at least one obesity-related health condition. By initially implementing a higher threshold, this will support health boards to embed appropriate care pathways and facilitate a gradual and more manageable progression towards the SMC criteria.

Given the projected increase in type 2 diabetes prevalence over the next 20 years, it is clear that the current care model and will be unlikely to meet the needs of our population.⁵ NHS England has successfully implemented several digital programmes for type 2 diabetes prevention and remission.⁵⁵ Collaborative working with the Centre for Sustainable Delivery at the Golden Jubilee hospital who host the accelerated national innovation adoption (ANIA) programme provides healthcare professionals and policy leads with a route to design and implement digital programmes at scale, on a Once for Scotland basis. This capability would support the widespread implementation of these guidelines into practice.

Consultation on this guideline highlighted the need for robust professional education on obesity and type 2 diabetes prevention and the guideline group agreed that this is a key component of guideline implementation. As part of the implementation of this guideline there is an opportunity to prioritise the development of a national professional education programme on obesity or weight management.

Quality improvement methodologies can be used locally to implement the guidelines. The Quality Improvement Journey contains generic advice and tools to use quality improvement methods to support local implementation. NES also delivers the Scottish Improvement Leaders programme and Scottish Quality and Safety Fellowship programme to develop individuals to lead local implementation projects to improve the quality of care.

5          Public Health Scotland. Scottish Burden of Disease: Future prevalence and burden of diabetes. 2024. [cited 10 Sep 24]. Available from url: /www.scotpho.org.uk/media/2422/2024-06-04-scottishburdenofdisease-diabetes.pdf

9          Public Health Scotland. Referrals to NHS board commissioned weight management services. [cited 10 Sep 24]. Available from url: https://publichealthscotland.scot/publications/referrals-to-nhs-board-commissioned-weight-management-services/referrals-to-nhs-board-commissioned-weight-management-services-1-october-2019-to-30-september-2021/

43        The Scottish Government. A healthier future: type 2 diabetes prevention, early detection and intervention: framework. [cited 11 Sep 2024]. Available from url: https://www.gov.scot/publications/healthier-future-framework-prevention-early-detection-early-intervention-type-2/

55        Ross JAD, Barron E, McGough B, Valabhji J, Daff K, Irwin J, et al. Uptake and impact of the English National Health Service digital diabetes prevention programme: observational study. BMJ Open Diabetes Res Care 2022;10(3).