A WIRRAL CIC has reported that its diabetes prehabilitation service is resulting in “significant” patient benefits.

The community based and patient-centred service was launched in April 2023 to reduce surgery postponements, tackle waiting lists, and improve postoperative outcomes for patients - utilising a personalised prehabilitation approach as opposed to a traditional clinical model.

It uses Graphnet Health’s population health platform and analysis of hospital waiting lists at Wirral’s Arrowe Park Hospital to identify and support diabetes patients that are most at risk of having surgery postponed.

Since the programme was launched 178 patient referrals, average HbA1c drop from 73.4mmols to 63.25mmols over course of 12 weeks,  average BMI drop from 34.2 to 32.99 over course of 12 weeks and average weight drop from 98.41kg to 95.45kg over course of 12 weeks have been recorded.

Lucy Holmes, Wellbeing Lead at One Wirral CIC said: “Once identified, patients are contacted within 48 hours and booked in for an appointment with a diabetes prehabilitation health coach, in a local community setting, such as a library.

“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 population health and data-driven approach means we are able to contact the right people at the right time and give them the best intervention before their procedure.

“We look at their lifestyle and they’re encouraged to participate in activities, including the free diabetes exercise sessions that are held in the community each week.

“Their medications are also assessed. It means we’re looking at a person from a holistic point of view, not just clinically and not just non-clinically. It’s a true community-based, multi-disciplinary team approach.”

Fifty-eight people have been reviewed by a diabetes specialist nurse, 37 have had medication added, following a review (such as SGLT2i, metformin or gliclazide), 19 patients have received support with their insulin, and 6 patients have commenced on Libre sensors (a sensor-based glucose monitoring system).

Initially, the service supported two Primary Care Networks - Moreton and Meols PCN and North Coast Alliance PCN, funded by the North West Coast Clinical Networks. However, the service has now been extended across Wirral to all Primary Care Networks. The goal is for the approach to be adopted nationally. 

The early identification of patients at risk of having their surgery postponed removes the need for GP surgeries to make referrals. The service also receives referrals directly from secondary care, for people that have had their surgery postponed, and have diabetic risk factors.