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Self-management preventative education and physical activity programme for diabetes prevention

The aim of the project is to develop an integrated care pathway designed around patients to try and avoid the onset on type 2 diabetes for people across South Gloucestershire


The South Gloucestershire CCG Long Term Conditions (LTC) programme group have identified self-management and diabetes prevention as one of a number of priorities for 2015/16.

This is an opportunity for Public Health South Gloucestershire, CCG, Primary Care and voluntary sector to work in partnership to develop an integrated care pathway designed around patients to try and avoid the onset on type 2 diabetes.

The vision is for a co-ordinated, tailored and effective programme for pre-diabetics (those with raised BMI, BAME risk communities, cardiovascular disease, a family history of diabetes) identified via primary and community care that offers non-pharmacological input such as self-management education (including generic self-management education sessions co-led by peers, interactive online engagement, telephone support, self-monitoring), client-centred physical activity and healthy eating advice.

We would look to recruit and train volunteers and health care professionals in local communities, ensuring the service is accessible widely across the locality and available for all those who are identified at being at risk.

The ambition would be to engage and work with all 25 GP surgeries, a wide range of health care professionals, including practice nurses and community pharmacists.  Initially we will pilot the programme in one GP surgery, we will then build on achievements learn from the experience, review performance, adapt and improve plans as necessary.

The self-management element will be innovative and based on evidence of effective elements including:

a) providing self-management education for people with specific conditions which is integrated into routine healthcare

b) generic self-management education courses co-led by peers / laypeople

c) interactive online self-management programmes

d) telephone support and telehealth initiatives and

e) self-monitoring of medication and symptom.

This may include integration of social media into the programme, self-led groups and self-recording portals. 

Referrals will be received from health professionals including GPs, community nurses, pharmacists where an individual has risk factors for developing diabetes (such as family history, raised BMI, cardiovascular disease etc.) and may also accept self-referrals.

The programme and referral pathways and communications will be developed by the South Gloucestershire LTC Programme Group working in partnership across health and social care with key input from a number of stakeholders.

For more details, please contact:

  • Clare Fleming, Public Health Programme Lead Obesity, Nutrition and Physical Activity, South Gloucestershire Council  or
  • Lisa Bryant, Project Lead, Department for Children, Adults and Health, South Gloucestershire Council

The initial pilot project will run from October 2015 to October 2016 with one GP practice.  Within this time a Pre Diabetes Project Team has be established to ensure a coordinated and joined up working process between South Gloucestershire Local Authority, Primary Care, CCG, and Voluntary Sector Groups. 

Educators’ will be identified and trained from within these groups, who will then deliver four courses to patients in the identified area from January to May 2016. 

Course evaluation will take place formally with the University of West of England, capturing both qualitative and quantitative data.

It is aimed that the project will build strong links between primary care, public health and local voluntary and third sector groups in this area.

People are empowered to self-manage and increases ability to care for themselves, leading to a feeling of control and results in better outcomes. Health care professionals become more competent working collaboratively. Contributes to NHS financial sustainability.

By acting early to prevent complications developing and treating patients as early as possible both limits their impact on the person’s life and saves the NHS money.  To prevent people developing diabetes will have a direct cost saving, also the human cost saving will be by reducing suffering from complications associated with having diabetes which 80% are preventable.

Clare Fleming, Public Health Programme Lead Obesity,Nutrition and Physical Activity, Department for Children, Adults and Health, Public Health and Wellbeing Division at South Gloucestershire Council said: Within South Gloucestershire we are committed to doing something collaboratively to stem the tide of people becoming patients who are at risk from the complications associated with this serious condition, and other related conditions.  We are aiming for individuals that are at risk of developing type 2 diabetes to be enabled and guided towards greater self-care and informed managers of their health.  The education component is to focus on patient empowerment, encouraging co- design, sharing and appreciating individual experiences.

The programme sessions will be matched to the needs of the target population in terms of availability, accessibility and location, as far as possible.  Sessions can be delivered by health professionals or non-health professionals at the pilot GP Practice.  The sessions will be delivered using predominantly group sessions (ideally between 10 – 15 people) on a weekly basis, including evening sessions.  The sessions will focus on a strong physical activity component as well as nutrition, general health and wellbeing advice.  We are currently recruiting individuals for the X-PERT Diabetes prevention training, this will include lay facilitators, pharmacists, health professionals, physical activity specialists and others.

Excellent relationships have been established with the pilot GP surgery and they are fully supportive to be involved with this innovative scheme.

The application for research governance is now complete and accepted. We are working with The University of West Of England to fully evaluating the pilot over the next year. The aim of the evaluation is to present a robust and transparent account of the impacts of the South Glos Diabetes Prevention Project for participants, to examine the implementation of the project and to assess some delivery costs. Where appropriate, the evaluation will be designed to complement and build upon the project’s performance monitoring plan. 


This Page was last updated on: 26 November 2015

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