Only 1% of people with type 2 diabetes in the UK attend structured education programmes that are proven to improve blood sugar control and reduce medication use. This project aims to fix that disconnect. The problem is stark: despite national guidelines recommending self-management education, referral and uptake have been falling since 2006. Many GPs remain unconvinced of the benefits, even though most patients say they want to attend. The researchers will systematically identify barriers at the patient, healthcare professional, and organisational levels, then build a tailored "embedding package" of solutions—including public awareness campaigns, clear evidence summaries for clinicians, and commissioning toolkits for health authorities. If successful, the package could transform routine diabetes care. The team will test it in 80 GP practices using a stepped-wedge trial, measuring changes in HbA1c and education uptake. An integrated ethnographic study will track whether the changes stick in real-world practice. The goal is not just to prove the package works, but to make it sustainable—so that effective self-management education becomes a normal, embedded part of diabetes care rather than an optional extra that almost nobody uses.
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Background: Type 2 diabetes (T2DM) is a serious chronic disease affecting ~3 million people in theUK(Diabetes UK 2013). Evidence demonstrates that structured T2DM self-management education improves biomedical and psychological outcomes, reduces diabetes medication, and is cost-effective (Davies 2008, Deakin 2006,Jacobs-van der Bruggen 2009, Khunti 2012, Trento 2010). The Diabetes National Service Framework and NICE recommend self-management education for individuals with T2DM (DoH 2001, NICE 2011). Nevertheless, referral to and uptake of self-management education remains low, and has been reducing since 2006 (Healthcare Commission 2006). In 2012, only 5% of people with T2DM were offered education and 1% attended (National Diabetes Audit 2013), with similar data from DAWN2 in 2013 (6%; Davies 2013a). The multi-factorial reasons for this disconnect occur at patient, healthcare professional (HCP) and organisational levels (Funnell 2006); in DAWN2, over half of GPs remained unconvinced about education benefits, whilst most patients wanted to attend education (Davies 2013a). However, local audit (NHS Cumbria, 2010) demonstrates structured education can be successfully embedded. We hypothesise that uptake of self-management education could be substantially increased if we understood and addressed barriers at patient, HCP and organisation levels, developing a tailored package leading to the integration of education in routine care. This project will develop and test such a package, assessing its cost-effectiveness and sustainability. It will include enablers at the patient (e.g. diabetes awareness, campaign), HCP (e.g. clear messages regarding evidence for effectiveness and cost-effectiveness of embedded self-management education) and organisation (e.g. commissioning toolkit) levels. Methods: Defined objectives across four workstreams (WSs) will be addressed, with continuous consultation/ collaboration with key stakeholders, including PPI groups. WS1 builds directly on the PDG (Davies 2013b) to develop an embedding package - a set of solutions to address barriers and enablers to uptake identified by systematically mapping existing qualitative research data, theory-based implementation and behaviour change literature onto an evaluation framework. A modified nominal group technique will be employed to engage stakeholders in designing the 'embedding package'. WS2 will be a feasibility study piloting the embedding package in 5-8 GP practices. This will ensure quantitative data collection methods are in place for the randomised controlled trial (RCT) and that data are accurate and complete. An integrated ethnographic study, beginning in WS2 and continuing through WS3 and WS4, will provide detailed contextual data on the implementation process, the sustainability of the change and the fit of the embedding package within routine practice (Jansen 2009). WS2 concludes with the refinement of the intervention package using data from the ethnographic study. We will also target aspects of behaviour change in HCPs and patients which affect referral to and uptake of structured education (NICE 2014, Michie 2011). In WS3, a stepped wedge wait-list RCT randomised at the practice level will compare the embedding package with usual care in 80 practices. Baseline data will be collected before randomisation. Practices will be randomised to receive the package from the start of the RCT (months 1-18) or to the wait-list group who will continue usual care for the first 9 months and receive the package for months 10-18 (see "Appendix_RCT design"). The primary outcome will be difference in HbA1c. Secondary outcomes will include: uptake to education, process outcomes (e.g. referrals to education), and biomedical outcomes additional to HbA1c. Primary analysis will be by intention-to-treat and use methods to account for practice-level clustering and repeated outcomes. The ethnographic study begun during WS2 will continue to refine the embedding package in
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