Structured Education For Type 2 Diabetes - Health Innovation Network
Structured Educationfor Type 2 diabetesA toolkit for optimal deliveryEnter the toolkit www.hin-southlondon.org
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesForewordThe Health Innovation Network (HIN)is a membership organisation, drivinglasting improvements in patientand population health outcomes byspreading the adoption of innovationinto practice across the health system.IntroductionDr Charles Gostling, Clinical Director (Diabetes), Health Innovation Network South London and GP, Lewisham4As the Academic Health ScienceNetwork for South London our workprioritises health challenges for localcommunities across a number of clinicalareas; including diabetes, dementia,MSK, cancer and alcohol. Our workincorporates cross-cutting innovationthemes to generate wealth and increasethe quality of care in our communities.We are proud to be collaborating withour partner and member organisationsto align; education, clinical research,informatics, innovation, training andeducation in healthcare. We supportknowledge exchange networks toensure the patient is at the heart ofhealthcare delivery and to support earlyadoption of healthcare innovations.Contents and context AcknowledgementsReferences4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesContents1Our approach to DiabetesOur team have used Joint Strategic NeedsAssessments to identify key areas of variationand risk. We have developed and refined, inconsultation with a range of stakeholders,our high level priorities below.Toolkit guide2 Type 2 diabetes3 Introduction to structured educationprogrammes4 What the person with diabetes thinksSupportingbetterself management5 How to commission structured education6 Successful referral processesProjects 2014-151Improving self-management ofinsulin therapy by improving access toand appropriate use of technologies.!2 Improving the integration of carepathways for management of unscheduledcare in hypoglycaemia and hyperglycaemia.3 Right Insulin, Right Time, Right Dose.4 Structured education and related supportfor self-management.7 Providers of structured education8 Menu of Type 2 education providersEnabling systemsfor integrationof care9 Next steps and resourcesInformation sources (references/footnotes)have been included on the base of each page.You can view a complete list of references here.Adopting newtechnologiesGuide to ents“ReferencesWhat peopleare saying4Next page4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesThe toolkit was informed bya representative group of serviceusers, commissioners andproviders who have contributeda number of resources andhave generously shared theirexperiences and expertise withthe Health Innovation Network.Why a toolkit?Structured education is an effective selfmanagement tool to help people diagnosedwith Type 2 diabetes understand and managetheir life long condition. Yet uptake is shockinglylow despite recommendations in NICE guidance1and the introduction of a QOF indicator2 forreferral to structured education programmes.This toolkit will address the causes of lowuptake and provide simple guidance on howto ensure high quality structured educationis easily accessible.!This toolkit makes commissioninghigh quality and accessible structurededucation programmes easier. Much of thehard work has already been done throughsharing best practice, providing meaningfulmetrics to benchmark performance andgiving you key performance indicators. It canbe amended according to local needs with amenu of options allowing you to assess therange of structured education available andprovide programmes to suit the ‘harder toreach’ individuals within your CCG.Who is the toolkit for?12 Commissioners of structured educationprogrammes. Providers. Referrers into structured education. People with diabetes, their families or carers.NICE, Clinical Guidance 87 (2014) Type 2 Diabetes: The Management of Type 2 Diabetes. DownloadNHS England, BMA & NHS Employers (March 2014). 2014/15 General Medical Services (GMS) contractQuality and Outcomes Framework (QoF). NHS England Gateway Reference: 01264G2ateway reference: 01264Back to contentsAcknowledgementsReferences4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesUsing the toolkitThe fundamentals What is diabetes structured education?Diabetes courses provide information on how to manage diabetes through diet,physical activity and medication. They are run by health professionals – usually aThe twomost common programmesdiabetes specialist nurse or dietitian often in a groupsetting.in South London are:Find out more about the two most common programmes nationally:Diabetes Education for Self-Management forOngoing and Newly Diagnosed (DESMOND)4The X-PERT Diabetes Programmefor people with Type 2 diabetes!4 Links to useful and relevant resources can be found within the toolkit or via the Health InnovationNetwork’s website. These include exemplar service specifications, health professional and patientresources, score cards, links to useful YouTube clips and case studies. 345678Department of Health & Diabetes UK (2005). Structured Patient Education in Diabetes. Report from the patient education working group. DownloadDeakin, T., Cade, J., Williams, R. and Greenwood, D C., (June 2006). Structured patient education: the Diabetes X-PERT Programme makes a difference.Diabetic Medicine, 23(9): pp.994-54HSCIC. Health and Social Care Information Centre. National Diabetes Audit 2010-2011. Report into the data quality of Diabetes Structured Education. 2012 DownloadCotter, B. and Grumitt, J., (2011). GP commissioning: Shaping diabetes care in Bexley. Diabetes & Primary Care, 13(6); pp.375-380. WebsiteDiabetes Modernisation Initiative (2014). Living well with Diabetes, Learnings report from the Diabetes Modernisation Initiative. DownloadNICE, Quality Standard 6 (2011) Diabetes in Adults Quality Standard. DownloadBack to contentsAcknowledgementsReferences2Structured education programmesfor people with Type 2 diabetes are aneffective and cost efficient way of improvingoutcomes and are a key part of diabetes selfmanagement when linked with collaborativecare planning, screening and medications3,4.Acting early to prevent complications limitstheir impact on the person’s life and savesthe NHS money4.However access to structured education isvery poor and there is unacceptable variationacross South London5.When people with diabetes, serviceproviders, referrers and commissioners workcollaboratively real change can happen allowingeducation to reach a greater number of thepopulation, as has been demonstrated inBexley, Southwark and Lambeth6,7.NICE states that structured education shouldbe offered to every person with diabetes and/or their carer around the time of diagnosis,with annual reinforcement and opportunityto be repeated as necessary8.It is vital to record and report those whoare not attending the structured educationoffered (usually DESMOND or X-PERT) andprovide a suitable alternative that meets theirindividual needs3.High quality alternative education programmesdo exist for harder to reach groups andinnovative ways should be sought to allowpeople with diabetes to access different typesof learning. See the menu of options.4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesDiabetesThe national pictureThe costs of complications of diabetes9 10bn per yearMyocardial infarction, ischaemic heartdisease, heart failure and other CVD million3500Diabetes costs the NHS 10 billion per year,accounting for 10% of the NHS budget9.Excess inpatient days3000 16.9bn by 2035Kidney failure, other renal(kidney-related) costs25002000Public health forecasting predicts that anaging population and rising prevalenceof obesity will increase NHS spending ondiabetes to 16.9 billion by 2035, accountingfor 17% of the NHS budget. It is a leadingcause of blindness in the UK10 and over 100amputations are carried out each week inpeople with diabetes due to complications– 80% of which are preventable.Neuropathy1500Stroke1000Foot ulcers and amputations5000Total: 7.7 billion22,000 deathsOther: dyslipidemia, erectiledysfunction, ketoacidosis, depression,gestational diabetes, diabeticmedicine outpatients, hypoglycaemia,hyperglycaemia and retinopathyEach year 22,000 people with diabetesdie prematurely5.Biggest risk groupsType 2 diabetes is more common in peopleof black and south Asian origin, and tendsto present at a younger age in these ethnicgroups.5910Back to contentsAcknowledgementsReferencesHSCIC. Health and Social Care Information Centre. National Diabetes Audit 2010-2011. Report into the data qualityof Diabetes Structured Education. 2012 DownloadHex. N., Barlett. C., Wright. D., Taylor. M. and Varley. D. Estimating the current and future costs of Type 1 and Type 2diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabetic Medicine 2012.DOI: 10.1111/j.1464-5491.2012.03698.xNHS England (2014). Action for Diabetes. Download4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resources“The main health and economic cost of diabetes is that of complications. Improvingglycaemic control through self-management will ultimately reduce the costs. Increasingattendance at structured education for Type 2 diabetes could save each CCG 1.7 million peryear*16. 50% of people show signs of complications at diagnosis. This makes it all the morenecessary for people with diabetes to understand what they can do to positively affect theirown health and self-manage their diabetes11.”Further informationFor more information on diabetesprevalence modelling for yourborough please use the toolprovided by Public Health England.You can download it here.The picture in LondonThe picture in South LondonData suggests a 75 per cent increase12 inthe incidence and prevalence of Type 2 diabetesin London over the last decade. The risingprevalence of diabetes is believed to be due toan ageing population and unhealthy lifestylesleading to obesity.The diabetes prevalence model for local authoritiesshows than in 2014 there were 174,627 people withdiabetes over the age of 16 in South London andthis is expected to rise to 249,848 by 203012.2* Figure based upon cost savings of 367 million per year across the NHS with X-pert, divided by 221 CCGs in England.111216NHS England CCG Map. Download (accessed 9th September 2014).Health Committee, London Assembly (April 2014). Blood Sugar Rush; Diabetes time bomb in London. DownloadDeakin T. The Diabetes Pandemic: Is structured education the solution or an unnecessary expense? Practical Diabetes 2011; 28; 1-14Back to contentsAcknowledgementsReferences4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesIntroduction to structured education programmes“NICE8 recommends that well-designedand well-implemented structurededucation programmes are likely to becost-effective for people with diabetesand should be offered to every personand/or their carer at and aroundthe time of diagnosis, with annualreinforcement and review.Structured education programmes for peoplewith Type 2 diabetes are an essential componentof effective diabetes management. Most peoplewill spend only 1.5 hours with a health careprofessional per year, the rest of the time theyare required to make daily lifestyle decisions thatmay have a significant impact on their healthand overall quality of life13.The aim of structured education is for peoplewith diabetes to improve their knowledge, skillsand confidence, enabling them to take increasingcontrol of their own condition and integrateeffective self-management into their daily lives.High-quality structured education can have aprofound effect on health outcomes and cansignificantly improve quality of life.581314HSCIC. Health and Social Care Information Centre. National Diabetes Audit 2010-2011.Report into the data quality of Diabetes Structured Education. 2012 DownloadNICE, Quality Standard 6 (2011) Diabetes in Adults Quality Standard. DownloadSteinsbekk, A., Rygg, L., Lisulo, M., Rise, M. and Fretheim, A., (2012).Group based diabetes self-management education compared to routine treatmentfor people with type 2 diabetes mellitus. A systematic review with meta-analysis.BMC Health Services Research, 12; 213. WebsiteNational Diabetes Audit (November 2013), Are diabetes services in England and Wales measuring up?A summary of findings from the National Diabetes Audit 2011–12 for people with diabetes and anyoneinterested in the quality of diabetes care. DownloadBack to contentsAcknowledgementsReferencesNational Diabetes audit data shows that as few as 12% of people with Type 2 diabetes are offeredstructured education with only 2% taking up the offer5. This poor provision has been recognised, andreferral to a structured education programme was made a Quality and Outcomes Indicator incentivein 2013/4. Despite this, preliminary work in South London suggests that not all providers collect dataregarding uptake at structured education programmes. In boroughs where increasing uptake has beentargeted, for example in Lambeth & Southwark, uptake is now in excess of 40% of those referred14.SE offered and attended rates across South London according to the National Diabetes Audit (NDA) dataPercentage of diagnosed patients45.9Offered (%)45%40%Attended (%)38.9England and Walesoffered (%)35.835%England and Walesattended MwucdeBCKiLaLeRianGrSoWCCG4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesUptake of these programmes has beenalarmingly low at around 2%14.Education can be flexibleThe current NICE guideline8 does not specifythe exact format, intensity, or the setting fordiabetes education.Not attending a course is wasteful, not onlyin terms of finance, but also a lost opportunityfor people with diabetes.Different models existTo meet the requirement of the QOF, structurededucation has to be delivered to a minimumstandard and meet key criteria. These were definedin the report from the Patient Education WorkingGroup3 – programmes should:There are a number of structured educationmodels. The most commonly providedprogrammes are: Diabetes Education forOngoing and Newly Diagnosed (DESMOND),X-PERT, and the Diabetes Manual. Have a structured written curriculum Have trained educatorsClinically effective Be quality assured Be audited.Group based structured education programmesare clinically effective. Meta-analysis of 21studies showed significant reductions in HbA1cat 6, 12 months and 2 years as well as significantimprovements in knowledge, self-managementskills and empowerment13.The evidence NICE guidance recommends programmesto give people knowledge and motivationto manage their condition8. Education of people with Type 2 diabetes isalso cost effective. Data from X-PERT showsthe programme costs are outweighed bysavings made from the reduced need forcardiovascular and diabetes medication16.DESMOND also produces cost savings throughreductions in weight and smoking rate15. There are a number of other types of structurededucation programmes for people with Type2 diabetes which have undergone or areundergoing clinical trials and user evaluation.A full list of these programmes can be foundin our menu of Type 2 education providers.Cost effectiveThe cost of providing structured educationcourses is in the region of 65- 250 per patientand given the scale of implementation withapproximately 80 commissioning groups runningthe DESMOND programme and a similar numberrunning the X-PERT programme across the UKthe cost to the NHS is considerable15,16.Back to ment of Health & Diabetes UK (2005). Structured Patient Education in Diabetes. Report from the patient education working group. DownloadNICE, Quality Standard 6 (2011) Diabetes in Adults Quality Standard. DownloadSteinsbekk, A., Rygg, L., Lisulo, M., Rise, M. and Fretheim, A., (2012). Group based diabetes self-management education compared to routine treatmentfor people with type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Services Research, 12; 213. WebsiteNational Diabetes Audit (November 2013), Are diabetes services in England and Wales measuring up? A summary of findings from the National DiabetesAudit 2011–12 for people with diabetes and anyone interested in the quality of diabetes care. DownloadGillett. M., Dallosso. H.M., Dixon. S., Brennan. A., Carey. M.E., Campbell. M.J., et al. Delivering the diabetes education and self managementfor ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis.BMJ 2010; 341:c4093Deakin T. The Diabetes Pandemic: Is structured education the solution or an unnecessary expense? Practical Diabetes 2011; 28; 1-144
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesBest practice case studiesProjects in South London boroughs haveshown that uptake of existing structurededucation programmes can be improvedthrough a variety of interventions, includingbetter marketing and organisation.BexleyLambeth and SouthwarkIn Bexley attendance at the X-PERTstructured education course improvedfrom only 40 people in 2009 to over 1000people in 20104. This was achieved througha variety of methods:The Diabetes Modernisation Initiative inLambeth and Southwark sought to increasenumbers of people attending structurededucation programmes, in this instanceDESMOND. In particular increasing theproportion of people booked onto a coursethat actually attended. Consulting with people with diabetes toidentify venues and timings for courses Using lay-educators as it was realisedthat people are not always inclined tolisten to healthcare professionals Ensuring robust administration of thereferral and booking process, includingelectronic referral systems.From the year 2011-12 to 2012-13 the bookedto attend ratio in Southwark increased from74% to 90%. Strategies for increasing uptakehad included awareness training for primaryhealthcare practitioners.4View video:4John Grumitt, MD Metapath Solutions(Vice President, Diabetes UK, NHS EnglandCommissioning Board, Diabetes CRG).Email: John@grumitt.co.ukDeakin, T., Cade, J., Williams, R. and Greenwood, D C., (June 2006).Structured patient education: the Diabetes X-PERT Programmemakes a difference. Diabetic Medicine, 23(9): pp.994-54Back to contentsAcknowledgementsReferences4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesWhat the person with diabetes thinksStructured education is one aspect of diabetes self-management. For many people,diabetes is one of several long-term conditions they have to deal with day to day.Feedback from South London patientengagement groups concluded that.people with diabetes want to feel thatthey have received all the information theyneed to understand their diabetes and selfmanage effectively.Lessons learnt from interviews withnon-attenders include: All healthcare professionals need toprovide consistent key messages ondiabetes and how to self-manage Effective and useful signposting tolocal structured education is required Having enough time with a healthcareprofessional to ask questions and fullyunderstand their diabetes Access to a Dietitian and practicaladvice for day-to-day implementation.Most structured education is designed tomeet these requirements yet patient uptakeis generally poor.Source: Diabetes Modernisation InitiativeBack to contentsAcknowledgementsReferences4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesWhat people with Type 2 diabetes told us17Why they do not always attendFeedback from people who have attended The majority had never been offeredstructured education by a healthprofessional and didn’t know it existed. They liked the peer support andinformation about diet.Research17 has succinctly grouped the abovereasons into the below three themes: these are themost common reasons for patients not to attendcommissioned Structured Education courses: The term ‘Structured Education’ wasoff-putting. The benefits of the coursewere not ‘sold’ to them. It was felt there was a lack of follow-upand need for refresher information.1 The referral process felt like a tick-boxexercise. They felt there was no individualisation. A more personalised approach wasrequested– phoning people, inviting and‘selling’ the benefits of the course. Timing of referral – some felt that the timewas wrong, as they had either just beendiagnosed, or started tablets. Location and timing was very important –venue and accessibility (transport links/carparking) were key barriers to attendance. Competing commitments such as work. Some would have preferred modularcourses and e-learning with on-lineoptions instead. Did not like the idea of group learning –individual one to one education wouldhave better met their needs.Winkley, K., Evwierhoma, C., Amiel, S A., Lempp H K., Ismail, K. andForbes, A. (August 2014)Patient explanations for non-attendance at structured diabetes education for newly diagnosedtype 2 diabetes: a qualitative study. Diabetic Medicine doi: 10.1111/dme.12556Back to contentsAcknowledgementsReferences“Everybody shouldbe informedof the condition”“When first diagnosed givenmedication and diet information,wanted more informationbut not told where to get informationand support from – if you don’thave the network you don’thave the support”“ no parking so you’re talkingan hour and a halfon the bus”Not enough information about the programme/perception of benefit, for example not beinginformed of the course by a health professional,not perceiving benefit of attending the course2 Unmet personal preferences such as parking,competing personal issues because of workor caring for others, preference for alternativessuch as internet course/one to one sessions3 Shame and stigma of diabetes including notwanting others to know of diabetes diagnosis.“Because I work nights,because my wife is disabled,I haven’t even got timeto go to the foot clinic.The answer would be no”“Menu of educationoptions whendiagnosed”4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesHow tocommissionquality structurededucationCommissioning structured education programmes for people with Type 2 diabetesmust be done with effective service user engagement and must be robustly basedon public health needs. As with any commissioned service there will be a need tounderstand accessibility to the intervention, especially in terms of uptake.Back to contentsAcknowledgementsReferences4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesSystematic engagement andfeedback from service usersIt is essential to decide who the targetaudience should be. NICE state that educationshould be available to all people with newlydiagnosed Type 2 diabetes. The CCG OutcomeIndicator Set 2014/15 will suggest measuringthis. However, people with long-standingType 2 diabetes may also benefit fromstructured education. Individual CCGs shoulddecide their local remit, especially provisionfor longstanding diabetes.Services which have undertaken and actedon patient feedback have seen a significantimprovement in patient attendance rates6,7.The Network strongly recommends the inclusionof a patient feedback system as part of the servicespecification. Each provider should be asked toroutinely collect course satisfaction questionnairesfrom all attendees and report the findings, withremedial action plans via their internal quality andgovernance process and local commissioning leads.The Network appreciates that manyof the commissioning teams and serviceproviders are already delivering best practiceand local quality and performance initiatives.We would welcome your feedback and inputon the above suggestions. We are keen tofurther develop joint working in partnershipacross all CCGs to build on best practice andquality initiatives, to improve health outcomesand use of resources across South London.67 Type of programme such as group education,one to one or online (see menu of differenttypes of structured education available). ‘Harder to reach’ populations including peoplefor whom English is not their first languageor those who do not want to attend groupeducation – what are the alternative options?AcknowledgementsReferencesWho may have multiple long-term conditions? Are people homebound or living in nursing/residential accommodation? Do they have other specific needs includinglearning difficulties or a mental health illness? What are their cultural or religious needs?Programmes must be consistent with NICErequirements and/or QISMET certification.2THEDIABETES Practicalities such as course times and venues(access via public transport or car parkingavailability); can you use community venuessuch as shops, libraries and religious buildings?Downloadthis documentSELF MANAGEMENTEDUCATIONQUALITYSTANDARDQISMET DSME Quality Standard version 1Cotter, B. and Grumitt, J., (2011). GP commissioning: Shaping diabetes care in Bexley. Diabetes & Primary Care, 13(6); pp.375-380. WebsiteDiabetes Modernisation Initiative (2014). Living well with Diabetes, Learnings report from the Diabetes Modernisation Initiative. DownloadBack to contents Other important considerationsGet involved!Consider the needs of the local people:11 November 2011SC QISMET 20111QISMET is an independent body developedto support self-management providers andcommissioners to achieve the highest possiblequality service for people living with long-termhealth conditions.4
123456789Why a toolkit?Type 2 diabetesIntroduction tostructured educationWhat the personwith diabetes thinksCommissioningReferringProvidersMenu of Type 2education providersNext stepsand resourcesService level agreement must specify: Method of referral – consider a self-referralprocess in addition to referral by healthcareprofessional.Your diabetes - how to take better control2As a person living with diabetes you need to get as much support and information aspossible to help you manage your diabetes and lead a full life.If you are living with type 2 diabetes you can attend DESMOND, a free coursedelivered by healthcare professionals to help you learn more about your diabetes.Electronic Administration SystemsClinicians require skilled administration supportto provide electronic patient administrationsystems and formal databases enabling: Effective management of all referrals in atimely fashion Effective use of their resources by improvingcourse utilisation, and maximising attendance Provision of patient accessible information tomaximise choice of venue and timing of course Effective integration of care and timely transferof information from referral to discharge Systematically and routinely identify allpatients who declined the opportunity toattend before or after booking on a course,enabling the service provider and GP to taketimely action and follow up Enables access to a complete and easilyaccessible database to assess serviceperformance Provide data that can identify “cold spots”where further initiatives from the Network andothers may be required to improve patientuptake of education, and reduce the variancein delivery of NICE standards of care across allsections of the population.(Please note: The course is not suitable for people who are housebound, aged under 25, or with type1 diabetes. The course is delivered in English.)An alternative course for people with type 1 diabetes is available at your hospital,please ask your doctor about this.What is DESMOND?Desmond is an interactive course designed to help people with diabetes learn about: What diabetes is How you can look after your diabetes How you can keep well and follow a healthy lifestyle, with practical tips on healthy livingand making good food choices. What care you should expectWho is it for? Anyone diagnosed with Type 2 diabetes (recent or longstanding). Adults aged 25 and over and living in Lambeth and Southwark.Downloadthis documentYou will be part of a group of people who have been told that they have diabetes. Relativesare also welcome to attend.Why should I come?We hope to create a re
3 Introduction to structured education programmes 4 What the person with diabetes thinks 5 How to commission structured education 6 Successful referral processes 7 Providers of structured education 8 Menu of Type 2 education providers 9 Next steps and resources! Guide to symbols Important information 2 Downloads " 4 Next page What people are .
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