Abstract

1. Introduction

Type 2 Diabetes Mellitus (T2DM) is a serious yet preventable health condition often caused by poor lifestyle choices. T2DM occurs when the pancreas is unable to produce sufficient amounts of insulin to mediate the higher levels of glucose entering the bloodstream. Impaired insulin production can lead to the development of other chronic conditions such as heart disease, stroke, blindness, and kidney failure [1,2,3]. Those considered at a high risk of developing T2DM are typically diagnosed with prediabetes [4,5,6]. Prediabetes is diagnosed using the measurement of HbA1c, with values between 42 to 47 mmol/mol (6.0 to 6.4 mmol/L) indicating prediabetes [7,8].

Diabetes has become a major concern in the United Kingdom (UK). In 2012, GBP 15.1 bn was spent on T2DM, with the costs predicted to reach GBP 39.8 bn by 2035/36 [9]. Preventable complications of T2DM also have significant financial consequences; for example, annual hospital costs relating to adverse events in diabetics range from GBP 1523 for transient ischemic attacks to GBP 20,954 for end-stage renal disease [10]. Conversely, patients achieving targets for HbA1c, cholesterol, and blood pressure led to significant annual healthcare cost savings, ranging from GBP 859 to 1037 per patient [11]. Thus, the prevention of diabetes and related complications is paramount.

This is especially true in Wales. In 2016, the prevalence of diabetes among Welsh residents aged 17 and older was 7.3%. By 2020, this figure had increased to 8%, the highest prevalence among the four nations of the UK [12,13]. NHS Wales spends approximately 10% of its annual budget (an estimated GBP 500 million) on the diagnosis and treatment of diabetes [13]. In response, in 2016, the Welsh Government formed the Diabetes Delivery Plan, a long-term strategy for both the treatment of pre-existing diabetes and the prevention of diabetes in the general population. Lifestyle interventions were highlighted as a key preventive measure. Launched in 2022, the All-Wales Diabetes Prevention Programme (AWDPP) is one such lifestyle intervention which emphasises dietary advice and SP [14].

SP involves referring patients with prediabetes to non-clinical, community-based interventions via a link worker, also known as a community navigator or health advisor [15]. Promoting a person-centred approach, SP offers patients access to therapeutic activities within a safe environment, coupled with mentor support. Research suggests that SP can lead to numerous benefits, including increased confidence and productivity [16], reduced levels of depression and anxiety, [17,18], and a reduction in the number of general practitioner (GP) and accident and emergency (A&E) visits [19,20]. SP activities can also reduce diabetic causal factors, including reduced waist circumference and decreased body mass index (BMI) [21]. Such effects can be vital in the long-term prevention of T2DM.

The objective of this evaluation was to conduct a social return on investment (SROI) analysis of the MY LIFE programme, an innovative lifestyle intervention developed by the Conwy West Primary Care Cluster, one of the largest clusters in Wales, with 11 GP practices and a practice population of approximately 64,000 people. The MY LIFE programme aims to prevent diabetes, reduce obesity, promote physical activity and improve mental wellbeing (Figure 1).

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Figure 1

MY LIFE referral process.

An overview of SP programmes signposted by the diabetes technician (DT):

• NERS consists of two supervised physical activity sessions per week, lasting approximately 1-h. NERS is delivered by an exercise professional who provides support throughout a 16-week period. The activities involved are primarily exercise and fitness classes.

• KE is a 12-week programme delivered by a registered dietician which includes weekly or fortnightly weigh-ins to measure progress. The dietician provides advice on healthy weight loss, eating habits, goal setting, physical activity, meal planning, dining out, and food labels.

• SW is a 12-week programme delivered by a SW group consultant with a focus on weight management advice and guidance, telephone support, buddy systems, and online support.

The DT plays a crucial role in the MY LIFE programme. During the eight-week evaluation period, participants received information and advice regarding exercise and diet from the DT every two weeks (Table 1). Participants received a catch-up call (15–20 min) with the DT at weeks two, four and six, obtaining advice on diet and physical activity, and referral to online educational materials and video content, which was especially relevant when pandemic restrictions limited attendance at in-person SP activities. Catch-up calls helped to determine how participants were engaging with the MY LIFE programme.

2. Materials and Methods

The SROI analysis compared the cost of implementing the MY LIFE programme with the social value generated. SROI is a type of social cost–benefit analysis (social CBA) [22]. Social CBA is recommended by the HM Treasury Green Book to assess interventions and their effects on wellbeing [23]. SROI uses the outcomes relevant to stakeholders and assigns monetary values to those outcomes. Examples of outcomes for participants in the MY LIFE programme were ‘mental wellbeing’ and ‘good overall health’.

Mental wellbeing was assessed using the Short Warwick–Edinburgh Mental Wellbeing Scale (SWEMWBS), a 7-item questionnaire used to assess the mental wellbeing of members within a population [24]. Good overall health was measured using the EuroQol EQ5D-5L questionnaire, a 5-item questionnaire to assess mobility, self-care, usual activities, pain/discomfort, and anxiety/depression [25].

After the quantity of outcomes was determined, outcomes were then monetised using the HACT Social Value Bank (SVB), which uses wellbeing valuation to estimate social value [26]. Wellbeing valuation offers a consistent and robust method for estimating the monetary value of relevant and material outcomes that often do not have market values. Wellbeing valuation was applied using two social value calculators: the social value calculator derived from the SVB, and the mental health social value calculator derived from SWEMWBS. In this study, the social value calculator was used to monetise the outcome of good overall health [26] with values assigned only to those participants who improved by a score of 0.05 or more on the EQ5D-5L utility index. A change of 0.05 or more in the utility index is considered ‘clinically relevant’ [27]. The mental health social value calculator was used to monetise ‘mental wellbeing’ based on the individual SWEMWBS scores at baseline and eight-week follow-up [28].

SROI evaluation involves five main stages: (1) identifying stakeholders, (2) developing a theory of change, (3) calculating inputs, (4) evidencing and valuing outcomes, and (5) estimating SROI ratios [22].

Ethical and governance approval for this study was granted by the NHS Integrated Research Application System (IRAS) in July 2021 (IRAS ID: 300887).

3. Results

3.2. Theory of Change

After the main stakeholders were identified, a theory of change was developed to illustrate the relationship between inputs, outputs, outcomes, and impact (Figure 2).

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Figure 2

Theory of change.

4. Discussion

The SROI analysis showed that the DT plays a key role in generating social value for prediabetic participants, with SROI ratios ranging from GBP 4.67 to 4.70 for every GBP 1 invested for DT + SP activity, and from GBP 4.23 to 5.07 for the DTO. The findings also indicated that both groups of MY LIFE participants showed a reduced frequency of NHS health service resource use at the eight-week follow-up, with the exception of DTO participants who reported an increase of one outpatient visit.

The results suggest that positive social value outcomes were mainly a result of contact with the DT. It was estimated that between 54% (using the Social Value Calculator) and 67% (using the Mental Health Social Value Calculator) of the social value awarded to participants in the MY LIFE programme could be attributed to engagement with the DT, who provided telephone support and motivation to participants every two weeks during the eight-week intervention. Such a result highlights the importance of the DT in supporting prediabetic patients and preventing disease progression.

Although participants who engaged with the DT + SP experienced 33% to 46% more social value than the DTO group, the increased cost associated with the delivery of SP resulted in similar SROI ratios for both groups. The results in this study were undoubtedly affected by COVID-19 restrictions, which may have reduced the number of MY LIFE participants enrolled in SP activities. Some 50% of participants who completed baseline and follow-up questionnaires chose not to engage with SP, and a greater percentage of these participants were over the age of 50. Older people with prediabetes were likely to have been more hesitant to attend in-person SP activities during the pandemic.

5. Conclusions

This research showed that the role of the DT was key in generating a positive SROI ratio. Regular contact with the DT and referral to SP led to improvements in good overall health and mental wellbeing for prediabetic patients. The results indicated that participant utilisation of NHS resources was reduced after participation in the MY LIFE programme.

Although the results of this study appear promising, there were important limitations, such as a lack of randomisation, a small sample size, the use of only one research site (Conwy West), insufficient monitoring of SP attendance, and reductions in availability of SP due to COVID-19 restrictions. The results showed that the total social value generated was greater for participants who engaged with a DT + SP activity. However, this greater social value did not ultimately provide higher SROI ratios due to the costs involved with delivering SP programmes. Future healthcare policy should support the role of the DT, while continuing to measure the effect of SP for prediabetic patients at a time when COVID restrictions are not in place.

Acknowledgments

Funding Statement

This research was funded by KESS 2, in partnership with Bangor University and Conwy West Primary Care Cluster, grant reference 80815.

Author Contributions

N.H., M.L. and R.T.E. designed the study concept and acquired funding. N.H., M.L. and R.T.E. contributed to the study design. A.S. led the data collection. A.S. and N.H. analysed the data. N.H., A.S. and A.W.J. drafted the manuscript. A.S., N.H. and A.W.J. contributed to interpretation of the findings, reading, and approving the final draft. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Medical and Health Sciences Ethics Committee of Bangor University (Reference number: 2021-16934) on 5 July 2021.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Footnotes

References