Treating the blind-spot of healthcare inequalities

Health inequalities is a much bandied about term – and means different things to different people. But what is glaringly evident are woeful discrepancies in the diagnosis and treatment of type-2 diabetes, especially amongst minority ethnic patients.

Cold, hard facts are, as always, powerfully persuasive.

Consider these, for example:

• There are 9 million people living with type-2 diabetes in the UK, with an estimated one million undiagnosed.
• Inequalities are inherent in the prevention, detection, care and outcomes of patients diagnosed with type 2 diabetes.
• There are huge variations in the delivery of the eight care processes expected to be followed for people living with diabetes. In south London alone, this varies between 25 per cent and 52 per cent, way below the desired target of 80 per cent.
• Many people living with type-2 diabetes do not access the appropriate services that are available to them – and many do not know what services are available.
• There are significant financial, organisational, IT and time barriers amongst multidisciplinary teams (MDTs) of healthcare professionals in primary care that make it hard to co-create integrated plans of care and education for people with type-2 diabetes.
• More than 16 million people in England have an incurable long term health condition and over three million of those have three or more long term conditions.
• People with long term conditions account for around 50 per cent of GP appointments, 64 per cent of outpatient appointments and 70 per cent of inpatient bed days.

Anuj Saboo, a self-confessed ‘data geek’ and his business partner Jonathan Abraham, are joint founders of digital health firm Healum. Using personalised digital plans, Healum aims to improve the consistency of care and reduce health equalities for people living with type-2 diabetes at Integrated Care System (ICS) level.

It sounds a Sisyphean task; and in many respects it is. After all, changing systems and procedures in healthcare is a Herculean undertaking – altering cultural attitudes and refining communications in a multi-ethnic city such as London, is on another level altogether.

His chemist father’s sudden death from cancer prompted Saboo’s foray into healthcare IT. An expert in AI who studied at the University of Essex, he parleyed his passion for healing into digital applications that “have an impact on people’s lives and actually go to my heart. Not only that, but also affects people and has an impact in shaping and changing their mindset and changing their lives as a whole.”

Saboo, CTO, and Abraham, CEO, admit to feeling frustrated prior to founding Healum eight years ago. “Not just about the inequalities of access to basic medical care, but some of the biggest inequalities, such as health literacy and understanding and navigating choices that are available to access to self-care,” Saboo said.

Their approach

Working alongside Academic Health Science Networks and ICSs to deliver personalised care, Healum started working with the Health Innovation Network (HIN) in South London in 2018. The initial ambition was to address a pressing issue in the delivery of the eight commonly performed diabetes care processes.

The HIN pulled together a consortium of clinical leads and project managers working on the provision of diabetes care in primary care across the 12 Clinical Commissioning Groups (CCG).

Following the consortium, the HIN worked in partnership with key commissioning stakeholders in South London to rollout a suite of digital solutions across 35 GP surgeries that would support primary care staff to consistently deliver care processes, tailored education and personalised support for patients with type-2 diabetes.

Multidisciplinary teams of staff at a number of surgeries were trained in the Year of Care best practice approach to care and support planning. The care planning software called ‘You & Type 2’, accompanying apps and personalised communication tools were designed to support new roles in Primary Care Networks (PCNs).

These linked healthcare workers and health and wellbeing coaches to work alongside GPs, practice nurses and healthcare assistants.

As Saboo explained: “For us, Healum is about enabling groups of healthcare professionals and people with long term conditions to be able to work together to understand the best set of choices that are available to people and to provide support and help at those moments that matter in people’s lives, to give them the best chance of acting on those choices.”

The software enabled healthcare professionals to collaboratively create and deliver personalised care plans with patients in order to bring the best support across the whole community in a way that was accessible on their smartphone.

These organisations worked together to secure a project funded by the NHS Diabetes Test Bed programme to deploy and evaluate the efficacy of these solutions in improving treatment targets, reducing the variation in care, and in improving health outcomes.

Main impacts

The interim results indicate that it has made it easier for people with type-2 diabetes to get the most out of the health and care system, and to manage their condition better.
The Healum software and app enabled clinicians to create and share personalised care plans in partnership with patients that have helped to:

1. Improve health outcomes through reductions in blood sugar levels and BMI.
After three months, 73 percent of users who were still actively using the app had reductions in their HbA1c (blood sugar levels). In the group of users that were not using the app, only 40 percent had a reduction.

Patients who were consistent monthly active users over three months had an HbA1c reduction from previous to latest measurement by 9.78 percent on average, and a BMI reduction of 1.56 percent on average.

People who had a reduction of BMI after three months, used the app four times more than people who either lost no weight or gained weight. People who reduced HbA1c used the app six times more than those that either had no reduction or saw increases in HbA1c.

2. Boost patient experience. People felt more informed and prepared before their care planning appointment after receiving personalised video messages from the CitizenUK platform which were sent via text from Healum’s system.

These videos helped people to understand their set of test results better and prompted them to think about what they wanted to talk about in their care planning appointment. Patients could add these needs to the mobile app ahead of the appointment. Impressively, 98.6 per cent of videos explaining the patient’s lab results were opened, with 78.6 per cent watching the clips to their conclusion.

3. Shift the conversation between patients and primary care staff to encourage patient agency over their care. So far, over 1,000 care planning appointments have taken place using the software, with a third of those appointments resulting in health objectives that were completely unique to the individual and expressed in a human way.

The health objectives ranged from quitting smoking, trying to fit in last year’s clothes, people’s personal relationships, taking up healthy hobbies, reducing stress, sleep patterns and cutting out certain foods.

Over 500 goals were created in the app by patients to support these specific health objectives, which were then shared with the primary care team.

4. Increase motivation to make daily healthy choices and improve self-care capabilities through custom goals. Over 3,000 healthy actions were taken by patients using the app as part of their daily routine to manage their diabetes.

These included logging activity, accessing educational resources, reviewing progress or informing themselves about their test results. The tracking and completion of actions related to goals around sleep, meals and mood which were more popular than tracking weight and step goals (which tend to dominate a lot of traditional health apps).

5. Addressing inequalities experienced by patients from ethnic minority communities in being able to access support for their self-care and diabetes management efforts. Over 50+ articles, videos and local services were carefully curated in partnership with the HIN. Resources were shared in many languages, including Gujarati, Bengali, Urdu, Punjabi and Somali.

Some of the most popular resources that were viewed were those targeted at ethnic minority communities including ‘Diabetes during Ramadan’ and ‘Managing Diet and Lifestyle in Urdu’.

This showed the demand for self-care support and education amongst people from different communities.

6. Reduce variation in care through the enhanced ability of over 101 healthcare professionals to follow best practice. The software was designed to support the recording of the eight care processes as part of the standard care received by patients.

Over 1,000 patients’ eight diabetes care processes were recorded in the software. These results were then sent to patients via a personalised video message with a link to the app for them to access.

This best practice approach to care planning saw an improvement in the delivery of care processes by GP practices in South London increase from 45 to 52 percent in six months.

7. Improve efficiency of multidisciplinary teams. Care plan creation grew consistently month-on-month since we started tracking appointments, increasing by 13.64 per cent on average each month between August 2021 – January 2022. 

Creating digital plans of care and support has previously not been possible. In over a third of cases the care plan involved more than one healthcare professional working on the plan which usually included a practice nurse and healthcare assistant.

Staff were involved in the co-design and implementation of the software in order to make it viable and efficient for multidisciplinary teams to work on creating care plans together.

Abraham is adamant in his and Saboo’s belief that everyone should have equal access to health and care services, irrespective of their background. He reflects on the impact that You & Type 2 was able to have in six months.

“By working together in collaboration with patients from many different communities alongside GPs, practice nurses, healthcare assistants, link workers, health and wellbeing coaches, commissioners, we have been able to rollout a digital solution that supports people in making the choices and taking the actions that they need to manage their health in a way that works for them personally.”

Ultimately, it’s the patient who counts. One who took part in ‘You & Type-2’ applauded the approach. This patient – whose identity has been concealed at their request – said: “The diabetes care planning with my doctor that I have recently had has been most helpful. I have learned a lot of new and useful information about my diabetes and also the care that I should be getting from the doctors that has previously been unavailable.”

And healthcare professionals appear to welcome the innovative advance. Oliver Brady, Programme Director for Diabetes and Mental Health at the Health Innovation Network (formerly project manager at South West London Health and Care Partnership) claims You & Type 2 was clearly designed to make it easier for people living with diabetes to access the care and support they need.

Dr Brady explained that the care and support planning software developed in partnership with clinicians and Healum enhanced this conversation by making the process of completing the care plan more efficient – so the focus can be on the conversation and what is important to the person living with diabetes to create meaningful goals and actions to work towards.

“The model helps GP practices to offer people with diabetes a more holistic and person-centred annual review process to support with self-management of their diabetes,” he added

Meanwhile, Dr Neel Basdev, Diabetes Clinical Lead, South London and Partner at Springfield Medical Centre, admitted that one of the biggest challenges within primary care during the pandemic has been handling the reduction of routine care for conditions such as diabetes.

This has meant reduced time with people to support them in managing their health. “You & Type 2 gives healthcare professionals a tool to help individuals self-manage their diabetes when they are unable to see a clinician.”

Next Steps

Following these initial positive interim results, Healum is now inviting any ICS to use its personalised care planning software, connected apps and live learning system as part of their efforts to reduce health inequalities and to support Primary Care Networks in managing the efficient delivery of care to patients with long term conditions.

Analysis of the project and its impact on health outcomes and delivery or care will continue throughout 2022. A service evaluation will be published later this year, showing the full impact of the tech solutions on health outcomes, patient experience, clinical workflow and the delivery of personalised care.

First featured in Health tech world here.