Category Archives: Publicity

2nd Cohort PreDM results just in

The second cohort of patients has now completed their Eat4Health course.  They acheived a fantastic 4.5kg average weight loss, or the equvalent of 5% of their 96Kg starting weight through the course of the sessions.  Congratulations, that is a massive effort.

PreDM project stand at Newbury Show


We have had our final planning meeting and full steam ahead for the show, looking forward to a sunny weekend according to the forecast.  Come and see us on Stand 301 south of the main showground arena (towards the funfair corner).  We are looking to screen as many people as possible (age 25-84 who haven’t already got diabetes) using the QDiabetes tool and then offering enrollment and advice from the Eat4Health team and on the spot HbA1c screening for diabetes via a finger prick test.  The HbA1c test tells us what you blood sugar has been like over the last 3 months.

We will post our results here.

Newbury PreDM project comes to Royal Berkshire Show


As part of our project to promote early intervention for Diabetes to the Newbury and District CCG area, we have managed to get a trade stand at the Royal Berkshire Show 21-22nd September 2013 in Newbury.  This is a fantastic chance to spread the word to the anticipated 60,000 attendees many of whom may be from rural and isolated farming communities.

We are looking to offer QDiabetes Screening via iPads associated with Eat4Health advice and Point Of Care Diabetic Screening.  Come and see us there and check out your diabetic risks.

Interview transcript from Paul Coia Show on BBC Radio Berkshire 27th August 2013


5.16 pm—Paul Coia

Now doctors in West Berkshire say the chance of getting diabetes can be cut by as much as half if people take part in a ground-breaking new scheme. A pilot is taking place where they are scoring people’s chances of getting the condition by looking at their family history, their lifestyle and blood sugar levels. The risk of heart disease and stroke is also reduced by the scheme.

And one man from Newbury who has seen it working close up is Martyn Williamson

Paul Coia: Hi there Martin,

MW: Hi there, Paul.

PC: Not only have you seen it close up, you have seen it closer than anybody could. You were one of the victims in all this. You actually had problems with your medical conditions. Didn’t you?

MW: Number of difficulties, yes, that’s right.

PC: When did you realise that you might be at risk of diabetes.

MW: To be perfectly honest, Paul, I never considered diabetes ..I have got one or two other issues. I had a letter from Dr West, our GP. Basically, if I cut to the chase, he said, we have estimated that you have higher than average risk of developing diabetes and we estimate your personal risk to be 32.4 percent over the next 10 years. It was a wakeup call, if you know what I mean.

PC: Definitely, how did you feel seeing that then?

MW: Old.

PC: May I ask how old you are?

MW: I will be 68 on Thursday. I don’t feel 68 but there we are

PC: No, no, you should feel young and you are quite right especially when you have been given a second chance. You got this wake up call. Presumably your doctor then referred you to this pilot scheme.

MW: The letter then goes on to say We would like you to consider doing the following: One of them is attend a tailored 3-month lifestyle intervention course called Eat4Health. And that was indeed the course I went on.

PC: So what does that involve?

MW: Well, it’s over 10 weeks. We met on Friday evenings for couple of hours, and each week takes one particular topic. Would be interested in knowing the topics..? Behaviour change was one week, healthy eating was another session, goals and rewards, physical activity internal and external triggers –that’s for road eating, fats and sugars food labelling, dealing with evening outs and takeaways and of course, alcohol.

PC: Oh dear. See if I went along they would be ashamed of me, because I love all that, I love grazing, I love the curries, I love a pint of lager now and again.

MW: We get on really well then Paul.

Both giggle

PC: I probably will look at the list of dos and don’ts very good but probably, forget it. What made you follow the advice?

MW: That’s interesting because that would have been under normal circumstances the reaction you had just described would have been me. However, there are number of things that have triggered me to want to do something as a matter of some urgency about weight and lifestyle. One of them is..I have got two artificial hips. Whilst my mobility is much better than it was it still could improve I had noticed that my own attempts had a marked effect on my mobility. So I was really really anxious to give this my best shot. There was that and the fact that I didn’t particularly fancy having diabetes. I know I have a few heart problems. How could I not want to do it?

PC: Be honest and forgive the impertinence of the question, but would you describe yourself as a bit lardy.

MW: Errr…errmm….heading that way, yes. It hurts to say it you know, but yes.

PC: Do you have people around you who were saying you know Martyn you pulling the pants now; you are looking a bit chubbed up.

MW: It has been said, not actually in those words but the inference was there.

PC: You probably wouldn’t have listened to that but this medical advice made a difference to you. Tell me the difference it has made to your life.

MW: Well, I can give you one concrete example. One of my pleasures in life is to walk around the local Penn woods with my dog.  I hadn’t done that in five years. I now do it every morning.

PC: Brilliant. That’s fantastic. So would you recommend this scheme to other people?

MW: Yes, I would. The only proviso I would say is like anything that involves a small element of will power it’s only going to work if you really wanted to. I really wanted to and everyone else who was on the course did as well. It was a success.. As such it gets a 10 out 10 from me.

PC: Brilliant and this is the first in the country apparently.  Could be the first of many more. It’s great that it made a difference to you and presumably if anybody thinks they can benefit from this in the area, they can talk to their GP.

MW: So I understand, yes. I just wish I had heard of this, years ago. It’s life changing.

PC: What a great recommendation! Martyn Williamson, thank you very much indeed. Martyn Williamson, as he said, had his life turned around by the new initiative of Newbury and District Clinical Commissioning Group.


Further surgery “goes live” with PreDM project

A further surgery goes live with sending out invitations to the PreDM project.  North Hants Hospital have agreed to process the blood tests for their patients using the same proforma as the Royal Berks Hospital making actioning and processing between surgeries seamless.

Discussed local publicity campaign to promote the idea and process amongst the wider population when the E4H sessions go live.

First E4H Session already booked up and equivalent number of questionnaires completed online.

HSJ Article mentions the PreDM project

The original article in the HSJ is password protected but here is a copy

Information overload: CCGs and data innovation

14 February, 2013 | By Sean Riddell

Clinical commissioning groups have more data available to them than ever before. Sean Riddell looks at how it can be used to deliver real change.

We are living in the “open data” era. The government has committed to making more and more data freely available: with over 40,000 files, is said to be the largest data resource in the world.

Within the NHS, the transparency agenda has seen more data than ever before made public − including quarterly prescribing reports for every primary care trust in England and detailed analyses of hospital spending on drugs for conditions such as HIV and AIDS.

Clinical commissioning groups and individual GPs are also feeling the impact of the drive for data. A significant milestone is the launch of the GP Extraction Service  − which will, for the first time, release national data from GP records to try to improve patient care and efficiencies.

‘For clinicians, the only way to effect change is to integrate the derived knowledge into their clinical management system’

CCGs are also beginning to contract bespoke data extraction services to help them gain a better and deeper understanding of local health services. This data can be used for a multitude of different purposes − from creating risk profiling dashboards that identify patients at risk of unscheduled hospital admission, to monitoring prescribing spend across a locality.

But how does the drive for “open data” translate into real change? Liberating the data is only the first step. The information then has to be translated into knowledge and, finally, integrated into clinical workflows if it is to make a difference on the front line.

Data disconnect

Data is not much use in isolation – it’s what you do with it that matters. There is a real risk of a data disconnect if clinicians are bombarded with more and more data without any intelligent interpretation or attempt to integrate it with how they work.

Let’s consider the typical GP, who will regularly receive many different pieces of information and guidance about how they should be working − including, for example, the latest National Institute for Health and Clinical Excellence guidelines or new local protocols for specialist referrals.

While this information is useful and relevant for GPs, the way it is communicated − typically on paper − is a disconnect with their largely electronic workflow.

Most GPs spend their entire working day within a single clinical software system. For these clinicians, the only way to effect change is to integrate your derived knowledge into their clinical management system. By making it a seamless part of how they do their job, you can start to make a difference.

Making the data work

A good example of how this can work is an innovative project carried out within a leading GP clinical system to identify patients with undiagnosed diabetes.

Following work with a national research body, the software provider embedded a new algorithm into its software. The algorithm automatically interrogates patients’ medical records, searching for blood test results that show a high blood sugar (HbA1C) level but no clinical diagnosis of diabetes.

‘Identifying at-risk patients is still only part of the story − the real test is what you do about it’

During consultations, the software highlights these patients via an automated alert reminding the GP to investigate the reason for their high blood sugar. The alert remains on the system until the GP confirms an investigation and conclusion (ie the patient has diabetes or there is another reason for the HbA1C score).

Because it is fully integrated into the GP’s clinical system, this alert becomes a seamless part of the way the GP does their job − in this way it starts to effect change.

At a national level, the software provider estimates that the algorithm could identify 57,000 patients with diabetes, based on a high blood sugar level which has not been followed up.

Of course, identifying at risk patients is still only part of the story − the real test is what you do about it. This brings me to my final point about how data can improve healthcare.

Evidence-based IT

Integrating new ways of working into clinical software is a huge step forward but it’s not the end of the data trail. In my opinion, the real power of data can only be measured when you close the loop and measure what difference your intervention has made. I call this evidence-based IT.

Here is another innovative example of how data is being harnessed to deal with the nation’s diabetes epidemic. At the Falkland Surgery in Berkshire, which has 14,500 patients, GPs are using QDiabetes, a stratified risk predictor embedded within their clinical IT system, to identify patients with a one-in-five risk of developing diabetes in the next 10 years.

‘With all patients there was a definite psychological sense of hope and enthusiasm that was not there at the beginning’

Having identified the most at risk patients, the GPs compared the effectiveness of different interventions. Fifty-two patients were invited to take part in either a healthy eating or a healthy exercise regime to help them lose weight and increase activity to head off the disease.

The initial results showed good compliance in both groups, and measurable improvements for a majority of patients after 10 weeks, including weight loss and reduced waist circumference.

Although not statistically significant, the results were encouraging enough for the initiative to be proposed for roll out across 12 other practices with a total 100,00 patients in the locality. The Newbury and District CCG is considering making it part of its quality, innovation, productivity and prevention programme.

Project lead Dr Tim Walter said: “The results are very promising, and we are delighted that this important preventative work in a key group of patients is likely to be tested elsewhere.

“What was very interesting was the psychological impact, which we didn’t set out to measure. At a follow-up meeting with all the patients there was a definite psychological sense of hope and enthusiasm that was not there at the beginning.”

Find out more

Sean Riddell is chief executive at the EMIS Group