One Wirral CIC has launched a diabetes prehabilitation service to help reduce surgery postponements, tackle lengthy waiting lists and improve postoperative outcomes for patients.

The new service uses population health data and analysis of hospital waiting lists to identify those patients who are most at risk of having their surgery postponed.

After being adopted by two primary care networks (PCN) – Moreton and Meols PCN and North Coast Alliance PCN – the service is now being extended across Wirral to all PCNs.

The diabetes prehabilitation service uses the Cheshire & Merseyside Combined Intelligence for Population Health Action (CIPHA) population health management system on Graphnet Health’s CareCentric platform. CIPHA surgical waiting lists at Arrowe Park Hospital in Wirral are then used to identify diabetic patients awaiting surgery who have a HbA1C over 69mmol/mol or a BMI over 40.

Dr Dave Thomas, Wirral diabetes GP lead, said: “… a service where we’re getting people fit and healthy, and optimising their diabetes care prior to their operation can only benefit the patients. From a Wirral-wide point of view, it’s going to help reduce surgical waiting times, reduce complication rates, and it will allow us to reduce hospital stays.”

Once a patient has been identified they are contacted within 48 hours and booked in to see a diabetes prehabilitation health coach at a local community setting. Anyone with a HbA1c over 69mmol/mol will automatically be booked to see a diabetes specialist nurse who will explore medicines management and optimisation.

Each patient, regardless of who they see once they’ve been identified as being at risk, will start on a personalised prehabilitation lifestyle plan, which they’ll follow up until surgery.

By identifying these high risk patients, and making steps to improve their health, the need for GP surgeries to make referrals is removed. In addition, the service also receives referrals directly from secondary care, for people who have surgery postponed already and have diabetic risk factors.

Hope for a national approach

Lucy Holmes, wellbeing lead at One Wirral CIC, said: “The population health and data-driven approach means we are able to contact the right people at the right time and give them the best intervention before their procedure, without anyone slipping through the net.

“We look at their lifestyle and they’re encouraged to participate in activities, including the free diabetes exercise sessions that are held in the community each week. Their medications are also assessed. It means we’re looking at a person from a holistic point of view, not just clinically and not just non-clinically. It’s a true community-based, multi-disciplinary team approach.”

Ultimately, it hopes the approach will be adopted nationally, as Holmes explained: “We’re so pleased to be able to roll this out across Wirral, but it’s an approach that could easily be lifted and shifted. We would love to see it adopted nationally, because we have seen the many benefits of getting people fit before surgery.”

In September of this year Cheshire and Merseyside integrated care board (ICB) signed a deal with C2-Ai to expand its NHS Waiting Well initiative, which uses technology to identify patients on waiting lists who are at risk of deterioration. The AI-backed decision support model will now be deployed to the nine acute trusts in the region.