There was a cluster of data-driven innovation projects, including projects focusing on AI algorithms to personalise care and identify those at risk to prevent future complications (projects 8, 11 and 32), and emerging projects exploring real-time decision support to enable better triage and case finding (project 12). This aligns with the aspirations of participants to use innovation to better tailor care to meet and support individuals’ needs. It was notable that while two projects mentioned in the survey focused on non-invasive medical devices, participants did not identify this as an unmet need. As we can see from this concentrated clustering, several ‘how might we...?’ questions and ideas are not currently being targeted, representing opportunities for future innovation.   

Across the workshops, participants discussed the need for more person-centred education and supported self management resources to enable people living with diabetes to get the best use of technology and devices. It was also noted that technology can be ineffective or damaging if the person is in a bad place, therefore support needs to be ongoing and not episodic or time limited. We identified one online resource seeking to educate people about using positive displacement pumps (project 24). However, there remains a gap in resources that support people to understand how current and emerging technologies could support their goals, identify the best option to suit their needs and educate them on how to use them.   

Technology can significantly impact people’s quality of life, and participants felt it was important to understand the pros and cons of using different technologies for diabetes care. For example, one person gave an account of using a tubed pump and its restrictive impact on her quality of life compared to another participant who had a non-tubed pump and a closed loop system and felt they were enabled to have the lifestyle they wanted.

Related to this was frustration about being “locked in” to using the same device for several years without being able to change to an alternative that better suits your lifestyle when it becomes available.   

Participants also discussed the drain on time and energy of continuously doing personal research to understand what technology is available, device compatibility and what their health board offers that would best suit their requirements. Participants felt there was a need to communicate the benefits and challenges of different technology and devices to allow people living with diabetes to make an informed choice and find “their own balance”. It can be challenging for health services to provide guidance due to the technical variation in each person’s setup, so there is often a reliance on peer support. However, there were worries about the advice given on unmonitored Facebook groups, suggesting a need for quality assurance mechanisms for peer support.  

There were frustrations from health professionals and people with lived experience about the discrepancy between what technology (medical devices) exists and what is available through the health service, as well as variation between health boards. It was suggested that there should be a Scotland wide list of available technology rather than by health board. 

Central to this challenge was an ambition to design and deliver care pathways that can flex to suit the changing needs of the person, their lifestyle, life stage, condition and goals. We identified very few innovation projects relating to this theme. The data-driven innovation projects, e.g., application of AI to personalise care pathways (project 11), represents a significant opportunity to use clinical, experiential and lifestyle data to tailor care models to the person’s condition. However, there was a need to consider this alongside the person’s circumstances, goals, and care preferences. For example, one group shared an idea of a framework to support good conversations where the initial diagnosis appointment could be aided by an algorithm to personalise care, including a discussion of the person’s readiness to use technology. Another group discussed the potential of a new non-clinical ‘health coach’ to support self management through remote trigger monitoring and tailored education. An alert could be raised to a ‘health coach’ who would be able to respond to triggers with advice and flag to clinicians when appropriate. This could be a more proactive and responsive approach to diabetes care and potentially reduce the demand on clinical staff time.  

We identified a need for tools and conversations that communicate what resources are available and support the person to access the right resources at the right time. This goes beyond clinical and statutory services, including resources such as third sector and community assets, peer support and quality-assured digital health apps that may be relevant to the person. One interview participant pointed to the need to embed these in care pathways, e.g., at diagnosis highlighting specific digital resources recommended as part of their routine care. Resources such as ORCHA (quality-assured digital health apps) and ALISS (crowd-sourced catalogue of community resources) were suggested to support this. Aligned with this, workshop participants identified an opportunity for innovation that helps people living with diabetes to navigate the system and find the services and support that are relevant to them. One group conceptualised this as a ‘tube map’, allowing the person to see where they currently are and navigate to the resources that are available to them (see Figure 10 for an attempt to illustrate this concept visually).

We learned about the lack of awareness among both health and care professionals and people living with diabetes about the services they can refer to and access. When participants living with diabetes raised challenges during the virtual workshop, a health professional pointed out that there were health board commitments and services already in place in response (e.g., structured education), suggesting that the messages they think are being communicated are not getting across. During the in-person workshops, a health professional discussed the challenges they have had in raising awareness of a psychology service among GPs. In our interviews, a health professional also highlighted challenges in communicating with patients outside of clinics, suggesting that asynchronous digital communication could help provide more regular and ongoing support. This highlights the need for new approaches for communicating to service users what services and resources are available, and resources to cope with the resulting rise in demand due to greater awareness. This should not only be for newly diagnosed, as in the workshops we learned that some participants who had been living with the condition for many years felt forgotten. 

Education:

We identified five highly interactive educational resources (projects 13, 14, 15, 19 and 21) targeting children and young people, using approaches such as gamification and high-quality visualisation to engage in learning and management of diabetes. However, we did not find any projects or resources using similarly innovative approaches to develop education for adults living with diabetes. Our workshop participants identified a pressing need to focus on designing highly engaging, interactive and intuitive educational resources for all people living with diabetes and health and care professionals. Participants questioned whether existing educational resources are designed around the needs of minority communities, and those with low literacy and numeracy and stressed this as a key requirement for any new educational resources. This was seen as a gap that cut across several challenge themes, presenting an opportunity to address stigma and dispel myths, and provide engaging education about healthy lifestyles and mental wellbeing for people living with diabetes.  

Participants wanted new forms of education for health and care professionals that feel engaging, enriching and useful rather than a tick-box exercise. Participants in the virtual workshop challenged the suggestion of in-person workshop participants that new diabetes-specific education for health and care professionals should not be mandatory. They agreed so strongly with the need for education that they felt this should be seen as an essential part of the job. This, in turn, requires that adequate work time is provided to complete the education and a clear delivery strategy.  

There was a strong message from workshop participants that new forms of education for people living with diabetes and health and care professionals should be co-designed and facilitated by both a clinician and a person with lived experience of diabetes.  

Mental wellbeing:

We identified several digital resources for mental wellbeing that could be better integrated within more flexible care pathways (projects 17, 22 and 23). One project (16) offered a fun and engaging toolkit to support communication between people living with diabetes, loved ones and health professionals.   

Peer support was a cross-cutting theme, with participants highlighting the role this plays in supporting mental health and wellbeing. We identified one project seeking to better understand and enable peer support (project 6). Participants across the workshops discussed how mental health impacts people’s ability to engage with their diabetes care. A gap was identified in resources and education for health professionals to have the confidence to discuss mental health as part of routine diabetes care.  An action plan for supporting Mental Health and Wellbeing screening has been developed nationally in NHS Scotland. Findings here indicate it would be appropriate to align innovation investment to this key area.  

The mental load of living with diabetes was a focal point during discussion within the virtual workshop, highlighting that the overwhelming number of variables to consider could be challenging to problem solve on your own. One participant referred to a study which found that people living with diabetes make, on average, 180 more decisions daily about their health. The non-clinical ‘health coach’ idea (see Flexible Care Pathways above) was discussed as a positive and helpful way to alleviate some of this anxiety by being able to talk through something in the moment. 

Lifestyle:

We found only one project relating explicitly to lifestyle, and this specifically targeted adolescents (project 12), however many of the resources identified offer lifestyle information (projects 4, 24, 25, 26 and 27). This challenge was seen to be best tackled through innovative new forms of education and incentives-based approaches. A gap was identified in supporting health professionals to raise the subject of physical activity without worrying it would disengage the person. Participants suggested that integrating data from lifestyle apps within clinical systems (e.g., Fitbit), would provide health professionals with a “way in” to engage in person-centred conversations around lifestyles. They also suggested linking with leisure centres and other community resources to offer incentives and practical support. 

Participants challenged the notion that lifestyle is a choice for many people. They stressed that the current cost of living crisis exacerbates these issues. The financial implications of healthy lifestyle choices were seen as a barrier for many people living with diabetes, including the ability to buy healthy food or pay for energy to cook healthy meals. They suggested an opportunity for dietitians to work alongside food banks to meet the needs of people living with diabetes.   

One participant at the virtual workshop highlighted a range of initiatives and strategies being rolled out in their region (Greater Glasgow and Clyde) that are available to people living with diabetes who are experiencing financial difficulty (e.g., Ready Steady Ping to pay for energy cards). As we could not find further information about these resources online or verify if these initiatives specifically target people living with diabetes, we have not included them in the innovation mapping project list, but they are included as ideas (see Figure 10). There may be potential for further work to engage with local councils to understand how initiatives targeting food poverty can specifically consider the needs of people living with diabetes, and how we can increase awareness of their availability within a more tailored and flexible care pathway.  

Health professionals highlighted that for people with diabetes to be able to adapt their lifestyle, they needed to be in a good place mentally; however, this was impacted by personal circumstances and inequalities. 

Health and digital inequalities:

We did not identify any innovation projects specifically targeting health or digital inequalities. This theme was core to discussions about education, technology, mental wellbeing and lifestyles. Participants stressed that services are designed to meet the needs of “traditional clients” leading to minority communities struggling to access services. For example, participants highlighted the need for health services to think more creatively about how they identify, engage and communicate with ethnic groups who are at higher risk of diabetes and health inequalities to ensure services are getting to the people who need them most. This included tailoring any new educational resources (see Education above) to ensure they meet the needs of different ethnic groups and consider how they can support enhanced access for people who cannot access digital resources due to cost or a lack of confidence.  

Integrating user data 

Participants highlighted frustration with technology companies who withhold users’ data, restricting integration with other devices and requiring the health service to licence proprietary software to view data. One participant pointed to innovative approaches to procurement in the Netherlands requiring companies to make data accessible. We identified one innovation project (31) led by an NHS board, who were working collaboratively with technology companies to integrate data from medical devices with existing NHS clinical data. Key to this is ensuring that procurement contracts specify data integration standards to ensure that technology companies comply. Information governance was identified by interview participants as a barrier to data integration, highlighting the need to streamline this process to support pace. Participants also highlighted the opportunity to integrate user data from widely used consumer lifestyle apps (i.e., myfitnesspal), activity trackers (i.e., Fitbits – see project 5), wearables and remote monitoring devices.  

Implementation timescale 

Interview and workshop participants highlighted the need for more agility and responsiveness when implementing new policy and technology for diabetes care. They highlighted that policy changes can take seven years to be implemented in clinics, and further delays in procurement and licencing mean that technology is outdated by the time it is implemented. 

"Every month the gap between what we want to deliver and what we're able to deliver is getting wider." Interview participant  

 This can result in people using technology that is not approved or supported by the NHS, leading to frustration that health professionals cannot use their data as part of their consultation. Participants living with diabetes saw addressing this as vital to person-centred conversations that support them in understanding their triggers.  

Implementation and resourcing 

Increasing access to technology for all people living with diabetes and better use of data were suggested as quick wins to improve the quality of life for those living with diabetes. However, health professionals highlighted that implementing new technology requires more than just paying for the kit; it needs funding to implement and additional capacity to ‘fund the change, not just the tech’ (Gerhold, 2023). This also applied to any new diabetes-specific education developed for health and care professionals; resources would be needed to back-fill staff to give dedicated time to complete it.    

Managing expectations 

A challenge that has been raised across the mapping activity is the need to manage expectations of what technology can achieve. Health and care professionals stressed that patients often have the perception that technology will solve all their diabetes challenges. During the virtual workshop participants with lived experience also raised this as an important point, calling for better communication of the benefits and drawbacks of different devices. Participants also discussed the burden of technology such as a closed-loop system, the importance of getting your set-up right to begin with and continuously managing that. 

Variation in resources and services 

Participants came from across Scotland, highlighting variation in the resources, and service provision available in different geographical areas. This reiterated the significant benefits of accelerating the delivery of ‘Once for Scotland’ care models for diabetes and continuing to invest in data and digitally enabling infrastructure to underpin these models. Participants identified that they would prefer a single means of getting access to information, services and support rather than using multiple digital systems. This aligns with the vision of the Digital Front Door which featured in conversations and opportunities to streamline diabetes care processes.