Overview

The project is an initiative aimed at reimagining the self-management of type 2 diabetes among older adults. This endeavour takes a holistic, design-led approach that seamlessly integrates NHS leadership with community-driven support, crafting a care model that is not only clinically robust but also deeply rooted in the lived experiences of those it serves.

The Challenge

Type 2 diabetes is a growing public health challenge in the UK, particularly among older adults who face unique and often overwhelming obstacles in managing their condition. The current healthcare system frequently leaves these individuals feeling isolated, burdened, and under-supported, leading to suboptimal health outcomes and significant strain on NHS resources. This project addresses this critical issue by bridging the gap between formal healthcare services and the everyday realities of living with diabetes, empowering people to take control of their health with the support of their communities.

The Approach

The project adopts a bottom-up strategy that harnesses the strengths of both the NHS and local communities. While the NHS provides the essential medical oversight, ensuring that care is evidence-based and aligned with national health standards, the true innovation lies in the program’s emphasis on community engagement. By involving local community members, volunteers, and peer mentors—many of whom have personal experience with diabetes—the program creates a collaborative environment where people feel supported at every stage of their journey.

Intervention Strategy

The intervention strategy is designed as a layered pyramid, emphasising a structured approach to achieving positive health outcomes. At the foundation, systemic changes in the built environment, supported by policy and infrastructure, create an enabling context for health improvement. Moving upward, the strategy incorporates people-centered care pathways that empower individuals in decision-making, ensuring that care is tailored to the person rather than just the condition. The strategy also integrates programs and services that reinforce these care pathways, providing necessary support as individuals navigate their health journeys. At the apex, the intervention strategy culminates in practical tools and technologies that facilitate these programs, all contributing to the ultimate goal of achieving enhanced health outcomes and improved quality of life.

Key Interventions

Community-Driven Support: The program empowers local communities to actively support individuals managing diabetes. Volunteers, often those who have successfully navigated their own diabetes journey, offer practical advice, emotional support, and encouragement. This grassroots involvement enhances the accessibility and relatability of healthcare, bridging the gap between clinical care and the day-to-day challenges of living with diabetes.

Participatory Design and Stakeholder Engagement: Central to the project is its participatory design methodology. Through public storytelling sessions, collaborative workshops, and co-design activities, the project engages stakeholders—including those living with diabetes, healthcare providers, and policy advisors—to ensure that the care pathways developed are both effective and empathetic. This approach ensures that care is not imposed from above but is co-created with those it serves.

Health-Ally Program: A flagship initiative of the program, the Health-Ally Program, pairs individuals with peer mentors who guide them through their diabetes management journey. This initiative focuses on personalised care, addressing not just the medical aspects of diabetes but also the social, emotional, and psychological challenges that accompany it.

Outcomes and Impact

The project aims to significantly improve health outcomes and quality of life for older adults by equipping them with the tools, knowledge, and support needed to manage their diabetes effectively. Anticipated outcomes include better adherence to treatment plans, reduced complications, and a stronger connection between primary, secondary, and community care. By fostering a more integrated and people-centred healthcare system, the project also seeks to alleviate the burden on the NHS, making care more sustainable in the long term.

Future Scope

The success of this project has the potential to extend beyond diabetes care, offering a scalable model that can be adapted to other chronic conditions where self-management is critical. By refining and expanding this community-driven, bottom-up approach, the model can contribute to a broader transformation in healthcare, where individual empowerment and community involvement are at the forefront of care.

Conclusion

The project represents a paradigm shift in how we approach chronic disease management. By prioritising people-centred design, community collaboration, and individual empowerment, this project not only improves the well-being of those it serves but also strengthens the overall health of the community. It is a blueprint for a future where healthcare is not just a service, but a shared, supportive journey that empowers every person to live their best life.

Acknowledgements

A sincerely thanks to everyone who has supported this project. A special thanks to Dr. Partha Kar and Emma Nieminen for their valuable guidance and support. I’m also grateful to the teams at Diabetes UK, Annex Communities, and the University of Glasgow’s School of Health and Wellbeing for their collaboration and dedication. A heartfelt thank you to the community members and volunteers who shared their experiences—your stories shaped this work. Lastly, I appreciate the encouragement and advice from my mentor Dr. Micharl Pierre Johnson and colleagues, which have been essential in bringing this project to life.