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Type 2 Diabetes Mellitus (T2DM) is a growing problem in England, with approximately 3.1 million (6.7%) people living with T2DM and a further 5 million at high risk of developing T2DM as of 2017. England’s National Health Service is undergoing rapid transformation aimed at improving population health through multi-sectoral partnerships to align and integrate needs, priorities, and goals across healthcare, public health, prevention, and social care. This qualitative study sought to understand the impact of healthcare transformation on T2DM prevention and care in England.  Theory and Methods: This study is underpinned by the understanding that health systems are complex adaptive systems characterised by continuing self-organisation, non-linear interactions, interdependent and dynamic relationships, and multiple feedback loops. With this in mind, we conducted 38 semi-structured in-depth interviews with 11 persons with T2DM (PWDs), 14 healthcare professionals/providers (HCPs), and 13 health policymakers/decision-makers (PDMs). Participants were purposively and snowball sampled. We conducted thematic analysis in QSR NVIVO11 to inductively identify themes and subthemes from the data, drawing on grounded theory techniques including line-by-line analysis and the constant comparative method.  Results: Three key themes emerged. All interviewees (across PWDs, HCPs, and PDMs) emphasised the urgency of England’s growing T2DM burden and its contributors, including obesity, socio-economic deprivation, and unhealthy food environments, as a key driver of transformation. Increased awareness of T2DM at population-level was mentioned as a parallel development.  Additionally, participants highlighted how a person-centred, holistic approach is crucial to the transformation of T2DM prevention and care. Within this theme, each interviewee group highlighted contrasting, yet overlapping, subthemes. PWDs noted their preferences for empathetic, joined-up care that considers their cultural and ethnic differences and backgrounds. HCPs described shared care planning, cultivating patient-provider relationships, and multidisciplinary teams as characteristics of high-quality, holistic care provision. PDMs pointed to population-level needs driving development of policies and initiatives to tackle T2DM, especially in health and social care integration.  Participants also identified system-level barriers to transformation and integration. Participants across all groups reported funding and human resource limitations as key challenges impacting the care continuum, from primary prevention to acute hospital-based care. PWDs observed that the health system, especially primary care, was under strain as a result. HCPs explained how organisational and change management factors, namely strategic leadership and national and local priority-setting, were critical drivers of transformation. HCPs and PDMs noted the impact of factors outside the health system, particularly democratic cycles and political agendas, on sustainability and scalability of transformation efforts.  Discussion: This study offers insights into the multi-layered factors that impact healthcare transformation on T2DM prevention and care in England. From a complex adaptive systems viewpoint, these factors span systems hardware (e.g. organisational restructuring, capital investments) and software (e.g. cultural shifts, clinical practice improvements), and bottlenecks to meaningful, sustainable transformation often occur at the nexus of the two (e.g. mindset and practice change aligned to strategic priorities and resource allocation). This study also demonstrates that the health system is an open system affected by a multitude of external factors, including inequality, structural environment, and socio-political climate.

Improving Type 2 Diabetes prevention and care in England – what can healthcare transformation achieve?: A qualitative study