REMEDY : BNSSG referral pathways

Pre-diabetes and the National Diabetes Prevention Program

Checked: 08-03-2018 by hana.cavill Next Review: 04-03-2019

Service Overview

Pre-diabetes

An HbA1c of between 42 and 47 indicates patients are at high risk of diabetes and can be considered 'pre-diabetes'

Evidence suggests that Type 2 DM can be prevented or onset delayed if patients at risk are identified and make lifestyle changes.

Patients identified should be offered an annual check in practice to include HbA1c and vascular risk assessment. They should also be given a letter of invitation for the National Diabetes Prevention Program (NDPP)

National Diabetes Prevention Program

Funded by NHSE, The National Diabetes Prevention Programme (NDPP) began active rollout across BNSSG in June 2017. This programme is offered to patients with a HbA1c 42 – 47mmol, who are consequently at risk of developing Type 2 DM.

Delivered by an external provider, Living Well Taking Control, the programme provides an initial 1:1 assessment, followed by 8 weekly groups which focus on behavioural intervention and lifestyle modification. Further group follow up at 3,4,6,9 and 12 months is also provided. Groups are currently running across Bristol, South Gloucestershire and North Somerset.

All GP practices are now able to refer eligible patients into the NDPP, and it is recommended that every patient is referred where possible.

Lifestyle App

BNSSG are also currently trialing a Digital Lifestyle app on behalf of NHSE until April 2018. Some areas will be able to offer at risk patients the opportunity to take part in a digital lifestyle programme designed by OurPath (www.ourpath.co.uk) rather than the face to face NDPP. Once the trial ends, NHSE will evaluate Digital results before this product may be widely available.

For further details about the NDPP please contact Lisa Bryant – lisa.bryant@southglos.gov.uk

Referral to NDPP

When a diagnosis of pre-diabetes is made then patients should be invited to attend the NDPP. This can be done by generating a self-populating letter of invitation in EMIS which can then be given or sent to the patient.

In order to generate the letter in EMIS please use the following guide:

1. When a patient is diagnosed with pre-diabetes (HbA1c 42-47) then use the NDPP template (it should come up if you search either NDPP or pre-diabetes).

2. Once in the template then tick the 'Referral to NDPP' box. 

3. On saving the template a pop up should appear 'Pop up NDPP referral letter'. On ticking this box you will get a pre-populated letter you can save and print out to give/send to the patient.