By implementing effective strategies, we increased patient referrals to the National Diabetes Prevention Programme. The number of primary care referrals more than doubled, with 42 GP practices actively participating in the initiative. Through our efforts, we engaged with 3,680 patients and referred 2,130 individuals to the program.
Background
Between June 2021 and March 2023, NHS Midlands and Lancashire CSU (MLCSU) were commissioned by the Black Country and West Birmingham CCG (subsequently the Black Country ICS) to support GP practices to increase referrals to the National Diabetes Prevention Programme (NDPP). The Black Country ICB has one of the highest diabetes prevalence rates in England. The NDPP is designed to support adults who are at a high risk of developing type 2 Diabetes Mellitus. Participants are referred to a structured educational programme and attend a series of group sessions to empower them to make sustainable lifestyle changes to reduce their risk of developing type 2 Diabetes Mellitus.
Action
To help practices increase referrals to the NDPP, we worked collaboratively with local NDPP providers and primary care commissioning leads to maximise GP practice engagement. With the appropriate information governance, we carried out an early implementation test at Thornley Street GP Practice to test processes prior to at-scale rollout across the Integrated Care System (ICS) footprint. We provided practices with:
* A dedicated secure NHS mail inbox for queries and transfer of data from primary care
* Pathway documents to provide practical information to support practice engagement and implementation of NDPP
* Clinical system searches to identify all eligible patients for referral within a practice
* Direct discussions with eligible patients to encourage referral to NDPP
* Electronic transfer documents including clinical library codes to inform practices of the outcomes of patient discussions.
Impact
In the first year of our support, referrals from primary care more than doubled (799) compared to the previous year (364).
In total, during this programme of support, we have:
– Engaged with 42 GP practices in the Black Country and West Birmingham
– Contacted 3,680 patients and referred 2,130 to the NDPP programme
In February 2023, a personalised video test of the concept was trialled across 5 practices. The video was personalised with the patient’s first name, GP practice, postcode, gender and blood sugar level result. 279 videos were generated with 61% of patients who had opened the video choosing to be referred or requesting more information. Results showed high levels of engagement and high levels of action taken by patients.
This project has shown that the at-scale approach employed by MLCSU for referrals is an effective means to increase diabetes prevention and support GP practice primary care capacity.
Feedback
Thank you very much for all your support and assistance. Clearly, this exercise has been very useful. I will share the results with our team. Ikbir Kaur | Practice Manager, Hilltop Medical Centre