How a commissioning support unit increased primary care referrals from the Black Country Integrated Care System to the NHS Diabetes Prevention Programme

Between June 2021 and March 2023, NHS Midlands and Lancashire Commissioning Support Unit (MLCSU) were commissioned by the Black Country and West Birmingham Clinical Commissioning Group (subsequently the Black Country Integrated Care System [ICS]) to engage with practices and directly with patients, to increase referrals into the National Diabetes Prevention Programme (NDPP). 

The NDPP is a structured educational programme designed to empower adults to make sustainable lifestyle choices to reduce their chances of developing type 2 diabetes mellitus (T2DM)​[1]​. Referring eligible patients into a programme that supports them to make positive changes to their diet, weight and physical activity, can significantly reduce the risk of developing T2DM. 

It is estimated that there are approximately 2.4 million people in England at high risk of developing T2DM. The Black Country ICS has one of the highest Quality and Outcomes Framework diabetes prevalence rates in England, at 9.2% compared to the national average of 7.3%​[2]​. While the number of people with diabetes is rising and increasing demand on primary care, the NDPP can start to reduce the numbers of people developing T2DM. 

GPs and their teams can identify and refer people at high risk of T2DM, who can benefit from the NDPP. 

Prior to MLCSU support, GP practices would identify suitable patients for referral on an individual basis; for example, at a long-term condition review or consultation. MLCSU developed a novel approach of generating referrals at scale. Practices were provided with a newly developed clinical system search to help identify eligible patients and practical pathway documents were developed to support engagement and implementation.

Historically, there was a large variation between practices in recruiting patients to the NDPP, which was worsening health inequalities. MLCSU developed criteria to apply to NHS Digital ePACT2 dashboard data to help identify practices most in need of support. Highest priority was provided to large practices with a high diabetes prevalence in areas of high deprivation, which historically had completed less than ten referrals.

Working collaboratively with local NDPP providers and primary care commissioning leads, practices were contacted to explain the support available, and a series of webinars were run to raise awareness and support engagement. Following successful engagement, practices ran the search and returned an eligible patient auto-report via NHS mail, to a dedicated and secure NHS mail inbox. 

MLCSU pharmacy technicians undertook motivational discussions with patients remotely to promote referral to the NDPP provider. Practices were informed of outcomes for coding in the patient’s record via electronic transfer documents containing structured clinical vocabulary codes for accepted/declined NDPP. To provide governance and assurance around the flow of data, a data processing impact sssessment and a data processing agreement were shared with practices. 

In total, between June 2021 and March 2023, the MLCSU Medicines team has:

  • Engaged with 42 GP practices in the Black Country ICS;
  • Contacted 3,680 patients;
  • Referred 2,130 to the NDPP. This is a referral rate of 58%.

In February 2023, the service was further developed with the aims of improving the NHS cost effectiveness and providing alternative methods of engagement for patients. A personalised video test of concept was trialled across five practices. The video was personalised with the patient’s first name, GP practice, postcode, ethnicity, gender and HbA1c result. It described why the patient was eligible and explained the NDPP offer. Three text messages were sent to patients, the first telling them to expect a link to a personalised video, the second providing a link, and the third was a reminder to complete with a feedback survey. At the end of the video, patients could select to be referred or request more information. A total of 279 videos were generated; 61% of patients who had opened the video chose to be referred or requested more information. These results show high levels of engagement and action taken by patients, and demonstrates that using technology to engage patients in healthy lifestyle programmes can have a positive impact on uptake, in a more cost-effective manner.

Learning from this project highlights practice engagement through stakeholders, including GPs with specialist interests and practice-based pharmacists, is critical for success. Data quality is also a barrier to effective clinical system searches, so introducing processes to ensure up-to-date contact information is essential.

This project has shown that the approach employed by MLCSU is an effective means to increase referrals of patients into the NDPP and can be delivered at scale and remotely across many GP practices. It also supports the reduction of demand on GP practices by delivering the NDPP patient engagement. The use of personalised videos and motivational phone calls was effective and well received by patients. 

Jin Samra, senior pharmacist, Medicines Programme Support Team, MLCSU
Jonathan Horgan, director of Pharmacy Services, MLCSU
Claire Morrissey, Community Digital Health Programme Lead, Black Country ICB
Anna Stone, GP Partner Thornley Street Surgery, Royal Wolverhampton Trust

To contact us about this programme, email:

  • This article was amended on 5 July 2023 to add Claire Morrissey and Anna Stone as authors
  1. 1
    NHS National Diabetes Prevention Programme . NHS England. (accessed May 2023).
  2. 2
Last updated
The Pharmaceutical Journal, PJ, May 2023, Vol 310, No 7973;310(7973)::DOI:10.1211/PJ.2023.1.185900

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