NHS Appointment Letter

NHS England and NHS Improvement Letter and Briefing

Classification: Official

Publications approval reference: 001559

29 September 2020

Dear colleagues,

Type 2 Diabetes Prevention Programme and Type 1 diabetes glucose monitoring

In recent months, diabetes services across the country have shown extraordinary professionalism and resilience in the face of unprecedented challenges. We would like to thank you all for maintaining care to such a high standard throughout the pandemic response.

On 31 July, Simon Stevens and Amanda Pritchard wrote to NHS leaders to set out priorities for phase 3 of the NHS pandemic response. This letter and associated implementation guidance of 7 August include a focus on accelerating the restoration of non-COVID-19 health services; increasing the scale and pace of work to reduce health inequalities and to improve prevention, including a specific reference to accelerating referrals into the NHS Diabetes Prevention Programme.

As part of our Diabetes Prevention Programme recovery plan, we want to continue to support diabetes patients with the offer of virtual support to prevent and manage diabetes, and the technology to enable this, where clinically appropriate. To support this we would like to draw your attention to:

• changes in the delivery of the NHS Diabetes Prevention Programme so that we can accelerate our support offer
• the re-stand up of our Long Term Plan commitment to offer continuous glucose monitors to pregnant women living with type 1 diabetes
• progress on uptake of flash glucose monitors across the NHS

Healthier You NHS Diabetes Prevention Programme

At the end of July, the Department of Health and Social Care (DHSC) announced a package of actions to address the challenge of obesity in England. While the risks of obesity and type 2 diabetes to health have been well documented, in the last few months we have also seen that they increase risk of dying from COVID-19.

We have therefore further expanded access to the Healthier You programme, which helps people at high risk of type 2 diabetes to make lasting lifestyle changes. People are now able to self-refer for this support alongside direct referral from general practice. Further details of eligibility and how this works is provided in the briefing appended to this letter. This is being supported by a focused communications and marketing campaign to reach people from black and south Asian backgrounds who are at increased risk of developing type 2 diabetes as well as serious adverse outcomes relating to COVID-19.

The self-referral route is intended to complement – and not replace – the GP referral route. We therefore encourage general practitioners to restart/continue referrals from primary care. We have extended the window for referral of patients with an eligible blood test reading to 24 months to support this.

There are materials to help you promote the Healthier You service on the PHE Campaign Resource Centre.

Continuous glucose monitors – pregnancy

The NHS Long Term Plan includes the commitment that “by 2020/21, all pregnant women with type 1 diabetes will be offered continuous glucose monitoring [CGM], helping to improve neonatal outcomes.” The CONCEPTT trial has linked CGM with a reduction in rates of pre-eclampsia for pregnant women with type 1 diabetes, and a reduction in adverse neonatal outcomes (large for gestational age, neonatal hypoglycaemia and neonatal intensive care admission) for their babies.

The national Maternity and Diabetes teams have agreed that the Local Maternity Systems (LMS) should lead this work at system level from 20/21. The following LMS deliverable has been agreed: “all pregnant women with type 1 diabetes are offered continuous glucose monitoring by March 2021”.

Systems should work up plans to enable them to offer CGM to their patients by March 2021 and ensure compliance with the data reporting requirements.

To deliver best value a ceiling rate of £2000 will be provided per patient receiving a CGM device for 12 months. Funding will be allocated to LMS on a fair-shares basis, based on local incidence of type 1 diabetes and predicted rate of pregnancies.

There is an existing supplier framework available with devices available at a competitive price point, so the ceiling rate will not unduly restrict choice.

The Diabetes Technology Network has worked with providers across the market to develop a suite of training materials to support the adoption, uptake and optimal use of CGM in this cohort. This will be available to systems for free.

Further information will be shared around the support offer, training and data reporting requirements in due course.

Flash glucose monitoring

We would like to draw attention to your success in the roll out of the Freestyle Libre: we now have access, as at the end of June 2020, to 31% of all those living with type 1 diabetes. A recent audit, undertaken by the Association of British Diabetologists (ABCD) and published in Diabetes Care looks at the first cohort of over 10,000 NHS patients to benefit from Flash. This has shown marked improvement in HbA1c, reduction in hospital admissions and improvement in mental health parameters. This is encouraging to see: thank you for your ongoing support with delivery.

Funding for Flash is ringfenced until March 2021, at which point it will be built into clinical commissioning group (CCG) baselines for the ongoing prescribing of diabetes technologies. We would encourage systems to take account of the recent evidence of effect and consider further expansion in use of this self-management device. For example, in supporting efforts to provide remote support to our at-risk communities and levelling up the present socioeconomic and ethnic disparities; both of which are linked to poor glycaemic control in the type 1 diabetes population.

We would encourage using existing virtual platforms to help in education of those living with diabetes to lessen face-to-face contact while standardising pathways where initiation can be done in primary care with necessary specialist support.

There is also a range of existing free virtual tools to help healthcare professionals to upskill their knowledge in technology if needed, supporting further access:

• Diabetes Technology Network:
• AGP Academy

Thank you for your hard work in supporting patients to prevent type 2 diabetes and - for those already living with the condition – supporting them to access technology to help them manage their condition well.

Yours sincerely,

Briefing: COVID-19: New Healthier You referral route

This briefing sets out new arrangements for delivery of the Healthier You NHS Diabetes Prevention Programme as part of our ongoing response to the COVID-19 pandemic.

Healthier You helps people at high risk of type 2 diabetes make lasting lifestyle changes to reduce their risk. It is an evidence-based, 9-12 month programme which provides support to achieve a healthier weight, improve nutrition and increase physical activity. Last year, nearly 120,000 people attended a local Healthier You service. At the start of the COVID-19 pandemic, we rapidly transitioned the service to fully remote delivery rather than via face-to-face groups. Participants now attend remote groups by telephone or videoconference or access a digital programme.

Our research has highlighted that people with type 2 diabetes are at twice the risk of death in hospital with COVID-19, compared to people without diabetes, independent of other risk factors. Furthermore, people from black and south Asian ethnic backgrounds are not only at higher risk of serious adverse outcomes with COVID-19 but also at higher risk of developing type 2 diabetes.

To ensure we can fully utilise the capacity of the Healthier You programme and support our most at risk communities, we have expanded access to the programme allowing a self-referral model alongside direct referral from general practice.

Eligibility to self-refer to the Healthier You programme will be based on the Diabetes UK risk tool (a validated type 2 diabetes risk assessment tool) which can be completed on the Diabetes UK website, nhs.uk or on Healthier You service providers’ websites. People scoring at or above a specific (and different) risk threshold will be signposted to self-refer with their local Healthier You provider, bypassing the need for blood testing to identify non-diabetic hyperglycaemia (a requirement for referral from general practice), given the current reduced capacity and access relating to routine phlebotomy services.

Reflecting the greater risk for people from black and south Asian backgrounds of developing type 2 diabetes, as well as of serious adverse outcomes relating to COVID-19, we have developed a focused communications and marketing campaign to reach these communities and encourage wider self-assessment of risk and appropriate self-referral to their local Healthier You programme. There are a range of assets available to systems to support these activities.

We are also asking local systems, where appropriate, to re-engage general practice with offering referral to Healthier You to their population with non-diabetic hyperglycaemia (NDH). As NDH is defined biochemically as raised glycaemia (but below the threshold for diabetes), people identified with NDH are at particularly high risk of developing type 2 diabetes. Recognising the reprioritisation of clinical focus over the previous months and challenges relating to routine phlebotomy services, we have extended the eligibility window so that any adult with a blood test within the last 24 months indicating NDH (and not known to have diabetes) can be directly referred to the Healthier You programme. A free-to-access e-module on NDH and the Healthier You programme is available for healthcare professionals.

General practices will be notified when their patients self-refer to the Healthier You programme, providing consent has been obtained, and will be kept updated regarding progress and outcomes. People who attend the Healthier You programme, regardless of whether they were referred or they self-referred, will receive a fully remote or digital service at the current time. Face-to-face delivery will not resume until it is safe to do so; a separate communication will follow in advance of any such changes.

Appendix A and Appendix B give more information on the risk assessment tool.

The set of FAQs on the self-referral model below will support engagement with key stakeholders. Further information or questions should be directed to .

Healthier You NHS Diabetes Prevention Programme: self-referral model FAQs for healthcare professionals

1. Why has the referral route into the programme changed?

In response to the COVID-19 pandemic, the Healthier You NHS Diabetes Prevention Programme has expanded access by moving from a referral only route (from general practice) to add a self-referral route via an online risk tool.

This additional referral route was introduced to help our population at risk of type 2 diabetes to benefit from the Healthier You programme, recognising the capacity and clinical pressures faced by general practice during the COVID-19 pandemic and reduced capacity in phlebotomy services. It also aligns with plans to reduce inequalities relating to the development of type 2 diabetes; in particular, promoting uptake of Healthier You in people from black and South Asian ethnic backgrounds, who tend to be at higher risk of type 2 diabetes at younger ages.

2. How is the programme being delivered safely with social distancing rules in place?

New referrals into the programme are offered the option of the 'remote group' service – attending group sessions via telephone or videoconference – or an online service using websites and apps.

3. How can eligible participants refer themselves onto the programme?

Eligibility to self-refer to the Healthier You programme will be based on the Diabetes UK risk tool (a validated type 2 diabetes risk assessment tool) which can be completed on the Diabetes UK website, nhs.uk or on Healthier You service providers’ websites.

People scoring at or above a risk threshold will be signposted to self-refer with their local DPP provider (identified by postcode). It is possible that this risk threshold may change once further data is available on the self-referral pathway.

Anyone scoring at or above the risk threshold will be eligible to join, provided they are aged 18-79, not pregnant and do not have a current type 2 diabetes diagnosis.

4. How long will the new self-referral model be in place?

This route will be available until at least the end of March 2021.

5. Can healthcare professionals still refer patients into the programme the original way?

Yes. Please continue offering the programme to people who are identified as having non-diabetic hyperglycaemia via HbA1c or fasting plasma glucose (FPG) testing during clinical care; it is important that referrals into Healthier You continue from GP practices where possible.

6. Is the programme different for people who self-refer compared to the programme offered for people referred by their GP practice?

No, the same programme will be offered regardless of the route of the entry.

7. Are GP practices informed if someone has self-referred?

Healthier You providers will share details of people who have self-referred to the programme with their GP practice (provided consent has been obtained) and will update the practice at key points in the Healthier You journey, including first attendance, completion of the programme and discharge (if completion not achieved).

8. NICE recommends an annual review for people with non-diabetic hyperglycaemia. Should GP practices also conduct annual reviews for people who have self-referred to the Healthier You programme?

NICE guidance PH38 recommendations for annual review relate to people with non-diabetic hyperglycaemia (NDH). If someone who self-refers to the Healthier You programme already has previously been identified with non-diabetic hyperglycaemia, it is expected that processes should already be in place for an annual review with their GP practice.

However, many people who have self-referred to Healthier You on the basis of a Know Your Risk score may not have a glycaemic result recorded (HbA1c or FPG). NICE PH38 recommends that anyone highlighted to be at increased risk of type 2 diabetes by a validated risk filter, such as the Diabetes UK Know Your Risk tool, should be offered a blood test to check for non-diabetic hyperglycaemia or undiagnosed type 2 diabetes. Therefore anyone who self-refers to Healthier You should be offered such testing by their GP practice if and when sufficient phlebotomy capacity is available.

Follow-up and recall arrangements are likely to vary depending on the outcome of this blood test. If NDH is revealed, NICE guidance recommends yearly glycaemic monitoring. If the person is found to have normoglycaemia, NICE recommends monitoring every three years (they are classed as moderate risk of type 2 diabetes due to the elevated risk score).

9. What happens if someone self-refers to Healthier You but is then found to have type 2 diabetes?

If someone is found to have previously undetected type 2 diabetes after self-referring to Healthier You, they may continue on the programme provided they appreciate that messaging around preventing type 2 diabetes will no longer be applicable for them. However, they may still benefit from support regarding improving nutrition, increasing physical activity and achieving a healthy weight.

Whether they choose to remain on Healthier You or not, it is important that full usual care is initiated as for any new diagnosis of type 2 diabetes, including referral for structured education, completion of diabetes care processes and appropriate pharmacological management.

10. Is it a problem if someone has self-referred to Healthier You but is found to have normoglycaemia on blood testing?

No, they should continue on Healthier You as they still have various risk factors for the development of type 2 diabetes.

11. How should GP practices code self-referral to the NHS DPP in the clinical record?

Follow the guidance of your local team. If there are no reasons why this may not be suitable (such as local incentive schemes based on coding data), it would be reasonable to use the same code for self-referral as would be used for referral by a healthcare professional (‘Referral to the National Health Service Diabetes Prevention Programme’ – SNOMED: 1025321000000109).

The same codes can be used for the self-referral pathway as for HCP-referral pathway; there are codes for programme started (SNOMED: 1025271000000103), completed (SNOMED: 1025251000000107) and not completed (SNOMED: 1025211000000108).

12. How should GP practices code a person’s Diabetes UK risk tool score?

The Diabetes UK risk tool is a rebrand of the Leicester Diabetes Risk Assessment tool. The numerical score can be input into the clinical record using the code ‘Leicester Diabetes Risk Score’ – SNOMED: 1025601000000108.

13. Do self-referrals count towards an area’s allocation of places on the programme?

The self-referral model is designed as an additional route into the programme, over and above general practice referrals. It is not intended to replace current methods and pathways for referrals from primary care. Referrals from general practice should therefore continue as allocated capacity allows and should be stepped back up wherever possible. Self-referrals do not count towards these allocated places and local health economies will have sufficient capacity to meet their normal profiled demand. Any sites with queries about places, or currently profiled activity, should discuss this with their regional team.

14. Will the provider take baseline glycaemic readings for people who self-refer?

No, the provider will not perform any blood testing for anyone on the programme (self-referred or referred by GP Practice).

15. When will the delivery model for Healthier You revert to group face-to-face?

The Healthier You programme will continue to adhere to Government guidelines regarding social distancing. Any changes to this advice will inform decisions regarding mode of delivery of the programme.

Appendix A

Appendix B

Step 1: Access the Diabetes risk tool at:

Step 2: Complete the risk assessment. A risk score will be displayed on screen and if the participant provides an email address the results will also be emailed to them.

If the participant gets a Moderate score 16-24 or a High Score 25-47 and meet the eligibility criteria they will be presented with a link to access the DDP Healthier You Programme.

Access the Diabetes risk tool at:

Step 3: From the results page the Participant will be directed to find their local Healthier You Provider via the postcode look up tool.