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Increasing patient referrals into the National Diabetes Prevention Programme in the Black Country and West Birmingham CCG

Increasing patient referrals into the National Diabetes Prevention Programme in the Black Country and West Birmingham CCG


We were commissioned by Black Country and West Birmingham health system to engage with GP practices and directly with patients to increase referrals into the National Diabetes Prevention Programme (NDPP). The NDPP is designed to support adults who are at a high risk of developing type 2 Diabetes Mellitus (T2DM). Participants are referred into 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 T2DM.


The collaborative project team between NHS Midlands and Lancashire CSU (MLCSU) and the health system provided a coordinated response to help increase referrals from primary care. This involved:

  • A dedicated email inbox helpline for NDPP queries from primary care
  • Pathway documents to provide practical information to support practice engagement and implementation of NDPP
  • Development of clinical systems searches to identify patients eligible for referral to the NDPP.
  • Direct discussions with eligible patients by pharmacy to encourage referral to NDPP
  • Development of electronic transfer documents (EDT) including approved clinical language for IT systems (SNOMED codes) to inform practices of patient discussions.

An early implementation test with the help of Thornley Street GP Practice was fundamental to the success of the project, refining processes for rolling out to other practices.


Figures from the NDPP provider (Ingeus) show that referrals from primary care have more than doubled in the period since MLCSU engaged with practices, 799 referrals compared to the year before – 364 referrals from primary care before MLCSU got involved.

Since the programme commenced we have:

  • Contacted directly an additional 1930 patients and referred 1144 of these to the NDPP. This is a 59% referral rate for patients that answered the call.
  • Engaged with 21 GP practices in the Black Country and West Birmingham region

  • Worked collaboratively with Ingeus and primary care commissioning leads to maximise GP practice engagement.

  • Diabetes prevention programmes can significantly reduce the progression to T2DM and lead to reductions in weight and glucose compared to usual care.[1]

NPDD Case study chart NPDD Case study chart
"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

1. A systematic review and metaanalysis assessing the effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes mellitus in routine practice