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Increasing patient referrals into the National Diabetes Prevention Programme


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 increase referrals into 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 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 type 2 diabetes mellitus.


To help practices increase referrals into 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 roll out across the 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.


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
  • MLCSU pharmacy technicians undertook motivational discussions with patients remotely to promote referral to the NDPP provider

In February 2023, a personalised video test of 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 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.

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

NDPP Case Study Graph