Increasing referrals to the National Diabetes Prevention Programme – The Scott Practice, North East and Yorkshire

Case study summary

The Scott Practice in Doncaster is made up of 11.2 whole time equivalent GPs serving a patient population of over 14,000. Low referral rates to its local National Diabetes Prevention Programme (NDPP) prompted the practice to look at ways to address this by applying learning from the General Practice Improvement Leads programme. The programme is delivered by NHS England and NHS Improvement and part of the support available through the General Practice Forward View.

The idea

Increase referral rates to the local NDPP and improve consistency of information given at diagnosis.

Developing a clear aim

One of the Advanced Nurse Practitioners (ANP) participated in the programme and worked alongside one of the GPs to drive forward the project.  To be clear about what they wanted to achieve, the ANP and GP worked with the wider practice team to develop the following aim statement.

For all patients diagnosed with prediabetes to be offered referral to the NDPP within 3 months of diagnosis or at annual review.

By achieving this aim it was hoped that it would ultimately lead to the reduction of diabetes amongst the practice’s patient population.

Inconsistencies and a lack of clarity

Information from the local NDPP showed that over three months the practice had made zero referrals to the programme, which identifies those at high risk of diabetes and refers them on to a behaviour change programme.  Whist the GP and ANP had their own thoughts and observations as to the reasons why, they undertook process mapping to involve and get input from the wider practice team.  By mapping the patient diagnosis process a number of issues came to light.

  • Results coming into the practice were being distributed to different clinicians e.g. GPs, registrars, ANPs and Healthcare Assistants (HCAs). This was unhelpful as it was leading to inconsistencies in the management of results and diagnosis.
  • There was a lack of clarity amongst some clinicians as to what constituted pre-diabetes and with interpreting test results. For example, not all were consistently diagnosing patients with HBa1C 42-47 or results being coded as normal.
  • Where a diagnosis has been made there were inconsistencies as to how it was dealt with and the information given e.g. some patients were informed promptly others not, some had telephone calls, some referred to the practice nurse who led on diabetes, some patients were referred to the NDPP but not all.
  • Incorrect read codes were being used on patient records making it difficult to flag patients that needed to be referred to the NDPP.  This was also creating issues when trying to identify which patients needed to be called in for an annual review.

The findings focused the team on which areas needed to be addressed as a priority; staff training, better capturing and consistency of information given and designing a more streamlined process.

Involving HCAs more

The team found that it was not necessary to have a GP involved in the process and that with adequate training it could involve HCAs more.  The GP conducted a training session for all HCAs where she went through what is prediabetes, how they can assist patients with self-care, the type of questions and conversations that needed to be had with patients during the appointment e.g. discussions around lifestyle, importance of weight loss, family history.  All patients would be offered the opportunity to be referred to the NDPP, alternatively if the patient declined a referral they could still be monitored annually via annual review.  The training also went through what advice should be given at diagnosis that can help self manage lifestyle and better control of health.

The GP and ANP developed a template for HCAs to use which captured key points of the appointment/review, ensuring the patient was aware of the diagnosis and the importance of weight loss, whether the patient has been offered a referral to the NDPP and accepted or declined this. Importance of annual blood test to monitor the condition as well as the addition of the correct read code was also added so an annual review with the HCA could be set up and flagged closer the time.

Both the ANP and GP tested the template between them first before rolling it out.  Following this they conducted a series of small cycles of change with the template and tweaked as more staff used and provided feedback on its usage e.g. adding in the read code to decline referral to NDPP or patient not suitable for NDPP, such as in patients with dementia or mental health problems where group based work may not be appropriate. They also added a direct link to a patient information leaflet on NDPP which is now interpreted into alternative languages.

Redesigning the process

As part of a larger project to streamline the process of managing the HBa1c results coming into the practice, the team agreed to the following changes.

  • All HBa1c results 42-47 will now go to the ANP to filter/triage. Admin time is allocated so that the ANP has sufficient time to process the results.
  • Patients with a new diagnosis of prediabetes will be referred to the HCA to discuss the results of the tests and offered referral to the NDPP, as well as advice on lifestyle changes.
  • Newly diagnosed patients will have a repeat blood test in 6 months and annual review with the HCA.
  • Results whereby the patient is already known to have prediabetes will be picked up by the ANP who will check if they had previously been offered or been on the NDPP programme. If the answer is no they will be referred back to the NDPP or referred to the lead GP to ascertain whether they would be suitable for oral treatment. Cases where patients’ blood results show they have good control of their diabetes on their current medications will be filed by the ANP providing there are no outstanding clinical issues.

In the new process no GP involvement is required unless a patient requests to see a GP.  All GPs are encouraged to complete the same prediabetes template for this scenario.

After two weeks of testing the new process the team found there was a delay in the referral process to the NDPP, as HCAs were unclear who to send the referral request to for completion once a patient had accepted.  With additional training HCAs learned how to load and complete the prepopulated form and how to send a task to the secretaries to email to the correct department, this resulted in a smoother process and less delay.


  • Over 3 months 26% of all the practice’s prediabetic patients were referred to the NDPP, with a further 58% of referrals for those patients newly diagnosed with prediabetes. The practice intends to keep building on the changes made so referral rates continue to increase.
  • The benefits for patients have been significant. Early diagnosis and advice on self managing lifestyle, weight loss and better control of health, has helped make changes that can reduce the risk of diabetes.
  • Triaging of patients has improved, making it a simpler and quicker process for staff and patients.
  • One of the key outcomes has been that GPs do not need to be involved in the process as patients can be dealt with by HCAs and the ANP, who have the necessary clinical skills and expertise required to deal with patients at pre-diabetes stage. For GPs this has helped ease workload and focus on those patients who need to see them.
  • As part of a Primary Care Network the work the practice has done can be shared and replicated across the network, helping to improve population health by reducing diabetes levels across the network’s patient population.

“With the skills I learnt on the General Practice Improvement Leads programme we’ve been able to improve our referral rates to the NDPP, as well as improve the quality of care we have given to patients diagnosed with prediabetes. We’re really positive about the changes we’ve made and hope to build on the good work that’s already been done with our next project.” Lisa Scott, Advanced Nurse Practitioner, The Scott Practice

“With the work that has been done regarding pre-diabetes at the Scott Practice, we have developed an efficient multidisciplinary approach to diagnosis, education, recall and NDPP referrals. We are beginning to see the benefits of this with a significant reduction in GP time spent on pre-diabetes but also with results of our first cohort of patients completing the NDPP course showing weight loss and improvements in their HbA1C results. Having been able to work alongside an ANP with advanced leadership skills developed through the General Practice Improvement leads programme, the overhaul of system was far more manageable and has resulted in a robust, education-driven MDT approach. I fully believe that this change will result in reduced rates of conversion to diabetes in the future and will thus improve health in this group within our community.” Dr Liz Gomersall, GP lead for Diabetes, The Scott Practice

If you would like to find out more about participating in the General Practice Improvement Leads programme, along with details on how to apply, visit our web page.